Clinical guideline for homeless and vulnerably housed people, and people with lived homelessness experience [2020-03]

KEY POINTS

  • Clinical assessment and care of homeless and vulnerably housed populations should include tailoring approaches to a person’s gender, age, Indigenous heritage, ethnicity and history of trauma; and advocacy for comprehensive primary health care.
  • As initial steps in the care of homeless and vulnerably housed populations, permanent supportive housing is strongly recommended, and income assistance is also recommended.
  • Case-management interventions, with access to psychiatric support, are recommended as an initial step to support primary care and to address existing mental health, substance use and other morbidities.
  • Harm-reduction interventions, such as supervised consumption facilities, and access to pharmacologic agents for opioid use disorder, such as opioid agonist treatment, are recommended for people who use substances.

Homeless and vulnerably housed populations are heterogeneous and continue to grow in numbers in urban and rural settings as forces of urbanization collide with gentrification and austerity policies. Collectively, they face dangerous living conditions and marginalization within health care systems. However, providers can improve the health of people who are homeless or vulnerably housed, most powerfully by following evidence-based initial steps, and working with communities and adopting anti-oppressive practices.

Broadly speaking, “homelessness” encompasses all individuals without stable, permanent and acceptable housing, or lacking the immediate prospect, means and ability of acquiring it. Under such conditions, individuals and families face intersecting social, mental and physical health risks that significantly increase morbidity and mortality. For example, people who are homeless and vulnerably housed experience a significantly higher prevalence of trauma, mental health conditions and substance use disorders than the general population. Canadian research reports that people who experience homelessness face life expectancies as low as 42 years for men and 52 years for women.

A generation ago, homeless Canadians were largely middle-aged, single men in large urban settings. Today, the epidemiology has shifted to include higher proportions of women, youth, Indigenous people, immigrants, older adults and people from rural communities. For example, family homelessness (and therefore homelessness among dependent children and youth) is a substantial, yet hidden, part of the crisis. In 2014, of the estimated 235 000 homeless people in Canada, 27.3% were women, 18.7% were youth, 6% were recent immigrants or migrants, and a growing number were veterans and seniors.

Kevin Pottie, Claire E. Kendall, Tim Aubry, Olivia Magwood, Anne Andermann, Ginetta Salvalaggio, David Ponka, Gary Bloch, Vanessa Brcic, Eric Agbata, Kednapa Thavorn, Terry Hannigan, Andrew Bond, Susan Crouse, Ritika Goel, Esther Shoemaker, Jean Zhuo Jing Wang, Sebastian Mott, Harneel Kaur, Christine Mathew, Syeda Shanza Hashmi, Ammar Saad, Thomas Piggott, Neil Arya, Nicole Kozloff, Michaela Beder, Dale Guenter, Wendy Muckle, Stephen Hwang, Vicky Stergiopoulos and Peter Tugwell
CMAJ March 09, 2020 192 (10)
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