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Proquest Dissertations INFIRMARY SERVICES FOR HOMELESS PERSONS IN TORONTO: A CASE STUDY SUZANNE JEAN ZERGER A DISSERTATION SUBMITTED TO THE FACULTY OF GRADUATE STUDIES IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY GARDUATE PROGRAM IN SOCIOLOGY YORK UNIVERSITY TORONTO, ONTARIO JUNE 2008 Library and Bibliotheque et 1*1 Archives Canada Archives Canada Published Heritage Direction du Branch Patrimoine de I'edition 395 Wellington Street 395, rue Wellington Ottawa ON K1A0N4 Ottawa ON K1A0N4 Canada Canada Your file Votre reference ISBN: 978-0-494-46024-5 Our file Notre reference ISBN: 978-0-494-46024-5 NOTICE: AVIS: The author has granted a non­ L'auteur a accorde une licence non exclusive exclusive license allowing Library permettant a la Bibliotheque et Archives and Archives Canada to reproduce, Canada de reproduire, publier, archiver, publish, archive, preserve, conserve, sauvegarder, conserver, transmettre au public communicate to the public by par telecommunication ou par Plntemet, prefer, telecommunication or on the Internet, distribuer et vendre des theses partout dans loan, distribute and sell theses le monde, a des fins commerciales ou autres, worldwide, for commercial or non­ sur support microforme, papier, electronique commercial purposes, in microform, et/ou autres formats. paper, electronic and/or any other formats. The author retains copyright L'auteur conserve la propriete du droit d'auteur ownership and moral rights in et des droits moraux qui protege cette these. this thesis. Neither the thesis Ni la these ni des extraits substantiels de nor substantial extracts from it celle-ci ne doivent etre imprimes ou autrement may be printed or otherwise reproduits sans son autorisation. reproduced without the author's permission. In compliance with the Canadian Conformement a la loi canadienne Privacy Act some supporting sur la protection de la vie privee, forms may have been removed quelques formulaires secondaires from this thesis. ont ete enleves de cette these. While these forms may be included Bien que ces formulaires in the document page count, aient inclus dans la pagination, their removal does not represent il n'y aura aucun contenu manquant. any loss of content from the thesis. Canada ABSTRACT Housing, income, and health system reforms driven by a neoliberal agenda have created unprecedented growth of Toronto's homeless population, and enhanced the complexity of their health problems and how they find and receive health care. These reforms have limited the capacity of the universal health care system to address the needs of homeless and underhoused persons, and driven the development of targeted homeless- health care services. By giving voice to the providers who bear the brunt of health care delivery for these individuals, this study enables a rich understanding of the layered meanings of these targeted services within a universal health care system. I argue that while these targeted services are characterized by innovation and sensitivity to the unique needs of the homeless population, they are under-resourced and ultimately reproduce stratifications seen in the broader health care system; the providers are unwittingly entrenching a separate tier of health care for the growing number of persons with needs not met by the universal health care system, and reinforcing the intent of reforms aiming to commodity health care. My analysis focuses on the tensions the homeless population's unique set of needs cause providers in the hospitals at the point of discharge, and those in the community agencies increasingly burdened with the responsibility to care for them. Under pressure to discharge patients, hospital-based providers struggle to release homeless patients not sick enough to justify a hospital bed, but with nowhere to go to recuperate safely. Many of these patients end up in emergency homeless shelters with aftercare needs shelter- iv based providers are unable or ill-equipped to provide. A Homeless Infirmary which originated at the onset of Toronto's homeless crisis in 1998 and opened about a decade later in 2007 expressly to alleviate this tension serves as a case study. Using a political- economy framework, this study describes the specific historical-cultural context in which this Infirmary emerged, and how it has developed. Though multiple sources of information are used to understand this context, in-depth interviews with both hospital- and community-based providers best illuminate how this systems-created tension plays out on the frontlines of care. v ACKNOWLEDGEMENTS Several people were especially helpful to me throughout the preparation of this dissertation. Dr. Pat Armstrong, my supervisor, provided consistent encouragement and support as well as timely and insightful reviews of numerous drafts. Drs. Tania Das Gupta, Stephen Longstaff, Isolde Daiski, Karen Anderson and Allan Moscovitch also gave generously of their time and expertise. Audrey Tokiwa and Rhonda Doucette patiently helped me navigate the numerous administrative steps. I was also very privileged to work with Alice Broughton, Pat Larson, and Tracy Warne on this project; these compassionate, intelligent women tirelessly serve persons experiencing homelessness in their community, and are great inspiration to me. These three, along with the many individuals I interviewed for this study, are admirable advocates within systems which too frequently dismiss persons who lack life's basic necessities. My greatest debt of gratitude, though, goes to Robert Teigrob, for his unwavering kindness and support. vi TABLE OF CONTENTS Page# INTRODUCTION 1 Background 3 Study Foci 6 The Role of Public Health vs. Medicine in Health Disparities 7 Study Framework and Contributions 15 Outline of Chapters 19 POLITICAL ECONOMY AND HOMELESSNESS, HEALTH, AND 21 HEALTH DELIVERY SYSTEMS The Political Economy of Health Disparities: Neoliberal 22 Globalization Trends The Canadian Context: An Eroding Infrastructure 30 Defining Homelessness: Who's In and Who's Out? 38 Health Care Delivery 48 Housing and Health. 57 Summary 65 METHODS 68 Conceptualizing Homelessness 69 Study Participants 71 Interviews: Content and Approach 75 Other Information Sources 78 Analytical Strategies 83 Advisory Team 85 Summary 86 HOMELESS HEALTH SERVICES IN TORONTO: PROVIDER 88 PERSPECTIVES Overview of Homeless Health Services in Toronto 100 Health Care for Homeless Persons in the Hospital Setting 110 Health Care for Homeless Persons in the Community 124 Funding and Accountability 143 Summary 152 vn TABLE OF CONTENTS, continued V. THE HOMELESS INFIRMARY 155 Va. Development and Design of Homeless Infirmary Services in 157 Toronto Vb. Referrals to Sherbourne Homeless Infirmary 168 Vc. Clients Served by Sherbourne Homeless Infirmary 178 Vd . Short-Term Impacts of the Homeless Infirmary 184 Ve. Long-Term Impacts: The Role of Targeted Services within a 191 Universal Health Care System Vf. Summary 200 VI. CONCLUDING REMARKS 204 REFERENCES. 210 viii LIST OF TABLES Table III-1 Interviewee Location, Type and Number 74 Table III-2 Referral Forms: Selected Variables 81 Table V-1 Referrals to Sherbourne Homeless Infirmary 171 Table V-2 Sherbourne Homeless Infirmary Clients 179 ix LIST OF FIGURES Figure IV-1 Ontario Health Insurance Plan (OHIP) Cards (1990, 1995) 104 x LIST OF APPENDICES Appendix A) Study Protocol 226 Appendix B) Study Consent Forms 231 XI CHAPTER I INTRODUCTION In 1998, leaders of health care associations in Toronto ominously predicted, in a letter to then Health Minister Elizabeth Witmer, "The medicare principles of universal, accessible, comprehensive and portable health care are a myth for Ontario's homeless population and their situation will worsen significantly... " [cited in (Golden et al. 1999:103)] Some vivid indications of this prediction becoming a reality a decade later came in the form of some stories relayed by providers caring for homeless persons in Toronto: A manager of a homeless shelter described a naked man, wearing only a hospital bed sheet and a colostomy bag, being dropped of at the door of his shelter upon being discharged from the nearby hospital. A homeless-outreach worker described an acutely suicidal woman with a crack addiction wearing a urostomy being discharged from a hospital in the middle of the night, left to walk through crack alleys to her temporary residence at a downtown women's shelter. A simultaneous deterioration of the public health and housing infrastructure and of the capacity of the universal health care system has created a gap in care between hospitals and the street; these stories describe what happens when people fall through that gap. Using a political economy framework, this thesis attempts to understand the factors which led to the dire 1998 prediction and to the situation with homeless-health care a 1 decade later. A case study of a program designed to address this gap focuses the discussion. The providers in hospitals and homeless-targeted agencies who have borne witness to these systems changes throughout the past decade offer their insights into how those changes have affected their ability to care for persons who are homeless in their community, and how they have navigated the resultant tensions. Housing, income, and health system reforms driven by a neoliberal agenda have created unprecedented growth of Toronto's homeless population, and enhanced the complexity of their health problems and how they find and receive health care. These reforms have limited the capacity of the universal health care system to address the needs
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