Caring for patients with lived experience of homelessness.

OBJECTIVE: To guide family physicians working in a range of primary care clinical settings on how to provide care and support for patients who are vulnerably housed or experiencing homelessness. SOURCES OF INFORMATION: The approach integrates recommendations from evidence-based clinical guidelines, the views of persons with lived experience of homelessness, the theoretical tenets of the Patient's Medical Home framework, and practical lessons learned from family physicians working in a variety of clinical practice settings. MAIN MESSAGE: Family physicians can use simple and effective approaches to identify patients who are homeless or vulnerably housed; take initial steps to initiate access to housing, income assistance, case management, and treatment for substance use; and work collaboratively using trauma-informed and anti-oppressive approaches to better assist individuals with health and social needs. Family physicians also have a powerful advocacy voice and can partner with local community organizations and people with lived experience of homelessness to advocate for policy changes to address social inequities. CONCLUSION: Family physicians can directly address the physical health, mental health, and social needs of patients who are homeless or vulnerably housed. Moreover, they can champion outreach and onboarding programs that assist individuals who have experienced homelessness in accessing patient medical homes and can advocate for broader action on the underlying structural causes of homelessness.

Soigner les patients ayant connu l'itinérance.

OBJECTIF: Guider les médecins de famille de divers types de pratique familiale quant à la façon de dispenser des soins et du soutien aux patients logés précairement ou qui vivent l'itinérance. SOURCES D'INFORMATION: L'approche intègre les recommandations tirées des lignes directrices cliniques fondées sur les données probantes, l'opinion des personnes avec une expérience vécue de l'itinérance, les principes théoriques du cadre de travail du Centre de médecine de famille et des leçons pratiques provenant de médecins de famille qui travaillent dans des contextes cliniques variés. MESSAGE PRINCIPAL: Les médecins de famille peuvent utiliser des approches simples et efficaces pour identifier les patients itinérants ou logés précairement; franchir les premières étapes pour faciliter l'accès au logement, à l'aide financière, à la gestion de cas et au traitement de la toxicomanie; et collaborer en faisant appel à des approches anti-oppressives et qui tiennent compte des traumatismes pour mieux venir en aide aux personnes qui ont des besoins sur les plans social et sanitaire. Les médecins de famille ont un solide pouvoir de plaidoyer et peuvent s'associer aux organisations communautaires locales et aux personnes ayant vécu l'itinérance pour revendiquer des réformes politiques qui tiennent compte des iniquités sociales. CONCLUSION: Les médecins de famille ont la capacité de répondre directement aux besoins sociaux et aux besoins en matière de santé physique et de santé mentale des patients itinérants ou logés précairement. En outre, ils peuvent promouvoir les programmes d'approche et d'intégration qui aident les personnes avec une expérience vécue de l'itinérance à accéder aux centres de médecine de famille et peuvent militer pour l'adoption de mesures générales visant à contrer les causes structurelles sous-jacentes de l'itinérance.

Waiting for care: effects of Ontario's 3-month waiting period for OHIP on landed immigrants.

OBJECTIVE: To describe the experiences of a group of new immigrants and caregivers of new immigrants who were subject to the 3-month waiting period for the Ontario Health Insurance Plan and needed to access health care services during that time. DESIGN: Qualitative study using a phenomenologic framework. SETTING: Participants were recruited through the Scarborough Community Volunteer Clinic in Toronto, Ont. Interviews were conducted in person at the clinic or by telephone. PARTICIPANTS: Seven participants were interviewed who themselves needed to access health care during the 3-month waiting period for the Ontario Health Insurance Plan or who were caring for someone who did. METHODS: Seven semistructured, in-depth interviews were conducted using an interview guide; these were recorded and transcribed verbatim. Data were analyzed for themes to arrive at the essence of the participants' experiences. MAIN FINDINGS: Participants believed that there was a lack of clear information and a lack of help from officials. Other common themes included poor social situations, financial loss or threat of financial loss related to health care, a choice to delay seeking care owing to cost, difficulty accessing alternative care, and appreciation for those who advocated on their behalf. Other themes that arose included emotional hardship, poor health outcomes or threat of poor health outcomes resulting from not seeking care, the importance and unpredictability of health, as well as negative impressions of Canada as a country as a result of the negative experience of seeking care. CONCLUSION: New immigrants to Ontario who need to access health care services during the 3-month waiting period for provincial health insurance and the caregivers of such newcomers can have potentially very negative experiences. They might be unable to access care without financial barriers and might, therefore, choose to delay seeking health care until the end of the waiting period; this can lead to emotional hardship for themselves and their caregivers as well as to potentially poor health outcomes. This potential for an overwhelmingly negative experience for some new immigrants to Ontario might lend support to the argument that this policy be eliminated.

Immigration Status as the Foundational Determinant of Health for People Without Status in Canada: A Scoping Review.

Migration is increasing at unprecedented rates worldwide, but inadequate mechanisms for granting citizenship or permanent residence have rendered many immigrants without legal status. We study the health of people without immigration status in Canada, building on a 2010 review on being without status and health. We employ an expanded definition of health, guided by the WHO Social Determinants of Health (SDoH) framework. Using a scoping review methodology, we reviewed literature from 2008 to 2018 on the SDoH of people without legal immigration status in Canada, selecting 33 articles for analysis. We found that structural determinants of health, such as stigmatization and criminalization, and intermediary determinants, such as fear of deportation and healthcare avoidance, produce ill health. We show how different social positions are produced by SDoH, finding immigration status to be the foundational determinant of health for people without status in Canada. We argue that lack of immigration status as a SDoH is missing from the WHO framework.

Teaching poverty and health: importing transformative learning into the structures and paradigms of medical education.

Background: As a paradigm of education that emphasizes equity and social justice, transformative education aims to improve societal structures by inspiring learners to become agents of social change. In an attempt to contribute to transformative education, the University of Toronto MD program implemented a workshop on poverty and health that included tutors with lived experience of poverty. This research aimed to examine how tutors, as members of a group that faces structural oppression, understood their participation in the workshop. Methods: This research drew on qualitative case study methodology and interview data, using the concept of transformative education to direct data analysis and interpretation. Results: Our findings centred around two broad themes: misalignments between transformative learning and the structures of medical education; and unintended consequences of transformative education within the dominant paradigms of medical education. These misalignments and unintended consequences provided insight into how courses operating within the structures, hierarchies and paradigms of medical education may be limited in their potential to contribute to transformative education. Conclusions: To be truly transformative, medical education must be willing to try to modify structures that reinforce oppression rather than integrating marginalized persons into educational processes that maintain social inequity.

Contexte: En tant que paradigme favorisant l'équité et la justice sociale, l'éducation axée sur la transformation vise à améliorer les structures sociétales en inspirant les apprenants à devenir des agents du changement social. Dans une visée d'éducation transformatrice, le programme de doctorat en médecine de l'Université de Toronto a mis en place un atelier sur le thème de la santé et la pauvreté auquel participaient des tuteurs ayant une expérience vécue de la pauvreté. Notre recherche visait à examiner comment les tuteurs, en tant que membres d'un groupe confronté à l'oppression structurelle, ont compris leur participation à l'atelier. Méthodes: Cette recherche qualitative s'est appuyée sur une méthodologie d'étude de cas et sur des données d'entrevue, en utilisant le concept d'éducation transformatrice comme prisme pour l'analyse et l'interprétation des données. Résultats: Nos résultats s'articulent autour de deux grands thèmes : les décalages entre l'apprentissage transformateur et les structures de l'éducation médicale, et les conséquences inattendues de l'éducation transformatrice au sein des paradigmes dominants de l'éducation médicale. Ces divergences et ces conséquences non voulues ont permis de constater que les cours qui sont ancrés dans les structures, les hiérarchies et les paradigmes contribueront peu à l'éducation transformatrice. Conclusions: Pour que l'éducation médicale soit véritablement transformatrice, il faut qu'il y ait une volonté de modifier les structures qui renforcent l'oppression plutôt que de faire entrer les personnes marginalisées dans des processus éducatifs qui perpétuent l'inégalité sociale.

Implementation and impact of an online tool used in primary care to improve access to financial benefits for patients: a study protocol.

OBJECTIVES: Addressing the social determinants of health has been identified as crucial to reducing health inequities. However, few evidence-based interventions exist. This study emerges from an ongoing collaboration between physicians, researchers and a financial literacy organisation. Our study will answer the following: Is an online tool that improves access to financial benefits feasible and acceptable? Can such a tool be integrated into clinical workflow? What are patient perspectives on the tool and what is the short-term impact on access to benefits? METHODS: An advisory group made up of patients living on low incomes and representatives from community agencies supports this study. We will recruit three primary care sites in Toronto, Ontario and three in Winnipeg, Manitoba that serve low-income communities. We will introduce clinicians to screening for poverty and how benefits can increase income. Health providers will be encouraged to use the tool with any patient seen. The health provider and patient will complete the online tool together, generating a tailored list of benefits and resources to assist with obtaining these benefits. A brief survey on this experience will be administered to patients after they complete the tool, as well as a request to contact them in 1 month. Those who agree to be contacted will be interviewed on whether the intervention improved access to financial benefits. We will also administer an online survey to providers and conduct focus groups at each site. ETHICS AND DISSEMINATION: Key ethical concerns include that patients may feel discomfort when being asked about their financial situation, may feel obliged to complete the tool and may have their expectations falsely raised about receiving benefits. Providers will be trained to address each of these concerns. We will share our findings with providers and policy-makers interested in addressing the social determinants of health within healthcare settings. TRIAL REGISTRATION NUMBER: Clinicaltrials.gov: NCT02959866. Registered 7 November 2016. Retrospectively registered. Pre-results.