Homelessness is a complex and challenging phenomenon, not only in the US, but also in its neighbor to the north: it is estimated that in Canada, somewhere between 100,000 and 300,000 people become homeless in any given year, while well over 35,000 people experience homelessness at any given time become homeless. given night in the land.
THE PROBLEM
The increasing economic pressures facing people at all levels of society – combined with other recent public health disruptions such as the pandemic – have put a spotlight on the growing crisis. The causes and solutions to homelessness are multifaceted and often politically charged.
“Prior to the pandemic, I worked with several colleagues from Western University Arthur Labatt Family School of Nursing, the Lawson Health Research Institute and ICES – formerly known as the Institute for Clinical Evaluative Sciences – on topics related to housing effectiveness interventions and other approaches to helping people experiencing homelessness,” or PEH, says Richard Booth, RN, associate professor at Western University Arthur Labatt Family School of Nursing in London, Ontario.
“One evaluation direction we began to explore was using secondary health care administrative data to better understand homelessness,” he explained. “In some of our previous studies, the use of healthcare administrative data was a secondary objective to the primary intervention under investigation; for example, housing interventions or shelter delay interventions.”
That all changed in late 2019 when the Public Health Agency of Canada (PHAC) published a significant expression of interest in funding, after which the Labatt Family School of Nursing decided to apply and propose a two-arm study to address homelessness in Canada using both qualitative and quantitative methods.
“We were successfully funded and the Homelessness Counts project came to life in late 2020,” Booth recalls. “My co-principal investigator, Dr. Cheryl Forchuk, led the qualitative arm of the study and has traveled across Canada multiple times over the past three years to every province and territory, interviewing PEH and other service providers to better gain insight into contemporary homelessness.
“With over 400 interviews, I’m pretty sure Dr. Forchuk has assembled the largest collection of voices and experiences on homelessness in Canada during the height of the pandemic,” he continued.
From a quantitative perspective, Booth led aspects of a larger analysis to refine and test a case ascertainment algorithm that could be used to identify cases of homelessness within healthcare administrative data.
“Working with ICES Staff Scientist Dr. Salimah Shariff and other colleagues at ICES, we have begun using a previously developed and validated case ascertainment algorithm that can be used in secondary healthcare administrative data to identify cases of people who have recently experienced an episode of homelessnessBooth said.
“The development of an algorithm like this had not yet been attempted within the Canadian data science research domain, and we felt that if we were able to generate an algorithm with reliable sensitivity, we could use this approach to address aspects of to better understand the homelessness phenomenon,” he says. continued.
Most Ontarians receive medically necessary services under the single-payer, provincially funded Ontario Health Insurance Plan (OHIP), which includes primary and specialty physician services, emergency department visits, hospital stays, laboratory and diagnostic testing, and other community health care services.
This data is collected prospectively and made available in centralized databases at ICES, an independent, non-profit research institute. Its legal status under Ontario’s Health Information Privacy Act allows it to collect and analyze health care and demographic data without consent for evaluation and improvement of the health care system.
ICES consists of a series of linked databases, connecting more than 100 different health sources and health-related data on Ontario residents (more than 15 million inhabitants), covering more than 30,000,000,000 records and several hundred thousand variables, over a 30-year period. year.
“From this point forward, with our PHAC Homelessness Counts study launched in the fall of 2020 during the height of the pandemic, we aimed to generate multi-dimensional interpretations of homelessness in Canada,” said Booth. “From a data science perspective, we quickly realized that our case identification algorithm could be used to generate immediate and important policy insights.
“We were able to calculate the testing, infection and complication rates of COVID-19 vaccination coverage of PEH versus others in Ontario. Both studies demonstrated the usefulness of this algorithm and how it can be used to help generate policy and practice insights, especially on contemporary issues.”
PROPOSAL
Homelessness is a complex phenomenon with many moving parts, and no simple solutions exist. The Homelessness Counts project is intended to be a small element in a larger movement needed to address today’s homelessness.
“Homelessness is evolving in its complexity and nuance due to the pressures experienced during the pandemic and other socio-economic environmental factors currently impacting society,” Booth explains. “While our project and the use of data analytics to address questions about homelessness are far from a panacea for homelessness, we believe our methodological approaches can be deployed by others to provide more timely and accurate interpretations of homelessness and health and generate well-being. of this vulnerable population.
“In many ways, unless something is quantified, it can be overlooked in policymaking,” he continued. “Our approaches allow us to quickly and cost-effectively quantify homelessness along with other variables of interest; for example, health care utilization, individual health, comorbidities, residential location, etc. This ability allows us to enumerate the situations faced by PEH, providing evidence to confirm the existence of these situations.”
For example, in ongoing and future work related to this project, staff has identified and enumerated new, concerning trends within PEH populations, including the significant burden of Alzheimer’s disease and related dementias, and the high mortality rates from opioid toxicity compared to other cases. subpopulations and the entire population of Ontario.
“We believe our approach gives us much better opportunities to generate quantitative evidence and population-level insights into the realities faced by PEH,” Booth said. “While far from a solution to homelessness, having more accurate numerical insights into the problems at hand can help generate more targeted and proactive solutions.
‘We have generated a methodological publication explaining this our approach to case identification, including its benefits, limitations and other considerations,” he added.
MEETING THE CHALLENGE
Western University’s Arthur Labatt Family School of Nursing was fortunate to partner with Ontario ICES to complete several aspects of the larger Homelessness Counts project, Booth noted.
“Since most Ontarians receive health care under the single-payer, provincially funded Ontario Health Insurance Plan (OHIP), we can use administrative data, including homelessness definitions within this data, to create cohorts of people who have recently become homeless, he explained. .
“While other health care organizations, such as the United States Veterans Affairs, and insurance companies may have linked such databases, in Ontario we are exceptionally fortunate to have an organization like ICES that can investigate population-level phenomena,” he added. “You can find more information about ICES at their short YouTube video describing their data and organization.”
RESULTS
The three collaborating organizations managed to sum up several contemporary phenomena in PEH populations, including increased testing, infections and complications of COVID-19 infection during six waves of the pandemic.
Additionally, they identified reduced COVID-19 vaccination coverage in PEH, an increasing trend of mortality from opioid toxicity in PEH in recent years, and increasing trends of dementia in PEH populations.
They have other preliminary findings from various projects related to Homelessness Counts, but these are still being finalized.
“Two weeks after the publication of our article in CMAJ opened When we outlined COVID-19 testing, infection and complication rates among people with a recent history of homelessness in early 2021, individuals experiencing homelessness were added to Ontario’s early COVID-19 vaccination priority list,” Booth reported.
“Although a temporal association does not imply causation, we suspect that our findings in this work may have been used to inform early vaccination distribution efforts and to prioritize PEH populations,” he said.
ADVICE FOR OTHERS
“Having the ability to ask robust and important questions about data, and having the insight to know what is an appropriate question to ask of large data sets, is far more important in this type of work than any specific piece of software.” technology,” Booth advised. “Researchers and practitioners must confirm that the underlying data is of good quality or they risk producing results that follow the ‘garbage in/garbage out’ process – or worse, causing harm or to spread.”
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