Naheed Dosani, M.D. is a palliative care physician based in Toronto who cares for homeless and vulnerably housed individuals in his community. He founded Palliative Education And Care for the Homeless (PEACH) program which has inspired similar models around the world, including the United States.
Through PEACH, interdisciplinary teams provide community-based hospice and palliative care to vulnerable individuals regardless of their housing status or factors such as poverty or substance abuse. PEACH brings housing, mental health, and health care providers together to plan an individual’s care while recognizing that person’s circumstances.
Dosani also practices palliative care at William Osler Health System in Brampton, Ontario, in a program that has garnered international attention for its innovations. His leadership also led to the development of Journey Home Hospice, Toronto’s first hospice for people who experience homelessness.
Dosani recently spoke with Hospice News about the palliative care needs of the homeless and how providers are moving toward addressing them.
What inspired you to address hospice and palliative care needs among the homeless?
I grew up the son of two refugee parents, who came to Canada with literally nothing in the middle of the 1970s from a country called Uganda. Essentially, they were fleeing persecution and war. I grew up in a home that was really focused on social justice and understanding the social determinants of health and what community well-being was all about. So as I pursued medicine and health care, I have a keen interest in providing care for people experiencing structural vulnerabilities.
I was working in my residency when I met a gentleman who was in his 30s and presented with a widespread head and neck cancer to a shelter I was working at. He presented in a pain crisis, and I got a better understanding of who he was. I learned that he had been diagnosed with cancer a year before, but he had a mental illness, schizophrenia, and a substance use disorder. He was an IV drug user on the streets.His tumor grew, and he started to experience pain that continued to worsen. He did what any one of us would do, he went from hospital to hospital, [emergency department to emergency department] seeking the kind of pain control that anybody should have access to. I carry him very close to my heart all the time.
He was denied access to pain medicines that would have actually improved his quality of life.
This was a very disturbing situation. He did develop some trust in me, and I built that rapport with him. I showed up to the shelter the next day to support his pain, and I learned that he had actually died overnight. He overdosed on a combination of alcohol and street drugs.
This was my first exposure to providing health care for people experiencing homelessness, but also supporting people with palliative care needs. I later went on to pursue a palliative medicine residency at the University of Toronto and during my training became very aware of the fact that people who experienced structural vulnerabilities like homelessness, poverty, people with mental illness, refugees,immigrants, and others lack access to palliative care in an inequitable way.
During my training, I learned that this is an issue, the overlay of social justice and palliative care, and when I graduated I launched the [Palliative Education And Care for the Homeless (PEACH)] program, a mobile palliative care program that aims to support the needs of people experiencing homelessness.
Do you have a sense of how great the need is among the homeless population for palliative care and hospice?
Absolutely. In North America, Europe and Australia, people experiencing homelessness represent one of the sickest subpopulations that’s out there. We know that among people experiencing homelessness three-quarters deal with one or more chronic diseases. This is a population that’s 28 times more likely to have Hepatitis C, five times more likely to have heart disease and four times more likely to have cancer. People experiencing homelessness are eight times more likely to present to the emergency department as compared to you and I.
When presenting to the emergency department, they’re four times more likely to be admitted to the hospital. So this population is sicker, has more diseases, gets sicker, gets diagnosed later and therefore has significant care needs. But the real kicker on this data is that people experiencing homelessness typically have a life expectancy of less than half that the expectancy for the general population.
The average life expectancy for people experiencing homelessness is 34- to 47-years-old. In our work in palliative care for people who experience homelessness, we recognize that homelessness itself is a life-limiting illness. It’s not what we would often think of as a life-limiting illness from a biological or medical framework, but from a social determinants of health framework. We realize that the palliative care needs of people experiencing homelessness are great. They are immense. There is a hugely under net under met need in communities across North America.
Can you introduce me to the PEACH program, how it got started and how it works?
The PEACH program was initiated in July of 2014. Upon graduating from the University of Toronto, it was launched as an initiative of the Inner City Health Associates in Toronto, Ontario, Canada, an organization that represents more than 90 physicians and other health care professionals working in more than 55 street and shelter based settings.
PEACH was launched as a new mobile street- and shelter-based palliative care program that aims to meet people’s needs wherever they’re at, be it under a bridge, in a shelter, or on the street. So no person falls through the cracks when dealing with homelessness and dealing with a serious life-limiting illness. We started as a team with myself and a street nurse driving around and providing care out of the back of my Honda Civic.
Within six years it developed into a 24/7 interprofessional care model that includes four palliative care physicians and a health navigator or home care coordinator, an interprofessional home and community care team, including nursing, social work, occupational therapy and physiotherapy, and integrated within housing models across the city. The team cares for any given week between 100 and 110 patients, and has now cared for hundreds and hundreds of cases across the city.
This is clearly a humanitarian effort, but is there a business model behind it? How are you financing this work?
The funding for the PEACH program emanates largely through provincial health care funding. In Canada, we have a Medicare system, and Inner City Health Associates is the organization where the PEACH program resides. Through funding via the Ministry of Health and long term care in Ontario, funding is derived for parts of the PEACH program, and elements of our programming do come through philanthropic funding.
A lot of the work that is done through the PEACH program is also leveraged through community partnerships with housing agencies, shelters, restaurants to be able to really optimize our efforts. In the sense that we provide community-based outreach, palliative care for clients, and then housing, providers are more comfortable in housing clients to support them. We find that there’s a mutual benefit in many cases to support people experiencing homelessness with their health care needs through palliative care, but also their housing needs through the housing agency.
How do you locate and identify patients in this population?
I think it’s important to note that palliative care needs for people experiencing homelessness have some similarities to a mainstream housed population, but there are some distinct differences. People experiencing homelessness die at age that is typically much earlier than people who have homes. That means that when we see someone who’s you know 40- or 50-years-old, we consider them to be of a geriatric age, because of what their bodies have gone through.
One of the important things is how we identify people who may be appropriate for the PEACH model. We’ve spent the last six years working really hard on research and education — to educate people about what the PEACH initiative is really about. So we receive about half of our referrals from health care services, emergency departments, primary care, and hospitals. We get over half of our referrals from non-health care workers, and we’re really proud of that. We’ve worked with social care workers, social service providers, people like housing workers, outreach workers, to really spend a lot of time trying to educate them and teach them about what early palliative care can look like in this population. They may not know the medical specifics of why they’re referring to the feature program, but they can know that someone is declining. That’s how clients are getting identified right now, and it’s working really well.
What strategies to use to communicate with these patients regarding their care needs? Do you encounter any fear or mistrust of the health care system?
People experiencing homelessness have various interacting concerns, on multiple levels, with institutions with health care, which has led to an overall mistrust of the health care system and those who work within it. One of the surprising things that we find is that many of the people we aim to reach out to are kind of surprised when we reach out, because we are gentle, because we approach with caution, and because we’re so supportive.
Recently we had a gentleman say that he never had someone spend more than 20 minutes with him, sitting and talking about how he feels. What’s the catch? There’s no catch; we’re really here to help you and support you. One of the major strategies that we’ve tried to utilize in our work is trauma-informed care.
Trauma is very prevalent in the populations we work with. I hope that trauma-informed care goes from buzzword to a pervasive reality within our health care systems in the coming years. We try to utilize this set of approaches to really meet the needs of this population so that we can meet them where they’re at.