Patients experiencing homelessness are more likely to remain in the hospital after their medical condition has been treated than patients not experiencing homelessness.

Experts say that this type of delayed discharge can affect not only the health system — since patients occupy beds reserved for people with ongoing medical conditions — but also the health of patients themselves.

“These patients occupy a bed but do not require the intensity of services that are provided by that care setting: in this case, acute care,” Kateryna Metersky, RN, PhD, associate professor of nursing at the Daphne Cockwell School of Nursing at Toronto Metropolitan University, told Medscape News Canada. “However, they continue to utilize healthcare resources and services such as medical and nursing care, if needed, and they continue to have their nutritional and hydration needs met.” Metersky did not participate in the study.

The study was published on July 17 in JAMA Network Open.

Delayed Discharge

Lucie Richard, a health geographer and health services researcher at MAP Centre for Urban Health Solutions in Toronto, and colleagues examined data on 51,377 hospital patients aged 16 years or older in Ontario who were discharged between 2022 and 2024. This population included 11,168 patients who had recently experienced homelessness, based on an assessment during a medical visit within the past year. The researchers compared this group to 40,209 similar patients who had not experienced homelessness but who lived in neighborhoods with the lowest level of material resources.

Around 9% of patients who had recently experienced homelessness received a designation of “alternate level of care (ALC),” a delayed discharge status describing patients who occupy beds but don’t require the intensity of care provided in the hospital. This rate was more than four times higher than the ALC designation rate for matched patients, of whom 2% had a delayed discharge.

Among patients with an ALC designation, those who had recently experienced homelessness had a longer delayed discharge stay than those who hadn’t experienced homelessness, even after researchers adjusted for demographic and clinical factors.

While researchers attempted to match patients who had experienced homelessness with similar comparator patients, key differences remained between the two groups. For example, patients with a recent experience of homelessness had higher rates of chronic obstructive pulmonary disease, liver disease, and intellectual or developmental disability.

Other research in Canada, the United States, and the United Kingdom has found high rates of ALC designation among patients experiencing homelessness. But these studies did not include a comparator group of people who did not experience homelessness, as the new study did.

Acute Care, Community Supports

The authors of the current study pointed out that their observation, which was similar across various regions of Ontario, “indicates that discharge planning for patients without stable housing is, to some extent, impeded by widespread structural or logistical barriers.

“For example, many postacute and community care programs require a fixed address or specific living conditions, limiting safe transition options,” they wrote. “Hospitals and staff may also demonstrate moral or institutional risk aversion when discharging to shelters or temporary accommodations, prolonging stays until a more secure setting is available.”

But regional variations in rates of ALC designation and lengths of stay “suggest that local shelter system capacity and other community infrastructure may also be associated with ALC practices,” they added.

“In an ideal case scenario, the acute care system would be connected, and care should be seamlessly integrated with housing supports, community supports, mental health services, and addiction care,” according to Metersky. 

“We know that housing is one of the biggest solutions to many of these acute and chronic challenges that patients experiencing homelessness have,” she said, “but hospitals are not designed to replace stable housing.”

The authors suggest that certain regions may benefit from short-term respite healthcare units for patients who are experiencing homelessness, underhoused, or socially isolated — such as Sherbourne Health’s Acute Respite Care Program in Ontario. Specialized outreach groups aimed at helping patients experiencing homelessness may also benefit certain regions, they wrote.

These kinds of efforts would not only alleviate pressure on hospitals but could also improve patients’ health, said Metersky. “Sometimes patients who have been deemed clear for discharge or ALC will develop another medical condition, such as a nosocomial infection, due to their length of stay,” she said. “They may also experience physical deconditioning, because you’re not as active as you normally are in the community when you're lying in bed or staying in the hospital room for most of the day,” she added. “There can be a loss of independence, disruption of sleep, social isolation, and worsening mental health.”

The study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care, under the Applied Health Research Question program. The work was also supported by the MAP Centre for Urban Health Research, based at St Michael’s Hospital and Unity Health Toronto. Richard and Metersky reported no relevant financial relationships.