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Homelessness & Health in Canada

 | 
Manal Guirguis-Younger
, 
Ryan McNeil
, 
Stephen W. Hwang

Part III-New Approaches: Innovations to Address Homelessness & Health

Chapter 13. The Development and Operational Context of an Emergency Shelter–Based Hospice in Ottawa, Ontario: A Qualitative Study

Manal Guirguis-Younger et Ryan McNeil

Texte intégral

Introduction

1In Canada and internationally, there is growing recognition that homelessness is a significant public health challenge (Hwang 2001), with homeless persons experiencing high levels of morbidity and mortality (Cheung and Hwang 2004; Hwang 2000; Garibaldi, Conde-Martel and O'Toole 2005). Over the past two decades, research has demonstrated that homeless persons experience high incidences of chronic and infectious diseases, such as hiv/aids (Culhane et al. 2001; Robertson et al. 2004), hepatitis C (Nyamathi, Dixon and Robbins 2002; Roy et al. 2001), respiratory diseases (Snyder and Eisner 2004) and diabetes (Hwang and Bugeja 2000). In addition to these challenges, homeless persons frequently have co-morbid mental health or substance use challenges (Fisher and Breakey 1991; Grinman et al. 2010) that increase the complexity of care and, in many cases, serve as a barrier to medical care (Gelberg et al. 1997; Hwang 2001).

2As the number of homeless older adults increases (Hahn et al. 2006; Stergiopoulos and Herrmann 2003), there will be a growing need to adapt services to the needs of this population and, in particular, to provide palliative care (i.e., end-of-life care oriented toward managing pain and symptoms, rather than curative treatment). This is especially true given the cumulative burden of disease experienced by this population (Cohen 1999). However, in spite of the growing need for palliative care services among this population, the palliative care system has been slow to develop strategies to ensure that homeless persons are able to access needed care at end of life (Cagle 2009; McNeil, Guirguis-Younger and Dilley 2012a).

3Previous research has noted that the palliative care system has largely been developed in accordance with a series of assumptions (i.e., that prospective clients are housed, supported by caregivers and, in many cases, have the financial resources to pay for supplementary care) that do not reflect the circumstances of homeless populations (Cagle 2009; McNeil, Guirguis-Younger and Dilley 2012a; McNeil et al. 2012b). Furthermore, while homeless populations have high levels of alcohol and/or illicit drug use, palliative care services typically operate under abstinence-only policies that constrain access to care (McNeil and Guirguis-Younger 2012). Accordingly, homeless persons are typically unable to access much needed care at the end of life, often dying alone and unsupported (Hwang 2001).

4In Ottawa, a coalition of community leaders began working toward developing palliative care services for homeless persons in the early 2000s. This effort culminated in the opening of the Ottawa Mission Hospice in 2002, Canada's first emergency shelter–based hospice. The Ottawa Mission Hospice is a 16-bed palliative care program integrated into an emergency shelter in downtown Ottawa and is operated in conjunction with Ottawa Inner City Health, a homeless health care organization that coordinates health care services delivery to homeless persons in multiple shelter-based locations. The Ottawa Mission Hospice provides palliative and supportive care to homeless individuals and, in recognition of high levels of substance use among this population, operates under a harm reduction policy that permits managed alcohol use and off-site illicit drug use. An evaluation of the impact of this facility has shown that it reduces overall costs to the health care system by minimizing hospital stays and admission, while increasing overall satisfaction with care among homeless persons (Podymow, Turnbull and Coyle 2006).

5This initiative represents a significant innovation in the care of homeless persons who are dying, in that it is a unique palliative care model that aims to provide care in a community context that is familiar with and accustomed to serving this population. Furthermore, given that it has been demonstrated to produce positive outcomes, there is a need to document its development so as to inform the continued evolution of palliative care services for those who are socially marginalized in Canada. This chapter provides an account of the development of end-of-life care services for persons who are homeless in Ottawa, and in particular the Ottawa Mission Hospice, based on qualitative interviews with those involved in its development and ongoing operation. Specifically, it explores the factors that led to the development of this service, as well as the current structures that support its ongoing operation.

Methods

6We undertook qualitative interviews with health and social services professionals over a five-month period (April to August 2007) as part of a case study of palliative care services delivery to homeless populations in Ottawa, focusing on the Ottawa Mission Hospice. We used a qualitative case study design to facilitate the study of the development of the Ottawa Mission Hospice and the individual, social and structural factors that shape palliative care services delivery in that setting (Yin 2003).

7We relied upon a purposive sample of health and social services professionals involved in palliative care services delivery to homeless persons in Ottawa, all of whom worked directly for or in collaboration with the Ottawa Mission Hospice. We drew upon the expertise of an advisory committee made up of local and regional experts (e.g., senior health and social services administrators) to identify potential participants. In addition, the lead author (Manal Guirguis-Younger) had previously undertaken research on the palliative care needs of homeless persons in Ottawa (Guirguis-Younger, Runnels, Aubry and Turnbull 2006) and thus drew upon existing contacts with health and social services providers. Thirty individuals were sent a letter or email that outlined the study and study procedures and invited them to participate in an interview. Twenty-one individuals agreed to participate and represented a wide range of professional backgrounds, including health and social services administrators, physicians, nurses, social workers and personal support workers. Approximately half of our participants were employed by the Ottawa Mission Hospice or Ottawa Inner City Health, while the remaining participants worked collaboratively with this organization to provide palliative care to homeless persons.

8An interview topic guide was used to facilitate interviews with participants. This interview topic guide was designed to encourage conversation regarding the individual, social and structural dimensions of palliative care services delivery to homeless populations. Given our interest in exploring palliative care services delivery at the Ottawa Mission Hospice, this interview guide included sections focusing on a range of topics related to palliative care services delivery in this setting, including but not limited to: (1) how the Ottawa Mission Hospice was developed, (2) how it was situated within the larger landscape of health care services for homeless persons in Ottawa, and (3) how organizations collaborated with the Ottawa Mission Hospice. Interviews ranged in duration from 45 to 120 minutes, were audio recorded and later transcribed verbatim by research assistants. One of us (Ryan McNeil) reviewed the transcripts while listening to the accompanying audio recordings to ensure the quality of the transcription and make any necessary changes.

9Our analysis focused on factors that shaped the development and delivery of palliative care services to homeless individuals at the Ottawa Mission Hospice. We imported the interview transcripts into NVivo qualitative data analysis software (version 8) to facilitate coding. We drew upon constant comparative analysis methods to code the data, whereby we identified emerging categories and expanded them by constantly comparing the data (Strauss and Corbin 1990; Glaser and Strauss 1967). We developed a coding tree inductively, and revisions to this coding tree were made on a continuous basis as the data were coded. Once the final thematic categories were established, the lead author recoded sections of the data to check the credibility of these categories and ensure reliability.

10This study was approved by the institutional research ethics boards at Saint Paul University and the University of British Columbia. We obtained informed consent prior to interviews, and participants were given a duplicate copy of the informed consent protocol for their records.

Results

Pioneering Work: Identifying and Responding to Unmet Palliative Care Needs

11The Ottawa Mission led efforts to develop palliative care services for homeless populations in recognition that homelessness is a significant barrier to accessing mainstream palliative care services. The Ottawa Mission and partnering organizations acknowledged the complexity of the issues surrounding palliative care in the context of homelessness and identified the need to develop an alternative service delivery model responsive to the needs of this population. Two critical factors shaped the initial planning of palliative care services for homeless persons in Ottawa. First, key stakeholders identified factors contributing to a gap in palliative care services for homeless populations. Second, those involved in developing the Ottawa Mission Hospice shared a philosophy of providing compassionate palliation responsive to the unique needs of homeless persons.

Incompatibility of Homelessness and Mainstream Palliative Care Services

12The palliative care system has been developed in accordance with a series of assumptions regarding the social and structural context of service delivery (Lewis et al. 2011). Participant accounts indicated that many of these assumptions did not reflect the needs and circumstances of homeless populations. Specifically, participants noted that, while the palliative care system assumed that its clients were older adults with housing and caregiver support, these assumptions did not reflect the experiences of homeless persons. In this context, participants emphasized that homeless persons had vastly different experiences and needs due to intersecting individual characteristics (e.g., high levels of substance use and mental illness) and structural factors (e.g., homelessness, poverty, food insufficiency, etc.). For example:

[There was] an appreciation in the community that there was a group of people that were chronically homeless, with complicated health problems, and not a really good understanding of whether the chronic homelessness was a cause or an effect of the physical health.... But, basically, the community deciding that, on some level, it doesn't really matter. You have to address the problem and that's really where Inner City Health came from... to look at the chronically homeless and see if we could find better health care.
– Administrator, Emergency Shelter

13In the local context, key stakeholders identified the need to develop an innovative approach to providing palliative care services to homeless persons and, given the promise that emergency shelter–based health services have shown elsewhere, identified an emergency shelter–based hospice as a potential model. Participants reported that this model of care was identified as having the potential to minimize barriers to palliative care services for homeless populations, such as stigmatization of homeless persons and substance-use or behavioural policies. In addition, those involved in the development of this service perceived a shelter-based service delivery model as having other benefits, notably that staff have demonstrated cultural competence in providing care to this population. For example, one participant noted:

[Homeless persons] deserve a way to die that represents the way they lived. They are uncomfortable in the traditional hospital care, where their friends are not allowed in. They are uncomfortable being told what [the] parameters of their dying are. They really need their own model. We are ready to house that model and see if it works.
– Executive Director, Emergency Shelter

Ensure Basic Rights around Death and Dying

14Mainstream palliative care services are a part of a long tradition that aims to meet the health and social needs of dying individuals and their families (Chochinov 2002). In this context, considerable attention has been paid to how to best develop respectful services that allow individuals to die with dignity (Sepulveda et al. 2002). Given that these are the cornerstone philosophies of palliative care, they were identified by local stakeholders as guiding principles to inform the development of palliative care services for homeless individuals. Participants articulated that, in addition to pain and symptom management, promoting dignity and respect was a critical component to providing shelter-based palliative care services and countering the widespread discrimination experienced by this population in other palliative care settings. Participants emphasized that it was important to foster an environment in which clients could receive social, emotional and spiritual support and that promoted social inclusion and self-worth:

They have been faceless and nameless for long periods of their lives. One thing, which has been very important, is to give people a place to be acknowledged.
– Mental Health Worker

The biggest thing is supporting them . . . praying for them, and then they don't die alone.
– Outreach Worker

Respecting the Unique Social and Personal Needs of Persons Who Are Homeless

15Participants indicated that identifying the unique needs and life circumstances of homeless populations was critical to the development of the Ottawa Mission Hospice. Those involved in planning this health care service consulted with community stakeholders and homeless persons to identify unique challenges that shape palliative care services delivery to this population. This ongoing dialogue focused on how to ensure that this model was responsive to the needs of this population. In this context, it was critical that services account for issues typically associated with palliative care (e.g., pain and symptom management), while also accounting for challenges associated with providing care to homeless persons (e.g., substance use, mental illness, etc.). For example, participants emphasized that there was a need to take a different approach to substance use than the abstinence-only approaches common in health care settings. For example:

At the end of the day, we are all part of one community.... The more you marginalize people, the less safe the community is for everybody.
...Where we have some common ground is there.... For example, injection drug users.... It's not like they think that the wild and crazy behaviour and injection drug use is a good thing. They don't.
...I think, we have the opportunity, if we can get past that [i.e., injection drug use], there is some common ground.
– Administrator, Emergency Shelter

16One of the anticipated challenges posed by providing palliative care to people who use drugs was managing pain and symptoms associated with terminal illness. For example, participants indicated that administering the recommended dosages of pain medication (e.g., narcotics, opioids, etc.) were insufficient in managing pain among those with histories of drug dependence. In this context, participants indicated that they identified a need to tailor their strategies to the individual needs of clients and, in some cases, exceed recommended dosage levels. Participant accounts indicated that this was a delicate balancing act, whereby they had to weigh the client's needs against the potential risks:

We weren't one hundred percent sure of the volume of dying homeless and some of the complexities of managing [their health needs], like people who are addicted to narcotics and you have to control their pain. How much [pain medication] do you give? What is pain? What is addiction?
– Physician

17In addition to these challenges, participants indicated that homeless persons may exercise individual agency and thereby choose to forgo treatment. Participants acknowledged that there were many reasons why individuals may make this decision, including concerns regarding potential adverse side effects (e.g., pain, nausea, etc.) and fears that they would be sedated. For example:

If somebody [i.e., a client] looks at me and says, "Don't try to give me any of those wacko-pills or make me into a zombie," that is the end of it. Fair enough, you don't want medication. That is the answer. End of story.
– Mental Health Nurse

18Some participants indicated that, while they acknowledged the importance of promoting agency among clients, it was often difficult for them to understand choices that had potentially negative health consequences:

He's an adult and he makes choices for himself. We support him in whatever those choices are. The choice about whether or not he goes into housing is not mine and it's not yours.
– Administrator, Health Services

Recognizing the Non-linear Trajectory of End of Life among Homeless Persons

19Participant accounts emphasized that homeless persons had end-of-life trajectories far different than those of individuals receiving care in mainstream palliative care settings, who are typically in their final hours or days of life. On the contrary, participants indicated that palliative care for the homeless potentially prolonged life because of treating previously unmanaged health conditions (e.g., hiv, hepatitis C, etc.). As one participant noted,

We have a guy, he was supposed to die five years ago. He hasn't. He had bipolar [disorder] that had never been treated. He went on medications for his hepatitis C and hiv. He looks like the walking dead, but he's still here.
– Mental Health Nurse

20In this regard, participants indicated that palliative care in the context of homelessness was akin to long-term or continuing care in that it often (although not always) lasted longer than palliative care provided in mainstream settings. Participants identified this as a potential benefit because it allowed them to build trust and rapport with clients and thus improve the overall quality of care. This was especially important given that homeless persons often lacked the support of family and friends. Whereas participants noted that it was important to attempt to reunite clients with family, they also needed to provide care and support in the absence of this. For example:

Talking with them, spending time with them, playing cards with them. Bringing them down to the big TV room, taking them out for a walk. Making them happy. They feel safe.
– Care Worker

Maintaining Compassionate Palliation in the Context of Homelessness

21Addressing the complex social care needs. Participants reported that, in addition to palliative care needs, homeless persons have complex social care requirements. Participants noted that, because homeless persons have difficulty meeting everyday survival needs (i.e., obtaining food and shelter), palliative care services need to address these needs and, moreover, foster a safe environment. For example:

He told me, before he came here, that at times he had nothing to eat.... That was hard, but then I said to him, "Now you are here and now we are going to take care of you and try to let you have as less pain possible. You will have food and you will have clothing. You will have what you need."
– Client Care Worker

22In addition, participants noted that, due to the absence of caregiver support, homeless persons were in need of social support:

As a nurse, you're spending all the time in the evening helping the client go through whatever emotional things they need to go through. Or, they might come back drunk or they maybe in pain and you have got to deal with pain management.
– Nurse

23Commitment to minimizing suffering at the end of life from a harm reduction perspective. Participants emphasized that it was important to integrate harm reduction strategies into palliative care so that clients would not face barriers to necessary care as a result of continued substance use. In this regard, harm reduction programming was identified as a form of palliation insofar as it minimized the potential suffering associated with withdrawal. As one participant noted,

I could have a patient who is dying, who requires end-of-life care who still wishes to drink. They can drink, but what we do is we decide with the patient how much he can have in a day and we will dispense it as medication.
– Nurse

24Although abstinence should not be the goal, participants identified that it was important to provide support to those who wished to discontinue drug or alcohol use. Accordingly, it was felt that palliative care should also include detoxification programs:

We have a protocol here for detox. If we have to detox them, if they're in withdrawal, then we have a protocol to help them with their alcohol withdrawal. We also have a protocol for drug withdrawal.
– Nurse

Building a System of Services

25Three major themes emerged in regards to the development of palliative care services at the Ottawa Mission Hospice: (1) consultations with clients and community stakeholders, (2) partnership building with Ottawa Inner City Health and researcher and educators and (3) defining the operational principles of palliative care services.

26Consulting with clients. The Ottawa Mission Hospice emerged out of a dialogue between the organization and a group of emergency shelter clients. These consultations were critical in ensuring that homeless persons had a voice in the development of palliative care services, which had the potential of increasing the ability of these services to meet their needs. Specifically, following the death of a longtime shelter resident, the Ottawa Mission's executive leadership consulted with a group of peers who provided support to that individual. These consultations aimed to identify the parameters of services focused on the unique needs and wishes of people who are homeless.

[The client's friends] sat with him until he died. It was a moment that they hadn't experienced—that dignity that they were allowed to have with somebody who was on the streets. . . . After that, I met with those five people and I said, "Do we need a place like this for people to die?" They said, "Yes."
– Emergency Shelter Director

27This consultation provided a foundation for launching culturally competent services. In addition to this early dialogue, the conversation around the nature and implementation of these services continued with the clients, specifically around the structure and governance of service.

I said, "What would the rules be?" Because I knew they wouldn't be regular rules. We chatted back and forth and decided [that] we needed respect and dignity for the person. [Friends and visitors] couldn't come in high. They couldn't bring alcohol or drugs to the person. They were part of the caregiving team. They wanted to be able to talk to the doctor.
– Emergency Shelter Director

28The involvement of clients in their own care took place in many levels. The ongoing nature of this dialogue is an important feature in the ultimate success of building services that work and extending these services into multiple areas of the death and dying experience.

29Consultation with community stakeholders. Following initial consultations with emergency shelter clients, the Ottawa Mission brought the issue of palliative care for homeless persons to the larger community of service providers, with the goal of increasing awareness of the need for an alternative palliative care services delivery model. The Ottawa Mission identified that it was advantageous to involve the local hospitals and academic institutions in order to build support within the community and encourage the development of a shelter-based hospice.

I started becoming part of every advisory group I could find that was talking about palliative care.... I sat in on, I cannot tell you how many meetings—medical meetings. I kept giving the message: these people deserve dignity.
– Emergency Shelter Director

30One of the most difficult issues to reconcile among organizations was incorporating harm reduction strategies as part of palliative care. This became an important point of consideration in terms of finding a way to work together. Discussions took place to ensure that no one organization has to compromise its ideology or philosophy of care, while at the same time ensuring that services met the needs of those who used alcohol or drugs at the end of life.

[Some agencies] do not allow alcohol, but they weren't doing palliative care. They were doing convalescent care. [Other agencies] had managed alcohol programs. That was the whole idea. If you prescribed alcohol, they didn't have to drink Listerine. It's a range of harm reduction. We are always struggling, trying to find a middle ground. There's a set of rules now that we each can work by and understand where everybody is.
– Emergency Shelter Director

31Partnership with Ottawa Inner City Health. Whereas the Ottawa Mission had extensive experience providing emergency shelter services, it lacked experience providing health care services, and thus sought out opportunities to formally partner with a health care organization. In this context, the Ottawa Mission developed a symbiotic relationship with Ottawa Inner City Health, an organization with a mandate to provide care to homeless persons in the Ottawa region. The Ottawa Mission would provide the infrastructure, resources and staffing, including the program administrators, while Ottawa Inner City Health would provide health care services in coordination with its partnering agencies (i.e., a network of shelter-based health services, local hospitals and other community agencies). An important benefit of this approach is that it situated the shelter-based hospice within the larger context of health care services available to homeless persons in Ottawa. For example:

There was sort of an understanding that we needed to integrate across the [health and social care] system. Other partners were gradually brought on board. [Ottawa Inner City Health] was a pilot project. The focus was primarily on a set of deliverables: palliative care, short stay convalescent care and alcohol addiction. Those were picked by the community as being the three priorities.
– Administrator, Health Services

32The Ottawa Mission and Ottawa Inner City Health would share in the decision-making on matters relating to the shelter-based hospice. In this regard, while there was a need to maintain some continuity between the hospice and emergency shelter in general, there was a recognition that a different set of rules were needed for the hospice due to its unique demands.

We had to really be very respectful around what [the Mission's] constraints were. There are some people who would say, "Well, they're dying. Anything they want to do is fine." Well, that would be what a health care provider would say but that's not what you say if you're running a shelter that has two hundred other people. You basically have to say, "Yes, this person's going to get a lot more leeway than anybody else because of the situation that they're in but, if they're disrupting the operations of the Mission, if they're threatening or injuring the staff and other clients, these are the conditions under which we can and can't take care of them."
– Administrator, Health Services

33Because the Ottawa Mission was well-established within the community, it was able to generate financial support for the hospice through donors that was critical in establishing this service. As a registered non-profit and heath care organization, Ottawa Inner City Health was able to secure funding for health care services from a variety of sources, including the local health authority and the provincial government.

Every organization that's part of Inner City Health has, in fact, not just given what they originally said that they would give, but everybody has given more. Ottawa Inner City Health process, to some extent, was just bringing people together around the table to figure out who can offer what.
– Administrator, Health Services

It was a partnership between the Mission and the Ottawa Inner City Health. It grew out of that initial meeting where the Mission, all the other shoulders were together, we knew that we needed palliative care services as a group. We agreed to bring in the health piece of it and the Mission was kind enough to bring the infrastructure side of it. They fundraised, they developed a beautiful wing, and provided excellent facilities for us, and we provide the health care.
– Physician

34Community–academic partnerships. Partnering with universities provided the opportunity for research and program evaluations, which lent credibility to the work undertaken by the Ottawa Mission Hospice. In this regard, Ottawa Inner City Health first emerged as a pilot research program operated in conjunction with the University of Ottawa, with the expectation that all of its programs be evaluated, including the hospice. A pilot study was undertaken to look at the efficacy of programs across the Ottawa Inner City Health system, which included an evaluation of the Ottawa Mission Hospice. The evaluation indicated that the Ottawa Mission Hospice was successful in decreasing health care costs, while increasing the quality of and satisfaction with care. This positive evaluation helped to validate the benefits of this service delivery model. As one participant noted:

There is a great deal of scientific evidence that supports what we're doing.... [There was] an independent evaluation, which produced very promising results. You've spent a very small amount of money and in fact you're showing good results.
– Administrator, Health Services

35Continuity of care in palliative care services. The partnership with Ottawa Inner City Health was critical to facilitating continuity of care across services providing care to homeless persons in Ottawa. This continuity was important due to the complex co-morbidities experienced by most hospice clients. In particular, because medical personnel typically worked in multiple locations across the Ottawa Inner City Health system and regularly met to discuss patient care, they were knowledgeable of the overall needs of their clients. For example:

We have rounds here at the office every week and there are patient reviews. Anybody who we have that's new, we get the whole history and the story and hear about things on an ongoing basis.
– Administrator, Health Services

36Given the special needs created by homelessness, one of the operational principles of effective service provision became a flexible delivery of what is necessary at various points of service contact. That is, individuals did not need to be physically at the hospice or imminently dying to receive palliative care.

We do palliative care in other places [i.e., partnering agencies] besides the [Ottawa Mission Hospice]. Not everybody that is palliative is necessarily at the [Ottawa Mission Hospice]. People can go where they want to be and receive services, as long as we can do it safely.
– Administrator, Health Services

Discussion

37Clearly identifying the factors contributing to service gaps in palliative care for those who are homeless and marginalized was a crucial step toward a more equitable service delivery model. Consistent with other studies (Cagle 2009; Lewis et al. 2011; McNeil, Guirguis-Younger and Dilley 2012a), our data suggest that the mainstream palliative care system is not suitable to address the needs of homeless persons due to its structure and parameters of service delivery (e.g., abstinence-only approaches). Our participants associated homelessness with many social barriers that constrained access to equitable health care, including but not limited to stigma, poverty, substance use and complex co-morbidities. Homeless service organizations and allied health organizations were uniquely positioned to identify the nature and dynamics of these barriers and to propose an alternative service delivery model. Accordingly, the Ottawa Mission Hospice may be understood to be the product of the desire of these organizations to help homeless persons die with dignity and access to best care.

38In this context, two factors informed the development of the Ottawa Mission. First, key stakeholders acknowledged that palliative care services would best respond to the needs of homeless individuals if they were integrated into services already accessed by this population (i.e., an emergency shelter). Second, there was recognition that palliative care services needed to incorporate a wider range of social care services to address the complex needs of this population, especially given the non-linear nature of their end-of-life trajectories. Specifically, the Ottawa Mission Hospice identified a need to combine compassionate palliation and harm reduction strategies (i.e., providing managed alcohol consumption services, providing harm reduction paraphernalia and allowing off-site illicit drug use) and situate this service within a larger network of homeless health care services. Participants believed that this was necessary to facilitate access to services and ensure continuity of care, echoing the findings of other studies emphasizing the important role that public health services should play in palliative care services delivery to underserved populations (McNeil et al. 2012b; McNeil, Guirguis-Younger, Dilley 2012a).

39Importantly, the Ottawa Mission Hospice demonstrates how community leaders and the affected community (i.e., homeless persons) can work together to develop and implement innovative solutions to community challenges. Whereas service providers, researchers and administrators spearheaded the development phase, early consultations with homeless persons were critical in informing the development of this initiative. Involving potential clients in defining the parameters of palliative care service delivery helped to ensure that the resulting service delivery model was client centred. Equally important was the consultation and brainstorming that took place with community organizations involved in the delivery of health and social services to homeless persons, given that palliative care may be initiated outside of the Ottawa Mission Hospice. Those concerned with developing palliative care services responsive to the needs of homeless populations in their community would benefit from similarly involving diverse partners and homeless persons in the planning of these services.

40An important element in maintaining the momentum of this initiative was building partnerships, and in particular formally partnering with Ottawa Inner City Health. Ottawa Inner City Health played a critical role in mediating relationships across a range of health and social care services that enhanced continuity of care. Many of Ottawa Inner City Health's partnering organizations developed formal and informal service agreements with one another with respect to the provision of palliative care. Furthermore, Ottawa Inner City Health continued to serve as the backbone of service integration in that it coordinated the delivery of health care services across this system. While a complete description of the operational context of Ottawa Inner City Health is beyond the scope of this chapter, it should be noted that a great deal of organization development was necessary to ensure the continued success of this service and that partnering organizations, including the Ottawa Mission, informed its development.

41The partnership with educational institutions and with mainstream services (e.g., hospitals) provided some infrastructure at the inception of the corporation and allowed the use of existing resources and procedures. The involvement of researchers allowed the rigorous evaluation of palliative care services, notably their impact on clinical outcomes and cost effectiveness (Podymow, Turnbull and Coyle 2006). A partnership that comprises academic ngos, community-based ngos and clients would be a formidable voice in eliminating health inequities and generating information for evidence-based public health practice (Robinson et al. 2007). Documenting the various stages of this process can serve as a guide for other communities looking for some direction on how to develop palliative care services for homeless or underserved groups.

42The lessons learned in the development of the Ottawa Mission Hospice are instructive to all those who may wish to develop innovative service delivery models to meet the needs of homeless persons in their community. Accordingly, the processes outlined in this chapter, while focused on palliative care services delivery in a particular case, are likely transferable to other settings. Although communities and their challenges vary widely in accordance with the unique social, political and economic factors within those communities, our findings demonstrate that, if there is agreement around fundamental service goals, then it is possible to develop innovative services responsive to the needs of homeless populations.

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Auteurs

Full Professor in the Faculty of Human Sciences at Saint Paul University and an affiliated researcher with the Centre for Research on Educational and Community Services at the University of Ottawa. Dr. Guirguis-Younger's research focuses on the delivery of palliative and supportive care to homeless and marginalized populations

Postdoctoral Fellow at the British Columbia Centre for Excellence in hiv/aids and Faculty of Health Sciences at Simon Fraser University. His current research focuses on the social-structural production of harm among drug-using populations. His previous work explored the intersection of homelessness and health, and in particular interventions to improve health outcomes among homeless populations

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