By Andria Bianchi

Over the past number of years, Canada’s housing crisis has made news headlines. Many of these stories have focused on the fact that the demand for homes exceeds supply. Other news stories have highlighted that aspiring home owners are shut out of purchasing due to record-high housing costs.

Another subject that has been discussed in the news, and one that – from my perspective – deserves even greater attention, is the need for affordable and accessible housing to be developed and maintained. It is presumably the case that having affordable and accessible housing available for residents is valuable in and of itself. However, having this type of housing available is also directly related and relevant to the strength of our health care system for at least two reasons.

First, we know that housing is a social determinant of health. People who are insecurely housed are at increased risk of experiencing food insecurity, chronic illness, infectious disease, as well as so much more.

The second reason that housing is directly related to our health system is because a lack of accessible, affordable, and available housing means that some people who are admitted to hospital may have no suitable discharge destination. In other words, some patients may be medically ready for discharge, but remain admitted for a greater amount of time. To demonstrate this challenge, consider the following case:

Ms. W is a 53-year-old teacher who lives in the east end of Toronto, Ontario. Ms. W has lived in a 3-storey walk-up apartment building for the past 15 years. Ms. W lives alone and immensely values her independence. Three weeks ago, Ms. W was in a bicycle accident. A person walking nearby saw Ms. W lying on the ground next to her bike and called Emergency Medical Services, who brought her to the local acute care hospital. While in acute care, it was discovered that Ms. W had a severe concussion, multiple fractures, and a broken hip. She required surgery and remained in acute care for 3 weeks. Ms. W was motivated to get back to her “old self” and was transitioned to a nearby rehabilitation hospital with the hope that she could regain her previous cognitive and physical functions. Unfortunately, due to Ms. W’s previous medical comorbidities, as well as some unanticipated consequences associated with her accident, Ms. W plateaued after 2 weeks of rehab, remained reliant on a wheelchair, and was unable to walk up stairs safely.

At this point in time, Ms. W was medically ready to be discharged, but her apartment building is a walk-up (i.e., no elevator or accessible entrance). From the clinical team’s perspective, the only possible discharge options were: (1) discharge Ms. W to her apartment, where she would be carried on a stretcher to her (small) unit, and require a paid service to transport her out of her home when needed, (2) discharge Ms. W to a long-term care home (LTC), (3) discharge Ms. W to a different, accessible building. None of these options were immediately available, affordable, nor desired. Consequently, Ms. W remained in-hospital for a longer than necessary period of time.

As an ethicist working in a post-acute care setting, I can say with confidence that versions of the above scenario arise all too frequently. The lack of available, affordable, and accessible spaces for Canadians means that some medically stable patients may need to remain in-hospital (i.e., use hospital beds and resources) for longer than necessary periods of time.

In relation to the above scenario, each discharge option may seem reasonable upon first glance. However, there exist meaningful and important challenges associated with each.

The challenge with the first option is that Ms. W would be unable to navigate living in her apartment building in a way that contributes to her overall health and well-being. With Ms. W being unable to walk up multiple flights of stairs, she would need to rely on (and pay for) external providers to carry her outside whenever needed. This may be unfeasible from a financial perspective, nor desired from a quality of life standpoint.

The second option of discharging to LTC is a possibility, but Ms. W may be hesitant to pursue this option because of the setting and population of residents who live in LTC. As a 53-year-old teacher who values independence, the idea of residing in a communal environment with LTC residents may be undesired, particularly when thinking about quality of life and mental well-being. Furthermore, even if she agreed to LTC, she may have to wait for years to get a place at a desired location.

The third option of discharging to an accessible building may seem most reasonable, but the lack of affordable places make this plan moot. This option, namely, the one that may be most seemingly reasonable, is the one that requires changes to occur in regard to public priorities and commitments. Building residential spaces that are available, accessible, and affordable (the 3 As) will be of benefit to (a) all individuals’ health and well-being, since housing is a social determinant of health, as well as (b) our health care system given the number of people who are or may be in positions like Ms. W. Ultimately, insofar as housing is a social and systemic determinant of health, this ought to be a priority.

Andria Bianchi, PhD, is a Clinical Ethicist at Unity Health Toronto – Centre for Clinical Ethics, where she offers ethics support to post-acute care settings. She is also an Assistant Professor (status-only) at the Dalla Lana School of Public Health – University of Toronto.