Nowhere to go: exploring the social and economic influences on discharging people experiencing homelessness to appropriate destinations in Toronto, Canada

Objectives A main component of discharging patients from hospital is identifying an appropriate destination to meet their post-hospitalization needs. In Canada, meeting this goal is challenged when discharging people experiencing homelessness, who are frequently discharged to the streets or shelters. This study aimed to understand why and how the ability of hospital workers to find appropriate discharge destinations for homeless patients is influenced by dynamic social and economic contexts. Methods Guided by critical realism, we conducted semi-structured, in-depth interviews with 33 participants: hospital workers on general medicine wards at three urban hospitals; shelter workers; and researchers, policy advisors, and advocates working at the intersection of homelessness and healthcare. Results Historical and contemporary social and economic contexts (e.g., shrinking financial resources) have triggered the adoption of efficiency and accountability measures in hospitals, and exclusion criteria and rules in shelters, both conceptualized as mechanisms in this article. Hospitals are pressured to move patients out as soon as they are medically stable, but they struggle to discharge patients to shelters: to prevent inappropriate discharges, shelters have adopted exclusion and eligibility rules and criteria. These mechanisms contribute to an explanation of why identifying an appropriate discharge destination for people experiencing homelessness is challenging. Conclusion Our results point to a systems gap in this discharge pathway where there is nowhere for people experiencing homelessness to go who no longer need acute care, but whose needs are too complex for shelters. Systemic changes are needed to better support hospital and shelter frontline workers to improve discharge processes.