Where a hospital stay can last for years due to a lack of housing
Inside Toronto's Centre for Addiction and Mental Health, there are dozens of patients languishing in hospital - some, for years - who do not need to be there, in the eyes of their doctors.
These patients, who are battling serious mental illness, are in-patients at the downtown hospital simply because there is nowhere else for them to go. In most cases, they need housing - the kind with built-in support services that can help keep people from landing back in an ER.
But this kind of housing is in short supply in Toronto, with a waiting list of tens of thousands of people that swells faster than it can be cut down. So, these patients are left in what's known as an Alternative Level of Care (ALC) - a last resort bed when more appropriate community services, from supportive housing units to a long-term care beds, are simply out of reach.
The wait for housing is long ... it can take months and, in some circumstances, years," said Melonie Hopkins, the hospital's transition manager. In her more than two decades at CAMH, she said getting patients into supportive housing has only gotten harder. That squeeze has ripple effects, she explained, from those beds being unavailable to acutely ill patients to patients without acute need being stuck in an institutional setting where recovery could be challenging.
It's yet another symptom of Toronto's housing crisis spilling over into its health care system. Earlier this year, the Star spent time in the emergency room of St. Michael's Hospital, where health workers cared for more than 4,500 homeless patients in 2022 - some turning up not for medical need, but simply for lack of emergency shelter.
It's an expensive reality. In 2018, Hopkins was among a team of researchers who found it cost $51,000 to $58,000 more per year, on average, to have a patient in an ALC bed rather than housing with the highest level of support. It's a conservative estimate, Hopkins said, with a 2020 report from city hall and the United Way putting the average cost of a month-long hospital stay for someone without shelter at $10,900, versus of $2,000 on average for supportive homes.
While CAMH has been able to reduce the number of patients in its care since it hovered above 100 in 2020 - a result, it says, of targeted funding for new homes - as of Monday, there were still 59 patients in hospital who could be discharged if they could access proper living set-ups.
When we get housing - whether it be supportive housing, (housing for people with developmental disabilities), long-term care - that's what gets people in the community, living their lives. That's what reduces our ALC rates, that's what makes our health systems function better because now someone who is acutely ill can access a bed at CAMH," Hopkins said.
Typically, between 50 and 60 per cent of ALC patients were waiting for high-support housing, she said - the majority of cases, compared to the 15 to 20 per cent waiting for long-term care, and the less than 20 per cent waiting for housing for individuals with developmental disabilities.
It's an issue that was raised in an assessment released last year by the Wellesley Institute and the Canadian Mental Health Association's Toronto chapter. As of 2019, it said 960 people in Toronto were waiting for housing with 24-hour support services. Another 2,386 people were waiting for homes with daily supports, and 15,491 for homes with occasional supports. Five to six per cent of those waiting for the highest-level supports were ALC patients at CAMH, it said.
As of September 2022, Toronto's overall wait-list for mental health and addictions supportive housing had swollen to more than 24,000 people, according to data from The Access Point.
Over the next decade, the report estimated between 82 and 101 new 24-hour supportive housing units would be needed to address the need coming from the downtown hospital. (The development of new supportive housing can make use of dollars and resources like land from multiple levels of government, as well as partnerships with non-profit groups.)
In some cases, ALC patients are in hospital voluntarily. In others, they're legally bound to stay. Hearing documents from Ontario's Consent and Capacity Board, which deals with involuntary cases, offer a glimpse of how patients can end up stuck in hospital. Last year, it heard the case of a middle-aged man who had struggled with homelessness, staying in shelters or boarding houses when he wasn't in the hospital.
Battling symptoms of schizoaffective disorder as well as other mental illness, CAMH argued it wasn't comfortable discharging the man only for him to land back in shelters, fearing a regression in his well-being in that environment after making progress during his hospital stay.
The man needed 24-7, high-intensity supportive housing, his doctor argued, as well as a community treatment team and an outpatient psychiatrist. But despite his social worker actively" presenting the man's case at housing meetings, the hospital had been unable to secure that kind of supportive home. Under the circumstances, the board confirmed the man's involuntary status.
In recent years, the hospital has rolled out new programs to try to cut down its ALC patient load, including a partnership with LOFT Community Services to operate a 30-unit transitional care facility for people dealing with homelessness and complex mental health needs age 55 or older. Since March 2021, it has operated out of CAMH's College St. site. Other providers also received funding to create different levels of supportive housing, Hopkins said, which meant people could move on from higher-level to lower-level supports as they're ready.
All that helped, she said, with CAMH seeing a drop from 109 ALC patients in July 2020 to 56 at the end of December. But there was a toll on the quality of life and recovery for each patient still left waiting in an ALC bed, Hopkins noted - let alone the tangible cost to the public system.
It's millions of dollars," Hopkins said, looking back at recent years. If we would have gotten them out before they were designated as ALC, the cost savings are just mind blowing."
Victoria Gibson is a Toronto-based reporter for the Star covering affordable housing. Reach her via email: victoriagibson@thestar.ca