Meeting patients where they are: Integrating housing and health supports to address root causes of health inequities

Background: Health systems worldwide continue to struggle with addressing the social determinants that affect health outcomes, often leaving patients to navigate fragmented care. In Toronto, homelessness remains a pressing health equity challenge, with over 15,000 people unhoused on any given night. 50% of homeless individuals face multiple health challenges and live half as long as the average life expectancy. This instability drives high emergency department (ED) use - at the University Health Network (UHN), 100 unhoused patients accounted for over 4,300 ED visits in 2023. These figures underscore the urgent need to address housing instability as a key driver of health inequities and improve timely access to care.

 

The Social Medicine Housing Solution at UHN, Canada’s #1 hospital, was created in response. By embedding housing and health supports at the point of care, the program meets patients where they are and ensures that services reflect the needs and lived experiences of those most affected.

 

Approach: The Social Medicine Housing Solution brings together the hospital team, community partners, and lived experience partners to implement an integrated and evidence-based model of care that is grounded in data and analytics and shaped by continuous stakeholder input. Guided by a housing first, harm reduction and health equity focused framework, the program supports patients through three key interventions:

• Supporting patients in securing housing and maintaining housing stability: The program provides housing stability, case management and care services that are tailored to each individual’s medical, social, and mental health needs.
• Preventing homelessness by providing financial assistance to secure housing: Provision of rental arrears and/or first/last month’s rent through a Homelessness Prevention Fund.
• Integrated healthcare system access: Increased access enabled through accompaniment services to ID verification and health card provision services, removing logical and systemic barriers to care.

 

A Lived Experience Advisory Panel was engaged at every stage of this project, from design through implementation and evaluation, ensuring that each of the project’s interventions reflect the patient’s perspective, goals, dignity, and agency.

 

Results: Preliminary results demonstrate early impact. The Social Medicine Housing Solution has provided patients with housing and stability supports, prevented evictions, and increased access to care. These interventions have contributed to sustained housing stability, reduced ED visits and easier access to preventive care. Beyond individual outcomes, the program has strengthened cross-sector partnerships and created new pathways for shared accountability between hospitals and community partners, reinforcing an integrated approach to health and housing.

 

Implications: The Social Medicine Housing Solution highlights how care can expand beyond traditional service delivery to address the root causes of health inequities through community-driven interventions.

 

It demonstrates that embedding social care within healthcare systems particularly through housing can create measurable improvements in health outcomes.

This program offers a replicable model for integrating care in alignment with population health priorities. It highlights the importance of co-design, strong community partnerships, and flexible care delivery - bringing services directly to patients instead of expecting them to navigate fragmented systems.