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Development and Implementation of a Medical Respite Program for People Experiencing Homelessness:An Analysis of a Cross-sectoral Partnership
People with lived experience of homelessness (PWLEH) undergo worse health outcomes despite frequent acute care use, often because their functional and social needs remain unmet. In response, a homeless shelter and the provincial health authority formed a partnership to implement a medical respite program. We describe this collaboration by conducting a qualitative study, interviewing people involved in planning and implementing the program (n=25). Thematic analysis was performed. Stakeholders were motivated by a common desire to address the health inequities experienced by PWLEH, and frontline service providers felt a sense of teamwork. However, due to logistical limitations, an evolution of partnerships, and lack of role clarity, there was no singular program vision, resulting in lack of stakeholder support and conflicts between partner organizations. Health care for PWLEH must be multidisciplinary and cross-sectoral. The synergies and challenges described shed light on how future partnerships can be navigated.
Homelessness, respite care, cross-sectoral partnerships, health equity
More than 235,000 people in Canada experience homelessness each year. This includes people living on the streets, in unsuitable living environments, or in temporary residences, motels, or other unstable housing.1 People with lived experience of homelessness (PWLEH) have worse health outcomes than people who are stably housed. These associations tend to be complex, varied, and bi-directional.2 Adverse outcomes associated with homelessness include a higher risk of infectious disease, serious traumatic injuries, drug overdose, violence, and death due to exposure.3,4 Homelessness can also affect outcomes for chronic diseases and mental health and substance use [End Page 61] disorders.3,4 People with lived experience of homelessness must often choose between competing priorities, such as obtaining the basic necessities of life and meeting health care needs.5,6 As a result, PWLEH may forego seeking medical care, especially if it is perceived as being discretionary (e.g. preventive care).7 People with lived experience of homelessness are more likely to repeatedly visit emergency departments than people who are stably housed for a multitude of reasons.8,9 These include social support and transportation barriers that impede their ability to attend health care appointments,10 leading to a disproportionate use of the emergency departments, which are available all hours of the day.11
These barriers to accessing resources and care are further exacerbated during times of acute illness. People with lived experience of homelessness are frequently discharged from the hospital or emergency departments back to shelters or to the streets with little follow-up or continuity of care, leading to the loss of any gains in health that may have been made while in care.12 This results in increased hospital readmissions and the revolving door phenomenon of frequently being in and out of hospital.13 Medical respite programs (MRPs) have been designed as a potential solution to serve PWLEH to bridge their medical and social needs, particularly in the convalescent period after acute illness or hospitalization.14 Models vary based on the needs and resources of the local community, but typically provide nursing care along with case management and assistance in addressing social barriers (e.g. housing and social assistance applications).14 In view of the need to provide more holistic care for PWLEH during acute illness, a medical respite program was established in Calgary, Alberta, via a partnership between The Calgary Drop-In Centre (the DI), the province's largest homeless shelter, and Alberta Health Services (AHS), the provincial health authority.
Given that social and housing needs are inextricable from health, health interventions for PWLEH necessitate partnerships that cross the health, social, and homeless-serving sectors.15 Despite their importance, few have described these cross-sectoral partnerships and the collaborative processes required to develop and implement complex interventions for PWLEH.16 That is, studies describe health interventions for PWLEH, but none focus on the characteristics of the partnerships underlying the interventions. Identifying potential barriers and facilitators in collaborations is essential in effecting change.17 Using the Bergen Model of Collaborative Functioning (see Methods), our qualitative study aims to describe these collaborative processes in the development and implementation of the MRP established in Calgary, Canada from the perspectives of the program administrators and service providers involved in these collaborations. Our study findings have the potential to inform future cross-sectoral partnerships in the development of complex interventions for PWLEH.
Methods
Theoretical framework
The Bergen Model of Collaborative Functioning18 was used as the theoretical framework to explore the collaboration between AHS and the DI in the development and implementation of the medical respite program (Figure 1). While this model has been used previously in other health-related research (primarily in the context of health promotion involving non-governmental organizations,19,20 but also [End Page 62]
Adapted from the Bergen Model of Collaborative Functioning.
Citation: Matenga T, Zulu JM, Corbin J, Mweemba O. Contemporary issues in north-south health research partnerships: Perspectives of health research stakeholders in Zambia. Health Research Policy and Systems. 2019;17.
in relation to hospital settings,21,22 community-academic partnerships,23 and primary health care delivery24), this is the first time to our knowledge that it has been applied to a partnership between the health and homeless-serving sectors. The model has three broad categories of collaborative processes: input, collaboration, and output, each consisting of various sub-domains. For this paper, we focused on only the input and collaboration categories and aimed to understand the barriers and facilitators within each, rather than commenting on these separately as outputs. Descriptions of the mission, partner resources, and financial resources involved in the partnership are among the inputs. The leadership, roles and structure, communication, and interactions of the numerous inputs are all described in the collaboration domain.18,25
Methodological approach
This study employed an inductive, qualitative descriptive approach. This methodology is suited for studies that do not take on a specific qualitative underpinning (i.e., to provide evidence for an existing theory) but rather aims to describe the phenomenon of interest as it is.26 Bradshaw, Atkinson, and Doody describe the qualitative descriptive approach to be a naturalistic approach,26 with a relativistic ontological position. This methodology also privileges subjectivism, where each participant's perspective is respected, as is the subjectivity of their experiences during their involvement with the MRP.
Context
The study was set in Calgary, a major city in Alberta, Canada. In 2021, the population of Calgary was 1.4 million.27 The most recent point-in-time enumeration of the homeless population in Calgary found that 2,911 people experienced homelessness in 2018, of whom 68% were deemed chronically homeless.28 Recognizing that point-in-time counts underestimate the rate of homelessness (by missing those experiencing hidden homelessness, such as those who couch surf, and by missing those who cycle [End Page 63] in and out of homelessness),29–31 this rate of approximately 208 per 100,000 people is comparable to that of other Canadian cities of a similar population size.28,32,33 The largest of the city's emergency shelters is the DI. On average, the DI provides shelter to 423 clients, sees 14,057 visitors in the Health Services clinic, and serves 592,384 meals, daily.34 Alberta Health Services is the provincial health authority, responsible for delivering publicly funded health services to the entire province of 4.48 million people.35
Program description
A medical respite program was established in Calgary in 2019, through a partnership between the DI and AHS. Patients were eligible for the program if they were: 1) experiencing chronic homelessness; and 2) in need of medical support and eligible to receive it as an outpatient through the AHS Home Care program. Patients were most commonly referred to the program at the time of discharge from the hospital, though referrals were also accepted through the community (e.g., from clinics or from homeless shelters). Alberta Health Services Home Care made the final decision about whether patients referred to the program were accepted, based on whether patients both required and were appropriate for home care services. Subacutelevel medical supports were provided by visiting nurses and/or health care aides, and included wound care, optimization of both acute and chronic diseases not requiring hospitalization, and assistance with activities of daily living (e.g., bathing, dressing, medication administration). In addition, nurse practitioners conducted assessments twice per week, and on-site pharmacists provided in-house medication decision support and patient education. The DI dedicated a full-time housing case manager to the medical respite program to support the clients' housing and social needs (e.g., obtaining identification, opening bank accounts, applying for income support).
The MRP was physically located in the DI in its own dedicated space, occupying one of the upper floors. Medical supports were provided through ambulatory care ("Home Care") nursing staff from AHS who visited the patients daily. The program was named by stakeholders the "Home Care in Shelter" (HCIS) program. It had capacity for 16 patients, with 11 beds for patients requiring full-time (24 hours per day, 7 days per week) support and/or physical space. The remaining five spots were chairs for ambulatory patients requiring intermittent support (e.g., parenteral antibiotics, intermittent wound care) to come and go throughout the day. These ambulatory patients slept in the same area as the rest of the DI's general population, rather than in one of the 11 beds in the dedicated MRP space. The median length of stay in the program was 14 days (IQR 6, 20 days).
Study participants
Individuals who were involved in the planning, implementation, or service provision of the MRP were invited to participate in the study. We used a key informant sampling strategy, where the operational leads of the medical respite program were asked to invite stakeholders to participate in the study by sending them an invitation email. The stakeholders responded directly to the study team if they were interested in participating. A snowball sampling method was also used for recruitment, in which study participants were asked to suggest up to three other stakeholders for study participation. The participants were provided an email invitation that they could forward to the suggested stakeholders.
Data collection
Semi-structured in-depth interviews and open conversations were [End Page 64] employed as the main form of data collection for this study. The facilitators used an iteratively drafted and pilot-tested interview guide (available from the authors upon request) to conduct the interviews.36 Participants were asked to describe the MRP (specifically its structures and processes), as well as any barriers and facilitators that affected the program's development and implementation. Demographic data were also collected for participants, including role in the program and organizational affiliations, professional training, and years of experience.
All interviews were conducted over the phone, co-facilitated by two investigators (KT and IN) from December 2020 to April 2021. The phone conversation was recorded using an audio recorder, and additional notes were taken by the interviewer as the conversation took place. Interviews generally lasted between 40 and 60 minutes. Transcription of the audio files was carried out using rev.com, a transcription service provider. Interview transcripts were reviewed for clarity and completeness by IN and KT. Interviews continued until the research team found that saturation had been reached, where no new themes were being identified.
Data analysis
Data were analyzed using a thematic analysis approach.37,38 First, three members of the study team (KT, IN, EG) read the interview transcripts, noted potential patterns, and familiarized themselves with the data. Second, two investigators (IN, EG) carried out line-by-line open-coding, which was reviewed by a third investigator (KT).37 Code generation was data-driven and primarily inductive. Previously analyzed transcripts were reviewed again, to look for these newly generated codes through constant comparison.39 Codes were mapped onto and categorized into Theoretical Domains Framework (TDF) and Consolidated Framework of Implementation Research (CFIR) constructs where relevant. The TDF and CFIR are both implementation science frameworks.40 For example, codes that captured descriptions of the implementation climate were categorized into the CFIR domains: compatibility, learning climate, relative priority, and tension for change. Because interviews included data that extended beyond the implementation of the MRP, neither the TDF nor the CFIR frameworks adequately captured all the data. The codebook, therefore, while informed by the CFIR and TDF frameworks, was not limited to these frameworks.
Codes were grouped into potential themes. The study team met to discuss, refine, and modify these themes, and to determine how they were related. The themes were reviewed to ensure they reflected the data, after which each theme was defined and named. To ensure rigour, a systematic record of codes and memos was kept to document the discussions and the evolution of the themes.41 Lastly, an analytic narrative based on the themes was created. All coding and analyses were conducted using NVivo software (QSR International Pty Ltd. Version 12).
Ethical considerations
The University of Calgary Conjoint Health Research Ethics Board (Study ID: REB19-1209) approved this study. The study followed an informed consent protocol, where researchers communicated the study objectives, risks, and outcomes to individuals who were interested in taking part, who then provided consent to participate. To maintain confidentiality of the research participants, all identifiable information from the interview transcripts and subsequent documents were removed, with names being replaced by participant numbers. [End Page 65]
PARTICIPANT CHARACTERISTICS
Results
Study demographics
A total of 25 stakeholders were interviewed for the MRP program evaluation (Table 1). Most were affiliated with AHS (48%) or the DI (16%). Stakeholders came from a variety of professional backgrounds and roles in the program, including administrative as well as front-line service provider roles. The involvement of individual stakeholders and collaborators evolved over time, from the initial planning and development to the implementation then operationalization of the program (Figure 2). Most stakeholders involved in the planning stage were administrators and health care providers with significant professional experiences working with PWLEH. Few involved in the actual operationalization of the program had also been involved in the initial planning and development stages.
Themes
Box 1 summarizes the themes that emerged from our analysis. The themes are categorized by the input and collaboration domains of the Bergen Model of Collaborative Functioning.
Vision
Theme 1: There was a collective desire among all stakeholders to address health inequities that exist for people with lived experience of homelessness. The stakeholders involved in the early planning stages of this program ("original stakeholders") were [End Page 66]
Temporal changes in stakeholder involvement during the planning, implementation, and operation of the MRP.
physicians who regularly provided care for PWLEH and had a long history of working with and advocating for PWLEH. Nearly all interviewed stakeholders shared a common understanding of the needs of PWLEH. The main gaps in services that were described included lack of harm reduction options in current acute care delivery models and hospital practices of discharging patients to the streets without adequately addressing the housing and social issues that are intricately linked with health. Many noted that PWLEH hesitate to seek care due to prior negative experiences with health care providers:
Many of them either won't go to a doctor, don't like doctors, whatever, or, you know, been treated terribly in the past. So, they're gun shy. There's a lot of addiction medicine, and there's a lot of social work.
—Participant 18, Community Partner
Medical respite programs were explored as one potential solution to the challenges faced by PWLEH.
Theme 2: Despite a common overarching desire to improve the health of people who are experiencing homelessness, the partnership could not translate this into a singular vision due to a changing stakeholder group and logistical limitations. The MRP reportedly began as a vision of the small number of physician stakeholders, who were described by others as "activists" for PWLEH (Participant 14). In their initial vision (see Figure 3 for timeline), the MRP was meant to provide comprehensive, trauma-informed acute-level care for PWLEH in shelter (or in outreach), to mitigate issues of transportation and accessibility of health services, and to address reluctance to seek care stemming from [End Page 67]
. SUMMARY OF THEMES, ORGANIZED INTO THE INPUT AND COLLABORATION DOMAINS OF THE BERGEN MODEL OF COLLABORATIVE FUNCTIONING
prior trauma and stigmatization. The physicians' proposal for the MRP was presented to the DI, who supported and advocated for the innovation. However, they faced logistical limitations such as inability to obtain physician funding and external grant funding for operations and building permit and zoning restrictions (leading to an inability to provide supplemental oxygen outside of portal units, for example). Ultimately, the AHS [End Page 68] Home Care portfolio agreed to staff and operate the program. Stakeholder involvement changed with time, with the operationalization and implementation of the MRP being undertaken by different individuals from those who initially envisioned the program. As a result of logistical restrictions and evolution of stakeholder involvement, the care that could be provided in the MRP was much less acute than was initially envisioned. Detoxification and harm reduction as initially envisioned (e.g., managed alcohol program) were also not possible:
I mean, I think that's the crux of the problem, right? There's just so many people involved and the project changed hands so many times that I think it lost … [the initial] perspective. [Others] came in with their own perspective and didn't necessarily know what the original history was.
—Participant 22, DI
The program that was operationalized deviated from the initial vision put forth by the original stakeholders, resulting in their disappointment and disengagement. These changes also resulted in confusion on the part of the other stakeholders about what the program's vision and objectives were:
When I first got started, I'm not sure that I was clear on what the mission or the vision or the objective or any of the goals were. I think everybody was not on the same page. I'm not sure they will ever be on the same page. We had lots of conversations about what [the original stakeholders] were hoping to accomplish initially, and what we were feasibly able to do. We couldn't run an acute care unit in a homeless shelter.
—Participant 25, AHS
Theme 3: The unique contributions of each of the partner organizations were not considered in the development of the program objectives. Because the initial vision for the
Timeline of the changes to the vision of the medical respite program.
[End Page 69] MRP originated from a small number of physician stakeholders whose focus was on the provision of medical care, non-medical aspects of care such as housing were not considered a priority, despite the DI's resources and experiences in this area:
[Housing] came closer to the end of the discussion, like after Home Care was involved, because it really seemed like it was happening. The notion of having clients transitioned directly from the home care beds to some sort of housing arrangement rather than going back into a shelter was something that people talked about a lot.
—Participant 24, Community Partner
[The stakeholders involved in housing at the DI] really didn't come online until right before inception, really, because housing was actually deemed out of scope in the initial development of the program. A lot of the initial design was looking strictly at health outcomes.
—Participant 17, DI
The increasing involvement of other stakeholders outside of the original physician group resulted in housing becoming a major part of the MRP's objectives.
Partner resources
Theme 4: The skills and human resources offered by the two major partner organizations were diverse and complemented one another. The DI had housing case managers well versed in housing assessments and pathways to housing, nurses who had been following patients living with chronic homelessness and staying at the DI for many years, and adult care workers who could provide coverage overnight. Alberta Health Services provided ambulatory (Home Care) nursing staff, as well as health care aides who were provided through a contractor. The full scope of AHS services was available (e.g., access to social workers, occupational therapists, physical therapists) through standard referral pathways in the Home Care program.
Theme 5: There were critical individuals and organizations missing in the development and operationalization of the medical respite program. Participants noted that many important individuals and organizations were missing in the planning and development stages of the MRP. They were absent for two reasons: 1) there was a lack of interest by these other parties; and 2) the MRP stakeholders failed to intentionally engage with and involve them in the early stages of planning. These included individuals and groups within AHS who were not part of the Home Care portfolio, for example emergency medical services (who could have played a role in managing acute medical issues, which may have allowed for higher-acuity patients to be eligible for the program), and addictions and mental health support (to facilitate harm reduction approaches and detoxification services). The Drop-In Centre's resources were similarly not optimally used. In particular, the DI had existing health services and health care staff who were not included in the program operations, despite their experience and knowledge of the patient population including with issues surrounding addictions and mental health. Lastly, despite the MRP being a bridge from inpatient to outpatient care, there were few connections made with community organizations and providers:
That was an obstacle on the community side, of truly coming together to solve problems … they were all competing for more or less the same bucket of funding, and they weren't incentivized or rewarded or whatever the right word is to work together [End Page 70] just for the benefit of solving a problem in the delivery of care.
—Participant 3, Community Partner
Financial resources
Theme 6: The contribution of financial resources corresponded to decision-making power, resulting in power imbalances that favoured one organization over the other. Alberta Health Services provided most medical staff for the program, including nursing staff and health care aides, through the Home Care portfolio. The DI covered some of the gaps in funding through the flexible use of existing resources. They created a fundraising campaign to raise money to renovate the space. They also provided in-kind contributions for all non-medical human resources such as the adult care workers who provided overnight coverage and the case managers who provided housing and navigation support. The MRP was therefore made possible through the contributions of both organizations.
Many noted there was a power struggle between the DI and AHS stakeholders, with both sets of stakeholders feeling a sense of ownership for the program due to their respective contributions. Some stakeholders felt that because AHS was providing financial contributions (through the provision of health care staff), they held decision-making power:
Funding was by far the biggest constraint because we needed funding to support this program, and funding was coming from Alberta Health Services but through … Home Care. Home Care had their own perspectives as to how this looks, and they're used to managing things differently than acute care settings.
—Participant 4, Community Partner
AHS Home Care said 'we're doing this this way, this is our program, it's our money'… [They're] calling the shots and so then it was just them.
—Participant 15, Community Partner
Others felt that because the MRP was situated within the DI building and because of the key role the DI stakeholders played in the planning of the MRP, the DI should have at minimum an equal role in making decisions. Ultimately, interview participants described the general perception that contribution of financial resources resulted in decision-making power that favored AHS stakeholders:
When it came to the upper management, that of course was where … things got rocky, and … I think at one point the DI truly wanted to just, they wanted to run the beds. But, with the funding coming from Alberta Health Services, management was handed over to them.
—Participant 1, DI
Leadership
Theme 7: Executive and operational leadership from both organizations were highly supportive of the program. All interviewed participants reported receiving high-level support from executive leadership of both organizations, which resulted in both flexibility and progress in the implementation of the MRP. Similarly, operational leaders were described as approachable, and were recognized for their ability to promote trust, openness, and respect among the staff. Operational leaders from both organizations [End Page 71] were on site, so they were able to help solve problems that arose. As a result, frontline providers felt "there was so much enthusiasm and great support for [them] to work [their] way through [the program] and make the partnership and the care delivery work. It really [seemed to be] flourishing well" (Participant 14, AHS).
Theme 8: Stakeholders had different ideas about leadership and decision-making structure. While a grassroots approach was undertaken in the envisioning of the program, a more traditional and hierarchical leadership structure was used in the program implementation. The original physician stakeholders felt that, in keeping with the grassroots approach to the initial envisioning of the program, decisions should be made through group discussion and consensus:
One of the challenges was going from sort of a grassroots kind of collective of people that were advocating for something to happen to an actual leadership structure that would operate beds when they work. You know, like you go from a group of people that are doing this basically on a volunteer basis … they have a lot of ownership in the project, but eventually that has to transition to be somebody's responsibility. None of us were providing our own staff that we're accountable for. So, you need to transition it to an organization that's actually paying somebody a salary to execute the vision and have responsibility for those people, the physical space … all of it. So, the challenge was going from a kind of grassroots collective advocacy to what ultimately had to be a very organized, institutional kind of relationship, and [somehow] maintaining the interests of everybody who was involved all the way along that process.
—Participant 24, Community Partner
Furthermore, because of the many stakeholders involved at different times, many—including those in leadership positions—were unaware of the overall direction of the program and the rationale for decisions that had already been made:
I think the decision that the project would go ahead was already made … and I have no idea how it was made or who made it … and to me this was so confusing to the point [where even] the director of the portfolio had no idea how [they] even got to where [they] were.
—Participant 7, AHS
More fundamentally, there was debate about whether a non-health organization should be leading a health intervention such as the MRP. Stakeholders from the DI and other community partners in the homeless-serving sector felt that they should have been the decision-makers due to their familiarity with and knowledge of the needs of PWLEH. Stakeholders from AHS felt differently, noting that community organizations are unlikely to have the needed health expertise (given that they are not health organizations) to provide services that meet the expected standards of care:
From the Drop-In Center's perspective at the time, I think they would have liked [AHS] just to fork over the money and let them do it. But [AHS] really believed that [it was their] responsibility to deliver that kind of health care. And [they] weren't prepared just to give another agency—a non-health care agency—money to do that.
—Participant 12, AHS [End Page 72]
Roles and structure
Theme 9: There was a lack of role clarity, especially for the original stakeholders. Study participants reported the presence of many involved stakeholders from different organizations without knowing exactly what each person's role was:
The biggest complaint against the Home Care in Shelter program was that there were more providers at the table than there were clients that [it] had the ability to serve at one given time, [which] definitely muddied the waters.
—Participant 17, DI
There were at minimum the 25 stakeholders (i.e., those who participated in this study), but the MRP only had capacity for 16 patients at one time, so there were more stakeholders involved in making decisions about the program than there were patients in it at any given time. The lack of role clarity affected the original physician stakeholders disproportionately who, after being the ones who envisioned the program, were left without formal leadership roles. Additionally, without physician funding, the MRP was operated by nursing staff and nurse practitioners, so the physician group also had no formal service provision roles in the program.
Communication
Theme 10: Communication among frontline providers was described as complicated and inconsistent. Due to the number of stakeholders involved, and without a clear organizational or leadership structure, communication was described as complicated. The different frontline providers all had different managers to whom they reported, so it was difficult to know whom to approach about certain issues. On top of that, the involvement of numerous agencies and stakeholders meant there were many conversations happening in silos, without a consistent or systematic way to update the broader group of individuals involved in the patient's care.
The lack of shared information systems contributed to communication barriers and resulted in duplication of effort and inefficiencies. Some care providers such as the health care aides used a system of paper charting, while the DI staff used the DI's databases, and AHS providers used their own electronic medical information systems for charting. One organization could not access the other's documentation:
[Providers were] all charting on different documents [which made it] difficult to kind of have that communication … and not everybody was always involved or at the table with certain essential conversations.
—Participant 16, Community Partner
Interactions
Theme 11: A positive team environment encouraged learning, feedback, and open discussions. This was true both for frontline service providers and program administrators. Frontline providers felt that they worked well together as a team, complementing each other's skill sets. They frequently sought each other out, whenever they needed help or had questions (see Supplementary Table 1 for supporting quotations, available from the authors upon request).
Operational leaders also encouraged feedback from the frontline providers, holding regular meetings for the sole purpose of program quality improvement. In these meetings, barriers to processes were identified, and solutions were brainstormed. For example, when providers identified concerns about the lack of addictions and mental health supports, operational leadership reached out to the addictions and mental health [End Page 73] portfolio of AHS for resources and support. The approach taken by the stakeholders was to implement the project as soon as possible, then make changes as needed; the MRP was meant to be a quality improvement project from the start.
Theme 12: Conflicts between stakeholders from the two organizations stemmed from differences in organizational culture and a negative prior history of working together. Stakeholders described very different organizational cultures, with the DI needing to be highly flexible in their operations due to the MRP's fast-paced and changing environment as well as significant limitations in resources, and AHS being perceived as being rigid, hierarchical, slow-moving, and bureaucratic. Alberta Health Services stakeholders acknowledged the presence of organizational differences, but noted that many of the rules and regulations (which were perceived as being bureaucratic and the cause of delays) were necessary in the operation of a large organization, and for the safety of the staff:
The reason for the culture clash is actually there are other factors at play – like unions taking a really strong stance about the conditions under which their people can work, and occupational health and safety who [abide] by a specific set of regulations. So, there are things that create the culture sometimes that I think people don't understand. It's not just [the organization] being difficult.
—Participant 12, AHS
Beyond organizational differences, DI and other community partner stakeholders also described a sense of mistrust in AHS that preceded the development and implementation of the MRP:
Home Care [was] not trusted in the homeless-service sector as a partner or area of Alberta Health Services that [could] still deliver care to this population. There [were] a lot of negative experiences with the … staff not serving this population well, so there [wasn't] a lot of trust in that provider:
—Participant 22, DI
A small number of AHS stakeholders reported that these pre-existing biases deepened with the MRP. For example, an incident was described where misinformation was spread about the MRP not accepting a patient due to AHS intolerance of patients actively struggling with substance use, when in fact the AHS frontline providers had taken much initiative in offering an MRP spot to the patient, who ended up not showing up:
I would constantly hear—Home Care won't do this, or Home Care won't do that. I'll give you an example. A client was supposed to go to the [MRP]. About three or four days later, I heard from [the hospital nurse coordinator] that there was a physician there saying that the [MRP] doesn't work because they can't get anybody into [the beds] and referenced this particular client. So, I called the physician, and I told him that we had the bed ready, and the client declined to go. He said that he was told that Home Care wouldn't accept the client. What had actually transpired was that [the client] was due to go to the taxi that was going to take him to the DI, but his girlfriend showed up just before … and he decided that he wouldn't go. I had [our MRP nursing] case manager call [the homeless shelter where the client was staying] every day to connect with him … because his [spot was] still there. He declined and he never did come to the [MRP], but then that story was out there that Home Care [End Page 74] wasn't supportive [of addictions] and put too many barriers up. I had to do a lot of myth busting.
—Participant 5, AHS
Discussion
Interventions meant to improve health for PWLEH are necessarily complex, involving multiple people, organizations, and sectors. Our study aimed to understand the cross-sectoral collaborations in the development and implementation of a medical respite program for PWLEH to guide the future development of similar complex interventions for this population. We found that the factors that facilitated collaboration and led to synergy were that stakeholders had a common recognition of the health inequities faced by PWLEH and a desire to mitigate these at a systems level, the willingness of both partner organizations to devote resources to the intervention, and the positive collaborative environment surrounding the providers. Barriers existed in the input and collaboration domains of the Bergen Model of Collaborative Functioning, and resulted in antagony (the reverse of synergy in the Bergen Model). Because there was no consistent or singular program vision (due to changing stakeholders and compromises made because of logistical limitations), operational decisions were not well understood by the team. There was also lack of clarity about the roles and scope of individual stakeholders, issues with power imbalances, differences in expectations regarding leadership and decision-making structure, and fundamental differences in organizational culture of the two partner organizations that negatively affected the collaboration. To produce synergistic cross-sectoral partnerships, collaborations require thoughtful planning (rather than solely relying and capitalizing on windows of opportunity)42 and guidance by a clear and mutual vision.
Others have described the importance of cross-sectoral partnerships in the areas of community health and health promotion.15,43,44 As we have, these studies have noted that having a common goal and mission and making program expectations explicit rather than implicit are necessary ingredients for a successful partnership.15,43 While clear roles and responsibilities may be difficult to ascertain for all involved stakeholders, particularly if the team is large, such delineation is needed to retain support from stakeholders.15 Our findings suggested that due to historical experiences and organizational reputations, there was a lack of trust between the organizations that predated the intervention, which was further exacerbated by the power imbalances that resulted from the difference in contributions (financial vs. in-kind). Others have also noted the importance of trust in cross-sectoral collaborations.44 Strategies to increase trust include having shared power and leadership,44 having leadership present and available,45 using resources efficiently,45 and having a clear goal that cannot be undermined.46
Due to the upstream systemic barriers that lead to a wide variety of specific health and social needs, interventions to improve the health of PWLEH necessitate the involvement of a community-based multi-disciplinary team that crosses organizations and sectors.47–51 Literature on these complex and multi-faceted interventions has tended to focus on needs assessments,16 detailed description of the intervention,52,53 or evaluation of outcomes.54,55 To our knowledge, there have thus far been no studies describing the cross-sectoral, inter-organizational, and inter-professional partnerships and collaborations [End Page 75] of interventions for PWLEH—this has been recognized as an evidence gap.49 There are multiple approaches to implementation of innovations. These include top-down approaches (where leaders take a commissioner role) or bottom-up approaches (where leaders take a facilitator role).56 Interventions in health and homelessness have traditionally taken a bottom-up, often grassroots, approach,57 which relies on community-led advocacy and activism to respond to local needs and priorities. This has the advantage of including a diverse set of expertise and experiences to meet the complex needs of PWLEH.56 On the other hand, top-down approaches benefit from a clear leadership structure, engaged administrators, and ability to build on existing processes and structures to ensure sustainability and to facilitate program expansion.58 While top-down approaches have generally been associated with large organizations and corporations, they can also be effective in cross-sectoral collaborations. One example is the Collective Impact Framework, which promotes the formation of a backbone organization, where leaders are identified and developed to manage and coordinate program initiatives. The MRP in Calgary represents a meeting of a bottom-up innovation (envisioned by the original physician stakeholders involved in the provision of care of PWLEH) with a top-down approach (where decisions are made not horizontally but vertically by leadership and decision-makers).59 Our findings therefore demonstrate not only the complexity of bringing together a large group of stakeholders from a variety of organizations and backgrounds, but also the tensions that stem from fundamental differences in approaches to innovation. Regardless of whether an innovation takes a bottom-up or a top-down approach, the common factors for success include having a shared set of goals, creating structures to allow coordination and planning, intentionally involving stakeholders to ensure a diversity of voices, communication, and trust.56,60–62
Our study leads to important tangible applications. Due to their effectiveness in improving health and housing, MRPs have become increasingly common, particularly in North America.14 The National Health Care for the Homeless Council has produced a document for health care administrators that outlines, step-by-step, points to consider in the creation of a MRP.63 In 2021, the National Institute for Medical Respite Care published standards for MRPs.64 While both documents provide important practical considerations in the development of MRPs (for example, advising that MRPs ought to provide safe accommodations available 24 hours per day, or recommending that MRPs assist with coordination and access to comprehensive support services), neither provides guidance on the more fundamental issues that lie at the heart of the intervention—what are the program vision, mission, values, and objectives, and who ought to be involved to ensure its success? Our study findings suggest that these questions have profound implications for the success of the implementation and operationalization of a medical respite program. Based on the barriers and facilitators identified in our study, we make the four following recommendations to ensure the success of cross-sectoral collaborations in the development of future medical respite programs: 1) mutually and explicitly define program vision and objectives so that subsequent operational decisions can be understood by all involved parties; 2) share decision-making across partner organizations, with specific attention paid to potential power imbalances across decision-makers and partner organizations; 3) create an organizational structure with [End Page 76] the scope and role of individuals being clearly defined; and 4) cultivate a positive, team-based environment to encourage learning and feedback.
There are several limitations to this study. First, despite an overall high response rate, certain stakeholders are missing. They include individuals from organizations who were contracted by AHS to provide home care services (i.e., health care aides providing much of the daily care for the patients of the medical respite program). Multiple requests were made for participation by both the research team as well as the key informants (with whom the contracted organizations had an ongoing professional relationship), with no response. Second, while we initially intended to include other data sources such as field observations to triangulate the data provided in interviews, we were unable to conduct this phase of research due to provincial and institutional restrictions relating to the COVID-19 pandemic. Field observations would have provided context for the inter-organizational and inter-professional interactions that were discussed during the interviews. Last, transferability of our findings may be limited, as our study focuses on a local intervention. However, the identified barriers and facilitators to the cross-sectoral partnership described by participants are not specific to the operational details of the intervention. We have also explored a partnership between the provincial health authority and the largest homeless shelter in the province. The prominence of the organizations in their respective sectors, along with the other mitigating factors mentioned, increases the transferability of our findings.
Health care for PWLEH must involve multidisciplinary and cross-sectoral collaborations to be effective. In recognition that stable housing is the root cause of ill health for PWLEH, it is of utmost importance that we consider collaborations between the health and homeless-serving sectors for delivering health services to this population through complex interventions. The successes and challenges we describe in this paper shed light on how partnerships between very different organizations can be navigated in future programs.
ESHLEEN GREWAL, PETER HOANG, and KAREN TANG are all affiliated with the Department of Medicine, University of Calgary. Karen Tang is also affiliated with the Department of Community Health Sciences and the O' Brien Institute for Public Health, University of Calgary. IFFAT NAEEM is affiliated with the W21C Research and Innovation Centre, University of Calgary, Alberta, Canada.
