"Access to healthcare is a human right": a constructivist study exploring the impact and potential of a hospital-community partnered COVID-19 community response team for Toronto homeless services and congregate living settings.

BACKGROUND: Individuals experiencing homelessness face unique physical and mental health challenges, increased morbidity, and premature mortality. COVID -19 creates a significant heightened risk for those living in congregate sheltering spaces. In March 2020, the COVID-19 Community Response Team formed at Women's College Hospital, to support Toronto shelters and congregate living sites to manage and prevent outbreaks of SARS-CoV-2 using a collaborative model of onsite mobile testing and infection prevention. From this, the Women's College COVID-19 vaccine program emerged, where 14 shelters were identified to co-design and support the administration of vaccine clinics within each shelter. This research seeks to evaluate the impact of this partnership model and its future potential in community-centered integrated care through three areas of inquiry: (1) vaccine program evaluation and lessons learned; (2) perceptions on hospital/community partnership; (3) opportunities to advance hospital-community partnerships. METHODS: Constructivist grounded theory was used to explore perceptions and experiences of this partnership from the voices of shelter administrators. Semi-structured interviews were conducted with administrators from 10 shelters using maximum variation purposive sampling. A constructivist-interpretive paradigm was used to determine coding and formation of themes: initial, focused, and theoretical. RESULTS: Data analysis revealed five main categories, 16 subcategories, and one core category. The core category "access to healthcare is a human right; understand our communities" emphasizes access to healthcare is a consistent barrier for the homeless population. The main categories revealed during a time of confusion, the hospital was seen as credible and trustworthy. However, the primary focus of many shelters lies in housing, and attention is often not placed on health resourcing, solidifying partnerships, accountability, and governance structures therein. Health advocacy, information sharing tables, formalized partnerships and educating health professionals were identified by shelter administrators as avenues to advance intersectoral relationship building. CONCLUSION: Hospital-community programs can alleviate some of the ongoing health concerns faced by shelters - during a time of COVID-19 or not. In preparation for future pandemics, access to care and cohesion within the health system requires the continuous engagement in relationship-building between hospitals and communities to support co-creation of innovative models of care, to promote health for all.

Delivering collaborative mental health care within supportive housing: implementation evaluation of a community-hospital partnership.

BACKGROUND: Approaches to address unmet mental health care needs in supportive housing settings are needed. Collaborative approaches to delivering psychiatric care have robust evidence in multiple settings, however such approaches have not been adequately studied in housing settings. This study evaluates the implementation of a shifted outpatient collaborative care initiative in which a psychiatrist was added to existing housing, community mental health, and primary care supports in a women-centered supportive housing complex in Toronto, Canada. METHODS: The initiative was designed and implemented by stakeholders from an academic hospital and from community housing and mental health agencies. Program activities comprised multidisciplinary support for tenants (e.g. multidisciplinary care teams, case conferences), tenant engagement (psychoeducation sessions), and staff capacity-building (e.g. formal trainings, informal ad hoc questions). This mixed methods implementation evaluation sought to understand (1) program activity delivery including satisfaction with these activities, (2) consistency with team-based tenant-centered care and with pre-specified shared lenses (trauma-informed, culturally safe, harm reduction), and (3) facilitators and barriers to implementation over a one-year period. Quantitative data included reporting of program activity delivery (weekly and monthly), staff surveys, and tenant surveys (post-group surveys following tenant psychoeducation groups and an all-tenant survey). Qualitative data included focus groups with staff and stakeholders, program documents, and free-text survey responses. RESULTS: All three program activity domains (multidisciplinary supports, tenant engagement, staff capacity-building) were successfully implemented. Main program activities were multidisciplinary case conferences, direct psychiatric consultation, tenant psychoeducation sessions, formal staff training, and informal staff support. Psychoeducation for tenants and informal/formal staff support were particularly valued. Most activities were team-based. Of the shared lenses, trauma-informed care was the most consistently implemented. Facilitators to implementation were shared lenses, psychiatrist characteristics, shared time/space, balance between structure and flexibility, building trust, logistical support, and the embedded evaluation. Barriers were that the initial model was driven by leadership, confusion in initial processes, different workflows across organizations, and staff turnover; where possible, iterative changes were implemented to address barriers. CONCLUSIONS: This evaluation highlights the process of successfully implementing a shifted outpatient collaborative mental health care initiative in supportive housing. Further work is warranted to evaluate whether collaborative care adaptations in supportive housing settings lead to improvements in tenant- and program-level outcomes.

Key concerns among pregnant individuals during the pandemic: Online cross-sectional survey.

OBJECTIVE: To determine common sources of concern among pregnant individuals during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: A cross-sectional, open, online electronic survey from May 9, 2020, to June 14, 2020. SETTING: Electronic survey open internationally and advertised through Canadian-based social media platforms. PARTICIPANTS: Eligible participants understood English and had been pregnant during the COVID-19 pandemic (ie, were pregnant at the time of survey completion or had delivered an infant on or after March 11, 2020). MAIN OUTCOME MEASURES: Potential sources of concern related to the pandemic, calculated as the proportion of participants who endorsed each concern among those for whom the concern was relevant. Differences in the proportion of individuals endorsing each concern were compared by parity using modified Poisson regression. Frequency of concerns was examined in terms of level of distress, as per the Kessler Psychological Distress Scale (K6), using multivariable linear regression. RESULTS: Out of 1477 participants, 87.3% were Canadian. Top concerns included the following: hospital policies related to support persons during labour (80.9%), not being able to introduce the baby to family and friends (80.1%), and developing COVID-19 while pregnant (79.2%). Primiparous participants were more likely than multiparous participants to be concerned about accessing in-person prenatal classes (51.5% vs 13.3%; relative risk = 3.88; 95% CI 2.02 to 4.98) and cancellation of hospital tours (35.0% vs 5.6%, relative risk = 6.26; 95% CI 4.25 to 9.20), among other concerns. The mean (SD) K6 score was 6.7 (3.8) within the moderate to high distress range. Number of concerns reported was associated with K6 score in both primiparous (ß = 0.24; 95% CI 0.20 to 0.29; P < .0001) and multiparous (ß = 0.30; 95% CI 0.24 to 0.36; P < .0001) individuals. CONCLUSION: Pregnant individuals have unique concerns during the COVID-19 pandemic and the findings indicate the importance of targeted support strategies to meet the particular needs of both primiparous and multiparous pregnant individuals.

Missed connections: Unintended consequences of updated cervical cancer screening guidelines on screening rates for sexually transmitted infections.

OBJECTIVE: To examine the effects of the updated 2012 cervical cancer screening guidelines on the rates of sexually transmitted infection (STI) screening in primary care. DESIGN: Retrospective chart review. SETTING: Five academic family practice units at St Michael's Hospital in Toronto, Ont. PARTICIPANTS: Female patients, aged 19 to 25, who had at least 1 visit with a physician at 1 of the 5 academic family practice units during a 12-month period before (May 1, 2011, to April 30, 2012) or after (November 1, 2012, to October 31, 2013) the release of the updated guidelines. MAIN OUTCOME MEASURES: Number of women who received Papanicolaou tests or underwent STI screening; rates of STI screening performed during a Pap test or a periodic health examination; screening rates for HIV, syphilis, and hepatitis C; and the methods used for STI screening before and after the release of the updated guidelines. Results Before the release of the 2012 guidelines, 42 of 100 women had Pap tests and 40 of 100 women underwent STI screening. After the release of the guidelines, 17 of 100 women had Pap tests and 20 of 100 women received STI screening. Female patients were less likely to undergo STI screening under the 2012 guidelines compared with the 2005 guidelines (odds ratio 0.38, 95% CI 0.19 to 0.74; P = .003). CONCLUSION: Implementation of the 2012 cervical cancer screening guidelines was associated with lower rates of STI screening in the primary care setting. Primary care physicians should screen at-risk women for STIs at any clinically appropriate encounter and consider using noninvasive self-sampling methods.