A consortium of population health professionals, physicians, frontline staff, and community partners in Toronto established the Community Assessment and Risk Evaluation (CARE) program, a rapid risk assessment and clinical population medicine intervention to respond to challenges faced by people experiencing homelessness (PEH). The intervention also helped characterize health needs and mitigate risks among this population. Staff from various Toronto area shelters worked with population health professionals to group residents according to their health and support needs using the CARE tool. The five-item, open-access tool gathered data on immunization status, general health risk, support needs, substance use, and housing-specific support needs. Additional content concerning cognitive, behavioral, and general health status are currently in development. Automated and customized CARE dashboards were developed to provide shelter and primary care colleagues with secure, real-time information on resident needs, and comparisons with system-wide data. The authors assert that CARE demonstrates how collaborations of health and social service personnel can deliver rapid health assessments, and support enhanced care and protections for vulnerable populations. CARE also illustrates the need for expanded services for people experiencing homelessness with complex health and substance use needs.

What We Know: People experiencing homelessness (PEH) face an elevated burden of chronic and communicable disease, mental health, substance use disorders, and unmet health and support needs. Health professionals and housing providers lack real-time data to drive and enhance services.

What This Study Adds: The team’s development of the Community Assessment and Risk Evaluation (CARE) Program and corresponding tool can help the medical community respond to challenges that people experiencing homelessness face, as well as characterize their health needs. It also can give health care professionals a way to mitigate risks associated with PEH. Automated and customized CARE dashboards provide shelter and primary care colleagues with secure, real-time information on resident needs, and comparisons with system-wide data.

Rapid and Collaborative Population Health Assessment for People Experiencing Homelessness in Toronto: The CARE Program

Aaron Orkin, MD, MSc, MPH, PhD, et al

Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada; MAP Centre for Urban Health Solutions, St. Michael’s Hospital, Toronto, ON, Canada

Pre-embargo article link (Link expires at 5 p.m. EDT Sept. 25, 2023)

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