Adapting Primary Care Models to Meet the Needs of People Experiencing Homelessness: An International Review

Context: People experiencing homelessness (PEH) face several social and health challenges, including stigma and discrimination, and barriers to access healthcare and navigate health systems. These barriers contribute to unmet needs and a nearly 30-year gap in life expectancy compared to the general population. While the health and social consequences of homelessness have received considerable attention in the literature, we know less about how health systems have adapted and reformed to better meet the needs of PEH.

Objective: To uncover the types and features of primary care models that may contribute to improved access to primary care for PEH across selected high-income countries’ health systems.

Study Design: Scoping review of academic and grey literature between 2015-2021, and 10 expert informant consultations.

Setting: Primary care in non-traditional settings in high-income countries.

Population Studied: PEH.

Results: A wide range of primary care models in non-traditional healthcare settings are in place across high-income countries. Usual sites for these services include shelters and facilities that serve individuals with substance-use disorders, mobile outreach, and hub- and-spoke models. While most of the models targeted the general population of PEH, some focused on families, youth, specific genders, and Indigenous peoples. We did not uncover any robust evaluations of the impacts on access or health outcomes, but we see some indication of positive experiences among clients, frequent contacts, and potentially reduced emergency department visits. We identified six considerations for improving access to primary care in these settings: Foster positive relationships between PEH and healthcare providers; Include peer support workers and interprofessional team members to address complex needs; Establish a welcoming and inclusive environment to encourage access and social connectedness; Support system navigation and build connections to mainstream care; Enable collection and sharing of health information to improve care continuity and support evaluation; Adopt sustainable and adaptive funding models.

Conclusions: The challenges faced by PEH are similar across countries, though approaches to improve primary care vary. Overall, there is a lack of sustained or large-scale reforms to primary care that align with the needs of PEH. Future reform efforts could incorporate these considerations to improve care experiences and health outcomes for this population.