Disparities in Delayed Discharge Among Patients Experiencing Homelessness

Importance: Patients experiencing homelessness face particular barriers to hospital discharge, which may result in an alternate level of care (ALC) designation, a delayed discharge status describing patients occupying beds while not requiring the intensity of care provided in the hospital. Evidence quantifying disparities in ALC designation among patients with recent experience of homelessness relative to matched comparators is limited. Objective: To compare ALC rates among hospitalized patients with a recent experience of homelessness and matched patients from neighborhoods with the lowest level of material resources. Design, Setting, and Participants: This population-based matched cohort study was conducted in Ontario, Canada, among 51 377 hospital patients aged 16 years or older discharged from April 1, 2022, to March 31, 2024. Exposure: Patients with a recent experience of homelessness, classified using a validated definition using health administrative data. Unexposed patients from neighborhoods with the lowest level of material resources were matched 4:1 on age, sex, year and month of admission, health region, and Charlson Comorbidity Index. Main Outcomes and Measures: ALC designation and duration of ALC. Weighted standardized differences and negative binomial models were used to assess significance of disparities. Results: The study included 11 168 patients with a recent experience of homelessness (mean [SD] age, 48.5 [16.5] years; 7384 male [66.1%]) and 40 209 matched comparators (mean [SD] age, 49.6 [16.7] years; 25 561 male [63.6%]). Patients with a recent experience of homelessness had a more than 4-fold higher ALC designation rate (9.1% [1014 of 11 168] vs 2.0% [810 of 40 209]; weighted standardized difference = 0.32; rate ratio, 4.51 [95% CI, 4.11-4.95]). Health region-level variation was substantial, ranging from 2.39 (95% CI, 1.40-4.01) times higher in the Central West region to 7.88 (95% CI, 5.21-12.11) times higher in the Central region. Among patients designated an ALC, those with a recent experience of homelessness had a significantly longer ALC stay duration (incidence rate ratio, 1.22 [95% CI, 1.09-1.37]; difference of margins, 4.7 days [95% CI, 2.1-7.4 days]) after adjusting for key demographic and clinical factors. Conclusions and Relevance: In this cohort study of hospitalized patients in Ontario, Canada, recent experience of homelessness was significantly associated with higher rates of ALC designation and increased lengths of ALC stay, reflecting structural barriers to accessing safe discharge locations and gaps in transitional and postacute care. Regional differences suggest that local capacity and supports may mitigate or exacerbate challenges. Interventions such as medical respite and supportive housing are critical to reducing delayed discharge among patients experiencing homelessness and promoting equitable health system performance.