Toronto Community Addic/on Team St. Stephen s Community House How Integrated Case Management Helps Individuals with Complex Substance Use Na/onal Case Management Conference September 27, 2013 Funded By:
Introduc)ons Janet Stevenson, Ac)ng Manager of TCAT and has been with the program since early 2010 Tom Henderson, Manager of St. Michael s Withdrawal Management Service, Coordinated Access and Central Access
Evolu)on of TCAT Challenges were iden)fied by Withdrawal Management Services (WMS) and the community Subgroup of individuals accessing the system at a high frequency; Poor outcomes; Clients lost in the system
Evolu)on of TCAT WMS/Central Access/Ontario Hospital data collec)on showed that: 2.7% of WMS service users had 30% of the admissions, total of1852 admissions in 2009/10 Ontario Hospitals Emergency Department sta)s)cs: 69% of pa)ents were discharged home with no support services Pa)ents with diagnosis of personality disorder at largest propor)on of visits, 12.9% with 10+ visits 32% of those with substance related disorder had more than 1 ED MHA (Mental Health and Addic)on) visit
Evolu)on of TCAT Toronto Central LHIN approved funding for TCAT and the pilot program began in January 2010 Pilot project lead by St. Stephen s Community House and co- lead by St. Michael s Hospital
Toronto Community Addic)on Team Provide community based, mobile, intensive case management Eligibility: Complex substance use issues and 8+ admissions to wms in the previous 12 months or 5+ visits to emergency departments in past 2 months or 20+ visits to emergency departments in past 12 months Voluntary program Harm reduc)on Client- directed service
Partners Transi)on House Concurrent Disorders Support Services (CDSS) Regenera)on Community Services Mainstay Housing St. Michael s Hospital Virtual Ward St. Joseph s Hospital Toronto East General Hospital University Health Network Mount Sinai Sunnybrook Women s College Toronto General Hospital CAMH Emergency Department Alliance Value and Affordability Task Force City of Toronto (ESS, Shelters, Streets to Homes, Downsview Dells) Inner City Health Associates, Centre for Research in Inner City Health St. Christopher House Dixon Hall Fred Victor Na- Me- Res Inner City Family Health Team
Intensive Case Management (ICM) Counselling Iden)fy/implement harm reduc)on strategies Planning/goal sehng Advocacy Housing support Benefits/income assistance Health (mental, physical, emo)onal, spiritual) Medica)on Legal Issues Primary care and psychiatry Community accompaniment Financial management/ budge)ng Trustee Program Iden)fica)on Liaise/coordinate with other service providers Assessments and referrals
Trustee Program Began in 1997 and con)nued to expand since Voluntary on the part of the par)cipant Involves case management as well as trusteeship Client centered Harm reduc)on focus
The greatest support for me is the trustee program in order to know where my money is going to. And that has been very helpful because of the way I get when I m drinking, ending up being robbed. But now I constantly have money.
Suppor/ve Housing for People with Problema/c Substance Use Ini/a/ve (SHPPSU) The goal of this ini)a)ve is to increase the health and social outcomes of people with problema)c substance use who are frequent users of the addic)on treatment system and emergency services by providing stable housing and appropriate support services. The program is based on the Housing First model, which provides suppor)ve housing to people without requirements for engagement in addic)on treatment or abs)nence
TCAT Expansions In 2011 TCAT received 64 SHPPSU units in partnership with Regenera)on Community Services and Mainstay Housing In 2011 TCAT was granted an expansion by TCLHIN 92 ICM spots (not akached to SHPPSU units) 5 more FTE case managers 1 crisis support and intake worker 1 recep)onist New office space Increased hours Crisis support and Intake Worker M- F 1-9pm Weekend hours rota)ng schedule of case managers on Saturday and Sunday In 2012 TCAT was granted an expansion by TCLHIN 16 further SHPPSU units (total now = 80 housing units)
Integrated Model Of Care As TCAT con)nued to expand and be a leader in the addic)ons sector it became increasingly important to create a formalized model of integrated care that represents the program and the engagement with other system players This model focuses on: crea)ng a posi)ve client experience that supports client choice non- judgemental service provision fostering meaningful, trus)ng rela)onships across transi)on points and throughout the journey of care; collabora)ve, integrated support; and a source of hope that extends beyond the case manager- client rela)onship.
Integrated Model of Care Principles A client focus will guide program ac)vi)es and func)ons The program will con)nue to build on exis)ng strengths The program will aim to reduce/minimize duplica)on Services must be accessible and easy to understand Responsive clients are contacted/connected within a short response )me To suit the client popula)on and complexity, the program must be flexible and adapt to individual client situa)ons Informa)on sharing and consistent communica)on will be a part of program structure in order to increase the level of collabora)on and integra)on Defined roles and accountabili)es will be clearly outlined and shared amongst the team 14
5 Key TCAT Func)ons Advocacy Naviga)on & Access Support & Rela)onships Trusteeship Educa)on & Awareness 15
ODSP/ OW Peer Supports CCAC CDSS WMS Support & Rela)onships Addic)ons Services Crisis Services Advocacy Trusteeship Shelters Primary Care Client & Case Manager Transi)onal Housing Specialty Care Naviga)on & Access Educa)on & Awareness Suppor)ve Housing Providers Acute Care CASH/SHPPSU Community Support Services Toronto Police Service / Jail Jus)ce / Proba)on Officers Community Task Forces & Coali)ons 16
TCAT can advocate on my behalf, as a third party. They have the power and when they call my other workers, they listen. It s amazing. Just the way they talk to other workers and contact them is helpful. They respect my decisions. If I don t want to do it, then that s fine. With their support, I take my own responsibility.
Recommenda)ons from Integrated Model of Care Explore flow and transi)ons through program, based on client, program and system needs Inves)gate and develop internal case conferencing prac)ces
Stabiliza)on Scale Stabiliza)on is not linear: An individual may appear stable but s)ll require a significant amount of staff support in order to maintain stability; A person may be stable in some aspect of his/her life, but not in another; Recovery is not a linear process, need to have flexibility built into the model.
Stabiliza)on Scale Guiding Principles Be flexible and adaptable, adjus)ng the appropriate level of intensity rather than the concept of full discharge; Incorporate a planning perspec)ve upfront and con)nued assessment of needs along the way; Align and leverage exis)ng case management prac)ces that build on exis)ng tools and approaches. Duplica)on of exis)ng prac)ces and tools should be avoided; Trigger stability planning and communica)on within the TCAT team and with other partners; Support a balanced caseload that consists of a range of intensity; Recognize and build partnerships such as asercare supports, recrea)onal therapy and voca)onal rehabilita)on; Recognize professional judgment as central to any decision- making; Respect for staff )me and exis)ng demands.
Profile Descrip/on Level 1 Low Stability Constant crisis, chao)c events Using substances, osen in dangerous forms/quan))es Extreme difficulty working towards iden)fied goals Client focused on Survival, gehng basic needs met Housing typically not maintained (homeless) Difficulty accessing services outside of TCAT High use of ED or other healthcare providers Regular interac)ons with the legal system Poten)ally permanent func)onal impairments (physical/cogni)ve) Level 2 Medium Stability Housed May or may not be using substances; signs of changing usage pakerns (controlled use and/or safer use) Some cycles of relapse Periods of increased mo)va)on regarding goals Minimal Crises and ability to deal with crises has increased Ability to manage and take charge with many basic daily tasks May or may not have changes in social networks Minimal ED usage, typically have access to primary care Level 3 High Stability Self- directed, internal mo)va)ons Sustained housing More consistently reliant on new social networks Controlled use or sobriety Produc)ve, busy and ac)ve during the day Employment, volunteering and/or school Very limited/no ED/WMS admissions Regular access to Primary Care
Level of Service by Client Profile Client Profile TCAT Level of Service Level 1 Low Stability Contact is typically intense and frequent (generally involving daily contact) In some cases, contact is sporadic or challenging due to difficul)es reaching the client Level 2 Medium Stability Contact is s)ll frequent (e.g. One x per week) but less intensive Level 3 High Stability Low intensity, typically connect every 2-3 weeks for check- in Minimal ad hoc requests for help
I am a woman who sunk into deep alcoholism in my 30s. I'm a very well educated, ar)culate white woman raised in suburban Toronto who most describe as akrac)ve. I drank because I was miserable. I hated the life I'd created for myself. I disliked almost everyone in my life. And importantly, I was desperately lonely. Alcohol helped quell my immediate overwhelming feelings of anxiety and disappointment with my life. I lost years of my life and suffered severe health consequences. No one ever told me how painful dying from alcohol is. I lived with a pot beside me to throw up in. My skin itched and )ngled. I couldn't sleep on my right side because on my enlarged liver. My mouth was always dry. My thinking was very fuzzy. My head hurt except when drunk. I put myself in very dangerous vulnerable situa)ons. No one expected me to come out of it. Aser being told that alcohol would kill me, I kept drinking. People who knew just waited for me to die. I am not exaggera)ng in the least when I write this. I had no one who really cared about me in my life. My alcoholism and distress, sadly, demonstrated how uncared about I was. Group treatment programs were not effec)ve for me. I found them to be slogan- filled, vapid, "triggering" experiences that didn't touch on my deep pain, only my behaviour. I s)ll don't have the caring family and friend network I would love to have. However, I now have the support of an incredible psychiatrist, GP and intensive case manager. I am a excep)onally fortunate person. I know I am one of the lucky few. For the past 5 months, I've been sober
Stabiliza)on guide in prac)ce Trigger case managers to assess where each client is at and the poten)al transi)on points; Supervision tool to assess intensity of caseloads for each case manager; Ensure level of service matches the client need this can help build TCAT capacity and effec)veness; Assist with educa)ng new staff, partners and funders about TCAT s client popula)on; Iden)fy gaps in services and poten)al partnerships that can support transi)ons (ie asercare).
Case Conferencing Prac)ces Reviewed current case conferencing prac)ces within the program, as well as inves)gated exis)ng approaches among other stakeholders and partners; Created procedures and a tool to be used for all case conferences, which aligns with our integrated model of care; The new procedures have led to the formaliza)on of roles, improved structure of mee)ngs, ac)ons items, increased accountability, transparent program expecta)ons and further integrated service provision.
Case Conference Form
Benefits of TCAT Mobile, community based; Flexible, voluntary, client- directed; Harm reduc)on based; Provide integrated service across sectors (ex: wms/hospital sehngs); Intensive case management in conjunc)on with trusteeship program; Partner within SHPPSU Ini)a)ve.
I really trust my case manager. They are one of the few people around who have my best interest at heart. I think we have a connecfon too. I feel very much that they re there for me.
Current TCAT Capacity Team of 14 staff total Total capacity of 172 clients
Current Outcomes 69 individuals currently housed in SHPPSU ini)a)ve 102 individuals have been housed since incep)on of SHPPSU 92 individuals currently enrolled in TCAT- ICM TCAT SHPPSU TCAT ICM only Visits to Emergency Department 53% reduc)on 76% reduc)on Admissions to WMS 64% reduc)on 60% reduc)on
Case History 44 year old male Trauma)c childhood Began consuming alcohol at 17 yrs old Became homeless at 18yrs old Possibly has acquired brain injury Possibly has cogni)ve impairments Primary substance of us is non- palatable alcohol Severe physical health concerns No healthcare connec)ons (other than emergency services)
Intake assessment Connected with TCAT in January 2010 350+ visits to emergency departments in 2009 Daily non- palatable alcohol consump)on Highly intoxicated all day everyday (other than when admiked in hospital or wms) Restricted/barred from most services in the city of Toronto No contact with family No significant posi)ve rela)onships in his life Extreme physical health concerns: Infec)ons Skin lesions Open wounds Incon)nence Celluli)s C- difficile MRSA Lice Pancrea))s Liver Disease Possible ABI and/or cogni)ve impairments Homeless Mobility barriers
2010-2012 Began engaging with TCAT Case Manager on a daily basis Focused on rela)onship building and daily safety Assessed presen)ng issues and was able to map other community supports and services involved and begin coordina)on of service Facilitated complex case conferences to ensure open communica)on which was based on understanding of flexibility and quick response (chao)c nature of daily life for this client required quick, flexible response from supports)
Engaged with voluntary trustee program and connected to primary care through drop- in Began addressing basic needs Harm reduc)on (specifically regarding non- palatable alcohol consump)on) Complex health concerns posed extreme safety risk both himself and community - lead to mul)ple Form 1 and 3 this required coordina)on between myriad of service providers lead by TCAT case manager Advocacy on behalf of client with systems Discharge plan created and agreed to by client with team of supports in place to surround transi)on back to community Community treatment order granted Liaise with shelter and ongoing contact to con)nually communicate about progress and goals
2013 Has been in managed alcohol program for 10 months Ongoing rela)onship with TCAT case manager and trustee Has primary care through mul)- disciplinary health team Re- established familial rela)onships speaks to his parents monthly and has visit every 3 months Has daily rou)ne and controlled alcohol use means he is sober (his baseline) 95% of the )me ED visits in past 9 months = >20 Smiles, laughs and jokes again Has hope for his future
My case manager helped me bring out the frustrafon in me, get it out of my system, the anger, the frustrafon. I was in a shell, hiding from myself. I was blocking off. If it was not for my case manager, I would sfll be out there drinking heavy, smoking crack, popping pills, I would not be housed, which I am now. I would not be seiled down. I can see that it made a big difference.
Q & A
Thank you!! Janet Stevenson Ac)ng Manager TCAT 647.678.7047 sjanet@sschto.ca Tom Henderson Manager St. Michael s Withdrawal Management Service 416.864.6060 ext. 5720 HendersonT@smh.ca