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Autumn 2007 | Vol 11 No 1

Focus

Taking care to the streets

Shared care teams reach out to people who are homeless

By Anne Ptasznik

The cheery, yellow waiting room of the health care clinic at the Adelaide Resource Centre for Women, a city-run centre serving about 80 homeless women daily in downtown Toronto, has an eye chart, baskets of condoms, a folded-up wheelchair and a scale. A wall poster reminds women to get a Pap test. Women come here for health care and to get help with housing and life skills and to join social activities. There’s no sign that this is also the office of a psychiatric outreach team.

The clinic is run by the Shared Care Clinical Outreach Service, which provides medical and mental health care for homeless people visiting shelters and drop-in centres at eight sites in the city. The service began in 1998 and is funded by the Ministry of Health and Long-Term Care, and run by the Centre for Addiction and Mental Health (CAMH) in partnership with St. Michael’s Hospital and the University Health Network’s Toronto Western Hospital.

The service works on a primary care support model through shared care teams. Each site has a full-time registered nurse and outreach worker; a salaried general practitioner visits one or twice a week, and a consulting psychiatrist visits regularly. In preparation for the doctor’s visit, on-site team members engage and assess individuals who may need health care services.

The predictable hours of operation, visible location and familiar faces strengthen communication among clients and service providers. Kelly Yardy, an outreach worker with the service, explains that many women who come to the Adelaide centre don’t think they have a mental illness. “Part of how we build trust is by not labelling this as a mental health clinic and by addressing women’s physical health concerns.”

The clinic is quiet today. It’s “cheque day” for those on social assistance, so some women are shopping and taking care of other needs. The women here write their names on a list and wait to be seen. One woman has a cough and sits rubbing her shoulders. A blonde woman comes in and hands a urine sample to Gemma Cruz, the team’s registered nurse. Another woman with a visor and backpack, looking like she’s heading out for a day in the sun, stops by to ask for calamine lotion and bug spray.

Chiara Tassone, manager of the shared care service, as well as a CAMH inpatient unit for people with schizophrenia, says, “It’s usually through primary care that we develop a rapport, for example, if a nurse or case worker sees that somebody has a cut on her knee, they’ll approach that person, and say, ‘Hey, I notice you cut your knee,’ and then tend to the wound, through that developing a relationship.” It is that relationship, sometimes taking long months to develop, that eventually opens the door to dealing with the mental health issues.

Shaei*, who stops in to see Cruz, says she started coming to the clinic four years ago when she was staying at a nearby shelter and had no family doctor. When she developed more serious mental health problems, “The clinic was my only lifeline. I didn’t have a hard time trusting them because they’ve always been good to me.”

Dr. Kate Greenaway, a newly graduated family physician working with the Adelaide team since 2006, says, “If it’s the first visit, I don’t do anything except try to respond to medical issues and reinforce that we’ll be here.” Patients are only now beginning to tell her about their paranoid thoughts or fears about what might be going on. Greenaway has experience working with mental health issues but appreciates the back-up from the team’s psychiatrist, Dr. Avery Krisman.

Krisman values that the team does not look to him to medicate symptoms but that they are interested in their clients as people and in his contribution to understanding them as people. Krisman works at making patients feel comfortable but acknowledges that sometimes his status as a psychiatrist is an “unbridgeable gap.” He appreciates having other team members with whom patients can connect and who can help obtain necessary supports like housing and income assistance.

Staff also accompany clients to appointments and provide them with clothing and blankets. They often need to be creative in meeting clients’ needs, for example, taking them to buy new shoes if they fear there are homing devices in shoes provided to them.

"It's usually through primary care that we develop a rapport." It is that relationship that eventually opens the door to dealing with mental health issues.

The team may consult with the staff of various social agencies that offer programs like fabric arts and computer classes. But it is usually at the drop-in, downstairs from the clinic, where they begin connecting with clients. Oriana and Melissa, staff with the Fred Victor Centre Women’s Day Program drop-in, call the shared care team when they notice a client experiencing difficulty. As if to illustrate this, a staff member tells Yardy that she is concerned about a disoriented woman lying on the ground outside. Yardy knows the client and says she will check on her and that likely the woman will come upstairs and lie on the team’s couch.

The service can sometimes help prevent hospitalization, although the benefit of Tassone also being the manager of an inpatient unit is that she can facilitate admission when needed. The teams have also worked to house clients successfully, even those who have been homeless for many years, but will continue to provide medical and psychiatric care for clients who remain on the street if clients choose to continue seeing them. “For those who are not bothering anybody and choose to live their lives in a certain way, we’re not going to turn our backs on them just because they choose to live differently.”

*not her real name