Toronto Community Addiction Team Janet Stevenson, Manager of TCAT Funded By:

1.Expand knowledge about the TCAT program and our integrated model of care 2.Examples of innovative care coordination approaches 3.Demonstrate the effectiveness of service collaboration across sectors Right service, right time, right place Objectives of Presentation

Origin of TCAT Challenges were identified 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 2.7% of WMS service users had 30% of the admissions, total of1852 admissions in 2009/10 Ontario Hospitals Emergency Department statistics: – 69% of patients were discharged “home” with no support services

Toronto Community Addiction 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 reduction Client-centred service Trauma-informed practice

Continuum of Substance Use Historical Model of Substance UseRealistic Continuum of Substance Use

TCAT Programs and Services Intensive Case Management SHPPSU (Supportive Housing for People with Problematic Substance Use) Voluntary Trustee Program Psychiatry Clinic Primary Care Clinic Peer Training and Development Program Art Manuel House – Managed Alcohol Program

TCAT Integrated Model of Care 7 Client & Case Manager Advocacy Navigation & Access Support & Relationships Trusteeship Education & Awareness Crisis Services Primary Care Specialty Care Toronto Police Service / Jail Justice / Probation Officers Access Point Supportive Housing Providers Transitional Housing Shelters Acute Care ODSP/ OW Addictions Services Peer Supports WMS CCAC CDSS Community Support Services Community Task Forces & Coalitions

“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.”

TCAT/UHN Integration Began in July 2014, coordinated by MidWest Toronto HealthLink Automatic notification system between hospital emergency departments and TCAT Case Managers

Visits decreased 49% between the pre- integration quarter and the end of Q3 (Jan-Mar 2015) TCAT/UHN Integration

The decrease in client visits has taken place in spite of the increasing number of clients enrolled in the initiative. TCAT/UHN Integration

In terms of the automated notification system, what is working? Know where clients are, especially those who are harder to connect with and have complex needs Able to connect with clients in hospital more quickly to assure they are receiving the support they need and that hospital staff are aware of any concerns/issues. Better in tune with clients’ health and can support them in new injuries or medical developments. Decreased amount of time spent calling hospitals to locate clients. Allows case managers to follow up with clients Provides greater insight into hospital usage

100% of those surveyed say yes. “If the system were city wide it would greatly improve things.” “Implementing programs to increase communication between community agencies and hospital is imperative to seamless transitions in care. It is important to have that degree of communications with all hospitals.” TCAT/UHN Integration Based on your experience with the automated notification system, should the notification system be implemented in all downtown hospitals?

Sharing our learning and experience thus far Expanding notification system to other hospitals Singular s upon visit Continual education of hospital staff regarding TCAT program and integration initiative to ensure optimal integration of care o Consents o Role of case manager TCAT/UHN Integration Improvements and Next Steps

TCAT/UHN Integration 15-20% of enrolled clients account for 100% of the ED visits at UHN hospitals These results reaffirm what TCAT already identified – that there is a sub group within the population we serve who frequently access emergency services. This sub group also share some common characteristics: chronic underlying trauma and mental health concerns complex health issues and cognitive impairments daily non-beverage alcohol consumption chaotic living and behaviour patterns chronic homelessness, social isolation and excluded from all residential care mobility barriers very high rates of acquired brain injury In response to the needs of the sub group population identified, we most recently created Art Manuel House

Art Manuel House – Managed Alcohol Program Art Manuel House provides appropriate, stable housing coupled with a well- developed and integrated model of support, including a managed alcohol program (MAP) for ten residents 24 hour, harm reduction based, high-support housing Approved for funding in late 2014, co-lead program between Regeneration Community Services and St. Stephen’s Community House April 2015 – started moving residents in

Art Manuel House – Managed Alcohol Program Trans-disciplinary team approach, including in house primary care and access to ongoing psychiatric care Each resident has an individualized coordinated care plan Focus on community building, stability, wellness and recovery Peer led social-recreation activities, support and education with activities of daily living and life skills training Managed Alcohol Program (MAP): supervised by Medical Director of the program, Dr. Tomislav Svoboda. Dosed wine will be provided to residents according to their individualized care plan Residents will be supported in taking responsibility for their own health and wellness and be encouraged to self-monitor their alcohol intake. The goal is to transition residents into alternative (and less) supportive housing options

Art Manuel House – Managed Alcohol Program Expected outcomes after 6 months: Seamless integration of support to address complex needs Significant reduction in ED visits and use of emergency services Stabilization of health Increased stabilization of behaviour Improved wellbeing Reduced alcohol use overall and significantly reduced use of non-beverage alcohol Improved sense of community and life satisfaction

“My quality of life has grown tremendously since engaging with TCAT. My whole outlook on life has changed and I am now enjoying it to the fullest!”

Questions

Thank you!! Janet Stevenson Manager Toronto Community Addiction Team St. Stephen’s Community House P: ext 3210 C: