Please describe your work setting, sharing with readers the mandate of the program and some detail about the population of focus.
I have the privilege of working on the RainCity Housing First Assertive Community Treatment (ACT) Team, which is part of the At Home/Chez Soi, a 5-year research demonstration project exploring new approaches to caring for the large portion of Canada’s homeless population who struggle with major mental illness. At its core, the Housing First model used by our team is a simple one. We start by providing quality housing to all participants without requiring them to “prove their readiness” by being in substance use recovery, consenting to active psychiatric care, or ceasing any drug use. The team seeks to honor the social determinants of health for the client and attempts to foster relationships with the clients by following the guiding principles of self-determination, choice, and harm reduction. Having started to address the basic need for a decent place to live, the team then provides comprehensive wrap around services including primary care, psychiatric treatment, substance use counseling, and vocational support.
The housing provided as part of the project is “scattered site.” Clients are supported to live in market apartments throughout Vancouver. This kind of housing has been proven to help with the reintegration of clients into their communities. The majority (80%) of the care provided by the team is outreach-based, therefore I am out in the community seeing clients in their homes several times a week.
What are some common health conditions you encounter and how do you prioritize to address these health needs?
The clients I work with generally face similar health conditions as seen in adults in the general population. However, their homelessness has resulted in their receiving disjointed and sparse medical care. This fragmented care means clients have received very limited illness prevention and health promotion, leading to a higher vulnerability to early onset of chronic illnesses such as COPD. There is also a significantly higher prevalence of HIV and Hepatitis C. Most of the clients I work with are also on psychiatric medication, many of which contribute to obesity, dyslipidemia, diabetes, and hypertension (metabolic syndrome).
In terms of prioritizing health care needs, I focus on educating clients on treatment and health promotion options, diagnoses and prognoses. My hope is that this kind of focus on education and client autonomy empowers the people I work with to make their own independent choices.
Although there is a significant prevalence of mental health and addiction issues among the general population, we as health care providers may sometimes feel stumped when working with clients who continue to place themselves at risk due to their mental illness or substance dependence. What practical and philosophical approaches do you find helpful in such circumstances?
While recognizing that mental illness or substance use can sometimes interfere with health care decision-making, I feel there is a danger and tendency to attribute any behaviors we as service providers see as destructive, or do not understand, to these underlying conditions. These kinds of assumptions can interfere with understanding the countless other barriers that may interfere with clients more assertively safeguarding their health.
I try to guard against this danger by combining a harm reduction approach with an active curiosity about the circumstances faced by clients and their reasons for making the choices they do. This allows me to sometimes identify barriers and work to remove them by taking advantage of some of the unique resources I have access to as part of the ACT team, such as in house counselors, appointment accompaniments, and assertive outreach.
Motivational Interviewing also helps me to respect clients in precontemplative or contemplative stages of change, be patient, and honor their freedom to make their own choices. I have found that leaving my own judgment aside as much as I can and consistently reinforcing my availability to clients at any time has resulted in our being able to build strong relationships. My hope is that in the context of these relationships I’m able to at least monitor health statuses, work through treatment options, and generally be available when clients reach a stage where they are ready to identify and address more of their health needs.
Often this population requires the support of added services, which can include much work on the part of the provider in filling forms, contacting resources and connecting individuals. How do you manage this workload and navigate engagement to address these various requests from clients?
Working within a transdisciplinary team, I am extremely fortunate to work directly with many other professionals and often this means that client are able to access internally, services that I would otherwise be referring out to. These services (psychiatry, counseling, vocational support) are all available without red tape or waitlists and I am acutely aware of the fact that most other practitioners are not able to access them with the same availability and ease for their clients.
The nature of our team also allows me to work intimately with these other professionals, communicating daily in a way that makes it possible to provide exceptional coordination of care. In addition to being efficient and reducing my workload significantly, this setup is quite cost effective.
However, outside referrals are still often required and those remain time consuming. Providing primary care for this marginalized, complex and chronically underserved population is very much a work of passion. I often spend long hours outside of the office contemplating different cases, and the different ways I could always be improving on the care I provide for clients.
What additional training or practice tools have you found useful in your work? Any bookmarks on your computer which you might recommend to your colleagues?
Here is a random list of resources, links and books that I have found extremely helpful for maneuvering the mental health system to providing excellent care to complex individuals.
- BC Guidelines is a staple for me that allows me to check in with BC standards when needed.
- Rapid Access to Consultative Expertise (RACE) is a great service offered here in BC, which has become very useful in my autonomous practice within a high complexity population.
- Mental Health Emergency Services (MHES) is a nurse and Vancouver police department partnership as well as offers a 24 hrs nursing run crisis line. This is a great resource to give to clients to call if needed or to use as a consultation service for some of the more risk associated mental health cases.
- For more information on the Mental Health ACT, I would highly recommend Gerrit Clements workshops. His workshops are excellent at going into the legalities and purpose of the Mental Health ACT for health care providers.
- The Clinical Handbook of Psychotropic Drugs is a great resource for starting, stopping and changing psychiatric medication.
Jodie Foster is an NP in Vancouver who works within the Raincity ACT team as well as the VCH ACT team.