By Stephanie Mancini
Published in December 2018
As we head into winter, we can see the challenges of Waterloo Region’s 1.6% vacancy rate with affordable housing almost impossible to find. Across the Region, some 350 people are staying in shelters by night, and become “roving people” by day, carrying their belongings, seeking warmth and a place to be. We estimate another 60 people are camping/living rough/finding warm stairwells, parking garages, or sheds. This is a resilient group, facing a lot of complexity, and living in survival mode, supporting one another, living day to day.
This group of 350-400 people must be understood in the context of rising drug use along with complex mental health challenges. Nonetheless, if housing is a basic need particularly in winter months, what does it mean when that housing is not available?
When we sit across the table from each other, how do we respond in creative ways to walk with the person before us, respectfully, thoughtfully and creatively? One way we have responded is with a practical and responsive way of support.
“Can I see a nurse?” is an often heard statement as people walk up the stairs at St. John’s Kitchen and drop into the medical clinic nestled into the back corner of the building. This is a hub of relationship based health care, embedded where people are comfortable, providing the kind of care people want, when they want it.
In one instance, an outreach worker and NP meet with a young person, who is awaiting a spot in a treatment program; he is actively managing a substance use issue and trying to stay away from drug activity; but we’ve heard that police are clamping down in his area of town. They wanted to remind him that drug related offences can result in significant jail time – something that can greatly impact the rest of his life. Some team time was spent talking about the medications he was prescribed by his doctor – one he won’t take because of a side effect. Yes, nod the nurses, that is a known reaction to that particular medication. Maybe we can visit his doctor with him and talk about offering a regular injection for him here at the clinic to help stabilize his mental health challenges, and help him to reduce his dependence on other substances.
A nurse accompanies a health worker from another agency to visit a woman who has faced incredible health issues, but who has fortitude and determination to keep living her active life. Recently a job café team helped her to clean up her back yard that has accumulated a lot of stuff, and the nurse is helping her to navigate the complexities of the by-law officer pressures in her life. The nursing care embeds in this deep problem-solving to help her to stay as strong and healthy as she can be.
In another situation, the team manages to support a person through a possible eviction process – he is smoking in his room in shared housing, making it dangerous and unhealthy for others in the place. Can he wear a nicotine patch to reduce the craving, and be reminded regularly by his support team to go outside to smoke? He is determinedly undiagnosed within the health care system, but has troubles remembering from one moment to the next. He has repeatedly been asked to leave almost every available housing option in town, because others move in with him, and take over his place. So, while we navigate the current situation, we are problem-solving within the housing system to think of where he might go next – he is unable to live in the shelter system or on the street safely.
Another team of outreach workers and nurse work intensively with a man who qualifies for Long Term Care, but his substance use and anger makes it hard to find a suitable place for him. “Find me a place to stay” he shouts. He needs heart medication to stay alive, a few nights on the street meant he spent 4 days in hospital afterwards. He needs to be part of the solution, so we have to weigh the responsibility and consequences of leaving him one more night on the street, so that the next day he might follow the steps needed to stay in the shelter. His behavior relates to the decline in his health – as major organs start to fail, people’s behavior changes. We check in constantly, make sure he has his meds, navigating his choice for freedom and his complex health situation, while we look for a more permanent supported housing situation.
A young man who has lived on his own since he was very young, recently lost his partner of many years to an opiode overdose. An extremely resourceful man, he has decided he would benefit from some support to change the trajectory of his life. Nurses treated an abscess, an outreach worker went to court with him, and we held a memorial service for his partner so he can mourn her loss. In the meantime, he has agreed to connect with housing workers to get some help finding more stable housing.
The team is diverse – the work of outreach at St. John’s Kitchen creates a welcoming space along with the daily meal. Street Outreach workers link at St. John’s and across the community to build relationships and problem-solve around housing, healthcare, legal, income support and all the inter-related issues that pile up for people.
The health care supports build on top of this network. Our Specialized Outreach Services team consists of 3 primary care/mental health/addiction outreach nurses, plus a Social Worker and a Peer Addiction Worker, seeing some 300 people a year, with over 3,600 visits tracked. The Nurse Practitioner works with 400 people a year. Dr. Berrigan and Evelyn work as a team, seeing another 200 people a year, serving as family doctor for people who have often not had stable health care before. KDCHC hosts a Nurse Practitioner/ID clinic/Chiropodist one morning a week, and recently, the Centre for Family Medicine’s Community Ward team has added some Nurse Practitioner and Social Work time to assist people facing chronic illnesses. Sanguen Health Centre offers HepC and harm reduction supports. We collaborate deeply with the LHIN-based pilot palliative project through a Nurse Practitioner who embeds her work within the SOS team. A clinic host welcomes people, listens actively to people’s situations, and connects them to the right supports. Dr. Robyn Fallen, a local psychiatrist, spends a morning a week with us, consulting, seeing patients, helping us to understand complex situations. Overall we hold around 2,000 patient records, as people cycle in and out in their changing life situations.
Only deep relationships of trust help to make sure our care is not episodic. We work with agility to ensure the professional embeds in meaningful ways into a person’s life. This approach integrates primary care, mental health, and addictions and unifies the work of multiple agencies. This is the kind of support that can respond to the realities that people deal with each day.
