What is the Program?
Elevate NWO, formerly AIDS Thunder Bay, is a community-based organization that provides hepatitis C, HIV and harm reduction services to communities in northwestern Ontario and hosts one of the 15 hepatitis C teams funded by the Ontario Ministry of Health and Long-term Care. The team is based in Thunder Bay.
Elevate NWO emphasizes an integrated approach to service delivery, including the delivery of its hepatitis C services, as a way to reduce the effects of poverty, inadequate housing, food insecurity and social isolation on its clients. The hepatitis C team, hosted by Elevate NWO since 2011, consists of:
- two treatment nurses
- one outreach worker
- one case manager
- one community developer
The team has access to the broader resources of the organization, which includes a director of client services, other support staff, intake workers and a dedicated complement of peer workers. The team is supported by an infectious diseases specialist based in Thunder Bay.
Why Was the Program Developed?
Elevate NWO is one of 15 hepatitis C teams in Ontario. The teams were developed as part of a strategy to improve hepatitis C prevention, testing, treatment and support services. The primary mode of hepatitis C transmission in Canada is injection drug use. People who have used injection drugs in the past or who are currently using injection drugs may experience significant barriers to adequate and appropriate healthcare, including treatment for hepatitis C, in traditional settings.
The Ontario Ministry of Health and Long-term Care recognized this and established the Ontario Hepatitis C Nursing Program in 2007. Through this program, the Ministry of Health and Long-term Care wanted to increase access to treatment in under-serviced communities with high rates of hepatitis C.
Lessons learned from the Ontario Hepatitis C Nursing Program highlighted the need for more support for clients. The report recommended an expansion of the Ontario Hepatitis C Nursing Program to include a comprehensive approach to care. Sixteen hepatitis C teams were created to ensure a coordinated, comprehensive approach to the support and treatment of people at risk for and living with hepatitis C. As of July 2014, fifteen teams are currently in operation.
The goal of Ontario’s hepatitis C strategy is to provide care and treatment services to help curb the spread of the virus by ensuring that people have access to prevention information and materials, are tested for hepatitis C regularly, and have access to treatment when they test positive. Its main objectives are
- to increase access to hepatitis C care and treatment among priority populations
- to increase knowledge and awareness of hepatitis C to prevent transmission among priority populations
- to increase collaboration, coordination and evidence-based practice across the system responding to hepatitis C
Each team consists of an outreach worker(s), a community coordinator, nurse(s), psychosocial support workers, usually registered social workers, and peers. The teams also have at least one consulting physician.
How Does the Program Work?
Elevate NWO has a regional identity with a catchment area about the size of France. Although efforts are underway to increase direct client services in other communities, most in-person services are only available in Thunder Bay.
The agency’s roots are in HIV prevention and support; however, since 2012, hepatitis C and HIV client services have been integrated. Practically, this means that direct client services, which include information services, the distribution of harm reduction supplies, and support programs, such as social outings, the food bank, and some support groups, are integrated.
An integrated, multidisciplinary hepatitis C team is a natural fit at Elevate NWO, where clients are already accustomed to receiving a number of services at one time in one place. This team coordinates Thunder Bay’s hepatitis C prevention, treatment and support work, including the distribution of harm reduction supplies and information, hepatitis C treatment, case management and other psychosocial support for clients who are at risk for hepatitis C or who live with hepatitis C. Referrals for hepatitis C testing are made to the public health unit.
Community development
Community coalitions
Part of the hepatitis C team’s mandate is to engage other service providers in discussions about hepatitis C. The goals of this community engagement are to reduce hepatitis C transmission through greater access to harm reduction supplies and accurate risk-reduction information and to increase rates of engagement in treatment and support for people living with hepatitis C.
A community developer engages the community by participating in coalitions of service providers, such as the local poverty reduction coalition and the local homelessness coalition. By working in this way, Elevate NWO is increasing awareness of hepatitis C among service providers across the city of Thunder Bay who may work with people at risk for or living with hepatitis C.
In 2012, the community developer also convened a hepatitis C network to further strengthen linkages among service providers who may work with clients at risk for or living with hepatitis C. Despite the strong relationships being built, it has been challenging for Elevate NWO to increase the profile of hepatitis C in the community because a variety of priorities compete for the attention of service providers.
One strategy that the community developer has used to improve engagement around the issue is to make sure that every person on the network’s committee is invested in the network’s activities. This is done by ensuring that the campaigns the network launches and the concrete actions it takes are relevant to the work of each of the members.
Road shows
Twice a year, the hepatitis C team tours smaller communities in the district to deliver presentations about hepatitis C, HIV and Elevate NWO to service providers. This is one way that the team promotes its services and connects with nurses and social workers across northwestern Ontario. Although this has been a good way to improve the team’s profile in its catchment area outside of Thunder Bay, the distances across the district continue to make it difficult for staff to maintain strong relationships with service providers year-round.
Prevention
Prevention services at Elevate NWO, like the rest of its programs, are integrated. This means that presentations, information sharing, risk-reduction counselling and the distribution of harm reduction supplies raise awareness of both hepatitis C and HIV. Outreach workers from Elevate NWO work through strategic partnerships with other organizations around Thunder Bay, including local shelters, soup kitchens and the local Boys and Girls Club. A few times a week, outreach workers and peers distribute harm reduction supplies and provide client support on the street, following a set route around town.
Treatment
Elevate NWO’s hepatitis C team includes two treatment nurses who work with Thunder Bay’s infectious diseases specialist to assess, monitor and treat clients with hepatitis C. The nurses work in the Elevate NWO office and at the infectious diseases specialist’s clinic. Nurses provide information and assess whether clients are ready for treatment. They make sure that clients have a primary care provider and that all of the necessary blood work and other baseline tests have been done before treatment is initiated.
Nurses also play a key role in identifying barriers clients may have to treatment, including mental health challenges, lack of adequate financial support, lack of adequate food and other issues.
Finally, nurses are responsible for monitoring clients during and after treatment. Clients are given the flexibility of choosing where to get their care: they can attend nursing appointments at Elevate NWO or at the infectious diseases specialist’s clinic. Having staff always available to see clients at Elevate NWO, which is a community-based site that has strong support services, is very important for many clients. They can come in for treatment, use the food bank and talk to a case manager all in the same visit. This one-stop shop approach is key to ensuring treatment adherence, especially for clients who may be challenged to keep appointments and who may not be feeling well.
Support
The case manager provides support services for clients by offering harm reduction supplies and counselling, accompanying them to appointments, advocating on their behalf for other services when needed, and facilitating referrals for specialized counselling for mental health and addictions.
Although the case manager works with any client in need, they work particularly closely with clients who are preparing to go on treatment and who are currently on treatment. They provide help to reduce systemic barriers to treatment such as inadequate housing, food insecurity and financial instability and provide counselling to clients who may need it as they initiate and continue treatment. Counselling may be for pre-existing concerns such as depression or substance use or to provide support in dealing with the side effects that clients may experience as a result of treatment.
Biweekly support groups offer people living with hepatitis C peer support, education on treatment and living well with hepatitis, and an opportunity to socialize with people who have similar experiences.
Peers
As a community-based organization, Elevate NWO has always relied on the work of peers to provide services. The organization and its services are integrated, so peers may be living with HIV or hepatitis C or they may be co-infected.
Peers are hired annually, through a hiring process that includes an application and an interview. When hiring peers, staff look for people who are already engaged at Elevate NWO, who are friendly and approachable, who demonstrate commitment and who have a personal understanding that harm reduction works to help people who use substances remain healthy.
Peers are hired every March and receive an honorarium for their work. Peers must complete five workshops (HIV 101, HCV 101, Sexually Transmitted Infections 101, Harm Reduction 101 and Getting to Know Your Community, a workshop about community resources) before starting to work with clients. Peer team meetings are used to refresh and reassess peer knowledge, and peers are expected to attend other agency-wide training.
Peers are involved in direct client services, by distributing harm reduction supplies and providing peer support to clients through support groups and during social events. Since 2014, Elevate NWO has had a peer leader who is responsible for coordinating the peers and managing the harm reduction supplies room.
The current outreach worker on the hepatitis C team is a former client and peer worker of the organization, a testament to the agency’s commitment to building the capacity of people with lived experience to be meaningfully involved in providing services to the community.
Telehealth
Access to the Ontario Telemedicine Network (OTN) has made connecting with clients across northwestern Ontario easier for the hepatitis C team at Elevate NWO. Clients can receive care from treatment nurses in Thunder Bay via video and telephone links set up in healthcare centres in their communities.
Through telehealth, clients on treatment can access specialized hepatitis C care without having to travel to Thunder Bay. Given that the currently available treatments for hepatitis C can take as long as a year to complete and may have significant side effects, this support is crucial for clients. Knowing they can access a healthcare provider with expertise in hepatitis C from their home communities encourages clients to seek care and support rather than stop treatment. Although nurses prefer to see clients in person, the OTN has improved healthcare access for people living with hepatitis C in remote communities.
Elevate NWO has also piloted telephone-based case management for clients. This service, which has been successful, keeps people in communities outside of Thunder Bay who live with HIV or hepatitis C connected to service providers. This is key for clients in smaller communities who may feel socially isolated.
Telehealth and telephone-based case management have also strengthened the hepatitis C team’s network of service providers outside Thunder Bay. The team has had to connect with service providers (physicians, nurses, counsellors, community health workers) in communities nearer to clients so that clients have access to in-person services when needed.
Next steps
Elevate NWO has a regional mandate and is working to foster strategic relationships with service providers outside of Thunder Bay. As of August 2014, Elevate NWO is working with a physician in Sioux Lookout, a community five hours north of Thunder Bay, to provide harm reduction supplies in the community. Local peer educators are being trained to provide information about safer drug use and to distribute harm reduction supplies in the community.
Required Resources
- Outreach worker. Provides hepatitis C and HIV prevention services and education, including presentations and harm reduction supply distribution, to clients and other service providers.
- Community developer. Builds relationships and partnerships with organizations and agencies to raise awareness about hepatitis C in the community and builds relationships with service providers who may have a similar client base.
- Case manager. Works with clients with hepatitis C who need counselling or other psychosocial support, as well as clients who are starting treatment or who are on treatment. Monitors the health progress of clients and facilitates referrals to other services.
- Treatment nurses. Follow up with clients who have been referred for treatment, work with them to make sure that they are ready for treatment, and monitor their progress during treatment and for six months after treatment.
Challenges
There are a number of challenges the hepatitis C team faces in doing their work:
- Systemic issues. Lack of appropriate housing, access to quality food, and sufficient spaces for mental health and addictions treatment are all challenges for Elevate NWO’s clients.
- Geography. Elevate NWO serves a catchment area roughly the size of France but provides most of its services in Thunder Bay. It is difficult to maintain client and service provider relationships at such far remove. The agency has used a number of strategies to reduce the impact of distance on client services, including developing strategic partnerships in other communities, visiting remote communities as often as possible and using telehealth for counselling and treatment.
- Reaching Aboriginal communities. Elevate NWO’s catchment area includes a number of Aboriginal reserve communities and Thunder Bay has a significant community of urban Aboriginal peoples. Maintaining strong relationships with Aboriginal-focused service providers remains a challenge.
Evaluation
Elevate NWO conducts an annual Health Agenda Review to determine client satisfaction with services. Client satisfaction is assessed through a client feedback survey (see Program materials). Typically, the client survey is distributed at the Elevate NWO Christmas party in December. Respondents are entered into a draw for a $100 food card.
The survey is advertised in the weeks leading up to the party with an announcement in all food bank bags distributed at Elevate NWO’s offices. At the same time, Elevate NWO reminds clients of the steps that have been taken at the agency to respond to feedback from the previous year.
Client feedback in 2013 was overwhelmingly positive:
- 100% of clients who accessed health clinic appointments rated them as excellent or good
- 95% of clients who accessed harm reduction services rated them as excellent or good
- 94% of clients who accessed the support group rated it as excellent or good
- 88% of clients who accessed the hepatitis C nurses rated their care as excellent or good
The agency also tracks the number of people on treatment and their success rates. Between 2009 and 2013, the hepatitis C team started 48 people on treatment. Of those, 32 achieved a sustained virological response, a 66% success rate.
Lessons Learned
There are a number of lessons the hepatitis C team has learned in doing their work:
- Use a team approach. A team approach provides clients with multidisciplinary support and a one-stop shop for healthcare, case management, harm reduction supplies and referrals. It’s also helpful for staff to be able to draw on the expertise of colleagues.
- Use an integrated approach. Elevate NWO became more effective at meeting the needs of clients when hepatitis C and HIV services were integrated. More resources were available for clients and more support was available for team members.
- Make community work meaningful. Building a community network on an issue such as hepatitis C can be challenging because service providers are already very busy. One strategy that Elevate NWO has used to increase engagement in the network is to ensure that the work of the committee directly influences the work of committee members. This way, each member has a stake in the network’s activities and may be more engaged.
Program Materials
- Client feedback survey
- Client feedback survey: We Listened! [a document indicating how the agency responded to the previous year’s feedback]
Contact Information
Holly Gauvin, Executive Director
Elevate NWO
574 Memorial Avenue
Thunder Bay ON P7B 3Z2
hgauvin@elevatenwo.org
807-345-1516