Ontario Hepatitis C Team: Sanguen Health Centre

What is the Program?

Sanguen Health Centre (Sanguen) provides community-based services for individuals at risk for or living with hepatitis C in Kitchener, Waterloo, Guelph, Cambridge and the surrounding areas. Sanguen is one of 15 hepatitis C teams in Ontario. As one of the teams, Sanguen is mandated to provide multidisciplinary care to its clients. The health centre is staffed by a physician, treatment nurses, social workers, outreach workers, a community coordinator and a dozen peer workers.

Sanguen offers direct client services such as harm reduction supply distribution, counselling, support groups, case management, hepatitis C testing and hepatitis C monitoring and treatment.

What makes Sanguen unique among the hepatitis C teams is that it is a stand-alone clinic that deals exclusively with people at risk for or living with hepatitis C. The clinic is not part of a larger organization but rather is run as a private, not-for-profit health centre. This is one of Sanguen’s core strengths because its mandate to provide prevention and treatment services to people at risk for or living with hepatitis C is not overshadowed by the competing priorities that may exist in organizations such as hospitals or community health centres. This ultimately allows Sanguen’s staff to solve problems and fill service gaps quickly, making the team responsive to the needs of clients.

Why Was the Program Developed?

Sanguen Health Centre 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, 15 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?

Building relationships with clients

Sanguen Health Centre is committed to client-centred care. Building relationships with clients is the first step in providing care in this way. All Sanguen’s services are designed to reduce barriers and close gaps that clients can experience when accessing health and psychosocial support. Peers, outreach workers, social workers, nurses and a physician are available to help clients, making Sanguen a place where clients can access a broad range of services. If the services they need are not available on site, Sanguen staff can link them to resources elsewhere.

One of the most important ways that staff put clients at the centre of care is by meeting each of them where they are at. This means that staff do not necessarily invite clients to be tested for hepatitis C or talk to them about treatment when they first meet. Rather, they talk to clients about things that concern them in a more immediate way: not having enough to eat, not having a stable place to live, wanting to be trained to use naloxone or needing a pair of clean socks.

In addition, client-centred care at Sanguen means that client-identified gaps in care are addressed. Many of Sanguen’s support and community groups evolved out of a need that clients identified. For example, when a women’s only group was identified as a gap in services at Sanguen, the health centre developed a weekly support group exclusively for women.

Outreach services

Sanguen has two clinic sites: one in Guelph and one in Waterloo. However, staff spend a lot of time outside of the clinics in the community so that current and potential clients can see staff about their health and psychosocial concerns. The outreach schedule is stable, which means that clients can expect to see the same staff in the same place from week to week or month to month. This shows clients that Sanguen staff are reliable, consistent and, most importantly, easy to find.

All staff members, including Sanguen’s physician, provide some form of outreach services a couple of times a month. In this way, clients do not have to come to Sanguen’s fixed sites to get harm reduction supplies, information, counselling and case management, and hepatitis C testing. Outreach services are available for clients on treatment including blood work, medication delivery and follow-up care. Rather than go to a clinic, clients can go to places they already frequent: soup kitchens, shelters, parks and other agencies.

Outreach services build rapport with clients by letting them become familiar with staff in an environment that’s comfortable for them before they come to Sanguen’s clinics. Seeing a familiar face in the clinic that they once met in the community can improve a client’s comfort level on their first visit.

Using social media to build relationships

Sanguen staff also use social media to build or maintain relationships with clients. Most staff have an active presence on Facebook or Twitter. Sanguen’s Facebook page allows clients to see when and where services will be available.

In addition to providing useful information, the hepatitis C team’s active presence on social media allows clients to learn more about the team before engaging with it. It is also just one more way for established clients to reach out and stay connected without having to travel to the clinic or one of the outreach locations. This has been especially true for clients who have gone through treatment and may no longer come to Sanguen as often as they did in the past.

Anecdotal evidence suggests that the social media presence, especially among youth, has increased word of mouth referrals to Sanguen’s services. In this way, even people who do not have social media accounts are being reached through their friends.

Building strong community partnerships

Community coalitions

Sanguen’s catchment area includes the cities of Kitchener, Waterloo, Guelph and Cambridge, as well as the surrounding areas, and its work in these communities would not be possible without the strong partnerships it has developed with other organizations that serve the same clientele.

One of the ways that Sanguen has improved services for clients is through participation in community coalitions and networks. Sanguen’s community coordinator sits on a number of committees, including the Wellington Guelph Drug Strategy, the Sex Workers’ Action Network, the Poverty Task Force and the Women’s Health Alliance.

Ultimately, the goal of this community work is to improve services for people at risk for hepatitis C, for people living with hepatitis C and for their families. By joining these community networks, Sanguen improves its own knowledge of other community resources that it uses to support its clients, raises the profile of Sanguen in the community to increase referrals to its services, and improves the knowledge of other resources in the community about hepatitis C and related issues such as harm reduction.

Community partnerships

In addition to participating in the planning and advocacy efforts of community networks, Sanguen collaborates with other community groups at a practical level, offering many services in partnership with other organizations.. For example, street-based outreach services are delivered in partnership with AIDS Committee of Cambridge, Kitchener, Waterloo and Area (ACCKWA) and HIV/AIDS Resources and Community Health (ARCH) in Guelph. Sanguen also partners with local organizations such as soup kitchens, food banks, shelters and substance use treatment centres in the area to offer services such as harm reduction supply distribution and hepatitis C testing.

Sanguen staff meet other service providers where they are at, as they would do for clients. Staff have found that this approach builds support for their work, increases knowledge about harm reduction and hepatitis C and improves overall collaboration. Practically, this means that Sanguen’s workshops and services are tailored to their partners’ needs. For example, one organization that wanted to provide harm reduction services to their clients, but was not comfortable distributing supplies themselves, partnered with Sanguen to provide supplies to clients on a weekly basis.

Peer work

Both Sanguen sites have at least five peers involved in service delivery. Peers are defined as people with lived experience of HIV, hepatitis C, homelessness, sex work or drug use or a close family member with one of those experiences. Peers are paid for their work as well as any peer supervision or training activities they attend.

Peers are heavily involved in Sanguen’s work, facilitating support groups, doing street- and venue-based outreach, and attending workshops where the audience may benefit from hearing the peers’ experience. The fact that peers share a language and culture with Sanguen’s clients helps to engage and retain clients in services offered by Sanguen.

Monthly training is provided to peers where they learn about hepatitis C, harm reduction, peer-client boundaries and active listening. A practice called peer supervision, where each peer speaks to a Sanguen social worker once a month about both personal and professional challenges, has also improved peer satisfaction with their work and engagement at Sanguen. Peer supervision was established when other staff noticed that peers were not discussing problems with work or their personal lives for fear of losing their jobs. Monthly sessions with a social worker provide peers an opportunity to identify challenges they are experiencing and find solutions to address them.

Hepatitis C treatment

Sanguen has three full-time treatment nurses who work closely with an on-site physician. The nurses are responsible for hepatitis C testing, patient monitoring, treatment initiation and follow-up. Nurses work in the clinic, on the street and in venue-based outreach in the community. Sanguen’s nurses and physician provide outreach clinics where testing and treatment are available at six sites regularly, including in a Stonehenge Therapeutic Community and in a provincial women’s prison.

At Sanguen, treatment is defined in a broad sense. For example, important components of successful hepatitis C treatment could include supporting a client to get treated for their mental health issues or substance use or helping them find stable housing. Providing wraparound support for clients, whether they are on treatment or not, can improve a client’s health outcomes. For clients on treatment, this type of support may increase the likelihood that they achieve a sustained virological response.

Treatment information

As part of its commitment to client-centred care, Sanguen follows the lead of clients when it comes to treatment. If the client feels ready, the physician and one of the nurses will prepare the client to start treatment.

The first and often most crucial step is the pre-treatment talk, where a nurse will go over what treatments are available, explain the potential side effects and answer any questions a client may have. This is also an opportunity for the nurse to find out if there are any barriers to treatment, such as unstable housing or mental health issues, that may interfere will treatment adherence. Sanguen’s nurses recognize that for many clients there may never be an ideal time to treat, and therefore it is acceptable to initiate treatment if most, but not all, of the barriers have been eliminated or reduced.

For clients on treatment, Sanguen is a one-stop shop

Sanguen typically treats between 50 and 60 people at any given time. Sanguen employs three full-time nurses. From appointment to appointment, clients see the same nurse. This improves relationship building between client and clinician and facilitates continuity of care from appointment to appointment.

For the time that clients are on treatment, Sanguen acts as a one-stop shop. Medication dispensing, blood work and psychosocial support are offered at Sanguen’s two fixed locations as well as through specific outreach venues so that clients can receive care in locations convenient for them. It is key for clients to be able to make a single stop for their hepatitis C related healthcare because they may be feeling unwell. This improves the likelihood that clients will remain in care and stay on treatment.

Post-treatment

Clients are followed for 18 months post-treatment. They can continue to access Sanguen’s prevention, testing and support services for as long as they wish after treatment has been completed or stopped: no one is turned away. Some clients continue to return to Sanguen for blood work and for mental health support, for example.

Next steps

Sanguen is currently developing a plan to create a van-based mobile outreach program. The addition of a van will improve street outreach by making it easier to serve clients on the street, especially in winter.

Required Resources

1. Community coordinator. Develops partnerships and relationships with other agencies to improve service delivery for Sanguen’s clients.
2. Manager, outreach, education and prevention services. Manages the peer program, develops relationships with frontline service providers. Offers workshops, education and prevention services to clients and other agencies.
3. Nurses. At least one nurse for every 25 clients on treatment. Provide testing, treatment and monitoring services.
4. Social worker. Provides psychosocial assistance to Sanguen clients, including case management, counselling, accompaniment, advocacy and referrals.
5. Peers. Provide peer support, outreach services and referrals to people at risk for or living with hepatitis C.

Challenges

Sanguen staff face a number of ongoing challenges when doing their work:

1. Stigma. Stigma related to drug use and hepatitis C continues to impact both clients and service providers. This can be a challenge when clients or service providers acting on their behalf seek other psychosocial or health services in the community.
2. Slow progress. Working with people who may be street involved, who may be living with addiction and who may lead chaotic lives may mean that client progress is incremental. Service providers may be challenged when clients do not make changes in their substance use, for example, as quickly as they hoped or do not make healthy decisions.
3. Engaging hard-to-reach clients. It is critical that Sanguen reach out to as many people who may be using drugs or living with hepatitis C as possible. Staff have experienced challenges engaging clients in one community where no obvious network of people who use drugs exists. One way that Sanguen has tried to improve client engagement has been to be out in the community as much as possible, in other venues and on the street, and to be persistent with engagement, building trust with clients over months and sometimes years.

Evaluation

Sanguen Health Centre has been evaluated in a number of ways in recent years:

1. A pilot process evaluation prepared by the University of Waterloo found that Sanguen “appears to be successfully providing services to their clients, keeping users engaged and encouraging use of the support groups.”
2. An outcome evaluation prepared by the Centre for Community-based Research found that clients “contacted through outreach, screening, start-of-treatment, and post-treatment were satisfied and enthusiastic” about Sanguen’s services.
3. There has been periodic reporting to the Ministry of Health and Long-term Care. Between April 2013 and March 2014, Sanguen provided treatment to 85 people, of whom 47 achieved a sustained virological response. At the time of reporting, some of these clients had not finished treatment or were waiting for results to confirm their sustained virological response.

Lessons Learned

Sanguen Health Centre has learned a number of important ways to provide effective services to their clients.

1. Work within the client’s agenda. Sanguen’s ultimate goal is to prevent and treat hepatitis C, but that may not be something that clients want to address initially. Instead, staff meet each client where they are at and listen to their needs and address them one by one.
2. Be flexible. Flexibility in creating relationships with clients and other service providers has improved Sanguen’s capacity to establish and maintain these relationships. Both service providers and clients need to feel like working with Sanguen improves service delivery.
3. Provide supervision for peer workers. Providing specific, paid time for peers to see a social worker has improved the integration of peer workers in the health centre. These meetings provide dedicated space for them to talk through their personal and professional problems while also allowing them to build relationships with other team members.

Program Materials

• Sanguen Health Centre’s Hepatitis C Program: Outcome Evaluation
• Pilot Process Evaluation of the Sanguen Health Centre Hepatitis C Team

Contact Information

Chris Steingart, executive director
29 Young Street East
Waterloo  ON N2J 2L4
(519) 603-0223
csteingart@sanguen.com