What is the Program?
The Positive Service Coordination Program (PSC) based at LOFT Community Services in Toronto provides short- and medium-term intensive case management for people living with HIV who cycle through the health and judicial systems as a result of being homeless, living with a mental illness, using substances or experiencing a physical or mental health crisis.
Clients who qualify for PSC’s services are known as members and are paired with a case manager who, with the member’s consent, works to support them to establish priorities for their health and well-being and achieve their goals.
Case managers work with members to find permanent, stable housing; ensure they have appropriate identification documents and are receiving their maximum social assistance benefit; engage them in HIV-specific care, primary care and mental health care; and make active linkages to appropriate community organizations. PSC operates from a harm reduction model, meaning members can continue to use substances as they engage with the program.
The objective of PSC is for members to set personal goals, be housed, be engaged in care and be engaged in the community by the time they graduate from the program. During the time members spend with a case manager—anywhere from six to 18 months—case managers make active links to and help members navigate available community and clinical services. If individuals are engaged in services through intensive case management, it is less likely that they will disengage from care in the future.
PSC employs three full-time case managers to work directly with PSC’s members. The program is led by a full-time coordinator who maintains relationships with community and clinical partners, supports the case managers and works with members as needed.
Although LOFT Community Services employs the coordinator and the case managers, PSC has a strong working collaboration among 17 Toronto-based community and clinical partners1, including healthcare institutions and facilities, community-based organizations and housing providers. Two housing intake workers from partner agencies are on-site at LOFT to coordinate housing for members.
In 2011, the Addictions Supportive Housing Program was established for PSC members with the most entrenched substance use who needed more long-term case management. A separate team of case managers provides similar services to members of this program. Although this case study will focus on PSC, more information on the Addictions Supportive Housing Program can be found at the end of this case study.
- 2-Spirited People of the 1St Nations; Casey House; Fife House; Fred Victor Centre; McEwan Housing and Support Services; Prisoners’ HIV/AIDS Support Action Network (PASAN); Seaton House Shelter, Infirmary Program; Sherbourne Health Centre, Infirmary Program; St. Michael’s Hospital, HIV/AIDS Psychiatry; St. Michael’s Hospital, Positive Care Clinic; The 519 Church Street Community Centre, Trans Program; Toronto HIV/AIDS Network; Toronto People with AIDS Foundation; Action Positive; Latinos Positivos; Africans in Partnership Against AIDS; The Maple Leaf Medical Clinic.
Why Was the Program Developed?
Positive Service Coordination (PSC) was developed in 2009 to address two ongoing challenges that McEwan Housing and Support Services, a LOFT program, was facing. First, McEwan received referrals for housing and support services when people were discharged from hospitals, clinics and jails. It was often difficult for McEwan to reach these potential clients because of the lack of coordination between the discharging facility and McEwan, and many of them were lost to care.
Second, other community agencies—many of whom became formal partners in PSC—were referring potential members who were high users of the health and judicial systems to McEwan for respite care, housing support and community support. These members had very high needs when referred that were not being met through existing LOFT programs and services.
LOFT and its community partners worked to develop a program that coordinated wraparound services for high-need clients. It was expected that such a program could strengthen the referral process, reduce gaps in care, improve overall member care and ultimately improve client health outcomes.
How Does the Program Work?
Referrals
Most referrals come from Positive Service Coordination (PSC)’s community and clinical partners. Because PSC members tend to be disengaged from care when they are referred, many referrals come from services that people access when they are in crisis, such as mobile outreach teams or hospital emergency departments. Referrals are processed and intakes are performed within two days of being received to reduce the likelihood that people are lost to care.
All referrals are screened and assessed based on need. The assessment takes into account the person’s number of emergency department visits in the last two months and in the last year; number of hospitalizations; number of admissions to withdrawal management programs or day programs within the last year; and number of legal charges in the last year. Any potential member who scores higher than a 10 on the assessment qualifies for PSC. Individuals who qualify for PSC and have significant addictions are referred to the Addictions Supportive Housing Program’s case management service. As of February 2015, there are 60 clients in PSC.
Partnerships
Although LOFT leads PSC, the program is a cross-sectoral partnership among 17 partners. This partnership is governed by a memorandum of understanding that all partners have signed. LOFT hosts three in-person meetings a year of the PSC partners to maintain relationships and address any issues that have arisen since the last meeting.
The community and clinical partnerships that LOFT fosters are one of the keys to the success of PSC. Each partner brings a specific and necessary expertise to the care of PSC members. By collaborating and combining their expertise, the partners enable the PSC case managers to address member needs holistically.
PSC staff work closely with partners; the collaboration varies according to the needs of clients. For instance, appropriate housing—transitional and respite—is coordinated with Fife House, Fred Victor Centre, Casey House, Sherbourne Infirmary and McEwan House, depending on member needs. Psychiatric care is offered on-site at LOFT Community Services by St. Michael’s Hospital.
PSC partners are both sources of referrals for the program and key stakeholders in the care of many of PSC’s members. Although each partner is critical to the success of member care, the level of engagement of PSC partners in the program varies according to the types of services they offer. For example, partners who provide services such as housing and healthcare are called upon more often than partners who provide cultural or linguistic services that are only requested by members who identify with a specific cultural or linguistic group.
Intensive case management
The core service of PSC is intensive case management. The goal is for members, by the time they graduate from PSC, to have set personal goals, be housed, be engaged in care and be engaged in the community. Community engagement varies for members: it may include actively participating in events hosted by PSC’s partners, volunteering, or preparing to return to work or school.
After referrals have been assessed and individuals have been deemed to qualify for support, PSC’s case managers triage the new members. Two case managers take on members whose needs can be resolved in six to nine months. Although these members may be homeless and may be disengaged from healthcare, their needs are expected to require less time to address than those of other members. The third case manager works with members who may need more long-term support, typically lasting between 12 and 18 months.
Members are paired with one of the case managers and they meet to discuss their goals and develop a personalized care plan. Members and the case manager fill out an Ontario Common Assessment of Need (OCAN) form to understand the member’s baseline needs. Completing this form also helps members determine their priorities for services. Members can provide consent for the case manager to discuss their care with PSC’s partners, making it easier for the case manager to make appointments and coordinate care on the member’s behalf.
Critical to the success of PSC is the presence of housing intake workers on-site at LOFT. Both housing intake workers are employed by HIV housing providers. Having this expertise on-site allows the case manager to focus on the other needs identified by the member. Typically, new members meet with the housing intake worker the same week they first meet with their case manager. Members tend to enter transitional housing or respite care, if appropriate, as a stop-gap measure until their case manager and the housing intake worker can find permanent housing. When they enter transitional housing or respite care, members receive a higher level of support that gives them the opportunity to stabilize their health and their lives so they are ready to enter permanent housing when it becomes available.
The case manager coordinates a member’s care. Some members enter the program without a primary care provider. PSC members have priority access to primary care providers who have experience working with people living with HIV who may also be living with mental illness and substance use challenges. Priority care means members do not have to wait to receive appropriate and non-judgemental primary care.
During the first few months, the case manager makes and accompanies members to appointments with primary care providers and HIV care providers and, if necessary, schedules a first meeting with HIV psychiatry, which is available once a week at LOFT’s offices. Depending on the member’s goals, the case manager may also make linkages to AIDS service organizations and other community-based organizations.
Through the first few months of engagement, a case manager and a member may see each other up to four times a week. This intensive engagement builds familiarity and trust. Case managers strengthen this relationship by helping members to achieve the goals they have identified for themselves. Through these efforts, and by modelling behaviour that members can use to advocate for themselves, case managers bolster member self-confidence, which improves member self-management.
Gradually, as a member’s circle of care widens and they take on more responsibility for their care, members become more independent. When a member resolves problems or overcomes barriers without the help of their case manager, the case manager reinforces the member’s success.
Building relationships with other service providers
Case managers must also build strong relationships with other service providers to make sure members receive optimal care. Typically, case managers build these relationships by being present at meetings to discuss the member’s care and raising the member’s concerns with service providers in a respectful way.
Graduating from the Positive Service Coordination Program
PSC is meant to be an intensive, short- to medium-term program for people who are disengaged from services and have complex health and social needs. By the end of their engagement with the program, members typically have permanent housing, have a primary care physician and are being monitoring by an HIV healthcare provider and an HIV psychiatrist (if needed). Members are also pursuing the personal goals they set for themselves when they enrolled in PSC, such as returning to school, reuniting with family or getting a job.
Although members graduate from the program, they remain general members of LOFT Community Services through McEwan’s General Member Association. This program provides members with social support and reduces isolation after graduation. Members who experience crises or challenges in their recovery after graduation are re-enrolled in PSC with their case manager, who supports them to re-engage in services.
Occasionally, members disengage from the program. Case managers continue to follow up with these members, understanding that they may need time. Case managers leave messages in places members are known to frequent and leave member files open for months. When members return, case managers reassess their needs and continue to support them to engage in services.
Addictions Supportive Housing Program
Although PSC offers intensive comprehensive support to members, the short-term nature of the program is insufficient for some of them. In 2011, LOFT received funding from the Toronto Central Local Health Integration Network for the Addictions Supportive Housing Program (ASH) for people living with HIV who have significant addictions and who have had a significant number of hospitalizations, admissions to withdrawal management programs and incarcerations in the previous year. LOFT, in partnership with Fife House, has 32 rent-geared-to-income suites for ASH members. Referrals for ASH are processed through PSC. There is no time limit on engagement in ASH.
ASH provides services for members with the most complex substance use problems and allows them to engage in their care through a supported housing model. Three case managers work full-time with ASH members, the same way that PSC’s case managers work with their clients. They use OCAN to identify client goals, coordinate appointments and services for their members and engage members in care.
Next steps
In 2015, LOFT Community Services, as a result of the Positive Service Coordination Program (PSC), was identified by the Toronto Central Local Health Integration Network and the Mid-East Toronto Health Link (one of nine Health Link services in various regions of Toronto that focus on improving client care in specific areas) as a pilot site for a new care coordination planning program for people with complex mental health and substance use challenges. The pilot builds on the work of PSC and the Addictions Supportive Housing Program by trying to improve care planning for clients through an interagency multidisciplinary care team. In the pilot, a case manager will assemble a unique team of service providers for each client who will meet to develop a coordinated care plan.
Required Resources
- Program coordinator. Maintains relationships with partners. Provides direction to case managers. Provides services to a small case load of members.
- Case managers. One for every 16 members. Coordinate services and provide support, advocacy and accompaniment services for members. Maintain relationships with other service providers engaged in member care.
- Housing intake workers. Coordinate temporary and permanent housing for members, in conjunction with the case manager.
- Strong partnership agreement with a variety of community and clinical partners that outlines structured roles and responsibilities to ensure ongoing seamless support for members.
Challenges
LOFT has identified a number of ongoing challenges for PSC:
- Partner differences. With 17 partner agencies, LOFT is working across multiple organizational systems, cultures and guidelines. Although they are all working to increase client well-being, it can be challenging to coordinate communication and workflow across community and clinical services. Currently, LOFT and other partners are piloting a coordinated care planning project that may reduce communication challenges among partners.
- Discharge planning. Some PSC members start their time in the program by entering treatment for mental illness or substance use. Typically, these services are not offered through a PSC partner, which means that discharge planning with the case manager does not always take place. PSC case managers must ensure that they proactively follow up with external service providers to know when discharge will take place. This makes it easier to move members from the facility where they received treatment to transitional housing or respite care.
- Limited employment opportunities for members. When PSC members are stable, some want to work. Although some of PSC’s partners offer employment and volunteer opportunities, there are not as many opportunities as needed. PSC would like to build stronger ties with educational institutions and employment services to provide members with additional opportunities so that members who want to work can do so.
- Stigma. Stigma remains a barrier to appropriate care for PSC members. Service providers outside the network of PSC’s partners may stigmatize substance use, mental illness and HIV. Most PSC members live with all three, making strong engagement in care a challenge for them. Case managers advocate on behalf of members, modelling behaviour that members can use to advocate for themselves, which may reduce the impact of stigma on their health outcomes.
Evaluation
Positive Service Coordination (PSC)
In 2012-2013, PSC members had the following demographic makeup:
- 100% were living with HIV
- 100% had a diagnosed mental illness
- 90% had concurrent mental health and substance use challenges
- 35% were co-infected with hepatitis C
Despite members’ complex needs, the following outcomes were reported for the same period (2012-2013):
- 95% reduction in emergency department visits compared with the previous year
- 93% reduction in days spent in hospital compared with the previous year
- 86% of members housed permanently
In 2012-2013, 97% of members agreed/strongly agreed that they were satisfied with the program overall and would recommend the program to others.
Addictions Supportive Housing Program (ASH)
The goal of the ASH program is to reduce inappropriate use of the healthcare and judicial systems by heavy users.
In 2013-2014, the program showed significant successes. ASH members reduced their emergency department visits by 98%, their hospital stays by 92% and their withdrawal management program visits by 95% compared with the previous year.
Lessons Learned
Five clear lessons have been identified by PSC staff:
- Strong partnerships. PSC is a collaboration among 17 community and clinical partners. Each partner contributes their expertise to member care, and together the partners enable PSC to offer a range of services to meet each individual member’s stated needs. This strong collaboration means that each partner can work to its strength and call on the strengths of other partners when needed to address the holistic needs of members.
- Priority access to primary care providers. Members of PSC or ASH who do not have a primary care provider when they enter the program are guaranteed access to one who has experience working with similar clients. This means that members do not have to wait to receive primary care from an experienced and non-judgemental provider.
- On-site housing intake workers. Housing intake workers from two partner agencies are on-site at LOFT. This has meant that connections to housing can be made more quickly and more seamlessly. Members can meet with the housing intake worker the same week they enroll in PSC. Additionally, having an on-site housing expert means that the case manager can focus on the other aspects of a member’s care plan.
- Staff persistence. PSC members have complex care needs. Many of them live with trauma and multiple co-morbidities and may be mistrustful of service providers, and they may not fully engage with services the first time they are offered. It is key that staff take a flexible approach with members and continue to follow up with them when they may be having difficulty remaining engaged in their care.
- Anything is possible. Members may be coming to PSC when they are at their most vulnerable, both physically and emotionally. However, the coordinator and the case managers never assume that members cannot achieve the goals they set out for themselves. This trust in members’ abilities encourages self-management.
Program Materials
Other Useful Materials
Information found on the CATIE website
Contact Information
Kay Roesslein, program director
LOFT Community Services
KRoesslein@loftcs.org
416-929-6228 x 223