Addressing the Frequent Fliers

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Addressing the Frequent Fliers

• How one program is decreasing the use of
  Emergency Departments by housing and supporting
  the chronically homeless and mentally ill in
  Calgary using the Housing- First' approach

Pam Thompson, MD, CCFP CAEP09 Director, The
Alex Pathways to Housing June 11, 2009
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Disclosure
I do not have an affiliation (financial or
otherwise) with any commercial organization that
may have a direct or indirect connection to the
content of my presentation.
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Learning Objectives

• 1.  To understand the principles of Housing
  First
• 2.  To understand the key elements of the
  Pathways to Housing model and the
  relationship between homelessness, housing and
  the use of acute care services
• 3.  To explore the role of the Emergency
  Physician in the housing continuum

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From the ER to the Community
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The Continuum
Housing
Prevention
Services
Approaching / Entering Homelessness
Entry to Homelessness
Leaving Homelessness
Least Challenging
70-80 of Homeless Less Significant and
Services required
Severity of Homelessness
10-20 of Homeless and Services required
10 of Homeless Most Significant and Services
required
Most Challenging
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Current Housing and Service Programs A
series of steps (assumes consumers need to be
housing ready)
3 unwarranted assumptions a. referrals work b.
skills learned are transferable c. need treatment
before housing
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Fast Facts about Calgarys Homeless

• Total number counted in 2008 4,060 people
• 140 individuals surveyed as part of a Calgary
  Homeless Foundation survey1 found the following
• 95 self-reported substance use
• 32 self-reported mental illness
• 148 ER visits in the past 3 months
• 308 inpatient visit in the past year
• Many have dual diagnosis of mental illness and
  addictions
• 1 Gicomin, Marina, Tanasescu, Alina.
• Assessing Vulnerability in Calgarys Homeless
  Population. Calgary
• Homeless Foundation. PowerPoint. 2009. 8 June,
  2009.
• lthttp//www.calgaryhealthregion.ca/programs/injury
  prevetion/docs/prof_
• only/cipc_event09_homelessnessafety_mgat.pdfgt

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Calgarys 10-Year Plan to End Homelessness
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Housing-First
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Core Beliefs
Core Beliefs
Housing is a basic human right, not a reward for
clinical success
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• Mission
• To end homelessness for people who suffer
• from psychiatric disabilities by providing
• housing first and treatment to aid recovery and
• re-integration into the community.
•  

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Our Clients
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Average Length of Homelessness Prior to Entrance
into the Program
7.7 years
of Clients with a past or present addiction
98
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How it all works
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Our Team
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Evidence-Based Practices

• Assertive Community Treatment (ACT)
• Harm Reduction
• Integrated Dual Disorder Treatment (IDDT)
• Illness Management and Recovery (IMR)
• Supported Employment (SE)
• Family Psychoeducation

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Cost of Homelessness

• The average cost of homelessness
• in Calgary is estimated to be
• 134,000 per person per year1
• Costs incurred
• Hospital - average 800/day 24,000/month
• Shelter - 25 - 50/day 1,500/month
• Incarceration - 110/day 3,300/month
• Other Police involvement, EMS, courts,
  out-patient health services
• 1Data from research compiled by Calgarys
• 10 Year Plan to End Homelessness

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Pathways to Housing Cost Reduction

• Pathways costs 34,000/client per year
• Including housing, 24/7 support provided by the
  Assertive Community Treatment (ACT) team
  Administration
• Key partners have recognized the value of this
  kind of collaboration for both the client
  (comprehensive service delivery) and the system
  (cost savings)

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Million-Dollar Murrays Profiling our own
Frequent Fliers
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Irene
19 year old female

• 22 ER Visits

6 EMS transports Chest pain non-cardiac
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Colin

• 32 EMS transports
• 20 due to ETOH ingestion

11 police contacts
54 days in burn unit Due to severe frostbite
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Strategies Using the Evidence

• Irene, May 2009 5 Emergency Calls/Unscheduled
  Visits to Office
• Irene frequently claiming that she was a crisis
  with chest pain and needed to go to the ER
• Family Physician nothing was physically wrong
• Psychiatrist (met with her throughout the
  month) did not have any significant concerns
  (SI)

Despite reassurances from Physicians and Nurses,
Irene still felt that she had to go to the ER
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The Evidence Outcomes

• A review paper on the Effectiveness of Housing
  and Support for homeless, mentally ill clients
  published in 2007 by Nelson, Aubry Lafrance
  revealed
• significant reductions in homelessness and
  hospitalization and improvements in other
  outcomes (e.g. well-being) resulting from
  programs that provided permanent housing and
  support, ACT, and ICM.
• Nelson, G., Aubry, T., (2007). A Review of
  Literature on the Effectiveness of Housing and
  Support, Assertive Community Treatment, and
  Intensive Case Management Interventions for
  Persons With Mental Illness Who Have Been
  Homeless. American Journal of Orthopsychiatry, 77
  350-361.

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The Evidence Housing Outcomes

• Of 6 studies that compared some form of standard
  treatment with housing and support there was
  clearly greater improvement in stable housing for
  consumers who participate in housing and support
  interventions
• Two studies revealed significantly lower costs
  associated with supported housing
• Nelson, G., T. Aubry, and A. Lafrance. (2007). A
  Review of Literature on the Effectiveness of
  Housing and Support, Assertive Community
  Treatment, and Intensive Case Management
  Interventions for Persons With Mental Illness Who
  Have Been Homeless. American Journal of
  Orthopsychiatry, 77 350-361.

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The Evidence - Housing Outcomes

• A study in New York from 1993-1997 compared
  housing tenure for clients in the linear
  residential treatment approach vs. Pathways
  Housing-First model
• After 5 years
• 88 of the Pathways clients remained housed
• 47 of the clients in the linear residential
  treatment approach remained housed
• Tsemberis, S., Eisenberg, M. A., (2000). Pathways
  to Housing Supported Housing for
  Street-Dwelling Homeless Individuals With
  Psychiatric Disabilities. Psychiatric Services,
  51(4), 487-493.

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Number of Community Contacts for All Clients in
Pathways 12 months prior to Admission, Since
Admission
61 Reduction
63 Reduction
68 Reduction
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MHCC RESEARCH DEMONSTRATION PROJECT IN MENTAL
ILLNESS AND HOMELESSNESS

• Vancouver people with a mental illness who
  struggle with substance abuse and addictions
  issues
• Winnipeg urban aboriginal population
• Toronto ethno-cultural diversity including new
  immigrants who are non-English speaking
• Montreal different mental health services
  provided to homeless people in Quebec
• Moncton rapidly growing city with a shortage of
  mental health services pilot focused on rural
  population

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More Information

• Contact the Program
• Dr. Pam Thompson Program Director
• pam_at_pathwaystohousing.ca
• [phone]
• See our Website
• www.pathwaystohousing.ca
• Information on Calgarys 10 Year Plan to End
  Homeless
• www.endinghomelessness.ca