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I had no name for four days, until my grandmother gave me a name. I had a heart and kidney operation when I was two month old because my mother drank and did drugs when she was pregnant with me, so I was in the hospital for five years on and off, I would have to go to Montreal. I believe I was not held too much ‘cause I have trouble when somebody touches me. When I was six or seven my sisters, that are three years older, made me smoke cigarettes so I would not tell on them, but my mother found out and she started giving me cigarettes at that age, but she did not want my sisters to smoke.
This is around the time fathers start teaching their kids how to hunt and survive on the land, but my parents were separated and my mother’s boyfriend is the worst hunter I have ever met, I am 24 now and I have never seen him shoot an animal Just missing the animal. I would go to the dentist alone, my mother would not take me.
I was not like the other kids because of the operation so I was made fun of by the other kids, I would breath heavily even when I was staying still.
I moved back to my father when I was 7 or 8 years old; my father did not expect me to go live with him but my mother did not want to take care of me.
I got into fights every day ‘cause I was from another town, I didn’t tell my father that it was happening every day.
I did well in school, my father was the shop teacher and his now wife the grade 5 and 6 teacher.
To me my relation with my father wasn’t enough for me. I remember him playing with other kids a lot. He was busy most of the time. Middle of grade 8 I ran away to my mother, ‘cause I didn’t like the way my father and girlfriend raising me, they wanted me to be perfect, I was at the top of my classes, got As and Bs but I found school to be boring, it wasn’t challenging enough, and getting into fights almost everyday was hard on me cause I didn’t have any friends outside of school or my friends were my father and girlfriend friends kids I just didn’t find them interesting I was glad but I wasn’t happy.
When I moved back to my mother I got worse cause I started taking marijuana and drinking staying up all night then my father called or my mother just sent me back at 14 years old. I stayed at my dad’s for a few weeks they I just left with what I was wearing, staying at apartment buildings boiler room.
I started baby sitting so I could have something to eat every day. I was getting $ 20 a day plus a free breakfast and lunch, I would buy a pack of cigarettes and I would find somebody to spit for weed. I would wear the same clothes for months one pair; it took me 3 or 4 months till I would go get my clothes from my father’s place, he would not ask it I was alright. I would just take my clothes and leave right away. I was hanging around with my cousin who is five years older and she was drinking every day and I would get invited to go to the legion and bar, we would steal almost every day so we could drink. A lot of people ask if I was her bodyguard cause we would be together everyday, at sixteen we had one bed nothing else and her other friend would stay with us and party every day, but I ‘d have to get up at six in the morning to baby sit and I would, but I would sleep for an hour or less because of partying so the person I baby sat for I moved in with him then I was there 24/7, the baby got so attached to me she would start crying if I left the apartment instead of wanting to be with her father.
17 or 18 years old I moved back to my mother so I could be close to my grandmother even though my relationship with my mother is bad, if I did not come back home one night I would lose my bedroom. I got my first job at 19 as a stock boy. It taught me a lot, how to organize, but I was still sleeping only a few hours a week cause me and my cousins hanging out but it was a one way friendship cause I would give them things and they wouldn’t give me back and I would fight with them a lot.
20 or 21 I moved back to my father but I only stay a few days then I would couch serf then I got into a place that helps young people and they got me a room for 100 dollars a month.
I got my 2 job staying there as an assistant cabinet maker, I liked the job but I would have to walk there mornings, back home for lunch then back there, back home and it wasn’t close, but I got depressed and decide to go to Ottawa 2004. I got a place when I got here but I moved out after 2 months then I was homeless sleeping outside and at the shelters, drinking every day. I didn’t need any money I could get alcohol and drugs for free. In 2005 then I came back to the capital of the territory cause my grandmother passed away but I didn’t make it cause I had to go to my mother’s, but if I did I don’t know what I would do I was so angry at my mother and relatives cause I knew how they treated my grandmother. I cared about my grandmother but I was scared cause I have almost killed somebody before and I might if I see my mother.
2005 I got another job as an apprentice electrician but as usual I got depressed and moved back to Ottawa after working for 3 months, I was homeless drinking everyday. I was homeless cause it’s hard being in OW they don’t give enough money to last the whole month for food and other stuff so staying at a shelter is easy cause we do not need to buy food.
I have tried to change my lifestyle but was hard I needed something to eat but I didn’t want to go to eat at the shelter cause I know everybody and they would want me to drink and it’s hard to make friend that don’t drink cause I’m an alcoholic. Last year I black out and somehow fractured my foot and pelvis and broke my wrist. After that I started to think differently but I would still drink but not as much, but it’s hard to get on the right track cause I’m and alcoholic, cause of my depression (self induce mood disorder). It’s hard to live on welfare cause there is not enough time to buy food for the whole month and the food banks don’t give enough so I will have to go to the shelters to eat and would see my old drinking friends, the thing that’s harder is making new friends.
There is a lot that are missing cause I wanted to forget the bad things that happened to me.
I have been homeless in Ottawa for 2 and a half years, sleeping outside in the winters and summer. Sleeping outside in the winter is very hard I would find a vent that’s letting hot air out so I can stay warm or break into a apartment building and sleep at the top floor stair case. Getting food to eat is easy when I was downtown I would just go to the shelters or the drop-in centers that serve meals, when I slept in the West-end or somewhere far from downtown I would not eat for 3 to 4 days sometime cause my friends are on OW, being on OW is very hard there is not enough money to buy food for the whole month and going to the food banks they don’t give food that will last a week. I didn’t want to stay at shelters because of the smell, being in a room with 4 to 12 people, some who don’t wash for weeks, and most people who stay at the shelters are crack heads. They aren’t the best people to get along with. Staying outside was alright but I would have to get up early so when people are going back to work wouldn’t see me sleeping there, when people saw me sleeping in places they would call the cops then I would have to find a new place to sleep. It very hard to find places to sleep where I would not bother people, I would always clean up my mess so people would not notice somebody sleeping there.
I’m an alcoholic I don’t have any trouble getting alcohol I’ll drink everyday In the parks with people, the cops know we are drinking there but only if they see something or somebody complain they would talk to us, even the people who cleans the parks didn’t call the cops because we would clean up every thing when we were done drinking.
I have tried to get jobs but didn’t get any offers, probably because of how Id look all my cloths look old, I don’t have that many clothes cause I don’t want to carry to many bags and if I left them at my friends they would start wearing them or somebody else would take them. Its very hard finding people who I can trust. Its very hard not to be homeless because of how much I would get out of OW, and its hard to get new friends and try to change my life style cause I would have to go eat at the shelters and I’ll see my drinking friend. I would say no but they would always talk me into drinking cause I have been drinking since I was fourteen and I didn’t do anything else, that is another story.
I suffer from depression and I have been diagnosed (self induce mood disorder) I have a hard time keeping my jobs because of my depression, I drink because of my depression I now its not the right thing to do but drinking makes my body feel different and I forget for a while that I’m depressed.
Gerry was brought for a tour of the Mission Hospice by his mental health worker. He was tired, asked to lie down, hopped into bed, looked around, smiled and said “now I’m home”. He was recently out of prison and was deathly ill from AIDS. Normal HIV/AIDS care had been denied to him on the basis of “non‐adherence” which had nothing to do with his wishes and everything to do with his mental illness and therestrictions imposed on him by the criminal justice system. He had been living in a halfway house were he was being penalized by staff because of his diarrhea. He had lost 25 kilos in less than a month.
Gerry had faced many challenges in his life including developmental delays, ADHD, schizophrenia, injection drug use, hepatitis and AIDS. He had spent as many years living on the streets as in prison. Despite the challenges of dealing with his addictions, compulsive stealing and numerous medical complications, Gerry quickly became a favorite with clients, staff and volunteers at the Hospice. His medical care was complicated by the severity of his mental illness, poly substance abuse and compulsive antisocial behaviors but his sense of humor, flair for the dramatic and genuine affection for those around him made it impossible not to enjoy his presence. Despite the complex nature of his medical problems, the challenge of caring for Gerry was always keeping him out of jail. Not a normal end of life goal in most hospices but, often an important one at the Mission Hospice.
Gerry had spent most of his life excluded from the services he needed because of his behavior and illnesses. His violence had led him to be permanently barred from almost everywhere. The sense of belonging and acceptance that he gained at the Hospice brought incredible joy in his life. Having the Hospice staff available to deal with the challenges of caring for Gerry provided an opportunity for his previously estranged family to spend time with him and to resolve much of the conflict which had characterized their family life for many years.
Gerry told us that being at the Hospice was the happiest time in his life. Gerry died very peacefully holding his mothers hand, snuggling in his bed with a brother at sitting on either side. Shortly before passing away,Gerry thanked everyone for making his dreams come true. He said that he had finally gotten everything he wanted in life.
What is the Mission Hospice Program?
The Mission Hospice Program is a partnership between the Ottawa Mission and the Ottawa Inner City Health. The program provides palliative care to terminally ill people who are homeless or street involved.
Palliative care services include:
The Mission Hospice Program serves men, women and couples, and is committed to welcoming everyone who is homeless and in need of end of life care.
The intent of the program is to provide safe home where people can live well for their remaining days. The program is operated through a partnership between the Mission who provides all aspects of housing, transportation and spiritual care and the Ottawa Inner City Health who provide palliative care.
How Does the Program Operate?
The Mission Hospice program provides clients with the equivalent of a home and a family, so they can access palliative care services like other citizens. Many of the staff who works at the Hospice is employees of Carefor (formerly VON Ottawa), an agency which is renowned for it’s expertise in palliative care. The partnership with Carefor not only provides access to highly qualified staff but, insure that the quality of care is comparable to what is provided to other citizens in the region.
Staff at the Hospice includes client care workers who are hired to provide personal care, assist with hygiene, medications and monitor the client’s needs just as family members would. A palliative care nurse specialist coordinates all aspects of care for the clients and supervises the work of the client care workers. Physicians and nurse practitioners from the Ottawa Inner City Health and/or the client’s own family doctor and specialists provide the medical care required in each case. Palliative care services are available through the Community Care Access Centre, which includes visit nursing, shift nursing, physiotherapy and occupational therapy. The Mobile Pain and Symptom Management Team from the Elizabeth Bruyère Health Centre provide expert consultation to assist with complex symptoms.
Volunteers at the Hospice include people from all walks of life who are trained in palliative care by the Mission. Clients’ biological and street families and friends are welcome to help with care or volunteer at the Hospice. We have access to spiritual caregivers from all religious denominations and the aboriginal community.
Who is Eligible for Admission?
Clients who are homeless or street involved can be accepted for admission if they are:
How does the Mission Hospice Program differ from “Mainstream” Palliative Care Services?
The palliative care services which clients in the Mission Hospice receive are the same as everyone else in Ottawa. However, unlike other Hospices, clients can receive palliative care and still receive treatment for other health problems. The goal of admission can be to provide end of life care, but clients can also be admitted for a short stay to improve their health sufficiently to return to their independent housing or street life.
The Mission Hospice Program recognizes that life on the street is very unhealthy and that this reality has a negative impact on life expectancy. As a result, clients who are admitted because they appear to be close to the end of life may regain their health when they are housed, fed and cared for. Instead of focusing only on end of life care, the Mission Hospice Program attempts to improve the quality of life, life expectancy and function for those living with a terminal condition.
The Program ascribes to a harm reduction philosophy. Clients are not required to abstain from using drugs or alcohol to receive services provided that their behavior does not pose a risk to others. The staff attempt as much as possible to help the clients control their substance use without imposing conditions which make care inaccessible. The philosophy of the program is that substance use is like any other disease and therefore the staff has an obligation to help the client manage their disease. Clients may not engage in illegal activities on the premises. Many of the clients in the Mission Hospice also live with mental illness or challenging behaviours. The Mission Hospice Program sets modest expectations for behaviour, is respectful of street culture and allows clients to die in a familiar setting.
Isn’t It Dangerous to Give Pain Medication to People who are using?
People who live with addictions experience pain when they are terminally ill just like everyone else. Pain management is one of the most important indicators of good quality palliative care. The staff has very quickly learned how to manage pain and other symptoms even when people continue to use other drugs or alcohol. The focus of care is to manage pain, insure the dosage and combination of medication is safe for the clients, and that medication is not diverted to others. We encourage clients to be as open and honest as possible with staff about what they are using so that we can insure their safety.
What Outcomes Are You Hoping for?
Our goal is to provide the best quality of life possible for our clients for the days that remain for them.
This means providing an atmosphere that is safe, secure, and respectful and suited to their needs. This program also provides an alternate to hospital care and saves the health care system an average of $50,000 per person.
We encourage our clients to continue to live well, spend time with family and friends, go on outings and generally enjoy life. Some of our clients tell us that their time at the Hospice was the happiest time in their lives.
Gerry was a typical Hospice client. Homeless since the age of 13, he was well known to the Mission and other shelters for more than 20 years. Totally estranged from his family, he lived with AIDS, Hepatitis, drug and alcohol addiction and, a severe and persistent mental illness. Palliative care services for Gerry began long before he moved to the Hospice. In his final year of life, the Mission helped him to achieve many of his goals: a fishing trip, end of life planning including the details of his funeral service and internment. The Mission organized a wedding so he could marry his sweetheart and welcomed his friends and staff from other shelters to be involved in his end of life care and his memorial service. The palliative care program at the Hospice created an opportunity for the homeless community to care for its own.
The Mission Hospice program provides support in end of life planning, when clients feel ready to address these issues. Clients who wish to die at the Hospice can do so surrounded by family, friends, staff and volunteers. A service is held for each of our clients to provide a chance for their community to mourn and comfort each other. This program does more than simply take care of the dying: it has strengthened our community and brought meaning and dignity to the end of life for a group of people desperately need and deserve it.
The Special Care Unit (SCU) is a short stay program for men who would benefit from extra help with medical, mental health or addictions. The majority of people who are admitted to SCU stay less than 3 months and move on to housing.
The Special Care Unit is operated through a partnership between the Salvation Army Ottawa Booth Centre and Ottawa Inner City Health. The SCU has staff to help you which includes Personal Support Workers (available 24 hours per day), an SCU Case Worker, and Front Line Workers, Nurses and Doctors as well as a mental health Nurse practitioner.
Admission to SCU
Clients are accepted for admission to the SCU on the understanding that they wish to participate in the program and, are willing to work with staff to achieve their health and housing goals.
When you are admitted to SCU you need to be available to meet with the nurse and the SCU Case Worker within the first twenty four hours (on week‐days) or on the Monday following a week‐end admission. If visiting nursing services have been arranged for you by the Community Care Access Centre you need to stay in SCU until the home care nurse has visited you. The health care team normally visits the SCU on Monday and Friday. If you have been asked to be available to see the doctor you should check with the staff to see when medical rounds are for that week.
You will be asked lots of questions concerning any health problems you may have, and may need to have blood work or x‐rays as part of the admission process. If you are prescribed medications, they will be delivered to SCU and administered by the staff.
When you meet with the SCU Case Worker he/she will explain the rules of SCU and will give you a Salvation Army identification card, identifying you and your bed number. The SCU Case Worker will discuss your goals for housing and will assist you in obtaining a health card and drug card if you require them.
Expectations of SCU Residents
Clients who are living in the SCU have special privileges in recognition of their health problems. However, there is an expectation that clients will cooperate with staff to address their health needs and work closely with the SCU Case Worker to arrange suitable housing upon discharge from SCU. If you are living in the SCU you have access to your room 24 hours a day which means that you should be available to meet with staff regarding your needs. If residents are never in SCU and are not available to work with staff we will assume that you do not required assistance from SCU staff and you will be discharged to the main shelter.
SCU is a communal living situation. We expect that you will treat each other and staff with courtesy and respect. Residents are expected to shower and change into clean clothing at least every two days. Residents are expected to keep their personal area tidy and to help with chores in the lounge and common areas. If you need help with showering or keeping your room tidy please ask the staff for help.
SCU is a harm reduction program meaning that you are not required to abstain from using drugs or alcohol to receive care. However, smoking and use of drugs or alcohol on the Salvation Army Ottawa Booth Centre premises is strictly prohibited and may result in your discharge from SCU. We cannot prescribe methadone.
Admissions: The electronic data base indicated 4071 different admissions to the TED program. This compared poorly to the number of bed days and reflects the inconsistency of staff in recording an admission as a reportable event. In future, it will be important to address this weakness in this aspect of data collection as we will want to have accurate data which will allow us to measure uptake of treatment and care as the next phase of analysis.
Unique Clients Served: 636 new clients were admitted to OICHI from the TED program during the first year of operation. This far exceeds the target of 120. Although the staffing is not sufficient to address the needs, the uptake and acceptance of the service from the target population was gratifying. Of the new clients admitted 631 had at least one admission to the monitoring unit while under the influence of drugs or alcohol. Many clients are “regulars” in the monitoring unit having many per week.
Flow from TED Program: 321 individuals “graduated” from the TED program during the first year. At the beginning of the year the outflow of clients was dramatic because of housing available through Intensive Case Management programs (CMHA and Sandy Hill) and bed availability in other OICHI programs. Unfortunately, access to supportive housing is currently very poor leaving many clients stuck in other OICHI programs for long time periods. This situation is now backing up beds in the TED program where clients who are engaged in treatment and care cannot move on to other programs due to lack of beds.
The TED program is intended to be a low barrier access program which accepts referrals from any source. This objective is confirmed by the referral patterns for year one. The paramedic referrals (4) will be used as a baseline to measure the impact of the diversion program in the upcoming year.
Condition of the Patient on Admission
One of the concerns in opening the TED program is the safety of clients. In the past, many of these individuals would have been referred to hospital and therefore it is important to assess whether this change in the care system has had a negative impact on the safety of individual clients. On arrival to the unit, the client is assessed by front line staff( to the extent that they will cooperate with the assessment). Most clients are assessed as stable and can proceed to go to bed. Those assessed as being unstable are admitted to the observation unit and transferred to their own bed once stable.
9 clients were transferred to paramedics based on observation and 12 times the nurse was consulted by phone prior to calling paramedics and the patient was not transferred.
7 clients were transferred to paramedics and in 9 instances the nurse was consulted by phone prior to calling paramedics and the patient was not transferred
No client transferred to paramedics because of respiratory distress, in 5 instances nurse was consulted by phone for respiratory issues but did not result in transfer of patient. In our setting depressed respiratory rates are usually associated with Opiate overdose which is reversed easily by the administration of Naloxone.
8 patients transferred to paramedics, in 21 instances the nurse on call was consulted prior to calling paramedics and the patient was not transferred to paramedics
7 clients were transferred to the care of Ottawa Police pending assault charges
Other Observations on Admission
In 1/3 of admissions, there is a need for nursing intervention or PRN medication administration on admission. This demand for nursing care is additional to the care needs of the individuals who are staying in the 46 beds on this unit. This level of demand for nursing services will justify the need for nursing staff on site 24/7.
The cost analysis:
There were a total of 649 episodes of care which would qualify as an emergency diversion. Of those events, 618 episodes of care are verified by the metrics as being true emergency diversions where care was provided in TED rather than in hospital ER. Based on the metrics, all these individuals would have been transferred to hospital ER via paramedics if the TED program were not in place. 24 individuals were transferred to hospital from TED and 7 persons were taken to cells (ie charged) by Ottawa Police. According to our first year of data, only about 4% of individuals who would have been taken to hospital ER actually require care which care most appropriately be provided in a hospital ER.
Using a very conservative estimate of cost of initial assessment ($250 paramedics, $250 ER assessment) excluding any intervention in the hospital x 318 individuals generates a cost of $309,000. This compares favorably to the cost ($139,000) of providing this service in the TED program.