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CUPSCalgary.com
CUPS Coordinated Care Team
Transitional Support for Vulnerable Calgarians
Darryn Werth & Elaine WilsonCalgary Urban Project Society
CUPSCalgary.com
Calgary Urban Project Society
CUPS is a non-profit organization dedicated to helping individuals and families in Calgary overcome poverty
CUPSCalgary.com
A Broader Community Issue: Poverty in Calgary
• 1 in 10 Calgarians live in poverty (Vibrant Communities Calgary, What is Poverty, 2012)
• 1 in 5 Calgarians are concerned about not having enough money for food (United Way and The City of Calgary, Signpost II, 2011)
• 1 in 3 Calgarians are concerned about not having enough money for housing (United Way and The City of Calgary, Signpost II, 2011)
CUPSCalgary.com
CUPS MissionThrough integrated health, education and housing services, CUPS
empowers people to overcome the challenges of poverty and reach their full potential.
Low-income and marginalised
Calgarians who are empowered to
overcome poverty and reach their full
potential
Improved mental, physical and spiritual health
Nurturing families with resilient children
Safe and stable homes
CUPSCalgary.com
CUPS• Key Goals:
Solid base of wellbeing Stable environment Improved quality of life
• 26 years in Calgary• 60% private funding & 40% government funding• 470 volunteers donating 14,544 hours• 8,418 individual participants• 57 organizational partnerships• 170 staff
EDUCATION
HEALTHHOUSING
CUPSCalgary.com
The Alberta Adverse Childhood Experiences Survey 2013
Adverse Childhood Experiences
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Downstream Prevention
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CUPS Programming
Tertiary prevention: primary health care, mental health support, substance use support, outreach support
Primary prevention: pre-natal & post-natal care, early child development, family development
Secondary prevention: housing programs, basic needs support,
pediatric care
CUPSCalgary.com
CUPS Activities: HousingHousing
• Key case management
• Graduated rent program
• Community development
Supports
• Crisis intervention fund
• ID assistance• Bursaries• Tax assistance• Nutrition program
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CUPS Activities: Education
Parent Education
One World Child Development
Center
Family Development
Center
CUPS Education programs disrupt the intergenerational cycle of poverty by offering research-based early intervention and two-generation approach support programs
that focus on childhood development and overall well-being of parents and the family.
CUPSCalgary.com
Primary carePrenatal care
ObstetricsPediatrics
Hepatitis C clinicOn-site lab
Shared care mental health
Visiting specialistsOutreach clinics
Dental clinicOptometry
DieticianFoot care
CUPS Activities: HealthPatient centeredTeam-based care
ContinuityComprehensive
Enhanced accessContinuous QI
Education & research
CUPSCalgary.com
Calgary• 1.2 million people, >3500 homeless on any given night• Homelessness has increased from 447 people in 1992 to 3601 in 2008• >23,000 households live in poverty (make less than $20,000 and spend
more than 50% in housing)• Calgary’s Ten Year Plan to End Homelessness started in 2008, coordinated
by the Calgary Homeless Foundation
Calgary Winter 2014 Point-In-Time Homeless Count
CUPSCalgary.comCalgary Winter 2014 Point-In-Time Homeless Count
CUPSCalgary.com
Homelessness and Health• Homelessness is linked to poor overall health• Complex relationship• Higher rates of mental illness• Trauma, violence and suicide• Infectious disease• Drug and alcohol use• Chronic disease burden
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Hospitalization and Homelessness• Challenges of acute care use and homeless population are
not new• Homeless individuals have been shown to be 2-4 times
more likely to have a repeat emergency department (ED) visit within 7 days
• Frequent ED users are often homeless and from low socio-economic levels
• Individuals may be accessing ED for non-medical reasons• Limited ability in ED to meet complex needs of individuals • 25-28% of acute care high users in Canada are from low-
income neighbourhoods
CUPSCalgary.com
Top 5 Reasons for ED Visits 2005-2006
in CanadaHomeless Percentage %
Mental and behavioral disorders 35
Symptoms, signs and abnormal clinical findings 18
Injury, poisoning and consequences of external causes 14
Contact with health services 14
Diseases of MSK and connective tissue 5
Others Percentage %
Injury, poisoning and consequences of external causes 25
Symptoms, signs and abnormal clinical findings 19
Diseases of respiratory system 11
Contact with health services 9
Diseases of MSK and connective tissue 6
Source: National Ambulatory Care Reporting System, CIHI, 2005-6
CUPSCalgary.com
Top 5 Reasons for Inpatient Hospitalizations 2005-2006 in
CanadaHomeless Percentage %
Mental diseases and disorders 52
Significant trauma 7
Respiratory diseases 7
Skin subcutaneous and breast diseases 6
Digestive diseases 3
Others Percentage %
Pregnancy and childbirth 13
Circulatory diseases 12
Newborns and other neonates 12
Digestive diseases 10
Respiratory diseases 7
Source: Discharge Abstract Database, CIHI, 2005-6
CUPSCalgary.com
Calgary ED SceneAlberta Health Services data (2013)
Top 3 reasons for ED visit Patients with > 10 ED visits Patients with >10 ED visits who are of no fixed address (NFA)
398,159 visits to ED in 2013 773 individuals 167 individuals with a total of 3247 visits
1. Injury 1. Alcohol abuse
2. Non-specific signs and symptoms
2. Non-specific signs and symptoms
3. Abdominal pain 3. Cellulitis
Average # visits per NFA patients = 19
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Challenges with the Current Situation• Patient factors
Homelessness and poverty Leaving AMA, non-compliance Addictions, mental illness, cognitive impairment Mobility, disability Lack of transportation Lack of ID and AHC
• Health system factors High volumes in the ED Inadequate knowledge about social determinants of health Social stigma Inadequate knowledge of community resources in ED Health information privacy Lack of a shared electronic health record Lack of a provincial responsibility for vulnerable populations
CUPSCalgary.com
CUPSCalgary.com
A Potential Solution….CUPS Coordinated Care TeamA community based team that will provide intensive case management and transition
care to vulnerable, low-income patients presenting to the Emergency Departments
• Funded by Green Shield Canada Foundation – 2 year pilot project at the Foothills Medical Centre
• Innovative strategy aligns Alberta Health Services, CUPS and community stakeholder priorities
• Case management focus• Community based• Stakeholder engagement• Partnerships
• Green Shield Canada Foundation• Innoweave• University of Calgary
CUPSCalgary.com
Case Management• Case management provides more continuous care that helps
guide client through the process• Assessment, planning, facilitation and advocacy • Intervention that extends into the community, providing
upstream care• Flexible and dynamic • Various models and definitions of case management• Coordinate housing, financial supports, addictions treatment
and mental health resources, thus improving care and avoiding unnecessary presentations to acute care facilities
CUPSCalgary.com
Case Management of ED Users• Research has shown that an intensive case
management approach for vulnerable and/or frequent users in the ED may lead to: Better health outcomes Support managing co-morbidities Increase in staff satisfaction Reductions in homelessness Reduction in alcohol and drug use Cost savings Patient satisfaction
CUPSCalgary.com
Community Based• Individuals presenting to ED may have other
needs that are not addressed by treating medical issue alone
• Benefit from more appropriate and consistent medical and social services
• Frequency and availability for follow-up in the community has been shown to improve outcomes
• Improved communication
CUPSCalgary.com
Target Population• Homeless, vulnerably housed, low income• Chronic and/or complex health conditions• Substance use issues• Mental health concerns• Lacking social supports in the community• Unattached to Primary Care Provider
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Stakeholder Engagement and Collaboration
• Met with numerous community partners and departments/working groups within Alberta Health Services
• Engaged with University regarding research support• Support from Green Shield Canada Foundation
CUPSCalgary.com
CUPS Coordinated Care Team• 1.0 FTE RN, 1.0 FTE Psychiatric RN• AHS acute care site privileges and EMR access• Access to other databases as needed –
including the Calgary Homeless Foundation HMIS
• Referrals from ED staff, inpatient units as well as community partners
CUPSCalgary.com
Inputs Outputs Outcomes -- Impact Activities Outputs Short Medium Long
Funder Greenshield Canada
Foundation Staff Medical Director Project
Lead 2 RNs CUPS Health Clinic
supports CUPS Housing and
Education supports Infrastructure Health care supplies Telus Wolf EMR Mobile devices Laptops AHS EMR CHF HMIS database Formal Partnerships AHS (service
agreement) Foothills Hospital Informal Partnerships Calgary shelters U of C The Alex Elbow River East Calgary FCC Triple AIM Edmonton ARCH CHF Mental health and
addictions Home Care EMS Calgary Case
Management Group
Participate in discharge planning
CHW accompaniment patients to community appointments
Provide transitional care, wound mgmt & follow-up following discharge
Referral to community health
Referral to community social services
Coordinate mental health care management and surveillance
Accompaniment and coordination for community addictions treatment and services
Provide Education to hospital staff and community partners
Communicate with acute care and community partners
Patient and population health advocacy
Data management Quality improvement Research
# referrals to CCT # treatment referrals # ODT referrals # of withdrawal
management consults (detox)
# referrals to ID clinic # medication coverage
applications # housing assessment
referrals # outreach/case mgr
referrals # primary care referrals # primary care intakes # of dental referrals # of eye care referrals # of mental health
referrals # of ER visits # EMS /911 calls # inpatient admissions # of inpatient 30-day
readmissions # ICU admissions Quality of life indicator Patient satisfaction
survey scores Staff satisfaction survey
scores # mental health f/ups in
community # referrals to wound
care # referrals to home care # Calgary Police
Services (CPS) contacts # referrals from CPS
Immediate advocacy for patient needs
Improved immediate
communication between acute care and community providers
Improved system
navigation for patients Patients connected to
appropriate housing resources
Attachment to Primary
Care/Medical Home Obtain valid health
insurance Attachment to case
manager
Connected to appropriate mental health services
Connected to
appropriate addictions services
Improved adherence to chronic disease management plans
Reduced inappropriate
use of acute health care systems and facilities
Increased knowledge of
factors contributing to emergency department visits
Continuity with primary
care provider
Improved mental health outcomes
Appropriate housing
placement Decreased ER visits Decreased hospital
inpatient stays Decreased EMS use Stable income support
Improved hospital staff
knowledge of community resources for vulnerable populations
Improved patient health & quality of life
Reduced systems
costs Improved
communication & coordination between agencies and systems providers
Reduced stigma for
vulnerable populations
Improved social determinants of health for vulnerable populations
CUPSCalgary.com
Anticipated Benefits• For patients
System navigation Advocacy and compassion Patient education - better understanding of health needs and concerns, follow-up
required Linkage to health and social supports Transitional care Reduction in morbidity and mortality
• For hospital Reduce demand on acute care services, both inpatient and ED Enhanced collaboration between acute care and community partners Better understanding of demographics of population (medical diagnosis, mental
health, social needs) accessing ED to support development of future interventions• For community
Improved communication and coordination between agencies Advocacy Improved continuity of care
CUPSCalgary.com
Data Collection• Looking to show effectiveness and success
How are these best defined? In this context?
• Some of the data we are collecting: Demographics: AHC status, housing stability, Hospital visit: admitting diagnosis, interventions
received, discharge plan Health needs: PCP, problem list, # of medications,
quality of life Addictions and mental health: accessing care, diagnosis
CUPSCalgary.com
Evaluation• Plan to assess the structure, process, and outcomes of the
intervention to determine whether it is effective and what the key success factors are U of C Green Shield Canada Foundation Innoweave
• Not a RCT - pre/post intervention data• Hopeful that this partnership between CUPS, AHS, and
community agencies will help to improve community-based care for these vulnerable patients and will ultimately lead to improved economic, social and health outcomes for this population
CUPSCalgary.com
The Early Days…• Patient demographics
~70% male Majority are homeless Needs include PCP attachment, discharge planning, addictions support
& mental health support• Referrals
Psych Emerg and SW Education with staff about program Staff champions
• Community engagement Community partners referring patients to ED Collaboration with Calgary Case Management Group
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Potential Challenges• Data collection!• Limited resources • Case loads• Triage process
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Sustainability• Alignment with Alberta Health and provincial goals of
improving transition care for vulnerable populations• Alignment with the provincial primary care strategy and
enhancement of the medical/health home for patients• Ongoing quality improvement efforts and initiatives• Research partnerships
University of Calgary Canadian Association of Community Health Centers Southern Alberta Primary Care Research Network Canadian Primary Care Sentinel Surveillance Network
CUPSCalgary.com
Break the Cycle
CCT
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ReferencesBodenmann, P. et al. 2014. Case management for frequent users of the emergency department: study protocol of a randomised controlled trial. BMC Health Services Research 14: 264.
Chambers, C. et al. 2013. High utilizers of emergency health services in a population-based cohort of homeless adults . Am J Public Health. 103(S 2): S302-S310.
Calgary Homeless Foundation. 2014. Point-In-Time Homeless Count: Winter 2014. [http://calgaryhomeless.com/wp-content/uploads/2014/06/Winter-2014-PIT-Count-Report.pdf].
Canadian Institute for Health Information. 2006. National Ambulatory Care Reporting System. Ottawa: ON. CIHI.
Canadian Institute for Health Information. 2015. Defining High Users in Acute Care: An Examination of Different Approaches. Ottawa: ON. CIHI.
Canadian Medical Association. 2013. Health care in Canada: What makes us sick? Canadian Medical Association Town Hall Report.
Fine, A. et al. 2013. Attitudes towards homeless people among emergency department teachers and learners: a cross-sectional study of medical students and emergency physicians. BMC Medical Education. 13 (112):
Frankish, C. J. et al. 2005. Homelessness and Health in Canada: Research Lessons and Priorities. Canadian Journal of Public Health. 96 (S2): S23-S29.
Forchuk et al. 2008. Developing and testing an intervention to prevent homelessness among individuals discharged from psychiatric wards to shelters and No Fixed Address. Journal of Psychiatric and Mental Health Nursing. 15: 569-575.
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Forchuk et al. 2015. Homelessness and housing crises among individuals accessing services within a Canadian emergency department . Journal of Psychiatric and Mental Health Nursing. 22: 354-359.
Gaetz, S. et al. 2013. The State of Homelessness in Canada, 2013. Toronto. Canadian Homelessness Research Network Press. [http://www.homelesshub.ca/ResourceFiles/SOHC2103.pdf].
Guriguis-Younger, M. et al. 2014. Homelessness and Health in Canada. University of Ottawa Press. [http://www.press.uottawa.ca/homelessness-health-in-canada].
Hwang, S. et al. 2009. Hospital Costs and Length of Stay Among Homeless Patients Admitted to Medical, Surgical and Psychiatric Services . Medical Care. 49 (4): 350-354.
Kumar, G. & Klein, R. 2013. Effectiveness of case management strategies in reducing emergency department visits in frequent user patient populations: a systematic review. Journal of Emergency Medicine. 44 (3): 717-729.
Pillow, M. et al. 2013. An emergency department-initiated, web-based, multidisciplinary approach to decreasing emergency department visits by the top frequent visitors using patient care plans. Journal of Emergency Medicine. 44 (4): 853-860.
Pines, J. et al. 2011. Frequent Users of Emergency Department Services: Gaps in Knowledge and a Proposed Research Agenda . Academic Emergency Medicine. 18 (6): e64-e69.
Sadowski, L. et al. 2009. Effect of a Housing and Case Management Program on Emergency Department Visits and Hospitalizations Among Chronically Ill Homeless Adults: A Randomized Trial. JAMA 301 (17): 1771-1778.
Tricco, A. et al. 2014. Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis. CMAJ. 186 (15): E568-E578.
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