Connecting marginalized patients with the right level of care

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When Charlene Crews comes to work at St. Michael’s Hospital she’s never entirely sure how her day will unfold. As one of three transitional case managers for the Coordinated Access to Care from Hospital (CATCH) Homeless program, Charlene is responsible for working with homeless patients who have been referred by their acute care physician and linking them to vital support services within the community, following their discharge from hospital.

“I feel very fortunate to be part of this program,” says Crews. “Before this initiative vulnerable patients would be discharged from hospital without any direct support in place for additional care.”

CATCH-Homeless offers multidisciplinary transitional support, including case management, peer support, nursing, and primary and psychiatric care. The team identifies client needs, offers treatment of an acute episode of illness and initiates referral to the appropriate level of long-term support. In addition, case managers help clients meet their immediate basic needs by helping them access the Ontario Disability Support Program, showing them where they can find food and clothing banks and assisting them in establishing roots in the community.

CATCH is the first program of its kind in Canada. A partnership between St. Michael’s Hospital, Toronto North Support Services and Inner City Health Associates, it was set up to help people who tend to rely on the emergency department for their healthcare to find the right level of care in the community. In addition to St. Michael’s, the program serves homeless people presenting to St. Joseph’s Hospital and the Centre for Addiction and Mental Health and hopes to expand to other settings serving homeless people with unmet health needs.   CATCH Homeless, which began in 2010, just accepted its 1,000th referral and has received positive feedback from clients and system stakeholders.  “This program and Charlene in particular are the reason I am where I am today,” says a CATCH client who asked that his name not be used. “Before I met her my life was spinning out of control. She has been my sounding board and has pushed through barriers and opened doors in the community that I never could have done on my own. Falling to addiction and recently a separation, I truly believe the CATCH program and Charlene in particular has been the building block I needed to refocus my life.”

Vicky Stergiopoulos, psychiatrist-in-chief at St. Michael’s Hospital, was the driving force behind the program. “There was a huge gap in our health care system around access to follow up care in the community for our marginalized patients,” Dr. Stergiopoulos explains. “Through the creation of CATCH-Homeless we eliminated the numerous barriers that existed and created a central hub for patients to be referred to where they have access to both medical and non-medical community support before their discharge from an acute care facility.”

The success of CATCH-Homeless has a lot to do with its model of care. The only rule is that a client cannot have any form of stable housing and is not connected to supports. Should a client stray from the program for a short time, which sometimes happens, he or she can return without having to be referred again. All he or she has to do is reconnect with his or her transitional case manager. This sets CATCH apart from other agencies that assist vulnerable patients.

Crews says she believes that although access to a long-term case manager is an important aspect of this program, sometimes all the client really needs is a friendly voice on the other end of the phone. She worked closely with one client who she felt would benefit from stable housing. No matter how hard she tried to convince the client that stable housing would increase his quality of life, he was adamant that staying outside was safer for him. She respected his decision but brought him a sleeping bag so he would have somewhere warm to sleep. It wasn’t permanent housing but it did make a difference in his world.

The program team consists of a project coordinator, three transitional case managers who are provided to St. Michael’s, St. Joseph’s and CAMH by Toronto North Support Services, one St. Michael’s family physician and two St. Michael’s psychiatrists, including Dr. Stergiopoulos. Physician funding comes through Inner City Health Associates.