HIV/AIDS: Unified delivery of care between St. Michael’s Hospital and Casey House

In the early ’80s, Human Immunodeficiency Virus (HIV) sent waves of shock around the world as more than 24.8 million people died from Acquired Immune Deficiency Syndrome, or AIDS. As their immune systems weakened, people suffered the rampant effects of one of the most baffling diseases modern medicine has ever known.

The Public Health Agency of Canada indicates that by the end of 1996, there were actually 20,000 AIDS cases. Currently, there are 56,000 cases of people living with HIV/AIDS in Canada, and approximately 4,200 people are becoming infected with HIV every year. Many believe it will be another decade before a breakthrough vaccine will be introduced to eradicate HIV/AIDS.

Under control but climbingIn recent years hospitals have been moving towards integrating the full spectrum of health-care services for all health-care populations, including AIDS. Although substantial HIV/AIDS health-care services exist today, there are still drug access, health-care access and other access issues for these underserved populations, such as women, children, heterosexuals, Aboriginals and intravenous drug users (IDUs). To date, one of the most successful hospital-hospice affiliations for HIV/AIDS is that of Toronto’s St. Michael’s Hospital and Casey House. Why are they closer than other health-care facilities to improving HIV access and care?

Partnership establishes decades of HIV care When Casey House first opened its doors back in 1988, the Ministry of Health and Long Term Care requested they establish a hospital affiliation, primarily for operational type purposes. Several hospitals were given this opportunity, but only St. Michael’s Hospital initiated the affiliation. “I think it had a lot to do with our missions and values, and aligning with the people that we care for,” suggests Dr. Kevin Gough, Medical Director, HIV Service Head, Division of Infectious Diseases, St. Michael’s Hospital. “It is a relationship that started way back in 1988.” Gough believes it had a lot to do with St. Mike’s opening the first HIV clinic in Toronto, and so it was a natural progression. Gough continues: “HIV /AIDS was this unknown disease…By the time it became more of a problem here in Toronto, Casey House was established. It has been a match made in heaven.”

Does this affiliation bog down the system? According to Dr. Gough, on the contrary. “In our weekly consultation, where the specialists come in, we review the interdisciplinary rounds, we go through the residence at Casey House, and discuss some of the medical issues. We often strategize around plans to work on patient care and keep them there. So instead of sending them to the ER, they get a specialist’s input on site, which helps people stay well without being transferred into the hospital.”

“From the inception of Casey House, we have had an affiliation agreement with St. Mike’s,” says Joan Lesmond, Chief Nursing Executive and Director of Medical Practice for Casey House. “Casey House was built as a standalone specialty hospital. We have our own management structure, our own board and we share support with the medical advisory committee…. For example, our residential rounds is where we talk about the complexity of client care. That’s basically the relationship.” Lesmond adds that Casey House also sees clients from St. Mike’s, who come to Casey House because they no longer fit the criteria to be at St. Mike’s. “We really are acute, but less acute than St. Mike’s so there is that continuum of care model. Patients go back and forth to support environments, depending on the acuity of care.”

Casey House has the expertise of providing care across the spectrum of the disease both within their residential and their community programs. The primary care physicians provide on-call coverage for Casey House on evenings and weekends. Plus, there are onsight consultations once per week where they have multidisciplinary case rounds. There is an infectious diseases consultant, a psychiatrist and dietician, plus other services. St. Mike’s also provides infection prevention and control, pharmacy services, and supports staff at Casey House, providing access to hospital-based, tertiary care.

If there ever is a patient who does not qualify for medication (due to income, personal finances, citizenship, etc.), then there is HIV Medication Access Project or HMAP. HMAP is a process where the medication is made accessible to individuals so that all the patients who are at St. Mike’s and at Casey House have access to medication.

The future role of HIV Centres”I think there is a need for affiliation among the institutions that care for people with HIV,” said Ron Rosenes, Vice Chair, Sherbourne Health Centre. “…The first issue is accessing medical services, and then these marginalized groups need social services and mental health services.” In terms of medical access, Rosenes feels it’s not just primary health-care, but because their illness often develops in many different directions, people with HIV need services from a variety of specialists. To Rosenes, the question then becomes whether specialized services can be delivered in a primary care clinic, or whether people need to have good hospital-based specialized care. At this point in time, a good primary care centre will be able to link a person with HIV to specialized care at surrounding hospitals.

The major hospitals in downtown Toronto, such as St. Mike’s, Toronto General Hospital (TEGH), Sunnybrook & Women’s College Health Sciences Centre and the Toronto Western Hospital all have a number of specialists who have developed expertise in dealing with the needs of people with HIV, and all these hospitals have a number of specialists who see a fair number of HIV people in their practices.

“I can’t say whether hospitals should develop this expertise (for HIV) as they are having enough difficulties just managing themselves medically,” says Rosenes. “The primary care clinics that the government is moving to establish are clearly, for me, offering the best opportunity for establishing the continuum of service that moves beyond the medical and into the social realm.”