2. CUPSCalgary.com
Calgary Urban Project Society
CUPS is a non-profit organization dedicated to helping
individuals and families in Calgary overcome poverty
3. 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)
4. CUPSCalgary.com
CUPS Mission
Through 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
5. 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
8. CUPSCalgary.com
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
9. CUPSCalgary.com
CUPS Activities: Housing
Housing
• Key case
management
• Graduated rent
program
• Community
development
Supports
• Crisis intervention
fund
• ID assistance
• Bursaries
• Tax assistance
• Nutrition program
10. CUPSCalgary.com
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.
11. CUPSCalgary.com
Primary care
Prenatal care
Obstetrics
Pediatrics
Hepatitis C clinic
On-site lab
Shared care mental health
Visiting specialists
Outreach clinics
Dental clinic
Optometry
Dietician
Foot care
CUPS Activities: Health
Patient centered
Team-based care
Continuity
Comprehensive
Enhanced access
Continuous QI
Education & research
12. 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
14. 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
15. CUPSCalgary.com
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
16. CUPSCalgary.com
Top 5 Reasons for ED Visits 2005-2006
in Canada
Homeless 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
17. CUPSCalgary.com
Top 5 Reasons for Inpatient
Hospitalizations 2005-2006 in Canada
Homeless 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
18. CUPSCalgary.com
Calgary ED Scene
Alberta 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
19. CUPSCalgary.com
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
21. CUPSCalgary.com
A Potential Solution….
CUPS Coordinated Care Team
A 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
22. 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
23. 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
24. 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
25. 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
26. CUPSCalgary.com
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
27. 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
28. 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
29. 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
30. 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
31. 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
32. 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
34. CUPSCalgary.com
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
37. CUPSCalgary.com
References
Bodenmann, 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.
38. CUPSCalgary.com
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.
Poverty is linked causally to an increased likelihood of chronic health concerns and of educational and skill-based deficits. Growing up in poverty increases the likelihood of living in poverty as an adult and experiencing those health and educational deficits.” (Calgary Poverty Reduction Initiative, Recent Trends, 2012)
Solid Base of Wellbeing
Physical, mental emotional and spiritual health
Readiness for productive activity
Stable Environment
Housing that provides a stable base from which to survive and thrive
Adequate necessities in the home to provide nurturing and safe environment
Engaged, supportive community
Improved Quality of Life
Drug and alcohol independency
Stress reduction
Education
Higher income
This graphic is from the Robert Wood Johnson Foundation who has done research on ACEs
RWJF is a partner in a research project that CUPS has recently become engaged with
In addition to these, ACEs have been identified as the root of other social issues such as:
Poverty
Isolation
Conflict with the law
Parenting difficulties
The original ACEs study was done between 1994-1998 in the U.S., surveying 17,000 individuals
In 2013, a telephone survey of 1,200 Albertans was completed
Key findings were:
Before the age of 18, 27.2% experienced abuse & 49.1% experienced family dysfunction
ACEs usually occur in clusters; having one ACE increases the probability of experiencing another by 84%
Dr. Suzanne Tough, who was the principal investigator with the Alberta Adverse Childhood Experiences Survey, and a good friend of CUPS, has identified three mechanisms to preventing the effects of ACEs:
Firstly by preventing the exposure of children to ACEs
Secondly by identifying those at risk for ACEs & providing interventions
Finally by providing targeted treatments for those suffering from ACEs
This is the plan to stop the spread of the ACEs disease!!
CUPS’ programming addresses all three mechanisms!
Housing services help vulnerable adults and children secure housing, as well as build the skills and community connections needed to maintain it
CUPS offer housing assistance through Key Case Management, a Graduated Rent Program, and Community Development, all which aim to provide housing stability
Support programs provide crisis management, referrals, assistance in obtaining ID, educational bursaries, nutritional education, and help with filing taxes
Parent-focused programs:
Nurturing Parenting and Supporting Father Involvement
Child-focused programs:
Pre-natal to Three and One World Child Development Centre
The Family Development Centre provides support for the family unit as a whole.
- Higher levels of morbidity and mortality, higher incidences of alcohol and drug use, higher rates of mental illness, infectious disease
Data from the Canadian Institute for Health Information
This study tracked ED use mostly in Ontario
Proportion of the homeless who received ER services in the past year: 32 – 40% 9,10
ER visits by the homeless: mental health and behavioral disorders were the most common reasons.
Hospitalizations by the homeless: mental health and behavioral disorders were the most common reasons.
Mental health reasons not even in the top 5 reasons for ER visits/hospitalizations in the rest of the population.
Study excluded Quebec
3247 total # of visits by homeless patients divided by 5 ER/UC sites = 650 visits per site
Divided by 365 days/year = 1.8 patients per day per site
Excluding weekends, 260 working days in a year = 468 patients/site/year so this team of 2 case managers will be able to help 4 patients per day per hospital (2 hospitals).
Aim to help 700-900 patients per year between 2 hospitals and 2 case managers.
Total # visits by
NFA patients
Avg Visit per NFA patient
3247 (0.8%)
19.44
In Alberta, 5% of patients utilize ~70% of all acute care spending
Mental illness, addictions, poverty, housing instability and food insecurity – additionally medical complexity, all lead to high burdens of illness
Social: HOUSING FIRST
Multiple examples of ED case management programs across Canada – Vancouver (Friendly Faces), Edmonton (ARCH), Winnipeg, Toronto (CATCH-ED)
We will use a mixed methods approach to evaluate the intervention, encompassing both quantitative and qualitative assessments using: granular clinical and administrative data, primary survey data, and interview and focus group data from both providers, patients and community partners. Our comprehensive evaluation will ensure that, in addition to considering final outcomes, we gain a complete understanding of how the intervention’s structure and processes, in relation its context in which it is deployed, influence its success.
Some discussion here – any solutions? Things that have worked for other agencies
Other barriers?