Self Provision of Alcohol and Drugs Ottawa s Managed Alcohol Program: A Fundamental Component of an Overarching Strategy for the Care of the Homeless

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1 Self Provision of Alcohol and Drugs Ottawa s Managed Alcohol Program: A Fundamental Component of an Overarching Strategy for the Care of the Homeless April 24, 2013 Dr. Jeffrey Turnbull Founder & Medical Director Ottawa Inner City Health Inc.

2 Overview Alcoholism and homelessness Treatment Options + Harm Reduction Ottawa Inner City Health Project The Managed Alcohol Project Conclusion

3 The Impact of Alcohol WHO 2011: 3.4% of global death and 4.6% of DALY Health Canada: 2012: 4-5 million Canadians high risk drinking 2003: $14.6 billion Current alcohol abuse: % of homeless adults % of homeless report a history of alcoholism over their lifetime Heavy alcoholism, more than 20 drinks/day common Use of non-beverage alcohol e.g. mouthwash/hand Sanitizer is frequent due to low cost and availability Homelessness & Inequity in Canada 300, 000 to 450,000 homeless / day 1.3 million unsustainable housing 868,000 use food banks per month 12% of children live in poverty

4 53 year old woman Chronically homeless Alcoholism x 40 years Chronic schizophrenia Heart disease Drinks bottle of wine before entering the shelter OR-- Sleeps on grates- doesn't want to give up her bottle which she can not bring in Case - Alice

5 Risks to Homeless Alcoholics Refusal of shelter entry Violence: physical/sexual Exploitation Intoxication Trauma Hypothermia Untreated acute and chronic medical and psychiatric illness Police arrest

6 Following an inquest into the freezing deaths of 3 homeless alcoholic men, the pattern to achieve in-shelter abstinence from alcohol was noted to involve heavy consumption prior to shelter entry, followed by early-morning alcohol seeking behavior to prevent withdrawal

7 Alcoholism Homelessness and Service Use- ER Chronic alcoholics heavy users of emergency services relative risk of for frequent ER visits alcoholism a characteristic of 81% of the homeless seen in ER Alcohol intoxication Alcohol withdrawal seizures Trauma Hypothermia Infections, cardiovascular disease, psychiatric disease, primary care

8 Alcoholism Homelessness and Service Use- Hospital and Police When compared with housed persons, the homeless have increased rates of chronic illness and longer hospital stays (4 days longer) with higher costs (extra $4000 USD) per admission. Mean age at death of homeless is years Police encounters are frequent for public drunkenness 70% of homeless alcoholic men have a history of imprisonment

9 Summary Homeless alcoholic individuals have increased use of crisis services, ambulances, frequent police contact, deprivation of primary care, increased medical complications and increased mortality.

10 Treatment Options While treatment of alcoholism using detoxification and abstention is clearly the best option from a health perspective, the likelihood of compliance and rehabilitation in chronically homeless alcoholics is extremely low Factors that may preclude sobriety: poor social support psychiatric illness lower levels of cognitive and social functioning lack of stable housing duration of addiction lifestyle preferences refusal of treatment

11 Treatment Options Despite the common occurrence of chronic homeless alcoholics in the streets of every industrialized city in the world, this population has been grossly under recognized in program development, intervention trials and clinical literature. In response, a managed alcohol harm reduction program was developed for these long-term homeless individuals with refractory alcoholism.

12 Harm Reduction Harm reduction is a policy aimed to reduce the adverse health, social and economic consequences of substance use without requiring abstinence.

13 Ottawa Inner City Health Project Initially introduced in 2001 as a pilot project to manage the chronically homeless with complex health needs unable to access mainstream services due to behavior or lifestyle

14 OICHP Partners Ottawa Hospital University of Ottawa Royal Ottawa Hospital Community Care Access Centre Community Health Centres The Mission The Salvation Army Fee for Service Physicians ACT Teams Homes for Special Care City of Ottawa People Services Volunteers Anglican Social Services Cornerstone Shepherds of Good Hope Canadian Mental Health Association Wabano Centre for Aboriginal Health Centre for Addiction and Mental Health Carefor Youth Service Bureau Bruce House Ottawa Police Options Bytowne Howard Society

15 Model of Service

16 Specialized Services Residential Care 16 bed Wet Program 30 bed Men s SCU Program 16 bed Women s SCU Program 15 bed Hospice Program 45 unit Housing Program (Oaks) serving seniors and graduates from Managed Alcohol Residential Aging at Home for Women Ambulatory Care Primary Care Clinic Dental Clinic Scattered Supported Housing 10 SSH units 8 Senior Women s units

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18 Managed Alcohol Programs in OICH: Subjects referred by shelter staff, police, colleagues or community workers. Criteria: chronically homeless severe alcoholics and for whom abstinence-based programs had failed or been refused.

19 2001

20 2010

21 Copyright 2006 CMA Media Inc. or its licensors Podymow, T. et al. CMAJ 2006;174:45-49

22 Clients are given up to a maximum of 5 ounces of wine or 3 ounces of sherry hourly, on demand, from 7:30-21:30 seven days per week. The program employs a client care worker to supervise the subjects, help with activities of daily living, aid in social benefit applications, accompany to medical appointments, and dispense regular medications.

23 Managed Alcohol Programs Medical care is provided 24 hours/day by nurses and a physician associated with the project Record keeping is performed using a secure, on-line medical record system

24 Managed Alcohol Programs Staffing WET FTE Oaks FTE Front Line Workers CCW RN Physician Mental Health Nurse Admin Staff Team Leader Manager Activity Coordinator

25 Copyright 2006 CMA Media Inc. or its licensors Podymow, T. et al. CMAJ 2006;174:45-49

26 Harm Reduction Treatment Outcomes Successful treatment for condition for which patient was admitted which accords with Canadian standard for care 85% Primary Health Care Needs and Screening for Disease completed 89% Reduction in Risk Behaviors including substance abuse 64% Appropriate use of hospital and EMS services 91% Compliance with Recommended Medical treatment 95%

27 Fig. 1: Monthly numbers among study participants (n = 17) of visits to the emergency department (ED) and police encounters before and during the program Podymow, T. et al. CMAJ 2006;174:45-49 Copyright 2006 CMA Media Inc. or its licensors

28 Harm Reduction Demographic Information Age Gender: 109 Male, 17 Female, 1 Transgender New Admissions (N=127) WET Oaks Mental Health 71% 69% Physical Health 50% 40% Housing 1% 52%

29 Program Costs WET Oaks Cost per Patient $97.58 $88.50 Alcohol Consumed (oz) per person per day Tobacco Consumed (pouches)

30 Program Outcomes Reason for Discharge WET Oaks Housing Obtained or Moved Transferred to Another Program 3% 26% 4% 2% Non Compliance 4% 0 Deceased 0 (4)

31 Program Outcomes - Compliance Does the client make appropriate use of physician & nursing services? Does the client attend medical or other appointments as scheduled? Does the client identify the need for change in their current lifestyle or habits? Does the client participate in activities outside of the OICH program? WET ( ) Oaks ( ) 98% 96% 87% 95% 71% 5.6% 20% 94%

32 Program Outcomes Self Care WET ( ) Oaks ( ) Does the client maintain the routines of daily living? 96% 99% Does the client attend to expectations regarding personal hygiene? 66% 95% Is the client physically active (relative to their ability)? 100% 98% Is the client connecting with family and friends? 95% 84% Is the client volunteering/working or going to school? 15% 34%

33 Program Outcomes Management of Illness WET ( ) Oaks ( ) Screening for Infectious Diseases addressed during stay Stabilization and management of chronic physical health conditions during stay Stabilization and management of mental health issues during stay 91% 92% 89% 89% 91% 89% During stay, did the client cooperate with dressing changes, glucosan, BP monitoring etc > 80% of the time? During stay, did client take medications as prescribed >80% of the time? 96% 90% 92% 95% Were they successfully treated for the reasons they were admitted? 80% 89%

34 Program Outcomes- Disruptive Behavior Did the client consume alcohol out of the program? Did the consumption of these substances ever result in a problem? Is there a reduction in incidences with police/ambulance (as per program logs)? WET Oaks ( ) ( ) 99% 45% 99% 39% 95% 60%

35 Client Admission Arrests Pre- Admin Arrests Post- Admin Approx. cost per pre-admin Approx. cost per post- Admin 18/06/ $19, $ /04/ $3, $ /07/ $34, $1, /10/ $10, $ /10/ $35, $1, /04/ $11, $ /04/ $22, $2, /07/ $11, $ /04/ $11, $1, /06/ $6, $ /12/ $2, $ /06/ $3, $ /11/ $6, $ /09/ $2, $ /11/ $4, $ /06/ $5, $ /08/ $5, $ /10/ $2, $ /07/ $3, $678.00

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37 Targeted Engagement and Diversion (TED) Men and Women who are homeless who have complex medical care needs substance use disorders mental health disorders may be in conflict with the law psychosocial problems heavy users of social and health services (including ED& paramedic services) socially unacceptable behaviours (violence, aggression, bizarre behaviours)

38 Targeted Engagement and Diversion (TED) (cont d) 80 individuals at any time, 120 per year Unmet Care Needs: Physical Health Care needs Housing Mental Health Substance Abuse Financial Legal Family/Social

39 Conclusions A managed alcohol strategy using the principle of Harm Reduction: Is one of several important strategies for dealing with alcohol abuse within the homeless environment Leads to improved: Self care Health related outcomes Reduced judicial and emergency medical service A greater sense of community Cost-effectiveness Is sustainable