D5-b - Bridges to Housing –a Powerful Example of Comprehensive Team Based Care

5. Community and social accountability
 

  • Date: Friday, September 20, 2019
  • Concurrent Session D
  • Time: 9:45am 10:30am

  • Room: Pier 8
  • Style: Presentation (information provided to audience, with opportunity for audience to ask question)
  • Focus: Balance between both (e.g. Presentation of a best-practice guideline that combines research evidence, policy issues and practical steps for implementation)
  • Target Audience: Leadership (ED, clinical lead, board chair, board member, etc.), Clinical providers, Representatives of stakeholder/partner organizations

Learning Objectives

  • Learn how partners came together across Provincial Ministries, organizations, and disciplines and began a project to support 25 long term homeless individuals with complex needs and got permanently funded
  • Learn about the psychological screening tool to help shelter counsellors identify those with probable developmental disability to help support proper identification
  • Learn what made the partnership successful, and how the 25 individuals’ health became stabilized as they became successfully housed after years in the shelter system    
  • Learn how outcomes were measured and what factors made the difference  

Summary/Abstract

The Bridges to Housing team came together in 2016.  Organizations included -- the Inner City Family Health Team, the City of Toronto, St. Michael’s Hospital/CAMH, Community Living Toronto, and Surrey Place to put in a proposal to try to support homeless individuals living at either Seaton House or at Women’s Residence to get the proper assessments, and support.    After being funded, the Clinical team initially included a Nurse Practitioner, Psychologists, Health Promoter, an APSW worker, and two City case managers.  Research and oversight was included.      Initial challenges were overcome—how to locate people with a suspected Developmental Disability in the shelter system?  How to adapt the long psychological assessments necessary in order to properly identify and diagnose those with a Developmental Disability?  How do organizations come together across sectors and ministries with different organizational cultures and disciplines?    The Comprehensive Team came together, and all 25 Bridges to Housing clients began receiving care.  The primary care, mental health and addictions, and cognitive challenges were enormous but all 25 clients were successfully housed.    The project received on-going funding for the core team along with one year funding for three additional staff—O.T., B.T. and Peer Recovery Coach.  The initial research with St. Michael’s and CAMH was concluded and Surrey Place began the second phase of research.  We will present the early findings from our second phase of research, and what we have learned so far.    

Presenter

  • Jo Connelly, Executive Director, Inner City Family Health Team
  • Dr. Sylvain Roy, Neuropsychologist, Inner City Family Health Team

Authors/Contributors

  • Jo Connelly, Executive Director, Inner City Family Health Team
  • Dr. Sylvain Roy, Neuropsychologist, Inner City Family Health Team