Lindsay Jolivet

Want to Help the Homeless Thrive? Give Them Homes

2012-12-13T12:17:36-05:00

When Tessie Orcino entered the Toronto East General Hospital's psychiatric ward two years ago, she didn't know she had taken the first step to ending nearly a decade of couch-surfing and homelessness.

The Philippines-born mother of three wouldn't be returning to her sister's care this time around.

"It's killing me. It's just toxic for me," Orcino recalled telling the doctor.

Her relationship with her sister was strained and Orcino's mental health was poor. She said a life as a single mother with a mortgage had simply been too much to manage. "I worked three jobs, four jobs, not sleeping. Forgetting about myself. I just wanted my kids to have the better things that I didn't have as a child," she said.

The doctor sent her to a women's shelter where a worker had her sign up for a project called At Home/Chez Soi, run by the Mental Health Commission of Canada. Soon, Orcino was part of the largest research project on homelessness and mental health of its kind in the world. She was given a choice of apartments to live in, a rent subsidy and a case worker for support.

The five-year project has housed about 1,000 homeless people with mental illness in cities across Canada since it began. The study randomized about 1,000 more applicants into a comparison group that was offered only the services they would already have access to in their cities. Randomization ensured researchers weren't only studying people who were motivated enough to apply for At Home in the first place.

At Home is based on the idea that people should receive housing first, instead of waiting until they're deemed ready to re-enter society. Participants don't have to accept treatment for mental illness or addictions, but most of them have chosen to get help. As the study approaches its final months, researchers say many participants are thriving.

Orcino has been accepted into George Brown's Assistant Cook program beginning in January. She volunteers, sits on committees, and says she wants to help women who have been abused. About 80 per cent of participants have been successfully housed, although some are in their second apartments.

There are five local studies across the country, each with its own specifications. In Toronto, care is geared toward the city's high proportion of ethnic minorities, nearly half of the homeless population.

Those involved with At Home say it's ground-breaking research with the potential to drastically alter not only our approach to homelessness or social policy -- but our entire health care system.

It's in part about gathering data that clearly demonstrates to policy-makers how health is inextricably linked to social situation, income and environment. That knowledge isn't new. But the researchers in this study say it's rarely addressed in our policies or understood by the public.

Orcino and many of her fellow participants illustrate a relationship research has established elsewhere: health begins long before a visit to the doctor, at work, at home, and in our neighbourhoods.

"It's like a game of musical chairs, when there are fewer chairs, those that are least able to compete for these chairs will be left standing," said Vicky Stergiopoulos, one of the Toronto site's principal researchers. She said a lack of elements such as affordable housing and employment opportunities for low-skilled workers are some of the main reasons people end up homeless in the first place.

Stergiopoulos said policies that address inequalities are lacking throughout North America, and those that do exist are often poorly implemented. At Home is investigating how well housing first works for homeless people with mental illness but it's also assessing cost-effectiveness. "It was both to close gaps in the knowledge base but also to make the case, the business case, for funding in Canada," Stergiopoulos said.

According to preliminary results, the costs of housing first are offset by savings in other social services. Patricia O'Campo, another principal researcher with the Toronto study, said that for every dollar spent on housing first, the system saved 54 cents from fewer days spent in jail, in the hospital, and fewer visits to the emergency room. For those who used services the most, those savings amounted to $1.54 for every dollar spent.

She says those are promising results for a study that promotes spending money on social programs during a time when that hasn't been a priority. "Right now Canada is on a path of increasing health inequities and that has a lot to do with the kind of policies that are put in place," she said. "Not just health policies but social policies, labour policies, economic policies. All of those impact the way in which health inequalities are expressed in society."

Stephen Hwang, one of the principal investigators for the Toronto site of the study, said Canada is falling short in several areas that affect population health, including income distribution and child poverty. "Canada is doing much worse than it thinks it is in addressing the social determinants of health," he said.

UNICEF ranked Canada 24th out of 35 industrialized countries this year in a report on child poverty. Similarly, the Conference Board of Canada gave Canada a "C" grade for income inequality based on what it deemed a significant increase in the gap between the rich and the poor in recent years.

Hwang said the At Home study could provide ways to improve those scores. "What we think we are going to achieve is an intervention that radically changes people lives and provides benefits to society at a very reasonable cost."

For now, the benefits are most apparent when we look at individuals whose stories are documented as part of the research. Take Steven Roberts, a young aboriginal man who suffered from depression and alcoholism when the study began. He moved to Toronto five years ago before discovering he was HIV positive. "It all just spiralled downhill from there," he said.

Roberts was diagnosed with depression the same year and he gave up his apartment to be with his partner. "From there I was in and out of shelters and in and out of that relationship." He was living at the Salvation Army Gateway shelter two years ago when he applied for At Home.

This December 3, Roberts will have been sober for six months. He lives in an apartment at Church and Wellesley and he has just completed training as a facilitator for harm reduction outreach, to help others with similar struggles.

"It's my way of giving back to the community," he said. He's also part of the Positive Youth Outreach advisory committee for the AIDS Committee of Toronto. Roberts says he's going to apply to the University of Toronto's Transitional Year Programme with the goal of becoming a social worker.

However, the first test of whether At Home will produce the kind of large-scale change its proponents hope to see will come at the end of March, when the original funding allotment for the project runs out. It's unclear whether the program will be given ongoing funding to support the people it provided with apartments.

Faye More, Project Site Co-ordinator for Toronto, says she's optimistic the funding will continue but she awaits word from the federal government. Participants have to pay 30 per cent of their rent during the study, which most pay using social assistance. If the funding were to end after March, those tenants would have to cover the entire cost of the rent.

"In some cases they wouldn't be able to do that. They wouldn't be able to afford it," More said. It's crucial for participants to remain supported, she added, in part because it opens the door for follow-up research on how they're doing.

Still, More said some have commented that $110 million is a lot to spend researching a method based on a simple concept -- homeless people benefit from housing. Organizations in the U.S. have already implemented housing first. But Faye says it's about taking action, here.

"One can say, 'Well that's common sense, that's common sense.' Yeah, well who did it? We did."

Lindsay Jolivet is an intern with the Evidence Network of Canadian Health Policy (EvidenceNetwork.ca). Her work has been published in the Montreal Gazette, Huffington Post Canada and broadcast on the CBC.

Aging in Developing Nations: Beyond Depression

2012-10-31T14:13:11-04:00

Twenty per cent of seniors in the South American country of Ecuador live in extreme poverty, mostly in rural areas, according to a World Health Organization advisor on healthy aging.

Enrique Vega Garcia told a conference panel that the numbers are similar across Latin America and in much of the developing world. Many of these people have poor access to medical treatment and suffer ill health as a consequence.

Garcia spoke during a Winnipeg conference last month, entitled "Age-Friendly Rural and Remote Communities and Places." The conference was hosted by the University of Manitoba's Centre on Aging and co-sponsored by the Province of Manitoba's Seniors and Healthy Aging Secretariat.

The event invited academics, policy makers and representatives from seniors' organizations from countries worldwide to discuss solutions to the social and demographic impacts of an aging society.

The concept of "age-friendly," coined by the World Health Organization , stresses the need for communities to develop transportation, streets, housing , and social engagement for seniors to remain happy, active members of society.

But in developing nations, the issue goes far beyond building better sidewalks and housing. Vega Garcia recalled speaking to an older man in South America with serious health issues. The man was also dealing with family issues at the time, and Vega Garcia asked if he was depressed.

"Oh, son, I have no time to be depressed," the man replied.

Vega Garcia says impoverished seniors don't have time to enjoy old age, either, and that's a problem.

"The people don't have time to play," he said.

Responsibilities to family, community and the need to make a living for survival trump seniors' efforts to stay healthy in these areas. Vega Garcia says age-friendly in these cases means finding ways to alleviate some of the stress and responsibility of life in old age.

The Director of the University of Manitoba's Centre on Aging, Verena Menec, said we need to address the demographic shift caused by an increasing number of older people.

"It's an issue in every part of the world. Especially in developing countries."

Menec said age-friendly is a positive solution to a complex issue. She said the initiative has grown rapidly since its inception in 2006.

"It has come to be an international movement," she said.

Her ongoing research will likely measure how the health and quality of life of seniors varies in communities that have embraced age-friendly. Part of the challenge, advocates say, is changing a common perception of older people as a burden on society.

Helen Hamlin, a 90-year-old resident of New York City, relies on a mantra to dispel the myth.

"Older people are resources, not burdens," she says.

The mantra stresses seniors' contributions to society as volunteers, tax-payers, and caregivers in their communities. Hamlin is the International Federation on Ageing's main representative to the United Nations. She speaks from experience when she says that aging has gotten "a bad rap."

"When people look at me and say, 'Oh, you're that age?' I say of course. I'm proud of it."
She says she's healthy, she lives alone, and it's a good life.

"There are many people who continue to live and they don't like themselves," Hamlin said.
"You need to remind yourself that it's okay to be old."

Lindsay Jolivet is an intern with the Evidence Network of Canadian Health Policy. Her work has been published in the Montreal Gazette, Ottawa Magazine, The Sudbury Star and broadcast on the CBC.

The Small Town Where Seniors Rule

2012-10-29T17:55:51-04:00

Five years ago, you could buy a plot of land in Gladstone, Manitoba for one dollar. Residents were leaving in droves and the town, made up in large part by seniors, was dying.

Businesses were moving into the cities, taking taxpayers with them. Many towns in rural Manitoba and Saskatchewan suffered with the same problems; issues that threatened their future existence.

"People had lost faith in our community. They didn't trust the future," Gladstone Mayor Eileen Clarke said. "It caused a lot of mental and emotional stresses."

But shortly after Clarke became mayor in 2006, the municipal council, along with its Age Friendly Committee, attended a workshop about the World Health Organization's new concept of "age-friendliness." The workshop was one aspect of the province's Age-Friendly Manitoba Initiative, aimed at making communities more liveable for seniors.

The mayor was inspired. She overhauled the town's planning strategy, held public consultations and formed a new vision for Gladstone. Soon Gladstone had a new privately-funded housing project with 17 apartments and suites, an enhanced handi-transit service, and the building of an "age-friendly" walking trail, along with more community events and partnerships between organizations.

A few years later, Gladstone's property values have increased exponentially and its population has grown by nearly 10 per cent. The town saw $9 million of commercial development in the first year after the changes, Clarke said.

"We have no properties left. We are working with a land owner to develop more properties and we can't do it fast enough," she said.

Clarke said younger people have also started moving back. "The last two, three years, many of our children who are married with children, they're moving back to our community."

Gladstone's mayor was a delegate at a Winnipeg conference this month, hosted by the University of Manitoba's Centre on Aging and co-sponsored by the Province of Manitoba's Seniors and Healthy Aging Secretariat. Entitled "Age-Friendly Rural and Remote Communities and Places," the event explored where our communities fall short of meeting seniors' needs and how to improve them.

Norma Drosdowech, a retiree and an advocate for seniors' issues, said the problem is often one of communication. "We go to the hospital and we come home and nobody says how was your experience?" she told a conference panel. Drosdowech said understanding seniors' needs is simple.

"You ask them to share with you their fears, their desires, their hopes and what's going wrong and right in their lives. It's really not complex. It's that we don't ask."

In rural remote communities, the challenges can be more complex. Bill Ashton, the Director of the Rural Development Institute at Brandon University, said these areas deal with extreme cold and a chronic lack of housing and transportation to areas with better services.

"Those get worse as you get out of the cities," he said.

Ashton said cash-strapped municipalities can't always fund major development projects but there are creative solutions. While speaking with First Nations communities recently, he learned of a program to prevent seniors from getting lonely. "Often, younger members of the community actually get assigned to visit elders," he said.

Proponents of age-friendly say it also has the potential to make our health care system more sustainable.

Jim Hamilton, the Associate Director of the Centre on Aging, says we underestimate the importance of social connection on physical and mental health, which is at least as important as physical activity and nutrition. He says hospitals and clinics are designed around treating those who are already sick, not keeping people healthy in the first place.

"My health doesn't come from my annual check-up with my doctor," Hamilton said. "My health comes from how well I'm connected to my community and my friends, and what I do in terms of social engagement, and my own physical activity and my own diet and nutrition."

Hamilton says libraries, arts councils, and local events all contribute to our health and it's time we started looking more closely at making sure those elements exist in our communities.

Lindsay Jolivet is an intern with the Evidence Network of Canadian Health Policy. Her work has been published in the Montreal Gazette, Huffington Post Canada and broadcast on the CBC.

Helping the Old Die at Home

2012-10-15T07:00:04-04:00

Most seniors say they want to die at home. However, about half of seniors are dying in hospitals, according to research by Verena Menec, the Director of the University of Manitoba's Centre on Aging. She says many of these patients don't need to die in the hospital. They could be dying in more comfortable settings if we had the services to provide them. But often, we don't.

Menec, who is also an expert with EvidenceNetwork.ca, says hospital care isn't structured to treat frail, elderly patients with chronic illnesses. "It's very stressful to the person who is dying in that setting but it can also be very stressful for the family," Menec says. Many patients bounce in and out of emergency rooms several times at the end of their lives.

"Imagine a 90-year-old person, coming in, frail, confused. They're coming through an emergency department and they die in an emergency department. There's no family, there's that whole bustle of the emergency department," Menec says. "I think that's really sad."

Given the numbers, it seems a daunting task to grant a senior's wish to die at home. Dr. Louise Coulombe set out to meet that challenge when she founded a home care palliative care practice in Ottawa.

She drives around the city delivering palliative services to patients in their homes. Back at her office, the computerized management system calls out the names of patients who are due for a visit. The cold, digital voice contrasts with Coulombe's description of her very personal interaction with patients.

"You basically see people in four dimensions at home. You walk in and immediately you know they're different from everybody else. You see them in depth, not just where they are now but where they have been."

Coulombe gets into her car to visit 89-year-old Russell Peacock, a man with thyroid cancer who lives alone in a small bungalow. Coulombe calls him a great talker. As soon as she arrives he launches into a story. "Oh I had a terrible day today. Yesterday I mean. I went shopping with my brother ... He was exhausted and so am I." Coulombe interrupts his tale repeatedly to tell him to sit down, not to tire himself out further.

Peacock could live from three months to six months or more.

"Well here I am. I don't know how long it'll be but I don't care. You just live it day by day anyway. You know? Live everything day by day." He's lived in this house since shortly after he returned from serving in the Second World War. He still remembers the date he moved in, October 13, 1947.

"Fifty-four years I've been here. Oh jeez, imagine that. A whole life gone." Peacock's wife, Vera, died here and this is where he'd like to stay. "So we stayed here and I'm still here. Still keeping me in my house. Between the doctors there and palliative care I can handle it, you know?" he says, laughing.

Dr. Coulombe says our medical system is slowly changing to accommodate practices like hers.

"We started to feel that we could conquer death and we're learning, in the last fifteen, thirty years that we can't. And we're beginning to see that this is part of life. Before it was separated completely and you died in a dark place in a hospital and that's how you did it in this society."

Advocates like Sharon Carstairs say the strain on the system will be damaging if we don't change how we deliver health care -- and soon. "We're actually going to go backwards unless we make a significant change in the way we deliver care." Carstairs retired from Canada's Senate after 17 years advocating for a bigger focus on palliative care. She says we need to reinvent the health care system to avoid debt from rising costs.

"We need more doctors, we need more nurses, we need more health care professionals generally who are trained in palliative medicine. We need greater research and we need home care," she says.

Hospital deaths are also a cost issue; full beds can cost the Canadian system about a thousand dollars a day in hospital, compared to about fraction of the cost in a long-term care institution. By the Ontario Home Care Association's estimate, a long-term care bed can cost as low as $126 a day. Home care can be even less expensive depending on the type of care the patient needs.

Carstairs says we need to face the reality that 100 per cent of people die. She says it's essential to provide more settings where patients can be comfortable and surrounded by family at the end of life. Where care can do more than treat illness -- it makes it easier to write a happy ending to a life story.

Lindsay Jolivet is a graduate from Carleton University's Master of Journalism program. She is an intern at EvidenceNetwork.ca and her work as appeared in the Montreal Gazette and on CBC radio.

Check out an audio version of this article here.