deinstitutionalization

Let me start by saying that I realize I'm touching on a controversial subject.  I'm going to talk about it anyway.  

A few nights ago I was at a meeting about disability rights legislation.  Yay advocacy and policy development!  Anyway, at the end, for the "check out" (gotta love meetings run by social workers...) we had to share a barrier we thought was faced by the disabled community or that we were currently facing.  I talked about lack of adequate access to mental health care, some people talked about attitudes, others about accessability and employment, all the normal things.  What surprised me, was the number of people who talked about institutionalization and how important it was that we continue with deinstitutionalization.  

I'm not sure why it surprised me.  It's not exactly an unfamiliar concept for me, and for that matter it is something our government is currently working on.  Our newest Assertive Community Treatment team was set up to take referrals only from the long term mental health care facility, at least in it's initial stages.  In otherwords, it was designed to be intensive support for deinsitutionalization.  

The thing is, in my experience, institutionalization, in some way, is necessary, until we come up with better options for psychiatric treatment.  I spent eight months doing practicum in Assertive Community Treatment, the most intensive form of community mental health care my province has to offer.  The clients have a team of professionals and twenty four hour on call support.  They have daily contact, sometimes twice daily, observed meds and assistance with just about anything you could need assistance with.  Unfortunately, even with this very intensive level of support it was necessary to make two referrals to the long term care facility during my eight months.  Of course during that time we had many success stories as well.  

See the thing is, despite everything the team was doing, these clients simply could not be maintained in the community.  One woman was living in a rodent infested house with rotting floors, sleeping in a urine soaked bed, the house was in and out with drug dealers and the dirt was incredible.  She absolutely refused to take meds or to move.  Eventually the police had to remove her from the home and the public trustee made the decision to stop paying her rent.  The last time I saw her, she was doing okay in hospital, but certainly not well enough to live out again.  Another was so mentally ill and so drug addicted she jumped off a bridge, thankfully not too high up.  The courts didn't know what to do with her many crimminal charges and once release from jail or hospital she'd disappear for days at a time without taking her meds.  Because of her spinal injuries, she was referred to long term for her own safety.  

And then there are the forensic patients.  We have a special locked ward for them.  And seriously, I've been on the "worst" ward in the long term care facility.  The patients there are very, very mentally ill.  They are affected in ways that I cannot even begin to imagine.  Maybe with time, and patience and new treatments something will change, but until then... where will they go if their insitution is shut down?  

Finally there are the geriatric patients.  I've got news for you, schizophrenia doesn't end with middle adult hood, brain injuries don't magically heal.  And while we do have specialized homecare services, some clients just need more then that.  

So, i do agree with deinsitutionalization.  I want to be very clear about that.  I also don't agree with the institutions of the past, however, I want to make it very clear that there is a time and place in which long term psychiatric care facilities are necessary, and I don't think closing them all, especially without replacing them, will do the community a whole lot of good. 

dumped on the door step

The other night a taxi stopped in front of the shelter.  This isn't all that unusual as people are always calling to get picked up from the drunk tank.  In this case though, the taxi was dropping someone off... I guessed almost immediatly what had happened, and I was right on the mark. 

We have a relationship with the downtown hospitals.  They'll call us and we'll send someone out in the van to pick up clients and drive them home or to the shelter.  They understand, for the most part, that we fill up, and with the exception of the brand new staff, understand that the shelter does not have any reserved beds even if a patient has given us as their address.  We will work with the hospital to try and find that person a place to go, and if worst comes to worst, they'll let the client spend the rest of the night in their waiting room and we'll pick them up in the morning in time for coffee.  It's not an ideal arrangement, but it works for the most part.  

Unfortunately, because of the way the hospital is divided, our shelter actually falls in the catchment zone for one of the suburban hospitals...how, I don't know, but it does.  This means, that when an ambulance picks up one of our clients from the shelter or surronding area, they generally wind up almost on the edge of the city, outside of our driving boundaries, and if the buses have stopped running for the night, with no way to get back downtown.  This particular hospital has somewhat of a relationship with us, simply by default, but not in the same way as the others.  And so, when that cab pulled up, I just knew it was going to be a person dump.  

And so, an old lady wound up on my steps, in the winter, with no jacket, no way to get anywhere, and our shelter was full.  Even though I'd turned away numerous people that night, I let her in, because really, what was I to do, the cab had driven away, and she wasn't one of our regulars who I knew could be "street smart".  It turned out, she had a house, but didn't have keys and so had no way to get in.  The hospital had given her a cab voucher to get to us, and assumed that we'd take care of the situation for them...how nice of them.  

I was pissed off.  SO, I did something I rarely do, I called up the hospital, and politely, gave them a piece of my mind...I think may have scared the poor girl in the ER, not something I'm proud of.  See the thing is, I can totally empathize with them.  This woman is a frequent flier, and there was nothing medically wrong with her.  Brought in by ambulance, she presented without her jacket and keys.  The hospital would have given her cab fare home, but despite repeated calls to her land lord, she had no way to get inside, and they were unable to reach anyone else for her to stay with.  They then sent her to the homeless shelter, thinking we could give her a place and help her out in the morning.  She also contributed to the situation by lying and saying she was a regular of ours when in truth, she was brand new and had no idea what she was getting herself into.  

I explained to the hospital that we need them to PHONE first before sending us something.  That maybe together we could work out a plan.  I explained that we fill up quickly at night and so unless they call first there is no gaurantee that a person is going to get in.  I talked to two different people, and I think I got my point across.  What I really wanted to say though was "dumping people on the doorstep of a shelter is NOT okay".  I really felt for this woman even though her lifestyle is likely what caused this situation in the first place.  And despite being medically cleared, she really did not look healthy.  

The thing is, hospitals are not homeless shelters.  They aren't set up to house clients because they have no place else to go.  The emergency room is not set up, nor should it have to be, to deal with people like this woman who present over and over and over and over and over.  I'm not sure what the answer is though.  Obviously we need some sort of a different system.  Personally, I think perhaps a lock smith might be a good assest to our emergency system.  I can't tell you how many people we house when they get locked out for the night.  Makes me double check my spare set of house keys everytime.  

James goes to the hospital

It's funny, some of the homeless WAY overuse the medical system, constantly presenting to emergency services and emergency rooms.  There are others though, like James who don't get medical care until it's almost too late.  Because James' drinking is a little more controled then some of the others, he doesn't wind up passed out in the street quite as much and so he doesn't have the (sometimes daily) frequent medical care of others in his cohort.  So, when James got pnemonia, it wasn't till he was passed on in a pool of his own vomit in the back of the shelter that he started his contact with the medical system.  

The paramedics, were horrible.  I seriously, have so much respect for them, they do a crazy job, but each time they insult one of my clients or talk about them like they're stupid and just a burden on society I get more and more angry.  There's some good ones, and the first responder fire fighters are usually awesome, but the paramedics... wow, they're getting to me!  Anyway, they treated him like crap even though he was super cooperative and friendly with them.  There was no rudeness on his part, just some smiling (he loves to grin) and he did his best.  

There's a funny part to this story though.  I was talking to one of this client's good friends at the shelter and asked how he was doing.  Turns out though, somehow, none of this client's friends knew what had happened to him, infact, they were all quite worried as he'd just disappeared into thin air.  So, I made an oops with client confidentiality, assuming they knew he'd been hospitalized, but I think it'll be okay.  

Anyway, the client I was talking to was super relieved and decided he'd get the whole gang together to go visit their friend in the hospital.  These particular clients are the very, very chronically homeless.  They're the ones you see passed on in doorways and on sidewalks.  They're the ones who haven't bathed in years.  One of them wears a hood all the time, dresses all in black and has ear buds, which I discovered in one of his less intoxicated moments are to keep the voices out.  They're almost always intoxicated to some degree and well, if you didn't know them, they'd look pretty scary.  

What I laugh at, is the poor staff at the hospital as these guys come through the door.  If you or I was to visit a friend it would be one thing, but these guys are something else.  I'm so glad they're going though.  It shows the strength of the community.  Hopefully these guys don't pull a fast one though... our clients have been known to bring drinks and get their friends drunk while visiting!  When you're wearing 8 layers of clothing (you only think I'm exagerating), it's pretty easy to get stuff in.  

old and drunk

Whenever pension cheques come out the drunk tank fills up with those over sixty five, many of whom are definitely elderly.  Some of them are still quite spry, but others are just WAY to old to be sleeping in a cold cell on an inch thick mat.  And yet, every pension day, there they are, drunk as anything and creating a fuss or making a "nusiance" of themselves somewhere.  Often it's as simple as they can't get themselves home because they're too drunk to walk.  I have one person who forgets to use her walker when she's drinking and forget's she can't walk well without it.  She holds it in one hand and carries it.  

And then, then there's mr. nicholas.  Somehow, he manages to get drunk almost every day.  He hobbles in with his walker, usually after passing out somewhere, landing at the hospital and getting picked up by the police.  Everyone knows mr. nicholas, he's a fixture.  And sadly, he has no memory left.  He often does not remember that he has an apartment in a nice area or even where that area might be.  What he remembers, is how to drink, and drink he does.  I'm not sure there's a record for drunk tank admissions, but I think he'd probably get it.  

What do you do with a person like that?  He spent some time in psych after being declared incompetant, but you can't hold him forever.  Once he was "stabalized" he was found really nice housing and set free.  He returned right back to where he was, drinking on the strip.  If he was placed in a nursing home I suppose he'd have to be locked in the way my grandmother is.  Only in her case, she thinks the nursing home is a nice hotel and that she still lives at home.  

The thing is, the guy is happy.  This is his life, and this is what he likes to do.  The problem is, it's a drain on the system.  He drinks, he passes out, someone calls an ambulance, then there's the hospital work up, then the police car ride and then the drunk tank fee.  And once he's released, the cycle starts all over again.  

and again

and again

and again

sick and homeless

This week seems to be healthcare week on the blog, or maybe ill health week, or something like that...  The image on the left is rhinovirus, or the common cold.  One of those things we all get, all hate, and most of us get over pretty quickly.  I've been blessed enough that I haven't had a cold yet this winter (no wait, I did, that one I had before I got strep throat...) In anycase though, whatever cold I did or didn't have is such a distant memory that I can't remember it (what a sentance).  

There are a lot of things most of us take for granted when we're sick.  Things like being able to buy ourselves some cold medicine, make some tea and curl up in a warm bed - even if we do drag ourselves to work.  We can look our symptoms up on the internet and get an idea of what's what (although this can backfire...trust me).  Most of us have friends or family who can drive us to the doctor, or the hospital if we're really sick.  People who'll help take care of us or our families if we need a little help.  Gosh, most of us know that if we've got a stomach bug we can at least have the privacy of our own bathroom to puke our guts out in.  

When your homeless, things change.  Homeless shelters are definitely NOT the place to be staying if you're sick, but for some people there are no other options.  I have a client right now who has cancer and has to have some major surgery.  She and her partner are looking for a place to live because once she gets out of the hospital recovery will take some time and she knows the shelter really isn't the best place to do it.  We try and be understanding of people's dificulties but the fact of the matter is we are only open 21 hours a day and people need to find someplace else to be during those 3 hours.  

Another thing about the shelter is how germs spread.  While we do our best to keep things clean the truth is people are still sleeping on mats side by side on the floor.  So when one person gets sick, well, everyone's getting sick.  That's one thing about the shelter, it's never quite.  There is always someone coughing, wretching, gagging etc...  One night there wasn't and I was worried and when around and checked to make sure people were breathing, fortunately it started up again.  

Recovering from being sick is a lot different when you don't have a safe comfortable place to do it and when you don't have healthy nutrious food to eat.  Illnesses seem to last longer or just never go away.  I know for some of my clients they haven't felt "healthy" in years.  

once again, a post with no answers... 

health issues and homelessness

Everyday I am amazed by the number of people who come into the drunk tank with serious health issues who are on no medications other than pain killers.  When a person is intaked we have to ask them about health issues as well as their medications so that if anything happens we have complete information to give the paramedics and we can chose to monitor them more closely if we're concerned.  

The one the bothers me the most is the number of people I work with who have untreated HIV.  Of course, there is no cure for AIDS, but in today's day and age there are effective ways of controlling it. Antiretrovirals should be assessable for everyone in Canada considering we have public heathcare and government funded prescriptions for those who cannot afford medications.  And they are, but there's a segment of the population that is totally missed.  I'm not going to blame this on the healthcare system.  Well, that's not completely true, I think there is more the healthcare system could be doing, but I also see tons of good things going on and this isn't going to turn into a rant about the heathcare system.   

Today, I'm going to write about personal responsibility.  Oh, I agree there are many barriers facing the homeless, and I will write for hours about them, but not today.  The truth is, people need to take responsibility for taking their medications.  Of course there are a variety of reasons why they don't, but seriously, if you're HIV positive, take your meds, it's really not that hard!  If you don't have meds, go to one of the MANY clinics available to you and get on some.  

One sad fact though, after talking to some people about this, one of the reasons many people don't take their meds, is because they don't care if they live or die, or they simply want to die.  Many people are so beaten down that they just don't care anymore.  You can't make someone care.  A doctor can prescribe all the meds in the world, but they can't make that person fill the prescription, and even if it's filled, they can't make them take their meds.  We can provide all the HIV education in the world, but it doesn't provide a sense of self esteem and self worth.  

Health is a lot more complicated then diagnosis and prescriptions... 

frequent caller

  One of the things we try and work on at the shelter is cutting back on the number of 911 calls and wasted emergency room visits among the homeless.  Studies of my city have shown that there is a group of homeless/mentally ill/both citizens make up an average of 1 in 7 visits to the downtown hospital and each one comes in an average of once a week; mostly for non-emergency situations.  We try and help people find other ways to deal with their situations.  

Right now though we have a client who is seriously abusing the 911 system which is of course a strain of resources and costs the public a whole ton of money.  It's one thing to call 911 because you have a real emergency, that's a good thing, that's what it's there for.  Then there are the people who call 911 for non emergencies because they have no transport to get to the hospital or don't really comprehend the non-severity of the situation.  Then there's calling 911 and making up complaints for an unknown reason, that's what this client is doing.  

The most likely reason the client is doing this, is that they need something.  The thing is, calling 911 telling them you can't breath and getting an ambulance to the hospital doesn't provide anything in the long term.  When you're hurting, and lonely, and lacking personal attention this works really well, in the short term.  You get paramedics, nurses and a doctor (or probably nurse practitioner) looking after you.  In the short term you probably get at least a bit of TLC.  Although, if this is the 5th time this week tempers may be getting shorter.  We're trying to work with the emergency call center to cut down on unnecessary ambulances, but then this client just goes to another drop in, and there are many in the area.  So what can be done?  

There's no easy answer in a situation like this.  Obviously the 911/hospital system is not the place for this client to have her needs addressed, but I'm not sure that such a place currently exists.  If group homes were actually group homes that might work, but warehousing her somewhere else really won't do any good.  I think maybe we should give her the number of a crisis line and see if she can call that sometimes instead of 911, and we should also try and pay a little attention to her.  

What will happen, is that social assistance will stop paying her ambulance bills, she'll wind up with a huge amount of debt and start getting less and less on her welfare cheque.  As this will give her less money to fund her substance abuse this may actually get her attention.  However, there are other ways of getting alcohol and again, it really doesn't address the route of her problem.  The hospital staff will get sick of her, and she may resort to more extreme measures to get the attention (or whatever it is) she needs.  

This post has no answers, only more questions... 

and this is how

Jim is sleeping at the back of the shelter. With his head under his jacket his indistinguishable from those sleeping around him. It is only once I wake him, he's the last one up, that I realize who he is.

Jim was once a very successful man. The wife, kids, dog, car in the garage type of success. Jim liked to have a few drinks after work and on the weekends, but eventually those drinks began to have him and things began to fall apart. It seems like such an easy solution, "quit drinking" but it's just not that easy. Jim tried, his wife tried, everyone tried, and things worked, for a while. Things even fell apart and Jim came to the shelter for a while, but he got himself together and went back to his suburban life, sleeping on a mat crammed in between two others only a memory.

As such things do however Jim's life, and his drinking, took another down turn. Things at home got worse and worse and Jim found himself back on the streets. That little sore on his leg turned into a major infection and his back started acting up. Jim kept drinking. Eventually we convinced him to get his leg looked at, but after the initial IV treatment he didn't follow through. And so now he's limping through life.

When I first met Jim he seemed like a person just down on his luck and struggling with his addiction. He was clean, polite, and hopeful. Not to sound crass, but Jim is now indistinguishable from the rest of the homeless he beds down with each night. He is no longer taking care of himself, and his spirit, his sense of hope, is gone, or at least taking a long vacation. I miss it. Jim now sleeps the majority of his day, always tired, depressed. He has no plans to get out of this lifestyle. No plans beyond sleeping, and drinking.

He fell apart before our eyes, and we couldn't stop him. At least we're there to break the fall, cushion the landing and provide a hand back up once the wind returns to his lungs. We can't do the breathing for him though. That's his job.

the itching problem

Itch, itch, scratch, scratch, ewwww! That is work these days, because well, the normal scabies and lice problem seems to have gotten worse. I've been catching our shelter cleaners taking short cuts while cleaning the mats, and the clients sleep so close together that transmission is inevitable, but seriously, itchy!!

This week I took Erik to the urgent care center to get wound care and to deal with a "rash". It was a great revelation to him when the nurse told him he needs to bathe more. He was quite pleased that she gave him some lice shampoo and some scabies cream. He took her advice quite seriously too, and was not the least bit embarrassed about his problems (as you and I might be). Rather, he was just happy that he had a solution to his horrible itching.

Lice and Scabies are part of living in a shelter I guess... We keep the mega size bottles of lice shampoo in our cupboard as well as multiple tubes of the scabies cream. On the whole, we're pretty used to the entire thing. It goes through phases and right now, we're in a bad phase. Apparently the urgent care center is not as used to this as we are. The nurse phoned us rather freaked out "Erik has scabies and lice, and well can you come get him, we can't keep him here and oh my, oh my, panic etc..." We kind of wished they'd at least give him the first treatment there, but oh well. It guess it can be frightening (?) for some people. It's not like I want to have to deal with either of them, but if I do, I'll certainly live... I might even get time off work for treatment!

For some of our clients though, the recent outbreak is a source of some contention, and they've decided that sleeping on the street, itch free, is a better option. I'm not so sure about this, seeing as it's till below -30 but to each his own I guess. It certainly is less crowed outside! It was one of these clients who dubbed it "the itching problem" and from now on, that's what I plan on calling it.

Happy Scratching!

blue christmas

As many of us in helping professions know, the holidays are not a happy time for everyone. In fact, for many people, the holidays are a time of stress, business, frustration and sadness. Society places great pressure on people to be happy and joyful while having the perfect holiday with family and friends. Unfortunately for most people this just isn't the case.

Friday night at street ministry, I was tired, stressed and fed up with the entire Christmas season (one week till my holidays)! I couldn't handle the kitchen, so I was happy to sit down with some of our guest and eat dinner. As I've talked about before, I see many of the same people at street ministry as at work, and these two were regulars in both the shelter in the drunk tank.

Deena is a woman who is probably only in her 40s. She looks like she's seventy and is now wheelchair bound. A while back she had to have her head shaved due to a bad lice infestation and she's a very small woman. Despite the fact that I see her on an almost daily basis, she isn't someone I've ever had a good talk with, and I really don't know much about her story. So we sat, and ate and talked, and as we talked, tears slowly began to drip down her face.

Deena has never known much of her family. She was adopted out to a white family and lost contact with her biological family. She has never been able to have a "family christmas". The one relative she was able to remain in contact with her brother, is now gone. Not only is he gone, but he was shot dead over the holiday season a number of years ago. After telling me this, she stops talking. Her boyfriend explains that those who were responsible for his death got out of jail recently, making things all the harder.

More then anything, Deena wants to spend a Christmas for her family, something that is now impossible. Oh, and she's dying she says, they've found cancer, and she doesn't know how long she'll live. This is secondary to the Christmas thing. She knows her body doesn't have much left in it, a life of living on the streets and in shelters while consuming copious amounts of alcohol just doesn't lead to good health. The good news though, she thinks she and her boyfriend have an apartment for the new year!

hot yoga

I don't know that I ever blogged about going to hot yoga, but I went about a month ago for the first time. It felt good, but the 90 minute class was also somewhat overwhelming. Yesterday, bestest bud and I went again, only this time to a different studio and a 60 minute class. It was awesome!

The new studio is only a block from my house and feels like it's a few degrees cooler, or at least less humid. It was a better temperature for me, and just felt healthier; so did going for only 60 minutes instead of 90. Hot yoga feels awesome and cleansing. I felt SO good when I was done! I'm a bit sore today, but not excessively so, and bestest bud and I are going back after church.

As usual, my mind is in over drive, and while I wasn't thinking about things too, too much during the class, afterward I was thinking about how wonderful it would be for my clients to have the same experience. There's something so cleansing and freeing about it. There are so many challenges to them having this experience though. Even if we found volunteer teachers, and a location, then you have to get people there, convince them they want to do it, convince them to drink water, to change their clothes, to shower, to be vulnerable, to do "stupid" poses. Hmmm. Things to ponder, things to ponder. Besides, if it's not something they want to do, how is it empowering?

a mild health care rant

Health care seems appropriate to rant about while I'm waiting for this season's first episode of House MD to download, alas, my guilty pleasures, medical dramas.

Anyway, I have this client, well, a lot of client's actually who have issues in our health care system, sort of like how, well, they have issues in our social and societal systems. A typical story might be something like this. It's time for a story, so imagine for me now, the following.

You are a person in your early sixties, life has been hard, and you have been broken in many ways. Your addictions are very encompassing, and you have very little social or family support. You get sick, but just keep trying to drink away the sick feeling, you're old, you're tired, who cares. Eventually, you're found passed out drunk somewhere and wind up in the emergency room where they tell you, you have - insert infection/condition here- and give you a prescription, and tell you to get some rest.

See but here's the thing. You never wind up filling your prescription, or you do, but you lose it. Or you go to the pharmacy, but find out your welfare benefits have been cut off, or you drop it off, but forget to pick it up, and then forget which pharmacy you brought it to in the first place. Oops. And so you stay sick. And it gets worse, and worse. You wind up at the hospital three times in two days, clogging up the emergency room and frustrating the medical staff. You're not sick enough to be admitted, if you would take your pills and get some rest, but the thing is, you're not going to do that. It's hard to find rest when you're kicked out of the shelter, so you wind up drinking, and spending the night in the drunk tank.

The people in the drunk tank are quite worried about you, and you tell them that you just want to die, that living like this isn't worth it. You've had it. Everything hurts, and you can't breath. And so, seeing as you're in obvious -pain, trouble, unable to breath - they call an ambulance to take you BACK to the hospital.

See where the problem is? The problem is not with the health care system itself necessarily, but on the after care and followup. How much money could be saved if there was a way to get people to take their medications. How much money could be saved if there was a safe, clean place for them to sleep. How much more still, if we invested money in the prevention of homelessness/addiction in the first place!