Pat Larson, MN, Nurse Practitioner
Sherbourne Health Centre
Toronto, Ontario plarson@sherbourne.on.ca
“The best way to find yourself is to lose yourself in the service of others” M. Gandhi

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Context
Behavioural Issues
Prevention/planning
Responding
Discussion

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Solutions are unique to the setting
We’re a learning environment...
Underpinning of values/principles
Pro-active/Prevention based stance
Responding “in the moment”
Your contribution to our development
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An acknowledgement

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Community based agency
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Partnerships (ie. Naturopathy, chiropractic…)
Infirmary
Primary care programs
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Homelessness
LGBTT community
Newcomers
Local community
Health Bus (volunteer RNs, outreach)

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Community-based, stand-alone model
20 beds (9 open at present)
Serves the Greater Toronto area
Referrals – self, community (shelters, drop-ins, community agencies and providers) and hospitals (~12 in area)
Opened April, 2007

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Community Health Worker (CHW) - 24/7
RN – 24/7
Case Manager
NP
Consulting MD
Manager and Admin Assistant
Partnerships (housing worker, pastor…)

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Program values
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Social justice
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Community/belonging courage
Harm reduction
Independence, self determination
Participation in program, health care plan
Trauma model
Kindness AND therapeutic value

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Homeless/underhoused
Fractures, cardiac problems, diabetes, HIV, endocarditis, pneumonia, skin infections/cellulitis, osteomyelitis/bone infections, post surgically, post childbirth
Majority also have substance use issues
More men than women, but priorize women
Most leave to go to shelters; occasionally client is housed upon discharge

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Short term
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Maximum stay 3 weeks; average ~ 10 days
Acute need
Written, faxed referral
Referee remains responsible for information transfer
Hospital visits w/ some referred clients
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 acuity ability to safely discharge clients

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Your setting
Your experiences?
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Issues
Anything you would like to share?
Things we might address?

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Focus on referral
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Adequate resources to process
Follow up with referees/client/supports
Ask difficult questions “are you barred?”
Program self-determination
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Ability to say no to clients
Client meets program criteria?

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Intent
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Primarily - planning/managing
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Consider - restriction
Shelter restrictions
Evidence or history of violent behaviours
Referee reluctant to provide information or details
Client vague/reluctant re details
Evidence of difficulty participating in previous programs

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Contingency Planning
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Frank
Involve community supports
Substance use
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“How will you manage your cravings?”
“Do you plan to use? How could you reduce your use?”
History of Violence or Barrings
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“What will be different in this program?”
Risk from Partners/others
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Safety plan; involve management/security
Triggers
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“What are your triggers? What is your plan to avoid? Manage?

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Discussions about
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Expectations
Participation in program
Consequences of not respecting responsibilities
Independence
Contracts
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Client developed
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Staff developed

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No illegal substances on-site
May use/imbibe, behaviour is the focus, not substance use
“What is your substance of choice?”
“How can we help you not to use? To use more safely? To use less while you’re ill?”

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Understanding and re-framing of people’s life experiences
Therapeutic responses
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Self responsibility
Assist clients w/ coping strategies
Trauma of being discharged
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Clients
Staff

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Attempts to triangulate - “Manipulation”
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Making unrealistic demands
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“You’re not going to discharge ME, are you?”
Evasiveness
Not being honest
Not participating
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Refusing to meet w/ providers, to get out of bed, have treatments….

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Disrespect - intolerance
Theft
Threats
Violence
Smoking inside/risk of fire
Substance use on the premises

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Clean, bright environment
Minimal sharing of bedrooms
Safe spaces, quiet areas
Able to go outside (smoke, appointments)
“This is the nicest place I’ve ever stayed.”
“I feel like I’m at the spa.”
On-site security
EMR – team care plans, rounds, reviews

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Diversity
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How do we live it?
Social Inclusion
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“Radical inclusion”
Respect, dignity
Ambivalent responses to acceptance
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Resenting being cared for

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Accountability
First episode - not meeting responsibilities
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Responsibilities, rules, consequences
Repeat behaviours
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May result in discharge from program
Serious issues (violence/threats/theft)
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Discharge from program,
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? Charges?

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All staff trained in Non violent Crisis
Intervention
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Focus on understanding own responses
Minimal staffing levels
Timing of responses
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In the moment
Can this wait? Should this wait?
Can this be ignored?

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“Enforcer” role (“bouncer/security”…)
Who should respond to client?
Challenging particular behaviours
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“I’m not feeling comfortable with ..”
“I need to speak with you about…”
Alone versus with support
Clarity
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Consistent messages
Easier to say than do

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Acknowledge client’s efforts and progress
Importance of humour
Staff training and support
Differences of opinions
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Staff cohesiveness on the big issues
Recognizing when we’re inconsistent
Addressing our inconsistencies

Thank you for the opportunity!
Feedback
Discussion