Bridging the gap to bring healthcare to the homeless

Judith Sigouin, Social Worker, takes to the streets of Montreal, where she meets her clients to offer them support and guidance.

This article about the Connexion program is the second in a series presented in 360.

The Connexion team is made up of two social workers and one active nurse who take to the streets of Montreal to work with the homeless that are disconnected from services offered in our CIUSSS.

Myriam Kaszap, a Street Nurse for eight months and Judith Sigouin, a Social Worker with Connexion since 2013 spoke to 360 about their experiences with this unique program based out of CLSC Metro.

360: Can you describe a typical work day?
Connexion: A typical day is one filled with the unexpected. If we tell ourselves, today I gave an appointment to a client, I will drop by a resource centre then head over to the office to record my notes and look after administrative matters, that rarely comes to pass. Most often, the moment you arrive at the shelter, there are four people waiting for you with heavy needs, and it escalates from there. On an ideal day, we would grab our backpacks and hit the streets, see clients and follow up on cases that began two weeks prior, but this almost never happens.

360: How do you set your objectives and know when they’ve been met?
Connexion: It is very difficult to measure performance in our line of work. Ultimately, we want to get homeless people off the streets, ensure that they take their medication, find them an apartment, and connect them with healthcare professionals on a long-term basis.

That said, it can take time to reach our objectives, no matter how cautious we are to do everything necessary. Oftentimes, in terms of performance we have accomplished a great deal, but in terms of measurable objectives, it appears as though we’ve achieved little.

At other moments, seemingly smaller interventions, like this morning I cleaned four sores—that is considered a successfully completed task, but what has been achieved in the grander scheme?

One action means a lot in a person’s life—like sending someone back home to the north. These interventions require many phone calls, follow ups and discussions. But because every case is different, we have to change our way of working every time.

If a person isn’t connected to the system, we don’t know what types of problems they may have, whether cognitive, for instance, or geriatric, or maybe relating to substance abuse. It could also be a combination of these, or all three, or perhaps a personality disorder? With these cases, no one wants to get involved and the ball gets tossed around.

That’s why every case is extremely long. They require complex clinical discussions, and we have to adapt our approach to each, so inevitably, we advance at a slow pace.

A team working in mental health, for instance, will provide mental health care to a patient. For us, we have to contend with illegal papers in Canada, or seniors requiring a placement in a long-term care facility, or perhaps handle questions concerning Aboriginal culture. Also, of course, men and women are different. That’s the reality on the street. It takes time to navigate all these differences and develop a customized approach for each.

360: Can you provide an example of a successful intervention?
Connexion: Recently, two First Nations women were sent home to their region. The process was long but we have to celebrate small victories. Although their health problems are far from being overcome, we strove for a long time to send them back to their community, and we succeeded!

It took ages because our clients had chronic drinking problems, and the flight by air would be long. We needed to provide a sedative, but they didn’t have health insurance. Doctors are often reticent to take on our clients because they are intoxicated, so it can be a challenge. Next, we had to negotiate with the airline companies and with the women to settle on a departure date. It’s a communal effort. We would estimate that about half of the people refuse to leave in the end, which damages our ties with the airlines.

In the end, though, you have to fulfill that person’s wish. If they want to be in their community, with their family, we must make those arrangements, even if the family is not able to give them the help they need. An airline ticket is expensive, so to provide that for free, to ensure that the client doesn’t squander that opportunity, that is certainly a victory. It involves a real team effort!

360:  What do you do when a client refuses help?
Connexion: There are people we see regularly whom we can monitor. Sometimes, they see us interacting with their friends and finally they come see us. But if it doesn’t work out, we don’t force anyone.

That said, if a person is at risk, we reevaluate. Are they making an informed decision about not wanting our help, or are they experiencing delirium or are perhaps in an advanced state of dementia?

Being homeless isn’t necessarily a problem that needs to be fixed. It is a way of life for some. It is important to respect people’s needs and their rhythm. Our professional responsibility is to employ clinical judgment to determine if an individual is in danger. It’s always important to consider, “What is the person’s choice?”.

360: Do you both follow the same patients?
Connexion: Generally not. We consult one another, we know each other’s clients. And, often, we collaborate. With our clientele, we have to be generalists.

360: What type of medication do you carry with you?

Connexion: We only have access to Tylenol and ointment, clean syringes and bandages. Most of the time, we need more. But in situations where the person does not have a healthcare insurance card, it’s difficult. There are organizations that do help, but it is complicated. We have to build a bridge between a system and a client, when often there is a great gulf between them.

360: What do you do in instances where more specialized care is needed?

Connexion: Clients cannot lie in a stretcher for long, and want to be spoken to with respect. That’s why they end up going from hospital to hospital. Our responsibility is to guide people to services. There are some medical and psychiatric services that we can’t offer but that are available in hospitals, therapy centres and in shelters. We persevere, even though we don’t always have the full cooperation of those who need the help, and the partners offering it.