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News

Jim’s Story: What Can Be Done to House Our Most Vulnerable Residents?

It isn’t lack of knowledge or politics that holds us back, but logistics, experts say. Last of two.

By Katie Hyslop 2 Sep 2016 | TheTyee.ca

Katie Hyslop is The Tyee’s education and youth reporter. Find her previous stories here.

Union Gospel Mission is one of the biggest service providers for low-income and homeless people living in Vancouver’s Downtown Eastside neighbourhood. The Christian charity provides 1,000 meals a day across Metro Vancouver. It found housing for 200 people last year, runs shelters and drug and alcohol programs, and has strong street outreach teams.

But “Jim” can’t go to the mission for a meal or a place to sleep right now.

The 44-year-old First Nations man, who struggles with fetal alcohol syndrome disorder, drug and alcohol use and trauma from an abusive childhood, is banned from the mission and its block of East Hastings Street. (We have chosen to change Jim’s name to afford him privacy. Find the first part of his story here.)

The order is part of his sentence for assaulting and threatening to stab a UGM employee in February.

Helping people like Jim poses special challenges for all service organizations.

“It’s tough to connect with someone – number one – who struggles to meet appointments,” said Jeremy Hunka, public relations specialist at the mission, speaking broadly about the challenges of providing services to people like Jim, made particularly vulnerable by their developmental, mental health, and drug use issues.

“It’s even more difficult to connect with someone who has violent tendencies or outbursts of anger,” Hunka adds. “It makes it very difficult to get certain people into housing if they are violent or threatening to the landlord, for example.”

Jim’s violence and threats, in part the result of his FASD, have contributed to his seven months of homelessness in the Downtown Eastside. Spending four of those months stumbling through the provincial court system on three charges of assault and one of uttering threats hasn’t made his housing search any easier.

The Union Gospel Mission is sympathetic to his plight, but can’t solve his problems on its own.

And the problem is bigger than Jim. The Vancouver Police Department estimates 300 people in the city have mental health issues so severe they’re a danger to themselves and others.

We know the solutions, says Simon Fraser University health sciences researcher Dr. Julian Somers. Research like the national At Home/Chez Soi study – Somers was lead investigator in Vancouver – have shown outreach mental health teams, supportive housing scattered across the community, and choices in where to live and access services are all effective in reducing homelessness among mentally ill and drug addicted people.

But changing the status quo requires three things B.C. hasn’t been great at in the past: consulting people in need about services and supports they want; collaborating, communicating and coordinating between ministries, governments and nonprofit service providers; and providing adequate health and housing resources in all the communities that need them.  

It isn’t lack of knowledge or politics that are holding us back, Somers says.

“It’s logistics,” he says. “At some point people have to do work and design new programs and design alternatives and make the case for them beyond what I’ve done, at the level the Treasury Board [the provincial cabinet committee responsible for budget decisions] would need. There are a lot of steps involved in making these things come into action.”

$26.5 million in services over five years

Using records from the Downtown Community Court and provincial health and social service agencies, Somers identified 323 people with mental illness, the majority having a secondary mental health diagnoses or addiction issues, who were also the court’s top offenders and the neighbourhood’s heaviest users of health and social services.

From 2007-12, the 323 people cost the system $26.5 million in income assistance, prescription drugs, community doctors and days spent in hospital, Somers says.

But the real costs were much higher. The City of Vancouver spends $30 million annually on policing, emergency responders, emergency and permanent housing and outreach services with mental illness and drug addictions. Some $360 million a year is pumped into the Downtown Eastside’s 260 service and social housing organizations – almost three-quarters of which comes from municipal, provincial or federal coffers. On top of that there are court and prison costs.

Yet for all the funding, huge gaps remain.

Jim, for example, needs supportive housing that includes daily supervision to ensure he shows up at his appointments, takes his medications and has access to health services. His chances of avoiding problems would increase in an environment where there were constructive activities to engage someone with behaviour issues and an IQ around 70.

But that kind of housing is almost impossible to find.

BC Housing has 5,220 supportive or subsidized housing units for homeless or near homeless people across Vancouver, and has promised to build another 2,100 across the province.

But the supports accompanying the housing vary from building to building, making it difficult to ensure the almost 3,000 people on BC Housing’s Supportive Housing Registry waitlist will get into the housing program they want or need.

The Crown corporation doesn’t know how long people wait for housing. In an email to The Tyee, a BC Housing spokesperson noted that just over 600 waitlisted people were housed last year, about 80 per cent of them in Vancouver. (The Tyee requested an interview with Housing Minister Rich Coleman, but he was unavailable.)

And people like Jim need more than accommodation. They need supportive housing that includes mental health and addictions treatment to help stabilize their often-chaotic lives.

Without supports, the pressures increase on police, hospitals and community services.

In 2009, the emergency room at St. Paul’s Hospital, which services the area including the Downtown Eastside, saw about 5,800 mental health and addiction visits. By 2014, that had risen to 10,500, a 90-per-cent increase.

Three years ago, the Vancouver Police Department called on the province to open 300 new long-term mental health beds as part of a plan to meet the needs of people with serious mental illnesses.

But by last fall, only 55 new beds had been created.

The Tyee requested an interview with a health ministry official regarding the status of the treatment beds, but received an email statement instead.

The province has also provided funding for two more Assertive Community Treatment teams of mental health professionals in Metro Vancouver. Five ACT teams now work with 420 mentally ill and addicted people in the region. Another Assertive Outreach Team works with the emergency rooms at St. Paul’s and Vancouver General hospitals connecting mental health and overdose patients with community services.

Together the teams have achieved impressive improvements in the lives of the people they serve – a roughly 50-per-cent reduction in emergency room visits, 50- to 65-per-cent reductions in violent offences and, for outreach clients in particular, a 70-per-cent reduction in negative police contact.

But it still isn’t enough, Somers says. He believes such efforts will continue to fall short until government ministries and service providers start identifying and working with the neighbourhood’s most prolific offenders and service users.

“And once identified, consider providing them with services that deliberately integrate resources that cut across health, housing, vocational supports,” he added.

Mandate to share info needed, says MLA

That kind of collaboration is possible. The Representative for Children and Youth’s office has access to data about B.C. children from all relevant ministries.

But sharing information about adults is trickier, says Melanie Mark, former associate deputy representative in the office of the children’s representative and now NDP MLA for Mount Pleasant. Unlike children, whose parents or even government can decide whether to share their information, adults have privacy rights that can limit information sharing.

Mark knows Jim from his involvement in her byelection campaign this year and recognizes the need to protect his privacy rights.

But she agrees with Somers that teams of service providers need a mandate to share their common clients’ information amongst each other and work together.

“We can’t be leaving people like [Jim] to their own devices,” said Mark, adding that collaboration with civil liberties organizations could help government balance people’s privacy rights and service needs.

Service providers and government have launched efforts to collaborate and share data on mental health issues in the Downtown Eastside. The province launched its Mental Health Strategy in 2010, though Mark notes the last annual progress report was released in 2012.

And the City of Vancouver launched the Mayor’s Task Force on Mental Health and Addictions in 2013 in response to the VPD’s mental health report. Composed of representatives from the health, justice, housing, education, urban indigenous and non-profit sectors, as well as people with lived experience, the task force released 23 recommendations for improving services, including echoing the VPD’s call for 300 new long-term mental health treatment beds.

While that recommendation remains unfulfilled, others have been implemented, including an expansion of Assertive Community Treatment teams, creation of Assertive Outreach Teams, opening a nine-bed mental health emergency psychiatric unit at St. Paul’s Hospital and improved information sharing between the health authority and VPD.  

Last year Vancouver Coastal Health unveiled its Downtown Eastside Second Generation Health Systems Strategy, a multi-year plan to improve services by coordinating between – and in some cases combining – their existing services in the neighbourhood to meet the community’s stated needs.

And in June the Vancouver Police Department announced its mental health strategy, outlining policies and protocols for interacting with individuals suffering from mental illness, as well as collaborating with mental health-related services and supports.

Both strategies focus on diverting people from emergency rooms and jail cells and promoting long-term treatment and stability.   

But while Vancouver Coastal Health and the Vancouver Police Department work together on mental health issues, there is no official mandate for B.C. police forces and health authorities to collaborate on strategies for dealing with people with mental illness.

There’s also no new money attached to the police department and health authority strategies. As the police plan notes, “where a person receives insufficient services or support, they will ultimately fall back on the VPD as the last line of help, and this can create risk for the individual, the community, and the VPD.”

Many BC communities need services: Somers

This isn’t just a Downtown Eastside or even a Vancouver problem. Somers estimates a dozen B.C. communities have a small core group of people with the same mental health, addictions and criminal issues. Using a rough formula of 100 people per 100,000 population, a city like Prince George can expect to have 80 to 90 people committing a large number of offences and using many services.

Somers and his team did another Downtown Eastside study to find out where homeless and mentally ill residents hailed from. Just 40 per cent of the more than 400 people interviewed had lived in Vancouver 10 years before the study. The rest came from elsewhere in B.C. or outside the province.

That’s not surprising. The further north you go in B.C., to communities like Comox, Quesnel, and Prince George, the more people you’ll find. “Those are all areas that actually have comparatively very few services and supports for people,” Somers says.

Providing services for troubled people in their own communities so they don’t have to move to Vancouver is just as important as finding solutions for people already here, he said.

And success will only be possible if the provincial government consults widely, Somers said. The consultations must include everyone, including the people who need services, who need a chance to consider service options and offer their perspective on what’s needed.

Without that kind of approach, people in need will go where there are services – the Downtown Eastside, where Vancouver Coastal Health estimates there’s a 15 to 20 per cent annual population turnover.

Somers’ idea is similar to the community-based poverty plans the provincial government touted a few years ago. The government said every community was different and hyper-local plans would be far more effective than a province-wide approach. That process, tried, with little success, to use existing community resources to solve poverty.

But treating mental illness, addictions and homelessness in B.C. communities is going to cost money. Somers says he’s presented his research to officials in several different government ministries and they all seem to agree the cost of doing nothing is too high.

“So surely we could do something that’s better for them and possibly, over the long-term, is even less expensive for the public,” he said.

Somers suggests creating an all-inclusive program for mental health and addictions treatment in the Downtown Eastside that meets people’s immediate and long-term needs, including mental and physical health-related resources like housing, access to healthy food and treatment.

But stabilizing people would just be the beginning of a multi-year program. “Once their lives are no longer all about surviving the day to day, they’ll need something to do,” he said. Job creation, identifying opportunities and employment readiness preparation need to be part of the approach, he added.

NDP MLA Mark wants the province to develop an adequately resourced government-wide strategy for responding to all mental health, addictions and homelessness issues in B.C.

“People need to be reading from the same songsheet around what that plan is, and what role do people play in that plan,” she said, adding government would be responsible for the coordination between ministries, other levels of government and nonprofit services.

“You have to have it clear in people’s mandate that they have a responsibility to work together, and how are they going to work together.”

Additional resources to the Downtown Eastside will be a tough sell. A million dollars a day is already spent on services and housing.

But research by Somers and his colleagues from 2007 showed the $644.3 million British Columbians’ annually spend on services only for homeless people with mental illness and addictions issues – roughly $55,000 per person – would drop to less than $37,000 if proper services and housing were provided.

Adequate services would have meant mean savings of about $211 million in 2007 by reducing the need for costly interventions. The same study estimated providing housing and appropriate services would cost about $179 million per year – an expense more than covered by the resulting savings.

Mark says constituents are already telling her that they want a ministry of mental health, with a mandate to work with other ministries to address gaps in services that leave people with mental health issues vulnerable to addictions, homelessness and crime.

But Mark isn’t making any promises that the NDP, if it forms government after next spring’s provincial election, would create such a ministry or province-wide strategy.

Like Somers, Mark says it’s possible for any government to create a strategy and co-ordinate actions across ministries. But unlike Somers, who sees the lack of province-wide strategy as evidence of the difficult logistics involved, Mark believes it is all about political will.

“We need to shed a light on just how bad it is to get that political mobilization,” she said.  [Tyee]

ONE IDEA: ‘PRINCESS ROOMS’

Like most people, Jim needs people in his life who genuinely care about him. Tricky when the people best suited to help him are paid professionals.

He needs a place like the Princess Rooms. Funded by the province and run by Raincity Housing, Princess Rooms has been providing transitional, temporary housing to people with combined mental health, addiction and behavioural issues for 15 years.

Named for its Princess Avenue location, the residence has 42 units -- mostly single rooms -- plus space for medical check-ups and a kitchen, where a chef serves one meal per day. The home’s support staff meets regularly with residents, forming close relationships while also keeping an eye on their living conditions.

The key is having enough staff, says Bill Briscall, Raincity’s communications manager, “so that if there’s something chaotic happening on the second floor a staff member can be involved in that, and then this staff member over here can still have a conversation and be completely invested in that conversation.”

Not everyone wants to live in the Downtown Eastside where the Princess Rooms are. But the community is home for some and leaving would leave them worse off, Briscall says. “What we can do better is recognize that and make this neighbourhood a better neighbourhood at the same time,” he says. “We don’t have to choose one over the other.”

— Katie Hyslop

ST PAUL’S MENTAL HEALTH HUB

While Vancouver has been waiting three years for 300 long-term mental health treatment beds, there have been developments in short-term mental health care.

In June city council approved a $1-million investment into the capital costs of a new mental health and addictions treatment hub at St. Paul’s.

The hospital hopes to cut the current 10,500 annual emergency room visits in half by diverting people with psychiatric needs to the 10-bed hub.

Operating costs will be covered by the provincially funded Providence Health Care and Vancouver Coastal Health.

The Vancouver Police Foundation will provide money for a transition centre to connect homeless discharged patients with services instead of releasing them to the streets, says St. Paul’s head of psychiatry Dr. Bill MacEwan.

“You get some support in terms of food, a bed, there’s a shower,” he said, adding discharged patients can stay at the transition centre for up to 48 hours. The concept has been tested at the Rotary Transition Centre at St. Michael’s Hospital in Toronto, where only 30 per cent of patients discharged with the centre’s support returned to St. Michael’s within a month.

MacEwan hopes the hub and transition centre will start accepting patients by December. The hub and transition centre come in addition to St. Paul’s nine-bed emergency psychiatric unit opened in 2014; 75 mental health in-patient beds; and an off-site transition program for up to 12 people receiving outpatient care.

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