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CUPS Coordinated Care Team
Transitional Support for Vulnerable Calgarians
Darryn Werth & Elaine Wilson
Calgary Urban Project Society

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Calgary Urban Project Society
CUPS is a non-profit organization dedicated to helping
individuals and families in Calgary overcome poverty

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A Broader Community Issue:
Poverty in Calgary
• 1 in 10 Calgarians live in poverty
(Vibrant Communities Calgary, What is Poverty, 2012)
• 1 in 5 Calgarians are concerned
about not having enough money
for food (United Way and The City of Calgary, Signpost II,
2011)
• 1 in 3 Calgarians are concerned
about not having enough money
for housing (United Way and The City of Calgary,
Signpost II, 2011)

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CUPS Mission
Through integrated health, education and housing services, CUPS
empowers people to overcome the challenges of poverty and reach
their full potential.
Low-income and
marginalised
Calgarians who are
empowered to
overcome poverty
and reach their full
potential
Improved
mental, physical
and spiritual
health
Nurturing families
with resilient
children
Safe and stable
homes

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CUPS
• Key Goals:
 Solid base of wellbeing
 Stable environment
 Improved quality of life
• 26 years in Calgary
• 60% private funding & 40% government funding
• 470 volunteers donating 14,544 hours
• 8,418 individual participants
• 57 organizational partnerships
• 170 staff
EDUCATION
HEALTHHOUSING

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The Alberta Adverse Childhood
Experiences Survey 2013
Adverse Childhood Experiences

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Downstream Prevention

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CUPS Programming
Tertiary prevention: primary health care, mental health
support, substance use support, outreach support
Primary prevention: pre-natal & post-natal care, early
child development, family development
Secondary prevention: housing
programs, basic needs support,
pediatric care

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CUPS Activities: Housing
Housing
• Key case
management
• Graduated rent
program
• Community
development
Supports
• Crisis intervention
fund
• ID assistance
• Bursaries
• Tax assistance
• Nutrition program

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CUPS Activities: Education
Parent
Education
One World Child
Development
Center
Family
Development
Center
CUPS Education programs disrupt the intergenerational cycle of poverty by offering
research-based early intervention and two-generation approach support programs
that focus on childhood development and overall well-being of parents and the family.

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Primary care
Prenatal care
Obstetrics
Pediatrics
Hepatitis C clinic
On-site lab
Shared care mental health
Visiting specialists
Outreach clinics
Dental clinic
Optometry
Dietician
Foot care
CUPS Activities: Health
Patient centered
Team-based care
Continuity
Comprehensive
Enhanced access
Continuous QI
Education & research

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Calgary
• 1.2 million people, >3500 homeless on any given night
• Homelessness has increased from 447 people in 1992 to 3601 in 2008
• >23,000 households live in poverty (make less than $20,000 and spend
more than 50% in housing)
• Calgary’s Ten Year Plan to End Homelessness started in 2008, coordinated
by the Calgary Homeless Foundation
Calgary Winter 2014 Point-In-Time Homeless Count

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Calgary Winter 2014 Point-In-Time Homeless Count

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Homelessness and Health
• Homelessness is linked to poor overall health
• Complex relationship
• Higher rates of mental illness
• Trauma, violence and suicide
• Infectious disease
• Drug and alcohol use
• Chronic disease burden

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Hospitalization and Homelessness
• Challenges of acute care use and homeless population are
not new
• Homeless individuals have been shown to be 2-4 times
more likely to have a repeat emergency department (ED)
visit within 7 days
• Frequent ED users are often homeless and from low socio-
economic levels
• Individuals may be accessing ED for non-medical reasons
• Limited ability in ED to meet complex needs of individuals
• 25-28% of acute care high users in Canada are from low-
income neighbourhoods

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Top 5 Reasons for ED Visits 2005-2006
in Canada
Homeless Percentage %
Mental and behavioral disorders 35
Symptoms, signs and abnormal clinical findings 18
Injury, poisoning and consequences of external causes 14
Contact with health services 14
Diseases of MSK and connective tissue 5
Others Percentage %
Injury, poisoning and consequences of external causes 25
Symptoms, signs and abnormal clinical findings 19
Diseases of respiratory system 11
Contact with health services 9
Diseases of MSK and connective tissue 6
Source: National Ambulatory Care Reporting System, CIHI, 2005-6

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Top 5 Reasons for Inpatient
Hospitalizations 2005-2006 in Canada
Homeless Percentage %
Mental diseases and disorders 52
Significant trauma 7
Respiratory diseases 7
Skin subcutaneous and breast diseases 6
Digestive diseases 3
Others Percentage %
Pregnancy and childbirth 13
Circulatory diseases 12
Newborns and other neonates 12
Digestive diseases 10
Respiratory diseases 7
Source: Discharge Abstract Database, CIHI, 2005-6

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Calgary ED Scene
Alberta Health Services data (2013)
Top 3 reasons for ED visit Patients with > 10 ED visits Patients with >10 ED
visits who are of no
fixed address (NFA)
398,159 visits to ED in 2013 773 individuals 167 individuals with
a total of 3247 visits
1. Injury 1. Alcohol abuse
2. Non-specific signs and
symptoms
2. Non-specific signs and
symptoms
3. Abdominal pain 3. Cellulitis
Average # visits per NFA patients = 19

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Challenges with the Current Situation
• Patient factors
 Homelessness and poverty
 Leaving AMA, non-compliance
 Addictions, mental illness, cognitive impairment
 Mobility, disability
 Lack of transportation
 Lack of ID and AHC
• Health system factors
 High volumes in the ED
 Inadequate knowledge about social determinants of health
 Social stigma
 Inadequate knowledge of community resources in ED
 Health information privacy
 Lack of a shared electronic health record
 Lack of a provincial responsibility for vulnerable populations

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A Potential Solution….
CUPS Coordinated Care Team
A community based team that will provide intensive case management
and transition care to vulnerable, low-income patients presenting to the
Emergency Departments
• Funded by Green Shield Canada Foundation – 2 year pilot project at
the Foothills Medical Centre
• Innovative strategy aligns Alberta Health Services, CUPS and
community stakeholder priorities
• Case management focus
• Community based
• Stakeholder engagement
• Partnerships
• Green Shield Canada Foundation
• Innoweave
• University of Calgary

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Case Management
• Case management provides more continuous care that helps
guide client through the process
• Assessment, planning, facilitation and advocacy
• Intervention that extends into the community, providing
upstream care
• Flexible and dynamic
• Various models and definitions of case management
• Coordinate housing, financial supports, addictions treatment
and mental health resources, thus improving care and
avoiding unnecessary presentations to acute care facilities

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Case Management of ED Users
• Research has shown that an intensive case
management approach for vulnerable and/or
frequent users in the ED may lead to:
 Better health outcomes
 Support managing co-morbidities
 Increase in staff satisfaction
 Reductions in homelessness
 Reduction in alcohol and drug use
 Cost savings
 Patient satisfaction

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Community Based
• Individuals presenting to ED may have other
needs that are not addressed by treating
medical issue alone
• Benefit from more appropriate and consistent
medical and social services
• Frequency and availability for follow-up in the
community has been shown to improve
outcomes
• Improved communication

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Target Population
• Homeless, vulnerably housed, low income
• Chronic and/or complex health conditions
• Substance use issues
• Mental health concerns
• Lacking social supports in the community
• Unattached to Primary Care Provider

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Stakeholder Engagement and
Collaboration
• Met with numerous community partners and
departments/working groups within Alberta Health
Services
• Engaged with University regarding research support
• Support from Green Shield Canada Foundation

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CUPS Coordinated Care Team
• 1.0 FTE RN, 1.0 FTE Psychiatric RN
• AHS acute care site privileges and EMR access
• Access to other databases as needed –
including the Calgary Homeless Foundation
HMIS
• Referrals from ED staff, inpatient units as well
as community partners

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Inputs
Outputs Outcomes -- Impact
Activities Outputs Short Medium Long
Funder
 Greenshield Canada
Foundation
Staff
 Medical Director Project
Lead
 2 RNs
 CUPS Health Clinic
supports
 CUPS Housing and
Education supports
Infrastructure
 Health care supplies
 Telus Wolf EMR
 Mobile devices
 Laptops
 AHS EMR
 CHF HMIS database
Formal Partnerships
 AHS (service
agreement)
 Foothills Hospital
Informal Partnerships
 Calgary shelters
 U of C
 The Alex
 Elbow River
 East Calgary FCC
 Triple AIM
 Edmonton ARCH
 CHF
 Mental health and
addictions
 Home Care
 EMS
 Calgary Case
Management Group
 Participate in discharge
planning
 CHW accompaniment
patients to community
appointments
 Provide transitional
care, wound mgmt &
follow-up following
discharge
 Referral to community
health
 Referral to community
social services
 Coordinate mental
health care
management and
surveillance
 Accompaniment and
coordination for
community addictions
treatment and services
 Provide Education to
hospital staff and
community partners
 Communicate with
acute care and
community partners
 Patient and population
health advocacy
 Data management
 Quality improvement
 Research
 # referrals to CCT
 # treatment referrals
 # ODT referrals
 # of withdrawal
management consults
(detox)
 # referrals to ID clinic
 # medication coverage
applications
 # housing assessment
referrals
 # outreach/case mgr
referrals
 # primary care referrals
 # primary care intakes
 # of dental referrals
 # of eye care referrals
 # of mental health
referrals
 # of ER visits
 # EMS /911 calls
 # inpatient admissions
 # of inpatient 30-day
readmissions
 # ICU admissions
 Quality of life indicator
 Patient satisfaction
survey scores
 Staff satisfaction survey
scores
 # mental health f/ups in
community
 # referrals to wound
care
 # referrals to home care
 # Calgary Police
Services (CPS) contacts
 # referrals from CPS
 Immediate advocacy for
patient needs
 Improved immediate
communication between
acute care and
community providers
 Improved system
navigation for patients
 Patients connected to
appropriate housing
resources
 Attachment to Primary
Care/Medical Home
 Obtain valid health
insurance
 Attachment to case
manager
 Connected to
appropriate mental
health services
 Connected to
appropriate addictions
services
 Improved adherence to
chronic disease
management plans
 Reduced inappropriate
use of acute health care
systems and facilities
 Increased knowledge of
factors contributing to
emergency department
visits
 Continuity with primary
care provider
 Improved mental health
outcomes
 Appropriate housing
placement
 Decreased ER visits
 Decreased hospital
inpatient stays
 Decreased EMS use
 Stable income support
 Improved hospital staff
knowledge of
community resources
for vulnerable
populations
 Improved patient
health & quality of life
 Reduced systems
costs
 Improved
communication &
coordination between
agencies and systems
providers
 Reduced stigma for
vulnerable populations
 Improved social
determinants of health
for vulnerable
populations

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Anticipated Benefits
• For patients
 System navigation
 Advocacy and compassion
 Patient education - better understanding of health needs and concerns,
follow-up required
 Linkage to health and social supports
 Transitional care
 Reduction in morbidity and mortality
• For hospital
 Reduce demand on acute care services, both inpatient and ED
 Enhanced collaboration between acute care and community partners
 Better understanding of demographics of population (medical diagnosis,
mental health, social needs) accessing ED to support development of future
interventions
• For community
 Improved communication and coordination between agencies
 Advocacy
 Improved continuity of care

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Data Collection
• Looking to show effectiveness and success
 How are these best defined?
 In this context?
• Some of the data we are collecting:
 Demographics: AHC status, housing stability,
 Hospital visit: admitting diagnosis, interventions
received, discharge plan
 Health needs: PCP, problem list, # of medications,
quality of life
 Addictions and mental health: accessing care,
diagnosis

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Evaluation
• Plan to assess the structure, process, and outcomes of
the intervention to determine whether it is effective
and what the key success factors are
 U of C
 Green Shield Canada Foundation
 Innoweave
• Not a RCT - pre/post intervention data
• Hopeful that this partnership between CUPS, AHS, and
community agencies will help to improve community-
based care for these vulnerable patients and will
ultimately lead to improved economic, social and
health outcomes for this population

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The Early Days…
• Patient demographics
 ~70% male
 Majority are homeless
 Needs include PCP attachment, discharge planning,
addictions support & mental health support
• Referrals
 Psych Emerg and SW
 Education with staff about program
 Staff champions
• Community engagement
 Community partners referring patients to ED
 Collaboration with Calgary Case Management Group

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Potential Challenges
• Data collection!
• Limited resources
• Case loads
• Triage process

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Sustainability
• Alignment with Alberta Health and provincial goals of
improving transition care for vulnerable populations
• Alignment with the provincial primary care strategy
and enhancement of the medical/health home for
patients
• Ongoing quality improvement efforts and initiatives
• Research partnerships
 University of Calgary
 Canadian Association of Community Health Centers
 Southern Alberta Primary Care Research Network
 Canadian Primary Care Sentinel Surveillance Network

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Break the Cycle
CCT

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Questions?
Thank you!
Darryn Werth
darrynw@cupscalgary.com
Elaine Wilson
elainew@cupscalgary.com

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References
Bodenmann, P. et al. 2014. Case management for frequent users of the emergency department: study protocol of a randomised
controlled trial. BMC Health Services Research 14: 264.
Chambers, C. et al. 2013. High utilizers of emergency health services in a population-based cohort of homeless adults. Am J Public Health.
103(S 2): S302-S310.
Calgary Homeless Foundation. 2014. Point-In-Time Homeless Count: Winter 2014. [http://calgaryhomeless.com/wp-
content/uploads/2014/06/Winter-2014-PIT-Count-Report.pdf].
Canadian Institute for Health Information. 2006. National Ambulatory Care Reporting System. Ottawa: ON. CIHI.
Canadian Institute for Health Information. 2015. Defining High Users in Acute Care: An Examination of Different Approaches. Ottawa:
ON. CIHI.
Canadian Medical Association. 2013. Health care in Canada: What makes us sick? Canadian Medical Association Town Hall Report.
Fine, A. et al. 2013. Attitudes towards homeless people among emergency department teachers and learners: a cross-sectional study of
medical students and emergency physicians. BMC Medical Education. 13 (112):
Frankish, C. J. et al. 2005. Homelessness and Health in Canada: Research Lessons and Priorities. Canadian Journal of Public Health. 96
(S2): S23-S29.
Forchuk et al. 2008. Developing and testing an intervention to prevent homelessness among individuals discharged from psychiatric
wards to shelters and No Fixed Address. Journal of Psychiatric and Mental Health Nursing. 15: 569-575.

38. CUPSCalgary.com
Forchuk et al. 2015. Homelessness and housing crises among individuals accessing services within a Canadian emergency department.
Journal of Psychiatric and Mental Health Nursing. 22: 354-359.
Gaetz, S. et al. 2013. The State of Homelessness in Canada, 2013. Toronto. Canadian Homelessness Research Network Press.
[http://www.homelesshub.ca/ResourceFiles/SOHC2103.pdf].
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[http://www.press.uottawa.ca/homelessness-health-in-canada].
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populations: a systematic review. Journal of Emergency Medicine. 44 (3): 717-729.
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visits by the top frequent visitors using patient care plans. Journal of Emergency Medicine. 44 (4): 853-860.
Pines, J. et al. 2011. Frequent Users of Emergency Department Services: Gaps in Knowledge and a Proposed Research Agenda. Academic
Emergency Medicine. 18 (6): e64-e69.
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Chronically Ill Homeless Adults: A Randomized Trial. JAMA 301 (17): 1771-1778.
Tricco, A. et al. 2014. Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a
systematic review and meta-analysis. CMAJ. 186 (15): E568-E578.

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