Sanguen Report FINAL**

SANGUEN HEALTH CENTRE
Expanding Hepatitis C Services &
Supports in the Region of Waterloo
An Environmental Scan and Literature Review
2016
SANGUEN HEALTH CENTRE

1

ACKNOWLEDGEMENTS
We would like to express our deepest gratitude towards the staff (Michelle Steingart, Pete
McKechnie, Violet Umanetz, Ash Lowenthal, Shauna Groulx, Natasha Campbell, Martine Stomp,
Tracy Hobson and Jenn Greenwood) and service users of Sanguen Health Centre in Waterloo and
Guelph who have shared their space, their knowledge, and their lived experiences with us over the
course of creating this report. You were tremendous in supporting us to cultivate an
understanding of occupational therapy in this field, and we are forever grateful for the
opportunity to work with—and learn from—you. This report would not be what it is today without
your help. To community partners and allies in the Regions of Waterloo and Wellington, most
notably Becki Linder and ARCH, Lynn Macaulay from HHUG, and the staff at St. John’s Kitchen
and Hospitality House— thank you for taking the time to talk with us, and for showing us
firsthand some of the amazing initiatives that are taking place in the region.
We would also like to thank Lindsay Castle, our preceptor, and Dr. Chris Steingart and Colin
McVicker, our mentors at Sanguen, for their guidance and encouragement over the past eight
weeks. Your support and expertise have been vital in the completion of this report, and your
passion towards facilitating positive change within the region is inspiring.

2

MEET THE AUTHORS
OF THE REPORT

Rachel Schooley is a student occupational therapist in the Master’s of
Rehabilitation Science (Occupational Therapy) program at McMaster University.
She completed her Bachelor’s of Arts degree in Sociology and Women’s Studies at
the University of Guelph in 2012.
She can be reached via email at schoolhr@mcmaster.ca
Matt Harrigan is a student occupational therapist in the Master’s of Rehabilitation
Science (Occupational Therapy) program at McMaster University. He completed his
Bachelor’s of Human Kinetics at the University of Windsor in 2014.
He can be reached via email at harrigm@mcmaster.ca

3

Occupational therapy is a holistic approach that considers the personal, environmental,
and occupational elements that contribute to, or detract from, engagement in
meaningful occupations. Occupational therapists (OTs) assist people in creating
occupational goals, and work with them to identify issues that impact occupational
performance. In the context of the occupational therapy lens, one is able to assess the
tangible needs of people who access services at Sanguen Health Centre—physical,
economic, and housing needs—as well as the intangible needs—those connected to
spiritual, social, and mental health and wellbeing. In utilizing an occupational therapy
lens, all aspects of the person are considered, and the role of environment is
appreciated as intricately
connected and influential to the
person’s ability to participate,
engage in and perform the
occupations they need to do, want
to do, and are required to do.
Occupations consist of how one
occupies space and time—the
activities of daily living, as well as
specific goals that are meaningful
to the client. It is with these
occupations in mind that we
consider how an expansion of
services at Sanguen Health Centre could assist clients to better facilitate occupational
engagement and optimize occupational performance. In this report, we consider the
current strengths and gaps in services that impact engagement in meaningful
occupation for the Sanguen client. Utilizing the focus of an occupational therapy lens,
we present a report that we hope will inform the reader of the benefits of increasing
services at Sanguen Health Centre in the Region of Waterloo.

4

MAIN MESSAGES
FROM THE LITERATURE AND CONSULTATION WITH
PARTNERS IN THE KW REGION AND CANADA
1
2
3
Expanding Sanguen’s inter-professional team will
allow for improved provision of services.
Evidence supports the implementation of diversification of services via
interprofessional teams to facilitate Hepatitis C treatment initiation
and adherence. Supports that focus on the client’s physical, mental,
cognitive, and environmental factors are essential in addressing all
aspects of a person’s health and wellbeing.
Expanding on Sanguen’s successful launch of mobile
health services will result in increased access of at-
risk populations not currently engaged with health
care.
Sanguen has already provided numerous services to hundreds of people
in the Region of Waterloo via the mobile community health van.
Increasing staffing and resources for the van will allow Sanguen to meet
the needs of the community in Kitchener/Waterloo, and beyond.
Sanguen has a critical role to play in Housing First
initiatives in the Region of Waterloo.
There is great potential for Sanguen to provide housing services
alongside current Sanguen supports, in order to best serve people at risk
of and living with Hepatitis C by providing specialized services that will
allow clients to initiate, and stay retained in, treatment. Housing First
programs are proven to be a cost efficient, effective and person-
centered model of practice.

6

Sanguen Health Centre

Mission
Sanguen is a not-for-profit, community-based health care agency. Their mission is to
meet the needs of people in Waterloo Region and Guelph living with or at risk for
Hepatitis C through education, outreach, support, and medical care. 1
Vision
Sanguen’s vision is to be an effective Hepatitis C organization. Through education and
outreach, Sanguen hopes to increase awareness of the importance of Hepatitis C among
persons at risk, the public and minimize its potential impact in the future. 2
History
Dr. Chris Steingart, an infectious disease physician, recognized that there were many
people living with Hepatitis C in Waterloo Region and Guelph-Wellington, who could
benefit from medical treatment and support. Dr. Steingart opened an office in Guelph
and began to treat people with Hepatitis C in April of 2007. Sanguen was registered as a
not-for-profit in May of 2008 and received charitable status in May of 2009. Sanguen
continues to provide Hepatitis C testing, treatment, support, outreach, and education
to patients who have, or who are at-risk of, Hepatitis C. 3
Services
• Support through physician services, case management and advocacy for those
in/waiting for treatment
• Outreach services providing education about Hepatitis C and harm reduction
• Hepatitis testing/screening
• Collaboration with community partners to create & improve Hepatitis C
initiatives
• Community Health Van

1
Sanguen health centre (2016). “About sanguen health centre” [Online]. Available: http://sanguen.com/about-sanguen-health-
centre [2016, February].
2
Ibid.
3
Ibid.
CHAPTER 1:
Introduction

7

Hepatitis C
Hepatitis C is a chronic liver disease caused by
the Hepatitis C virus (HCV). Canadian
national estimates from 2011 show that
332 500 people were HCV positive. 4 5
The
most common symptoms of Hepatitis C
infection include fatigue, reduced appetite,
pain in muscles and joints, nausea, abdominal
pain, and jaundice—many of which impact
occupational performance.
Hepatitis C causes inflammation of the liver,
which can lead to cirrhosis, and eventually to
liver cancer.6
Some people are able to clear HCV
from their body early on in the infection; however, it progresses to a chronic infection
in about ¾ of infected people.7
People can live without symptoms of infection for
decades, and in the 2011 study by the Government of Canada, it was discovered that
approximately 44% of those infected were not aware of their infection status.8
HCV spreads through contact with infected
blood. 9
In Canada, between 70-80% of
people became infected by sharing needles,
pipes, spoons and cookers. 10
The
asymptomatic earlier stages of Hepatitis C
infection means that many people may
unknowingly spread HCV to others. For this
reason, harm reduction practices are
essential in minimizing the risk for
contracting Hepatitis C.

4
Government of Canada (2015). “Hepatitis C” [Online]. Available: http://healthycanadians.gc.ca/diseases-conditions-maladies-
affections/disease-maladie/hepc-eng.php [2016, February].
5
Challacombe, L. (2015). “The Epidemiology of Hepatitis C in Canada” [Online]. Available: http://www.catie.ca/en/fact-
sheets/epidemiology/epidemiology-hepatitis-c-canada [2016, January].
6
Government of Canada (2015).
7
Challacombe, “The Epidemiology of Hepatitis C in Canada,” 1.
8
Government of Canada, 2015.
9
Ibid.
10
Ibid.
This dragon is the logo on Sanguen's Community
Health Van. Some patients refer to Hepatitis C
treatment as "slaying the dragon."

8

Harm Reduction
An integral element of Sanguen
services is the philosophy and
practice model of harm reduction.
Sanguen, through its outreach and
mobile health van services,
provides harm reduction supplies to
people—an essential part of the
process for prevention and
treatment of Hepatitis C. HCV is
more resilient than HIV, more
infectious through blood contact,
and is ten times more easily
transmitted through contaminated
needles. 11
Preventing Hepatitis C
through the provision of harm
reduction supplies means that the
cost of treating the disease is avoided.
International recommendations for the management of Hepatitis C infection now
recognize the importance of harm reduction programs, with several studies showing
that Hepatitis C treatment in combination with harm reduction practices can lead to
substantial reductions to HCV prevalence.1213
Research literature suggests that people
who use injection drugs—particularly those who are marginalized and are experiencing
poverty and unstable housing—are less likely to seek health care due to a fear of stigma
and discrimination.14
Sanguen ensures accessibility to health care not only through a
non-judgmental environment with staff that are knowledgeable and supportive, but
also by providing patients access to harm reduction supplies. Research evidence
supports practices that assist people to engage with health care and prepare for
Hepatitis C treatment through an understanding of lifestyle needs fostered by
community-based, interprofessional support that follows harm reduction models.15 16

11
Strike et al. Best Practice recommendations for Canadian Harm Reduction Programs that Provide Service to People Who use drugs and
are at risk for HIV, HCV, and Other Harms: Part 1. (Toronto, Working Group on Best Practice for Harm Reduction Programs in
Canada, 2013), 8.
12
Grebely et al., “Expanding access to prevention, care and treatment for hepatitis C virus infection among people who inject
drugs,” International Journal of Drug Policy, Vol. 26, No. 10 (October, 2015), 893.
13
Strike et al., 2013, 4.
14
Grebely et al., 2015, 895.
15
Ibid.
16 Mason et al., “Beyond viral response: A prospective evaluation of a community-based, multi-disciplinary, peer-driven model of HCV
treatment and support”, International Journal of Drug Policy, Vol. 26, No. 10 (October 2015), 6.
http://www.catie.ca/en/hepatitis-c/key-messages/harm-reduction

9

Hepatitis C often requires treatment apart
from antiviral medication. Hepatitis C can
interact with multiple elements of a person’s
life, including finances for treatment,
relationships, mental health, substance use,
and coping with the side effects of HCV and
its treatment. 17
Many of these factors,
including mental health, addiction, poverty
and unstable housing, can impact an
individual’s ability to successfully begin and
adhere to the medication regime necessary to
treat HCV. 18
Patients with multiple
comorbidities often require comprehensive
rehabilitation involving multiple health care
professionals (e.g. physician, psychologist, nurse, social worker, occupational therapist,
etc.), who are each able to bring diverse perspectives, assessments and interventions
together for a holistic view of the patients’ issues.19
Healthcare professionals need to
remain client centred and recognize people as unique, autonomous beings who are
more than just their positive HCV diagnoses. Thus, a holistic, interprofessional team
that incorporates medical specialties, primary care, and behavioral health approaches
to treatment is fundamental in order to provide high quality rehabilitation and patient
care and to increasing the amount of patients who can access HCV treatment.20 21

17
Canadian Working Group on HIV and Rehabilitation (2012).”Rehabilitation supports for people living with HIV and hepatitis C
[Online]. Available: http://librarypdf.catie.ca/pdf/ATI-20000s/26444.pdf [2016, February].
18
Bonner et al., “Time to rethink antiviral treatment for hepatitis C in patients with coexisting mental health/substance abuse
issues,” Digestive diseases and sciences, Vol. 57, No. 6 [June, 2012], 1470.
19
Korner, M. “Interprofessional teamwork in medical rehabilitation: a comparison of multidisciplinary and interdisciplinary team
approach,” Clinical rehabilitation, Vol. 24 [June, 2010], 745-746.
20
Norrefalk, J. R. (2003). “How do we define multidisciplinary rehabilitation?”, Journal of rehabilitation medicine, Vol. 35, No. 2
[March, 2003], 101.
21
United States Department of Health & Human Services (2011). “Combating the silent epidemic of viral hepatitis: Action plan of
viral hepatitis [Online]. Available: http://www.hhs.gov/ash/initiatives/hepatitis/actionplan_viralhepatitis2011.pdf [2016, February].
CHAPTER 2:
Inter-professional
Collaboration
Defining Interprofessional
Collaboration:
“Positive interaction of two or more
health professionals, who bring their
unique skills and knowledge, to assist
patients/clients and families with their
health decisions.”
Through this method of collaboration,
team members share responsibilities,
resources, and accountability to
develop mutual client-driven goals.
CAOT (2006). “CAOT position statement: Occupational
therapy and primary health care” [Online]. Available:
http://www.caot.ca/default.asp?ChangeID=188&pageID=188.

10

Evidence Surrounding Interprofessional
Collaboration for Hepatitis C Treatment

The American Association for the Study of Liver Diseases (ASSLD) best practice
guideline recommends that people with Hepatitis C, along with mental health and
addiction comorbidities, receive treatment delivered by an interprofessional team of
healthcare professionals that provide ongoing support for their mental health and
addictions to ensure safety and effectiveness of
antiviral treatment. 22
Thus, interprofessional
teams that combine infectious disease care with
mental health, addictions, and other supports are
essential in supporting patients with
comorbidities in preparing for, and successfully
undergoing, antiviral treatment. 23
Healthcare
providers, including psychologists, social workers
and OTs, conduct psychological, cognitive and
physical assessments and implement evidence-
based interventions to address depression, anxiety
and stress management, promote a healthy
lifestyle, and enhance patient adherence to the
HCV treatment regimen.24
In a study conducted in
the United States, participants who received
follow-up phone calls, motivational enhancement counseling, and referral to
community mental health and addictions services were 2.4 times more likely to address
their barriers and become fit to receive Hepatitis C treatment, compared to patients
who only received enhanced medical care.25
Research suggests that a commonality
amongst HCV team approaches is that the hepatology provider (i.e. physician) remains
central to Hepatitis C medical care, while other healthcare professionals provide
ongoing psychosocial support for comorbidities such as mental health conditions and
addictions that might otherwise impact their ability to successfully complete Hepatitis
C treatment. 26
This is the structure that has allowed Sanguen to reach and support so
many of their clients.

22
Ghany et al., “Diagnosis, management, and treatment of hepatitis C: an update,” Hepatology. Vol. 49 (April, 2009), 1362.
23
Hill, et al., “Capacity enhancement of hepatitis C virus treatment through integrated, community-based care,” Canadian journal
of gastroenterology, Vol. 22, No. 1 (January 2008), 30.
24
Bonner et al., “Rethinking antiviral treatment for Hepatitis C”, 1470.
25
Evon et al., “A randomized controlled trial of an integrated care intervention to increase eligibility for chronic hepatitis C
treatment,” American journal of gastroenterology. Vol. 106 (October 2011), 1777.
26
Bonner et al., “Rethinking antiviral treatment for Hepatitis C”, 1472.

11

How Occupational Therapy Can Support
a Hepatitis C Interprofessional Team
Although there is limited evidence on the utilization of occupational therapy in
Hepatitis C treatment, an overwhelming body of evidence supports the use of OTs on
interprofessional community health teams. In Ontario, OTs fulfill the requirements
necessary to be rehabilitation specialists on an Assertive Community Treatment (ACT)
team.27
ACT teams provide treatment, rehabilitation and support to individuals with
mental health conditions.28
On an ACT team, OTs provide a unique dual service, as they
function as generalist mental health workers and as specialists that provide knowledge
and support through an occupational perspective.29
Research has also shown that an
inability to fill a daily schedule with meaningful activities increases the risk of relapse
in those living with addiction.30
OTs examine addictive behaviours through two
occupational risk factors. Occupational imbalance exists when people have insufficient
time to meet physical, social, mental and rest needs due to a narrowing of daily
occupations, as addiction becomes the most meaningful occupation. Occupational
deprivation occurs when internal and external factors such as poverty, environment,
and physical and mental health prevent participation in meaningful occupations. With
an understanding of these occupational determinants of health, an OT can enable
people develop or re-engage in life roles, assist in developing a daily schedule, and help
in modifying environments to be accessible in affording opportunities for occupational
engagement.31
OTs can also support those with cognitive and physical deficits caused
by the side effects of the Hepatitis C medication or by other comorbid conditions. OTs
enable people to manage daily activities that are impacted by health and environmental
issues. This can be achieved through modifying environments to accommodate for
limitations, recommendations for assistive equipment, and cognitive (remedial and
compensatory) strategies to assist with schedule management.32
Thus, OTs provide a
unique perspective to a interprofessional team and can be utilized in many areas of
chronic disease management. As well, the broad scope of occupational therapy enables
OTs to support individuals at any level of wellness, from supporting people to develop a
daily schedule of meaningful occupations during treatment, to empowering people in
their community reintegration post-treatment.

27
Ontario Ministry of Health. Standards for assertive community treatment teams (Toronto: Ontario ministry of health and long
term care, 1998).
28
Ibid.
29
Krupa et al., “Reflections on…occupational therapy and assertive community treatment,” Canadian journal of occupational
therapy, Vol. 69, No. 3 (June, 2002) 154.
30
Helbig et al., “An exploration of addictive behaviours from an occupational perspective,” Journal of occupational science, Vol. 10,
No. 3 (November, 2003), 143.
31
Ibid., 142.
32
Krupa et al., “OT and ACT”, 155.

12

How Occupational Therapists can
Address Occupational Challenges
On a community healthcare team, OTs can address occupational issues at many levels.
Through the use of their dual service as general mental health workers and specialized
healthcare providers, OTs can assist the patient, the team, and the system-level players
in improving the mental, physical and cognitive health and wellbeing of people in the
community.33

33 Krupa et al., “OT and ACT”, 155-157.

13

Mobile health units (MHUs) are a form of
healthcare service that were developed in
response to evidence that many
communities and vulnerable populations
were not accessing and receiving the
appropriate level of care for their health
needs.34
Mobile health units extend beyond
the clinic and provide preventive,
diagnostic, curative, and educational
interventions to populations in need.35
These services are often provided by an
interdisciplinary health team, including
physicians, social workers, community
health workers, registered
dieticians, counsellors and dentists.36

34
CA Codes, “hsc:1765.101-1765.175” [Online]. Available from: http://www.leginfo.ca.gov/cgibin/displaycode?section=
hsc&group=01001-02 000&file=1765.101-1765.175 [2016, February].
35 Khanna et al., “Mobile health units: Mobilizing healthcare to reach unreachable,” International journal of healthcare management,
Vol. 9, No. 1 (January 2016), 2.
36 Ibid., 3.
CHAPTER 3:
Mobile Outreach
Mobile Health Unit
Definition:
Special purpose vehicle that
“provides medical, diagnostic, and
treatment services, in order to help
ensure the availability of quality
healthcare services for patients who
receive care in remote or underserved
areas and for patients who need
specialized types of medical care
provided in a cost-effective way”
CA Codes, “hsc:1765.101-1765.175” [Online]. Available
from:http://www.leginfo.ca.gov/cgibin/displaycode?sect
ion= hsc&group=01001-02 000&file=1765.101-1765.175
[2016, February].
Mobile Health Unit
“This allows people to take on their own health care, on their own
terms. More importantly it works for people who are homeless, who are on
the streets and whose lives are upside down for whatever reason.”
Source: Capital Health, “New mobile outreach van takes health care to the streets,” [Online]. Available from:
http://www.cdha.nshealth.ca/media-centre/news/new-mobile-outreach-van-takes-health-care-streets [2016, February].

14

37

37 The Alex, (2016). “Mobile health program” [Online]. Available: http://www.thealex.ca/programs-services/health/health-bus-
program/ [2016, February].
The ALEX
Provides individualized services, housing support and accessible
medical care to the most vulnerable populations in Calgary.
Along with a clinic, the ALEX operates three mobile health buses
that provide different services to populations within Calgary.
1. The ALEX Community Health Bus is staffed by physicians,
registered nurses, nurse practitioners, and a resource worker,
who provide referrals to community resources, education and
health promotion, testing for various diseases, cholesterol
levels, heart rhythm, and urine analysis.
2. The ALEX Youth Health Bus provides health care to
underserved youth in high schools. Physicians, registered
nurses and resource workers provide STI testing and
treatment, pregnancy and sex testing and support, referrals
to community services and general health support
3. The ALEX Dental Health Bus provides oral health
screenings, education and support to youth in high-need
areas.
Mobile Health Initiatives in Canada

15

38

39

38
City of Ottawa, (2015). “Site needle & syringe program” [Online]. Available: http://ottawa.ca/en/residents/public-health/healthy-
living/clean-needle-syringe-program [2016, February].
39
Mobile outreach street health. “Mobile outreach street health information sheet [Online]. Available:
www.cdha.nshealth.ca/mobile-outreach-street-health-information-sheet%20(3).pdf [2016, February].
The City of Ottawa Clean Needle & Syringe Program
Developed in 1991 to prevent the spread of communicable diseases,
primarily HIV and Hepatitis-C, and to minimize the risks associated
with substance use.
A segment of this project includes a mobile van that travels to
locations around the city seven days a week and provides supportive
counseling, health education and promotion, testing for Hepatitis C
and HIV, provision of vaccinations, and referral to health and social
services.
Mobile Outreach Street Health (MOSH)
Provides accessible primary health care services to people who are
homeless, insecurely housed, street involved and underserved in
Dartmouth, Halifax, Fairview and Spryfield of Nova Scotia.
In November 2009, the MOSH program officially launched their own
mobile van service, providing on-the-spot services, including blood
work, wound and vein care, STI, HIV and Hepatitis C testing,
distributing of harm reduction supplies, birth control and condoms,
vaccinations, health promotion, and assistance in obtaining a health
card and organizing referrals to mainstream healthcare.
“We’ve created an innovative and collaborative approach to
delivering primary health care services to those who are sometimes
underserved”
Source: Capital Health, “New mobile outreach van takes health care to the streets,” [Online]. Available from:
http://www.cdha.nshealth.ca/media-centre/news/new-mobile-outreach-van-takes-health-care-streets [2016, February].
Mobile Health Initiatives in Canada

16

Evidence Surrounding the Effectiveness
of Mobile Health Outreach
Mobile health units are becoming a more common form of healthcare, as they are
successfully increasing access and providing healthcare to at-risk populations that are
currently not being cared for by traditional health services.40
Research indicates that
MHUs are useful for preventive and health promotion activities.41
The Family Van, a
MHU aiding underserved communities in Boston, state that 50% of their regular clients
who had a health issue on their first visit had controlled the condition within
subsequent visits, and that 25% of their clients are referred for follow-up health or
social services.42
Thus, mobile health services may serve as a transitional service for
referral to healthcare, or as alternatives for patients who do not wish to access
mainstream services.43
Furthermore, a study done in Massachusetts evaluated a MHU
that screened a high-risk population for Hepatitis C and HIV.44
Only 1 out of the 202
participants reported being Hepatitis C positive. However, after screening 176
participants, 29% were positive for Hepatitis C. The participants, many of whom were
not receiving primary health care, stated that clinic hours are often not sufficient, and
that they do not have transportation to get to the clinic.45
By providing at-risk
populations with flexible and non-judgmental healthcare, MHUs may minimize barriers
of mistrust and transportation.46
MHUs have also been found to reduce healthcare costs
substantially, as they can deliver less expensive healthcare when compared to
emergency department costs.47
In 2008, researchers created a return on investment
algorithm that estimated the cost of running the Family Van.48
Researchers calculated
that $312,5668 was avoided annually through the Family van rather than through
emergency department visits. Although annual van expenses totaled $565,700, due to
the finances saved by diverting patients from hospital admission into community
treatment, a return on investment ratio was calculated as 36:1.49

40
Khanna et al., “Mobile health units”, 5.
41
International committee of the red cross, (2006). Mobile health units: methodological approach [Online]. Available:
www.icrc.org/eng/assets/files/other/icrc_002_0886.pdf [2016, February].
42
The family van, (2015). Our impact [Online]. Available: http://www.familyvan.org/our-impact/ [2016, February].
43
Oriol et al., “Calculating the return on investment of mobile healthcare” BMC medicine, Vol. 7, No. 1 (June, 2009), 28.
44
Zucker et al., “Mobile outreach strategies for screening hepatitis and HIV in high-risk populations,” Public health nursing, Vol. 29,
No. 1 (January, 2012), 29-31.
45
Ibid.
46
Marval, R. (Personal communication, January 25, 2016).
47
Song et al., “Mobile clinic in massachusetts associated with cost savings from lowering blood pressure and emergency
department use,” Health affairs: Project hope, Vol. 32, No. 1 (January, 2013), 39.
48
Oriol et al., “Return on investment of mobile healthcare”, 29.
49
Ibid.

17
Sanguen Mobile Outreach Program
The Sanguen Community Health Van is an initiative that was several years in the
making. After years of working with people who have, or who are at-risk for, Hepatitis
C, Sanguen became aware that many people in the Kitchener-Waterloo region
experience barriers to accessing services. After countless meetings, a review of the
literature and diligent effort, the Sanguen Community Health Van initiative began in
December 2015. Currently, two outreach workers, a social worker, and a nurse provide
healthcare and social services to an at-risk population at four locations in Kitchener
one night per week. A strategic route has been developed to provide healthcare access
and other services to an underserved community at shelters, parks and motels for
individuals and families who are unstably housed and homeless. Staff is currently
developing relationships and trust within the community, through quick, friendly
interactions on the van, and by arriving to the locations on consistent and timely basis.
Sanguen has received numerous monetary and supply donations from the local
community, which has gone a long way to support the van project and keep it in
service. An expansion to Cambridge locations will occur in March, along with a second
night in Kitchener in the spring.
Since the launch, weekly statistics indicate that the Sanguen Community Health Van is
accessing people who do not typically access health and social service supports,
including the Sanguen clinic, kitchens and community drop-in centers. There has also
been a surprising demand for the basic necessities, such as clothing, feminine hygiene
products, underwear, socks, food and water. As the summer months approach, staff on
the Community Health Van project that the van will become increasingly busy with
client contacts and supply distribution. Just recently, Sanguen developed a formal
partnership with Waterloo Region Public Health to secure its own needle syringe
program agreement through local public health departments. This will allow Sanguen
to distribute sterile harm reduction equipment and safely dispose of used syringes.
Current barriers to the van initiative include funding and underestimated staff hours.
Sanguen is currently using its own nursing and social work employees to staff the van
shifts, resulting in these employees working longer hours during the week. As well,
funding is a barrier to the longevity of the van initiative. Sanguen is currently
consulting with potential partnering agencies to recruit more staff and obtain more
funding in order to meet the demand of services, especially as the warm weather
approaches and as Sanguen expands to more nights.

18

Services Provided by the Sanguen Community
Health Van

19

Sanguen Community Health Van
Estimated Statistics as of March 1, 2016

20

How Occupational Therapy Can Support the
Sanguen Mobile Community Health Van
The role of an OT in mobile healthcare is not yet well defined. However, based on the
evidence of the skills and perspective that they offer to a interprofessional team, OTs
are well suited to work in this area of practice. Occupational therapists are able to employ a
dual-role to function as generalist mental health workers that provide supportive
counseling, and as specialists that provide knowledge and support through an
occupational perspective with a specialized focus on the person, their environment and
their occupations.50 Although it is not as easy to provide traditional occupational
therapy services on the van, as the interactions are often quick, it does allow OTs the
opportunity to be non-judgmental, flexible and client-centred, which will be essential
to building rapport and developing therapeutic relationships.51
The development of
these relationships may permit the opportunity for referrals to the clinic for health and
social services, including OT, at a later date. There may also be potential to schedule
appointments to meet with patients at the mobile van locations, much like meeting
individuals at a clinic. However, a larger van with seating would be required in order to
administer assessments or implement strategies, while also maintaining
confidentiality.
Furthermore, OTs could utilize the space in the van for other purposes not related to
mobile outreach. These include transporting large assistive equipment such as
wheelchairs to client’s homes.52
Moreover, as Housing First models emerge in the
Region of Waterloo, occupational therapy has an essential role in assisting people with
eviction prevention. Thus, the OT could use the space in the mobile health van to clear
and transport excessive materials out of a person’s home, such as in hoarding
situations.53

50
Krupa et al., “Reflections on OT and ACT, 154.
51
Marval, R. (Personal communication, January 25, 2016).
52
Sandiford, M. “Reaching Out: Today's Activist Occupational Therapy (Full Version)”. Filmed [August, 2012]. YouTube video,
25:31. https://www.youtube.com/watch?v=LIcfyQ3RwT0.
53
Ibid.

21

CHAPTER 4: Housing First
Housing First: An Evidence-Based
Program Model in Canada
Canada is currently navigating a response to what has become a crisis of homelessness
and lack of affordable housing.54
The current national response to homelessness relies
heavily upon emergency health care and crisis services, such as emergency room visits
and emergency shelters for housing.55
However, the cost of responding to Canada’s
housing problem in a reactive way has become undeniable: homelessness alone costs
the Canadian economy an estimated $7 billion, or more, per year.56
The irony is that
this is essentially the cost to ignore homelessness; national investments to programs
that target homelessness and increase housing and supports for those that experience
persistent homelessness are not sufficient in actually addressing and eradicating
homelessness, thus costing Canadian taxpayers and the Canadian economy.57
An evidence-based solution has emerged via the preventative nature of Housing First
(HF). In a Canada-wide study consisting of five Canadian cities of different size and
cultural composition, the At Home/Chez Soi report demonstrates the effectiveness of
the HF model. HF as a evidence-based program model has been adopted Canada-wide,
with recognition that adequate housing is a human right and a social determinant of
health, and that permanent housing and supports should be the basis of treatment.58

54
Stephen Gaetz, Tanya Gulliver & Tim Richter. The State of Homelessness in Canada: 2014 (Toronto: The Homeless Hub Press,
2014), 3.
55
Paula Goering, et al., At Home/Chez Soi Final Report (Calgary, AB: Mental Health Commission of Canada, 2014), 6.
56
Gaetz et al., 2014, 6.
57
Goetz et al., 2014, 6.
58
Goering et al., 2014, 6.
“Homelessness describes the situation of an individual or family without stable, permanent, appropriate
housing, or the immediate prospect, means and ability of acquiring it. It is the result of systemic or
societal barriers, a lack of affordable and appropriate housing, the individual/household’s financial,
mental, cognitive, behavioural or physical challenges, and/or racism and discrimination. Most
people do not choose to be homeless, and the experience is generally
negative, unpleasant, stressful and distressing.” (CHRN, 2012: Canadian Definition of
Homelessness).

22
Housing First in the Region of Waterloo
In 2014, Ontario released its poverty reduction strategy, in which HF is a key
intervention in the commitment to ending homelessness in the province.59
The
Region of Waterloo is engaged in the efforts to reduce homelessness and improve
housing stability for those experiencing episodic and persistent homelessness.60
Waterloo Region has propelled many housing initiatives that assist those who are unable
to afford and access safe and stable housing in recent years, based in the recognition of
housing as not only a provision of shelter from physical elements, but also a provision of
choice and autonomy, which contributes to mental, physical and social health and wellness
that facilitates occupational engagement.61 62 A wide span initiative in the Region of
Waterloo is STEP Home (Support To End Persistent Homelessness), consisting of 13
interrelated programs that focus on three main areas: intensive support programs,
supportive housing, and street outreach.63 STEP Home emerged from Waterloo Region’s
“All Roads Lead To Home” report, which identifies the importance in prioritizing the end of
persistent homelessness in the region.64 HF has demonstrated cost effectiveness, both at a
national and regional level. The At Home/Chez Soi study report evidenced that the
implementation of the HF program model resulted in decreased ER visits and use of
emergency shelters for
participants. 65 This
meant significant long-
term savings, with every
$10 invested in HF
services resulting in an
average savings of
$21.72.66 These savings
have been echoed by
initiatives studied in the
Region of Waterloo,
with costs of HF
program models costing
considerably less than
emergency services. 67

59
Government of Ontario, A Place to Call Home: Report of the Expert Advisory Panel on Homelessness, (Ontario: Ministry of Municipal
Affairs and Housing, 2015).
60
Gaetz et al., 2014, 16.
61
Region of Waterloo. Affordable Housing Strategy: Community Begins at Home. (Waterloo, ON: Region of Waterloo Community
Services, 2008).
62
Regional Municipality of Waterloo Community Services. All Roads Lead to Home: The Homelessness to Housing Stability Strategy for
Waterloo Region 2012 (Waterloo: Region of Waterloo Social Services, 2012).
63
Social Planning, Policy and Program Administration. STEP Home 2012-2014 Report (Waterloo, ON: Regional Municipality of
Waterloo, 2014), 2.
64
Regional Municipality of Waterloo Community Services, 2012.
65
66
Ibid, 7.
67
Ibid, 5.

23

Occupational Therapy and Housing First
Housing First does not consist of housing on its own—people need to be engaged in
necessary supports in order to optimize the success of HF initiatives.68 These supports may
remain consistent for the long-term, or they may fluctuate as the person’s needs change.
For example, although the HF group in the At Home/Chez Soi study had a lower use of drop-
in center meals, the use of food banks increased.69 This transition indicates a transition of
roles for the person who has become housed—learning to cook for oneself, especially after
experiencing persistent homelessness, could greatly benefit from OT services. OT in HF is
an emerging area of practice, and OTs are extremely well suited to work in this area: OTs
recognize the importance of housing in fostering occupational engagement, and employ a
specialized focus on person, environment and occupation.70 OTs can engage with clients in
any environment, and can enable clients to develop goals that are holistic, client-centered
and client-directed.71 Recovery through
mental illness, substance use issues and
chronic illness are often life-long
processes, and requires learning how to
manage symptoms in healthy ways to
work towards re-engagement in
meaningful occupations and social
roles.72

OT goals and interventions may include
disease and disability self-management,
social skills training, addiction and
trauma counseling, as well as activities
of daily living, home safety, community
integration, implementing a healthy
routine, transit training, and suicide
intervention through enabling people to re-establish a sense of purpose and/or meaning
through occupational engagement.73 Another client-centered intervention that has been
noted by the authors of this report during their practicum at Sanguen has been the
implementation of activity scheduling, which reflects the qualitative information from the
At Home/Chez Soi report—once housed, participants reported that their daily lives changed
from being survival oriented and described as “killing time,’ to incorporating meaningful
occupations and establishing routines.74

68
69
Ibid, 21.
70
Erin Hoselton & Erin Duebel, “Housing First: An Emerging Area of Occupational Therapy Practice” [Webinar]. In CAOT Lunch &
Learn Series. (2015, December 1). Retrieved from:
http://caot.adobeconnect.com/p2uup4w4h4w/?OWASP_CSRFTOKEN=e4b6048c9880b66c4f09fb360322be4e604e0e83a1629705631e
cb2147ab540c on December 21, 2015.
71
Hoselton & Duebel, 2015.
72
73
Hoselton & Duebel, 2015.
74
Goering et al., 28.

24
Sanguen’s Role in Housing First
Programs that implement the HF model and maintain a person-centered and harm
reduction approach are more likely to meet the complex and individual needs of those
experiencing homelessness.75 Many Sanguen clients experience homelessness or unstable
housing, impacting the prevention and treatment of Hepatitis C. Often, programs require
that individuals maintain a period of sobriety before housing support is offered, which is
often an ineffective way of supporting those with addiction and substance use issues.76 In
the At Home/Chez Soi study, all participants had one or more serious mental illness, more
than 90% of participants reported at least one chronic health problem (including 20%
living with Hepatitis C), and 73% of participants reported substance-related illnesses.77
Homelessness is often the result of multiple system and individual factors, such as lack of
services, mental health and substance use issues, poverty, stigma, trauma and abuse.78 This
was reflected in the At Home/Chez Soi study, with well over half of participants reporting
emotional and physical abuse in childhood, and 38% reporting sexual abuse. 79
Homelessness is also strongly associated with stress and distress— 36% of participants in
the At Home/Chez Soi study reported symptoms of consistent moderate to high suicide
risk.80 Living in shelters and on the streets means that a significant amount of energy is put
into basic survival,81 and often those using substances do as a coping mechanism.

The STEP Home report recognizes that persistent homelessness is a complex social issue,
and one that requires the “collective efforts of multiple organizations, individuals and
sectors.”82 It is crucial to consider need on an individual basis in order to reflect the
complexity inherent in requiring housing assistance.83 Adding to this complexity on a
system-level is the current switch to an equity-based focus for housing services in the
Region of Waterloo.84 Although focusing on equity will ensure that those who are in the
greatest need of housing will receive services in a timely and effective manner, it also
means that the care Sanguen provides to its clients may interfere with their ability to
obtain housing. The development of a Sanguen housing facility, with supports specific to
Hepatitis C treatment and prevention, would maximize services for those experiencing
homelessness and in need of treatment for Hepatitis C. Policy implications of At Home/Chez
Soi echo the need for partnerships and collaborations at a community level, and to be
aware of the need to adapt the philosophy and practice of HF to meet the needs of specific
populations, such as those at risk for or living with Hepatitis C. 85

75
76
Ibid, 6.
77
Ibid, 16.
78
Ibid, 9.
79
Ibid, 16.
80
Ibid.
81
Ibid,., 8.
82
Regional Municipality of Waterloo, 2012, 2.
83
84
Amber Robertson & Marie Morrison, Region of Waterloo Community Homelessness Prevention Initiative Supportive Housing Program
Standards, (Waterloo: Region of Waterloo Community Services, 2015), 15.
85

25

CHAPTER 5
Next Steps
Sanguen Health Centre is successfully addressing the prevention and treatment of
Hepatitis C in the Region of Waterloo. Through the use of evidence-based program
models and ensuring that clients receive the highest level of supports possible,
Sanguen is able to provide high quality healthcare to its patients. There is great
potential for Sanguen to expand its services, demonstrated in information gathered in
both an environmental scan and a literature review. Sanguen’s services have the
potential to reach more clients, and to better serve existing and potential clients via:

2
Expanding the interprofessional team. Diverse
clinical and support services, such as
physicians, psychologists, nurses, outreach
workers, social workers, occupational
therapists and peer supports allows for a more
holistic and effective provision of care for
Sanguen clients.
Expanding the mobile health initiative at
Sanguen to include more staff, additional
workspace, as well as additional options for
van use, would allow Sanguen to offer more
services to people and the potential clients
already being served through the community
health van.
Exploring options for housing that meets
the needs of people waiting for, needing to
begin, or currently on treatment for
Hepatitis C would allow Sanguen to
continue with an excellent provision of
care for clients experiencing homelessness
or unstable housing.
1
2
3

26

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