harm reduction project 25: meeting of the minds
TRANSCRIPT
Using Harm Reduction Strategies
with Frequent Users of Emergency
Services: Project 25
Marc Stevenson
David Folsom
Kris Kuntz
Project 25 Background
3 year pilot funded by the United Way
Unprecedented Collaboration
35 chronically homeless “Frequent Users”
Outreach with partner agencies
Housing First Model
Intensive case management
Emphasis on data collection
Goals
Decrease use and cost of emergency
services
Housing stability and sustainability
Improved quality of life
Preventative care through medical home
Obtain income
Housing
Housing First Model
25 Sponsor Based Housing Vouchers
10 Housing subsidies through MHSA funds
Scattered site model
33 permanently housed
Who are the “Frequent Users”?
Chronically homeless
13 men and 3 women
Avg. age of 50 with range of 41 to 61
>90% have severe alcohol dependence
>90%have co-occurring disorder
>80% have complex medical problems
Failed multiple treatment programs
Intensive Case Management Services
Outreach/relationship/basic needs
Jail/hospital visits and D/C planning
Prescription P/U & delivery
Life Skills Coach home visits
Weekly/daily med management
Identification & education about trauma
Landlord mediation/education/relationship
Quick response to crisis in housing
Go-Phones/landlines/24 hour emergency number
Payee services
Harm reduction with tobacco/alcohol
What is Harm Reduction?
A range of public health policies and interventions designed to reduce harmful consequences of human behavior- even if this behavior is illegal (Wikipedia)
Starts where the client is
Moves towards better health and responsibility
Goal is improved quality of life
Achievable without demand for abstinence as a condition for assistance
http://gilgerald.com/storage/research-papers/09%20report%20harm.pdf
Examples of Harm Reduction
Needle exchange programs
Condoms/safe sex, STD/HIV prevention
Seatbelts
Designated driver
Methadone clinics
Managed Alcohol
Programs
Key Features (Drug Use)
Focus on reducing harm rather than use
Drugs are a reality of society
Harm reduction should provide a
comprehensive public health framework;
Priority on immediate (and achievable) goals
Harm reduction values pragmatism and
humanism
(Ritter and Cameron 2006)
Needle Exchange
Most studied harm reduction intervention
Became more prominent with HIV
Reduce risk/incident of HIV and Hep C
Enhancements can include case
management, primary care, and referrals
In San Diego, needle exchange programs
allowed in City, but not in County
Harm Reduction: Alcohol
Meets people where they are at with
drinking
Does not label people as “diseased” or
“alcoholic”
Empowers people to choose own goal:
safer drinking, reduced drinking, or
quitting
Realistic goals that they can accomplish
Anderson, Kenneth. (2010) How to Change Your Drinking: A Harm Reduction Guide to
Alcohol. The HAMS Harm Reduction Network
Managed Alcohol Programs
Originated in Canadian homeless shelters
In winter, many homeless alcoholics froze
to death rather than enter shelters that
required sobriety
Provide alcohol to shelter residents-
quantity varies
Goals are typically pragmatic (reduce ER
use) and humanitarian (prevent people
from freezing to death on the streets)
Past Research
Shelter Based Managed Alcohol Program,
Ottawa, CanadaPodymow et al (2006). Shelter-based managed alcohol administration to chronically
homeless people addicted to alcohol. Canadian Medical Association Journal, 174(1), 45-49.
1811 Eastlake, Seattle, Washington Larimer et al. (2009). Health Care and Public Service Use and Costs Before and After
Provision of Housing for Chronically Homeless Persons with Severe Alcohol Problems.
Journal of American Medical Association, vol. 301, n13.
Glenwood Residence and Wakigun
Residence, Hennepin County, MinnesotaThornquist et al. (2002). Health Care Utilization of Chronic Inebriates. Academic
Emergency Medicine, vol 9, n4.
Harm Reduction Alcohol: Concepts
Harm Elimination/Abstinence
Recovery Readiness
Moderation Management/Controlled Use
Substitution Therapy
Relapse/Overdose Prevention
Environmental Prevention
Alternative Approaches
Stages of Changehttp://gilgerald.com/storage/research-papers/09%20report%20harm.pdf
P-25: Harm Reduction Alcohol
Abstinence is our main goal
For some HR is not an option…
Some are going to drink with or without us
◦ Reduced drinking
◦ Safer drinking
◦ Encourage abstinence
Reduce harm in other areas such as health,
mental health, and trauma
Reduced Drinking
Drinking later in the day
Switching to lower alcohol beverages
Establishing reduced drinking goals
Planned drinking with monitoring
Assistance with alcohol purchase to
support reduced drinking plan
Daily/weekly drinking allowance
Safer Drinking
Drinking in home
◦ TV, DVD’s, and radio
Make it back to apartment
◦ Decrease interaction with Police and Ambulance
Eating before drinking
Vitamins
Cell phones/House phones
◦ 24 Emergency On-Call Phone
Encouraging Abstinence
Setting goals for abstinence days
◦ Setting goals for abstinence hours
Participation in home detox
Agreeing to an in-patient detox program
Agreeing to residential S/A treatment
Encouraging 12-step meeting attendance
Developing a HR Group
Harm Reduction Psychotherapy
All problems including trauma
No punitive sanctions for substance use
or for refusing medications
Encourages open and honest talk
Encourages plans and decisions about life,
health and substance use
Not an all-or-nothing process
HR and Trauma Informed Care
Recognition of trauma
Focuses on improving functioning over
“fixing” something “broken.”
Healing occurs in context of relationship
Promotes safety
Objective, neutral language
Goal of practicing healthier adaptive
behaviorsSAMHSA National Center for Trauma Informed Care http://www.samhsa.gov/nctic/
www.traumainformedcare.com
National Alliance to End Homelessness, “Addressing Post Traumatic Stress Disorder Caused by
Homelessness.” 2012
Medical Home
Using St. Vincent de Paul Village Family Health
Center on site at SVdPV
Federally Qualified Health Center
Serves homeless and tenants in FJV PH
UCSD Dual Residency Program- “One white
coat”
Limited dental services
Accessing Medical Home
Home visits/street visits
Incentives to make appointment
Created “Urgent Care” for Project 25 patients
High frequency of appointments
Strong communication between case manager and doctors
Case manager transports to and from and sit in appt.
Medications
Use of medications that would not
normally be prescribed to these patients
Tied to the plan and treatment goals
CM delivers meds to participant daily
Does not deliver if intoxicated
Constantly assessing and reassessing
Close communication with doctor
Results: Is it working?
Data Partners
Hospitals◦ Alvarado Hospital
◦ Alvarado Pkwy Inst
◦ Kaiser Foundation
◦ Palomar Pomerado Health
◦ Paradise Valley/Bayview
◦ Promise Hospital
◦ SD Sheriff Psych Unit
◦ SD County Psych Hospital
◦ Scripps Health
◦ SHARP HealthCare
◦ Tri-City Medical Center
◦ UCSD Medical Center
◦ VA Medical Center
Ambulance◦ EMS Rural/Metro
◦ American Medical Response
Other Partners◦ County of SD HHSA
◦ SD Sheriff ’s Dept
◦ SD County Public Defender
Shelters◦ Catholic Charities
◦ Salvation Army
◦ SD Rescue Mission
◦ St. Vincent de Paul Village
◦ Veteran’s Village of San Diego
Change in Service Use
0
100
200
300
400
500
600
Baseline 2010 Last 12 months
Ambulance
ER Visits
Hosp Admis
Hosp Days
Arrests
Jail Days
Perm Housing Days
Client 1 Example: 1 Year Prior to P25
Homeless 57 year old male
Each month spent entire check on alcohol in a
few days
Soiled clothing
Amassed $131,404 in emergency services
costs
Services Participating In
Agreed to P-25 as payee
Assisted with alcohol purchase and delivery
Progressed to daily alcohol allowance
P25 Life Skills Coach assists with grocery
shopping
Now has IHSS worker weekly
Improved self-care and hygiene
Sees his SVdPV Clinic Doctor twice a month
Participates in med-management
Results
Maintains daily drinking plan
Some abstinence days with home detox
Later start time for daily drinking
Maintained housing18 months
Pays his rent portion
Pays for his entertainment (cable)
Supplements with available food resources
2010 Pre Cost: $131,404
56 ER Visits ,
$29,010 34
Ambulance
Rides ,
$10,966
53 Hospital
Days,
$82,961
2 Arrests, 41
Jail Days ,
$6,317
48 Shelter
Days ,
$2,112
Last 12 Months Total Cost: $41,914
3 ER Visits,
$2,532
3
Ambulance
Rides,
$1,209
5 Hospital
Days,
$11,636
Housing,
$3,228
Supportive
Services,
$23,309
Savings: $89,490
Client 2 Example: 1 Year Prior to P25
Homeless on streets since 1986
Ostomy patient (alcohol related condition)
Covered in feces in a blanket
Severe and persistent mental illness
Vodka on daily basis
Failed out of an ACT Model
Services Participating In
Obtained SSI through HOPE SD
Agreed to P25 as his payee
Weekly clinic visits with doctor
Grocery shopping trips
Calls P25 staff on daily basis
Planned monitored drinking episodes
Results
Maintained housing for18 months
Long periods of abstinence
On moderated drinking plan
Faced lease violations for behavioral
issues due to alcohol
Substitution to low alcohol content
beverage
2010 Total Cost: $171,912
48 ER Visits,
$19,995 45
Ambulance
Rides,
$13,478
64 Hospital
Days,
$129,485
1 Arrest, 4
Jail Days,
$698
149 Shelter
Days,
$6,556
4 PERT
Visits,
$1,700
Last 12 Months Cost: $27,211
1 ER Visit,
$830 Housing,
$3,072
Supportive
Services,
$23,309
Savings: $144,701
Overall Progress SVdPV 15
Homeless in 2010Enrolled from July
2011 to June 2012
Enrolled from July
2011 to June 2012
CategoryServices Costs Services Costs
Service
Decrease
Cost
Decrease
Ambulance
Rides462 $147,922 123 $48,246 73% 67%
ER Visits600 $416,885 148 $99,524 75% 76%
Hospital
Admissions111 NA 38
NA66% NA
Hospital
Days439 $1,055,787 166 $505,768 62% 52%
Arrests52 $7,800 12 $1,800 77% 77%
Jail Days309 $42,333 191 $26,167 38% 38%
$1,670,727 $681,505 58%
Things to consider…
Not for Everyone
Is HR possible in your program?
Is HR a fit for your population?
Is there a sub-set of your population that
have poor outcomes?
What is your agency’s view on HR?
Are there options other than abstinence?
Are you equipped for the these labor
intensive services?
Advocacy
Discussing the “why” with participants
Explaining Harm Reduction Model to
landlords
◦ “Aren’t they in a program?”
Discussing model with judge and legal
system
Discussing the model with funders
Budgeting for Harm Reduction
Lessons Learned
Extremely labor intensive
Getting staff on board
Needs constant attention and assessment
Understand cycles of progress
Apply strategy to stage of progress
Questions?
Contact Info:
Marc Stevenson 619-233-8500 x 1070
Dave Folsom [email protected]
Kris Kuntz 619-233-8500 x 1033