A new road to health on the street

For one regular visitor to the Youth Services Bureau's downtown Ottawa drop-in centre, it started off as a small problem -- more an annoyance than a real concern. Her mouth piercing had become infected, but alongside the other challenges that came with being homeless -- finding food and shelter, simply surviving-it didn't seem to warrant too much attention. In time, though, that small problem blossomed into a full-scale crisis. A trip to the emergency room led to a long-term hospital stay. The infection had spread and, even after treatment, she still lives with its effects.

Andrea Poncia, an HIV/AIDS educator who works at the bureau, thinks things would have turned out differently if the YSB had an integrated health service in place at the time.

"Youth come to our drop-in all the time," she says. "We have a relationship with them. So if somebody comes in with a problem like that, we can say 'is that okay?' 'Do you need to see a nurse?' And she could just head downstairs to see her. There's no reason something like this has to get so far out of control."

The good news is that the YSB -- in partnership with a local clinic, the Sandy Hill Community Health Centre -- recently opened precisely this kind of health service within its downtown drop-in, in an attempt to overcome the multiple barriers that keep street-involved youth from seeking medical care when they need it.

The bureau successfully sought provincial health funding after it commissioned the consulting firm KPMG, in 2008, to study how homeless and under-housed youth in Ottawa dealt with their health problems and how their situations could be improved. According to YSB executive director Alex Munter, the report confirmed what youth workers had known for some time: "Youth have been telling us that they struggle with issues such as navigating the health care system, waiting too long before seeking care, needing support in getting health cards when they get lost, and a lot of other issues," he says.

Still, the statistical portrait that emerges from the KPMG study is chilling. It shows that young people without stable housing face an elevated risk of dying and that many of them live with chronic pain. Although 86 per cent of YSB's clientele had some sort of health problem, only 61 per cent of them had sought treatment, and a full 25 per cent of those who were being treated did not follow medical advice. As a result of their inability to access routine health care, street-involved youth showed up at emergency rooms eight times more often than the rest of the homeless population. That over-reliance on emergency rooms is not only less effective but also very expensive: the KPMG study calculated that a clinic for street-involved youth would save the health care system $265,000 each year by reducing the health risks young people face and avoiding trips to emergency.

So what's been done since then? Backers of the YSB/Sandy Hill health centre -- opened in late October -- believe they've arrived at a new model of care that not only addresses the inadequacies of the past, but also breaks new ground. In addition to incorporating the best of what's being done by youth-oriented health centers in other Canadian cities, they say, the Ottawa clinic promises to set a new standard by taking the concept of integration of services to a new level.

What the Ottawa model shares with other initiatives in places like Toronto and Halifax, says Andrea Poncia, is a commitment to bring health services to where the youth are, and to deliver those services in culturally appropriate ways.

"There's a lot of stigma around youth, around homelessness, and particularly around youth who use substances," she says. "This creates a dilemma, because often youth don't want to go to a clinic where there are a lot of adults in the waiting room. Some of them may have been dealing with systems all of their lives and others may be being bullied by adults, and these are reasons for staying away from those places. What we offer, like some centers in other cities, is a youth-friendly environment where we can deliver services in a way that feels safe for youth."

Poncia adds that the "unique piece" that makes the Ottawa centre distinct from its counterparts elsewhere in North America is that it brings primary health care, mental health services and addictions counseling together in one place. Partly, this is important because it makes it easier for youth facing multiple challenges to deal with all those issues simultaneously.

"In a situation where service-providers are not in direct contact with each other," says Poncia, "the onus is put on the youth -- who are already dealing with homelessness, poverty, physical and mental health issues, addictions-to coordinate their own care. They have to manage all these appointments, keep a relationship with the service providers and keep all the phone numbers-and that's difficult to do for a young person, particularly when you are homeless."

More importantly, Poncia continues, bringing primary care, addictions counseling and mental health care together into one package promises a greater impact because it recognizes the systemic, cause-and-effect relationships that put homeless youth in greater danger.

"The mental health issues and the addictions," she says, "are often the things that lead to homeless. And then the homelessness in turn creates the physical problems like chronic pain from having frostbite, or sleeping on the ground, or carrying a big backpack or not having good shoes to wear. Or perhaps if you have no home you might exchange sex for a place to stay and that puts you at higher risk for HIV or STIs. That's why it's important to have continuity of care. If we can address the problems that lead to homelessness and get people into housing, then it will be easier to avoid the conditions that lead to the physical health problems."

Ultimately, says Poncia, the impact of the new health center will be scrutinized carefully and success measured in a number of ways. There is the expectation that HIV and Hep C infection rates should fall, and that the discouraging statistics on the risks of death and disease for street-involved youth should improve. In a less tangible way, clinic staff want to see a greater number of cross-referrals between services. For some young people, having more effective links between services may give them a better chance of moving more quickly off of the street and into stable housing. For others, it may simply mean being better able to avoid the "triggers" that increase the dangers involved with life on the street. Either way, with the unforgiving Ottawa winter on the way, its clear that this initiative comes not a moment too soon.

Stephen Dale is an Ottawa writer and guest editor at rabble.ca.

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