Evaluation of The Annex Harm Reduction Shelter
Prepared by Joyce Bernstein, PhD
Toronto Department of Public Health
October 1997
Acknowledgment
Background and Executive Summary
The Purpose of this Report
Description of the Annex
Summary of Discussions
Results and Recommendations
Appendices
References
ACKNOWLEDGMENT
Many individuals participated in this project. Special thanks
are due to the following:
- Staff and administrators from many areas of Seaton House who
participated in individual and group discussions.
- Individuals associated with outside agencies, who agreed to
be interviewed for this project, including staff from the
Addiction Research Foundation, Anishnawbe Health, Central
Neighbourhood House, City of Toronto, COTA, Dixon Hall,
Metropolitan Toronto Police Force, Parkdale Community Health
Centre, Riverdale Hospital, Seaton House Advisory Council, St.
Michael's Hospital, Street Patrol, and the Wellesley Central
Hospital.
- Residents of the Annex, who attended group and individual
discussions, as well as those who completed questionnaires
prepared for the purpose of this study.
- Lynne Benson, of ASAP, for preparing written manuscripts of
all discussion sessions.
BACKGROUND and EXECUTIVE SUMMARY
Events leading to the creation of The Annex:
- The 1996 freezing deaths of three homeless men in downtown
Toronto focused public attention on the dangers faced by homeless
Torontonians on cold winter nights. The inquest into the deaths
of Eugene Upper, Irwin Anderson, and Mirsalah-Aldin Kompani
addressed the situation faced by the large number of elderly,
homeless men living in downtown Toronto, many of whom are
alcoholics and especially vulnerable to exposure.
- The report on the inquiry into these deaths1 included several
recommendations, proposed to help prevent future freezing deaths
in Metro. Among them was a call for the creation of a hostel
specifically designed to shelter clients with 'round the clock
alcohol addiction'.
- The response from Metro Community Services was the creation
of The Annex, associated with Seaton House, Canada's largest
men's hostel.
How is the Annex Different From Other Hostels?
- There are many reasons why homeless alcoholics have often
chosen to avoid services. The Annex program attempts to minimize
resistance due to the fears of many potential clients. These
'outreach' efforts have attracted individuals who had, in the
past, chosen to stay on the street and deal with the cold, rather
than negotiate a shelter. The Annex mandate calls for an
"exceptionally tolerant and low-demand environment," commonly
labeled as a harm reduction approach.
- One of the defining features of the program initially was the
safe, overnight bottle storage offered to all clients. This
policy was intended to eliminate the fear of alcohol
confiscation, a common occurrence at most local hostels. Annex
staff hoped this new strategy would eliminate the need for the
guzzling of a bottle's contents before entering the hostel, a
practice that caused further intoxication and problematic
behavior in clients entering a facility.
How is it Working?
- The harm reduction policy has been significant in many ways;
statistics regarding deaths among the homeless recorded by Seaton
House show a fewer deaths among their clients since the opening
of the Annex.(see Appendix One.) While other factors, such as
climate changes and the availability of alternative facilities,
make it difficult to attribute the decreased risk solely to this
new service, these statistics, along with the evidence in this
document, make a strong case for the contribution of the Annex
toward reducing deaths.
- Utilization statistics indicate a steady increase in the
number of men using The Annex nightly during this first winter of
operation.(see Appendix Two)
- Discussions with all associated with the project (residents,
staff, administrators, outside contacts) indicate a high degree
of success with this needy and resistant target population. (See
'Summary of Discussions')
- The key ingredients of this successful outreach effort have
been:
- the caring, non-judgmental attitude of the staff, who
take the time to talk with the men on an individual basis,
- the resulting calm, quiet atmosphere in the hostel, which in turn
promotes client compliance
- concentration on small interventions with clients, intended to reduce the harms
associated with chronic substance abuse, exposure to the
elements, and lack of permanent housing.
Recommendations:
- The experience of staff with the Annex program should be
shared to create more awareness of harm reduction principals.
Staff exchanges(of the type described between Wellesley Central
Hospital and Seaton House) and the meetings of various local
professional organizations could provide excellent forums for
information sharing. Procedural materials such as those developed
by Annex staff are hard to find and likely in high demand, both
locally and on a much broader basis. In addition, there is
considerable opportunity and need for sharing the Annex
experience to date through academic channels(conferences,
publications, Internet, etc). The lack of materials available for
planning the Annex underscore the need for publicizing this
experience.
- The renovation of Seaton House will incorporate a new model
of service delivery. A 'levels of service approach,' mentioned
repeatedly in this evaluation, was widely supported by staff,
clients and administrators, and is therefore highly recommended.
Planning for this new approach must include recognition of the
importance of communications between the levels within the 'new'
Seaton House, which will offer varying degrees of support to
clients. Procedural issues around clients who move between levels
can be difficult (as evidenced by the Annex-Seaton House
experience) and will require strong communications between staff
responsible for different areas of service. Staff visitation and
assignment rotation has contributed to improving communications
between the Annex and Seaton House, as well as providing a more
diversified experience for staff, in danger of burnout in this
highly demanding work.
- Better daytime services are clearly needed for homeless men
in downtown Toronto. Staff expressed special concern for their
older clients, many of whom suffer from various chronic
conditions, including heart disease, cancer and AIDS, yet spend
most of their waking hours on the streets. The closing of
hospitals in the downtown core will further restrict the
alternatives available in caring for these men.
A pilot project focusing on providing men leaving the Annex
with a link to morning medical appointments and social services
is urgently needed. It was widely supported by the individuals
participating in this evaluation. Similar early morning
activities(escorting residents to early appointments, bringing
them to a bank for safe storage of their money, etc) have been
carried out by Annex staff voluntarily. While staff and residents
report these activities are extremely helpful in promoting better
relations for clients with medical and social service workers,
Annex staff cannot continue to perform this function after
working a twelve hour night shift without serious impact on their
job performance.
Such a pilot would concentrate on coordination of existing
services, rather than creation of new facilities It would provide
an opportunity to work with men before they begin their(usual)
daily drinking. More contact with these men during the day would
likely lead to other pilot projects and suggestion for daytime
alternative to existing facilities, which are not equipped to
cope with elderly, frail homeless clients.
- Moving to a more open policy of drinking in the evening is
not justified on the basis of these discussions. Residents were
not complaining about the need to stop drinking in the evening;
as well, evidence of a decrease in street deaths indicates there
does not appear to be a large population of men who choose to
stay out in the cold in order to drink during the night.
Furthermore, many residents were adamantly against such a policy,
fearing the peaceful atmosphere that generally exists in the
Annex might be disturbed.
- A policy regarding payment for Annex services should be
developed which would incorporate a number of possible
alternatives. The present policy of offering all Annex services
free of charge is the source of much conflict with other
facilities at Seaton House which do require payment. The high
degree of satisfaction expressed by residents makes the argument
for a small fee for service policy all the more compelling.
Several innovative suggestions for flexible payment schemes
were offered throughout these discussions; these included forms
of 'workfare', voluntary payment for more permanent residents,
payment to be held and credited to an individual who 'graduates'
to independent housing, etc2. In general, however, a small
contribution(which should include money or willingness to help
with cleaning, meals, etc), would likely impart some extra value
to the service.
The obvious challenge in the above would be to avoid creating
a barrier to service delivery; thus, those entirely unable or
unwilling to comply would be exempt. It would also be
advantageous to be able to offer the service free to newcomers,
who want to 'test' the hostel.
- The presence of neighbourhood conflicts and hostilities
were sited a number of times; these will not go away and must be
addressed. The impending renovations which will undoubtably add
to any existing neighborhood disturbances make these efforts all
the more necessary. Meetings of Seaton House and Annex staff with
representatives of neighbourhood associations are needed.
Selected residents of these facilities should also be involved.
Police community representatives could be very helpful in
moderating these meetings. Issues affecting homeless men and the
need for community alternatives could be addressed at these
meetings; discussion of the goals of the Annex, the ideas behind
Harm Reduction, and the successes observed to date would also be
advised. A long term goal would be to establish membership of
Seaton House residents in neighbourhood associations.
THE PURPOSE OF THIS REPORT
This report reviews the Annex's first year of operation. It
includes:
- Description of the Annex, (page 8)
A brief description of the Annex program, with policies and
procedures presented in Appendices.)
- Summary of Discussions, (pages 9 - 26.)
Discussions with: Annex residents (pages 9-10), staff at the
Seaton House Hostel and Mens' Residence (pages 11-17), Annex
staff (pages 18-21), administrators within the Hostel system
(page 22), and professionals from outside agencies who have had
contact with the Annex (pages 22-26).
- Results and Recommendations (pages 27-30)
A summary of the major discussion issues and associated
recommendations.
DESCRIPTION OF THE ANNEX
The mission of the Annex Harm Reduction Program is to provide
shelter and
services to socially isolated persons in crisis.
- The Annex is open from 8:00p.m. to 8:00a.m. There is space
(mattresses on the floor) for approximately 40 men to spend the
night. Soup, sandwiches, coffee and fruit are available.
- Most of the residents are alcoholics. In addition,
approximately 30-40% have mental health problems.(See Appendix Two)
- As the 'harm reduction' label implies, staff focus on
minimizing the effects chronic alcohol and/or other drug use have
on their clients, without demanding total abstinence. The way in
which staff at the Annex approach clients is significantly
different from other programs. Their mandate appears in Appendix
Three. The intent is to offer services in a tolerant, respectful
and non-judgmental fashion, in order to encourage participation
and compliance.
- The description of a less demanding environment does not
imply one that is less orderly. In fact, the procedures to be
followed by Annex staff in working with clients are completely
specified in a detailed policy description. (see Appendix Four)
This degree of organization, combined with strict enforcement of
minimal regulations requiring client behavior, has resulted in an
unusually quiet and calm hostel atmosphere, highly praised by
many residents.(see page 9 )
SUMMARY OF DISCUSSIONS
This evaluation is based upon a series of
interviews with individuals who have had contact with the Annex.
These include Annex residents, staff at both the Annex and Seaton
House, individuals working in the field from outside agencies,
and administrators with the Hostel system.
Recommendations based upon these discussions
appear in the final section of this document, beginning on page
27.
Discussions with Annex Residents:
Residents, in both group and individual interviews, were asked
to discuss what they liked and disliked at the Annex.
What they liked:
- The men expressed strong appreciation for the quality
of the care. They feel comfortable and cared for by the
staff. These are extremely lonely men, who have very little,
either materially or socially. Only a few mentioned any living
family in Toronto.
- Many of the men talked about the respect they felt
they received from the workers, as compared to other places they
had stayed. The general feeling was this respectful
attitude affected the entire shelter environment; the residents
were also, as a result, more respectful of one another. As one
said, "The respect bounces right back. It's like - you own a
dog. You kick him around. Sure it's going to bite. Somebody would
kick you around all day - you'd bite too, right? Plain and
simple."
- The fact that liquor can be held on the premises for
residents sets up a more trusting relationship between incoming
men and staff. The obvious general attitude is that
bringing the subject of liquor possession out in the open has
significance far beyond the fact that the bottle can be returned
in the morning. "No b.s." several commented. As one of
the residents further explained, "The staff is beautiful
here--they are. They do not play games. You got a bottle, you
turn it in. In the morning , 'Here is your bottle, go on
outside.'" Thus, this act of what can be labeled as Harm
Reduction is perceived as an important act of faith.
- Many of these men talked about their own significant
health problems and the security Annex staff have given them in
handling their illnesses. A major concern among the
elderly homeless is falling sick or dying on the street. "I
have a bad heart," one of the older men revealed, "and
they (staff) watch over me....Thank G-d there is a place like
this for people like us."
- Many men mentioned the fact that the Annex is much
quieter than other shelters. This is largely due to the
fact that the staff and residents share a relatively confined
area; thus, small altercations are spotted quickly and fairly
easily handled before they escalate. The lack of noise and
violence is obviously very important to
the residents' feeling of well-being in the Annex; it was
mentioned repeatedly in interviews. One man described how
upsetting the constant fighting was at other shelters he had
used. "All of a sudden the guys start screaming and yelling
at you. That is not easy on you because you are going through a
lot." In fact, a number of residents expressed doubt that a
more lenient drinking policy could succeed at the Annex as they
feared this might lead to fights and violence.
- The issue of payment was raised with respect to how
cheated they had felt at other places, paying significant amounts
of money for dirty accommodations.
- The restrictions other shelters place on return
visits is also a strong source of resentment. More than
just inconveniencing them, the men were generally indignant when
speaking about limitations that did not allow them to return to
certain hostels too frequently. "It's freezing outside -
bloody cold -- and they turn us away. They shut their door. What
are we, animals?" The Annex has no such rules, and this
clearly is important to the men in their perception of this
facility as welcoming, comforting and almost a home.
- The availability of food in the accessible kitchen
area also contributes to this more home-like atmosphere.
Men expressed appreciation at being able to open the refrigerator
and choose something for themselves.
What they would like to change:
- The men were specifically asked about changes they
would like to see made at the Annex. The majority agreed
with the man who said, "This place is 100%..it is clean, it
is quiet." When pressed for some suggestions, a few were
offered. The most popular request, by far, was for extended
hours. Most men would at least like to see the Annex doors open
earlier in the evening. A few of the older men mentioned they had
no where to lie down if they were tired or sick. Other requests
included lockers to combat a small degree of theft (bus tickets,
in the cases mentioned), more hot water for showers, better
mattresses, residents being encouraged to clean up after
themselves more thoroughly after meals, and coffee and bus tokens
for appointments.
- When asked to state what they did not like about
staff, not one man of the approximately twenty interviewed had
any criticism to offer.
Discussions with Seaton House Mens' Residence (MR) and
Hostel Staff:
Input from three sets of staff interviews are
included in this section. All were to be held in group sessions
at Seaton House; one session was one-to-one, as only one staff
member came. Approximately 15 individuals were involved in total.
While additional staff members were encouraged to attend either
individual or group sessions, there was a reluctance on the part
of staff to participate. Because many staff members chose not to
contribute to these group sessions, this input cannot be regarded
as representative of all staff opinions.
These discussions focused on problems staff are
dealing with in the Mens' Residence and Hostel. Some of these are
directly relevant to Annex operations; some are not as obviously
related but come up in the discussion of the Annex because
comparisons are naturally made.
- These interviews generally imparted a feeling of how
difficult working with such large, needy population can
be. Many of these workers feel tremendous compassion for
these men, but it is extremely hard to derive a great sense of
accomplishment when so much is missing from their clients' lives.
" It is hard to feel like you are making a difference,"
one worker said. The mandate of Seaton House to "take
everybody" which includes "mostly psychiatric survivors
and substance abusers." With such a difficult group there
have, of course, been incidences of violence over the years,
often highly dramatized by media coverage. This has contributed
to Seaton House's an unsavory public reputation; it has nicknames
such as "Satan House". The negative perception of this facility
casts a stigma on its workers as well. This, coupled with the
accolades currently being collected by Annex staff, is often
understandably hard for workers to reconcile.
- In fact, given the widely diverse and often extremely
problematic residents at Seaton House, and the very limited
staffing available, the relatively peaceful environment during
the daytime hours in which these interviews were conducted would
likely be surprising to those unfamiliar with the facility.
On Harm Reduction:
- These Seaton House staff are generally supportive of
the Annex program and the concept of Harm Reduction.
Said one addictions counselor, "All the guys that I see..they
have been to every program that you can think of and there is
little change..they are just going around in circles. If you want
to see change, you have to break the cycle; you have to deal with
lifestyle - if that does not happen, then sobriety is really
unrealistic....The Annex is a little bit different from the
others, from what I hear from my friends that work there. Those
clients, you can see a kind of little change in their eyes - they
got sparkle in their eye now, where they did not have
before."
- It is not unheard of for an Annex staff member to
give a small drink to a client "with the shakes" to help
him through the night. There were some questions raised about
this practice, but most agreed it made sense.
- But there was some conflict expressed by a more
traditional social workers with respect to the concept of Harm
Reduction. One person, in particular, expressed concern
about a potential mixed message stemming from Harm Reduction;
does it water down the message to these clients that they should
be working toward health, that they were not meant to suffer the
miseries stemming from chronic substance abuse?
Differences in Staffing:
- Resident to Staff ratios are extremely high at Seaton
House, in comparison with the Annex. Given that many of
the clients at the main building are extremely difficult, this
represents a terrible burden for most staff members.."We have
men dying of AIDS here, we have drug addicts, we have alcoholics
and the list goes on..We do the best job we can with what
resources we have...So, I would just like to tell whoever is
listening to this tape, that this is what we are up against. So,
when we get a bad mark against us, just remember what we are up
against, and what resources we have...We are dealing with
hard-core street people." In the words of a second
participant, "You got someone who is incontinent--whose bag
breaks in the middle of the night. And the nurses are not here
then. Who's going to clean them up? What about the guys in the
room with them? It is not fair to them either --especially in the
dining room and we do it a lot- we do it a lot. As counselors we
try to get them alternate accommodations as soon as possible. And
as soon as other people hear it is (a referral) from Seaton
House, they do not want any part of it."
- Added to these overwhelmingly difficult issues, the
social worker's caseload during the day is tremendous.
This is especially true of men who need extra nursing or
psychiatric treatment. One counselor described a current personal
caseload of 67 men. "My caseload is 67 right now. Most of
those guys are psychiatric survivors and substance abusers. Now,
how am I supposed to case plan with someone, someone who does not
want the help and does not want to make any changes in his life?
The best I can do is chip away and offer him hope. Let him know
what resources are available. But if I've got six files in my
basket and a waiting room full of men I cannot adequately case
plan with this person because I haven't got the time. I am being
rushed and I am under pressure to see other
people....."
- Furthermore, the physical set-up of the main building
is a major barrier. Many people (in this group and
others) suggested separating the men according to their personal
needs. "(Now) we have got them all mixed together with all
their problems - all sorts of problems...you could segregate them
a little bit for their own personal needs. That way, you could
pay more attention to those needs and design a program that would
help them. This way it is just like soup." One or two
suggested a graduated system, according to need for supervision.
Smaller spaces where staff can keep a better eye on things were
definitely a popular concept. One relatively new staff member
described the current set-up as "a large chaotic environment.
The way it is now-there is a guy flipping out at the other end of
the hostel--you just cannot sit down and talk with any of the
residents for any length of time."
On the size of the Annex Program:
- According to those interviewed, a tremendous demand
has been created by the Annex and, quite often, Seaton House gets
the overflow of those who cannot be accommodated. Also,
Men's Residence and Hostel staff have no way of booking men into
the Annex - "they are always crowded" - this is very
frustrating. One worker was adamant that beds should be booked
for one night only. The perception was that beds are reserved for
certain individuals until 2 a.m., eliminating the possibility of
booking someone else into the facility before that time, even if
there are no-shows.
- However, there is also a strong argument for not
expanding the capacity. In the words of one staff
member, "(Annex Staff members) sit with the clients for 12
hours. There are three of them there for 38, so they really get
to know them...They are not just a demon--they are a person. I
probably don't want to see it get much bigger because you will
lose that intimacy."
- There is also a problem with the physical
space. There is not much room to move around within the
space provided for the Annex. While the compact nature of the
facility is a plus in terms of supervision, larger rooms would be
ideal.
On Barred clients:
- Clients who are barred at Seaton House are sometimes
sent to the Annex; they are usually easier to handle in the
smaller facility. However, this is sometimes taken as a slight by
the Seaton House worker who likely had a major problem initially
dealing with the client. It can appear to the worker that the
client's negative behavior is being overlooked or even
rewarded. They expressed the frustration that those who
have made trouble for them in the main building get rewarded with
a bed in the Annex, and take that bed away from someone who may
need it more. They also wanted to know whether an individual
would get a refund from his Seaton House payment, in such a
case.
On Communications between the facilities:
- Some staff expressed interest in working at the
Annex. Some visit there on their own. These workers
seemed enthusiastic about being given an opportunity to do a
staff exchange with the Annex; a similar project was conducted
between Seaton House and the Wellesley Hospital e.g. "You
would not believe how positive that was, because now they have
better insight into what we do and we have better insight into
what they do..we have good relations with the Wellesley Hospital
now because of that."
- When one client has dealings with both Annex and
Seaton House staff there can be lack of communications.
Differences in working hours can be a further barrier. "Memos
can only do so much," offered one staff member. But joint
meetings have proven difficult in the past.(see next item)
- Some staff would like joint meetings with Annex,
Mens' Residence, Hostel, and Intake. The separate nature
of the programs causes some hard feelings. But there have been
some problems in the past over these types of meetings. Also
staff feared that with so many issues to discuss, they could
never get through such a meeting. Some of the issues that could
be discussed in joint meetings include:
- the booking of clients - how long should a man be allowed
to keep a bed in the Annex?
- the disparity in the amount of paperwork required in the two
settings (funding different)
- the need for more coordination when Annex residents spend the
day at the Men's Hostel. There was a suggestion that Annex staff
could come over and speak with Intake on this matter.
- staff being recruited from Dixon Hall to the Annex is an
issue -Annex staff appear 'cliquey'.
Issues around payment:
- Seaton House staff appear to be quite troubled by the
fact that payment is not required of Annex residents. This topic
came up repeatedly. They are at a loss to explain
this disparity to their clients, despite the differences in
service. There is some feeling that men will go to the Annex just
to avoid having their checks put on hold. Also, as mentioned
above, they can come to Seaton House during the day and act up,
and then go to the Annex at night. This worker felt this acted to
remove incentive for some of the men to work on their
problems.
- The issue of how much money men at the Annex were able to
keep from various sources was a recurrent theme. There is
confusion over this and staff would like clarification. They
noted the "mixed message" they have received that the
Annex is not a part of Seaton House, but "we are not supposed
to tell Family Benefits or General Welfare if someone is in The
Annex." There is also some confusion over who is funding the
Annex, whether they are under Hostel Services Division or the
General Welfare Act (as Seaton House is)
- Another aspect of the payment issue was brought up by
a number of staff. The regulations requiring staff to
demand payment from residents can set up an adversarial
relationship with Seaton House residents.
On Day Programming for The Annex:
- Many Seaton House staff members were anxious to see a
day program start at the Annex. Currently, a lot of
Annex residents hang out at the Seaton House Hostel during the
day, and there are conflicts. One suggestion was that the second
floor of the Annex be opened for day programs. There were
compromises offered to a full day program, as well.
Neighborhood Problems:
- There was a lot of frustration expressed over the hassles men
living at Seaton House have had with other Cabbagetown residents,
residents associations, and the police. There is also realism.
"You got a lot of affluent people in Cabbagetown right now,
buying up homes there. And rightfully so. I mean if it was me, I
would be concerned. I am not saying I wouldn't. But there has got
to be some kind of middle ground."
Other issues raised and suggestions:
- Suggestions from Dietary Staff: Concerns
over meals and vitamins. Would like to see hot meals provided.
But allowing Annex staff into main building for meals "opens
a whole can of worms" around barring issues. Dietary staff
are also concerned about food storage - especially in hot
weather. They feel the Annex needs more professional supervision
of its kitchen facilities.
- The amount of paperwork and computer entry Seaton
House Intake Workers must do is a burden. This was an
important issue to at least two of the workers in the focus
group. They naturally compare this to what they see as much
looser requirements at The Annex. Suggestions on how to deal with
this were offered, including one idea that an early morning
accounting of who had been staying at the Annex be taken by
Seaton House staff.
- Many staff talked about the need to feel more
supported by co-workers and supervisors. Other
participants spoke about the burn-out that comes after years of
work in a facility such as Seaton House. "..after you have
worked there for several years, in order to keep your sanity, you
develop a mechanism where you are less able to accept the
interaction with clients that you could have when you first
started here and you were eager...so there is a wearing down of
the staff." Related to this was the guilt several workers
mentioned, stemming from their frustrations of having to deal
with such a needy population on such a "superficial
level". As one staff member put it. "It's hard to feel
like you're really helping."
- A reliance on casual staff was seen as a negative by
several participants. They felt continuity of staff was
important in building trust and security among residents.
- Outreach problem is obvious." ..For the
guys that have died, you know, I feel sorry for them, but I
believe, I do not know if anyone else believes that, that they
wanted to be out there. I do not think it was necessarily any
agency's problem why these guys died outside, they wanted to be
outside. Some of these guys they have a bottle of booze-you got
to understand the way they think sometimes; they do not want to
be inside. They do not want to be told where they can drink,
where they cannot drink, where they can sleep, where they cannot
sleep, who they can hang with, who they cannot hang
with."
- Changes in recent years to clients and the system
were also brought up as a reason to promote changes at Seaton
House. "I remember in the old days this place would
be jammed. Intake was in the basement and it was accessed by
every group, every agency and their mother. They have changed all
of a sudden and sometimes I wonder have we changed for the better
or have we changed for the bad. The clients have changed now.
They are younger -- they are harder, they are more aggressive,
and they are not frightened..And crack is on the scene. When I
look at the old days, it was bitters, Lysol, a kind of rubbing
alcohol, it was different. But now it is more serious and we have
to change because of the public pressure....The way it is now,
Seaton House, it does not work because it is too big."
- The need for some public relations for Seaton House
was also acknowledged, to deal with residents' problems and the
public image. It will help workers to de-stigmatize the
place as much as possible, as was evidenced by focus group
comments of Seaton House staff.
- Seaton House staff expressed interest in a training
session on psychiatric problems. Staff at St. Michael's
hospital are anxious to help pursue this idea.
- Seaton House staff felt that the Annex program had
definitely saved lives. Statistics regarding deaths
among homeless individuals are difficult to collect and analyze
for many reasons3. However a study restricted to known residents
of Seaton House, summarized in Appendix One, indicates hopeful
results in this first year of the Annex's operation.
Discussions with Annex Staff:
Along with a focus group dedicated to the evaluation, the
discussions below are based upon earlier sessions with Annex
staff and observation of the environment in the facility. In
addition, two individuals unable to attend the scheduled group
meetings took the time to be interviewed on their days off from
work.
Harm Reduction:
- The adoption of the Harm Reduction principals has
resulted in a focus on small, positive changes that can be made
within this extremely needy population, rather than the
traditional insistence on abstinence, which is
unrealistic. Thus, a move from the consumption of
Chinese cooking wine to a less toxic substance can be discussed
with the client and supported. Along with this concentration on
small steps toward less harmful practices, staff try to look at
other changes that can be made to help the clients achieve
increased stability in their chaotic lives. This has included
help and advice with managing and banking money, making and
keeping appointments with various agencies, and assistance in
obtaining housing.
- Again, the Harm Reduction policy of allowing bottle
storage for the night is a key factor in establishing a trusting
relationship between the staff and clients, and makes working on
these other issues possible. This trust allows for more
honest communication between the worker and resident. "It
(trust) has developed here almost instantly," one worker
said. "I know, at another shelter that I worked at
personally, it took years."
- Harm reduction principals lead to the use of a less
authoritarian attitude. There is room for humor. The
power of humor in dealing with certain situations was
well-demonstrated during the course of one focus group held in
the main building at Seaton House. When a loud shouting match
broke out in the hallway between two residents, one of the Annex
staff calmly opened the door and told the men,"Hey, could you
keep it down out there? We are having a meeting in here and some
of us are trying to sleep." The two men who had been
fighting stopped immediately, looked at the staff member in shock
and confusion, and quietly walked away together.
- This more caring environment also affects the way
residents respond to one another. Staff spoke of clients
being especially respectful of one another in The Annex
environment, something many of the residents commented upon
themselves. "If you are respectful to them, then they are
respectful to each other,"noted one staff member. Said
another, "These guys are comfortable here, because they know
that no matter what kind of shape they came in, at least they
will be able to get into the shower, get cleaned up, have a bite
to eat and nobody will rag on them about their addiction because,
for the most part, a lot of guys we see are programmed to death.
In and out of programs, steady, And, it has not worked this
far."
- One interesting example of how the policies affect
behavior was given with reference to one client who is barred
from the main facility "until (the year) 2020."
Surprisingly "he is one of the favorite clients in the
Annex." He has severe brain damage, but responds very well
to the gentle treatment Annex staff have been giving him. "I
was hoping to have breakfast with him this morning," one of
the staff mentioned.
- There still, of course, are frequent incidents that
do have to be broken up; the behavior of many in this population
is undeniably difficult, not surprising after years "of training
in street life and jail". However, the staff generally
seem to have little problem managing the group. "Kicking out
one guy because he happened to throw the first punch, or
something, does not work. Because then we are doing exactly what
we don't want to do --putting them back on the street. So, making
it work out right there, say, "you sit there, you sit there and
don't talk to each other, for ten minutes." And then it
always goes away, you know, it ALWAYS goes away. You know they
forgive and forget a lot faster than we would."
- Another staff member offered that despite the fact
that arguments do flare up easily among this frustrated, largely
alcoholic population, "they all know each other and I think
that helps. They look out for each other." He
attributed this in large part to the small size of the Annex,
which fosters closer relationships among the men. "We get all
this information coming into us from our resource guys. They'll
say, 'Look you better keep your eye on so and so, or he is not
doing so well today.' And that kind of stuff, is almost like a
little community of its own, which is real important because in
the most part shelter guys just button up. They don't want to say
anything. They don't say anything and that is a lot of the
problem." He went on to describe how this jailhouse mentality of
not speaking up for fear of retribution is a major barrier in
most hostels. "I know at another shelter that I worked at..it
took years and years before guys would come up and say, "you know
something, that was wrong, this is what happened."
The Payment Issue:
- One justification for charging at the Men's Residence but not
the Annex is the great distinction Annex staff noted between the
two facilities. Most obviously, the former is a home with
twenty-four hour access, along with hot meals, a bed, and,
"something as basic as a place to go to the bathroom."
They were also quick to add that one of the reasons the Annex
exists is that it is well-known that some men will not pay to
come in out of the cold. "It's either us or the blower(i.e.
sleeping on an outdoor vent), they said." Another added,
"I also think, quite frankly, it is not the Hilton Hotel.
They get a mat on the floor, they get a sandwich and some soup at
night and breakfast in the morning and they get shown the door at
8:00...It is not like they are living high off the
hog."
- The payment issue can also get in the way for those
who want to do Harm Reduction. They want to concentrate
on connecting their clients with whatever services are available
to them, whatever might help. And this requires that the worker
has "a level of acceptance where you are not jumping all over
them the minute they show up." Still, staff are not
completely adverse to instituting some type of payment
scheme.
The Importance of Companionship at Night:
- Staff members also spoke about the fact that they are
available to the men all night. If someone does not want
to sleep, they are free to come in to the office to "hang
around with us..We have no hard, unbendable rules..Instead of
sitting in your bed, staring at the ceiling, come and hang with
us, whatever you want to do. That makes a huge difference because
it is away from that jail mentality, you are locked up, be quiet,
keep your mouth shut and stay in your room. It is a completely
different approach."
On Day Programming:
- Annex staff expressed a strong desire to see a day
program established, or at least some attempt at helping the men
to manage their day as they leave at 8 a.m. Staff
members talked about all the overtime they are currently doing to
help fill the void of a day program. "We come in a lot on our
days off now, you know, and I've go to the point where I don't
want to any more...But its hard to practice Harm Reduction only
twelve hours a day - its bigger than that." Staff are
deriving tremendous satisfaction in helping this very difficult
population. But one worries that they will soon begin to burn
out; warning signs were heard in these interviews.
- Other suggestions for expanded programming included a
card room and pool table. One social worker expressed a
strong desire to do some teaching on lifestyle or other practical
skills. "I'd like to be able to give some type of
hope."
Additional Future Needs:
- There is a significant concern regarding what will
happen as these residents get older and sicker. The
Annex staff envision them still depending on them for services.
They also worry about those who are HIV positive or otherwise
sick. How will they be cared for? One suggestion was to try
supplying a few emergency beds for daytime hours. One suggested a
10 bed hospice. "There is a huge crack in the system and
these guys are falling into it,..they are falling into the Annex.
Nobody is dealing with the psychiatric, substance abusing
population."
Other issues:
- Turning men away is upsetting for these workers, but
there are limits. They often have to refuse to take in
the younger men, who are less vulnerable. "We try to refer
them, but other places won't take them"
- One worker talked about the negative assumptions that
often affect those managing these cases. He told one
story of a Seaton House resident throwing a temper tantrum and
breaking a window. The man was very sorry afterward, cleaned up
the mess, and in fact paid for the damages. However, when this
worker looked at this man's file several weeks later, there was
no mention of the apology or the payment.
Neighborhood conflict:
- Several staff members expressed frustration with the
attitude of many of the area residents towards men staying at
both The Annex and Seaton House. They went on to
describe how police seem to be targeting these men lately, moving
them out of the neighborhood. "Many of these men have lived
here for 30 years. How can you suddenly tell a 60 year old man,
who has no safe place to go but a park bench on a freezing day,
that he can not stay here?"
Interviews with Hostel Management
(The manager of Seaton House and the Director of Metro
Toronto's Division of Hostel Services were each interviewed. The
main purpose of these sessions was to provide background
information for the evaluation.)
Day programs:
- These men expressed some hesitancy about expanding
the mandate of the Annex too quickly. There is
reluctance to push too far too fast.
- Having said this, however, there are 'a myriad" of
possibilities for expansion which would combine training and
possible employment opportunities. For example, one idea would be
an arrangement with Metro that reassigned some of the many
cleaners at Seaton House to other buildings, replacing them with
Seaton House residents, who could work for much less pay. The
idea would be that no one would have to lose their job, but in
the process some of the residents would acquire true work
experience. "That way you would be helping a bunch of guys in
a tangible way...Teach them what it means to get up every morning
and work. Teach them life skills and job skills. Break their
cycle of homelessness." Such expansion would more
satisfactorily address the fear that the routine of long term
life at Seaton House "becomes indistinguishable in many ways
from life in jail, so that the threat of incarceration becomes
mute."
Physical expansion of Seaton House:
- The advantages of the more physically compact layout of the
Annex will likely be considered in the design for the new
facility. A new system will probably be based upon levels of
service, as this would allow for segregation of clients according
to need. As one of these managers stated, "The job is easier
in small clusters. Problem identification is quicker and linkages
can be made more quickly."
Other Urgent Issues:
- The hostel system is terribly over-crowded.
In May of this year, facilities were 99% full.
- Other social factors are likely to put even more
strain on the system. These include:
- the current increase in construction in Metro. These building booms have
historically served to eat-up the availability of low-cost
housing; these residences are often taken up by transient
workers. This may be a serious factor during the coming season.
- De-institutionalization transferred a lot of care giving
responsibilities onto parents who are now getting older. As these
parents become less able to care for their dependent adult
children, more will look to hostels.
- There is a large segment
of the population who are socially incompetent. Again, their
parents are ageing, representing another potential influx to the
system.
Discussions with representatives of outside
agencies (including the Addiction Research
Foundation, Anishnawbe, Central Neighborhood House, COTA,
Parkdale Community Health Centre, Riverdale Hospital, the Seaton
House Advisory Committee, St. Michael's Hospital, Street Patrol,
and the Wellesley Central Hospital. In addition, the constable
from 51 Division who was unable to make that focus group was
interviewed separately.)
Problems in Working with the Annex:
- The main purpose of this session was to learn about
any problems community workers had in trying to work with the
Annex. As indicated in the discussions below, a high
degree of support was expressed for the facility. Only a few
criticisms were raised, including:
- Telephone contact can be difficult. The hours during which
the Annex is open do not overlap with most other agencies. Often
the only solution is to try and phone there at 7:30 a.m.
- It is also hard for clients to wait until 8 p.m. to see if
they can be admitted. There is nothing else available in the
neighborhood in the early evening. This means clients often just
line up and wait outside the facility, especially difficult on
extremely cold days.
- Another worker commented that he feared so many good
workers had been taken from Dixon Hall to join the Annex that it
had done a disservice to Dixon Hall. "The truth is Metro pays
more," he said.
Harm Reduction:
- All participants expressed strong support for the
harm reduction principles guiding the Annex project.
Several recommended that staff document the expertise they are
gathering to share with other workers, as they saw the project as
"innovative and an incredibly important demonstration
model."
- Another participant described the main feature of a
Harm Reduction programs as an attempt to try and bring some
stability into a life. "That is the only way to
eventually work on other problems," he said. He felt the
philosophy was also significant because it acknowledges the fact
that one can still work on achieving better health, even when
using drugs. Others strongly agreed with his evaluation. Another
strong supporter of the concept went on to ask, "How can we
simply rely on the single abstinence message, especially for this
population. It doesn't make sense, There are no jobs, no homes,
no families. So, we are telling them to stop for WHAT? The drugs
help dampen the symptoms. For the mentally ill portion of this
population the street drugs very often have fewer side-effects
than the psychotrophic meds!"
- Several said they were very impressed that a facility
such as the Annex was being tried. "We all know
there are men on the streets who, for whatever, reason, have not
or can not stop substance use at this time. Why penalize them for
that? This is a common sense approach."
- Another contributor, with years of experience with
homeless men, stated firmly that success in working with this
population "always, always, always, comes down to
attitude".
- From the Metro constable, "The Annex program should
have been thought of many years ago." He would also be
in favor of trying a pilot wet hostel, but has some reservations
as to how to police it, specifically with respect to a drunk in a
group setting -"especially if there are strangers involved.
But it might work with a known group of residents." He went
on to say,"The old(non-Harm Reduction based) system
encourages drinking."
- One of the workers talked about a very aggressive
client who, in the past, has often gotten into street fights and,
as a result, has been sent to jail several times. He
hasn't been in jail since the Annex opened; he is still
aggressive but the quick response of staff to his aggressive
behaviour has worked well with him.
- The moderator asked if perhaps the Harm Reduction
model was not as significant as the fact that there are small
resident to staff ratios at the Annex and a small space in which
the program operates. "Absolutely not,"
answered one participant."You could not use the small space
without the Harm Reduction Model and have it work." Others
agreed. The feeling expressed was that so much of the program's
success was based on the respectful way staff treated the
residents. "People don't want to believe that, that respect
is so key, but it's true,"summarized one of the workers,
"but that doesn't mean you don't use limits - people on the
street need boundaries, and they respect yours."
Day program issue:
Neighborhood problems:
- Residents associations seem to favor the out of
sight, out of mind philosophy. But pushing men out of
the neighborhood has consequences to the program. It is a mixed
message. "Most homeless men are not a public
danger."
Payment issue:
- As in other sessions, there seemed to be division
within the group as to whether some type of payment could be
collected for service at the Annex. Two individuals
spoke passionately about the need to keep money out of it, in
order to perpetuate the Harm Reduction principle. They generally
did not see a conflict in charging for other Seaton House
facilities, agreeing with other groups that the services offered
varied considerably. Others saw the possibilities of adapting
some type of payment scheme, preferably voluntary, or based upon
some type of workfare.
Other issues raised:
- Illicit drugs and paraphernalia policies: Do
they exist at the Annex?
- Recovery services are not cost effective on the
surface. There is a need to call attention to the bigger
picture. If some of these men can be kept out of the prison
system, it becomes more cost effective. Further discussion
revolved around the perception of this group that funders tend
dismiss homeless people, but what we do in Toronto is
special.
- Only Dixon Hall and Council Fire(closed since these
discussions took place) receive those who are using and are on
the streets. Hopefully Metro will open more places like
these (and the Annex)
- The Inquest on the Homeless has led to better
coordination but there are lesser resources.
- One worker brought up the need for some respite for
workers - maybe shift rotation. A high degree of burnout
can be expected from Annex workers, who are apparently giving so
much to the program.
- There is fear of impending closure of other older
facilities. Other programs will have to pick up the
slack.
RESULTS AND RECOMMENDATIONS
Major points of discussion:
- The Annex program has been highly successful in a
number of ways.Clear evidence of this success is found
through statistics indicating a steadily increasing client base
of homeless substance users, the traditionally 'hard to reach',
intended clients of the service, and the enthusiastic reports of
virtually all professionals and clients associated with the
service. The statistics available regarding deaths among the
homeless in Toronto offer further evidence of these
achievements.
- Without a doubt, the single most important factor in
the success of this program is the staff. They are
extremely caring and treat the men coming to the Annex with
respect. The policy of holding bottles, perhaps, is what
initially attracts many men to the Annex, but again, the key to
winning their trust and opening the door to further work with
them is the attitude of the Annex workers. The peacefulness in
the atmosphere created is of primary importance to clients, as
was the opportunity to talk with staff who were available to
listen. The jailhouse atmosphere, often used to describe hostel
settings, is eliminated.
- This project serves as a clear example of the
potential benefits in harm reduction programs. The long-term
savings in health costs associated with this type of programming
is well documented4. Despite this, The Annex was started
with a strong measure of reluctance. Staff reflect on their own
initial misgivings, fear of "The Wild West Show" is how they
phrase it. The program was started very much through a common
sense, informal approach to Harm Reduction. No major studies or
literature reviews were available; a lot of first hand knowledge
and experience with the target population was. These programs do
exist, but information sharing is time consuming and often not
done.
- There have been effects on Other Parts of Seaton
House. With an approaching renovation, things
will continue to change. The Annex was originally
intended to relieve some of the pressure on Seaton House staff,
by focussing on more difficult clents. The environment of the
Annex proved more conducive to dealing with clients who had been
previously had troubles at the larger hostel; many had been
barred.
However, there are resulting complications; the increased
utilization of Seaton House facilities creates more demand on
workers. Changes in the delivery of services at this facility
will continue as a major renovation of Seaton House is planned.
Discussions with both staff and administrators focus on the need
for a renovation which will foster service delivery in '
levels.'
- Among the issues raised in discussions was the need
to provide some daytime indoor alternatives, seen by some to be
natural extension of The Annex services. There is no
doubt that there are few indoor alternatives available to Annex
residents during the day. The existing day programs were
characterized as generally unsuitable, and unsafe for the more
vulnerable of these men in discussions. Of special concern are
sick or elderly residents who have no place to rest indoors
between 8:00 a.m. and 8:00 p.m. This problem will get worse as
the population ages, along with other anticipated changes likely
to strain future housing supplies come into play. The need for
day programming was supported by virtually all of those
questioned.
Recommendations:
RECOMMENDATION #1:
The experience of staff with the Annex program should
be shared to create more awareness of harm reduction principals.
Staff exchanges(of the type described between Wellesley Central
Hospital and Seaton House) and the meetings of various local
professional organizations could provide excellent forums for
information sharing. Procedural materials such as those developed
by Annex staff are hard to find and likely in high demand, both
locally and on a much broader basis. In addition, there is
considerable opportunity and need for sharing the Annex
experience to date through academic channels(conferences,
publications, Internet, etc). The lack of materials available for
planning the Annex underscore the need for publicizing this
experience.
RECOMMENDATION #2:
The renovation of Seaton House will incorporate a new
model of service delivery. A 'levels of service approach,'
mentioned repeatedly in this evaluation, was widely supported by
staff, clients and administrators, and is therefore highly
recommended. Planning for this new approach must include
recognition of the importance of communications between the
levels within the 'new' Seaton House, which will offer varying
degrees of support to clients. Procedural issues around clients
who move between levels can be difficult (as evidenced by the
Annex-Seaton House experience) and will require strong
communications between staff responsible for different areas of
service. Staff visitation and assignment rotation has contributed
to improving communications between the Annex and Seaton House,
as well as providing a more diversified experience for staff, in
danger of burnout in this highly demanding work.
RECOMMENDATION #3:
Better daytime services are clearly needed for
homeless men in downtown Toronto. Staff expressed special concern
for their older clients, many of whom suffer from various chronic
conditions, including heart disease, cancer and AIDS, yet spend
most of their waking hours on the streets. The closing of
hospitals in the downtown core will further restrict the
alternatives available in caring for these men.
A pilot project focusing on providing men leaving the
Annex with a link to morning medical appointments and social
services is urgently needed. It was widely supported by the
individuals participating in this evaluation. Similar early
morning activities(escorting residents to early appointments,
bringing them to a bank for safe storage of their money, etc)
have been carried out by Annex staff voluntarily. While staff and
residents report these activities are extremely helpful in
promoting better relations for clients with medical and social
service workers, Annex staff cannot continue to perform this
function after working a twelve hour night shift without serious
impact on their job performance.
Such a pilot would concentrate on coordination of
existing services, rather than creation of new facilities It
would provide an opportunity to work with men before they begin
their(usual) daily drinking. More contact with these men during
the day would likely lead to other pilot projects and suggestion
for daytime alternative to existing facilities, which are not
equipped to cope with elderly, frail homeless
clients.
RECOMMENDATION #4:
Moving to a more open policy of drinking in the
evening is not justified on the basis of these discussions.
Residents were not complaining about the need to stop drinking in
the evening; as well, evidence of a decrease in street deaths
indicates there does not appear to be a large population of men
who choose to stay out in the cold in order to drink during the
night. Furthermore, many residents were adamantly against such a
policy, fearing the peaceful atmosphere that generally exists in
the Annex might be disturbed.
RECOMMENDATION #5:
A policy regarding payment for Annex services should
be developed which would incorporate a number of possible
alternatives. The present policy of offering all Annex services
free of charge is the source of much conflict with other
facilities at Seaton House which do require payment. The high
degree of satisfaction expressed by residents makes the argument
for a small fee for service policy all the more
compelling.
Several innovative suggestions for flexible payment
schemes were offered throughout these discussions; these included
forms of 'workfare', voluntary payment for more permanent
residents, payment to be held and credited to an individual who
'graduates' to independent housing, etc2. In general, however, a
small contribution(which should include money or willingness to
help with cleaning, meals, etc), would likely impart some extra
value to the service.
The obvious challenge in the above would be to avoid
creating a barrier to service delivery; thus, those entirely
unable or unwilling to comply would be exempt. It would also be
advantageous to be able to offer the service free to newcomers,
who want to 'test' the hostel.
RECOMMENDATION #6:
The presence of neighbourhood conflicts and
hostilities were sited a number of times; these will not go away
and must be addressed. The impending renovations which will
undoubtably add to any existing neighborhood disturbances make
these efforts all the more necessary. Meetings of Seaton House
and Annex staff with representatives of neighbourhood
associations are needed. Selected residents of these facilities
should also be involved. Police community representatives could
be very helpful in moderating these meetings. Issues affecting
homeless men and the need for community alternatives could be
addressed at these meetings; discussion of the goals of the
Annex, the ideas behind Harm Reduction, and the successes
observed to date would also be advised. A long term goal would be
to establish membership of Seaton House residents in
neighbourhood associations.
APPENDICES
APPENDIX ONE
Staff at Seaton House keep records on the number of deaths
among clients known to the facility. These are recorded below for
the period January 1, 1993 through September 30, 1997.
| Year |
1993 |
1994 |
1995 |
1996 |
1997** |
| Street deaths |
1 |
1 |
1 |
4* |
0 |
| Other deaths |
6 |
9 |
20 |
23 |
12 |
| Total |
7 |
10 |
21 |
27 |
12 |
*All occurred before the Annex opened.
**Through September 30, 1997
APPENDIX TWO - ANNEX UTILIZATION STATISTICS FOLLOW:
[Not available on APOLNET]
APPENDIX THREE
THE ANNEX MANDATE FOLLOWS:
To reduce harm to a target population of homeless and indigent
men who find themselves in crisis.
Harm, as defined, being in crisis from physical and mental
illness or trauma, social misery, economic misfortune, the
effects of violence, harmful behavior or chronic substance
abuse.
To use innovative techniques and provide alternatives in order
to try and reduce the harmful effects of chronic alcohol, drug
and substance abuse.
To empathize and use a non-judgmental approach toward our
clients and to treat everyone with tolerance, understanding and
respect.
To focus more on, reducing harm associated with substance
abuse and less on controlling consumption.
To use innovative techniques and an atmosphere of tolerance
and acceptance in order to try to reduce harm to psychiatric
survivors allowing them to function at a socially acceptable
minimum level.
To intervene and use all necessary community care providers in
a crisis situation.
To provide a shelter with an atmosphere of safety, protected
by minimal house rules and social control.
As part of The Annex's multi-service harm reduction strategy,
residents are assisted in accessing health, housing, and social
services.
To function under the service philosophy that focuses on
minimal expectations and a policy of inclusion verses
exclusion.
APPENDIX FOUR
THE LIST OF FORMAL ANNEX PROCEDURES FOLLOWS:
Start of shift
Setup common room; plug in television, distribute ash
trays.
Setup food service area; put soup on to warm, fill up coffee urn,
put out creamers, sugar, stir sticks, spoons, sandwiches, fresh
fruit.
Setup washroom; put out towels, soap, shampoo
Inspect living and sleeping areas.
Access voicemail, return calls, post messages for staff and
clients.
Read communication log and respond to entries from previous
shift, from management or from outside agencies.
Admission
One staff opens door to residence and checks names off
manually in daily admissions log.
Directs new arrivals to office.
Checks the general condition of residents and immediately
responds to other staff any men who appear overly intoxicated or
in distress.
One staff does intake. Checks referrals, assesses needs, refers
elsewhere when necessary, books new arrivals into computer,
counsels clients if needed, sets up future counseling sessions if
requested.
Food Service
Ons staff does food service, which involves refilling coffee
urn, mixing extra juice as required and handing out utensils,
condiments and serving those clients who are unable to serve
themselves. Observes residents' behaviours, conditions and
degrees of intoxication and tries to forsee any potential
problems or issues. Interacts with clients informally, makes new
arrivals feel welcome. Enforces minimal house rules.
Housekeeping
All staff share laundry duties, washing and drying towels and
linen as required in order to assure a steady supply of same.
Staff issue beds to clients and issue a pillow, 2 sheets and a
blanket to each man as needed.
Staff pick up discarded clothes, towels and linen. Clothes and
linen are cleaned by staff and recycled.
The food service area is kept clean and disinfected on a
continuing basis.
The food service counter, utensils, appliances are kept in a
hygienic state on an ongoing basis as required.
The common area is swept and mopped as necessary. Any spills are
immediately mopped up. The tables are wiped and garbage discarded
as required.
Residents are encouraged to participate in maintaining a clean,
orderly environment.
Hygiene
Staff assess resident's state of cleanliness and use
appropriate intervention skills to encourage residents to shower,
using delousing soap if necessary and to turn in soiled clothes
which are washed, dried and returned to the client. Clean
underwear, socks and t-shirts are offered when needed.
Clients, upon entering the premises, may be requested by staff to
shower and/or have their clothes laundered. Clients are
encouraged to seek this service on a regular basis.
Staff provide hair-cutting services on request.
Staff provide help with nail-cutting on request. If a client in
unable to cut his own fingernails or toenails staff will help him
do so. If the client's nails require medical attention the client
will be referred to the Seaton House First Aid unit or Seaton
House's in-house physician. The annex staff use all available
resources inside and outside of the program to insure a steady
supply of clothing and footwear. Discarded items are recycled
whenever possible and reused.
Hygiene Intervention
If a client shows resistence upon initial solicitation toward
his general state of cleanliness, excluding lice infestation
which is non-negotiable, the client will be allowed entry into
the program in order to build trust after which an on-going
negotiation will be started which may include:
contracting/negotiating, washing the resident's clothes and
ensuring the return of his belongings, having the resident wash
his own clothes, bribing the resident with cigarettes, offer the
resident payment in the form of cigarettes in return for services
washing his own clothes as well as other laundry, facilitating
peer pressure, continuing trust building, etc.
Negotiations can take many forms, with the central focus being
inclusion versus exclusion. Staff are encouraged to be innovative
and experimental in developing innovative techniques.
Delousing
If it is known that a client is infested with lice, it is
mandatory that they be deloused. The resident will be provided
with new clothes and his infested clothes will be deloused.
Proper use of R &C Delousing Shampoo and Kwellada Cream will be
closely monitored by staff.
Delousing Intervention
If a client refuses delousing, staff will use appropriate
intervention and negotiating techniques to encourage the resident
to clean up. If the negotiation is unsuccessful, the resident may
be referred elsewhere.
Counselling
Staff use their knowledge of basic counselling skills whenever
requested by clients.
Counselling in the areas of addictions, housing, health care and
access to social services are done as required. If a client wants
to talk about any issues affecting him, staff provide an ear and
try to be non-judgmental and empathic.
In the area of addictions, staff will provide counselling
services on an as-requested basis.
Clients are not pressured into participating but are informed on
the availability of help.
Advocacy
Staff act as advocates for clients whenever requested and
contact appropriate agencies to try to fulfill needs aw well as
special ones as need dictates. Health issues are a primary
concern. Social service and housing needs are dealt with as
needed.
Agencies contacted on an ongoing basis include: QSMHC, Clarke
Institute, area Hospitals, detoxes, Seaton House Intake Dept.,
Salvation Army, Dixon Hall, Strachan House, Wellesley Crisis,
East General Crisis, Barnwell Centre, Street Hotline, Street
Patrol, Seaton House Hostel and Residence, Veteran's Affairs,
Provincial government agencies, etc.
Liaison
Staff will, when possible, forge links with service providers
in the community whose services may be useful to the residence of
the Annex. Staff are encouraged to take part in training, or
become involved in resource groups with other service providers.
e.g:
Health care providers:
Hospitals social workers, discharge planning teams, nursing
teams, crisis intervention teams, doctors, after care providers,
mental health outreach, etc.
Social Service Providers:
Seaton House Intake, welfare, FBA, People living with AIDS (PWA),
COTA, mental health court support services, Senior Link, Harm
Reduction Task Force, etc.
Housing Providers:
Strachan House, Street City, Seaton House Men's Residence,
Houselink, Barnwell Centre, Launder House, Oakwood Manor,
Cityhome, etc.
Follow up
Any initiatives taken by or started on behalf of clients (e.g
appointments, successful housing links, health care, medications,
addiction programs, etc.) Will be followed up by staff to try and
ensure their success. Follow up is to be achieved through any
appropriate means such as phone calls, letters and visits.
Support
Any positive steps taken by, or for clients will be supported
by staff. Eg: visits when in hospital, assistance in carrying out
plans to return home, maintaining some level of contact with
clients who have moved into the community.
A designated staff member is scheduled each week to fulfill the
role of an advocate as well as a liaison and support person.
Whenever possible, the same staff will always perform these
functions in order to ensure continuity.
Emergencies and First Aid
In the event of an emergency or life-threatening situation,
the staff member first on the scene takes immediate charge of the
situation and directs other staff members in their duties until a
shift supervisor arrives on the scene. Upon arriving, the shift
supervisor assesses the situation and takes charge of
coordinating the emergency procedures. In the event of a fire,
the shift supervisor in the Seaton House Men's Residence in
charge of and responsible for coordination of all staff on duty
and all procedures outlined in the Seaton House Policy and
Procedures Manual take precedence. The same is true in the event
of an outbreak of contagious disease.
The First Aid Unit staff in Seaton House Men's residence are
available to administer to the Annex clients' needs and for
referrals to outside medical agencies as the need dictates. The
FAU provides support in the areas of distributing prescription
medications and follow up as well as providing for temporary stay
in the Men's Residence medical ward when required.
Severe Intoxication
If staff observe that a client is severely intoxicated to the
point of unconciousness, 911 must be called immediately. In cases
where a client is concious but very intoxicated, the client will
be kept in an are clearly observable by stafff until such time
that he can get up without aid and walk.
Seizures
If a client is observed going into a seizure, staff will
respond immediately . Two staff will attempt ot stabilize the
client by placing him into a recovery position without in any way
restricting the client from riding the seizure out. A pillow or
makeshift cushion will be placed underneath the clients head to
prevent head injury. The third staff will immediately place a
call to 911 and request an ambulance. That being done, the same
staff will lock up the office, aid staff with crowd control and
direct emergency personnel to the scene.
The name of the fire captain and a badge number of the responding
police officer are to be taken down and recorded as well as the
hospital where the client is being transported to. If the client
ends up in the hospital for an extended period of time, the
follow up staff member will visit and provide support to him.
REFERENCES
1. "One is too Many", Toronto Coalition Against homelessness,
May 25, 1996.
2. Rosalak, Boris, "The Next Step", unpublished internal
document of Seaton House.
3. Dianne Patychuk, Janet Phillips, David McKeown, "Death
Among the Homeless in the City of Toronto," May 25, 1996.
4. "Report of the Task Force into Illicit Narcotic Overdose
Deaths in British Columbia," Office of the Chief Coroner,
September, 1994.
Dr. Joyce Bernstein, PhD
Toronto
Department of Public Health
Tel.: (416) 392-7450
Fax: (416) 392-1560
[This report is reprinted on the APOLNET web site with permission
from the author.]
|
|
|