Expanded Funding for Transformative Healthcare Delivery for People Who Are Unhoused/Homeless

FOR IMMEDIATE RELEASE – Thanks to its success in connecting vulnerable populations in Halton to critical primary care services, Support House's Community Health Centre (CHC) Mobile Health Team has been awarded a funding extension through April 2027.

The program was initiated through a collaboration between Support House, Connected Care Halton Ontario Health Team (CCHOHT), Halton Physicians Association, Oakpark/Churchill Neighbourhood Centre, the Mental Health + Addictions Alliance, and people with lived experience, including family and caregivers.

The extension has been provided through the province’s Interprofessional Primary Care Team (IPCT) funding to further expand and enhance vulnerable populations' access to primary care in Halton.

"The CHC Team is a robust demonstration of collaboration between the Connected Care Halton Ontario Health Team, the Burlington Ontario Health Team, its partners and the Halton Physicians Association," said Paul Gregory, Executive Director of Support House. "Front of mind in the development of our CHC was how our team will foster trust and relationship building between its clients, primary care and the healthcare system at large."

The CHC breaks down barriers to healthcare for clients with high LOCUS scores (averaging 3.6) through a comprehensive team that includes 0.5 FTE Physicians, 3 Nurse Practitioners, 2 Registered Nurses, 1 Social Worker, 1 Peer Support Worker, 1 Clinic Coordinator, and 1 Manager. Services include primary care, preventative care, harm reduction, chronic disease management, peer support, mental health care, addictions medicine, and service connection, with 33% of services addressing social determinants of health.

The CHC team is providing support through encampments, local shelters, the Churchill Neighbourhood Centre, and other community partner sites in the Halton Region. Community and assertive outreach is also being conducted in Halton's most vulnerable encampment areas.

"This extension of our funding will allow us to continue to expand and enhance access to primary care," said Christina Jabalee, Senior Director of Community Health. "This includes improving service delivery and care pathways for people who are unhoused with complex mental illness, substance use and other medical concerns. Improving access to primary care will help improve people's health outcomes and our overall community wellness."

Breaking down barriers through values-driven care

The CHC focuses on relationships and holistic health needs, with 60% of clients engaging in multiple visits, with an average of 11 touchpoints per client and 45-minute consultation times. The program emphasizes continuous improvement through a robust engagement plan to ensure clients’ voices are heard.

The CHC draws on elements of the Chronic Care Model (CCM), a framework designed to improve care for people living with chronic health conditions. With a focus on individuals with severe and persistent mental illness and substance use, the clients served by the CHC team include individuals diagnosed with schizophrenia, bipolar disorder and schizoaffective disorder, substance-induced psychotic disorders and personality disorders.

"Re-establishment of trust, and by extension relationship, between the individual and primary care is the principal goal of the CHC," Gregory explained. "If an individual is attached to a primary care provider in the community, every effort will be made by the team to reestablish the relationship to facilitate ongoing, proactive, and effective care and to reconnect people back into our existing system. If an individual is not currently attached to primary care, the CHC interprofessional team will provide primary care and build that trust."

Community Health: Meeting People Where They're At

Improving primary care services to vulnerable populations was identified as a community need and is community-driven. Halton Public Health reports that one in 10 Halton adults (18-64) have been diagnosed with a mood and/or anxiety disorder, and from 2006 to 2015, the rate of ER visits for mental illness increased by 24%, with the rate of hospitalizations increased by 36%.

The CHC provides mobile care for life transitions and urgent needs, same-day service for primary care and mental health, and clinician connection within 2-3 days. To date, the program has served 338 unique clients and coordinated 143 specialized referrals through partners.

"The CHC is a great example of people coming together as one team to ensure the quality of care and quality of life for those often most at risk," said Gregory. "For those who are vulnerable and underserved, whose issues are often not given the attention needed, the CHC is helping to remove the barriers to accessing care by meeting people where they are in the community."

The CHC is working closely with Support House's Response Team, which has successfully addressed many social determinants of health and successfully housed people living in encampments and shelters. The Response Team obtains referrals through the Region of Halton's By-Name database, which prioritizes services for the unhoused/homeless population based on the highest acuity.

A local strategy for more connected health

The CHC aligns with the Ontario Government's Your Health: A Plan for Connected and Convenient Care strategy, which includes a commitment to connect more people to primary care by creating interprofessional primary care teams to make access to care more convenient for those with the greatest need. These interprofessional primary care teams will provide direct care to vulnerable and marginalized people and those without a family doctor. This will help connect people to care without having to visit emergency rooms and experience long wait times.

This approach includes identifying barriers to people accessing their primary care provider, attending appointments with the client and primary care provider, and facilitating virtual appointments, among other strategies.

The Primary Care EOI submission was embraced by the CCHOHT and worked on through a highly collaborative and multidisciplinary group, including the Halton Physicians Association, The Mental Health + Addictions Alliance, Oakpark/Churchill Neighbourhood Centre, Halton Region and people with lived and living experience including family and caregivers. The proposal was supported by many physicians, specialists and Family Health Teams across the Region of Halton.

"The CHC program is a true expression of a community coming together to identify a need and working collaboratively to address it," Gregory added. "This interprofessional project brings together health professionals who have not traditionally worked together, enhances care for an underserved population, and builds strong relationships."

Referrals are accepted from community partners, primary care providers, specialists, ERs, and other acute care services. The referral process emphasizes a "no wrong door" approach and does not require a physician's referral.

About Support House

Support House (supporthouse.ca) has provided support services and housing for people with mental health, substance use and addiction concerns in Halton since 1984. Support House provides low-barrier, harm-reduction approaches to providing accommodation and support to people with multiple needs to address housing stability issues.

Everyone deserves and has a right to housing.

FOR MORE INFORMATION CONTACT:

Paul Gregory, Executive Director, Support House
1-833-845-9355 ext. 134
paulg@supporthouse.ca