ACTION BASED CARE OVERVIEW
Action Based Care (ABC) is a methodology we have developed to provide dynamic immediate care for those who, for one reason or another, have found themselves outside the existing public health structures. In this section we describe how it is applied in Urban Core situations. For a wider perspective on ABC, go to actionbasedcare.com.
The Challenge
Since 1987 we have been adapting our practices to meet the challenge of a dramatically changing patient base. Prior to 1995, referrals to our home care nursing service in Vancouver's Downtown Eastside —Canada’s poorest neighborhood — were mostly elderly and retired labourers living in the numerous single room occupancy (SRO) hotels.
While illegal drugs have always been prevalent in this area, by the mid 1990’s the urban drug scene had become much more aggressive: open drug dealing and injecting of heroin and cocaine and smoking of crack in alleys and doorways had become the norm.
An epidemic of drug use, fueled by low prices and easy availability, swept across the city. Those caught up in it were forced by their need and economics into the Downtown Eastside. The closing of Riverview Mental Hospital exacerbated this. We saw an influx of people living with mental illness also being driven into the Downtown Eastside by economic necessity.
Elderly alcohol-using loggers and miners were joined by a new cohort of chaotic patients, many of whom were HIV+ and were in the palliative stage of their disease.
Aboriginals were and are the majority and they are increasingly female. And they increasingly bear the burden of death and dying in the DTES.
By 1997 the Downtown Eastside had the highest HIV rates in the developed world and the health authority declared a public health emergency. Many services were developed at that time to cope with the situation. Money for services continues to pour into the area. Many of these services work in silos; often there is poor communication between services and over-lapping of mandates.
While illegal drugs have always been prevalent in this area, by the mid 1990’s the urban drug scene had become much more aggressive: open drug dealing and injecting of heroin and cocaine and smoking of crack in alleys and doorways had become the norm.
An epidemic of drug use, fueled by low prices and easy availability, swept across the city. Those caught up in it were forced by their need and economics into the Downtown Eastside. The closing of Riverview Mental Hospital exacerbated this. We saw an influx of people living with mental illness also being driven into the Downtown Eastside by economic necessity.
Elderly alcohol-using loggers and miners were joined by a new cohort of chaotic patients, many of whom were HIV+ and were in the palliative stage of their disease.
Aboriginals were and are the majority and they are increasingly female. And they increasingly bear the burden of death and dying in the DTES.
By 1997 the Downtown Eastside had the highest HIV rates in the developed world and the health authority declared a public health emergency. Many services were developed at that time to cope with the situation. Money for services continues to pour into the area. Many of these services work in silos; often there is poor communication between services and over-lapping of mandates.
This new cohort are often multi-diagnosed: they have history of substance use, HIV disease, Hepatitis C and/or mental illness. We originally had few skills in approaching this population. We found our agency's protocols did not address the needs of these young, drug-using people, often in the advanced stages of AIDS. The Home Care Nursing Program makes a lot of assumptions such as a home, a phone, and family and friends support. It is also 3 strikes you are out; that is if you are no home x3 you are discharged from the program.
We realized then that this was not going to work for the people we were trying to see. So we teamed up with the Street Nurses, accompanying them in their harm reduction van to learn how they approached this population. Physician Sue Burgess began to do outreach to some of the most marginalized people in the hotels and on the streets and so we teamed up with her. Thus began the development of our Action Based Care model incorporating Harm Reduction principles and meeting people where they were at. We will be speaking more about this later.
Every inner city strikes the same picture but in Vancouver the DTES is really a ghetto. The area we are talking about is small, a total of 10 blocks square. It is a dangerous area. Aggressive drug dealers on every street and alley; violence, weapons and murders come with the territory. Way back then the police advised us then that they always traveled in pairs in DTES. We adopted this practice. Originally it was for our safety but it soon became apparent that 2 brains and 4 eyes on a chaotic situation made for faster, safer and more efficient care. The residents have to adapt to the hostile environment too. Street-based survival skills that are honed to the business of living another day.
We realized then that this was not going to work for the people we were trying to see. So we teamed up with the Street Nurses, accompanying them in their harm reduction van to learn how they approached this population. Physician Sue Burgess began to do outreach to some of the most marginalized people in the hotels and on the streets and so we teamed up with her. Thus began the development of our Action Based Care model incorporating Harm Reduction principles and meeting people where they were at. We will be speaking more about this later.
Every inner city strikes the same picture but in Vancouver the DTES is really a ghetto. The area we are talking about is small, a total of 10 blocks square. It is a dangerous area. Aggressive drug dealers on every street and alley; violence, weapons and murders come with the territory. Way back then the police advised us then that they always traveled in pairs in DTES. We adopted this practice. Originally it was for our safety but it soon became apparent that 2 brains and 4 eyes on a chaotic situation made for faster, safer and more efficient care. The residents have to adapt to the hostile environment too. Street-based survival skills that are honed to the business of living another day.
The Irritants
But there are issues that get under everybody's skin-that disturb us clinically and ethically. It is important to be honest about these on a day to day basis. Many are aboriginal; many have differing beliefs about taking white man’s medicine such as ARVs.
They are often young. We are talking teens to late 40’s.
Many of these conditions made worse against a background of HIV and other epidemics.
Their attitudes toward the medical system, our attitudes towards marginalized, drug using folks.
Even the patient themselves become irritants, blocking a nurse’s perceptions of the care needs. The often difficult behavior, the endless just-a-minute-I’ll be right –back dashes down the street to buy drugs. The excuses! The anger and self-pity! These are not always easy people to like. And in the back of our minds is the thought “If she isn’t really ill, then I don’t have to visit and put up with this crap.”
HIV is an irritant in a class all by itself. Even the insanity of crack, fentanyl and crystal meth is left behind by the endless two-way hassles caused by a disease that never stops. It’s difficult enough to be drug addicted without the major irritation of fatigue, infections etc that go along with this disease.
We say “look at her, she made $400 last night on the street and you’re telling me she’s palliative??”We say “Why doesn’t she die? Her CD4 is <10; she has MAC, CMV, lymphoma, pneumonia!!!” She says “I’m 20 now, will I make it to 30??”She says “If I go to the hospital, I know I’ll die!”
Their attitudes toward the medical system, our attitudes towards marginalized, drug using folks.
Even the patient themselves become irritants, blocking a nurse’s perceptions of the care needs. The often difficult behavior, the endless just-a-minute-I’ll be right –back dashes down the street to buy drugs. The excuses! The anger and self-pity! These are not always easy people to like. And in the back of our minds is the thought “If she isn’t really ill, then I don’t have to visit and put up with this crap.”
HIV is an irritant in a class all by itself. Even the insanity of crack, fentanyl and crystal meth is left behind by the endless two-way hassles caused by a disease that never stops. It’s difficult enough to be drug addicted without the major irritation of fatigue, infections etc that go along with this disease.
We say “look at her, she made $400 last night on the street and you’re telling me she’s palliative??”We say “Why doesn’t she die? Her CD4 is <10; she has MAC, CMV, lymphoma, pneumonia!!!” She says “I’m 20 now, will I make it to 30??”She says “If I go to the hospital, I know I’ll die!”
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Action Based Care works. A model of care delivery that we have developed over the past 30 years to reach this chaotic, multi-diagnosed population. It looks like this:
Being consistent and reliable
Having a non-judgmental approach and accepting that abstinence from drugs is not an option for this population. Triggers are everywhere.
Refusing to be put off by an abrasive welcome and remembering we are guests in their home, whatever that home may be.
Working collaboratively with the person to establish a plan of care which recognizes the person’s autonomy. Developing a trusting relationship is key and requires us to be in it for the long haul.
Seeing past the behavior on the street to the person within. Supporting the patient but not the habit.
Refusing to be put off by an abrasive welcome and remembering we are guests in their home, whatever that home may be.
Working collaboratively with the person to establish a plan of care which recognizes the person’s autonomy. Developing a trusting relationship is key and requires us to be in it for the long haul.
Seeing past the behavior on the street to the person within. Supporting the patient but not the habit.