Innovative Community Based Care Community Transitional Care Team Canadian Association of Nurses in AIDS Care April 2007
CTCT Homelike community transitional residence for IDU s requiring long-term IV antibiotics
Background Operational since April 2005 Is a joint program between Vancouver Coastal Health and PHS Community Services Society 9 bed capacity, 5 wks average LOS Staffed by RNs, mental health workers, case manager, counselor and physicians
CTCT Care Model Interdisciplinary team providing medical care and support for pt s with chronic and acute addiction issues Addresses complexity of DTES residents socio-economical, medical, addiction, compliance issues, palliative Aiming to improve IV antibiotic completion rates through model of care and support Building bridges with other health care providers and social service systems Various on-site programs
Primary Program Goals Increase retention and treatment adherence Decrease repeat hospital stays for the same condition Decrease barriers to health services Facilitate transition from CTCT to community Others: Decrease Hospital LOS and cost To utilize Harm Reduction approach to reach difficult populations
CTCT Quantitative Review 87.5% Treatment completion rate 94% Discharged to stable housing Cost effective Opens Hospital ALC beds Mean hospital days saved 48.6 per client 44% co-infected with HIV 55% co-infected with HCV
Results compared to Non-IDU s on Home IV Therapy IDU NIDU n=32 n=63 Completed Course Apparent clinical resolution Failures Readmission cont d treatment Left Program AMA Relapse 28 (87.5%) 21 (87.5%) 0 1 (3.2%) 2 (6.25%) 2 (6.25%) 50 (79%) 46 (73%) 0 4 (6.3%) 2 (3.2%) 4 (6.3%) * 6 mos follow-up: 1 IDU relapsed (OM) vs 4 NIDU (all OM)
PICC Line Complications Comparison IDU NIDU No problems 11 (46%) 48 (76%) Occlusion cleared with TPA 5 (15.6%) 21(33%) Catheter pulled out by patient 2 (6.25%) 0 Broken hub/broken line 6 (25%) 4 (6%) Rash from dressing adhesive 1 (3.2%) 0 Phlebitis 1 (3.2%) 3 (5%) Line Infection 0 1 (2%) PICC repaired 4 (12.5%) 9 (14%) PICC removed 2 (6.25%) 9 (14%) PICC replaced 2 (6.25%) 8 (13%)
Health Care Utilization Impact 3 months pre and post CTCT (n=24) Acute Utilization ED Utilization 600 500 539 70 60 66 400 300 200 100 62 Acute Days 50 40 30 20 10 24 ED Visits 0 Pre Post 0 Pre Post
Qualitative Review High level of client satisfaction Better client outcomes ie. Infection, housing, nutrition, stability, etc. Decreased using (per client reports) High standards of Holistic care Concerted time spent engaging with residents Knowledgeable non-judgmental, culturally sensitive team Psychosocial and medical needs addressed
Stakeholders Thoughts All agreed there was a need for alterative models of care and treatment for those who use injection drugs, requiring long-term antibiotics They ve got conditions the require treatment. Until those conditions are treated, its our obligation as health care providers to provide them (with) services that suit their needs, and are accessible to them
Client s Personal Story IDU cocaine 30 years HIV/AIDS, Disseminated MAC Paranoid Schizophrenia Multiple ED visits and hospital admissions (hx. Osteomyelitis, soft tissue infection requiring IV abx.) Poor compliance, first hospital admission < 60 mins, hx LAMA Street entrenched, difficulty adjusting to rules and structure
Client s Personal Story CD4 = 10 upon CTCT admission Difficult threatening behavior Refused treatment Upon leaving CTCT CD4 = 90 ARV compliant Decreased psychotic episodes and paranoia Weight gain Trusting of staff Arranged housing for post-d/c
Stories Matter As human beings, we live our storied lives. We make sense and extract meaning from our lives with the stories we tell others and ourselves. Sometimes we move beyond our life constraints by creating and living a new story. From The Storied Lives: The Cultural Politics of Self-understanding (Rosenwald & Ochberg, 1992)
Maslow s Hierarchy of Needs. Spiritual Self Actualization Ego Needs (Love) Social Needs Security Needs Physiological Needs (food, shelter, warmth)
HIV Nursing at CTCT Hurdles Active drug use On-site drug use Erratic lifestyles PICC Lines Post discharge ARV administration
HIV Nursing at CTCT Why it works Fulfills Maslow s Hierarchy of Needs Unconditional positive regard Therapeutic relationships Low threshold (medical, psychosocial) Holistic approach Skilled staff Harm Reduction increased self worth better health choices/outcomes
HIV Nursing at CTCT Therapeutic interaction, teaching and role modeling healthy life and health choices Moves us beyond the helpers and the helped roles Reminds us: people are more than the sum of their medical and psychiatric diagnoses Encourages individual stories Client centered
Stories matter
Conclusion Goals being met Excellent patient outcomes Residents needs addressed holistically Lower cost per bed day
References Rosenwald, G. C. & Ochberg, R. L. (Eds.) (1992). Storied Lives: The Cultural Politics of Self-Understanding. New Haven: Yale University Press. Marsh, D. et. Al. (2006). Community Transitional Care Team: Antimicrobial therapy for injection drug users. Vancouver, BC: Vancouver Coastal Health.