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At a community symposium on health care and homelessness attended by over 250 Londoners, a research team from Lawson Health Research Institute announced the results of a nine-month, federally funded project tackling the issue of homelessness from within hospital walls. 

The No Fixed Address (NFA) strategy reaches and supports patients during the crucial transitional period when they are being discharged from the hospital and re-integrated into the community. The approach was initially tested with strong success for mental health patients across the city and the second ‘version’ of the project was extended to medical units at London Health Sciences Centre’s University Hospital and Victoria Hospital.

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“Many of our patients with lived experience of homelessness were saying that their journey started with a hospital discharge,” explains Dr. Cheryl Forchuk, Assistant Scientific Director at Lawson and NFA project lead. “They were often experiencing major transitions in their lives and then experienced a hospital stay. Normally a relatively short visit, they aren’t able to gather the information and make a plan to be able to leave the hospital with somewhere to stay.”

Through partnerships between service providers and non-profit organizations, the NFA strategy helps prevent homelessness by providing timely and accessible supports to patients who would otherwise be discharged into homelessness. Staff from the Canadian Mental Health Association Middlesex, Salvation Army’s Housing Stability Bank, and Ontario Works in the City of London provided direct, on-site patient access to housing and income support databases

“Lawson’s No Fixed Address research project is the first evaluation anywhere of a strategy that aims to reduce the number of hospital patients being discharged into homelessness,” says Dr. Forchuk. 

Over nine months, 74 people experiencing medical health issues accessed the NFA program. Of those, 54 per cent were also experiencing mental health challenges. 

All of the study participants were in imminent danger of homelessness. Through the supports provided as part of this research study, half were able to arrange housing before being discharged.

“We were able to help a lot of people, with 50 per cent successfully securing housing,” shares Dr. Forchuk. “With the results and feedback we received, we learned a lot about how we can make the program even better.” 

They found that there is a need for the supports to be extended as a transitional program in the community post-discharge, as the length of stay in the medical units tended to be short. 

The project’s previous phase, involving acute and tertiary psychiatric care in the London region, prevented homelessness in 95 per cent of cases. “Going into the medical units, we found that people have highly complex needs that often involved mental health challenges.

By simply using the same approach that we did for those in psychiatric care, we helped half of the people find housing. To best serve the needs of everyone, we want to follow them after discharge.” 

The team sees a solution in having a housing support worker provide transitional, wrap-around services that follow the person. They would continue to meet and work together after the hospital stay, helping to access community programs. 

“This role would be embedded in both the health care system and the homeless serving system, supporting individuals who have complex physical and mental health issues as they are also navigating homeless resources.” 

This project is funded by the Government of Canada's Homelessness Partnering Strategy’s (HPS) Innovative Solutions to Homelessness funding stream.  

Overview and Numbers 

Fast facts on homelessness and health care 

• Stable housing after discharge is associated with higher quality of life, reduced substance abuse and fewer hospital admissions.
• Homeless clients are four times more likely to be readmitted to hospital within a month compared to low-income matched controls. 
• Hospital care for homeless clients costs an average of $2,559 more per client.
• Finding appropriate housing or avoiding a potential eviction takes time – it is important to start as soon as possible during the discharge process.

Implementation of first phases of No Fixed Address 

• Access on the unit to a housing advocate and income support staff.
• The initial intervention was accessed by 219 acute psychiatric clients, as well as 32 clients within a specialized tertiary care psychiatric hospital - only 3 became or remained homeless.
• Expanded to be an immediate wrap-around service with offices set up in the hospital mental health units.
• Staff from the Canadian Mental Health Association Middlesex (CMHA), Ontario Works (OW), and Salvation Army’s Housing Stability Bank (HSB) have on-site access to housing and income support databases.
• Clients can access service by drop-in or appointment.
• Services include assistance for finding housing, financial assistance, such as rent/utilities in arrears or first/last months’ rent for a new home, and access to high quality used furnishings, household supplies and a cleaning service.

Expanded second phase of No Fixed Address 

• Program ran from July 2018 to March 2019 (9 months).
• 74 people accessed the program.
• Complex situations with both mental health and physical problems: 100% had medical issues and 54% had mental health issues.
• Lengths of stay were very short.
• People could not attend drop-in due to medical issues, so they relied on referral from staff.
• Although they were all in imminent danger of homelessness, 38 people (50%) were housed as a result of this program.

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What were the main housing needs? 

1. Help finding a place to live
2. Money for deposit
3. Financial support
4. Transportation support 
5. Help getting benefits 

Recommendations and learnings for future models

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• Housing support worker needs to be a transitional support since work will be needed after discharge.
• Social work not the only key players (patient care facilitators, nursing staff, etc.). 
• The transitional housing support role needs to be well embedded in the homeless serving system, as well as health care.
• People have physical and mental health issues and are also going to be navigating homeless resources.
• Despite the low success rate, many people were housed who would have otherwise been discharged to homelessness.
• We learned a lot about what was needed in an area where there was a knowledge vacuum.
• Future plans involve implementation with improvements to the model.

In 2012, researchers from across Ontario, led by a team at Lawson Health Research Institute, started the first multicenter randomized controlled trial to evaluate implementation of a transition coordinator for young adults with type 1 diabetes as they transferred from paediatric to adult care. 

“There is a huge difference between the kind of care that they receive as children compared to adults, and that is consistent across Canada and most other countries,” explains Dr. Cheril Clarson, associate scientist at Children’s Health Research Institute, a program of Lawson, and a paediatric endocrinologist at Children’s Hospital, London Health Sciences Centre.  

With children, patient visits involve a variety of specialists from different areas, such as the physician, nurse educator, dietitian and social worker. “The naturally build up a long-term relationship with the team, as some children might start the program when they are 2 or 3 years old as an example.” Dr. Clarson adds that the child’s caregivers are an integral part of the process and the care team also gets to know them very well. 

Moving into the adult program means that the patient now has more responsibility and autonomy over their own care. They have to remember to go to appointments, fill prescriptions and maintain their daily diabetes care. 

“During the emerging adulthood period, your attention is taken up by many other things – leaving home, starting post-secondary education, figuring out your identity and independence,” says Dr. Tamara Spaic, Lawson associate scientist and adult endocrinologist at St. Joseph’s Health Care London. “And on top of that they need to manage their diabetes every day. They are in a completely new system with a new care team – it’s a major transition. For many, they stop coming to appointments regularly and they don’t keep up with all of their own care.” 

As young adults struggle to find their footing in a new system, there are significant short and long-term consequences when it comes to their health. Some will experience acute complications like high sugars leading to diabetic ketoacidosis and hospital admission or severe low blood sugars where they can lose consciousness and have a seizure. 

“Different studies show between 30 to 60 per cent increased risk of complications like retinopathy, myocardial infraction, stroke and kidney disease in those who do not follow their care plan,” notes Dr. Spaic. “We see a bump in this young adult period where levels spike and their diabetes isn’t being controlled – this has impacts for both the individual and the system.” 

The study enrolled 205 young adults with type 1 diabetes between the ages of 17 and 20. Patients were recruited from three paediatric centres and their care was transitioned to three adult centres. The multi-centre partnership included Children’s Hospital; St. Joseph’s; Children’s Hospital of Eastern Ontario; The Ottawa Hospital; and, Trillium Health Partners in Mississauga.

Participants were randomly assigned to two groups, with 104 patients in the structured transition program and 101 patients receiving standard care. Patients were seen in the paediatric care setting for six months and then transferred to adult care, where they continued with either the transition program or standard care for one year.

The core component of the program was a transition coordinator, a nurse who is a certified diabetes educator. The coordinator followed the young adults throughout the transition, interacting with the paediatric health care team to establish a base of support as they moved into adult care. They attended visits, established appropriate contacts for the patient, provided support for diabetic care, problem solved and helped navigate the system. In addition to face-to-face meetings, they were available via text messages, emails and phones calls. 

“We had a high recruitment rate for the population and type of study, and a high number of participants followed the full program,” says Dr. Clarson. “Our results at the end of the intervention showed that the program worked very well. By providing additional support through a transitional coordinator, the results showed better outcomes all around.”

Compared to the baseline, study participants attended more care visits, were more satisfied with their care, suffered much less distress associated with diabetes, had better management on a daily basis and reported less emotional burden of diabetes.
The team then took it a step further and spent another year following the participants to see if they were able to sustain the behaviour and positive outcomes. They did not find a difference between the control and intervention groups. 

“Unfortunately, we found no difference in the number of visits they attended, their satisfaction with care and management of their diabetes,” explains Dr. Spaic. “When they didn’t have the intervention, they essentially went back to baseline. Out hope is to see the program extended.”

Dr. Clarson adds that they developed the program so that it can be integrated in different ways, and also in difference areas of health care beyond diabetes. For example, they found that the preferred method of communication with the coordinator was text. This is an easy way to provide the fundamental support of a coordinator for longer, and it is cost-effective.

“Our patients really loved the intervention. By the end of the study, they felt more comfortable being able to navigate the adult health care system. They felt empowered and responded well. They wanted to continue the program.” The next step for the researchers is to evaluate support through a virtual transition coordinator.

“Closing the Gap: Results of the Multicenter Canadian Randomized Controlled Trial of Structured Transition in Young Adults With Type 1 Diabetes” was recently published in the journal Diabetes Care by the American Diabetes Association. 

Learn more about the study and read about Nicole Pelcz, study participant, who found out at 13 years old that she had type 1 diabetes. 
 

In the media: 
Diabetic teens fall back to old habits after transition care, study says – London Free Press
 

Mental health services are rooted in relationships. When it comes to delivery, and specifically community-based and outpatient services, connection and communication between the individual and care provider need to be the focus. 

When we think of youth in particular, technology is a regular form of communication for them. 

“Our research team at Lawson is looking at how technology can assist in the delivery of mental health services for youth in a way that still supports the important components of treatment,” says Dr. Cheryl Forchuk, Assistant Scientific Director at Lawson. “In our work with youth, they’ve talked about wanting the technology they are already using integrated into their care.”

In the health care sector, the use of technology needs to be carefully tested and implemented, to ensure it is not only meeting the needs of those using it but also that it complies with the standards for privacy and security. 

On February 7, 2019, Lawson Health Research Institute and InputHealth welcomed community members and stakeholders for the announcement of a new health care technology solution that is being researched by Dr. Forchuk and her team, with generous contributions from the provincial government.

TELEPROM-Y is a mobile-based TELEMedicine and Patient-Reported Outcome Measurement Youth study aiming to improve access to specialized services and reduce inpatient mental health admissions for youth. The initiative is one of 11 that received funding from Ontario’s second round of the Health Technologies Fund (HTF), a program of the Ontario Ministry of Health and Long-Term Care administered by Ontario Centres of Excellence.

TELEPROM-Y received $395,109 in provincial funding with $494,630 in matching contributions for a total investment of $889,739. 

InputHealth’s CEO Damon Ramsay and Chief Medical Officer Puneet Seth, along with Jennifer Moles from the Ontario Centres of Excellence were on hand with Dr. Cheryl Forchuk to hear more about how the technology and funding will help support youth. Project contributors Woodstock General Hospital and Youth Opportunities Unlimited (Y.O.U.) also attended the announcement. 

This project is taking a unique approach to creating connections with youth. Researchers will use an electronic Collaborative Health Record (CHR) developed by InputHealth, an innovative Canadian digital health software company, which allows for secure communication. Patients will have access to virtual visits, prompts and reminders, text or email messages, and educational materials delivered by phone. 

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InputHealth's Puneet Seth and Damon Ramsay provided a demonstration of the software being used in the study. 

Dr. Forchuk explains that “the study is focusing on an important transitional period. The majority of mental illnesses occur between the ages of 16 to 25 years old.” The research team is recruiting participants between these ages who have symptoms of anxiety and/or depression, and are receiving outpatient services from a hospital-based mental health care program at London Health Sciences Centre, St. Joseph’s Health Care London and Woodstock General Hospital, or community-based services from partner organizations. 

A key aspect is to assess whether the technology is effective and efficient, while acceptable to both the staff and youth using the app. 

“Careful evaluation is essential to make sure we are doing the right things for the people we serve,” adds Dr. Forchuk, who is also the Beryl and Richard Ivey Research Chair in Aging, Mental Health, Rehabilitation and Recovery. 

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The mobile software will also be evaluated on its ability to improve the ease of access to care; monitor mood and behaviour changes for earlier intervention; enhance information exchange between patient and health care provider; and, support the overall experience for the youth. 

Other project contributors include St. Michael’s Hospital Centre for Excellence in Economic Analysis Research, The Forge (McMaster University), Thunder Bay Regional Health Sciences Centre and Western University.  

The study extends previous findings from the Youth Mental Health Engagement Network study (Y-MHEN), which developed, delivered and evaluated an interactive web-based personal health record, the Lawson SMART Record (LSR), to assist mental health patients in managing their care and connecting with care providers.

The Health Technologies Fund is a program of the Ontario Ministry of Health and Long-term Care and is administered by the Ontario Centres of Excellence. Program supports the development of made in Ontario health technologies by accelerating evaluating, procurement, adoption and diffusion within the Ontario health system. 
 

A new study from Lawson Health Research Institute and Western University suggests that fecal transplants could be used as a treatment for non-alcoholic fatty liver disease (NAFLD). The randomized controlled trial published in The American Journal of Gastroenterology found that fecal transplants in patients with NAFLD result in a reduction in how easily pathogens and other unwanted molecules pass through the human gut and into circulation, known as intestinal permeability. The results could have implications for the treatment of numerous conditions including metabolic syndrome and autoimmune diseases. 

“Intestinal permeability plays a role in the development of metabolic syndrome which is a major cause of coronary and cerebrovascular disease. It has also been associated with autoimmune diseases like multiple sclerosis (MS), rheumatoid arthritis, systemic lupus and type 1 diabetes,” explains Dr. Michael Silverman, Associate Scientist at Lawson and Professor at Western’s Schulich School of Medicine & Dentistry.

Many NAFLD patients have increased intestinal permeability which triggers inflammation, increased fat in the liver, insulin resistance and elevated levels of triglycerides in the blood. The human microbiome – the diverse collection of microbes in our body – is thought to play a role. Previous studies have shown differences between the gut microbiome of NAFLD patients compared to healthy individuals. 

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“Our team wondered whether we could change the gut microbiome of NAFLD patients to reduce intestinal permeability,” says Dr. Jeremy Burton, Lawson Scientist and Associate Professor at Schulich Medicine & Dentistry.

The trial included 21 NAFLD patients from London Health Sciences Centre (LHSC) and St. Joseph’s Health Care London. Patients were randomized to receive a fecal transplant using stool from a healthy donor or a placebo (the patient’s own stool). Fecal material was delivered to the small intestine using endoscopy. Patients were followed for six months to assess changes to their gut microbiome, intestinal permeability, percentage of liver fat and insulin resistance. 

While the researchers found no changes in percentage of liver fat or insulin resistance, they observed significant reduction in intestinal permeability in those patients who had elevated intestinal permeability at the study’s start (seven patients in total). They also observed changes to the gut microbiome in all patients who received a fecal transplant from a healthy donor. 

“Our study demonstrates that intestinal permeability can be improved through fecal transplant from a healthy donor,” says Dr. Laura Craven, a recent PhD graduate from Schulich Medicine & Dentistry and first author on the published study. “This suggests that fecal transplant could be used as an early intervention in the treatment of NAFLD to reduce intestinal permeability and prevent inflammation”

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Dr. Laura Craven

“Our findings have implications for other conditions too,” adds Dr. Silverman, who is also Chair/Chief of Infectious Diseases at Western, LHSC and St. Joseph’s. “Changing the gut microbiome could hold promise in preventing and treating metabolic syndrome and autoimmune diseases associated with increased gut permeability.”

The team hopes to next conduct a large multi-centre trial to further investigate FMT as an intervention for NAFLD and as a therapy to reduce intestinal permeability. 

NAFLD is an obesity-related disorder and is the second-leading cause of liver transplant in North America. While reversible if treated early, its progression can lead to liver failure or cancer. Current therapies are not overly effective and the prevalence of NAFLD is increasing. 

Dr. Silverman is a pioneer in the field of fecal transplants, including their use as a treatment for Clostridioides difficile (C. diff). He is involved in multiple studies examining the potential of fecal transplants as treatments or supportive therapies for numerous conditions including multiple sclerosis (MS) and different types of cancer.

“In order to conduct this research, we need stool donors,” notes Dr. Silverman. “By donating your poop, you can help us assess the value of fecal transplants to treat a variety of diseases.”

The team is in need of young, healthy stool donors for fecal transplants. All donors are required to go through a screening process. Those interested in becoming a stool donor can contact Dr. Seema Nair Parvathy, Research Coordinator, Fecal Transplant Program, at 519-646-6100 ext. 61726.

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Drs. Michael Silverman (left) and Jeremy Burton (right)