The RPNs on ICHA’s regional mobile teams provide care for those experiencing homelessness in the GTA.
It’s true that no day in nursing is alike. For the RPNs at Inner City Health Associates, where they are working changes daily too.
These nurses’ clients are in the shelter system or homeless on the streets. This understandably adds a layer of complexity and confusion among clients, communities and health system providers. How are patients supposed to navigate a system that is otherwise dependent on a home address?
Last September, the ICHA launched a regional mobile nursing program to provide community care in three distinct geographies across Toronto. While the program is still actively undergoing its phased expansion, the result will be to integrate nursing into the over 80 sites that ICHA supports.
In each region, there are two teams with RPNs, one specializing in primary care and another in substance cases. Once a week, a family physician and psychiatry specialist provide care at these locations, and all work together in an integrated manner to deliver high-quality and tailored continuity of care.
Shaye Martorino, RPN is the Nurse Manager at ICHA leading the regional mobile nursing teams. She knows the value and impact of being a part of a multidisciplinary healthcare team that meets its patients where they are – in the shelter system or the streets.
During the pandemic, ICHA, alongside city, hospital and community partners, operated a COVID-19 isolation site that provided nursing support 24 hours a day, seven days a week.
Nursing complemented peer, harm reduction, shelter and housing support to ensure that clients discharged from hospitals who were unhoused could receive the care they needed in a dignified environment. Martorino’s previous experience with mental health and substance care attracted her to the role.
“Given that we work with marginalized communities, I anticipated that it wouldn’t be a position that everyone would be comfortable in supporting and providing that level of care that was required at that time, especially with it being a pandemic.”
In the beginning, Martorino says she focused on the gaps in care, harm reduction and substance care.
“As things transitioned, an Enhanced Shelter Support Program was designed,” she explains. “We thought, okay, COVID restrictions are changing, and people are moving around now. How can we evolve this and integrate nursing deeper? So, part of that was we want to ensure that we’re providing equal care and nursing services to all the shelters we’re supporting. So that’s why we came up with the regional mobile model.”
By meeting clients where they’re at, Martorino says she’s better equipped to break down barriers to care. For many of their patients, mobile nursing is their first positive experience with the healthcare system.
The regional teams focus on client autonomy, giving patients the information, support, time and space to decide how they want to access care. This can mean providing wound care, access to STI tests, referrals for testing and specialized care and general mental and physical well-being.
“We meet them where they’re at early on, support them, stabilize and eventually transition them to long-term community providers,” Martorino says. “Whether that’s around wound care, vaccines, phlebotomy, not all of our clients that we’re supporting are at the point within their care that they can access community resources. We also have to look at the social determinants of health and how that affects others.”
Although a lack of housing is the backdrop barrier to all of their work, the most powerful social determinants of health for their patients are income and resources, as it affects access to medication. ICHA can cover a small portion of the costs of client medications every year, but for many, this will not be enough for all their medication needs.
Shaye says her team also functions as an advocate for clients.
“Whether or not it’s for support with transportation, or trying to get them in with a dentist or transitioning their care to a family doctor, or with a housing centre, the amount of time and energy that goes into it is substantial.
I can’t imagine having a client who is unwell being able to do all that,” she says.
Justin Gathara, RPN is a primary healthcare nurse at ICHA. Most of Gathara’s patients have never seen a family doctor for a general checkup, including blood work that most Canadians typically have.
“You encounter clients who have had major issues their whole lives, and nobody has ever really taken the time to investigate any of it or find out what’s going on. And a lot of clients either are refugees or newcomers to Canada,” Gathara adds. “They don’t know anything about how the system works. ‘This is how you find a family doctor’.”
Finding a doctor that takes new patients, which is increasingly difficult for everyone, could mean travelling across the city. Gathara says that this is something his clients, who are living in shelters, simply can’t afford.
“That’s where we come in,” he explains. “For the first time in years, we’re able to chat about health concerns, take a family history to learn about predispositions to genetic illnesses, and then we can test for those. We can get up to date with the vaccinations that they haven’t had since they were children. So, one of those barriers that we can tackle, first of all, is not finding access to a primary care provider in the community.”
After years working on an acute medicine floor in a hospital, Eric Dasilva, RPN moved to community nursing and the mobile care unit during the COVID-19 pandemic. This was a side of nursing Dasilva didn’t know existed and for the past two years, he has found working with those experiencing homelessness and struggling with substance use to be a valuable learning experience.
“A lot of our clients don’t have permanent addresses,” Dasilva explains. “They’re in one shelter, and then they are in another shelter. So, when doctors even want to follow up with them, sometimes they don’t know where they are. Sometimes they’re just suddenly kicked out of the shelter. So, all these things really play into our clients’ ability to get proper treatment.”
Dasilva says it’s his job to listen to the whole story the client is telling as he provides care.
“I remember I had one client who was an older gentleman. He explained he got injured on the job in the 1980s and said the doctor prescribed him a bunch of narcotics. Next thing you know, he has an opioid addiction. Then he loses his job. He can’t drive. And now he has no income. His closest doctor was a 30-minute walk. All these things started piling up on him,” Dasilva says.
He says there is a lot of stigma about various types of care, including methadone, to treat opioid addiction. His job is to build trust with patients who haven’t had primary care and de-stigmatize treatments.
Gathara has also found himself having to help clients regain trust in a system plagued by sterotypes “I recently had to send somebody to the emergency room because he was hurt pretty badly. But when he came back, he explains that the health care workers in the ER didn’t treat him with the kind of respect and the kind of professionalism that you would expect,” he says.
“There’s a notion or preconceived idea of how homeless people are, or maybe they’re just seeking pain medication, or it’s all an act, for example. And that plays into what they’ve experienced their whole lives of going to the hospital or the emergency with an actual issue, but kind of not being taken too seriously or being dismissed a little bit,” he says. He adds it makes his job harder to build up that trust.
“I would like other people, specifically nurses and other healthcare workers, to remember that this is somebody’s someone. It’s somebody’s son, somebody’s father, somebody’s brother. We work with them a lot of the time, so we get to hear their stories from them. So we know that they have children. We know they have grandchildren who love them. We know they have parents who are worried about them,” Gathara says.
After years working on an acute medicine floor in a hospital, Eric Dasilva, RPN moved to community nursing and the mobile care unit during the COVID-19 pandemic. This was a side of nursing Dasilva didn’t know existed and for the past two years, he has found working with those experiencing homelessness and struggling with substance use to be a valuable learning experience.
“A lot of our clients don’t have permanent addresses,” Dasilva explains. “They’re in one shelter, and then they are in another shelter. So, when doctors even want to follow up with them, sometimes they don’t know where they are. Sometimes they’re just suddenly kicked out of the shelter. So, all these things really play into our clients’ ability to get proper treatment.”
Dasilva says it’s his job to listen to the whole story the client is telling as he provides care.
“I remember I had one client who was an older gentleman. He explained he got injured on the job in the 1980s and said the doctor prescribed him a bunch of narcotics. Next thing you know, he has an opioid addiction. Then he loses his job. He can’t drive. And now he has no income. His closest doctor was a 30-minute walk. All these things started piling up on him,” Dasilva says.
He says there is a lot of stigma about various types of care, including methadone, to treat opioid addiction. His job is to build trust with patients who haven’t had primary care and de-stigmatize treatments.
Gathara has also found himself having to help clients regain trust in a system plagued by sterotypes “I recently had to send somebody to the emergency room because he was hurt pretty badly. But when he came back, he explains that the health care workers in the ER didn’t treat him with the kind of respect and the kind of professionalism that you would expect,” he says.
“There’s a notion or preconceived idea of how homeless people are, or maybe they’re just seeking pain medication, or it’s all an act, for example. And that plays into what they’ve experienced their whole lives of going to the hospital or the emergency with an actual issue, but kind of not being taken too seriously or being dismissed a little bit,” he says. He adds it makes his job harder to build up that trust.
“I would like other people, specifically nurses and other healthcare workers, to remember that this is somebody’s someone. It’s somebody’s son, somebody’s father, somebody’s brother. We work with them a lot of the time, so we get to hear their stories from them. So we know that they have children. We know they have grandchildren who love them. We know they have parents who are worried about them,” Gathara says.
Ariana Bof, RPN a primary care nurse at ICHA, agrees. She moved from a hospital job to ICHA’s isolation site at the beginning of the pandemic and then transitioned into community spaces going into different shelters.
Like the others, Ariana says the job comes with many learnings.
“To be honest, I never wanted to do anything with mental health. I thought, ‘No, I don’t want to do mental health,’” Bof says. “Three years later, I don’t think I would trade my job for anything else. I love going to work. I needed a change.”
She explains that when she saw the posting for her role on the WeRPN site during the pandemic and told her mother she was applying for a job in a community care setting, her decision was met with concern.
“I said, ‘Mom, my friends that work in hospitals get hit.’ It happens everywhere.” She says there is a lot of misunderstanding about the patients she cares for daily. “A lot of the time, you have grown men sitting in front of you and crying about things. To always fear them is kind of ridiculous because they are human as well.”
As Martorino points out, community care services, like ICHA’s mobile team, can take much-needed pressure off hospitals and other critical care institutions facing staffing shortages. The connection her team is building with clients provides an outreach, harm reduction from a trauma-informed lens that will decrease the number of visits to the ER.
The designated spaces for care in shelters also means that any negative experiences or traumas from past hospital visits or critical care institutions aren’t present.
“We’re sort of a bit more informal, so to speak, compared to hospitals,” says Gathara. “I know sometimes with a whole hospital setting, it can be a little bit intimidating for clients to be there. But clients build that rapport and that relationship with us quite quickly because we’re in a safe space. As for them, and we listen to what their concerns are, we pay attention to what their needs are, and we respect whatever concerns and whatever past traumas they’ve had with the healthcare system. And that way, they kind of understand, and we work together that way.”
The team agreed that community nursing comes with big rewards.
“Some of the most rewarding experiences I’ve had is something as simple as giving someone a band-aid. Because they’ve felt so comfortable with me to come to me to ask for that care,” Shaye explains. “That speaks volumes if you have an understanding of the folks that we’re working with. Just them walking in the door because you’ve made that space comfortable and welcoming. You’re building that connection. And I think seeing that connection action is like the biggest reward, for sure.”
Gathara adds that connection is often a new experience for their clients.
“Sometimes you help somebody deal with something that nobody has been helping them with, and they turn around and say, ‘thank you so much, this has been a thorn in my side and thank you for taking the time’. That really does warm my heart. And I can go home and say it was a good day. I did something small for somebody. So, my world is a little bit better today.”
