Okay, I'll get started to reward those who are here on time, and it's also being audio taped with the slides, so if when you participate and, you know, are involved in conversation, please use the microphone so that it gets picked up so that people who are watching from home can hear. I'm going to start by introducing us, I think, and then we'll get started. So my name is Dr. Sarah Coleman. My name is Sarah Coleman. Sometimes the doctor's in front of it. I'm a geriatric psychiatrist from Toronto, Canada. I work on the inpatient unit at the Center for Addiction and Mental Health, and I also am involved in the Psychogeriatric Act team through ReConnect Community Health Services, which is a community agency in Toronto. I'm going to introduce my colleagues. So we have here Dr. Claire Stanley, and she did her medical school residency at U of T, and she's done a number of electives with me as well. So she's been drawn to geriatrics and hopefully in the near future will be part of our subspecialty training program. As part of her residency program, she did a research elective around the Psychogeriatric Act team that we're going to be discussing later today, first doing a literature review logic model and now involved in a lot of quality improvement initiatives to try and get us as close as possible to the gold standard of act, with some caveats that we'll talk about today. And she helped to publish a paper in Frontline Reports, and we've done a number of grand rounds together as well. So this is Claire. And then Catherine Edmond is a registered nurse working in community mental health in Toronto. She graduated from the University of Manitoba with a Bachelor of Nursing degree in 2017, and she's worked on many ACT teams until last year when she very enthusiastically took on the nursing role, the RN position for the Psychogeriatric Outreach Team at Unity Health Toronto. So that's based out of what used to be called St. Michael's Hospital, and she's involved in health care advocacy related to affordable housing, rights for unhoused individuals, as well as with the Decent Work and Health Network. So thanks so much for joining us. I'm actually going to start, before we get to our formal slides, with a land acknowledgement. I've noticed there haven't been many of those here, and as a traveller here, I had to do some research to learn about the Indigenous peoples of this land. So I'll just mention that the Indigenous people of the San Francisco Bay Region are known as the Ramaytush Ohlone, and at present, unfortunately, they actually don't hold any land in their traditional territory due to the history of colonialism. If you'd like to learn more and potentially contribute to helping with rematriation efforts, with cultural revitalization and ecological restoration, the work that they're doing, you can go to ramaytush.org to learn more. I certainly am planning on doing that as well. Okay, so today we're here to discuss psychogeriatric outreach, adapting outreach to better service an aging population, and we don't have any formal disclosures. This is for all three of us, but Project Dignify, including staff salaries, are supported by a donation from the Odette Family and Louis L. Odette Urban Angel Fund for Homelessness. So what we're hoping to do today is do an overview of the current landscape of psychogeriatric outreach and the identified challenges in caring for this population, to review the ReConnect Psychogeriatric Outreach Team, to review Psychogeriatric Intensive Case Management Team, and to review common challenges faced by geriatric and general adult community-based teams in providing geriatric care. And then we're hoping to spend a bunch of time on some simulated vignettes, and hopefully we'll have lots of audience participation and we'll probably be able just to have a small group discussion. This seems like it would be better in a bit of a smaller space, but we'll make do. So the objectives are to identify the challenges faced by general adult assertive community teams in providing care to older adults, to distinguish the core components of geriatric ACT teams from the traditional ACT team model, to describe a novel team-based program designed to support older homeless adults experiencing mental illness, and to teach and practice identifying and managing complex medical, psychiatric, and ethical presentations in the geriatric population through simulated vignettes. So I'm going to turn it over to Dr. Stan Lee for some background. Hi everyone. Okay, so we'll start on a little bit of background about ACT and geriatric outreach, and then we'll kind of go from there. So in terms of assertive community treatment, hopefully this is familiar to most of you, but essentially it was developed in this era of de-institutionalization by Stein and Test in the 1970s, and the idea would be that it's an alternative to hospitalization for patients with severe and chronic mental illness. So their goals were to reduce hospitalization and essentially improve psychosocial functioning for patients with severe and chronic mental illness, and the idea was really that it was going to be assertive outreach, that it would aim to provide services for difficult-to-reach populations, and there was a greater emphasis on teamwork and team responsibility to provide care in a variety of domains. That includes mental health, substance use, social skills, and vocational training, and teams were traditionally interdisciplinary, including social workers, nurses, psychiatrists, and other mental health specialists. So of course, since its implementation, there's been lots of research about assertive community treatment, and generally they have supported outcomes in, for example, patients are more likely to live independently, to have fewer hospital admissions, to remain in contact with mental health services, reduce time spent in hospital, improve patient satisfaction, as well as family satisfaction. And so, you know, these are- these are good outcomes of assertive community treatment. There has been some more inconsistent, I guess, findings with regards to things like social functioning, psychiatric symptoms, and quality of life, but generally these are the kinds of outcomes that have been supported. And so over time, assertive community treatment has been, you know, well studied and developed, and so there's been adaptations of this model to service unique patient populations. And so, for example, there's been successful adaptations to forensic populations, youth, and dual diagnoses. So that kind of brings us to the geriatric population, and what about them? So taking a step back and looking at geriatric outreach in general, we know first and foremost that older adults who live with severe mental illness are a complex population, and that's for a variety of reasons. Includes things like comorbid, acute, and chronic medical conditions, cognitive impairment, having decreased social supports, reduced financial resources. And so to better serve this population, there's been increasing recognition of the need to develop and study interdisciplinary community outreach services for older adults. And so certainly there's been, you know, a few systematic reviews that have looked at this, and they found promising outcomes for these models, including that it helps to improve psychiatric outcomes, providing an essential bridge between patients' pharmacological and psychosocial needs. But some of the challenges in these models is that they're different models, and so there's inconsistency in structure and composition, which tends to limit the generalizability of these models. So what about ACT teams? So these are just general ACT teams servicing older adults. So there was a study done, this was in Toronto by a couple of our colleagues, Dr. Tao and Dr. Cohen, who were looking at exploring practitioners' perspectives of servicing older adults with severe mental illness within, you know, general adult ACT teams. And so some of their findings are highlighted here, including that older adults do represent a significant minority of patients within ACT models, and some of the key issues that they identified or that practitioners identified is that older clients understandably have more physical health needs and functional impairments, which can be challenging to manage. Cognitive impairment tends to add an added layer of complexity, not only understanding safety issues, but management, the etiology, providing care for these kinds of clients. And there's different kinds of dispositions for these types of clients. So for example, does the client have capacity to live on their own? Do they need to go to a long-term care facility? And then there is variable geriatric expertise amongst these teams, and it can be, at least in the Toronto-based context, difficult to access geriatric specialist care. So we kind of postulate that Psychogeriatric ACT represents a promising model to services patient populations. I've highlighted a few of these things already. First and foremost, it's designed to manage complex patient populations. It's been shown to be a reproducible model, and I'll touch on this again a bit later, looking at some of the research and literature that has gone into studying the fidelity of the ACT model. And as I've highlighted, it's already been adapted to service unique patient populations. So going into some of the literature, and I'll focus more on intensive outreach services for older adults with severe mental illness. This was one of the main studies that was done, and to our knowledge, the only randomized control trial that's been done, looking at a geriatric-specific assertive community treatment team. This was published in 2014, and it was done in the Netherlands. And so I'll highlight a little bit about this team, because I think it'll be a helpful kind of compare and contrast to some of the teams that we'll talk about a bit later. But you can see here that the team structure is composed of a substance use specialist, a rehabilitation worker, social worker, nurses, both psychiatric and specializing in more physical health needs, and a psychiatrist. So generally kind of models a traditional assertive community treatment team. Their inclusion criteria for this study was that they were looking at adults over the age of 65. They did drop that to 60 after a year because of difficulties with recruitment. They were also looking for a presumption of severe mental illness and problems in four or more of these domains. So daily functioning, daytime activities, addiction, financial problems, somatic problems, housing issues, police contacts, although they found it difficult to actually find this information in the referral process, so they did drop that after a year as well. And then lastly, they had to have difficulties engaging in treatment. So either unwilling to use mental health services, or had a history of involuntary admissions, for example. And so in total they had 64 people in the study that were randomized to act in treatment as usual. Treatment as usual in this study, the difference between that and act was that there was a higher caseloads and individual responsibility, but treatment as usual did still include geriatric specific teams and there was still, for example, social work involvement and outreach as well. But essentially they randomized clients to these two types of teams. Act understandably had smaller caseloads and a more focus on team-based responsibility. And I'll note that they did exclude clients with moderate to severe cognitive impairment. So this is just like a little break and to understand a little bit about fidelity of the ACT model. And so this is one of the scales that's commonly used to assess essentially like what makes an ACT team an ACT team, what are the core components of that sort of team. And so this this scale is called the Dartmouth Assertive Community Treatment Scale. We'll often refer to it as the DACS as well. And it was developed or published in 1998. It's a 28 item scale that looks at measuring implementation from one being not implemented to five being fully implemented. And there's three general categories here. So first is human resources being the structure and compositions. So having things like a small caseload, team-based approach, having a practicing team leader, the continuity of staffing. That's kind of criteria that are encompassed in human resources. The second is organizational boundaries. So looking at, you know, having explicit admission criteria, responsibility for admissions and discharges. And then the last is nature of services, which is more so looking at does the team have, for example, dual disorders treatment group, which is part of that kind of component of the ACT model, individualized addiction services. And so this is something we'll touch on later, but I wanted to bring it up now because they brought it up in their study and we'll bring it up again with some of our other models. And generally a score four or more is high fidelity, three to three point nine is medium, and less than three is low. And so in their study overall they found that their ACT team had a moderate fidelity. Again this is true to the traditional ACT model. They scored low in the domain of nature of services because, for example, you can see they didn't have things like a dual disorders treatment group, they didn't have a consumer on the team, which is part of this as well, and their frequency of contact was, they also scored low in that domain. Some of the key findings from this study is that overall they showed that they had better, clients had better engagement in ACT as compared to treatment as usual. And so there was more contact within three months in ACT team as compared to treatment as usual, and there was much a significantly less dropout rate. So you can see 18.8% in ACT as compared to 50% in treatment as usual. Fortunately they didn't produce a better outcomes with respect to things like psychosocial functioning, which was one of their primary outcomes, and they also didn't find significant differences between unmet needs and mental health care use. And they, part of this is they postulated this may be due to some, you know, difficulties in their study. So for example, they commented on selection bias and that patients who dropped out of treatment as usual may have, may have had worse psychosocial outcomes which weren't measured. And it's also possible that the ACT group also retained clients who had worse prognoses because they were better at engagement. And they also comment that perhaps there wasn't a lack of, or there was a lack of robust enough difference between ACT as compared to treatment as usual. And that, you know, as I highlighted before, treatment as usual still was geriatric specific care, still included outreach, so maybe there just wasn't a robust enough difference between the two groups. And there's been some other models that have been studied over time. So this is a study that, again, looks at a very similar kind of ACT, traditional ACT team, specific, specifically designed to service older adults. And you can see here, I just put some of the kind of components of the team. So it's still an interdisciplinary team model. You can see it closely represents a traditional ACT kind of structure with social workers, nurses, psychiatrists. And they also had a service user, vocational specialist, substance use disorders expert. And these are all part of the kind of traditional ACT criteria. And they had small caseloads as well. And this was another part of the same kind of team. And they comment on the key differences from this team was that they had three adaptations for older adults. So firstly, that they had increasing knowledge about the complex interplay between physical and mental health needs, learning about community resources that are specifically available for older adults, and taking care not to let ageism affect services as well. So that was, those were the main changes that were made by this team, but otherwise closely resembled a traditional ACT model. And so without further ado, I'll bring back up Dr. Coleman to talk about Psychogeriatric ACT. Thanks Claire. Okay, so we're gonna talk about the ReConnect Psychogeriatric ACT team in Toronto. ReConnect is a community agency and they recognized that there was a gap in care for treating older adults with severe mental illness. And so they decided that they were going to create an ACT team to address this gap. The population that we're meant to treat are adults with chronic mental and physical health conditions, to provide comprehensive collaborative care uniquely tailored to older adults. And our aims are to support independent living, to optimize mental and physical health and to improve function mobility and quality of life. So the the admission criteria, they need to meet five of six, they need to live in the GTA, the Greater Toronto Area, they have to have serious mental health problem which impairs community functioning and it needs to be a long-standing history. So we don't just take people who have dementia because there are other outreach teams that are dedicated to treating people with dementia, but we also don't exclude people who have dementia. So if somebody had schizophrenia or schizoaffective disorder or severe depression or bipolar disorder or a substance use disorder that was significant or a significant personality disorder and now they've developed dementia, they could be accepted onto our team. But if it's de novo dementia in later life or major neurocognitive disorder, to use the DSM-5 language, then we would we wouldn't accept them onto our team because that's not what this team was created to serve. We want to be able, they need to have difficulties with their activities of daily living or difficulty sustaining a safe living situation and Kate's going to talk a lot more about the issue of homelessness or under housed adults a little bit later in this talk and difficulties meeting basic survival needs. Also we want them to have multiple recent hospitalizations and or emergency room visits and or a significant decline in social, physical, occupational functioning and that they don't currently have ACT team support or a multidisciplinary team, although sometimes some of these people have switched from other ACT teams, which seems to be a phenomenon that happens in many places. So this is the team composition. So there's a team lead who also works as a case manager, three case managers, three nurses who are also case managers. We have an occupational therapist who's seven hours per week and we have behavioral therapists through ReConnect that service other teams within the agency but also can help us if needed. We have myself, I'm a geriatric psychiatrist and I'm two days a week and then we also have a geriatrician, so geriatric medicine doctor who is available one day per week equivalent. It's not really two days per week but that's what they call it for me anyways. And so there are small caseloads. Clients are seen daily to weekly depending on their needs and there's a 24-hour coaching line. There are two weekly team meetings and continuous communication via something called Hypercare, which is a confidential way of sort of texting about patient issues. So Claire has done a lot of work in looking at the characteristics of the clients. We're trying to get a sense of who we're seeing and who we're serving. And so when we collected this data we had a caseload of 61 people, the majority male, majority with psychotic disorders, so schizophrenia, schizo affective disorder. You'll see dementia is here as one of the top three diagnoses. So that's not, they don't only have dementia but but that's sort of the main issue. They might have personality or something on top of it. And then the top three unmet needs that we note in this population were having difficulties with their activities of daily living, physical disability or illness, and social isolation. So we, not in a formal sort of RCT way and not using, often when we do fidelity to an ACT model you'll have an external observer come in and see if you're doing what you're supposed to be doing, sort of meeting the bar of ACT, right? Using this, using a scale, the DACTS is what we've talked about. There's another scale called the TeamACT that can be used. In this case what we're doing is we're using the DACTS kind of as a quality improvement tool. So we're doing it ourselves internally and so maybe it's not as, from like a research perspective, as you know free from bias but it's still useful and that's the thing about quality improvement, right? Is that you want to do something that's useful that's going to help you get better. And so what we've done is we've looked at our team using the DACTS and tried to find the low-hanging fruit of where we can improve, things that were within our control to improve, to get it closer to a gold standard ACT team with caveats that are intentional actually because we're serving a geriatric population and I'm going to talk about that. So we're doing pretty well compared to that RCT but maybe we're biased and but so far, you know, overall we have a moderate fidelity to the ACT score. Human resources was moderate. Occupational boundary is quite good. Nature of service is not as good but some of those are intentional and we'll take a look, okay? So this is the DACTS broken down and I'm going to just focus on the areas where we struggle and we're trying to ameliorate. The first is continuity of staffing which really was not in our control and I think it was the great COVID migration. Since I've been on the team, this team started in 2020, November, or maybe it started slightly before but that's when I joined. So right in the thick of COVID, we've had a full like a hundred percent turnover of all of our staff, and then some. And so ideally you have in an ACT team people staying on for like at least two years at a time and a low turnover rate and we have not had that experience although it seems to be stabilizing. I'm gonna like knock on whatever wood is here, right? But certainly that's been a struggle and that's not a struggle that's unique to us. We don't have a substance use specialist so for every 50 people you're supposed to have one substance abuse specialist on your team, someone who has two years of education. Periodically with some of our staff we have but not consistently. And similarly we don't have a vocational specialist but that actually is not unintentional. Like the the reason to have vocational is with younger people. With older people who are in their retirement age anyways, it's not necessary that there's a vocational expert on our staff. That said, it is important that there's meaning and purpose to life at any age and so we need to think of ways like what's an equivalent to a vocational staff on the team and how can we build someone in that's going to be helping like a rec therapist or someone who helps with volunteer opportunities or there are also sort of through the agency there are a lot of programs that could add value and meaning to life like day programs etc that are more unique to this population. If we look at organizational boundaries, we don't necessarily take as full responsibility for treatment services as a ACT team serving the general population because a lot of our patients or clients are in supportive housing because of their age right and so then there's more built-in supports as well and so there's a lot more liaising with other teams who are also helping. Trying not to do overlapping work and giving too much support to someone to the detriment of others who would need our support and also but we did identify that responsibility for hospital admission and discharge planning has been a bit of a struggle for us and so one of our QI cycles was looking at how we could improve that and so Claire developed a sort of form letter that we're sending with information about the ACT team with the phone number to connect with the person's primary case manager and with my most recent notes to every single person who we find if we hear if we figure it out that they've been admitted to hospital to try and be involved in the admission and the discharge planning and it's improved so since we since we initially did this scale the scoring and then finally when we look at the nature of services in order to be a true ACT team there's supposed to be a lot of face-to-face contact and again the COVID factor so initially we we were struggling very hard to figure out what was the good thing to do what was the right thing to do when it came to face-to-face with our older vulnerable impoverished clients who are at a very high risk from contracting and dying from COVID. Is it better to be more on the phone and more distant versus in person and caring for them one-to-one and this was something that I know anyone in in any field but especially in geriatrics was struggling with right like how do we navigate the risks and benefits of having more in-person contact versus the risks of COVID and so I think possibly some of these numbers were lower and are improving now because we didn't have as much face-to-face contact before and we're trying to get back to it now. Other gaps so we don't have a concurrent disorder treatment group we don't have a concurrent disorder model so the substance piece is missing and also we don't have a consumer on the team and one thing when we were talking with our team and looking at this and troubleshooting how to improve it is that they've heard from our clients or our patients that what they really want is an older adult working on our team because oftentimes they'll look at us and say I got the best compliment from a non-whelper I think maybe you were there Claire where I was not giving this man benzodiazepines and he had a an addiction issue and he wanted me to give him more benzodiazepines and I wasn't and he was angry with me and he said get out of here I need a doctor who's older than 21. I was it was a great I'm not 21 I'm not even I'm more than double that so it was it was a really nice compliment even though it was a difficult situation but all to say is that I think oftentimes people who are older some of them don't some of them don't want to go anywhere near older adults but some of them would value having an older adult on the team and so we're talking with management about trying to include someone who's older on our team to help with those issues but we have some added value on our team so there's DBT informed care and DBT groups that sort of train throughout the program which is great I'm a geriatric psychiatrist on the team maybe that's added benefit I think geriatric medicine also added benefit we can do comprehensive reviews try and de-prescribe medical meds etc we have an occupational therapist not enough but built in a bit and we have access to behavior therapists as well I already mentioned these so I'll just be like high staff turnover difficulties visiting and then also there is a bit of a focus on privacy which makes it hard sometimes to be able to communicate adequately about our patients and I think that's a common issue that people have that you need to be able to communicate regularly people communicate through email you need to be able to do that and at the same time there are issues around privacy with being able to effectively do it so how do you balance those concerns but on the other side even despite the turnover it's like I don't know how they find all these angels to be doing this work which is like not easy work and not well enough paid work at the case workers everyone that's come on has been so fantastic and passionate about the work that they're doing and there's a can-do attitude right so like not like oh that's not my job or you know we're not going to do that like something needs to be done and it gets done I remember at the beginning I I work at an academic center where there's like much red tape and then I work at this community center where there's a lot less and there's pros and cons to both I remember we wanted to have pocket talkers because our patients have our hard of hearing and so when we go into community it's hard to communicate with them sometimes they can't hear us and the manager was like sure we'll get them tomorrow right whereas if I were at KMH it would be a whole process of applying and approval and you know it's just like sure of course you need you need an auditory assister to be able to do the work let's just get it for you lots of communication between the team more and more psychiatric resident involvement which is great because of exposure and then also person power to be able to support these people like it's an additional psychiatrist and plans to increase team members and we've also gone from not being available on the weekends to available on the weekends which has been a huge improvement and then being part of this community agency there's lots of other offerings so they have transitional housing or temporary housing when people need just like a break from their housing for some tune ups we have that as an option I could start clozapine not in hospital but in a more supported setting than their home DBT groups there's also a CBT for psychosis group that's been started there's transportation available to take people places and there's day programs so lots of other supports within the agency that help to enrich the act team so that's a quick summary and I'm gonna hand it over to Kate thanks so I'm gonna describe another psycho geriatric outreach program project dignify this is an intensive case management program for homeless older adults our population is homeless and precariously housed older adults living with chronic mental illness so we know that homelessness and living with mental illness are highly correlated in Canada the number of homeless older adults living with mental illness is increasing so our team was developed to address a gap in care services for this population we understand this gap to be a result of system level failures lack of social supports and lack of ongoing access to mental health care the goal of the team is to secure housing support independent living and optimize physical and mental health so our team is relatively new we started to accept our first referrals about a year and a half ago so I'm gonna provide a bit of context for the development of a relatively niche team in our urban center homelessness is a significant and growing problem among older adults with Canadian data broadly from 2005 to 2016 shelter users over 50 increased nearly 10% focusing in on our city Toronto we have 27% of older adults reporting difficulty paying rent and the population of seniors experiencing homelessness doubled from 2009 to 2011 homeless shelter use among the older adult population also increased and this was the only group to have increased shelter use people 50 to 60 and 65 plus are 24% of shelter users and recently in September 2022 we saw 10% of individuals using shelter over 65 finally from 2018 to September 2022 so covering the years of the pandemic the number of older adults over 65 using shelter almost doubled similar trends have been reported in u.s. urban centers like New York City Chicago Massachusetts and then here in San Francisco we designed our team to attempt to capture this specific population with the goal of providing services that improve their biopsychosocial situation our team's inclusion criteria is that the individual is 60 or older homeless or at risk for homelessness has a mental health disorder and requires outreach based case management to contrast us a little bit with an ACT team we work with people who do not necessarily have severe and persistent mental illness although this has been typical for our clients so far but we have the capacity we has the capacity to follow people with severe mental illness but we've also worked with people with experiencing acute exacerbations related to their mental health so for for example to illustrate this one of our clients had a very serious suicide attempt on the eve of an eviction our team was able to take them on found that they weren't receiving social entitlements coordinated their finances and then just last week he was able to move into lower rent housing for seniors so our team has the flexibility to do this which fills a bit of a gap left by ACT teams which can't take clients on in that situation some of our clients are housed but there is typically a risk of eviction related to their decompensation their mental well-being we provide diagnosis and treatment intensive case management supportive counseling housing support medication management all in the community by outreach or at our office and I'm going to talk a bit more about that on our next slide when I describe our team. So we have a relatively small team. There's just three of us working full-time. The healthcare disciplines are designed to meet the needs of this population. Each team member carries a relatively small caseload, so 10 to 15 clients, acts as primary case manager for those clients, but then, sort of similar to an ACT team, will draw upon the specialization of other team members depending on the needs of the client. So we have an RN, which is me. I'll be involved with all complex physical health concerns, medication administration in the community, and metabolic monitoring. Then we have our OT, who is able to perform cognitive and functional assessments in the community, including MOCAs, which is a benefit to this population. And then we have our homeless outreach counselor, who has experience with therapeutic counseling and addictions counseling, and is specialized in working with the homeless population. We have a part-time operations lead, who facilitates our weekly rounds, accepts and coordinates new referrals, and supports general team operations and performance. And then we have our geriatric psychiatrist, who provides specialized psychiatric care along the biopsychosocial framework. They're available to us a half day a week. Finally, we also have rotating trainees, including psychiatry residents. And I'd say our service provides a unique learning opportunity at the intersection of geriatric psychiatry and severe mental illness. So I'm gonna go into our next section, which is on common challenges faced by both of our teams. But we're gonna start with homelessness and housing insecurity, which is more specific to our team. So homelessness and housing insecurity can be examined as a result of structural factors, systemic failures, and individual circumstances. The structural factors significant to our team are lack of adequate income, lack of affordable housing, and systemic racism and discrimination. Systemic failures are the result of inadequacies in other systems to support and prevent homelessness in vulnerable people. So this will involve unsupported transition from child welfare, as well as from disability support to old age security at age 65, inadequate discharge planning or lack of available post-discharge supports, limited access to addictions and mental health supports or facilities, and also minimal support for refugees and immigrants. What I would highlight here is the individual circumstances because this is where our team is able to respond most effectively. Many of our clients become homeless after a personal crisis, such as the loss of a supportive family member. This is often a parent that was caring for them who has died. Behaviors related to mental illness and substance use often make housing situations precarious and then cognitive changes with age compound this. Physical health issues, such as incontinence and inability to perform ADLs can also put someone's housing at risk or they're admitted to hospital and not able to return to housing after they're discharged because of lack of supports on site, but then they're also not necessarily eligible for long-term care. So looking a bit more closely at mental health and homelessness specifically, I'm gonna explore this link through the lens of some of the clinical cases we've encountered with Project Dignify so far. Clients have been referred to our team after an eviction or having a restraining order from their housing following a violent incident in the context of untreated psychosis or intoxication from substance use. We're aware that a hallmark of mental illness is lack of insight into mental and physical deficits. So another situation related to this, we've encountered a number of times is people who lost contact with usual treatment sources during the pandemic became increasingly socially isolated and then didn't accept supports related to treatment for bed bug infestation and their inability to cooperate led to a eviction risk or an eviction in some cases. In a couple of cases, we've had clients who are fortunate to get housing in a transitional unit, but after a long history of homelessness living on the street, they're not used to the boundaries associated with that kind of a unit. We'll see them smoking in their unit. This will lead to a warning. We will try to institute some behavioral interventions, but then because of a lack of supports on site, these behavioral interventions aren't consistently effective and then the person ends up either discharged or evicted, just reflecting the lack of supportive housing available to this population specifically. Finally, financial issues related to mental illness and substance use are also a significant factor. Navigating social assistance programs can be challenging and people fall through the cracks and this leads into the next slide. On financial insecurity. So I alluded to this, but a specific issue around financial insecurity that Project Dignify clients have faced is the transition from government disability funds, which come from the provincial government to old age security funding at the age of 65. If you're not up to date on your taxes or you don't apply for these programs, you can be left without an income for up to six months. I'm not sure if that's typical, but that's been our experience. So we've seen people become homeless or go into crisis when they're facing this transition. So an example to illustrate this was one of our clients who turned 65 during the pandemic, lost all sources of income. He was panhandling to get enough money for food. He also started using substances. Simultaneously, he lost connection with his family doctor who's providing treatment for schizophrenia. Eventually he was admitted to hospital with homicide after expressing homicidal ideation. While he was admitted to hospital, he was connected with a public trustee who was able to coordinate his finances. But even with this robust intervention, it was still several months before he had an adequate income. So he was living on very little money. So even post-discharge, he was quite distressed, not able to get an adequate amount of food, nearly had a relapse during this process and needed hospital admission again. So it significantly delayed his recovery goals post-discharge. There's also, of course, the complex interplay between mental illness, financial insecurity and medical comorbidities. According to Statistics Canada, the proportion of seniors living below low income measures has risen dramatically. Living in poverty is linked to poor health, morbidity and mortality. Statistically significant risk factors associated with poverty are being a smoker, self-reporting, being anxious and depressed or one or the other, and being food insecure. And then I just say anecdotally, all of our Project Dignify clients face one, if not all of these risk factors, so which causes a significant challenge. And I'm handing it over to Claire. Thank you. Okay, so a couple other common challenges. So this slide is referring to the geriatric giants. Hopefully this is familiar to most of you, this kind of concept, but essentially this expression refers to the principle of chronic disabilities of old age that impact physical, mental and social domains of older adults. And so there's a lot of different ways geriatric giants can be presented and conceptualized, but I've highlighted some of the common ones here. And this is certainly a very, very common thing that arises regardless if you're providing psychiatric care or physical healthcare. And this is something that has come up a lot on the team. So things like dementia, orthostatic hypotension, delirium, polypharmacy, frailty, depression, falls is a really big one, and incontinence. And it can be challenging in a general kind of adult team to navigate and manage some of these issues, especially if the team isn't as comfortable with addressing these kinds of things. And so this really highlights some of the value of having a geriatric-specific team where there is increasing knowledge and comfort to understand, identify and manage some of these issues. So for example, if a client on the team, and I'll refer specifically to the Psychogeriatric Act team, has a fall, there is an occupational therapist that we highlighted that can go in and help to assess the mobility of the client who can help to look at their living environment and implement kind of safety features. Do they need handlebars in the shower? Do they need gate aids to make sure we can kind of prevent future falls? And we know falls is something, for example, that has really large morbidity and mortality in this population. And then we highlighted some of the other components. There's a geriatrician who can come in and help do a medical assessment, look at medications. Can there be deprescribing? Is orthostatic hypotension contributing? And of course, like Dr. Coleman, or a geriatric psychiatrist can go in and kind of also assess their mental health and their medications, et cetera. Elder abuse is something that also comes up time and time again in this population. We know elder abuse can be categorized into different domains. So I've highlighted them here. Physical abuse, emotional abuse, neglect, sexual abuse, and financial abuse. And so without giving too many hints, we'll maybe go into some of this a bit later. But all to say is this comes up quite a bit in terms of these different domains of abuse. And it's a very vulnerable patient population. Interestingly, when you look at actually the literature, specifically looking at elder abuse and severe mental illness in this kind of intersection, there's actually really not a lot there, which is kind of unfortunate. There have been studies, of course, that have looked at the association between things like low socioeconomic status, physical impairment, psychological distress, social isolation, sorry, as risk factors for abuse. But there's limited in terms of other correlations between specifically severe mental illness. There was a case control study that looked at elder abuse resulting in severe traumatic injury. And they did indeed find that individuals suffered disproportionately more with pre-existing, they call it medical conditions, but they're medical and psychiatric. So these were things like heart disease, dementia, which include Alzheimer's disease. They talk about mental illness, although they didn't specify what kind of mental illness, as well as drug and alcohol abuse. So without further ado, this will lead us nicely into some of our clinical vignettes. And I will kind of go through the slides here, but I'll let Dr. Coleman. Yeah, so the way we're gonna do this is we're gonna run through two clinical vignettes. And then we're gonna have some questions for you guys to discuss with us. And maybe ask the wisdom of the room to sort of contribute to, it's not an ideal setting with everyone sitting facing us here, but it is what it is. We'll make it work. So either we can pair and share, if you wanna do it that way, or people can come up to the mic because there aren't many people to share some of the answers to the questions that we pose to you. So we're gonna do two different clinical vignettes that address some of the types of issues that we focus that are specific to this population and hope to have a lot of input. We're gonna make you work a little bit, okay? So the first one is a patient who's a 61 year old woman, single. She was living in a private retirement residence, boarding homey residence kind of place. And she'd been transferred to us from a general act team. And I didn't really think much about it because she sort of had just chronic, stable, treatment-resistant schizophrenia. So history of also type two diabetes, on clozapine, also oxybutynin, not an ideal medication for older adults. So that's like one thing we sort of have our lens of does this person really need this? It's quite anticholinergic in addition to the clozapine and metformin to manage her diabetes. And she chronically had, I think, oh, I don't know if it's on the next slide or not. I'll just, okay. So she chronically had delusions and auditory hallucinations that she was in hell and didn't bother her so much, but they were there all the time. And so I was just sort of managing clozapine blood work and things were going on fine. And then we weren't sure who this guy was, but this friend slash boyfriend came out of the woodwork and picked her up a couple of weeks before Christmas. And I thought, oh, isn't that nice? Her family's coming, her friend to like pick her up and take care of her before Christmas. Isn't that lovely? Only like we started getting really strange voicemails and emails from him that didn't make a lot of sense. And we were worried that she wasn't gonna get her clozapine blood work because she was no longer in the supportive housing situation. She was staying with him. And then he asked us if her care could be transferred to a different team and started to become sort of threatening verbally abusive towards various members of the team, quite misogynist toward me. And we started to worry. And then we learned that this man actually had stolen all of this woman's property. So he previously was, so we didn't, it wasn't sort of given to us in hand over or anything, but she previously owned a number of homes in the Toronto area. So you can imagine it's sort of like San Francisco. Someone owns a number of homes in the Toronto area. They're quite wealthy, right? When she had had a hospital admission, he had taken her from the admission, picked her up, taken her to the bank, gotten her to sign POA over to him and taken all of her homes, which he then put into a corporation that he owned. And he, in the past, then tried to ship her back to her home country, which was in Eastern Europe, where she quickly decompensated. And her family who were there, who we've never been able to reach, sent her back to Toronto and she was missing for a week and then showed up at the airport a week later. So I think the team had asked him to pick her up, even though if she were under my care, I would not have requested that. And she had gone missing. There were also a number of other strange events that had happened. Anyhow, we started to worry. We didn't know what to do. We started to try and get him to let us see her, to see if we needed to bring her into hospital against her will because she was in an unsafe setting. And he was refusing to tell us where she was. After a lot of work, we found out that he had a home in Toronto where he was keeping her. He also had a home outside of the city where he had a wife and a child. And on Christmas Eve, I went to find her with police presence, because I was quite worried about who this guy was. And he had gone back to his wife and child for Christmas and had left her locked out, wandering the streets with nowhere to go. So we brought her, I drove her back to her home. So this just brings up some, there's much more to the story, but brings up issues around elder abuse and financial abuse being the most common form of elder abuse. And there've been ongoing issues with this lovely man over time. But just bringing up, we wanted to ask some questions to you around elder abuse in general. So I'll let Claire ask the questions and then maybe we can see if people have some answers that they wanna provide from their own experience. Okay, and maybe I'll just read them out and then give it opportunity for everyone to think about them. So we kind of gave a little bit of this away, but it's okay. Yeah, what type, what are the types of elder abuse? What type of elder abuse does this situation represent? What are some of the red flags when dealing with a substitute decision maker? How do you manage this? How would you manage the situation in your clinical practice if you were kind of faced with this? And we were also curious to know what are some of the laws and or services in your jurisdiction to support a clinical team when they're faced with maybe a situation of elder abuse or something like this? So we thought we could open it up for discussion in terms of whether maybe any of you have any experience or any thoughts about these questions. And we're gonna pause for like a good minute to make you feel uncomfortable so someone gets up and speaks. Morning. I was wondering why she's on 545 milligrams or whatever of clozapine. She's 62 years old is my understanding and with the diagnosis of schizophrenia clozapine requires that you do a white blood cell count every two weeks and that in itself is my opinion unless she was refractory to other antipsychotics I wouldn't see that she should be on clozapine. So she yeah so she was refractory to other antipsychotics and everything else had been tried already but and so she she was the most stable on the clozapine but it certainly caused all kinds of problems including constipation. The blood work she was down to one month because she'd been on it for so long but certainly that was that was the only medicine that kept her somewhat sort of stable. Wondering about though people's experience with abuse specifically right with this issue of abuse and what the what what you would do if you were in this situation or what do you know about the legal framework within You Can Work to help protect your patients when you see these vulnerable people are faced with various forms of abuse. This is my husband coming up now, so he said he's gonna save the day. I am a psychiatrist, I know about this case, but just from my own experience, I guess the striking thing here is financial abuse. In my jurisdiction, which is also Toronto, as a general psychiatrist, pretending I don't have knowledge from my wife as a geriatric psychiatrist, I do know that there are in Toronto, and I imagine, because walking around San Francisco, we actually saw something like this. There's a legal clinic, that's the Advocacy Center for the Elderly in Toronto, and we saw something with a similar name here, and I imagine most jurisdictions have some sort of legal organization that you could turn to for guidance around where you could go. And there's like a hierarchy in my jurisdiction of who can be an SDM and a process to remove that. I imagine the same thing would be in America, but I don't know. Each state's probably different. Come on up, come on up. Come tell us. So we have Child Protective Services. Yeah. We don't have an equivalent to Child Protective Services in Canada. Okay, so you should just call the Adult Protective Services. Adult Protective Services? Yeah. So there's Adult Protective Services available, yeah. And then they should investigate. And they would investigate. Yeah, anybody can, you know, if you have a suspicion, call the psychiatrist, social worker, even anybody in the community. Okay, so anybody, I'm just gonna repeat it because I think it can call Adult Protective Services, so that's a great service. We don't have that. We do have the public guardian and trustee and involved in this case, and they were doing an investigation, and they were doing it prior to our knowledge about it based on the financial abuse already, but it's taken, I think, like two, three years, and still there's been no beneficial outcome. So even when there are these services available, the speed at which they're able to do the work is sometimes frustrating. Okay. Of course, it looks like both financial abuse and maybe I'll say physical since you looked her out of the house as well. Yeah, financial and neglect, I would say, right? Neglect. There were other situations where there was some physical abuse as well, so all the kinds, and possibly sexual as well in this case. I wonder if we should move on to the next case because we also want to leave time for general questions. Let's do it. All right, so our gentleman is a 79-year-old man with a long history of homelessness, estranged from his family for many years. Prior to coming to, I'm gonna look at it from him presenting at hospital. Prior to coming to hospital, he was living in a poorly maintained rooming house, which was unregulated. He had no family doctor or access to primary care. Psychiatric diagnoses are schizophrenia and polysubstance use, including alcohol and cannabis. His medical history includes osteoarthritis, COPD, AFib, hearing impairment, and cataracts. Previously, his medications were olanzapine, 15 milligrams, and trazodone, 100 milligrams. So when he was referred to our team by the inpatient unit, he had been admitted to hospital after being picked up by police. Police were called by shop workers who were familiar with him when he presented as disorganized, incoherent, and inadequately dressed for the harsh winter weather. While at hospital, he decided he didn't want to return to the housing on discharge due to abuse, theft, and potential financial abuse by the landlord. He was really fearful to return to this housing. In terms of his baseline mental status and function, he has ongoing auditory hallucinations that are familiar voices telling him that he will die or directing him to commit suicide. He typically has good insight into his physical well-being and is engaged in follow-up appointments. He has insight into his diagnosis of schizophrenia. At baseline, is usually not distressed by his auditory hallucinations and acknowledges the benefit of his medications. He always uses cannabis daily and has no insight into its effects on his symptoms of schizophrenia. Typically, it increases his level of disorganization and paranoia, but he actually has spiritual beliefs about the use of cannabis and has no interest in reducing its use. To describe it further, I'm gonna go back to kind of like the framework that I use to talk about homelessness and housing insecurity. So for this gentleman, the structural factors that led to his admission to the team are a lack of affordable housing. So for him, a block away from the homeless shelter that he was staying at, he saw a for rent sign and the landlord offered him a room and this was a basement room for $800 a month. He didn't sign a lease. The landlord just brings him down to the bank every month, has him withdraw money and takes the cash from the client. So typically, he doesn't even get receipts for this unless he asks. So there's like a high potential for financial abuse or financial abuse is actually taking place. And then while he's admitted to hospital, the landlord just disposes of all of his belongings, among them important tax documents and identification. While he's in hospital, the landlord also insists that he owes money for rent, but luckily we're able to advocate otherwise because he never signed a lease. So we just, and given that he didn't wanna go back to this housing, we were able to just move on from that. But now we have this client who's homeless again. Very fortunately for this client, we were able to secure a bed in a transitional unit and then he was fortunate enough to get transitional housing. In terms of system failures, he lost usual sources of treatment and support during the pandemic. He didn't get medications for an extended period of time and without outreach-based supports, he became very unwell and requires a longer hospitalization. So for his individual circumstances, he has no formal or informal supports leading up to the hospital admission. He was losing his bank card frequently. He doesn't have a phone. And when he goes into the bank, he's experiencing discrimination by the bank manager. They're basically telling him he forgets everything. He can't manage anything. They're just very derogatory towards him. And so he becomes fearful of going there and then has no access to his money. Other people living in this rooming house, which is in a pretty rough area, steal from him or frequently ask him for money in cigarettes and he doesn't feel safe to say no. Though when he's financially organized, he's someone who completes his taxes yearly, connects with supports in the community. So he has an income. He goes to drop-ins and participates in meal programs and goes to a health bus, which is how he was actually getting some treatment for schizophrenia, but still always has his daily use of cannabis and alcohol. So are questions for this fellow? I can, I'll read them out. Okay. So firstly, what variables and or gaps in services have contributed to homelessness in this case and or in your, oops, sorry, in your clinical practice? What are categories of housing that could be considered for someone with severe mental illness who are experiencing homelessness? And we're just curious about hearing your kinds of experiences with this as well in different kinds of settings and contexts. And in this population, what are some potential barriers to maintaining housing? What are barriers that maybe you face in your clinical practice? And what have you experienced as necessary services towards finding and maintaining housing for people with severe mental illness? So I'm gonna suggest based on what happened last time that maybe you find a partner, you discuss this with your partner. We'll give you like five, seven minutes to do that. And then you can come up with some answers to share with the rest of the group so that we can all learn from each other. So if you're sitting next to someone, then you already have a partner, but if you're not, maybe find someone who doesn't. Groups of three are okay also. Maybe just chat about experiences that you've had and then maybe you'll feel more bold and able to share with the rest of us so we can learn. Okay. I'll maybe ask then for people to come up and share their thoughts on some, all part of these. And if you want to, given that we're a small group, you can also share your background. That might be helpful for us to know, but no pressure. Just to help us to have this conversation. Yeah, go ahead. I'm a retired psychiatrist from North Carolina. Welcome. I think the problems of this 79 year old gentleman with apparently chronic schizophrenia is the failure of deinstitutionalization. This man needs a system of care that surrounds him. He needs housing. He needs nursing. He needs pharmacy. And all these people need to work together. He has osteoarthritis. He's on olanzapine and trezodone, which really can cause orthostatic hypotension and falls. And he probably does not have a retirement income. To support him to have, to rent an apartment. One of the potential barriers to maintaining housing for people with chronic mental illness is the stigma. A lot of people don't want neighbors who are mentally ill. I suspect that this 79 year old is not going to be aggressive or violent. He needs a lot of support and care because of his frailty. So my recommendation is for the county or the state to find him a place that has all that system of care to surround him. Yeah, so we often talk about failures of deinstitutionalization, right? That institutionalization is not necessarily the answer because if we look at the state of our long-term care homes where many of our patients end up, they're not fantastic by any stretch. They're not sort of humane environments that we would want to live in or want our loved ones to live in necessarily. They are very institutional. And with deinstitutionalization, if you want it to be successful, you need to put tons of support into community, right? Tons of support so that there can be a wraparound system to help support people in community in more home-like, smaller environments. So like smaller supportive housing programs that are available, which probably for the state are cheaper, right? Than a full institution, but they're still expensive and there needs to be the will to put money into allowing people with many complex issues to have like a dignified life as they're aging. And there doesn't feel like a huge amount of will, at least in our setting. I don't know if others have thoughts, yeah. Yeah, I guess what I would say in terms of this client and an institution is that that's really the last thing he wants. His goal in life right now is to have a house, which is probably not gonna happen. He's like, I'm 79 years old. Why don't I have my house? And yeah, unfortunately that's outside of what is in the realm of possibility for him, but he's someone who has always been extremely independent and got by, like survived for 79 years this way and is hoping to have an apartment with wraparound supports that would come to him and really meet him where he is at. Yeah. I think the wraparound support is needed here. This gentleman is in a serious risk of falls. And if he breaks a hip, he has a 25% chance of dying within a year. Yeah. So that's really a serious type of thing. So I agree with the wraparound services. Thank you. Thank you. Other thoughts from other people? I saw lots of conversation. There you go. You can do it. Good job. Okay, hi. I'm a psychiatrist in the community setting in Quebec. I work mainly with a geriatric population. So what I've seen from my not very long experience is so there's first the cost of, sorry, an apartment housing is very high. It's getting higher and higher these days. So this is one of the barriers that I've seen. And also we have a lot of people in our hospital that stay in the hospital waiting for a place to go. They are willing to go in like whatever facility or family-based home that could breed them, but they don't exist yet. So there's a lot of funds towards it, but nobody wants to create those houses. So that's, I think, the other barrier that I've faced. We have in our own area like a house that takes in a lot of patient, mental illness patients that use drugs, but because most of those patients are usually refused elsewhere. But so this is kind of something that could be like a nice option, but it's not for all patients. So, yeah. I am not a psychiatrist, but I've worked in the field of mental health for 20, 25 years. Patient, outpatient, emergency department, you name it. And one thing, you know, kind of from the sum of experiences I've realized, the U.S. is terrible at prevention. So what that translates to is anytime you need anything as a patient, as a clinician, as a physician, you go to the emergency department. Send them to the emergency department, right? And then from there, you know, the emergency departments who are doing better, which is most of them, have some kind of social worker, case manager, something like that, and they can connect, right? If there's something in the community, and, again, we're terrible at prevention, so sometimes there's not, that's the person who can connect. But you have to go through the loudest, the most expensive, the most stimulating, sometimes the most degrading way to get there, which is awful, and it makes me very sad. In terms of housing or the lack of housing, the Bon Secours Mercy Health System, last I knew, 56 hospitals, huge, right? Huge, huge health system here on the East Coast, or over on the East Coast. They had created, over the course of 20, 21 years, 800 housing units in urban Baltimore. Urban Baltimore is notoriously kind of rough, and they're, what do they call it? It's like a community hospital. It's a small community hospital in a really terrible neighborhood. Was constantly seeing higher mortality, higher morbidity, turnover, lots of homelessness. So they started a little at a time and built out housing, and they found all of the clinical measures and outcomes got better. I mean, ta-da, it's not rocket science, right? But I look at that, and I look at that example, and I'm like, why don't we do more of this? It just, it's just the simple fact of we're not preventative. We are so reactive, and we're going to spend the money over here because we don't, it's not, there's not an in-your-face need until there is an in-your-face need, and then we say, well, we don't have any money because we spent it over here, right? So I guess that's my long way of saying we use the emergency department pretty inadequately, and that's the go-to here. Yeah, it's the go-to, I think, lots of places, even in Canada where we have socialized medicine, right? Like, we still use the emergency room, and the emergency room is terrible for older adults specifically, right? Because, like, there isn't necessarily geriatric-friendly approaches to what's going on, and so there are, like, there are systems in place to help support in some ways. There's sort of gem nurses, geriatric emergency medicine nurses, or social workers who can help try and, again, get people filtered to the right direction, but there aren't necessarily the resources that they need to provide, right? And sometimes going to the emergency gets you to jump a queue, but oftentimes there isn't, like, the queue is still very long. Yeah, like, I guess a number of our clients have been referred from the emergency department, so there's the benefit of them getting connected to, like, a robust outreach service from them, but it's certainly not perfect, because usually they're coming into the emergency department, they're homeless, they get referred to us, but we have no idea where they are, and so go on the description on the referral, some information about where they might be, and go ahead and search for them, basically. Sometimes the emergency department social worker is able to come with us, and then we can ID them, but it's a challenge, and I think, adding to your point about the housing, that's something I think about a lot, and I'll reflect that, yeah, they probably could put more money into housing and less into, like, even programs like ours, and you wouldn't have as many people facing this kind of a crisis, but that's just not the way the system... Pardon? Yeah. I'll just say it into the mic. So you were just saying that stigma prevents society from putting money into populations that make us uncomfortable, which certainly we, yeah. Or they're just sort of, even, I don't know that people are that uncomfortable. They are, but often they just don't even think about it, right? That's the other thing, that ageism in general. So there's like lots of intersections of problem. Ageism, like older people are not, there's not enough attention paid, and especially if you have older people who have severe mental illness together. That's not something that, you know, people, people are very happy to donate to children with cancer, which is an important thing to donate to, but a lot less to donate to older adults, and the government's saying, right, there's just not that will in the same way. I was just gonna reflect, as a resident, I work on call a lot in the emergency department, just generally, and I think there's also a sense of, almost like helplessness, like you have tons of people come in. We have huge volumes, like there's, and so much homeless people, and older adults, and people with various sorts of issues, and sometimes it's like, who is, you're kind of faced with the situation is what's bad enough, and what's the situation like at that moment, which is awful, and I think a lot of us feel, yeah, moral distress as a result, because it's like, we want to help people, obviously that's why we go into this, but sometimes you just can't, and you have to turn people away, and a lot of people come to our eMERGE being like, I need housing, and we're like, I'm sorry, we just, you know, we can't help you, and sometimes they get to the inpatient unit if there's something else going on, and they can get housing, but a lot of the times it's like, you're just faced with people at eMERGE, and you have to, unfortunately, navigate these really sad and difficult situations, so yeah, just echoing a lot of what you were saying. Yeah, I'll say that there is a way to get into supported housing more quickly, more quickly being like, within a year, instead of within five to seven years, but you need to be in hospital to do so, so it's the same, the way in is problematic, I don't know if that's, like, I see people nodding, so I think that's the same in lots of places, like, if I have a patient on my inpatient unit who has nowhere to go, I can jump a queue to get them in a transitional housing unit, and then that transitional housing unit can jump a queue to get them into supportive housing, so instead of waiting five to seven years in the community, they can wait probably six months in the hospital, still taking up a hospital bed, to then wait six to twelve months in the transitional unit to then get in, so it's a year and a half instead of five to seven years, right, but I can't, if I see them in the community on my ACT team, and I know that they need this in order to be successful and not be hospitalized, I can't get them to jump the queue, I can't get them in because they're in the community, so it doesn't make, like, so the system doesn't make sense, it's the preventative versus reactive, you can't, when you see it coming, you can't prevent it, you can only get them in once they're in the highest resource-intensive, most expensive setting, to then be able to get them into a more appropriate setting afterwards is probably less expensive, and part of our issue is that the pots of money are, they don't talk to each other, right, supportive housing is funded differently than hospitalization, and so everybody's looking at their own budget and they're not looking together at how to, like, improve overall wellness and, you know, Maslow's hierarchy of needs, like, it's not, there's not sort of an overarching plan. So we have, like, a few more minutes, just open to any questions or comments or thoughts or reflections that anyone has. For your presentation, I found it very inspiring. I was just wondering, do you know of other, like, programs like yours in, like, your province or in Canada, or is it, like, the first one specifically for a geriatric population? So there's two different programs, so there is another, apparently, Geriatric Act team in the East End of Toronto, we're in the West End, but it doesn't have a geriatric psychiatrist, it doesn't have, it has, like, some of their, so we've been in conversation with them, right, but aside from that, no, like, this is why they created it, because there wasn't this, there wasn't this program at all, and the reason I got involved with it when I saw the job description was that I've been saying for years, like, we need to have a Geriatric Act team, and then I was like, oh, they're creating a Geriatric Act team, let's be the change we want to see in the world, right, so it's, it's, it's useful to have specifically dedicated to this population. There are other models, though, like Dr. Tao is looking into building more capacity into regular Act teams, rather than necessarily having a geriatric-specific Act team, so there are different ways of thinking about approaching this problem. And then your program? Yeah, I guess, yeah, ours is Intensive Case Management program, somewhat similar to the Act team, but with more flexibility, and I don't know of any other programs that... Claire's done research. Yeah, I've done a bit of, like, part of what I'm doing is also, like, a bit of a scoping review about these kinds of services, and I'll just say there's really not a lot out there, like, and not to say that there aren't programs, but I think these programs, part of the reason we're so, like, passionate about it, because they are pretty novel and different, and that's why, like, when I presented some of the background, there's, there's really only like that RCT about the Geriatric Act team, and then there's some of these other models that have been highlighted, but I think they are, as I mentioned, they're a bit different than these teams that we've mentioned. I think these teams are a little bit more, you know, adapted, I guess, to service the population, as opposed to, like, an Act team that services older adults. They're kind of uniquely adapted to, to figure out, okay, what are the issues faced by these, these kinds of teams, like, what do they need, how do we need to change the model to service this population, but, yeah. Anything else? Okay, so then you have, like, four minutes of time in your day, and we're happy to answer any private questions if you were too shy to go up to the microphone. We'll just, yeah, we'll thank, we'll thank both of our teams, so we'll thank, like, my team at ReConnect, and also Dr. Studiopolis has been helping us with respect to doing some of the research around this team, so that we can share this information more broadly, and hopefully it can be replicated if it's useful, and then Michael Tao. Yeah, Michael Tao's our geriatric psychiatrist, who was really involved in the creation of this presentation, but couldn't come. And then the Project Dignify team listed all of our team members, including our two team leads, and Dr. Jillian Olson is a geriatrician who works with the homeless population in Toronto. We leaned on her research a lot for our slides. And we have references, and all of the slides are available. Happy to answer anything else after as well. Thank you so much for coming and attending, and participating.

psychogeriatric outreach

innovative care models

older adults

severe mental illness

Psychogeriatric ACT Team

Toronto

independent living

interdisciplinary approaches

elder abuse

financial insecurity

Project Dignify

systemic improvements