The findings are organized and presented in the following sections: (1) participant characteristics, (2) intervention characteristics, (3) program processes, and (4) impacts and opportunities for improvement.
Vulnerable clients were described (by self and providers) as “invisible” within the system and being socially isolated. They were also characterized by providers as having “brittle support systems”, being disconnected from family, and having “no one looking out for them.” Clients and providers described complex health issues that include, but were not limited to developmental disabilities, anxiety, depression, renal failure, immobility, and pain. Life challenges that prompted referral to the program included homelessness, financial insecurity, elder abuse, bereavement, and caregiver burden. As stated by one care coordinator: “Life has kind of dealt them a crappy hand. A lot of times it’s about the social determinants of health and some people just aren’t as privileged as others … and there’s just not the supports in place, or there are supports but they’re not readily acceptable to people and it prevents them from really getting the help that they need …” (VP Coordinator 2).
Intervention Characteristics - The Little Things are Big.
The analysis revealed one overarching meta-theme that describes the characteristics of the intervention, ‘the little things are big’. Clients and providers frequently referred to the program’s ability to address ‘the little things’ that often go unnoticed at the systems level, but that have a big impact on client health and quality of life: “We have fairly large caseloads and we don’t have like the days to spend working on the smaller tasks that are big for our patient. Like we put in the care plans, we put in the services for them but...it was the little things, like she [the client] wasn’t able to wash her hair and her daughter was burning out and didn’t have contact with anyone in the community.” (Community case manager).
The ‘little things’ commonly involved assisting with personal and practical needs (personal care, groceries, meal preparation, finances, home maintenance) that kept clients healthy, safe, and in some cases prevented them from being evicted and/or being able to remain in their homes. “I have a gentleman that I’m working with, he’s got ALS [Amyotrophic Lateral Sclerosis] and he needs somebody to go to his house and just help him get his lunch from his stove to his table, that’s it. I mean it seems like such a simple thing, but he had a great deal with difficultly doing that” (VP care coordinator 1). Jane, a VP client, shared the following: “He helped me with my portable air conditioner, setting it up and so we got it running...I have a medical alert button and he put it all together...and made a phone call that took like an hour with these people, but he saved me $300 …”.
Social support was perceived as a little but significant thing for clients, staff and students “A lot of people think you have to constantly be doing physical things for people or sending referrals, but a lot of people just want someone to talk to … especially vulnerable people who don’t often get the opportunity to just sit and chat with somebody. It is very beneficial, and I love seeing people’s lives change, specifically for the better, just through the support that we’re able to give them” (VP coordinator 2).
Some clients received friendly visits from WECCC volunteers and/or were connected with WECCC’s community partner programs. All participants described the importance of therapeutic communication and listening skills as being the core component of the program intervention. Molly stated: “That was a comfort to me to know that there were individuals concerned with little, old me in the sense that … we all come from different parts of a community and they’ve included everybody and that’s a very emotional thing for me to have support from people that I don’t even know.”
Clients receive ongoing, free support and this was perceived as a “big thing” for clients and the program.
“Obviously there’s no cost so that’s a big thing, but we never tell them they’re discharged from our program so we can see them once a week until they feel supported which I think is a huge relief for them because they don’t want to tell us their whole story, be done with us in four weeks and then move on to their next worker. So that’s a big thing for us. Even when … we’re not seeing them on a weekly basis, we continue check-in calls whether that be monthly, six months, one year so it’s a huge relief for them … to know they always have our support (VP coordinator 3).
The little and big things are addressed through three key processes: (1) taking time, (2) advocacy, and (3) empowerment. Each process is reported in the following text.
Taking time was a key process that enabled the sub-process of advocacy and empowerment: “… when we go to a home, we’re having a conversation with the client at a pace that’s appropriate to them with intentions of building a report with client and in doing so, they begin opening up about things that they want to work on, difficulties that they’re having that they often have not shared with other people...” (VP coordinator 1). The importance of this process was echoed by another care coordinator: “Most other professionals that go out to people’s homes, they are so focused … that it’s a pretty quick conversation. Whereas our conversations are much more open ended … ‘so what is it that you think you could do? What would you need to improve [your] quality of life?’ This is a very big question and is not trying to fit their answer into some predetermined kind of things that you can offer. So, it takes time” (VP coordinator, 2).
Time spent listening and communicating therapeutically was highly valued, whether it occurred face-to-face or by telephone - “I appreciate how they don’t just [say] o.k. here is what we talked about last visit and drop a bunch of papers in front of you and you know it’s all curt like it is with a lot of offices you know. They take the time to discuss with you between your options which ones are best for you …” (Hunch).
Receiving a monthly check-in call was the most frequently valued intervention reported by clients and providers. In some cases, the call filled a gap when other services had run out and offered a sense of security and social connectedness: The client asked me when I talked to him last, ‘Would you be able to call and just check up to make sure I’m doing okay? Can you please call me in a month just to check in?’... So, I’ll call again in another month (VP coordinator 2).
The process of advocacy encompassed activities such as researching programs and services, contacting providers and community organizations, and explaining the client’s complex health and living situation. Advocacy work was successful in securing vital care and services, such as free and/or affordable transportation for clients, funding for medical equipment, prescription medications, assistance with activities of daily living, and temporary housing.
A community case manager from the regional health authority described the following example of advocacy work:
“I have this mid 70s lady who falls into the category of having a brittle support system, had a fire in the summer in her condo, she’s on hemodialysis. She … was missing dialysis a lot, was going to the ER with shortness of breath … A constant ride to dialysis was the reason she was missing it plus she was suffering some depression … It took a lot of coordination, but we were able to get her rides. I was able to get her providers to start early, to get her ready for dialysis, get her on and off transport … WECCC dug deeper and was able to connect with the social worker and found funding to get this ride and now her dialysis times have been changed... The patient is now going to dialysis.”
Greg shared an example of advocacy when facing homelessness after being discharged following a recent hospitalization: “I’ve been [living] with a broken back over 10 years ago when I went backwards down the basement stairs … I ended up with a fractured skull and a cerebral hemorrhage … He [VP care coordinator] helped me find a place and he booked me in a [rest home] for about nine months … and did some work on getting me an electric scooter …. [my] mobility is not getting better...”
Writing personal health goals was identified as the key process for client empowerment by six clients and all of the other stakeholders: “I think the most important part of it is the establishing of SMART [Specific, Measurable, Attainable, Relevant, Time-Bound] goals. Those provide direction and they also help actually motivate the clients to achieve the goal that they have identified.” (VP coordinator 1).
Some participants were affirmed by the power of goal setting for clients living in precarious life circumstances. Shawn explained: “You would like never put that two and two together yourself but to have somebody say to you ‘Yes you know this is something that you can do.’ That just makes you feel productive as a person, definitely.” The program administrator from a partner community program shared the following: “One of our clients who is palliative … there’s a persistent level of depression … but you know she was still able to make some goals. She was still able identify that ‘I would want to do this, this and this’ before it all ends for her.”
The nursing students validated the value and power of goal setting for empowerment. Brianna explained: “You’re asking them ‘what can you do to improve your quality of life?’...and it helps people realize, ‘Oh I can change this. I don’t want this to be my life the way it is’ and we help with figuring it out … A lot of the time too we would help make goals for the patients and say, ‘o.k. we’ll do this to help you get to here’ and by the time we called the next week... they’ve done it on their own.”
Making social connections was one of the most identified goals reported by clients and staff. “Getting out more is the number one reason people are referred to us, it’s just people are so isolated and so getting out more is one of the biggest goals” (VP Coordinator 2). Clients were empowered to improve their social connections and their personal well-being through intentional connections to community activities, such as card groups and yoga. “We’re empowering them to create one linkage that leads to the next in the community so just getting them involved in other programs so they have some kind of care circle in their life” (VP Coordinator 3). Transportation provided by the local hospice enabled attendance at some programs. “You know I get to meet people and get out of here...with the rheumatoid I wake up with pain every day...my goal is to get back swimming … See if that benefits it [the pain]. There’s other things Hospice offers, other programs, ‘Living with Chronic Pain’ is one of them” (Greg).
A few clients were empowered to use their talents to give back to the community. “We had one client who was good at knitting or crocheting so we suggested that maybe she find a program where she could knit, knit hats for babies... … we did have a few clients who were heavily involved in advocacy for low income people as well as homeless people … (nursing student volunteer). One participant described how she made woven mats from plastic milk bags for people living on the streets, and another participant set up a Facebook group to promote social connection and advocacy for the homeless and those at risk for homelessness.
Impacts and opportunities for improvement
The qualitative data suggest positive health impacts for clients and benefits for the community and the health care system. In most situations, the program serves as a safety net that supports people who are falling through the cracks of the formal care system.
“One of our clients, who had a stroke, she lost function in her right arm and her right leg … she was given a manual wheel chair and for two years she lived in an environment in which she was literally going in circles right because she didn’t have use in one of her arms in order to keep this wheel chair straight and she lived like that for two years! To me that sounded like an absolute system failure but one that really could have been avoided had she called the system, called the LHIN, called the doctor, any of these kinds of people who would’ve been able to intervene and should have intervened but she didn’t … if our clients are receiving monthly check-in calls, something like that will not happen.” (VP Coordinator 1)
All of the clients reported benefits from increased social interaction and a connection with their community. The participants described multiple examples of how the program is directly reducing use of emergency services, preventing homelessness, improving client safety, and in a few cases, averting attempted and completed suicides.
“One member tried to kill himself … When he was released, he was sent to our program through the social worker. He had no other supports just himself and he lives with his brother, so we set him up with the crisis number and made a goal for him and his brother to be a support system for one another. They get out walking at least once a week and they hold each other accountable … He also wanted to work part time … so I gave him a number to the unemployment centre in his area, and he reached out to them himself … created his own resume, and he actually landed himself a job” (VP coordinator 3).
Although long-term community investments are needed, short-term support for securing safe housing and preventing homelessness was reported as a positive impact of the program: One client with hoarding behaviours described how the program enabled her to avoid eviction by negotiating a plan to reduce the clutter: “I had the fire marshal come in here … my house was ransacked and then I just let it go because I suffer from depression … and alcoholism. She’s (the landlord) given me like a week to get one room done and a week to get another room done and he’s [the volunteer] helping me out … He’s helped me out, period! (Jane).
All eight clients reported support for managing chronic health issues such as pain, anxiety, depression, renal failure, and diabetes. Coordinators were able to assist clients to access dialysis appointments, prescription medications, and primary care in cases where clients had no family physician. In some situations, the coordinator attended primary care visits to add context to the situation. A nursing student volunteer discussed success with helping a client navigate management of her chronic pain:
“I had a patient who was in chronic pain and she had no, she didn’t have a family doctor, she didn’t have any management of her pain at all. She had tried non-pharmacological things and it wasn’t working, so she was sleeping until 2:00 pm every day and then going to bed early cause … she couldn’t function … Her main thing was figuring out that pain … she was so socially isolated … because she couldn’t handle it … We got her a family doctor. We had VON [Victorian Order of Nurses] connect with her to help with pain management and we also signed her up with hospice … so that when she had that pain managed then we can work around the social isolation which was getting her involved with the wellness program in the community.”
Through this evaluation, we learned from care coordinators and volunteers that training programs should include specific content and tools for responding to the needs of individuals experiencing complex mental health concerns. Sustainability opportunities include technology, funding, and volunteers. Many clients do not have internet, electronic devices, and/or are not tech savvy. Permanent funding for program coordination and volunteer training will be essential for long-term sustainability. As stated by one coordinator: “I think the main resource that we require more than anything is volunteers … I think that is the key to it all. For myself, I am struggling to keep up just because of the kind of manpower issue. And the main reason for that … you don’t have a volunteer base big enough in order to be able to have that time.”