When people are admitted to hospital, navigating the system can sometimes be overwhelming, especially when faced with a multitude of barriers, i.e. having no fixed address or a lack of identification. CUPS Connect 2 Care (C2C) and Calgary Allied Mobile Palliative Program (CAMPP) is a community-based, collaborative and mobile team that has coordinated and navigated complex social and medical care for six years and counting.

Programs like these lead to more collaboration with health care and social services, thus improving discharge planning and patient access to what it is they need for their wellness. To access C2C, people must have presented themselves to emergency departments at least six times or have had two inpatient admissions in the past year, be experiencing homelessness or vulnerably housed. A referral to CAMPP means that person has received a life limiting diagnosis.

People experience homelessness differently and present to acute care for many reasons, such as physical/mental health, substance abuse or lack of social support. Relationships with acute care settings, partners and our own CUPS integrated team are what enables us to best connect people to services i.e. primary care, housing, finances, medication and other supports.

Allow us to introduce and thank some of the recent funders who have supported the operation of C2C/CAMPP, including the Calgary Homeless Foundation, Alberta Health Services and the Calgary Foundation. We’re also grateful for ongoing funding from the City of Calgary’s Community Safety Investment Framework (CSIF) — which supports the Mental Health and Addiction Strategy — that has expanded our health navigation capacity. All funding opportunities positively affect our impact and how many people we can serve.

What is the Connect 2 Care team? 

C2C helps people make the transition back to community following hospitalization, a move often fraught with uncertainty and anxiety. We pair Calgarians with an integrated team of Health Navigators (HNs), nurses and palliative care workers. Our clients face multiple barriers when trying to access resources they need for themselves. They must often choose between priorities — food, shelter and personal safety — over other health issues which, if left untreated, can steadily worsen.

“It is a professional relationship, but we often become, for some of our clients, a natural support, who is there to support and help them,” Eric Lopatinsky, C2C program lead, said. 

“We try to provide whatever it is they need that will improve their life, whichever way they want.” 

The city’s support improves health outcomes and assists CUPS in reducing case loads and wait times. Even so, demand for this service remains at an all time high, which, to us, illustrates program importance. Ongoing support is what is needed to help people with the changes they want in their lives.

Removing barriers and reducing trauma

Navigating these systems is possible with the right supports. Because of C2C, we’ve experienced decreases in client emergency department visits, hospital admissions and client days spent in hospital. For instance, if a person wants help retrieving their identification, this can be an easy first step to instill trust between them and their case manager. Without ID, you can’t apply for income support. Similarly, a person can’t apply for resources, often housing programs, without completed taxes. This is just one of many barriers the people we help come up against.

CUPS is ready to help people whichever way they need — be that first month’s rent and damage deposits, access to housing or social supports. As HNs, our team is there to transport clients to appointments, accompany them inside and take notes. Receiving a medical diagnosis is hard enough — going through it alone can be heartbreaking.

We’re right there beside people to give them the time to process at a pace that works for them. Equally as important, we’re there to listen. These moments are key for people to best understand and be active participants in their own care. 

“We support them through all these often traumatic and very scary situations, such as connecting with doctors and income support workers,” Lopatinsky said.

The relationships we build, and sometimes just being a familiar face, help at CUPS and partner agencies. Circumstances that may once have prompted a 911 call are assessed and the HNs’ extensive knowledge of who these people are and the traumas behind what it is they’ve experienced prove vital when called.

Our HNs can divert that person to a community service or facilitate transition to acute care without emergency responders. CSIF funding enables faster crisis intervention for socially vulnerable Calgarians and reduces overuse of emergency and acute care services. When we help people adhere to their care plan, lives improve.

New challenges met with ingenuity 

At the onset of COVID-19, Lopatinsky said CUPS worked with the medical officer of health to create the safety protocol that allowed the team to continue face-to-face care, including client transport. When health appointments moved online, our clients experienced another obstacle — access to a mobile device or computer.

“We’ve been able to meet with our clients and help them make these calls, or Facetime, to connect with their workers,” Lopatinsky said, noting that phones have been provided when client funding allows it.

Meeting people where they’re at

“We can move a client into housing, but if they don’t have a natural support system or activities they’re doing, they’re isolated,” Lopatinsky said, noting that loneliness can lead to depression. 

Others might be trying to seek access to palliative care for themselves. 

“As tough as losing clients is, sometimes it’s just being there to walk them through end of life,” he said. 

Lopatinsky said he will never forget his clients over the years, and those who have passed on. 

“Many of these people didn’t have family or anyone to remember them,” he said. “We’ve done a great job creating memorials at CUPS with their names and faces. Their stories are engrained in us.”