Programming Connection

TAHAH: Towards Aboriginal Health and Healing Program 

Vancouver STOP Project
Vancouver, British Columbia
2013

How Does the Program Work?

Location

The TAHAH program is located at the Vancouver Native Health Society (VNHS), one of the busiest clinics in Vancouver’s Downtown Eastside. Established in 1991, the clinic embraces a harm reduction philosophy in the treatment and support of its clients. In addition to providing a broad range of healthcare services, VNHS offers several harm reduction services: methadone maintenance, addictions counselling, diabetes awareness, Sheway (providing assistance to women and their infants struggling with issues of addictions) and the Positive Outlook Program. TAHAH clients have full access to the range of clinical and social supports offered at VNHS.

VNHS values a collaborative model of providing care, treatment and prevention and has long-term, established partnerships with other Vancouver-based clinical and community services, such as St. Paul’s Hospital and BC Housing. TAHAH clients are given assistance to access these other services.

Relationship with the Positive Outlook Program

TAHAH is a sub-program of the Positive Outlook Program, which is also based at VNHS. The Positive Outlook Program provides care, treatment and support services to people living with HIV. In addition to nursing care and outreach services, the program offers drug and alcohol counselling, social work services, maximally assisted medication therapy, daily breakfast and lunches, a weekly food bank and a rent supplement program. It is open seven days a week, so TAHAH clients can access the Positive Outlook Program on the weekends, when TAHAH is closed.

Many TAHAH clients access some form of services from the Positive Outlook Program, such as its breakfast and lunch program or its drop-in space. TAHAH staff are able to check in with and monitor their own clients when they visit the Positive Outlook Program. The two programs also case conference together every morning; this unique relationship is very important as is allows for continuity of care for clients and support for staff.

Peer health advocates

Peer health advocates are a critical component of TAHAH. The program employs four peers, each of whom work four hours per week. All of the TAHAH peers are clients of the Positive Outlook Program and were initially engaged in peer work via a 2005 community-based research project partnership with Simon Fraser University. This partnership offered peers a year-long community-based researcher training program, which gave the peers a foundation of knowledge and skills related to the peer role.

Most of the peer health advocates, who themselves still experience many of the challenges faced by TAHAH clients, have been working with VNHS since 2006. This is a significant demonstration of their commitment to their work.

The case manager or a nurse checks in with the peer health advocates weekly to debrief, identify areas for improvement, solve problems and ensure that the peers are engaged in active self-care work and burnout prevention.

TAHAH is in the process of reinvigorating its support system for peer health advocates to help them to provide the best possible services for TAHAH clients. Given the small caseload of TAHAH, the commitment of the existing peers and the intensity of the peer training, which cannot be replicated easily, TAHAH does not recruit new peer health advocates.

Identifying potential TAHAH clients

TAHAH clients are First Nation people living with HIV in extremely marginalized circumstances and in a state of significant instability. This instability may relate to their HIV status (e.g., they may not be adhering to antiretroviral therapy or may be unable to start it), but it may not. It may also relate to other health or social aspects of their lives (e.g., issues with adherence to methadone; homelessness.) Almost all clients are living with addiction and some live with mental illness.

All TAHAH clients are referred to the program by a healthcare provider, usually the VNHS physician or a Positive Outlook Program staff person. Less frequently, the referral comes from a member of the STOP outreach team. The people who provide the referrals recognize the instability described above and refer clients who require more support than their services can provide.

Once a person is identified as possibly being interested in the services that TAHAH provides, a more intensive engagement process begins. A TAHAH nurse and the case manager will engage the person at VNHS, in their home or on the street, depending on the circumstance. For example, they may approach the referred individual while they are visiting the Positive Outlook Program to tell them about TAHAH. Other times they may visit a person out in the community while they are on outreach. In all cases, the purpose of the first contact is to introduce the program and start to build trust between the person and TAHAH.

Initial and ongoing client engagement: building trust and stability

Although one of the main goals of the TAHAH program is to reduce HIV transmission by ensuring access to HIV treatment, considerable work must often be done to help the client to build stability before they can be ready to consider HIV treatment. Stabilization can include addressing the client’s fundamental survival needs, such as housing and food, and addressing their other health issues.

Once a person is identified as a possible TAHAH client, the nurses and case manager begin a gentle but thorough assessment. By using a medicine wheel intake form, they are able to develop a comprehensive picture of the client and start to develop a care plan. However, given that most new TAHAH clients are managing multiple complex issues, it is rare that the intake process is conducted in one visit. Rather, the team works through the assessment over time, so as not to overwhelm the client.

TAHAH is very flexible and carries out different activities each day to meet the unique needs of individual clients. Each morning, the nurse on duty and the case manager at TAHAH meet first with the Positive Outlook Program staff team, as all TAHAH clients are also Positive Outlook Program clients, and then on their own, to discuss client needs and develop a plan for the day. It is during these discussions that the nurse or case manager may determine that a peer health advocate should be engaged in a client care plan. However, not all clients work with peers. The decision to involve a peer is based entirely on the unique needs of the client.

Although each person’s relationship with TAHAH is different, after intake a person is typically engaged in intensive case management where their immediate needs are met. For instance, they may be given access to safe housing, treatment for infections and wound care. Clients will also be supported to have initial (and then ongoing) viral load and CD4 tests to assess their health in relation to their HIV infection. TAHAH staff will liaise with family physicians, specialists, peer health advocates and other external health and social service providers, to ensure that clients are receiving the comprehensive care that they require. The support is intensive and very responsive to the client.

TAHAH connects with clients through a combination of approaches. Clients can drop in to access the services of the case manager, but most of the support work happens on the street and in people’s homes. The nurses, the case manager and the peer health advocates do considerable outreach work, checking in with TAHAH clients and attending to pressing health crises. During both clients’ drop-in visits to TAHAH and TAHAH staff members’ outreach interactions, the clients are often concerned about issues that are more acute and immediate than their HIV status, and these frontline interventions also help to build a solid relationship. Genuine and therapeutic connections flourish in this context; these connections, in concert with increased access to survival supports, such as food and shelter, nurture TAHAH clients in their progress toward improved well-being.    

On-site HIV treatment and access to healing

TAHAH clients have access to HIV specialists, family physicians, nurses and a variety of allied healthcare professionals on site. First Nation traditional knowledge, supports and ceremonies are also available in the clinic, often via an elder, which can really make a difference in a client’s ability to access Western health and social services. The TAHAH team will work with a client for months through intensive care management, clinical care and system navigation to build stability in their life and help them to become ready for antiretroviral therapy. This work includes providing ongoing education about the challenges the client may face while on treatment, particularly during the first month of treatment. For clients who are particularly hesitant to start treatment, peer health advocates can be very helpful at this stage of care, as they can talk, peer to peer, about what it is really like to start HIV treatment.

When a client chooses to access HIV treatment, they will work closely with the on-site HIV specialist and undergo appropriate resistance and genotype testing before starting a regimen. Clients typically access medication in one of two ways: through a pharmacy located next door to VNHS, with which VNHS has a very good relationship, or through the Positive Outlook Program’s medication program. For those who do not show up to pick up their medication at the Positive Outlook Program, staff will conduct outreach to try to deliver it to them. If staff members are aware that a client has run out of medication and they cannot locate them to give them more, they will notify the client’s physician.

By providing intensive case management and ongoing clinical monitoring, along with access to First Nation traditional care, TAHAH staff members help clients to adhere to their treatment regimen and can determine if a client’s care will need to be changed (e.g., changing the treatment regimen or the intensity of support). The on-site physicians and infectious disease specialist work closely with the team and the client to monitor treatment uptake and progress.

The activities outlined above are part of an intensive one-on-one model of care that focuses on client-centred care and client autonomy. While TAHAH aims to support clients with education, support and peer counselling, it also promotes the value that clients have the right to choose and to make informed decisions about their health and well-being.

“Graduation” from TAHAH

Once a client has remained stable in multiple aspects of their lives (e.g., they have been stably housed and on HIV treatment for a period of time), they are able to graduate out of the program. Typically, people only graduate from TAHAH when they are stable and/or move out of the Downtown Eastside community (and cease to access services at VNHS.)

It can take a long time for clients with complex life realities to build a secure and stable foundation for their lives. The TAHAH team must work at a pace that is suitable for the client and on the issues that are most important to the client. Although some people do move on, graduation rates are low because of the length of time it can take for some people to stabilize. The TAHAH team members are committed to the relationships that they build with clients over the long term and they will continue to provide support as needed. However, the low graduation rate had been a challenge for TAHAH given that the program has capacity for only a small caseload—if none of the existing clients graduate, the program is unable to take on new clients. TAHAH typically graduates one or two people per year.