Calgary’s Assisted Self-Isolation Site integrates health and social supports for people experiencing homelessness
This Equity in Action story is distilled from an interview with Sam Hung, Program Manager at the Assisted Self-Isolation Site (ASIS). The interview took place in April 2021, and its details should be considered within the context of that time period.
At the end of the day, it’s really about housing. Housing as a basic human right. I would say to government that they need to put more money into housing. If you put money into affordable housing, into some type of guaranteed income, into something to address this really important social determinant in health so that people can have their own homes – we wouldn’t need to spend as much money on projects like the Assisted Self-Isolation Site in the future.
The Assisted Self-Isolation Site, or ASIS, opened in Calgary in April 2020 to provide a safe space for people who are experiencing homelessness to self-isolate during COVID-19. Our program is run through The Alex non-profit health and social services organization which has expertise in providing health services, housing programs, and social supports. The ASIS provides a temporary home with increased medical supports to make sure that people who have tested positive, or have come into contact with a known case, can isolate and not have their health worsen due to COVID.
Shifting from downstream medical focus to upstream comprehensive supports
Initially, the ratio of staffing was heavily skewed towards medical staff, we had many nurses and medical office assistants, but only four case managers to make up the social support staff. Very quickly, we realized we needed more community support workers. They have become the backbone of a lot of our work because they’re the ones doing check-ins, delivering meals and basic need items, chatting on the phone for hours if clients get lonely, and being there to assist in de-escalation.
ASIS is run out of a hotel that has room for up to 93 clients. So far, 90 has been our max and we’ve been as low as eight people last summer. We shift our services to meet the needs of the community. When we have low numbers of people that are isolating, we use our resources for purposes other than isolation, and that’s been a silver lining of ASIS. We do prioritize close contacts and people who test positive, but when we have enough room and don’t need to respond to outbreaks, we take in people who just have symptoms. And then we’re like, okay, what else can we work on while people are here?
We’ve opened what we call internally Tier 3. Tier 1 and Tier 2 would be more prioritized COVID-related cases. Tier 3 is for people who need stabilization in a place that’s more medically supported than a shelter, but is not necessarily a hospital, for example to complete a round of antibiotics or receive wound care. The length of stay for these people is the same as for those who are close contacts, 14 days max. We’re relieving stress on the shelter system and preventing hospitalizations, for example by treating infections in the community, in a place where people can also access appropriate and informed social supports.
Tier 3, which represents a smaller pilot within the larger pilot, is our way of showing the value of providing comprehensive support. We were finding that we were doing a lot more for clients beyond providing accommodation. In some cases, COVID isolation was almost a reason for people to focus on chronic health issues, or get into housing, or stabilize on opioid agonist treatment. If someone needs a place to stabilize before going to transitional housing or a permanent housing program or even treatment, and it’s within 2 weeks, we accept them as well.
We’re trying to use the resources and team we’ve built for purposes other than isolation to show that there really is value in such a highly integrated social and medical team. It’s really 50-50, and I’ve never seen a place where it’s so equally weighted in terms of how the supports are offered. That highly integrated level of collaboration between the social and medical resources has allowed us to be successful, and not just in terms of our staff but for our funders as well. I don’t know of a time when senior levels of Alberta Health, Alberta Health Services, the Ministry of Community and Social Services and the Calgary Homeless Foundation have continuously worked together before, but we have collaborated for a year now, and found common ground for goals. If there can be more funding streams that allow for this merging of funds to work on overlapping mandates, I think this model has shown success. Yes, there can be challenges to ensuring a truly integrated team, rather than the health team and the social team, but when it works, it’s beautiful and the impact is seen in our clients.
For us, success isn’t just the number of people of who successfully completed isolation. If someone is uncomfortable – for example going through intense withdrawal, is without social supports, is lonely, or has suicidal thoughts – that's not really a successful isolation. It’s successful in that we prevented other people from getting COVID, but it can be really triggering and not trauma-informed to be in a hotel room for 2 weeks by yourself. I think success would be providing for people’s needs while they’re here so they can isolate in a dignified, safe, and comfortable manner that aligns with their own goals. We can help them if they want to detox or help keep them safe if they do not. We can provide social supports or a way for them to connect with their existing supports, we can provide a break from the street where they get three meals a day, the dignity of having their own bathroom, and the choice to sit in their bathtub for as long as they want. We understand that, when we’re in a COVID-19 surge, and our numbers are hitting 90 and we can only manage the bare bones, public health is the primary mandate. But when we do have the opportunity to address all those other things, that’s really where we want to land.
Prioritizing a harm reduction and Housing First approach to keep people safe
We’ve been successful because of our staff team and the values we hold. We didn’t waver on harm reduction and Housing First principles. Harm reduction and Housing First really do work. We see successes beyond what traditional programs might count as successes. We know harm reduction goes beyond offering safe supplies. It’s really in how you problem solve with clients and how you do risk management. The whole pandemic response through ASIS has been one of navigating harm reduction, because if a client wants to leave, we then have to navigate harm done out in the community as well as harm to the client in that situation. Adhering to those principles of reducing harm and taking a whole-of-community approach enables ASIS to navigate complex situations.
In the early days especially, we didn’t know how far we could push with creative case plans to keep people inside. As soon as we had our first client leave against medical advice, who was COVID positive and who left because they couldn’t access alcohol, we were like, okay, we’ve got to change how we do things. Because we can’t have people leaving because they can’t access a legal item that anyone with a home can buy and enjoy in their own home if they were self-isolating. Our clients shouldn’t be denied this privilege due to not having a home.
For a lot of people, staying at ASIS represents a barrier to their income because they cannot access their usual ways of making money, whether it be bottle picking or panhandling, or if they’re in the sex trade or dealing. They can’t afford their regular smokes. In these cases, we’re a hindrance to our clients, as we’re disrupting their daily activities and ways that they get by, so how can we meet them halfway? We started providing cigarettes for free just because it helped people to stay inside. That stuff doesn’t fit in the budget anywhere. The Alex is footing the bill through their donations.
Even though we’re not technically a housing program, we use Housing First principles in that we believe there should be no barriers or low barriers for housing. We shouldn’t be creating barriers for self-isolation. So whatever traumas, triggers, tri-morbidities that clients bring with them, the only reason we wouldn’t let someone stay is if their case is too medically intensive to manage and they need to be in a hospital. Whatever people bring with them, we try to work with them until we have evidence that we can’t manage it. Then we try to find a safer place for them.
The Assisted Self-Isolation Site has been a big learning process. It has shone light on gaps in the whole system in terms of equitable access; the stigma and continued control that people, including organizations and funders, feel like they can have over people experiencing homelessness; and the expectations we have of people who have homes versus people who don’t. Like, why can’t they drink and use in their own home if we’re providing a home for them to isolate in? While here, if people are considered at high risk for transmitting COVID-19 to their community or shelter, they get formed1 to hospital. Nobody has that happen to them in their own home. There are people who are COVID-19 positive going out to bars and restaurants and parties. Do we form them? No, we don’t because that’s considered a right that can’t be taken away from them. The only difference is whether they have housing or not. I’m hoping what we take away from that is an ethical revisiting of how we treat people who are experiencing homelessness.
Collaborating across sectors to integrate health and social supports at all levels, from funders to frontline staff, results in a comprehensive model of care to address complex challenges of people who are experiencing homelessness. Initiatives that address the structural and social determinants of health and root causes result in better outcomes for individuals, the community and the system – for example, reduced strain on health services including hospitals and improved used of resources.
Using a harm reduction approach and Housing First principles assists organizations to navigate complex situations and ensure respectful options for people experiencing homelessness, including tailoring interventions to consider their needs and goals.
Attention to personal and organizational values and ethical issues sheds light on power imbalances between service providers and people who are experiencing homelessness, and what rights they are denied compared to people who have homes.
1Note: getting formed refers to involuntary isolation in a hospital setting; this may happen when a person with COVID-19 refuses or is unable to isolate and poses a significant, ongoing risk to others despite attempts to mitigate the risk using less coercive methods.
The Assisted Self-Isolation Site (ASIS) was opened and operationalized by The Alex. The Alex is a non-profit health and social services organization that has provided integrated and accessible supports and thoughtful, comprehensive care to Calgarians for almost 50 years. With a full complement of health, housing, and community programs, The Alex is a hub of supports and outreach services for people who are experiencing poverty, trauma, social isolation, or health challenges including addiction.
The Calgary Homeless Foundation advises governments, service providers and community leaders on how to best leverage their combined resources and programs in a unified fight against homelessness.
To learn more about the initiative described in this story, contact the National Collaborating Centre for Determinants of Health, at [email protected].
Do you have an idea for an Equity in Action story? If you have heard of other health equity-promoting COVID-19 pandemic response initiatives in Canada that we should share, please let us know.