Sherbourne Health brings care to underserved with Health Bus expansion

Sherbourne Health, a Canadian leader in proactive care for underserved communities, has recently expanded its Health Bus program to serve individuals experiencing homelessness or who are under-housed in downtown Toronto’s Moss Park neighbourhood.

Called the Moss Park Interprofessional Primary Care (IPC) program, this initiative is a collaboration between Sherbourne Health and Street Health that provides low-barrier primary care, mental health supports and connections to social services. It is funded by the Toronto Central Local Health Integration Network and Ministry of Health and Long-Term Care.

The program utilizes Sherbourne’s Rotary Club of Toronto Health Bus, a state-of-the-art mobile health clinic, and operates specifically on evenings and weekends – outside of normal business hours – to meet the complex needs of individuals located within the Moss Park area.

The IPC team comprises nurse practitioners, case managers and community support workers who bring aspects of lived experience to their work. This integrated multidisciplinary team collaborates to provide services like the diagnosis and treatment of conditions, case management, harm reduction supplies, overdose prevention, and referrals to healthcare providers and community supports.

“Those who are homeless or under-housed often face multiple barriers to accessing primary care, such as a lack of health coverage or ID, prioritizing other needs like food and shelter, poor access to telephone and internet service, and experiencing stigma in traditional healthcare settings,” said Clayo Laanemets, IPC Team program coordinator. “The Health Bus and IPC program are critical for reducing such barriers by delivering a model of care that is accessible, convenient and non-judgmental to this population.”

Moss Park is a downtown Toronto neighbourhood, and has one of the highest concentrations of shelters within Toronto. As a large proportion of the population in this area experience homelessness or precarious housing, many live with chronic health issues related to mental health conditions and substance use and cannot easily access traditional models of primary care.

As a result, Moss Park has the highest rate of emergency department visits for mental health and addictions in the mid-east Toronto sub region, at 2.5 times the rate of the average ER visit, despite two-thirds of patients accessing the ED already having a primary care physician.

To alleviate some of this strain, a crucial purpose of the IPC program is to reduce the number of emergency department visits in the Moss Park area.

“With access to supports like case managers and nurse practitioners, clients can avoid utilizing ED services when acute emergency care is not needed,” said Chantel Marshall, program & services director, urban communities at Sherbourne Health, who oversees the Health Bus/IPC program. “This in turn, helps prevent worsening of the symptoms that warrant going to the ED in the first place.”

Case managers help with the social side of health, and assist with acquiring identification, and accessing financial aid, housing and food banks. Community supporter workers (CSWs) also offer navigation to community supports and harm reduction services through the distribution of supplies like Naloxone kits and overdose prevention training. Clients can comfortably access the bus to receive these kinds of services in a non-judgmental and safe space.

“We create a welcoming environment to support developing meaningful relationships with our clients and the community,” said Marshall. “It’s important that our team includes CSWs who bring elements of lived experience to their work. This helps establish an initial relationship, and the more trust and comfort clients feel, the more likely they will be open to continuing to connect and receive services from our entire team.”

The IPC team made its first stop in Moss Park on December 11. Since then, the program has expanded to six days a week, averaging 21 visits per stop, with each stop lasting around three hours. Notably, 40 percent of visits are clients engaging in complex interactions with nurse practitioners and case managers, and case managers have a 74 percent success rate when referring clients to community resources and supports.

The Health Bus, which has been serving Toronto’s communities for over 20 years, was rebuilt as a state-of-the-art mobile health clinic in 2017. It has key features such as two private and fully equipped consultation/exam rooms, and an integrated wheelchair lift.

The systems on the Health Bus are also able to connect to other providers in the healthcare system. Nurse practitioners can access SCOPE, a virtual interprofessional health team that supports healthcare providers through a single point of access to nurse navigators, internal medicine, radiology and home and community care.

Another onboard capability includes ONE Mail, a provider-to-provider encrypted email service to communicate about patient care. EMR technology is also fully accessible and synced with Sherbourne Health’s onsite EMR system, which allows for a smooth transition of clients to Sherbourne’s health team at its centre.

To enhance outreach and communication for the program’s services, Sherbourne Health also developed a new website, healthbus.ca, which launched at the organization’s Annual General Meeting in June. The website includes real-time updates and interactive features, including a GPS tracker showing the Health Bus’s current location, a ‘meet the team’ page, a function that displays the unique services at each stop, and a 360-degree virtual tour of the bus.

Jamie Louie is Public Affairs Lead at Sherbourne Health.