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					Harm Reduction in Housing:
   Strategies and Tools
         Updated: June 1, 2010
                    Fife House
• Fife House is an innovative, client-focused provider of
  secure and affordable supportive housing and support
  services for persons living with HIV/AIDS.

• Fife House is recognized as a North American leader in
  its delivery of services, which are focused on enhancing
  quality of life, building on individual strengths and
  promoting independence - recognizing that access to
  secure and affordable housing is a key determinant for
  the health and well-being of people living with HIV/AIDS.

• www.fifehouse.org
                          OHSUTP
Vision
Substance use services will be relevant and meaningful to all people
living with HIV/AIDS and those at risk for HIV.

Mission
To enhance the treatment, care and support provided to people living
with HIV/AIDS and those at risk for HIV.

Mandate
The Ontario HIV & Substance Use Training Program (OHSUTP)
provides training to substance use service providers in Ontario in order
to increase knowledge of HIV/AIDS and promote skills development.
                      Group Guidelines
•   To build a safe, respectful, and supportive learning environment for the workshop.
•   Some of you have chosen to be here, while some of you have been mandated to be
    here by your work.
•   We value diversity and learn from comparing and contrasting experiences.
•   Many participants have a close personal connection to the issues we will be
    discussing and this must be recognized.
•   Everyone participates in his/her own way.
•   Risk taking and self-disclosure is encouraged and supported.
•   Everyone has the right to pass.
•   All voices are heard.
•   Use “I” statements.
•   Everyone uses his/her own strengths and resources.
•   Everybody is encouraged to express her/his own needs and speaks for him/herself.
•   One person speaks at a time.
•   Confidentiality is maintained. (context of coworkers and people you know outside of
    work)
•   Learning is a process. Open yourself to the possibilities.
        Harm Reduction in Housing
Goal:
 To increase participants‟ understanding of the complex intersection of
 policies, practices, regulatory and legislative environments that impact
 housing providers‟ abilities to develop and provide Harm Reduction
 programs and practices.

Objectives:
• To introduce legal and regulatory frameworks for housing.
• To provide examples of policies, practices and tools for use and/or
  adaptation for better housing outcomes for clients.
• To increase harm reduction policies and practices for service
  providers as they relate to housing.
                          Outline
• A brief overview of harm reduction
   – Determinants of Health
• What types of housing exist in Ontario?
• What are the regulatory and other legal contexts that
  may impact harm reduction practices and policies?
• How can we support our clients to increase their skills
  and strategies around housing?
Harm Reduction as we know it…
• Sun Screen
• Bicycle Helmets
• Condoms
• Seat belts
• Designated driver
• Blood alcohol levels
• Nicotine patches/gum
• Needle Exchange
              Drug Strategies
• Some communities have developed strategies to
  address issues relating to substance use.
• These typically have “4 pillars”:
  •   Prevention
  •   Harm Reduction
  •   Treatment
  •   Law Enforcement
• All four are needed to effectively respond to
  substance use issues.
Harm Reduction: Part of the Puzzle
“Harm reduction complements approaches that seek
 to prevent or reduce the overall level of drug
 consumption. It is based on the recognition that many
 people throughout the world continue to use
 psychoactive drugs despite even the strongest efforts
 to prevent the initiation or continued use of drugs.
 Harm reduction accepts that many people who use
 drugs are unable or unwilling to stop using drugs at
 any given time…
Harm Reduction: Part of the Puzzle
… Access to good treatment is important for people
with drug problems, but many people with drug
problems are unable or unwilling to get treatment.
Furthermore, the majority of people who use drugs do
not need treatment. There is a need to provide people
who use drugs with options that help to minimize risks
from continuing to use drugs, and of harming
themselves or others. It is therefore essential that
harm reduction information, services and other
interventions exist to help keep people healthy and
safe.”                     - International Harm Reduction Association
            Continuum of use
• No Use - the person does not use alcohol or other substances.
• Experimental Use - the person tries a substance out of curiosity
  and may or may not use it again.
• Social or Occasional Use - the person uses the substance in an
  amount or frequency that is not harmful (e.g., a drink on a social
  occasion).
• Medication Used as Directed - the person uses a medication as
  prescribed, under medical supervision. The risk of harm is
  minimized.
• Harmful Use - the person experiences negative consequences
  of medication or substance use, e.g., health problems, family,
  school, work problems, legal problems.
• Dependence - the person is psychologically and/or physically
  dependent on a prescribed or non-prescribed substance and use
  continues, despite the person experiencing serious problems.
           Stages of Change
• Helps in understanding where a person is in
  their awareness of problem behavior and their
  desire to change
  – Developed by Prochaska, DiClemente and Norcross

• Breaks down the process that people typically
  move through to change a (problem) behavior

• Normalizes set backs and repeating the process
    Stages of Change
           PRE-
       CONTEMPLATION


MAINTENANCE      CONTEMPLATION




    ACTION      PREPARATION
  Harm Reduction and Abstinence
• Harm reduction and abstinence are highly
  congruent goals.
• Harm reduction expands the therapeutic
  conversation, allowing providers to
  intervene with active users who are not yet
  contemplating abstinence.
• Harm reduction strategies can be used at
  any phase in the change process.
                  Key Principles
• Not just needles:
   – Harm Reduction is an umbrella term that sets a framework for
     the design and delivery of policies, programs, services and
     actions, that work to reduce the health, social and economic
     harms to individuals, communities and society that are
     associated with many activities, including substance use.

• The goal is to prevent or reduce the harms associated
  with substance use, without necessarily requiring a
  person to stop using.

• Does not judge licit and illicit substance use as good or
  bad, but rather as part of human behaviour.
                Key Principles
• Recognizes that abstinence is on a continuum of
  substance using behaviour and may not be desirable or
  achievable for some.

• Calls for non-judgmental and non-coercive strategies
  and approaches and aims to provide and/or enhance
  skills, knowledge, resources and support for people to
  live safer, healthier lives.

• Believes that substance use is a complex social issue
  which should be approached from a health perspective,
  not a criminal justice one.
                 Determinants of
              Health and Vulnerability
Key Elements of a Population Health Approach:

• Address Determinants of Health recognizing that they are complex
  and interrelated.

• Our understanding of what makes and keeps people healthy
  continues to evolve and be further refined. A population health
  approach reflects the evidence that factors outside the health care
  system or sector significantly affect health.

• It considers the entire range of individual and collective factors and
  conditions - and their interactions - that have been shown to be
  correlated with health status. Commonly referred to as the
  "determinants of health," these factors currently include…
             Determinants of Health
•   Income and Social Status
•   Social Support Networks
•   Education
•   Employment/Working Conditions
•   Social Environments
•   Physical Environments
•   Personal Health Practices and Coping Skills
•   Healthy Child Development
•   Biology and Genetic Endowment
•   Health Services
•   Gender
•   Culture
    Some of the goals of Harm Reduction
              for a “drug user”
•   Save lives                  • Reducing social isolation
•   Safer drug use              • Increasing validation and
•   Reducing drug use             normalization
•   Getting off drugs           • Reducing risky or harmful
•   Improved emotional state      behaviors
•   Improved health and         • Intact and better
    better nutrition              functioning families
•   Improved living situation   • Reducing violence and
                                  aggression
•   Stable income               • Higher self-esteem
•   Improved social             • Greater ability to love and
    relationships                 be loved
•   Reducing stigma
  Harm Reduction and Substance Use
• “Reducing the harm” (not necessarily stopping the use)
• Initiatives and strategies which reduce the negative consequences
  of substance use for:
   – Substance users
   – Friends/families
   – Communities
• Strategies can incorporate:
   – Safer substance use techniques and behaviours
   – Managed use
   – Abstinence
• Should ideally support the needs of individuals and address
  community concerns:
   – e.g., discarded needles
         What Kinds of Housing?
• Emergency Shelters
• Transitional Housing
• Supportive Housing
• Hospice/Hospital
• Co-ops
• Corrections related housing; Mental Health related
  Housing
• Private Market Housing
• Scattered site
• Many of these can be Rent-Geared-to-Income (RGI)
  Housing and may provide Wet, Damp or Dry Programs
      Who are You to Your Client?
•   Shelter Worker
•   Support Service Provider
•   Case Manager
•   Health Care Provider
•   Landlord/Agent of the Landlord
•   Owner of the Building
•   Multi-relationship?
               Regulatory Environment:
             Acts, Standards, and Policies
Key Acts, Standards and Policies:

•   Social Housing Reform Act and Regulations
•   Residential Tenancy Act and Regulations
•   Long Term Care Act and Regulations
•   Personal Health Information and Protection Act
•   Personal Information Protection and Electronic Documents Act
•   Employment Standards Act
•   Occupational Health and Safety Act (Bill 168)
•   Child and Family Services Act
•   Human Rights Code
•   Innkeepers Act
•   Toronto Hostel Shelter Standards and other Municipal Standards

The following website is where anyone can look up any Acts online:
 www.e-laws.gov.on.ca
Other Acts, Standards, and Policies
· Blind Persons Act                 · Labour Relations Act
· Change of Name Act                · Long Term Care Act
· Child & Family Services Act       · Medical Marijuana Policy
· Employment Standards Act          · Mental Health Act
· Family Law Act                    · Occupational Health & Safety Act
· French Language Services Act      · Residential Tenancies Act
· Harm Reduction Policy             · Workplace and Safety Act
· Health Care Consent Act
· Health Protection & Promotion Act
· Homemakers & Nurses Services Act
· Human Rights Code
 How we support our clients with
   Harm Reduction practices to
increase their skills and strategies
         around housing
           Making Plans with Clients
• Create plans with active participation of client and other support
  service providers
• All plans should be:
    –   Solution-focused and track successes
    –   Identify person(s) responsible for activities/tasks
    –   Always be considered as works-in-progress
    –   Harm Reduction is a key component of each of the services provided by
        Fife House


• Case Management meetings can provide information, feedback,
  tasks/activities for all of the plans described below
• At Fife House, standard plans include: Housing Plan, Moving Plan,
  Plan of Service, Discharge Plan
              Housing Plans
• On going, task specific and broad
  comprehensive tool including housing specific
  goals, tasks and activities but also harm
  reduction goals, tasks and activities as they
  relate to housing
• Some subjects to consider: review of housing
  history; review of legal frameworks; review of
  preparatory work required to access housing;
  budgeting; housing choices and selection;
  applications and work to complete them; short,
  medium and long term goals
                Moving Plans
• Time limited or task specific plan that addresses
  both physical, logistical, financial and emotional
  issues regarding any move
• Some subjects to consider: 1st and last month
  rent; moving costs and funding/budgeting;
  household items; furniture; telephone (land line)
  and deposits; change of address; orientation to
  neighbourhood; create checklists
                Plan of Service
• Ongoing, task specific and broad, comprehensive tool
  including services provided by Fife House, with some
  specifics; also includes services provided by other
  service providers
• Includes assistance with daily living activities,
  homemaking, personal care support, advocacy, referrals
  etc.
• Harm Reduction is a key component of each of the
  services provided by Fife House as briefly described
  above
• Developed both privately with each client and in Case
  Management meetings
                   Discharge Plan
• Ongoing, task specific and broad comprehensive tool
• Used to guide and assist any client in leaving any
  housing; can be completed even before a client has
  moved in; can capture multiple plans or goals
• Some subjects to consider:
   – Identical to Moving Plan but including more effort to focus on
     successes of client in housing
   – Efforts to enable future successes in housing
   – Referrals to address any services that are ending by virtue of the
     discharge or future needs
   – Create checklists
• Developed both privately with each client and in Case
  Management meetings
Preparatory: Review Housing History
• Review complete housing history
• Identify what worked and didn‟t work - in general and in
  specific to substance use - as well as options to continue
  success and address challenges
• Some topics can include:
   – Rental payment
   – Guests
   – Neighbours
   – Relationship with landlord
   – Notices received and outcome
   – Arrears
  Preparatory: Referrals and Plans
• Identify referral needs based on both successes and
  challenges:
   – Emotional, Social, Psychiatric, Medical, Educational,
     Employment, Financial/Budgeting, Nutritional, Practical Support,
     Physical Environment
• Identify barriers that client can address to try and obtain
  housing and create plans to address those barriers such
  as:
   – Lack of ID, Legal status, Arrears, Income, Relationships, etc…
• Create ongoing Housing Plan
   – Short-term; Medium-term; and Long-term Goals
• Identify who is assigned which tasks
       Review Housing Models
• Review social housing agencies and
  processes, and, private market housing
  options and processes
  – Include emotional issues related to housing
    searches such as stress, anxiety and anger,
    lack of privacy, preparedness, budgeting etc.
• Review relevant legislation such as
  Residential Tenancy Act, its forms and
  processes
       Review Housing Models
• Review completed housing application(s)
  status
  – Check for missing or outdated information and
    update as necessary; keep copies
• Review incomplete or new housing
  application options and complete as
  necessary; keep copies
• Add all of the above to Housing Plan;
  update as necessary
       Applications for Housing
• Complete all applications and include all
  required documentation
  – Keep copies
• Ensure contact information and alternate
  contact information is included, as well as
  consent forms when needed
  – Pay attention to mailing addresses
       Applications for Housing
• Provide letters for missing identification
  proving that replacements have been
  sought
• Always ensure „update‟ information is sent
  in writing as new information arises
• Add all of the above to Housing Plan (and
  other plans as applicable)
  – Update as necessary
     Case Management Meetings
• Identify attendees/participants based on current support
  network; update as necessary
• Identify schedule, format and documentation
• Schedule can vary; format should remain relatively
  constant with amendments as needed
• Some subjects to consider including:
   – Physical Health, Mental Health, Substance Use, Income and
     Budgeting, Behavioural Issues, Household Items, Furniture,
     Telephone, Services provided by housing provider
   – All of the above can include Harm Reduction though this may be
     where service providers have different approaches
• Can begin to create
   – Housing Plan, Moving Plan, Plan of Service and even Discharge
     Plan
            Housing Offer Made
• Ensure all documentation needed is available for
  presentation at signing of tenancy agreement or
  occupancy agreement
• Identify moving needs, household item needs, furniture
  needs, telephone needs
• Review Tenancy Agreements, Occupancy Agreements,
  Service Agreements and strategize based on previous
  housing experience successes, challenges, and work
  completed to date
• Implement Moving Plan
• Make new referrals as necessary
         Harm Reduction Practices:
     Tools & Techniques – Client Driven
• Participation in developing all plans, in case
  management, and orientation
• Identifying gaps in services or service needs
• Follow through with referrals and accessing other
  programs and services
• Discussion with ODSP and OWP staff for access to
  other funding
• Budgeting
• Direct deposit of income
• Direct payment of rent and/or other charges
• Consent forms
         Harm Reduction Practices:
     Tools & Techniques – Client Driven
• Access „moving programs‟
• Securing own telephone
• Safety strategies and plans
• Participation in one-on-one meetings, meetings
  with all clients at any particular program
• Guest and visitor strategies
• Acquisition of substances strategies
         Harm Reduction Practices:
     Tools & Techniques – Client Driven
• Reporting damages and plans for addressing
  costs
• Participating in programming activities
• Participating in evaluative and research activities
• Practicing infection control
• Training for client
         Harm Reduction Practices
Tools & Techniques - Landlord/Agency Driven
•   Guest and visitor policies and practices
•   Barring policies and practices
•   Medication policies and practices
•   Substance use policies and practices
•   Complaint policies and practices
•   Safety plans with and for clients
•   Conflict Resolution policies and practices
•   Crisis Prevention and Intervention
         Harm Reduction Practices
Tools & Techniques - Landlord/Agency Driven
• Verbal and written warnings
• Formal and informal mediation
• Landlord and Tenant Act notices
• Landlord and Tenant Board mediation and
  mediation agreement
• Landlord and Tenant Board hearings
         Harm Reduction Practices
Tools & Techniques - Landlord/Agency Driven
• Child care or facilitating visitation
• Provision of substance use related tools either
  on site or off site
• Provision of sexual health tools either on site or
  off site
• On call systems
• Developing programming activities
• Rent Banks
• Transportation assistance
• Staff training; joint staff and client training
         Harm Reduction Practices
Tools & Techniques - Landlord/Agency Driven
• Agency/housing related forms and explanatory
  documentation for clients
• Arrears repayment plans
• Appointment accompaniment
• Orientation and Intake processes
• Program rules and review with clients individually and in
  group settings; include clients in reviews and revisions
• Individual and group meetings with clients
• Meal programs
• Informal counseling
• Provide telephone and internet
• Pain Assessment
     Harm Reduction Practices:
 Organization Policy and Staff Training
• Staff Training and Educational Activities
  including establishment of Core Competencies
• Meeting shelter standards (if applicable)
• Promoting Peer Involvement and training
• Activities including Greater Involvement of
  People with HIV/AIDS (GIPA), Mental Illness,
  Addictions, etc
           Harm Reduction Practices:
            Substance Use Related
• Provision of substance related harm reduction equipment:
   – Needles, swabs, filters, water, ties, cookers, crack pipe stems, screens,
     Vitamin C, straws, Lip Balm,
• Provision of sexual health related risk reduction supplies such as
  barriers, lube, information, access to testing for STIs and other
  infections
• Overdose Policies and practices Overdose training Early Warning
  Systems
• Methadone
• Confidentiality/Risk Assessment (substance use and sex activities)
• Drug Treatment Centres, Day Program Treatment Centres, Drug
  Counseling – individual, Drug Counseling – group, In-Patient
  treatment programs, Out-Patient treatment programs
         Harm Reduction Practices:
          Other Service Referrals
• Anti-Retrovirals during pregnancy, Anti-Retrovirals for
  Post Exposure Prophylaxis
• EMS
• Child care
• Transportation assistance (RIDE, tokens, cab chits)
• Appointment accompaniment
• Incontinence
• Health and Safety polices and practices
• Universal Health Precautions
• Pastoral services
• Support Groups
           Harm Reduction Practices:
            Other Service Referrals
•   Supervised visits (children)
•   Probation and Parole
•   Legal Services
•   Employment training
•   Clothing
•   Weather related products ie sunscreen, lip balm, etc
•   Nutrition information, Meals On Wheels, Food Banks
•   Furniture Banks
•   Library and internet access
  What are some
approaches/methods
    we can use?
Fife House Harm Reduction Policy
Fife House recognizes that harm reduction is an integral approach in
addressing the supportive housing and support service needs of the persons
we serve. Fife House values harm reduction as one approach along a
continuum of interventions that address the use of substances. The idea of
reducing the harms associated with substance use is neither a new concept nor
an alternative approach. Instead, it has emerged as an extension of existing
and accepted public health practices.


Definition of Harm Reduction
Harm reduction is a holistic philosophy and set of practical strategies that seek
to reduce the harm associated with substance use. Harm reduction prioritizes
giving accurate information and providing supportive services without bias to
people who use substances so they can make and carry out informed decisions
for themselves.
 Fife House Harm Reduction Policy
Harm Reduction Values
In addition to the core values (Section 2.0), Fife House endorses the following set of
values which derive from a harm reduction philosophy as follows:
  • People who use substances are competent to make choices;
  • Using substances is neither good nor bad, it is the person‟s relationship to the
    substance and the consequent behavior that results which is important;
  • People who use substances have as equal a right to housing and support services as
    people who do not;
  • People, whether or not they use substances, will be treated with dignity and respect
    in a non-judgmental and equitable manner;
  • Fife House will communicate its harm reduction policy to individuals, communities
    and community agencies.
Harm Reduction Strategies
 • The specific harm reduction strategies employed may vary by program. The
   Executive Director will monitor which programs use which strategies and will report
   this information to the Board of Directors (through the Executive Committee) on a
   quarterly basis.
    Checklist of Supportive Strategies
•   Build change based on the client‟s strengths.
•   Invest in the process, not the outcome.
•   Engage your client‟s ambivalence.
•   Don‟t get too attached to the outcome.
•   Challenge your own ambivalence.
•   Show people they have some control e.g.,
     – “I used less”
     – “I waited two hours.”
    Harm Reduction Practice Tips
• Be non-judgmental and self-aware.
• Be patient with yourself and the client.
• Be realistic in your expectations.
• Listen well – actively and empathetically.
• Remember you are witnessing their important events
  and struggles. You will be affected.
• Regular participation in the harm reduction process can
  reduce “magical thinking” or dissociative behaviours
  associated with substance use.
• Create an opportunity for the client to think of
  themselves as part of a community.
  Harm Reduction Practice Tips
• Interventions that imply pathology or require the wearing of labels
  are not useful.
• Keep asking what‟s working and why? What doesn‟t and why not?
  Who is being reached? Who is not?
• Experience tells us that a higher level of participation by the client
  (over time) often means more sustained change.
• Be objective, reflective, a mirror. Resist evaluating or projecting.
• Ask yourself: What do you want to achieve? What do you want to
  prevent?
• Ask the client: What do you want to achieve? What do you want to
  prevent?
• Empowerment adds to peoples‟ skills and abilities.
                         Contacts
Jason Zigelstein
Director of Residential Services, Fife House
490 Sherbourne St., 2nd Floor
Toronto, ON M4X 1K9
jzigelstein@fifehouse.org
416.205.9888
www.fifehouse.org


Nick Boyce
Provincial Director, OHSUTP
nboyce@ohsutp.ca
1.866.591.0347
416.703.7348
www.ohsutp.ca

				
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