A Plan for the Deployment of Four Outreach Workers To Provide Prevention, Education And Support Services to the IDU Community in the City of Toronto

Author(s): 
Walter Cavalieri, MSc, MSW, RSW (May, 1998)

Proposal to the AIDS Bureau, Ministry of Health, Province of Ontario, for the Deployment of Four Outreach Workers To Provide Prevention, Education and Support Services to the IDU Community in the City of Toronto (Excluding Scarborough and North York)
 

SUBMITTED TO THE AIDS BUREAU, ONTARIO MINISTRY OF HEALTH

by the MEMBERS OF THE PLANNING COMMITTEE:

Anne-Marie DiCenzo,
Cindy Reardon,
Farid Sajid,
Kim Stanford
LaVerne Monette,
Liam Auld,
Paula Buskard,
Paula Yeoman,
Raffi Balian,
Roger LaRade,
Shaun Hopkins,
Walter Cavalieri,
Consultant.


TABLE OF CONTENTS

Preface
The Problem


Working Toward Addressing the Problem
The Outreach Worker Program
Program Goal
Criteria For The Development of The Program Proposal
The Program Development Process


Findings
Services
AIDS Prevention Within the Context of the Data
Working Within The Context of Harm Reduction
Just What Is Outreach
Type of Location / Service
Host Agencies
Worker Qualities
Identified Under-served Populations
Identified Geographic Locations
Hours of Operation


Site Selection
The Dialectic Between Geographically-based and Population-based Site Selection
Program Foci
Preferred and Alternative Locations


Site A - Toronto Downtown / West End
Queen West Community Health Centre -or- The Meeting Place


Site B - Toronto Downtown
The Works -or- Regent Park Community Health Centre


Site C - Toronto West: Former Cities of York and Etobicoke
Syme-Woolner Neighbourhood and Family Centre -or- Davenport-Perth
Neighbourhood Centre


Site D - Toronto: East York
South Riverdale Community Health Centre -or- Alternatives


The Outreach Worker
The Relationship Between the Host Agency and the Outreach Worker
The Advisory Committee:
Monitoring / Mentoring / Providing Guidance for the Outreach Worker
Coordination with Other Outreach Services
Mechanism for Settling Disputes
Protocols
Hiring Committee
Orientation and Training


Peer Support Workers
Orientation and Training
Special Considerations


The Host Agency
Host Agency Responsibility
Host Agency Orientation


Evaluation


Appendix A
Job Description: AIDS Prevention / Harm Reduction Community Outreach Worker


Appendix B
Budget


Appendix C
Recommendations to the AIDS Bureau


Appendix D
Recommendation to Public Health


Appendix E
Recommendation to the Host Agency
 


PREFACE:

THE PROBLEM

At the Canadian Association of HIV/AIDS Research Conference held in Ottawa in May, 1997, results from studies in Vancouver and Montréal indicated a dramatic increase in HIV infection in the injection drug using communities. Although, to date, the rate of infection is not so high in Ontario, the AIDS Bureau of the Ontario Ministry of Health recognized the potential for a serious elevation in the infection rate in injection drug users and has been working toward finding practical interventions to prevent this from happening.


WORKING TOWARD ADDRESSING THE PROBLEM:

THE OUTREACH WORKER PROGRAM

In September1997, the AIDS Bureau held a consultation meeting with community-based representatives to discuss ways to reach people who inject drugs, in order to deter the spread of HIV. One of the results of this meeting was the Bureau's decision to provide funding for 15 Outreach Workers who would be strategically placed around the province, working with community partners to complement existing services.

Using data from current research as well as estimates of the number of drug users in areas of the province in relation to their population, certain locations were identified as needing additional resources and strategic interventions. These locations included Ottawa, which will have two Workers, the newly expanded City of Toronto, which will have six Workers and nine other areas in the Province which will have one Worker each. The proposal put forward in this document addresses the siting and duties of four of the Workers in Toronto. It does not address the siting and duties of Workers in the former Borough of North York or the former City of Scarborough.

The AIDS Bureau specified that funding for these Outreach Workers will be allocated to agencies with a demonstrated history of leadership and expertise in HIV/AIDS and will serve to support the existing infrastructure in being a value-added initiative.

PROGRAM GOAL

To stanch the spread of HIV among people who inject drugs, their families and their community.


CRITERIA FOR THE DEVELOPMENT OF THE PROGRAM PROPOSAL

The AIDS Bureau developed a list of criteria for the development of the proposal. The Bureau specified that the programme should:

Be developed locally, in consultation with existing services which serve the community of
concern;
Include a Peer component;
Complement - not duplicate - existing services;
Access the HIV Program at the Addiction Research Foundation for training;
Define and demonstrate mechanisms for the involvement of other community services;
Assist in reaching those not presently accessing services;
Develop staffing and hours of service which accommodate the needs of the community;
Work toward reducing the isolation of members of the community of concern;
Include a comprehensive orientation plan for the Workers;
Include a mechanism for supporting the Outreach Workers; and
Include an evaluation component.


THE PROGRAM DEVELOPMENT PROCESS

A Planning Committee was formed to decide on the location and duties of four Outreach Workers who would be placed within the city of Toronto (with the exception of the former Borough of North York and the former City of Scarborough, each of which would have its own Worker and its own set of priority services). The Planning Committee was composed of people who provide services to people who inject drugs and people who use those services. Shortly after the Committee began meeting, they hired a Consultant to assist them in preparing the final proposal.

Following the recommendations of the AIDS Bureau, the Planning Committee elected to do an environmental scan to determine where the services of Outreach Workers would be most valuable in the area of Toronto under scrutiny, who needed services, and what the services were to be like. To gather the necessary data, they framed five questions which they felt needed to be addressed:

What should Workers do?
Where should they do it?
What should Workers be like?
What don't you like about existing services?
Who else should we reach?


A questionnaire was prepared by the Consultant, based on these questions, and a research team composed of the five consumers on the Committee was trained to administer these questions.

Effort was made to reflect the diversity of race, gender, culture and age among the people in Toronto who are injecting drugs, as well as the differences that exist among neighbourhoods.

More than 50 people were interviewed, mostly service users with current drug use experience, but also service providers and dealers. Representation from the entire catchment area of this proposal was achieved.

Interviews were conducted both individually and in focus groups. Focus groups were held at a variety of community agencies, including Black CAP, The Works, West Central Community Health Centre, Youthlink Inner City, Parkdale Community Health Centre and PASAN, and in the Don Jail.

Key staff of a number of agencies were also interviewed, including Keith Whitney Homes, Two-Spirited People of the First Nations, Asian Community AIDS Services, AIDS Committee of Toronto, The Works, Queen West Community Health Centre, Parkdale Community Health Centre, PASAN, Etobicoke Public Health and York Public Health.

The data was collated and analysed by the Peer Team and recommendations were brought to the entire Planning Committee for discussion. The recommendations in this document reflect the findings revealed in the data and represent the collective wisdom of the entire Planning Committee.


FINDINGS:

SERVICES

The data provided by people who accessed services strongly supported that the Works, Toronto Public Health's flagship Needle Exchange / Harm Reduction program, is "doing the right thing" for people who inject drugs, in that the Works recognizes that AIDS Prevention is not merely about safer sex and safer shooting, but is impacted by the determinants of health, especially poverty and lack of housing, and by barriers to care caused by classism and stigma. They also expressed the same level of appreciation and support for several agencies located west of Yonge Street, which had also developed comprehensive, user-centred Harm Reduction / AIDS Prevention programs.

By and large, "more of the same" was heard, over and over again. "More" usually meant extended hours ("24 x 7" was almost a mantra); more vans and mobility; more "drop-in" services; more workers; more visibility; more accessibility, not just to Harm Reduction services but to those other necessary health and social services from which people who use (or are assumed to be using) drugs often feel barred. "The same" meant doing what is currently being by the Works and by the established, comprehensive Harm Reduction / Needle Exchange programs.

New services which were identified as desirable included many of those offered in some European and Australian jurisdictions: safe shooting rooms, heroin prescription, drug substitution programs for both heroin and cocaine (including easier access to methadone), "user-friendly" detox programs, assistance and support in "home detox", ready availability of alternative therapies and palliatives such as massage, "wet" hostels and housing programs, health promotion services regarding Hepatitis C, etc.


AIDS PREVENTION WITHIN THE CONTEXT OF THE DATA

From the data, there evolved an expectation that all Workers / Programs would, within the parameters of their community's needs and the service objectives:

Work within a Harm Reduction paradigm
Include a Peer component
Develop liaisons with people in jails / prisons to provide transitional support when they return to the general society
Connect with IDUs who are not accessing Harm Reduction services (see the list below: "Identified Under-Served Populations")

Provide comprehensive Harm Reduction services directed at enhancing and enabling both safer drug use and safer sexual practices, including materials, education, personal support, etc.
Provide direct services on a schedule determined by the needs and input of the consumer
Provide counselling and support regarding a variety of issues, not limited to addiction and AIDS Prevention
Provide individual and community education
Provide good referrals and support the members of the community of concern in carrying through on the referrals. (Medical referrals were one of the most frequently mentioned, but the list included treatment programs, welfare and other entitlements, housing, legal, etc.)
Broker and advocate for services for their constituents, individually and systemically
Accompany constituents to services when necessary - including emergency services, court, medical appointments, etc.
Provide individual advocacy
Address systemic issues
Develop a Harm Reduction centre or drop-in, as required by community, which provides safety and hospitality


WORKING WITHIN THE CONTEXT OF HARM REDUCTION

Over the years, a style of service delivery developed in the former City of Toronto which for lack of another name might be labelled the "Toronto Model". It lies to the right of European approaches, but has drawn on them (especially since the International Harm Reduction Conference in 1994), and is also strongly influenced both positively and negatively by what is happening in the United States, in terms of both policy and service delivery in the face of policy. It differs from what has been offered in Montréal and Vancouver in that it has been, since its inception, decentralized and client-centred. The ethical, philosophical and practical underpinning of this style of delivery of service to people who use / misuse drugs is known as Harm Reduction.

While the explicit goal of Harm Reduction is to mitigate the harms to individuals, families and society which might result from drug use and drug distribution, implicit in this treatment and service philosophy are a number of other "givens".

First of all, employing a Harm Reduction approach means that you provide health and social services to people without requiring them to stop using drugs as the ticket for admission to - or receipt of - these services.

It means, as well, that the level of availability and quality of service and treatment that these people receive will be no less than that provided to others who may not be using drugs.

Finally, it means that services will be offered without discrimination, prejudice or negative judgment, and that the quality of those services will not be compromised because of discrimination, prejudice or negative judgment. Succinctly stated, a Harm Reduction approach answers to the principles of public health and social justice.

Within the construct of Harm Reduction, AIDS Prevention outreach, narrowly defined, is merely one part of the approach. In fact it is a small part of AIDS Prevention. AIDS is viewed systemically, and AIDS Prevention takes place within the context of a range of complementary supportive services.

Among the elements integral to this model of HIV/AIDS Prevention / Harm Reduction with drug users are the following:

Services:


"Full Service" Harm Reduction program, including health promotion supplies, anonymous HIV testing, Hepatitis inoculation, TB testing, etc.
Counselling / support
Group programs
Escorting to and support at court, hospital emergencies, etc.
Assistance in finding and securing housing
Referrals / brokering / individual advocacy regarding accessing services, including:

Detox and treatment services
Schooling
Employment programs
Job training
Welfare and other entitlements
Timely medical care from doctors or nurse practitioners for major medical problems as well as minor medical treatments
Goods:

Clothing / bedding
Food and Nutrition
TTC tickets for appointments

"Drop-in":
A safe place to take a break and, on occasion, to "crash"
Telephone access and mail services, including the acceptance of collect calls
Peer employment / volunteering

Miscellaneous personal needs:

ID storage and retrieval; storage of personal property; etc.
Financial assistance, such as holding money

Community education and community development:

Public education, using Peers
Drug user advocacy
Systemic advocacy


The provision of these services is undergirded by an emphasis on addressing behaviours rather than populations, what people do rather than who they "are". Labels are deconstructed. To the degree which it is possible, people are not judged. Services are available to everyone, whether they inject drugs or not, for everyone is at risk of AIDS.

Outside the former City of Toronto, in the annexed sections of the new city, drug use actually exists! Ample evidence of it was provided by all the constituencies which were polled. However, services in these areas are non existent, not assertive, not established or invisible. "More of the same" is simply not acceptable. The need seems to be for the development of relationships with the people who are using drugs, advocacy for community and agency support, community development, and service advocacy, provision and coordination. The most difficult people to reach might well be those who are living and using away from the downtown core, in and around the former cities of York, East York and Etobicoke.


JUST WHAT IS OUTREACH

One of the issues which the research team addressed was the definition of outreach in the context of the Toronto reality. The simplistic definition of outreach limits it to "street outreach" - that is to the activities of Workers (usually two - and never less) who do their work detached from an "office", on foot or on or in a vehicle, providing services in the locations where the population of interest congregates or works. It is this . . . and much more. It may also include such things as home visits and home deliveries; developing secondary distribution schemes; escorting clients to appointments; supporting clients at court; client finding through a variety of means; informing and mobilizing agencies, communities, media; agency liaison and education, etc.

The work of the "Outreach Worker" is seen by service users as both individual and systemic, and just exactly what it means will depend on the needs of the community of concern and the total neighbourhood environment.


TYPE OF LOCATION / SERVICE

There was a virtual consensus in favour of service locations which provide both a fixed site / drop in and a highly mobile outreach component comprising a van (or bicycles / dickee-dees / motorcycles were also suggested) and people on foot . . . a service that would:

Be able to go where people are using, make home deliveries and home visits, provide service outside the confines and constraints of mainstream agencies, where members of the community of concern people often do not feel welcome; combined with

Provide a user-friendly drop-in where respectful, caring, nonjudgmental "social work" (in its purest sense - not as practised) could take place.


HOST AGENCIES

Regarding the Host Agencies, service users had more to say than did the service providers. They were very clear that Host Agencies should be workplaces in which the Outreach Workers will get ongoing support for their work and which are committed to Harm Reduction and where the Worker is respected and treated equitably. This stated concern for the well being of the Outreach Worker may indicate that the service user sees the Worker as equally marginalised within mainstream organizations, recognizes the reality that, within traditional agencies, stigma may be contagious, causing Outreach Workers to be subjected to the same discriminatory treatment as clients, and that Workers who are supported and respected are better able to support and respect their clients.

The experience of discriminatory behaviour on the part of mainstream agencies may also be seen in the recurrent suggestion that the new Workers should be housed separately from established agencies, in "storefront" location. It is equally possible that this was to assure later, more convenient hours of access.

The connection of Outreach Workers to medical services was noted as important, but only as a means of access, and only if the services are respectful of the person who uses drugs.


WORKER QUALITIES

Repeatedly in the data, Outreach Workers from the Works, Street Health Community Nursing Foundation and the Queen West and Parkdale Community Health Centres were singled out as models for the new Outreach Workers, along with individual workers at a few other agencies. These people were seen as highly experienced in and knowledgeable about drug use and drug-use risks, HIV/AIDS, health issues, including sexual health issues, and services and service personnel at various agencies and, therefore, capable of providing effective referrals and linkages.

Supporting the knowledge base of the Outreach Workers were expectations that they would not judge people for what they were doing to survive, not scorn them, treat them with respect and love. The concept of showing love for one's clients - of thinking from one's heart, of embodying one's humanity - is becoming recognized and accepted in numerous contemporary therapeutic schemata, including self-relations and narrative therapy, where it is seen as a skill and a force that can heal, invigorate, reconnect, calm and encourage. It is also a cornerstone of Harm Reduction.

Beyond this, it as expected that the Outreach Workers would be accepting of differences; without bias regarding race, gender, culture or age; accessible; politically committed; willing to take risks and go the extra mile for people; trustworthy; honest; good listeners; skilled at counselling; etc.

The work itself would be delivered from a Harm Reduction perspective - that is, that use of drugs not be viewed as a barrier to services, and that the person seeking services would be recognized as the decision maker.

One person interviewed described the Outreach Workers as "four horsemen against the apocalypse."

A number of respondents from the service user pool expressed concern that the Outreach Workers might be exploited: that they not be paid sufficiently or be respected by managements for their perspective and expertise. Several also expressed concerns about the exploitation of Peers - educating them indifferently, not giving them much support, using them briefly and then dropping them. Many people interviewed saw Peers as a valuable, necessary part of the service delivery system.


IDENTIFIED UNDER-SERVED POPULATIONS

The dominant groups identified as underserved, by members of those groups themselves as well as by others, service users and service providers alike, were:

Native people, both trans-gendered and heterosexual, who are injecting drugs and for whom Harm Reduction services are virtually nonexistent;
Youth in general, but particularly those living in squats below King Street West - especially west of Bathurst Street - many of whom are bilingual, support themselves through independent entrepreneurial activities
IDUs who are not accessing Harm Reduction services, including
Loners - people who use at home and don't access any particular community of users
People who were unaware of services
Disabled people
Casual users
People who are just starting out
Women who are under the control of their partners
Young mothers
People just discharged from jail or prison
People with psychiatric disorders
Asians - particularly Chinese and Vietnamese - who hang out in Chinatown and are very isolated because of the stigma attached to drug use within their culture


IDENTIFIED GEOGRAPHIC LOCATIONS

"Hot spots" within the catchment area of this project were identified by service users, service providers, dealers and the police. They were marked on a map of the city and compared to locations of existing Harm Reduction / Needle Exchange sites. From this map, and from the research data, it became clear that although additional services would be useful downtown to address the unmet needs of existing communities and particular populations, there were other "geographic" considerations which needed to be addressed, namely that:

Though there were services situated in the west end of the new City of Toronto (i.e., in the former cities of York and Etobicoke), they were not being well utilized by people who use drugs. Many people who are using drugs live in particular housing complexes and high rises, which may support their own drug-using communities. Many are of African or Caribbean background. Consumers and police identify a number of "hot spots" in this area.

The City of York has a "conservative" public health Harm Reduction / AIDS Prevention program, with limited ties to the African-Canadian community.

"The Junction" is served by the Works van only. The use of street drugs appears to be very high in this neighbourhood, and there is an active and frequently hostile neighbourhood association.

Etobicoke's Needle Exchange and its satellite sites have been unable to engage the residents of this large area, many of whom live in high rises and come downtown to score and use. In Etobicoke, the vast majority of people who use the Exchange are diabetics. Further, the actual exchange of needles has dropped off significantly in the past year. It is speculated that users are purchasing needles from pharmacies; however, there is no research to back this up.

Though there are no Needle Exchanges or Harm Reduction services in the east end of Toronto, there were a number places identified as "hot spots" of drug activity. These include:

Queen Street, east of the Don Valley, at least as far as Leslie Street;
Danforth Avenue, at Greenwood Avenue, Main Street and Victoria Park Avenue;
Victoria Park Avenue, north of Danforth Avenue as far as Eglinton Avenue;
Don Mills Road through Thorncliffe and Flemingdon Parks; and
O'Connor Drive and Eglinton Avenue.


HOURS OF OPERATION

It is clear that the people who use drugs want and would make use of round-the-clock services, seven days a week. This is their drug-use pattern. Short of that, they would like services provided much later into the evening than is currently the case, in those areas not currently served by the Works van, and definitely on weekends and holidays.

They further urged that all Needle Exchange / Harm Reduction services, both in-house and outreach, be centrally coordinated, so that they can telephone and be informed of the location of (and perhaps even put in touch with) the closest available service or service provider.


SITE SELECTION

THE DIALECTIC BETWEEN GEOGRAPHICALLY-BASED AND POPULATION-BASED SITE SELECTION

The Planning Committee saw no conflict in selecting two sites particularly in terms of geography (South Riverdale Community Health Centre / Alternatives and Syme Woolner Community Centre / Davenport Perth Community Centre), one in terms of population targeted (the Works / Regent Park Community Health Centre), and one because the community of concern and the geographic considerations coincided (Queen West Community Health Centres / The Meeting Place).


PROGRAM FOCI

Although the four Outreach Workers are construed by the funder as a "program," to a large degree what each of them does will directed by the vagaries of population, geography and agency. Though the overall goal is to stanch the spread of HIV among people who inject drugs, their families and their community, the pursuit of this goal (objectives and actions) will vary somewhat from site to site. That notwithstanding, the Workers will join in their attempts to provide or catalyse as many as possible of the services recorded above in the section entitled "Findings: AIDS Prevention Within the Context of the Data." It is expected that the Host Agency will give the Workers its support in doing this.


PREFERRED AND ALTERNATIVE LOCATIONS

A discrete investigation regarding the suitability of community agencies was conducted by the Consultant, once the general location of the sites and the focus of the specific services had been determined, and the results of this were brought back to the Research Team and the entire Planning Committee in the form of recommendations. It was decided to list a first and an alternate choice for each site. This was particularly critical since Harm Reduction - let alone AIDS Prevention - programs directed toward the populations of concern are not available in some of Toronto's most needy neighbourhoods. Fully developed Harm Reduction programs exist only in the downtown core.

The agencies which the Committee recommends are listed below:


SITE A - Toronto Downtown / West End

Location: Queen West Community Health Centre -or- The Meeting Place

Objective: To develop and deliver HIV/AIDS Prevention / Harm Reduction services with a particular focus on transient youth, including those living in squats below the western end of King Street, many of whom are bilingual and support themselves through independent entrepreneurial activities.

These services will increase the knowledge of safer drug use and sexual behaviour in the identified community; improve access to needed Harm Reduction and AIDS prevention supplies; assuage isolation through the enhancement of community; nurture self efficacy through the involvement of community members as Peer or Volunteer Support Workers; improve on the effectiveness of referrals; facilitate access to services; provide safer transit from incarceration to the general community. Preference should be given to a worker whose first language is French.

Recommended Activities:

To work within a Harm Reduction paradigm to:

Provide AIDS Prevention / Harm Reduction / Health Promotion outreach and services to members of the community of concern, where they work and where they live
Develop mechanisms to include community members (Peers) to assist in the delivery of services
Provide the mechanism and support for secondary distribution of Harm Reduction supplies and material, as needed
Develop and maintain liaisons with community members in jails / prisons to provide transitional support when they return to the general society
Provide direct services "after hours" and on weekends and holidays
Provide general counselling and support to community members
Provide education to agencies on issues of concern regarding the community
Provide good referrals and support community members in carrying through on the referrals
Accompany community members to services / appointments when necessary
Broker and advocate for services for community members, individually and systemically, and accompany people to services as necessary

Develop partnerships with other agencies doing complementary work and / or whose services are or need to be accessible to community members
Conjointly with community members, develop community-enhancing programming, e.g., a drop-in which provides safety and hospitality, an educational / leisure activity group, newsletter, etc.
Encourage and facilitate the use of services of the Host Agency and in the community

Queen West Community Health Centre, located just south of Queen Street West on Bathurst Street, has established its credibility with people who use drugs and people with HIV/AIDS through about six years of work with this population. People on the street recognize the support that they get there and have acknowledged the accessibility and practical knowledge of its staff.

It is situated in the right neighbourhood for ease of access to these young people, has been developing community credibility, and is already providing some services to them. These youth have indicated that they need a "secondary distribution" scheme. They also point out the need for a bilingual (French / English) Worker.

An alternative site is The Meeting Place, a drop-in located at the northwest corner of Queen Street West and Spadina Avenue. This is a very busy site, has a very good street reputation and a highly committed and accessible staff. They work in liaison with other agencies regarding health and entitlement issues, have a working knowledge of Harm Reduction and realistic expectations of their clients. A drawback is that, unlike the Queen West Community Health Centre, they do not have a Harm Reduction program in place or access to the range of services that a community health centre can offer. However, they have a history of doing imaginative and socially responsible individual and community work.

 

SITE B - Toronto Downtown

Location: The Works -or- Regent Park Community Health Centre

Objective: To develop and deliver HIV/AIDS Prevention / Harm Reduction services with a particular focus on Native people, including those who identify as transgendered, who are not accessing their traditional services because they are either unwilling or unable to abstain from using drugs, and for whom Harm Reduction services are virtually nonexistent.

These services will increase the knowledge of safer drug use and sexual behaviour in the identified community; improve access to needed Harm Reduction and AIDS Prevention supplies; assuage isolation through the enhancement of community and self respect; nurture self efficacy through the involvement of members of the community as Peer or Volunteer Support Workers; improve on the effectiveness of referrals; facilitate access to services; provide safer transit from incarceration to the general community.

Recommended Activities:

The Outreach Worker, acting in concert with the existing program, will:

Provide AIDS Prevention / Harm Reduction / Health Promotion outreach and services to members of the community of concern, where they work and where they live
Develop mechanisms to include community members (Peers) to assist in the delivery of services
Develop and maintain liaisons with community members in jails / prisons to provide
transitional support when they return to the general society
Provide services "after hours" and on weekends and holidays
Provide outreach service "on foot"
Provide general counselling and support to community members
Provide education to agencies on issues of concern regarding the community
Provide good referrals and support community members in carrying through on the referrals
Accompany community members to services / appointments when necessary
Broker and advocate for services for community members, individually and systemically, and accompany people to services as necessary
Develop partnerships with other agencies doing complementary work and / or whose services are or need to be accessible to community members

Conjointly with community members, develop community-enhancing programming, e.g., a drop-in which provides safety and hospitality, an educational / leisure activity group, newsletters, etc.
Encourage and facilitate use of services of the Host Agency and in the community

The staff of two non-Native agencies in Toronto provide nonjudgmental Harm Reduction services to a large number of Native people - Parkdale Community Health Centre and The Works. Both have community credibility. The Works, because it has both mobility and a fixed site, because it does not restrict its full services to residents of a small catchment area, and because it already has extensive established contacts with transgendered Natives, can provide services to a larger, more varied group of urban Natives, and hence it is the preferred choice. Ideally this Worker should be Native, but emphasis must be primarily on the person's ability to do the job well.

Regent Park Community Health Centre provides an excellent alternative site for this Worker. Regent Park is the only community health centre in Toronto which has adopted officially a Harm Reduction policy. They have also provided Harm Reduction education for their board and staff.

The disadvantage to Regent Park Community Health Centre is that it does not currently have any concerted outreach to Native people; nor, because it is not mobile, does it provide services to the large, varied client base served by the Works. On the other hand, this community health centre has long been doing outreach to women in poverty, many of whom are Natives, - including women who work the streets - and is located in the centre of one of Toronto's a major prostitution and drug tracks. (N.b., if the service were to go to Regent Park Community Health Centre, there could be an increased emphasis on service to women.)


SITE C - TORONTO WEST: FORMER CITIES OF YORK AND ETOBICOKE

Location: Syme-Woolner Neighbourhood and Family Centre -or- Davenport-Perth Neighbourhood Centre

Objective: To develop and implement HIV/AIDS Prevention / Harm Reduction outreach strategies which will encourage the residents of the former cities of York and Etobicoke to engage in safer drug user / safer sex practices; to establish or work with work sites at various locations throughout this area, in collaboration with other programs, and endeavour to engage in such strategies as secondary distribution of Harm Reduction supplies; to enhance the network of health care and support for members of the population if concern; and to do outreach to agencies and community leaders to gain their support and collaboration.

These services will increase community members' knowledge of safer drug use and sexual behaviour; improve access to needed Harm Reduction and AIDS Prevention supplies; assuage isolation through the enhancement of community; nurture self efficacy through the involvement of community members as Peer or Volunteer Support Workers; improve on the effectiveness of referrals; facilitate access to services; provide safer transit from incarceration to the general community.

Recommended Activities:

To work within a Harm Reduction paradigm to:

Provide AIDS Prevention / Harm Reduction / Health Promotion outreach and services to members of the community of concern, where they work and where they live
Develop mechanisms to include community members (Peers) to assist in the delivery of services
Provide the mechanism and support for secondary distribution of Harm Reduction supplies and material as needed
Develop and maintain liaisons with community members in jails / prisons to provide
transitional support when they return to the general society
Liaise with existing Harm Reduction services and workers in the area in order to develop and provide coordinated and effective means of client finding and service delivery, including, for example, outreach in bars and businesses, radio "spots" and public service announcements, etc.

Provide direct services "after hours" and on weekends and holidays
Provide general counselling and support for members of the community
Provide education to agencies on issues of concern regarding the community
Provide good referrals and support community members in carrying through on the referrals
Accompany community members to services / appointments as necessary
Broker and advocate for services for community members, individually and systemically
Develop partnerships with other agencies doing complementary work and / or whose services are or need to be accessible to the community, e.g., hospitals, community centres, community health centres, etc.
Conjointly with community members and staff of agencies in the area, develop community-enhancing programs, e.g., drop-ins which provide safety and hospitality, an educational / leisure activity group, newsletter, etc.
Encourage and facilitate use of services of the Host Agency and in the community

The Syme Woolner Neighbourhood and Family Centre already has an Outreach Worker who works with youth involved with drugs and is affiliated with the African youth project at the Donwood Treatment Program. They have a Harm Reduction approach to their work, are community centred, and are said to be sex-positive and gay-positive. They are definitely interested in a Worker being stationed there, and are recommended by the current AIDS Prevention Worker in Toronto Public Health, City of York. Though the Worker would see this Agency as her / his home base, a great deal of work would be done off site, with other agencies in the York - Etobicoke area.

An alternative home-base site is the Davenport-Perth Neighbourhood Centre. It is both a community centre and a community health centre. They have an outreach program to neighbourhood prostitutes, in collaboration with public health, have an interest in AIDS Prevention, though it has not been a high priority, and have a physician licensed to provide methadone. They, like all other centres, said that there is a need for internal education about people who inject drugs, but that there is a willingness to change. There are two major drawbacks: (1) Space - this is a very busy centre and it already has a space problem. (2) Location - though it is close to a hot spot - The Junction - it is not terribly close to the former cities of York and Etobicoke.


SITE D - TORONTO: EAST YORK

Location: South Riverdale Community Health Centre -or- Alternatives

Objective: To develop and deliver HIV/AIDS Prevention / Harm Reduction outreach strategies which will appeal to people who use drugs who live / hang out east of the Don Valley; along Queen Street East, at least as far as Leslie Street; Danforth Avenue, at Greenwood Avenue, Main Street and Victoria Park Avenue; north of Danforth Avenue along Victoria Park Avenue as far as Eglinton Avenue; along Don Mills Road through Thorncliffe and Flemingdon Parks; and at O'Connor Drive and Eglinton Avenue. The Outreach Worker will also establish work sites at various locations around this geographically large area, in collaboration with other programs, and will endeavour to engage in such strategies as secondary distribution of Harm Reduction supplies, community organizing, agency networking, etc.

These services will increase community members' knowledge of safer drug use and sexual behaviour; improve access to needed Harm Reduction and AIDS Prevention supplies; assuage isolation through the enhancement of community; nurture self efficacy through the involvement of community members as Peer or Volunteer Support Workers; improve on the effectiveness of referrals; facilitate access to services; provide safer transit from incarceration to the general community.

Recommended Activities:

To work within a Harm Reduction paradigm to:

Provide AIDS Prevention / Harm Reduction / Health Promotion outreach and services to members of the community of concern, where they work and where they live
Develop mechanisms to include community members (Peers) to assist in the delivery of services
Provide the mechanism and support for secondary distribution of Harm Reduction supplies and material as needed
Develop and maintain liaisons with community members in jails / prisons to provide
transitional support when they return to the general society

Identify and liaise with existing Harm Reduction services and workers in the area in order to develop and provide coordinated and effective means of client finding and service delivery, including, for example, outreach in bars and businesses, radio "spots" and public service announcements, etc.
Provide direct services "after hours" and on weekends and holidays
Provide general counselling and support to community members
Provide education to agencies regarding issues of concern about the community
Provide good referrals and support community members in carrying through on the referrals
Accompany community members to services / appointments as necessary
Broker and advocate for services for their constituents, individually and systemically, and accompany people to services as necessary
Develop partnerships with other agencies doing this work and / or whose services are or need to be accessible to community members, e.g., hospitals, community centres, community health centres, etc.
Conjointly with community members and staff of agencies in the area, develop community-enhancing programs, e.g., drop-ins which provide safety and hospitality, an educational / leisure activity group, newsletter, etc.
Encourage and facilitate use of services of the Host Agency and in the community

South Riverdale Community Health Centre has been selected because of its comprehensive health services, its history of using community volunteers, its interest in AIDS - the health centre has done some community research, and its physicians have been attending workshops on drug use / Harm Reduction. They have a new building at Queen Street East and Carlaw Avenue, which opens next month, and have space. The South Riverdale Community Health Centre has a history of working in partnership with agencies in its community.

Alternatives, a mental health program located on O'Connor Drive in East York, is a second choice. They do mental health outreach and have noticed drug use among their clients and in their catchment area and are concerned. One of their staff was an Outreach Worker at the Parkdale Community Health Centre and was one of the key informants in the research and has discussed the project with the executive director, who is interested in and supportive of this project. At the very least, this Agency could become a valued partner, especially for outreach to people with "concurrent disorders".


THE OUTREACH WORKER

THE RELATIONSHIP BETWEEN THE HOST AGENCY AND THE OUTREACH WORKER

The Outreach Worker shall be respectful of the Host Agency's culture and administrative rules and protocols and to this end shall receive supervision within the Host Agency. However the Worker's service accountability shall be determined and guided by the Advisory Committee.


THE ADVISORY COMMITTEE - MONITORING / MENTORING / PROVIDING GUIDANCE FOR THE OUTREACH WORKER // COORDINATION WITH OTHER OUTREACH SERVICES

It is recommended that an Advisory Committee be set up to provide monitoring, mentoring, guidance and support for the outreach workers, to ensure coordination among elements of this program and to provide liaison with other harm reduction programs in the city of Toronto, in order to ensure that services are coordinated and not duplicated. The recommended model for this is as follows:

The Advisory Committee would consist of the persons from each of the four sites to whom the Outreach Workers report (hopefully these will be people with decision making power), four consumers of service and the four Outreach Workers. This Committee would:

Provide service / program guidance for the Outreach Workers;
Refine the goals and objectives of each Outreach Worker, within the parameters of the information provided by the research data and outlined in this document;
Ensure that there is liaison between these Outreach Workers and their counterparts in North York and Scarborough as well as with the Toronto Public Health program - The Works - and its satellite Needle Exchanges;
Ensure the coordination among existing Harm Reduction services by supporting the Outreach Workers' attendance at meetings of a front-line sub committee of the Needle Exchange Coordinating Counsel;
Ensure that ongoing evaluation is taking place, both of the project as a whole and at the individual sites, and that information from this evaluation is used to keep the services functioning responsively to the needs of the populations of interest.
Ensure that a mechanism is developed which will ensure that the Peer Support Workers at these four sites will be able to meet periodically as a group and network with one another.

It is anticipated that the work of the Advisory Committee will be most intensive in the first couple of months, while the programs are being set up. After that, the Committee will decide how often it needs to meet. One two-hour meeting each month is a reasonable expectation. Periodic meetings with the representatives of the AIDS Bureau must be held in order to review the progress of this initiative.


MECHANISM FOR SETTLING DISPUTES

In the case of a disagreement between a Worker and her / his Host Agency, the Worker will have recourse to consultation, conciliation and support from the supervisory person in another Host Agency according to the following schedule:

The Worker in Site A will access the supervisor in Site B;
The Worker in Site B will access the supervisor in Site C;
The Worker in Site C will access the supervisor in Site D; and
The Worker in Site D will access the supervisor in Site A.


PROTOCOLS

The General Protocols of the City of Toronto, Department of Public Health, Injection Drug Use Project will serve as a basis for any Needle Exchange activities which might occur.

HIRING COMMITTEE

It is recommended that a hiring committee be struck at each Host Agency to tailor the job posting for the Outreach Worker to both the personnel policy of Host Agency and the requirements of the job, and that the Hiring Committee review résumés and cover letters of all applicants, develop a process for screening and interviewing the applicants, interview candidates and recommend the hiring of the successful applicant. Staff of the Host Agency on the Hiring Committee should be supplemented with representatives of the community of concern, and an experienced Outreach Worker from outside the Agency. Members of the Planning Committee, who put together this document, may also be considered.

ORIENTATION AND TRAINING: OUTREACH WORKERS

Outreach Workers will receive orientation, as needed, in Harm Reduction practices and outreach skills and HIV / AIDS Prevention from the HIV program at the Addictions Research Foundation, in partnership with appropriate community agencies. The Outreach Workers will familiarize themselves with agencies, programs and services in their communities as well as with other front-line Harm Reduction services in Toronto. It is strongly recommended that Workers also receive training in first aid, basic health issues of people who use drugs and how to address them on the street, emergency overdose treatment, vein care and injection technique, etc., and be able to provide anonymous HIV testing (or have swift access to it).

It is also very important that the Outreach Workers receive a thorough orientation to their Host Agencies and that they are integrated into the Agency as much as possible.

It is recommended that the Outreach Worker have access to this document.



PEER SUPPORT WORKERS

ORIENTATION AND TRAINING

Potential Peer Support Workers have expressed the wish to have access to the same level of training as the Outreach Workers, including a thorough Agency orientation, and this is supported and recommended.

As representatives of the Host Agencies, and as co-participants in the delivery of Harm Reduction services, this is surely not too much to expect. Peer Support Workers should also have training in basic listening / attending skills. A micro-skills approach, because it is lucid, structured, succinct and effective, is a possible modality. It is also recommended that, if possible, the Peer Support Workers participate in joint training with the other Peers so as to establish an internal support structure.


SPECIAL CONSIDERATIONS

Peer Support Workers should be members of the community of concern who have credibility and respect within that community, are committed to working for positive change, support the principles of Harm Reduction, and possess the requisite personal skills to carry out the job.

Peer Support Workers must be given clear, written descriptions of what is expected of them and provided with a code of conduct which respects simultaneously their position as a Peer from the community of concern (and the reasons why they have been selected in the Peer role) and their responsibility to do the job which they have agreed to do.

The issue of Peers' using or not using drugs is one which continues to come up. Peers are peers because they are (or have been) using drugs. Their work as Peers Support Workers should not be contingent on their abstaining from the use of drugs. on the other hand, they also have a job to do. The expectation is that they will report for work capable of doing their contracted job.

Peers deserve, and may need, ongoing support, monitoring, mentoring and guidance at a higher level of intensity than do trained workers. Becoming a Peer Support Worker may enhance their vulnerability, destabilize their lives, distance them from some of their community supports, frustrate them. On the other hand, becoming a Peer Support Worker can be - and often is - an experience which opens them up to an appreciation of their value and efficacy and a revised vision of their future.

It is recommended that the Peer Support Worker have access to this document.


THE HOST AGENCY

HOST AGENCY RESPONSIBILITY

The Host Agency, together with the Outreach Worker, will develop a local AIDS Prevention / Harm Reduction program, in consultation with existing services (e.g., treatment programs, Needle Exchanges and other related local programs), to address the situations, needs, goals and objectives identified in this proposal.

The designated supervisory staff from the Host Agency will participate as a member of the Advisory Committee.

That the Host Agency will encourage and support the development of partnerships with other agencies serving the community of concern.

That the Host Agency will provide space and administrative support needed for the Workers to do her / his job. This will include a telephone capable of receiving collect calls.

It is recommended that the Host Agency have access to this document.


HOST AGENCY ORIENTATION

The Host Agency administration and front-line personnel will acquaint themselves with other Harm Reduction programs aimed at reducing the risk of contracting HIV/AIDS for people who inject drugs.



EVALUATION

Though there are somewhat different objectives / activities at each of the four sites, the evaluation tools will be essentially the same.

Four types of evaluation must take place within this project: iterative, outcome, impact and process.

Iterative evaluation. Iterative evaluation is ongoing and is used to shape the work as it is being done.

Both quantitative and qualitative information about encounters and occurrences, in the form of outreach statistics, client anecdotes and material from informal discussions with service users and service providers, etc., will be collected and analysed. It will also be incorporated into ongoing project development meetings with the supervisor and Advisory Team, and used to assess levels of awareness and needs and to inform future service provision. This will ensure flexibility and will allow the program to respond to user feedback in a timely manner. This evaluation will take place on a regular basis, preferably weekly.

Outcome evaluation. Outcome evaluation will be used to determine how well the program has reached its objectives.

Focus groups of consumers will be held to address the reach, impact and effectiveness of specific program activities in meeting their objectives;

Focus groups of consumers will be used to examine their expressed willingness to change and maintain safer behaviour and to confront unsafe behaviour among other members of their communities;

Community building (service user) will be assessed by attendance and participation at drop-ins or groups, utilization of services, interest in volunteering and in Peer Support Worker positions;

Community building (service provider) will be assessed by the number of agencies or service providers who become engaged in community partnerships for the delivery of Harm Reduction / AIDS Prevention services;

Quantitative data will be kept on referrals to and from other agencies to evaluate number of referrals and trends;

Statistics will be kept on the number of people being reached by each activity / project, in-house or in the community, to assess utilization of service;

Statistics on the number of Harm Reduction supplies distributed, either directly or through secondary means, will be recorded and examined in order to assess utilization of service;

Statistics will be kept on the number and type of educational events and presentations; and

Statistics will be kept on unmet needs and requests for services, for current and future planning.

Process evaluation. Process evaluations will be used to determine whether the methods and activities have been accomplished in a timely manner.

Focus testing of all materials and workshop strategies will be conducted as appropriate;

Reactive surveys will be used to measure response of participants in public presentations where Project members are speaking;

Feedback will be sought from agencies or service providers engaged in community partnerships regarding their level of satisfaction with those partnerships and the impact, if any, on their agencies;

Feedback will be sought from agencies and service providers to whom referrals have been made regarding their perception of the appropriateness, quality and "success" of the referrals; and

Feedback will be sought from service users who have received referrals on the appropriateness, quality and success of these referrals.

Impact evaluation. Impact evaluation will be used to determine how will the project has reached its goal.

The goal of the program, to stanch the spread of HIV among people who inject drugs, their families and their community, cannot be measured within the time and means of this project.

Evaluating the achievement of the overall goal of this project in Toronto is the responsibility and obligation of the AIDS Bureau.


Appendix A

JOB DESCRIPTION
AIDS Prevention / Harm Reduction Community Outreach Worker

The AIDS Prevention / Harm Reduction Community Outreach Worker will develop the internal and external strategies needed to provide services listed in this document as the activities of the work site where she / he is employed.

In addition, she / he will:

Identify, recruit, organize training for and supervise Peer Support Worker staff;
Collect and / or supervise the preparation of materials which will promote Harm Reduction / AIDS Prevention within the community of concern;
Participate in meetings with other Harm Reduction Workers, including those who are part of this project;
Liaise with other AIDS Prevention / Harm Reduction Workers in Toronto, as needed;
Work collaboratively with colleagues from various community agencies to enhance outreach and community building activities;
Work within a client- or expert-centred paradigm;
Work within the protocols of the Host Agency; and
Maintain records and statistics as required.

Accountability
The Outreach Worker shall be respectful of the Host Agency's culture and administrative rules and protocols and to this end shall receive supervision within the Host Agency. However the Worker's service accountability shall be determined and guided by the Advisory Committee.

Minimum requirements

Education: Post secondary education in health or social services and / or the equivalent in life experience.

Experience: Minimum of one year's experience working with people who use drugs, employing a Harm Reduction perspective.

Skills

Excellent organizational skills
Excellent "people skills"
Well-developed referral skills
Experience in program design, delivery and evaluation
Experiencing in training and education, especially in the areas of safer sex and safe drug use
Highly knowledgeable about Harm Reduction and AIDS Prevention
Excellent oral and written communication skills
Proven commitment and dependability
Ability to work as part of a team
Current or former experience in injection drug use may be an asset.



Appendix B

BUDGET

The issue of salaries is thorny. If each of the four Workers is paid the same rate, their salaries may not be comparable to those of similar employees at the four work sites. If their pay rate is based on the pay rates for comparable work at work sites, their pay rates may not be the same, and yet they will be doing what might be construed as essentially the same job. In either scenario, they might well feel they are being treated inequitably.

The above notwithstanding, I am suggesting, for the purposes of this budget, a salary of $36,000.00 per annum, plus benefits.

 

Salary - Outreach Worker $36,000.00

Benefits (calculated at 19%)$6,840.00

Peer Support Worker (500 hrs @ $15.00/ hour honorarium)$7,500.00

Administration fee (4% of total grant) $2,660.00

Rent $2,000.00

Local Travel $1,300.00

Telephone / pager / cell phone $1,500.00

Postage $500.00

Miscellaneous capital expenses $500.00

Printing, stationery, advertising materials, etc. $5,000.00

Peer Support $1,000.00

Program Supplies$1,500.00

Miscellaneous$300.00

TOTAL$66,600.00


If corners can be cut here, I would recommend that monies be made available for hospitality and travel subsidies for service users and / or transportation subsidies for Peer Support Workers.


Appendix C

RECOMMENDATIONS TO THE AIDS BUREAU

It is recommended here that the AIDS Bureau consider, in the future, funding for the purchase and operation of vans to expedite more effective outreach.

It is recommended that the AIDS Bureau convene a task group to develop a code of conduct and a bill of rights for Peer Support Workers.

It is recommended that the AIDS Bureau reconvene The Planning Committee three months after the Project has been initiated in order to undertake an interim review of the work done to date at the four sites and to suggest changes in current service delivery practices, as necessary, and direction for future activities.

 

Appendix D

RECOMMENDATION TO PUBLIC HEALTH

It is recommended that the Main Line become the information hub for all Needle Exchange / Harm Reduction services in the new City of Toronto, both in-house and outreach, so that people who need to access these services can phone the Main Line and be informed immediately of the location of (and perhaps even put in touch with) the closest available service or service provider.

It is recommended that Public Health negotiate to have Host Agencies not currently officially designated as Needle Exchange sites be designated as such.


Appendix E

It is recommended that the Host Agency actively encourage and support the solicitation of material donations and additional funds for this project from complementary sources, in order to enhance the services provided by the Project, e.g., food, transportation, clothing, additional Peer Support Workers, etc.

 

Region: