The value of peer support to improve emergency department experiences for racialized people with mental health issues

By Raymond Cheng, Ontario Peer Development Initiative; Steering Committee member, Community of Interest for Racialized Populations and Mental Health and Addictions

In brief

The use of peer support in the emergency department (ED) is an emerging practice. In this issue of Promising Practices, we profile two scenarios: One is the inner city hospital with the dense and diverse populations it serves, and its use of a Community Support Worker; the second is the future establishment of peer navigators in the Central Local health Integration Network (LHIN) at two sites – one in the city, and another serving a broader suburban area. Each offers some lessons and implications for their respective use by racialized people with mental health issues.

This Promising Practice arose from the work of the Community of Interest for Racialized Populations and Mental Health and Addictions (COI). The COI supports knowledge exchange activities to improve provincial policy, planning and service delivery for racialized populations and mental health and addictions. Currently, work is focused on mental health related emergency department (ED) use by racialized populations. 

In September 2012, the COI conducted a sector scan and follow-up interviews to identify promising practices in this issue area. Shared care was identified as a possibility; this was one of several promising practices identified through this process. The COI identified instances where shared care was either being used or in the process of being implemented, and contacted key informants to obtain more information.

Additional promising practices are available on the COI website. For more information, please click here or contact ssubramanian [at] ontario [dot] cmha [dot] ca (Sheela Subramanian) (Canadian Mental Health Association, Ontario).

Promising Practices profiles innovative practices and initiatives from around Ontario.

Using peer support in emergency departments

The use of peer support in the emergency department (ED) is an emerging practice. Two scenarios are shared here. One is the inner city hospital with the dense and diverse populations it serves, and its use of a Community Support Worker. The second is the future establishment of peer navigators in the Central Local health Integration Network (LHIN) at two sites – one in the city, and another serving a broader suburban area. Each offers some lessons and implications for their respective use by racialized people with mental health issues.

People from racialized populations are likely to experience heightened stress in an unfamiliar environment such as the emergency department, and are possibly hampered if their first language is not English. Furthermore, for those who seek help for mental health issues, whether on their own or accompanied by family and friends, any additional support during such a hard time is likely welcome.

1. Peer support in the inner city hospital

The St. Michael’s Hospital’s ED aims to provide a range of care for people with mental health and addictions issues. It offers a needle exchange program and a transitional centre for people who have been discharged but have nowhere to go in the community. It also pioneered the Community Support Worker Role. The position was created as a result of one of St. Michael’s 4 Community Advisory Panels (CAP): the Homeless and Underhoused CAP . As the hospital website notes:

“The CAP recognized that many homeless and under-housed clients were arriving at the St. Michael's Emergency Department (ED) with no one to advocate for them. Working with ED staff, they helped to create a new, permanent position to provide support for homeless and under-housed clients in Emergency and help them link to community services when they are discharged. The person in this new position also acts as a mentor to other staff in the ED to help them communicate and understand the unique needs of vulnerable clients.”

The championing of peer support reflects the hospital’s commitment to health equity as expressed in its values-based practices. They include the following which may support the needs of racialized people living with mental health issues: cultural sensitivity training for all staff and students; anti-discrimination policies; interpreter services; patient advocates; and diverse spiritual care.

The Community Support Worker (CSW), Frank Fournier, is mostly present in the ED during working hours. Among their many tasks, the CSW:

  • Introduces themselves to vulnerable individuals who present at the ED Explains the functions of the ED, and if necessary, other hospital services
  • Establishes an understanding with vulnerable clients to be able to advocate with other ED staff to promote patient-centred care and meet patient-expressed needs
  • Uses an individualized informal and caring approach to conduct further intake and enquire about the client’s non-medical needs, such as food and clothing
  • Navigates the individual’s requests for community resources, education around harm reduction, or access to the Safe Exchange
  • Needles Program as needed
  • Facilitates next steps after discharge from ED, whether it is to help with transportation or even to guide a client to their next destination

If the client has made repeated visits, be acquainted with the client’s background and history so that communicating with the hospital and linking to the client’s community partners
are prioritized, maintaining continuity of care

2. The Central LHIN – Development of peer navigators

In its April 2014 newsletter, the Central LHIN announced new funding for mental health and addictions peer support navigators at North York General Hospital (NYGH) and Southlake Regional Health Centre (funding will come through the Krasman Centre, a consumer/survivor initiative operating in York Region). The initiative, which will launch later this spring, will result in peer support being available in the EDs of these two hospitals.

In addition to helping clients in stressful clinical environments, the peers will help clients navigate the system after discharge. Theresa Claxton-Wali, the project coordinator, emphasizes a few key points:

  • The principles of empowerment and respect are paramount to this non-medical model of care
  • The LHIN has been a strong proponent of peer support in the past and the fiscal investment is a sign of that commitment
  • Peer navigators expect to be part of the team of care in the ER. They will play a distinctive nonmedical role by addressing clients’ self expressed needs around practical recovery
  • information. They would also provide direction on community resources, and would do so in an empathetic manner that is informed by lived experience.
  • There is an expectation of follow-up care through phone calls and if necessary, inpatient unit visits and stronger linkages to primary care and community resources

Moreover, Claxton-Wali has stronger hopes for how the Krasman Centre sees its vision expanding to all hospital EDs and into community crisis supports including Mobile Crisis Intervention Teams (MCIT) thereby providing peer support along with professional intervention wherever an individual might seek or encounter support for their distress and perhaps averting a visit to the emergency department altogether.

Ideally, peer workers would educate the professional staff at hospitals about the nature of recovery-driven peer support, consumer/survivor initiatives in the community, and lay the
groundwork to more closely integrate the LHIN’s mental health and addiction agencies. In time, all consumers would in time benefit from the collective knowledge provided by the improved continuity of care within that LHIN.

Improving care and reducing ED department use

The examples shared suggest three benefits to a Community Support Worker/Peer Supporter role:

  • Medical needs are met by those trained to provide them; non-medical needs expressed by clients are best assisted by peers who know the system and “have been there” before
  • Clinical health assessments are expedited by better communication and an advocate acting on the client’s behalf Any follow-up is done holistically and geared to health outcomes, because the patient is truly connected and is at the centre of the healthcare system

Opportunities and Challenges of Peer Workers

Frank Fournier mentions that as a peer, he is inordinately more “streetwise” and thereforeperceptive about individuals who are in the ED.

For example, he has spotted and stopped people who were at risk of harming themselves while in the unit (by using street drugs in the ED washroom, for example). Also, working with people who are going through a hard time in the ED is itself stressful. There can also be special circumstances where a client is also involved with the justice system.

The Benefits for Racialized Populations

The job posting for the Krasman Centre peer navigators mentioned that a second language is an advantage. With the provincial network of peer organizations throughout the province, and allied efforts such as CMHA Toronto’s Open Doors Project, there are already organizations that are capable of partnering to delivering this kind of innovative care.

The potent mixing of lived experience, a common language, shared beliefs or experience, and understanding of mental health is a crucible for a viable and recovery-driven vision of care that racialized people can ideally use.