Casey Schapel is the harm reduction lead for Casey House, a specialty hospital in Toronto, Ontario, that provides ground-breaking care to people living with and at risk of HIV.
Casey discusses his experience in implementing supervised consumption services at Casey House, to help mobilize knowledge through the Hospital-based Supervised Consumption Services Community of Practice. His responses were edited for clarity and length.
Can you provide a brief description of your hospital/site, including what services you provide and how clients/patients access the site?
Casey Schapel: The hospital is small. We have a 14-bed inpatient unit for sub-acute, palliative, or respite care. It is staffed 24/7 by nurses and has allied health and physicians during the week. We also have a robust outpatient clinic with a nursing clinic and a range of allied health services that include mental health services, harm reduction, physiotherapy, recreational therapy, registered massage therapy, as well as social work and case management.
We have two sites for supervised consumption services (SCS)—the inpatient unit and the outpatient unit.
In the inpatient unit, the SCS is open 24/7 and is located on the unit, steps away from client rooms. The same nurse who provides the person's care also supervises the client while they use the SCS. Generally, when a person is admitted to the inpatient unit, they can tour the SCS and, if they wish to use it, they sign a client agreement. Throughout their admission, they are able to ask their nurse for access to the site. Currently, that site is only available to admitted patients. That site is for eating, snorting and injection.
The outpatient SCS opened in April 2022 and has three booths. The inhalation booth opened in November 2022 and is available for inpatient clients who may prefer to smoke their drugs. This booth operates during regular outpatient service hours, Monday to Friday from 10 a.m.to 4 p.m., with a last call at 3 p.m.. Staff include harm reduction workers and nurses. In the next month, we will onboard people with lived experience (peer workers) into this team.
Both SCS sites are embedded in existing programs. We try as much as possible to provide SCS training to all Casey House staff so that everyone who works here works in an SCS site. This is because the SCS is just a part of the holistic range of services that our hospital offers. For us, supervised consumption isn't a standalone service, it's just another one of the care options that clients can access. In the same way that an outpatient client might come in for our hot lunch program or a physiotherapy appointment, they can visit the outpatient SCS.
How did your organization identify the need for a hospital-based supervised consumption service?
Casey Schapel: Casey House originally started 35 years ago as a hospice for people living with HIV and AIDS. Over the past 20 to 30 years, the nature of HIV changed, so the hospice became a hospital. The HIV and AIDS movement has been closely tied to harm reduction, so there was an increase in people who were using drugs and were seeking either palliative care or sub-acute health care. At that time, hospital staff felt they didn't have the resources or the knowledge they needed to provide care to these individuals, which led to the development of harm reduction working groups, education, and distribution of harm reduction supplies. It was kind of a natural, organic evolution.
As well, a lot of the people who would come to our hospital at that time were using drugs. Many people who required more acute care would tell our staff that they would rather die here than be sent to another hospital because of the stigma they experienced in those spaces. So, it became really apparent to us that not only were we responsible for making people feel comfortable, we also needed to meet the needs of the people who were accessing services here.
What resources were required to get things up and running?
Casey Schapel: At the beginning, we focused on research and engagement for the feasibility study. Research that required engagement of clients, engagement of the board, education for our donors.
Once we were at a point where all those pieces had fallen into place and we had the go-ahead for the development, we had to do a lot of training of all staff. We initiated working groups that included nursing staff, to help develop the SCS workflow and help design how the space would actually look. This also had the benefit of helping to build buy-in among staff who were going to work there, because they were able to contribute to the planning and set up from the beginning. We also engaged clients in the initial feasibility stages.
For the construction stage, we also compensated clients to participate in interviews to get a sense of their needs in terms of the actual physical design of the space. We wanted to make sure the people who were going to be using the site felt it was a comfortable space.
In terms of resources, we took a whole-organization approach. We needed to involve Operations and Facilities, who are not used to building supervised consumption spaces, so they had to learn about the requirements. And allied health staff, who may not be working in the SCS, required training on overdose procedures and understanding of harm reduction principles.
We also implemented mandatory harm reduction education for all staff—from front desk, kitchen, cleaning and custodial, through to senior management—to really make sure that we were able to embed harm reduction as a philosophy within the organization. We created a Harm Reduction Capacity Building Training Series, with four modules, which are publicly available:
- Part 1: Principles of Harm Reduction
- Part 2: Trauma Informed Care
- Part 3: Racial Injustice and the War on Drugs
- Part 4: Indigenous Awareness in Harm Reduction
Who were the key stakeholders that you and/or your team consulted with?
Casey Schapel: We consulted with several groups:
- Clients and other people who use drugs were crucial stakeholders.
- Private donors funded the SCS, so we had to consult them around what the SCS would look like.
- We engaged the Casey House board of directors, who needed to approve the process of applying for the exemption.
- We also engaged other harm reduction leaders and SCS sites in Toronto. To develop our SCS, we relied heavily on the processes that other SCS sites followed. There's a real need to share among the harm reduction community and many sites provided our staff with shadow shifts. And as potential referrers to our inpatient SCS, it was important to have the harm reduction community be aware of what we were doing.
How are you evaluating your outcomes/objectives/goals related to the service?
Casey Schapel: We are lucky enough to have an evaluation team on site. In the initial stages, we used surveys to gather information about staff experiences of working in a SCS. We also used surveys to gather client feedback.
We also use a baseline tool that measures multiple domains of social determinants of health, and we use that data for evaluation. It is useful in terms of general data collection and for identifying how many people experience homelessness when they leave our doors, how many people report challenges with mental health and require referrals, etc.
We’re just starting a case study on the inhalation booth using an appreciative inquiry lens with clients, to build a story bank of their experiences and identify what are the barriers to accessing inhalation services. We will also be using the case study approach to evaluate staff experiences with inhalation SCS, specifically. We’re gathering all this information now so that we can compile those reports and share them.
What are some of the challenges that you and your team encountered? How did you address them?
Casey Schapel:
There were some privacy and confidentiality challenges. One was around documentation and the other around staff communication.
- Many community SCS sites in Ontario use a system called NEO, which anonymizes the data on client visits to the SCS. But as a hospital, we can’t use this system because we have a legal requirement to record clients’ use of the SCS as part of their health record. So the challenge was how to follow this legal requirement while protecting clients’ privacy and confidentiality. To solve this issue, we developed forms and put clear boundaries in place around not including that information in a discharge summary, for example, and not putting that information into wider data systems that other hospitals and doctors can access. We also have the capacity to lock parts of a client’s chart from anyone not directly involved in their care.
- To ensure SCS staff could communicate with each other if they needed support while providing SCS services, we implemented the use of radios. But this created a privacy challenge around not using SCS client names while communicating on the radio. So we developed procedures for using the radios for communication that require staff not to identify clients and only use their radio within certain parameters. We have since moved to a more discreet method of communication without radios based on feedback from clients.
Not having inhalation. Over time, we started to see a slew of clients who were smoking fentanyl. Since they were not injecting, eating, or snorting their drugs, they were not able to use our inpatient SCS site. The outpatient inhalation SCS site for inpatients and outpatients has helped solve this problem and we are in the process of implementing inhalation SCS on the inpatient unit.
Training and education for nursing staff during a nursing turnover/staffing crisis has also been a significant challenge. An ongoing challenge has been finding the time during onboarding to provide the large amount of education that staff—especially inpatient nursing staff—need to work in an SCS. At the moment, we are trying to fine tune what onboarding looks like. It may be worth setting aside one day for training and orientation before nurses even begin their shift work, to be able to provide all the training and education that is required.
What factors influenced implementation success?
Casey Schapel:
Several factors helped us implement SCS successfully, in particular staff and leadership buy-in, expertise in HIV activism and harm reduction, appropriate staffing,
- Senior leadership and board buy-in means that we have someone who can write position statements for the hospital on decriminalization of drugs, for example. So even beyond the direct provision of care, we have been able to embed and advocate for harm reduction as a philosophy and push for the things that impact our clients beyond our four walls.
- Staff buy-in was possible because we communicated to them that a federal exemption for our SCS space would allow them to support clients with their needs while still remaining in good standing with the College of Nurses and protecting their nursing license.
- Our history of HIV activism and of harm reduction work meant that the SCS naturally made sense at our hospital.
- Having enough staff with the right training helped us ensure we could meet our clients’ SCS needs.
What do you wish you had known before embarking on this journey? What surprised you the most?
Casey Schapel:
- I’m not a nurse by background, so for me, it was surprising how limited the knowledge of harm reduction is among nursing staff and medical staff, in general. Had I known that going in, I probably would have changed the education and training timeline, and perhaps gotten into some of those philosophical aspects of SCS a lot earlier.
- Also, having worked in the community setting prior to working at Casey House, what was really surprising to me was the sheer amount of policy and procedures work that needs to be done. With the inhalation site, there were no other hospital-based SCS sites in Ontario to share policy and procedures guidance with us. So, we had to create those as we were going along. It was a real “build things as you go” process that was not clear at some points.
Could you provide any final words of advice to other hospitals looking to implement supervised consumption services?
Casey Schapel:
- Starting the journey of harm reduction early is important. Not just the SCS piece, but what do policies look like around distributing harm reduction supplies on an inpatient unit? Who are the allies within the hospital who support harm reduction? What processes are already in place for patient engagement? And how can you put these processes in place and use the feedback to drive the development of an SCS? Adding harm reduction knowledge or philosophy to job descriptions for all staff is also important. And embedding education for all staff so everyone has a baseline level of knowledge of harm reduction and trauma-informed care.
- Know there are other hospitals out there that are doing this work. We know that people who use drugs deserve and require health care as much as anyone else. If you are the only person in a hospital doing this work and feel isolated pushing this agenda, know that you are not alone. There are other people who feel that way. So finding those allies is crucial to making a hospital-based SCS happen.