Joseph Berry has diabetes, heart problems and suffers from depression. His leg muscles give him trouble.
Over the last two years, he's been admitted to hospital a half-dozen times and spent a total of four months there. He's had quintuple bypass surgery.
But the main reason the 62-year-old Winnipegger has spent so many days in hospital is there's been no place for him to go. He's lacked the supports that have allowed him to be released.
"It was dragging me right down," he said Thursday. "I was admitted at least five or six times to different hospitals over a two-year period."
Berry is one of the first clients in a new program launched by Winnipeg health officials to better meet the needs of people who have become chronic users of ambulance and emergency-room services and experience long hospital stays for a lack of a better alternative.
The Winnipeg Regional Health Authority has leased the 20th floor of the downtown Manitoba Housing highrise at 185 Smith St. to provide a transitional home for people like Berry.
'Unless you provide a (suitable) setting, it's a revolving door. And what we're trying to do is get rid of that revolving door'
The new facility is mainly catering to people between 30 and 60 years of age with multiple health problems, including mental-health or addiction issues that put them at risk of becoming homeless.
Most are poor and have no family supports. Some use hospital emergency services so frequently ER staff know them by name.
"They're heavy users of 911, they're heavy users of emergency departments and they are often individuals that end up staying in hospital for a very long time," said Réal Cloutier, vice-president of community care for the WRHA.
Discharging such patients can be difficult without proper community supports in place, he said.
"Unless you provide a (suitable) setting, it's a revolving door. And what we're trying to do is get rid of that revolving door," Cloutier said.
The new Transitional Supported Care (TSC) program has been in place for less than two months. It will provide round-the-clock services for up to 20 clients at a time until they can be properly assessed and find suitable housing. The program has an annual budget of $2.5 million.
Cloutier said the number of Winnipeggers who might benefit from such a service is likely "in the hundreds." And if the experiment proves successful, more of these units will likely be created.
The WRHA is currently struggling to find solutions to long waits for service at hospital emergency rooms as well as long off-load wait times for ambulances at hospitals.
Finding a better way to deal with chronic health-system users would help ease these problems. It would also free up more hospital beds.
At an estimated cost of $320 per client per day (less any monies recovered from social assistance), the TSC program won't be cheap.
"(But) it's still far cheaper than a bed at $700 a day at Health Sciences Centre," Cloutier said.
Given the strains on the health-care system, the program was set up quickly.
"A new program like this often takes years to develop. We put it together in a very short time frame," said Carol Rampaul, a social worker who manages special contracts for the WRHA's home-care division.
Two private companies under contract to the health authority are providing 24-hour service to the clients. One company supplies health-care aides to look after any home-care needs while the other helps clients with "behavioural-management" issues and assists them in getting them to medical and social-services appointments. WRHA home-care case co-ordinators oversee the program.
So far, five clients have moved in. Each has his or her own bachelor suite. Meals are provided.
Clients must participate in meetings designed to help them find permanent housing, but apart from that they can come and go as they please. There is a 10 p.m. curfew, but if a participant plans to be away overnight, their only obligation is to alert the office beforehand.
Although the WRHA is running the program, TSC is a housing initiative -- not a health program, per se, Cloutier said. The provincial Department of Housing and Community Development is a partner.
The head of a downtown shelter for homeless people said the WRHA's transitional supported-care program is "a great idea."
Lisa Goss, executive director of the Main Street Project, said she likes that it offers round-the clock supports and intensive individual case management so clients can obtain or maintain permanent housing.
"I believe this initiative will complement the services provided by Main Street Project and the new TSC program will most certainly fill a gap," she said.
As for Berry, he said the program has been a godsend. And he hopes it will lead to a permanent home and the supports he needs to live more independently.
"She (Rampaul) said when I first came in here I never smiled, and now I'm smiling," he said.