Toronto CAISI Project Charter

The Toronto CAISI Project has an organic project charter. This means that as the project grows and as service providers and homeless clients contribute to it, the project has responded to them and has added components to meed their needs. Below is the current charter arranged into appropriate headings.

Vision

Agencies and clients integrating care to end chronic homelessness.

Mission

To end and prevent chronic homelessness

To decrease the plight of chronic homelessness at the individual and community levels

To improve service by decreasing fragmentation

To make program that is useful to and accessible by multiple communities

To assist agencies and service providers become more efficient.

Goals

To integrate care among agencies who serve those who are homeless by:

- creating IT infrastructure

- fostering the development of community capacity

- facilitating individual-level care

- facilitating population-level care and advocacy

- empowering clients to be proactive participants in their care and co-developers in the project

- engaging front-line agencies and staff as co-developers

- creating a plan for sustainability.

Objectives

IT Infrastructure Objectives

To develop a software tool that includes health record, case management and communication/triage functions, which facilitates integrated individual and population level care by allowing service providers in various settings to disclose and receive personal health information from other agencies with client consent.

The software will function to perform:

• Health intake
• Referral
• Queuing
• Program admission and discharge
• Multi-agency case management
• Individual level reports
• Population level reports
• Consent management

The software will meet the highest privacy and security standards possible.

Developing Community Capacity Objectives

To promote intra- and inter-agency development and communication to improve the effectiveness and efficiency of service provision through implementation and use of the tool.

Promoting agency development & communication will involve:

• enhancing relations among and between key stakeholders
• increasing communication between and within agencies about individual client care
• educating service providers about homelessness and service provision
• promoting software adoption
• fostering interest:
  • ensuring service providers are active participants in co-development
  • ensuring service providers have control over changes to their job duties
  • ensuring that the perception of benefit is greater than cost
• fostering support:
• ensuring administrative/organizational buy-in
• ensuring peer buy-in
• provide conflict resolution, mediation, problem solving
• provide organizational support for privacy and accountability:
•  utilization of integration tools ; training (train the trainer)
• resources (dedicated staff, people, infrastructure, technology)
• promotion, excitement, perception, dissemination certification (inspire confidence, credibility)

Individual-Level Care Objectives

1. reduce duplication care between agencies
2. reduce fragmentation
3. increase continuity of care/treatment between and within agencies and over time
4. Early assessment and appropriate referral
5. appropriate treatment
6. Multi-agency case management
7. Support movement from streets and shelters to housing

 Population-Level Care Objectives

Increase knowledge of health issues affecting homeless persons and develop systems to improve client benefits from population programming

1. Real time needs assessment for chronic homeless
2. provide data to support evidence based policy making and program planning
3. Real time data relevant to advocacy for supportive housing / resources
4. real time data to assist in TB control, Influenza pandemic planning / outbreak control

 Empowering Clients Objectives

1. client access to their data
2. client ability to directly contribute to their client care data
3. client participation in requirements gathering
4. client participate in reviewing software acceptability
5. client participation in testing software functionality
6. client participation in client adoption
7. client participation in agency utilization

Engaging Front-line Co-developers Objectives

1. to facilitate requirements gathering and priority setting by frontline staff
2. to facilitate collaboration between agency staff in project codevelopment
3. to facilitate reviewi of software acceptability by front line staff
4. to facilitate testing of software functionality by front line staff
5. to facilitate staff involvement in client adoption
6. to facilitate staff involvement in agency utilization

 Sustainability Objectives

To lay the groundwork for the sustainability of the tools and lessons created and learned, as well as the system-wide application of these tools and lessons after the conclusion of the project

 Strategies

1. Make work easier for front line agencies
2. Provide better individual / population care
3. Software System for multi-agency integration of client care
4. multi-agency population care
5. Developed by front line agencies / workers
6. Open source IT development (free to all)
7. jurisdictions
8. Innovation
9. cross sectoral
10. compliant with community IT standards / technical alignment with other systems
11. Open Development
    1. Rapid and frequent release of changes
    2. Build on currently available systems
    3. Front line agencies custom develop/co-develop with project team
    
    

Activities

IT Infrastructure Activities

Community Capacity to adopt integration Activities

Integration of Individual Level Care Objectives Activities

Integration of Population Level Care Objectives Activities

Agencies and front-line staff as co-developers Activities

Client participation Activities

Outcomes

CAISI Project Management

The SCPI-funded Toronto CAISI Project is a Toronto community wide project led by a team of developers which is sponsored by St. Michael's Hospital. Project partners included in the original application for funding include Toronto Public Health, Toronto Emergency Medical Services and Seaton House Men's Hostel. The project is meant to extend beyond the funded period and the original applicants, and as such is a community wide project that is not affiliated with any one agency or organization.

Project Organizational Structure

Project Funder: City of Toronto Shelter Support and Housing Administration SCPI program

Funded (Proponent) Organization: St. Michael's Hospital

St. Michael's Hospital Principal Investigator (Organization Proponent): Tomislav Svoboda

Stakeholder Input / Interrelations

External Reference Committee CAISI Expert Advisory Board ,  CAISI Client Advisory Board