The Toronto Client Access to Integrated Services and Information (CAISI) Project aims to reduce the plight of chronic homelessness by enhancing the integration of care between agencies at the individual and population levels using an electronic information system. The project includes:

1) The development of the open source system software.

2) Building community and agency capacity in using the system to integrate care between agencies.

At the individual level, the project includes the rapid assessment of clients, referral to appropriate shelters and agencies, managing waiting lists into services, support multi-agency case management ultimately leading to client placement into appropriate housing or community placement.

At the population level, the project enhances the ability of the community to gather data that can be used by activists and decision makers to help effect positive social change leading to the end of chronic homelessness. That is, advocate for more affordable and supportive housing and more appropriate facilities (e.g. client centered harm reduction long term care programs) for clients the community currently finds difficulty caring for.

The system is client centered, clients give access to agencies to enhance the integration of care they receive. Clients are helping inform how the system will function. The project is being developed by front line agencies to improve the care of their clients.

The software is an enhancement and expansion of the OSCAR McMaster system, an open source Ministry of Health approved electronic medical record. It includes integration with major community IT networks among agencies caring for those who are homeless. These include shelters, drop in centres, outreach teams, hospitals, public health and Toronto ambulance.

The approach is an 'open development' or 'just do it' approach with a release early and often philosophy. Users are co-developers who work with program developers and software programmers to make rapid improvements to the system on a real time basis. The software is open source meaning that it is owned by the community and can be freely downloaded and enhanced by anyone.

CAISI Vision

The CAISI vision is: Agencies and clients integrating care to end chronic homelessness.

What does 'integration of care' mean?

The CAISI vision is 'Agencies and clients integrating care to end chronic homelessness'. By integrating care we mean integration at the individual and at the population levels.

Integration at the individual level

At the individual level integration means enhancing care for individuals who are homeless to ultimately improve their movement from streets and shelters into housing. This movement can be facilitated through:

1. Early intake and appropriate referral - this means identifying chronic health and social problems early and referring clients to community programs and shelters that are best equipped to help with those problems. This is in contrast to waiting for these problems to reach a point of crisis or urgency.

2. Multi-agency case management - this means offering homeless clients the opportunity to get care from multiple agencies who are all working with a single case management plan. This can be facilitated through a common information system that tracks care provided by the multiple agencies so that a new case management plan isn't started every time a client enters a new agency be it a shelter, hospital or outreach team.

3. Support movement from streets and shelters to housing - this means that integration at the individual level is driven by the ultimate goal of ending homelessness for the individual being cared for. Homelessness ends for an individual when they have a place they can call home that they contribute toward the payment of (through earnings or social assistance) and in which their basic needs are met.

Integration at the population level

1. Real time needs assessment - this means that with the CAISI system participating agencies will know at the push of a button how many homeless persons are living on the street or in shelters with severe mental illness, addictions and or disability. This and other type of information in the form of population level reports at the agency, program and community levels will allow agencies and planners make real time decisions based on needs assessment and indicator type data that is immediately available. With this system, agencies and planners will no longer rely on available research to have access to this type of data.

2. Real time advocacy Advocates for those who are working toward ending homelessness will have access to data as described above to better advocate for systemic change to end chronic homelessness such as more supportive housing / and resources for ending homelessness.

3. Public Health Tools The CAISI system will provide tools useful for TB control (e.g. knowledge of latent TB infection status at the individual and population levels), influenza and pneumococcal vaccine planning (knowledge of immunization rates among those who are homeless and subgroups of the homeless), pandemic planning / outbreak control (exposure information such as lists of who has been potentially exposed to TB or other infectious diseases through detailed program or bed admission records).

The following table outlines the agencies that have joined the CAISI project:

click the table to enlarge it