How Ottawa can integrate outreach into their homeless system: A Playbook

One of the biggest concerns about our modern homeless system is that it is reactive rather than proactive. We wait until a person loses their home and comes to an emergency shelter before we even start thinking about how we can solve their problem.

In few other fields do we really accept such a delayed reaction. No, we actively seek out problems so that they can be solved before they become overwhelmingly significant.

The same thing should be done with homelessness, and one of the most effective ways of doing this is through outreach — going out into the community and looking for people experiencing homelessness.

But, startlingly few cities across Canada really employ this tactic. Not only does outreach make our response to homelessness more proactive, but it also allows us to collaborate better.

Most homeless systems are notoriously bad at inter-sector collaboration. When a person shows up at a homeless shelter, they have full access to all the services offered there. But, what about if what they really need is at another shelter or another sector altogether? What about if their needs change over time or it comes time for them to transition to a more independent form of living?

What then?

Outreach provides a unified way of entering the homeless system, so that each individual’s needs can be evaluated and they can be connected with the best resources for them. It’s founded on the idea, that whereever a homeless client shows up, they can access services specific to their needs.

I live in Ottawa, and so I took it upon myself to think about how outreach could specifically be integrated into our existing homeless system. All of the steps I came up with below could be generalized to any city, anywhere. Here’s a playbook for how it all could be done.

And, if you want to learn more about the larger system this would all fit into, check out: https://medium.com/@averyparkinson23/what-it-takes-to-solve-homelessness-rather-than-manage-it-95d6be56699e.

People & Partnerships

The way outreach is conducted is based on the Pathways to Housing Model — the initiator of the Housing First Model which identifys clients through two streams: hospital discharge and street outreach.

Similar methods were also used in Streets to Homes, Torontoas well as the Calgary Homeless Foundation.

Outreach Personal

We require three kinds of outreach personal.

Firstly, outreach workers who comprise the Mobile Case Management Team. These individuals will be trained frontline workers who go out into the city and engage with potential clients with the intent of referring those who are interested to the emergency shelters and eventually transitional housing or housing first agencies.

Secondly, intake workers. Intake workers will be trained frontline workers. One or two will be employed per emergency shelter depending on demand. Their purpose will be to

• first connect with clients using their shelter
• referring clients to other shelters
• facilitating their connection to transitional housing or housing first

Third, discharge planners. Discharge planners will be employees of three of Ottawa’s kinds of public institutions (hospitals, correctional facilities and foster care). Their purpose is to identify clients who would be discharged into homelessness and connect them with the homeless shelter.

Institutions

Emergency shelters — these shelters employ intake workers (see above) and are the places where clients will go immediately after intake.

Public institutions — correctional facilities, hospitals and foster care are all institutions which the homeless system needs to form parternships with in order conduct effective outreach. This will be done through discharge planners (see above).

Transitional housing and housing first — while not central to how outreach is done, these long term establishments will first be notified about a client in the outreach procedure (see below).

Tools

Two specific tools will be made use of in the outreach process.

Firstly, the Service Prioritization Decision Assistance Tool (SPDAT). This is a questionnaire and evaluation framework used in Edmontonin order to measure the acuity of a client’s needs. Both MCMT outreach workers and Intake workers would need to be trained in conducting the SPDAT.

• Full SPDAT
• SPDAT training for frontline workers

Secondly, the Homeless Management Information System (HMIS). The HMIS is a centralized data bank accessible to all institutions in the city’s the homelessness system, in particular, the MCMT, emergency shelters and transitional housing and housing first. For each client in the homeless system, relevant information from the SPDAT is stored. This system was implemented and shown to be effectiveby the Calgary Homeless Foundation.MCMT Outreach Workers

Outreach zones

The majority of Ottawa’s unhidden homelessness seems to be concentrated in the downtown area — Lowertown, the Byward Market and Centertown — particularly near commercial buildings.

We can subdivide this area into regions, each of which will be assigned to one or two discharge workers (depending on what working model is more effective). The size of each region will depend on the concentration of homeless individuals. So, for example we might have

• R1 = st. patrick, rideau, king edward and sussex
• R2 = rideau, king edward, colonel by, laurier
• R3 = king edward, laurier, cobourg, murray
• R4 = king edward, laurier, rideau, charlotte
• R5 = elgin, o’connor, gladstone and rideau
• R6 = gladstone, rideau, bank, lyon
• R7 = st. patrick, king edward, bolton, sussex

where each of the listed roads form the boundary of that region. Since adjacent regions share bordering roads, each outreach worker will be responsible for the sidewalk that borders their region.

It might also be worthwhile to put in zones in Vanier

• R8 = montreal, mcarthur, st. laurent, vanier
• R9 = mcarthur, donald, st. laurent, vanier
• R10 = prince albert, donald, st. laurent, vanier

As well as Little Italy,

• R11 = scott, byron, parkdale
• R12 = scott, gladstone, parkdale, bronson

Now, these are just estimates based on what I think the relative concentration of homeless people across the city. The way the actual regions would be discerned is by

1. Establishing the concentration of unhidden homeless people across the city (conducting a survey, experience of current frontline workers).
2. Mapping this population to find the key streets.
3. Grouping these streets into regions based on proximity and density. Streets that are adjacent to one another will constitute the same region and more densely populated regions will be smaller. The idea is that one or two outreach workers will be able to thoroughly cover their entire region once a day (factoring in the time it takes to converse with clients, conduct the SPDAT and depart on discharge calls).

Another element to factor into these regions are services that individuals not formally enrolled in the homeless system tend to access. These could include addictions counselling, mental health support centres, walk in clinics and food programs. We will call these places supplementary locations.

In order to identify what such locations are, we would either need to conduct a survey and/or use the experience of current frontline workers. Once a list of locations is established, each facility would be assigned to the zone that it is in, and so the outreach worker in charge of that zone would be responsible for frequenting it once a day.

For instance, R5 could contain Operation Come Home as well as the Metis Nation. R6 could contain Appletree, Centertown Community Health and the Ottawa Chinese Community Service Centre.

Another element to factor into these regions are the public institutions which have partnered with the homeless sector in order to conduct discharge planning. These institutions should include correctional facilities (Ottawa-Carleton detention centre), hospitals (Ottawa General, Montfort, Queensway Carleton and the Royal Ottawa) as well as foster care (Children’s Aid Society of Ottawa, Partners in Parenting).

Each such institution could be assigned to a couple regions that they are closest to, and so the outreach workers in charge of that region would be responsible for answering those discharge calls. Now, when a discharge call is received, it is possible that the outreach workers who would otherwise answer it are presently occupied. In these cases, another worker who is free could take it. The idea is just to have some sort of prioritization.

For instance, the Royal Ottawa Hospital could be assigned to R11 and R12.

Employment

The position of being an MCMT worker would most likely be a full time position. This might change depending on the realistic demand for their serivces — something which might change depending on the time year or general events taking place at that time. However, if an MCMT team is employed so that each worker is fully occupied during peak outreach times, in times when services are not in high demand, they can go and help as a standard out reach worker at an emergency shelter in the area that could benefit from assistance.

In this way, MCMT workers should probably not be employed by specific emergency homeless shelter or not for profits in order to limit policy conflict and inequitable distribution of resources or leverage over the outreach process.

Instead, MCMT workers could be employed by either the Alliance to End Homelessness when it becomes more actionable. In the case where the Alliance to End Homelessness Ottawa does not have enough funding to support these workers, they could instead be employees of the City of Ottawa.

Alternatively, emergency shelters could be required to donate to the Ottawa Alliance to End Homelessness Ottawa to cumulatively cover such the outreach workers’ salaries, as their work would be benefiting each emergency shelter.

Discharge Planners

Discharge workers would be employed at each institution that partners with the Ottawa Homeless Sector. Some such institutions already have discharge planners or people who fill equivalent positions (the hospitals), and so this responsibility could just be added to their typical discharge procedure.

Outreach Procedures

There are three different procedures, depending on where the client is first met.

Procedure 1: MCMT

This procedure is used when the client is first contacted by an MCMT outreach worker while they are in their zone — either on the street or in one of the supplementary locations. Upon the outreach worker making contact and conversing in order to build some degree of comfortable exchange

1. Establish if the client is experiencing homelessness (of any kind)
2. Establish if the client would like assistance finding housing, accessing support or food.
3. Establish if the client has met with an outreach worker before, and if so how long ago.
4. If never or longer than 6 months, proceed with step 4
5. If less than six months, proceed with step 5.
6. Conduct the SPDAT
7. Use the results to inform what housing first or transitional housing centre would be most appropriate for the client as well as the best emergency shelter in the short term.
8. Contact the emergency shelter as well as the housing first agency to see if they have space for the client.
9. if the emergency shelter says they do not have space, contact others until one is found
10. if the transitional housing center says the do not have space for the foreseeable future (specific time to be determined by the homeless sector), let the emergency shelter intake workers know about this information — it then becomes their responsibility to find a transitional housing or housing first agency.
11. Offer to accompany the client to the emergency shelter.
12. if the client agrees, proceed with 1a.
13. if the client declines, proceed with 1b.
14. input the SPDAT results into the HMIS.

Procedure 1a: If the client agrees

1. proceed to the shelter with the client
2. Tell the intake worker which transitional shelter the client will be going to, how long and when the coordinating meeting is supposed to happen. In the absence of this information, tell the intake worker this.

Procedure 1b: If the client disagrees

1. give them directions to the shelter
2. notify the shelter that the client should be arriving unaccompanied
3. the shelter should notify the outreach worker by the end of the scheduled day to inform them if the client has arrived or not (see example below).

Procedure 2: Discharge Planner

This procedure is used if a discharge planner meets a client who will be discharged into homelessness and would like assistance.

1. use the MCMT group chat to notify the team that a client is in need of evaluation as well as the address
2. remain with the client until the MCMT outreach worker arrives

The outreach worker would then continue from step 3 of Procedure 1

Procedure 3: Intake Workers

This procedure is used if a client first seeks assistance at a specific emergency shelter. After the client is sent to the intake worker, the intake worker would

1. Establish if the client has met with an outreach worker before, and if so how long ago.
2. If never or longer than 6 months, proceed with step 4
3. If less than six months, proceed with step 5.
4. Conduct the SPDAT
5. Use the results to inform what housing first or transitional housing centre would be most appropriate for the client as well as the best emergency shelter in the short term.
6. If the emergency shelter is the one the client has arrived at, the procedure is done. If not, continue with step 5.
7. Contact the emergency shelter as well as the housing first agency to see if they have space for the client.
8. if the emergency shelter says they do not have space, contact others until one is found
9. if the transitional housing center says the do not have space for the foreseeable future (specific time to be determined by the homeless sector), let the emergency shelter intake worker at the appropriate shelter know about this information — it then becomes their responsibility to find a transitional housing or housing first agency.
10. Offer to accompany the client to the emergency shelter.
11. if the client agrees, proceed with 3a.
12. if the client declines, proceed with 3b.
13. input the SPDAT results into the HMIS.

Procedure 3a: if the client agrees

1. Use the MCMT group chat to call a worker to the shelter and ask them to accompany them to the final shelter.

Procedure 3b: if the client disagrees

1. give them directions to the shelter
2. notify the shelter that the client should be arriving unaccompanied
3. the intake worker at the final shelter should notify the previous intake worker by the end of the scheduled day to inform them if the client has arrived or not (see example below).

Now, it’s worth noting that I am very much not an experienced frontline worker, and so all of these procedures would have to be verifyed in accordance with those standards.

Communication

Communication needs to be facilitated in three groups

• amongst the MCMT outreach workers
• between the MCMT and the intake frontline workers at each homeless shelter
• between the MCMT and the discharge planner at each public institution

In the past, when it comes to communication between the frontline workers, walkie talkies are typically used as a system for each emergency shelter. However, that system would most likely pose challenges here if workers are out of range. For this same reason, it would not work in order to communicate with discharge planners and so using one universal method that is sufficient for all three communication groups is preferred.

As such, since most working people have cell phones, I suggest using group chats, for instance iMessages or WhatsApp depending on the kind of phone each person has.

The first group chat would be between the MCMT workers and would be used to

• request assistance
• notify the others of a situation
• explain a development

or any other general conversation that is necessary to their work.

Here is an example of the group chat

The second set of group chats would be between the MCMT workers and the intake frontline workers at each homeless shelter. There would be one group chat for each emergency shelter consisting of all the MCMT workers and the intake workers at the given shelter. The purpose of this group chat would be to

• ask if there is room for a client at the shelter
• determine if a referred client has arrived at the shelter
• request than an outreach worker be sent to accompany a client to another shelter.

Here is an example with the Shepherds of Good Hope Intake Workers

We could also consider doubling these group chats — one between all the MCMT workers and each specific set of intake workers and one between the MCMT workers working in the zone of the emergency shelter. That way, all the MCMT workers would not have to be concerned with exchanges that don’t involve them. On the other hand, this increased level of conversations could lead to easy miscommunication or inefficiency.

The way to get around that might be reverting to the first model (one group chat per shelter) and simply having a policy that outreach workers check their phones every 10 minutes to check for missed notifications.

The final set of group chats would be between each the discharge planners and the MCMT workers — with one group chat per public institution. The purpose of this group chat would be to request outreach workers be sent to evaluate potential clients. The same idea of doubling the group chats as was used for the emergency shelter intake worker chats could be applied here as well.

Here is an example with the Royal Ottawa Hospital Discharge Planning,

Real time lines of communication would also have to exist between the MCMT team and transitional housing/housing first agencies (as well as the emergency shelters and transitional housing although that is beyond the scope of this project).

This could also be facilitated using a group chat, however it might be slightly less immediate than the other three. It’s purpose would be to ask if a transitional housing or housing first agency is able to take a client entering the system.

Here is an example with the YMCA family transitional housing centre.

Summary

1. The Ottawa Alliance to End Homelessness should employ a Mobile Case Management Team of trained outreach workers who go out into city streets and visit centres frequented by potential clients with the intent of helping them enter the homelessness system.
2. Each outreach worker should be assigned a “region” — as well as supplemental locations. The team should latently communicate to answer discharge calls.
3. Under the Ottawa Alliance to End Homelessness, parter with public institutions — specifically hospitals, correctional facilities and foster care — in order to have existing or new discharge planners notify the MCMT when a client would otherwise be discharged into homelessness.
4. Each emergency shelter should employ 1–2 intake frontline workers who receive new clients and coordinate their timely departure to transitional housing or housing first.
5. The overall goal of outreach particularly of the MCMT and intake workers should be to identify a client’s entire path with in the homeless system — the emergency shelter will often be just the first step.
6. The MCMT and intake frontline workers should make use of the SPDAT in order to determine client needs and immediately refer them to the appropriate housing first/transitional housing agency and emergency shelter.
7. The city homeless sector should make use of the HMIS to store this information and make it accessible to all involved in the homeless system.
8. Three sets of group chats — MCMT, MCMT + intake frontline workers and MCMT + discharge planners — should be used to ensure latent communication.

And of course, this recommendation could be generalized to any city. The underlying principles are

1. Using outreach workers responsible for specific city streets and location frequented by homeless individuals.
2. Partnering with public institutions for effective discharge planning and the emergency sector for intake.
3. Using a tool to evaluate each client’s needs and match them with services. Having a centralized way to store and update this information.
4. Have a way for these outreach workers to communicate in real time.

Now this is not everything that needs to go in to implementing such an outreach system, the hardest part would be to form the partnerships relevant to doing so. But, it is a glimpse of how we can relieve two of the central short comings of our current response to homelessness.