HOMELESSNESS TASK GROUP - CivicWeb

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HOMELESSNESS TASK GROUP

INTERIM REPORT – MAY 24, 2016

Background

On October 22, 2015, Terrace City Council discussed the creation of a

Homelessness Task Group (HTG). The timeline and intent of the potential group

was identified.

As the community has grown in recent years, so has our homeless population.

Responding to the increase of homelessness in our community, in 2015 Council

started to seek solutions to address the complex needs related to homelessness in

Terrace.

The City of Terrace has been collecting data on homelessness for the past three

years. In 2014, 67 community members were identified as homeless. In 2015 that

number rose to 73 and this year 101 homeless persons were identified.

The Homelessness Task Group (HTG) connected in late 2015. Membership was

solidified and the Terms of Reference were developed. The Terms of Reference

were adopted on January 25th, 2016. The HTG consists of 8 voting members as well

as two liaisons from City Council and two City Staff members.

The mandate of the HTG is outlined in the Terms of Reference as follows:

Enhance partnerships across sectors to better support homelessness initiatives.

Facilitate interagency collaboration.

Identity short term actions that align with established initiatives.

Establish the groundwork for a multi-organization, longer term, shared housing project targeting Terrace’s most at-risk homeless populations.

Deliver recommendations to Council for consideration regarding options to address homelessness in the City.

The Task group has met four times since the Terms of Reference were adopted. To

date, we have developed six preliminary recommendations.

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Associated with each recommendation are the priority actions to help move the

recommendation forward. Following this six-month interim report the Task Group

will complete a Homelessness Action Plan to present to Council with final

recommendations. The final report will build on this interim report.

The Homelessness Task Group is comprised of members from the following

organizations:

BC Housing

Kermode Friendship Society

Ksan Society

Ministry of Children and Family Development

Ministry of Social Development and Social Innovation

Northern Health

Salvation Army

Terrace and District Community Services Society

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Preliminary Recommendations

The following section outlines the key recommendations of the HTG to date, up

until May 3, 2016. Each recommendation includes supporting information and lead

organization(s) where applicable.

These recommendations are preliminary and will continue to be developed over the

remaining duration of the group.

Recommendation 1: Provide up to-date community and resource

information to all homeless and at risk of homelessness individuals in our

community.

Review, update, and determine distribution plan for survival guide. Add list of available public washrooms to the survival guide. Post survival guide in all relevant public places.

See Appendix 1: Current Survival Guide

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Recommendation 2: Ensure up to date resource information is available to

all service workers in our community in the form of the Housing Resource

Directory.

Further develop and refine the Resource Directory that was developed by

Northern Health staff into a PDF and downloadable reference booklet for all

resources related to housing and housing opportunities in Terrace.

Distribute Resource Directory to all key agencies and make available for

download online. The Homelessness Task Group will develop a distribution

plan with Northern Health.

This Resource Directory will serve as the go-to guide for community services

for all service agency workers and any organization/ individual that has

frequent contact with the homeless population.

See Appendix 2: (DRAFT) Resource Directory

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Recommendation 3: Support the development and success of a

Homelessness Intervention Program (HIP). (To be combined with the

Integrated Case Management Team (ICMT) in Terrace).

Homelessness Intervention Program - HIP

Using the Prince George HIP as a model, work to develop a HIP in Terrace.

HIP will be a cross-agency initiative that utilizes a coordinated, integrated

approach to addressing homelessness. The HIP project brings all of the

involved partners together who work with the homeless population in a

community

HIP has the goal of reducing homelessness and improving client health, well-

being and self-sufficiency

See Appendix 3: HIP Media Release from Prince George, example HIP brochure

from Prince George, and Homelessness Intervention Project Review and

Assessment Report.

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Recommendation 4: Mental Health and Addictions Support

Integrated Case Management Team (ICMT) Implementation

People who are homeless are among the most vulnerable in our society and

often have mental health, illness, or addictions challenges. The detrimental

impact of homelessness on physical and mental health is enormous.

Homelessness can both contribute to, and be a result of, mental health and

addictions challenges. Effective treatment is evidence-based, easily

accessible and has the active involvement of the person being treated.

Examples of treatment include withdrawal management (detox), residential

and outpatient treatment, and counselling as well as substitution therapies

(e.g. methadone maintenance therapy).

Northern Health is introducing new programming in communities across

Northern B.C. to support people with severe mental illness and substance use

challenges. The program will better connect northerners with crucial mental

health or substance use services, when and where they need them the most.

The goals of the ICMT are to improve health, social functioning and access to

care for Intensive Case Management clients. This is a wraparound service

that includes outreach.

The target population is 19+ with problematic substance use or concurrent

disorders and is part of a continuum of community services and will provide

education and consultation locally and regionally in the NW. ICMT is a client

centered, strengths based approach.

Addictions Dialogue Committee

Given the inextricably linked issues of homelessness and mental health and

addiction:

o The HTG will share information where appropriate with the Addictions

Dialogue Committee.

o The HTG will work with key stakeholders to identify primary sites

where needles are a concern.

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o The HTG will identify an agency that might be willing to take on the

role of needle pickup and drop-off and explore possibility of mounted

sharps boxes in the community.

o Review feasibility of providing sharps containers in suitable City of

Terrace Facilities.

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Recommendation 5: Public Washrooms

There is a need for additional publicly available washrooms.

Leisure Services is currently running a trial of having the washrooms in

George Little Park available to the public between 10am-7pm every day.

Following this trial and the feedback from the homeless count/survey (which

included a question on washroom needs) the HTG will make a

recommendation in the Final Report regarding public washrooms.

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Recommendation 6: Strategic Long Term Planning

These are some strategies that the Homelessness Task Group is considering as

potential long term planning tools:

Continue to lay the groundwork for a multi-organization, long term, shared

housing project targeting Terrace’s most at risk homeless populations.

This includes emergency support to address basic needs of someone who

suddenly becomes homeless (e.g. emergency shelters) as well as rapid

transitions out of homeless shelters into appropriate long term

accommodation and supports (if necessary).

That the city of Terrace, in collaboration with key stakeholders, spearhead

the creation of a “Housing First Program”.1

The City of Terrace endorse and adopt a ten year plan to end homelessness

guided by the document “A Plan, Not a Dream – How to End Homelessness in

10 Years”, by the Canadian Alliance to End Homelessness. 2

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http://www.housingfirsttoolkit.ca/sites/default/files/pdfs/CanadianHousingFirstToolkit.pdf

2 http://homelesshub.ca/sites/default/files/A-Plan-Not-a-Dream_Eng-FINAL-TR.pdf



http://homelesshub.ca/sites/default/files/A-Plan-Not-a-Dream_Eng-FINAL-TR.pdf

Appendix 1

TERRACE

STREET SURVIVAL GUIDE

The Street Survival Guide was developed by participants of TDCSS Employment Services Employment Programs. Unemployed, seeking employment? Contact our office at 250-635-7995. Thank you.

Call TDCSS @ 250-635-3178 to suggest changes or additions to this schedule, thanks!

February 2016

DAILY FOOD RESOURCES

DAY LOCATION TIME

Monday

TDCSS Homelessness Outreach Program - Soup Kitchen

3312 Sparks St (Carpenters Hall)………………………………………………………………………………. Hungry Kids Project (Kids Only) - Kalum Community School Society

Various Local Schools, 250-615-7167 or email: [email protected] or school admin……………… TYES Drop In Youth Program - Meal, Snack, Care Products and Refreshments

3221 Eby St. 250-635-3178………………………………………………………………………………………

Coffee: 8:30am-2pm Lunch: 11:30am Breakfast & Lunch Items 11am-1 pm & 2:30-6pm

Tuesday


3312 Sparks St (Carpenters Hall)………………………………………………………………………….…… Kermode Friendship Society - Hot Breakfast

3313 Kalum St, 250-635-4906…………………………………………………………………………………... Parkside Secondary School - Food Share (for students only)

3824 Eby St, 250-635-5778……………………………………………………………………………………… Ksan House Society - Donation Room (no food items)

4838 Lazelle Ave, 250 635-2373………………………………………………………………………………... Hungry Kids Project (Kids Only) - Kalum Community School Society


3221 Eby St. 250-635-3178………………………………………………………………………………………

Coffee: 8:30am-2pm Lunch: 11:30am 8:00-9:00 am 12:00-1:00pm 10:00am - 2pm Breakfast & Lunch Items 11am-1pm & 2:30-6pm

Wednesday


3312 Sparks St (Carpenters Hall)………………………………………………………………………………. Ksan House Society - Donation Room (no food items)

4838 Lazelle Ave, 250-635-2373……………………………………………………………………………….. Salvation Army -Food Share (unless Food Bank is operating)

3236 Kalum St, 250-635-5446…………………………………………………………………………………... Hungry Kids Project (Kids Only) - Kalum Community School Society

Various Local Schools, 250-615-7167 or email: [email protected] or speak to school admin….. TYES Drop In Youth Program - Meal, Snack, Care Products and Refreshments

3221 Eby St. 250-635-3178………………………………………………………………………………………

Coffee: 8:30am-2pm Lunch: 11:30am 10:00am - 2pm 1:00pm Breakfast & Lunch Items 11am-1pm & 2:30-6pm

Thursday


3312 Sparks St (Carpenters Hall)………………………………………………………………………………. TDCSS Homelessness Outreach Program - Food Share

3312 Sparks St (Carpenters Hall)………………………………………………………………………………. Ksan House Society - Donation Room (no food items)

4838 Lazelle Ave, 250-635-2373……………………………………………………………………………….. Zion Baptist Church - Soup Kitchen (closed mid-June and reopens September)

2911 South Sparks St, 250 638-1336………………………………………………………………………….. Hungry Kids Project (Kids Only) - Kalum Community School Society


3221 Eby St. 250-635-3178………………………………………………………………………………………

Coffee: 8:30am-2pm Lunch: 11:30am 11am (come early) 10:00am - 2pm 4:00-5:30pm Breakfast & Lunch Items 11am-1pm & 2:30-6pm

Friday


3312 Sparks St (Carpenters Hall)………………………………………………………………………………. Kermode Friendship Society - Hot Breakfast

3313 Kalum St, 250-635-4906…………………………………………………………………………………... Ksan Place - Food Share

101-2812 Hall St, 250-635-2654………………………………………………………………………………… Hungry Kids Project (Kids Only) - Kalum Community School Society

Various Local Schools, 250-615-7167 or email: [email protected] or speak to school admin…... TYES Drop In Youth Program - Meal, Snack, Care Products and Refreshments

3221 Eby St. 250-635-3178………………………………………………………………………………………

Coffee: 8:30am-2pm Lunch: 11:30am 8:00-9:00am 1:00-3:00pm (come early) Breakfast & Lunch Items 11am-1pm & 2:30-6pm

Saturday

Salvation Army - Food Share (Bring your own bags)

3236 Kalum St, 250-635-5446…………………………………………………………………………………... Seventh Day Adventist All Nations Centre Church Service

3312 Sparks St (Carpenters Hall), 250-635-3232……………………………………………………………..

1:00pm (come early) 3pm-? (Food after church service)

Sunday Seventh Day Adventist Church - Bread of Life Soup Kitchen and Food Share

3312 Sparks St (Carpenters Hall), 250-635-3232……………………………………………………………..

10:00am-5:00pm (Food after church service)

3 meals/week (any day)

Transition House, 250-635-6447 (for women and children only) K’san Residence and Shelter, 250-635-5890…………………………………………………………………….

12:00pm Lunch 5:00pm Dinner

Scheduled Days

Terrace Churches' Food Bank – 4643 Park Ave (under Dairy Queen)

Please Bring along proof of address and gov’t issued ID for yourself and your dependents

Food is distributed to users via alphabetical order – check their Facebook Website for details…………

Various Times Usually 9:30am-1pm (come early)

mailto:[email protected]

TERRACE

STREET SURVIVAL GUIDE

The Street Survival Guide was developed by participants of TDCSS Employment Services Employment Programs. Unemployed, seeking employment? Contact our office at 250-635-7995. Thank you.

WANT TO HELP, VOLUNTEER OR DONATE?

Please contact TDCSS’s Homelessness Outreach Program at 250-635-3178 ext 422

Hospital – Mills Memorial 4720 Haugland Ave

Discount Shopping

Salvation Army - 3236 Kalum St

Hospital Auxiliary Thrift Shop - 4544 Lazelle Ave

TDCSS CORE Store – 2nd Hand Furniture (by train station)

Park Avenue Medical Clinic 4634 Park Ave

Laundromats

Court House 3408 Kalum St

Showers & Aquatic Centre - 3320 Kalum St

$2/shower or during free Public Swim Fridays 8pm-9:30pm (times subject to change)

Spotless Cleaners Laundromat - $4/shower

Health Unit - 3412 Kalum St Health Unit Services: Ministry of Children and Family Development, Mental Health & Addictions Counselling and Treatment for Adults and Youth, Specific Medical Services, Speech & Hearing, Environmental Health Department

Free Community Programs - Adults & Children Kermode Friendship - 3313 Kalum

Family Place - 4553 Park

Women’s Centre - 4542 Park Skeena Diversity - 4617 Lazelle

Ksan Emergency Shelter – Women & Children Only 4838 Lazelle Street

Public Library Services: Books, DVD’s, Free Children’s & Youth Literacy Programs, Free Computer Lessons for Adults, Book Clubs, Book Sales, Book Delivery for Homebound Patrons

Ksan Emergency Shelter – Families & Individuals 2812 Hall Street

Senior Citizen Services

Happy Gang Centre

Terraceview Lodge

Terrace & District Community Services Society - 3219 Eby St Youth & Family Services, Employment Services, Counselling & Support Services, Community Living Services

Legal Aid-Legal Services Society & Indian Residential School Survivors Society 207 - 3228 Kalum St

Soup Kitchen & Food Bank Addresses: Soup Kitchen - 3312 Sparks Ave & Food Bank 4643 Park Ave

Emergency Services RCMP, Fire Department & Ambulance 3205 Eby St

Employment Centre – WORK BC 4622 Greig Ave

BC Services Centre & Ministry of Housing and Social Development - 3250 Eby St Services: Driver’s and other licenses, Medical Services Plan, Birth Certificates, etc…

Employment Insurance Office (E.I.) – Service Canada Call 1-800-206-7218 or visit their website first: www.servicecanada.gc.ca/eng/home.shtml

MLA Office - Voice Concerns to your Local Politician!! 104 - 4710 Lazelle Ave

Call TDCSS @ 250-635-3178 to suggest changes or additions to this map, thanks!

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HELP LINES Alcohol & Drug Referral Service 1.800.663.1441 BC NurseLine 1.866.215.4700 Child Find BC 1.888.689.3463 City of Terrace - After Hours Trouble Line 250.638.4744 Crime Stoppers / TIPS 1.800.222.8477 Crisis Line - For persons in Emotional Distress 1.888.562.1214 Crisis Line - Teen 1.888.564.8336 HealthLink BC 811 Reporting Child Abuse (no area code req'd) 310.1234 Kids Help Phone 1.800.668.6868 Problem Gambling Helpline 24hrs 1.888.795.6111 Quit Now! Smokers Help Line 1.877.455.2233 Sexual Assault Centre - 24hrs 250.635.1911 Suicide Distress Line 1.800.784.2433 Transition House Women & Children in Crisis 250.635.6447 VictimLINK - 24hr Help & Information Line 1.800.563.0808 Youth Against Violence Line 1.800.680.4264 Indian Residential School Survivors Society 1.250.635.4499

EMERGENCY

EMERGENCY NON-EMERGENCY Police 911 250.638.7400 Fire 911 250.638.4734 Ambulance 911 250.638.1102 Hospital 250.635.2211 250.635.2211

http://www.servicecanada.gc.ca/eng/home.shtml

Appendix 2

Appendix 3

Source: Ministry of Social Development and Social Innovation – Prince George (May 2016)

MEDIA RELEASE FOR PRINCE GEORGE HOMELESSNESS INTERVENTION PROGRAM (HIP)

The Homelessness Intervention Project (HIP) was launched in March 2009 in Prince George, with the goal of reducing chronic homelessness and to assist some of BC’s most vulnerable people though an integrated, cross agency, multipronged intervention to help improve client health, well‐being and self‐sufficiency. The foundation of the project is a coordinated, client centered approach that involves partnering with key community stakeholders via a Memorandum of Understanding (MOU) and drawing on the unique mix of existing services and resources in PG. Referrals to HIP can be received from any source, including self‐referral. Agencies on the MOU are responsible for the assessment for eligibility into the HIP program. To be eligible for HIP a person needs to meet the following criteria:

Chronically homeless‐ continuously or episodically for one year or more and have

serious mental health and/or addictions

HIP clients will receive priority access for available housing and supports

HIP Clients also have priority access to primary Health Care and mental health

services,

Priority access to Income Assistance, and

Access to life skills programs to support HIP clients with maintaining a residence,

and reducing barriers to employment.

o Participation in the HIP program is entirely voluntary on the part of the

client.

o Each person will have their own plan to address his/her needs

There are currently 37 Active HIP clients.

23 of these HIP clients are currently housed and are receiving continued HIP

supports

The HIP project brings all of the involved partners together who work with the homeless population in our community. HIP client care meetings are held weekly and planning is focussed on sharing available resources and expertise with the common goal of helping the HIP clients realize a measure of success.

Homeless Intervention Project

Participating Agencies

Prince George

• AWAC– An Association Advocating for Women and Children

• Prince George New Hope Society—Baldy Hughes

• BC Housing

• Canadian Mental Health Association

• Carrier-Sekani Family Services

• Central Interior Native Health Society

• Elizabeth Fry Society • Forensic Psychiatric Services • Kopar Administration Ltd.

• Ministry of Justice • Ministry of Social Development and

Social Innovation

• Northern Health Authority

• Phoenix Transition Society

• Prince George Metis Housing Society

• Prince George Native Friendship Centre

• Prince George Nechako Aboriginal Employment and Training Association

• Prince George Urban Aboriginal Justice Society

• RCMP

• The Northern John Howard Society of BC

HIP agencies share specific, need-to-know personal information about clients to assist them to find housing and to provide coordinated services to them.

Homeless Intervention Project

Prince George

Outreach and

Support

Services

All information supplied to or obtained by HIP staff will be treated in accordance with the privacy requirements in the Freedom of Information and Protection of Privacy Act (for public sector agencies) and the Personal Information Protection Act (for

Central Interior Native Health Society

Carrier Sekani Family Services

Prince George Native Friendship

Centre

Homelessness Intervention Project (HIP)

Prince George

� HIP assists people who have

been homeless at least a year and have mental health or addiction problems, to find proper housing and support services

� Each person will have their own plan to address his/her needs.

� Each person will receive priority access to housing and support services to help maintain stable housing.

Referrals � Contact an Outreach Worker or

ask for help at any community

agency listed on the back of this

brochure

Outreach Workers

AWAC– An Association Advocating for Women and Children

144 George Street Prince George 250 562-6262

PG Native Friendship Centre

Ketso Yoh 160 Quebec Street

Prince George 250 563-1982

Prince George & District

Elizabeth Fry Society 1575 5th Ave

Prince George 250-563-1113

Canadian Mental Health Association

1152 3rd ave Prince George 250-564-8644

Central Interior Native Health

1110 4th Ave Prince George 250-564-4422

HIP Principles

� Person-centered approach � Holistic, strength and

community based � Evidence based service

models � Cost effectiveness � Innovative and Creative

practices � Care/Service Accountability

and continuity � Service Integration � Maximize 24/7 outreach

and services.

� For general program inquiries please call the Integrated Care Coordinator Tanya Parent at

250 645-3937

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Homelessness Intervention Project: Review and Assessment

Homelessness Intervention Project

Review and Assessment

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Introduction On March 2, 2009, the Province launched the Homelessness Intervention Project (HIP). HIP aimed to

reduce chronic homelessness1 and assist some of BC’s most vulnerable people through an integrated,

cross-agency, multi-pronged intervention that considered the unique circumstances of each community.

The project’s goal was to place 1,720 chronically homeless people living in five BC communities in stable

housing over an 18-month period.

The foundation of the project was a coordinated, client-centred approach that involved partnering with

key community stakeholders and drew on the unique mix of existing services and resources in each

community. By building off of this strong foundation, and placing a priority on housing the chronically

homeless, HIP sought to test and demonstrate how a focus on increased collaboration can result in

increased efficiency and effectiveness of government and community resources.

In addition to implementing the coordinated, integrated approach and meeting the aggressive housing

target, HIP also sought to collect critical information about client demographics, client outcomes from

this project, and best practices for British Columbia’s continuing efforts to fight homelessness and

chronic homelessness across the province.

This report provides an overview of the project, results, challenges and lessons, and the project’s key

successes.

Project Overview HIP was launched in five communities: Surrey, Victoria, Vancouver, Kelowna and Prince George. Across

these communities, homeless counts suggested that 1,720 of those who are homeless could be

considered chronically homeless. HIP set a target of housing all 1,720 chronically homeless in 18

months.

HIP’s approach from the beginning was to get results early and fast, and to “learn by doing”. The

foundation of the project was a coordinated, client-centred approach that involved partnering with key

community stakeholders and drawing on the unique mix of services in each community.

The project was launched with no additional budget, and challenged the project partners to focus on

increased collaboration and integration to maximize the benefit of the supports and services already in

place in the communities.

The project established the first ever government platform to track clients and monitor progress across

the partner agencies, allowing for the collection of demographic information about the client group

being assisted through a “secure lab”. Importantly, information sharing agreements were also

1 For HIP, the chronically homeless were defined as people who have been cycling in and out of homelessness for

more than one year, and who had mental health and addictions challenges. Experience in other jurisdictions

suggests that focusing on the chronically homeless is a critical first step to address homelessness.

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developed to allow front-line agencies and care practitioners to share client information while

protecting client privacy.

Project Phases HIP was divided into 2 phases. This approach allowed the teams to get started immediately with setting

up targets and performance measurement tools to track successes.

Phase 1 (March – September, 2009)

The first six-months of the project built on the success of existing programs and services and

strengthened collaborative structures in the five communities by:

Establishing collaborative and cooperative teams;

Implementing a research agreement and measuring progress via a shared monitoring framework

and web-tool;

Focusing programs and services on the chronically homeless;

Continuing to explore, develop and implement key policy initiatives (i.e. Vancouver client flow

management; approach to integrated care management; access to housing; and, integrated housing

and supports pilots in Vancouver and Surrey, block leasing, rental supplements).

Phase 2 (September, 2009 – August 2010)

By the fall 2009, the province had learned enough to provide clearer direction about the shape of the

integrated teams. Best practice guidelines were developed for client-centred care and were adopted by

the five communities. These guidelines extended the project’s collaborative foundation to establish a

“single integrated team” and an integrated program in each community that was centred on the client,

and provided integrated care across the spectrum of health and social services that clients need to be

successful: including housing, income assistance, life skills, employment, health services, and mental

health and addictions services (see Figure 1).

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Figure 1: Model of HIP approach to client care management

HIP phase 2 continued all key elements of the project’s initial scope including:

Developing frameworks for Integrated Client Care and Operational Integration

Service delivery models in each community to fill gaps, redeploy resources and align roles to best

support service delivery, and meet HIP targets in each community;

Integrating care management for the chronically homeless in each community;

Information sharing agreements to support integrated care management;

Strengthening teams and decision making structures

The integrated care framework was intended to be flexible, and its implementation varied according to

the resources and players in each community. HIP Community Teams maximized the benefits of existing

facilities and services, placing a priority on this population and coordinating resources. This approach

helped over 85 per cent of HIP clients remain housed after twelve months. These guidelines are now

being leveraged to implement pilot projects for youth in transition, and adults leaving correctional

facilities who are at risk of homelessness.

Project Transition (August 2010 – February 2011)

In the first 18 months of the project, community teams succeeded in housing 3,209 clients, and

connecting those clients to the supports and services that they needed to retain their housing, and be

successful in transitioning off of the street. As a result of this success, the province extended the HIP

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pilot project. The approaches used in the HIP project have become a standard way of doing business,

and are informing new integration initiatives building on the project’s successes. However, some

aspects of the project, such as counting client targets, have been discontinued, and the Research

Agreements that determined some provincial level aspects of client information sharing have also

expired.

Results Setting targets for this project was extremely important in order to assess whether clients were

achieving success. Targets were set by estimating the number of chronically homeless in each

community as a percentage of the most recent community homeless count.

In 23 months, HIP partners housed 3914 homeless people in BC. Of these clients, 85% remained stably

housed during the subsequent 12 months.

As well as housing 3914 clients, project partners were able to leverage the relationships that were

formed through HIP to address specific issues or opportunities in their communities, such as opening up

housing units to create a progression of housing into and out of the Burnaby Centre for Mental Health

and Addictions, or to address a sudden increase in street homeless on the boulevard of downtown

Victoria.

Based on focus group consultations, service providers, police and government staff have noticed a

visible decrease in the number of street entrenched individuals “sleeping rough” in their communities,

and attribute these successes to HIP, other integration initiatives and partnerships, and the strong focus

currently placed on assisting these vulnerable clients.

In addition to providing better, more responsive and integrated care for these clients, the project

provided the partners and the province an opportunity to better understand the demographics of this

vulnerable group. The following data was collected about the chronically homeless in the five

communities:

Of the 3914 people housed:

2068 were among the most street entrenched and vulnerable

85% have remained stably housed over 12 months

84 % received income assistance

30% were self identified as aboriginal

35% were female

20% are 31 and under, 74% are between 32 and 61, and only 6% are over 61

Analysis of Outcomes

In order to complete an evaluation of client outcomes, the project looked to another database with

client information across the required agency sources. Simon Fraser University (SFU) has a government

and university approved, secure, and anonymous inter-ministry database that can match individual level

information from Corrections, Ministry of Health Services, and Ministry of Social Development.

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At the time of the evaluation, the SFU database contained 536 identified HIP clients from the 5

communities, of which 362 had been enrolled in the program for 6 months or more and have more than

two years of historical data, allowing for a comparison between pre and post-HIP. While this is a viable

sample, the SFU client-base consists only of people who have been sentenced in BC. What this means is

that the SFU evaluation examines the client outcomes for that subset of individuals who are chronically

homeless, mentally ill or addicted, and use many of the most expensive social programs, including social,

health and justice systems.

Among the 536 individuals, nearly one third are female (29%) and over one quarter are self-identified as

Aboriginal (27%). The average (mean) age of participants at the time of enrolment was about 38 years.

Over one half of participants (52%) had not completed secondary school. Nearly three quarters (74%) of

the participants had been diagnosed with both a substance use disorder and at least one additional non-

substance related mental disorder.

HIP participants received significant amounts of financial support from the Province prior to their

enrolment in the program. On average, participants received $55,380 prior to entering HIP. A further

$11,840 is associated with lifetime MSP services per person. On average, this subset of HIP participants

had been convicted of 8.4 offenses per person prior to enrolment in the program. Indirect costs, such as

ambulance, police, and emergency room services would increase the overall public costs for services to

these individuals. In total, the results indicate that significant public investments have not been

sufficient to prevent individuals from becoming homeless. Improved outcomes, such as sustained

housing, improved health, and improved public safety may require additional investments, changes in

program delivery, or both.

Preliminary outcome results from the participation of these clients in HIP are available. The results

indicate significant increases in shelter payments for HIP participants and increases in outpatient

medical services. This is an expected result of transitioning from chronic homelessness to housing. HIP

is also associated with improvements in public safety as indicated by significant reductions in offending

among participants.

These results suggest that HIP has identified individuals with complex needs who have been in contact

with diverse publicly administered services including justice, health, and income assistance. The fact

that HIP participants are homeless at the time of enrolment is evidence that previous public programs

have been insufficient to promote rehabilitation and recovery. The SFU evaluation notes that “the short

term outcome data indicate that HIP has the promise to succeed where previous interventions and

initiatives have failed”.

Further analysis is necessary in order to extend this preliminary research. This would include examining

the client outcomes over a longer time frame and understanding changes in which services the clients

accessed over that longer time frame.

Community Results

A single integrated team was created in every community. Teams included the regional Health

Authority, regional BC Housing staff, the Ministries of Social Development, Health Services and Public

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Safety and Solicitor General, and an extensive list of local community groups and non-profit

organizations. Each community achieved significant gains in terms of serving the chronically homeless.

Vancouver has new integrated teams to provide health and social services in designated Single Room

Occupancy units throughout the city. Using existing resources, agencies were able to address some

systemic barriers to dealing with the chronically homeless, including opening an additional 44 spaces as

a temporary measure to address the need for post-Burnaby Centre for Mental Health and Addictions

treatment. A new supportive housing facility was opened in Mission, with health services from the local

health authority, some spaces within which have been dedicated to clients departing BCMHA. Spaces

were identified in an existing downtown Vancouver supportive housing facility to better prepare clients

for BCMHA treatment. This was all done within the first 12 months of HIP operation. This initiative won

a Premier’s Award in 2010.

In Surrey, the city, service providers, government agencies and health authorities quickly moved to

adopt HIP and house the chronically homeless. They created a new integrated team known as the

Surrey Homelessness Outreach Works. This team was fully integrated and effectively used community

resources to house HIP clients. This initiative won a Premier’s Finalist Award in 2011.

Like Surrey, Prince George has developed a strong community-based integrated team. Partnerships

with the Central Interior Native Health Society and the Northern Health Authority Community Response

Unit (CRU), along with Assertive Community Treatment (ACT) teams, provide priority access to services.

The HIP partnership also created new capacity to seize unique opportunities and solve problems as they

arise. For example, in the summer of 2010, Victoria faced an increasing problem with the concentration

of homeless people, drug and sex trade, interference with local businesses and camping on the

boulevard at the 900 block of Pandora Street. The Ministry, the City of Victoria, Victoria police, BC

Housing, the Greater Victoria Coalition to End Homelessness, and the Vancouver Island Health Authority

coordinated to provide housing, services and supports, and enforcement. As a result of focused effort,

upwards of 60 people were housed within a few short weeks. This initiative won a Premier’s Finalist

Award in 2011.

In Kelowna, partners built on the success of existing integration initiatives and case management

models. Working in collaboration with BC Housing, the City of Kelowna and Canadian Mental Health

Association has resulted in new transitional and supportive housing units in the community.

Challenges and Lessons Learned A HIP Review was undertaken to ascertain how well the project was implemented, and to collect the

lessons, experiences and recommendations from the participants. The following observations are

collected from surveys, interviews and community focus groups of key project participants. Additional

feedback from these tools has been attached as Appendices:

B. Summary of Community Focus Groups Feedback

C. Summary of Survey to Community Team Members

D. Summary of Survey to Other Project Team Members

8


E. Summary of Telephone Interviews

Strong Focus

The clear focus of HIP allowed the partners in the community to mobilize around a specific group of

clients. Most partners felt that this client group was a good place to focus, and saw the work as

“bringing focus to a very vulnerable and often difficult client group” that might not otherwise have been

housed or received the services and supports being offered.

In particular the Specialized Community Assistance Program (SCAP) was identified as being a good model for better service to clients. While it is too early to assess the client outcomes from that work, partners pointed to the 30 month duration of the program and the ability to provide long-term care management as being necessary to help the chronically homeless transition off of the street and develop the life skills necessary to stay off the street. Partners at the community level reported that clients received quicker access to supports and services. These partners also report much better outcomes for the clients, and identified HIP as being an important part of the communities’ visible successes in addressing the needs of homeless people. The five HIP communities met and exceeded their targets for attaching clients to housing and supports.

Initial targets for the project were set at 1720 clients, and by the end of the project, the communities

had housed 3914.

Counting was an important aspect of the HIP project, and something that the province had not done

before. While there were challenges in ensuring that client privacy was maintained, the tracking of HIP

clients housed and their retention and attachment to supports and service rates were an integral part of

demonstrating success in the project.

Lesson Learned: Establish a clearly defined focus on a target client group, with input from the target communities Lesson Learned: Set clear tangible short term targets, within the context of longer term objectives

Governance and Accountability

A key success factor was the strong and clear direction by key decision-makers in launching the project.

The Ministry of Social Development’s leadership was described as “strong” and “active” by the partners.

Partners in the communities felt that the project involved MSD more than they had been before, and at

a different, more “street level”. Virtually all partners felt that the involvement of MSD as an active part

of the teams was a huge gain, and appreciated that the project brought a wide range of government

ministries and agencies to be involved and engaged.

In one community, MSD was initially not welcomed into the fold of community based service providers

until the gains of integration were starting to be seen, and the collaborative relationships were

developed. In another community, there was also an initial sense that government getting involved in

this kind of integration project was threatening to service providers. This delayed the implementation

of some aspects of the HIP project by several months, but once the relationships were better

established, the integration teams in that community became very strong and effective.

9


Government partners felt a strong connection to the corporate policy and governance of the HIP project

(see Figure 2), but some non-governmental community partners wanted a stronger direct connection to

both HIP corporate and to the data collection and dissemination. Most partners felt that there was

excellent communication at the executive and senior management levels, and amongst partners at the

street level, but a lack of vertical communication between the executives of some agencies, through

their management structures, and out to the front line street workers. The project team tried to address

this challenge by issuing communications that showed the high level endorsement of the project and its

objectives, but this messaging was apparently not always successful in reaching all affected managers

and staff.

Figure 2: HIP governance structure

Lesson Learned: Establish a strong mandate and governance structure, and ensure both are

communicated throughout the partner organizations

Action Orientation

Some HIP partners felt that the project got off to a rocky start, but developed as the project was

implemented, adapting to the needs of the partners and the community and developing clarity as the

community integration teams began working together. One reason for the project’s initial challenges

may be because of the way the project was designed – where guidelines were developed but the detail

of the implementation was left to the new community teams to determine. Another possible challenge

was due to the project was being implemented in communities which had demonstrated leadership in

implementing other homelessness initiatives, meaning that the new HIP teams had to determine how

10


they integrated with any existing teams and projects, and forcing them to quickly adapt the HIP model

to meet the existing circumstances and needs of the community.

Having the autonomy to make changes, and adapt the HIP structure helped the community teams keep

up with their clients and their needs. Partners identified the need to be flexible and adaptive, and the

need for “freedom” when providing quality service to the clients. They also identified the need to

maintain a strict client focus, and to be able to work with them wherever they are. They felt that they

were able to do this through the HIP project.

Lesson Learned: Start quickly and adjust as necessary, but try to provide additional frameworks to assist

with initial start-up

Client Information Sharing

Information sharing was determined to be a critical component of an integrated program and was identified as the single greatest challenge facing the project partners. What partners discovered through this project was that the current system of privacy protection and the individual agency cultures around information sharing inhibited the exchange of client information, even once the clients had signed a consent form authorizing that sharing. In some cases, there was distrust between the partners as to how the information would be used, and for what purpose the government might want to collect the data. What partners did agree on was that the sharing of information was critical, and that this is a systemic issue that needs to be addressed at a provincial level. All partners recommend further work to balance the interests of client privacy and the need to provide data and information for better, more integrated services in order to achieve integration. Partners working on the integrated teams also expressed the need for a common data collection and

retrieval system. The communities were not all collecting data in the same way, or through the same

tools despite the availability of a common web-based tool. By using different tools, the project created a

large amount of extra work on the back end of the data collection to ensure accuracy.

Lesson Learned: Establish the client information sharing framework prior to the start of the project

Lesson Learned: Require the use of common data collection and retrieval systems when working on

collaboration and integration initiatives

Common Tools and Processes

Participants supported the concept of integrated care planning and care management. In particular they

liked the ability of the care plan to provide a picture of the interactions between clients and providers.

However, implementing care planning was difficult. In order to work in an integrated fashion, teams felt

they needed one consistent care planning and management tool – electronic and available to all

partners. To complicate the issue, there was an expectation that a single electronic tool could be used

for the project, and the teams were depending on that tool being made available. Throughout the

project, it became clear that due to technical and copyright concerns, the tool would not be available to

11


partners. This delayed the implementation of the care planning aspect of HIP for several of the

community teams.

Due to the delay in implementing a complete care planning and care management system, partners felt it was still too early to see effects of true formalized case planning.

Lesson Learned: Provide and require the use of common case planning tools early in the project

Policy Change

One challenge that the project had was the scope of its authority. The project was designed to be

flexible and adapt to the community needs. The concept was that the communities determine how best

to meet the targets within existing resources. The corporate team was there to support the community

teams to assist in making high level decisions and to support them with various frameworks, guidelines

and communications materials. Some of the issues identified at the community level required more

resources than were available corporately, or were in conflict with current provincial policy. While some

policies could be changed, others were harder to tackle and would not be resolved over the course of

the project.

Lesson Learned: Clearly establish the scope of the work, and the ability – if any – to change policy,

regulation and legislation

Resourcing

HIP partners were tasked with working differently, and creating efficiencies without new funding.

Community partner reaction to this challenge was mixed. Many saw the inclusion of no new money as a

good thing; it forced the partners to work differently, avoided competition for funding when trying to

work collaboratively, and it underlined the need to be integrated in order to be successful. However,

other partners felt that the lack of funding created additional pressure. Those partners pointed out that

they were shifting resources to focus on this project, creating pressures elsewhere in the system. In

addition, while HIP was meant to be done with no additional funding, project partners did point to new

resources such as newly available housing units that were instrumental to the success of the project.

Teams also identified several areas where resources were lacking:

Mental health and addictions resources were not always available to the teams, or were fully

committed in the communities.

A limited number of rental supplements, which were critical for accessing market housing for

these clients.

In many communities, there are gaps in the types of housing and supports available to this client

group, and a challenge in moving clients through the natural progression of housing: from highly

supported to less supported and even complete independence. Without the availability of these

units, and a review of the alignment of the incentives to encourage this progression, client flows

will slow or stop and it becomes difficult to assist new clients coming off the street.

There are limited human resources and capacity available to do outreach and follow-up with

clients to ensure that they maintain their housing and do not “decompensate” and return to

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their street lifestyle. When staff were dedicated to these clients with a smaller caseload, staff

felt that they could properly support the clients.

Ongoing funding is required for many of the innovative solutions developed in the communities.

For example, the opening of beds to support client flow into and out of Burnaby Centre for

Mental Health and Addictions created an opportunity to help clients stabilize, then get clinical

treatment, and finally to move out of the treatment phase and into recovery at a different

location. Community partners such as BC Housing, MSD and Vancouver Coastal Health pooled

resources for this initiative, but the long term sustainability of the solution will require specific

ongoing funding.

Lesson Learned: Understand and have access to project resources: staff, housing, health services.

Develop contingency for identified gaps when resources do not exist, or cannot be reallocated

Collecting and Evaluating Data

Over the course of the HIP project, the Ministry of Social Development and the secure lab negotiated

the collection of data and matched that data across the different sources. Numerous Ministries, Health

Authorities and BC Housing invested resources to supply information into the lab. Information about

the number of clients housed via HIP, housing status and demographics was shared in bi-weekly and

monthly reports. However, there were significant challenges in getting timely access to the full range of

information needed to support the planned approach to the evaluation. By March, 2011, 12 of the

original 17 organizations had provided data to the Lab2 at least once.

Some challenges surrounding data management included:

Partner scale and complexity: All data retrieval and management processes had to align

effectively with the multiple technology systems and requirements of each data partner. In

some cases, those technologies changed or were upgraded over the course of the project. To

meet the security and technology requirements of each partner and system, three separate

retrieval methods were deployed. Using different retrieval methods was the best solution to

accommodate each partner’s needs, but added complexity to the project.

Real time Reporting and Currency of Data: All partners were required to provide data on bi-

weekly or monthly intervals in order to update the information on the clients already included in

the Lab cohort, or to provide information on new HIP clients. This meant that all data sources

had to be refreshed on a regular basis, either as complete data set replacements or incremental

merging of data sets. Additionally, because the focus of the HIP project was to continuously

connect homeless people with housing and supports, the client cohort in the Lab was always

increasing.

Identity data quality: Quality issues with identity data were common. It was therefore a

challenge to associate some of the HIP clients with other partner data sources.

Data security and handling processes limited utility of Lab data: To keep the data secure, extra

steps had to be implemented such as additional security and privacy protocols, chain of custody

2 The Provincial Health Authority was not expected to provide data to the Lab.

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processes and documentation. For security reasons, the Lab was not connected to any

networks and had no access to external systems. The final stage for all data retrieval was

physically carrying the data into the Lab. This security measure meant that data extract,

transformation, and load processes could not be fully automated, and all data retrieval work

needed to be performed by researchers on systems external to the lab. Additionally, HIP client

identities could not be disclosed to partners. Therefore, partners could not use the HIP client

cohort to externally validate the reported values coming from the Lab, which was a frustration

for some partners in the communities who did not feel the lab data was reflective of their

successes.

Despite these challenges, the tracking of client’s housing status was an important part of the HIP

project. In many cases, this was the first time that community partners had access to near real-time

information about their progress in housing the homeless. While many participants expressed

frustration with the process and barriers for collecting and evaluating data, community partners

generally felt that the project was more successful in implementing information sharing processes than

provincial partners (see Appendices C & D). This could be because provincial partners were more

focussed on the process challenges while community partners were focussed on using the information

to assist clients and demonstrate results.

Lessons Learned: Enlist subject matter experts to design and establish the evaluation and

performance measurement frameworks. Keep track of targets in order to show success and report

out to stakeholders. Design data collection and integration processes that are efficient and will

result in reports that measure results accurately and in a timely way.

Build Relationships and Trust amongst the Partners

One major success identified by HIP partners was the forging and strengthening of relationships and

trust between partners in this initiative, including government, agencies, service providers, and clients.

This kind of strong focus to assist a very vulnerable client group in an integrated fashion drew the

partners together and led to a better understanding of the community’s needs, resources, processes

and gaps in services. It also strengthened the partnerships and relationships, leading to new and

increased capacity for this project and for other integration initiatives in the field. Partners in the

communalities felt this led to better collaboration and a decreased competition for resources. In some

communities the teams were able to leverage this new relationship to help implement other local

initiatives.

Building trust between service providers and with government was an important theme of the

collaboration and team work of the HIP project. Building trust was also an important factor in working

with clients. Partners spoke of how working with the client as a team made it easier to connect the

client to services, made the client feel more supported and more comfortable, and lead the client to be

more trusting of the partners and of the help and support that they could provide.

Lesson Learned: Build on existing capacity, experience and successes in the communities. Building

relationships and trust amongst the partners is key.

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Empowered the Community to take Leadership

Front line workers (especially government staff) really felt that HIP gave them the permission to go out

into the community and work differently. The guidelines and service framework were meant to be

flexible enough to be adapted to the local community context. This was something that the integration

teams found critical to the successful implementation of the project. Allowing the project to be shaped

and developed at the community level also allowed the partners to link the work into existing and new

community, local government, provincial and federal projects and initiatives.

Lessons Learned: Empower the community teams to take leadership and adapt the project frameworks

for the unique conditions of the community. Get out into the community, and create the permission to

work differently.

Housing

Certainly one of the major successes of the project was the HIP partners’ ability to connect BC’s most

vulnerable people with housing, and providing a safe place where they could start to get the services

and supports they need to transition from the street lifestyle. Community teams worked hard to find

available units, and to secure new units for the project.

BC Housing’s outreach workers played a key part in connecting clients with housing in the five

communities. Community teams were able to place clients in both subsidized and market rental

housing. Some key factors for housing success were identified by the communities:

Outreach workers

Availability of units along the entire continuum of housing: shelters, subsidized and supportive

housing, Single Room Occupancy (SRO) and private market rental units

Rent supplements for accessing market housing

Availability of security deposits

Relationships with community-based collaborations and initiatives

Service delivery model where all agencies involved in providing services to the client, plan and

case manage in an integrated and collaborative manner

Cooperation with municipal, provincial and federal government agencies for new project

development and funding.

Government and non-profit organisations are now working even more collaboratively than before to

identify and remove barriers to services that assist individuals to break the cycle of homelessness.

Learning about Clients

The HIP project discovered and validated demographic information about the client group and the

services and approaches that are effective for assisting them to be housed and remain housed.

Data collected tells us about the chronically homeless with mental health and addictions in the five HIP

communities, their gender, the representation of Aboriginals, and age ranges. This information can be

used to focus the services and supports for these client groups.

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We also heard from our partners that the communities now have a stronger understanding of the

services and supports that they are supplying, and can make better decisions about how to connect the

clients to what they need. These clients are almost always in a state of crisis – especially when they

come to the program, and teams need to be able to capitalize immediately on opportunities to connect

the clients to services, lest their situation worsen in the short term. Knowing the client needs, the

services available, and having the relationships with the community partners allow the teams to react

quickly and effectively when an opportunity to help a client presents itself.

We also learnt firsthand about what kinds of housing works for clients. For example, community teams

leaned about client mixes in buildings. In one community, the team was able to secure a large number

of units in a single building to transition their HIP clients off of the street. The building had excellent

services and supports, and was also the site for the SCAP pilot, allowing access to additional resources

like life skills training. But the teams soon found that there were too many HIP clients in the same

building, and the mix was having a negative effect on both the HIP clients and on the other tenants.

Conclusion HIP set out to house 1,800 people within 18 months and succeeded in housing 3,209 in that time period.

As a result of this success, the deputy ministers instructed the teams to extend the HIP project

indefinitely. As of January 2011, HIP had housed just under 4,000 people, more than half of whom can

be confirmed to be chronically homeless, and 85% of whom remain stably housed after a year.

The housing retention numbers from the Secure Lab show that through initiatives such as HIP we can

help stabilize chronically homeless clients in housing, and work with them to address their needs. Many

partners felt that there were noticeable changes in the communities, and in the clients, and attributed

those changes to the focus on these vulnerable clients through HIP and other innovative community

initiatives and partnerships.

HIP was implemented using existing resources better and more creatively. At the agency-to-agency

level, the partners had to develop structure and processes to identify, dedicate and track resources, as

well as establish collaborative decision-making and dispute resolution structures, and support

information sharing for decision support and monitoring. HIP has taught us a new way of doing business

to support this complex client population.

HIP has also provided valuable lessons in how to address integrated service delivery and collaboration

between government agencies and with communities. We are leveraging these lessons to undertake

new projects focusing on youth, adults leaving correctional facilities and young parents on income

assistance.

On September 21, 2011, HIP was the recipient of the national Excellence in Public Service Delivery

Award presented by the Public Sector Service Delivery Council in recognition of the project’s

commitment to client service through integrated service delivery.

A-1


Appendix A: Definitions Used in HIP

Term Definition(s)

Aboriginal An Aboriginal person is identified in accordance to the Constitution Act of 1982, Part 11, Section 35(2), as "the Indian, Inuit and Métis peoples of Canada". Canada's Aboriginal population is distinct and diverse. The Constitution Act recognizes the aboriginal peoples of Canada as the Indian, Inuit and Métis peoples of Canada. Identification of persons of Aboriginal descent is generally based on voluntary self-disclosure, or, as applicable, on the ability to confirm status from other information sources.

Chronically Homeless Homeless individual who has been continuously homeless for more than a year, or has cycled in and out of homelessness for over a year.

Employment Support Services include transitional employment services, supported employment services, work experience, self-employment support and consumer-run businesses or co-operatives. Supported employment assists people with mental illness and/or addictions find and keep competitive employment within their communities. “Competitive employment” refers to work in the community that anyone can apply for and pays at least minimum wage; the wage should not be less than the normal wage (and level of benefits) paid for the same work performed by individuals who do not have a mental illness.

HIP Clients Individuals who have been continuously or episodically homeless for more than a year (i.e. chronically homeless) AND have a severe and persistent mental disorder or addiction.

Homeless Individuals and families who are living in public spaces without legal claim (e.g. on the streets, in abandoned buildings, in tent cities); or in temporary accommodation (e.g., a homeless shelter; a public facility or service such as a hospital, care facility, rehabilitation or treatment centre, correctional facility in which the person cannot return to a stable residence; or ‘couch surfing’ or staying in a guest room); or individuals and families who are financially, sexually, physically or emotionally exploited to maintain their shelter.

Housing and Support Continuum

Describes a housing spectrum that is bound by street homelessness on one end and private market housing on the other end. The continuum inherently implies that individuals are able to move along this housing pathway gaining additional stability and independence at each stage. Elements or stages of the continuum are: living on the streets, emergency shelters, transitional or supportive housing, independent non-market housing or rent assistance in the private market, and private housing market in the form of both rental and ownership.

Life Skills Support

Life Skills Support services include a wide range of flexible support services and individualized skill training and assistance, usually provided in the client's natural home environment, which may vary in intensity and may include assistance by addressing any or more of the following areas: Personal Care, (personal hygiene, self-care skills); Household Management (laundry, cleaning, nutrition, food preparation,

A-2


menu planning, shopping); Liaison/Advocacy (liaison and advocacy to fully utilize existing community, health and municipal services); Money Management (budgeting, banking); Housing Support (liaison/support to landlord, utility companies); Self-Management (problem-solving, decision-making, communication, interpersonal skills, goal setting); Community Integration (building social contacts, use of public services – transit); Health services (monitoring medication compliance, crisis management, ongoing access to health service).

Mental Disorder

A severe and persistent mental illness or neuro-developmental disorder, such as one or more of the following conditions: a. A severe and persistent mental illness such as a diagnosis of schizophrenia

spectrum disorder, bipolar disorder or major mood disorder. b. A severe and persistent substance use disorder of greater than six months. c. A severe personality disorder – e.g., paranoid personality disorder,

borderline personality disorder, antisocial personality disorder. d. Chronic post-traumatic stress disorder e. Severe neurodevelopment disorder, (an impairment of the growth and

development of the brain or central nervous system which occurred during birth, infancy or childhood), including those with fetal alcohol spectrum disorder and autism spectrum disorder.

f. Acquired brain injury.

Outreach Services Services delivered by a broad range of Outreach workers to the homeless at their current location; e.g. to people sleeping outdoors, those who are ‘couch-surfing’, at immediate risk of homelessness, hidden or absolute homelessness, at community partner service provider agencies, temporary housing locations, and in the client’s home once housed. Services include, but are not limited to referrals to social and health services, housing and income assistance.

Stable Housing / Accommodation

Housing is defined as a self contained structure (includes SROs) that provides a dwelling for individuals and families. Stable accommodation is defined as allowing for tenancy of more than 30 days. This range includes supported, transitional housing, independent, social or private market housing. Being housed does not include emergency shelters, transition houses or camp sites.

Transitional Housing Transitional housing is intended to offer a supportive living environment with tools and opportunities for social and skill development. While transitional housing has limits on the length of stay, it is an intermediate step beyond emergency shelters (maximum 30 day stay) along the housing continuum.

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Appendix B: Community Focus Group Feedback

The Community Focus Groups yielded hundreds of pages of feedback and commentary. The following is

a high level rollup of those discussions. In some places, the exact words of participants are included. To

add structure to the material, the feedback is presented in sections based on the following themes:

Establish Accountability and Focus on Results

Establish Clear Governance

Promote Innovation

Establish Program Collaboration

Establish Service Integration

Establish Accountability and Focus on Results – Integrate efforts to meet a real need or solve

a real problem. Establish the partners’ accountability and commitment to do this together.

Establish an agreed definition of “chronically homeless” & HIP Clients

HIP clients were defined as “Individuals who have been continuously or episodically homeless for more

than a year (i.e. chronically homeless) and have a severe and persistent mental disorder or addiction.”

Most partners felt that this client group was a good place to focus, and saw the work as “bringing focus

to a very vulnerable and often difficult client group” that might not otherwise have been housed or

received the services and supports being offered. Some felt that the definition expanded the focus for

some agencies, putting them in contact with a wider range of clients with more challenging barriers.

While there was general agreement that this client group was extremely vulnerable, and in great need,

some partners expressed that they would have liked the communities to be involved in the selection of

the target client groups, depending on the need in the community. In some communities there was also

some initial difficulty in defining homelessness (street entrenched versus in shelters or no-fixed-

address). Despite these challenges, most partners felt that the intended target group was clearly

established and made sense as a focus.

Implement teams in the five HIP communities within 90 days

The idea behind HIP was to get started quickly, to start focussing the services and supports that are

already in place in the communities on the these vulnerable clients, and the develop the pilot iteratively,

building on the housing successes, and expanding, adjusting, and focussing the processes as necessary.

Because of this strong focus on immediate results, it made sense to launch this work in communities

which had demonstrated a commitment to taking a lead in resolving homelessness through various

community and local government mechanisms. By building on these activities and successes, and

ensuring that the provincial government supports and services were well integrated into community

teams, the project could be established quickly and “learn by doing”. HIP was launched on March 2,

2009. By June 2009, teams were established in the 5 identified HIP communities: Vancouver, Victoria,

Surrey, Kelowna and Prince George. By July the teams had already attached hundreds of British

Columbians to housing.

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Establish and monitor targets numbers of HIP clients to be housed in each community

HIP established target numbers of chronically homeless clients in each of the communities based on

estimates from the communities’ homeless counts. This process was initially contentious as not all

communities were comfortable with the target numbers established. Counting homeless people is often

difficult due to differing methodologies and different definitions of “homelessness”. But after the

project was implemented, the community partners felt that the targets were helpful in gauging their

successes, and provided a tangible way of demonstrating their successes. In many of these communities,

they had never counted the number of clients they were helping before, and this served to build a sense

of accomplishment and to further motivate the teams.

Targets and Counting Clients Housed

In order to track community progress against the target numbers of clients housed, the project

developed two mechanisms to count and track clients housed. The first was a Webtool, accessible to all

the front line workers doing client intake, and the HIP Secure Lab which collected client data from

various partners and reported back on client demographics and on performance measurement versus

targets. There were significant successes and challenges to implementing the data collection function of

the secure lab, and both of these perspectives were reflected in the partner feedback. In general,

partners felt that the process was difficult, overly complex, and they were disappointed that the

protection of privacy rules did not permit them to see or interact with the Lab data in the way they

wanted or expected. However, the data that came back was identified as useful and positive, both for

showing success and for motivating the partners.

Governance structure

MSD had the lead accountability for the implementation and management of the project. Partners

universally felt that the there was a strong understanding of MSD’s accountability, and felt that the

ministry did a good job managing the project. Most partners felt that the Ministry provided the

necessary corporate support and liaison roles. While not all partners in the communities received the

target reports, those partners that did receive them found them useful. One community experienced a

delay in implementing the Information Sharing protocols, while they waited for the Ministry staff to

work with the Office of the Chief Information Officer (OCIO) on privacy concerns. Community teams

were also disappointed that the Ministry could not negotiate the use of the BC Housing Case

Management Tool at a provincial level for use in the HIP communities, and by all of the HIP partners.

However, nearly all community partners felt that the Ministry did a good job of leading the project, and

were particularly happy with the involvement of the ministry at all levels of the project – from deputy

minister and ADM level support and leadership, to the corporate supports and assistance, to the

involvement of Ministry staff at street level, working with clients.

Establish Clear Governance – Establish clear roles and responsibilities. Establish ways to get

decisions made and implemented

Cabinet’s strong mandate

Community partners and government partners found the strong and clear direction of Cabinet to be

B-3


critical to the development and implementation of the project. The Core Elements of HIP were seen as a

clear way to communicate the direction of Cabinet

Ministry SD Involvement

MSD’s leadership was described as “strong” and “active” by the partners. People in the communities felt

that the project involved MSD more than they had been before, and at a different, more street level.

Virtually all partners felt that the involvement of MSD as an active part of the teams was a huge gain,

and appreciated that the project brought a wide range of government ministries and agencies to be

involved and engaged.

In one community, MSD was initially not welcomed into the fold of community based service providers

until the gains of integration were starting to be seen, and the collaborative relationships were

developed. In another community, there was also an initial sense that government getting involved in

this kind of integration project was threatening to service providers. This delayed the implementation

of some aspects of the HIP project by several months, but once the relationships were better

established, the integration teams in that community became very strong and effective.

Government partners felt a strong connection to the corporate policy and governance of the HIP

project, but some non-governmental community partners wanted a stronger direct connection to both

HIP corporate and to the data collection and dissemination.

Involvement of other Ministries and Agencies

Partners felt that the project was successful in bringing ministries and agencies together to work with

the communities. “HIP made sure that each organization is held accountable for their piece of the pie.

Organizations are anteing up when before they might have passed the buck” saying that they only deal

in some part of the system of supports. Partners also felt that the project brought together players at a

higher level to be engaged in developing solutions for challenges at the local level.

However, this was not always the sense in all five HIP communities. In some communities, there was not

strong sense that this project was wider than MSD (and BC Housing) – of it being inter-ministerial.

Several communities wanted a stronger partnership with Health Authorities (especially mental health

and addictions and Acquired Brain Injury supports), the Ministry of Child and Family Development

(MCFD) and with corrections and law enforcement.

Community governance

A key principle of the project was that the community needed to be central to the development,

implementation and decision making of the project. The model of the project was set provincially and

formalized through the Service Framework and the Operational Guidelines, but the implementation was

meant to provide the flexibility to adapt the model in the community, allowing the partners, including

the service providers to be engaged, and to determine how best to work together and focus on the

clients. Community partners formalized their implementation through the creation of community driven

action plans that outlined the structures of community based governance, resources, and the design and

implementation of integrated teams, and through MOUs that formalized their commitment and

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participation. This structure allowed the teams to be flexible and open to adjusting the approach and

implementation to accommodate the needs and concerns of the partners.

This strong focus on community governance was also meant to encourage innovation and efficiencies at

the community level – where the knowledge of what exists, what works, and where the gaps are is the

strongest. This lead to the development of community based solutions to systemic issues, like the Lower

Mainland Client Flow project that opened new beds to support clients moving into and out of the

Burnaby Centre for Mental Health and Addictions.

“More resources are always wanted, but the project worked by having the community partners with

resources come together over a common focus.”

Rocky start

Some HIP partners felt that the project got off to a rocky start, but developed as the project was

implemented, adapting to the needs of the partners and the community and developing clarity as the

community integration teams began working together. One reason for the project’s initial challenges in

the community may be because of the way the project was designed – where guidelines were

developed but the detail of the implementation was left to the new community teams to determine.

Another possible challenge was because the project was being implemented in communities which had

demonstrated leadership in implementing other homelessness initiatives, meaning that the new HIP

teams had to determine how they integrated with any existing teams and projects.

Communication

Some partners felt there was a lack of communication vertically within some of their partner agencies. Although most felt that there was excellent communication at the executive and senior management levels, strong communication and excellent formal and informal communication amongst partners at the street level, some identified a lack of vertical communication from the executives of some agencies, through their management structures, and out to the front line street workers. Teams would report speaking to people within the organizations who were not familiar with the project, or were directing staff to do things that contradicted the goals of the project.

Promote Innovation – Empower and motivate the partners to be creative and self-initiating.

Implement performance based incentives for teams vs. Innovation

One aspect of the core HIP model that was not implemented was the performance incentives for teams,

and the reallocation of funding from teams that were not producing results. This was determined very

early on the project to be contrary to the team, relationship and trust building that was required to

effectively develop and implement an integration project at the community level. Instead, the corporate

team re-characterized this as the need to empower the communities to take ownership and leadership

of the project at the community level, and determine which resources were available, and how best the

teams could collectively allocate and partner to provide services and supports to their common clients.

Get started immediately on housing chronically homeless clients, and adjust and improve by learning

from mistakes and successes. (do/learn/adapt)

Having the autonomy to make changes, and adapt the HIP structure helped the community teams keep

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up with their clients and their needs. Partners identified the need to be flexible and adaptive, and the

need for “freedom” when providing quality service to the clients. They also identified the need to

maintain a strict client focus, and to be able to work with them wherever they are. They felt that they

were able to do this through the HIP project.

Community teams felt that iterative processes work for a project like this, but in order to get up and

running quickly, the project team must be aware of what is already in place in the community, to work

with existing strengths, and to be able to adapt to meet the unique needs of the community. Some

community partners felt that there was not enough research done into the HIP communities and how to

best capitalize on what was happening already. They felt that this would have provided more traction

and an even faster start. They suggested pulling the communities together in a focus group and doing

some conceptual work up front to determine the specific challenges and barriers in each community, for

example: the lack of SROs and temporary housing in some communities, and the reliance on market

housing. The group could also have looked at the communities’ unique client groups in more detail,

perhaps focusing on local issues such as criminality.

In some cases, the communities proposed innovative solutions that the province was not able to

accommodate due to regulatory or legislative barriers that could not be adjusted within the time frame

required by the community’s identified opportunity.

One success from this project’s approach is that community teams are continuing the do/learn/adapt

approach, looking to continue building on their successes, and are in the process of determining where

their expertise and focus is most needed in their community.

Empower

Community partners described the project and its strong mandate as “the authority to help make

change”. HIP is primarily an integration project that challenges and empowers front line staff and their

management to go out and work better together. Partners in the communities spoke a lot about

“permission” to:

Work more closely together, coming from the strong mandate, and through the senior

leadership.

Do some of the things that they were doing before, specifically around using the resources in

the community differently, more effectively and reducing the duplication of work.

Go out and talk to partners and other players and figure out where the relationships weren’t

working, and address the challenges.

Empowering community teams to work differently and to adapt the HIP model as necessary also

allowed the teams to capitalize on opportunities quickly. In many of the communities, partners spoke of

how the teams developed new initiatives using their strong collaborative relationships. For example,

they mentioned integrated courts and the reallocation and use of rent supplements from various

community partners, which were critical to the successes in housing individuals in some communities.

Establish Program Collaboration – Build ways for the partners to manage policy, programs,

resources and information across agency boundaries.

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“For me it has been putting in the missing pieces of the puzzle.”

Relationship & Trust

Partners identified “competition” among the service providers in the system as an initial challenge to

integrated approaches. However, by working together, liaising and helping each other, building trust,

and capitalizing on synchronicities they felt that they were able to build trust and reduce turf protection.

“The message is commonality, don’t work against each other.”

Partners also pointed to the newly built and strengthened relationships with other government partners

and agencies, like the RCMP, who may not have been integrated in a project like this before.

In most communities, the HIP teams were able to piggyback on or leverage other initiatives happening

around homelessness or integration initiatives around services for disadvantaged people. This meant

that they were leveraging existing partnerships rather than starting from scratch. These relationships

allowed them to get started much more quickly.

In fact, some partners considered the strengthening of these relationships as more important that even

the comprehensive understanding of the services and supports available in the community: “I have been

on many community tables where they have tried to come up with comprehensive lists of services

available. Those are somewhat helpful, but they are very limited. The reality, in my experience, is that it

is the networks that are more important. If you are referring to an agency who you have no idea about,

you are probably not going to do it. You don’t know what you are sending your client into. The

importance of knowing “if I send this person over here, John, who I know and have met, is going to

receive them, and I know that John is going to treat my client well.” That is really important.”

Government / Ministry coming to the table as a meaningful partner

This project was seen as a fundamental shift in the way the ministry works, being much more engaged

and receptive to working collaboratively at the front line worker level and at street level. The addition of

Ministry Employment and Assistance Workers (EAWs) and case workers working remotely at various

locations such as shelters was considered a “critical big win”. This is seen as an important step in

integration, and an “important tool in the toolbox”.

Collaboration

HIP partners felt that the project was very helpful at formalizing and furthering many of the informal

relationships, partnerships and collaborations that were already in place in many of the communities.

They felt that the project created a sense of “the community” through the collaborative focus, and client

centered partnerships. Partners identified this kind of collaboration as allowing a “bird’s-eye view” of

the system of supports in the community – allowing the community teams to see the gaps and the

overlaps, and redeploy and address those challenges. Some partners described HIP as “working

smarter”, and really appreciated the way that the community was brought together to be part of the

design and implementation in their community. Collaboration was achieved by having a formal

mandate to work together and is supported by regular joint meetings. Meetings help make sure that as

changes happen, there are no gaps in service that form. The tables that were created were necessary for

sharing challenges and for problem solving.

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“There is a place for the organic and the flexible, but within a larger context – a big picture.”

“HIP was a great way for government agencies and service providers to meet and have a better

understanding of what each other do. It provided a place to work together on systemic issues, case

manage people, analyze gaps in service as a community.”

Communication

Collaboration and the development of relationships between partners are based on communication and

on the development of trust. Teams found that the HIP mandate allowed them the opportunity to go

out and learn from each other, and develop collaborative understanding of the services, challenges and

opportunities that exist in the community. One example in particular that was the discharge of clients

from hospital. Before HIP there was sometimes a lack of communication between the hospital and the

shelters, but the stronger communication between these partners has greatly reduced this occurrence:

“I have heard a real change in the relationship between the shelters and the hospital. They used to

complain very regularly about (clients being) discharged, put into a taxi and sent to a shelter, without the

shelter knowing. Now it is really rare that I hear that. And if I do hear that, they said, “oh yes, we

phoned them up and they are back on track.”

Teams also felt that communication with government and between government partners was also

greatly improved. One partner relayed an example where a client had been earmarked for housing by

both BC Housing and by the local health authority. Through their participation at the HIP table and other

integration initiatives, they were able to understand the overlaps in their allocation of housing, and

correct those processes.

Learning from each other

Linked to building better relationships and collaborative partnerships is the opportunity to learn from

each other. Partners felt that they were able share and learn about how best to provide care to these

vulnerable clients in a holistic way. So much of the service and support that gets provided is about

dealing with a client’s immediate crisis, and staff at the front line don’t often have the time or

opportunity to learn about what supports and services are being provided by other partners, or how

those services might or might not be appropriate for the client and their crisis; for example one team

spoke about the opportunity to learn from ACT and the Ministry of Health about assisting these clients

and some of their health challenges.

Funding

HIP was tasked with working differently, and creating efficiencies without new funding. Community

partner reaction to this challenge was mixed. Many saw the inclusion of no new money as a good thing

as it forced the partners to work differently, avoided the challenge of working collaboratively while

trying to access a limited pool of funding, and underlined the need to be integrated in order to be

successful. However, other partners felt that the lack of funding created additional pressure. Those

partners pointed out that while they were shifting resources to focus on this project’s vulnerable target

group, they were creating pressures elsewhere in the system for other client groups not included in the

project. One example of this was the redeployment of shelter workers to do outreach work: “I had to

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shift some resources. I had to orientate them differently. I now have shelter workers out in the

community doing the housing support, doing the business for the rent subsidy, because these outreach

workers are swamped... We don’t have enough outreach workers”.

Overall, partners were quite proud of their accomplishments in working together within their existing

funding and resources to meet the project targets. As one partner said “Look at what we can do with no

(new) resources, imagine what we could do with resources”.

“This is an issue, something we are all facing. It wasn’t so much about the money; it was about the

people and trying to provide the service. “

It should be noted that while HIP was meant to be done with no additional funding, project partners did

point to new resources that were instrumental in the success of the project. Throughout the course of

the project renovations on several of the government owned SROs were completed and were made

available for occupancy. This allowed the project teams in Vancouver to place many chronically

homeless clients in what amounted to new housing resources. Along those same lines, the SCAP

program leveraged additional funding to connect clients to life and employment skills services and

supports to prepare them for their eventual reconnection to work or volunteer activities in the

communities. One of the real advantages of the SCAP program that was identified by partners was the

long term case management provided.

Redeploying resources

Partners all indicated that the redeployment of resources takes time. Often it is difficult to shift staff

resources to work differently without creating a service gap or increasing the work load of other staff.

One community assigned a specific resource to work on this. In many cases, clear redeployment of staff

resources was difficult or impossible. Many felt that they were running the integration work off the sides

of their desks. Aligning contracts to reflect the HIP project was also a challenge.

These challenges aside, the partners did feel that through collaboration and service integration, that

they were are using people’s time better, and getting better results with less duplication.

Establish Service Integration – Establish ways for partners to provide client services and care

across agencies and disciplines based on the needs of the client. Implement integrated teams developed

around the unique players, services and resources in each community

Integration in General

Partners found that, through HIP, coordination and integration was now happening at the street level as

well as the management level, and found great benefit in learning from each other and understanding

the approaches being taken, especially with government and government agencies. Integration has

created more direct contact with a worker, making things more timely and expedient. The project

created an understanding of the processes and policies of each agency and partner, eased tensions, and

created a common understanding and approach to helping this vulnerable client group. It also allowed

the partners to quickly connect with people who were knowledgeable about the appropriate resources

available from a given agency and be able to access them, cutting down on barriers and frustration.

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“Being able to call a team or someone who is connected to this client, makes it so much easier to actually

delivery the services that they need.”

Priority access / Queue Jumping

Priority access was challenging and controversial for some partners. The idea of priority access or

“queue jumping” was that once these vulnerable clients were connected to the program, that they

would be connected to services and supports immediately, jumping ahead of other “less vulnerable”

clients if necessary. This was difficult for some service providers, such as health services who were not

able to prioritize a HIP client over another individual with similar immediate health needs. Some

agencies felt that the priority access created two classes of client – HIP clients and non-HIP client - and

were not comfortable with this. On many cases community partners developed services that were

targeted to the HIP client group but were available to other vulnerable people as well. An example of

this is the SCAP program, where services were made available at housing facilities where SCAP clients

were housed, and although the services (life skills training for example) were targeted to the clients,

other tenants (HIP and otherwise) in the facility were able to participate and access those services as

well.

MHSD redeployed EAWs to different locations in the community. This was very successful, and the staff

that were involved felt much better connected and integrated into the community. This redeployment

also allowed them to provide priority, immediate access to income supports in most communities,

whether they were equipped to connect clients to income assistance supports or to the HIP program

itself “on the fly”, or whether they provided priority access by bringing the client into the office and

connected them there. Partners felt that this process was a success and resulted in “less barriers, less

bureaucracy, and less frustration”.

Housing access was prioritized when possible. One partner told of an example of having been working

with a client for several months, and then, when they were able to coordinate through integrated

teams, managed to secure housing and supports easily and quickly for their client. One partner pointed

out that “Connections to housing are faster and new connections to housing are being formed.”

Response around health supports was mixed – some got connected quickly through the HIP network,

others found that they needed more robust access, or more health support resources to draw on.

Centralized Intake

Screening for HIP clients was often centralized. But intake itself was not always completely centralized -

although it was built around a network of providers who are working closely together. In many cases,

the community implementation relied on the BC Housing HOP and AHOP workers to identify and

coordinate the intake of HIP clients into the program.

Building trust

Building trust between service providers and with government was an important theme of the

collaboration and team work of the HIP project, and it was also an important factor in working with

clients. Partners spoke of how working with the client as a team made it easier to connect the client to

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services, made the client feel more supported and more comfortable, and lead the client to be more

trusting of the partners and of the help and support that they could provide.

Care Management & Care Plans

Participants supported the concept of integrated care planning and care management. In particular they

liked the ability of the care plan to provide a picture of the interactions between clients and providers.

However, implementing care planning was difficult for the communities. In order to work in an

integrated fashion, teams felt they needed one consistent care planning and management tool –

electronic and available to all partners. To complicate the issue, there was an expectation that a single

electronic tool could be used for the project, and the teams were depending on that tool being made

available. Over the course of the project, it became clear that due to technical and copyright concerns,

the tool would not be available to partners. This delayed the implementation of the care planning aspect

of HIP for several of the community teams.

Partners said that clients who did get integrated care are getting better care: a “Cadillac”. Their client

files are kept up to date, and the team is having ongoing communicating with each other around the

client’s needs. Despite the difficulty in implementing it, care planning is happening robustly in

communities where tools have been developed that allow the teams to discuss clients on a person by

person basis.

Partners did indicate that follow-up on care planning can be very challenging for various reasons

including: resource intensity, the fact that providers are often kept completely busy responding to

crises, and the fact that connecting with the clients (who may not have regular schedules) can be very

difficult.

Others communities were able to implement care plan follow-ups, including visiting clients at their

school, or at their housing, reminding them about appointments or even attending the appointments

with them.

Due to the delay in implementing a complete care planning and care management system, partners felt it was still too early to see effects of true formalized case planning. Client information sharing

An important factor in responding to client needs is the sharing of client information. Partners identified

that this information is shared in two ways: informally and formally. Informal information sharing is the

day to day discussions and phone calls that service providers have while attempting to help clients in

crisis get assistance. This kind of information sharing is impermanent, immediate, and depends on the

relationships and knowledge of individual workers and service providers. Community partners feel that

this type of information sharing is working smoothly. However, it’s primarily useful for responding to

immediate client needs, but does not allow for longer term care planning and follow-up. This kind of

immediate short-term sharing leads some partners to describe the process as being “made up as we go

along”.

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Community partners felt that once attempts are made to formalize the sharing of information, that

“nothing moves, everything shuts down”. Partners felt that it was especially difficult to formalize the

sharing of client health information, even with client consent and with the aim of providing better, more

integrated services and supports. Partners felt that this was often a barrier presented by an

organization’s policy or risk aversion, since much of the information is available through other channels.

All partners identified the need to address the entire issue of information sharing at a provincial level –

not just for this project, but for any integration initiatives. One tool that partners wanted for HIP was a

common repository of client information in the community so that they knew who was being served by

whom, when, and to what degree. Some describe this repository as being like spokes from a wheel: “It

should look at the client at the centre and then spokes coming out... We could look at John Doe. We

could see his nurse, his PO, his mental health office, doctor, support workers. Some people we are

working with have 4 or 5 different organizations working with that one person.” In order for the care

planning to be successful, the documentation needs to be current. Providing up-to-date information to

the service providers reduces the amount of time each provider spends trying to get caught up on the

client’s situation, reducing frustration and annoyance for the clients, and maximizing the efficacy and

efficiency of the time each partner spends interacting with the client.

Partners talked about how some people feel they shouldn’t know too much about their clients, but that

at other times there is an essential need. They requested a provincial approach be developed around

the policies and the protocols needed for large scale client information sharing.

While HIP never achieved a full formalized process for client information sharing in most communities,

some communities were able to build off of existing processes, MOUs and Information Sharing

Agreements. This was particularly useful in Victoria, where an existing agreement allowed the team to

share client information and mobilize quickly around housing a specific group of chronically homeless

people who were camping on a downtown boulevard.

Some of the partners’ comments around information sharing: “An information flow might be useful. Understanding how the flow of information works, the

contact points along the way. Would be useful to have some guidelines on that to be certain that we are doing it right.”

“There is hyper sensitivity about [Freedom of Information] FOI right now. Need common sense for this – need to change the culture and perceptions”

“Need to understand the parameters around how we can talk to each other. Need to be clear on the processes that allow us to share and work together.”

“Concerns about information sharing means extra steps and work when people should be getting a straight answer. “

“(There is a) Serious lack of data” “(Partners) Need Information that is consistent, that is organized in a particular way, that is easy

to access.” There is some distrust between partners, and specifically of government getting client data, and

of sharing the data. There is a perception in some parts of the community that there might be ulterior motives for wanting this information.

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There is distrust that the disclosure of information could negatively impact the client, for example that knowledge of a previous drug addiction might impact the client’s future housing options.

Some non-profits were afraid of information sharing because of its potential to breach their accreditations, which jeopardizes their contracts

Better Service to Clients

When asked if the project was providing better service to clients, the project partners all felt it was.

They also noted that this is a different way of doing business for many of them – especially the

government partners. “I can definitely see that with my caseload, because I deal with both worlds. I am

seeing clients who are just coming in and out of the office who are just part of the general pool, and then

I see mine who they are on my caseload. I am connected with their doctor, their psychiatrist, their social

worker. So all my (clients), I have got them onto PWD or PPMB. (They) have been on the system for

years and years, they would have been eligible for it ages ago, but there was no follow through. They

didn’t have anyone to sit down with them and say, ‘we are calling the doctor right now, we are booking

the appointment, I will walk you over.’ I see a huge, huge different in the quality. The more I do HIP

work, the less I want to do the other work, because I have a vested pride in it. I can see

accomplishments. I can see things moving forward. Whereas I don’t get that as much in my generalized

caseload… You give them the instructions, the resources (then) you see them back in the same place 3, 4,

6 months down the road. It is harder to follow through. Yes I have noticed a difference, especially

working in the system here. “

One project participant found that the project provided her with the opportunity to engage clients

where they are, giving the worker a much better sense of the client’s needs: “…yesterday I was out with

the police at 5:00 am, sitting on a sidewalk with one of the homeless people going through his PWD

application. A normal EAW can’t do that. We have the luxury to actually go to a hotel and see that ‘John

Doe has no sheets, he has no clothes, he is getting victimized, he is not eating.’ In some ways we also

become advocates and we can actually speak for people who may not be able to speak for themselves,

and we know how to navigate through the systems.” Another participant thought that this was the

project’s strongest outcome: “Biggest success out of HIP is that people care about the tenants and what

is working. We see where they live. (They are) not just a number. “

This theme was echoed by another participant who noted that this project gave her the opportunity to

“work with the person, and not just the paperwork”: “We are given the opportunity to work beyond the

Plexiglas so speak. In the district office you are processing people, you are not able to go that extra mile

to go out into the community to get them connected up to the resources that they need to be out there

doing what it is that they need, to meet their basic needs. So we are able to provide those opportunities

to the clients because we are in this position...With integration I’m dealing with the person.”

Seeing changes in the communities but still more to be done

Although these observations are anecdotal, project participants felt that they were seeing positive

effects for the clients and in the community, though it was difficult to necessarily correlate the HIP

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project with these changes: “These are the people that I deal with 5 days a week. I do see the changes,

especially with that group of (street entrenched clients). I see not only the numbers changing, quality of

life changing, especially with (new housing) opening and people who haven’t had a chance to be in that

type of supportive housing environment. I see them in there, I go visit them a couple of times a week.

Yes, things are changing. Not just from HIP – but a shift is happening.”

Another participant from Victoria commented specifically on the examples in that community:

“Certainly speaking to everything that happened on the 900 Block, and that happened within the HIP

framework. The first day that this started happening, it had been identified as an issue out there, on the

boulevard, we were able to pull together with our partners. When (the MSD team member) approached

me for that, she said, “how do we find out who these people are.” We went to our VICOT partners and

ask for a list. From that we had a very definitive cross section of our population. To go through that,

client by client, and work so closely with the ACT teams to be able to take those names and see who is

eligible for their services, it moved so much more quickly than it usually would have. And it was so easy

to identify where the gaps were. I think 710 Queens was certainly borne of the information that we

found, just with that list. Absolutely it was solution focused, but that framework and those relationships

really gave us the opportunity to identify and to somewhat resolve some of those issues. I don’t think it

would have happened without HIP.”

Another partner said: “One of the things that I appreciate about what HIP has done, is it gave us a

mechanism to truly make a difference in people’s lives. And you see where they were a year and a half

ago, and how far they have moved forward in their lives. It has been because of the commitment, and

the ability of the people to work together. That was the point of the project and I think that has worked

fairly well for a lot of people.”

A SCAP provider had similar comments about the clients: “I think we definitely get to see the benefits of

that in our (SCAP) piece. We are there to provide supports to them for 30 months... Some of these guys,

historically have had dealings with my other programs, and they have cycled through and cycled

through. Now they have come to this place where they have stopped cycling. They still have a lot of

their historical behavioural stuff that they are working through and it is not like they went and put on

suit this morning and walked out to a brand new life. One of the guys, he has put on weight, he looks

solid, healthier. The subtle kinds of things. Knowing that he has a fairly decent place to sleep tonight

after being on the streets for years, I get to see that piece of it.”

Another project partner noted that through the various initiatives in his community, even the RCMP

were seeing a noticeable impact on the community: “I would run into the (RCMP) Staff Sergeant. And

the first thing he would say to me, ‘things are really improving in the community, particularly on the strip

here.’ ... Historically there have been a lot of problems there. When they saw that decrease that was

very significant. “

Generally, project partners agree that there have been positive outcomes for clients attached to the programs, and that the integration and partnerships developed through the project have had, and will continue to have huge positive impacts on the community.

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Appendix C: Survey Feedback # 1

A note on the survey responses: Many of these comments are presented verbatim from the responses.

Survey #1

In order to collect feedback from partners who were not able to attend the Community Focus Groups, or

who may not have felt comfortable sharing criticisms openly at the meeting, a survey was distributed to

all those identified by the Community Leads as key HIP contacts in the community. The following

document presents their responses.

1. As a result of HIP, is there better collaboration, coordination and communication between you

and your partners working on homelessness issues?

All respondents felt that there was much better collaboration, coordination and communication

between the partners. Specifically, people mentioned the relationship building between agencies, the

information sharing and updates between partners working with the clients, a better understanding of

the referral pathways in the community, increased systemic navigation skills for the staff, and a better

relationship with clients. One respondent expressed concern that the gains made in collaboration could

be lost if a strong central body is not there to provide ongoing leadership.

2. What did HIP do well? What are the areas or opportunities for improvement?

“Can't say enough about how wonderful it is having both housing and social service reps meeting with

us on a regular basis to improve client outcomes.”

Some of the successes of the project identified by the respondents were that the project:

Provided opportunities for collaboration and a focus on the homeless population.

Opportunity to cooperatively achieve results and show successes

Focus on case management

Opportunities to look at helping this client group from a systemic perspective, and in some

cases, to tackle the ‘elephants in the room’.

Housing first works provided people can get the supports they need to remain housed.

A fuller appreciation and understanding of what we do, and what we can do collectively

I think that MSD staff attached to the HIP project believed in the project. MSD staff were committed to

seeing better outcomes for the chronically homeless and hope that this work continues with further

direction, and additional support from government."

Identified areas for improvement included:

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An Integrated Case Planning Tool

A Provincial Information Sharing Agreement signed off by the Deputies and CEO's

The ability to review funding models as a group, and a more powerful voice in redirecting

funding as necessary

A BC Housing, Provincial, and Health Authority agreement to service the most vulnerable and

chronically homeless.

Communication and information sharing between government agencies still can be improved.

Information from the Secure Lab can be improved. Information and referrals between agencies

can be improved.

Better funding formulas for some community service providers so they don't feel the need to

compete with each other to gain statistics to obtain keep their level of funding.

More addictions resources. Outreach workers and rehab services are desperately needed. At

the moment there are very few services available and addiction is a central cause of

homelessness.

3. Implementation of Project Components:

Almost all respondents felt that the “definition of the HIP client group” and the “focussing of

services and supports” on that client group was successful (75%) or somewhat successful (16%).

Again, most respondents felt that the integrated teams were successful in arranging “priority

access to services and supports” for the HIP clients (54%) or somewhat successful (33%).

58% of respondents felt that the communities had successfully implemented “Integrated

intervention teams and an integrated program”, and 42% felt that the teams and the program

had been somewhat successfully implemented.

42% of respondents felt that the teams had successful implemented “integrated care

management” for HIP clients, while 58% felt that care management was somewhat successfully

implemented.

Half of the respondents felt that “information sharing processes as necessary to support client

care management” had been successfully implemented in their communities; while 42% felt

that the processes had been somewhat successfully implemented. 8% felt that the information

sharing processes were not implemented.

45% felt that the “redeployment of resources as necessary to support client care management”

had been successfully implemented in their community, while another 45% felt that it had been

somewhat successful, and 9% felt that it had not been implemented.

4. What challenges did you have implementing the HIP model?

“Competing demands for service by equally-in-need populations.”

Resources

o No new funding or grants, and not enough high level direction from government

partners and publicly funded organizations to approve or shift the dollars paid to non-

profits. Organizations maintained their status quo for access to programs.

o Finding that there were not specific resources available, which were somewhat

uncontrollable. Such as, lack of safe and affordable housing for a person on IA within the

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community, or obtaining a medical GP where there are simply no available doctors in

the community.

o Some partners felt that some were more committed than others in terms of their time

and resources.

o One other challenge that cropped up was the lack of housing alternatives. This could

not be dealt with effectively until the 710 Queens Street project came on line."

“Obtaining and sharing the necessary information, including use of the BC Housing Assessment

Tool. “

“Unable to achieve Information sharing agreement across all agencies. Work around is that

each Agency obtains a consent to participate from participants. This appears to be acceptable to

all parties.

“Systems! A shared system was something people really wanted to see -- a way to

communicate that ‘Bob’ had been referred to various resources, etc. In the end, we used paper

(consents) and held ongoing, weekly meetings to discuss priority placements, etc.

“Reluctance of having the MOU sign-off completed by some agencies, even though the MOU

had been approved by the Office of the Chief Information Officer.”

“Desired information from the Secure Lab has not been received, making planning for HIP clients

more challenging. “

"Initially it was gaining the trust and willingness of all the different partners. This was dealt with

by MSD staff who provided background and assurances about how the process would work. The

leaders of this group were determined to get everyone working together and made sure they

pushed hard for what needed to be done, but were flexible enough to make sure everyone was

heard and their opinions considered.

Once the first couple of meetings were completed and progress was being made, the partners

saw the benefit in it and really came together. Trust was built over the first half of the project

and continued on throughout.”

"Challenges were getting right people at table and keeping them engaged. Ongoing

understanding the different perspectives and making sure we were honouring and recognizing

the great work already being done in the community. ongoing"

“It appears that there is still some ‘protectionism’ from some agencies in that they feel they are

the only ones capable of providing the required care for their clientele. This has resulted in few

referrals to new programs such as SCAP, and marketing plans had to be put in place to address

this situation. "

“Fear or reluctance to take on the most difficult clients in a housing first model. The HIP/S2H

model had to modify itself to use supportive housing to house S2H clients and do an exchange

of clients that were housed in transitional housing to a 2nd step supportive housing so that S2H

clients could move to the lowest barrier housing. “

“The Private Market was not interested in the risk of having the chronically homeless housed in

private market housing. We dealt with these issues by continuously communicating the need to

support the HIP client group and tested new ways to provide supports through many

organizations in partnership e.g. 710 Queens/Queens Manor. The group has been hard to

manage. Cool Aid has been working with the hardest group from the 900 Block at 710 Queens.”

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"The SHOW team had informational sharing difficulties. Much of the work had to be done off

the sides of desks.

“The HIP client criteria, referral process and numbers have been frustrating since inception.

BC Housing and MSD were phenomenal about bringing resources to the local hubs. “

“All HIP members were extremely adaptable to meeting with us at our weekly meetings and

making themselves available via phone to answer any of our questions. There were times that

they were not able to make the weekly meeting but could always be reached by phone.”

"Communicating the intention: In Victoria, a very committed group of individuals and service

providers worked for years on meeting the needs of Victoria's homeless. When HIP rolled out, it

was pretty fast and it took quite a while to develop trust within the community. I think I was

able to accomplish this by having my hand up first when it came to providing resources (usually

an outreach worker, process or contact); following through on promises and straight talk --

when I ran into barriers, I communicated out.”

“The "no new money" was a corker! However, over time it made sense to the stakeholders

when I said, how can we and ask for more when we are spending a tremendous amount of

money now, and can't clearly indicate who is doing what?”

“The client mix at Ted Kuhn Towers (in Surrey) was problematic and more support was required

at times: this can be planned ahead of time for future initiatives. Local service providers were

called upon to provide extra support making an integrated team at this site. This team has been

very successful. "

5. The HIP framework included tools such as the Operational Guidelines, the Information Sharing

materials, the HIP website and the Service Framework. How useful were the following tools in

implementing HIP in your community?

25 % of respondents found the Operational Guidelines useful, and the remaining 75% found

them to be somewhat useful.

33% of respondents found the Service Framework document useful, and 66% found the

framework somewhat useful.

50% of respondents found the Information Sharing Agreements and materials to be useful, 33%

found them somewhat useful, and 17% found them not useful.

75% of respondents found the HIP Website and web materials to be somewhat useful, with 8%

saying they were not useful and the rest saying that they didn’t know if they were useful or not.

18 % of respondents found the Reports and Counts to be very useful, 72% found them

somewhat useful, and 9% didn’t know if they were useful.

6. What additional tools, if any, would have been useful to implement HIP

“Integrated Case Planning Tool, and a Provincial Information Sharing Agreement signed off by

the Deputies and CEOs as well as the ability to review funding models as a group similar to the

old LMDA agreement when Federal/Provincial Training and Employment Program plans needed

to be made. We need a BC Housing, Provincial, and Health Authority agreement, let’s call it a

BCHAP Agreement to service the most vulnerable and chronically homeless. “

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“A website that was accessible to partners involved and where data could be stored to show

progress”

“Effective information and reports coming from the Secure Lab.”

"Increased access to addiction and mental health beds and supports. Mobile addiction and

mental health services.”

An information sharing agreement established prior to the project starting.

A consistent and predictable referral process, client criteria and statistics.

Affordable housing and additional dollars.

“Increased subsidies, housing start-up kits”

“Perhaps a little more regular reporting out on results.”

“Systems -- the community really pushed for a system where all partners can track the resource

links, access, number of contacts, placement requirements (e.g., health; using, etc.) and which

partner was taking the lead with the various clients; a more centralized process.”

7. Were the roles and responsibilities of the HIP partners clear? Did you understand what impact, if

any, the HIP project had on your work? Did you feel well supported in your role in the project?

What additional supports, if any, did you need?

“The roles were not always clear; however, the positive impact of the HIP project in bringing

together service providers was evident. Yes, there was good support.”

“No, yes, and somewhat. I have to say that this is the most exciting project I have ever been

involved in. I felt supported in the early days of the project when we were in the planning stage.

The implementation was rough and difficult; we were finding that some of the tools and

technology wasn't coming as we thought in the early days. It was difficult to get much buy in

from the community as the Ministry leading HIP when we were not able to provide some of the

tools we said would be there. However, the pre-existing relationships and partnerships

benefited us with moving HIP forward in a small way. I was very engaged. “

“The roles were clearly defined and well supported”

“I feel roles and responsibilities were clear. The HIP project impacted my work through assisting

to do my job a lot easier. I was surrounded by support, learned a ton of information about the

community partners and their roles and developed excellent working relationships with other

agencies to assist clients.”

“For me as a government employee, the roles and responsibilities of the HIP partners were very

clear. The HIP project took considerable time away from my other duties, but the results have

been worth it. The HIP project has resulted in increased partnerships, improved client service,

and our services are operating at an integrated level. “

“It was disappointing that the initial promise of tying resource enhancements to project

outcomes did not materialise. (Our community) is hugely disadvantaged from a resource

perspective and much more could have been accomplished with dedicated resource

enhancement.”

"HIP roles and responsibilities were questionable. Clear definitions for all entities involved;

including a hierarchy and reporting structure would have been very helpful at (the beginning).

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We were well supported by two of the three partners.

We needed more Health Services and affordable housing."

"The participation of all partners was well defined and our agency felt well supported. We had

the ability to influence some outcomes and gave complete flexibility to our staff to do whatever

was needed to make the program successful.

The MSD staff realigned several services and were instrumental in shaping the outreach services

and ensuring the program was well integrated. The community partners as well as clients

embraced the program because it assisted all of them in getting the work they do, done."

“Roles were clear. Having access to the HIP team members to answer questions, to discuss our

client concerns and help in formulating a care plan, helping to connect to resources has been

invaluable. It truly feels like we are approaching the wrap around concept of care that we have

talked about for years.”

"The HIP roles and responsibilities were clear to me; however, some of the partners struggled to

understand the roles in the early days.

I really appreciated the Provincial calls -- sharing best practices, even the bruises, meant a lot. I

think my level of engagement was very high -- it was a terrific vehicle in making community

connections, and most importantly, housing the chronically homeless. I also greatly appreciated

the HQ, centralized support -- whenever I needed help, it was delivered; pretty great. It took a

ton of time, and that meant my other responsibilities got pushed aside -- that was a bit hard on

my direct reports, so having one more full-time resource would have been great."

8. Has HIP contributed to better/improved outcomes for clients? If HIP had not been implemented,

would you have achieved the same outcomes? What specific service integration or operational

integration gains provided the best support for clients?

“Yes clients have had better/improved outcomes. I don't think that we could have broken down

previous "silos" that individual service providers had created as quickly without HIP. “

“I think that HIP has contributed to better outcomes for some clients. I think that HIP showed us

that what gets measured gets managed as a result of the implementation. We hadn't counted in

this way before. I think that we need to conduct further research to determine what specific

service provided the best supports by studying the outcomes for individuals tracked through the

secure lab. “

“I think the HIP has improved the communication between some agencies and that has led to

more seamless service for clients”

"Absolutely. It is unclear if the same outcomes would have been achieved without HIP as

outreach workers have been engaging in the roles for at least three years in this community.

However, the HIP project did open communication and options for outreach staff to turn to

when barriers were faced.

Service integration between MSD, Mental Health and Addictions and Housing had the most

positive impact upon the work that was undertaken with the client population."

“I believe that HIP has contributed to better/improved outcomes for clients. While it may be

argued that most of the services were provided to clients in the past ways of doing business, I

believe that clients now receive a fuller complement of services, and receive them in a timelier

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manner. There really was no way to measure client involvement with services in the past, and

at least we are on our way to achieving that now. This means that more effective planning can

occur. BC Housing stats are significant in that outreach workers have place over 300 homeless

clients in secure and safe residences, and there has been an 85% retention rate (over one year’s

period) of this housing with clients who historically have had difficulty retaining housing for any

extended period. This retention period illustrates the value of on-going supportive services as

people move along the housing continuum.”

“Clients definitely have benefited from this initiative. We would not have achieved the same

outcomes without HIP. A focused, cross-agency and cross Ministry approach has assisted in

development of a vision and dedicated strategy to support this marginalised and poorly served

population. “

"Yes. Unlikely that we could have achieved as many people housed in the same time frame

without the added supports. EAW and priority access to (housing).”

"It is safe to say that the HIP program has resulted in better outcomes for those who were

involved as clients. The integration of services was well beyond what was occurring before the

program started.

The service delivery model improved by linking all the service providers together to work more

effectively to help clients as a group rather than reacting as an individual service provider. The

HIP program helped people move through the various levels of housing and helped focus the

needs of the clients. The barriers that were present were removed and specialized teams were

asked to take on difficult clients when needed.

Everything that was done was in the best interest of the clients."

“Absolutely has contributed to better/improved outcomes.”

“I don't think for a minute we would have made the headway we have housing the homeless

without HIP. Because of HIP, we had the political support to push when things got tough... This

project meant we had to tear down barriers, fix the integration gaps and make it work! A good

example is the 900 Block Pandora Project, which, in a very short period of time, housed over

80% of the people identified -- it took great cooperation, buy-in and ongoing collaboration with

all the partners to achieve this success.”

9. Any final comments?

“HIP has made some huge positive impacts upon the lives of some of the most challenged

persons in our community. It enabled workers to help those clients who were once seen as the

unreachable and too overwhelming!”

“The HIP project has provided a very useful and transferable model that will be employed for

other areas of focus (i.e. community court) for our Region. I look forward to seeing what other

areas of collaboration and integration will occur as the result of this initiative. “

“This was a successful initiative in the community of Surrey and shows what can be

accomplished with good-will, a common vision and a collaborative approach to service delivery.”

"Tom Keenan was very good at the community engagement on a 1:1 basis. He was able to build

the hub model and implement in our community with little resources.

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The HIP meetings became repetitive and non-productive when the aforementioned problems

went unaddressed for some time."

“It was a worthwhile program and the timing was crucial to Victoria. The end result was moving

many people who had long term histories of homelessness, to appropriate housing. The

program has a dramatic effect in the social nuisance issues related to people living on the

streets and brought all the service providers together to work effectively to assist common

clients.

“Want very much for HIP to continue beyond project stage and would like to see it expanded to

include other representatives (i.e. Addiction Services).”

“Thank you so much for the opportunity! I learned a ton -- some of the growth was painful, and

that produced the best results for our clients! We have well established processes and touch-

stones through ongoing meetings, various communities and enriched relationships with our

community partners (who are pretty darn fabulous, by the way). “

D-1


Appendix D: Survey Feedback #2

A note on the survey responses: Many of these comments are presented verbatim from the responses

Survey #2

In order to collect feedback from government and agency partners who worked at a provincial level with

the project, a second survey was distributed. This survey was directed at project partners who were

part of the corporate teams, and who worked at a managerial level to support the project. The following

document presents their responses.

What challenges did you encounter (directly or indirectly) with the HIP model? How were those

challenges dealt with?

Respondents found that there were several key challenges to implementing the project. The first of

these was getting partners to allocate resources to the project (health resources were especially difficult

to connect to), and then to ensure that those resources that were assigned to the project translated into

workers, supports or systems on the ground. One approach to this challenge was to separate the

project into smaller units of work, each with less dedicated resources and separate mandates, such as

the Secure Lab and Outreach work, and then attempt to manage the information flow between those

smaller projects.

Managing information flow and communication was also identified as a challenge amongst partners.

Specific communication issues identified included:

Recognizing and sharing learnings from the project

Formalizing the existing informal communication

Sharing client information

Coordinating release from institutions

Another theme identified by the respondents was the building of commitment, trust and relationships

between partners. It was sometimes difficult for organizations to let their own interests go and support

the larger interests of the community teams and specifically the target client group. This actually

delayed the implementation of some aspects of the project, such as SCAP, in some communities.

Another contributing factor of this challenge was that a number of groups were already working in the

communities collaboratively and felt the project was duplicating a process already in place. This resulted

in a challenge of getting commitment to attend meetings.

Finally, one respondent found that in the beginning the project lacked definition and clarity, especially

around goals. This resulted in challenges in developing an Evaluation Framework.

The sharing of information and client data between HIP partners was an important part of the

project's implementation. What challenges did you encounter with the information sharing through

this project, and how were they resolved?

D-2


Client consent agreements that allowed the community teams to share client information were

identified as a major challenge. One community created a smaller focus group to identify who should be

on the information sharing agreement. Another resolved the issues by limiting the information gathered

on the HIP clients that could be shared with the partners, but still allowing for some information to be

shared. Other communities never completely resolved the information sharing agreement issues, and

were not able to get all parties in the community to sign the agreement.

Another respondent identified a general lack of clarity regarding information governance to be a major

challenge. This included the ownership, custodianship, policies, semantics and operational support, as

well as the ability to manage and overcome the roadblocks put up by organizations which did not want

to, or were unable to share information.

Finally, one respondent identified the “secure lab” as an experiment that was unsuccessful due to the

privacy rules.

The Secure Lab produced reports and data around the demographics of HIP clients and the numbers of

clients connected with supports such as housing and income assistance. How successful a tool was at

the secure lab, in providing you with information about the project and to support monitoring and

decision making?

Reponses around the Secure Lab were mixed. Some respondents found the aggregated information

provided to be useful in tracking progress and informing the program planning. Others found that the

reports and tracking were only somewhat useful. Finally, many identified the fact that the lab was not

able to fully deliver on the cross referenced data as originally intended, to be disappointing.

What additional tools, if any, would have been useful to implement HIP?

Responses included:

“A centralized in-take process”

"More resources. Better access to MH & AD services. More funding for supportive housing

units"

“A tool to provide data ensure where extra attention may need to be focused to support

client success."

Stronger leadership and governance

Were the roles and responsibilities of the HIP partners clear? Did you understand what impact, if any,

the HIP project had on your work? Did you feel well supported in your role in the project? What

additional supports, if any, did you need?

Most respondents felt that the roles as responsibilities were very clear, and felt supported in their roles

on the project. Specifically, one respondent was very pleased with way in which the Ministry began

focussing its services to the homeless.

D-3


Several respondents pointed out that the roles and responsibilities started out as unclear or undefined,

but became clearer as the project developed, due in no small part to the commitment and time invested

by partners. Finally, one respondent felt that the roles and responsibilities were never clearly defined,

and did not feel supported in their role on the project.

In your experience, has HIP contributed to better/improved outcomes for clients? If HIP had not been

implemented, would the same outcomes have been achieved?

This was a difficult question for many respondents to answer, especially since many of the respondents

in Survey 2 were engaged at a higher corporate or management level:

“unknown; at a minimum, did focus some attention on a set of clients, which we can assume

resulted in some changes; unclear if other approaches would have been more effective,

such as focusing on existing community resources, and directly partnering with them to help

them do more”

“Although HIP had a overall positive outcome for the community, a number of

organizations, government agency and Ministries were already engaged in a very

collaborative partnership and working towards the goals of HIP “

"We are unsure of the impact on clients and would welcome the opportunity to review an

outcome evaluation. While thousands of clients have been housed since March 2009, it is

not clear how many were housed as a result of HIP, verses programs already in existence. It

is our impression that HIP was successful at building community connections, which may

have provided benefits for clients."

Others felt confident enough in the change to comment specifically:

"For our SCAP conference we actually did some research on the internet and from what we

saw, HIP has had better results than other jurisdictions...

SCAP has been able to improve upon HIP results and so I think we are proving that both

programs are making a difference in the five HIP communities and from our conference, our

community partners have said they have notice a significant difference in the number of 911

calls, hospital visits, police/justice involvement so we are getting outcomes in other areas as

well."

“Yes HIP did contribute to better the lives of the HIP clients and improve the outcomes for

those clients, If HIP had not been implemented I think it would have taken longer to help

those in need of housing find housing and have the support sere vices they needed attached

to them “

“Yes, I think HIP contributed to better outcomes. However I believe a lot of partnerships

and protocols were already in place (in our community). I believe there is better

cooperation between funders and our respective contractors.

As a result of HIP, is there better collaboration, coordination and communication between you and

your partners working on homelessness issues?

D-4


Most respondents strongly agreed that collaboration, coordination and communication are stronger as a

result of HIP. A few respondents also added the following comments:

"Collaboration and communication was already very strong in the community however HIP

increased the number of partnerships in the collaboration. For those clients that were

seeking priority for housing and supports and better quality of life HIP had a positive effect

”SCAP is really making a significant difference in how various agencies work with clients. For

example in Vancouver the Mental Health team has created a one-page document for each

client that all agencies review weekly which lists the appointments and activities the client

will be participating in each day that week to ensure no duplication of services and that they

are delivered in a logical manner best suited to the client.”

What did HIP do well? What are the areas or opportunities for improvement?

Some of the things that respondents felt HIP did well:

Bringing a focus to serving the homeless by making them a top priority

Bringing all the organizations to the same table to discuss, develop and implement a process

of housing and supports

Communicating its purpose, mandate and client group

Disseminating data and community information through its monthly status reports

Building community connections, particularly between income assistance workers and other

partners working on homelessness issues

Identifying and working to lessen barriers to information sharing

Opportunities for improvement included

Clarifying the day to day work of the project participants, verses the purpose and mandate

Coordinating with existing BC Housing programs and provincial housing strategy

A greater understanding of the clients and their needs for support services and who in the

community can provided those services

Keeping the momentum of the teams in the communities

Identifying learning gaps and applying learnings

Reconsidering how to approach information governance

Any final comments?

One respondent felt that the project should have progressed more slowly and methodically, and kept a

smaller scope. Another comment was that the project should “follow the money”; a reference to the

need to examine the funding going towards helping this client group in more detail.

Survey Results

D-5


Respondents felt that the project was successful (57%) or somewhat successful (43%) in developing and implementing a commonly understood definition of a HIP client.

42% felt that the project had been successful in focussing services and supports on the HIP clients, 43% felt that the project was somewhat successful in this regard, and 5% did not know.

57% of respondents felt that the project was successful in prioritizing access to services and supports for the HIP clients. 14% did not feel the project was successful in doing this, and 29% did not know.

29% thought that the project had successfully implemented the integrated teams and an integrated program. 57% thought the project was somewhat successful in doing this, and 14% did not know.

57% felt that the project had been somewhat successful at implementing integrated care management for HIP clients, 14% felt that the project was successful, while another 14% felt that the project had not been successful at all. A final 14% did not know.

71% of respondents felt that the project was somewhat successful in implementing information sharing processes as necessary to support client care management. 14% felt the project was unsuccessful and 14% didn’t know.

14% felt that the project had been successful at redeploying resources as necessary to support client care management. 57% felt that the project had been somewhat successful in redeploying, 14% felt that the project was unsuccessful, and another 14% didn’t know.

29% found the Operation Guidelines to be useful. 42% found them somewhat useful, and 29% didn’t know.

14% found the Service Framework useful, 43% found them somewhat useful, and 43% didn’t know if they were useful.

14% of respondents found the HIP Website and web materials to be somewhat useful, 43% did not find them useful, and 43% didn’t know.

E-1


Appendix E: Telephone Interview Feedback

Phone Interviews

Telephone interview were conducted with key members of the project teams, executives and other

corporate resources. The following section paraphrases the feedback from those discussions.

What are your reflections on the HIP project in terms of process – how the project worked (or didn’t) to build collaborative programming and business relationships? i.e. As a result of HIP, is there better collaboration, coordination and communication between you and your partners working on homelessness issues? The majority of respondents felt that the project had been successful – in terms of the process and collaboration:

HIP galvanized efforts – brought people together who didn’t traditionally work together.

Leadership was great and process was open and transparent.

New relationships have formed. Changed perceptions of partners. Made process more efficient.

MSD is now seen as a collaborative partner.

Did a tremendous job – integrated work of agencies at a local level.

Communication is front and centre. Brought people together.

Process was different in different communities, and the communities achieved different levels

of integration.

Very good agreement on intentions. Without housing stock, none of this would have happened.

Integrated intervention never really happened.

The level of collaboration and communication has significantly improved.

Excellent from the start. Always a willingness to engage and discuss the role of local

governments in the project.

Very purpose driven work. We felt we had the support of cabinet and Ministers. As a result

there are better working relationships with community partners.

A model on how to roll out a program with a very short timeline.

HIP was a catalyst for change. It raised the profile. It was successful at a provincial level, but

some of the success was lost in translation to a regional level. Was better when housing was

part of MSD.

Supported what was happening already and increased focus on chronically homeless. Not sure

what additional impact HIP had.

We needed to find a way to work with those already working on this, to come together

collaboratively and find ways to leverage support to pull things together.

Others were looking to the next steps of the project. :

I thought it had fantastic leadership and communication was open and transparent. Not sure if

this effort will continue. Opportunities for dialogue have dried up.

Integrated Offender Management is a good legacy of HIP. The 30 days after people leave closed

confinement is the most important.

E-2


What are your reflections on the HIP project in terms of tools – were the tools the right tools, and were they effective? (Tools include Operational Guidelines, Service Framework, Website, Information Sharing Protocol templates, and reports) Response to the project was definitely mixed. What worked for some partners didn’t work for others.

Service Framework and Operational Guidelines were great. Gave support to going out and doing

things differently.

Guidelines were done particularly well.

Were the right tools. While complex, they provided great information. The website was difficult.

Tools were great for allowing us to demonstrate the reality of the issue. The processes involved

were a bit top-heavy. Website was a bit disappointing.

Sharepoint and operational guidelines were useful. Lab reports were not helpful.

Website wasn’t very useful.

Web tool worked for one community.

HIP reports –were at the right level to see how we were doing to provide support services

Data capture tool needs to be mandated on the front end for all users.

Challenge with using two systems for reporting.

Info sharing protocol templates is biggest challenge

Information sharing was difficult due to health authority’s privacy concerns.

Building off the flexibility of the project, some community teams took the tools and adapted them to

meet their own needs:

Don’t think they were the strongest point of HIP – got a bit lost, some tools were used, and

some weren’t

Secure lab reports was more frustrating than useful. We just focused on our own successes

instead.

People used what worked and disregarded the rest.

Tools didn’t really work so we developed our own local way through consents.

What are your reflections on the HIP project in terms of information sharing – what worked and what didn’t?

The information sharing in integrated teams is based on relationships. HIP formalized

communications, documented it and allowed people to communicate in a different way.

It seemed to take a lot of time to resolve issues around information sharing. FOI issues were

biggest challenge.

All about being more creative in finding ways to share info without violating privacy. Most

successful were the clinical teams just getting together.

Need better internal communications.

Very good information shared through the provincial committee. Have to trust intentions of

partners.

Regular meetings were helpful for sharing information. We felt comfortable sharing at the table.

E-3


Information sharing is the biggest barrier to integration. Paper consents worked better than

having a centralized system. Need information to do good work. Need to get an information

sharing agreement right away to make this effective.

A web based tool for information sharing would have been helpful. Thought we were going to

have a case planning tool, but it didn’t happen.

What worked is that we were able to track our clients. Were able to get numbers we didn’t have

before.

Didn’t get the feeling that there was enough connection with CLBC at the local level.

We need to do this better and be willing to share some of the risk to make this work.

Just getting together and sharing information worked really well.

The intention behind the information sharing was good but the research agreement was flawed.

Wasn’t enough agreement on some of the fundamental components supporting the research

agreement.

Frustration with the delay in getting agreements approved at the CIO’s office.

Several respondents felt that the project needed to spend longer setting up the information sharing

framework, and making sure that the project partners had enough expertise to carry out the technical

challenge of implementing the Secure Lab, and completing the evaluation and research as well as

reporting on the targets.

Complex challenge that didn’t succeed. The information sharing framework was terrible.

Information sharing already happens on the ground. This just delayed things and we lost

momentum. Need to get agencies on board before initiating something as big as this.

Didn’t handle the numbers effectively. The research wasn’t handled in an effective way. Too

many data sets.

Didn’t quite work the way we wanted. Those making it work on the ground level were looking

forward to the formalization to make it easier. Needed better high level support.

Did you get “good” data out of HIP? Was it what you needed to make the decisions you needed to support? What are your reflections on the challenges of data coordination for this project?

One of the major challenges faced by the project was the disconnect between what partners thought

that the Secure Lab was going to deliver, and what it could deliver. There was a misunderstanding that a

central database was going to be able to share “actual client names” or some form of unique identifiers.

Due to privacy concerns this was not possible, and was disappointing to many partners. Furthermore,

the community partners were further disappointed when the Lab was unable to acquire and integrated

data from all 17 of the data partners.

Didn’t really get the data we needed. But we could count people.

Some agencies contributed more than others. Some data didn’t go beyond simple things like

whether they were on income assistance.

Secure lab reports was more frustrating than useful. Made people feel that what we were doing

in the community wasn’t being recognized. Focus on successes rather than numbers from lab.

E-4


Need a legislative framework that makes it easier to exchange information. Too many partners.

Data wasn’t useful for on the ground decisions. More for cabinet level.

Didn’t get good data. Underestimated how difficult this was going to be.

Quality varied. Made it difficult to evaluate what was going on.

We kept track locally. We had more confidence in our own data. Data we did receive didn’t align

with local data.

Data was useful for connecting with local governments to ensure they were in the loop.

Data was useful for demonstrating progress. Consent allowed us to communicate with each

other on the ground.

Didn’t get the data we thought we would (with respect to the target groups we served). Were

confused about this.

Data was okay but we began to question it.

What are your reflections on whether the HIP approach has contributed to better/improved outcomes for clients? Some respondents were dubious about the contribution of HIP towards better client outcomes:

Better outcomes but largely just due to existing circumstances.

Need to be cautious not to take credit for things that would have happened anyway. BC Housing

provided the housing...this is what made the big difference. We are also counting federally

placed clients that would have been placed without HIP.

But the majority thought that the project realized various levels of success at assisting these vulnerable

clients:

We have more people housed. We understand collaboration better, and these people are

relatively stable.

Some of the outcomes we saw never would have happened without HIP (on the ground stuff).

We got chronically homeless people off the street. Now it is about sustainability.

Collaborative, community approach working well. Adding on some dollars with SCAP, outcomes

are better. Having the providers see MSD as partners – very useful.

The concept of integrating services into housing was right direction. The short coming was not

being able to target support resources from other ministries into the housing projects or get the

health authorities to the table in a meaningful way.

Did a good job on the front lines but didn’t do a good job moving resources around.

HIP started the conversation. It was an impetus for collaboration. But we didn’t feel other

government partners were in it the same way as MSD.

HIP housed people and demonstrated the need goes beyond just housing. Need to be better at

supporting each other’s outcomes. We continue to underestimate the potential of these clients.

Time will tell. Anecdotal evidence at this point only.

Many of our clients are staying housed. We needed HIP to make this happen.

E-5


Increased coordination and transparency. Going to local government in a coordinated way made

it clear to municipalities what the expectations were.

Real changes in people’s lives. Once people were housed they were open to detox and

treatment.

Anecdotally, people have better wrap around support. Number of people housed is huge.

Integration is just vital. We get better results when we have the right people in the room

together.

The HIP Model involved a series of core elements. How successful was the project in developing and

implementing these elements?

A commonly understood definition of a HIP client: 7.5/10.

Mostly successful. “Sometimes understood but not agreed to”

The focussing of services and supports on the HIP clients: 6.75/10.

“This improved over time. Everyone benefited, not just HIP clients. What helped was focusing on

case management”.

Priority access to services and supports for the HIP clients: 6.2/10

Some respondents commented that priority access was piecemeal, and varied by location.

“Reality was you couldn’t always make them a priority due to circumstances. Challenged by

recruitment and retention. Some communities better than others. Better approach – getting

access faster. Guiding team made sure this was happening. Good job on housing but not on

services”

Integrated intervention team(s) / integrated program / Integrated care management for HIP

clients: 6.94/10

“This really varied between. This is hard because it is resource intensive. BC housing needed to

give more direction to their service provider. Need more commitment. Difficult to get buy in

from Mental Health. The guiding team was great. Good job at community level.”

Information sharing processes as necessary to support client care management: 5.97/10

“Those with consent forms did better than those without. Once core elements were in place

then it improved. Took too long to get info sharing approved. Worked around barriers by getting

client consent. Breakdown between agencies hindered progress”

Redeployment of resources as necessary to support client care management: 5.07/10

“Got a bit lost really. BC Housing was the only one who really re-deployed resources. We really

just assigned people. We didn’t see where the money was going. We relied heavily on provincial

support. We couldn’t give resources or we would have had to break other commitments. It’s

hard to house chronically homeless in one place. We didn’t re-deploy just increased focus. This

is where it all broke down

Any final comments?

Was excellent result for the timeline that was imposed. Cabinet mandate was really important.

E-6


MSD might not have been the right lead. This seems to be more BC Housing’s mandate. SD had

strong voices which probably influenced decisions. People really listened to Allison. Helped with

buy-in for HIP.

FOI act needs to be amended. Lab wasn’t worth the effort. Emphasizes that we aren’t serious

about seeing this be successful. Need a new approach. Government isn’t in silos anymore. Need

to be able to deliver. We need to set ourselves up for success. If government wants to do more

of these integration projects then we need to make changes and learn from our mistakes.

Need ways to continue to connect.

Need to focus on youth, women, and criminal justice clients.

Have executive buy in prior to project starting. Everybody on the same page. Like to see this

extended to other communities.

The community piece worked well. Integration needs to improve to ensure resources are

allocated effectively.

Data – really critical to have experienced people managing the data – fewer players – start with

a small group and build up. 18 (data sets) is way too many – never done more than two or three

(data sets at a time). We bit off more than we could chew.

End result has made a significant impact on the community. So much was the people wanting to

do something. Setting was right. The outcomes were good.

Different communities have come up with solutions that require funding. We have found

successes and need to build on them. Learn and expand. Get the right people doing this work. If

we don’t learn from this and expand then what is the point?

Need for coordination for MSD resources. Need to think through the data component. More

complex than we originally thought.

Biggest success was getting people on the ground talking about same client group

HIP is an excellent idea and should be rolled out more broadly. What is the ongoing legacy of

HIP?

Resource inequity is quite startling. Disappointed that we weren’t able to better allocate

resources.

Given the ambitious nature of the project and the timelines, I think it was a fantastic job. Earlier

connections with municipalities would have been beneficial. Always room for increased contact

with local governments to keep them in the loop so they are aware of what is happening in their

community.

Rent supplements are the key...a good focus.

Organize groups to do collaborative assessments. We need to reduce competition, especially

when the housing market is small.

It was good to know this was a priority, but it didn’t seem like some of the partners really

thought this. Focus didn’t necessarily switch to the hard or impossible to house.

It’s hard when people don’t have money to bring to the table.

I learned a lot and was able to leverage opportunities. The project had great champions.

Need to find ways to make this approach a part of organizational culture. Research is an

important support for this.

Documents

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