Red Deer’s System Framework for Housing and Supports · Alina Turner was hired as an expert advisor to assist with the process. The Community Housing Advisory Board (CHAB) which

2016-2018RED DEER’S SYSTEM FRAMEWORK FOR HOUSING AND SUPPORTS

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Red Deer’s System Planning Framework for Housing and Supports 2

ACKNOWLEDGEMENTS Dr. Alina Turner (Turner Research and Strategy Inc.)

To the following agencies who shared shelter data with Social Planning:

• Safe Harbour Society – People’s Place • Central Alberta Women’s Emergency Shelter • Youth & Volunteer Center (49th Street Youth Shelter/Youth Winter Inn)

To each and every community stakeholder that attended one of the community consultations

To the group of individuals with lived experience who partook in a focus group

Urban Aboriginal Voices Society for organizing consultations with the Aboriginal community

Human Services, local senior management within: Child and Family Services, Disability Services, Office of the Public Guardian, Alberta Works

Alberta Health Services, local senior management within Addictions and Mental Health

Chayla Van Koughnett, Housing Data Analyst, Social Planning

Ryan Veldkamp, Community Facilitator, Social Planning

Scott Cameron, Social Planning Manager

This report was prepared by:

Franklin Kutuadu, Research and Evaluation Coordinator

Roxana Nielsen Stewart, Social Planning Supervisor

Janell Bunbury, Program Coordinator – Housing

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Table of Contents

Executive Summary .......................................................................................................................................... 6

Introduction .................................................................................................................................................. 6

The Approach to the Systems Planning Framework .................................................................................... 7

Housing First Approach to Integrated System Planning ............................................................................... 8

The Goal of Integrated Systems Approach ................................................................................................... 9

Strategic Priority Directions for 2016 to 2018 .............................................................................................. 9

Key Program Components ............................................................................................................................ 9

Performance Measurement, Service Standards and Quality Assurance .................................................... 10

1.0 Introduction ....................................................................................................................................... 11

1.1 Policy Context for Systems Framework ........................................................................................... 12

1.2 Housing First Approach to Integrated System Planning .................................................................. 14

1.3 The Goal of Integrated Systems Approach ...................................................................................... 15

1.4 Process/Background on this Systems Framework Review .............................................................. 16

2.0 Defining “System Planning Framework for Housing and Supports” ..................................................... 18

2.1 What is System Planning? ............................................................................................................... 18

2.2 Who is System Planning For? .......................................................................................................... 18

2.3 Essential Elements of System Planning ........................................................................................... 18

2.4 Key Program Components of a Homeless-Serving Systems Structure ............................................ 19

2.5 Roles ................................................................................................................................................ 19

3.0 Understanding Housing and Homelessness in Red Deer ...................................................................... 21

3.1 Housing Market Trends and Homelessness in Red Deer ................................................................. 21

3.2 Population and Local Economic Situation ....................................................................................... 21

3.3 Rental Housing Market Information ................................................................................................ 21

3.4 Core Housing Need and Housing Affordability ................................................................................ 22

3.5 Defining the Population ................................................................................................................... 23

3.6 Shelter Use Patterns ........................................................................................................................ 23

3.7 Point in Time Homeless Counts ....................................................................................................... 25

3.8 Estimating Homelessness Prevalence ............................................................................................. 26

Red Deer’s System Framework for Housing and Supports

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4.0 Strategic Priority Directions by 2018 ................................................................................................... 27

Priority 1 ..................................................................................................................................................... 27

Priority 2 ..................................................................................................................................................... 27

Priority 3 ..................................................................................................................................................... 27

Priority 4 ..................................................................................................................................................... 27

5.0 Capacity of Current Housing and Homelessness System ...................................................................... 28

5.1 Revising the Coordinated Entry ....................................................................................................... 28

5.2 Revising the Prioritization Criteria ................................................................................................... 29

5.3 Enhancing Coordinated Access Process .......................................................................................... 30

5.4 Current System Capacity and Performance .................................................................................... 31

6.0 System Framework for Housing and Supports ..................................................................................... 34

7.0 Components of the Framework........................................................................................................... 35

7.1 Coordinated Entry ........................................................................................................................... 35

7.2 Coordinated Access Process (CAP) .................................................................................................. 37

7.3 Rapid Rehousing .............................................................................................................................. 38

7.4 Intensive Case Management ........................................................................................................... 39

7.5 Supported Housing .......................................................................................................................... 39

7.6 Permanent Supportive Housing ...................................................................................................... 40

7.7 Transitional Housing for Youth ........................................................................................................ 41

7.8 Indigenous Cultural Support ............................................................................................................ 42

7.9 Household Amenities Warehouse ................................................................................................... 43

7.10 Landlord Engagement Services ........................................................................................................ 43

8.0 Performance Measurement, Service Standards and Quality Assurance ............................................... 45

8.1 Performance Targets ....................................................................................................................... 46

8.2 Data Sources .................................................................................................................................... 47

8.3 Standards of Service and Quality Assurance ................................................................................... 47

9.0 Conclusion .......................................................................................................................................... 49

9.1 Calling all System Players ................................................................................................................. 49

9.2 We will be Successful....................................................................................................................... 49

10.0 End Notes ........................................................................................................................................... 50


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Figures

Administrative System Framework for Housing & Supports _______________________________________ 15 Figure 1. Percentage of Owner and Renter Households Spending 30% or More of their Income on Shelter, 1986 to 2011 ___ 22 Figure 2. Acuity and Chronicty of Homelessness ________________________________________________________ 29 Figure 3. Program Matching _______________________________________________________________________ 30 Figure 4.

Tables

Table 1. Cluster Analysis of Peoples Place Shelter Data from 2011 to 2015 ____________________________________ 24 Table 2. Shelter Stays and Average Number of Days ______________________________________________________ 24 Table 3. Prevalence Rate of Homelessness in Red Deer ____________________________________________________ 26 Table 4. Current Program Capacity and Performance _____________________________________________________ 31 Table 5. Current System Map ________________________________________________________________________ 32 Table 6. Targets Moving Forward _____________________________________________________________________ 33 Table 7. Human Services Mandated Outcome and Indicator and Performance _________________________________ 45


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Executive Summary

Introduction

Red Deer’s System Framework for Housing and Supports is an evidence-based, integrated systems framework that facilitates the coordination of services to individuals and families experiencing homelessness to improve their housing stability outcomes. It is a person centered approach which emphasizes three characteristics. First, it aims to consider aspirations and capacities expressed by the client or those speaking on their behalf, rather than needs and deficiencies. Second, it attempts to include and mobilize the individual’s family and wider social network, as well as to use resources from mainstream services. And finally, it emphasizes providing the support required to the client to achieve goals, rather than limiting goals to what a particular service provider typically can manage.

The System Framework seeks to identify “priority populations” and appropriate service pathways for each person or family, through a coordinated entry, housing first program models with higher standards of service and key performance measures. The Framework is also intended to guide the shared efforts of other stakeholders beyond the homeless-serving system such as the human services, health and criminal justice systems. This alignment and integration at a service delivery level will lead to the identification and intervention of at-risk households to avoid housing loss and assist those housed to retain their housing by reducing systemic gaps.

This work builds on EveryOne’s Home: Red Deer’s Five Year Plan to End Homelessness 2014-2018 which advocated for the creation of a system framework “…we will be successful in ending homelessness in Red Deer when we have a system of care that can effectively and efficiently:

• Prevent/divert vulnerable individuals from becoming homeless, or

• Ensure those who are homeless have permanent, appropriate housing and the supports they require within 28 days of presenting for services within the system.”


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The Approach to the Systems Planning Framework

The City of Red Deer adopted a comprehensive three pronged approach to the system planning framework. Dr. Alina Turner was hired as an expert advisor to assist with the process. The Community Housing Advisory Board (CHAB) which is an advisory committee to Red Deer City Council hosted the community consultations and provided oversight to the review process.

• System Mapping: System mapping is an approach identifying and presenting components of a system. This approach provided information on the nature of housing and homeless services in terms of the local service-delivery landscape; a client’s touch points with our current homeless system and their interaction with other public systems which allows us to map the client’s journey through the system.

• Research, Secondary Analysis and Literature Review: An Ethnographic study was undertaken in the summer of 2015 as a way of better understanding homelessness in Red Deer. A secondary analysis using information gathered from emergency shelters, current programs and services, and point in time counts were used to estimate demand and capacity of the current system to meet the need. The literature review focused on the coordination of strategies within other plans to end homelessness in mid-size cities similar to Red Deer. Systems approach to housing and homelessness plans from across Alberta, Canada, the United States, Australia and the United Kingdom were all examined to identify best practices in focus priority areas, standards of service, performance measurement and quality assurance measures.

• Community Consultations: A broad stakeholder group was consulted in designing this framework. These included housing and support service providers, emergency shelter providers, funders, sub-populations representing various groups such as the Aboriginal Domain, and persons with lived experience. Within the Province of Alberta key Ministries that have shared accountability and mandates to support vulnerable individuals experiencing homelessness were also consulted.


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Housing First Approach to Integrated System Planning

As with EveryOne’s Home: Red Deer’s Five Year Plan to End Homelessness 2014-2018, this Framework is based on a housing first approach. System planning using Housing First as a guiding philosophy is a method of organizing and delivering services, housing, and programs that coordinate diverse resources to ensure that efforts align with homelessness reduction goals. This is outlined in the figure below.


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The Goal of Integrated Systems Approach

The overarching goal of the integrated systems approach is to support the goal of ending homelessness in Red Deer through a “no wrong door” approach. This means that no matter where a person enters the system through the coordinated entry, he/she can access any services that are needed. Service-access is not granted on a “first-come, first-served” basis. Rather, streamlined assessment and referral protocols will be used to ensure that people receive the services they need and want at any given time. Thus rather than relying on an organization-by-organization, or program-by-program approach, the system framework aims at the delivery of initiatives in a purposeful and strategic manner for a collective group of stakeholders to support client outcomes. The shift to a system approach is reflected in these two questions:

Question many programs ask now: “Should we accept this individual/family into our housing/program?”

Question systems should be asking: “Of the options available, which housing and service option is best for each individual/family?”

Strategic Priority Directions for 2016 to 2018

Moving forward the focus will be on longest-term shelter stayers and rough sleepers and targeted prevention, diversion and rapid rehousing measures to stem the flow into homelessness for the highest acuity individuals and families amongst the at-risk and transitionally homeless populations.

• Priority 1: House 115 of the longest-term shelter stayers to bring the average length of stay in shelters down to 4 days.

• Priority 2: House 43 rough sleepers who are not connected to shelter, eliminating street homelessness.

• Priority 3: Develop targeted prevention, diversion and rapid rehousing measures to stem the flow into homelessness for 800 high acuity youth, families, and singles.

• Priority 4: Fully operationalize a systems planning approach to most effectively meet community priorities, including the immediate rollout of coordinated entry and outreach, program and system key performance indicators, and contractual re-negotiations across all funded programs.

Key Program Components

While no perfect homeless-serving system exists, there are key components that we know to be essential in any system that can reduce homelessness. After analyzing the current needs and assessing the capacity of our current programs and services within our local system the proposed targets for each program type are outlined below. These programs will be complemented by a coordinated entry system, Indigenous Cultural Support, Household Amenities Warehouse and Landlord Engagement Services.

Priority 1 & 2 will eliminate chronic and episodic homelessness.


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Projected Program Targets

Program Types Expected Spaces per Year

New Spaces Created

Total New Clients Served over 3

years (2016-2018) Permanent Supportive Housing (Place Based) 47 0 30

Supported Housing (Place Based) 21 0 15

Intensive Case Management (Scattered Site) 100 15 99

Rapid Rehousing (Scattered Site) 90 15 522

Youth Program (Place Based and Scattered Site) 12 0 12

Prevention- Scattered Site (Funded by Homelessness Partnering Strategy)

55 15 270

Total 325 45 948 *The additional new spaces created are based on increased investment in existing program models and turnover in existing spaces to house new clients.

Performance Measurement, Service Standards and Quality Assurance

Service standards based on the fidelity elements of the housing first program model will be linked to the operational performance of each service provider and how they are expected to meet these standards. It is important to highlight that the proposed targets will only be realized if investments across funding portfolios ramp up at minimum: Occupancy rates to 95%, Negative exits reduced to 15%, Length of stay/turnover increased/reduced depending on program type.

Once service standards are articulated and formalized through the contractual process, the quality assurance process will equally be established. The quality assurance process will go beyond the normal case management to include: issues related to clients and staff, landlord relationship management, community safety, grievances and serious incidents and how they are managed and resolved including appeals to the Social Planning and the Community Housing Advisory Board. It is the expectation that as part of this system framework a client and service provider advisory panel will be formed to provide inputs about the functioning of the systems as a whole including service quality for continuous improvement.


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1.0 Introduction

Many studies have confirmed the negative effects of homelessness on health status, social well-being and quality of life especially those who are chronic and episodically homeless or those living on the street1. However, it is important to note that homelessness is not typically a permanent state of living; for the majority of homeless individuals, it is a temporary experience2. Often homeless individuals move in and out of homelessness; some become stably housed, while others remain vulnerably housed3. In Red Deer, the number of individuals and families accessing an emergency shelter bed between April 2014 and March 2015 was 911. The total number of those enumerated as the last Point in Time Homeless Count in 2014 was 137 which was less than half of the number of 279 in 2012. Although the most recent figures indicate a downward trend, the overall number of people estimated to be absolutely homeless is still nearly 1% of the city’s population as at 20154.

Housing programs and services are implemented principally to improve the housing outcomes for individuals and families who are experiencing homelessness or at risk of being homeless. To achieve this, The City of Red Deer developed its 10-year plan, EveryOne’s Home Red Deer’s Vision and Framework on Ending Homelessness by 20185 in 2008 and the Province of Alberta launched “A Plan for Alberta: Ending Homelessness in 10 years” in 20096. The Government of Canada indicated its commitment to end homelessness through its Homelessness Partnering Strategy (HPS)7 which was renewed in 2013. Since that time, a range of prevention intervention programs and services have been undertaken in Red Deer with significant successes. From April 1, 2009 to March 31, 2014, the cumulative number of individuals still housed and receiving services and newly housed was 467 through the Outreach and Support Services Initiative (OSSI) grant through the Province of Alberta. Since 2011, another 114 individuals received housing supports through the Homelessness Partnering Strategy (HPS) grant.

While significant strides have been made, a lot of work still remains to be done to end homelessness by 2018. A critical part of this has been reviewing our current programs and services in line with the strategies contained in “Everyone’s Home 10 Year Plan to End Homelessness”. With a better understanding of the nature and complexity of homelessness in Red Deer, changing landscape of funder mandates there is a need for ‘systems-responses’ to prevent and reduce homeless. This must encompass engaging and leveraging mainstream resources that are integral to providing assistance to obtain or maintain housing for those experiencing homelessness. Through this approach a more holistic system of supports can effectively and efficiently be created to provide the right intervention at the right time to the right individual or family. The timing to review our system could not be better. All of the current projects that receive funding through the OSSI grant expire on June 30, 2016. Therefore, it was a logical time to build upon the great work that has already occurred and look for ways to further improve the service delivery to individuals who are experiencing homelessness.

Red Deer’s System Framework for Housing and Supports is an evidence-based, integrated systems framework that facilitates the coordination of services to individuals and families experiencing homelessness to improve their housing stability outcomes. It is a person centered approach8 which emphasizes three characteristics. First, it aims to consider aspirations and capacities expressed by the client or those speaking on their behalf, rather than needs and deficiencies. Second, it attempts to include and mobilize the individual’s family and wider social network, as well as to use resources from mainstream services. And finally, it emphasizes providing the


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support required to the client to achieve goals, rather than limiting goals to what a particular service provider typically can manage.

The System Framework seeks to identify “priority populations” and appropriate service pathways for each person or family9 through a coordinated entry, housing first program models with higher standards of service and key performance measures. The Framework is also intended to guide the shared efforts of other stakeholders beyond the homeless-serving system such as the human services, health and criminal justice systems. This alignment and integration at the service delivery level will lead to the identification and intervention of at-risk households to avoid housing loss and assist those housed to retain their housing by reducing systemic gaps.

1.1 Policy Context for Systems Framework

This work builds on EveryOne’s Home: Red Deer’s Five Year Plan to End Homelessness 2014-2018 which advocated for the creation of a system framework “…we will be successful in ending homelessness in Red Deer when we have a system of care that can effectively and efficiently:

• Prevent/divert vulnerable individuals from becoming homeless, or

• Ensure those who are homeless have permanent, appropriate housing and the supports they require within 28 days of presenting for services within the system.”

Guiding Principles of Everyone’s Home: Red Deer’s Five Year Plan to End Homelessness

• Ending homelessness in Red Deer is possible.

• Safe and secure housing for all citizens are critical to end homelessness, no matter what the individual’s circumstances and vulnerabilities may be.

• The responsibility for ending homelessness is a community endeavor.

• Through systems changes in policies, procedures, partnerships and processes, homelessness can be prevented.

• Supportive individual, family and community relationships are necessary for people trying to obtain safe, secure and appropriate housing.

Everyone's Home: Red Deer’s Five Year Plan to End Homelessness 2014-2018

Goal # 3

“Leverage community partnerships to develop an effective and efficient coordinated system of care to prevent and mitigate homelessness and to re-house individuals who are recently homeless.”


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Goal #4

“Leverage community partnerships to develop an effective and efficient coordinated system of care that appropriately houses chronically and episodically homeless individuals and provides them with the support services they require.”

Strategies

• Work with The City of Red Deer, Province of Alberta, Government of Canada and community stakeholders to inform policy that will support an integrated coordinated system of care. The Housing First philosophy will guide this work.

• Establish a coordinated community intake process. • Improve the integration of support services and housing.

A Plan for Alberta: Ending Homelessness in 10 Years

• Coordinated Systems are a priority area of focus, stating that “Ensuring governments, agencies, and communities work together in an integrated, efficient way towards shared objectives.” Strengthened integration of housing and homelessness systems will contribute to this priority.

The Homelessness Partnering Strategy (HPS) has defined coordination of resources as follows:

Planning, developing partnerships and implementing solutions in support of a Housing First approach or a broader systematic approach to addressing homelessness, which includes activities to:

• identify, integrate and improve services on an ongoing basis; • work with the relevant sectors to identify barriers to permanent housing and opportunities to address

the barriers; and • maximize all investments by coordinating funded activities to avoid duplication and gaps, ensuring that

funding is used strategically to maximize results.


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1.2 Housing First Approach to Integrated System Planning

The philosophy of a “Housing First” approach was a guiding principle in the original EveryOne’s Home Red Deer’s Vision and Framework on Ending Homelessness by 2018 and remains embedded in the intent of the current five year plan, EveryOne’s Home: Red Deer’s Five Year Plan to End Homelessness 2014 to 2018.

Housing First is defined as “a recovery-oriented approach to homelessness that involves moving people who experience homelessness into independent and permanent housing as quickly as possible, with no preconditions, and then providing them with additional services and supports as needed.” Housing First uses the following core principles10:

• Immediate access to permanent housing with no housing readiness requirements • Consumer choice and self-determination • Recovery orientation, focusing on individual well-being, including harm reduction • Individualized and client-driven supports • Social and community integration

The application of Housing First consists of several components:

As a Philosophy – Housing First can be a guiding principle for an organization or community that prioritizes getting people into permanent housing with supports to follow. It is the belief that all people deserve housing, and that people who are homeless will do better and recover more effectively if they are first provided with housing. This belief holds regardless of the level or intensity of individual and structural issues that led to their homeless state11. It prioritizes housing as the first and most primary need to address for people experiencing homelessness. Other barriers, illnesses or challenges can be addressed once a person has been housed and the chaos of homelessness has been eliminated from a person’s life. Treatment and support services are voluntary, individualized, culturally appropriate, and flexible with various levels of duration and intensity12.

As a Systems Approach – Housing First can be considered embedded within a systems approach when the foundational philosophy and core principles of Housing First are applied across and infused throughout integrated systems models of service delivery. It is central to many coordinated approaches to ending homeless such as 10 Year Plans. Within a ‘system of care’ approach, all services and program elements within the homelessness sector – including many mainstream services - are guided by the principles of the model. As such, each program and service is expected to support and operationalize Housing First, each having a specific role to play in the larger system.

As a Program Model – Housing First can be considered more specifically as a program when it is operationalized as a service delivery model or set of activities provided by an agency or government body. While Housing First programs are important to reducing homelessness, it is the re-orientation of the entire service system towards Housing First as an approach that is essential13. Considerable work is required at the point of entry through a coordinated access so that across the system, standardized screening, referral and intake process are streamlined to ensure people entering the system get access to targeted services, no matter where their first point of contact is either through the street, shelters or public systems14. This is what is reflected through Red Deer’s Systems Framework for Housing & Supports.


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Administrative System Framework for Housing & Supports Figure 1.

1.3 The Goal of Integrated Systems Approach

The overarching goal of the integrated systems approach is to support the goal of ending homelessness in Red Deer through a “no wrong door” approach. This means that no matter where a person enters the system, he/she can access any services that are needed. Service-access is not granted on a “first-come, first-served” basis. Rather, streamlined assessment and referral protocols will be used to ensure that people receive the services they need and want at any given time15. Thus rather than relying on an organization-by-organization, or program-by-program approach, the system framework aims at the delivery of initiatives in a purposeful and strategic manner for a collective group of stakeholders to support client outcomes16. The shift to a system approach is reflected in these two questions.


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Question many programs ask now: “Should we accept this individual/family into our housing/program?”

Question systems should be asking: “Of the options available, which housing and service option is best for each

individual/family?”

A goal was to use the systems framework as a structure to inform the Request for Proposal process for the Outreach & Support Services Initiatives (OSSI) grant. The outcomes outlined within the OSSI grant are:

• Those housed within the program will remain stably housed. • Those persons housed in the program will show a reduction in inappropriate use of public systems. • Persons housed in the program will have a stable income source. • Persons housed in the program will be engaged in main stream services.

While the underlying purpose of the system framework review was to inform the Request for Proposal process, many positive spinoffs have occurred, such as providing information for the next HPS Community Plan update, positive conversations with other funders and systems about integration, and renewed community interest in Red Deer’s plan to end homelessness.

1.4 Process/Background on this Systems Framework Review

The City of Red Deer adopted a comprehensive three pronged approach to the system planning framework. Dr. Alina Turner was hired as an expert advisor to assist with the process. The Community Housing Advisory Board (CHAB) which is an advisory committee to Red Deer City Council hosted the community consultations and provided oversight to the review process.

• System Mapping: System mapping is an approach identifying and presenting components of a system17. This approach provided information on the nature of housing and homeless services in terms of the local service-delivery landscape; a client’s touch points with our current homeless system and their interaction with other public systems which allows us to map the client’s journey through the system.

• Research, Secondary Analysis and Literature Review: An ethnographic study was undertaken in the summer of 2015 as a way of better understanding homelessness in Red Deer18. A secondary analysis using information gathered from emergency shelters, current programs and services, and point in time homeless counts were used to estimate demand and evaluate the capacity of the current system to meet the need. The literature review focused coordination of strategies within other plans to end homelessness in midsize cities similar to Red Deer. Systems approach to housing and homelessness plans from across Alberta, Canada, the United States, Australia and the United Kingdom were all examined to identify best practices in focus priority areas, standards of service, performance measurement and quality assurance measures. After this a “straw dog” System Planning Framework for Housing and Supports was presented to the Community Housing Advisory Board (CHAB) who approved it to be shared with the community as a starting point for conversation and input.

• Community Consultations: A broad stakeholder group was consulted in designing this framework. This included: housing and support service providers, emergency shelter providers, funders, sub populations


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representing various groups such as the Aboriginal domain, and persons with lived experience. At the same time that community consultations were occurring, Social Planning met with senior management of provincial departments with accountability and mandates to support vulnerable individuals experiencing homelessness. They included: Disability Services, Child & Family Services, Alberta Works, Office of the Public Guardian, Mental Health & Addictions. Overall six consultations were held. The first consultation provided a general overview of the proposed systems framework. The subsequent consultations focused on specific components within the Framework such as: diversion and prevention, emergency shelters, outreach & engagement (including coordinated access process), rapid rehousing, youth housing programs, housing resources, intensive case management, supported housing, and permanent supportive housing.


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2.0 Defining “System Planning Framework for Housing and Supports”

2.1 What is System Planning?

Red Deer’s system planning is based on the concept of horizontal system integration between the homeless-serving system and other support systems. System integration can be defined broadly as the provision of services with high levels of coordination, communication, trust, and respect among service agencies so that they are better able to work together to achieve common objectives19.

Systems integration aims to align services to avoid duplication, improve information sharing, increase efficiency (e.g. reduce wait times) and provide a seamless care experience for individuals and families. System planning requires a re-organization of the service-delivery landscape using the principles of Housing First, tying together the activities of diverse stakeholders across diverse systems towards the shared goal of reducing and preventing homelessness20. A homeless-serving system contains a variety of local or regional service delivery components serving those who are homeless or at imminent risk of homelessness21.

System of care is a strength-based, culturally relevant, participatory framework for working with children and families. A system of care approach utilizes inter-agency collaboration, individualized programming and community-based service provision. This approach is traditionally used with children and youth who have considerable physical, mental, social, emotional, educational and developmental needs. It can also be adapted for adult populations with complex needs.22

While the terms “System of Care” or “Continuum of Care (CoC)” is used in other communities across Canada and the United States. Red Deer has chosen to use the term “System Framework” to be clearer in the intent of the work and to eliminate confusion about the word “care” as it is a common medical term. Red Deer’s System Framework for Housing & Supports is consistent with the goals and strategies outlined in EveryOne’s Home 10 Year Plan to End Homelessness.

2.2 Who is System Planning For?

First and foremost, System Planning is for the clients – to provide the most efficient seamless service to assist those experiencing homelessness and to support them to keep their housing. System Planning is also for service providers to provide clarity in the role they play within the system of supporting those individuals. Finally, System Planning is for funders to support them in targeting their resources, reporting back on the outcomes and to inform policy makers of where changes need to be made.

2.3 Essential Elements of System Planning23

Planning and Strategy Development – follows a systems approach grounded in the Housing First philosophy.

Organizational Infrastructure – is in place to implement the homelessness plan/strategy and co-ordinate the homeless-serving system to meet common goals.

System Mapping – make sense of existing services and create order moving forward.


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Co-ordinated Service Delivery – facilitates access and flow-through for best client and system-level outcomes.

Integrated Information Management – aligns data collection, reporting, intake, assessment, and referrals to enable coordinated service delivery.

Performance Management and Quality Assurance – program and system levels are aligned and monitored along common standards to achieve best outcomes.

Systems Integration – mechanisms between the homeless-serving system and other key public systems and services, including justice, child intervention, health, immigration/settlement, domestic violence and poverty reduction.

2.4 Key Program Components of a Homeless-Serving Systems Structure

1. Prevention 2. Outreach 3. Emergency Shelter 4. Transitional Housing 5. Rapid Rehousing 6. Supported Housing 7. Permanent Supportive Housing 8. Affordable Housing 9. Other Support Services

Note: Some of the above components are out of the scope of funding through the Outreach & Support Services Initiative (OSSI) grant. For example: emergency shelter and affordable housing. The system framework recognizes that more than one funder or source of funding is needed to ensure a complete integrated system. The components that are eligible for OSSI funding and their performance measurement and quality assurance indicators can be found in Section 7.0.

2.5 Roles

The City of Red Deer

The City of Red Deer oversees the grants from the Federal Government as the Community Entity (CE) and the Provincial Government as the Community Based Organization (CBO). In taking on this responsibility The City of Red Deer fulfills these roles:


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Funder and Performance Manager

• Manages the funding streams to meet community priorities and targets, compliance monitoring and reporting requirements to funders;

• Ensures comprehensive outcomes measurement, program monitoring and quality assurance processes are in place;

• Implements and supports the uptake of service standard for programs within the system.

Knowledge Leader and Innovator

• Implements Housing First and other innovative program adaptations to meet local needs leveraging existing and new resources;

• Ensures research supports the implementation of the local plan to end homelessness; • Shares best practices at regional and national levels; • Champions homelessness issues in the local community, provincially and nationally; • Consults and engages with diverse stakeholders to support plan implementation; • Implements capacity building initiatives, including training and technical assistance across the homeless-

serving sector.

System Planning Lead

• Assists with the design of the systems framework; • Works with stakeholders to integrate the homeless-serving system with key public systems and services,

including justice, child intervention, health, and poverty reduction.

Provincial Systems

Within the Province of Alberta there are six key Ministries that have shared accountability and mandates to support vulnerable individuals experiencing homelessness. At a cross ministerial level, a vision has been developed for integrated housing and supports. This being “High Quality, Appropriate Non-Market Housing and Supports are Available for Vulnerable Albertans”. The six Ministries that have been identified are: Health, Alberta Health Services, Service Alberta, Infrastructure, Seniors, Justice and Solicitor General, and Aboriginal Relations. At a Central Region or Red Deer level, these provincial systems also have a responsibility to be an integral be part of Red Deer’s System Framework for Housing and Supports.

Community

Housing and the provision of supports is not the responsibility of the provincial or municipal government alone, nor is it the sole responsibility of community-based organizations. An ongoing spirit of partnership among governments and community – including businesses, not-for-project agencies, faith community, industry and private citizens – helps to ensure a system of housing and supports is in place for current and future generations.


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3.0 Understanding Housing and Homelessness in Red Deer

3.1 Housing Market Trends and Homelessness in Red Deer

The nature and magnitude of homelessness varies from one municipality to the next. Our review of the literature identifies four major structural explanations that can be used to account for differences in the prevalence of homelessness across many municipalities24. This includes socio-demographic trends, particular economic conditions, housing market and safety net. The first three in the context of Red Deer are described below.

3.2 Population and Local Economic Situation

According to the 2015 Municipal Census Report25, Red Deer’s total population reached 100,807 for the first time. This indicates an increase of 2,222 new residents or 2.2 percent over the previous census in 2014. While population growth is one factor of housing demand, in Red Deer higher levels of number of households has also been a factor in the high need for housing. Household formation rates have consistently exceeded population growth for several decades. A combination of demographic, social and economic factors contributed to rates of household formation exceeding those of population growth, although in each case the impact of particular previous factors varied26. This means the population growth is not the only factor driving increases in the number of households. Social trends such as the growth in the proportion of non-traditional families – growing proportion of lone parents, increased proportion of couples without children at home, falling marital rates and increased common-law conjugal arrangements – have all contributed to the growth of households.

Red Deer’s local economic performance is linked to housing and homelessness through labour market, housing market, migration and income. Weak labour markets, low migration, reduced rental demand and reduced energy prices for 2015 have led to declines in many of Alberta’s economic indicators27. The overall loss in economic output has had negative effects for the job market in the province including Red Deer. For example, the unemployment rate reached 5.5 percent in November 2015, an increase of 2.1 percentage points from the November 2014 rate of 3.4 percent. The overall employment rate reflected a decline from 72.2 percent in 2014 to 66.7 percent in 201528. Reduced income growth and job prospects have contributed to reduced demand for rental housing in 2015.

3.3 Rental Housing Market Information

Housing market indicators such as vacancy rates, rents and house prices and their impact on affordability for individuals and families are fundamental to the issue of homelessness and the operation of housing and support programs. As an indicator in the trends of rental market housing, a two-bedroom apartment is used as a unit of analysis. According to the results of Canada Mortgage and Housing Corporation’s October 2015 Rental Market Survey, the overall universe of purpose-built rental two bedroom apartments in terms of rental supply increased by 191 units from 2462 units in 2014 to 2653 units in 2015. The overall apartment vacancy rate for Red Deer was 5.8 percent in October 2015, up from 1.8 percent in the previous year reflecting the availability of rental housing. The trend indicates increased availability from a low of 1.5 in 2012, this figure improved to 1.7 percent in 2013 and 1.8 percent in October 2014, indicating slight ease in the rental market.


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The cost of shelter in the rental market also showed an incremental surge in the average rents charged for two bedroom apartments. The average two-bedroom apartment rent in Red Deer was $1036 per month in October 2015 compared to $966 in 2014. In October 2012, the average rent for a two-bedroom apartment was $867, it further went up to $937 in 2013. The average rent continued to rise to $966 in October of 2014 to its current figure of $1036 in 2015. All this has implications for the Housing First programs, especially the scattered site model as available units in the rental market impacts program’s ability to house clients. It also affects client’s housing stability as increases in rent without corresponding increases in their income could lead to housing loss and risk of homelessness. The higher rents impact client support dollars from program and support services.

3.4 Core Housing Need and Housing Affordability

Data from Statistics Canada29 indicates that about 1,735 households (4,236 individuals) are experiencing extreme core housing need. The definition of being in extreme core housing need is when an individual spends 50 percent or more of their income on shelter or rent or have a household income under $20,000/year. By the end of 2018, this group is estimated to grow to 2,081 households or 4,967 individuals with significant impact on those who are at risk of homelessness. Similarly, the proportion of households that spend 30 percent or more of their income shelter varied based on housing tenure (own or rent)30.

Percentage of Owner and Renter Households Spending 30% or More of their Income on Figure 2.Shelter, 1986 to 2011

Source: Statistics Canada, Censuses of Population, 1986 to 2006 and National Household Survey, 2011

However, the data indicates households that rented comprise a greater proportion of household spending – 30 percent or more of their income on shelter compared to owner households. Households in Red Deer that paid 30 percent or more of household total income toward shelter costs represented 26.5 percent of non-farm, non-reserve households with total income greater than zero. A lower proportion of owner households paid 30

17.9 17

44.5

39.7

35.7

43.4

11.2 10.3 14 15 14.8

18.3

0

5

10

15

20

25

30

35

40

45

50

1986 1991 1996 2001 2006 2011Years

Percentage Tenant households Owner households


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percent or more compared to tenant households in Red Deer from 1986 to 2011. The importance of this measure is not limited to knowing the amount of income spent on shelter. Increasing costs of shelter increases the risk of homelessness.

3.5 Defining the Population

There is now national consensus that homelessness must be understood as a continuum of physical living conditions from being ‘roofless’ and absolutely homeless to precariously housed and at imminent risk of homelessness31. The following four typologies have been developed to capture the range of living situations within homelessness in Canada:

1. Unsheltered, or absolutely homeless and living on the streets or in places not intended for human habitation;

2. Emergency Sheltered, including those staying in overnight shelters intended for people who are without housing, as well as shelters for those impacted by family violence;

3. Provisionally Accommodated, referring to those whose accommodation is temporary or lacks security of tenure;

4. At Risk of Homelessness, referring to people who are not homeless, but whose current economic and/or housing situation is precarious or does not meet public health and safety standards32.

Homelessness has also been categorized based on duration, or length of time in homelessness. Chronicity refers to the individual’s length of stay in homelessness, including stays at shelter, sleeping rough or institutional stays (hospital, detox/treatment, remand/corrections). Homelessness in Alberta has typically been classified by the following three typologies to indicate length of time in homelessness:

Chronic Homelessness – Continuously homeless for a year or more, or have had at least four episodes of homelessness in the past three years. In order to be considered chronically homeless, a person must have been sleeping in a place not meant for human habitation (e.g., living on the streets) and/or in an emergency homeless shelter33.

Episodic Homelessness – Homeless for less than a year and has had fewer than four episodes of homelessness in the past three years34.

Transitional Homelessness – Homeless for the first time (usually for less than three months) or has had less than two episodes in the past three years35.

3.6 Shelter Use Patterns

EveryOne’s Home: Red Deer’s Five Year Plan to End Homelessness 2014-2018 identified emergency shelters as a point of entry and shelter use patterns as one of the indicators of ending homelessness: “Ensure those who are homeless have permanent, appropriate housing and the supports they require within 28 days of presenting for services within the system.”

We were very fortunate to have Red Deer-specific data to analyze. Safe Harbour Society, Central Alberta Women’s Emergency Shelter and the Youth & Volunteer Center shared data from the shelters they oversee.


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With the People’s Place data we were able to analyze shelter use patterns over a four-year period using cluster analysis. While very useful, the data from Safe Harbour Society’s Mats program, the Women’s Emergency Shelter and the 49th Street Youth Shelter did not contain unique individual identifiers and could not be analyzed in the same manner or depth.

Cluster analysis36 focuses on shelter stay patterns based on length of stay and rate of readmission into the shelter. The cluster analysis of 1,365 unique individuals using People’s Place emergency shelter from 2011-2015 show on average, individuals spend about 8 days in shelter per year. Of these, a very small number are using the majority of the shelter beds: 13.6 percent of long term shelter users’ make up 56.6 percent of the shelter stays.

Table 1. Cluster Analysis of Peoples Place Shelter Data from 2011 to 2015

Cluster Transitional Episodic Chronic

Number of Unique Clients 1,179 166 20

Cluster as Percentage of Total Number of Clients 86.4 12.2 1.5

Average Days in Shelter (Over 4 years) 16 111 340

Average Days in Shelter (1 year estimate) 4 28 85

Percentage of Total Shelter Beds Used 43.3 41.3 15.2

Source: Safe Harbour Society, Peoples Place Shelter, 2011 to 2015.

Table 2. Shelter Stays and Average Number of Days

Total Days in Shelter (4 years) 44,616

Total Unique Individuals (4 years) 1,365

Average Days per Individual (4 years) 33

Estimated Average Days per Individual (1 year) 8 days

Source: Safe Harbour Society, Peoples Place Shelter, 2011 to 2015.


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Through the shelter data, we also estimate about 86.4% of shelter users (683 individuals) are transitionally homeless. There is likely a large overlap between the transitionally homeless and those experiencing an extreme core housing need. There is a higher likelihood that youth and families are amongst the “at risk and transitionally homeless” populations compared to singles in the emergency shelter system and sleeping rough. It should be noted that Red Deer does not have a family shelter, so there is no shelter option for those with children in our community. Research work that has looked at youth homelessness indicates that youth are less likely to be long term shelter users.

3.7 Point in Time Homeless Counts

Another source of data for the system planning has been our Point in Time Homeless Counts. The City of Red Deer has undertaken two Point in Time Homeless Counts in 2012 and 201437. These counts serve two important functions: they provide a snapshot of our overall homeless population and enable us to examine how this population changes over time.

The scope of the counts covered unsheltered, sheltered and provisionally accommodated. The unsheltered includes people who lack housing and are not accessing emergency shelters. In most cases, people are staying in places that are not designed for or fit for human habitation. The sheltered and provisionally accommodated included those enumerated at emergency shelters, short-term transitional housing facilities and public systems that agreed to participate. The information obtained related to the demographic and housing issues of those experiencing homelessness.

The two Point in Time Homeless Counts revealed the following:

• A total of 137 people were found experiencing homelessness on October 16, 2014 compared to 279 in 2012 on the same day and time. This result shows a decrease of 51 percent between 2012 and 2014. In 2012, out of the total of those experiencing homelessness, 184 were unsheltered and 95 were sheltered. Comparatively, in 2014 only 22 people were unsheltered – either they spent the night on the street, in parks, in alleyways, squatting, or couch surfing.

• Shelters were operating above 80 percent capacity on the night of the count in both counts. The shelters with spaces available were for specific designated sub-populations.

• In both counts more than three quarters of people experiencing homelessness in Red Deer were male. In 2014, 15 percent of respondents were homeless youth under the age of 25 compared to 37.1 percent in 2012. In 2014, 40 percent of respondents indicated this was their first time homeless.

• In 2012, Aboriginal people made up 44 percent of Red Deer’s homeless population compared to 24 percent in 2014. Aboriginal people constitute only 5.2 percent of Red Deer’s residents, as per Statistics Canada Census, this indicates an over-representation of the Aboriginal sub-population in Red Deer’s homeless population. In both counts, Aboriginal people are homeless for nearly 2X times as long as non-Aboriginal people.


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• Although the number of those who reported addiction declined from 39 percent in 2012 to 26 percent in 2014, it is still one of the main barriers to housing stability. More than half of respondents in both counts indicated they had a mental illness.

3.8 Estimating Homelessness Prevalence

Prevalence rates are annual estimates or a count of the total number of people who use either the shelter or are sleeping rough. Prevalence estimates allows society to judge the scale of homelessness, and can be used to report trends and to target services to prevent or ameliorate the circumstances of homelessness through knowing both the locations of the homeless and their characteristics38. Using shelter data, point-in-time count data and estimation of rough sleepers, we estimate that over the course of one year, an estimated 0.8% of Red Deerians or 831 individuals will experience absolute homelessness. That is, they will access an emergency shelter or sleep rough in our community.

Table 3. Prevalence Rate of Homelessness in Red Deer

Shelter 2014-2015 Unique

Individuals

Singles Emergency Shelter (includes Mats) 468

Women's Emergency Shelter 403

Youth Emergency Shelter 40

Sub-Total Shelter 911

Estimated Duplication 13.2%

Re-calculated Shelter 791

Rough Sleepers 40

Total Individuals Experiencing Homelessness 831

Estimated Prevalence Rate (2015 Red Deer Pop. 100,807 total) 0.8%

Source: The City of Red Deer, 2015


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4.0 Strategic Priority Directions by 2018

Moving forward the focus will be on longest-term shelter stayers and rough sleepers with targeted prevention, diversion and rapid rehousing measures to stem the flow into homelessness for the highest acuity individuals and families amongst the at-risk and transitionally homeless populations.

Priority 1

House 115 of the longest-term shelter stayers (13.6%) by the end of 2018. This would reduce the average length of stay in the shelter by 100% (from 8 to 4 days). This direction would also reduce the pressure on the emergency shelters and maximize the best use of the space. The function of the shelter would shift. Within the homelessness support system, they would be the right-service for emergency support.

Priority 2

House 43 rough sleepers who are not connected to shelter, eliminating street homelessness.

Priority 3

Develop targeted prevention, diversion and rapid rehousing measures to stem the flow into homelessness for 800 high acuity youth, families, and singles groups within the at-risk and transitionally homeless populations.

Priority 4

Fully operationalize a systems planning approach to most effectively meet community priorities, including the immediate rollout of coordinated entry and outreach, program and system key performance indicators and contractual re-negotiations across all funded programs. We cannot serve all 4,967 individuals at risk, nor is it the role of the homeless-serving system to do so. The focus will be on the top 16% highest acuity individuals at risk or transitionally homeless.

Priority 1 & 2 will eliminate chronic and episodic homelessness by 2018.


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5.0 Capacity of Current Housing and Homelessness System

While no perfect homeless-serving system exists, there are key components that we know to be essential in any system that can reduce homelessness. After assessing the current state of the local system, as part of the process in moving forward with the system review it was necessary to take a deep look into how the current programs are doing and to ask some critical questions in terms the current system’s capacity to reduce homelessness39. Learning and adaptation is achieved through experience, research, analysis and flexibility which are critical to long-term success. Understanding the effects of external forces and changing values helps to address risk, maximize opportunities, and maintain the capacity to adapt40.

Critical Questions and Decisions

• Is the system reducing the number of people experiencing homelessness?

• Are resources targeted effectively to those with the greatest needs, including those who are unsheltered, and chronically homeless?

• Does the community have the right balance of interventions (permanent supportive housing, rapid re-housing, etc.) to respond to local needs?

• Is the system exiting people from homelessness to housing quickly and using the right size of intervention based on their needs?

• How can the community align resources and design its system most strategically?

• Do strong connections exist between the homeless response system and intake processes for mainstream services?

5.1 Revising the Coordinated Entry

The current intake process is a decentralized coordinated system with multiple assessment points all employing the same assessment and referral process. However, this has resulted in lack of consistency in standardized intake and assessment with multiple staff and organizations over a small geographical area, increasing the length of stay in homelessness for clients. A new hybrid model of centralized coordinated intake with mobile outreach for shelters, assertive street outreach and discharge planning/intake from systems will be implemented for Red Deer’s System Framework for Housing & Supports.

The new Coordinated Entry component will be managed by one agency but delivered with mobile outreach for shelters, assertive street outreach and discharge planning/intake from systems. This agency will complete intake using the Service Prioritization Decision Assistance Tool (SPDAT) and will be responsible for regular training and workshops on the SPDAT with all of the funded components within the system framework. This will ensure standardized and consistent assessments. The Coordinated Entry component is also responsible for diversion and connecting individuals who or are at-risk or transitionally homeless and fall within the lower acuity range, to resources outside the homeless-serving system.


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5.2 Revising the Prioritization Criteria

While diverse services may exist in the homeless-serving system, it is essential to develop processes to effectively match client needs to the right service, at the right time so having a coordinated entry and assessment process in place that uses common acuity measures and prioritization processes to determine program match and eligibility is a key ingredient to a well-functioning system41.

Acuity speaks to the severity of a presenting issue. In the case of an evidence-informed common assessment tool like the SPDAT, acuity is expressed as a number with a higher number representing more complex, co-occurring issues that are likely to impact overall housing stability42. Acuity levels as indicated by the SPDAT scores do not necessarily reflect shelter use patterns. We can have long-term shelter stayers who score low on the SPDAT. In order to implement the direction approved by the Community Housing Advisory Board to focus on the long term shelter stayers and rough sleepers in addition to individuals who are experiencing chronic or episodic homelessness and have a high acuity score, we need to re-think how programs determine access. Our homeless serving system needs to ensure longest-term stayers are prioritized. That step will occur through the Coordinated Access Process. Along with acuity score, length of time in homelessness will become a factor in prioritizing which client receives service first.

The following diagram developed by The Calgary Homeless Foundation illustrates this point:

Acuity and Chronicty of Homelessness Figure 3.


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5.3 Enhancing Coordinated Access Process

The Coordinated Access Process (CAP) is a method of matching individuals and families experiencing chronic and episodic homelessness to a housing first program that meets their needs. The purpose of CAP is to streamline access and referral to housing programs. Great work has been occurring through the current Coordinated Process (CAP). Clients have been successfully matched to existing programs. The fundamentals of the CAP process will remain the same; program matching will still be based on client acuity, available program space, client choice, and program fit. Focusing on the length of stay in homelessness will be added to the prioritization criteria and an adjustment will be made to the acuity score for program matches.

The author of the SPDAT tool recommends that those individuals whose acuity score is between 35 and 60 be matched to an Intensive Case Management Program. Those individuals whose acuity score is between 20 and 34 be matched to a Rapid Re-Housing program. This slight change also supports the overall goal of housing long term shelter users, rough sleepers and individuals who are experiencing chronic or episodic homelessness with a high acuity score. This priority population will be the first to access any available housing option.

Program Matching Figure 4.


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5.4 Current System Capacity and Performance

The table below highlights the capacity and performance of the current programs that receive funding through the Outreach & Support Services Initiative (OSSI) grant. Current program occupancy is only at 54 percent and is uneven across programs (low of 31%, high of 98%).

Table 4. Current Program Capacity and Performance

Program Capacity Average Capacity

Occupancy Rate*

The Buffalo 39 38.4 98%

Harbour House 8 7.8 98%

Safe Harbour Supported Housing 35 30.6 87%

New Beginnings 20 11 55%

Red Deer Housing Team 150 45.8 31%

Arcadia Housing First 5 5.4 108%

Total 257 139 54%

*Occupancy rate is calculated using the number of clients who are currently housed and does not include those in intake. Source: The City of Red Deer, 2015 The table on the following page is an analysis of Red Deer’s current system map. This data shows there is a high rate of negative exists, variability in program costs despite being similar program type, and turnover/occupancy rate variability. There is high Rapid Rehousing and Prevention program capacity relative to Permanent Supportive Housing/Intensive Case Management programs despite system priority on individuals experiencing chronic and episodic homelessness.


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Table 5. Current System Map

Program Name

Program Type

Homelessness History Caseload Turnover

Rate Negative Exits (%)

Positive Exits (%)

Total Annual Funding

Funding/ Program

Space

The Buffalo PSH Chronic 39 26% 40% 60% $690,000 $17,692

Harbour House PSH Chronic 8 50% 25% 50% $442,000 $55,250

Arcadia ICM Chronic/ Episodic 6 0% 100% 0% $125,000 $20,833

Red Deer Housing Team ICM Chronic/

Episodic 101 n/a 31% 65% $1,216,212 $12,102

Supported Housing SH Episodic 35 51% 38% 58% $264,000 $7,543

Youth Mobile Outreach & Family Reunification

Outreach Chronic/ Episodic 5 n/a n/a n/a $185,000 $37,000

HPS Housing Outreach Program - Prevention Activities

Prevention At-Risk 25 48% 35% 65% $92,683 $3,707

PATH Program Prevention At-Risk 15 167% 12% 88% $110,831 $7,389

Red Deer Housing Team RRH Chronic/

Episodic 50 n/a 31% 65% $1,216,212 $24,570

Red Deer Housing Team RRH Episodic 25 64% 27% 73% $166,247 $ 6,650

New Beginnings RRH Episodic 20 50% 25% 70% $160,782 $ 8,039

HPS Housing Outreach Program

RRH Episodic 1 0% 0% 100% $ 23,171 $23,171

PSH: Permanent Supportive Housing ICM: Intensive Case Management SH: Supported Housing RRH: Rapid Rehousing-


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Current system capacity in the OSSI/HPS funding portfolio requires significant changes to meet Red Deer’s goal of ending homelessness. Most significantly, performance must be enhanced across the board to maximize investments. Secondly, Intensive Case Management capacity must be enhanced to meet current gaps.

Table 6. Targets Moving Forward

Program Types Expected Spaces per Year

New Spaces Created

Total New Clients Served over 3

years (2016-2018) Permanent Supportive Housing (Place Based) 47 0 30

Supported Housing (Place Based) 21 0 15

Intensive Case Management (Scattered Site) 100 15 99

Rapid Rehousing (Scattered Site) 90 15 522

Youth Program (Place Based and Scattered Site) 12 0 12

Prevention- Scattered Site (Funded by Homelessness Partnering Strategy)

55 15 270

Total 325 45 948 *The additional new spaces created are based on increased investment in existing program models and turnover in existing spaces to house new clients.

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6.0 System Framework for Housing and Supports

This diagram outlines Red Deer’s System Framework for Housing and Supports. The roadmap shows how to navigate through the system from a client perspective.

Red Deer’s System Framework for Housing and Supports 35

7.0 Components of the Framework

The following section outlines the program models described in the diagram above. Red Deer’s System Framework for Housing & Supports is comprised of 10 components:

• Coordinated Entry • Coordianted Access Process • Rapid Rehousing • Intensive Case Management • Supported Housing • Permanent Supportive Housing • Transitional Housing for Youth • Indigenous Cultural Support • Household Amenities Warehouse • Landlord Engagement Services

7.1 Coordinated Entry

Coordinated Entry is a single place or process for individuals experiencing homelessness to access housing and support services. The goal of this system-wide program is to meet the needs of the most vulnerable and highest acuity first (triaging) while ensuring all individuals and families who come into contact with the homeless system are assessed and provided with appropriate supports to exit homelessness. Collaboration, communication and knowledge sharing among community stakeholders are essential in order for a coordinated entry system to be successful.

In the absence of a Coordinated Entry system, individuals and families experiencing homelessness are often faced with the daunting task of finding help in a fragmented system. With coordinated and efficient intake processes, those seeking assistance are directed to defined entry points, assessed in a uniform and consistent manner, prioritized for housing and services and then linked to available interventions in accordance with Red Deer’s Framework of Housing and Supports

Coordinated Entry creates a more efficient homeless serving system by:

• Helping people move through the system faster by reducing the amount of time people spend moving from program to program before finding the right match;

• Reducing new entries into homelessness by consistently offering prevention and diversion resources upfront, reducing the number of people entering the system unnecessarily; and

• Improving data collection and quality and providing accurate information on what kind of assistance individuals and families need.

Red Deer will implement a hybrid model of Coordinated Entry with centralized intake that uses mobile outreach for shelters, systems and assertive street outreach. One service provider will be responsible for implementing the unified coordinated entry and assessment system for all populations including single adults, families and


youth. Specific efforts will be made to engage long-term shelter stayers and rough sleepers to connect them to permanent housing.

A hybrid model of Coordinated Entry includes:

• Intake for all Housing First programs in Red Deer • Central location for in-person service • Mobile outreach in the emergency shelters and/or other service providers locations • Mobile outreach to systems (hospital, correction facilities) • Assertive street outreach • Initial screening for prevention and diversion • Common consistent process for assessments and referrals

In order to be successful, Coordinated Entry must include the following elements:

Diversion & Prevention

Diversion is defined as resources to assist those seeking housing and supports to find and maintain housing outside of the homeless serving system. It is not about turning people away, but involves the “lightest touch” possible by leveraging natural or existing resources such as family supports and community resources. Initial screening to identify immediate needs and to screen for prevention/diversion will be conducted for all individuals and families who request service. Assistance offered may include connection to mainstream services such as government supports, mental health and addiction services, counselling programs; basic system navigation; family reunification for youth; and basic housing search assistance.

Prevention is defined as resources to assist individuals at risk of homelessness or newly homeless for the first time. These individuals and families would be referred to a prevention program funded by the Homelessness Partnering Strategy (HPS) or other community resources such as Income Support, etc.

Assertive Outreach & Engagement

The goal of assertive outreach is to connect with individuals and families experiencing homelessness where they are at. Assertive outreach is a purposeful, proactive and persistent approach to engage individuals in housing and supports. Outreach will be conducted in the following areas:

• Street outreach that seeks to build relationships with rough sleepers with the goal of doing an intake assessment to move people into housing and engaging them in services.

• Outreach at emergency shelters in Red Deer with the goal of moving long-term shelter stayers into housing. Work with shelters to identify individuals who require more support to exit homelessness after 7-10 days.

• Outreach to systems such as hospitals, correctional facilities, etc. • Outreach at other locations in the community where individuals experiencing homelessness access

services.

Developing a strong outreach strategy is crucial to engage and connect individuals and families who historically have not been connected and/or are not utilizing existing services. It is also important that outreach services


are provided to Indigenous individuals and families in a culturally appropriate manner and that consideration is made to engage effectively with youth.

Standardized Assessment & Intake

It is important that standard intake practices are applied at every point of entry for every client to ensure consistent assessments. Red Deer uses the Service Prioritization and Decision Assistance Tool (SPDAT) as the standardized tool for intake. Regular SPDAT training and refresher sessions are also an important component of standardized assessment and intake.

Comprehensive intake assessments will be conducted at multiple and appropriate access points throughout the community including emergency shelters, hospitals and correctional facilities, other locations where individuals experiencing homelessness access services, in addition to the Coordinated Entry office location.

Key Performance Indicators

• Number individuals/families completing an initial triage/diversion screen. • Number of individuals/families diverted from the homeless-serving system. • Number of individuals/families referred to a prevention program. • Percentage of engagements with individuals/families during outreach. • Percentage of individuals who are staying in a shelter or sleeping rough who agree to work with an

outreach team to complete an intake within three months of the first encounter. • Number of intakes conducted at each outreach access point. • Number of SPDATs completed. • SPDAT assessments will be completed within 30 days of a client agreeing to work with an intake worker. • 90% of outreach clients will be successfully matched to a housing first program within 90 days. • Number of SPDAT training/refresher sessions.

7.2 Coordinated Access Process (CAP)

The Coordinated Access Process (CAP) is a method of matching individuals and families experiencing chronic and episodic homelessness to a housing first program that meets their needs. The purpose of CAP is to streamline access and referral to housing programs. It is a client-centred approach that provides a consistent and transparent process of prioritizing individuals and families for housing programs. The target population for CAP is Individuals and families experiencing chronic or episodic homelessness; prioritizing those who have been homeless the longest and have the highest acuity. Individuals who are long-term shelter stayers and/or rough sleepers will be prioritized for service.

CAP follows a triage model which means the most vulnerable individuals with the highest acuity and the longest length of time being homeless are matched to housing program first. This is not a typical “wait list” but is rather about making a best possible match based on length of homelessness, acuity, client need, and availability of program spaces. All Housing First programs funded by The City of Red Deer must participate in the Coordinated Access Process.


Prioritization Guidelines:

• History of homelessness – long term shelter stayers and rough sleepers • Acuity – Service Prioritization Decision Assistance Tool (SPDAT) score

Individuals Families Eligible Programs

SPDAT 35-60 SPDAT 54-80 Permanent Supportive Housing & Intensive Case Management SPDAT 20-34 SPDAT 27-53 Rapid Rehousing & Supported Housing


• Number of clients enrolled in CAP. • Of the client enrolled in CAP, length of time homeless. • Number of clients matched to a housing program. • Of the clients matched to a program, the percentage housed within 3 months. • Length of time from enrollment in CAP to housing placement.

7.3 Rapid Rehousing

Rapid Rehousing provides targeted, time-limited financial assistance and support services for those experiencing episodic homelessness in order to help them quickly exit homelessness. The program will assist individuals and families with finding and maintaining permanent housing. There are no conditions (e.g. sobriety) for clients to participate in the program. Program participation and housing are not linked so that loss of one does not lead to loss of the other.

This is a scattered site model which involves renting appropriate housing units in the community. The length of program support is 6-12 months. Case management supports are provided to assist with housing and life stability in a client centered, solution focused manner. Individualized case management support occurs with clients on a regular and timely basis through home visits.

The target population is episodically homeless individuals and families who have been homeless for less than a year and have fewer than four episodes of homelessness in the past three years. Individuals who are long-term shelter stayers and/or rough sleepers will be prioritized for service. Rapid Rehousing is for those with moderate acuity who have a Service Prioritization Decision Assistance Tool (SPDAT) score in the range of 20-34. All referrals into the program must come through the Coordinated Access Process.


• Minimum 90 clients served/year. • Expected caseload of 20-25 clients/case worker. • At any point in time, maintain 95% program capacity. • At any point in time, 85% of clients housed through the program will remain stably housed. • Recidivism rate – No more than 15% of clients will return to homelessness. • Those persons housed in the program will show a reduction in inappropriate use of the public systems.

i.e. Reduction in emergency room visits, hospitalizations and incarcerations. • Those persons housed in the program will demonstrate improved self-sufficiency.


• Persons accepted into the program will demonstrate engagement in mainstream services (e.g. physical health, mental health, addictions, counselling, financial, legal service, employment, education).

• 85% of clients leaving the program will report an increase in income from employment and/or benefits. Where clients are unable to increase income, 95% will maintain a stable income source.

7.4 Intensive Case Management

Intensive Case Management (ICM) provides longer term case management and housing support to high acuity individuals and families experiencing homelessness. The program will assist clients with finding and maintaining permanent housing with the aim of moving clients toward increasing self-sufficiency. There are no conditions (e.g. sobriety) for clients to participate in the program. Program participation and housing are not linked so that loss of one does not lead to loss of the other.

This is a scattered site model which involves renting appropriate housing units (both market and non-market) in the community. The length of program support is 12-18 months. Case management supports are provided to assist with housing and life stability in a client centered, solution focused manner. Individualized case management support occurs with clients on a regular and timely basis through home visits.

The target population is chronically homeless individuals who have been continuously homeless for a year or more, or who have had at least four episodes of homelessness in the past three years. Individuals who are long-term shelter stayers and/or rough sleepers will be prioritized for service. Intensive Case Management is for those individuals with high acuity who have a Service Prioritization Decision Assistance Tool (SPDAT) score in the range of 35-60. All referrals into the program must come through the Coordinated Access Process.


• Minimum 100 clients served per year. • Expected caseload of 15-17 clients per case worker. • At any point in time, maintain 95% program capacity. • At any point in time, 85% of clients housed through the program will remain stably housed. • Recidivism rate – No more than 15% of clients will return to homelessness. • Those persons housed in the program will show a reduction in inappropriate use of the public systems.

i.e. Reduction in emergency room visits, hospitalizations and incarcerations. • Those persons housed in the program will demonstrate improved self-sufficiency. • 85% of clients leaving the program will report an increase in income from employment and/or benefits.

Where clients are unable to increase income, 95% will maintain a stable income source. • Persons accepted into the program will demonstrate engagement in mainstream services (e.g. physical

health, mental health, addictions, counselling, financial, legal service, employment, education).

7.5 Supported Housing

Supported Housing provides housing and support services for individuals and families experiencing episodic homelessness. This is a place-based model where clients are housed in a location with other tenants with comparable complex and co-occurring issues. There may be conditions (e.g. sobriety) for clients to participate in this program. The support services are linked to the housing itself meaning that case management will only be


provided to clients while living in the housing units. However, it is also important for the landlord role and the support services role to be separate and distinct.

Staff are available to assist participants on site but do not provide 24/7 staffing. A house/peer mentor may live on site to provide good neighbor/good roommate skills. Case management supports are provided to assist with housing and life stability in a client centered, solution focused manner. Individualized case management support occurs with clients on a regular and timely basis through home visits.

The target population is episodically homeless individuals and families who have been homeless for less than a year and have fewer than four episodes of homelessness in the past three years. Individuals who are long-term shelter stayers and/or rough sleepers will be prioritized for service. Supported Housing is for those individuals with moderate acuity who have a Service Prioritization Decision Assistance Tool (SPDAT) score in the range of 20-34.


• Minimum 25 clients served per year. • Expected caseload of 20 clients per case worker. • At any point in time, maintain a 95% occupancy rate based on units available. • At any point in time 85% of clients housed through the program will remain stably housed. • Recidivism rate – No more than 15% of clients will return to homelessness. • Those persons housed in the program will show a reduction in inappropriate use of the public systems.

i.e. Reduction in emergency room visits, hospitalizations and incarcerations. • Those persons housed in the program will demonstrate improved self-sufficiency. • 85% of clients leaving the program will report an increase in income from employment and/or benefits.

Where clients are unable to increase income, 95% will maintain a stable income source. • Persons accepted into the program will demonstrate engagement in mainstream services (e.g. physical

health, mental health, addictions, counselling, financial, legal service, employment, education).

7.6 Permanent Supportive Housing

Permanent Supportive Housing (PSH) provides long-term housing and support to individuals who are homeless and experiencing complex mental health, addiction, and physical health barriers. This program provides an appropriate level of service for chronically homeless clients who may need support for an indeterminate length of time while striving to move the client to increasing independence. There are no conditions (e.g. sobriety) for clients to participate in the program. The support services are linked to the housing itself. The delivery model incorporates support services in the operations of the housing and staff members work in the facility to provide support to clients. However, it is also important for the landlord role and the support services role to be separate and distinct.

This is a place-based model where clients are housed in a location with other tenants with comparable complex and co-occurring issues. 24 hour staffing is provided on site. The key features of permanent Supportive Housing are: clients may live in their homes as long as they meet the basic obligations of tenancy such as paying rent; clients have access to the support services they need and want to retain housing; clients have a private and secure place to make their home, just like other members of the community with the same rights and


responsibilities. Case management supports are provided to assist with housing and life stability in a client centered, solution focused manner. Individualized case management occurs with clients on a regular and timely basis through home visits.

The target population is chronically homeless individuals who have been continuously homeless for a year or more, or who have had at least four episodes of homelessness in the past three years. Individuals who are long-term shelter stayers and/or rough sleepers will be prioritized for service. Permanent Supportive Housing is for individuals with high acuity who have a Service Prioritization Decision Assistance Tool (SPDAT) score in the range of 35-60. All referrals into the program must come through the Coordinated Access Process.


• Minimum 55 clients served/year. • Caseload of clients/case worker. • At any point in time, maintain a 95% occupancy rate based on units available. • At any point in time, 85% of clients housed through the program will remain stably housed. • Recidivism rate – No more than 15% of clients will return to homelessness. • Those persons housed in the program will show a reduction in inappropriate use of the public systems.

i.e. Reduction in emergency room visits, hospitalizations and incarcerations. • Those persons housed in the program will demonstrate improved self-sufficiency. • Persons accepted into the program will demonstrate engagement in mainstream services (e.g. physical

health, mental health, addictions, counselling, financial, legal service, employment, education). • 85% of clients leaving the program will report an increase in income from employment and/or benefits.

Where clients are unable to increase income, 95% will maintain a stable income source.

7.7 Transitional Housing for Youth

Transitional Housing for Youth is a model of housing that provides a supportive environment for youth while assisting them to become self-sufficient and make a successful transition to adulthood.

Two types of housing models will be provided for youth:

• Transitional Housing – This is a place-based model where clients are housed in a transitional house with other youth with comparable issues. In this group setting, youth can gain the skills and confidence to manage the details of independent living on their own. A House Mentor may live on site to provide good neighbor/good roommate skills.

• Scattered Site Housing – This housing model which involves youth renting appropriate housing units (both market and non-market) in the community.

Case management supports are provided to assist with housing and life stability in a client centered, solution focused manner. Individualized case management support occurs with clients on a regular and timely basis through home visits.

The target population is homeless youth between the ages of 16-24 who are without a permanent place of residence; live on the street, in shelters, or in places that are not intended or suitable for permanent residence;


are “couch-surfing” or temporarily living with others for short periods of time. Youth with mid to high acuity who have a Service Prioritization Decision Assistance Tool (SPDAT) score in the range of 20-60. All referrals into the program must come through the Coordinated Access Process.


• Minimum 12 clients served/year. • Expected caseload of 6-8 clients/case worker. • At any point in time, maintain 95% program capacity. • At any point in time, 85% of clients housed through the program will remain stably housed. • Recidivism rate – No more than 15% of clients will return to homelessness. • Those persons housed in the program will show a reduction in inappropriate use of the public systems.

i.e. Reduction in emergency room visits, hospitalizations and incarcerations. • Those persons housed in the program will demonstrate improved self-sufficiency. • Persons accepted into the program will demonstrate engagement in mainstream services (e.g. physical

health, mental health, addictions, counselling, financial, legal service, employment, education). • 85% of clients leaving the program will report an increase in income from employment and/or benefits.

Where clients are unable to increase income, 95% will maintain a stable income source.

7.8 Indigenous Cultural Support

The Indigenous sub-population is over-represented among those experiencing homelessness in Red Deer. Providing cultural support is crucial to the housing success of Indigenous individuals and families experiencing homelessness.

The goal of Indigenous Cultural Support is to provide support to Indigenous peoples (First Nation, Inuit, and Metis) experiencing homelessness who may require such support services to help them maintain housing through cultural reconnection. This includes planning, facilitating and creating opportunities for individuals and families to learn and grow in their understanding of the traditional Indigenous culture through sharing circles, ceremonies, and access to resources such as Elders. Indigenous individuals and families participating in Housing First programs in Red Deer are eligible to access these cultural supports.

This program does not directly house clients, but instead works with the Housing First programs in the community to provide Indigenous cultural supports for those who may need it. They will collaborate with community agencies and housing programs to offer Indigenous Cultural Supports to clients. This includes assisting with client case management from an Indigenous perspective such as going out with a case worker to meet clients in their home, attending appointments or meetings with clients for the purpose of providing support.


• Number of individuals and families who accessed Indigenous cultural support services. • Type of Indigenous cultural support services provided. • Duration and intensity of Indigenous cultural supports.


7.9 Household Amenities Warehouse

The Household Amenities Warehouse provides furniture and essential household items to individuals and families transitioning out of homelessness and into permanent housing. The warehouse may also be used as temporary storage for clients’ belongings as a result of loss of housing while waiting to be rehoused. Individuals and families transitioning out of homelessness and enrolled in a Housing First program in Red Deer are eligible to access the Household Amenities Warehouse.

All housing programs funded by The City of Red Deer can make referrals to the Household Amenities Warehouse. The warehouse will work in collaboration with the housing programs to ensure clients have the opportunity to choose their own household furnishings at no cost. Items for the warehouse may be donated by the community or purchased through agreements with retailers.

The operation of the Household Amenities Warehouse may expand to include an additional employment readiness and work experience component. This would be specific to warehousing and include basic skills, employment readiness, safety tickets/certification, job applications/preparation.


• Number of individuals and families who received assistance from the Household Amenities Warehouse. • Type of furniture and household items provided. • Number of relationships built with retailers and community organizations. • Work towards sustainability of the Household Amenities Warehouse through a social enterprise model.

Models of this successfully occurring in other communities within Alberta and Canada are documented.

7.10 Landlord Engagement Services

The goal of Landlord Engagement Services is to engage landlords in Housing First programs and increase the pool of housing units available for clients participating in Rapid Rehousing and Intensive Case Management scattered-site programs. This includes landlords, property owners, residential property managers, and property management firms.

It is the responsibility of Landlord Engagement Services to:

• Recruit landlords to provide housing units for individuals and families experiencing homelessness. This includes identifying new landlords and managing relationships with existing landlords.

• Develop effective marketing materials to assist with landlord recruitment and address potential barriers to landlord participation.

• Educate landlords about Housing First (e.g. presentations, in-person visits, community meetings, and newsletters).

• Host events specifically for landlords to promote communication and knowledge exchange (e.g. information sessions, workshops, and appreciation events).

Landlord Engagement Services acts as a liaison between landlords and housing first programs, therefore it is essential to work in collaboration with Housing First programs. The responsibility of showing units to clients,


reviewing the lease, making arrangements for move-in, following-up on rent payments, and supporting clients in addressing landlord and tenant issues remains the responsibility of the case workers in each program.


• Number of landlords recruited. • Number of units of rental housing secured. • Retention rate of landlords.


8.0 Performance Measurement, Service Standards and Quality Assurance

Performance measurement is a process that systematically evaluates whether your efforts are making an impact on the clients you are serving or the problem you are targeting43. Performance is fundamentally measured by a positive change in the problem you are aiming to address. From a client perspective, change is defined by a measurable improvement in client knowledge, skills, behavior, or condition. Performance measurement can happen at any level— system, program, and individual44. Performance measurement at a system or community level seeks to uncover whether your entire homeless support system is working relative to its goals. If it is, what makes it work? If it isn’t, what part does not work and how can you fix it? System-wide effectiveness may look at all homeless support programs in the community. At the program level, performance measurement assess the impact that one program has on its clients. It involves looking at program-level outcomes and the changes in the clients that result from participating in the program.

In Red Deer and Alberta, the 10 year plans to end homelessness have adopted an outcomes-based performance and funding model that uses measurable performance standards to monitor and evaluate program and client level outcomes. The performance standards reinforce an overall vision and strategy for improving the homeless services system and working toward ending homelessness45. Red Deer’s overall system goal is to ensure those who are homeless have permanent, appropriate housing and the supports they require within 28 days of presenting for services within the system. The mandated outcome–based performance measures from Alberta Human Services relate to: housing stability; reduction in use of public systems; improved self-sufficiency; and, engagement in mainstream services with indicators to measure those outcomes. For example, the outcome indicator for retention is stated “At any given reporting period, 85% of the people accepted into the program will still be permanently housed”.

Table 7. Human Services Mandated Outcome and Indicator and Performance

Outcome Indicator

Those housed through the program will remain stably housed.

At any given reporting period, 85% of the people housed will still be permanently housed

Indicators 2014/15 Red Deer Results 2014/15 Provincial Results

Annual retention rate (total caseload in year – negative exits in year)/ (total caseload in year)

96% (April 1, 2014 – March 31, 2015)

91% (April 1, 2014 – March 31, 2015)

Cumulative retention rate (total clients housed – negative exits)/ (total clients housed)

79% (cumulative since April 2009)

73% (cumulative since April 2009)


8.1 Performance Targets

While the results of our current system indicate progress towards ending homelessness, there is still work to be done to reach the projected targets. In order to reach the goal of ending chronic and episodic homelessness by 2018, changes need to be made. Most significantly, we must enhance performance across the board to maximize investments. It will be necessary to introduce Key Performance Indicators (KPIs) across all of the projects. These KPIs will form part of the deliverables within the RFP and the agreements with the service providers.

For the purposes of our system framework, performance measurement will occur at three levels: system, program and client. For each performance measure, indicators and targets have been assigned to measure them to ensure accountability and continuous improvement. System performance targets are intended to reflect performance across multiple projects of a given type or across a range of projects and project types and subpopulations46. The program measures reflect both client outcomes and operational targets for each program. Performance measurement will include both process and outcome measures.

System Level Performance Measures:

• Overall homelessness is reduced by 60% by 2018. • Chronically and episodically homeless numbers are reduced by 20% by 2018. • 85% of clients are stabilized in permanent housing by 2018. • Usage of emergency shelters is reduced by 15% by 2018. The average length of stay in shelter is

reduced to 4 days. • 90% of clients have improved self-sufficiency at program exit. • Inappropriate use of public systems is decreased by 25% among clients at program exit. • 50% of homeless programs participate in integrated information system by 2018. • 90% of clients will be successfully matched to a housing first program within 90 days.

Program Level Performance Measures:

• Length of stay in program. • Occupancy rate of 95% for all programs. • Number of clients served. • Housing retention of 85% for all programs. • Destinations at exit. • Return to Homelessness. • Improved self-sufficiency. • Engagement with mainstream services. • Reduce negative reasons for leaving program. • Turnover rate increased/reduced depending on program type.

Based on the above performance benchmarks an appropriate monitoring, evaluation and reporting framework will be developed. At the system wide level, Red Deer’s System Framework performance will be monitored and evaluated annually to determine the extent to which it is progressing in meeting the targets. At the program level, The City of Red Deer will work directly with each program to set and establish a work plan for performance targets. These targets will be contained in the Logic Models included in the service provider’s contract. This will


be monitored and evaluated by The City of Red Deer to ensure projects are meeting their performance benchmarks.

8.2 Data Sources

To tie diverse service providers together into a well-coordinated system, shared information becomes essential. Integrated information-management systems allow for a common means of collecting and sharing longitudinal person-level information about those accessing the homeless-serving system. There are three primary data sources that will be used by The City of Red Deer to collect data on the system, program and client level measures.

• Homeless Management Information System (Efforts to Outcomes Database) and client level outcome information including emergency shelter information.

• Homeless Point in Time Counts that will be conducted every two years covering both sheltered and unsheltered population experiencing homelessness.

• Other relevant data that captures pertinent information about structural determinants of homelessness which impacts systemic-level performance will be collected to determine progress in ending homelessness.

8.3 Standards of Service and Quality Assurance

A service standard is a public commitment to a measurable level of performance that clients can expect under normal circumstances. Service standards are integral to good client service and to effectively manage performance. They help clarify expectations for clients and employees, drive service improvement, and contribute to results-based management. Service standards reinforce accountability by making performance transparent which increases confidence in the system. Service standards, such as Standards of Practice Case Management for Ending Homelessness, will be developed at both the program and system levels to assess quality across the homeless-serving system. Service standards will be developed in consultation with clients, funders and service providers to make sure they are meaningful, consistent with client priorities, match the priorities of the system framework, and are achievable within available resource allocations. The standards of service will reflect the fidelity elements of the housing first approach to program delivery. The standards will be closely monitored and regularly reviewed and updated as appropriate.

Quality Assurance is essential if ongoing performance measurement is to provide an accurate and complete picture of the system and program level performance. Quality Assurance links the numerical aspects of performance management already discussed to complementary qualitative processes in a feedback loop of continuous improvement. Quality Assurance not only covers areas like case management practice, but also issues of staff, client and community safety and the management of grievances and serious incidents.

The Quality Assurance Process will involve a systematic approach to improve and strengthen the quality of program and services including the following activities:

• Establishing a client advisory panel to provide input into system and program functioning and how they are addressing client needs.


• Direct monitoring and remediation of service standards, financial, outcome and contract compliance information.

• Introducing and supporting risk management measures, particularly relating to safety and resolving grievances.

• Setting basic standards for each ‘program type’ operations, based on the housing first philosophy, best practices and related client outcomes47.

• Assessing individual programs through a peer review process utilizing common standards to identify strengths that can be shared and challenges that can be overcome.

• Developing standard tools programs can use to enhance quality. • Providing opportunities for programs to collaborate and learn from each other. • Conducting trainings and providing learning opportunities for program staff.


9.0 Conclusion

9.1 Calling all System Players

To ensure success, all systems need to work together.

Homelessness is a complex issue and cannot be solved by the homeless-serving system by itself. The six Ministries that have shared accountability and mandates to support vulnerable individuals experiencing homelessness; Health, Alberta Health Services, Service Alberta, Infrastructure, Seniors, Justice and Solicitor General also have a responsibility to be part of Red Deer’s System Framework for Housing and Supports. In order to be successful all players, provincial systems, businesses, not-for-profit agencies, industry, faith community and private citizens need to come together and work as an integrated system that focuses on the client and seeks a way to support the client versus slotting the client into a program. An effective strategy for responding for homelessness will need to respond to the variety of social issues that accompany housing instability, including mental health, addictions, poverty, family violence, child intervention and justice system involvement. The goal will be to “turn off the tap” into homelessness through a coordinated effort among the service delivery agencies and government systems. We need our provincial and federal partners to lead critical policy changes to prevent discharging into homelessness. Finally we need all the levels of government to take a critical, forward moving action to put more affordable housing in our community. Affordable, appropriate housing is the answer to ending homelessness.

9.2 We will be Successful

The framework described in this document provides a system map of how all stakeholders – government, agencies and the public – can work together to end homelessness. It will take all stakeholders within our community working together to achieve this goal. We can achieve this goal and we will do it, together.


10.0 End Notes

1 Whittaker, E., Swift, W., Flatau, P., Dobbins, T., Schollar-Root, O., & Burns, L. (2015). A place to call home: study protocol for a longitudinal, mixed methods evaluation of two housing first adaptations in Sydney, Australia. BMC public health, 15(1), 342.

2 Aubry, T., Klodawsky, F., Coulombe, D. (2012). Comparing housing trajectories of different classes within a diverse homeless population. American Journal of Community Psychology, 49, 142 – 155.

3 Azurdia, A. X. (2015). Housing and Homelessness: Two Models of the Relationship Between Quality of Life, Physical Health, and Mental Health (Doctoral dissertation, University of Ottawa).

4 City of Red Deer (2015) Estimation of Prevalence based on City of Red Deer’s 2015 Municipal Census, Population number and growth rate, Shelter Utilization and Estimation of those sleeping rough

5 Red Deer and District Community Foundation. (2014). EveryOne’s Home: Red Deer’s Five Year Plan to End Homelessness 2014 to 2018. http://www.reddeer.ca/media/reddeerca/about-red-deer/social-well-being-and-community-initiatives/housing-and-homelessness/Five-Year-Plan-to-End-Homelessness-1520332---Apr-2014.pdf

6 Alberta Secretariat for Action on Homelessness. (2008). A Plan for Alberta: Ending Homelessness in 10 Years. http://humanservices.alberta.ca/documents/PlanForAB_Secretariat_final.pdf

7 Government of Canada. (2014). Homelessness Partnering Strategy Directives 2014-2019. http://www.esdc.gc.ca/eng/communities/homelessness/funding/directives.shtml

8 Mansell, J., & Beadle-Brown, J. (2004). Person-centred planning or person-centred action? Policy and practice in intellectual disability services. Journal of Applied Research in Intellectual Disabilities, 17(1), 1-9.

9 Greenberg, G. A., & Rosenheck, R. A. (2010). An evaluation of an initiative to improve coordination and service delivery of homeless services networks. The journal of behavioral health services & research, 37(2), 184-196.

10 Gaetz, S., Scott, F., & Gulliver, T. (2013). Housing First in Canada: Supporting communities to end homelessness.

11 Pearson, C. L., Locke, G., Montgomery, A. E., & Buron, L. (2007). The Applicability of Housing First Models to Homeless Persons with Serious Mental Illness, US Department of Housing and Urban Development, Office of Policy Development Research. Accessed on-line at http://huduser. org/portal/publications/hsgfirst. pdf on December, 30, 2012.

12 Polvere, L., Macnaughton, E., & Piat, M. (2013). Participant perspectives on housing first and recovery: Early findings from the At Home/Chez Soi project. Psychiatric rehabilitation journal, 36(2), 110.

13 Turner, A. (2015). Performance Management in a Housing First Context: A Guide for Community Entities.

14 Turner, A. (2014). Beyond Housing First: Essential Elements of a System-Planning Approach to Ending Homelessness.

Also, see 9 above.

15 See 9 above.


Gaetz, S. (2010). The struggle to end homelessness in Canada: How we created the crisis, and how we can end it. The Open Health Services and Policy Journal, 3, 21-26.

17 Canadian Centre on Substance Abuse. (2014). Systems Approach Workbook: System mapping tools. Ottawa, ON.

http://www.reddeer.ca/media/reddeerca/about-red-deer/social-well-being-and-community-initiatives/housing-and-homelessness/Five-Year-Plan-to-End-Homelessness-1520332---Apr-2014.pdf

http://www.reddeer.ca/media/reddeerca/about-red-deer/social-well-being-and-community-initiatives/housing-and-homelessness/Five-Year-Plan-to-End-Homelessness-1520332---Apr-2014.pdf

http://humanservices.alberta.ca/documents/PlanForAB_Secretariat_final.pdf

http://www.esdc.gc.ca/eng/communities/homelessness/funding/directives.shtml


18 The City of Red Deer. (2015). The Experiences of Homelessness in Red Deer: An Ethnographic Perspective Report. http://www.reddeer.ca/media/reddeerca/about-red-deer/social-well-being-and-community-initiatives/housing-and-homelessness/The-Experience-of-Homelessness-in-Red-Deer-An-Ethnographic-Perspective.pdf

19 See 9 above.

20 See 16 above.

21 Rush, B. R., & Nadeau, L. (2011). Integrated service and system planning debate. Responding in Mental Health-Substance Use. London: Radcliffe Publishing Ltd, 148-75.

Albanese, T. (2010). Performance Measurement of Homeless Systems. from https://www.onecpd.info/resources/documents/PerfMeasurementHomelessSystems_Presentation.pdf

Austen, T., Pauly, B. (2012). Homelessness Outcome Reporting Normative Framework: Systems Level Evaluation of Progress in Ending Homelessness. Evaluation Review, 36(1), 3-23.

22 Homeless Hub (2013). Retrieved from http://homelesshub.ca/solutions/systems-approach-homelessness/systems-spectrum


24 Lee, B. A., Price-Spratlen, T., & Kanan, J. W. (2003). Determinants of homelessness in metropolitan areas. Journal of Urban Affairs, 25(3), 335-356.

25 The City of Red Deer (2015). Municipal Census Report. http://www.reddeer.ca/about-red-deer/population-and-demographics/census/

26 The City of Red Deer. (2013). Demographic and Socio-Economic Trends, Red Deer: Analysis of Federal Census and National Household Survey (1981 to 2011) (Report No. 2). Red Deer, Alberta, Canada: The City of Red Deer.

27 Canada Mortgage and Housing Corporation. (2015). Rental Market Report, Alberta Highlights.

28 Statistics Canada. (2015). Labour Force Information, Catalogue no. 71-001-X. Ottawa, Canada: Statistics Canada

29 Red Deer and District Community Foundation. (2014). Red Deer Housing Options Framework

30 See 25 above.

31 Gaetz, S. (2012a). Housing First. Homeless Hub topic. www.homelesshub.ca/Topics/Housing-First-209.aspx

Gaetz, S. (2012b). The Real Cost of Homelessness: Can We Save Money by Doing the Right Thing? Toronto: Canadian Homelessness Research Network Pres

32 Canadian Homelessness Research Network. (2013). Canadian Definition of Homelessness. Retrieved from http://www.homelesshub.ca/ResourceFiles/CHRNhomelessdefinition-1pager.pdf

33 Alberta Secretariat for Action on Homelessness. (2013). A Plan for Alberta: Ending Homelessness in 10 Years, 3 Year Progress Report. Government of Alberta.

34 Alberta Secretariat for Action on Homelessness. (2013). A Plan for Alberta: Ending Homelessness in 10 Years, 3 Year Progress Report. Government of Alberta.

35 Calgary Homeless Foundation (2014). System Planning Framework. http://www.homelesshub.ca/sites/default/files/CHF%20System%20Planning%20Framework.pdf

http://www.reddeer.ca/media/reddeerca/about-red-deer/social-well-being-and-community-initiatives/housing-and-homelessness/The-Experience-of-Homelessness-in-Red-Deer-An-Ethnographic-Perspective.pdf

http://www.reddeer.ca/media/reddeerca/about-red-deer/social-well-being-and-community-initiatives/housing-and-homelessness/The-Experience-of-Homelessness-in-Red-Deer-An-Ethnographic-Perspective.pdf

https://www.onecpd.info/resources/documents/PerfMeasurementHomelessSystems_Presentation.pdf

http://homelesshub.ca/solutions/systems-approach-homelessness/systems-spectrum

http://homelesshub.ca/solutions/systems-approach-homelessness/systems-spectrum

http://www.reddeer.ca/about-red-deer/population-and-demographics/census/

http://www.reddeer.ca/about-red-deer/population-and-demographics/census/

http://www.homelesshub.ca/Topics/Housing-First-209.aspx

http://www.homelesshub.ca/ResourceFiles/CHRNhomelessdefinition-1pager.pdf

http://www.homelesshub.ca/sites/default/files/CHF%20System%20Planning%20Framework.pdf


36 Aubry, T., Farrell, S., Hwang, S., & Calhoun, M. (2013). Identifying the Patterns of Emergency Shelter Stays of Single Individuals in Canadian Cities of Different Sizes. Housing Studies, (ahead-of-print), 1-18

37 The City of Red Deer. (2012). Red Deer Point In Time [PIT] Homeless Count 2012

http://www.reddeer.ca/media/reddeerca/about-red-deer/social-well-being-and-community-initiatives/housing-and-homelessness/Red-Deer-PITFinal-Report--Nov---2012.pdf

The City of Red Deer. (2014). Point in Time Homeless Count http://www.reddeer.ca/media/reddeerca/about-red-deer/social-well-being-and-community-initiatives/housing-and-homelessness/2014-Red-Deer-Point-in-Time-Homeless-Count-Full-Report.pdf

38 Statistics Bureau of Australia (2012). Census of Population and Housing: Estimating homelessness,2011. http://abs.gov.au/ausstats/[email protected]/Latestproducts/2049.0Main%20Features22011

United Kingdom. (2015). Evaluating the Extent of Rough Sleeping A new approach. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/6009/1713784.pdf


40 The City of Red Deer. (2015). Social Policy Framework. http://www.reddeer.ca/media/reddeerca/city-government/plans-and-projects/ongoing-plans-and-projects/SPF-FINAL---Sept-3-(2).pdf

41 See 38 above.

42 OrgCode Consulting, Inc. (2014). The Difference Between Having Higher Acuity and Being Chronic. http://www.orgcode.com/2014/03/10/the-difference-between-having-higher-acuity-and-being-chronic/

43Albanese, Tom. (2010). Performance Measurement of Homeless Systemshttps://www.hudexchange.info/resources/documents/PerfMeasurementHomelessSystems_Presentation.pdf

43 United States Department of Housing and Urban Development (2015). System Performance Measures An introductory guide to understanding system-level performance measurement

44 Spellman, B., & Abbenante, M. (2008). What Gets Measured, Gets Done: A Toolkit on Performance Measurement for Ending Homelessness

45 National Alliance to End Homelessness (2010). http://www.endhomelessness.org/page/-/files/3466_file_The_Columbus_Model_Peformance_Measurement_Evaluation_FINAL_WEBSITE.pdf


47 Corporation for Supportive Housing (2015). Connecticut Supportive Housing Quality Policy Review. http://www.csh.org/csh-solutions/community-work/housing-development-and-operation/assuring-quality-in-connecticut



http://www.reddeer.ca/media/reddeerca/about-red-deer/social-well-being-and-community-initiatives/housing-and-homelessness/2014-Red-Deer-Point-in-Time-Homeless-Count-Full-Report.pdf



http://abs.gov.au/ausstats/[email protected]/Latestproducts/2049.0Main%20Features22011

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/6009/1713784.pdf

http://www.reddeer.ca/media/reddeerca/city-government/plans-and-projects/ongoing-plans-and-projects/SPF-FINAL---Sept-3-(2).pdf

http://www.reddeer.ca/media/reddeerca/city-government/plans-and-projects/ongoing-plans-and-projects/SPF-FINAL---Sept-3-(2).pdf

https://www.hudexchange.info/resources/documents/PerfMeasurementHomelessSystems_Presentation.pdf

http://www.endhomelessness.org/page/-/files/3466_file_The_Columbus_Model_Peformance_Measurement_Evaluation_FINAL_WEBSITE.pdf

http://www.endhomelessness.org/page/-/files/3466_file_The_Columbus_Model_Peformance_Measurement_Evaluation_FINAL_WEBSITE.pdf

http://www.csh.org/csh-solutions/community-work/housing-development-and-operation/assuring-quality-in-connecticut

Documents

Red Deer’s System Framework for Housing and Supports · Alina Turner was hired as an expert advisor to assist with the process. The Community Housing Advisory Board (CHAB) which