A Big Step Forward Ending Homelessness in Canada
Reaching Home: Canada’s Homelessness Strategy was released today. It is the biggest overhaul of homelessness funding in Canada in the almost two decades that federal funding has been available for homelessness in the country. There is plenty to be excited about – a doubling of homelessness funding and an extension of the program to 10 years to name a couple.
I am most excited about three things that all needed to be inter-related if success is to be achieved: that communities must be accountable to achieve a 50% reduction in chronic homelessness, that there is a data-driven performance-based approach, and the requirement to use coordinated access.
For my readers outside Canada, some elements of this will be familiar to how your funding works. But I know of no place that requires a 50% reduction in chronic homelessness, even though many jurisdictions place an emphasis on reducing chronic homelessness. A big high five to Canada's leaders for having a target in this regard.
A community cannot reach a 50% reduction in chronic homelessness without a benchmark to compare it against. Whether we look at PIT count data, period-prevalence counts, or even service users throughout a year, a 50% reduction is nothing to sneeze at. The only way to achieve the target is to have an unrelenting focus on housing and an unprecedented use of data to measure progress against the aim, as well as target and prioritize who will get assistance. By putting requirements in place to reduce chronic homelessness by 50%, the days of first come, first served and "lucky to have a case manager who knows their way around the system" days are over. Furthermore, communities need to know a lot about the inflow into chronic homelessness to manage and target outflow out of chronic homelessness. Chronic homelessness isn't an accident – it is manufactured by the policies, programs and approaches that a community has in place. In many instances the only way to get out of the current state of chronic homelessness is to redesign the entire system of care. That may be long overdue in some communities.
A data-driven, performance-based approach makes loads of sense. There are no "feel good" and "let's just try our best" approaches to ending homelessness. The data-driven approach may be a stretch-goal for some communities to start because any data-driven approach has to go from collecting data (which happens in various degrees now) to using data to refine program approaches. I think it also forces some communities to look more critically at the big picture. System performance measures become, in some ways, more critical than any specific project's performance. If you have one or two great programs, but eight or nine underperforming programs, the overall community performance will suffer. Data-driven, performance-based approaches make all investments accountable to outcomes.
Finally, I am excited to see the movement to Coordinated Access. While many US communities have felt the pain of moving towards this manner of doing business, there are tremendous lessons to be learned of how to leverage community resources to the maximum gain based upon presenting issues and circumstances of the individual program participant. Canadians experiencing homelessness can come to expect that they will be triaged and served based upon needs, not luck. Homeless service providers will be forced to help people get housing and supports through a system of care rather than around a system. Transparency will reign supreme in how priorities are set and matching occurs. Data moves to real(ish)-time when Coordinated Access is brought to scale. As I have blogged about before there are different approaches to putting this in action, each with relative pros and cons.
Kudos to the Government of Canada for reimagining what an end to homelessness can look like, for making significant investment to make it happen, and by making bold statements and targets to achieve the aim.
What Is An Acceptable Rate of Death?
For the last month I have been working on a data set to better understand unsheltered homelessness. Yes, I have been working on that when I should have been blogging. And returning emails. And other functions necessary for running a business (which I am reminded of from time to time that OrgCode is).
Since early 2015, over 5% of the population included in the data set has died.
To be clear, three types of people died: someone's parent, someone's sibling, someone's child.
They were old and young. They were of different races and ethnicities. They had different lengths of homelessness.
As you might suspect and expect, the rate of death is higher than the general population, where just under 1% of the population dies every year.
Death is something I have come to embrace in my work on homelessness. It doesn't get any easier, nor do I get immune to it. I have given up thinking that it results in urgency for people to act. My newsfeed had this story in it today: www.cbc.ca/news/canada/british-columbia/homeless-man-spends-dying-hours-at-vancouver-tim-hortons-1.4689842 where a person who is homeless spends their dying hours in a coffee shop. At least it makes the news.
Across all age cohorts, people who are homeless are three times at greater risk of death. The literature shows that the average age of death of a person who is homeless is about 50. In 1900 that was the life expectancy. People who are homeless get the same illnesses that housed people get, just at rates 6 times higher. They also experience advanced chronological ageing.
Rates of death in individual cities seems to be on the rise too. Maybe it is opioids. Maybe it is weather phenomenon. Maybe it is known causes of death amongst people who are homeless like higher rates of cardiovascular disease. The Washington Post did an interesting article on the matter back in April.
What I do know is that we need to act with urgency if we are going to reverse what seems to be the new normal. We need to prioritize people for housing, knowing that some of those we house will also die, but with greater dignity. We need to focus our attention on cures to homelessness, not bandaids. Housing is good health care.
5 Core Principles
In ending homelessness, we need to work with urgency but not with haste. We need to focus on that which we know, not that which we think. And regardless of whether we are operating a shelter, outreach program, day service, Rapid Re-Housing or Permanent Supportive Housing program – or any other program for that matter – we need to ensure we are aligned to the same 5 core principles of the work.
Principle 1: No requirements for housing readiness
Two criteria need to be met for someone to be housing ready. 1. They are homeless. 2. They are breathing. That’s it. There are no programs that people need to graduate through or transitional or provisional housing stays where people demonstrate acquisition of skills. The hard work comes once we get the person or family housed to provide them the supports necessary for them to stay housed. We need to progressively engage and build upon their strengths to make this possible.
Principle 2: Client choice and supported self determination
We need to fiercely support choice within realistic parameters of what is possible. Choice is not carte blanche. But choice must be meaningful and centred on the needs and wishes of the individual or family. Do you present service and housing options to program participants or do you create a service pathway that they must follow? Is the person you are supporting at the centre of the decision-making or are they a bystander to decisions that are made for them?
Principle 3: Supporting a recovery orientation
It is our duty to promote mental health recovery. It is our duty to practice from a harm reducing lens. It is our duty to understand the supports necessary to help people recover from the experience of homelessness. For many – especially those that have been homeless for many years of their lives – they actually need to grieve the loss of their routines and habits they once participated in while homeless in order to forge ahead with a healthy, new reality of being housed.
Principle 4: Individualized support plan and client-centred supports
No two support plans should ever look the same because no two people are ever the same. We must push back against designing programs with people to work their way through and instead focus on customizing the supports to the needs of each individual or family. We must reject linear, milestone, one-size fits all approaches to services and appreciate that each journey that progresses to life stability will be unique, often non-linear and person specific.
Principle 5: Promoting social and community integration and meaningful activities
The people we engage need to integrate with the community and neighbourhood fabric within which they find themselves in a post-homelessness reality. If the support worker is the only support they have or if the person is socially isolated, we are doing the support part wrong. People need activities to look forward to, participate in and provide fulfillment.
Planned Disengagement
In time-limited housing support programs, when and how we end the housing support process requires careful thought.
Disengagement has a slew of other names in our sector. Graduation. Program exit. Program end. Service delivery conclusion. etc. I am going to go with disengagement, and in this blog, I am talking about planned, voluntary termination of time in a program because the program participant has been successful in the program. I am not talking about involuntary, unplanned ends of program involvement.
Because we are looking at disengagement in the context of time-limited programs, the time factor is a variable that should, whenever possible, exist as a goal post rather than fixed absolute. For example, having a six month program that expels people from a program because six months is up rather than because goals were reached, will have the unintended consequence of having people return to homelessness. The time factor should have us reverse engineering the milestones that need to be reached to allow for the self-sufficiency after disengagement to occur.
Disengagement is best implemented by having a transition process when goals are reached and self-sufficiency seems to be intact. To be clear, I don't know if there is any absolute way of accurately measuring self-sufficiency, so this is more of an informed opinion on the part of the housing support worker and the program participant than having a finite checklist of criteria to be met. (For example, I am not advocating communities dust off the Self-Sufficiency Matrix and start using it as the measure for ending supports.) What we can measure, though, is whether goals are being reached and whether a variety of life skills have been learned. It can be helpful use tools like the Effective Exit Worksheet that you can get from the Products section of our website.
Disengagement is worth acknowledging as a milestone in the journey of being in a program and exiting homelessness, but I am not sure it is worth celebrating with cake and whatnot the way some programs do. By the time we get to disengagement I would expect that supports would have gradually been withdrawn to the point where the supports end with a whimper rather than a bang. And besides, disengagement is really about the program participant growing, changing and adapting to the point where they can integrate all of the knowledge and skills development received through the case management support; it isn't about taking a victory lap of some sort.
Speaking of the program participant interests, I think disengagement is more likely to be successful if we keep them front and centre in the planning of the disengagement. At the start of the program the participant should know that disengagement is the goal in the time-limited program. The program participant should know, transparently and from the beginning, what the criteria are for disengagement.
Disengagement may mean the end of case management support from a housing worker, but that does not mean that all supports from other community providers must also come to an end. For disengagement to work well there can be a whole process of linking the program participant to alternative community resources, and where necessary and with consent, to have information about the disengagement shared with other community service providers.
It is not uncommon for program participants to have concerns before or during the disengagement process. It is best that there is open dialogue to name these and address each one. It can be helpful to start this process months before the actual disengagement.
Being Authentic in Ending Homelessness
This week I am channeling my inner Brene Brown and focusing on what it takes to be authentic. This has been top of mind for me lately. I went fishing Saturday, which is one of the activities I do that lends itself to being self-reflective. My grandfather once had a sign up in his house that said, "Fishing: a jerk on one end of the line waiting for a jerk on the other." Fishing is time to focus on whether or not I am being a jerk.
To be authentic, one must:
Cultivate courage to be imperfect, set boundaries, and be vulnerable;
Exercise compassion that comes from realizing and accepting we all are made from strengths and struggles;
Nurture connection and sense of belonging that can only happen when we believe we are good enough;
Invite grace, joy and gratitude into life.
The courage to be imperfect is really hard. I live this a lot, but it is scary. The VI-SPDAT is a good example of having the courage to be imperfect because the tool is not perfect, people often use it wrong, and I spend every day (well, part of each day) thinking about what to improve upon it and the other SPDAT products next. The SPDAT products are the best and worst part of my contributions towards ending homelessness. It has changed how communities go about addressing homelessness, but it also has its haters. Having the courage to be imperfect often means inviting haters into your life whether you want them there or not. I would love to Taylor Swift them all and "shake it off" but that is easier said than done. Why? Because the hatred of the tools often becomes personal and is about the creator not the tool itself. That makes me feel lonely and self-conscious and inadequate.
Exercising compassion is also really hard. I am a work in progress in this regard. As a younger man I would pounce on the weakness of others to make a point or exert influence. On my weak days, I still see the ugly side of myself. I can talk a good game of being strength-based - and I try hard to be - but I am also weakness-influenced. Thankfully this has never been the case for me with people who are homeless. But it happens sometimes where I struggle to exercise compassion with service providers that, say, argue against the merits of Housing First. I wish I knew how to enter into relationship with them in such a way that would make them more open to another point of view, but alas, staying focused exclusively on the merits of the debate gets muddled by my inner-voice trying to silence their opposition.
Nurturing connection is something I struggle with because a) I am on the road all the time; b) I struggle to trust people; c) I live with low self-esteem; and, d) I am, at heart, an introvert masquerading as an extrovert much of the time (which is exhausting). Maybe it is a history of getting burned. Maybe it is because I have met many awful people with alternative motives. But nonetheless, nurturing connection is something that is worthwhile because I have also seen the benefits of doing so. I have learned that being vulnerable enough to let people into my life that want to be my friend, talk about things other than work, support me in my low points and share with me in my highs, is gratifying. Some of the finest people I have ever met on this planet work in the field of ending homelessness.
Inviting grace, joy and gratitude into life is something I am continually learning to lean into. There are many moments of grace that can be glossed over or missed. There is joy that is waiting to be fully celebrated. And when I go fishing, in addition to reflecting on being a jerk, it also allows me the chance to reflect on things for which I am grateful. Not lost on me is that I get to work on ending homelessness as my life's work - even with haters. I get to see amazing things organizations and entire communities are doing to work towards ending homelessness. I get to share successes with others. I get to lead an incredible team of talented people. I get to keep learning and keep being challenged to be better and better and better. My eldest son even made his 7th Grade Oral Speech about me this year, which makes me well with pride.
I know of no one that is perfect in the pursuit of ending homelessness. But I know there are people I aim to be more like in my pursuit. I know there are people I can continue to learn from and grow from in this pursuit. And I know that when I am open to grace, those moments come to me. It makes me pause, most of the time, take a satisfied breath, and realize there is a real gift to living the most authentic life I can.
A Move Towards Ohana Zones?
As communities struggle with outdoor homelessness, more and more are looking to Ohana Zones as they are called in Hawaii, sanctioned tent cities as they may be called elsewhere. In some communities these are strictly for single adults, while other communities consider these for families with children. Some have premade structures and tents, while other communities require people to bring their own tent or create their own structure. Some are service rich environments with professional staff onsite, while others allow the campers to self-govern. Some have running water and other amenities onsite, while others rely on bottled water and portable toilets. The truth is, there is so much variation it is difficult to provide a comprehensive outline of exactly what constitutes a sanctioned place such as these, other than to say government allowed, encouraged or created it.
Let us look at this critically. I have six questions:
1. Does a sanctioned tent city solve street homelessness?
A sanctioned tent city does not take care of street homelessness in the way that many proponents would like. These are not jails or prisons. You cannot force people to stay in a tent city - sanctioned or otherwise. Yes, you may have some people who were living on the street make use of them. You will still have unsheltered homelessness outside of the sanctioned tent city. The response to this from communities is often along the lines of, “We will enforce existing laws making it very difficult for anyone to stay anywhere other than the sanctioned site.” So, you increase police and court costs and still have very vulnerable people who will refuse to use the sanctioned tent city. And then you have a public relations nightmare on your hands because you spent so much on the sanctioned tent city and expended political capital to put it in place and the general public still sees people staying outside.
You may also have the unintended consequence of having other people who had been precariously housed gravitate to them, or have people exit bricks and mortar shelter to live in the tent city.
2. Isn’t it a cheap fix?
In most instances sanctioned tent cities are expensive to operate. If it is professionally run and operated there are the infrastructure costs and staffing costs. This quickly gets into the millions in community after community and doesn’t actually solve the problem of inadequate supply of bricks and mortar shelter or affordable housing. If it is not professionally run and operated there are still the possibilities of infrastructure costs, but also the increased likelihood of policing costs to address unfortunate instances on the site. People living in congregate settings tend to have conflict.
3. What’s the end game?
There is no end game in sight once sanctioned sites start because communities are not concurrently investing in and/or creating the housing supply that would get the community to the place where the sanctioned sites are not needed. If a community envisions people transitioning through the sanctioned site then there needs to be a concurrent strategy and action plan in place to get people housed out of the sanctioned site. Most sanctioned sites have a fixed size. What is the plan when the current Ohana Zone fills up? Create another one?
4. Who is served?
The population aimed to be served is remarkably acute and complex. If the intention is to serve those that would otherwise be unsheltered, a sanctioned camp likely needs a staffing compliment that surpasses that which is found in a typical shelter. Why? Because study after study shows that unsheltered persons are generally sicker, less connected to services, and have a shortened life expectancy. Go ahead and check out Montgomery et al. Homelessness, Unsheltered Status, and Risk Factors for Mortality Public Health Rep. 2016 Nov-Dec; 131(6): 765–772 or Cheung AM, Hwang SW. Risk of death among homeless women: a cohort study and review of the literature. CMAJ. 2004;170(8):1243–1247 or Cousineau MR. Health status of and access to health services by residents of urban encampments in Los Angeles. J Health Care Poor Underserved. 1997;8(1):70–82 or Hwang SW, Lebow JM, Bierer MF, O’Connell JJ, Orav EJ, Brennan TA. Risk factors for death in homeless adults in Boston. Arch Intern Med. 1998;158(13):1454–1460 or Stergiopoulos V, Dewa CS, Tanner G, Chau N, Pett M, Connelly JL. Addressing the needs of the street homeless. Int J Ment Health. 2010;39(1):3–15 or Levitt AJ, Culhane DP, DeGenova J, O’Quinn P, Bainbridge J. Health and social characteristics of homeless adults in Manhattan who were chronically or not chronically unsheltered. Psych Serv. 2009;60(7):978–981 or Nyamathi AM, Leake B, Gelberg L. Sheltered versus nonsheltered homeless women: differences in health, behavior, victimization, and utilization of care. J Gen Intern Med. 2000;15(8):565–572
Better to invest in professional street outreach services with connections to permanent housing and integrated with health care.
5. We spent a long time making mistakes that led to wanting a sanctioned tent city. Shouldn’t we double-down?
The need for expanded shelter services did not happen overnight. It would appear as though someone was asleep at the switch in long-term homeless system planning, or there was a lack of appetite to invest strategically along the way to prevent the need for a quick fix. Let finger pointing begin on whose fault that was.
6. What should we do instead?
I get it. You have acute needs. The community is bursting at the seams with homelessness. You need housing, appropriate permanent shelter, professional staffing, and a plan. Most sanctioned tent cities are an idea in search of a comprehensive strategy. Yes, the thought of doing the right things comes with a hefty price tag, but compare that to the hollow outcomes and expense of providing sanctioned campsites, and it is a no-brainer.