Bringing Lethbridge Home Bringing Lethbridge Home Prepared for Housing and Urban Affairs Presented by SHIA to City Council 2010

Social Housing in Action City of Lethbridge

October 2010

Table of Contents

Table of Contents .................................................................................................................................. 2

Background ........................................................................................................................................... 3

Bringing Lethbridge Home ..................................................................................................................... 4

Our Vision .......................................................................................................................................... 4

Our Mission ........................................................................................................................................ 4

Our Core Beliefs ................................................................................................................................. 4

Our Values and Guiding Principles ..................................................................................................... 4

Our Goals and Targets 2010-14 ......................................................................................................... 5

The City of Lethbridge, SHIA and the Housing First Program ................................................................ 6

Lethbridge “Housing First” ..................................................................................................................... 7

History & Mandate: ............................................................................................................................. 7

Broadening the Scope of Housing First to Community: “Every door is the right door” ........................ 8

Intensive Case Management .............................................................................................................. 9

Furniture Bank .................................................................................................................................... 9

Training, Technical Assistance and Staff and Organizational Development ..................................... 10

Research and Evaluation ..................................................................................................................... 11

Data Collection & Analysis ............................................................................................................... 11

Priority Service Areas .......................................................................................................................... 11

Currently Funded and Priority Housing First Programs (2010-11) .................................................... 11

Contract Administration .................................................................................................................... 14

Housing First Budget 2010-11 ............................................................................................................. 14

Appendix A Housing First System Map ................................................................................................ 15

Appendix B Bringing Lethbridge Home Community Plan to End Homelessness and Action Plan ........ 16

Background

Since 2005, Lethbridge has focused on ending homelessness and in June 2009, City Council approved a revised 5 Year plan, “Bringing Lethbridge Home” that focuses, along with the provincial plan, on the core beliefs of a Housing First approach, rapid re-housing, client centered community support services and the prevention of homelessness.

This Service Delivery Model has been carefully designed by Social Housing in Action (SHIA), in consultation with clinical and service delivery experts and community stakeholders and grounded in the provincial and community plans. SHIA is the community-based organization dedicated to ending homelessness through a Housing First approach and represents a healthy and collaborative cross-section of community leaders and organizations that includes citizens, service providers, funders, government, and various organizations including people of aboriginal ancestry.

According to the Homeless Census 2008 and 2009, it is painfully clear that homelessness is one of the most critical social and economic issues facing our community. Increasing homelessness, low vacancy rates and a high proportion of the community living with low incomes all contribute to the current condition. Building critical partnerships, initiatives and strategies to literally provide permanent housing and the 'right' supports to the hundreds of individuals and families whose circumstances have forced them to live without access to secure, affordable and safe housing in Lethbridge is the priority.

Bringing Lethbridge Home represents a profound change in the way we address homelessness in our community. Rather than moving and shuffling the homeless people of our community from service to service, from street to emergency shelters and just managing homelessness simply results in a constant cycle in and out of homelessness. Bringing Lethbridge Home focuses squarely on providing the right supports to get people into safe, secure and affordable housing. This Housing First focus lies at the heart of Bringing Lethbridge Home and is the key to ending homelessness in Lethbridge and Alberta.

Additional and extensive community planning over these past months has resulted in a customized and community-based systemic approach to house people and prevent further chronic and crisis/trauma induced homelessness. The priority target populations include youth with complex needs (ages 18-24) as well as the street and sheltered homeless people with the most complex needs. Lethbridge has adopted a principle that ensures “Every door is the right door” to ensure people receive the supports required to be successful in their search for housing and secure permanent tenancy.

Bringing Lethbridge Home

Our Vision Bringing Lethbridge Home … Permanent Housing for all people living in Lethbridge

Our Mission To ensure permanent housing for all people living in Lethbridge by creating and implementing an innovative, systemic and comprehensive plan

Our Core Beliefs We believe that Lethbridge will end homelessness through a Housing First approach:

Prevention of homelessness through emergency assistance, eviction prevention strategies, employment opportunities, income support and required support services

Rapid Re-housing of people who find themselves in a homeless situation The availability of community and coordinated client-centered support services for all people as required

to access and sustain permanent housing and restore stability in their lives

Our Values and Guiding Principles We believe…

Any response to ending homelessness is based on Housing First; giving people who are homeless the safety, security and dignity of their own home before all else

All people have the right to be housed. Permanent housing is accessible, safe and affordable A community is strengthened economically and the health and social well being of people improves

through equal access to safe and affordable housing Innovation is required for access to safe and affordable housing Support services are integral for the successful housing of all people The creation of opportunities for self reliance, social integration and community participation, including

activities such as employment which supports people to successfully sustain their housing The leadership and support of all orders of government is essential to ensure all people are able to

access housing opportunities and end homelessness Continuous learning and the development and implementation of evidence practice is critical Community involvement and volunteerism is required to achieve the strategic goals Cooperation and collaborative partnerships best serves the community

Overall Target: 750 homeless or near homeless are moved into permanent housing with supports by 2014

Year 2 Target: 50 chronic street and sheltered homeless or near homeless with complex needs are permanently housed with required supports

Mid-term Target: 300 more homeless or near homeless are permanently housed with supports

Overall Target: 1000 new affordable housing units created by 2014 Year 2 Targets: 200 new units and 5 Rapid Housing short-stay units are created Mid-term Target: 400 more affordable housing units and 30 supportive housing units

Overall Target: Community acceptance for supported or affordable housing developments and services

Year 2 Target: City of Lethbridge implements the project “Building Welcoming & Inclusive Neighborhoods (and Community). A City wide Social Marketing Campaign is funded to support the initiative.

Mid Term Target: Housing proposals and support programs are accepted by the neighborhoods impacted

Our Goals and Targets 2010-14 Bringing Lethbridge Home to end homelessness requires a comprehensive strategic plan with the achievement of the following goals and targets.

Goal 1- Develop and increase permanent housing opportunities

Goal 2- Reduce NIMBY (Not In My Backyard) through education, positive communication, and neighbourhood relations

Goal 3 - Continue to implement and expand a Lethbridge based “Housing First” approach

Overall Target: Lethbridge has a comprehensive Medical Detox Centre by 2012 Community Report Card presentation to the community through City Council and is published annually

Year 2 Target: Plan for Medical Detox Centre initiated. Report Card presented to City Council April, 2011

Mid-term Target: Support for Medical Detox Centre secured

Overall Target: Average length of stay at an emergency shelter is less than 7 days by 2014

Year 2 Target: Rapid Re-housing plan developed for emergency shelters with support from Pathways to Housing Community Outreach Team and other Outreach services

Mid-term Target: Number of sheltered homeless decreased to 2005 levels

Overall Target: Reduce the need for emergency shelter; short-term stays and for crisis situations only

Year 2 Target: Number of sheltered homeless reduced to 2008 levels. Number of Street homeless reduced. Mid-term Target: Number of sheltered homeless decreased to 2005 levels

Goal 4 - Provide enhanced and coordinated services for people who are homeless or near homeless

Goal 5 - Ensure access to emergency shelter and housing options when needed, but work to move people quickly to permanent housing

Goal 6 - Prevent people from becoming homeless

The City of Lethbridge, SHIA and the Housing First Program This Housing First Service Delivery Plan is submitted to Alberta Housing & Urban Affairs and the Government of Alberta. The purpose of the plan is to outline our plan to permanently house people in Lethbridge. We have clearly combined funding streams to ensure maximum impact on achieving the goals and outcomes of the local, provincial and federal funding streams.

In addition, the 5 year plan, “Bringing Lethbridge Home” is well aligned with the priorities outlined in the City of Lethbridge’s Social Policy “Building a Better Future” (www.lethbridge.ca/SocialPolicy ). Priorities focus on the social needs of Families with Children, Older Adults, Aboriginal People, New Canadians, Youth and People with Disabilities as well as the community assets of engagement, inter-agency and stakeholder collaboration and

voluntarism. As well, Social Policy projects and initiatives are well aligned and support the 5 Year Plan to End Homelessness and include the following:

• Building a Welcoming and Inclusive Community (Member of the Coalition of Municipalities Against racism and Discrimination)

• Poverty Reduction Strategy • Accessibility • Community initiative to Build Resiliency through Development Assets for Youth • Aging in Place

The City of Lethbridge is confirmed as the Community Entity for the homeless and housing initiatives in Lethbridge. Social Housing in Action is the designated Community Advisory Board mandated to oversee the implementation of “Bringing Lethbridge Home”(plan to end homelessness) through the Housing First approach. All of the plan’s goals support the Housing First approach. The majority of funds for the Housing First program are available through the Government of Alberta; however the federal Homelessness Partnering Strategy funds provide partial funding for the operations of essential services aligned with the Housing First approach.

Lethbridge “Housing First”

History & Mandate Based on an extensive community & clinical consultation process (Spring 2007) a Housing First Steering committee designed and implemented the Pathways to Housing Community Outreach Team (Pathways) through the Canadian Mental Health Association (CMHA). The Pathways approach utilizes Intensive Case Management (ICM), an evidence based approach to Housing First. It is aligned with the goals and outcomes of the 5 year Plan (Bringing Lethbridge Home) to End Homelessness and is integral in the systemic community efforts to end homelessness in Lethbridge.

The mandate of Pathways has been to provide the supports to people to secure and maintain permanent housing: secure, affordable and sustainable housing for the homeless and those at risk. The team has engaged the community, stakeholders and agencies to refer, create awareness of the service and educate stakeholders, maximize and access referrals, and to educate and improve the outreach service. Clinical supervision is integral to the process and activities and is aligned and augmented in a Case Management Model with existing community supports.

The outcomes are clear and fully aligned with the 5 year Plan to End Homelessness and the Provincial Plan:

1. Permanent housing for people who are homeless or near homeless 2. Connect homeless to community support and resources 3. Improve the health status of clients 4. Support stable tenancy for those currently homeless or at risk 5. Reduce use of ancillary services (police, EMS, ER, in-patient beds)

Although the Housing First model is designed by the stakeholders, it is grounded in evidence-based practice. Following evaluation of the current model, SHIA, in consultation with the other agencies, community stakeholders, clinical expertise and OrgCode, it was determined Pathways would be overextended in their capacity to continue admitting to the program at the current levels of operation and still maintain the integrity of the program and the follow-up required to support the most complex clients.

As a result of further community engagement and extensive consultation, all the funded agencies are transitioning to a Housing First approach. Pathways will continue to focus on the chronic homeless with the most complex needs. It has been determined that the scope and breadth of this approach is now extended to the community for clients that are not aligned with a currently funded Housing First Agency.

Broadening the Scope of Housing First to Community: “Every door is the right door”

The Lethbridge Housing First approach is the direct result of the Innovative Outreach Pilot Project program. It has been supported through multiple collaborative community partnerships. ICM is utilized for multi-barrier homeless or at-risk clients who require long-term housing and supports. Pathways provide Housing First Service to the most complex clients. Other selected agencies provide similar, but shorter term services to less complex clients. All funded agencies are currently building their capacity to fully utilize a Housing First approach through ICM. Community based case management will be introduced to support those clients with less complex needs that are not aligned with a Housing First agency. This broadened approach continues to be well aligned with Lethbridge’s 5 year Plan and the provincial plan.

A significant percentage of clients are the absolute homeless population with complex needs and are the priority within this Service Delivery Model. Pathways currently provide a variety of support services to this population. These services are being strengthened through augmenting the follow-up team and additional supports for youth with complex needs (18-24). These services include accessing housing options, getting people into the

Housing First Lethbridge: Process

NO

right housing, eviction prevention, and assisting people to find more appropriate housing. Through case management, Pathways also support client access to required services such as addiction and mental health services. Staffing includes a Case Manager, Clinical Supervisor, Outreach workers, and a Follow-up Team and Addictions Counselor aligned with support from collaborative partnerships and other agencies. However, through the outcome evaluation and in consultation with allied stakeholders and funded agencies, people with less complex needs and not aligned with a Housing First agency also require support; perhaps not as comprehensive as those with more complex needs. This has resulted in a model that will provide Community Case Management for those that require less intense support and follow-up to secure and maintain tenancy. The Lethbridge Housing First model and the anticipated outcomes are further defined through the System Map (Appendix One). Due to the systemic and comprehensive nature of the Lethbridge Housing First approach, it is imperative this model be clearly understood by all the stakeholders. A Housing First Committee of SHIA develops, implements and oversees the Housing First approach. Based on the monitoring and evaluation of the anticipated outcomes the committee collaboratively determines actions to continually improve the process and individual programs. The Core Process in the Logic Model/System Map clearly demonstrates the client centered approach that is utilized.

Intensive Case Management The Intensive Case Management (ICM) model has been adopted by all the Housing First Agencies including the Community Case Management team. The Pathways case conferences are conducted by the Clinical Supervisor. This is a multi-disciplinary conference and includes as standing members: Addiction & Mental Health, Alberta Health Services Outreach Nursing, Community Housing, Alberta Employment and Immigration, Lethbridge Legal Guidance, Alberta Assured Income for the Severely Handicapped (AISH), Lethbridge Resource Centre Case worker and the team. Case Management for complex cases are initiated by the Case Manager and include additional service professionals and agencies as required. Case Conferences will also be conducted with other Housing First agencies to further support their clients as required. Priorities for Housing First will be considered based on the Service Priority Assessment Tool (SPDAT). This assessment tool focuses on the client’s vulnerability, complexity and need for rapid housing. Due to the low vacancy rates and difficulty in obtaining housing, short stay units are utilized for people requiring stabilization prior to immediate housing. ICM also includes the provision of supports required to access and sustain safe and secure housing. These include support and advocacy in people’s ability to access emergency funding and income support, practical problem solving, connecting people to supports such as subsidized housing, money management planning, food cooperatives, cooperative kitchens, counseling services, or other required supports.

Housing First programs also support individuals in negotiating with landlords and utility companies, attend and advocate for individuals during court appearances, develop individual service plans to address goals related to housing, employment, skill development, supports and finances and provide support to landlords and support people in emergencies and in preventing evictions. Follow-up support is critical to the success of people sustaining permanency.

Furniture Bank Once housing is secured, people are also supported by the Housing First team in their efforts to access basic necessities such as basic household items, furniture, food, clothing and transportation.

As people access permanent housing, the Housing First programs require ready access to basic household items and furniture. The Housing First programs receive some donations and additional items are required on an ongoing basis. Following community consultation with stakeholders, SHIA’s goal in 2010-11 is to issue a Request for Proposals to secure space and operate a Furniture Bank that will store and deliver as required, these basic essentials, donated and secured basic household items for people to set up their a home.

Training, Technical Assistance and Staff and Organizational Development Continued training and ongoing education is a critical and a proactive component of the Housing First approach, prevention and rapid re-housing strategies. The investment in organizational and staff development will significantly contribute to the success of the Housing First approach as well as build and secure the capacity of the organizations to deliver the services as defined. The education and development programs continue to provide staff in all the programs the tools, skills and knowledge required to support successful housing first, prevention strategies and rapid re-housing.

Strengthened education and training opportunities are available to all Housing First Programs and agencies including allied services/agencies and stakeholders. Lethbridge has adopted the Intensive Case Management approach. Program staff access the ongoing training and education opportunities provided through SHIA and the City of Lethbridge. Lethbridge also consults with experts on policy issues, implementation and evaluation of the Lethbridge Housing First Program and evidence based practices. Training and education will continue through community programming, the annual provincial Housing First conference, national conferences, U of C Homeless Certification Program, SPDAT launched through OrgCode. These learning opportunities will continue to be strengthened. Minimum standards of training are in place for all staff and include at least the following:

• Intensive Case Management, Core Components, Process and Policy • Outreach Service and Follow-up Support Systems • Community Support systems and services • Assertive Engagement • Cultural Awareness and Competency • Addictions and Mental Health • Harm Reduction Strategies • Supportive Housing • Concurrent Disorders and o-morbidity • Landlord Tenant Act and mediation strategies • Effective Communication Strategies • Hoarding • Case Management and conferencing • Motivational Interviewing • Technical competency including an online data base system (ETO) for data collection, Case

Management, monitoring and evaluation. • First Aid • Workplace Health and Safety

In addition to the more formalized training and development, agency and front line staff support is required at a clinical, team, agency and organizational developmental level. A Housing First Specialist fulfills this role, monitors the client outcomes, ensures the viability and integrity of the inter-agency protocols and provides the support required.

Research and Evaluation

Data Collection & Analysis SHIA is supported through a Research and Evaluation Committee. This committee is responsible for ensuring a system is in place for the ongoing monitoring and evaluation of the Housing First programs and other activities of SHIA. A Lethbridge based monitoring and evaluation system is designed and currently being implemented to demonstrate the success of Housing First, the 5 year Plan and the achievement of the evidence based outcomes. Efforts to Outcomes database is implemented in all Housing First Agencies. Regular monitoring of the outputs and the outcomes as identified in the agency agreements as well as the Logic Model/System Map (Appendix A) occurs on an ongoing basis in an effort to continually learn, improve the programs and demonstrate Housing First is making a difference in the lives of people in Lethbridge.

The Homeless Census is an annual point-in-time count that is conducted in October and provides the additional information required for program planning as well as bring awareness to the community, program agencies and stakeholders regarding the prevalence and impact of homelessness. In addition, the research & Evaluation Committee is conducting current research on the profile of homelessness, homelessness among the Blackfoot people, NIMBY. A current survey is also identifying the additional research required for the successful implementation of Housing First as well as better informing the programs about homelessness in Lethbridge.

Priority Service Areas

Currently Funded and Priority Housing First Programs (2010-11) The 5 year Plan, Bringing Lethbridge Home clearly defines the expectations and services required to end homelessness through the Housing First approach, prevention of homelessness and rapid re-housing of people who have lost their tenancy. This occurs through the funding of core services to achieve the goals and outcomes. These include a one-stop Resource Centre with access to multi-disciplinary services, supportive housing and outreach services.

Coordination and Community Support systems are also critical for the ongoing and continued success of Housing First in Lethbridge. These include the Furniture Bank, Project Homeless Connect, a Housing Registry, planning and development for priority capital homeless projects, developing and maintaining positive community, government and landlord-tenant relations, organizational planning and development, training and education programs.

The priority for Housing First programs will be the permanent housing of the homeless people with the most complex chronic conditions currently living on the street and in shelters. Community and inter-agency protocols

for client engagement, assessment and intake, Case management, referral, planning, support and follow-up are currently being implemented through the Housing First Committee with the Housing First programs and allied stakeholders to meet this priority for 2010-11.

The Continued Implementation of Housing First in Lethbridge Agencies:

Housing First Agency Target Homeless Population Housing First Service

Anticipated Outcomes Budget

Pathways to Housing Community Outreach Team

- Homeless people with most Complex Needs (including Street and sheltered homeless) and additional team for Homeless youth ages 18-24

- Intensive Case Management for all clients

- Rapid re-housing and eviction prevention strategies

- 50 homeless people are successfully housed with supports

- 85% remain housed

$675,000

$120,000

YWCA Lethbridge - Transition and Outreach Services for women( with or without children) fleeing domestic violence and supportive housing for 50 women with complex needs

- Women and children transition to permanent housing

- 50 women are permanently housed with supports

$100,000

Niitoyis Women and Children Centre

- Supportive Housing for Women and Children transitioning from reserve to urban life. Following discharge provides continued support to women to maintain tenancy

- Successful transition from reserve to urban life in the supportive housing environment

- 85% remain successfully housed with supports

$180,000

Resource Centre Services

- Intake and referral service for sheltered homeless with/without complex needs

- Resource Centre client services will be provided in the community as much as possible

- 100% of shelter clients (with a length of stay greater than 3 days) are assessed and referred to Housing First agencies and services and are supported

$217,000

Woods Homes Emergency Youth Shelter

- Youth under 18 years - Funded through Service Canada

- Emergency Shelter for youth under the age of 18

$112,061

YPM Sunrise House - Supportive housing for youth 18 to 24 years

- Intensive Case management and follow-up support in transition to permanent housing and self reliance

- Successful transition to permanent housing

- 85% remain successfully housed with supports

$64,000

Community Case Management

- People without an affiliation to a Housing First Agency; without complex needs

- Homeless people without chronic complex needs are supported to locate housing options and supports as required

$75,000

Contract Administration As the Community Entity, the City of Lethbridge oversees the Contract Administration for approved funded projects. Contract administration at the City of Lethbridge is based on accepted industry standards and is grounded in municipal policy. The funding allocations are determined based on the needs in the community, alignment with the Housing First approach, the 5 year Plan and the agency’s ability to successfully achieve the intended outcomes. Recommendations are forwarded to City Council by SHIA for approval. At this time, currently funded agencies are established, have a proven track record to deliver the services and are prepared to commit to the implementation of the 5 year Plan.

Housing First Budget 2010-11

Housing First Service Delivery Budget HPS Funding

(Federal) HUA (Provincial) Total Housing First Programs Y.W.C.A. (Supportive Housing, Transition & Outreach Services) $50,000.00 $50,000.00 $100,000.00 Youth Emergency Shelter $112,061.00 $112,061.00 PHCOT (Pathways to Housing Community Outreach Team) $675,000.00 $675,000.00 Resource Centre Services $92,000.00 $125,000.00 $217,000.00 Native Women's Transition Home $100,000.00 $80,000.00 $180,000.00 Supported Housing for Youth (18-24) $64,000.00 $64,000.00 Housing First Coordination & Community Support Implementation "Bringing Lethbridge Home" $40,000.00 $130,000.00 $170,000.00 Community Case Management $75,000.00 $75,000.00 Housing Registry $10,000.00 $10,000.00 Contingency for Housing First projects can include: $60,870.00 $60,870.00 Planning & Development Priority Capital Projects Community Integration & Landlord Relations Housing First Program Training & Education Community Engagement, Education and Planning Rapid Re-Housing and Prevention $120,000.00 $120,000.00 Furniture Bank $70,000.00 $70,000.00 Case Management Software $25,000.00 $25,000.00

Total $394,061.00 $1,484,870.00 $1,878,931.00

Appendix A Housing First System Map

Appendix B Bringing Lethbridge Home Community Plan to End Homelessness and Action Plan