See yourself as a partner - Guide to Community Partnership Development: Annex A

As an example of engaging with the community is the System Mapping Survey Tool prepared for End Homelessness St. John’s by Dr. Alina Turner, Turner Research and Strategy. Some of the questions are very specific to St. John’s. Content could be adapted to your community’s needs.

St. John’s Housing First System Coordination Initiative System Mapping Survey

Survey Information

Welcome to the Housing First System Coordination Initiative!

As a cornerstone of St. John’s Plan to End Homelessness, system coordination is about finding ways of better working together to serve those at risk of or experiencing homelessness in our community.

The purposeful, design and management of St. John’s homeless-serving system is critical to meeting the community’s objective of ending homelessness. One of the key steps to successful community-based system coordination efforts is the inclusion of thoughts, ideas, and expertise from a diverse range of community stakeholders in the development of a Housing First System Coordination Framework.

To this end, End Homelessness St. John’s (EHSJ) has secured the technical assistance of Dr. Alina Turner (Turner Research & Strategy) to work alongside an Advisory Committee to develop the Framework.

A first step in this process is finding out more about how our homeless-serving system currently works from as many providers as possible. This survey is a key means of mapping the current system.

Note that the survey is comprehensive and will likely take about 15-30 min. to complete.

Likely, the lead manager or coordinator of a program would be best suited to fill out the survey; in some instances, this might be the executive director as well.

We encourage you to fill out as much of this survey as possible; results will drive the development of initiatives including new programming, coordinated entry and assessment, performance management and quality assurance.

The closing date for the survey is December 15, 2015 to give us enough time for analysis in preparation of a community consultation process in early December (stay tuned for details).

For more information and assistance - please connect with Alina Turner (Turner Research & Strategy,; 403-827-8722).

To connect with End Homelessness St. John’s, please contact Bruce Pearce (; 709-689-9615).

Program Inventory

This section aims to collect available information about the various programs available in St. John’s assisting those at risk of/experiencing homelessness.

Note, that each program will need to fill this survey out separately - even if it operates within one agency.

You may not have all the answers to the questions - do your best! The more information we have, the better our collective knowledge foundation is for system coordination.

1. Program name

2. Agency name

3. Name of person filling survey

4. Title of person filling survey

5. Program contact information

  • Address

  • Address 2

  • City

  • Province

  • Postal Code

  • Email

  • Address

  • Phone Number

6. What is the target population of the program?
Simply put, the target population of a program is the group of individuals for whom the program was intended and designed. An example would be chronically homeless men with a history of incarceration.

7. Is the program serving any of the following? (check all that apply)

  • (Checkbox) Adults without children
  • (Checkbox) Adults accompanied by children
  • (Checkbox) Unaccompanied youth
  • (Checkbox) Households fleeing domestic violence
  • (Checkbox) Other (please specify)

8. If this program is being delivered in partnership with another agency, please list these below and briefly describe each partner’s roles.

9. Please classify it as best you can according to the following program categories. See below for definitions.

We are following the program definitions outlined in the St. John’s Plan to End Homelessness and HPS.

Other (please specify)

  • Emergency shelters provide temporary accommodations and essential services for individuals experiencing homelessness. The length of stay is intended to be short, ideally 7-10 days. Shelters provide essential services to the homeless and can play a key role in reducing homelessness as these services often focus efforts on engaging clients in the rehousing process.
  • Transitional housing provides place-based time-limited support designed to move individuals to independent living or permanent housing. The length of stay is limited and typically less than two years, though it can be as short as a few weeks. Such facilities often support those with dealing with addictions, mental health and domestic violence that can benefit from more intensive supports for a length of time before moving to permanent 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. The important feature of the program is its 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. While support services are offered and made readily available, the programs do not require participation in these services to remain in the housing.
  • Rapid rehousing provides targeted, time-limited financial assistance and support services for those experiencing homelessness in order to help them quickly exit emergency shelters and then retain housing. The program targets clients with lower acuity levels using case management and financial supports to assist with the cost of housing. The length of support services is usually less than one year as it targets those who can live independently after receiving subsidies and support services.
  • Intensive Case Management (ICM) programs provide longer-term case management and housing support to moderate acuity homeless clients facing addictions and mental health. Programs are able to assist clients in scattered-site housing (market and non-market) through referrals to wrap-around services. ICM programs ultimately aim to move clients toward increasing self-sufficiency. Program participation and housing are not linked so that loss of one does not lead to loss of the other.
  • Assertive Community Treatment (ACT) programs provide longer-term case management and housing support to very high acuity homeless clients facing addictions and mental health. Programs are able to assist clients in scattered-site housing (market and non-market) through direct services. ACT programs ultimately aim to move clients toward increasing self-sufficiency. Program participation and housing are not linked so that loss of one does not lead to loss of the other.
  • Affordable housing is an intervention for low income households who cannot afford rents based on market prices. Tenants in affordable housing programs should spend no more than 30% of their gross income on shelter.
  • Outreach provides basic services and referrals to people who are sleeping rough and require more concentrated engagement into housing. Outreach aims to move those who are living outside into permanent housing by facilitating referrals into appropriate programs.
  • Prevention services provide assistance to individuals and families at imminent risk of becoming homeless. These services may include financial support (rent and utility arrears, damage deposit etc.) with case management to achieve housing stabilization and assistance navigating public systems, such as income assistance. Prevention services in the homeless-serving system can include eviction prevention, shelter diversion, discharge planning and support for broader policies.

Service provision

10. Please list the main services provided to program participants. In other words, case management, landlord liaison, rent supports, referrals, shelters, housing unit, etc.

11. Please list the eligibility requirements of the program.

These are requirements that restrict access to the program - such as age (must be under 18), gender (women) or sobriety (must be intoxicated at intake/sober etc.).

12. How does the program prioritize access between applicants who meet eligibility criteria? You may use a particular clinical assessment, or use a first-come-first-served approach.

13. How would you assess the level of acuity of program participants at intake? This is a broad characterization based on your assessment at intake. See below for more on acuity factors.

  • (Checkbox) High Acuity (high level of needs)
  • (Checkbox) Moderate Acuity (moderate level of needs) Low Acuity (low level of needs)
  • (Checkbox) Other (please specify)
  • (Checkbox) Acuity refers to the level of needs in the homeless population and considers a number of factors.

Acuity factors

  • Mental health
  • Substance use
  • Domestic violence
  • Medication
  • Physical ability/disability
  • Family situation physical
  • Health
  • Homelessness and housing
  • History
  • Self-care and daily living skills
  • Age
  • Gender
  • Ethnicity
  • Life skills
  • Personal motivation
  • Income
  • Employment
  • Legal issues
  • Education
  • Social supports and connections
  • System interactions
  • High risk situations

14. What percent of program participants would be considered chronically or episodically homeless an intake? See definitions below

  • Chronically homeless: A small portion experience long-term and ongoing homelessness as result of complex barriers, particularly related to mental health and addictions. About 40 chronically homeless persons are estimated in St. John’s or 5% of the total homeless population.
  • Episodically homeless: Some people who experience homelessness, experience recurring episodes throughout their lifetime. This group is likelier to face more complex challenges involving health, addictions, mental health or violence. About 10% of the homeless population, or 80 people, are estimated to be in this group.

15. What is the point-in-time program’s capacity? For instance, shelters report number of beds, case management reports caseload capacity.

16. About how many participants does the program serve during the course of 1 year?

17. How many applicants are there on the program’s waitlist?

  • (Checkbox) No waitlist kept
  • (Checkbox) Please indicate total number on waitlist

18. What are the program’s main referral sources?

19. What levels of interaction does the program have with the following support services?

Receive referrals from Refer clients to Coordinated service delivery Client-level data sharing General information sharing and networking
Child, youth, and family services (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Emergency shelters (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Transitional housing programs (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Outreach programs (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Rent supplement programs (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Affordable housing programs (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Supportive housing programs (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Case management programs (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Connections (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Police (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Ambulance services (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Hospitals (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Addictions treatment (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Aboriginal services (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Mental health services (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Veterans (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Poverty reduction organizations (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)
Prevention programs (Checkbox) (Checkbox) (Checkbox) (Checkbox) (Checkbox)

Other (please specify)

20. Can you provide the total amounts by funding source for the program?

Data and research

21. What information system(s) is in current use to collect data for the program?

22. Is the same information system in use across the agency?

23. A Point-in-Time Homeless Count provides a snapshot of the population experiencing homelessness to help us better understand the extent of the issue in a community, as well as key demographic information and self-reported needs.

Please indicate the following with respect to a Count in St. John’s.

Yes No Maybe
I/my program would like to be involved in the Count preparation (developing the data set, timing the Count, mapping street survey locations, volunteer training, securing supplies). (Checkbox) (Checkbox) (Checkbox)
I/my program would like to be involved in the Count implementation (survey administration, facility count, volunteer organization). (Checkbox) (Checkbox) (Checkbox)
Other (please specify) (Checkbox) (Checkbox) (Checkbox)

Participation in system coordination

This set of questions aims to assess your program’s experience of the levels of coordination across providers in the homeless-serving system as well as training and supports needs.

24. How would you assess your program’s willingness and capacity to participate in homeless system-level initiatives to improve coordination?

High level of interest/high level of capacity to participate High level of interest/low level of capacity to participate Low level of interest to participate
Developing coordinated entry to diverse providers (Checkbox) (Checkbox) (Checkbox)
Enhancing coordinated service delivery for shared participants between programs/agencies (Checkbox) (Checkbox) (Checkbox)
Improving data sharing between providers (Checkbox) (Checkbox) (Checkbox)
Developing common assessment and prioritization tools across providers (Checkbox) (Checkbox) (Checkbox)
Enhancing community of practice learnings between frontline staff and middle management across programs/agencies (Checkbox) (Checkbox) (Checkbox)
Introducing common performance metrics to track progress across providers (Checkbox) (Checkbox) (Checkbox)
Developing shared standards of practice to ensure service quality is consistent across providers (Checkbox) (Checkbox) (Checkbox)
Introducing a homeless point-in-time count to assess current and emerging trends (Checkbox) (Checkbox) (Checkbox)
Other comment (please specify) (Checkbox) (Checkbox) (Checkbox)

25. What supports would your program need to participate in these system coordination activities?

26. Do you have any other comments?

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