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Developed by: 
Blair Hiseler, Catherin McCall and Jessica Chong


Homelessness continues to increase in Waterloo Region at alarming rates.  According to the 2021 Point in Time Count (PiT), which is mandated to be completed by the Federal/Provincial Government every two years, the total number of people experiencing homelessness at that time was 1085, an increase over the 2018 PiT Count when the number was only 333.  In a letter to Regional Council dated November 09, 2021, Lesley Crompton from the Social Development Centre Waterloo Region (SDCWR) had this to say about the accuracy of the PiT number: “Based on SDCWR Eviction Prevention work and our PIT team’s account of all the places and people we missed during the three days, we know that the number is far greater and cannot be taken as being “accurate.” Lesley points out that quantitative indicators relied upon by governmental agencies when it comes to decision-making related to shelters are questionable in terms of reliability because there is little allowance for the lived experiences revealed by the narratives from the “underserved residents, including the homeless, hidden homeless and soon to be evicted homeless in the community”.  The responses captured are anonymous so there is no way to ensure that the people who responded are the same individuals who reflect in the PiT count information and, many chronically homeless individuals are not connected to support services so are not captured anywhere in the data collected. If we are to have a long-term and sustainable plan to combat homelessness, then we need to tackle the problem in the present time in a reactive manner. We also need to address the issue upstream, preventing people from falling into homelessness in the first place, and we need to ensure that once individuals are successful at securing housing, they are well supported so that they can maintain that shelter without regression. The current state response to the homelessness crisis is driven by a “housing first” vision which is reflected in the support system we have created.  This system aligns with fiscal, political and administrative priorities but providing more “roofs over heads” does not, and will not solve the current crisis, if there is not the provision for individualized person specific supports.  Accessing an administratively layered system to obtain housing for the chronically homeless is often hugely challenging.


Many chronically homeless individuals struggle all their lives with issues tied to childhood trauma, PTSD, learning disabilities, mental and physical health challenges, addictions and substance abuse, and many have a severe distrust of institutions and the individuals who work within those structures.

Problem Drivers

We have learned that working with vulnerable populations comes with risks for the organization and its workers. These risks are primarily, health and safety and privacy, which is why there are policies and procedures created to outline processes. However, as we have learned from those working in the field, the system has become protective and risk averse, limiting the amount of creative problem solving and collaboration between agencies.  It does not help individuals move forward in the system and prevents them from connecting with the necessary workers who need to know the detailed information. Instead, an individual will be wayfinding and have to share their story two, three, or possibly four times. This repetitiveness creates frustration and tension for individuals. Since this is acting as a barrier, it is creating an exorbitant amount of duplicate work for front line workers who are trying to help clients move onto the next steps of their housing journey.


Another problem we have identified is the lack of communication and collaboration between the systems:  health, housing, and mental health. There is a struggle identified by organizations that funding options are limited and issues are not being recognized by the systems. Advocacy is turning into a full-time job for many front-line workers, and leaders of the system. Due to the high crisis, limited funding, and supports for this work, many organizations are too occupied to collaborate and engage in creative opportunities. They are too busy keeping their dedicated people afloat, or continuously searching for dedicated individuals to take on the work. Many of the not for profits have also transitioned to focus on specific objectives that are not consistent with system objectives, and in turn do not align with other organizations’ priorities. This creates a lack of opportunity but also inconsistency for the clients accessing supports.


The final noteworthy problem identified was the lack of mental health and substance support within the system. You can’t put a time on crisis yet services are not available to support individuals unless at specific times that are most convenient for the agency providing the support. This leaves individuals in a volatile state as well as in a significant amount of risk. If services are not able to tend to crisis beyond scheduled hours, then the front-line staff need to be given the proper training and education tools to meet those needs. We heard from experienced front line workers who acknowledged that the population who are accessing services today have more complex mental health issues. Organizations need to change their training and education requirements so we are meeting clients’ needs.


It is well understood that housing availability and the need to treat housing as a basic human right rather than a commodity is an issue that goes beyond any individual organization or municipality. There is a need for funding, direct support and advocacy for this issue from higher levels of government in collaboration with those on the front line and those with lived experience.


The primary actors that are motivated to see change on this issue and see improvement in our own backyard are the municipal governments and the not-for-profit organizations with similar or overlapping visions of reducing homelessness in our community and making housing accessible to all. The necessary funding for this work is not guaranteed over the long term, and there are opportunities for more varied wraparound supports to be delivered to individuals who need them when in crisis. This gap has led to individuals regressing on the housing continuum or getting lost in the system, which creates inefficiencies for all involved.

Barriers to Solving the Problem

A barrier noted is the number of criteria an individual must have in order to move through the system. The eligibility to attain housing, even though housing is a right to all, continues to be a barrier, preventing movement through the system. A part of this approach focuses on getting the individual into housing but we are seeing that an individual who requires more support, often is not able to maintain their housing for a variety of reasons like mental health, addictions, and family violence. The wrap-around supports must be in place in order for housing to be a success for many. This highlights the lack of life skill supports within the current shelter system.

When looking at the systemic design of supports offered, there is little to no communication or funding from multiple systems. Based on the needs identified by the experts we consulted, there are three systems that intersect: Ministry of Health, Mental Health, and Housing. Traditionally funding has only flowed through Housing departments. Due to the increased prevalence of health and mental health needs among the homeless population, we recommend that the systems collaborate and set a standard of practice to include health care funding.


Another barrier identified is the health and safety barriers to providing services. A known gap of services is the limited outreach supports that are offered in the community to those who are unable to access shelter services. This also includes individuals who need additional supports once they are housed. There is a significant number of individuals who need supports in order to maintain housing stability. Without these supports, they will revert back into the system.


The proposed solution is to develop a framework for enhanced collaboration and interaction between organizations operating in the health, housing and mental health systems and deliver timely and comprehensive wraparound supports to individuals who need them. The solution is not looking to reinvent any one specific system, or portion of it, but rather function as the grease in the gears of multiple systems that already exist in Waterloo Region with dedicated front-line people working within them.

Persona - Meet Kevin

Our persona is Kevin G, who represents all too many individuals who are caught in the system and without customized supports available for the long term as needed, Kevin, like all too many others will never successfully find stable housing or exit the shelter system.


Kevin is a 26-year-old male, and after being frequently bullied he dropped out of high school before graduating. With his immediate family frequently changing their address as well, Kevin had no stable access to housing but stayed with family members and friends for a period of time until no longer welcome. Kevin has now been intermittently experiencing homelessness for seven years, and having built a sense of community and belonging he is reluctant to leave his familiar world behind. Kevin has struggled with mental health and addictions issues throughout his adolescent and adult life and has consequently been restricted from a number of local shelters for erratic and unpredictable behaviour. Each shelter has a different set of rules and values, including some in which substance use is condoned, and Kevin has had difficulty keeping up with the different philosophies.


Kevin has no reliable access to technology of his own, but will use devices owned by shelters or others when available. This inconsistent ability to communicate limits the resources that Kevin can access and as such he has been unable to develop a meaningful relationship with outreach workers who may have knowledge that is timely and of value to someone in Kevin’s shoes.

Solution Details

An individual like Kevin who has a complex life story will have varying needs at different points in his life. This could include harm reduction, peer mentoring to assist with stability in his life, navigating the system at all to find relevant supports, and advocating for himself in different situations. Kevin’s needs will vary over the long term, but they will also vary on a day by day basis. A solution of providing wraparound supports to individuals like Kevin in a timely manner, and from a trusted source are essential to his well-being.


A rapid response model of support is to be aligned on and communicated between the agencies involved to allow crisis-intervention at the moment it is needed. This would be similar to the mental health teams from CMHA (FACTT – Flexible Assertive Community Treatment Team/ACTT – Assertive Community Treatment) however with a broader ability to respond to any type of crisis leveraging formal and informal supports. For this approach to be successful, it will have to have access to stable funding and resources over the long-term to build relationships with the individuals it serves.

Intended Outcomes

Ease navigation of a complex system

  • Placing the experience of the individual at the centre of how the system works, and making that the primary objective will lend itself to a more effective way of serving those in need and meeting them where they’re at. A more holistic approach from organizations with sufficient resources will result in an individual receiving what they need at any point in their life.

Improve the efficiency of the organizations working in the system

  • Preventing duplication of efforts and multiple organizations that are partially meeting the needs of an individual will lighten the overall burden on the system. This streamlining will generate capacity with the resources already available to meet the needs of more people directly.

Facilitate collaboration between organizations

  • To enable rapid response to individuals in crisis or a deeper understanding of the causes and complicating factors behind homelessness itself.

Enhance community education of the issue

  • More education and attention being brought to the community on the lack of timely and effective supports. The fact that there is a need for organizations, and the front-line workers within them, to collaborate more effectively and improve the understanding of why this is essential work to have a vibrant community.

Who they Spoke to

While conducting our research and learning about the intricate housing system, we consulted experts in the field to gain the knowledge and insight of the successes and barriers. Thank you to the following individuals who taught us and provided resources.

  • Argo Kamberi, Amar Rajasansi, Elliott Lee, WRPS Community officers

  • Chris McEvoy, Region of Waterloo

  • Sara Escobar, Peregrine Outreach

  • Tony Stortz, A Better Tent City

  • Jay Straus, The Working Center, University Ave. Transitional Housing Program

  • Wayne Paddick, The Bridges Shelter

  • Kristine Dearlove, Habitat for Humanity

  • Steve Garrison, Housing Cambridge

  • Josh Perovic, Hemlock Burger Bar

  • Linda Jutzi, Downtown Kitchener BIA

  • Brian Paul, Supportive Housing of Waterloo

  • Abigail Asamoah, Frazer Heights Co-operative

Unintended Consequences

Backlash from not-for-profit organizations if they’re at capacity, unable to support with resources or may perceive a change as a threat or having a negative impact on them or their mission statement.

  • People with lived experience not seeing the value in change, or perhaps not being receptive to other supports. They may not see an issue with their current situation and be resistant to changes.

  • Staff wellness is compromised due to the disheartening duties of the work.

  • The homelessness shuffle.

  • Nonprofits receive health care dollars and then are confined within certain limitations within funding agreements; driving out nonprofits who were at the forefront of the gritty work.

  • Potentially enhancing competition between NPO’s and you might amplify the competition rather than collaboration.

Suggested Partners

There exists today a wealth of knowledgeable, dedicated front line workers in the homelessness space in Waterloo Region. A number of not-for-profits could be instrumental in implementing and sustaining a solution to improve the accessibility and timeliness of wraparound supports to individuals who have experienced homelessness. A successful improvement to the system depends on the individuals that work within it - those individuals need to be knowledgeable on the issue at large, the specific individuals themselves, dedicated to the work, empowered and capable of making decisions and adequately resourced to act quickly.


Upcoming / New Businesses:

  • Peregrine Outreach, Sara Escobar

  • Better City, Tony Stortz

Local Emergency Services:

  • CMHA, Here 24/7 Crisis services

  • WRPS, Community Resource Team/Impact Team

  • Ontario Health/ KW4 Ontario Health Team

National Organizations (to help with grants, information, knowledge, networking):

  • The Homeless Hub

  • Canada Mortgage and Housing Corporation

Financial Implications

Our research lead to conclusions that there can be positive financial impacts on the housing system. By putting in place requirements for increased funding and diverting existing resources from community to health, nonprofits may have the resources needed to improve health statuses and move people closer to stable housing. By creating regulated health positions in the housing sector, individuals experiencing homelessness will get their medical needs met on a regular basis.

There are housing settings that exist that are funded and supported by the Ministry of Health dollars. Providing more opportunities for funding, teaching nonprofits how to apply for additional funding, and understanding funding requirements in the various systems could lead to additional supports for those experiencing homelessness.


What we have seen is the allocation of funds being directed to the wrong places. There is a significant discrepancy of allocation of funding and what positions can be included within the funding. To help guide nonprofits, guidelines could be created to support them to determine how funding is used. If funding was redirected to the appropriate services, we would see a decrease in costs in other emergency services such as paramedics, police officers, fire department, etc. (

There's much more to learn about this solution! Download a copy of the full report with all sections via the link above! 

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