海角社区

Looking out at a sea of listeners,听Jacinta Brown听of Prince Edward Island海角社区 Community Outreach Centre听asked people to stand if they felt they were collaborating well with the medical field.听

Every seat in the conference room was filled with people听coming from across Canada to听attend the National Conference on Ending Homelessness听in October 2025.听

About a quarter of the room stood.听

And how many are working closely with the justice sector? Brown asked. Only a handful got out of their chairs.听

鈥淭ake a look around.听Not many听in the room are collaborating with justice.听That海角社区听telling,鈥� she said.听听

鈥淭hose are big gaps that you鈥檝e just now听identified听in your听communities and听can start taking some really targeted approaches to bridging.鈥�听

In Prince Edward Island, there is one coordinated access table for the entire province, bringing together a range of agencies working together to听identify,听support听and find housing for听an average of 289 people actively experiencing homelessness every month.听

Bringing sectors to the table听

After a听multi-year mission to break down the siloes between agencies, there are now organizations听representing听11 diverse sectors sitting at the coordinated access table, said Josh Constantinou, the Coordinated Access Coordinator with the John Howard Society of PEI.听

That includes听Indigenous partners,听corrections, medical,听addictions,听mental health, education, political leadership,听employment and tax system, child and family services,听and social programs.听

This creates a comprehensive set of agencies ready to pitch in and ensure people have all the tools they need to find and keep a safe and decent home.听

It also means people experiencing homelessness have a one-stop-shop to get access to resources, and听don鈥檛听need to navigate multiple systems or waitlists on their own, re-telling their story and journey to each agency.听

But it听wasn鈥檛听easy to reach this level of collaboration.听听

The first step, Constantinou said, was to gather the people that were already interested in being part of the coordinated access table and then see how to add one more person, one more sector听at a time.听

鈥淭hink about the benefits from the other person海角社区 perspective.听Don鈥檛听think: what can this person bring to us? Think: why would they want to come and be a part of this from their perspective, and how can it听benefit听them?鈥� Constantinou said.听

Sometimes, that meant听identifying听data that shows听the link between different sectors.听It海角社区听how Constantinou says they were able to bring the corrections system on board.听

鈥淢ost people, whether frontline or in management,听don鈥檛听want to see the same people coming back.听That海角社区听a shared goal, and we know that one of the pillars of the federal framework to reduce recidivism is housing鈥攕o听there海角社区听an opportunity to collectively support individuals to not re-enter听correctional facilities听after being discharged,鈥� Constantinou said.听

During the 2024 Point in Time count, Constantinou says they worked with听the听Provincial Correctional Centre听to ask the听roughly 120听people听who were incarcerated听if they have a permanent place to live when听they鈥檙e听released.听

There were 62 people who responded to the survey saying they had听nowhere to go.听

鈥淭hat was the first step to help the corrections sector听realize internally that听it海角社区听a big number听of folks. The prevalence of homelessness is听very high. And that introduces a very tangible, realistic conversation starter,鈥� Constantinou said.听

They built on that information and relationship. Now, as part of the John Howard Society听of听PEI海角社区 wraparound听housing听program, there is听a听dedicated housing and homelessness case manager听based primarily听in the听provincial听correctional centre meeting听with people听before听they鈥檙e discharged听to听provide a range of supports听including identification, employment听and housing options, and connecting them to social assistance.听

Overcoming resistance to joining coordinated access听

The community had听a very similar听approach to engage with the medical system, conducting a health survey with people experiencing homelessness, Jacinta Brown said.听

The survey听identified听that more than 80 per cent of the participants were experiencing co-morbid or tri-morbid mental health diagnoses.听

鈥淭hese are people experiencing substance use disorder, mental health challenges, chronic medical conditions, and on top of that, they were unhoused,鈥� Brown said.听

While it helped bring the medical field to the table, there were听some听challenges听getting a representative from the substance use system.听

鈥淲e had tried to get them on side for听a very long听time,听but there were concerns around that happening. We knew that was the target, but when we听couldn鈥檛听hit the target, we looked around at what existed within the same sphere,鈥� Brown said.听

They found several other programs working in the same area and were eventually able to bring on board the supervisor of a transitional unit for people exiting an in-patient substance withdrawal centre.听

鈥淗e was eager, and he agreed. And as soon as he was at the table,听all听his colleagues in similar programs started听asking, 鈥榳ell, if he海角社区 part of it, shouldn鈥檛 we be part of it?鈥欌�� Brown said.听

鈥淎ll you need to find is the one program or the one individual who is going to be your shining star in that sector that you want to collaborate with.鈥�听

Bringing organizations together with HIFIS听

The collaboration听doesn鈥檛听end with coordinated access.听听

Agencies across these sectors also contribute to the Homeless Individuals and Families Information System (HIFIS)鈥攁 data and case management system that allows participating agencies in the same community to access, collect and share local, real-time听homelessness data to ensure people experiencing homelessness are prioritized and referred to necessary resources.听

Usually, HIFIS includes many modules, allowing housing providers to input information about someone海角社区 medical history, mental and physical health, medications.听听

This can help听get听someone听matched听to听a housing unit that has the supports听they听need to be safe in their home.听

But in PEI,听they鈥檝e听removed most of the modules, limiting听the information in HIFIS听to the minimum needed听to house people appropriately.听

鈥淲e鈥檝e听changed the approach from 鈥榶ou鈥檙e either in or you鈥檙e out,鈥� to 鈥榟ere海角社区 what we鈥檙e asking and looking for, and the minimum we need from you to help us continue to care and support a person experiencing homelessness,鈥欌�� Constantinou said.听

Without this kind of collaboration, if, for example, someone was incarcerated, they would lose contact with the agencies supporting them and fall through the cracks.听

鈥淲hile somebody is in the community, we can do a lot of听good work听with them, but if they become incarcerated or go into detox or are admitted to a hospital and we lose contact for weeks or months, we lose a lot of progress,鈥� Constantinou said.听

鈥淭he more we can try to find a way to extend that continuity of care, the better the outcomes will be.鈥澨�

The consent form that people experiencing homelessness sign when they agree to have their information recorded in HIFIS allows agencies to record and share their housing history鈥攕uch as if they are staying at an emergency shelter or an in-patient treatment program鈥攂ut it doesn鈥檛 allow agencies to share what kinds of treatment or supports are being offered.听

It means connections can be made, without having to worry about听additional听privacy concerns and challenges.听

Why听this matters听

Prince Edward Island is a听relatively small听area, as compared to many other regions and communities working to end homelessness.听

But the work听they鈥檝e听done to bring a diverse range of sectors together and break down siloes is impressive, says Dawn Wheadon, the Canadian Alliance to End Homelessness鈥� lead Improvement听Advisor for PEI.听

鈥淭here are many communities across the country that are struggling to get collaboration from sectors or community organizations that aren鈥檛 mandated听to collaborate by their听funders,鈥� Wheadon said.听听

鈥淏ut PEI has shown you听don鈥檛听need to have it all figured out before you start. Begin with who you do have at the table, and use the tools provided by CAEH to formulate a working plan to expand.鈥�听

PEI海角社区 work to better understand the people entering and exiting homelessness, and their use of data to advocate to governments and bring sectors together is particularly remarkable, said Wheadon.听

鈥淲hen we听work as a community using the data to guide our next move,听and make an effort to move away from our historical approach of 鈥榤y clients, my program,鈥� to 鈥榦ur clients, our program, our community, our responsibility,鈥� we start to see results,鈥� she said.听

Still, PEI听isn鈥檛听done yet in their work to expand the cross-sectoral collaboration.听

They have their sights set on engaging with emergency medical services, Jacinta Brown said.听听

And she听says听there海角社区听still a long way to go engaging with landlords and the听public听to shift public opinion听so that everyone believes homelessness is听solvable.听