Hope for a New Future

Edmonton’s Heavy Users of Service Program (HUoS) helps people experiencing homelessness, addiction, and mental health issues get the care they need, while reducing costs to social services

Andy (not his real name) had a daily routine. Each morning, he’d wake up in his small camp in the river valley and head to a nearby convenience store to check the dumpster for food. Then he’d make the rounds to several other inner-city shops, dumpster-diving all the way.

“I had the nickname of the ‘7-Eleven Junkie.’ I’d visit each store seven times a day,” he says.

At the time, Andy was suffering symptoms of schizophrenia, which had appeared after a trip to Amsterdam. Once his mental illness took hold, he lost touch with reality and began self-medicating with street drugs. He lost his job and home, and began living in the river valley.

Owners and customers of the stores where he hung out were bothered by his aggressive panhandling and unpredictable behaviour. The police often detained Andy and took him to the Edmonton Remand Centre, but he’d always be released, only to return a few weeks later. In total, he spent a year and a half in police custody, but each time was too short for him to access any resources to help his situation.

“Everything is a hoop to jump through when you have addictions and mental illness; how are you supposed to jump through those hoops yourself?” asks Sergeant Tracy Ward of the Edmonton Police Service (EPS). Edmonton has a network of agencies that provide health care, mental health services, addiction services, housing assistance, and other social supports. However, it’s an incredibly complex system to navigate when you don’t even have a roof over your head, let alone a phone or the mental clarity to keep an appointment.

Rather than accessing services that can help appropriately, people like Andy may interact repeatedly with police or health care in unproductive ways. It’s a frustrating cycle that Ward, along with others in the public service and inner-city agencies, hopes to end through the Heavy Users of Service Program (HUoS), which addresses the underlying causes of misuse of services, such as homelessness, addiction, and
mental health issues.

In February 2016, Edmonton Community Foundation (ECF) provided Boyle Street Community Services with a grant for more than $64,000 for the operation of this program. The inner-city organization is a partner of the program, and hires two social workers and an administrative
assistant to help run HUoS along with Sergeant Ward and two constables.

“We really value that support and the flexibility in how we use it. We can’t do these programs without ECF and the people who give to the  Foundation,” says Ian Mathieson, Director of Operations for Boyle Street Community Services.

The story of HUoS goes back to 2012, when EPS, the City of Edmonton, and REACH (Edmonton’s Council For Safe Communities) met to discuss how they might bring the community together to reduce violence and help vulnerable people. Sixteen partner agencies were chosen to form the HUoS leadership group, which includes Ward, EPS constables, social workers, and an administrative assistant. The team works out of a former police station in downtown’s McDougall neighbourhood, renamed the Navigation and Co-ordination Centre.

Including Andy, seven people have now successfully completed the program and are being monitored to ensure they maintain their progress;
this has opened up spaces in the program for seven more clients, for a total of 15. Team members work together to directly address the client’s barriers to health and social services. For Andy, this meant having someone pick him up in the river valley and drive him to appointments for anti-psychotic injections and housing services. Once he was housed and treated for his mental illness, Andy’s improvement came remarkably fast, says Ward. He’s now living independently without drugs and has a job.

Getting clients to a good place takes a huge commitment of time and resources, says Pam Coulson, director of Urgent and Intensive Services
with AHS Mental Health and Addictions. She explains that HUoS helps clients with paperwork while advocating for them on all fronts — from financial resources and income, to finding homes and making appointments. “It’s looking at what they’re struggling with today, and moving forward,” she says.

This comprehensive approach seems to be working. Since the program launched in early 2013, EPS reports that the number of police  interactions with clients like Andy has dropped by 58 per cent (from 670 to 273). There has also been a 51-per-cent reduction in inappropriate Edmonton Transit System interactions and a 25-per-cent decrease in unnecessary emergency visits.

The project has also helped illuminate gaps in service and find creative solutions. Mathieson explains that one of the biggest challenges is finding stable housing for clients, largely because they suffer from mental health issues and addictions. To help remedy the problem, Boyle Street Community Services worked with McMan Youth, Family and Community Services Association, Alberta Works, and Assured Income for the Severely Handicapped (AISH) to rent a house in Mill Woods (“The Meadows House”) where two clients currently live with continuous supports. “Sometimes the existing systems won’t work so we found ways to collaborate and move quickly. We want to do more of that in the future,” says Mathieson.

This kind of approach is only possible because HUoS shares information about clients across agencies. Rob Sharman, Strategic Manager for the Edmonton Zone EMS, explains that before the initiative, case managers sometimes lost track of clients as they moved from one system to another (from hospital to jail, for instance). With HUoS, clients sign authorization papers so that they can always get the help they need, no matter where they end up. “You know, it’s not Disneyland for a lot of people at the end of the day,” says Madeleine Smith, a representative of REACH on the HUoS Leadership committee. However, the program helps clients be as safe and healthy as possible — and helps them retain their dignity.

Smith explains that REACH co-ordinates diverse organizations within Edmonton with the goal of making the city safer within one generation. Bringing together multiple resources for HUoS addresses gaps individual organizations wouldn’t necessarily be able to bridge on their own, she says. The EPS, for example, has far more experience than non-profits do at navigating and co-ordinating with the justice system.

In order to facilitate this efficiency, REACH has developed an app for the 24/7 Crisis Diversion Program, which assists vulnerable people experiencing troubling, but non-emergency, events. If workers in the program encounter clients of HUoS, they can set an alert on that client’s file to inform them if HUoS staff are looking to get in touch. This is important because case management work with clients can come to a sudden halt when they miss an appointment, court appearance, or other scheduled activity.

There are also benefits of the program to service providers, says Ward, particularly in terms of how well they understand clients. “Prior to the
program, there were just so many different layers of barriers that I didn’t understand. I would just think to myself, ‘Why don’t they go to a
shelter and get some help?’” she says. “But now, I know there are not enough workers, there’s not enough housing, and there are capacity issues in every level of service. Not to mention what the people have experienced; not only do they have addictions, but they have trauma, many have disabilities, and no assistance from any family members whatsoever.”

However, with help, people can overcome these troubles. Ward explains that Andy’s improvement happened remarkably quickly once he was
housed and treated for his mental illness. Now, he’s living independently, without drugs, and has a job. The drugs and mental illness masked an incredibly sharp wit and intelligence—for fun, he’s studying quantum physics from a book some members of HUoS recently bought him.

“There are a lot of success stories, and it’s just really heartwarming to see the change in people. [Andy’s] improvement is off the charts; and it’s exciting to know that with time we’ll be able to help more people,” says Ward.


HUoS is a collaboration between the following organizations:

COE Housing and Homelessness
George Spady Society
Hope Mission
Bissell Centre
Homeward Trust
Boyle McCauley Health Services
City of Edmonton
Alberta Health Services – Mental Health and Addictions
Boyle Street Community Services
Alberta Health Services – Edmonton Zone Emergency
Alberta Human Services
Bent Arrow Traditional Healing Society