Progress Report: Enhancing the System of Care for Islanders Experiencing Complex Issues

Enhancing the System of Care for Islanders Experiencing Complex Issues, release in July 2024, outlined several recommendations to improve the system of care for Islanders with complex needs who are experiencing homelessness. We would like to thank Carlene Donnelly, our Task Force for Complex Islanders, Community Advisory Committee and all government and community service organizations for the continued progress on these initiatives. 

Recommendation 1: Build a Model of Care for People with Complex Needs on PEI Experiencing Homelessness

• Minister's Task Force established in July 2024. The Task Force has a one-year mandate to help provide recommendations on developing an improved model of care. Task Force meets monthly
• Brain Story training sessions completed with relevant staff through the Alliance for Mental Well-Being. Training is free and continues to be a priority for community partners and government service entities
• Additional supportive housing projects undertaken by HLC and research continues on implementation of a Housing First model for PEI. Expect to pilot a Housing First model later this year in Charlottetown
• Community Outreach Centre (COC) provides case management with a care plan to those open to service and through the case management table involving community and government partners
• Data is collected through the Homeless Individuals and Families Information System (HIFIS) with all community partner organizations working with the unhoused population reporting client data.
• Exploring relevant software to improve and expand capacity of data collection.
• Recommendation by Special Advisor, through collaboration and consultation of Task Force and CAC, to build a distributed model of care under a main umbrella entity as the long-term plan for a model of care for people with complex needs experiencing homelessness. This model builds on current services that exist within the community.

Recommendation 2: Improve Coordination of Services

• Launched the Community Action Committee (CAC) in October 2024. The CAC is a community-level committee of service delivery organizations will also be created focused on system mapping and pathway improvements. The CAC is co-chaired by United Way of PEI and Mental Health and Addictions (Health PEI). CAC meets bi-weekly.
• Community resource capacity overview developed by CAC.
• Brain Story training sessions completed with relevant staff through the Alliance for Mental Well-Being. Continue to discuss additional training needs with CAC.
• Baseline data work being undertaken through UPEI.
• Improving reporting through HIFIS.
• Most recent Point in Time Count (fall 2024) by John Howard Society included the entire province for the first time.
• Project work beginning on discharge planning pathway processes from institutions to prevent discharging into homelessness.>
• New intake and service improvements at COC. CUPS ICAT exercise carried out.
• Extreme weather standard operating procedure developed in partnership with Department of Housing, Land and Communities (HLC), Salvation Army and other community partner organizations

Recommendation 3: Adopt a Prevention Philosophy

• Summerside shelter opened in Oct 2024.
• Research continues on Housing First model for PEI. Expect to pilot a Housing First model later this year in Charlottetown.
• Process improvements and intake tool implemented at COC. COC providing case management with a care plan to those open to service and through the case management table involving community and government partners.
• Brain Story training sessions completed with relevant staff through the Alliance for Mental Well-Being. Training is free and continues to be a priority for community partners and government service entities.
• Justice and Public Safety implemented therapeutic courts in 2024.
• Two Housing Summits held (Feb and June 2024) to increase awareness of issues with stakeholders.
• Working with Reach Foundation to create new programs for people with complex needs who are homeless.
• HLC has been collaborating with academic institutions on needs-based research and a broader framework on homelessness.
• Communications strategy planning is underway to address stigma surrounding Islanders with complex needs and homeless.

Recommendation 4: Appropriate Primary Care, Mental Health and Addictions Access are Critical

• Health PEI Mental Health and Addictions has implemented Open Access counselling, providing same-day access to trained counsellors for mental health and substance use concerns.
• Primary care clinic established at COC supported by physicians, nurses and other health care professionals to reduce hospitalizations and ER-demand for persons experiencing homelessness.
• Health PEI MH&A is holding weekly Open Access clinics at the Community Outreach Centre.
• Health PEI is evaluating the Addictions Transition Unit programming to identify opportunities to improve alignment with best practice and with population needs.
• Health PEI is increasing service scope and capacity in Community Addictions, including OAT and outpatient withdrawal management.
• Health PEI MH&A is improving case management through targeted training being developed in partnership with UPEI.
• Health PEI MH&A is expanding outreach capacity to support individuals with serious mental illness in community through Flexible Assertive Community Treatment Teams.
• Health PEI MH&A is increasing capacity in outpatient withdrawal management to support individuals in withdrawing from substance use in their home rather than requiring an inpatient stay at Provincial Addictions Treatment Facility.

Recommendation 5: Options for housing need to continue to be developed

• Housing starts set new records in 2024, the best starts since the 1970s. Q1 of 2025 also shows historic starts of 423
• Summerside Emergency Shelter (10-beds opened in fall 2024), bringing the total to 97 emergency shelter beds supported by the PEI Housing Corporation (PEIHC).
• New 12-unit supportive housing in Summerside in partnership with BGC Prince County.
• PEIHC added 11 supportive housing units in Montague this year.
• PEIHC developing an additional 24 supportive housing units in Charlottetown.
• Housing First pilot project under development.
• In 2024-2025, a total of 150 new government-owned social housing units were added through construction and acquisitions. An additional 10 units in Alberton and 30 units in Charlottetown will open in spring 2025. By the end of 2025, another 82 units in Charlottetown will be open.
• HLC has partnered with private developers through the Affordable Housing Development Program to add affordable housing units for clients of the housing registry. A total of 74 units have been completed with another 95 currently under construction.
• Two housing navigators supporting connection to housing and support services for Islanders.