*This CAEH Bright Spot was written by Tiffany Dorman, the manager of homelessness and supportive housing with the Regional Municipality of Halton. 

It was about a year ago. A supportive housing provider in Halton Region reached out to me. 

They said, “hey, we’ve heard what you’re doing with coordinated access. How can we get involved?” 

For me, that was one of many moments that really hit home. It reminded me why it mattered to have all those hard conversations, the growing pains and the work we’ve done over the last six years to build our coordinated access system.  

The interesting part is that, even though we act as the Community Entity overseeing millions in federal Reaching Home funding, this particular supportive housing provider was not one of our funded agencies. 

They had no obligation to take a referral from our coordinated access system—the process the Region uses to determine how supportive housing vacancies are matched to people on the By-Name Data 

And yet, they still reached out and asked if we could use our By-Name Data to identify people for the units they had coming available. 

Now that’s a sign of trust in the system.  

And it’s how we are addressing homelessness in Halton Region, as one community working together. 

Building coordinated access in Halton 

In 2019, the federal government launched Reaching Home, which introduced a requirement for funded communities to implement coordinated access as part of their work to reduce and end homelessness. 

As a Region, we took the time to truly understand the model. We learned everything we could, brought in OrgCode to guide us on best practices, and embraced the approach wholeheartedly. As an evidence-based system that brings together all the key agencies to prevent and end homelessness using real-time, local data—it just makes sense. 

At that time, Halton Region already had a Community Safety and Well-Being (CSWB) Housing Leadership Group, which brought together local housing and homelessness leaders, police services, and our local Ontario Health Teams. It created a strong foundation of cross-sector collaboration to build from. 

Once we fully understood Coordinated Access, we began engaging our CSWB stakeholders. 

We didn’t limit this work to Reaching Home-funded agencies. We engaged the entire community, because housing and homelessness are system-wide issues that cannot be confined to one funding stream.  

We brought everyone together and educated them about coordinated access: what it is, why it matters, what we needed to implement in Halton, and how critical their involvement would be.  

And we asked questions—a lot of questions. 

Coordinated access means a fundamental change—it’s worth the hard work 

It’s challenging to tell organizations that they will need to start using a new system, track new data, and adopt a shared Homeless Management Information System. 

Even harder to tell organizations they will no longer manage their own waitlists and will instead receive referrals through the Region.  

These are fundamental changes. The conversations were not easy. 

There was of course resistance—people didn’t want to change the technology they were using, they didn’t want additional oversight, and they didn’t want to lose autonomy when selecting their clients. 

But we were committed to bringing everyone on board and including everyone in the program design. So, we stayed focused on the why—why coordinated access was going to help us reduce and ultimately end homelessness. 

Instead of having these conversations in small groups, we held them in large, open forums. 

In Halton Region, we were completely transparent about the fact that we didn’t yet know how every detail would work—but we were committed to figuring it out together.  

We also learned very quickly that while senior leaders excel at strategy, they are not always best positioned to inform how a system functions on the frontline. That insight prompted one of our strongest decisions: deeply engaging the frontline. 

We established three working groups to help design the system: 

• Community Supports Group, for those making referrals into our homelessness response system; 

• Entry Points Group, including shelters and outreach; and 

• Housing Providers Group, for those accepting placements. 

We taught each working group about coordinated access, explained the best practices, asked for a lot of feedback, and ultimately co-developed recommendations that shaped our implementation. For us, this was coordinated access in action, built by the community, for the community. 

We saw coordinated access as the only meaningful way to address homelessness across the community, and as leaders, we made a conscious choice to champion the approach.  

We have not looked back. 

What We Learned Along the Way 

The biggest lesson has been that this work is fundamentally relationship-based.  

To do coordinated access well, the lead organization must genuinely know the community’s service providers, understand their challenges, listen to their realities, and be willing to help problem-solve whenever possible. 

We also learned that true system leadership requires being more involved than you might expect or want to be.  

Housing providers are doing their very best with the person in front of them and the information they have.  

But as a system leader, we see the entire continuum: people moving from unsheltered homelessness, into shelter, into housing, and sometimes back again. There were times when we needed to step in, even when we didn’t want to, simply because it was the right thing to do. 

One of the ways we operationalized this was by asking funded agencies not to evict anyone without consulting us first.  

With 15 supportive housing programs across Halton region, including those that are not funded through Reaching Home, we know that on the first try we won’t always place someone in a housing unit that works for them. Sometimes a placement simply isn’t the best fit, or the level of support isn’t quite what a person needs at that moment.  

When that happens, we work closely with the supportive housing providers to explore rehousing options within the system. Often a different program with a different model, environment, or support approach can make the difference between someone having a safe place to call home and falling back into homelessness. 

We also lean in to help stabilize situations that can be improved through stronger support plans or additional services. And on the other end of the continuum, we support providers in helping people find new units if and when they are ready to move into housing options that have greater independence and less supports.  

Because we see the full picture across all 15 programs, we’re often able to identify the next best step for someone—whether that’s more support, a different type of support, or less support as someone grows more stable and ready to move to a new unit. 

This hands-on, partnership-driven approach has strengthened relationships so much that we now have providers, including those we don’t fund, asking to participate in our coordinated access system and prioritizing individuals from the By-Name Data for available units. 

The Hard Conversations Got Easier 

Difficult conversations are a natural part of this work.  

But because our relationships are strong, those conversations no longer feel difficult, they feel like the same supportive, honest discussions you’d have with members of your own team.  

That is the benefit of building trust first. 

Still Learning, Always Improving  

Our system is far from perfect, and we continue to learn more every day.  

Right now, we are focusing on embedding lived experience into our programming and aggressively creating new supportive housing so we have enough units in our region for the people who need them.  

Because without enough housing, even the strongest system can only go so far. 

This project was funded by the Government of Canada.