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Visions Journal

A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

Community Navigator

Bridging homeless outreach

Suzanne Gessner, PhD

Reprinted from the "Social Support" issue of Visions Journal, 2011, 6 (4), p. 26

I was introduced to Donna* by a worker in our CMHA office. She asked if I could help Donna get on to Income Assistance. Donna was a victim in a violent gas station robbery in 2007, resulting in severe post-traumatic stress disorder. Donna has full-blown anxiety attacks when she is around anyone except her daughter. She breaks out in a sweat, her breathing and speaking become very difficult and she has to fight the desperate urge to flee. After exasperating dealings with WorkSafe and with her Employment Insurance medical benefits running out, Donna could no longer afford food or rent. The exercise of applying for Income Assistance (IA) was overwhelming and seemed impossible for her to do.

From Homeless Outreach to Community Navigator

BC Housing's Homeless Outreach Project was first piloted by Canadian Mental Health Association (CMHA) BC Division in 2006-2007. It has been very successful in connection homeless people with housing throughout the province. Evaluation of the initial pilot revealed that most homeless outreach clients, many of whom are living with a mental health and/or substance use problem, benefit from follow-up support.

 In October 2008, the Ministry of Housing and Social Development, in partnership with CMHA BC Division, announced Community Navigator, a two-year pilot program in response to the need. The program ran in six locations through CMHA branches: Prince George (Prince George Branch), Williams Lake (Cariboo/Chilcotin Branch) 100 Mile House (South Cariboo Branch), Cranbrook (Kootenays Branch), Kelowna (Kelowna Branch), and North and West Vancouver (North & West Vancouver Branch). Each of these communities participated in the Homeless Outreach Program, and Kelowna and Prince George also offer Aboriginal Homeless Outreach.

What is a Community Navigator?

A community navigator supports clients to address quality-of-life issues that affect their health, wellness and connection with the community they live in.

This is how one Navigator helped Donna, a Community Navigator client:
I immediately established a trusting relationship with Donna and assisted her through the IA intake process. I also assisted Donna in applying for Persons with Disability, and thankfully her application was accepted.

Donna and I worked on setting up a network of friends and services that she could access without experiencing anxiety. Initially, I would have to go to the bank with her as a support person. I would sit with her as she made a phone call to a friend to arrange a coffee. At first, the coffee would be drive-thru as she was not able to go into public places. Eventually we could go into a coffee shop. When Donna’s landlord suggested her dog was becoming a problem, I took Donna to make arrangements for dog obedience classes. I also assisted Donna through a WorkSafe appeal, accompanied her to see her new mental health worker, helped her with budgeting and attempted to get a consolidation loan for her.

Navigators may assist in many areas of a client’s daily life. They connect with clients contacted through the Homeless Outreach Program to provide one-on-one support for client-defined goals beyond housing. They also help clients access income support that they are entitled, such as Income Assistance, Persons with Disability (PWD), CPP disability benefits, GST rebates, income tax rebates, Climate Action Dividend, Shelter Aid for Elderly Renters (SAFER) and advocacy with income assistance personnel. Navigators play an important role in connecting clients with services for physical and mental health (including substance use problems) and advocate for their client at doctor appointments. But Navigators also work to foster social supports for their clients. For example, a Navigator may:

  • Facilitate supervised access visits with children in Ministry care

  • Recognize the clients’ skills by connecting them with community volunteer opportunities

  • Facilitate client involvement in leisure and recreation activities and engage community volunteers to develop support networks

  • Money management, banking, grocery shopping, and other life skills support

  • Investigate and assist with work opportunities

  • Liaise with landlords where necessary to help clients retain their housing

  • Attend court with clients and help clients resettle in community after  release from the justice system

At the launch of Community Navigator, we defined our top three goals: helping individuals access income, helping individuals access health care services, and helping individuals build stronger support networks.

Goal 1: Client income

One of the main goals of Community Navigator is to assist clients with accessing higher levels of income. The Persons with Disabilities (PWD) process was identified as being particularly difficult for clients to access on their own, and Navigators help clients with any and all possible means of support. This includes:

  • Basic income assistance

  • Canada Pension Plan, Guaranteed Income Supplement, Spousal Allowance

  • Employment Insurance

  • Rental Supplements

  • Rental Assistance Program

  • Income tax returns and other credits

Goal 2: Client health

Many navigator clients are dealing with a variety of ongoing health issues. Of the individuals we served, 43% had a permanent physical health issue, 43% had a substance use problem, 69% had a reported or diagnosed mental health issue and 39% experienced both a mental health and substance use problem. Some clients experience health problems in more than one of these categories.

Navigators spend a great deal of time connecting clients with health, mental health or substance use services. Completion of the PWD form required that the client be assessed by a doctor, and this has proven to be one of the biggest challenges of the program: finding doctors who are willing to take on the client and spend the time needed for the PWD process. In addition, Navigators estimate that they have secured regular GPs to provide ongoing care for about 46 clients, or less than 20% of the people served. While some clients may not want a regular GP, it is often the case that GPs will not take on Navigator clients as regular patients.

According to client descriptions, Navigators report that in many cases, their role as an advocate at doctor's appointments greatly improves the attitude of the doctor towards the client. This, in turn, results in better health outcomes for that client. Many clients experience stigma and discrimination from health care workers. This is supported by research on attitudes of health care providers.

Without Navigator connections, most navigator clients would usually only access emergency services, and then only when the problem has advanced to a stage that may be more difficult to treat. Although connecting client with health care services may be costly in terms of staff hours, the emergency option is far more expensive. Community Navigator provides a path that benefits both the client and the health care system.

Here are some examples of ways a navigator helps clients access adequate medical services and some of the challenges they may encounter:

  • Dental health—Process of navigating assessment, extraction and dentures can take up to six months.

  • Physical health—Process of moving clients from walk-in clinics to a family physician often takes several months.

  • Mental health—For some clients, the process is quick. For others, it may take several approaches. The Navigator role is critical to ensure the even when the client has access, the clinical staff are aware of any behavioural changes or challenges a client is experiencing in the home or community. Some clients will attend the initial appointment, but feel too overwhelmed or intimidated to continue.

  • Ongoing chronic health issues—As a navigator address one issue, another issue often comes up

  • Access to daily living aid and medical supplies not covered by medical, such as bath bars, walkers, tub chairs, wheel chair ramps, eye glasses, and other necessities.

  • Transportation to and from medical appointments

Goal 3: Personal support networks

Upon taking an individual as a client, Navigators work with the client to define short- and long-term goals. This includes talking with clients about their supports and ascertaining whether the client wants to address issues relating to personal support. In many cases, the client's mental disorder or substance use has severed many of their personal relationships. However, relationships and personal support networks are often not a priority until underlying issues like income and health are addressed. For clients who do wish to develop greater support, Navigators work with them to build their networks. Navigators have been trained through PLAN's (Planned Lifetime Advocacy Network) network facilitation program. They have also taken Wraparound training. This method works at building a team of both professional and personal support around an individual. To date, there have been some great successes with network development.

Housing issues: Where are they living?

At the time of contact with the Navigator, 31 clients were absolutely homeless, 17 were homeless due to crisis (e.g. living in a women's shelter), 51 were “hidden homeless” (e.g. couch-surfing, temporary or unsafe housing), one had just left a reserve and 122 were at risk of homelessness.

While Homeless Outreach workers are generally the ones securing housing for clients, many clients may need to change their housing after becoming a Navigator client. So Navigators spend about 10% of their time on housing-related issues. Approximately 23% of clients have been assisted with housing issues.

Client activity

Navigators are available to work on a large range of client-defined needs. We have made 1,829 connections with primary care physicians, housing providers, employment programs, recreation services and individuals who help to increase a client's personal support networks. On average, seven different community connections were made to each client.

What does all this mean?

Community Navigators are filling a gap on the housing continuum. Their role is crucial to supporting and enhancing the existing services for people who are homeless or at risk of homelessness. Whether helping clients apply for higher levels of income assistance, connecting them with a doctor who can manage their mental and physical health issues or working to build a network of people they can rely on, Community Navigators are a crucial part of an effective provincial housing strategy.

Donna, who overcame severe post-traumatic stress disorder and accessed income supports, connected with friends and service providers, appealed a WorkSafe decision and worked with her landlord, is just one example of Community Navigator’s successes. Donna’s Navigator says:
It has been one year since I met with Donna and she is now in a two-month Empowered to Work Mentoring Program. I hear from Donna less and less. She is busy and managing her anxiety and own life quite effectively.


About the author
Suzanne was the most recent Director of Public Policy and Community-Based Research at CMHA BC Division; she recently returned to her background in education and linguistics.
This article was adapted from Community Navigator project files.


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