Rats kept chewing through the floorboards of her RV. Sandy didn’t have anyone to help her in or out of her wheelchair so she could get around. She was scared.
“She was cold, distraught and crying, and basically hanging on to a sliver of hope,” said Casey Culley, one of the founding members of the Navigation Team. Staffed by Transition Projects and Central City Concern, the team focuses on making deep connections with people in large encampments.
Sandy, Culley said, “used to have a good life. But she didn’t know how to get one again.”
Today, with help from the Navigation Team, everything for Sandy has changed. Outreach workers kept coming to see her, day after day. They signed her up for Medicaid and helped with her Medicare. They connected her to a doctor. And eventually, they found her a place to live in supportive housing: an affordable apartment where she also receives medical support.
“And she has been happily living there for the last six months,” Culley said.
Sandy’s story was among the highlights of a briefing for the Board of County Commissioners on how street outreach and engagement efforts serve as the front door to the County’s homelessness response system.
Commissioners Susheela Jayapal and Sharon Meieran had called for the update last spring as part of the Board’s unanimous vote approving this year’s Joint Office budget, which used funds from Metro’s Supportive House Services measure to expand outreach, shelter and supportive housing.
Joint Office director Marc Jolin, joined by front-line workers, spoke Tuesday, Jan. 11, of the growing — and increasingly coordinated — outreach system that touches and welcomes thousands of people every year.
With funding for 85 workers across more than 20 street outreach programs, the Joint Office provides a full spectrum of support to people without shelter — from basic needs and information, to navigation to services like healthcare and shelter, to dedicated housing case management. The Joint Office also supplies survival gear to volunteer and mutual aid organizations that do their own outreach.
But no matter what service outreach workers are offering, Jolin said they each provide one essential component: the personal relationship that can bridge the gap between hope and mistrust.
“You’re talking often about people who are truly marginalized, who perhaps have given up hope that their lives can get better,” he said. “Outreach always begins with building trust, building relationships, so someone opens themselves up to the services and resources that are available to them. It’s something that can actually endure and does endure.”
Different outreach models to better meet people where they are
Every team funded by the Joint Office provides some level of basic survival support, Jolin said, delivering gear and survival supplies, and checking on people to see how they’re doing. That kind of work becomes particularly important during severe weather events. The Joint Office also supports nearly 90 volunteer and mutual aid groups by distributing supplies through a downtown warehouse.
But most teams are asked to focus on one of two kinds of models: service navigation or housing support and case management. And even between those two approaches, the work often overlaps and intertwines, Jolin said.
Navigation-based outreach workers — like the members of the Navigation Team operated by Transition Projects and Central City Concern — typically work to connect their clients to services provided by other agencies. That can involve signing someone up for the Oregon Health Plan, helping them apply for federal benefits, or working to obtain shelter and housing referrals.
Other outreach workers, like those employed by providers such as JOIN, Cascadia Behavioral Healthcare and the Native American Rehabilitation Association (NARA) serve almost as “housing case managers,” Jolin said. Those teams support basic safety and service navigation, but they “take on that responsibility” for traveling with someone side-by-side as they apply for healthcare, shelter or housing.
The outreach workers often help people move directly from the streets and into stable housing, meeting with them regularly to help overcome any barriers.
“They’re going to do all of that as part of an enduring case management plan that they establish with that individual,” Jolin said. “They’re really providing that whole continuum of support that’s necessary to get someone into permanent housing.”
Lived experience and tenacious relationships
Across all categories of outreach, Jolin said, teams bring different specialties to their work — elements that strengthen their relationships not just with the people they serve, but among a larger network of Joint Office providers who can be partners in meeting a client’s needs.
Some teams focus on particular geographic areas, such as East County or Old Town. Other providers, such as Cascadia, focus on serving people with acute behavioral health needs. Still others, such as the Urban League of Portland and NARA, provide culturally specific services, focusing on helping African American or Native American residents, respectively.
Despite her role as a manager, as Cascadia’s director of homeless and housing supports, Kim James, still does direct outreach herself. She told the Board that in every visit to a camp, Cascadia’s teams focus on building trust with those people who might otherwise never seek help or or have contact with the homelessness response system.
“It’s hard on the street,” James said. “We know people are experiencing trauma daily, and they carry forward a lot of that pain, that loss, that grief. Our team of clinicians are able to use their own lived experiences to provide compassionate care to help people transform their lives.”
The first step is often serving as “a lifeline to folks,” James said: providing “food, water, blankets, tents, socks, shoes and hygiene supplies.” Then, through regular engagement, outreach workers can get to know their clients and the barriers they experience.
And even if someone says they’re not ready to accept resources yet, the outreach workers keep coming back.
“We appreciate the fact that all individuals are unique,” she said, “and some people will require more outreach and engagement than others before accepting resources.”
Tanya Blackhorse, a NARA clinician and outreach worker, recalled “the first person who made me cry” during a housing assessment. It was back in 2018, and she was sitting with a man who told her the only thing he wanted “was something over my head,” even a shed, “just as long as I am dry and my stuff is safe.”
It took three more assessments, she said, to get the man qualified on a list of federal housing resources. He’s been housed since 2019.
“He is so thankful,” she said. “I see him now and again when I’m out delivering boxes in our community. I’m happy to see him all the time.”
System expansion under way
Just two years ago, the Joint Office was able to fund 47 outreach positions. Today there’s funding for 85. Ten new outreach workers were hired in December 2021 alone, part of plans to expand capacity for the Joint Office’s Navigation Teams, behavioral health outreach teams and culturally responsive outreach work.
Along with that expansion, the Joint Office is planning new avenues for connection.
The office is creating a “Safety on the Streets” team, akin to its shelter and housing teams, and planning to hire a new program specialist to lead that outreach work. That staffer would ensure outreach teams are coordinating among themselves and also working in sync with volunteer outreach work out in the community.
The Joint Office is also working with the City of Portland to launch a Street Services Coordination Center that will connect outreach teams to first responders and other public agencies, like Portland Street Response, which encounter people experiencing unsheltered homelessness.
Behind all of that, the Joint Office has joined a national data-improvement project called the Built for Zero Initiative. Built for Zero will help the Joint Office create a real-time, “by name” list of people experiencing chronic homelessness. Building the list will require improving the way outreach workers’ track their work and collect data.
“It’s a point of entry,” Jolin said of outreach. “It’s a relationship that can be incredibly empowering, but we need to turn that empowered relationship into the kind of resources, in particular housing, that people need to get off the street and not remain homeless.”
After the presentation, both Commissioners Meieran and Jayapal noted their own time shadowing outreach workers like Cascadia’s. For Commissioner Meieran, who works as an emergency room physician, that experience has also included making rounds with Portland Street Medicine.
She acknowledged the hard work by front-line staff on the streets, and said she wanted to see more work to coordinate outreach and data collection, along with more places where outreach workers could help someone access services.
“As the system becomes more complex, we need to coordinate and grow to meet the need. We need to know who is living on the streets and where they are, so the outreach teams can find them,” Commissioner Meieran said. “I am very concerned about how we coordinate, how we navigate.”
Commissioner Jayapal reflected on the need for more housing case managers who can do more than navigate someone to another set of services — wondering whether a more centralized coordination system would help more people off the streets.
But she said her experience with Cascadia’s on-the-street team, in particular, “was one of the most valuable things I’ve done in terms of understanding in outreach services.”
“I could see from the interactions between you and the people you were talking to that you had been out there before, that you understood the histories of the people you were talking to,” she said.