Programming Connection

STOP Outreach Team 

Vancouver STOP Project
Vancouver, British Columbia


  1. Lack of pre-existing model. With no precedent for the team’s structure, management has shifted and altered the team’s makeup to find an optimal operating structure and staff complement. Work continues to be done to find the right staff configuration, with the right roles and in the right settings. 
  2. Structural barriers. Mental health and addictions services are challenged to meet the needs of the most complex clients.  Waitlists and transitions among service settings provide structural barriers to engaging and maintaining some of these clients in ongoing HIV care. 
  3. Social workers. With a primary focus on biomedical interventions and outcomes as associated with treatment as prevention, social workers and other clinicians often struggle to prioritize issues that can be more immediate and important for daily survival.  This, combined with the lack of obvious measures of success relating to the social determinants of health has challenged social workers to understand the relative value of their practice.
  4. Limited resources.  While the STOP pilot was well funded, there were many priorities that led to pressures and some unmet needs.  The STOP team could have provided more care and even greater improvements to access with more resources such as physician sessions. Additionally,   the mandate to provide both expanded testing and treatment support services has overextended some team members. In addition, developing individual and effective care plans for each client is time-consuming, as is meeting the needs of dozens of clients to execute these plans.
  5. Collaboration with other service providers. It has been a challenge at times for the team to integrate its work with the work of other agencies in a neighbourhood with a many providers. Improved coordination of service delivery would result in greater efficiency and outcomes.  .
  6. Communication with the criminal justice system and other jurisdictions. Challenging communication with the federal justice system and other health authorities can have a negative health impact on clients who experience episodic incarceration, or who are transient, and who need strong continuity of care.
  7. Cheque day.  Provincial income assistance cheques are issued monthly, giving clients access to hundreds of dollars at a time. To reduce the negative impact this can have on clients’ lives, the team encourages clients to have cheques issued weekly or biweekly, and have rent withdrawn directly from their accounts. For clients who want it, the team will match them with a peer navigator that will support them to do something positive with the money.
  8. Weekend services. The team does not offer weekend service to clients though it does have a 24-hour telephone line for clients and service providers needing support or information.
  9. Transitions and discharge. Many of the team’s clients rely on outreach or require a tailored clinical service to remain engaged in care. There are limited spaces in long-term programs that have the capacity to do this. Despite limited capacity in the community, discharge must take place as there is a steady flow of referrals to the team.