Housing System Workshop

Narrative Summary & Critique of the Baseline Journey Map

What Durham’s frontline staff and leadership said when they mapped how a low-barrier single adult actually moves through the homelessness system.

Developed by the Bellwether Collaborative for Health Justice · 5 February 2026; revised 8 July 2026

Background

On Tuesday, December 2, 2025, the Durham Community Safety Department (DCSD) hosted an in-person workshop attended by frontline staff and leadership from homelessness system agencies. Two primary activities took place during this workshop, with this document presenting a summary from the “Baseline Journey Map” activity. This activity included reviewing a simple outline of how a low-barrier single adult may move through the homeless system in Durham, NC. The baseline journey map was designed not to be comprehensive, providing workshop participants a foundation to inspire discussion. Throughout the activity, participants were asked to give feedback on this map.

The findings of this report are organized by the six original map phases. Feedback from workshop attendees is then summarized into the following categories: 1) map phases, or critiques of the baseline journey map — including proposed changes to the steps; 2) pain points or bottlenecks in the system; 3) bright spots or areas of value; 4) where data is (or should be) involved; and 5) areas with questions.

Executive summary

The feedback from the homelessness system workshop participants reveals a system that is dedicated and collaborative, but strained by resource limitations, inconsistent practices, and structural constraints. Across all phases of the baseline journey map, several cross-cutting themes emerge.

Bright spots reflect a system defined by collaboration, commitment, and creativity

Despite challenges, participants highlighted several strengths that reflected a committed housing provider community. Frontline staff were frequently described as supportive communicators and willing to go beyond their formal responsibilities to assist clients. Durham’s coordinated entry was viewed as notably functional compared to surrounding areas. Participants perceived that clients experience genuine care from staff, and that landlord engagement can enable quicker housing placements. Participants described “doing a lot with a little,” capturing the resilience of providers working within constrained systems.

Map phases: diversion & stabilization

Participants noted that the baseline journey map oversimplifies the real pathways into and through Durham’s homeless response system. Key missing or misrepresented components included diversion and stabilization. Diversion and stabilization were described as strategies that should begin at Phase 1 and continue throughout the entire system, even after a person has entered shelter or been placed in housing. Participants emphasized that diversion and stabilization are not a one-time activity, but evolving, core components embedded in every phase.

Structural pain points: diversion & prioritization

Participants see diversion as an essential tool that can be effective but is under-resourced and inconsistent. Prioritization systems often disadvantage low-barrier clients, who score too low to receive referrals, causing them to “fall through the cracks.”

Capacity and resource limitations create system-wide bottlenecks

Across all phases, the most pervasive challenges relate to insufficient staffing, high caseloads, limited housing or shelter inventory, and long waitlists.

Inconsistent assessment practices lead to inequitable experiences

A central thread across discussions was inconsistent assessment and intervention fidelity. Participants described variation in how housing barrier assessments are administered, the interpretation of policies, the application of prioritization, and the quality and completeness of Homeless Management Information System (HMIS) data. This inconsistency directly affects client trajectories, sometimes determining whether someone receives housing or is deprioritized indefinitely.

Data systems are underutilized and not integrated across agencies

Key data-related challenges include: 1) HMIS data entry burdens that overload frontline staff; 2) incomplete or inconsistent case notes; 3) a lack of regional data sharing (e.g., across counties, private shelters); and 4) limited information about pre-Entry Point Durham (EPD) histories or patterns (e.g., repeated one-time assistance). Some participants questioned how to collect quality data while maintaining client dignity and meaningful engagement. Finally, there is no reliable mechanism to track long-term housing stability; the only way to know if people maintain housing long-term is if they become unhoused again.

Client-level barriers compound system-level limitations

Participants described barriers that clients experience, or barriers created by policies, that affect progress through the journey map: 1) lack of a reliable phone or stable contact method; 2) difficulty obtaining documentation (IDs, benefits paperwork); 3) limited income or inability to afford application fees or deposits; and 4) reluctance to engage with providers or mistrust of the system.

Phase 1 · Initial contact & assessment at Entry Point Durham

Map phases. The baseline map’s representation of a single, linear entry point was seen as inaccurate. While the baseline journey map presents Entry Point Durham (EPD) as the primary gateway, participants explained that people enter the system through multiple access points, including street outreach, hospitals, and community organizations. They also identified that the baseline map omits early functions such as diversion, data entry into HMIS, assignment of a point-of-contact, identification of emergency needs, and space for “pre-assessment” information-gathering that occurs before EPD assessments.

Diversion emerged as the central theme of discussion. Participants described that diversion is not a discrete step, nor something that ends after an initial attempt; instead, it should be treated as a continuous practice embedded throughout the entire journey.

Pain points. Participants described heavy reliance on phones for contacting clients, which disadvantages people without phones or stable numbers; high call volumes at EPD (80–90 calls per day); long waits for callbacks; and overextended frontline staff who struggle to complete all necessary assessments. Participants noted that these constraints also make it difficult to conduct accurate assessments, which require time and understanding of clients to gain the depth of knowledge needed.

A related concern was the inconsistent administration of assessments and interventions. Participants noted that housing barrier assessments are not applied uniformly, leading to uneven prioritization and variable client experiences. They attributed these inconsistencies to differences in training, human error, and varying interpretations of policy.

Participants also recommended improving client-facing communication in Phase 1 by providing clear, accessible information about next steps, expected wait times, and available resources, perhaps through resource guides. They emphasized that inconsistent messaging contributes to confusion and mistrust, and that setting expectations early helps clients navigate the system more effectively.

Bright spots. Despite challenges, participants pointed to several bright spots, including many low-barrier single adults self-resolve, strong frontline collaboration, supportive staff, and the widely shared perception that Durham’s coordinated entry system is functional and reputable compared to other regions.

Data. Participants highlighted the need for improved HMIS utilization and broader regional data sharing, noting that current data systems are underused and burdensome. Better use of HMIS, especially through complete case notes and shared access across counties, was viewed as essential to improving continuity, reducing duplication, and strengthening assessments.

Phase 2 · Crisis response assessment & referral

Map phases. Participants focused on how diversion, crisis assessment, and prioritization interact to shape client pathways. They reiterated that diversion remains effective when possible. Participants recommended that the map phases explicitly include a prioritization step, as this determines which clients can access rapid rehousing or other programs.

Pain points. Participants highlighted that shelter access is highly constrained. They described long waitlists, a lack of weekend intake procedures, and the difficulty of maintaining real-time bed inventory. The existence of private shelters not connected to HMIS compounds this challenge and leads to gaps in communication and tracking. Like Phase 1, participants expressed concerns about the crisis assessment and scoring process, noting that assessments may be inflated or administered inconsistently. Participants also perceive that clients sometimes misunderstand referrals as guarantees, prompting providers to withhold some details from clients to avoid false expectations.

Data and questions. A key theme was the challenge of determining whether a diversion or referral would be successful or sustainable. Participants questioned what metrics or assessment tools are needed to understand whether individuals diverted from shelter will be able to maintain stability.

Phase 3 · Stabilization (re-framed as Navigation)

Map phases. Across groups, participants strongly rejected the idea of stabilization as a single phase. Instead, they emphasized that stabilization is embedded throughout the entire journey, beginning at Phase 1. Several advocated for renaming Phase 3 “Navigation,” stating that the most accurate description of this stage involves case management initiation, resource coordination, documentation gathering, and prioritization.

Participants held differing views on what level of stabilization should occur before housing placement. One group of participants felt strongly that clients should increase income or gain employment before obtaining housing, expressing concern that people might otherwise lose momentum after securing housing. A separate group of participants described Housing First principles, emphasizing that stabilization cannot realistically occur before someone is housed.

Pain points. The ability of staff to do their jobs effectively is constrained by high caseloads, limited staffing, and time pressures. This leads many clients, especially low-barrier individuals, to receive limited follow-up or support. Finally, participants emphasized that Phase 3 is an essential moment for clear communication with clients about expectations, diversion possibilities, and prioritization, to reduce confusion later in the journey.

Bright spots. Participants described how people and agencies who truly care about clients go above and beyond. Case managers, shelter staff, and EPD staff often provide informal or de facto navigation support, even when it is not a part of their responsibilities.

Phase 4 · Housing placement

Map phases. Participants noted that the baseline map oversimplifies Phase 4, which is rarely an immediate “placement,” but more accurately a housing search process. One participant suggested reframing this phase as a housing pathway rather than a discrete placement step.

Pain points. The dominant narrative for Phase 4 was about limited housing options and long waitlists. Low-barrier individuals are often deprioritized due to low assessment scores, meaning they may experience longer waits or are ineligible for housing referrals. Participants also noted challenges such as contact information instability, prohibitive move-in expenses, incomplete case notes, and the elimination of “navigator” roles that formerly supported housing searches. Some participants pointed out that clients from outside Durham seek housing resources locally due to the system’s reputation, creating additional strain.

Bright spots. Participants emphasized that one-time financial assistance (e.g., deposits, one month of rent) is a bright spot and often a decisive factor for low-barrier single adults. They also highlighted the importance of landlord engagement, noting that relationships with landlords can lead to quicker housing placements.

Phase 5 · Wraparound services & referral

Map phases. Participants generally felt that Phase 5 is often minimal or not reached at all for low-barrier single adults. Many clients who self-resolve or who receive short-term assistance do not remain in the system long enough to receive wraparound supports.

Pain points. The system’s capacity constraints — including limited staff, limited participant availability, and variable quality across agencies — were significant barriers. Wraparound support is inconsistent and often inaccessible for this population.

Bright spots. When wraparound services occurred, preferred partnerships with trusted providers (e.g., mental health agencies) were cited as strengths, as they can improve service quality.

Phase 6 · Long-term stability

Map phases. Phases 5–6 were the least discussed, largely because participants felt that the baseline map’s final phases are not typically accessed by low-barrier single adults.

Pain points. Participants focused on the inability to know whether clients achieve long-term stability. Once housed, or once they receive one-time assistance, clients often disengage from the system, and participants have no mechanism to follow up beyond minimal required contacts. Additionally, policy changes across systems can leave both staff and clients uncertain about requirements for maintaining stability.

Data. Participants described a major data gap: long-term outcomes are largely unknown unless individuals re-enter homelessness and return to the system. This makes it difficult to evaluate program effectiveness, understand client trajectories, or identify long-term needs.