Bright Spot: Maricopa County | Developing peer support staff to provide engagement and navigation support

September 20, 2019

Develop housing navigation staff to provide engagement and navigation support

Check out this bright Spot if…

  • You need to coordinate outreach services 
  • You have limited capacity for targeted outreach and housing navigation
  • Some veterans experiencing homelessness in the community are hesitant to engage with traditional outreach staff
  • You want to try it!


The peer navigator program was born out of the lack of coordination between behavioral health, criminal justice, and homeless sector systems. The community found they had many chronically homeless veterans who were engaged by providers within these three systems but there was no one coordinating between them. A community advocate and retired law enforcement officer, Nick Margiotta, made the case to start a pilot to see if peer navigators could provide a more holistic view and work with veterans spanning these three sectors. 

The pilot started as a two member, part-time team, with one peer navigator dedicated to the project for just 10 hours per week. The community provider who employed the peer specialist donated the 10 hours, in-kind, so they could test the pilot without securing independent funding.  The team collected data on outcomes tracking engagement rates, housing placements and retention, criminal recidivism, hospitalizations, utilization of preventative health care, and mainstream benefits enrollment. They used this data to make a case for expanding the program and securing funding.  

Over time the community was able to secure additional funding and created a full program, hiring a project coordinator and 3 peer navigators to assist a total of 75 veterans (a 1:15 client to staff ratio is recommended). They created a referral protocol and targeted veterans who were hesitant to work with traditional providers and were considered some of the most challenging cases. Peer navigators, those with lived experience, were found to be the most successful at engaging and building rapport with these veterans.

This model can easily be applied to working with persons experiencing chronic homelessness. The funding may look different, but the navigation activities should remain the same. 

Key Action: Utilize Skill Set of Peer Support Staff

Peer navigators do it all. They start with outreach to targeted veterans, build rapport, develop case plans, conduct home visits, work as a liaison between clients and landlords, provide rides to important appointments, assist in completing paperwork and other case management duties. They are flexible, they are nimble, they meet the client where they are at. In addition, they serve as a friend and mentor to the veterans they work with. Sometimes the most important service they can provide is sitting down to have a cup of coffee and chat. 

Once the veteran has stabilized in housing the peer navigator can work with the VA (or other provider) to transition the client to more traditional case management and clinical services if the client so chooses.

Key Action: Collect Data and Test Processes at a Small Scale Before Full Implementation

Before fully implementing, the community tested the concept with a pilot program and collected data on outcomes.  When outcomes reflected success they built the case for expansion and full implementation and hired a program coordinator to handle all administrative elements.

The community used the following data to measure effectiveness: 

  • Housing placements and retention
  • By-name list active homeless number reduction over time
  • Engagement
  • Reduction in criminal recidivism
  • Reduction of hospitalization and inpatient care
  • Use of preventative health care services
  • Connection to mainstream benefits
  • Date of identification and housing


  • 90%+ housing retention
  • 98% engagement
  • 70% Reduction in hospitalization and inpatient care
  • 80% increase in preventative health care services
  • Average of 30 days from identification to housing (down from 75 days and the goal is 10 days)

For more infromation:

Contact Shane Groen (, Director Special Projects, Arizona Coalition to End Homelessness or Nick Margiotta (, President, Crisis System Solutions (Retired Phoenix Police)