Heavy Users of Service

Brief Description

The Heavy Users of Service (HUoS) project is a community collaboration staffed by Boyle Street Community Services and the Edmonton Police Service to support individuals who are most frequently interacting with emergency systems (police, paramedics, emergency rooms, etc). The clientele served often suffer from chronic, interweaving issues such as traumatic histories, mental illness, substance dependence and homelessness and work through a graduated system toward an overall objective of enhanced self-sufficiency. The HUoS uses a multidisciplinary approach in case planning to address the needs of their clients.


The main goals of the HUoS project is to:

  • Connect clients with appropriate supports and services to increase the quality of life for vulnerable individuals;
  • Improve practices and processes in working with partners to accommodate the needs of complex clients and increase justice and medical service providers’ capacity to provide effective and appropriate service; and
  • Address the gaps in service and/or inappropriate service usage for some of the city’s most vulnerable people.


The program targets individuals who are heavy users of services in the Edmonton area. This includes adults who are often:

  • The most frequent users of health, justice, and social services;
  • Involved in social disorder incidents as both victims and offenders;
  • Extremely vulnerable individuals with complex needs;
  • Disproportionately Indigenous and experiencing the intergenerational impact of residential schools, colonization and loss of culture and identity;
  • Mired by a range of mental and physical health issues, addictions, and homelessness, in addition to the long-term impact of fetal alcohol spectrum disorder;
  • Experienced deeply traumatic life events; and
  • For whom systematic barriers and gaps prevent or reduce access to supports, treatment, and programming.

The selection process involves referrals by partner agencies (e.g., Edmonton Police Services), with clients selected based on appropriateness using a number of different measures including: the Vulnerable Person’s Risk Matrix (VPRM), chronically homeless, addictions and/or mental illness. The selection process is facilitated by the case planning table which consists of members from representatives from various partner organizations. 

Core Components

The HUoS aims to reduce crime using collaborative intensive case planning, information sharing and service delivery between 16 partner agencies to provide wrap around supports to Edmonton’s most vulnerable population. Individual case plans are developed by a multi-disciplinary case management team to help identify needs and to bridge gaps in service provision and treatment and are reviewed at regular intervals. The purpose of the case plans are to help clients move forward from cycles of homelessness, health system, and justice involvement. HUoS teams also directly support clients by transporting them to appointments, advocating on their behalf and navigating the next steps of their case plans.

A key feature of HUoS is collaboration to produce positive and creative outcomes, prevent duplication of services, and reduce conflict of resources. HUoS addresses more than the client’s involvement in the Criminal Justice System, by focusing on client needs related to health, housing, income, and cultural supports as well.

Implementation Information

Some of the critical elements for the implementation of this program or initiative include the following:

  • Organizational requirements: Lead organization should ensure proper analysis of community needs and knowledge of other existing services, resources and organizations; Lead organization should be able to manage logistical elements which enable the program to happen; lead organization must have solid skills in outreach intake and assessment, case planning, program delivery, and post-program follow up.
  • Partnerships: The success of the HUoS program depends on its partnerships with Edmonton Police Services (EPS), and 14 other partner organizations including the City of Edmonton, George Spady Centre, Hope Mission, Bissell Centre, Homeward Trust, Boyle McCauley Health Centre, EMS, Alberta Health Services (Mental Health and Addictions, Edmonton Zone Emergency), REACH Edmonton, Alberta Human Services (Family Violence Prevention and Homeless Supports), Alberta Human Services (Employment and Financial Supports), and Bent Arrow Traditional Healing Society.
  • Training and technical assistance: Limited information on this topic.
  • Risk assessment tools: Vulnerable Person’s Risk Matrix (VPRM); Self Sufficiency Matrix (SSM)
  • Materials & resources: Limited information on this topic.

International Endorsements

The most recognized classification systems of evidence-based crime prevention programs have classified this program or initiative as follows:

  • Blueprints for Healthy Youth Development: Not applicable.
  • Crime Solutions/OJJDP Model Program Guide: Not applicable.
  • SAMHSA's National Registry of Evidence-based Programs and Practices: Not applicable.
  • Coalition for Evidence-Based Policy: Not applicable.

Gathering Canadian Knowledge

Canadian Implementation Sites

The HUoS project was implemented in Edmonton, Alberta in 2015 by Boyle Street Community Services and is on-going. Funding from 2017 to 2019 was provided through the Civil Forfeiture Grant, Government of Alberta.

Main Findings from Canadian Outcome Evaluation Studies

An evaluation report was completed for HUoS in 2016 by Three Hive Consulting using a mixed-methods design. The full period of evaluation is unknown.

Main findings from the evaluation study include:

  • Clients showed a 30% decrease in appropriate contact and 85% decrease in inappropriate contacts with police; and
  • Clients also showed a 81% decrease in interactions with City Peace Officers (primarily transit security).

Cost Information

A social return on investment (SROI) was conducted on the HuoS project in 2019. The findings have shown the following:

  • The ratio for HuoS was 3.41:1 , which shows that for every dollar invested in the program, an average of $3.41 in social value was created; and
  • This value is realized by a reduction in the cost of use of services (e.g., visits to the emergency department, EMS transports, inpatient admissions for acute and psychiatric care), interactions with Edmonton Transit Peace Officers and Police Officers (including arrests and incidents of incarceration), and victimization.


Three Hive Consulting. Inc. (2017). Heavy Users of Service: The HUoS Client Journey. [Unpublished report].

For more information on this program, contact:

Boyle Street Community Services

10116-105 Avenue

Edmonton, Alberta, T5H 0K2

Telephone: (780) 424-4106

Website: https://www.boylestreet.org/

Record Entry Date - 2021-09-29
Record Updated On - 2022-01-17
Date modified: