St. Michael’s Hospital’s Navigator Program helps homeless patients avoid repeat hospital stays by connecting them to housing, care, and social support.
Program Supporting Vulnerable Patients
At St. Michael’s Hospital in Toronto, a pioneering outreach effort is helping homeless patients navigate a complex health-care system. The Navigator Program, launched in 2019, aims to reduce hospital readmission rates among unhoused individuals by offering tailored, long-term support following discharge. Outreach counsellors like April Aleman guide patients through everything from securing ID to attending dental checkups and finding stable housing.
Urgency Behind the Initiative
The program was created after internal data revealed that 27% of homeless patients admitted to internal medicine at St. Michael’s between 2017 and 2018 were readmitted within 90 days—often for the same health issue. Dr. Stephen Hwang, the program’s founder, said patients frequently return to hospital without a family doctor, shelter, or phone—factors that make long-term recovery nearly impossible.
How the Program Works
Navigator outreach workers provide hands-on support for up to 90 days after a patient’s hospital stay. Each worker handles about 15 patients at a time, helping them access benefits, find housing, and connect with primary care. Services include small but impactful gestures like bringing fresh socks, toothbrushes, or a morning coffee—acts that help build trust and reduce social isolation.
Expanding the Model Nationally
After early success in Toronto, the Navigator Program expanded to Vancouver’s St. Paul’s Hospital in 2023 and will launch later this year at the University of Montreal Hospital Centre. In Vancouver, outreach worker Alex MacKinnon saw dramatic results with one patient who had visited the ER 26 times in two months—until housing and support reduced her emergency visits significantly.
Funding and Community Partnerships
The program in Toronto is funded by the St. Michael’s Hospital Foundation, while the Vancouver pilot is supported by Staples Canada. A randomized controlled trial involving 656 patients is currently underway to assess the program’s long-term effectiveness and potential for wider implementation across Canada.
Challenges Beyond Medicine
While the health care outcomes are promising, program leaders emphasize that many patients face deeper issues than illness—chronic poverty, trauma, and lack of social support. “It’s not just physical poverty. In some cases, it’s deep social poverty,” said Dr. Anita Palepu of St. Paul’s. The goal is for patients to leave the program with a roof over their heads, access to health care, and a renewed sense of stability.
Future of Hospital-Based Outreach
As demand for emergency services grows, initiatives like Navigator offer a model that’s both compassionate and cost-effective. “They just don’t have that relationship with the patient,” said Toronto navigator Fred Ellerington, explaining how hospital staff might miss subtle symptoms that outreach workers recognize. He and Hwang hope Navigator becomes a standard feature in hospitals across the country.
A Bridge to Stability
For patients like Aleman’s 82-year-old client, who was discharged on Christmas Day into homelessness, the program has been life-changing. Now living in a Toronto Community Housing seniors’ unit, she credits Navigator staff for helping her regain independence. “Everything I’ve been through… they’ve been there,” she said. For many, Navigator represents more than care—it’s a path to dignity and hope.
