Ontario’s homelessness crisis hit staggering record levels last year, with more than 80,000 people experiencing homelessness. Civic leaders in Toronto are looking to address this urgent crisis directly. They are helping lead the way in productive supportive housing projects that incorporate services including medical care, mental health resources and food pantry programs. These initiatives are helping to reduce the revolving door of hospital readmissions and in doing so, improve the quality of life for this vulnerable population.
St. Michael’s Hospital has chaired and facilitated these initiatives since their inception in 2019. That’s when Dr. Stephen Hwang first brought the Navigator Program to life. As innovative as this program is, it’s actually designed to meet the emerging healthcare needs of this homeless patient population. It provides them wraparound support through connecting them with stable, long-term housing, a family physician, and government benefits.
To our wonderful Navigator Program supporters— we’ve gone national! In 2023, it added a new branch at St. Paul’s Hospital in Vancouver. Since its launch, this program has provided care for more than 1,000 patients. Its work with vulnerable populations goes beyond the Mid-Atlantic.
Dr. Hwang’s research has shown that housing is the biggest challenge facing the homeless. A previous study of 129 homeless patients found a 27% 90-day readmission rate. This alarming statistic highlights the critical importance of developing impactful resources and support systems designed specifically for this young, diverse demographic.
April Aleman, in Toronto She works as a homeless outreach counsellor at St. Michael’s Hospital. She’s an important part of the process that gets patients connected to the resources they need and making sure they’re getting follow-up care. Aleman often checks in with her clients to confirm appointments and gather necessary information, asking questions like, “Do you have an emergency contact you want to put down?”
The Navigator Program’s success is shown in the program’s outcomes. Based on data from the last year, that has led to 67% of patients needing a family doctor finding one all thanks to the program. Navigators typically work with about 15 patients at a time for approximately 90 days, focusing on individualized care that addresses each patient’s unique circumstances.
Fred Ellerington, a navigator in Toronto, helps patients entirely with the transitional care issue – specifically preventing hospital readmissions. His work is foundational to equipping patients with the tools they need to get the care they deserve. This continued support enables them to stay in good health away from a healthcare facility.
Dr. Anita Palepu, an internal medicine physician at St. Paul’s Hospital, hopes people will understand the issue is more nuanced when it comes to homelessness. She states, “It’s not just a physical poverty. In some cases, it’s deep social poverty and isolation.” This critical understanding provides a glimpse into the complicated reality of homelessness. It highlights the extreme importance of bridging complex support systems that address medical and social needs.
The need for these efforts has been highlighted by an alarming, new and tragic statistic. At the time of writing in late June 2024, 135 unhoused Torontonians had died since the beginning of the year. This heartbreaking number underscores the immediate need for improved systems and policies to combat homelessness. The data the city released paints an unrelenting portrait of the destructive toll that homelessness exacts. This new information highlights the need for targeted resources to better serve this vulnerable population.
St. Paul’s Hospital outreach navigator Alex MacKinnon is out every day doing the work to confront these realities. Above all, he looks back on his most rewarding experiences—forming deep connections with patients. He recalls, “But then I began to work with her. It focuses on one extraordinary example that illustrates just how profoundly navigators can change their clients’ lives.
