From Providence Health Care’s The Daily Scan

For many patients, being discharged from the hospital is a welcome event that means a return to the comfort and stability of home. But what happens when a patient doesn’t have a home to go to?

“Anyone who’s worked with unhoused populations knows the challenges that come with follow-up care post discharge,” says St. Paul’s Hospital Medicine Outreach Social Worker Alexandra Mackinnon. “Navigating the health care system becomes exponentially more challenging when you’re unhoused, have few supports, and have no way of being contacted.”

A new pilot program at St. Paul’s aims to improve the hospital experience and post-discharge health and social outcomes for people experiencing homelessness. Funded by Staples, the Navigator Program launched in September 2023 and is modelled after a similar program at St. Michael’s Hospital in Toronto.

Meeting people where they’re at

As the program social worker, Mackinnon splits her time between the hospital and the community. She works closely with patients before and after discharge, then provides a warm hand-off to community case managers and other service providers.

“I meet people where they’re at in hospital, assess their needs and follow them for 90 days after discharge,” she explains. “This could involve attending follow-up appointments, connecting them to primary care, advocating for more supportive housing – and anything in between.”

The program recognizes that, compared to the general population, patients experiencing homelessness often have sub-optimal hospital experiences, are more likely to self-discharge, have higher readmission rates, and face unique struggles in following discharge plans.

“Having an outreach worker embedded in the hospital is beneficial because we have access to medical records and can bridge the gap in collaboration with community partners to get people the care that they need,” Mackinnon says.

She’s hopeful the pilot program expands and become a permanent fixture.