How St. Michael’s Hospital is trying to break the cycle of readmissions for homeless patients

April Aleman, a homeless outreach counsellor at St. Michael’s Hospital in Toronto, tracks the Uber she ordered for her 82-year-old client as it makes its way to a public health building on a quiet street tucked away from the bustle of downtown Toronto. When the vehicle arrives, Aleman unpacks a walker from the trunk and greets the woman with a warm familiarity. She slows her pace to match her client’s as they make their way into the clinic and approach the front desk.

“Hello, we have a dentist appointment,” Aleman tells the receptionist while helping the woman rummage through her purse to find a health card. They sit side-by-side on plastic chairs in a near-empty waiting room, leaning towards each other to complete paperwork on a clipboard.

“Do you have an emergency contact you want to put down?” Aleman asks, pen in hand.

“No, just you people,” her client quips, and they both laugh.

Aleman works at the Navigator Program, which helps steer unhoused people through a health-care system that can be especially challenging for patients without a fixed address or means to advocate for themselves. The program was established to break the cycle of hospital readmission and improve health outcomes.

Aleman’s client said she was admitted to St. Mike’s with COVID-19 in late December. When it was time for her discharge on Christmas Day, she was homeless for the first time in her life. She said a family member she was living with had kicked her out of the house.

The navigators took over her case and found her a shelter bed. In late January, Aleman helped her secure an apartment in a Toronto Community Housing senior’s building.

“Everything I’ve been through … they’ve been there,” said the woman.

Navigator started at Toronto’s St. Michael’s Hospital in 2019, and expanded to Vancouver’s St. Paul’s Hospital in 2023, collectively serving more than 1,000 patients since then.

One of the first clients from the Vancouver hospital was a woman who landed in the emergency department about 26 times in two months.

“Then I started working with her,” said Alex MacKinnon, an outreach navigator at St. Paul’s. MacKinnon said she helped the patient find housing and saw concrete change, despite the ongoing management of chronic illnesses.

Dr. Stephen Hwang created the program at St. Mike’s after examining readmission rates among homeless patients admitted to internal medicine between November 2017 and 2018. He found that 27 per cent of 129 patients returned within 90 days. Roughly a third of participants were readmitted for an identical diagnosis as their initial admission.

A randomized controlled trial is underway to establish whether the program cuts down on return hospital visits. The trial involves 656 people experiencing homelessness.

Hwang said there are already striking indicators that the approach works, such as the fact 67 per cent of Navigator patients who needed a family doctor obtained one through the program.

Navigators bring patients coffee, toothbrushes, and fresh socks when they’re admitted to the hospital.

These small acts help build strong relationships between outreach counsellors and their clients, said Dr. Anita Palepu, an internal medicine physician at St. Paul’s.

The program’s primary goal is to improve health outcomes, but it can also save money and hospital beds by cutting return visits. Hwang said he is working to launch the program at the University of Montreal Hospital Centre later this year and wants to see it in more hospitals across the country.

Long-term, he wants policies and programs to address the root causes of homelessness, including making housing and mental health supports more affordable. But for now, it’s essential to serve those with urgent health problems who end up on the doorstep of the hospital.