Dr. Stephen Hwang, a general internal medicine doctor and founder of the Navigator Program, is seen at St. Michael's Hospital in Toronto on Friday, May 9, 2025. (Photo: Nathan Denette / The Canadian Press)
In a quiet Toronto neighbourhood, April Aleman, a homeless outreach counsellor, gently guides her 82-year-old client into a public health building. After helping her out of an Uber and unpacking her walker, they head toward the front desk for a dental appointment. The client, who recently faced homelessness for the first time, jokes that Aleman is her only emergency contact. It’s a moment that reflects the trust built through the Navigator Program, an initiative designed to break the painful cycle of hospital readmissions among people without stable housing.
Aleman is part of a small team at St. Michael’s Hospital in Toronto, where the Navigator Program launched in 2019. It aims to support homeless patients who often slip through the cracks of Canada’s health system—patients who are frequently discharged without shelter, a phone, or a health card, only to return sicker within weeks.
The program connects these vulnerable patients to shelters, permanent housing, doctors, and vital services. Aleman’s client had been discharged on Christmas Day after being hospitalized with COVID-19. With nowhere to go, she was on the verge of spending the holiday homeless. But Navigator stepped in, offering her shelter and eventually securing her a spot in a senior housing unit. “They’ve been there through everything,” she said.
The Navigator model has since expanded to Vancouver’s St. Paul’s Hospital. Outreach worker Alex MacKinnon shared the story of a patient who had landed in the ER 26 times in just two months. After MacKinnon began working with her, the woman found housing, received ongoing care for her chronic conditions, and her hospital visits dropped dramatically.
The program's founder, Dr. Stephen Hwang, was moved to act after a study at St. Mike’s showed 27% of homeless patients returned to the hospital within 90 days—often for the same issue. His vision was to offer patients something more: a strong, steady advocate embedded within the hospital system.
Currently, a randomized controlled trial is underway involving 656 participants to measure the program’s effectiveness in reducing hospital readmissions. Early results are promising—67% of participants without a family doctor found one through Navigator.
Each outreach worker supports around 15 patients at a time over 90 days. They provide not only access to health care but also essential items like fresh socks, coffee, and toothbrushes—gestures that help build trust and connection. According to Dr. Anita Palepu from St. Paul’s, many patients suffer not just from physical hardship but from severe isolation and lack of support.
Navigators are also part of the hospital’s medical floor, giving them real-time access to patients’ records and enabling quick action. When one Toronto patient returned to the ER, Navigator Fred Ellerington’s team immediately noticed unusual behaviour and flagged it for further evaluation. That kind of relationship-based care is rare but crucial.
While reducing costs and freeing up hospital beds is a bonus, the program’s core mission remains patient well-being. Hwang is now working to launch Navigator in Montreal and hopes it will expand nationwide. His long-term vision includes deeper changes—more affordable housing and mental health resources. But until then, the goal is clear: help those who need it now.
