New Collaboration Focused on Helping Homeless/At-Risk Patients Navigate System Post-Discharge from ED


Ron Dunn - Downtown MissionWindsor Regional Hospital and The Downtown Mission are pleased to announce a new collaboration aimed at addressing the needs of our homeless, those at-risk of homelessness, and those suffering addictions or substance-related challenges – giving them improved guidance to support their own care after Emergency Department treatment.

This project, which involves formal coordination between ED staff and the Mission, will create the new role of “Mission Navigators,” who will be employees of The Downtown Mission through their Phoenix Recovery and Wellness Program.

A Mission staff member will be stationed inside the Emergency Departments who can help guide patients who present to the ED and are given guidance during their treatment as well as at discharge. Our ED and other hospital staff will connect with the Navigators to ensure discharged patients have support in the community and help ensure these individuals are aware of any follow-up care needs that have been arranged.

The position is expected to begin work later this month.

“Too many times individuals are discharged from the hospital with instructions for follow-up care but that follow-up care is missed and the person returns to the ED with exacerbation of their underlying issue,” said Dr. Don Levy, Chief of Emergency Medicine, WRH. “This concept is aimed at helping individuals with non-clinical assistance to help them navigate the system in our community, improve their health and wellness and hopefully prevent returns to the ED based on the same medical issue.”

A Navigator will be on-site, primarily at the Ouellette Campus from 2 pm to 10 pm, five days per week (with alternating weekend coverage) and work closely with a second Navigator stationed at the Downtown Mission offices at 664 Victoria Ave. The Navigator will also attend Met campus when necessary.

Patients who will benefit from this project mainly includes those who identify experiencing homelessness or are at risk of being homeless. The Navigator will engage with the patient– based on consultation with the ED team – to help coordinate housing, clothing and food needs or shelter requirements. For example, if the patient has indicated he/she has no place to sleep that evening, the Navigator can arrange for temporary shelter and other basic needs such as meals.

The Navigator will also provide peer support to patients and help them connect to various recovery and wellness programs at the Mission, such as an addictions recovery program, a women’s support group, the Distress Centre, Windsor Youth Centre programming or other community supports outside of the Mission.

The Navigator would also keep track of patients when they leave the ED doors to remind them of follow-up appointments, or to liaise and contact other community partners who could assist.

Media Release (PDF)