Pathway2Care: Integrated Outreach
Enhancing care transitions for those experiencing houselessness through improved communication and cross-sector collaboration
Introduction/Background
Through collaborative partnerships across multiple sectors, an Enhanced Navigation Resource Team was established to provide person-centred care for those experiencing houselessness. With support from the Chatham-Kent Ontario Health Team (CKOHT), this pilot addresses increased healthcare utilization and bridges communication gaps between health and social services. By adopting a unified approach to care provision, particularly for community members experiencing houselessness, this pilot aims to empower communities in overcoming systemic barriers to health equity and inclusivity.
Approach/Methods
Population Health Approach:
Local partners raised concerns about the growing population of individuals experiencing houselessness in Chatham-Kent, highlighting significant health and mental health challenges, the cycle of houselessness and hospital visits, the inability to follow treatment plans after discharge, barriers in communication between the housing and healthcare sector, and the increased strain that this places on healthcare and housing services. These discussions led to the formation of the Pathway2Care (P2C) Team, with a primary objective of improving the health and wellbeing of individuals experiencing houselessness. By addressing health inequities and tackling the root causes of illness, the P2C team focuses on delivering comprehensive support to this vulnerable population in Chatham-Kent.
The CKOHT and its partners have embraced a population health approach, recognizing that health and wellbeing are influenced by various interconnected factors beyond medical care. Segmenting the population by material deprivation and system utilization, we were able to learn more about this population from different perspectives.
Since 2019, the number of individuals experiencing houselessness has increased by 171%. The affordable housing crisis has intensified, with waitlists at an all-time high, leaving many without stable shelter. Many individuals cycling through emergency rooms and social services are unable to secure permanent housing, leading to worsening health outcomes and increased system strain.
In September 2023, a mapping session with community partners was held to examine the current state of the patient journey from hospital to community. This session revealed a significant gap in services available to individuals experiencing houselessness and their complex needs, leaving few options for them to access the care they require.
With this information, it was decided to focus on those at the top of the pyramid and considered to be the highest risk, which was defined as adults 16 and over experiencing houselessness with frequent hospital visits.
Alignment with OH Social Determinants of Health Framework:
Ontario Health’s Social Determinants of Health Framework was utilized as a tool to shift the focus from managing illness to promoting overall wellness. The P2C pilot seeks to break down the silos between health and social services, fostering an integrated approach that leverages existing resources and partner expertise to collectively address community needs.
Early exploratory work highlighted the importance of building a trusting relationship between the P2C Team and community members, recognizing that meeting people where they are at (both physically and mentally) and empowering them to take a lead in their care are crucial to the pilot’s success.
Furthermore, this pilot has redefined traditional power dynamics by positioning community partners as key leaders, leveraging their trusted relationships and deep understanding of the population. By involving individuals with lived experience to provide local insights, and drawing upon successful case studies, the pilot ensures that leadership and decision-making are rooted in community expertise. Through this collaboration, the outreach team was developed and their roles were specifically tailored to address the unique needs of vulnerable community members. The P2C Team—comprising a Community Paramedic, Housing Stability Worker, and Peer-2-Peer Leader—operates with in-kind support from partner organizations to pilot this innovative approach.
Continuous Quality Improvement
The P2C team incorporates continuous learning and improvement through Plan-Do-Study-Act (PDSA) cycles to refine both outreach efforts and the hospital discharge process.
For the outreach sessions at R.O.C.K and Hope Haven, the team regularly assesses service delivery and data collection to improve engagement with community members experiencing houselessness. Recent adjustments include optimizing the physical setup to ensure privacy, enhancing data collection forms with user feedback scales, and formalizing documentation through the Homeless Individuals and Families Information System (HIFIS). Feedback from these sessions is analyzed to identify areas for improvement, such as the effectiveness of support services and the number of emergency department diversions.
In the hospital discharge process, PDSA cycles will be applied to streamline transitions from hospital to community. The team will evaluate each step of discharge—Referral and consent, patient handover, initial care (P2C Team) coordination, and follow-up care—to ensure individuals receive continuous support. With a plan to track key metrics like readmission rates and patient satisfaction, the team will be able to make ongoing adjustments to better address the complex needs of individuals experiencing houselessness.
Collaborative Partnerships: Multi-Sector Appraoch, Community-Driven Design
Through strong partnerships with healthcare providers, social services, and community organizations, Chatham-Kent has demonstrated high levels of commitment and motivation to improving the health and wellbeing of this target population. This has been integral in being able to progress forward and developing the P2CTeam despite not having additional funding.
The Pathway2Care Team consists of:
- Community Paramedic: Provides medical treatments and diagnostics, including wound care, intravenous therapy, and monitoring of vital signs.
- Housing Stability Worker: Supporting housing stability and helping individuals transition from temporary accommodations to more permanent housing solutions.
- Peer-2-Peer Leader: Peer leaders play a crucial role by building trust through shared lived experiences, advocating for individuals’ needs, guiding them through complex services, and providing outreach and harm reduction support.
Integrated Care Approach
The P2C Team follows a coordinated care model, including joint bedside visits or introductions prior to hospital discharge. With consent, P2C team members meet with the community member and receive information together, reducing the need for the individual to retell their story multiple times. This approach fosters trust between the team and the community member, while streamlining communication and reducing stress during the transition back into the community.
Pilot Objectives
- Improve the health and wellbeing of individuals experiencing houselessness by addresses both health and social issues through a holistic and person-centred approach
- Enhance care transitions from hospital to community for adults experiencing houselessness
- Increase access to the appropriate level of community-based health and social care for adults experiencing houselessness
- Enhance patient navigation by improving cross-sector communication and service coordination
Pilot Activities
1) Outreach Sessions at ROCK
- Weekly Outreach Sessions are held at Reach Out Chatham-Kent (R.O.C.K) and Hope Haven during their regular drop-in times. R.O.C.K Peer-2-Peer Leaders, a Community Paramedic, and the Housing Stability Worker are all in attendance to provide care and navigation to anyone who attends. The aim of these outreach sessions is to initiate relationship building and bolster trust between the P2C Team and the target population. It has also presented an opportunity to address any health or social determinants of health needs.
2) Hospital Discharge for In-Patient Units at Chatham-Kent Health Alliance (CKHA)
- The P2C Team plays a crucial role in facilitating hospital discharges for patients experiencing houselessness as they transition back into the community. The team’s support includes meeting with patients while they are still in the hospital, coordinating their discharge needs—such as arranging transportation, securing medications, and addressing immediate concerns—and providing follow-up care once they transition back into the community. Ongoing navigation and support are offered to ensure these individuals receive continuous care, helping them access essential health and social services and avoid unnecessary readmissions.
Outcomes/Impact
This innovative initiative has shown how collaboration between health and social sector partners can effectively address the needs of our community. The pilot will be evaluated using the Quintuple Aim Framework, which aims to measure patient outcomes, patient experience, provider experience, system costs, and equity.
Early successes
Clinical Stats
(As of 03/20/2025)
- # Clinics held: 44
- # Individuals Assessed: 153
- # Individuals Unattached to PCP: 71
- # Referrals Direct/Indirect Referrals: 24
- # of ED Avoidance: 27
- # 911 Activations: 4
- # of Unhoused Clients: 82
- # Wound Care Assessments: 25
Hospital Discharge Referral Stats
(As of 03/20/2025)
- # of Clients Referred to P2C: 29
- # of Clients Discharged from P2C: 5
- # In-Person Visits with P2C Clients: 102
- # of Admin Tasks: 38
- # of Referrals to Other Agencies: 18
- # P2C Clients who Consented to all 3 Agencies: 20
A comparison of data for the three months before the implementation of the P2C team versus the six months following its introduction shows a 73% reduction in paramedic call volume with clients being cared for in this program.
Challenges & Lessons Learned
Through the development of this work and initial stages of implementation, the team has experienced several challenges and lessons learned.
Challenges:
- No funding for project: Each partner is currently contributing in-kind resources to help plan, implement and operationalize the P2C Team. The ongoing challenge is confirming sustainability and growth of this team. Evaluation and capturing the needs of this sub-population is important to help demonstrate the ongoing need for this Team.
- Capacity of Partners: Without funding available to do this work, partners are having to work on this project without increased capacities. Further funding will be essential for scaling and expanding the team to meet growing needs effectively.
Lessons Learned:
- Trust with the Target Population: Trust is a key enabler for success between patient population and partners. Shifting the power dynamic to the patients
- Collaboration amongst partners from different sectors: Decreasing the silos between partners from different sectors (ie Health, Housing, and Non-Profit Outreach) to serve a common population has been integral to the success of this work and a key to successfully employ the SDoH Framework. Historically, there have been numerous attempts in the past to work across sectors, but they have not been successful. The CKOHT was an important catalyst to connecting the right partners, at the right time to conduct this work!
Next Steps & Future Directions: What’s next for the Pathway2Care Team?
- Measuring Success & Completing a Developmental Evaluation: To achieve the above, the immediate next steps are to conduct an evaluation that will support a positive business case, improve outcomes for the targeted patient population, and to continuously learn more about the patient population needs.
- Exploring funding options and opportunities: Securing funding will enable confidence in the longevity of operations and increase the success of the P2C Team.
- Enhancing Communication via Technology: The team will enable seamless communication between members by incorporating technology solutions. (Secure team communication, cross-sector longitudinal record of community members)
- Scaling the initiative: The implications of the results from this pilot will guide the focus on team expansion and scaling, including having more referral sources, such as the ED and in the community. Additionally, utilizing the population health approach, it would be beneficial to work lower down in the population health pyramid and shifting the focus to prevention. Lastly, the initiative can also be scaled to include youth.
- Opportunities for expanding collaborative partnerships: Current needs are high in the community and based on current data, we are only aware of some of the more prevalent needs of this population. As the P2C team matures, we expect to have a better understanding of this patient population, which will provide focus to expanding collaborative partnerships within the community.
Conclusion: Partners & Contributors, How to Learn More & Resources
Collaborative Partners & Contributors
