UHN Social Medicine Navigators Evelyn Cheung, left, and Samera Mahamoudare part of a new program that aims to connect nurse practitioners and social medicine workers to vulnerable populations, facilitating long-term access to critical medical services.Sammy Kogan/The Globe and Mail
If a patient misses an important medical appointment, but can’t be contacted to reschedule because they don’t have a phone, standard procedure dictates that a doctor or nurse will write that the individual was “lost to follow up” in their chart.
When a person with diabetes can’t afford their medications or forgets to take them because they are moving around the shelter system, they will often be labelled as “non-compliant.”
It’s a reality that prevents many of the most vulnerable individuals, such as those living in poverty or those without housing, from getting care they need, leading to a cascade of worsening outcomes as a result. It’s one of the reasons why life expectancy for people experiencing homelessness is decades shorter than the average person in Canada.
Now, a program at Toronto’s University Health Network is hoping to break down some of those long-standing access barriers by pairing at-risk individuals with a dedicated team to help them access health care as well as social supports, such as cellphones, government assistance or transportation to appointments.
The new program, created and led by the Gattuso Centre for Social Medicine at UHN, will roll out this summer and will see a nurse practitioner and a social medicine navigator work together to provide support to people with the highest needs. The program will use data from Toronto Western Hospital and Toronto General Hospital to identify the highest users of the system and work to get them help. For instance, people who have visited the emergency room six or more times or who have had two or more hospital readmissions in the past year will be among those targeted by the program.
“What this is about is prioritizing these patients to ensure that we’re bringing different options and opportunities around social needs that are integrating social factors in the way we deliver health care,” said Andrew Boozary, a primary care physician and the Gattuso Centre’s executive director.
Unlike a traditional social worker, the social medicine navigator role is designed to be more flexible, visiting individuals in their homes or shelters and connecting them with a variety of supports, which could include help accessing provincial drug benefits so they can afford medication or accompanying them to medical appointments. The social medicine navigators are already working with patients in the community and this summer, will start working directly in teams with nurse practitioners.
The nurse practitioners will play an integral role, Dr. Boozary said, helping people get medication renewals so they don’t have to go to the emergency department for refills, and a host of other primary care supports at UHN and with other community partners.
Evelyn Cheung, one of the program’s social medicine navigators, said the role is an opportunity to make a difference during some of the most challenging moments in an individual’s life. She recalled the story of a patient who was recently diagnosed with liver disease that advanced quickly, causing her to lose her job and almost get evicted. Because she couldn’t pay her bills, the woman lost access to her cellphone.
Ms. Cheung connected the woman to a local organization that provides financial assistance to people facing eviction who helped her with rent payments so she didn’t lose her home. Unfortunately, her disease continued to progress and the woman died earlier this month.
“These are the types of people that we’re working with,” Ms. Cheung said. “They are high intensity and they need support right away.”
Samera Mahamoud, another social medicine navigator, recently connected with a man living in the shelter system who was once a law student, but dropped out after experiencing racism at the school. Ms. Mahamoud helped the man get access to medical care.
Dr. Boozary notes that the program can’t address many of the challenges in the system, such as the lack of affordable housing, but that this initiative is poised to make a tangible difference for some of most at-risk patients.
“This is not a silver bullet,” he said. “It’s just trying to will different options for people.”