Navigator Program for Homeless Adults

Recruiting in Palo Alto (17 mi)

Overseen byStephen W Hwang, MD, MPH

Age: 18+

Sex: Any

Travel: May Be Covered

Time Reimbursement: Varies

Trial Phase: Academic

Recruiting

Sponsor: Unity Health Toronto

No Placebo Group

Trial Summary

What is the purpose of this trial?

This trial tests the Navigator program, which helps homeless individuals manage their healthcare and social needs after leaving the hospital. It aims to reduce hospital visits and improve overall health over several months.

Eligibility Criteria

This trial is for adults over 18 who are homeless at the time of an unplanned hospital admission. It includes those without shelter, in emergency shelters, or in temporary housing. Participants must not have used Homeless Outreach services within 90 days and must be able to consent to the study.

Inclusion Criteria

I am 18 years old or older.

Identified as being homeless at the time of admission or anytime during the index hospital admission. This includes patients who are: unsheltered (absolutely homeless and living on the streets or in places not intended for human habitation), emergency sheltered (staying in overnight shelters for people who are homeless, as well as shelters for those impacted by family violence), or provisionally accommodated (whose accommodation is temporary or lacks security of tenure).

I was unexpectedly admitted to the hospital for a medical reason.

Exclusion Criteria

I have been helped by a Homeless Outreach Counsellor in the last 3 months.

I am unable to understand and agree to the study's details on my own.

Treatment Details

Interventions

Navigator Program (Behavioural Intervention)

Trial OverviewThe Navigator Program is being tested as a case management intervention for homeless individuals after hospital discharge. The trial will track follow-up with primary care, re-hospitalization rates, quality of care transitions, and overall health over six months.

Participant Groups

2Treatment groups

Experimental Treatment

Active Control

Group I: Navigator ProgramExperimental Treatment1 Intervention

In addition to receiving Standard Care, participants in the intervention arm will be assigned to a Homeless Outreach Counsellor. The Homeless Outreach Counsellor will connect with the participant as soon as possible during the admission and will provide support during the hospital admission and for approximately 90 days after hospital discharge.

Group II: Standard CareActive Control1 Intervention

Standard Care consists of support from Care Transition Facilitators who work with patients during their hospital stay to arrange discharge plans and make follow-up arrangements. Care Transition Facilitators do not routinely work with patients after hospital discharge. As part of the routine discharge process, the health care team provides patients with medical recommendations, appointments for follow-up care as needed, a written discharge summary, and prescriptions as needed. If the patient has an identified primary care provider, a copy of the discharge summary is sent electronically to the primary care provider.