Homelessness Navigator pilot at Horizon’s Dr. Everett Chalmers Regional Hospital supports safer transitions from hospital

Embedded navigator helps connect patients with community-based supports while improving patient flow and hospital capacity

(FREDERICTON) – A pilot project at Horizon’s Dr. Everett Chalmers Regional Hospital (DECRH) is helping to improve discharge outcomes for people experiencing homelessness while supporting more efficient patient flow and increasing hospital capacity for patients requiring acute care.

The Homelessness Navigator pilot, developed in collaboration with New Brunswick’s Department of Social Development, launched in September 2025. The project includes a dedicated navigator embedded within DECRH to support people experiencing homelessness who present to the Emergency Department or are admitted to hospital.

The navigator, who is employed by the department and integrated within Horizon’s team at the DECRH, works to address patient needs before discharge, such as identifying safe places to stay and connecting them with supports, to help reduce avoidable hospital readmissions.

“Improving discharge outcomes for people experiencing homelessness will have wider impacts across the health care system,” said Darci Greer, Patient Flow Manager at DECRH. “By strengthening transitions of care, improving access to community-based supports, reducing avoidable hospital readmissions, and optimizing length of stay where appropriate, this role is intended to improve patient flow and increase hospital capacity for acutely ill patients who require inpatient care.”

People experiencing homelessness often face complex health and social challenges that can lead to repeated Emergency Department visits and difficulties transitioning safely out of hospital. Early data from the pilot suggests that individuals referred to the navigator accessed Emergency Department services multiple times, highlighting the importance of coordinated discharge planning and connections to community-based supports.

During the first nine months of the pilot:

• 132 individuals referred to the navigator visited the Emergency Department 256 times
• 93 per cent of those visits involved individuals experiencing chronic homelessness
• 42 patients were admitted to hospital

Early observations suggest the initiative is improving care coordination for people experiencing homelessness. Patients are receiving seamless support throughout their care journey, care teams are collaborating more closely on discharge planning, and individuals are being connected with community services and supports.

Findings from the pilot project will help support decisions about potential adaptation or expansion to other regions within Horizon.

“People experiencing homelessness often require support that extends beyond their immediate medical needs,” said Natalie King, interim Clinical Executive Director of Horizon’s Operations, Patient Flow and Ambulatory Care program. “The Homelessness Navigator role helps bridge that gap by connecting patients with services and supports that contribute to safer transitions from hospital and a more stable path forward.”

The Homelessness Navigator pilot is modelled after a similar program at St. Michael’s Hospital in Toronto. Officials from St. Michael’s Hospital visited the DECRH earlier this year to share insights from their program and explore opportunities to further adapt the model to meet the needs of the Fredericton region. The visit reinforced the value of integrating housing and social supports into discharge planning and provided an opportunity to share lessons learned from the Fredericton pilot.

“Everyone deserves the opportunity to leave the hospital with dignity, hope, and a clear path to recovery,” said Social Development Minister Cindy Miles. “This partnership with Horizon demonstrates how collaboration between health care and social services is creating stronger connections to community supports and improving outcomes for New Brunswickers experiencing homelessness.”

This work supports Horizon’s 2025–2030 Strategic Plan commitment to excellence in hospital care by improving access to care and helping ensure patients receive the right care at the right time through more efficient use of resources.

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