Hospital & Community Care Navigator

Bridging hospital care and community support

The Hospital & Community Care Program supports individuals experiencing homelessness, instability, or complex health and social challenges who may need additional coordination beyond medical care.

Who This Program Supports

This program is designed for patients who may experience barriers navigating the healthcare system, including:

• Individuals experiencing homelessness or unstable housing

• High-risk patients connected to community clinics

• Patients with complex health and social needs

• Individuals struggling with substance use or recovery

• Frequent Emergency Department visitors

• Patients without safe discharge options

Our goal is to ensure patients leave the hospital connected to appropriate support rather than returning to crisis.

When to Contact the Program

Please consider contacting the Hospital & Community Care Program when a patient:

• Does not have safe housing to return to

• Requires coordination with community services

• Needs support navigating healthcare or follow-up care

• Is connected to outreach, recovery, or housing programs

• Would benefit from advocacy and care coordination

• May otherwise discharge to homelessness or instability

Early collaboration helps support safe and effective discharge planning.

What We Do

Hospital Liaison Support

• Advocate for patients experiencing homelessness or marginalization

• Work with hospital teams during admission and discharge planning

• Coordinate communication with community providers

Care Coordination

• Connect patients with housing, outreach, recovery programs, and health services

• Coordinate with clinics, outreach teams, and social supports

• Ensure continuity of care following discharge

Stabilization Support

• Help identify safe places for recovery and stabilization

• Prevent discharge back to unsafe environments whenever possible

Why This Program Matters

Patients experiencing homelessness or instability often return to Emergency Departments because they lack:

• Safe places to recover

• Coordinated follow-up support

• Access to housing or stabilization services

By bridging hospital and community care, this program helps:

✔ Improve patient outcomes

✔ Reduce repeated Emergency visits

✔ Support recovery and stabilization

✔ Strengthen coordination across systems

Referrals

Staff can contact the program directly for consultation or referral to the following email:

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healthsupport@awaccommunityservices.org

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