What We Do

We aim to serve people living in Hamilton who have no continuous primary care provider, who are homeless or marginally housed and who have complex health and social needs.

Our clients are individuals who reside in or have contact with specific agencies that provide shelter. Typically the individuals who use these services are experiencing absolute or relative homelessness. This includes those who are literally living on the streets or in shelters, in addition to those who face eviction and lack the resources to obtain alternate housing and those who live in housing that is considered substandard (usually referred to as ‘relative’ homelessness).

We bring health care and shelter together by providing health care within transitional housing programs. Case managers, social workers, nurses, family physicians and psychiatrists provide services to clients within shelters and other types of transitional housing. We help people move easily from acute care hospitals or from living on the street to within our shelters. When their lives have become more stable, we help them to receive ongoing health care from community family physicians. We strive to make the connection between hospitals and community seamless.



Our Goals:

  • Improve health, social stability and quality of life.
  • Decrease emergency department visits.
  • Decrease length of stay on inpatient wards.
  • Provide inter-professional health education learning environment for health and social service professionals.
  • Strengthen ‘bridges’ between acute health care, primary health care, social housing programs and social service agencies.
  • Always be open to new patients in need of our services by linking more stable clients with community family physicians.

We are addressing the needs of this population by coordinating and integrating the action that many organizations are already taking and enhancing this action with some key primary care roles in case management, nursing and family medicine. We have a strong focus on primary care, mental health and addictions treatment, along with chronic care and preventive health services.