
Housing and hope
How a community resource worker at Providence helps patients thrive after a hospital stay
STORY AND PHOTOS BY KATIE COOPER
Most people view their time in the hospital as a brief interruption from home, expecting to return to their regular lives with little disruption. However, for some patients, this isn’t the case. They may be unable to return to their previous residence due to new medical conditions or specific accommodation needs. In some instances, they never had a home to return to at all.
For this population, leaving the hospital can be a daunting experience, marked by significant life changes and uncertainty – especially when they lack a support system of family or friends. This is where Community Resource Worker Cristina Pascual steps in. Her work at Unity Health Toronto begins when patients are ready to move beyond the hospital and re-enter the community.

“Social Workers are the primary discharge planners, but when an alternate discharge location needs to be explored they get me involved,” she says of her position at Providence Healthcare, where they specialize in senior’s care, rehabilitation, palliative and long-term care.
The majority of Pascual’s patients are identified from social workers directly on the units – stroke/neurology, geriatric, orthopedic/amputee, transitional care, or palliative care. She also works closely with the Alternate Level of Care (ALC) team to facilitate transition plans for patients occupying a bed that no longer need the level of care the hospital provides.
“You’ve got patients who may have been living on their own and now they’re not able to either because it’s no longer an accessible unit for them or their care needs are fairly high and they can’t live independently,” Pascual says, adding she helps those patients navigate a variety of housing options including group and boarding homes, supportive housing, retirement homes and long-term care facilities.

For the patients that Pascual assists, there are often several barriers to finding them housing. Some have no IDs or expired health cards, and proof of status in Canada is required to apply for subsidized or government funded housing.
“They need a bank card to provide proof of bank statements and they need their income tax done because they are always asked for a notice of assessment,” she says. “A lot of these folks don’t have any of those documents.”
While three quarters of her role focuses on helping patients secure appropriate housing after leaving the hospital, the other part is dedicated to ensuring they have access to vital community resources and stable sources of income – as a roof over their head is just the beginning of what they need to flourish.

Doug, in his 70s, has spent the last year in and out of hospitals, currently receiving care at Providence. He was previously in the shelter system for over a decade. Pascual first crossed paths with him when he needed assistance obtaining a photo ID and bank account while waiting for a spot in long-term care.
“When I came to Providence, I couldn’t even get out of bed. I got that weak,” he says. Among other serious health issues, Doug shared that he has a shattered hip and chronic obstructive pulmonary disease (COPD). “They thought I would need oxygen 24/7,” he says.
‘I would be lost without her. It takes a lot off my mind knowing that somebody actually cares.’
Through regular exercises with an occupational therapist and physiotherapist, Doug’s physical strength improved to the point where he was able to get out of bed and use the bathroom unassisted. He also weaned himself off the oxygen tank.
“They’ve always been good to me,” he says about the staff. “It’s a good place with good people. They gave me a chance.”

As Doug’s condition improved and he became more independent, the Ontario Health At Home care coordinator, along with the hospital team, reassessed his situation and determined that community living would be a better fit. Pascual’s initial search for housing proved difficult, as options that met Doug’s needs – wheelchair accessible and affordable for a fixed income – were scarce.
Then an opportunity popped up in a senior’s affordable housing building that was barrier-free and offered recreational programming. Pascual accompanied him to view the accessible unit and he was accepted.
“I would say it’s a nice place,” says Doug. “There are things to do and the stores are close by.”

When it came time to sign the lease, Unity Health Toronto Occupational Therapist Cheryl Tanaka took the opportunity to have Doug practice using Wheel-Trans, the city’s paratransit service for people with disabilities. Pascual joined Doug on the journey to review the kitchen setup and ensure he could access the stove from his wheelchair. Although the unit is accessible, there are additional aides Doug will need – like bed rails and a shower chair – that Tanaka is helping to source.
“Everything that I own or will own has to have a purpose. And it’s gotta be in a spot where it’s functional,” says Doug. “And being in a wheelchair, to make my bed, I gotta be able to go around all sides.”
Besides securing the apartment, Pascual collaborates with social worker Celia Schwartz in setting up a Personal Support Worker (PSW), case management, and connecting Doug with a family doctor nearby. “With my health, I have to worry about medical stuff like my meds,” says Doug. “They’re setting all of that up, otherwise I’d be screwed. I would have to go to the hospital to get my prescriptions filled.” Pascual will also check in with Doug a few days after he moves in to ensure that the community supports and services the team has put in place are connecting with him directly.
“He’s not going to be alone,” she says. “But I’m not going to have that comfort until I know that he’s settled in his new home and that he’s thriving.”
When asked if he is looking forward to some privacy in his own place, Doug says “You know what, I’m going to say something really silly. I’m going to miss the people at Providence, the nurses. Outside of an occasional visitor, that’s who I talk to everyday.”

Pascual’s work in supporting individuals who are underhoused or experiencing homelessness is embedded in a broader network of 164 Social Workers across Unity Health. When asked if there should be more roles like hers, Doug replies without hesitation.
“Yes, absolutely. What she does is very important. When you leave a hospital there’s so much to set up and Cristina knows how to access programs that we don’t.” Doug mentions that he is old fashioned and not very good with technology.
“The population is aging. Us old folks aren’t going anywhere, we’re going to keep coming,” he adds. “I would be lost without her. It takes a lot off my mind knowing that somebody actually cares.”

Pascual has been at Providence Healthcare for the past six years. She has a background in gerontology and sociology and formerly worked in the community for 19 years in assisted living management. In that role, she was no stranger to the health centre. “I was sort of the middle person with my previous organization and Providence, helping to move some of their ALC patients back to the community.”
Despite the challenges with the health care system and not being able to support everyone in need of appropriate housing, Pascual says that sometimes it’s all about timing. “I will hear from one of my external partners that they have a vacancy and I jump on it right away, I’m like, ‘Yes! I have someone for you!’”

Among the cards and photos displayed along the window ledge of Pascul’s office sits a marble-carved walrus, a souvenir from Nunavut given to her by a patient she helped secure housing for. “Every time I see that I’m reminded of her, she’s just a lovely lady,” she says. “It really warms my heart every time she reaches out to tell me that she is doing really well. To me that’s a success. That’s why I love my job.”