An ill mother shows up at hospital emergency department. She’s stressed out, working at two part-time jobs to provide for her two children. Doctors find she has a viral infection that doesn’t require a hospital stay and tell her she’s free to go home.

That’s an all-too-familiar scene these days in overcrowded hospitals across Canada.

What normally happens next for such patients, however, may well be about to change in a dramatic way.

Today, the woman would likely be told simply to go home, get some rest and see a doctor in a few days if she continued to feel ill.

But in the future she would meet with a hospital worker before going home to see if she needs any followup help.

Using an iPad or by talking with the hospital worker, the mother would answer a series of questions, such as whether she’s stressed out about her children’s well-being, whether she’s lonely or has challenges buying food or paying her rent.

The next day she would be contacted by a social agency worker who could inform her of services available within her community that could help ease stress at home, such as letting her know of a special subsidy for her children or for housing. Like many people, the mother may not have known about such help because “the system” is too difficult to navigate on her own.

With the help of the hospital and the social agency, as well as from city hall, the patient might be better able to deal with putting food on her table and dealing with her rent, thus reducing the stress that causes her to become rundown and susceptible to illness.

An impossible dream?

Not at all, say experts championing a bold new initiative in downtown Toronto that has the potential of achieving dramatic, high-quality health care for needy patients across Canada.

Ultimately, it could also ease the rates of “hallway medicine” caused by crowded emergency wards.

The plan, known as the Social Medicine Initiative, was launched several weeks ago by the United Way Greater Toronto, the City of Toronto and the University Health Network (UNH), which includes Toronto Western, Toronto General hospitals, Princess Margaret Cancer Centre and Toronto Rehabilitation Institute.

Its goal is to address poverty and homelessness issues faced by many people in downtown Toronto — and in doing so improve their health levels.

It’s a different way of addressing health issues by better integrating social needs to health care.

Health policy experts have known for a long time that social factors are critical in determining the health of individuals. That’s why they are focusing more and more on the social determinants of health, notably income, education, housing, employment, social support networks as well as access to health care.

Bluntly, sick people won’t get better unless they have access to sufficient food, affordable housing, adequate social support and stable jobs.

As proof, the memorandum of understanding signed in August by the three partners cites recent data from UNH that indicates more than 57 per cent of high-needs patients with chronic disease live in low-income neighbourhoods or don’t have stable housing.

The aim of the initiative is to co-ordinate systems so it’s “easier for patients to access the services they need,” thus reducing the number of patients who require higher levels of care and decreasing the burden on the overall health and social services systems.

Driving the partners is the belief that hospital staff can better connect patients with city and social agencies, which in turn can connect people to local services, such as food banks, housing, daycare and community centres.

As if to validate the Toronto initiative, a major U.S. report released last week by a consensus committee of the influential National Academies of Sciences, Engineering and Medicine states that the most effective role for the health-care system is to tackle social needs that affect a community collectively, not just one patient at a time.

While the Toronto initiative is in its infancy, the need for such an ambitious plan is clearly evident. It’s now time to act — and quickly for the sake of all patients, not just our neediest.

Bob Hepburn is a politics columnist based in Toronto.