National Nurses Week: On The Front line of Care for Those Without A Home

When Cedric was released from the hospital following a 6-month stay due to major surgery and complications, he needed a place to recover and set all of his follow-up care appointments. Cedric was without a home at the time.

Denise McDaniel with Jorge at Pathway Recuperative Care

At National Health Foundation’s Pathway Recuperative Care program, Cedric found a place to recover from his health issues and more; Denise McDaniel, LVN, the Medical Coordinator at Pathway Recuperative Care’s Los Angeles location, treated him with love and kindness.

“At Pathway Recuperative Care, our nursing staff provides medical oversight which means we keep a close watch on their health to ensure they are healing appropriately and that all of their follow-up medical appointments are set and met,” shared Kelly Bruno, President and CEO of National Health Foundation (NHF), “more importantly, we care. We care deeply that our clients have an interruption in homelessness and if this triggers a desire to be connected with services to find their way into a permanent and stable housing situation, we walk that journey with them as well. But it is our exceptional nursing staff that is on the front line of delivering that life-changing care.”

For Denise and her counterpart at Pathway Recuperative Care’s San Gabriel Valley location, Tammy Grimes, LVN, a typical day involves caring for numerous clients while working with social workers and support staff as stable housing is secured.

“I get so excited when we have arranged for housing for a client. It gives them the opportunity to focus on something other than where they will lay their head each night,” shared Tammy. For Denise, the joy of seeing the smile on an individual’s face when they receive housing is the favorite part of her job.

Working with individuals who are without a home has brought Denise and Tammy face to face with the most common misconceptions about this population, “I see people fearing those without a home and that is something I would love to change,” shared Denise. For Tammy, the notion that everyone who is without a home is on drugs or alcohol is far from the truth, “ The truth is everyone has a story and they are all different.”

Denise is inspired by her clients’ tenacity, “I’m always humbled by the people I work with. They are willing to try and start over from scratch.” Tammy’s thoughts turn to the fundamental need for housing, “Living conditions make treating and coping with health issues more difficult. Health cannot be a priority if the individual is focused on their safety and where they will sleep at night. Mortality is higher living on the street.” Both nurses have one wish for their clients: Stable housing in a community that is safe and loving.

For Bruno, having exceptional staff working with clients has raised the bar of what compassionate care looks like, “On behalf of all of us at NHF, I salute our nurses and thank them for delivering far more than health. Through their compassion, strength and the love for what they do, they deliver a deep caring that is life-changing and inspiring to us all.”

Pathway Recuperative Care: Caring and Connecting

Cedric has been homeless for 6 months and has spent nearly half of that time in the Hospital. A liver transplant and a subsequent bout with pneumonia left the young man weakened and in need of care that extended well beyond his hospital stay. Through a partnership with National Health Foundation (NHF) and a local hospital, Cedric was able to receive continued care at NHF’s Pathway Recuperative Care.

Like many individuals who have undergone major surgery, Cedric had countless follow-up appointments he needed to make and manage. For individuals who have a home and resources such as a car and family support, such care is challenging, but manageable. For individuals without a home, the demands of post-operative care are rarely met and subsequent hospitalizations are frequently necessary.

With the help of staff at Pathway Recuperative Care, Cedric attended all of his appointments and his health has taken a turn for the better. His strength returning, the staff then turned their attention to connecting Cedric with all of the resources available to him and to finding a permanent and stable housing situation.  “The concept behind Pathway Recuperative Care is to provide care to the whole person,” shared Shakoya Green, Pathway Recuperative Care Program Director. “First we provide a safe and comfortable temporary home with medical oversight so that the patient may heal physically. Then we look at the situation that led to the individual losing their home and their health. By addressing the social determinants of health that challenged the individual, we can arrive at a path to health.” For Cedric, there was a need to connect him with the Department of Public Social Services to apply for financial benefits. Then staff worked with Cedric to secure a permanent home. He was connected with his birth mother in New Jersey who flew to Los Angeles to bring her son home.

When asked how he felt about his nearly 2-month stay at Pathway Recuperative Care Cedric responded, “ I am feeling incredibly blessed to have been at Pathway. After being in the hospital as long as I have, it was nice to reconnect with people. After getting a liver transplant I feel like I got a second chance and Pathway helped me on my way.” Green added, “Pathway Recuperative Care demonstrates and puts into action the idea that home is health. Without a ‘home’, a person cannot thrive and be healthy. We are so pleased that we were able to connect Cedric with his family and walk with him on this part of his journey.”

At The Intersection of Health and Education: National Health Foundation’s Be A STAR Program

National research has identified a significant link between education and health. High school graduates live longer, healthier lives than dropouts. College graduates have even longer life spans, better access to health care, better dietary and health practices, and overall better health. Unfortunately, about a quarter of California counties have high school dropout rates close to 20 percent or more, including Los Angeles at 17 percent. While there are numerous factors contributing to the dropout rate, one third of female dropouts say that pregnancy or becoming a parent played a role in their decision to leave school. Girls most at risk for teen pregnancy are Latinas from low income communities. There is critical need for education and support services to reach these adolescent girls at the greatest risk for pregnancy and subsequent dropout before they get pregnant, ultimately breaking the cycle of teenage pregnancy. 

With this information, National Health Foundation has implemented the Go Harold’s Way; Be a STAR (Successful Teens Acting Responsibly) Girls Program. Goals of this program include reducing the incidence of pregnancy, improving high school graduation/completion and connecting participants to health and social services and resources in their community. Since its implementation, NHF has provided more than 700 students with the tools and education they need to prevent unwanted pregnancies and abilities to make healthy life choices. 

Haydee and Yvonne are two participants of the Be a STAR Girls program at Ramona High School and are set to graduate in 2018. For Haydee, the program gave her key information she did not have access to beforehand, “I learned there’s many ways to prevent pregnancy and learned all the parts of the female anatomy and what they do. I feel confident about my reproductive health because I’m more informed about different topics that we learned in class.” The weekly topics touched on birth control and STDs as well as how to plan for the future. Yvonne admitted that before being in the program, ‘ditching school’ was a chronic issue. “Before coming to Ramona I was ditching a lot of school and now I come to class every day and will graduate next year. My plans after graduating school are to get a job and go to community college to help me have a career later in life.” In addition to committing to her future, Yvonne has a deeper appreciation for her body and her health, “In the Be a STAR class we got to talk about our physical bodies and how a woman’s body looks on the inside. We also lean to be more confident about our bodies. I now know how to protect myself from getting an STD.”When not in school Yvonne enjoys playing basketball with friends while Haydee likes to try new things. Both students have expressed that this program has given them the confidence to be able to make healthy decisions when it comes to their reproductive health. After graduation, both Haydee and Yvonne plan to attend community college laying the path for their future careers.

                                               

#SocialWorkMonth Profile: Sharonda Bazzell- O’balles, MSW, White Memorial Medical Center

Sharonda recalls the story of Robert who was in need of extra healing time after a hospital stay but who had also expressed an interest in conquering his substance abuse issues. As an individual who was without a home, Sharonda knew her patient could qualify for recuperative care, but would that be enough to keep him healthy and safe until room became available at a substance abuse program?

As a social worker at White Memorial Medical Center, Sharonda is one of the point people who, at the end of a patient’s stay in the hospital, sees to it that they are safely discharged. When a patient is discharged and they do not have a home to return to, Sharonda finds alternative solutions based on the patient’s most pressing needs. Some times the needs and the available services do not synch. Robert was a candidate for recuperative care and for the substance abuse program, but there was a significant gap between when his stay in recuperative care would end and the substance abuse program could take him in. The risk Robert was facing was a return to the streets and possibly missing the opportunity for the rehabilitation that he wanted to receive.

As a National Health Foundation Pathway Recuperative Care hospital partner, White Memorial Medical Center works hand in hand with Pathway staff to ensure the best possible outcomes for each client. For Robert, Pathway staff advocated on his behalf and they were able to secure additional time for him to stay at Pathway until a space became available for him at the substance abuse program.

Sharonda has found that many of her patients are not connected to the resources available, “The hospital routinely serves patients that have recently travelled to LA and are unfamiliar with the systems and how to access resources. I assist them by connecting them to the resources they need upon discharge.”  Navigating the many programs and options has given Sharonda a unique perspective on working with this vulnerable population, “ While it gives me comfort knowing that in recuperative care they are continuing to receive assistance during this moment in their lives, I would like to see an ongoing collaboration of agencies working together to close the gap in services and needs of our homeless population.”

Robert’s story is one with a happy ending. He recently completed his 90-day rehabilitation program.

Access to Fresh Foods is Taking Root in Historic South Los Angeles

March is National Nutrition Month. It is also the month that National Health Foundation is beginning to offer nutrition education classes in Historic South Los Angeles. As part of the Champions for Change Healthy Communities Initiative grant received from the Los Angeles County Department of Public Health, NHF will be conducting 30 minute to 1 hour long nutrition education classes at schools in the community with students and parents. Led by our trained and expert staff, these classes are intended to educate South LA residents about the importance of healthy eating and physical activity. Classes will cover topics such as the USDA’s MyPlate guidelines, the importance of drinking water, reading and understanding food labels, shopping for healthy food on a budget and everyday activities that can help maintain weight and fend off disease.

These classes are one part of the healthy story that is emerging from within South LA.  Our Health Academy students have worked with two, and are currently assessing 8, local food markets to see how they advertise and sell healthy options. They collaborate with store owners to improve the visibility of healthy foods, such as fruits and vegetables, and offer help with marketing these options to the community. Their efforts are working! More healthy foods are visible to consumers and one market owner has even changed his food procurement process to receive healthy food from a local produce distributor, making these healthy options more available and cheaper to the community. 

Together, these two approaches are intended to tackle the social determinant of health that is access to healthy and nutritious food. South LA is considered a food desert with few healthy food options available. Furthermore, food insecurity is an issue that many in the community face. The nutrition education classes are being offered with the expectation of shifting the trend of obesity and heart disease in the community.  By reinforcing the positive changes happening in South LA, including the availability of fresh produce at corner markets, we will ensure that every individual and every family has the access to the knowledge and ability to eat healthy and live their best, healthiest life.

Health and Dignity for the Homeless

Nancy Hu, a Social Worker with California Hospital Medical Center, Dignity Health, would like to see lower readmission rates, reinfections and fewer visits to the emergency department for her patients. Nancy works with patients who are about to be discharged from the hospital and the majority of her caseload is individuals who are without a home.

“I see myself as someone who advocates for my patients and collaborates with the nurses, doctors and case managers to work towards a safe discharge,” shared Nancy, “The challenge is that when someone is not able to heal in a clean and safe environment, it puts the person at a much greater risk of another hospitalization and further exacerbating their illness, all of which can be prevented.”

Since 2015, National Health Foundation’s Pathways Recuperative Care has become one avenue for safe discharge of homeless patients from partner hospitals. Pathways offers temporary housing with medical oversight to individuals who are without a home. The advantage for patients is that they can heal safely and are given the support needed to adhere to follow-up care schedules. For partnering hospitals the advantage is peace of mind, “The hospital feels reassured that the patients are able to go somewhere clean and safe to heal while getting assistance with follow-up appointments and housing,” says Nancy.

Not every homeless patient opts for accepting Recuperative Care and not all are a fit. As a social worker, Nancy assesses each patient who is homeless to see if they are appropriate for recuperative care, if they are motivated to get housing, and those who wish to recover from their medical condition. Not all homeless patients want to be housed, “Personally, it makes me sad because it doesn’t have to be that way. But I also know that we all have rights to make choices that we feel is best for ourselves and to choose to take help when it is offered.”

On any given day, Nancy is balancing and prioritizing between a victim of crime, someone who is homeless and being discharged while it is cold and raining outside, and another who is dealing with a life changing/altering diagnosis. We at National Health Foundation’s Pathways Recuperative Care are grateful to Nancy and Social Workers everywhere who are providing essential care to patients at their most vulnerable; upon discharge from the hospital.

Celebrating #SocialWorkMonth: Care and Compassion in the Face of Homelessness

Frank healing at NHF's Pathway Recuperative Care center.

Ron Jacobs, LCSW, Social Work Services at White MemorialMedical Center (WMMC) in Los Angeles, works closely with patients as they prepare for discharge from the hospital. Nearly every day Ron is faced with the challenge of discharging a patient who does not have a home to return to. 

“I make sure that those I serve are listened to and heard. I motivate individuals to enhance their strengths and abilities and help restore their sense of dignity while avoiding stigmatizing anyone as homeless,” says Ron of his role, “and I also realize that along with empathy, there must be action, resources and referrals.

March is #SocialWorkMonth and National Health Foundation(NHF) is celebrating the invaluable work that social workers do in the community, in particular the work of those who coordinate the discharge and referral of patients who are homeless.

 Until 2015, patients in Los Angeles County who were without a home and were discharged from the hospital faced completing their healing on the street. For many, a lack of follow-up care meant a certain return to the hospital. For social workers like Ron, it meant forming a connection with an individual upon discharge only to see them back in the hospital. “Knowing that there is a resource that is an alternative to the streets is a wonderful advantage we can now offer these individuals,” shared Ron, “Pathway Recuperative Care provides the opportunity for transitional healing, emotional support, resources and concrete solutions to enable our patients to reconnect with their community.”

Shakoya Green, MA, MSW, National Health Foundation’s Recuperative Care Program Director had this to say about Ron, “We simply cannot do what we do without Social Workers like Ron who go above and beyond their ‘job’ to really connect with their patients on a deeper level. Ron sees the whole person and addresses their needs from a place of love. We have been able to work closely together to achieve some incredible outcomes for our patients.”

Frank was discharged from WMMC last fall after several complex procedures. Ron ensured a smooth referral to Pathway Recuperative Care and helped to secure every possible form of care to ensure Frank recovered from his physical issues. Frank was able to benefit from the full spectrum of services that the partnership provided and has since fully healed physically and has been provided with a stable housing solution. “Frank’s case exemplifies what is possible when there is a ‘champion’ for the homeless who sees beyond the sometimes harsh exterior and works compassionately and diligently to ensure success,” added Shakoya.

Ron’s motto is a moving one, “I strive to meet each person as he/she is and I begin where the person is at in their journey in life. I try to remember that we are all ‘poor’ in one way or another and we all need some degree of healing at some time in our lives. There is no ‘healer and would be healed’. When we help someone in need, we are all better off. We all share a common humanity.”

All of us at Pathway Recuperative Care and National Health Foundation salute you, Ron, and all Social Workers.