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.”

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.

Two Men, Two Paths

Arnie and Mat arrived at National Health Foundation’s (NHF) Pathway Recuperative Care from partner hospitals in early December 2016. Both were in need of additional medical supervision and both were homeless. The similarities in their cases ended there. The task of delivering essential care and helping the two men find stable housing required an individualized plan that took into account their stories, their needs and their goals.

Arnie's multiple chronic medical conditions require monitoring and medication, both of which are challenging to maintain on a modest monthly social security check. He found himself unable to pay for rent and his condition deteriorated until he needed to be hospitalized. Upon discharge from the hospital he was homeless and in need of follow-up care. At Pathway Recuperative Care, Arnie worked closely with staff members on his care plan. This plan looks at the patient’s needs both medically and with respect to housing. Staff then began connecting Arnie to services available to him via the Department of Mental Health as well as medical services to ensure continuous improvement on both fronts. With Arnie’s motivation and Pathway staff persistence, he was able to secure stable housing that will ensure a sustained return to health.

For Mat, the struggle was no less intense. He came to Pathway Recuperative Care from a partner hospital with no money, no identification and no home. Struggling to recover from substance abuse, the 20-year-old had spent years in the foster care system and found emancipation to be more difficult than he had the skills to cope with. Upon arriving at Pathway Recuperative Care, the staff worked with Mat to reapply for General Relief, obtain a replacement Electronic Benefit Transfer card and kept him proactive in attending the necessary medical and social services appointments that would ensure his return to health. The last piece of Mat’s health plan was to secure stable housing.  Mat’s stable housing is such that he will receive the support he needs to maintain his health while acquiring the skills he needs to navigate adulthood.

For Pathway Recuperative Care staff, each patient has a vastly different set of circumstances that has led to the decline in their health and the loss of their home. “Each person who comes to Pathway is seen as an individual with distinct health needs. We take the time to understand their history and work with them to devise a plan that matches their needs and capacity for managing their progress to sustained health," explained Kelly Bruno, MSW, President/CEO National Health Foundation. For Arnie and Mat, the prospect of an end to homelessness was welcomed with large grins and a sense of accomplishment. “We find it impossible to speak about health without addressing the most fundamental social determinant of health: housing. Without a home, there can be no health,” asserts Bruno. With secure and supportive homes both Arnie and Mat can now turn their attention and energy towards their healing and health.