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.”

#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.

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.

Winter Clothing Drive for Recuperative Care

National Health Foundation is hosting a Winter Clothing Drive for Recuperative Care Program participants. These men and women are continuing to heal after a hospital stay and are transitioning to stable housing after having been homeless. Many come to our program without the basic necessities such as a change of clothes and cold weather apparel. Kindly consider sharing what you can! We will collect donations through January 30th.

ITEMS NEEDED FOR DONATIONS (both men and women)

Underwear (bras, panties, men’s boxer shorts-30-32, 34-36, 38-40, 40-42, 44-46)

T-shirts: Medium, Large, X-Large and XXL, XXXL

Sweat Pants: Medium, Large, X-Large and XXL, XXXL

Sweat Shirts: Medium, Large, X-Large and XXL, XXXL

White Tube Socks: Women Sizes 6-10 and Men Sizes 9-12

New or Gently Worn Coats- All Sizes

We are accepting donations at our recuperative care facility at:
5136 W Washington blvd. 90016, on Monday through Friday, 9-4

The Healing Journey

When Frank was discharged from a Southern California hospital, he was in need of intensive follow up care; he was also homeless.

For hundreds of Angelenos who are without a home, a hospitalization can cause a momentary interruption of homelessness, but the reality of receiving follow-up care and healing on the street is such that many homeless patients find their way back into the hospital.

National Health Foundation’s (NHF) Pathway Recuperative Care offers patients like Frank a safe and supported environment where they can continue their healing journey and, thanks to our continuum Bridge Housing program, find a permanent and stable home to return to upon discharge.

Patients spend an average of 7-10 days in recuperative care and this respite often triggers a desire in our guests to find a stable home; however, the process is often challenging and takes a team of individuals to connect the guest with the best possible permanent housing solution. Since our program began in 2010, we have helped more than 3,000 formerly homeless individuals heal and nearly half find their way home.

On #GivingTuesday, we are inviting the community to donate generously to NHF’s Pathways and Bridge Housing programs. Your donations will provide taxi vouchers for patients to be transported from the hospital to our facilities, personal hygiene supplies, clothing and basic furnishings to help a formerly homeless individual make a house into a home.

For more information about Pathway recuperative care, click here.

For more information on Bridge Housing, please click here.

Where Health and Care Meet: Frank’s Story

Frank, a 64-year-old Caucasian male, had a number of health issues that needed immediate attention, but he was facing an even larger issue than his failing health: he was homeless. For most of us who do have a place to call home, it is highly likely that we have a doctor, dentist and perhaps an urgent care clinic in our neighborhood that we feel we can turn to in the case of need. For the homeless, these basic needs fall to the wayside until an urgent health matter makes finding appropriate care a necessity and a challenge best tackled by a group of caring individuals.

When Frank came to National Health Foundation’s (NHF) PathwayRecuperative Care facility, he had been discharged from White MemorialHospital, a local partner hospital, and was in need of follow-up care. Denise, the LVN on Pathway’s staff immediately began the process of procuring a primary care physician for Frank at the Venice Family Clinic, knowing that Frank would need immediate support as well as prolonged follow-up for his chronic conditions once he was discharged from recuperative care. Upon further investigation, it was discovered that Frank would need to see a specialist for surgery. This set in motion a flurry of activity that most individuals would not think are part of accessing urgent medical care: A specialist from KeckMedicine of USC agreed to perform surgery but insurance issues needed to be addressed. In the mean time, Pathway staff worked with White Memorial to cover an extended stay for Frank in recuperative care, knowing that his health would deteriorate if he needed to wait for surgery whilst living on the street. With an additional 4 months of support from White Memorial, the staff at Venice Family Clinic then advocated for the patient and procured both the insurance clearance needed as well as made sure that the surgery was scheduled in the shortest time possible. With Frank’s most urgent medical needs met, there was one thing left to do: find Frank a place to call home.

Frank was the beneficiary of NHF’s Bridge Housing, a program that allows patients to stay in recuperative care for recovery and for the time that is needed to find a permanent housing solution. In Frank’s case, NHF was able to procure permanent supportive housing for him and once his most pressing health needs are under control, he will transition home.

Frank’s case is not an isolated one. For every homeless individual there is a health story that is unfolding. Thanks to partnerships with area hospitals and clinics, NHF is able to provide dignified and holistic solutions to the complex care needs of  our homeless neighbors.