“I have been to the worst place in the world, where I don’t ever want to go again, and to the best place in the world,” Ricky declared, spreading his arms open in reference to his new apartment. “When I first moved in, I cried for several days, now I can’t stop smiling. I wake up every day thinking, this is mine! I can make plans.”
Those are the words of Ricky Lopez, 57, a San Diego resident who lost his ability to work due to health problems and found himself living on the street for more than a year. Thanks to a project designed to offer homeless seniors a new start in life, Lopez now lives in a new building called Talmadge Gateway, where he is served by LeadingAge member St. Paul's Senior Services, through its Program of All-inclusive Care for the Elderly (PACE). (Read more about Lopez.)
According to HUD’s 2017 Annual Homeless Assessment Report to Congress (AHAR), the homeless population in the U.S. was about 550,000 “on a single night in January 2017,” which is considered a representative sample of the number of homeless at a given time. If defined by the number of people who experience homelessness “at some point” during a year, the number is larger, estimated to be 1.59 million, based on 2010 federal data. The latter dataset also estimated that about 2.8%, or 44,520, of those people were aged 62 and above. Those aged 50-64 were estimated to be 14.9% of the homeless, or almost 237,000. (The more recent AHARs, oddly, only offer an age breakdown with 3 categories: under 18, 18-24, and over 24.)
A fact sheet from the National Healthcare for the Homeless Council projects that the number of “homeless elderly” (which they define as those aged 65 and over) will increase to 58,000 by 2020. It also notes that the median age of homeless adults in the U.S. rose to 50 years (from 35 years) between 1990 and 2010.
Even for those only in their 50s, we must keep in mind that living on the street means premature aging in almost all cases. These homeless people may be younger than age 65, but they tend to show chronic illnesses more often seen among older people.
PACE and Partnerships Get Homeless Seniors Off the Streets
St. Paul's Senior Services, San Diego, CA, which offers the full continuum of services for older adults, has long served a modest number of seniors who have low incomes and are at-risk for homelessness. In recent years, however, it has found a way to serve many more such clients—such as Ricky Lopez—by using its Program of All-inclusive Care for the Elderly (St. Paul’s PACE) to offer supportive services in housing owned and operated by other organizations.
“A senior has to have a safe place to live to be served by a PACE program,” says Carol Hubbard, St. Paul’s executive director of home and community based services. “They must have a home, so we always had to exclude people that were homeless as part of the PACE, and that’s always bothered us, especially our CEO, Cheryl Wilson.” Hubbard says that almost 30% of the homeless people living on the street in San Diego are older adults.
St. Paul’s PACE now serves about 150 formerly homeless seniors, out of its total enrollment of 712. The PACE is celebrating its 10-year anniversary this year.
“In 2013, we were approached by the San Diego Housing Commission, which had a building called Parker Kier that the commission refurbished in downtown San Diego, and they wanted to see if we could serve 11 [formerly homeless] seniors in that building.” Hubbard says the building also has units for transitional adult youth, and for a mental health population.
“They gave us the 11 units on the 3rd floor which came with project-based vouchers and they asked if we could supply the necessary support services for qualifying seniors. That’s where it all started,” Hubbard says.
St. Paul’s created relationships with all the key homeless organizations in the city, some of which were housing seniors temporarily. Those organizations agreed to keep some of them in place, giving them long-term transitional housing while St. Paul’s worked with the housing commission and developers to secure the permanent housing and enroll them in PACE.
“We’d provide PACE services there and at our centers, while simultaneously working to move them into permanent housing,” says Hubbard. “We also hosted fundraising campaigns to provide furnishings and supplies so [they] could move in completely prepared for their new lives. We even had towels and bedding and food in the refrigerators.”
Later, St. Paul’s made a similar arrangement with Bridge Housing for the latter’s Celadon development that includes 63 units for seniors.
In 2017, St. Paul’s partnered with Wakeland Housing and Development Corporation, which has built thousands of affordable housing units around the state, to serve 59 residents in Wakeland’s new Talmadge Gateway building. It’s one of 8 projects in the San Diego Housing Commission’s “Housing First San Diego” action plan to create more than 400 permanent supportive housing units for the homeless.
Wakeland is attempting to build another building along the same lines in Grantville, a San Diego neighborhood. Hubbard says Wakeland is still working on its permissions and tax credits, so some details are up in the air. It would include 75 units for medically frail seniors who have experienced or are at risk of becoming homeless. The building would also house a St. Paul’s PACE center.
For St. Paul’s PACE, this is just the beginning; 98% of the previously homeless population continues to live in PACE permanent housing. As its reputation for successful homeless housing increases, it has been invited to participate in more partnerships.
Serving the homeless usually means coping with mental health or substance abuse problems. St. Paul’s has had to increase the mental health component of its work; it is contracting with mental health providers but intends to bring those services in house.
When it comes to substance abuse, says Hubbard, “That was initially a challenge for us, especially for people addicted to opioids. Our doctors talked to them with the message that ‘We’re going to address your pain’ so you won’t need them. It takes a while, and you have to build trust, but we’ve got people who were in walkers or wheelchairs and in constant pain who are now active, and volunteering with the church, and it’s because we gave them that knee surgery they have needed for years, or gave them that physical therapy they needed.
“The stories are so emotionally inspiring, and amazing to hear,” says Hubbard. “A lot of people have a notion that homeless people don’t want to get off the streets, but really, out of the 150 we have placed, there have only been 1 or 2 that left. It’s a stereotype we just can’t believe any more. They talk about how they are ‘a new person,’ and how PACE has saved their lives.”
Another such person is Athelia Johnson, 63, who lived on the street despite health problems and now, in affordable housing served by the PACE, says, “I am just finding out who I am.” She has even discovered a hidden talent for painting and has won an award for a painting in an art competition. (Read more about Johnson.)
“Using the PACE model is a win for everyone,” Hubbard says. “We get to serve more seniors, the developers get a building filled with people, and PACE provides all the wraparound support services—including social work, activities and medical services. This successful program proves what we sincerely believe: There is no health without housing."
A Mission to House the Homeless
Hearth, Boston, MA, has adopted “the elimination of homelessness among the elderly” as its mission, and housing with supportive services is the tool that makes it work.
“Our total of 186 [apartments] are for formerly homeless older adults or people deemed to be at-risk,” says Mark Hinderlie, president and CEO. “That’s our mission and focus, not generalized senior housing.” Hearth operates 8 buildings in the Boston area, 3 of them congregate housing, and Hinderlie says another 54-unit building is “in the pipeline,” pending the awarding of a low-income housing tax credits (LIHTC).
The permanent supportive housing the organization offers provides nursing, social work and personal care on-site, and a program manager who works with non-clinical participants. Hinderlie says that in this respect, “clinical” refers to people in publicly supported service programs like Group Adult Foster Care, a Medicaid program designed by the state.
In 2014, Hearth received a LeadingAge Innovations Fund grant that it dedicated to implementing the Screening, Brief Intervention and Referral Treatment (SBIRT) program, which is widely used to assess the severity of substance use and suggest appropriate treatment. Though the funding was time-limited—meaning the program is no longer actively supported—Hinderlie says Hearth does a version of the screening in-house, the first step in individualizing plans for each resident.
Mental health is another persistent issue with the homeless population, and Hearth has a contract with the state to provide mental health services to as many as 45 residents. Hinderlie says the state has overhauled its system to require a much higher level of clinical attention, but reduced the funding.
“Many providers have stopped participating in the program because they’ll lose money,” Hinderlie says.
Some Hearth residents are part of the Massachusetts Group Adult Foster Care (GAFC) program, which covers personal care services and medication management/administration, but does not cover living costs. Assisted living residents—Hearth has one assisted living building—can get coverage for services under GAFC.
“The program hasn’t gotten a rate increase since 2002 when it began,” says Hinderlie. “If people are eligible and have 2 or more activities of daily living (ADLs) they need help with they can get it. A lot of people who need such help don’t like getting people in their apartment. About half of our residents fit in that category.
“We’ve pieced together Group Adult Foster Care [for assisted living]; we won’t take people who don’t have it,” Hinderlie says. They don’t have stovetops, only microwaves, so we have to provide meals, and we get some money from the city, $1.72 per meal, so we’re supplementing that with philanthropy.”
Serving that group requires personal care homemakers, 24-hour coverage, and some clinical presence on weekends. “We also have RNs, LICSWs, and some LCSWs, and certified home health aides,” Hinderlie adds.
Hearth’s largest supportive housing buildings offer nurses, social workers and personal care workers on site.
Hearth has become involved with HUD’s Emergency Shelter Grants (ESG) program, with funds that it uses, for instance, to help someone close to becoming homeless stay in an apartment.
“We’re allowed to use that [money] for shallow subsidies,” says Hinderlie. “Maybe $1,500 to $2,000 can persuade a landlord not to make someone homeless.” A representative payee can be assigned to the client to help manage money.
“There are so many people at risk of losing their homes,” Hinderlie adds. “$80,000 a year, plus our philanthropy of $60,000 per year will keep 50 people housed. We got started in that because we realized we can’t build our way to house 2,500 homeless Boston seniors.”
Getting the "Small Stuff" Right
Catholic Charities of the Archdiocese of Chicago manages 22 subsidized senior housing properties totaling 1,660 units. Its tenant selection plan requires that every tenth vacancy must house a homeless person, age 62 or older, according to Vida Wojewski, asset manager for housing services. At a couple of properties, she says, the rule applies to people 18 years and older, but those candidates must be disabled.
Catholic Charities also has communities geared to homeless veterans—its St. Leo Campus residence is expressly designed for veterans, and its Bishop Goedert Residence gives priority to veterans.
Cynthia Grinage, senior asset manager, notes that many homeless residents “come with mental health challenges. They move in, and we offer a bed but they still sleep on the floor. They can also have challenges in trying to live in a structured environment. We make sure they come with social services to help them make the transition easier.”
Every building serving formerly homeless people has a service coordinator, and social service agencies provide wraparound services, including medical.
“We provide services with respect to transportation to a clinic, or help them get medication or help them apply for a Medicaid card,” says Wojewski.
Despite substance abuse or mental health problems, “a very high percentage, but not 100%” of residents stay in place once housed, according to Grinage. “Some leave because they can’t handle the structure, some are not willing to pay the rent, and some are not accustomed to the environment. Sometimes we have to terminate someone’s tenancy because of nonpayment of rent. But we work with them to make sure they do it.”
Formerly homeless residents are socialized to their new community in many different ways. Grinage says some of the other residents do look at these residents differently. Wojewski notes that some are “people persons” while others are happy keeping to themselves.
Grinage and Wojewski tell success stories, like that of a woman who had long worked the carnival circuit in the South but found herself living in a car. Catholic Charities staff gave her an apartment and found her furniture, and also learned that she’s a veteran.
“She has adjusted tremendously and is on the VA campus,” says Wojewski. “She has been hooked up with variety of programs; she is our greatest success story and is thriving.”
“It’s the small stuff that makes people happy,” says Grinage. We’re not in it for the income, but for the outcome.”