Project Title: Returning Home – Extended Care Beyond the Front Door
The purpose of the Returning Home project is to assure a more complete and responsive services to help member success in community placements and the ability to age in place when members articulate or identify very complicated and more than typical community supportive living needs.
· To support individuals for successful community living to avoid a return to homelessness.
· To assure a comprehensive plan for individuals including wrap around services for independent living, medical care, personal care, and wrap around community supports to support successful community living.
· To assure community living supports including personal care, medical care, assisted living, and education services for past members of Justa Center who are aging in place and may need assistance and wrap around services to support their community living.
· Comprehensive Assessment Process – a new in-depth, comprehensive assessment process will be triggered at any point by a Justa Center team member or a member who identifies complicated community placement needs. This assessment process will included assessment of all activities of daily living, medical and psychiatric needs, independent living skills and strengths and needs, social and spiritual needs or combinations of these needs.
· Integrated member community living plan – along with staff input and the comprehensive assessment, member input, a comprehensive action plan for community living shall be completed with the member’s full participation establishing the community living, medical, and assisted living supports needed for the member to succeed and “age in place” as much as possible. This will include referrals and arrangements for home health and other community support services needed.
· The Extended Care program social worker will assure coordination of services and act as primary intermediary with services at the Justa Center assuring a smooth transition for the member into the community, integration of services, and relational support for the member.
· Since the Justa Center service process is member driven and person centered, in a nonlinear way, the member or a staff person can trigger the comprehensive assessment at any point the relational process or service provision process.
· Indicators for triggering a detailed comprehensive assessment will include: indications of serious medical or mediation management issues by a member, a serious mental illness which a member needs assistance in management, memory impairment by the member, serious medical or psychiatric conditions potentially impairing a member’s ability to care for themselves, lack of ability to manage daily living in one or more areas, or any combination of these or other needs which might jeopardize a member’s continued successful community living or might trigger a return to homelessness.
· Critical to an individual member’s community living plan shall be consultation with the member about the need for ongoing home health care and ongoing psychiatric and/or medical care.
· The aftercare social worker will initiate consultation with a community home health agency when the comprehensive assessment indicates there may be a need for home health care.
· Each member will be placed with “community living kit” (a sort of welcome wagon welcome home kit) beyond the normal “starter kit provided by the Justa Center.
· This community living kit shall include: neighborhood and residential information, personal medical care information, doctors and home health care contacts, medication management information, transportation information to and from vital and critical services, grocery stores, doctors, hospitals, emergency contacts, with “discharge” medical and community living information, social and community living contacts, and red flags for the individual member to contact various supportive services.
· Typically, the community living after care social worker or another professional staff person will make a follow up visit with member in the first 72 hours with the member to review their plan and assure supportive services and member understanding of the plan and placement.
· The Justa Center staff along with the social worker will select and use a systematic comprehensive assessment framework and document to supplement and guide their professional knowledge and skills. Alternatives including adaptions of the SAIL assessment document for independent living, adaptations of the Vulnerability Index & Service Prioritization Decision Assistance Tool (VI-‐SPDAT) – Prescreen for Single Adults or other activities of independent or community living assessments available.
· MEMBERS ALREADY LIVING IN THE COMMUNITY: For members already in independent living or community living, referrals for after care may come from many different sources including staff members making routine visits for other matters, housing managers who might notices special or changing circumstances of members, medical care professionals, friends and family members, other residents at the members facility, or any other source. The aftercare will make timely visits, establish rapport as needed, do assessments and care planning with the member as needed. If necessary the aftercare social worker will do a comprehensive assessment and integrated care plan based on the needs and desires of the member living in the community with appropriate referrals to community services and home health care agencies as necessary.
· The aftercare program envisions two new Justa Center positions:
o Master’s Degree social worker with experience in serving people who are homeless, seriously mentally ill, people who medically fragile, or elderly or a combination of these elements.
o A program aide or associate who can help with basic tasks of placement, transportation, medication management, personal care arrangements, or other para professional tasks to support individual member independence and community living.
Justa Center Mission:
Justa Center exists to provide essential services that support seniors, age 55 and older, who are homeless in the metro Phoenix region. Services are grounded in a person-centered culture to support human dignity and the ethics of personal healing and self-determination. Currently, the nation’s only day resource center exclusively serving the growing number of homeless seniors living in shelters, on the streets, as well as providing wrap-around supportive services to support members returned to housing remain in housing.
Since 2006, Justa Center has strived to build strong trusting relationships, helping to identify goals for ending homelessness, and empower individuals to live in self-reliant way in the community. A core value lived out every day at Justa Center is to treat everyone with respect and dignity. Therefore, individuals served at the Center are called members, not clients, patients, or recipients.
Seniors entering into homeless is a growing world-wide crisis. In the United States, ten thousand (10,000) baby boomers turn 65 every day. The number of homeless seniors is expected to increase annually until it peaks in 2060.
Seniors experience homelessness for a variety of reasons, including:
· the lack of income to pay for housing (low government assistance, insufficient retirement income, current and historic low wages coupled with debt and medical expenses)
· the shortage of affordable and secure housing
· deteriorating physical and mental health
· a relationship breakdown and/or suffering from violence and abuse
· death of a spouse
· social isolation
· or a lack of awareness of available benefits and services.
Center Programs and Services:
Day-Center members move through the various services provided based on individual needs organized around six major areas.
- Intake Process identifies needs, personal plan development, and identity documentation.
- Resource Development including income from work, social security, disability, veterans’ benefits, or other sources that will sustain independent or community living.
- Housing Development to locate the best affordable housing setting based on needs and resources.
- Nursing and Medical Support Services providing first-aid, wellness checks, consultations, and referrals to assist in navigating the complex healthcare systems.
- Services Coordination support to overcome barriers which might be discovered in the relational Justa Center process. On-site providers from Social Security, Medicare/Medicaid, AZ State, and a pro-bono attorney available for members.
- On-site Resources such as daily mid-morning meal supplied by Meals on Wheels and community groups. Rental lockers, emergency clothing, showers and laundry, computer and telephone access, and more.
Extended Care for members achieving housing are supported
· Move-In support including transportation, starter kits for kitchen, bath, bedroom and personal care as well access to donated furniture to make the new location a home.
· Wellness Visits conducted weekly by Justa Ambassadors for members in housing to deliver food-bags along with limited household items not available with food stamps. These provide assessment and ongoing support that can include landlord mediation, transportation and support for medical procedures, and connecting members to available services to assist them to remain in housing while aging in place.
· Transition Support for members who are transitioning from independent living to managed care, when needed.
The Day-Center is open daily to homeless members seven days per week, closed only on Thanksgiving and Christmas days. From 2009 through 2018, Justa Center has served
· 4,721 Homeless Seniors
o 23% Veterans
o 28% Women
· 28% return to housing
o 2009-2014 – 23% remained in housing for greater than 1 year
o 2015-2018 – 76% remained in housing for greater than 1 year
· In 2014, the Extended Care Program started to address the challenges that caused members to lose housing within the first year of placement. As of 2018, 76% of members placed in housing are retaining housing for greater than one year, and of those less than 2% are losing housing after five years.
Last year, the rising demand for services was
· 723 New members
o 53% - experiencing homelessness for the first time
· 6% Members returning after an absence greater than 12 months (causes include moving back to Phoenix, losing local housing, release after incarceration, extended hospitalization, or completing a residency program for addiction and/or mental health)
· 29% returned to housing
Historically, only 25% of Justa Center members were aged 63 or older (at time of intake) with access to endowments such as Social Security and Medicare. In 2018, that increased by to 31%; and to-date in 2019, it is 36% of the new members. While this increases individual resources, the lack of available housing for fixed income and low-income members is declining so members are remaining homeless for longer periods.
Justa Center serves members of the community who often fall through the cracks of governmental support, family dynamics, and societal norms. For many, returning to a society that doesn’t understand what life on the street is like, they don’t know how to “fit in” again. While at Justa Center, we work with our members to help them regain their prior people skills, recognize social boundaries, and accept that they are welcome in their community.