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From hopeless to home Placer County’s Whole Person Care program launched in 2017 with a lofty goal of helping homeless people with the most severe needs. Since then it has connected the dots for those who had once fallen through the cracks.

Homelessness: A divisive topic to be sure, and one that has emerged at the forefront of local government and community discussions across the country. What can be done? Why are they here? Where should they go?

In 2017, the rate of homelessness nationwide increased for the first time in seven years — driven by surging numbers in California. The state is home to over a quarter of the nation’s overall homeless population.

While Placer County is a relatively wealthy pocket of Northern California, it is not immune to poverty or to homelessness. The county has a relatively low rate of homelessness, with about 1.73 homeless individuals per 1,000 residents in 2017 compared to 8.58 in urban counties such as San Francisco, or 2.42 and 3.75 in neighboring counties like Sacramento and Nevada. However, the number of people in Placer experiencing chronic homelessness — that is, typically, those who are homeless for longer than a year — is nearly triple the national average. These people often face multiple challenges: mental illness, substance use disorders, domestic violence and more.

So when the state of California announced the opportunity to apply for a program called Whole Person Care, the county jumped at the chance. Each county could customize their own pilot program, choosing from a menu of service “bundles.” Placer chose to focus on more intensive services for a core group of the most vulnerable homeless people.

The county was one of 18 initially selected by the California Department of Health Care Services to participate in the five-year pilot, to the tune of $20 million — up to half of which would come from matching federal dollars.

The basic concept was this: For the handful of people with the most complicated needs, services are fragmented and difficult to navigate. These are the people who cycle in and out of emergency rooms and jails. Whole Person Care would adopt a more holistic approach, providing intensive case management and encouraging different service providers to talk to one another, share data and get on the same page when engaging and treating clients.

The program began enrolling clients in spring of 2017. All clients are county Medi-Cal recipients, and most are referred by a shelter, jail or hospital — people whose repeated, frequent use of services indicates deeper root issues that demand a more permanent solution. On average, a single emergency department visit costs the health system about $2,500. Some of the chronically homeless people served by Whole Person Care had been admitted two, three, four or more times a month.

In many ways, said county Health Officer Dr. Rob Oldham, Whole Person Care was “an experiment.” Could a local health and human services agency connect the dots between fragmented service providers and invest in non-traditional methods — such as purchasing housing — to have a meaningful impact on the health of individuals who seemed trapped in a downward spiral? And in turn, could that approach reduce costs to the entire system of services?

Read on and listen to our full podcast series to learn how the program has played out over the last year, through the eyes of a few Whole Person Care clients.

CLICK HERE TO LISTEN TO THE FULL PODCAST SERIES, AVAILABLE FOR STREAMING OR DOWNLOAD ON ALL MAJOR PODCAST PLATFORMS INCLUDING ITUNES.

KARLY

Karly remembers a time, not so long ago, when she had a “normal” life.

“I had a job, I had friends. I had my own home and money in the bank,” she said. “I would take vacations every year and complain that it was Monday morning and I had to get up for work.”

Then she lost her job. Holed up at home looking for new jobs online, she began to isolate herself. It slowly worsened, and she began asking friends to bring groceries over, unable to leave the building herself. Every time she tried, her heart would race and her breath would quicken, and she would have to sit down.

Eventually, after several years of crippling agoraphobia, she lost her home and began to live in her car. She began drinking in an attempt to soothe her fears, but that only worsened her situation. One DUI and a few couch-surfing episodes later, she wound up at the temporary homeless shelter in North Auburn.

Karly’s mental health challenges and alcohol use are issues common to many homeless people. Roughly 40 percent of respondents in Placer’s 2018 homeless count reported having a serious mental illness, and a quarter admitted to a substance use disorder.

She finally reached out for help and began a regimen of medication to help calm her nerves. In 2017, she was one of the first clients signed on to Whole Person Care. Her case manager, Todd Perbetsky, worked with her to set goals that would help her regain independence: a job, an income and housing.

Subsisting just on a meager monthly Supplemental Security Income payment, there was no way Karly could afford market-rate rent in Placer County, where rent averages around $1,300.

But Karly’s ongoing anxiety made it difficult for her to jump straight back into the workforce. Perbetsky connected her with the county’s Employment Services team, and she began taking classes to boost her skills and confidence. Employment Services is one of many government and nonprofit partners working with Whole Person Care to fulfill clients’ needs.

“It was quite quickly apparent that this (was) terrifying for her,” said Employment Services counselor Judi Moore. “But she went through the process and realized that even though it was fearful, she could conquer some of those steps.”

She participated in mock interviews and job fairs, slowly becoming more comfortable. Simultaneously, Perbetsky began exploring less costly alternatives for housing.

The county had received a $1 million grant from Sutter Health as part of its Getting to Zero campaign, addressing homelessness in the greater Sacramento region. With those funds, the county purchased two homes, one with eight beds and the other with six, for Whole Person Care clients. The homes are managed by AMI Housing, a local nonprofit organization contracted for property management, who charges 30 percent of a homeless client’s income for rent, whatever that income may be. This is the threshold of affordability — a threshold that around 40 percent of homeowners in Placer County’s busy housing market exceed.

Karly applied and was accepted to one of the homes, a renovated building in Auburn where she had her own room and access to a full shared kitchen, living room and more.

“Once she moved in, you could see the change in her confidence level, and less anxiety,” Perbetsky said.

She was also approved as an In-Home Supportive Services worker, and began to earn money by helping elderly and disabled peoples with household activities. This role allowed her to re-enter the workforce on a part-time basis and become comfortable as she continues to take business classes and look for a full-time job.

“One year ago I was in the shelter, curled up on my bed not wanting to deal with people. (Whole Person Care) got me off of living on the streets, out of the shelter, clean and sober and in a home,” Karly said. “An actual home.”

SKIP

His given name is Egbert, but everyone calls him “Skip.” It’s a name he picked up from his father, who was in the Navy.

Skip is 70 and grew up in Placer County, relishing in the adventure of the outdoors — camping, fishing and gold panning along the North Fork American River. His pathway into homelessness is a little unclear, due to his lapsing memory, but he recalls “messing up really bad” after the death of a beloved cousin and the divorce of his parents.

Skip has been homeless off and on for many years, mostly roughing it outdoors until his old age and local laws caught up with him. He’s a familiar face in Auburn, from the KFC to his favorite breakfast spot, Mom’s Kitchen. And he’ll often be seen handing out tiny wooden dream catchers, crafted from sticks he’s collected while out and about.

“Dream catchers, they’re something special for somebody. People need to know what they are and what they are used for [...] to catch all the bad dreams. Good dreams go to the center,” he said.

Skip was one of the longer-term residents at the Auburn shelter when they referred him to Whole Person Care in 2017. Unlike Karly, Skip’s physical and mental frailty meant there was little chance of him gaining employment. So Perbetsky, his case manager, focused on improving his physical health and finding housing.

In the six months before Skip enrolled in the program he had visited the emergency room seven times, cycling in and out for an estimated cost of $17,500. After establishing regular care and getting to appointments with Todd’s help, this changed. In the first six months since he enrolled, he visited the ER just four times — and in the six months after that, just once.

And when Skip does wind up in the ER, Perbetsky knows immediately. Whole Person Care implemented a technology platform called PreManage, which sends information in real-time from emergency rooms and hospitals to case managers. Previously, case managers would rely on clients to tell them about medical emergencies, which was unreliable at best. Now, health providers and social workers are on the same page. As a result, more than 96 percent of Whole Person Care members connect with their case manager after an emergency room visit within seven days.

Housing proved to be a trickier puzzle. They first tried a board and care, where he would have constant supervision. But Skip, used to a certain level of freedom, didn’t mesh well with the stricter rules and structure of the facility. So then Perbetsky tried a room and board in Sacramento, where the problem seemed almost the opposite. Skip wandered off and got lost in the city, frightening his case worker and friends.

When the new homes purchased with Sutter grant funding materialized, Todd helped Skip apply. He interviewed and moved into the home in Auburn, where Todd hoped the natural setting and appropriate level of support would finally be the right match. When Skip qualified for in-home supportive services, Karly became his paid helper.

Skip cooks up some clam chowder, one of his favorite dishes, in his new home

But once more, Skip hit a roadblock. Smoking was against the rules, and after a few months he still couldn’t seem to remember not to smoke in his room despite verbal and written reminders. So, Whole Person Care staff had to get creative, retraining him over time to use a vape pen rather than cigarettes with Karly’s help.

This kind of hurdle — or worse — is not uncommon after someone moves into a home, especially for people who have been homeless for years.

“We continue working with them to make sure that things are going well to make sure they keep their house. It’s not uncommon to place someone and not have it go well,” said Geoff Smith, the program manager who oversees Whole Person Care. “We want to help them through that process and make sure that they can maintain their housing, or if something goes wrong to help them find something else.”

For Skip, the solution had come too late, and he was asked to leave the home in Auburn. Luckily, though, a 19-unit apartment building purchased by the county in Roseville was just opening its doors, and Skip snagged a spot.

There, he’s been able to stay compliant. Karly even followed him down the hill to the same building, and Perbetsky checks up on him regularly.

His new room is lined with dream catchers — as is Perbetsky’s cubicle, a sign of the elderly man’s love for his case manager.

Some of Skip's handmade dreamcatchers

“They care. You actually feel the care. You can feel it within your heart and you can see it in their eyes,” Skip said. “They're wonderful people.”

ELLEN

Ellen was staying at The Gathering Inn in Roseville when she started feeling tired and dizzy all the time. When that turned into pain, she headed to the hospital and heard some unexpected words from the doctor.

Cancer. Stage 3.

She had found herself at the shelter after a string of unfortunate events. The single mom had been supporting two daughters with her work at a gas station, when in 2010 her car broke down. Unable to pay to have it fixed and unable to get to work, she was forced to leave her job and find part-time work closer to home. It didn’t pay the bills, and by 2015 she was evicted. Her daughters, one now in adulthood, went out on their own, and Ellen had a string of unreliable roommates until she would up at the shelter.

“I was scared,” she said. “I expected lots of drugs, which isn't true. Most people believe that all homeless people are mental or drug addicts or alcoholics — and some of them are. But there's a lot of people that were just like me.”

Ellen found a rhythm at The Gathering Inn, thankful for the churches that provided places to sleep and her role in the laundry room that provided safety and purpose.

But that all came to a halt when she received her cancer diagnosis.

What followed was a string of chemo treatments and surgery. During initial rounds of chemo, Ellen was still at the shelter, sleeping on couches instead of the usual cots. But after surgery to remove the tumour, neither the shelter nor the street would do.

Instead, she moved to The Gathering Inn’s interim care program in Auburn, supported by Sutter and Kaiser. This is a five-bedroom house where homeless people who have been discharged from the hospital but need time to recuperate can rest and rehabilitate.

Recognizing the need for additional medical respite services, Whole Person Care established its own interim care house with eight beds on the county government center campus in Auburn. The Gathering Inn was contracted to run operations, since they had previous experience, and the building opened its doors in October 2017.

Ellen moved from one interim care house to another, still managing neuropathy symptoms and other side effects from treatment. But eventually, she was declared cancer-free.

Ellen continues a heavy regime of medication to manage lingering side effects of treatment

“Without the ICP house and respite care I would not have gotten through it,” she said. “I thank goodness they let me stay there as long as they let me.”

Time in the interim care program is limited, as there is much competition for bed space. With the clock ticking, Ellen started applying for apartments with the help of her case manager, Karyn Dirkse.

“It is a discouraging process with so little available,” Ellen said. Her income was even smaller than Skip or Karly’s — just a bit over $100 a month in back child support — and so the options were slim.

Ellen trained her sights on the second home purchased by Whole Person Care with Sutter grant funding: a beautiful property in Rocklin, dubbed the Phoenix House. She was accepted, and moved in just a few days before Christmas. While she is still experiencing lingering numbness and pain at times, she is looking to the future.

Ellen on move-in day, just before Christmas 2017

“[Here], I can get better,” she said. “That is exactly what I have in mind. To figure out what's wrong, get it fixed and then go back to working. I’m looking forward to my life being more like what it used to be.”

The Whole Person Care program is expected to serve at least 450 clients over the course of the pilot, with 200 having participated in its first year of services. As of December 2018, more than 85 members have been successfully housed.

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