The oldest homeless person I’ve known was in her early to mid 80s. Netta lost her house to foreclosure and had no family. She had nowhere to go so she continued living in her foreclosed home until the sheriff sent an ambulance to take her away. She was frail but not particularly sick or disabled. The hospital admitted her but she didn’t need hospital care and, without a disabling illness, the hospital couldn’t send her to a skilled nursing home. She had only Social Security and no idea what to do. Shortly after she arrived, the hospital recommended that she go to a homeless shelter. At that point, Netta disappeared and I haven’t been able to find her since.
I’ve always known seniors on the streets, people who are 60 or older all the way into their 80s, but they usually had a problem like drug abuse or mental illness. In the last few years, I’ve met many homeless seniors who were different. They were people who had worked throughout their lives; people who receive Social Security; people who expected their family would care for them; people who thought they had arranged a safety net for themselves.
The number of homeless elders I have encountered in Sonoma County who have come to homelessness through financial problems or illness has more than tripled. They may not be an extremely large proportion of the homeless people in the county, but the increase in people who in their younger years who were very productive and contributing members of society is definitely noticeable and concerning. Many other caseworkers I’ve talked to tell me they’ve observed the same thing.
As I’ve followed these people who are trying to negotiate Sonoma County’s system of care, the many ways that that system fails seniors is glaring. We need to seriously address the needs of all homeless seniors in Sonoma County with some particular focus on this new group. To do this we need comprehensive and specific housing, targeted health care, training for case outreach workers and daily living support. All these things will cost money but they are crucial to provide seniors with a minimum of shelter and prevent the daily humiliation of homelessness for the elders of our community.
The increase in people who should be enjoying retirement but instead are experiencing homelessness due to lack of affordable housing definitely happened before the fires. Two years ago it became impossible not to notice. In my experience, this kind of homelessness comes when a financial problem is coupled with health difficulties.
Some of this wave of senior homelessness is due to the Great Recession of 2007-2009. At that time, some people lost their homes and found that their family wasn’t willing or able to help. Sometimes, there was an offer of help in another location, but the elders wanted to retain their strong ties to friends, culture, doctors and familiar places in Sonoma County.
Other senior homelessness is the result of illness and disability. Sometimes this is the usual limitation of aging but, sometimes, catastrophic illnesses cause a severe and sudden change. Some of it comes when mental illness is not well managed as people age, or a long-term mental problem is exacerbated by retirement, isolation, loneliness, grief, and/or the death of a spouse or other family member.
I’ve also witnessed age-related issues of memory loss and dementia in a couple of people. These people lost their housing specifically because they were unable to manage their finances. They didn’t have the support system to identify the problem and get help before it reached the point of eviction or foreclosure. It might surprise you to know the number of landlords who are willing to put an elderly person out on the street if they don’t pay their rent.
I work with Susan, a woman in her late 60s with multiple health issues. Susan was raising two grandchildren and had custody of both teenagers. When she divorced, both she and her husband had to leave their house. She found a shared house for a while but her ex-husband became impaired and stopped contributing or helping with the grandchildren. At that point, she couldn’t afford rent. Susan is too old and too sick to return to work, so the three began living in a truck. It’s been over a year and the three of them are still living in a truck.
Senior homelessness is also not uncommon after the death of a spouse or family member, when the loss of that income can translate to the inability to support housing. The waitlists for low-income housing, even senior housing, is long and it can take years to reach the top. Many people aren’t prepared for death, even when there is a long illness. They don’t apply for senior housing before a tragedy strikes.
There are many stories like this.
I often check in on a gentleman in his mid 70s who has kidney failure and lives in his car with a catheter. And, I know an elderly couple with only each other for help. Both are diabetics and one has lost their legs and uses a wheelchair. They also live in their car.
Many elderly individuals lose their housing when they become ill and require hospitalization and a skilled nursing home for rehabilitation. If they lack a support system, this traumatic incident becomes the unraveling of their life and their path to homelessness.
Medical Care, HUD and Social Security
One key reason seniors lose their housing is the way we pay for nursing home care for poor and working class people. If a senior has Medi-Care and/or Medi-Cal insurance, the first month of nursing care is paid for but that does not always cover 100 percent of the bill. Nursing homes regularly encounter patients who cannot cover their co-pay from savings and they have developed systems to efficiently access all or part of an elders’ Social Security check to defray their costs. The Social Security check may be automatically diverted to the nursing facility, leaving the elder without the means to pay their mortgage or rent. At that point, the elder’s home and all of their property goes away and, when they are ready to leave the nursing home, there is nowhere for this formerly-housed elder to live.
If an elder is housed in subsidized low income or Section 8 voucher housing, they can lose their subsidy from the Department of Housing and Urban Development (HUD) when they are out of their home, even for medical care. I spoke with HUD and was informed that they will hold a person’s voucher for up to six months if a person is in skilled nursing. However, the information provided on the Social Security Administration’s website (ssa.gov) says a person only receives benefits for up 90 days if the nursing home is being paid for by Medi-Cal. And, the patient needs to submit a letter from a doctor.
The overlapping systems of Medi-Care, Medi-Cal, Social Security and HUD are complicated. It’s hard to imagine how any medically distressed elder could gather the necessary information and file the correct paperwork. Until I called HUD, I had never heard of the potential for a 90-day extension. I’ve also never witnessed a patient be informed of this by hospital discharge planners or skilled nursing staff. In addition, I asked coworkers if they knew of the extension — not one did.
That’s sobering, but even more concerning is that most of my coworkers didn’t know that people can lose Social Security benefits in the first place. Most people, including those who have training and want to offer assistance, don’t understand the rules and regulations of all the various systems. If nurses, social workers, hospital discharge planners, and skilled nursing staff, only understand how Medi-Cal, Social Security, HUD, Disability, impacts the particular facility where the senior is being treated, they cannot protect them from the loss of crucial services like their income and their housing.
Although a support system is crucial for an elder to survive a nursing home stay with their housing intact, it’s often difficult to keep an elder near their friends and family. A skilled nursing facility, even if it’s somewhere that takes Medi-Cal, does not have to take everyone. It’s very hard to get into local facilities and often people end up outside the county where they have no support for what can be a very difficult time in their life.
Unlike skilled nursing homes, a hospital does not take an elderly person’s Social Security check. But if a person is, say, dealing with amputation or cancer treatment, sometimes they can’t handle all the finances and responsibilities of keeping their home. They are too sick to manage the life they expect to return to. In my experience if an elderly person is hospitalized for a long time without intense family or friendship support, they tend to lose their housing. I’ve worked with hospitalized people who were evicted and their belongings set out on the street.
I think of Javier, a gentleman in his late 60s who was a truck driver all his life. He made fairly good money, never married and had no children. Perhaps because of the work he did, he had back problems and had to have a spinal fusion. Eventually, he got placement in subsidized housing through a rapid rehousing program at Catholic Charities. However, Rapid Rehousing programs only last two years and that money has run out. Javier was just diagnosed with brain cancer. Ironically, that sad diagnosis will keep him from homelessness because he’ll be eligible for a skilled nursing facility. If he didn’t have brain cancer, this man with a full spinal fusion would soon be homeless.
Problems With Care for Homeless Seniors
No one is paying attention or doing anything about this. The agencies in Sonoma County who are set up to serve seniors are not equipped to help homeless seniors. There are no shelters specifically for seniors. The governmental and nonprofit agencies have neglected to recognize this population and they don’t have the funding, capacity or know how to serve homeless seniors.
Consider our current shelter system. As I said, there are no shelters specifically for seniors. Here’s one way this becomes a problem. People in shelters are expected to care for themselves, including obtaining food. At Santa Rosa’s largest shelter, Sam Jones Hall, people stand in line for meals, pick up a tray, fill their plate with food, and find a seat to eat. If a senior has to use a walker, has arthritis or can’t use their hands for some other reason, they have to rely on those around them for help every time they eat.
The inability to control your bowels or bladder gets people kicked out of the shelters. No shelter that I know of accepts people who are incontinent either in bowel or stool. This policy includes the Nightingale shelter, which is specifically set-aside for people who are convalescing from hospital stays.
Recently our large shelters, including Sam Jones, began utilizing a “low barrier” Housing First model. In an effort to get the people most likely to die on the street into the shelter, the shelter provider stopped drug testing and allowed people to bring their pets with them. This makes the shelters very scary for people who don’t use drugs. For people who have lived conventional lives, the shelters are a cultural shock. Many of them have stereotypes about people who swear, have unusual behaviors, use drugs or dress unconventionally. Many have stereotypes about other homeless people.
Many people actually flee. They don’t have the tools or experience to evaluate the people with whom they are now expected to share sleeping quarters and bathrooms. They would rather sleep in their car, facing the lack of food and warmth on their own, then attempt to negotiate what feels like a strange and frightening world. But, living isolated and sleeping in a vehicle is a risk factor for greater health problems.
Shelters are only one of the many challenges for homeless seniors. For instance, homeless people are expected to fill out forms at every turn and case workers usually require forms when they meet with people. But, often possessions and documents are lost or stolen when people are homeless, and personal information is difficult to retain. People lose glasses and hearing aids routinely, so even if they have the ability to write and think clearly, they may not have the physical ability to fill out forms on their own.
Many case managers assist with forms, including applications for housing, but sometimes they don’t. Like anything else in life, given the personalities and people we interact with, we understand that some people are not kind. Whether or not a homeless senior suffers the humiliation and limitation of being unable to fill out necessary forms is just a roll of the dice. In our current homeless service system, there’s no formal plan for reasonable accommodations under the Americans with Disabilities Act (ADA).
The county’s In Home Support System, (IHSS) program will pay someone to provide assistance for people who need help with their daily needs. IHSS helps many elderly people stay out of skilled nursing homes because they can stay stable within their own homes. But, this program is not available for anyone who lives in a car, in a shelter or on the street. I know of people who had an IHSS worker who helped them cook, bathe or shop but, when they lost their home, they lost their worker.
I knew a guy named Sam who lived at home with a family member who worked for IHSS to take care of him. She paid her share of household expenses from her IHSS salary. Sam became ill and had to go to a skilled nursing home. The nursing home took some of his Social Security money and the caregiver lost her IHSS salary. By the time Sam was able to leave the nursing home, both he and his caregiver were homeless.
I witnessed this and have heard other social workers say that this is a common situation.
Institutions of Last Resort
Adult Protective Services (APS) is the county department that is the agency of last resort for any individual who, for whatever reason, is unable to care for themselves. We depend on them but, in actuality, they are very limited in whom they can help and what they can do.
I’ve worked Jamala, a woman who had multiple issues that were beyond my scope. Two years ago, her modular home was condemned and, when she didn’t leave, it was just dragged away. Like many other providers, I’ve made multiple referrals to APS on her behalf. She’s 75, has dementia and lives in a shelter where she is expected to do everything for herself. She also has other major disabilities. When I first met her, she was hospitalized with a severe infection. She’s been found living in her car with multiple cats. I’ve been trying unsuccessfully to get help from APS for this woman for the last two years.
Adult Protective Services generally serve people who are being abused by a caretaker or family member who is stealing their money. In that case, they can investigate and take an abuser out of the home. However, they are ill-equipped to serve people who need housing as well as a range of support services.
One large problem is that Adult Protective Services can’t help people who are independent. To receive their services, people have to be conserved but if a person is conserved they lose all autonomy and personal freedom. They lose control of their money and property, and can be sent to a mental hospital or any number of other institutions and forced to take medications. All this can be done without their consent.
If APS decides to help a homeless senior they report the problem to a public guardian in the District Attorney’s office. The public guardian applies to a judge who has to agree that this elder cannot take care of themselves. It’s a very serious matter and the judges take it seriously. Generally judges try to put people in the care of a family member. If there is no family member, there should be a public guardian through the county Human Services Department who will take charge of this person. But, I have never had a client who was able to get this kind of help. The county refused to appoint a public guardian for someone with dementia who I referred.
Adult Protective Services cannot help an elder or conserve them just because they are homeless. Adults have the right to fail and an adult who has not been conserved has the right to be homeless. APS is unable to provide shelter or food themselves but they have a program called “linkages” for help for homeless seniors. This program has very limited housing to offer, an exceptionally long wait list and regularly runs out of funding.
Jails are also a last resort institution. They, however, have no responsibility for people after they are released. Homeless advocates say that people are often released from jail in the middle of the night with nowhere to go.
Many homeless seniors regularly end up in hospital emergency rooms. But, it can be hard to get a homeless person admitted to a hospital. Homeless people are often simply treated in the emergency room and sent back to the street. When people realize this, we call the hospital callous. However, if a hospital or nursing home admits a homeless person, it’s illegal to kick them out without a discharge plan, which means that, in effort, these institutions become responsible for people the rest of our institutions are ignoring. It’s no wonder they hesitate to take it on. I don’t mean to absolve the hospitals but it is truly the entire community who is to blame.
This is the way we treat seniors in Sonoma County. It’s a brutal system without the basic safety and care that so many of them deserve. I write this because I know many people would be outraged if they understood the inhumane and degrading ways that seniors are treated; the Catch-22s, the illogical and even mean-spirited situations that can befall them.
I think of Jennie who lives in her car with her cat. She lives with advanced-stage breast cancer. Jennie spent her career as a registered nurse but the cancer used her money for medical expenses and caregiving help. She’s spent her whole life in Sonoma County and although she has family in Texas to help her, she says, “This is my home. I’m not going anywhere.” Sometimes I get frustrated and think, “She’s so headstrong.” But, other times I think, “Why shouldn’t she be able to stay where she has chosen to live her life? She has spent her life in service to others. Where’s the help for her now when she needs it.”
*All the names and some of the details in each story have been changed to protect the privacy of the individuals. The author of this essay, Brie Franta, whose name has also been changed, has worked in human services for 22 years, mostly direct services to individual homeless people. Currently she lives and works in Sonoma County.