Independence by the Bay: the Community Living Fund

“I don’t know how any senior can handle all of this stuff,” sighs Mary Anne Humphrey, 68, who suffers from limited mobility due to a spinal cord injury.

Humphrey is explaining the endless paperwork, social services, doctor appointments, benefit plans and medications that she juggles as a disabled senior.

Fortunately, Humphrey is one of 1,200 San Francisco County residents that have received help over the past five years from a unique Bay Area program that keeps older adults and the disabled living independently: the Community Living Fund.

“They just must be overloaded with the paperwork and ins and outs and ‘sign this’ and ‘do that,’” she says. “CLF helps with that, with a real comfort. It takes away a lot of stress.”

Spawned in 2007 by the county, the fund is a collaboration with the city of San Francisco and the local Institute on Aging with a single focus: help San Franciscans survive independently outside the four walls of institutional living.

Besides coordinating complex medical care and social services, more specific assistance by case managers includes transportation to doctors, preparing meals, paying bills, installing ramps, buying electric wheelchairs, or any other help needed to keep clients living on their own.

With San Francisco’s impressive history of community support for the underserved, the county’s board of supervisors created the Community Living Fund in 2007, responding in part to the Olmstead Act of 1999 which requires that disabled citizens wanting to live at home can do so. (The city and county of San Francisco share the same borders.)

“You can’t keep people in institutions if they don’t want to be there and you can provide for them in the community,” says Linda Edelstein, director of Long Term Care Operations for the county’s Department of Aging and Adult Services, which administers the program.

Participants come largely from the two county facilities that serve the poor: Laguna Honda Hospital and Rehabilitation Center, which provides skilled nursing and rehabilitation services for 780 seniors and adults with disabilities, and San Francisco General Hospital.

“Those are basically the have-nots of San Francisco,” says Edelstein. “They don’t have a lot of options.”

Creating the fund served another important function. It helped reduce the patient load at the new Laguna Honda rehabilitation facility, which re-opened in the summer of 2010, with fewer beds, as a state-of-the-art “holistically planned” facility emphasizing natural lighting, community gardens, and patient-directed care.

Keeping patients in hospitals is far more expensive than integrating them into the community, says Dustin Harper, program director for the fund.

“So it’s also in the county’s best interests,” says Harper, also director of Care Management for the Institute on Aging, which contracts with the county to provide direct services. Headquartered in San Francisco, the non-profit institute promotes health, independent living and community involvement for Bay Area seniors.

Most clients need help in three areas: coordinating their overall care, in-home supportive services, and housing assistance.

Clients are normally supported by the fund from six months to a year – sometimes longer – until they are stabilized and can live independently with existing social services.

Before the fund was created, patients either remained hospitalized or struggled after their release.

“Individuals that had been living in an institutional setting and coming back into the community had to be their own case manager,” says Harper.

Harper says housing is the most acute need for relocating patients.

“Sometimes that takes a couple of months,” says Harper. “Who’s going to pay the $5,000 to get the unit ready?”

The Community Living Fund assists 200-300 residents at any one time. Its existing case management staff of 12 includes 10 social workers, a nurse, and an occupational therapist.

After acceptance into the program, clients are first assessed and then receive a detailed care plan.

During the first month in independent living, case managers are required to see clients once a week. The next two months clients are seen every two weeks. After that they are seen monthly.

Two years ago, Tracey Sorrell suffered an aortic aneurysm followed by spinal cord damage. After rehabilitation, she moved into wheelchair-accessible housing in Chinatown, relocating from her three-bedroom home.

The fund provided her with additional furniture, dishes, a bathing chair, a power wheelchair, and other mobility assistance. Her case worker, Kari Kientzy, also helped coordinate in-home supportive services and physical therapy.

But Kientzy helped in other areas as well.

“Any time there was something on my mind, anything stressful as far as family was concerned, I was always able to talk to Kari about it,” says Sorrell, who sees Kientzy twice a month and talks to her whenever necessary.

Now stabilized in the community, Sorrell is being transitioned out of the program to make room for other clients.

“I’m going to miss her,” says Sorrell of Kientzy, who for three years has worked as a case manager.

“A lot of times the first month there are some challenges,” says Kientzy, recounting a common phrase heard from newly-released patients: “Maybe this isn’t going to be as easy as I thought it was going to be.”

Patients often need help as their benefits change from institutional living to independence. The morass of benefits paperwork can include in-home supportive services, social security, Supplemental Security Income, Medi-Cal and Medicare.

In many cases, managing medications alone can be an enormous challenge, especially when previously handled by hospital staff.

Just going to the pharmacy “is a big trip,” she says.

“A lot of our clients have complex medical, mental health, and substance abuse problems either past or present,” adds Kientzy.

She says some clients have been homeless for 30 years, are put into San Francisco General Hospital following a life-threatening illness, then rehab at Laguna Honda.

“For some people, being at Laguna Honda is the most stable they’ve been for a long time,” she says. The fund helps them transition into stable housing rather than back on the street.

How does Kientzy handle long days of bureaucratic red tape?

“There are days when it’s really rewarding and days when it’s really stressful,” she admits.

Harper says the fund’s success depends on the financial support of the city and county, with administrative overhead provided by his non-profit Institute on Aging. Without all three working in synch, he says, the program wouldn’t be financially viable. In fact, Harper says the state’s Medi-Cal program has tried unsuccessfully to mirror the model.

“It’s a very close collaboration between city and county and a non-profit,” says Harper. “That’s a big piece of why it works here.”

Harper and Edelstein say that the program is unique to California – and perhaps the country.

The fund receives $2.74 million annually out of the county’s general fund. Costs per client are about $800 per year.

One of the greatest advantages to the program, says Edelstein, is that expenses are flexible and can swiftly be directed to areas of greatest need.

“We can do as we wish (with the funds),” she says.

Approximately 70% of those who apply for the fund are eligible. Last August there was a waiting list of 27 patients awaiting assistance.

Eligible clients must be at least 18, a San Francisco resident, and have income up to 300% of the federal poverty level – currently $31,200. Applicants must also be unable to complete at least two of the Instrumental Activities of Daily Living (IADL): eating, dressing, moving, bathing, grooming, or going to the bathroom. Also qualifying are patients who require the care of a nursing facility or are unable to manage their own affairs because of emotional or cognitive impairments.

For those who qualify and can now live on their own, they cite a common mantra.

“Freedom,” says Sorrell. “I can go and come as I please.”

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