By Sherry Fox

“Boston’s Way Home” is Mayor Martin Walsh’s initiative to end veteran and chronic homelessness in the city by providing a pathway through health services and homes.

Last summer, the mayor invited community organizations, including Programs of All-Inclusive Care for the Elderly (PACE®), to partner in a “housing surge” targeting chronically homeless seniors, who had been without a home for a year or more and had some level of disability. The one-day event was designed to bring together government agencies and community organizations to provide housing and the support services needed for them to access and remain in stable housing.

Upham's Corner Elder Service Plan, based in Dorchester, MA, was the only PACE organization to participate in the first of two surge events last year. Upham's – which has PACE centers in Dorchester, Jamaica Plain and Roxbury – decided to venture beyond traditional enrollment methods and assume full responsibility for the complicated cases that came out of the initiative to demonstrate the merits of the PACE program to city officials.

During the first surge event, Upham's enrolled eight seniors, who were matched with housing and approved for support services all in one day. Mayor Walsh met with some of the new participants and visited the Jamaica Plain PACE Center, which provides the wrap-around services needed by formerly homeless seniors. The PACE staff works closely with housing managers to deal with issues as they arise so participants don’t face the loss of housing.

Pathway to Health and Housing

“One of the mayor's goals is to eliminate homelessness in the city by offering a pathway to good health and stable housing,” said Susan Kelliher, director of Marketing, Outreach and Promotions at Upham's. “The use of one-day surges is a strategy to bring together all the key players in one location so participants have the ability to obtain ancillary and health services and walk out with a place to live.”

“We’re committed to ending chronic homelessness,” said Emily Cooper, chief housing officer in the Executive Office of Elder Affairs. “About half of the chronically homeless in the city are over the age of 50, which is commonly referred to as ‘elderly’ in this population because they have physical symptoms of people who are 20 years older.”

The Boston Housing Authority would provide housing, but individuals involved in the surge event also needed the wrap-around support services, she noted. “PACE was one of the options.”

Elder Affairs works closely with MassHealth, the state Medicaid agency responsible for oversight of PACE. There are eight PACE programs throughout the state serving a total of 4,600 participants. Four of the programs are in the Boston area. The mayor’s office reached out to various senior care programs, including PACE, to ask if they wanted to participate in the surge.

“We were the only PACE program to participate the first time,” said Nancy Roach, director of Operations at Upham's. Upham's learned about the one-day July surge event just a month beforehand, she said. “There was not a lot of planning time. It was pretty miraculous.”

The Right Thing to Do

The first step was a pre-meeting with city and state officials that she attended with Mari Pérez-Alers, senior project manager at Upham's. “We were a little nervous about the population we would be enrolling,” Roach recalled. “This was out of our comfort zone – how do you sell this to your medical director? It was so counter-intuitive to how PACE works.”

At the end of the meeting, two things were clear, she said. “It was such an opportunity – at the end of the day, these folks have homes! And it seemed like the right thing to do.” It turned out to be an easy sell to the Upham’s team as well. “They were right on board,” she said. “All we could think about was the end result.”

“It was an opportunity for us to partner with other organizations,” noted Roach. “It was a challenge – a good challenge – a way to think outside the box to work with this population and adapt to their needs.”

“We asked the PACE organizations to step outside of what they usually do, and they did,” said Susan Ciccariello, director of Coordinated Care at MassHealth. “PACE enrollment typically involves progressive engagement with people over four meetings. The challenge with the surge is that you had to do that in an hour.”

Rapid Response Team

On the day of the surge last summer, homeless individuals identified by the mayor’s task force arrived by bus at the Labouré Center in South Boston at 5:30 a.m. They were served breakfast and then met with service and housing staff. The event ended around noon.

“We had to assess them, do an enrollment application, and get the assessment approved – all in one day,” Roach said. “Everything you know about PACE – getting to know the client, all that – did not happen.”

Upham’s had a number of staff members on hand for the surge event, including two from intake and three teams of nurses, rehab therapists and social workers to do assessments.

“It was a rapid response team,” said Pérez-Alers, who teamed with Roach and the clinical director to work with their state and city partners.

“It was unique for the individuals to be involved in a program like ours and a challenge for our staff as well,” said Roach. “But our staff was so on board. It was a process, but we worked through the challenges.”

For example, chronically homeless individuals are not good self-reporters, she noted. “They did not have a lot of information to share with us. The state gave us some data, but we didn’t see it until the day of the surge. If you’re not used to looking at claims data, it doesn’t mean anything to you.”

On-Site Screening

“Screening was done on site,” said Roach. “While approval usually takes 24 hours, MassHealth did it physically or electronically on the spot. The case manager working with the homeless person provided some information, and everyone could talk to one another, but we had very little time to do an assessment. This was our first time doing rapid response.”

The Upham’s team completed applications for 10 people in four hours and ended up enrolling eight of them.

“When the people moved into housing in the next few weeks, the PACE program could hit the ground running,” said Cooper. “They had chronic health conditions that had not been addressed in many years and were spread around the geographic area, but PACE programs are good about being mobile if people can’t get to their center.”

This group of individuals was a little different than traditional PACE participants, she noted. “You didn’t know if they would like PACE because they would have to see doctors and other people.”

“Rather quickly, we needed to make sure the individuals would remain housed without overwhelming them with everything that is thrown at them,” said Pérez-Alers. “We prioritized their needs. The first priority was housing stability. They needed furniture and food. It was a way for us to connect with them – a very tangible way to relate to them – and we got them adjusted to our program by taking these steps. They might not come to the PACE center every day, but it’s the way they pick up their meds and get what they need. Bit by bit, they connected better.”

After the surge event, the Upham’s rapid response team met to determine what the focus should be when assessing someone in a half hour or less, Roach said. “A lot was coming at them, and we needed to figure out how we could get what we needed in the shortest amount of time.”

Building Partnerships

“A great thing about the surge was having all those organizations together that can make the initiative happen,” said Pérez-Alers. “Building partnerships has been instrumental – learning about each other and supporting one another. We have held inservices with other organizations and hope to plan others to talk about the agencies and the homeless themselves to see if there are any other opportunities in the community that will need our services. That has opened the possibilities of working together with other organizations.”

“As a result, what is happening now is that some organizations are thinking, ‘If I can get this person housed, I can get them a program.’ That is really great,” said Roach. “It has brought a new recognition of what PACE can do.”

The relationship of PACE and housing is two-fold, Kelliher noted. “We worked very closely with the Boston Housing Authority so they understand what PACE is and that we can help them if they see participants not doing what they need to do.”

In addition, because the Boston Housing Authority properties house a lot of people, the question arises as to whether there are other people in a unit or building who are struggling, she said. “This has brought it to another level. Now that we have more participants in more of the residences, what kind of relationships can we develop? If a person isn’t going out, appears to be failing medically, etc., the housing authority now knows a little about what PACE can do.”

“It’s very helpful to provide examples of how PACE can help people remain living in the community that are palpable to housing managers,” Pérez-Alers said. “It provides a clearer picture of how PACE can provide supports. There is still room for improvement, but it was eye-opening in terms of how we needed to establish that relationship.”

Strategic Use of LTSS

"The relationship between Elder Affairs and MassHealth allows for a lot of overlap in thinking about long-term services and supports and how to use them strategically to get people into housing and stay housed,” Cooper said.

After the first surge event last summer, the other three PACE programs in the Boston area saw what an interesting model it was and participated in the second surge last November.

The city is continuing the Boston’s Way Home initiative. A third surge was held last month. Mayor Walsh wrote a first-hand account about the June 15 event.

Through the surge experience, “I’ve seen how fantastic the PACE model is and what it can do when paired with housing,” Cooper said. “Homeless providers are in love with PACE now. They want PACE to be involved with all kinds of formerly homeless people. They see PACE as a tool in their arsenal of keeping people housed. It’s a new relationship and a new partnership. Like all relationships, there are kinks to work out.”

Her office is getting calls from PACE programs in other areas of the state, such as Worcester and Springfield, asking to be involved. “We have been meeting with homeless planning groups throughout the state and bringing PACE providers from those localities,” she said. “I’m arranging marriages.”

Sherry Fox is communications manager at the National PACE Association.

Mayor Walsh (back row, center) visits with PACE participants and staff at the Upham's PACE
Center in Jamaica Plain, MA.

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