MULTI-MILLION DOLLAR MURRAY | ORANGE COUNTY-WPC
Murray had been homeless for over thirty years. He went back and forth from the east and west coasts, but much of his homelessness had been along the Orange County coast. Before facing homelessness, he went through many experiences that would lead him to this state. After a series of traumatic experiences since childhood, including abuse and later a bicycle accident that resulted in a brain injury and life-long tremor, Murray enlisted in the military in the late 1970’s. It was in the Navy where Murray began using drugs and alcohol. After suffering a brain aneurysm, an indirect result of cocaine usage, Murray was discharged from the military under "less than honorable" terms. He then moved to the east coast in an alcoholic blackout and thus began his homeless trajectory and alcoholism. Murray made his way to California, where his drinking had escalated to 4 pints of vodka a day. His second marriage dissolved as a result of his excessive drinking, and this set him on a dangerous course of multiple emergency room visits and arrests. He would be in the hospital almost 6 times a month and had hundreds of police encounters.
Then came on the scene, Tom, Outreach Worker from Coordinated Entry. Through repeated contacts and hospital bailouts, Murray and Tom developed a trusting relationship with each other that spanned over 10 years. Tom knew he could only do so much as Murray had gone to detox before, but would end up relapsing hours later after he left the facility. Tom tried everything, and yet, Murray continued to decline deeper. In July 2017, Tom brought Murray to Hoag Hospital ER for an injured wrist, as a result of a bad fall while inebriated. Murray was looked over and treated and was then referred to Illumination Foundation’s Recuperative Program under the County’s new Whole Person Care Recuperative program; which focuses on breaking the cycle of repeated usage of OC hospitals and emergency rooms. Both Tom and the Social Work Team at Hoag Hospital realized that Murray would be the perfect candidate for the WPC program.
Murray was transported (by Tom of course) to Illumination Foundation's Recuperative Care Center in Midway City, CA. The Recuperative Care team was fully aware and expecting that he would continue to drink, and the initial care plan would be on scaling back on the amount and frequency of his consumption and follow Harm Reduction. Within a day or two, Murray decided that he wanted to get sober! And this is when things became a little more complicated. Due to his severe drinking problem, Murray needed to get detoxed at a medical facility which was not an easily available resource for the homeless. With withdrawals being potentially fatal, and Murray adamant on not drinking, it was crucial to find him a solution. Illumination Foundation was incredibly resourceful and creative and in the end ensured a safe medical detox for Murray from alcohol. Murray is a regular visitor to the behavioral health team's counseling offices, seeking out support and guidance for relapse prevention, coping skills, and just the opportunity to connect on a human level. IF's case management and housing department are collaborating to find a permanent housing solution for Murray, and ultimately, to keep him off of the streets and out of the hospitals and institutions that became his second home.
Today, Murray is still alcohol free and going strong! He continues to be visited by Tom, and a couple of dear friends from the outside. Strawberry shakes are now Murray’s drink of choice. Murray continues to improve daily; his affect has cleared, his memory has improved, and he is a model client at the IF’s Recuperative Care Center. Murray even asked how he could be of service, and is now cleaning the dining room tables and chairs daily after mealtime. He recently told Tom that he is enjoying being sober.
None of this would have been possible without the coordination and efforts of so many: Tom, Hoag Hospital, Orange County Health Care Agency, CalOptima, and Illumination Foundation. As for Murray, if you ask him how he feels about the whole thing, his response is simple: "I am so grateful for everything, I cannot thank everyone enough.” Murray is an inspiration for many, and the hope at Illumination Foundation is that he blazes a trail for others to follow.
FELICITY | INLAND EMPIRE
Felicity was homeless for ten years. She had been struggling with substance use for many years, using it as a coping mechanism to block out her emotions of having been without a home. She faced traumatic experiences that had left her feeling lost, lonely, sad, helpless and isolated from our community. She had moved from county to county, but most recently ended up in Riverside, CA. While on the streets, her health declined dramatically as she struggled to manage her depression, diabetes and COPD. Due to her medical state, she required an oxygen tank 24/7, limiting her access to local shelters and programs.
A shelter in Coachella Valley connected Felicity with a case manager to help her find housing, but Felicity’s constant hospital visits caused the both of them to lose contact.
Felicity ended up at the Banning Healthcare Skilled Nursing Facility and with IEHP’s help she was referred to Illumination Foundation’s Recuperative Care.
At Illumination Foundation’s Recuperative Care, staff noticed Felicity continued to struggle with depression. She isolated herself in her room and slept throughout the day. Illumination Foundation staff began to engage with Felicity continuously and attempted to build a trusting relationship with her. Little by little, Felicity began to open up and allow the medical coordination and case management teams to help and support her. As she grew more comfortable and trusting with the staff, Felicity would leave her room to get her medication and socialize with her peers in the community room.
After so many years of deep sorrow, Felicity finally began to feel better. As she continued to work with IF staff, she remembered that she had been to a local clinic before her previous shelter visit. After some investigation, staff found that she had been a client at The Hope Clinic at Path of Life Ministries. Through a collaborative effort from both service providers and Felicity, she secured transitional housing with Path of Life Ministries where they would continue to support for her and tend to her medical needs and mental health.
Felicity came to Recuperative Care feeling helpless and isolated, but with daily, positive interaction with the staff, she finally feels a part of our community and ready to get back up on her feet.
She is now with The Path of Life Ministries transitional housing program awaiting a new home!
ANTONIO | LOS ANGELES
Before Antonio faced homelessness, he owned his own business doing landscaping and construction. He had his own apartment and lived a stable life, but his life flipped upside down when he became ill.
As each day passed, Antonio felt more sick and had no idea why. He suffered from severe abdomen pain and was unable to work, causing him to lose his housing. He managed to put together just enough to stay in a motel room while he addressed his health. He had been planning to move back home with his family, but he found himself in the hospital due to his deteriorating health.
While at St. Mary Medical Center, Antonio was diagnosed with cancer. Not only did he find himself alone and homeless, but with a deadly disease. Antonio was forced to stay in California to receive medical treatment.
When St. Mary Medical Center learned about his situation, they referred him to Illumination Foundation’s Recuperative Care where he could recover and heal during his treatment. After careful assessment of Antonio’s medical condition, Illumination Foundation found that IF’s Senior Recuperative Care program better fit his needs. Antonio was immunocompromised and needed a single occupancy unit during his medical treatments.
Once housed, an Illumination Foundation’s medical coordinator accompanied Antonio to his appointments to better understand the diagnosis and treatment options. Once staff knew that Antonio needed three chemo treatments per week for several months, they advocated and ensured that he would have all the support he needed to get to his appointments.
Chemo was draining, but Antonio knew there was more work to do. He worked alongside an Illumination Foundation case manager to find housing options post-treatment. The PICC line used for his chemo treatment made placement more challenging than usual. There were no other programs or shelters that would allow Antonio to stay, so they had to find a different solution. Antonio was determined to get back on his feet.
As time went on, Antonio began to feel better and found the strength to begin working light jobs. Having income meant that Antonio might be able to find an apartment!
Illumination Foundation had connected with Antonio’s family in Vegas and built a trusting relationship over the months of treatment. They often came to visit Antonio and show their support. They helped make sure he went to all his chemo appointments and even helped with the housing search efforts. Together, Antonio, staff, and his family were able to find an affordable room for rent in Long Beach.
Antonio’s family paid his first month’s rent to ensure he would have a little more time to rest and adapt to his new life.
After exiting Recuperative Care, staff and family continued to help Antonio transition into his new home.
Antonio has expressed his deepest gratitude for all the support and help staff provided him during his stay. His health continues to improve. He is back at work and loving his new home.
LESLIE & JOHN | LOS ANGELES
After two long years of living in the streets of Los Angeles, Leslie enjoys the comfort of a real bed, bathroom, dining table and even a small kitchen at Illumination Foundation’s Recuperative Care Center. She recalls the time her tent was slashed by a stranger in the middle of the night, and as she remembers she is frightened, but thankful that at least for that night the slashes only pierced the tent and not her skin. She faced many terrifying moments while on the streets, but thankfully Leslie wasn’t alone.
For 11 years, Leslie and John have been a team in the streets. The couple has been each other’s strength and shoulder to lean on through all their hard times. It wasn’t until two years ago that they ended up on the streets of Los Angeles. They lived in their tent and tried to keep to themselves. It was there where a C3 Outreach team found them and began working on connecting them to resources. While on the streets, Leslie and John went to the Union Rescue Mission for meals, and focused primarily on staying alive and together.
After a year of working with the C3 Outreach team, the couple was referred to the Star Clinic to address their deteriorating health. Leslie has down-syndrome and John faces various other chronic diseases. From there, they were both referred to Illumination Foundation’s Recuperative Care Program. They have maintained together throughout their process, eventually going from a dormitory setting to a studio type room at our Alhambra facility. After being in our program for some months and working together with their case managers and other staff at Recup to stabilize their health and secure permanent housing, Leslie and John approached the staff about their dream of getting married.
The staff was ecstatic to hear the news and got to work on pulling together all their resources to make this fairytale come true. First thing was securing a pastor. A staff member contacted Andy Bayles, CEO of the Union Rescue Mission, which had been providing the couple’s meals for months before they came to IF Recup. Andy gladly accepted to host the ceremony for the couple. Secondly, the happy couple needed wedding attire and wedding bands. Leslie’s case manager was able to find a donated beautiful gown for the bride and like any bride, Leslie was fitted for the dress. A staff member tried to find John a decent suit at a local shelter for homeless men, but unfortunately the suit provided didn’t fit him. In a happy turn of events, the gentleman distributing the clothing took John shopping for a brand new suit, shoes, and even socks for his special day, all on his dime. A donation of a gift certificate for wedding bands from a local jeweler was given, and Leslie and John got to choose their very own matching wedding bands. And there were donations for everything needed for a small reception: a chicken dinner, apple cider, and a beautiful wedding cake.
On the day of the wedding, Leslie walked the street alongside IF’s recuperative care as John’s face lit up to see her, more beautiful than ever in her gorgeous white gown and veil. The couple lead the wedding guests in a parade-like crowd down the street to a local rose garden where the ceremony would be held. The guest list included the C3 Outreach team that connected the couple with IF, many of IF’s own staff who had helped obtain the couple’s forever home and a local church friend.
It was a beautiful wedding that serves us as a reminder that even in the toughest of times love can prevail. We are so happy for the couple and grateful to all those who collaborated in making this fairytale a reality for Leslie and John. They are now permanently housed in LA county.
MARLO | LOS ANGELES
Marlo had been homeless on the streets of Los Angeles for over 3 years. He would stay at family members' places for a short period of time, but mainly slept outdoors. During those years, his health was diminished while out in the environment. He became homeless due to alcoholism and mental health needs; he continued his struggle for years.
His deteriorating health led him to go to the hospital multiple times a year. Finally, he landed at Martin Luther King, Jr. Community Hospital for shortness of breath and pneumonia, alcoholism, hypertension, and beginning stages of dementia. He was then referred to Recuperative Care through LA DHS.
While at Recuperative Care, staff worked with Marlo to get him stabilized and help him find housing. His case manager assisted him in obtaining the necessary documents in order to apply for housing. Staff helped him order a new California ID, his medical insurance card, and his SSN card. They began his application to SSI and took him to all his medical appointments. Marlo was also connected to much needed mental health services.
Marlo was reconnected to his family, and his sister and mother came out to the facility to visit and support him during his stay. After gathering his important documents, staff helped Marlo find housing and he moved into his own apartment at Huntington Park, CA. Marlo expressed his appreciation for all the staff did for him, and he was extremely happy to be able to have his own place.
JORGE | INLAND EMPIRE
Jorge faced many barriers that prevented him from finding housing and a job. With his history of incarceration, it was very difficult for him to find a job, and he became homeless with no place to go. After getting in an accident, he ended up at Loma Linda University Medical Center. He was treated and then referred to the Recuperative Care program through IEHP.
At Recuperative Care, Jorge was thankful to have a safe place to recover while being given the opportunity to turn his life around. While working with his case manager, Jorge was determined to find a solution to his housing needs. He wanted to also reconnect with his family and try to mend those relationships. Jorge was able to reestablish contact with his family, but they were not willing to let him move back in. However, they agreed to lend him money to find an RV for himself. With this great news, Jorge was active everyday trying to secure himself an RV at an affordable price. Soon, he was able to acquire an RV and an RV park to make a home for himself. He started working again by creating his own business as a handyman. Jorge was now able to provide for himself and have a stable home. He expressed his gratitude to the staff for their support and assistance that enabled him to have a brighter future.
STANLEY | ORANGE COUNTY
It was unknown how long Stanley was living on the streets, but he struggled with substance abuse, mental health, and chronic illnesses. Stanley was at St. Joseph Hospital for pancreatitis and other medical issues. His eyesight was severely deteriorated where he couldn't see more than a few inches in front of him. St. Joseph was able to refer Stanley to our Recuperative Care program to receive the care that he needed.
While Stanley clearly had a physical disability, he didn't let that stop him from working with staff to complete his goals. He was connected to REACH where they helped those with mental health and disabilities obtain resources to help them live a fuller life. With the help of staff and REACH, Stanley was connected to a clinic to help with his chronic illness and find him housing that would serve his needs.
With his disability paperwork previously on hold, his case manager helped him get the required documentation he needed to resume the process. Staff also assisted in getting him his needed medication obtain General Relief funds, and assisted in advocating for him to obtain housing.
Stanley was able to find a transitional shelter that would give him more support with his chronic illness and substance use. They had programs in place to help him overcome his challenges. Although he still had obstacles ahead of him, case manager was able to ensure he would have the assistance and support of REACH during his stay at the transitional shelter. With staff help, Stanley was confident he could move forward in his life to reach success.
RAY | LOS ANGELES COUNTY
Ray was originally from Florida, but came to California some years ago. With no family here, Ray had no support when difficult times came upon him. He struggled with alcoholism and mental health conditions. He found himself trying to survive on the streets and was homeless for one and a half years. These factors exacerbated his already poor health. He developed gastrointestinal issues and high blood pressure which continued to worsen without needed medical attention. When he came to White Memorial Medical Center, he was referred to Illumination Foundation’s Recuperative Care program for a safe place off the streets to recover.
Ray arrived at IF Recuperative Care with no identification and minimal belongings. With his history of substance abuse, all of the staff continuously encouraged him to push forward in the program. With the support from staff, Ray felt he was able to take strides to improve his outcomes.
Ray’s case managers worked with him to retrieve all his vital documents needed in order to find any sort of housing. He didn’t have anything on him and had to start from scratch. Ray went to the DMV to obtain a California ID, his social security card, and applied to increase his social security income.
While in the program, Ray attended Illumination Foundation’s Health Expo in order to get vision services as it had been awhile since his last eye exam. Thanks to the free services, Ray was able to receive a full eye exam and was prescribed and received new glasses. In addition, the exam with ophthalmologists revealed that Ray had glaucoma. The doctors volunteered to give him the follow-up care needed surgery at no cost.
With help from his county case manager (ICMS worker), Ray was able to find permanent housing. He got furniture and even went grocery shopping with his ICMS worker. Recup Staff was also able to coordinate with his ICMS worker to provide him with a TV antenna and TV in order to provide him with an activity that would help him cope with getting sober. Ray is now at home and working everyday towards a better life!
Randall | Los Angeles County
Randall had been living in his own apartment and had a regular job. Misfortune struck him as he suffered from two strokes that led him to be permanently disabled. Unable to work, Randall could no longer afford rent and moved in with his sister; however, things did not turn out well as disputes erupted between the two. After a huge argument with his sister, Randall had to move out. Not knowing where to turn and how to get out of his situation, Randall continued living on the streets for two years until his health began to deteriorate. He was suffering from severe depression, along with diabetes, high lipids, and high blood pressure. All these factors eventually led him to another stroke which landed him at Glendale Adventist Medical Center. He was then referred to Recuperative Care.
When Randall came to Recup, he wanted help to get off the streets and find a place he could call home. His case manager helped to increase his income in order to afford renting a room, and Randall went to work immediately looking for rental listings. Randall was able to have his social security income increased, and obtain his social security card and birth certificate. Medical coordinators were able to connect him to mental health services for his depression, and helped him learn how to get his health under control.
As his time was nearing an end, Randall finally found a room for rent. Illumination Foundation was able to extend his time at Recup by 4 more days in order to give him time to properly secure his new room. Randall was ecstatic to move in and have a roof over his head again. As staff and him parted ways, Randall expressed his gratitude for the efforts made, and the assistance and support provided by Recup staff.
JACK | ORANGE COUNTY
Jack had been homeless on the streets of Venice and Santa Monica for 5 years. He moved around until he found himself down in Orange County. He was a veteran and suffered from alcoholism and depression. Jack eventually found himself at Fountain Valley Regional Hospital and Medical Center for alcohol withdrawal. Thanks to the nurses and discharge staff at the hospital, they were able to refer Jack to Recuperative Care.
Jack arrived at Recup with nothing but a hospital gown on. Recup staff immediately provided him with clothes and supplies he needed for everyday living. When his case manager reviewed his documents, she saw that Jack did not have a proper ID card. Jack was accompanied to the DMV in order to obtain his identification card which was a crucial step to apply for housing. He welcomed the help of Recup staff to get him help for his alcoholism. They were able to get him accepted into the Safe Refuge treatment program in Long Beach where he would be able to stay for up to 2 years. Additionally, his case manager connected him with Bill, a liaison from the GPD program for homeless veterans. Bill worked with Jack in order to upgrade his discharge status, apply for monetary benefits, and apply for permanent housing through the HUD-VASH program.
Jack finally received hope after years of being a homeless veteran. He was very appreciative of the Recuperative Care staff who helped him in such a short period of time. He also mentioned that he was very excited at the prospect of reconnecting with his family and grandson once he was sober.
JOSHUA | INLAND EMPIRE
Joshua had been living in his car and struggled with substance abuse prior to coming to Recuperative Care. Being homeless and in unstable living conditions made it very difficult to manage his diabetes and his health. All of these factors caused an untreated diabetic foot ulcer to worsen over time until he had to go to the emergency room. At Rancho Springs Medical Center, the discharge planner was able to work with IEHP to get him referred to Illumination Foundation's Recuperative Care.
While in the program, Joshua's case manager worked with him to see what his options were. He came to the program with all his important documents and only needed to apply for Food Stamps. Along with help with social services, Joshua's case manager wanted to figure out a housing plan for him. During this time, he mentioned that he wanted to reunite with his brother who lived in Georgia. When Joshua's brother was contacted, it was discovered that his brother wanted him to come home and help him with his substance abuse. Joshua's brother told him he wanted him to come live with him in Georgia and help with the family, wanting to give Joshua a sense of purpose to have him stay away from drugs.
With the help from staff, Joshua was able to have a plan to stay with his mother in Lake Elsinore for a few days before making his way back to Georgia to be with his brother. Staff was able to provide him with gas money to help him on his trip.
JENNIFER | ORANGE COUNTY
Before arriving at Recuperative Care, Jennifer went through a difficult journey before finding hope for her future. At the young age of 3, Jennifer was taken away from her biological family. She grew up in the foster care system until she aged out at 18 years old. With no help or direction, Jennifer was forced to make it on her own. She moved from shelter to shelter in San Bernardino but was never able to settle in one place.
On a seemingly normal day, Jennifer was alone at a McDonald’s when a couple of women came up to her and befriended her. They gained her trust by making her believe that they were going to help her—instead, they deceived her and forced her into human trafficking. After several months, Jennifer managed to escape what would have been a dark fate. With the help of the police, she finally found temporary stability at Rachel’s House, a shelter that helps victims of human trafficking.
While she was there, staff noticed a drastic change in her behavior. She was admitted to the hospital for an assessment and was transferred to a state mental health program for a couple of months. There, she was diagnosed with bipolar affective disorder. After being treated to a stable state, she was able to return to Rachel’s House. However, with no management of her disorder, she soon became unstable again. This time around, she was admitted to St. Joseph Hospital. An avid supporter of Illumination Foundation’s Recuperative Care program, the discharge planner at St. Joseph Hospital referred Jennifer to the program.
While in Recuperative Care, Jennifer was determined to be proactive and stay positive about her case. She was strong-spirited, loving, and sweet. Although she had discouraging and rough days, she was still able to get through the day because of the encouragement and support from staff along with her strong faith. However, that did not mean she didn’t face many obstacles to finding housing. Jennifer encountered multiple doors being shut regarding placement. There were many times when she wanted to give up, but she decided to hang tightly to her hope. There was one day in particular where Jennifer was ready to throw in the towel. Since Jennifer’s faith was the key to her strength and hope, staff reached out to Lena Martinez from Anchor of Hope Ministries to provide additional support and morale. This helped Jennifer stay positive in her situation, and she was extremely thankful and appreciative of the community of people who supported her, believed in her, and worked hard to see her succeed.
Finally, her perseverance paid off! OC Rescue Mission opened their doors and provided her a spot for an intake and assessment. Lena personally transported Jennifer to and from her first interview and intake process. Jennifer made it past the first round and was asked to return for a second interview with Outreach Manager, Doug Hellman. Lena was unable to take her to her second interview, but made sure to not let Jennifer fall through the cracks. She reached out to fellow member, Michelle Riggan, who more than willingly took Jennifer to the interview. OC Rescue Mission stated that Jennifer was the perfect fit for their program! Jennifer’s last obstacle is only waiting for her background check to clear before she proceeds to transition there. We are truly happy for Jennifer as she takes the next big step to a stable life.
LOUISE | LOS ANGELES COUNTY
Struggling to sustain herself with her little income, Louise eventually lost her apartment. She found herself being homeless with no safe place to live. The poor living conditions caused her health to deteriorate over the years. After three years of homelessness, Louise's health caught up to her. She ended up at LAC+USC Medical Center where she discovered that she had uterine cancer. After two months of intensive treatment with the care of LAC+USC’s medical team, Louise was cancer-free. LAC+USC Med Ctr’s referral to Illumination Foundation Recuperative Care was exactly what Louise needed to recover from her surgery. Recuperative Care offered her a safe place to stay along with medical coordination and intensive case management.
In her time with Illumination Foundation, she obtained identification documents which was crucial in helping her access financial assistance. She was connected to resources like Access and SSI which was imperative to helping her become more self-sufficient. Louise worked with the Recuperative Care team to assist her in the healing process both medically and emotionally. Her active participation in continuously working on her housing finally paid off. After months of looking and waiting, Louise got her own apartment! Thanks to LAMP Community, Louise had a smooth transition into housing and they were able to assist her with furnishing her new apartment. Thank you to LA DHS for our continuing partnership in breaking the cycle of homelessness!
ROB | ORANGE COUNTY
Rob became homeless after losing his job. While on the streets, he struggled with substance abuse and was not able to manage his diabetes. This led to him having osteomyelitis in his feet, and it progressed until he landed at St. Joseph Hospital. Due to the severity of the infection, he had to have all ten of his toes amputated. The discharge planning team at St. Joseph worked hard to get Rob ready for Recuperative Care. They kept communication open with the staff at Recup to keep them updated on how Rob was doing. It was a challenge, but Rob soon was able to move on his own while using a wheelchair. He was ready for Recuperative Care.
Rob arrived at the facility with all his necessary documentation. He was determined to find housing and improve his health. He got treatment for his substance abuse and was very proactive as he worked with his case manager to find a place to live. However, it proved to be difficult to find a room and board that would help with his meals and that was handicap accessible. That did not discourage him from continuing to search.
Finally, with the help of staff, Rob was able to find a place in Santa Ana that would accommodate his needs. When the date got closer for him to leave Recuperative Care, he began to get nervous and unsure if he could make it on his own. Staff assured him that his feelings were normal, but they were confident he would be successful. With that in mind, Rob was able to move into his new home and begin moving forward with his life.
LILY | LOS ANGELES
Lily was homeless for 2 years with constant admittance to the hospital due to respiratory problems. Being outside with no shelter only caused her respiratory problems to get worse and prevented her from truly getting better after each hospital visit. It was when she got admitted to Long Beach Memorial Medical Center that they recognized she would be a fit for Illumination Foundation’s Recuperative Care program.
Time was a challenge for Lily and her case manager as they had little of it to find her placement. Lily had another challenge of anxiety and had trouble getting along with others in her dorm. But staff was able to accommodate her with a little more privacy which helped her. She was able to have a safe place to sleep, received meals, and recover from her illness.
With the help of her case manager, Lily was able to be placed at Grandma’s House of Hope where she can receive further help to get her back on her feet.
POLLY | LOS ANGELES
Polly came to Recuperative Care through a referral from Synermed. With a multitude of mental health diagnoses and medical issues, it was clear that Polly would be a tough case that required continued encouragement and advocacy.
Polly arrived with minimal belongings, a few medications (excluding her psychiatric medications), and without her therapeutic dog, Happy. Upon intake, she was distraught and continually expressed her concern about Happy and was apprehensive about being in a dormitory setting. The staff ensured her that reuniting her with Happy would be the number one priority along with providing her the best care and protection. She felt reassured and settled in for the night.
The next day, the staff kept their word and Happy was brought to the facility. He came with nothing but a bed. Polly became quite worried as to what he would eat and where he would sleep. The staff was able to find a sturdy kennel and food for Happy, which calmed Polly down tremendously. It became apparent that Happy was key to Polly’s emotional stability and feeling of safety. On that same day, she was taken to a methadone clinic to provide some much needed medication since she had little to none.
Over the course of several days, Polly and the staff experienced various barriers. Since Polly was without vital medications to aide with her mental disabilities (schizophrenia, bipolar and high anxiety), she had trouble sleeping, was paranoid of other clients and staff (males in particular), and had extreme difficulty communicating with staff. When she would attempt to communicate, her words were jumbled together and she would jump from one topic to another all the while running out of breath. Staff remained patient with her, but she knew she was not explaining herself thoroughly causing frustration within herself and volatile outbursts. Communication was a challenge, but the staff continued to show patience and compassion towards Polly which really helped in calming her during moments of frustration as she recognized their kindness and goal to help her.
One night in particular, Polly was experiencing acute back pain and urinary retention but could not properly communicate that to the staff. However, staff noticed a change in her and quickly responded. The medical staff explained how important it was for her to go to the hospital. She was reluctant because she did not want to leave Happy. Staff was able to reassure her that Happy would be safe and would be there when she returned. She finally agreed. Female staff transported Polly to the ER but on the way there, she became anxious and afraid of what the doctors would do. The staff comforted her and ensured that she would be safe and sound. They even stayed with her until she was safely checked in. In the ER, there was a young man who was rather nervous about being in there. Polly knew how he felt and provided that young man the same comfort that was given to her.
More obstacles surfaced that challenged Polly’s progress. The staff knew it was urgent that she obtain her psychiatric medications and took her to a mental health clinic in order to fulfill that need. They were able to obtain her prescriptions and drop it off at the pharmacy that same day. However, it was discovered that they would be unable to pick it up for another couple of days. Polly was informed by this bump, and she quickly became stressed and had another outburst. The staff deescalated the situation by calmly explaining that she had been able to remain strong without the medications since entering the program, that she has the support to get through the next couple of days, and the staff believed she could. She was able to calm down and agreed she could make it. Later on that day, Polly heard voices that were telling her that she was not wanted and that she was a joke. She came to the staff explaining how she felt and that she wanted to leave and return to North Hollywood. Understanding that she would fall off if she left, the staff sat down with her and told her that the decision was up to her, but that she would be greatly missed and that she was a joy to have. The staff continued to encourage her and point out her progress with the program. She began to cry and thank staff for making her feel accepted and said she would stay.
Her birthday came and the staff showered her with love, a birthday card, and some gifts. She had mentioned to staff that coloring was therapeutic for her as well as a bible, so the staff got her a bible, markers, and a couple of coloring books. She was so surprised and delighted that she broke down and cried, sharing that it had been over 20 years since she received a gift. Staff again reiterated that she was special, has a purpose, and a joy to have in the facility.
Polly’s journey has not ended, but the staff continues to engage with her and help her make progress towards independence. The staff has been grateful for all the assistance from Synermed and MedZed to get Polly on track with her health. Her case manager has mapped out a case plan with her that includes: placing housing applications for her through the LA Department of Mental Health and Department of Health Services, to take her to get her California ID, have her social security debit card reissued, and assist with legal aid to resolve her record.
Polly has shown tremendous improvement since first arrived, and no doubt challenges will continue to arise. But she has shown trust in the staff and her own willingness to make positive changes to her life. Now that she is on her needed medications and has started to assimilate to a group environment, she can continue to improve as long as she is reminded that she is going through a huge change with people that are here to assist her to her ultimate goal: medical and social control and independence.
Gil | Inland Empire
Gil struggled with alcoholism and IV drug abuse. Being homeless, this exacerbated his poor health as he also had uncontrolled diabetes. His health took him in and out of hospitals until he got to San Antonio Community Hospital. With IEHP, they referred him to Recuperative Care for his diabetes.
Gil arrived at Recuperative Care with no identification and no belongings. With his history of substance abuse, the staff encouraged him to get into a rehab program as the best way to move forward with his life. Gil was at a point that he wanted help as well, and agreed to get himself into a rehabilitation program.
With his IV drug abuse history, Gil became fearful that the needles he used for his insulin medication would gravely hinder his chances at being accepted into a rehab program. The staff agreed and quickly got ahold of his doctor to change his insulin administration method. With the staff’s advocacy, they were able to get Gil an insulin pen so that he would not need needles.
Meanwhile, his case manager worked with Gil to retrieve all his vital documents. Having lost all of them while en route to the emergency room, Gil had to start from scratch. He went to the DMV to obtain a California ID, but was told he owed money from a previous bounced check. When he returned without his ID, his case manager heard what happened and accompanied Gil to the DMV to figure out what the issue was regarding the owed fee. A DMV representative explained that the last time he ordered a driver's license, he paid with a check that bounced. So he owed the fee for the driver’s license and for the bounced check fee. With funds from Recuperative Care, Gil’s case manager was able to pay off those fees that he couldn’t afford and finally get his CA ID.
With those tasks out of the way, Gil and his case manager began reaching out to rehabilitation shelters. Gil found one that he was determined to go to: The Salvation Army Adult Rehabilitation Center. He called the center, but had to leave a voicemail with the help of his case manager. He was worried at first, but soon enough the center returned his call and completed a phone assessment right away. The intake coordinator on the phone verified to Gil’s case manager that they could save a bed for him and he could arrive the following day.
At 6:30am, Gil’s case manager drove him to Perris and stayed while they had him fill out forms and complete a drug and alcohol test as required by the program. Gil tested clean and was accepted to the 6-12 month rehabilitation program.
JooJoo | Orange County
“JooJoo” became homeless after losing his job when the company got sold. Unable to find another one, he ended up on the streets and tried to find a place to sleep anywhere from outdoors to the Fullerton Armory Emergency Shelter. Then an accident occurred that brought him to the hospital, he fell from his bike and fractured his hip.
JooJoo came to Recuperative Care through a referral from Fountain Valley Regional Medical Center to have a safe place to heal from his fractured hip. Regardless of his circumstance, JooJoo brought his contagious laugh. His main language was Korean, so it made it difficult for staff to communicate with him, but they managed. He connected with staff through his positive attitude and his laugh. He was proactive when it came to working with his case manager and compliant with whatever was needed of him.
JooJoo faced some challenges when trying to obtain documents. He needed a California ID, and the staff tried everything they could. However, since his permanent status renewal was still pending, they could not get him one until it cleared. Despite this bump in the road, the staff continued to assist him by having him apply for General Relief. When it was approved, they continued to get him more resources by applying for the Cash Assistance Program for Immigrants (CAPI).
The next step in JooJoo’s journey was to find him housing. Since he was not yet receiving any income, finding placement was difficult. Staff reached out to other organizations to see what was available and possible. They connected with Coast to Coast Foundation and the Anaheim Police Department who had a partnership to assist homeless individuals. With their gracious assistance, JooJoo was able to move into Streetlight Room and Board with free rent for 2 months. This was amazing as it would give JooJoo time until his income kicked in. The staff from Streetlight followed up with Recuperative Care staff and called to thank them for bringing JooJoo in and that he was a joy to have.
PATRICK | LOS ANGELES
At the age of 28, Patrick never imagined that he would end up being homeless and sick. It's been seven years since he had a home to call his own, and he'd been struggling to meet his basic needs ever since. During this time, he found himself in and out of hospitals as he was unable to maintain his health while living on the streets.
In September 2015, Patrick was assaulted with a knife on the streets of Los Angeles, which resulted in internal organ damages and he was rushed to LAC-USC hospital. Already a frequent user of the hospital system, he was identified as being eligible for the county's housing safety net program and was referred to Illumination Foundation's Recuperative Care to recover from his injuries.
Patrick entered the program with no forms of identification, no income, and no connection to social services. His Case Manager in Recuperative Care assisted him in obtaining his birth certificate, California ID card, social security card, and connected him to social services such as General Relief and food stamps. Additionally, Patrick was connected to mental health services and Access transportation to get him to his medical and social appointments.
As Patrick made a full recovery, Staff noticed a major change in his demeanor and outlook as he became more confident and hopeful in his prospects for a better life. In November 2015, he eagerly met with a Housing Navigator, whom would be able to assist him in locating a home through a housing subsidy. Patrick regularly met with his Navigator until he was able to find an apartment in Los Angeles, CA. He beamed with pride while exclaiming and showing staff the key to his new apartment, "See? Here's my key!"
On May 25, 2016, Patrick expressed his gratitude and said his farewell to the Recuperative Care team as he made his way to his new apartment excited to start a new life.
JUANITA | LOS ANGELES
Juanita was originally from El Salvador and came to the United States in the 80’s in order to take care of her sister. Unfortunately, her sister passed away some years ago, and with no job and nowhere to go, Juanita ended up homeless. Her declining health soon caught up with her as she was unable to manage her chronic knee pain, hypertension, and depression. Juanita ended up at the Downtown Women’s Center where they recognized her need for stability, and with the help of DHS, referred her to IF Recuperative Care.
When Juanita came to the Illumination Foundation Recuperative Care Program, she had nothing but a small purse and the clothes on her back. Scared but determined, she sat down with her case manager and the medical coordinators to figure out a care plan while she remained in Recuperative Care. This care plan, however, turned out to be a little more complicated than staff had anticipated.
Staff soon uncovered that her medical care was scattered throughout several clinics in Los Angeles County. Since Juanita’s full name followed the traditional naming patterns in Latin American countries (which consist of a first name, middle name, father’s last name, and mother’s last name), different medical facilities had registered her under two completely different names, as they were generally unable to accommodate this cultural difference. Because of this, continuity of care was almost impossible for her. Once staff figured this out, they sat down with her and helped her determine which facility would best accommodate her needs. Juanita established a connection with her primary care physician, and, soon after, was able to schedule a cataract surgery, which would greatly help her with her eyesight.
In addition to her complicated medical care, it was obvious that her estrangement from her family was difficult for her when she arrived at Recup. She had no means to contact or visit her daughter, which caused her a lot of sadness. Fortunately, she qualified for programs that would help with these issues. Her case manager managed to successfully connect her to transportation services for disabled persons. She also obtained a new cell phone, which allowed her to contact her family more frequently.
A crucial step for Juanita was determining her residence status in the US. She and her case manager tackled the issues surrounding this, which she was unclear about. She and her case manager managed to contact the legal aid agency that had helped her a few years back. The workers explained that Juanita was eligible to be a permanent resident, but she needed to establish proof that she had been in the U.S for more than a decade in order to submit the application.
This process took time, but Juanita stood determined as she knew this would be a major step in obtaining crucial services. With the help of connections at medical facilities, her case manager was able to obtain the majority of the evidence needed. However, the process has not been completed. During this time, Juanita was assigned an Intensive Case Management Services Provider through the Housing for Health Program in LA County. The case manager from this agency collaborated with her case manager at Illumination Foundation to help place her into permanent housing.
After patiently waiting for nine months, Juanita was finally placed into an SRO unit in Downtown Los Angeles. Because Juanita moved out before she could obtain all the evidence needed for her permanent residency, the process is being continued by her long-term case manager, who followed her after she was placed in permanent housing. Her move into her beautiful new home will always be representative of what can come from a successful partnering between different agencies.
GLORIA | LOS ANGELES
Gloria's story of homelessness began 10 years ago when her nephew drove her to Skid Row in Los Angeles and left her there with only 3 dollars in her pocket. With a slew of mental health diagnoses and worsening dementia, Gloria was not able to remember where she came from or where her family lived. With no one to advocate for her, Gloria simply stayed put and tried to survive as best as she could. She slept on park benches and was able to sustain a living by collecting recyclables or sell her hand-crafted jewelry to passersby on the side of the freeway.
For ten years, this became a living for Gloria until her health began to deteriorate. Now at the age of 68, and with worsening edema on her legs, she found herself going more and more to the emergency room for her medical care. In December 2015, Gloria checked herself into East Los Angeles Doctors Hospital and was admitted due to increase swelling of her legs.
A Social Worker at the hospital referred Gloria to the Illumination Foundation's Recuperative Care. While in Recuperative Care, her Case Manager was able to gather information about her true identity and found interesting information regarding her past.
Gloria was born in Korea in 1947 and immigrated to Mexico as a child during the Korean War. She met her husband in Mexico in the 1970s and shortly thereafter, came to the United States. It wasn't until her husband's death in the 1990s that her mental health worsened. Due to Gloria's legal status in the United States, she was not eligible for any public assistance or receive any mental health services to treat her psychotic & schizophrenic disorders.
While in Recuperative Care, the Staff was able to connect Gloria to a primary care physician and connect her to mental health services through Los Angeles County’s Healthy Way LA. Gloria was able to treat the edema in her legs and made a full recovery and could always be seen smiling in the hall ways to anyone who came her way.
Gloria's Case Manager at the Illumination Foundation was able to locate an organization that connected undocumented homeless individuals to board and care & assisted living facilities. On March 29, 2016, after 10 years of living on the street, Gloria was able to move into a board and care facility in Hollywood, CA. She is now receiving adequate medical care and is connected to the crucial mental health services that she needed.
CALI | INLAND EMPIRE
Cathanic, aka Cali, originated from Mississippi and experienced a great loss after the passing of a close family member. This tragic event caused him to develop a deep depression and he began to lose his way.
Cali had been bouncing from job to job across the United States for several years and has experienced countless episodes of homelessness along the way. During his stay in California, however, Cali unfortunately endured an extra-long episode due to newly diagnosed medical conditions, lack of financial resources, and social support. Cali had lost three jobs in a row due to constant over exhaustion, shortness of breath, and episodes of passing out. He was then diagnosed with hypertension, diabetes, and inflammation of his pancreas. He was in and out of hospitals, but without a stable home, Cali was unable to improve his health and manage it. Eventually, his medical condition would put him back in the emergency room; but this time with St. Bernardine Medical Center, who referred him to Illumination Foundation (IF).
While in the IF Recuperative Care program, Cali had a chance to learn how to improve and maintain his health with education from the medical coordinators. Cali exceeded expectations in the maintaining of his blood sugar levels, diet, and exercise. When his case manager began to work with Cali to figure out housing options, Cali expressed that his grandmother had been asking him to move back home to Mississippi for some time now. Recup staff worked hard to make his wish a reality. Once deemed medically stable, IF was able to sponsor this dream come true and bought his Greyhound ticket to Mississippi. Cali is now happily reunited with his family and housed within the comfort of his family’s home.
PAUL | INLAND EMPIRE
Paul faced many challenges that led to his homelessness. After losing his job, he was unable to afford his mortgage, and his home was foreclosed. With no shelter and being homeless for a year, Paul was unable to maintain his health and developed cellulitis to both his lower extremities as well as deep vein thrombosis (DBT). Even with these poor health conditions and no home, Paul was determined to remain productive and continued his job search. His deteriorating health eventually landed him in the emergency room at Riverside County Regional Medical Center. From there, Paul was referred to Illumination Foundation's Recuperative Care.
Paul came to Recuperative Care with all vital documents, county benefits, and an impressive resume; but, there was no employment in sight. He did not let this deter him as he stayed active in working closely with his Recup case manager to figure out his next steps for housing and employment. Everyday Paul went to the library and searched for jobs, sending out his resume to multiple locations. At the same time, Paul was able to focus on stabilizing his health conditions and became very knowledgeable in how to manage his DBT. After several weekly phone calls to various transitional homeless programs, his Recup case manager was able to transition Paul to a 90 day shelter program in the High Desert. After three months, his cellulitis resolved and it was time to leave Recuperative Care. Several weeks later, his case manager followed up with him and is proud to report that Paul was able to secure his old job as the Senior Payroll Coordinator at Soboba Casino and now lives 10 minutes from his office. Paul has expressed great gratitude to the Recuperative Care staff and IEHP for all their support.
ANDRA | INLAND EMPIRE
It is a great pleasure to report the success of one of our IE Recuperative Care graduates, Andra Williams, aka “Everybody’s Street Mama.” Ms. Williams had experienced over 4 years of homelessness in Riverside County. Even though she was in a tough situation, she was still an active community advocate to those sharing the streets with her.
Prior to her entering Recuperative Care, Andra was discharged from Riverside Community Hospital after being pepper sprayed in the face during an altercation, which resulted in issues of shortness of breath and near blindness. With a safe place to stay in the program, she was able to recover from the shortness of breath and was connected to all the specialists needed to secure a date for eye surgery. Ms. Williams had also been approved for Permanent Supportive Housing through the Path of Life Ministries several months prior to her entering into Recuperative Care, but was experiencing all the discouragement from landlords that came with securing a unit with limited income and credit.
One apartment application after the other and continuous landlord denials eventually built frustration within Andra, and she lost hope. As time was running out with minimal bridge housing options, and she began to become medically stable, the advocacy of IF’s Case Management team for her became crucial.
With Illumination Foundation refusing to send this client back to the streets and with the cooperation of Path of Life’s Community Shelter, the gap of housing was bridged and Andra was allowed to stay until a unit was secured. With IF staff’s help and Andra’s unfailing determination, an apartment was finally secured, utilities were turned on, and a move-in date was in place! Two months after her program exit date and move-in date into her very own apartment, Andra Williams made her appearance back at the shelter as a proud and encouraging volunteer. She continues to be, “Everybody’s Street Mama,” serving those in need and giving back to those who gave to her in times of her own need.
Lyn | Orange County
Lyn, her sister, and her mother, Janice, left Toledo, Ohio 30 years ago to start a new life in the West Coast. As a single mother with two PhDs, Janice provided for her children as best as she could, working as an educator in both Arizona and California. As the time passed, Janice’s mental health deteriorated and she was no longer able to provide for her family. Now at a working age, Lyn began contributing to the family by working as a clerk at a well-known airport in Arizona. However, a serious injury left her with limited mobility and unable to return to work, which then left an already struggling family with fewer and fewer resources. Lyn’s family began to live from motel to motel in Orange County, CA, with Lyn’s sister being the only member of the family working to sustain the family unit.
In 2015, Lyn’s sister suddenly passed away as result of a heart attack, which left Lyn and her mother in a vulnerable situation. Soon thereafter, they took residence in a van that a friend had allowed for them to live in, which was not the ideal situation for Lyn and her mother. Lyn’s extreme weight also made it all that more difficult for any shelter or transitional-type settings as a suitable option for temporary housing. To make matters worse, Lyn soon suffered serious burn injuries to her legs when the van floor heated up. She was taken to Hoag Hospital while her mother was taken to a nursing care facility in Anaheim, CA.
While at Hoag Hospital, Lyn was treated for her wounds and worked with staff to make a full recovery. Hoag Hospital reached out to Illumination Foundation Recuperative Care to assist Lyn with a safe transition of care, but due to her weight limitations, she did not meet criteria for admittance into the program. Knowing Recuperative Care would be the best option for Lyn, the staff at Hoag Hospital worked hard with Lyn to lose a significant amount of weight in order to meet criteria. Hoag Hospital staff then reached out to Illumination Foundation once more and Lyn was accepted into the program. During this time, Lyn had made the decision to be reunited with her mother, and hopefully, to be reunited with her family in Toledo, Ohio.
Lyn arrived at Illumination Foundation’s Recuperative Care on December 2, 2015. One of the challenges while in Recuperative Care was Lyn’s inability to ambulate, which was difficult given her weight. That did not deter Lyn as she worked everyday with Medical Coordinators in making small strides to gradually get her to ambulate. Additionally, IF Case Managers reached out to the Change of Life Foundation in order to secure the resources needed to reunite Lyn with her mother and then to her family in Ohio. IF Staff coordinated with Lyn’s cousin, who had agreed to fly in from Ohio to accompany Lyn and her mother on the flight back to Ohio.
Yet transporting Lyn and her mother to Ohio would prove to have its challenges; both Lyn and her mother had expired forms of government issued ID cards, which were required to board a plane. Lyn’s case manager worked feverishly in obtaining the necessary information and documentation to be able to pass TSA requirements.
By the end of her stay in Recuperative Care, Lyn was provided with the medical oversight and physical therapy needed to be able to be discharged in a stable condition. Lynch Ambulance Services was more than generous to provide a wheelchair accessible van free of charge to transport Lyn to John Wayne Airport while her cousin transported her mother. Lynch Ambulance also had donated one of their employee’s time off in order to get Lyn to the airport on time.
On December 21, 2015, Lyn was escorted by IF medical staff, along with her cousin and mother, to John Wayne Airport. Obstacles still faced Lyn and her mother once they arrived as they did not have proper ID to board the plane. The IF Nurse persisted in helping them both by successfully using their hospital bracelets, prescription medications, and discharge paperwork as forms of ID to get through airport security. After a four hour delay and advocacy on behalf of the IF Nurse, Lyn, her mother, and cousin were able to safely board American Airlines and fly home to their family in Toledo, Ohio.
james | Los Angeles County
James came to Recuperative Care as a referral from a caring nurse who wanted to make a difference in her patient's life. He was a U.S. Air Force veteran and served in the late 50's and early 60's, just missing the Vietnam War. He was a sweet elderly man who loved to converse with others; he had a story for every occasion. He also asked everyone he encounters their birthday and remembers them all! James said that he may not remember a name, but he never forgets a birthday. Before becoming homeless, James was once an engineer within a prominent company for many years, but unfortunately, was let go due to the company downsizing.
James' plight escalated from there, and he eventually found himself living in an abandoned motor home - left to him by a friend who had passed away. It had no electricity or running water, but it was a place off the streets. He knew someone who owned a business, and the man was kind enough to allow him to keep the motor home on the premises. Eventually, James found himself suffering from COPD and was on a 24-hour oxygen supply and breathing apparatus. He was also battling skin cancer. He had been very independent on his own, but admits, with sadness in his voice, that his condition was deteriorating; and he would soon need assistance with day-to-day living.
While at Recuperative Care, his case manager worked hard to connect him with non-profit agencies in Orange County, and took him to critical medical appointments at the VA. Case managers also took him to meet with a Social Worker at the VA/CRRC where they assist homeless Veterans. The social worker provided James with information for a Veteran Convalescent Home that James would be able to apply for. With the help of Recup staff, James was secured interim housing at a veterans assisted living home with an agency called Veterans First. James was scheduled to go into the home on a Friday morning, but there proved to be obstacles as he ended up being admitted into the hospital for the weekend. Luckily, he was stabilized and released from the hospital and was taken directly to the home. James now resides in a safe home with 24-hour care among his fellow veterans.
DAVID | ORANGE COUNTY
When St. Joseph Hospital referred David P. to Illumination Foundation’s Recuperative Care, he had been experiencing homelessness for 10 years. David had developed liver cirrhosis and peptic ulcer disease from years of drinking and frequently went to the emergency room for stomach pain. Another side effect was forgetfulness that made it difficult for him to look after his already poor health. Originally scheduled to stay at Recuperative Care for two weeks, David was instead referred to our Chronic Care Plus (CCP) program after learning about his past of frequent hospital visits; so he could receive long-term help with his medical and social needs.
When case management sat down with David to assess his needs it stood out to them that he had never had an eye exam in his life – staff immediately helped him get one. Over the course of his homelessness David had also lost all forms of identification, lost his income, and lost touch with his family. Case management helped him obtain income benefits, apply for SSI, and obtain a new ID and social security card. Due to his forgetfulness and chronic pain, getting these pieces of his life back together was harder for him than for others. It would often take more than one try for David to get through a given process – but he was willing to keep trying, and with staff advocating for him along the way, he was able to get an income and the basic documents he would need to begin rebuilding his life.
At one point during the process, David disappeared. Staff contacted the community agencies they had connected him to, but the agencies had not seen him. Staff then reached out to David’s estranged sister. When he had first entered Illumination Foundation and was asked if he had any family support, he said he had a sister but due to past issues they weren’t on speaking terms. When staff called his sister, she said David had not contacted her but she was concerned about him; and she kept in touch with Illumination Foundation until he returned. From then on David and his sister reconnected and stayed in touch.
David was welcomed back to Illumination Foundation after his absence, and with the renewed family support he began a productive period that has culminated in July 2015 with David moving into permanent housing. With the help of case management connecting him to a housing subsidy, he can now afford his rent, ending a decade of homelessness. At the board and care where he now resides, staff there also provide reminders for him to take his medications and keep an eye on how he’s doing, which is vital to his stability. David can now look towards a brighter future with stable housing, better health, and with the support of his family.
MARIA | LOS ANGELES COUNTY
Maria came to IF Recuperative Care shortly after the 2014 Christmas Holidays. She is a petite elderly undocumented homeless woman with breast cancer that resulted in a mastectomy. She was uncertain of her age and often confused her own date of birth. Some days she admitted to being in her early 60’s while other days she was admittedly 70’something. She had exhausted her couch surfing resources and was unable to stay with her only living relative due to her abusing that relative. With nowhere to live and needing follow up oncology care, county hospital negotiated with LA County’s DHS for her to come to IF Recuperative Care.
On arrival, IF Nursing Staff immediately began the tedious process of connecting her to both primary medical care and specialty medical care. Simultaneously, IF Case Management staff began the equally tedious process of securing her vital documents and connecting her to social services that would be beneficial to her.
Initially it seemed like no progress could be made on either front. Without documentation, she could not be connected to medical care and, being undocumented from Columbia, no documents were able to be investigated due to the Columbian Consulate being closed till late spring of 2015.
Eventually staff was able to connect Maria to a Primary Care Physician through LA County’s MyHealthLA program for undocumented residents who have no form of ID. The wait list for new appointments was lengthy but eventually she was seen and medications were updated and refilled.
Additionally a referral to oncology was submitted paving the way for follow up care related to the Breast Cancer. Or so we thought.As spring turned into summer, Maria became restless. She left the site daily as she attended Church regularly and she embedded herself into a local Senior Center. At night she struggled with the other women in the dorm, frequently getting up and disturbing those who were sleeping. She was frustrated and continued to argue with staff while expressing her need for a more permanent living situation without a dorm setting. From time to time, she would resort to calling the Police to report “abuse” only to beg them to find her a permanent place to live. IF CM Staff continued to pursue every possible avenue to obtain an ID and income and to secure safe and suitable housing for her. Everything seemed to lead to one dead end after another.
Through the summer, IF Nursing Staff continued to pursue specialty care for her oncological needs. This too proved to be an elusive goal. No oncologist in the county would see her without a CA ID and cash to pay for the appointment. Thankfully, she remained sturdy and appeared healthy with no indication that her health was declining. As summer turned into fall, IF staff continued to pursue and advocate for the medical care and vital documents that she needed while DHS continued to pursue the housing that she needed. Collaborative discussions were held daily as all staff worked tirelessly to help Maria find safe and suitable housing.
Finally after more than 9 months a light flickered on the horizon. DHS had found a Board & Care provider with a new pilot program. This program was targeting elderly undocumented folks with medical needs who were unable to live independently. The program staff came the following week and met with Maria and IF staff to begin the paperwork. Once approved, a final document was suddenly needed even as her bags were packed to move into her new home that same week.
After 9 months, it all came down to one critical document that required a 30 minute visit to and a signature from her Primary Care Physician. The soonest available time slot was several weeks after her scheduled move in day. In a supportive collaboration, DHS was able to intervene and advocated to the CEO of the clinic. After a brief conversation, the appointment was rescheduled for the day before the scheduled move. IF Recuperative Care Staff accompanied Maria to the appointment.
The final form was signed and completed and presented to the Board & Care the next day when Maria’s Recuperative Care Case Manager transported her to her new forever home. It was a long journey home but so worth all the hard work and persistence.