Homelessness and SNFs and Therapy – Lorin G., OT

 Over the last few months and over the last few years, working as an OT at skilled nursing facilities (SNFs) in the SF Bay Area, I have seen a lot of homelessness among the patients and residents.  Occupational therapy can have a profound influence with people experiencing difficulty in housing, but what can we do at a SNF?  Unfortunately, the homelessness often gets shuffled off to another department, like social services.  I am reminded of a short story, “Cop and Anthem”, by this American author pseudo-named O’Henry, where a homeless man in Manhattan is trying to get to “the Island”, probably Staten Island Prison, where he can stay and be warm and fed for the winter.  Similarly, SNFs can be a homeless shelter for a lot of people who need a place to stay. 

 More importantly, the occurrence of homelessness in SNFs and in our communities illustrates a lot of important factors about our society, like economics, resources, education, mental illness and crime, but also about the role of occupational therapy in helping people to lead a balanced and fulfilling life.  When I decided to study occupational therapy at SJSU, I was drawn to the field because of its heavy undertones of humanism and helping to change all kinds of people’s lives for the better.  Aiding the homeless at SNFs involves evaluation and analysis, client-based therapy, deep therapeutic use of self, and thinking of the larger context of an individual’s life and community.

Over the last few months I have literally seen dozens of people who describe themselves as homeless, some with more critical medical needs, like end-stage renal disease (ESRD) and chronic obstructive pulmonary disease (COPD) and many with lesser medical issues.  When I first started to work at a SNF with JTP, in one of my first articles on “COPD and Therapy”, I mentioned a man, pseudo-named Howard, who had chronic obstructive pulmonary disease, was morbidly obese (over 650 pounds), and had been living in a van.  He had been experiencing some major depression and had said that his van had been impounded because of a lapse in payments.  I mentioned in a second article that Howard had died one morning on his way back from the bathroom,  Another guy at the same facility, let’s call him “Johnnie”, was relatively healthy, about 53 years old, didn’t use a cane of walker for his functional ambulation, had a pacemaker, COPD, and a history of depression,  I had taught some therapeutic Tai Chi exercises to help him get into an exercise routine to better his breathing capacity, some relaxation techniques, and had tried to help connect him with a local job placement agency.  The Director of Rehabilitation (DOR), kept saying that he should move out of the SNF, but a abundance of housing options were not presenting themselves.  I am currently working with a 57 year-old woman, we’ll call her “Suzi”, staying at our SNF who has been homeless for a number of years after she had stopped working as a CNA about 18 years ago.  She has COPD, ESRD, a history of depression, and a history of staying in over 20 different SNFs over the last few years, according to one nurse, we’ll call him “Gerardo”, with whom I had recently talked.  She goes to dialysis about 3 times per week and often presents as fairly confused, not knowing the date or where she is.  On Thursday, September 22, I was trying to work with Suzi, but she kept calling 911 on her cell phone because she claimed she wasn’t getting the nursing or CNA attention that she needed with her supplemental oxygen machine.  I got the Rehab Department’s pulse oximeter to measure her oxygen levels…  they were at about 79% saturation according to this device, so it was time to teach some relaxation techniques and pursed-lip breathing.  When I next saw her, she was being taken to the emergency room by an ambulance that she had called.  I spoke to the Director of Nursing (DON) the next day and she said that Suzi had been a bit impulsive with calling the ambulance and that there was no unusual medical condition found.  “Gerardo” said he was happy later in the day when she went off to dialysis.

In all of the SNFs were I have worked and at the one where I am working, these homeless people, have generally been treated well by nursing and with regular attention from the therapists of the rehabilitation department.  The key for therapists to remember is compassion and caring.  Most of these people have been having trouble with housing for most of their adult lives.  We can try to help them as best we can, offering therapeutic exercise, education, motivation, whatever ADL training is needed and more, but we’re not going to change their lives completely. 

The cost of staying at a nursing home or SNF is expensive and there are different ways an individual can pay in California and around the country.  After a 3 medically-necessary medical stay an individual will qualify for Medicare through the federal government, which will fund the next 20 days stay 100 % with a $133.50 charge per day for days 21-100 (2).  There is long-term coverage insurance that can help many people, but not all.  With homeless people, there must be some financing on the part of the nursing home, or other available funds or program, like Medical, to cover the costs of the sta.  For many of these homeless, once the “100 days” is over it’s either time to move-on or arrange a medical necessity.  I spoke to a social services woman at the SNF where I work and she said that a person is responsible for a “share of cost” after Medicare has paid its 20 days.  This share of cost may be covered by Medical in California or may be deducted from an individual’s Supplemental Security Income (SSI) check.

As therapists, it’s good for us to keep our minds open as we work with all individuals in SNFs.  With people who are chronically challenged with a place to live, there is often 20 years of reasons why this is the case, drugs, alcohol, depression or other psychosocial problems, family, relations, abuse, etc.  There’s nothing we can do about the past, but it is our duty as therapists to work with an individual’s present and future to make the best living situation that we can. 

References:

1. Allison Baker, COTA, “The Truth About Homelessness”, accessed at Advance for Occupational Therapy at,  http://occupational-therapy.advanceweb.com/Article/The-Truth-About-Homelessness-and-Mental-Illness.aspx , on September 4, 2011.

2.  Accessed at: http://www.calregistry.com/housing/snf.htm on September 21,2011.

3.  Lorin G   COPD and Therapy, accessed at: Jackson Therapy Correspondents, at http://www.jacksontherapy.com/therapy-opportunities/jackson-therapy-correspondents/?article=COPD_and_Therapy_Lorin_G._%28OT%29, on September 24, 2011.  See also:  COPD and Therapy Ii, http://www.jacksontherapy.com/therapy-opportunities/jackson-therapy-correspondents/?article=COPD_and_OT_II_%E2%80%93_Lorin_G.__%28OT%29