Patrick Ball is a frequent flyer at Interfaith Sanctuary.
He’s been flitting in and out of the downtown Boise emergency shelter for months in his wheelchair, bouncing between the Veterans Administration Hospital and the shelter’s hotel rooms it is renting for medically vulnerable members of the homeless community. With an 82-year-old mother with a full house of other family members to care for, he has nowhere to turn for help caring for his daily needs as a low-income person with multiple sclerosis who uses a wheelchair and cannot walk on his own.
Ball, 63, left the VA Hospital last week after going for treatment of two sores he has on his body and took an Uber to Interfaith Sanctuary. He arrived still wearing hospital scrubs, a camo jacket, and a hat with the U.S. Navy logo, looking for friendly faces. Someone with his needs should be in assisted living, but he hasn’t found a facility that will take him and his government benefits.
“I keep coming back here because I like it here,” he said, gesturing to shelter staff. “This place, if they had doctors and nurses, they would take care of me, but they don’t.”
In the aftermath of the COVID-19 pandemic, elderly people with medical needs started showing up at homeless shelters across the Treasure Valley in record-breaking numbers.
The combination of rising rents at once-affordable apartments and the closure of two dozen assisted living facilities catering to low-income Idahoans fuels the problem, leaving homeless shelters at a loss for how to care for guests who cannot use the bathroom on their own, easily move around the shelter or may have dementia.
As of September this year, 1,028 people over the age of 50 have entered the waiting list for services through homelessness nonprofit CATCH, making older adults half of the people served this year. This is a sharp uptick from 520 adults in the same age group who were helped from the beginning of 2021 through this time last year. At that time, adults older than 50 were only 22% of the total population served by the nonprofit.
Problem hitting a range of providers
It’s not just Interfaith Sanctuary and CATCH seeing more people in need like Ball.
Every housing provider in the Treasure Valley, including Boise Rescue Mission’s four shelters, eviction prevention nonprofit Jesse Tree, and Corpus Christi House Day Shelter, have seen a sharp increase in homeless Idahoans they cannot care for. Long years on the street and with poor access to healthy food means these older members of the homeless community are rapidly aging, sometimes with bodies more than a full decade older than their actual age.
Medical problems get further exacerbated when members of the homeless community struggle with mental illness, addiction or dementia, or degenerative illnesses, like Parkinson’s, making it difficult for someone to feed themselves or even communicate with staff. And with fewer and fewer beds in assisted living for low-income residents available every day due to staffing shortages and closing facilities, it leaves those caring for these vulnerable adults with few options.
At a recent Boise/Ada County Homeless Coalition meeting, representatives from several shelters and from the valley’s two major hospital systems (St. Luke’s and Saint Alphonsus) shared what they’re seeing with the growing crisis of an aging homeless population.
Donald Ruffing from Corpus Christi House told the other homelessness providers and advocates on the call that several times a month, someone arrives at the day shelter from the hospital or a care facility with unfilled prescriptions, no care plan, and no place to go. He will often call Interfaith Sanctuary to see if they have any bottom bunks open for someone to sleep in, but more often than not, there is no space, and he’s forced to leave them on the sidewalk with other members of the homeless community for the night.
“I wheel them out in front of Corpus, I give them a bag of goods, and I make sure there’s a phone around so they can call 911,” he said, with an edge of frustration in his voice. “That is my process, and unfortunately, I do this a lot because I have no one to call. I do this when I close at 4:30. I’m sad to say this is what I’m doing, because there’s a good chance when I get there in the morning and I will have to check to see if anyone has died.”
Leslie Cohen, Saint Alphonsus Health System’s manager of care coordination & utilization review, said at the same meeting the hospital system has seen more low-income patients come in without any family to care for them or a safe place to go. The hospital prefers to keep those patients at the hospital while they try to get them signed up for Medicaid and in an assisted living family that has room for them, but if a patient wants to leave and return to a homeless shelter, they cannot make them stay.
“Sometimes the patient choice gets in the way (of finding them a bed),” she said. “They want to go back to whatever environment they were in prior and we do have to respect that. Those patients we see come in and out of the hospital multiple times.”
Staffing issues, low Medicaid rates fueling long-term care closures
Finding a bed in an assisted living facility for someone who is paying with Medicaid instead of out of their own pocket has been getting steadily more difficult in the past decade.
Facilities are often reluctant to take Medicaid patients because the rates they are paid for the residents’ care are often so low that the facility will barely break even or, more often than not, lose money on taking the resident. This became an especially acute problem after COVID-19 hit when staffing shortages made it nearly impossible to keep workers at these facilities that typically pay low wages for back-breaking work.
Since July 2020, the Idaho Department of Health and Welfare saw roughly 25 small assisted living facilities statewide close because of financial resources or because they could not staff the facility. Many of them were specifically targeted at caring for Medicaid recipients with mental illnesses. DHW’s Licensing and Certification Administrator Tamara Prisock says there are noticing requirements and rules to find new placements for any residents a care facility is discharging, but any facility still has the right to refuse admission or to remove a resident if a facility says they can’t take care of them.
“Staff shortages are forcing long-term care facilities to make some very difficult decisions, including discharging or refusing admission for individuals with conditions the facility feels they don’t have the staff to care for,” Prisock said.
Another layer to this problem is the licensing requirements for these facilities that make it difficult to keep certain residents. Robert Vande Merwe, executive director of the Idaho Healthcare Association, said facilities can be in danger of being closed by the state if a resident is abusive to another resident, even just once.
“Sometimes in that case (the facility will) send them to the hospital and the hospital says ‘Why are they here? Let’s send them back,’ and the assisted living facility doesn’t have any good answers so they have the suitcase on the porch and say ‘I’m sorry we can’t take that patient back’,” Vande Merwe said. “At least there’s a psych hospital for someone with a mental illness, but that hospital has to figure out a safe place for them when they leave. But if they have dementia and there’s abuse, there’s no such thing as a dementia hospital. They don’t qualify for a psych hospital. So where does that patient go?”
When patients are discharged or cannot find a bed, they can end up in Cooper Court alley in with a bag of their belongings.
Heavy burden on shelters
Both of Boise’s emergency shelters are grappling with this problem.
At Interfaith Sanctuary, Executive Director Jodi Peterson-Stigers has brought on partnerships with groups like Cascadia Assisted Care to help stop the gap for residents who cannot bathe or use the bathroom by themselves. This helps keep people safe in the shelter while they’re looking for a home of their own with home healthcare or an assisted living facility, but it’s not a permanent solution.
Interfaith also currently is using COVID-19 relief funds to operate a hotel with nearly 70 beds as a second hotel shelter to house medically vulnerable guests. At this location, because of the privacy, they can receive medical services from Blue Bird Health and work with the hospital systems to get more medical care to them, but it still isn’t all levels of care some guests need.
There are more permanent projects to address this problem on the horizon, like the City of Boise’s plans for a permanent supportive housing building next to the rebuilt Fire Station 5, but Peterson-Stigers says the population is so large a bigger intervention is necessary. She has plans for 22 beds for medically vulnerable patients, two hospice beds, and a medical clinic at the nonprofit’s new shelter proposed for State Street, but the nonprofit is still fighting a court challenge to the project approval, and it’s unknown when construction could possibly begin.
Funding for the hotel shelter is set to run out in December, and if there isn’t a way to find more beds, there could be dozens more people in the winter months without a place to go.
“It’s a very heartbreaking situation that we are surrounded by daily right now,” she said on the call with the Homeless Coalition. “…Losing the hotel, is going to take us to a whole other conversation level. We need assisted care facilities to be lifted up and wrap social services around that include mental health and behavioral health. It almost needs to be a homeless shelter setting with assisted care because that’s how large the population is.”
Aging residents are flooding into Boise Rescue Mission as well. Earlier this month, BRM President Bill Roscoe said the shelter had 34 people staying with them over the age of 65, including one guest who was nearly 80. This is roughly double the number of guests in that age group the shelter was caring for at this time in 2021.
Like Interfaith, BRM is seeing lots of these guests who are using wheelchairs and cannot shower or use the bathroom on their own. Roscoe said his staff cannot care for these guests, and they cannot stay long-term, but he will try to keep them in the shelter as long as possible until they can find a placement. But, this is difficult because of the long waiting list for facilities and the rising rents outpacing what extremely low-income seniors can pay on fixed incomes.
BRM does have a Recovery Lodge for patients dealing with medical issues that has the capacity, but you have to be able to still walk, shower, and feed yourself on your own to stay there. That precludes that being a place for most of these elderly patients to go, and they need to move on. Roscoe said the size of the population is getting so big it might require the government to start opening public facilities to care for elderly people in need, even though he is normal highly opposed to government programs.
“Unless the government wanted to get into the assisted living business and the way I feel about government service I usually say ‘God forbid’, but it could be one of those things where it could make a difference. It’s a terribly difficult situation.”
‘I don’t have anywhere to go’
Hospital scrubs and bracelets are a common site in Cooper Court alley these days.
Earlier this month, the popular spot for Boise’s homeless community had a smattering of tents and other hastily erected shelters up against the wall in the alley between Corpus Christi House Day Shelter and Interfaith Sanctuary. Members of the homeless community sat in folding chairs and slept on makeshift crash pads, chasing the shade as the sun moved across the sky throughout the day.
Several older people sat on walkers with baskets full of their belongings or in wheelchairs with bags hanging on the backs of their chairs. One man with a missing leg brightened up when he saw Interfaith Sanctuary Executive Director Jodi Peterson-Stigers moving through the crowd, greeting community members asking after them. She stopped at his chair and chatted for a moment, but the conversation quickly turned when she asked him about his housing and the coming winter.
With tears in his eyes, he bent his head and quietly murmured his frustrations with his situation. Interfaith Sanctuary has been full every night in recent weeks, and he said he didn’t feel comfortable going to Boise Rescue Mission because of his use of alcohol and marijuana.
“I don’t have anywhere to go,” he said, quietly looking at the ground and then wordlessly pointing at his empty pant leg.
Next to him, another older man in scrubs with a shiny bracelet fresh from the hospital sat slumped on his walker with his head down. Someone had placed a Mcdonald’s bag of food on his lap, but he didn’t budge from his stupor when several people called his name or shook his leg. Peterson-Stigers moved toward him and called his name several times, placing her hand on his neck to check his pulse before stepping back once she realized he was still breathing.
He soon woke up and opened the bag of food as she started down the alley towards Corpus Christi House, greeting more people with her Shelter Manager Miranda Jay as she went along. Peterson-Stigers shook her head slightly, looking down the alley at the tents and people looking for services.
“Cooper Court looks very different right now,” she said. “We can visually see the increase in homelessness within our community and the high, high level of need.”