Aero Methow Rescue Service Director of Patient Care Justin Porter and volunteer advanced EMT Bruce Hevly, rear, conduct the daily ambulance check, making sure all equipment is present and that supplies are up to date.
Federal grant may help create safer, healthier living situations
Feisty and independent. That’s how Lookout Coalition founder Raleigh Bowden described residents of the Methow Valley.
These are people with a very strong, self-sufficient nature who are determined to remain in their home as they age. But as health needs pile up, this stubbornness and independence can tip people over, even though they believe they’re fine. “It’s a very slow process of decay,” Aero Methow Rescue Service Director of Services Cindy Button said.
Physical and mental health issues or cognitive decline — coupled with poverty and other social factors — can make it difficult for people to maintain a safe living environment, said Rana Clarke, executive director of Jamie’s Place, which operates adult family homes in Winthrop.
No one chooses to live in such difficult conditions, Aero Methow Director of Patient Care Justin Porter said. Most of these people had been receiving health care when, for some reason, their situation escalated, he said.
The circumstances vary. Some people have no running water. They may have no food or no way to prepare meals. They may not be taking their medications. Some people aren’t mobile enough to use the bathroom orto take pets out. Sometimes garbage piles up. Some people end up in the hospital, but sign out against medical advice and end up at home, unable to care for themselves.
Still, over time, a person can acclimate to situations like this. Although it’s hard to accept, people can reach a point where they’re not aware of the extent of their needs, Button said. When people are unable to cope, they reach out for help. But by the time Aero Methow is involved, the situation has typically reached a crisis point, she said.
Financial challenges are always a contributing factor. “There’s a tremendous amount of poverty in the Methow Valley — many people have no idea,” Porter said.
These needs are typically not visible to the community at large. But local health care providers and social-service agencies encounter people in these circumstances with troubling frequency.
There’s a new grant-funded program that these providers hope will help people before they reach a crisis — and provide support so they have the independence they desire. The goal is to be proactive and provide help before someone gets to that point, Button said.
Care coordination
The Methow Valley Community Based Long-Term Care Network, a coalition of health care and social-service providers, has come together to support people in a dignified way and get them the help they need to be safe in their homes.
The network recently received a four-year, $1.2-million grant from the federal Health Resources & Services Administration (HRSA) that will pay for a part-time nurse or social worker. That person will provide case management, coordinating care between a primary-care provider, specialists, and social services to ensure that everything — from physical and mental health care to food, housing and transportation — is taken care of, said Raleigh Bowden, founding director of the new initiative and grant program.
The partnership includes the Lookout Coalition, Jamie’s Place, Room One, Methow At Home and Okanogan Palliative Care. They also work with the Methow Housing Trust and TwispWorks on housing issues. Aero Methow has its own care coordination program and is likely to become a partner, Porter said. Last week, the long-term care network hired a director to oversee the grant and they are interviewing for a care coordinator/case manager.
Having someone who’s dedicated to communicating with all the agencies involved in a person’s care will ideally connect people with the services they need so they no longer fall through the cracks, Clarke said. “It’s all about talking to each other — we all have the same goal, with different pieces of the strategy,” Bowden said.
Bowden, who’s spent a decade with the Lookout Coalition helping people with chronic health needs to lead safe, full lives, acknowledged that solutions are not easy. Some people will just say, “No, thank you,” she said. Still, the majority are open to getting help, Bowden said.
Although needs can seem overwhelming, there’s always some way to help — often the greatest impact comes from communicating and coordinating care with other agencies, Porter said.
Complex roots
The roots of these situations are complex. Someone may be caring for a spouse or partner, but may not have the physical or cognitive ability to provide all the care they need — they may even forget to provide meals, Clarke said.
Even hearing loss can contribute to problems, because when people can’t hear well enough to understand when someone calls to check on them, they may not ask for help, she said.
In addition to the physical and/or cognitive conditions that affect people’s ability to care for themselves and their living spaces, it’s even harder if there’s no help from family or friends, according to the team at Room One, the Twisp-based social-service agency. (Because Room One has many advocates and specialists, the information the agency provided to the Methow Valley News includes input from the entire team.)
The impacts of living in poverty tend to pile up, so people with limited income and resources have to make choices about what they can pay for. They may forego garbage collection because they need to feed their family, the Room One team said. “What we don’t often realize is that ‘cleanliness,’ broadly speaking, is a systemic privilege; it is not just someone’s decision to clean up,” they said.
Finding meaning
It’s not unusual for Aero Methow and the Lookout Coalition to be called several times a week when people don’t have a safe living situation and are in crisis. There are various reasons — people may know and trust the paramedics and EMTs, or they may need someone who can make a house call because they can’t get to a doctor.
Economics also play a role — if Aero Methow responds to a call but doesn’t transport the individual, the care is free.
Community members often ask Room One for help with their living situations when they’re unable to adequately heat or cool their spaces, if they have no power or water, or can no longer maneuver around their home, the Room One team said.
Porter is one of many local health care providers who’ve been trying to figure out how to help. He takes time to get to know people and to understand their needs and desires. “If people can make their own decisions, they have the right to live in difficult conditions, as hard as it is to see,” he said.
You have to address underlying issues — it’s not a simple fix like cleaning up a house, said Porter, who’s also a registered nurse and a paramedic.
“People have found meaning in their situation, and changing that can be scary,” Porter said. Often, the most meaningful thing is a relationship with a pet, so changes to housing that could threaten that bond can be particularly threatening, he said.
Porter works with the individual to find a solution that provides meaning in another way. He may ask people to describe a meaningful day and about their hopes and dreams. It’s noteworthy that they almost never describe their current situation, so they work together to explore how to get those meaningful days back, Porter said.
Moreover, there can be a lot of judgment about how someone “should” live, the Room One team said. In rural communities, people may choose to live off the grid or with fewer amenities. It’s important not to make people feel targeted or “othered” for the way they live, the team said.
Room One staff have to balance respecting those choices with paying attention to a situation where a person’s cognitive function is impaired and the living conditions pose safety risks, the team said.
“The health care system is full of crevasses,” Porter said. It doesn’t support these people even while they’re coping, let alone when they’ve lost the ability to cope, he said.
Clarke agreed. It’s even more challenging in a rural area, which has fewer resources overall, she said.
Moreover, the valley has a serious lack of paid caregivers, which has a significant impact on whether a situation is somewhat livable to when it becomes untenable, the Room One team said.
Another reason they need a grant for care management is that insurance companies don’t reimburse for the time it takes to coordinate the necessary care. Meanwhile, data show that outpatient, community-based care significantly reduces costs, Bowden said.
Interventions
Arriving at solutions involves myriad challenges. Systems that provide services for aging and vulnerable populations don’t fit together as perfect puzzle pieces to address all layers of people’s situations, leaving people with unmet needs, the Room One team said. Ideally, coordinating those systems will fill in those gaps.
Aero Methow does its own follow-up, checking in weekly on people who are particularly vulnerable, as well as after a 911 call, Porter said. They also have a consistent-care program, where, with the patient’s authorization, Aero Methow can share information with other agencies to help with their care.
Caregiving organizations in the Methow Valley already spend a lot of time strategizing about how to help people stay in their own home when that’s what the individual desires, Bowden said. They hope the grant will streamline the process and expand the available resources.
There are relatively straightforward interventions that can improve people’s health and quality of life. Being sure people have enough food will keep them from being hungry. Addressing skin ulcers can help people walk more easily. Transportation to the doctor can address a variety of health issues, Bowden said. Some people are very isolated and need more human contact. Simple interventions like grab bars in the bathroom can restore some independence.
Room One staff develop a relationship with the individual and work together to identify whom that person sees as supporters and resources, and then tries to fill in the gaps. That can include community services like Aero Methow or Methow At Home, health care providers, and family and friends, they said.
Some situations do require additional intervention. If someone’s capacity to participate in identifying a support network is impaired, all these groups work collectively to create a path to safety, the Room One team said. If there are imminent safety concerns, Room One connects with appropriate resources through 911.
Still, it’s very difficult to overrule someone’s decision-making capacity — the individual must be quite incapacitated, Bowden said. It’s an extreme step to ask Washington’s Adult Protective Services to intervene and most providers look for other solutions, Clarke said.
And even when people want mental-health counseling, there are many hurdles — and often a long wait time for appointments unless a person has the ability to pay for therapy out of pocket, according to local health care providers.
Room One works hard to balance individual choice and dignity with the need and desire to keep people safe and healthy — it’s at the heart of their work. There are a lot of success stories — and success looks different for everyone. A key component is that the community member (and their family and friends) have been part of the process and are happy with the outcome, the Room One team said.
Having money for professional coordination could be a game-changer, but there are ways that everyone can help. “Get to know your neighbors. Understand that while people live in a lot of different ways, everyone deserves connection and kindness,” the Room One team said.
