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Conjoint homeless prevention services for older adults
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Content
Conjoint Homeless Prevention Services for Older Adults
by
Greg Sanchez M.S.W.
Doctoral Capstone Project
Doctor of Social Work
Suzanne Dworak-Peck School of Social Work
University of Southern California
Capstone Advisor Board:
Eleanor Bolar, PhD
Jennifer Lewis, PhD
May 2020
Executive Summary
Conjoint Homeless Prevention Services for Older Adults
Older adult social services programs are facing a very serious problem across America. It
is estimated that 10,000 people retire each day (Administration on Aging, 2010). This
compounded with older adults whom have already retired on low incomes, are inundating adult
social service programs. Moreover, with the new medical technological improvements in
healthcare people are living longer, with an expected longevity rate of 18.6 years
(Administration on Aging, 2010). California’s current proposed solution is to allow counties in
the State of California the opportunity to apply and be provided grant funds to incorporate a
Home Safe (HS) homelessness prevention program to Adult Protective Service (APS) programs
across the state. While this is new and innovative, it also falls short of leaving many older adults
to fend for themselves because of narrow eligibility requirements and lack of coordination and
thus efficient care and consequences onto older adults. This is an unethical consideration and a
social justice issue in access and equity. While our society works to address the issues of
homelessness in the United States, this author feels the need to specifically look at the older adult
population 65 and older who face not only issues of abuse and neglect but increasingly issues of
homelessness simultaneously. Within the larger conceptual framework our national, state and
local governments, local communities, private organizations and philanthropists have identified
this as a need and have pledged to work on a master plan for aging, nationally and specifically
here in California. This work is focused toward addressing the increasing demand of an aging
society and particularly older adults, 65 and older. Established by Assembly Bill (AB) 1811
(Chapter 35, Statutes of 2018), and funded by the Administration of Community Living (ACL) a
program called Home Safe, (HS), a 3-year pilot program that is being made available across
California social service programs who have the infrastructure needed to implement the program.
The County of Fresno Department of Social Services (DSS) is one program who has applied for
and has received the authority to launch the Home Safe Program. The County of Fresno, Adult
Protective Services (APS) has completed the request for proposal process, was approved and has
received a grant allocation of $588,571 to implement the program. It is this author’s innovative
approach to assist in the exploration, process develop, evaluation and sustainability of this
program and through an organization system redesign model will be referred to as conjoint
homeless prevention services across programs. Conjoint homelessness prevention services will
work to close gaps in siloed services and work to coordinate two innovative approaches to help
prevent homelessness of older adults (aged 65 or older). The conjoint homeless prevention
redesign will demonstrate best practice approaches, while providing evidence based evaluative
on data outcomes on what worked and what did not work in areas of staff productivity, program
implementation, and efficacy. It is hoped that the system re-design model and successful
implementation of a conjoint homeless prevention program will be used to address the wicked
problem and Grand Challenge of older adult homelessness in America and even more make an
impact on prevention and intervention to eradicate homelessness amongst the older adult
population in America.
Table of Contents
Section I: Executive Summary
Section II: Conceptual Framework...………..………………………………………………....... 1
Research, Practice, and Innovation……………………………………………………… 2
Social Significance………………………...……………………………………….......... 3
Conceptual Framework, and Logic Model …….…………………………………........... 4
Section III: Problems of Practice and Solutions/Innovations.………….………………………... 8
History, Policy, Practice, ………………………………………………………….…...... 7
Existing opportunities for innovation………………………………..………………….. 8
How this Proposed Innovation/Solution Aligns with the Logic Model……………........ 10
Likelihood of success…………………………………………………………………… 11
Chapter IV: Project Structure, Methodology, and Actions Components……………………….. 13
Analysis of the market for the proposed project/innovation……………………………. 13
Financial Plans and Implementation Strategy………………………………………….. 17
Methods for Assessment of impact………………...…………………………………… 18
Stakeholder Involvement………….......………………………………………………... 20
Communications Products and Strategies.……................……………………………... 20
Ethical Concerns and Possible Negative Consequences……………………………….. 21
Section V: Conclusions, Actions and implications…………………………………………….. 24
Conclusions Within a Field of Practice………………………………………………… 22
Implications of the Project Innovation ………………………………..……………….. 23
Acknowledgments of Limitations and Risks: Recommendations for Future Work…… 25
Advancing to Next Steps……………………………………………………………….. 25
References…………………………………………………………………………………….... 27
Appendix 1: Logic Model……………………………………………………………………… 32
Appendix 2: CHPS Pamphlet..………………………….……………………………………… 32
RUNNING HEAD: Conjoint Homeless Prevention Services
Section II: Conceptual Framework
Older adult social services programs are facing a very serious problem across America. It
is estimated that 10,000 people retire each day (Administration on Aging, 2010). This
compounded with older adults whom have already retired on low incomes, are inundating adult
social service programs. Moreover, with the new medical technological improvements in
healthcare people are living longer, with an expected longevity rate of 18.6 years
(Administration on Aging, 2010). California’s current proposed solution is to allow counties in
the State of California the opportunity to apply and be provided grant funds to incorporate a
Home Safe (HS) homelessness prevention program to the Fresno DSS Adult Protective Service
APS Program across the state. While this is new and innovative, it also falls short of leaving
many older adults to fend for themselves. This is an unethical consideration and a social justice
issues in equity.
This capstone is one of 12 Grand Challenges described by the American Academy of
Social Work (AASW, 2018) and will work toward a stronger social fabric in the area of ending
homelessness. For this project, this author will be focus on older adults 60 and older. As our
society faces issues of homelessness across the United States, we need to understand the need to
also look at our aging population. We need to understand the complexities of this aging
population while paying close attention to their needs, vulnerabilities and issues related to the
prevention of homelessness. The purpose of this innovative project is to update the outdated
social work practices of California Adult Protective Service (APS) programs with regard to
homeless prevention for older adults.
Conjoint Homeless Prevention Services
2
The proposed new practice model is called Conjoint Homeless Prevention Services
(CHPS) for older adults, a redesign practice model for California APS programs, administration
and stakeholders and other county social services agencies looking to address the needs and
concerns of an aging population that is also facing issues homelessness. This project objective is
to redesign and demonstrate the effective implementation of (CHPS). CHPS is designed to
enhance the delivery system of the Fresno County Adult Protective Services while reducing gaps
in siloed services by iterating two conjoint services designed to address issues faced by an older
adult population while removing barriers and criteria to access and to mitigate the risks of
homelessness.
The capstone project will provide an overview of California CHPS homeless prevention
program, with emphasis placed on the design implementation of CHPS. Fresno County APS has
applied for and was awarded grants funds to implement a program called Home Safe. Home
Safe is a homeless prevention program for older adults who come to the attention of APS as a
result of abuse and/or neglect and whom face eminent risk of homelessness. This has not been
done before as APS has not had the resources designed specifically to provide homelessness
intervention services for older adult persons. During the implementation of Home Safe into APS
has created an opportunity for this author to redesign APS. The new design model is called is
CHPS therefore Home Safe and APS will be referred to as CHPS.
The objectives of the CHPS model is to first assist the County of Fresno with the
implementation of a conjoint homeless prevention services and to design, implement, and
evaluation the pilot project. It is hoped that this project will provide preliminary evidence of a
viable APS service delivery design aimed at reducing homelessness among older adults 65 and
Conjoint Homeless Prevention Services
3
older, within the county of Fresno California. CHPS primary goal is to address a new group of
older adults who were not previously eligible for APS or Home Safe. To be eligible for APS
Home Safe Program and older adult has to meet the criteria of being an older adult over the age
of 65 or dependent adult who has come to the attention of APS as a direct result of abuse or
neglect. If determined to be at risk of homelessness the older adult would then be referred to the
Home Safe program. CHPS will change this process and develop the program to allow older
adults to come into the program without having to have been victims of abuse or neglect. It is the
goal CHPS to redesign APS and provide a new methodology that will provide research data on
implementation that can be shared with APS, other counties, agencies, stakeholders, legislators
and most importantly funders.
Research, Practice, and Innovation
Older adult social services programs are facing a very serious problem across America. It
is estimated that 10,000 people retire each day (Administration on Aging, 2010). This
compounded with older adults whom have already retired on low incomes, are inundating adult
social service programs. Moreover, with the new medical technological improvements in
healthcare people are living longer, with an expected longevity rate of 18.6 years
(Administration on Aging, 2010). The growing population of American adults aged 65 and older
and their associated financial, health, and mental health concerns is leading to an increased need
for social service programs. Our local protective service programs have an opportunity to be a
part of California’s Disrupt Aging Plan.
Conjoint Homeless Prevention Services
4
Socially Significance
Older adult homelessness is a growing social problem, especially among older adults who
do not meet eligibility requirements for current APS services. Implications of not addressing
these issues forces increased need for temporary housing, increased need for room and boards,
increased issues of abuse and neglect which create issues of financial abuse. These issues lead to
increased issues of health and stress which leads to other issues such as depression, anxiety, post-
traumatic stress and substance abuse. These issues create the need for more hospitalizes that lead
to high costs of care into room and boards. As it is older adults, who live off of small incomes
but yet who are not eligible for means tested services are forced to make decisions between
paying for food, medications and housing. In review of the Department’s programmatic data,
most APS clients present with at least one of six different issues that could lead to homelessness,
if no intervention is provided. Older adults then are facing imminent risk of homelessness or
recently homeless and individuals that have experienced longer periods of homelessness or those
more likely to require longer term interventions who would be referred to programs due to abuse,
neglect, self-neglect, or financial exploitation.
Conceptual Framework, and a Logic Model
CHPS will be implemented will incorporate the following procedures:
(a) Remove access criteria for older adults who need access to homelessness prevention
services.
(b) Design strength based, client centered assessment model and hire two Homelessness
Case Managers to work with the older adults.
Conjoint Homeless Prevention Services
5
(c) Provide service descriptions complete with specific service deliverables and build a
collaborative team partnership.
As result of this project, implementation of service linkage and supports will be
established across collaborative agencies. Older adults will be provided CHPS and reintegration
services in the home so they can remain safely in their own home. The overall goal is to increase
and improve access to quality human services for older adult clients while creating sustainable
support plan for older adults to remain safely in their own home with a sustainable plan to
mitigate the risk of future homelessness issues. This proposed solution will use evidence based
practice model and a trans relational component that requires the development of social
relationships to study, to mobilize and to improve the overall service delivery relationships
amongst collaborative partners who work with the same population (Gehlert, Hall, & Palinkas,
2017).
Section III. Problems of Practice and Solution(s)/Innovation(s)
Proposed solution/innovation
Service and support to include client centered approach in conjunction with the best
trained case managers who are trained in homeless prevention. CHPS will have access to two
funding access points, the first one being Fresno County Adult Protective Services general fund
allocations and the Home Safe grant funds. The Homeless prevention case manager will work
with the client to develop a service plan that will include, but not be limited to addressing issues
of home repairs to comply with a judgement in order to keep your housing. The case manager
can help clients put together budgets and access needed additional resources such as access to
reduced food support programs, reduced utility expenses. The CHPS case manager can connect
Conjoint Homeless Prevention Services
6
the client with legal assistance when a client has been abused or neglected by another person
living in the home and needs to remove those individuals. CHPS will help to resolve problems
before an eviction notice is served and can assist through related activities such as accompany a
client to eviction related activities like filing paperwork, attending mediation and or even going
to court. With dual opportunities to access funds the program can offer limited short-term
financial assistance to help take care of past due rent, utilities or possibly property taxes and even
association fees. In situations of hoarding CHPS will work to make the necessary steps to
comply with city/county code enforcement officials to reduce the dangers of hoarding. Hoarding
cases will need to be assessed using structured decision capacity assessment tools to assess for
the additionally link to mental health services. In the county of Fresno this would be Older Adult
Mental Health.
For access to CHPS an older adult does not have to be a victim of abuse or neglect to
receive conjoint Homeless Prevention Services. Simplified access and direct communication
with a trained social worker on crisis line will be trained to listen to access points for CHPS. A
client, family member or community member can call the Adult Protective Services crisis line
and will need to inform APS crisis line social worker on issues that could lead you to an older
adult losing their home. It is at this point the trained crisis social worker will ask if there are
issues of abuse and neglect and if not proceed to intake and provide them with an opportunity to
complete a homeless prevention assessment. The client will be provided three options 1.)
complete an over the phone homeless assessment tool 2.) Accept a face to face in home
assessment or accept information to housing support programs in the community. The client will
be informed of his or her rights to decline services. There is no cost to participate and you do not
Conjoint Homeless Prevention Services
7
need to be low income.
Contribution to Improvements in one or more of the Grand Challenge for Social Work
Areas.
Sociopolitical outer exploration for my innovation begins with federal, state and local
governments working to address issues faced by older adults. This proposed solution will
contribute to improvements in how our state and local governments work to address issues of
homelessness across the state. This program will provide homelessness prevention service not
typically offered. The majority of APS services available to seniors are limited, due to program
requirements. CHPS will remove these eligibility requirement barriers and will enhance
coordination of services. The goal is to create a no-wrong-door approach where a senior
regardless of income can get the services and resources they need in order to live a safe and
healthy lifestyle. In recognition of the projected growth of California’s over-65 population of 8.6
million by 2030, the California legislature implemented an executive order calling for the
creation of California’s Master Plan for Aging, to be finalized by October 1, 2020. The Master
Plan will serve as a blueprint that can be used by the state government, local communities,
private organizations and philanthropy to build environments that promote healthy aging.
California’s current proposed solution is to allow counties in the State of California the
opportunity to apply and be provided grant funds to incorporate a Home Safe (HS) homelessness
prevention program to the Fresno DSS Adult Protective Service APS Program across the state.
While this is new and innovative, it also falls short of leaving many older adults to fend for
themselves. This is an unethical consideration and a social justice issues in equity.
Conjoint Homeless Prevention Services
8
History, policy, practice, and public knowledge and discourse, as well as the local
contextual environment
What is known about homelessness prevention services for older adults (ages 65 or
older)? Remarkably little, despite the public policy arguments that homelessness is an emerging
“birth cohort phenomenon” for the Baby Boomer generation that comprise 25% of the American
population in 2015 (citation). The development and implementation of homelessness prevention
initiative has likely been stymied by the lack of empirical examination of the “pathways to
homelessness” among older adults (Brown, Goodman, Guzman, Tieu, Ponath, & Kushel, 2016)
and the changes in the Older Americans Act (1980) which have resulted in the reduction or
elimination of APS services and increased APS criteria restrictions (Culhan, Metrau, Byrne,
Stino, & Bainbridge, 2013). As older adults at risk for homelessness often have associated
social, financial, health, and mental health issues, the implementation of homelessness initiatives
that close siloed gaps are that much more crucial (Brown et al., 2016). Based on the empirical
work, homelessness prevention for older adults is at the needs assessment stage, with few public
policies on homelessness among older adults being translated into actual programs (Greiner,
Barken, Sussman, Rothwell, & Bourgeois-Guerin (2016). Having identified no systems in place
to meet the complex needs of older adults at risk for homelessness, Greiner et al. (2016)
identified no systems in place to meet the complex needs of older adults at risk for homelessness.
The authors recommended the development of initiatives that address older homelessness
through the development of permanent housing, with integrated health and social supports, as
well as conducting risk profiles of factors that increase the risk of “first-time homelessness in
Conjoint Homeless Prevention Services
9
late life” (p. X).
Padgett, Henwood, and Culhane (2016) recommended the implementation of evidence-
based interventions, identifying three approaches that may have applicability to APS. However,
there are limitations surrounding the three programs identified by Padgett et al. (2016). The first
intervention, Rapid Response Housing (RRH) is tertiary prevention, as case workers intercede to
move homeless families from a shelter to independent housing in a very short period of time,
usually a week; families are also partial rental assistance for up to a year. Critical Time
Intervention (CTI) focuses on transitioning individuals with severe mental health issues out of
institutional placements. Through Permanent Supportive Housing (PSH) programs, social
workers secure permanent affordable housing and provide ongoing tenancy preservation and
crisis intervention services for adults with substance abuse and/or mental health needs. While all
interventions have elements that would be of benefit to specific populations of older adults, they
do not provide a secure pathway to prevent homelessness.
Existing opportunities for innovation
The CHPS program is part of a collaborative effort across the state of California and will
allow for current existing opportunity to redesign and innovate how we provide services to our
older adult population. According to the California Welfare Directors Association (CWDA), the
California State Association of Public Administrators/Guardians/Conservators, the California
Commission on Aging, and the California Elder Justice Coalition request $5.75 million General
Fund over three years to provide additional resources for APS social worker training (CWDA,
2019). This is an excellent opportunity to apply for additional grants and supports needed to
innovate APS. Sociopolitical outer context exploration for my innovation begins with federal,
Conjoint Homeless Prevention Services
10
state and local governments working to address issues faced by older adults. The governor of the
state of California has made a commitment to address issues that older adults face in California.
SACRAMENTO – Recognizing that California’s over-65 population is projected to grow to 8.6
million by 2030, Governor Gavin Newsom today signed an executive order calling for the
creation of Master Plan for Aging to be developed by October 1, 2020. The Master Plan will
serve as a blueprint that can be used by the state government, local communities, private
organizations and philanthropy to build environments that promote healthy aging.
Exploring funding, service grants, continuity of funding is only the beginning. At the
broadest level, the state and federal sociopolitical and funding contexts also influence the
exploration of innovative interventions or practices (Davies and Nutley 2008). The opportunity is
right (facilitator) to implement this program as part of a significant collaborative effort across the
state of California. According to the California Welfare Directors Association (CWDA, 2019),
the California State Association of Public Administrators/Guardians/Conservators, the California
Commission on Aging, and the California Elder Justice Coalition request $5.75 million General
Fund over three years to provide additional resources for APS social worker training (CWDA,
2019).
Fresno County DSS and program leaders will have an opportunity prepare 20 social
workers, three program supervisors, and two case managers to develop new role specialization of
investigation, protection and to provide supportive services to older who can benefit from the
CHPS program. Each social worker, including social work supervisors will need to be trained
specifically to work with older adults at risk for homelessness. The National Association of
Protective Services Agencies (NAPSA) has implemented a training and certification program
Conjoint Homeless Prevention Services
11
that provides specific knowledge and training specific to Adult Protective Service staff. NAPSA
training and curriculum can be utilized to provide training to APS staff to facilitate the
relationship-building necessary for implementing a homeless prevention practice model.
Additional staff training opportunities will be to engage and facilitate the process of motivating
an older adult to a supportive housing program while addressing the complex issues related to
neglect and abuse of an older adult using harm reduction methods.
Other opportunities include strategies to support housing stability include prevention and
diversion services, such as short-term housing for older adults at risk of homelessness or those
who have recently become homeless. Staff will need to understand the complexities of how to
navigate legal services, eviction prevention, heavy cleaning, and landlord mediation, among
other services. The goal of CHPS is to support the safety and housing stability of the identified
individuals by providing housing-related assistance using evidence-based practices for homeless
assistance and prevention.
How this Proposed Innovation/Solution Aligns with the Logic Model
Prior to the actual implementation input phases of the program, social work staff will
need to be trained on The Prevention Vulnerability Index-Service Prioritization Decision
Assistance Tool (PVI-SPDAT) which will be utilized by the APS SW for evaluating an
individual’s level of risk of imminent homelessness. The PVI-SPDAT is comprised of a series
of questions that are scored to determine the individual’s vulnerability, housing need and their
likelihood of becoming homeless.
During the intermediate phase in order to facilitate the process and implementation of a
warm handoff can create a barrier and create conflict on roles and responsibilities, a clear
Conjoint Homeless Prevention Services
12
definition and protocol will need to be developed for staff to understand their roles and
responsibilities. This is an area will require program adaptation that will include training on team
approach to client centered approach using collaborative approach. Social workers will need to
complete a homeless assessment tool with older adults which could be difficult for an older adult
to complete. It is important that the social workers use motivational engagement practice to
establish a good working relationship with the older adult in an attempt to prepare the client to
complete an assessment tool that will provide detailed information as to how to better serve the
consumer. Evaluation on efficacy and customer satisfaction data gathering will determine
outcome analysis. Data extracted from the APS LEAPS case management data base will be
provided to data analyst to analyze the measured outcomes to generate outcome data reports to
be reviewed with program managers, and stakeholders.
Likelihood of success
This is a perfect time to facilitate this program as the entire department is working across
programs to implement a program-wide strategic plan that strives to provide consumers with
better customer services and a vision that each client who experiences services from this agency
can say they had a good customer service experience. Success of a program lies in the success of
the proposed project. The likely hood of success lies in the evidence of successful
implementation and is driven by good outcome data. As this is still in the beginning phase of
implementation more data is needed however, as stories of success are shared amongst social
workers and case managers we are now seeing more cases referred for CHPS. Social Work
Supervisors are including identifying and consulting with social worker’s opportunities to refer
clients who will benefit for these services. Leadership is exciting and willing to support CHPS
Conjoint Homeless Prevention Services
13
and has approved implementation and willing to support the program. As long as there is
leadership willing to champion a new program there is a strong likely hood of success.
Administrative leadership collaboration among California DSS stakeholders will help to
facilitate and support training with the direct program manager and supervisor staff to best serve
their employees and clients. Training will include the use of the needs assessment and
instruments used as part of the program. These collaborative efforts may also likely lead to
innovative ways to market the project. Sociopolitical leadership and policy including initiatives
at Federal, State and Local government and local social services agencies support the initiative of
addressing the challenges faced by an increasing older adult population. While currently there is
a shift in government to facilitate ongoing discussion about older adults, we can still have
barriers that can reduce or limit funding levels and even cut funding to some programs. It is
clear that our society faces challenges, but it is evident at each level of government is working
toward improving the life experience of older adults. Funding is provided in a number of
initiatives that provide funding revenue to fund the workforce needed to work with this
population. National, state, public and academic stakeholders have worked strategically to close
the gaps in services and training that is needed to create a sustainable workforce that will be
prepared to meet the needs of the older adult population. Fidelity monitoring and support are
critical to continue program effectiveness. Ongoing supportive leadership is needed to maintain
sustainability through effective quality assurance evaluations and monitoring of program
outcomes. Training and fidelity support that is reliant on external expertise and process can be
considered the outer context Organizational Characteristics need to facilitate ongoing support
starts with intra-organizational leadership that supports a culture social network support Fidelity
Conjoint Homeless Prevention Services
14
support system. This can include ongoing definitions of program processes supported by clear
policies and procedures that are clear and specific to the program design. Program supervisors
need to provide ongoing supportive coaching and training to social work staff. New staff that
comes to the program will need training and ongoing support to ensure adherence to active
delivery of the innovation and implementation success of CHPS.
IV. Project Structure, Methodology, and Action Components
While ethical behaviors are part and parcel of the City of Fresno’s APS it still has made
and effort and is moving in the right direction. Social Workers and leadership are learning to
critically analyze and apply practice ethical considerations. In difficult situations, case managers
as a whole are learning to focus on the quality of their relationship with the individual in care, or
on their caseloads and are emphasizing ‘listening’, ‘proximity’ and ‘trust’. They presented
themselves as an ‘ally’ of the individual concerned or indeed as their ‘voice’. They said they
would respect and stress respect for the individual’s choices and personality. Moving forward
into the future. With growth in the use of communication technology in various aspects of social
work practice, social workers need to be aware of the unique challenges that may arise in relation
to the maintenance of confidentiality, informed consent, professional boundaries, professional
competence, record keeping, and other ethical considerations. In general, all ethical standards in
this Code of Ethics are applicable to interactions (NASW, 2019).
Having staff participate in training will help social workers, case managers, and human
service professionals be prepared to identify, understand and find ways to address issues in
ethical and values, it is these principles that will allow social workers to guide practice.
Administration is recognized the need for leadership and is currently providing training
Conjoint Homeless Prevention Services
15
managers and supervisors on leadership and decision making which has been identified as a need
for intervention. At the agency level, all program managers and line supervisors should be
required to attend a yearlong leadership training program and least three days per week, per
month is required. These will help managers and supervise staff to problem solve, apply critical
thinking and work through challenging ethical decision and value ethics. With pre-and post-
measurement analysis to identify older adults who were provided opportunities that lead to
employment, better mental and physical wellbeing. A qualitative goal attainment scale will be
provided to consumers of the program. State reports SOC (242) will be accessed quarterly to
evaluate of program and services provided.
Analysis of the market for the proposed project/innovation
The organization I am working in has been part of a collaborative partnership for 19
years and currently includes 27 members. This membership consists of diverse groups including
faith organizations, educational groups and governmental service providers. My organization has
been an active member with the central valley regional continuum of care since its inception. Our
organization is important to the services provided to the dependent and older adult population.
The request to implement this practice model and to incorporate housing to older adults 65 and
older has been part of the program services. Other organizations going back to 2019 under
Senate Bill (SB) 2 has made $9.5 Million dollars in funding to the City and as part of the Big 11,
can be eligible of another $3.1 million. These programs and fund will help support the
development of a new Home Safe initiative. What is being proposed as part of this plan is to
include a triage center, Bridge Housing, a funded Diversion program, expanded Coordinated
Conjoint Homeless Prevention Services
16
Entry, as well as outreach. These will be additional resources will help with the implementation
of CHPS.
To help assess the current housing problem in my county, clients in the APS case
management system have little to no alterative options. Our social workers face many issues
when it comes to helping clients find adequate support services, linkage to housing resources or
even place an older adult who has never been homeless find temporary shelter or housing help.
According the case management data base system an average of 500 clients are in program
services at any given time. According to the data a little over 60% require some type of housing
support or assistance through APS and housing support services which is currently not available.
Currently there are six different issues that put this client population at risk in no services are
provided.
The proposed plan will include updating Policy and Procedure Guide (PPG) intended to
provide APS clients with basic understanding and highlight APS program considerations and
requirements in view of working collaboratively with other organizational collaborative services
providers for the benefit of mutual clients. All eligibility determinations are made by the APS
staff. In order to be eligible for APS services there is certain criteria to be met, an individual
must be an older adult over the age of 65 or be a dependent adult between the age of 18 to 64.
Welfare and Institutions Code (WIC) §4512 Additionally a client needs to be a victim of abuse
and neglect to receive protection services.
The goal of building a task force collaboration among community agencies will create
increased network opportunities across integrated service programs that work with the same
clients and to reduce duplication of services with emphasis on addressing gaps in services to
Conjoint Homeless Prevention Services
17
increase and improve the access to quality human services for older adult, 65 and beyond
retirement from community social service programs. Gaps and fragmentation of services across
social service programs has left older adults with limited to no support during hard times of this
vulnerable population. Older adults 65 and older are exhibiting the economic impact of not
having enough sustainable incomes. Economy market has put many of the basic needs out of
reach such as housing, utilities, vehicle and transportation, food, clothing and personal goods as
all of these costs have increased who do not have equal access to quality human service delivery.
Many efforts to implement programs designed to improve the quality and outcomes of
human services have not reached their full potential due to a variety of challenges inherent in the
implementation process (Aarons et al., 2010). Consensus opinion exists around important key
features, such as leadership in implementation efforts, the need for ongoing consultation and
training, especially in early implementation phases, the need to address the impact of staff
turnover, and other core implementation drivers, but the body of concrete research evidence for
each core driver in many cases remains to be developed (Aarons et al. 2010). While ethical
behaviors seem ingrained in this organization’s DNA it still has made and effort and is moving in
the right direction. Social Workers and leadership are learning to critically analyze and apply
practice ethical considerations. In difficult situations, case managers as a whole are learning to
focus on the quality of their relationship with the individual in care, or on their caseloads and are
emphasizing ‘listening’, ‘proximity’ and ‘trust’. They presented themselves as an ‘ally’ of the
individual concerned or indeed as their ‘voice’. They said they would respect and stress respect
for the individual’s choices and personality. Moving forward into the future. With growth in the
use of communication technology in various aspects of social work practice, social workers need
Conjoint Homeless Prevention Services
18
to be aware of the unique challenges that may arise in relation to the maintenance of
confidentiality, informed consent, professional boundaries, professional competence, record
keeping, and other ethical considerations. In general, all ethical standards in this Code of Ethics
are applicable to interactions (NASW, 2019).
Having staff participate in training will help social workers, case managers, and human
service professionals be prepared to identify, understand and find ways to address issues in
ethical and values, it is these principles that will allow social workers to guide practice.
Administration is recognized the need for leadership and is currently providing training
managers and supervisors on leadership and decision making which has been identified as a need
for intervention. At the agency level, all program managers and line supervisors are required to
attend a yearlong leadership training program and least three days per week, per month is
required. These will help managers and supervise staff to problem solve, apply critical thinking
and work through challenging ethical decision and value ethics.
Other needed data is how services provided to older adults are unfair and lack equity in
regards to who receives social service programs and who does not which at the highest macro
level continues to be a concern of social justice that legislators and policy makers need to
address. Evidence that supports why we need to change societal norms about continues the costs
associated with the care and services provided as a result of older adults not being productive or
engaged.
Financial Plans and Implementation Strategy
In order to implement a program such as the Home Safe program with APS needs to have
sociopolitical support from Federal Legislation and local enactment such as Assembly Bill (AB)
Conjoint Homeless Prevention Services
19
1811 (Chapter 35, Statutes of 2018), which supported the implementation of a Home Safe, 3-
year pilot program that will serve individuals identified by APS that are experiencing
homelessness or are at imminent risk of homelessness due to elder or dependent adult abuse,
neglect, self-neglect or financial exploitation. Starting on September 1, 2019, the Fresno DSS
(DSS) APS program began assessing APS clients (new referrals and current cases) for housing
stability and vulnerability of imminent risk of homelessness. The money needed (first year of
operation) is estimated at $1million dollars, based on previous years APS expenditures and client
data will provide additional limited budget other source funding will be an additional $95,000.00
for a total of $1,100,000.00. The types of revenue sources I’ll pursue are Community Block
Service Grant Funds, and housing continuity of care Rapid Rehousing grant funds of $500,000
with a county match of another $500,000.00. The reliance of these funding sources is that
community block services grants are a limited, but available funding stream for this program
allocated to the adult protective service program. Home Safe grant funds have been requested
and approved and the program is its first of three-year pilot implementation which began August
1, 2019.
The current estimated costs of home care in the United States is $5 billion dollars, the
cost of fraud investigations is $1 billion dollars, and social service expenditures in assessment
staffing cost at 2.5 billion dollars for a total of 8.5 billion dollars. If older adults were provided
enough incentive and we changed the social norm and included older adults as viable alternatives
as workers, trainers, volunteers, care providers and worked with our collaborative partners in
other agencies such creative innovative ideas for older adults. Why is this problem socially
significant and why is it important to real people, and has applied implication? My proposed
Conjoint Homeless Prevention Services
20
innovation work to create a vehicle of engagement that I hope will create awareness, create
opportunity prevent the risk of homelessness and increase lifelong inclusion and self-
sustainability that leads to better physical and mental wellbeing.
Methods for Assessment of impact
Evaluation research design will have emphases on macro practice analysis with the target
population being the effectiveness of policy and program implementation service delivery of the
new APS process. The strength of this selected evaluative design model will provide data
program administrators, community stakeholders and consumers who need to know effectiveness
of the social program, services and policy. The cause and effects will be evaluated through
additional exploratory research questionnaire to the consumer. The validity is dependent upon
the independent variables or quality of service provided to the client. No control group will be
used or be provided random assignments. The macro practice conceptual framework will address
the problem, population, and arena (Netting, Kettner, McMurtry, & Thomas, 2012).
The use of the Adult Protective Services APS) LEAPS data based case management
system will be used to input and collect data. The LEAPS program is and unique as it is a web-
based application specific to APS. Social Workers are provided surface pro devises to input case
contacts, narratives, assessments and case notes. Data Analysis Technology will be used to input
and extract data from the social service program for clients referred to Adult Protective Services
for risks of homeless at intake, and throughout the case life up to case closure. Social Work staff
can use Surface Pro devices to engage clients and develop case plan activities with the client.
The use of the Adult Protective Services APS) LEAPS data based case management system will
be used to input and collect data. The LEAPS program is and unique as it is a web-based
Conjoint Homeless Prevention Services
21
application specific to APS. Social Workers are provided surface pro devises to input case
contacts, narratives, assessments and case notes. This application can also be used in the client’s
environment with the client to develop service plans that will guide the social worker and client
through the life span of the case.
Stakeholder Involvement
There are several relevant stakeholders who continue to be very involved and will
continue to be essential constituencies such as Federal legislature, State CDSS, local County of
Fresno DSS, Kings View, Turning Point. Behavioral Mental Health, In Home Supportive
Services, Public Authority, Fresno County District Attorney, Fresno County Sherriff
Department, Fresno Police Department, Clovis Police Department, Fresno County Public Health.
County Code Enforcement, Victim Services, Catholic Charities, Salvation Army, Housing and
Urban Development, Central Valley Regional Centers, Community Care Licensing, Local
Ombudsman’s Office, Social Security Administration. This external collaboration positively
impacts the implementation and funding for such a program. The Fresno DSS present that the
strength of support demonstrates the commitment to its community and has the support of the
stakeholder member.
Communications Products and Strategies
The Fresno DSS present that the strength of support demonstrates the commitment to its
community and has the support of the stakeholder membership. This diverse group including
faith-based, educational, and governmental service providers has proven to be supportive and
effective to the work the Department work with older adults and the many issues faced be an
ever-increasing homeless population. The Department partners directly with the FMCoC on the
Conjoint Homeless Prevention Services
22
Emergency Solutions Grant, CalWORKs Homeless Services Program, and the Housing
Disability Advocacy Program. The Department will continue to partner with the FMCoC in
providing services to the Adult Protective Services (APS) population. CHPS will continue as
partner with stakeholders and continue to build a team collaborative approach among community
agencies to increase network opportunities across integrated service programs. This will reduce
duplication of services with the emphasis on addressing gaps in services to increase and improve
access to quality human services for older adult population. CHPS will also participate in
community outreach activities and will have information pamphlets available for distribution to
the community. Effective implementation and utilization of this program will rely heavily on the
support of the communities and populations being served, to ensure that services are appropriate
and relevant.
Ethical Concerns and Possible Negative Consequences
Administration needs to have insight into the complexity of these issues and the
challenge of making good decisions that will offer suggestions and support that will offer help to
the implementation of this program redesign. Social workers and case managers base their
interventions on a multidimensional global assessment, which produces a systematic overview of
the individual’s entire biological, psychological, social and functional needs, in conjunction with
environmental conditions. They interact with the various actors involved (doctors, nurses,
careers, hospitals, social services, etc.) and monitor the actions being implemented (Corvol et al.,
2012). According the Health and Portability (HIPPA) Act, the major goal of the privacy rule is
to ensure that individual’ health information is properly protected while allowing the flow of
health information needed to provide and promote high quality health care to protect the public’s
Conjoint Homeless Prevention Services
23
health and well-being. The privacy rule strikes a balance that permits important use of
information while protecting the privacy of people who seek care and healing (HIPPAA, 1996).
V. Conclusions, Actions, and Implications
The County of Fresno APS is well aware of the increasing size and needs of the older
adult population. This department has been innovative in its mission to work toward addressing
these concerns by implementing the Home Safe program aimed at improving services for older
adults at risk for homelessness who do not typically meet APS program criteria.
While this is an innovative opportunity, it does not come without challenges or ethical
dilemmas. APS programs will need to undergo some restructuring to support the Home Safe
program.
The organizational challenges are for the agency and staff to be engaged and motivating
in implementing a new program while maximizing the allocated budget of $500,000.00 that will
be used to address the issues that leads to situational homelessness, causation and prevention.
This program began this operation as part of a grant funded program that is now in design and its
implementation phase. Social workers will have deal with the many ethical dilemmas such as
client’s autonomy, beneficence, non-malfeasance, and justice when working with clients and
applying new case management practices. Social workers will need to have insight into the
complexity of these issues and work through the challenges of making good decisions that will
offer suggestions and support toward the implementation of this program redesign.
Conclusions Within a Field of Practice
Many efforts to implement programs designed to improve the quality and outcomes of
human services have not reached their full potential due to a variety of challenges inherent in the
implementation process (Aarons et al.2010). Consensus opinion exists around important key
Conjoint Homeless Prevention Services
24
features, such as leadership in implementation efforts, the need for ongoing consultation and
training, especially in early implementation phases, the need to address the impact of staff
turnover, and other core implementation drivers, but the body of concrete research evidence for
each core driver in many cases remains to be developed (Aarons et al. 2010). Some general
conclusions to this program and capstone project it does not currently have any emergency
shelters who will take elderly individuals who need assistance with their activities of daily living.
This has been an ongoing problem and the Department is exploring options to partner with
homeless assistance providers and facilities in the area or open new facilities to assist the APS
population who is in imminent risk of becoming homeless, but is not yet homeless. I believe that
by increasing the accessibility of homeless prevention programs to help all vulnerable
populations with specialized needs will keep resources in our county available for other
individuals and families, while attending to the unique nature of an APS client’s situations.
Implications of the Project Innovation for Practice and Further Action
Having staff participate in training will help social workers, case managers, and human
service professionals be prepared to identify, understand and find ways to address issues in
ethical and values, it is these principles that will allow social workers to guide practice.
Administration is recognized the need for leadership and is currently providing training
managers and supervisors on leadership and decision making which has been identified as a need
for intervention. At the agency level, all program managers and line supervisors are required to
attend a yearlong leadership training program and least three days per week, per month is
required. These will help managers and supervise staff to problem solve, apply critical thinking
and work through challenging ethical decision and value ethics.
Conjoint Homeless Prevention Services
25
There is a need for enhanced training curriculum that includes recommended approaches
to behavioral ethics. Recommended approaches for social workers in APS is to have a revised
curriculum that will include updated training practice situations using the ethical principles.
Basic ethical principles include autonomy, beneficence, non-malfeasance, and justice. I would
recommend enhanced training to leadership and social workers to be able to understand and take
into consideration and be able to comfortably discuss informed consent, capacity, competence,
and confidentiality with clients and family members. This recommendation will help the
organization and social workers in APS to have a better understanding of the process of critical
thinking and how it facilitates problem solving in difficult ethical situations. Defining ethic,
understanding bioethics and the principals that directly impact our work, understand how an
ethical dilemma may affect our work, and examine our own values and believes and how that
might influence our own behaviors towards people whose beliefs differ from our own (Corvol et
al. 2012).
Critical analysis and thinking how to facilitate problems solving in difficult situations is
important for social workers to be able to apply. Social workers have to be able to discuss the
relations between these ethics to help clients understand and work toward informed, consent,
self-determination, capacity, and decision-making. The goal is to apply a problem-solving
technique to address these dilemmas that will allow consumers personal choice while working
toward safety. The principal ethical dilemmas reported by them related to the question of respect
for the autonomy of persons who placed themselves in danger, against the risk involved and also
against pressures exerted by family or community (Corvol et al., 2012).
Conjoint Homeless Prevention Services
26
Limitations and Risks and Recommendations for Future Work
With growth in the use of communication technology in various aspects of social work
practice, social workers need to be aware of the unique challenges that may arise in relation to
the maintenance of confidentiality, informed consent, professional boundaries, professional
competence, record keeping, and other ethical considerations. In general, all ethical standards in
this Code of Ethics are applicable to interactions (NASW, 2019). In situations when conflicting
obligations arise, social workers may be faced with complex ethical dilemmas that have no
simple answers. Social workers should take into consideration all the values, principles, and
standards in this Code that are relevant to any situation in which ethical judgment is warranted
(NASW, 2019). Despite asserting these values, social workers sometimes having acted against
the individual’s will. Their aim had been ‘to provide welfare for the people concerned’ and to
‘put in place those things required for encouraging the individual’s autonomy’ Collection and
sharing of personal data, gathering information about the individual through the use of
multidimensional assessment tools is considered to be a delicate undertaking by the case
managers. Some said they were embarrassed by having to enter an individual’s home and ask
personal questions. The question of assessment tools on needs relating to religion and sexuality
came in for particular criticism (Corvol et al.2012).
Advancing to Next Steps
Advancing to next steps is imperative to the success of CHPS to other county agencies
that provide adult protective services. As data is being accessed and evaluated on the
demographics of the older adult population more data is needed to evaluate how, what the
Conjoint Homeless Prevention Services
27
services needs are and the services provided to older adults across similar social service
programs. The program design template will be made available upon completion of the three
year Home Safe pilot project to be provided to stakeholders. The program design template will
be available to be used to either implement across other adult protective services agencies and to
be uses to inform stakeholders, legislators and policy makers. As our nation begins the process of
data collection continues to complete service surveys of programs across the state this project
can be shared as a model example of how CHPS can serve as a guide to address issues of abuse
and neglect while addressing issues of homelessness prevention amongst the same population.
Our older adults are a valuable resource that can help change current policy in a system that
enables, creates dependency prematurely and excludes millions because of means tested
eligibility requirements. At the macro level our legislators and administrative governing bodies
need to write legislation and policy designed to address the unfair equity in regards to who
receives social service programs. Older adults should not have to wait or be in victim of abuse
and/or neglect to be provided services that can prevent homelessness amongst our older
populations.
Conjoint Homeless Prevention Services
28
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Apendix-1
.
Provide
educati
on on
health.
.
.
.
.
.
.
.
.
.
Conjoint Homeless Prevention Services
34
Appendix-2
Conjoint Homeless Prevention services (CHPS) for Fresno County Adult Protective Services
(APS). The goal of CHPS is to work with persons at risk of losing their housing by offering
conjoint case management services that will mitigate the risk of abuse or neglect while working
to prevent the risk of homelessness.
How can Conjoint Homeless Prevention Services help you?
The Conjoint Homeless Prevention service program is meant to keep you in your current housing
situation, before you lose your home. You do not have to be a victim of elder abuse or neglect to
be eligible for services. You will be providing intervention support services by team of experts
in helping with issues of abuse and neglect while helping you with issues of homeless
prevention.
Your team will consist of one social worker and one homeless prevention expert. This team will
work with you to help resolve problems before you face losing your home.
• Assist with making changes/repairs to the home to comply with a judgement in order to
keep your housing.
• Accompany you to eviction related activities like filing paperwork, attending mediation
or going with you to court.
• Help develop a plan to remain a home owner, including working with you to develop a
budget, so you can afford to stay where you want to live.
• Connect you with legal assistance when you need to evict persons living in your home
that are taking advantage of you.
• Offer limited short-term financial assistance to help take care of past due rent, utilities or
possibly property taxes.
• Help you take the steps necessary to comply with city/county code enforcement officials
to reduce the dangers of hoarding.
• Link you to services in the community for support and continued success at remaining in
your home.
What Do I Have to Do?
You do not have to be a victim of abuse or neglect to receive conjoint Homeless Prevention
Services. You can call the Adult Protective Services crisis line and you will need to let the APS
crisis line Social Worker know that you are having issues with housing. There is no cost to
participate and you do not need to be low income.
Conjoint Homeless Prevention Services
Conjoint Homeless Prevention Services
35
Abstract (if available)
Abstract
Older adult social services programs are facing a very serious problem across America. It is estimated that 10,000 people retire each day (Administration on Aging, 2010). This compounded with older adults whom have already retired on low incomes, are inundating adult social service programs. Moreover, with the new medical technological improvements in healthcare people are living longer, with an expected longevity rate of 18.6 years (Administration on Aging, 2010). California’s current proposed solution is to allow counties in the State of California the opportunity to apply and be provided grant funds to incorporate a Home Safe (HS) homelessness prevention program to Adult Protective Service (APS) programs across the state. While this is new and innovative, it also falls short of leaving many older adults to fend for themselves because of narrow eligibility requirements and lack of coordination and thus efficient care and consequences onto older adults. This is an unethical consideration and a social justice issue in access and equity. While our society works to address the issues of homelessness in the United States, this author feels the need to specifically look at the older adult population 65 and older who face not only issues of abuse and neglect but increasingly issues of homelessness simultaneously. Within the larger conceptual framework our national, state and local governments, local communities, private organizations and philanthropists have identified this as a need and have pledged to work on a master plan for aging, nationally and specifically here in California. This work is focused toward addressing the increasing demand of an aging society and particularly older adults, 65 and older. Established by Assembly Bill (AB) 1811 (Chapter 35, Statutes of 2018), and funded by the Administration of Community Living (ACL) a program called Home Safe, (HS), a 3-year pilot program that is being made available across California social service programs who have the infrastructure needed to implement the program. The County of Fresno Department of Social Services (DSS) is one program who has applied for and has received the authority to launch the Home Safe Program. The County of Fresno, Adult Protective Services (APS) has completed the request for proposal process, was approved and has received a grant allocation of $588,571 to implement the program. It is this author’s innovative approach to assist in the exploration, process development, evaluation, and sustainability of this program and through an organization system redesign model will be referred to as conjoint homeless prevention services across programs. Conjoint homelessness prevention services will work to close gaps in siloed services and work to coordinate two innovative approaches to help prevent homelessness of older adults (aged 65 or older). The conjoint homeless prevention redesign will demonstrate best practice approaches while providing evidence-based evaluative on data outcomes on what worked and what did not work in areas of staff productivity, program implementation, and efficacy. It is hoped that the system re-design model and successful implementation of a conjoint homeless prevention program will be used to address the wicked problem and Grand Challenge of older adult homelessness in America and even more make an impact on prevention and intervention to eradicate homelessness amongst the older adult population in America.
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Asset Metadata
Creator
Sanchez, Greg
(author)
Core Title
Conjoint homeless prevention services for older adults
School
Suzanne Dworak-Peck School of Social Work
Degree
Doctor of Social Work
Degree Program
Social Work
Publication Date
08/11/2020
Defense Date
04/17/2020
Publisher
University of Southern California
(original),
University of Southern California. Libraries
(digital)
Tag
conjoint,homeless prevention,OAI-PMH Harvest,services for older adults
Language
English
Contributor
Electronically uploaded by the author
(provenance)
Advisor
Bolar, Eleanor (
committee chair
), Lewis, Jennifer (
committee chair
)
Creator Email
grsanchez5@icloud.com
Permanent Link (DOI)
https://doi.org/10.25549/usctheses-c89-363406
Unique identifier
UC11666379
Identifier
etd-SanchezGre-8924.pdf (filename),usctheses-c89-363406 (legacy record id)
Legacy Identifier
etd-SanchezGre-8924.pdf
Dmrecord
363406
Document Type
Capstone project
Rights
Sanchez, Greg
Type
texts
Source
University of Southern California
(contributing entity),
University of Southern California Dissertations and Theses
(collection)
Access Conditions
The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...
Repository Name
University of Southern California Digital Library
Repository Location
USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA
Tags
conjoint
homeless prevention
services for older adults