In 1991, 7 older professional women in Boston, including the mother of former U.S. Sen. Barney Frank (D-MA), came together with an ambitious goal: to end homelessness among older adults.

Things didn't go exactly as planned -- at least not at first. 

But the stubbornly determined women used each early challenge to make decisions that would shape their Committee to End Elder Homelessness -- later renamed Hearth -- for the next 20 years.

"They came together because they were just appalled by seeing so many older homeless people on the street," says Anne S. Garmey, Hearth’s director of institutional advancement. “They ended up buying a 9-bedroom Victorian home in Jamaica Plain. They furnished the whole place and expected demand to be immediate."

Early Challenges: Recruiting and Supporting the Homeless

The first challenge came early. Homeless elders did not flock to the tastefully furnished Jamaica Plain housing community.

Undeterred, the women realized they needed to find ways to connect with prospective residents. The Hearth outreach program they created now employs 6 case managers who work full time, connecting with clients primarily in local shelters. 

First case managers get to know their clients and gain their clients’ trust. Then they help clients apply for affordable housing. 

They also connect them with services and support them as they wait until an affordable apartment becomes available at Hearth or another housing property. Once housed, the team provides 6 months of stabilization.

The second challenge came after the house in Jamaica Plain was fully occupied. Organizers soon discovered that formerly homeless older adults needed more supportive services than originally anticipated.

A nurse was soon hired, followed by other clinical and support staff including social workers, to help residents address the unique physical and mental health challenges that emerge when you combine aging and homelessness. Twenty-two years later, Hearth now uses an expanded Housing Plus Services model to serve 198 formerly homeless individuals living in 7 housing sites and a 43-unit assisted living community.

Homeless Elders: A Diverse Population

Hearth's resident population consists of 2 distinct groups of homeless elders.

One group has lived on the streets for a relatively short period of time.

"They could be my parents or your parents," says Garmey. "They simply are poor. Some lose a job and then find that it’s very hard to get hired again. Some have a medical crisis that leaves them in poverty. Others may have lost a spouse who was their caretaker. Once they get acclimated to their new housing, these elders require the same amount of services and supports as the typical older adult living in subsidized housing.”

The second group of Hearth residents has been chronically homeless over many years.

"There is probably something that led to their homelessness, something that has been challenging in their lives," says Garmey. "They may have substance-use issues and possibly mental health issues. So even when they are housed, the level of support just needs to be greater so we can keep them safely housed long term."

Arrival at Hearth: Homless Elders Assessed by an Interdisciplinary Team

When a homeless elder comes to Hearth housing, the first order of business is always a full physical and mental health assessment. 

That assessment helps the site team collect valuable information about the resident and create a plan for keeping that person independent for as long as possible.

Each site team includes 4 members:

  • A site director oversees management of each building. This master's-level professional also keeps track of residents and coordinates the activities of the many volunteers who work in the building. 
  • A nurse makes sure each resident has a primary care physician. When requested, the nurse will accompany residents to doctor appointments "to be a second set of ears," says Garmey. Nurses also get involved in helping some residents manage their medications, although nurses do not administer medications.
  • A social worker helps residents cope with behavioral health challenges and crisis, deal with family issues, and engage in the community. Social workers also help assess residents’ eligibility for services and entitlement programs, including disability, food stamps or referral to a therapeutic day program.
  • A personal care homemaker offers in-home assistance to residents who need extra help to remain independent. "Often it is the personal care homemakers who get to know the residents first and really can tell when something is not going well," says Garmey. Funding for the personal care homemakers comes, in part, from the state's Group Adult Foster Care Program.

The site team is at the center of the Hearth model, says Garmey. Team members work hard to get to know everyone in the building so they will notice changes in behavior or health that may require an intervention.

“A big piece of our program involves gaining the trust of residents so they can develop a relationship with someone on the team," says Garmey. 

Partnerships with community service providers are another key element of the Hearth model, she says.

"Collaboration with community partners is a huge part of what we do," says Garmey. "Hearth is not out there doing it all ourselves.”

Mental Health Issues are a Challenge

Garmey acknowledges that behavioral health issues, especially among the chronically homeless, may be the biggest challenge facing Hearth housing staff.

“A handful of very challenging people takes up a lot of staff time and can make life difficult for other residents,” she says. “The key to meeting that challenge is having a really good team that knows how to work together and has dealt with these issues before."

Hearth's onsite teams fit that description. Team members work together to offer intensive services and supports to about 40 residents with serious mental illness who are clients of the Massachusetts Department of Mental Health. The team also works with a number of other residents "who either don’t carry a formal diagnosis or are not clients of the Department of Mental Health, but who nonetheless require just as much support and intervention,” says Garmey.

To find out more about Hearth's strategy for addressing residents' mental health issues, see our interview with Hearth's Director of Behavioral Health Debbi Cutler.

Housing Plus Services Long-Term Goal: Avoid Long-Term Care

With a retention rate of 94%, Hearth is "very good at keeping people out of long-term care for as long as possible," says Garmey. And that's what makes Housing Plus Services models such an effective tool to lower the cost of elder homelessness, she says.

"Homelessness for the older population is more expensive than for other age groups," says Garmey. "When older people are on the streets, they are going to the emergency room more frequently. In some cases, the hospital has no place else to release them except to long-term care, even if maybe they don’t need long-term care."

Despite the fact that it is saving health care dollars, however, Hearth still struggles to raise all the funds it needs to end elder homelessness.

“Over our history, we have housed 1,700 people,” says Garmey. “We haven’t ended elder homelessness, but we do feel we’ve made a dent in the problem. But we would love to have more staff. We would love to have more substance-abuse expertise. There is a lot more that we would like to do if we could."