Jeffrey Stevens' life took a sudden turn when he lost his roommate to health issues a couple years ago. The 73-year-old musician and the former founder of a community access channel on the Oregon coast lost financial support, stability and, ultimately, his home.
"That's when the support system fell apart," said Stevens. "Finding a compatible roommate, especially as an older adult, is a real challenge. We're set in our ways. But when it works, it works."
Stevens, who also has a disabling condition, was staying at a shelter funded by the Joint Office of Homeless Services when a caseworker referred him to the County's Homeless Mobile Intake Team. The team, part of Multnomah County's Department of County Human Services' Aging, Disability, and Veterans Services Division, works in partnership with the Joint Office and helps people experiencing homelessness connect or reconnect to existing resources, focusing on those who are aging and/or have disabilities.
It’s part of work spurred by Chair Jessica Vega Pederson to knit together a “one County” approach to homelessness — creating partnerships and other opportunities for vulnerable people while effectively investing funds from the Metro Supportive Housing Services Measure.
The “mobile” in Homeless Mobile Intake Team means case managers bring their expertise and services to clients where they are at — rather than requiring them to travel first to a government office.
Case manager Caitlin Lee said it’s not always fair or feasible “to expect or think that somebody experiencing homelessness will have all their government documents and their birth certificate and their I.D. and can show up to a government office for an hour interview, or 90-minute phone call, when you don't even have a place to charge your phone.
“So we bring Aging and Disabilities out to the streets, out literally to the people, which I love to do.”
Homeless Mobile Intake Team Case manager Caitlin Lee and Jeffrey Stevens.
Lee met with Jeffrey at his downtown shelter and conducted an assessment to determine his medical eligibility. Lee got Stevens approved for Medicaid and is actively guiding him on a path toward housing that best meets his needs.
But the work goes beyond assessments and determining eligibility. Lee arranges transportation and helps schedule doctor’s appointments. She addresses the many arduous hidden barriers that can complicate someone’s path to housing while also developing a genuine, trusting relationship with clients, which helps mitigate "service fatigue."
“There's something called service fatigue that a lot of homeless people have experienced, because they connect with so many different shelters and agencies, and they do that initial connection,” said Lee. “But then an employee leaves or they, you know, just disconnect and they lose hope.”
“I get to stay with you,” said Lee. “We develop a relationship. And I walk you and guide you out of homelessness. I don’t place you anywhere. I don't make your decisions. It's very labor intensive and human one-on-one. But I've always said you are the golden ticket to get someone out of homelessness. They need somebody to walk them through it.”
“What I like about the approach we're using is I'm not going to be looking for another place in six months,” Stevens said.
The mobile team relies on a diverse group of caseworkers and other staff — some who speak multiple languages and some who have lived experience. They build relationships with people, conducting assessments, identifying benefits such as food and medical support, and also providing short-term intensive housing case management.
Irma Jimenez, division director for the County’s Aging, Disability, and Veteran Services Division, devised the concept and helped secure its funding.
“After the COVID-19 pandemic, a deeply troubling trend of older adults experiencing homelessness began to emerge,” said Jimenez. "And those who are chronically homeless actually appear to be 15 to 20 years older than their actual age," she added.
Jimenez was watching a news report about outreach teams connecting with people experiencing homelessness. “And I thought it would be great for our team to either team up with existing teams already going out or have a mobile intake team, specifically for the community we serve.”
Before the Homeless Mobile Intake Team existed, connections to the Aging, Disability, and Veteran Services Division relied on phone calls and subsequent office visits.
But her team, she stresses, has brought the vision of a Homeless Mobile Intake Team to life.
“Building relationships with folks; having a presence in shelters and in the community and the new Behavioral Health Resource Center,” said Jimenez. “We are there, too.”
If someone has a physical disability and struggles to complete day-to-day physical activities, Jimenez said, they may be approved for Medicaid long term care services, which can allow a case manager to help them find not only a place to live but also appropriate support services so they remain housed.
The team's work can help open the door to long-term housing vouchers.
“We have 15 of our clients who were houseless on the street, who are now in apartments,” said Lee. “They are Medicaid approved. So they have significant care needs. We layer on in-home care. Sometimes people have someone they know that can go through the process of becoming a caregiver, but we set that up for them.”
Case managers also connect with service partners to help cover move-in costs and provide supportive services. This can include furniture or access ramps and home modifications for clients who need them.
The team launched in November 2022 and is fully staffed with four case managers and a case manager assistant. They work closely with partner agencies who can make referrals. Since November 2022, the team has served 295 participants, most of them 61 to 80 years old.Overall, the Aging, Disability and Veteran Services Division serves approximately 50,000 Multnomah County residents, Jimenez said.
“There is a lot of work that everybody is trying to do," said Jimenez. “And it is happening. We're serving.”
This month, the team’s work received the 2024 USAging’s Aging Innovations Award. USAging is the national association representing and supporting the nation’s network of Area Agencies on Aging, including Multnomah County’s Aging, Disability and Veteran Services Division. The 2024 USAging Aging Innovations & Achievement Awards, supported by Caregiving.com and Cumulus.care, recognizes Area Agency on Aging members that have found new and innovative ways to support older adults, people with disabilities and caregivers as they live in their homes and communities.
“These initiatives not only enhance the well-being of our aging population but also inspire others to strive for impactful and lasting change in their communities," said USAging CEO Sandy Markwood.
“It's always a great feeling whenever we get at least a thank you. It's like, yes, it's a win,” said Jimenez. “I'm really happy to show the continued work that Oregon is doing, to really meet the needs of our most vulnerable individuals. And I'm really proud of my team.”
Lee says there's often a perception that all people who are homeless or living without shelter have unattended addictions and/or mental health issues.
“And some of them are displaced by their medical condition," said Lee. “But I am always very surprised by how many struggle with conditions as they age, such as dementia. And without that family web or a safety web. We have placed quite a few people directly from the street into memory care.”
Programs like the Homeless Mobile Intake Team are literally what works, says Lee.
"I can come out and spend a few hours with Jeff, or go to a doctor's appointment with you and get what we need done."
"It's hard enough to be homeless," said Stevens. "But being involved, staying busy, and addressing the problem on the front lines was a lifesaver for me.
“They [case managers] have to believe in what they're doing,” he added, “because you're taking care of people, and people are pretty fragile, especially as they get older.”
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