Social worker and case manager persist in securing long-term placement

James* was in desperate need of help.

Diagnosed with anxiety, borderline personality disorder, depression and dementia, he also had a history of drug use and a criminal record. He had spent time in a homeless shelter, but after being physically abused there, he attempted to take his own life and was sent to an inpatient mental health treatment center in Central Arkansas.

While a typical stay at treatment center is about six days, James had been there for more than five months when Tori Horton, a social work case manager at Arkansas Blue Cross and Blue Shield, received a referral seeking long-term housing.

It would become the most challenging case of Horton’s career as she explored every avenue to get him help.

While a case worker may conduct two to three check-ins per month in a typical case, Horton noted 22 interactions in a single day for James’s case, with most days involving six to 11 interactions.

“I just didn’t know what was going to happen to this guy for a long time,” Horton said. “This was one of the hardest cases.”

The treatment center needed to discharge James because it is not a long-term facility, but staff there could not find a safe place that would accept him. And discharge to the streets was not feasible, due to James’ dementia diagnosis.

“He was so nice and begged for help,” Horton recalled. “He told me he did not want to be in a shelter.”

Horton began by sending referrals to around 40 skilled nursing facilities that had long-term care units and offered rehabilitation therapy. While James didn’t need therapy, he did need to be in a nursing facility because he was not able to keep himself safe and take his required medications. However, because of his past behaviors and lack of funds, James was denied by every facility she contacted.

It was the beginning of a difficult road to get James the help he needed. Horton met regularly with her team to brainstorm possible ways to help. Despite many setbacks, she never gave up.

Committed to helping

After James was denied admission to all 40 skilled nursing facilities, Horton completed a pre-admission screening and resident review (PASRR), a federal form that ensures people are being correctly placed in long-term care facilities. The first PASRR Horton submitted was rejected. Undaunted, she applied again. This time, it was approved, but the nursing homes wouldn’t take him because he didn’t have funding.

Horton knew if she could get his Social Security Income application approved, he would have funding to go into long-term care and receive Medicaid. But the clock was ticking because a PASRR approval expires after 30 days.

While she waited for his Social Security to be approved, Horton continued working on James’ behalf. She called Adult Protective Services, but because he was already at a safe place, they wouldn’t get involved. She was referred to the Office of Public Guardian but was told James had to have an income before they could take over his case. She reached out to his state representatives – to no avail.

“I didn’t know what else to do,” Horton said. “I felt all this pressure. I was doing everything I could think of. I felt like it was all on my shoulders. I was shocked there wasn’t some program for people without money.”

But funding wasn’t the only issue. James’ prior criminal record was keeping him from being considered for some housing options, so Horton reached out to Arkansas Legal Aid to begin the process of expunging his record.

While working with Legal Aid, she began preparing his Social Security disability application. An already difficult process, it was further complicated because James did not have a permanent address or phone number. During one call, she was on hold with the Social Security Administration for four hours. When it was her turn in the queue, they asked to speak with James. Luckily, they were able to reach him at the treatment center to continue the process.

James was eligible for Social Security, but he had to complete 18 pages of paperwork and schedule a phone interview – not such an easy thing for a person who doesn’t have a phone.

Another helping hand

During this period, someone suggested Horton look into a transitional house, which is usually a placement for people exiting a substance use rehabilitation program. They receive shelter, food and transportation while they look for a job and work to transition back into society.

James was accepted into transitional housing in Northeast Arkansas. James mistakenly thought the facility was a homeless shelter and, fearing another traumatic and abusive experience, he once again attempted suicide. He was immediately transported to a hospital in Jonesboro.

Because he was now in Northeast Arkansas, a new Arkansas Blue Cross team member stepped in to help with the case. Delaney Kirkendoll, a Behavioral Health case manager, previously worked in the Behavioral Health Unit at St. Bernards. She was in constant contact with hospital employees, encouraging them not to discharge James while continuing to reach out to possible contacts in the area.

 

After months of work, James had two pieces of good news: he was approved for Social Security insurance, and a skilled nursing facility in Blytheville accepted him.

“It felt like OK, finally, we’re seeing a little bit of light at the end of the tunnel. I’m thankful we were able to get that part for him, so he has some money coming in,” Horton said. “He’ll be good once he gets to a skilled nursing facility, but that’s the biggest challenge.”

James can’t start his long-term Medicaid application until he is in a skilled nursing facility or an inpatient facility. In June, he turns 65 and will go on Medicare.

Now that James is settled in a new place,  Kirkendoll visits monthly, bringing clothes, snacks and glasses. And Horton continues to work with Arkansas Legal Aid to get his criminal record expunged.

“He’s appreciative. I think he’s seen what we’ve done,”  Kirkendoll said. “He’s gone through a lot. It’s a big culture shock for him right now.”

Horton agreed: “He’s definitely doing a lot better than before we got involved. Hopefully, we’ll leave him in a good place. That’s what our goal is, and that he’s safe.”

 

* Names have been changed to protect the member’s privacy.