From Nursing Facility to a Comfortable Home
Daniel H., a Partnership member in Shasta County, was referred to a skilled nursing facility at the end of March 2023. Before Daniel's admission to the nursing facility due to a foot injury related to diabetes complications, he had been living in a one-bedroom, single-wide trailer with a family member, who provided In-Home Supportive Services (IHSS) to him. However, when his family member could no longer provide care for Daniel and planned to move out; Daniel was faced with having to return to the trailer by himself. After much contemplation, Daniel felt he needed to find low-income housing to better fit his needs.
Tonya, a Partnership social worker, met with Daniel on March 27 to get acquainted and further assess his circumstances to determine the best way to support him. Tonya worked tirelessly to investigate the low-income apartment options for him, including visiting sites that were accepting applications. Tonya was able to provide Daniel current housing resources from the local disability action center to give him a gauge of rent in the area. They discovered that the rent for the apartments was more than the total Daniel was paying for his current home. With Tonya's help, Daniel came to realize that his best option was to return to his current home.
In order to improve Daniel's living situation, Tonya supported him in addressing some of the family challenges that were not conducive to a happy and healthy home life. For example, Daniel's family member that was originally providing IHSS care for him continued to live in the trailer while Daniel was receiving care at the nursing facility. Tonya helped facilitate healthy family boundaries by helping this family member relocate since he could no longer act as Daniel's care provider, so the home could be properly set up for Daniel's return.
Daniel faced another problem: who would provide him with in-home care if this family member could not? Tonya meticulously explored other options for IHSS providers with Daniel, including suggesting for Daniel to consider another relative as a possible IHSS. This would ease Daniel's mounting anxiety of having a stranger coming into his home to care for him. To Tonya and Daniel's delight, another relative agreed to provide the IHSS care that Daniel needed. Tonya then worked together with Daniel to create a care plan with his relative that would set the stage for boundaries and expectations to fulfill Daniel's health care needs.
In order to prepare Daniel for the move home and to properly set him up for success, Tonya provided support in getting his relative set up with IHSS, made a follow-up appointment with Daniel's primary care provider and worked with the nursing facility discharge planner to ensure that home health and wound care were all set up upon his arrival to ensure his foot injury was well-tended to. Tonya also connected with Community Supports to set up medically tailored meals that are delivered daily and help to ensure that Daniel is able to follow a diabetic diet. Tonya also provided Daniel with guidance on how to take better charge of his own health and to advocate for his health concerns.
A constant barrier for Daniel was his limited income, which caused him a tremendous amount of anxiety. Tonya was able to introduce better financial solutions for Daniel, such as discovering his eligibility for increased food stamps, since his family member was no longer living with him. She educated Daniel on the process for applying for the increased food stamps and has a plan to follow up with him to ensure success in this. Tonya also suggested budgeting and some areas where he could easily cut expenses, such as cutting back on streaming subscriptions by only subscribing to one or two at a time.
On May 3, Daniel discharged back home successfully with Tonya's support and with his relative instated as his caregiver. Daniel also has the comfort of medically-tailored meals delivered to his home daily, which is a tremendous help in managing his diabetes. Daniel is connected with his primary care provider and the home health and wound care services in place for him are working as planned.
Now that Daniel is comfortably back in his home, Tonya will continue to work with him to ensure he is connected to a few additional resources. For his long-term housing and financial concerns, Tonya has contacted Shasta County Housing Authority and discovered that Daniel may be able to receive county HUD assistance with the rent, after an assessment of his home. With her guidance, Daniel was able to apply for both City of Redding and Shasta County HUD.
Tonya also plans to connect Daniel to Dignity Connected Living program, which has several services such as an adult day program, case management, and staff who can provide hands-on assistance in administering Daniel's medication. Tonya feels Daniel would really enjoy having a social outlet as well as a wider community of support.
"During our visits I witnessed Daniel take control of not only his health but his life," says Tonya. "We discussed ways he can advocate for his needs and created an action plan and Daniel took the lead while I offered support, guidance, and information. It was an honor to be invited into Daniel's life and create this working relationship."
