In the heart of one of the city’s poorest neighborhoods, Christiana Care is helping to deliver riches beyond measure in the form of care, respect, nourishment and hope to the homeless served by St. Patrick’s Center on Wilmington’s east side.
Long-known in the community for its services to seniors, the center fondly known as St. Pat’s recently broadened its mission to assist the homeless, as well. While a number of community-based services are in place to help the elderly (Meals on Wheels and transportation vouchers, for example), social worker Linda Brennan-Jones, BALS, BS, points out that the homeless population too often falls through the cracks.
For example, those who aren’t old enough to qualify for St. Patrick’s senior meal program and who lack money for bus fare must walk 17 blocks to Emmanuel Dining Room for a mid-day meal. Three Wednesdays each month, though, volunteer teams of Christiana Care employees and friends prepare and serve bagged lunches for those at the homeless sanctuary. Providing more than mere nourishment, Brennan-Jones explains that the sharing of simple sandwiches, fruit, water and a snack opens the door for conversation about health-related concerns and helps Christiana Care nurses and social workers embedded at St. Pat’s uncover needs and coordinate services.
Christiana Care’s relationship with St. Pat’s grew out of many cold winter nights when the homeless would arrive at the Wilmington Emergency Department seeking help. The problem was, most didn’t require emergency medical care—they needed assistance with shelter, food and clothing—but late at night the police had nowhere else to take them.
Committed to serving its neighbors, Christiana Care wanted to help, but an Emergency Department was not the place to coordinate social services.
Linda Brittingham, LCSW, BCD, director of Social Work, took on the challenge, and convened a community partnership meeting of leaders from all organizations in the city that serve the homeless.
“So many organizations were out there doing good work, but all of us were doing our own thing,” recalled Brittingham of the council’s start. “Christiana Care stepped in as a catalyst and got everyone talking to each other and working together.”
From that initial meeting grew heightened collaboration among the many organizations serving Wilmington’s most vulnerable citizens, and a special partnership emerged between Christiana Care and St. Pat’s.
Vital social and medical support
The needs of the homeless go far beyond cold weather. Recognizing that a social worker with experience addressing medical needs would be vital to helping his center’s changing clientele, Joseph P. Hickey, executive director of St. Patrick’s, approached Christiana Care proposing a partnership. He had recently received a grant from the state for an on-site social worker at his center. Brittingham’s social work team, he knew, was uniquely qualified to help those in his charge get help for both social and medical needs.
Christiana Care’s Medical Home Without Walls population health program, which helps coordinate care for this very same population—one that typically only seeks medical care through the Emergency Department—was the perfect fit for serving the people at St. Pat’s. So, not only do three Christiana Care social workers now have regularly scheduled days at St. Pat’s to provide care management services under Hickey’s grant, but additional support from Medical Home Without Walls added the on-site service of a nurse practitioner who, several times each month, takes blood pressure readings and does wellness checks. A community educator also regularly visits the center to help participants navigate the insurance system.
“St. Patrick’s Center helps many people with basic needs every day and is an important part of the eastside community,” said Hickey. “With the addition of social workers, nurses and others from Christiana Care on-site at the center, we now provide vital social and medical support services. Our partnership has led to significant improvements in the daily lives of many people.”
The partnership was an immediate success. In fact, since Christiana Care teamed up with St. Pat’s—and thanks to greater coordination of social services by the group Brittingham pulled together—the number of people using the Emergency Department for social needs has dropped an astounding 83 percent.
Good stories every day
Their unique presence at St. Pat’s allows the social work team to do things they say no one else has been able to accomplish. “We’re even getting people into residential rehabilitation programs where we can follow them several times a week and do real case management,” explained Carmela Longobardi, MSW, one of the social workers embedded at the center.
They helped a man who had been told for 10 years he didn’t qualify for an eye exam get both an exam and free glasses. They even helped one man get the job certification needed to return to the workforce.
“We do what medical social workers do best,” said Marie Hougentogler, BS, who came out of retirement to be part of the Christiana Care social work team assigned to St. Pat’s. “We tease out all the problems, we get people a medical family and then we work with them for their other issues, as well – things like housing and bus tickets to help them get to work. We’re getting people off of the street.”
According to Brennan-Jones, several in the community return to St. Pat’s each Wednesday, knowing that Christiana Care will be there to help them. For the first time, she explains, many are being followed medically and even have medical records. She calls it an example of population health case management at its best.
“Every single day good stories happen at St. Patrick’s!” agreed Longobardi.
Food for the soul
Bagged lunches aren’t the only sustenance Christiana Care delivers to help feed the homeless at St. Pat’s. Brennan-Jones was quick to approach the newly opened Au Bon Pain cafe in the Wilmington Hospital atrium asking them to donate unsold food to St. Patrick’s. They eagerly agreed if someone would arrange to pick it up and deliver it at the close of business each day.
In stepped those social workers, again! They’ve lined up a rotating schedule of willing Christiana Care employees to voluntarily transport leftover pastries, bagels, bread, salads and sandwiches every night to St. Pat’s. The next morning, the food is set out on a long table at the center where those in need are welcome to help themselves.
“It’s an amazing amount of food,” said Brennan-Jones. “Sometimes I have to make two trips to my car!”
“You can’t not want to help”
The social workers admit that each spends hours far beyond her work schedule serving St. Pat’s, and they keep encouraging Christiana Care to do more.
“We tell our friends about it. We serve holiday meals. You can’t not want to help,” said Hougentogler. “Everybody works together and shows true respect for the homeless. You get caught up in it. It’s very rewarding.”
Longobardi agreed. “Christiana Care has such a presence there and all of us involved want to do more. It’s just a feeling that we’re supposed to be there, in partnership with St. Pat’s, making a difference in our community.”