CSSW Feature Stories

Washtenaw FUSE (Washtenaw Frequent Users System Engagement) is one of four pilot programs selected by the Corporation for Supportive Housing to lead in a nationwide effort integrating housing, care management and health services to improve health outcomes for high risk adults caught in a revolving door of crisis services. The goal of this initiative is to address one of the most pressing policy problems currently facing states and the nation as a whole: rising public health care costs associated with fragmented and uncoordinated care.

John was referred to the FUSE program from a local homeless shelter. John grew up in foster care after being taken from his home due to a physically abusive mother; then spent much of his adult life with no home at all. He was incarcerated for fifteen years and spent a considerable amount of that time in isolation due to severe behavioral issues. Upon his release, John had no resources and nowhere to go. A community homeless outreach program began working with him to find housing in the area, however prison had taken its toll on his mental health. John developed trauma-induced psychoses and defense mechanisms during incarceration that would not allow for him to stay at any one place for an extended period of time.

John also suffers from diabetes, HIV/AIDS, a severe mental illness and substance abuse. Without the means to address his health condition, in a single year he was in the emergency room 21 times and admitted to the hospital six, typically for lack of insulin or acute detox.

Through FUSE, John receives access to preventative health care and stable housing. He has followed through with all of his doctor appointments, has taken his medications regularly and has yet to visit the emergency room. With a stable place to live, access to critical entitlements, health care coordination and an array of support services, he is successfully becoming more involved in the community. While there may be hiccups in John’s path, FUSE offers a plan and concrete support to get him back on his feet and to again live with dignity.

This is just the beginning of the difference FUSE is making in Washtenaw County. Through CSSW leadership and dedicated partners, FUSE is lowering healthcare costs in the best possible way—helping those in our community who are the most vulnerable get their lives back on track.

Click here for more information on the FUSE program.

Ruth and Syd Bernard ~ client profile

When you first walk into the Oaks ~ Adult Day Services, you notice something different from other programs for adults with memory impairments and cognitive difficulties. You see people socializing. Talking. Practicing yoga and Tai Chi. Cooking. Listening to music and playing board games; laughing. Living.

A five-day a week program, The Oaks, a program of Catholic Social Services of Washtenaw County (CSSW), provides stimulating activities designed to improve social interaction and mental acuity for its members while also providing much needed support for loved ones seeking a break from the demands of daily caregiving.

Syd Bernard has led the kind of life most would envy. He and his wife Ruth are happily married with two children and five grandchildren filling out their family tree. After receiving his doctorate at Brandeis University, he built a rewarding 40-year career at the University of Michigan as a professor of social work. He’s traveled extensively, has enjoyed an active social life and kept himself physically fit.

Nine years ago, Syd was diagnosed with age-related dementia.

“I just didn’t think that this could possibly happen,” says Ruth. “Syd had a fantastic memory and could find his way around anywhere. I put it down to the memory failures of normal aging. I was in a lot of denial, I refused to even think about it.”

After the initial shock, Ruth realized that her husband’s well-being was now in her hands. “I realized I had to take care of him. I’ve got to do this. But as Syd became more physically debilitated, I was becoming really tired—exhausted would be a better word. That’s when I knew I need to have outside help.”

Ruth tried home care and other day service options before choosing The Oaks, which stood out because of its therapeutic approach. What makes the Oaks a model for individuals with cognitive impairments is that it operates under five core values: comfort, care, compassion, dignity and respect.

The program has created structure and stimulation to Syd’s day. Equally important, the program gives Ruth the much needed respite she needs as well; helping her keep mentally and physically able to provide for her partner. And that’s the entire point. For comfort, care, compassion, dignity and respect aren’t simple slogans at The Oaks. They are the tenets from which the program is based.

When you look at two extraordinary people like Syd and Ruth Bernard, you can see how.

Profile of a typical client

•  90% of households report incomes at or below $15,000 a year with the median household income at $4,200.
• Individuals/families receiving assistance from the Emergency Food Program are the “most vulnerable”:  seniors, persons with a disability living on fixed incomes, single parent households, the unemployed and the underemployed.
• Over 40% are female-headed households and one-third has at least one member with a physical or mental disability.
• 42% represent children between the ages of 0 and 5 years of age.

Process for obtaining food

The CSSW Emergency Food Program prides itself in treating those seeking food with dignity and respect.  We understand that those seeking food are not there by choice but by unfortunate circumstances.

• Eligibility is based on self-reported income and household size
• A brief needs assessment and satisfaction survey are completed to ensure basic needs are met
• Referrals and additional information is provided as appropriate
• Pantry is based on a supermarket style “shopping” system where clients select groceries they need
• Amount of food is determined based on self-reported household size

The waiting area provides computers and internet access as well as a play area for the children to further respect the dignity of our consumers

Julia ~ client profile

Things couldn’t get much worse. Julia tried rehab, but kept relapsing; her husband and kids left long ago. Because of her chronic alcohol addiction she couldn’t hold onto a job. At 55, suffering from major depression, Julia was homeless…

Individuals like Julia battling these and other challenges don’t have to end up isolated, living in shelters or on the streets. In Ann Arbor, the CSSW Housing Support Services (HSS) program helps tenants of Avalon Housing maintain permanent housing and maximize personal independence.

Specifically, the program works with each client to determine the type and level of assistance necessary to sustain independent housing. Services include helping Avalon tenants access rental assistance, providing transportation, connecting them with community and employment resources, or help with daily living tasks and medication management. Whatever the need, the HSS team is available 24 hours a day, every day, providing onsite intervention.

For Julia, it worked.

When she first came to Housing Support Services, she had been homeless for more than two years—staying in hotels, sleeping on people’s couches, living in shelters.  Catholic Social Services helped her to get back on her feet, get the medical help she needed for her depression and other issues and connected her with outside resources.

Nearly three years later, she has a place to call home. She is sober, secure and hopeful. Julia’s outlook remains positive because she’s no longer alone—Housing Support is there—whenever, however she may need a helping hand.

Danielle ~ client profile

Danielle is a 20-year-old single mother and full-time nursing student. She has plenty of good friends, works as a nurse’s aide, is on the college Deans List, and has a wonderfully healthy and happy three-year-old daughter, Leesa. Four years ago, however, her life couldn’t have been more different. A former honor student and standout volleyball player, Danielle started fighting with her family, drinking, skipping school, and getting booted from the team for letting her grades drop. Often, she didn’t even bother coming home at all.

Then she found out she was pregnant.

That’s when she came to Catholic Social Services of Washtenaw County (CSSW) for help. Through the CSSW Father Patrick Jackson House program, she was given a stable home environment where she established a positive routine. Danielle went back to school, received prenatal care and counseling and enrolled in on-site parenting classes. She also began the task of repairing her broken family relationships.

A few months after her 18^th birthday, Danielle and Leesa moved into their first apartment with money she had saved while living at Father Pat’s. Two years later, she continues to excel in both work and school, determined to be the best role model possible for her little girl.  With the help she received through Catholic Social Services, this troubled teen has grown into a responsible young parent.