“Welcome to our Center,” smiled slender, pretty Alice Wong, Music therapist and Assistant Director of Adult Day Health Care at Laguna Honda Hospital. Her gracious hand flourished toward sunny rooms filled at noon with happily lunching “seasoned citizens.”

She added sardonically, “We close in four days.”

Massive budget cuts meant the San Francisco Department of Public Health would shut the Center’s doors to over sixty frail elders on Friday, February 20, 2009.

Said Alice, “Nobody is really looking at the psychological impact on these clients.” Her eyes welled up. “A lot of them can tell you that since the first day they’re not able to sleep. One is in a panic, asking, ‘Where can I go? What am I going to do?’ Some are crying every day. They are so worried and anxious.” As one client left in a wheelchair, a loud wail echoed down the hall.

LaNay Eastman, Margaret Baran, and Marie Jobling, three out of 38 members and stakeholders on the Long-Term Care Coordinating Council support an Aging In Place plan that has gained countrywide acceptance. Opposed to warehousing seniors in institutional care in nursing homes, the concept focuses on helping them live in their homes and communities and achieve the highest quality of life as long as possible.

Many communities have set up adult day centers, providing more than mere “baby-sitting.” Physical and occupational therapy help people maintain function. The on-site community provides a social network. This arrangement allows people to be in their own homes in the community with their families but have a time during the day when skilled professionals work to keep them going and involved. Clients at the Laguna Honda Center attend from two to five days a week.

Relative caregivers are freed from worry about their elder and can work during the day. Some receive MediCal reimbursements from In-Home Support Services to help defray costs and provide more income. Day Care Centers cost less than nursing home and hospital stays.

Of the 10 other Adult Day Centers in San Francisco, only the Laguna Honda Adult Center provides a comprehensive program with a highly skilled multi-lingual, multi-cultural staff of Russian-, Tagalog-, Chinese-, and English-speaking professionals able to communicate with clients in their languages. This special pairing of staff and clients took years to bring together. When the Center closes, they are assured of jobs elsewhere in the DPH system, but their beloved elders will be dispersed, and, like Humpty Dumpty, the unique program can never be put together again.

Folene Torres, 81, is a bright, giggling, tiny Filipino gentleman who was a high school math teacher, PE coordinator for 20 schools and a dance instructor in Sto. Tomas, Batangas Province. He laughed delightedly recalling that his pupils found him “very cute.”

Home alone two years ago, the extremely spiritual Folene derived no pleasure from “the sun and the beautiful nature.” His isolation made his arthritic hands and feet hurt badly. “I cried and cried for mercy and prayed that God would take me to the next life.” His family doctor reminded Folene, “You are a very social person,” and referred him to the Center. Marina Israelyn, the social worker accepted him: ”I was given a golden opportunity to stay here.”

The occupational therapy for his hands and physical therapy for his feet, as well as new acquaintances, eased his pain. “When they gave me good exercise, I was feeling fit. I was strong now.

“I will sing and dance, okay?” He laughed and performed a spirited dance while singing a beautiful Filipino song. The CNAs said later that another Filipino CNA named Jess Mandapat encouraged Folene and all the clients to dance. They loved this activity, and were very good at it.

“This is a very good place for me. I’m very sad they will close because, if I don’t go anymore to this place, what will happen to me? The same way I was before I came here—sad and lonely. I’m alone in the house. I have no conversation with other people. I will miss my friends, and all the staff [who] are friendly and good to me.”

Juliana Nwokelo, is an 85-year-old Nigerian lady who has been in the US five years. When her husband fell ill in her homeland, she refused to leave his bedside until after his death. Grief made her ill and depressed. She lost weight. Her arms looked like sticks. Her daughter forced her to come to the United States.

Juliana had been a very strong runner and won three prizes for racing in a 1936 ceremony for Queen Elizabeth. She, too, has arthritis and high blood pressure. Sitting at home, isolated in her new country without contacts or physical therapy, Juliana could not raise her left arm above elbow height. With therapy and a social network, she has gained weight and mobility. She flashes a wide, authoritative smile, and converses with love and intelligence.

The elders were told of the closure the week before Thanksgiving. One 80-year-old woman began a noticeable progressive decline, then died of pancreatic cancer. Alice choked with tears. “I cannot prove it’s related. But look at all the medical articles about stress. Stress is one of the causes of death.“

Conversation with three CNAs, Cathy Billups, 52, Jess Mandapat, 58, Mariah Watkins, 55, and social worker, Marina Israelyn, 48, revealed their shared fear that this forced move would cause more of their beloved elders to die.

Mariah reported that some centers have shorter hours—only morning or afternoon. Clients from 60 to 100 are terrified of being home alone.

I asked the staff how I could make it real to people who may not understand the potential death blow dealt to elders when their social safety net is ripped away—suddenly losing all the professionals who cared for them, along with all their friends.

Mariah: “Let them consider the things they may lose in their life, for example a foreclosed home. The younger person can go to the streets, but the 80-year-old elder will die out there.

“They’ve already lost everything—their looks, their ability to make decisions, their authority. ‘This [center] is just one more thing I lost. So, why do I want to live?’”

Cathy Billups: “I’ve been here for 25 years, even before the Center opened. There are people here who are like my family who have been here as long as I have. We call and see if they’re okay. When we’re not here, they want to make sure that we’re all right.”

Cathy was worried about the “extra stress on their mind, heart, and body to adjust to other people somewhere else when they don’t speak English.

“In the other Centers, they don’t help them to the bathroom like we do. They have program aides. This is the only Center in San Francisco that has certified CNAs that will do that.

“We have more wheelchairs. A lot of them don’t have wheelchairs.”

Said Jess, “We have Class B [licenses] so that, just in case nobody is home we can drive them back home.”

“For us it doesn’t make sense to close this program,” Alice said. Despite the City’s budget crisis, “one thing is important to note: We don’t use only General Funds like other City programs.” The Adult Day Health Care Center program generates revenue. “All these clients you see here are either reimbursed by MediCal or are private pay. So, though there may be a deficit, there are ways to balance the Center’s budget. We can do differently in the program and save a little money.”

Afraid for the clients they loved, the staff, including Marina, Cathy, Jess, and Mariah, offered to give up $800 a month in salaries to help the Center become “revenue neutral” so their clients wouldn’t be “thrown out in the street.”

Stakeholders on the Long-Term Care Coordinating Council, who had worked hard to see the program thrive, learned of Center closure in December 2008. Said Ms. Jobling, “Because it was a mid-year budget cut, the cuts came so fast and deep it was hard to know what to do. There wasn’t much time to organize.”

They hoped to delay closure and devise a more cost-effective plan either to provide for the Center’s continuation or ensure clients were transitioned more smoothly.

Said Marie, “People are really under the gun to find other placements.” The way they are structured and funded, Adult Day Care Centers cannot always take people immediately.

Accepting a new group means hiring more staff. That doesn’t happen overnight.

Taking unexpected clients means bumping people on existing waiting lists.

Some centers with openings don’t necessarily have the right languages for those needing placement.

Additionally, the stepped process involved when a client changes to a new program can take two to 12 months to complete.

Relocation to another center is a time-consuming procedure. Multiple appointments including home visits are required. The client must be assessed by a team to determine suitability. Making an appointment with a physician to sign off on the treatment plan can take a month or more. In some cases, the client must change their primary care physician, losing a doctor they have seen for years and who knows them well. This change is a huge adjustment for an elder.

Meanwhile, they can sit at home waiting, plunged back again into enforced isolation and depression.

Realizing these 60 vulnerable San Franciscans had no place to go, unable to persuade DPH to keep the Day Care open, LTCCC members worked feverishly to buy time for placement in other centers and were able to negotiate an extension to March 20 with Dr. Mitch Katz, DPH Director.

Staff reported that they were told if they spoke at City Hall, it might work to save the Center. “Half of our staff, family members, and two clients went to sit in at the Health Commission and Board of Supervisors’ hearings and tell them what kind of impact [the closing] is having,” Alice reported.

Both LTCCC members and the Day Center staff indicated that they believe the decision was taken long ago to close down the Center. Wrote Marie Jobling, “there are already discussions about permanently ending the program and using the saved construction dollars somewhere else.“ Two days before our interview, the staff attended a meeting in which documentation was handed to them indicating that the funds had been reallocated long ago. But there is no replacement for the Day Health Center. Testimony provided a the Health Commission indicated very few available spots in the city, and those that were available were inappropriate levels of care for most center clients.

In light of this predetermined plan, the group expressed feelings of betrayal that they had been encouraged to take blind elders in wheelchairs to sit for three hours in the Public Comment lines and beg the Supervisors and Commissioners tearfully to keep the Center open.

The group expressed great love for their clients and asserted they had learned important lessons about love and survival from them.

Said Alice, “As a therapist, I am preparing for closure, and for leaving this place. People need to know that, for many, this is like they’re leaving their home, not just leaving a program. These are human beings. They have a lot of emotions [wrapped up] in this place. It’s just not like you can just take it away.”

Carol

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