Maria came to IF Recuperative Care shortly after the 2014 Christmas Holidays. She is a petite elderly undocumented homeless woman with breast cancer that resulted in a mastectomy. She was uncertain of her age and often confused her own date of birth. Some days she admitted to being in her early 60’s while other days she was admittedly 70’something. She had exhausted her couch surfing resources and was unable to stay with her only living relative due to her abusing that relative. With nowhere to live and needing follow up oncology care, county hospital negotiated with LA County’s DHS for her to come to IF Recuperative Care.
On arrival, IF Nursing Staff immediately began the tedious process of connecting her to both primary medical care and specialty medical care. Simultaneously, IF Case Management staff began the equally tedious process of securing her vital documents and connecting her to social services that would be beneficial to her.
Initially it seemed like no progress could be made on either front. Without documentation, she could not be connected to medical care and, being undocumented from Colombia, no documents were able to be investigated due to the Colombian Consulate being closed till late spring of 2015. Eventually staff was able to connect Maria to a Primary Care Physician through LA County’s MyHealthLA program for undocumented residents who have no form of ID. The wait list for new appointments was lengthy but eventually she was seen and medications were updated and refilled.
Additionally a referral to oncology was submitted paving the way for follow up care related to the Breast Cancer. As spring turned into summer, Maria became restless. She left the site daily as she attended Church regularly and she embedded herself into a local Senior Center. At night she struggled with the other women in the dorm, frequently getting up and disturbing those who were sleeping. She was frustrated and continued to argue with staff while expressing her need for a more permanent living situation without a dorm setting. From time to time, she would resort to calling the Police to report “abuse” only to beg them to find her a permanent place to live. IF CM Staff continued to pursue every possible avenue to obtain an ID and income and to secure safe and suitable housing for her. Everything seemed to lead to one dead end after another.
Through the summer, IF Nursing Staff continued to pursue specialty care for her oncological needs. This too proved to be an elusive goal. No oncologist in the county would see her without a CA ID and cash to pay for the appointment. Thankfully, she remained sturdy and appeared healthy with no indication that her health was declining. As summer turned into fall, IF staff continued to pursue and advocate for the medical care and vital documents that she needed while DHS continued to pursue the housing that she needed. Collaborative discussions were held daily as all staff worked tirelessly to help Maria find safe and suitable housing.
Finally after more than 9 months a light flickered on the horizon. DHS had found a Board & Care provider with a new pilot program. This program was targeting elderly undocumented folks with medical needs who were unable to live independently. The program staff came the following week and met with Maria and IF staff to begin the paperwork. Once approved, a final document was suddenly needed even as her bags were packed to move into her new home that same week.
After 9 months, it all came down to one critical document that required a 30 minute visit to and a signature from her Primary Care Physician. The soonest available time slot was several weeks after her scheduled move in day. In a supportive collaboration, DHS was able to intervene and advocated to the CEO of the clinic. After a brief conversation, the appointment was rescheduled for the day before the scheduled move. IF Recuperative Care Staff accompanied Maria to the appointment.
The final form was signed and completed and presented to the Board & Care the next day when Maria’s Recuperative Care Case Manager transported her to her new forever home. It was a long journey home but so worth all the hard work and persistence.