The unique challenges of helping the elderly if they've lived most of their life on the street.

"Before I came here, I was living on the street six or seven years," Leonard says. "I was one of those people you pass by on the sidewalk. I guess I was fighting the whole world at that time."

Leonard came in off the streets of New York three years ago, after a caseworker from the Coalition for the Homeless spent months working to convince him. "His name was Jason," says Leonard with a smile. "He kept stopping by to see me." Eventually, says Leonard, something clicked, and he realized it was time to come in.

Now Leonard, 66, is living at the Domenech, a clean and light-filled apartment building in the Brownsville section of Brooklyn that opened in 2011. He's been here for nearly three years, and he's got his feet under him. His t-shirt and jeans are meticulously clean. His snow-white hair peeks out from under a baseball cap, and that smile comes easily and often. "I wouldn't leave here for the world," he says.

The 72-unit Domenech is one of 16 buildings around the city operated by Common Ground, a nonprofit dedicated to providing supportive and affordable housing for the homeless and those at risk of becoming homeless. All the residents here are seniors, and 40 percent of them, like Leonard, had been on the street for years before they moved in. Many have mental health and substance abuse issues that qualified them for placement in this type of  "supportive housing," with access to case-management services to keep them housed.

Most everyone develops healthcare needs as they get older, and for the long-term homeless, whose bodies have endured years of exposure to the elements, usually without access to regular medical care, the problems can be even more acute. "They're so vulnerable, so frail," says Brenda Rosen, executive director of Common Ground. "One of the underlying challenges that has always come up is how do we work with folks who are getting older? How do we do something different that will allow residents to age in place with better quality of life?"

The question is getting ever more urgent as Common Ground's population ages. By 2017, Rosen estimates, one third of the agency's residents will be over 62. Many have diabetes, heart disease, and other chronic conditions that can be treated and controlled with basic medical care and lifestyle changes -- things that are often way out of reach for people like Leonard, who have spent years living as "those people you pass by on the sidewalk."

That's why the Domenech was chosen as one of the locations for a ground-breaking pilot program called Elder Care Health Outreach, or ECHO. Tenants receive on-site medical care from a doctor and nurse practitioner who make regular visits to a clinical office within the building. They get counseling, support for taking their medication, advice on nutrition and exercise, and ongoing case management to help them deal with the often complex issues they face.

The goal of the two-year pilot program, funded by the Fan Fox & Leslie R. Samuels Foundation and the MetLife Foundation, is to provide better care to an at-risk population, reduce health-care costs and emergency room visits, and allow people to "age in place" -- to retain their independence and mobility as long as possible. Common Ground is working in partnership with the Center for Urban and Community Services to create a model program that could be replicated in similar housing facilities around the country.

For doctors, it provides an unusual opportunity to care for patients in a community context, allowing them to get to know patients in a way that is all too unusual in the American health-care system of today.

"The relationship is the treatment, in many ways," says Dr. Van Yu, a psychiatrist who is chief medical officer for CUCS. "You're able to create a relationship so much more easily here. Medicine in places like this is not rocket science, it's not sophisticated. It's kind of a 1950s model."

With a closer relationship to a primary care physician, says Yu, the quality of care goes up, and patient health improves. "If people get better integrated care, they're more healthy," says Yu. "They use the ER less, remain healthy longer, and they can stay in a place like this longer."

Joanne Miceli, the Domenech's program director, says she's seen an immediate benefit from having medical services in-house, especially for those residents who have been reluctant to seek medical care. "We have people who for months we've been trying to get to a doctor," she says. "Now they're seeing the doctor downstairs."

The benefits for the long-term homeless are particularly pronounced, says Yu. "One half to one third of homeless people are mentally ill. Mentally ill people are stigmatized in the  health-care system and receive low-quality care."

"it's a unique opportunity to do something for people who have been ignored," says Rosen.

"People who have been shunned," says Miceli.

At the Domenech, those who have been on the margins of society can start taking care of themselves, regaining health and strength that had been sapped by years of financial and emotional stress. "When you find yourself homeless, you go through the motions," says Miriam, a 76-year-old woman who came to the Domenech a year ago after losing her Manhattan apartment and spending a bruising 14 months in the city's shelter system. "You go through a malaise, and it takes a while to come out of it. I came here as a broken person, although I hid it quite a bit."

Leonard says that he has been using the new medical services to assess and treat the toll that years of drug and alcohol abuse had taken on his liver, pancreas, and kidneys. "My health is being taken care of, top-quality," says Leonard. "That's never been done for me. I was on my own, and I thought I was doing a good job of taking care of myself. I wasn't."

After a long time when he never thought beyond the end of the day, Leonard is setting goals and hoping to reconcile with his family -- six daughters whom he hasn't seen for nearly 20 years, and many grandchildren he's never met.  "I'm very, very happy that I'm here," he says. "If I was out there in the street, I would just lay down my head. But now, I'm happy to reach this age." 

Images courtesy of  Common Ground.

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