“It was so different for somebody to be trying to help me, to reach out and say look, we’re going to help you.”

“I’ve put rows of seats in there, and played football there”, says Howard, 58, pointing up at the famous exterior of the Pasadena Rose Bowl. “I’ve had a long history with this place”. Which is perhaps why Howard was drawn back here when two years ago he found himself homeless and living in his car.

One of the quarter of a million people in Los Angeles County without a permanent place to live, Howard is challenged not just by his living conditions, but by a host of chronic health problems. These include asthma, anxiety, sleep apnea, and depression, which have caused him to be a frequent utilizer of hospital emergency rooms. Howard has also struggled with cocaine addiction, although he has now been clean for 6 years. He was located by Delia Lezama, a health coach with Partners in Care Foundation, as part of a HomeMeds Plus program, which provides medication reconciliation, psychosocial, functional needs and safety assessments for health plans and medical providers caring for high risk patients.

“My angel” is how Howard describes Delia. She first met Howard several months ago after repeatedly exploring the area that he’d last been seen. “His healthcare payer, Health Net, and health care provider, Regal Medical Group, referred his case after trying unsuccessfully to reach Howard via phone and mail. I came to the parking lot here at the Rose Bowl, talked to a few people, and was able to locate him quite quickly”, explains Delia, understating the complexity and sensitivity required in her “detective work.”

In truth, Delia is a highly trained professional with a Masters in Social Work whose expertise helps clients like Howard connect with a host of community services and resources that can give them the support needed to dramatically improve their lives.

“The first time I met Delia, she sat with me for about two to three hours. In the middle I caught myself fixing to cry. It was so different for somebody to be trying to help me, to reach out and say look, we’re going to help you. I never remember that happening. I’ve been on my own since I was 17 years old. I‘ve always paid my way, but right now is real hard, so for someone to say, I see where you’re at, and we’re going to give you some support, I had to catch myself because I was like, wow, I think those are tears that are trying to come up there, you know?”

Following that first meeting, Delia prepared detailed case notes and recommendations, and collaborated with Howard’s case manager at Regal to set up a care plan. Top of the list was connecting Howard with People Assisting the Homeless (PATH), a community-based, non-profit organization that helps people find permanent, affordable housing and provides critical supportive services including employment assistance, counseling, substance abuse treatment and legal aid. Delia also tracked down a local church that offers regular meals for the homeless, and made sure that Howard followed up with his doctor appointments, including providing him with details of a transportation service in case he is unable to fuel or drive his car.
All of which has given Howard some much needed hope for the future. “I was sleeping behind that grocery mart,” explains Howard, pointing towards the nearby hillside, “It was killing me. I’d been there for a few months. People would talk to me, but I would never tell ‘em what was happening. I see a way out now. There’s a tunnel and there’s a little light at the end of it.”

And although Howard is still not in permanent housing, he is now in regular contact with his doctor and Delia, which has helped to stabilize his conditions and reduce his use of emergency services. As a result Regal Medical Group has extended the health coaching.

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