‘Close to my deathbed’: How being homeless in SLO County pushes seniors to the brink

At the end of 2023, Deborah Marino's mental and physical health were in decline, and there was little she could do about it.

At the time, Marino was in the middle of her sixth year of homelessness in San Luis Obispo County and moving from encampment to encampment along the Bob Jones Trail.

That year had been particularly difficult.

On at least four separate occasions, Marino said, San Luis Obispo police officers, city rangers and workers from Caltrans or Public Works confiscated most or all of the possessions she pushed around in a shopping cart, including twice in a span of four months.

Simply put, she was struggling to stay alive without consistent access to food, shelter, income and the medications she needed to deal with a host of worsening health conditions, including depression, early stage emphysema and most significantly, cancer.

The cherry on top? A four-month gap in coverage between Medicaid and Medicare as she approached her 65th birthday that Marino said nearly derailed her first real shot at housing in years.

"That hurt a lot, because I took high blood pressure medicine and I took my cancer treatment course, but more than anything else, (I missed) my psych meds," Marino said. "If I don't take those, I can't stay on track."

Marino's struggles with getting the care she needed were echoed by many participants in the focus groups The Tribune assembled to report this three-part series on senior homelessness.

Health care issues become a compounding issue for everyone as they age, but when a person loses the foundation and stability of steady housing, each of those challenges can layer one atop another in dangerous and even life-threatening ways.

Prior to 2024, monitoring the outcomes of these compounding issues was more difficult, as the San Luis Obispo County Sheriff's Office did not track deaths within the homeless population.

However, in the first year of data collection between Jan. 1 and Aug. 29, the coroner's office recorded 29 deaths among the county's homeless population. Of those 29 deaths, 15 were over the age of 55, and 12 of the 15 homeless senior deaths happened while the individual was unsheltered, according to coroner's office data.

"Coming from what I've been through, I was surprised I survived," said Marino, who eventually got into temporary housing before securing a long-term spot at a senior community in Paso Robles. "I didn't think I would."

Homeless seniors suffer worse health outcomes on the street Marino's struggles to maintain her health are far from an isolated incident among homeless seniors.

While homeless, Marino said getting — and keeping — appointments with her primary care doctor was a struggle, as she didn't have consistent phone or internet access.

That meant that like many homeless individuals living in San Luis Obispo County — which is already suffering from a shortage of medical professionals — she had to turn to the emergency room and urgent care centers at times to get even basic care.

Dr. Matthew Scales, chair of the Department of Emergency Medicine at Dignity Health French Hospital Medical Center , said San Luis Obispo County's homeless residents make up around 4% of daily emergency room traffic. On average, French Hospital's emergency room treats around 86 patients a day, meaning it's not unusual to treat three to four unhoused people in a given day, Scales said.

"The elder population is the fastest-growing group of people experiencing homelessness," Scales said. "Generally, they utilize healthcare resources disproportionately more than the younger people because of their age and issues that have developed."

Scales said homeless seniors seeking care are likely to present with "bread and butter" chronic health issues such as diabetes, blood pressure regulation, cardiac issues, heart failure, chronic obstructive pulmonary disease and other conditions that affect most seniors whether or not they're homeless.

Homeless Point-in-Time Count data suggests that in 2024, of the 152 unsheltered people over the age of 55 who agreed to be interviewed by county volunteers, 99 reported having a physical disability and 83 said they have some kind of substance use disorder, according to the PIT Count. Of that group, 62 said they receive disability benefits, including Social Security income, Social Security disability income and veterans' disability benefits.

As their top areas of medical concern, focus group participants reported respiratory and cardiovascular issues, poor dental care, a non-nutritious diet and other types of daily wear and tear from exposure to the elements.

Oftentimes, these outcomes are worse for homeless seniors than those who have housing, due to the toll exacted by living in the elements, physical overexertion from moving their belongings, poor hygiene and unhealthy diets, which make staying healthy and recuperation more difficult.

Scales said there is evidence that experiencing the wear and tear of homelessness as an older adult accelerates the deterioration of the body by worsening existing conditions and causing new ones that tend to be slower to heal.

Mentally, a chronic lack of access to nutritious food can cause more breakdowns in the nervous system and brain, which can manifest as memory problems.

"These individuals tend to have higher acuity of illness because they're not being treated on a long-term basis," Scales said. "There's quite a bit of ending up in the ER for some medical complaint, but really the issue is that they need social services. They need some kind of short-term assistance with housing, if that's even available."

Outreach, follow-up present challenges for older homeless adults In many San Luis Obispo County homeless encampments, navigating the healthcare system can be fraught with difficulties.

Danica Brookover, a community resources and services specialist with the San Luis Obispo Police Department's Community Action Team , said many times a potential client will have CenCal and other benefits but choose not to interact with the system due to distrust.

She said many homeless individuals don't believe police will work with them to better their situation, and avoid interacting with outreach workers — particularly those associated with the police such as the CAT.

As a result, CAT's outreach is often "not really successful," with just a handful of people accepting aid when it is offered, Brookover said.

Brookover said the COVID-19 pandemic is one of the primary drivers of a recent increase in older adults living in encampments over the past four years. She said many older encampment residents were housed prior to 2020, but lost their jobs and eventually housing due to rising rents.

"When you're an older adult, you don't really have the ability to gain new job skills or to go into a different field," Brookover said. "What you've been doing for the past 30, 40 years — that's all you know how to do, and once you lose that that job placement, you don't really have anything else or anywhere else to go."

Though older adults tend to score higher on the Vulnerability Index-Service Prioritization Decision Assistance Tool that CAT outreach workers use to assess which clients get priority for housing assistance, they are more likely to turn down housing placements than younger encampment residents.

Though the majority of older encampment residents have CenCal and are capable of getting some level of medical treatment, many decline offers of aid for similar reasons,

"One of the roadblocks to older adults in our unhoused community getting connected to resources and services is they don't feel like they're worthy of resources," Brookover said. "They don't feel like they're worthy of any medical treatment or mental health treatment due to their past traumas and their current situation — they don't feel that they are a part of society."

She said while there are circumstances under which a Community Action Team worker can use the "5150 hold" — a 72-hour involuntary psychiatric hospitalization for an individual who is a danger to themselves or others or is gravely disabled — the process of placing an involuntary hold on a person is lengthy and rarely successful when used locally.

While there may be a chance that the CAT could use the 5150 hold on more homeless individuals following the October 2023 implementation of Senate Bill 43 — which expands the 5150 hold to include people suffering from substance abuse disorders — Brookover said the process simply isn't equipped to deal with behavioral health problems within the homeless population en masse.

In fact, the CAT has only successfully placed one person in hospital care under a 5150 hold in 2024, Brookover said.

"We've been trying to get a few individuals in town on a 5150 hold for gravely disabled with SB 43 but it's really tricky, because we can only do the application work," Brookover told The Tribune. "We have to do a lot of back-end investigation and documentation as to why this person meets the requirements for a 5150 hold."

Even if an individual is successfully held at a hospital for 72 hours for a psychiatric evaluation and treatment, there's no guarantee that the person's mental or physical health will improve following their release, she said.

Most older homeless residents face significant technological challenges when engaging with services, such as unreliable phone and Internet access and literacy, Brookover said.

"It's just really challenging to try to get those holds to stick," Brookover said. "Even if they do stick and they're in the hospital for 72 hours, which is the maximum amount of time that they can stay in there, they get released back into society without any follow-up care."

Housing, health and community are intrinsically linked for seniors Amelia Grover, a social worker and manager of care coordination and social work at Dignity Health Marian Regional Medical Center in Santa Maria, said in the absence of shelter, older homeless adults experience longer recovery times from even minor injuries and illnesses even when they seek medical care.

Because San Luis Obispo County suffers from a shortage of medical professionals at most levels of care, there's less support for patients once they leave the hospital — particularly if the patient is homeless, Grover said.

Under 2019's Senate Bill 1152, California hospitals must provide homeless clients with a meal, clothing, a supply of necessary medication, opportunities to enroll in shelter and other services, but once a client has left the hospital's care, their outcomes are much harder to predict than a client who has shelter.

Grover said Dignity Health was actually ahead of this particular curve, employing a full-time staff member who can help homeless individuals leave the hospital with recommendations for services in hand and follow-ups set for medication or future appointments.

"One of the hardest parts about discharging a patient who's experiencing homelessness is the continuity piece, especially if patients don't have phones, or if they're unsheltered and they're living in environments that may not be conducive to their health conditions," Grover said. "That continuity piece is really hard — even just making sure that patients got their medication when they leave was a challenge, so this position really connected the dots."

Marino said when she was living in encampments, her medications routinely went missing due to theft or property confiscation by the city during cleanups, or they would often go bad without proper storage.

"If you're not having Maslow's Hierarchy of Needs — if you don't have food, clothing, shelter, your basic needs — your ability and your desire to prioritize your health is going to be more limited because you're in survival mode all the time," Grover said. "For those patients who are aging, you add on the added element of wear and tear on their mind and body, that might be contributing to the difficulty in navigating access or understanding the healthcare system."

San Luis Obispo resident Brad Dunlap, 55, said he's been without housing for around 25 years and often stays on the Bob Jones Trail near the 40 Prado Homeless Services Center, moving between the shelters and the street.

He said he's been lucky to avoid many of the persistent health issues associated with long-term exposure to the elements, but has had a hard time recovering when he's been injured and finding his way through the healthcare system.

His neck was injured during a snowboarding accident before he lost his housing and did not heal correctly, causing recurring pain and difficulty looking up, preventing him from working.

Dunlap said he travels light and avoids shelters, fearing for his safety in the communal living environment. Prolonged exposure to the elements have led to repeated illnesses related to a tree pollen allergy, and because he avoids shelters, it's hard to fully clean his body and clothing, Dunlap said.

As a result, Dunlap said he developed wounds on his hands and wrists from the irritation of constantly wiping his nose. He said those wounds eventually developed a staph infection that only healed when he was able to receive treatment and time to recover through 40 Prado's new collaboration with Community Health Centers of the Central Coast, which introduced a doctor and some recuperative care to 40 Prado's services.

"CHC is now installed in Prado so you can go see a doctor and make an appointment within a week or so," Dunlap said. "They'll even bring the medication to Prado so you don't have to go out to a pharmacy, which makes it a lot easier."

'Close to my deathbed': How housing improves health for seniors Marino's struggles to stay alive on the street stand in sharp contrast to where she is now.

As her body bore the physical toll exacted by living in encampments and her medications lapsed, Marino said she "put (her) nose to the grindstone" and decided to take a chance on 40 Prado Homeless Services Center's newly implemented Housing Focused Shelter Program.

The program was rolled out in 2023 to make the homeless shelter into a springboard for housing its clients, guaranteeing access to a place to sleep for at least 90 days so long as clients participate in CAPSLO's housing navigation.

Entering the program in December, Marino was able to use the guarantee of a bed for at least 90 days and the shelter's housing navigation services to get back on her feet and into housing.

In late February, Marino's case manager called her to share the news: She had been placed in one of the Housing Authority of San Luis Obispo's Paso Robles HomeKey affordable housing units in a renovated Motel 6.

"How soon can you be ready?" the case manager asked.

"I can be ready in an hour," Marino said.

A little over six months later, Marino has been able to use her temporary housing to find an affordable, long-term unit at a senior living complex in Paso Robles.

She said with her insurance issues resolved, a roof over her head and a basic income — a total of a little over $1,100 a month from her pension and Social Security before 30% is paid to her housing choice voucher as rent — she's been able to stay on her medications and begin to truly recover from homelessness.

Her cancer isn't in remission, but she's been able to manage its symptoms and stabilize her health since moving into the new apartment and getting back her Medicare coverage.

"Without my medications that I have now I would not be as sane, I would not be as healthy and I probably wouldn't be sitting here talking to you — I'd probably be close to my deathbed," Marino told The Tribune. "I felt that way before I got in here, and it took me about two months before I actually got back up on my feet and was actually becoming fully functional again."