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Phoenix's Most At-Risk Homeless Find Their Way, Thanks to a Team of "Navigators"

Russ Jefferson delivers turkeys on Thanksgiving Day.
Paul Rubin

Russell Jefferson waves at the two women standing in front of his apartment.

He hobbles through the crosswalk on Seventh Avenue south of Osborn, pushing a makeshift cart with groceries from a nearby Bashas'.

Jefferson's humble apartment of about a year is his first real home in a decade or so, he says. He is a battered 50-year-old who survived on Phoenix's cruelest streets — one previous sleeping spot was downtown on a grassy knoll at St. Mary's Basilica.

He says he's been homeless on and off for much of his life, and more often than not since he and his brother migrated here in 1985.

The women greet him with warm hugs, which he returns with a toothless smile.

Jefferson invites them in.

Shelves in the living room are packed with books (mostly self-help and potboilers) and movies. Handwritten motivational sayings are tacked up here and there.

A framed certificate showing that he once completed a program with the Salvation Army hangs on a wall, near a photo of Frankenstein, under which he has written his name: "Russ."

Jefferson is on a tight budget, but he's thrilled to have a budget at all.

"Poverty is very time-consuming," he says.

He pays his $192 portion of the monthly rent through a Phoenix nonprofit, HOM Inc., which helps homeless individuals and families affected by mental illness.

Jefferson was approved about a year ago for Social Security disability, which provides him a monthly check of $725.

The state considers Jefferson "seriously mentally ill," and he has access to certain services through Magellan of Arizona, a firm with a contract to provide treatment to thousands of people in Maricopa County and part of Pinal County.

His bevy of medications, which include antidepressants and other psychotropic drugs and painkillers for his bum feet, are covered through Magellan or AHCCCS, Arizona's version of Medicaid.

Jefferson says the two women and his unlikely friendship with Phoenix police officer Nick Margiotta (who heads the police department's Crisis Intervention Training program) keep him afloat.

"I'm just an old man with a lot of reasons to be gone by now," he says.

"My body is kind of falling apart. I'm an addict. But I'm alive, and I got these friends right here who really care for me. They are my support system. They are my saints. I'm just one of the lucky ones."

Listening in, the women say "awwww" in unison.

They are Jeanne Allen and Liz DaCosta, peer support specialists for Community Bridges, a nonprofit that offers behavioral health programs around Arizona.

The "peer" part of their job titles signifies that they, too, once were homeless and addicted to substances — illegal drugs, in each of their cases.

That the pair survived their own darkest times, rebuilt their broken lives, and now work hard to help people such as Russ Jefferson is extraordinary.

So, in his way, is Jefferson himself, a chronic shadow dweller who found a sliver of hope one day and grabbed at it.

That ray of light is an ambitious program led by the Arizona Coalition to End Homelessness.

It is called Project H3.


In late April 2010, social workers and about 150 volunteers hit streets, alleyways, parks, and other crannies (mostly in downtown Phoenix) for three mornings in a row starting at 3:30 a.m.

Their aim: identify the 50 chronically homeless people most at risk of dying.

The pre-dawn survey came as state and county officials were implementing unprecedented cutbacks in services to thousands of indigent adults (some of them homeless) with serious behavioral and substance abuse problems.

Those three nights marked the birth of the Valley's version of Project H3. Though its name sounds like a CIA operation, the three Hs stand for home, health, and hope.

The program began with little funding but much promise, says Arizona Coalition to End Homelessness executive director Joan Serviss.

Community Bridges and Southwest Behavioral Health promised in-kind contributions up front to Project H3 to cover the cost of the navigators. Great start, but Serviss says, "We didn't have the housing and the funding in general lined up. We just had a great and potentially very viable idea."

But after the successful April 2010 street survey, the city of Phoenix promised housing vouchers for 25 homeless people through federal Housing and Urban Development grants. Mesa and Glendale followed suit with vouchers of their own.

The Arizona Department of Economic Security agreed to provide $40,000 — not from "new" money appropriated by the Arizona Legislature, but by shifting some funds around in its line-item budget.

Catholic Healthcare West chipped in $45,000, a generous sum in difficult economic times.

Clearly, Project H3 was built on a lean and mean economic model. Much like its clients, the program will have to stay that way to survive.

"We can never say we know what the state budget will look like next year or after that," Serviss says, "but we are going to keep this going, whatever it takes. Project H3 means everything to many people."

 

A basic premise of Project H3 is that permanently housing the chronically homeless should be a starting point, not the final step. But first, people had to be located, interviewed, and evaluated.

The survey team's members had with them a "vulnerability index" developed by New York City nonprofit Common Ground, whose goal is seek to find and house the nation's 100,000 most at-risk homeless.

They wanted to know who was suffering from end-stage kidney or liver disease, who is HIV-positive or has AIDS, and who had been to an emergency room three or more times in the previous three months, or hospitalized three or more times in the previous year.

They also considered age (over 60 is a risk factor), plus a catch-all: mental illness, substance abuse, and chronic disease.

The Project H3 team found 262 people, of whom 208 agreed to answer questions, and this is what they learned:

The most vulnerable had been homeless for an average of almost eight years.

Fifty-five were military veterans, with almost half of those considered highly vulnerable.

The youngest person surveyed was 19, and the oldest was 77.

Half of the 208 interviewed reported a dual diagnosis of mental illness and substance abuse. (Most social scientists say that people routinely understate those issues, and that for more than half of the chronically homeless suffer from mental illnesses and addictions to alcohol and/or drugs.)

A third said they had been victims of at least one "violent attack" since becoming homeless.

The vast majority of the chronically homeless cycle repeatedly among the street, hospitals, and jail or other institutional care until they finally die.

Such troubles transcend the individual, at least financially. It costs taxpayers dearly when the homeless land in jail or in an emergency room on a regular basis.

Of course, the number of people surveyed (208) was little more than a drop in the bucket of the Valley's sprawling homeless population.

Hundreds more than that — no one knows the precise number — remain without permanent homes on any given night in Maricopa County. Almost 1,000 men, women, and children are sheltered at CASS (Central Arizona Shelter Services) on South 12th Avenue. Dozens more find temporary shelter through other area programs.

Clearly, risk factors for an early death increase exponentially without a roof over one's head.

But the notion of "housing first" actually is counterintuitive to traditional thinking. That model usually requires someone to be sober before being considered for permanent shelter.

Being off the streets and out of the elements (the Valley's oppressive summer heat and bitter winter nights) can make for a safer and potentially healthier life.

The illness and the addictions don't stop simply when someone finds a place to call home.

One of Project H3's tenets is to provide intensive one-stop assistance to its formerly homeless clients.

"We're into three prongs — behavioral health, health care, and recovery," says Phoenix police officer Margiotta, the "we" meaning Project H3, with which he has been closely involved.

"Some people still believe that all we need to do is to get folks into the behavioral health system and it's all going to be good. But it's not. Everything used to be in a silo, this agency here and that system there doing their own thing. That doesn't work. We do more than just get people into a halfway house. We — especially the 'navigators' — become totally involved in their lives."

That's where Jeanne Allen and Liz DaCosta of Community Bridges come in.

They work as navigators with 41 ex-homeless people, including Russ Jefferson, the friendly toothless fellow who loves motivational sayings.

(Another dozen or so Valley residents who have been deemed extremely vulnerable are monitored by other agencies.)

"We teach them how to use a cell phone, to make doctor's appointments, how to get money orders, what to do at a bank, all the stuff that most people take for granted," says DaCosta, a spunky 26-year-old originally from Gilbert.

"Most of them have nobody, and many are addicted to drugs and alcohol. Many have mental issues. These are my people."

No doubt, the lives of many have improved, dramatically in several instances.

But miracles, by definition, are rare:

The street still beckons many of the H3 clients — the guy who can't stay away from his old stomping grounds behind a funky building near Grand Avenue, the woman who landed in jail a few weeks ago for drinking in public on the cusp of an important meeting with mental-illness evaluators.

One of the original 50 slipped up badly enough to earn a short prison term on a drug charge earlier this year. He recently was released and, through channels, communicated with Allen and DaCosta, his onetime navigators. They say they will be trying to try to help him get back on his feet.

 

"We are not here to judge. We are here to help," Allen says. "What we do is to find out the most important thing to do for our people right now and we do it. We are peers, we've been to jail, we've done drugs, we've done bad things. We are them."


It is Veterans Day, a vacation day for most working stiffs.

But a 61-year-old woman we'll call Alice (she asked to be provided with a pseudonym) has just finished the graveyard shift as a part-time unarmed security guard at a state government office building on East Jefferson Street.

Alice has no family in Arizona (details are sketchy, but she apparently never had children) and was living in a Phoenix apartment before her employer cut her hours back last summer.

Her landlord evicted her in July. Alice was not yet 62, and so was ineligible for senior housing through the city of Phoenix.

First, someone helped her move her furniture and other possessions into a storage facility at the cost of $160 a month. Then she gathered up some clothes, soap and other sanitary items, a few mementos, and her beloved cat, Angel.

Alice stuck everything into a shopping cart (Angel was caged) and pushed it to her workplace, a few miles away. It was the middle of one of Phoenix's hottest summers on record.

That night, her work ethic intact, she reported for duty as usual.

Alice was a member of the working poor even before her employer cut her hours. Now, she had sunk into another category — the working homeless.

After her shift ended the next morning, Alice ended up in front of another building across Jefferson Street.

It was the City of Phoenix Housing Department.

The agency touts itself as "proud to say our various housing programs provide homes to more than 25,000 Phoenix residents. The department provides services and referrals to assist residents reach their goals and attain self-sufficiency."

Alice wasn't one of those 25,000.

Instead, kindly officials allowed her to sit inside the air-conditioned building during the day until closing. A fastidious sort, Alice would wash her security guard outfits in a bathroom sink there and hang them outside to dry.

After hours, she would step out to a bench with her cat and wait until night fell, maybe catching a few hours of sleep.

It's unclear where Alice got food for herself and Angel, though she allows that an occasional quart of goat milk did wonders for their health.

Alice would rub a bleaching cleanser on her legs to keep ants — real and imagined — at bay when she needed.

Eventually, someone at Phoenix Housing contacted Community Bridges, which quickly took note of Alice's plight.

Alice was vulnerable by any definition, and Allen and DaCosta were assigned to introduce themselves to her.

She is both headstrong and a bit dotty — a taxing combination — and asking anyone for help at first was out of the question.

"She needed stability and some friends," Liz DaCosta says. "There's nothing worse than having nowhere to go and no one to turn to. It's a feeling like no other."

The navigators slowly won Alice's trust by repeated visits to her place of work and improvised "home" at the housing authority.

At the same time, efforts to secure her a federal Section 8 housing voucher (for low-income people) were under way.

The voucher came through by early November, and Project H3 identified an apartment for Alice just west of downtown Phoenix.

The target date for her to move in was around Veterans Day, but a glitch arises.

The electric company is operating on a reduced schedule, and new customers have to wait a few days to get their power established. And the landlord won't allow Alice to move in without electricity.

Allen and DaCosta go to the state government office, where Alice has just finished her shift, to tell her what was up. She has her belongings stacked in the front lobby, and Angel's cage is draped with a thin throw blanket.

Alice wants badly to go to a grocery store to buy some goat milk.

"The cat needs to have it, too," she tells the women. "He got sick when I got sick. My stomach."

Alice gets into the back seat of the Community Bridges van, but she is on edge.

"Too much disappointment, too much discouragement," Alice mutters at the bad news about the housing delay. "Forgive me, my mind is on my problems. This ain't clickin' for me."

She's about to get out of the van, headed for parts unknown, when DaCosta speaks up.

 

"Actually, this is not a discouragement," she tells Alice, smiling warmly to emphasize her point. "This is just a step along the way. I want you in your apartment so much. We have your best interests at heart — from the moment I met you."

That resonates with the worried older woman, who stays put. Allen drives to a Fry's to get the milk, as she and DaCosta devise an impromptu plan.

This is what navigation is all about.

A few phone calls later, and Alice has a place to stay for the weekend, a room at the downtown YWCA.

Alice is openly skeptical but seems convinced when DaCosta tells her, "They'll have a hot shower there, and you will have your own room. You can bring your stuff up there, and we'll get the cat in there, don't worry."

(The navigators moved Alice into her new apartment the following Monday.)

As all this is happening with Alice, the navigators' 40 other clients also have an assortment of pressing needs.

"We are going to hit the eight corners of the world today," Jeanne Allen says.

One of those corners is an apartment complex near 36th Street and Thomas Road, where six H3 clients live.

Allen and DaCosta drive over to check in on all six, including a husband and wife. All but one is home and seem to be faring well.

The women drive client Lisa Stufano to a nearby drugstore to pick up her meds.

She lived on the streets of Phoenix for almost 15 years straight before Project H3 came along.

Stufano's story is sad: Born into a well-to-do Texas family, she apparently served a few years in the U.S. Army before serious mental illness — paranoid schizophrenia — intervened. She has had little contact with her family for years.

Stufano has been jailed often for crimes that include petty burglaries, drug possession, and prostitution. But she's managed to stay out of trouble with the law since the H3 team found housing for her last year.

Still, DaCosta says, no one knows what state of mind Stufano will be in when they show up.

"Last time, it was, 'You devil, you bitch,' a little out of control," DaCosta says. "You can't let it get to you. She knows that we love her."

Stufano answers the door of her second-story residence wearing a ball cap and a wrinkled blue dress. She has but one tooth left and looks much older than her 52 years.

This happens to be a good day for Stufano.

"The apartment's doing me wonders," she says. "I got the TV working. You should see an improvement in me today."

"I do," DaCosta says, smiling as always. "I'll never get over it. Are you clean?"

"I'm clean," Stufano replies, referring to recent illegal drug usage. "I love Phoenix once again."

After collecting Lisa's meds, the navigators drop by a McDonald's for a burger, which the skinny Stufano devours.

"I want to talk about your teeth," DaCosta says. "Teeth are important. When are you going to work on those dentures? Are you willing to get rid of that one tooth?

"Yes," Stufano says. "I can think about that now. I'm happy — at least I ain't got no big worries. Nobody's after me. I ain't having problems with the voices [in my head] right now. They aren't bothering me."

The navigators walk Stufano back to the apartment and say their goodbyes.

"Thank you from the bottom of my heart," she tells them.

"Awwww," they respond.


The sheriff's mug shot, dated June 23, 2005, is terrifying. It shows a shriveled woman of indeterminate age staring into nothingness, appearing closer to death than to life.

Jeanne Allen confirms that the creepy photograph is of her. It is almost impossible to reconcile the woman in the photo with the vibrant person whose upbeat spirit is so critical to the success of Project H3.

"It sure tells a story," she says of the mug shot. "When that day started, I honestly thought it would be my last one on this Earth. Then I got busted."

It was an arrest warrant for IV drug use.

Allen sat for four months in the Maricopa County Jail deciding whether she wanted to live or die, which would mean getting — and staying — straight.

Her dive into the abyss was dramatic. A mother of three (her children now are 21, 20, and 15), the Illinois native says she fell prey to hard drugs in the mid-1990s.

Allen says she literally walked away from her longtime job as a respiratory therapist at St. Joseph's.

"The double life was too hard," she recalls. "I was a meth addict, and I had it bad. I couldn't stay clean for the life of me."

 

She wound up on the streets of West Van Buren for the better part of a decade that ended in 2005. It was terrible, eking by in the most desperate and degrading ways possible.

Allen eventually cleaned up with extensive therapy (individual and group), prayer, stays at halfway houses, and a support system that eventually included her immediate family.

After almost a year of sobriety, Allen applied with Community Bridges for a position as a peer support specialist. She has been on the job ever since, working for a time at the CASS homeless shelter downtown and in other outreach settings.

Allen's bosses considered her a natural when Project H3 started to take shape, the same as they did Liz DaCosta.

DaCosta grew up in Gilbert, where she played softball at Mesquite High until dropping out at the age of 16. (She earned her GED later that year at Gateway Community College.)

DaCosta says she became a heroin addict when she was 19 and later switched her drug of choice to methamphetamine.

From then until she was 22, DaCosta says, "I was disconnected from everyone and everything that meant anything to me. I didn't know how I was going to get out of it. It's the worst feeling."

Then, in late 2007, DaCosta learned that she was pregnant. Estranged then from her family and on her own, she made a command decision:

"I had to choose between making a life for myself, or nothing."

DaCosta says she checked herself in at the county jail, to serve time on a warrant from a 2006 charge of attempting to buy heroin from an undercover officer.

"I had been through detox a few times before and it didn't work," she says. "I figured that being in jail would be a start of getting me off meth. Kind of my version of being 'in-patient.' It worked."

DaCosta spent about a month behind bars (the charges later were dismissed after she completed a drug diversion program) and then moved into a residential program run by the nonprofit New Arizona Family.

In May 2008, she gave birth at St. Joseph's Hospital to a healthy daughter, Skylar, who now is 31/2. The child's father is in prison.

DaCosta lived for more than two years at UMOM New Day Centers on East Van Buren Street, Arizona's largest homeless shelter for families.

She says she stayed sober, steered clear of the temptations looming back in Gilbert, and devoted her attentions to her baby and her own recovery.

Community Bridges hired DaCosta as a full-time peer support specialist in 2009.

It has been a perfect fit. She is organized, diligent, and buoyant about life and its possibilities.

"I feel so good at the end of the day," she says. "I've already wasted so much time. I'm still an addict. But I don't plan on wasting any more time on bad things."


It is Thanksgiving morning.

Liz DaCosta picks up Russ Jefferson and another formerly homeless client, Dennis Eldridge, at their respective Phoenix apartments.

Jeanne Allen is off for the day, which she is spending with her family.

The three drive over to the UMOM center — where DaCosta once lived — and park near the big kitchen. They pack more than 40 hot turkey dinners into the Community Bridges van for delivery to the other Project H3 clients in Phoenix and Glendale.

Both men are happy to help and happy to get out of their apartments to do something positive.

Eldridge is a quiet man in his mid-50s, a Native American from New Mexico who used to run marathons. Now, decades of severe alcoholism and 14 years of homelessness have taken their toll.

"Don't get me wrong: I am really thankful for the break I caught with Liz and them," he says, "but I have a tough time staying off the booze — always will."

The trio delivers the dinners one by one, apartment by apartment, visiting for a minute or two with those folks who want to chat.

Russ Jefferson greets Lisa Stufano with a hug and tells her how much better she is looking these days.

"I knew her on the streets when we were both at the bottom of the barrel," he says later. "That's pretty low."

On the way out of the apartment complex, DaCosta spots a man reaching into an overflowing dumpster for something. His filthy clothes look as if they're welded to his body.

DaCosta stops the van and asks the guys if she should give the man one of the remaining turkey dinners.

"Sure," Russ Jefferson says. "Looks like he's down on his luck."

DaCosta steps out of the van and grabs one of the bagged-up meals from the back. She walks over to the man and says hello, immediately disarming him with that smile of hers.

 

"Hi," she says. "Would you like a Thanksgiving dinner? We have an extra."

The man does a little bow in gratitude — he surely needs a meal.

But then he says in a surprisingly gentle twang, "No, thank you. There are people much more worthy than me, ma'am."

DaCosta doesn't miss a beat.

"No one is more worthy than you or anyone else," she says. "What's your name?"

"I go by Stoney."

DaCosta offers her hand by way of introduction.

He declines to touch her.

"I'm sorry, ma'am," Stoney says. "I'm really dirty."

Liz says she doesn't care.

"Please, enjoy this," she says, handing him the meal.

He takes it, smiling at her for a moment.

"Thank you and God bless you," Stoney tells Liz DaCosta. "You be careful, okay?"

She returns to her van, with several more stops left on her Thanksgiving run.

Stoney places his care package down on the driveway. He reaches back into the dumpster as she drives away.


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