A different kind of chance 

Joe Forehand likes listing facts and figures: He got his first job at age 9, and had his first drink at 12. The 67-year-old can count the years of intermittent jail time for drunk and disorderly conduct, 30-60-90 days at a stretch "on the installment plan." He's been sober for 25 years, the same amount of time he's worked for Goodwill Industries. Now, he counts two years living in the Barton Tower Apartments, where two Bibles are arranged on his coffee table.

"In my young life, I was jobless, I'd end up sleeping in cars," he said. "People get discouraged with you. I've been down and out before, but I'm not now."

Forehand found the Barton Apartments through a unique arrangement: Clients of Midtown Mental Health have priority on 30 units in this public housing facility, after Midtown's parent organization Wishard Hospital took over the lease in 2006 and rehabbed those apartments. Moving clients into a more supported and stable environment resulted in a million-dollar savings for Wishard, whose preventative care techniques reduced emergency room visits and hospital stays for at-risk populations.

The Indianapolis Housing Agency's Barton site is one of several facilities in line for even more work: Indianapolis Housing Agency recently proposed a multimillion-dollar project to overhaul its aging buildings.

Major construction is one thing. Inside the halls of Barton, some residents take it upon themselves to make small improvements, whether it's upkeep or adding décor. On the second day of January, Forehand's crisp 2009 calendar already hangs on the wall. A few Christmas decorations and stuffed animals line the windowsill, framing a postcard view of the Murat Theatre's spires. Forehand can tell you what he paid for each piece of furniture in his compact, tidy efficiency, and proudly displays the wooden wall clock he received for 25 years of service at Goodwill. This apartment is his. He takes pride in his home.

"Like here or anywhere you go, it's what you make of it," Forehand said. "If your floor's dirty, it's your fault."

Janice Cade, a Midtown community support specialist based at Barton, has known Forehand for as long as he's lived there. She administers his medicine each day, and on her day off, she calls to prompt him to take his pills. She said Forehand is the kind of person who worries about whether other residents have enough to eat. ("I can't stand to see nobody do without," he said, "even if I know they misuse their money.") And he knows to avoid those in the tower who drink, some of the ones who, as he puts it, "don't have a lot of age on them."

"He's well aware of what he has to do to keep sober," Cade said. "We talk about his sobriety a lot. Joe has a lot of old phrases he says, like 'You can't put yesterday's problems on today's plate.'"

He makes sure that today's plate is full. Forehand works three days a week at Goodwill, on the assembly line. He attends church, though he hasn't been for a while. He and his girlfriend of two years, another Barton resident, take her car to go out for Chinese food or visit her mother. If the Colts or the Pacers are playing, Forehand might watch on TV; otherwise he tunes to news and stock market reports in the morning, cartoons in the afternoon. Though he hasn't had a drink in years, he remembers the turmoil of the way his life used to be. He wasn't a "high class" drinker: He'd swallow rubbing alcohol or shaving lotion if he couldn't get beer or wine.

"You drink one or two or three, and it's a sedative for a while," he said. "After you drink so much, then you're depressed. The more you go, the worse it gets. It's a legalized drug. Now I haven't had a drug for 25 years. I stay completely away from it. Here, I stay pretty much to myself."

Even his sayings incorporate figures: One drink's too many, and a thousand's not enough. "You keep drinking and never get satisfied," he said. His face darkens to recall the details, but brightens again when he talks about his sisters, or Janice Cade, or his doctor or nurse or caseworker.

"Ain't no way to explain how much help I've had," he said. "Can't do a thing about the past. I can only deal with what's going on with me now."

For the present, that means a phrase Forehand learned when he regularly went to Alcoholics Anonymous meetings: one day at a time. Or he might use one of his maxims: You can't plow a field looking backwards. You might hit a tree.

Wishard: the safety net hospital

Wishard also wants to keep patients and clients moving forward, introducing programs that focus on preventative medicine and care. As a "safety net" public hospital, Wishard sees high traffic from uninsured patients unable to pay for the services they need. With an annual budget of about $500 million, resources must be carefully allocated, said Matt Gutwein, president and CEO of Health and Hospital Corporation of Marion County.

"The demand for our services vastly exceeds the supply," he said. "For every dollar we spend in one place, it's a dollar we don't have to spend in another place."

The lease at Barton Apartments provides 30 rehabbed units for clients; also offered are residential services like counseling, on-site nurses and rides to appointments. Clients generally receive referrals through Midtown, and the program already has generated a waiting list. Trying to prevent illness and emergency by treating root causes will stretch resources further, Gutwein said, and ideally improve the quality of life for clients in need.

"At Wishard we provide a lot of care to our homeless neighbors, and we're very happy to do that," he said. "They often come to us very sick, and our ability to prevent their illness is limited. It's not uncommon for a homeless neighbor to be found by police in a distressed state."

An ambulance ride to the emergency room often results. "That's a $1,500 cab ride," Gutwein said. "The ER is the highest cost venue we have to provide care, and that's not the kind of care we want to provide to anyone. It's not in your best interest as a patient to get your primary care at the ER."

Arranging housing for clients - and supporting clients in their new homes - already has shown positive results. In-patient care at Wishard costs $2,500 a day per person. One woman spent 59 days as an in-patient. After gaining housing about two years ago, she's spent zero days in the hospital. She now pays her own rent and has a job. Access to medicine and counseling helps her be a productive, well-adjusted member of society, Gutwein said. Her physical and mental health have improved dramatically.

Those now living at Barton used to spend an average of 10 days a year at Wishard as in-patients. After moving into their new apartments, clients now average one day a year in the hospital. The net savings equal $1 million, factoring in rent, cost of counseling, social work and nursing staff at Barton, and excluding ambulance rides.

Not included in the Barton study are the other costs that might've been saved, such as less traffic in the criminal justice system, or other fallouts from clients who traditionally managed mental health issues by self-medicating. This reaps benefits for the community, not to mention the savings for a hospital that needs to make each dollar count.

"When someone's in a bed 10 days a year, that means someone else is not in a bed," Gutwein said.

This matters more at Wishard than elsewhere. The average hospital has a 67 percent occupancy rate, and the average public hospital carries a 77 percent rate. Hospitals are considered "full" at 80 percent occupancy. For over a year, Wishard, a 350-bed facility, has operated at 98 percent occupancy. This hospital handles about 18,000 in-patient admissions a year, and 1.2 million out-patient admissions. Wishard can't turn people away, nor does it want to.

However, there are times when the hospital reaches capacity and simply can't accept new patients. In those cases, the facility goes on "diversion," sending people elsewhere for care. In the last 20 or so years, Wishard has been on diversion 5 to 10 percent of the time, and has at times reached a diversion rate of 15 to 20 percent. In addition to not being able to offer services to potential patients, a high diversion rate could cause Wishard to lose its status as a Level 1 trauma center.

In 2008, however, incidents of diversion were nearly wiped out. Senior management looked at the root causes and worked to improve turnaround times for beds, in part by updating technology, changing doctor's schedules and creating "bed huddles," where nurses and staff meet several times a day to discuss what needs to be done to make sure every bed is available. These measures helped eliminate the need to send patients elsewhere.

Wishard's preventative model for housing attempts to keep clients out of the hospital altogether. Providing a place to stay offers economic incentives for the hospital, too: The more services provided, the more ways the hospital can receive funding.

"This is where moral imperatives and economic incentives align," Gutwein said.

Understanding root causes

Not all clients who move to Barton are homeless; Forehand, for example, moved there from another Midtown-provided apartment because the rent was cheaper, and because he'd be able to get in-house support. But for those in need of services who have been homeless at one time or another, there is a team of professionals working to understand the root causes of a person's situation and provide support accordingly.

If a patient deals with mental health problems, medicine can help manage "a significant portion of the underlying cause of his or her homelessness," Gutwein said. "Other people are homeless and don't have those issues, and we want to address those needs. If someone needs dialysis, housing won't take away the need for dialysis."

Even if Wishard were able to offer unlimited housing, it wouldn't solve the complex issue of homelessness. Its causes are vast and varied, and not everyone accepts the offer to move into public housing. Advocates for the program realize it's a good alternative for certain patients. It's also a good partnership between two entities that need the support.

The Indianapolis Housing Agency praises the arrangement because Wishard's involvement allowed the building to get out-of-commission units "online," or habitable for residents. The Wishard units are mixed among all the apartments, not set off in a block; administrators are aware of the stigma mental health patients may face, though that's not necessarily particular to where one lives.

"That stigma is no more in housing than in the rest of the world," IHA Executive Director Bud Myers said. "Occasionally you'll see an issue or a problem, but it's not every day. There seem to be isolated issues where people aren't behaving, but in general it's worked pretty well."

Barton, built on Massachusetts Avenue in 1967 and partially renovated in 1994 and 2001, still needs more work. The concrete high rise looms above the chic strip of shops, restaurants and bars, stuck in time amid the surrounding renaissance of development.

Part of the IHA proposal calls for rehabbing all of the 245 Barton units to bring them up to par. Also included are renovations to Lugar Tower's 221 apartments, and the use of vacant land surrounding both of those sites. Overall, the project looks to improve 1,386 total housing units, currently home to some of the city's lowest income families. Each unit in the towers costs $30,000 to renovate.

The IHA board recently approved plans that will be submitted in May for approval from the state housing authority and the U.S. Department of Housing and Urban Development. IHA is looking at a project that will cost nearly $60 million, said Bruce Baird, IHA's director of strategic planning and development.

The much-needed improvements include extensive plumbing and electrical work, interior renovations such as new cabinets, flooring and trim, and upgrading lights and appliances for energy efficiency. Over time, the copper pipes in Barton and Lugar have grown so thin that wrenches used in repairs actually damaged materials and caused more leaks, Baird said. The older construction is showing its age.

"Anybody who owns and manages apartments, it's a challenging business," he said. "We've made investments over the years, but over time, the units wear out. Those become the major capital improvements.

"You're expected to maintain them, to improve them," he said. "It's standard fare for us. Our plan is more aggressive than what housing authorities in other cities are doing. It's going to put us on the cutting edge."

The housing authority here is one of the younger ones, Baird noted. While other cities were planning and building public housing in the 1930s and '40s, Indianapolis resisted for years. That changed under Mayors John Barton and Richard Lugar, namesakes for the towers. Both apartment buildings have waiting lists for the one bedroom/one bath units: As of December, 88 applicants sought housing at Barton, which has a 97 percent occupancy rate, and 29 wait for a spot at Lugar, which is 94 percent full.

Before Wishard entered the picture, the 30 units at Barton were in such bad shape they couldn't be rented, and IHA didn't have the money for repairs.

"They gave us the funds to rehab those units, and we gave their clients a leasing preference for those units," Baird said. "They also provide case management on site to help those residents. It's a great partnership."

Also slated in the project are renovations to the towers' communal spaces: an improved library and computer lab, health care facilities and community rooms. Through existing HUD funding, the IHA provides services for residents like job training and referral services, educational opportunities and matching people up with daycare.

"We do everything we can to help people with self-sufficiency," Baird said. "There's not a lot of money for additional activities and services, but increasing them is a goal for this year."

Additional phases include improvements to Beechwood Apartments and Hawthorne Place (Warren Township), Blackburn Terrace and Twin Hills (Center Township), Rowney Terrace (Center Township) and nearby Laurelwood Apartments (Perry Township), as well as Caravelle Commons on Indianapolis' near Northside. IHA reports that it will seek a variety of funding for the project, through Low Income Housing Tax Credits, HUD capital funds and energy efficiency financing.

Barton isn't the only site to lease apartments to Midtown clients, but it is one of the larger rental agreements. The lease at Barton is more efficient, too. With so many units in one place, fewer health and mental health professionals are needed. Gutwein said there are about 120 units around the city with this type of partnership: six units here, 10 there. Because Barton is owned by a government agency, business is more public.

"We don't typically tell people where they are," he said. "We don't advertise. There's a stigma or misperception that folks suffering from mental illness aren't capable of being very good neighbors."

So far, this experimental care model seems to be working. "This may be cheaper than sitting around and waiting for emergency room visits," Gutwein said. "We're increasingly expanding into the housing business mainly for persons we think would benefit most."

The program's success means its continuation, with potential for eventual expansion. Providing housing is one way Wishard deals with the problem of a fixed pot of resources and increasing needs, changing the way the resources are used to make the most of them.

A different kind of chance

Individuals in the program follow suit, learning to make the most of their resources. Joe Forehand works off his own budget, getting help from one of Wishard's financial counselors to manage his salary and Social Security. He parcels out this much for a shirt and a pair of shoes, that much for groceries at Aldi. He pays his rent and his cable bill, and smokes mini Dark Horse cigars, which are cheaper than cigarettes at $1.25 a pack.

Much as he likes numbers, they didn't always come easily. Bothered by his trouble with math, Forehand taught himself to double figures, and he'll rattle them off as quickly as an auctioneer.

"I started going to sleep like that, just figuring numbers," he said. "I thought to myself, Donald Trump didn't get rich not knowing how to figure."

He arranged the furniture in his small apartment so the dinette set divides the kitchen from the living room. Sitting at the table provides an easy view of both copies of a prized black-and-white photograph of himself, taken when he was 17 or 18. One photo is affixed to the fridge door, and its framed copy sits on his coffee table. His hair curls over his forehead, and his eyes stare directly into the camera. Why two photos, displayed so prominently?

"You want me to tell you the truth?" he asked, grinning. "I thought I looked good."

He stared at the picture a beat longer. That young man was a drinker, and would keep drinking into a marriage that lasted less than three years and produced one son, Joe, who died of complications from diabetes five years ago. The man in the picture would find his way in and out of jail, and into the now-closed Central State Hospital. This long path eventually led him to his own apartment in Barton, where a can of Raid and an unopened bag of Doritos share space atop his refrigerator. Nearby, clean dishes sit in the drainer next to the sink. Though he also found his last apartment through Midtown, he prefers the setup at Barton. When he has a problem or needs help, his community support specialist is there. She reminds him to take his medicine. She answers his questions.

He doesn't want anyone to think he got here on his own. He says he couldn't have done so well without the help he received through Midtown Mental Health, and from his job at Goodwill. Living at Barton gives him added support. "If I do have a rough time, I have a place to go," he said. "If this were 20 years ago, when they didn't have the apartments, I'd be in bad shape."

The pitfalls of apartment living are small sacrifices to Forehand. If someone on the elevator uses bad language (something that once contributed to his jail time and which he now abhors), he'll hop off and walk down the stairs instead. When people are drinking, he knows to stay away. Forehand pointed to the Bibles on the coffee table, which he can quote at will. Bible verses provide comfort, and so does his faith in God.

"I pray God will make a way for me today," he said. "He wants more for me than I want for myself. All I want for myself is peace of mind."

To Forehand, that means having faith he'll be led in the directions he should go. That he'll stay free of drinking. "God gave me a chance maybe when I didn't deserve it," he said. "When everybody else gave up on me."

But that was a long time ago. Now he's taking advantage of a different kind of chance, the kind that comes with looking forward and accepting help when it's needed. An entirely new way of figuring: one that adds up.

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