Finding Home, Hope, and a Future: Achieving Integrated Social Services at Harbor Care

By Ann Kelleher

Finding Home, Hope, and a Future: Achieving Integrated Social Services at Harbor Care tells the story of a trail blazing nonprofit in Nashua, New Hampshire. Originally named Harbor Homes, in July 1982 the newly incorporated organization began work in its remodeled group home supporting nine clients with persistent mental illnesses. Forty years later, the nonprofit, now named Harbor Care, owns twenty-eight facilities and is supporting over five thousand individuals and families, 93 percent of whom are low-income. Currently Harbor Care's clients, in a wide variety of groups needing assistance, access safe housing, medical/dental/mental health care, substance misuse treatment, and other critical supports such as food, transportation, and employment services. All are provided within an integrated system of social services. With the goal of helping clients become more independent, the nonprofit's policies and practices have significantly reduced homelessness in the city and assisted clients to live self-directed, productive lives. Finding Home, Hope, and a Future explains how such an extensive network of clients and services came to be by highlighting personal stories of individuals who helped build the pioneering organization.

• Language: English
• Publisher: Resource Publications
• Release date: Jun 2, 2023
• ISBN: 9781666773941

Ann Kelleher

Ann Kelleher, a retiree from Pacific Lutheran University’s Division of Social Sciences, has taken on a second career as a volunteer. She writes histories of pioneering, local nonprofits that have successfully responded to major societal issues. Finding Home, Hope, and a Future is the latest of these studies, which also include Pioneering Peacebuilder: A History of Holywell Trust.

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Introduction

Finding Home, Hope, and a Future: Achieving Integrated Social Services at Harbor Care tells the story of a trail blazing nonprofit in Nashua New Hampshire. Originally named Harbor Homes, in September 1982 the newly incorporated organization began work in its remodeled group home supporting nine clients with persistent mental illnesses. Forty years later the nonprofit, now named Harbor Care, owns twenty-seven facilities and is supporting over 5,000 individuals and families, 93% of whom are low-income. In 2021 Harbor Care’s clients accessed safe housing, medical/dental/mental health care, substance misuse treatment, employment services, food, transportation, and other critical supports,¹ all provided within an integrated system of social services. With the goal of helping clients become more independent, the nonprofit’s policies and practices have significantly reduced homelessness and assisted clients to live self-directed, productive lives.

Success began within a couple of years of the organization’s start as Harbor Homes with its focus on housing and supportive services for clients with mental illnesses. Then, fifteen years later, the nonprofit began merging with other nonprofits assisting people with a wide range of needs, such as substance misuse and HIV/AIDS. The coalition of nonprofits, then named the Partnership for Successful Living, provided its clients with increasingly integrated social services honed together through a problem-solving process. While developing its distinctive integrated services, which kept housing at their core, the Partnership also took on new categories of clients in need of assistance, including homeless veterans and low-income people without medical and dental care. The story is important to tell because it shows how integrated care, with services and housing, can work. Also it reveals the kind of thought, planning, luck, trial and error, study, and passion on the part of staff, clients, administrators, and Board members it took to create a thriving organization.

Finding Home, Hope, and a Future explains how such an extensive network of clients and services happened by highlighting personal stories of individuals who helped build the pioneering organization. Those contributing their reflections include clients, staff, senior personnel, and members of the Board of Directors. As we will see in Chapter 1, the Harbor Care story begins in 1982 with a young social worker who had a flat tire on his way to a job interview, three perceptive interviewers, and the compelling purpose the four of them discovered they shared.

People Matter

This book’s narrative emerges in the way that I learned about the evolution of Harbor Care, that is person by person, story by story. Each chapter centers around the stories of people who turned commitment into reality, augmented by additional information to flesh out an explanation for how the nonprofit grew. Together the narratives synthesize into an explanation for Harbor Care’s success according to a cross section of the people who know it best.

Finding Home, Hope, and a Future documents Harbor Care’s historical development chronologically, as outlined by the following chapter summaries.

•Chapters 1 Launching Harbor Homes, and 2 Risk Taking Rewarded, describe Harbor Homes Inc.’s origin, early expansion, and the functionality of its founding objective.

•Chapters 3 Mutual Attraction, and 4 Stepping Stones to the Partnership for Successful Living, explain the mergers of nonprofits as the Partnership became a fully developed coalition.

•Chapters 5 Support for Those Who Served, and 6 Explosive Expansion, narrate two other major expansions as the Partnership added categories of clients and relevant services.

•Chapters 7 Better Together from the Inside Out, and 8 More Than the Sum of its Parts, illustrate how the organization’s community forged integrated social services into a working system.

•Chapter 9 An Agency Ahead of its Time provides an analysis of general factors that made Harbor Care possible.

Who May Be Interested

Finding Home, Hope, and a Future is intended for two potential audiences. First, the portion of the general public interested in how to deliver social services effectively will find this book useful. Harbor Care provides integrated care and services centered around housing to major segments of society’s marginalized people. It therefore offers one of those flickering lights of hope in what at this writing, at the end of 2022, seems an American society contending with persistent and pervasive health and socio-economic problems. In addition, Harbor Care does its work by remaining true to its original mission, namely, actually helping people achieve traction in their lives. Although at its start as Harbor Homes the nonprofit’s clients were people with persistent mental illnesses, within a few years the mission proved applicable to other groups of marginalized people as the organization grew.

Social service practitioners comprise a second group of people to whom this story of Harbor Care will appeal. It presents a viable case study of how integrated social services can succeed in practice on a major scale. Examining this model will provide practitioners with information about delivering effective integrated services that might apply within their own organizations.

Part of the appeal of this book is it provides a response to the growing interest in integrated care. During the last decade academics in the field of social work have been writing about the provision of integrated social services. For example, the following quotes from one article illustrate definitions of integrated care,² and they clearly apply to what Harbor Care has been able to achieve.

. . . care resulting from a practice team of primary (medical) care and behavioral health clinicians, working together with patients and families, using a systematic and cost-effective approach to provide patient-centered care for a defined population. This care may address mental health, substance use conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of healthcare utilization.

. . . the management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.

These definitions include several pertinent phrases. For example patient centered, which readers of Finding Home, Hope, and a Future will discover as the Harbor Care guideline clients first. Also clinicians, working together with patients and families, using a systematic and cost-effective approach will prove directly relevant to this book’s description of Harbor Care at work.

The Harbor Care case study also provides ample examples of the article’s additional observations, including collaboration is considered a core element, and social workers engaged in three patient-centered activities: behavioral health treatment, care management, and referral for social services in providing integrated professional care. In effect the case study I explore in this book is an early example of effective provision of integrated services, most often without the need for external referrals. Essentially Harbor Care has been doing this kind of work for forty years.

Researchers have also highlighted the importance of housing, with one study documenting the feasibility of providing on-site integrated primary care and health screening in supportive housing programs.³ Harbor Care has a long history of demonstrably effective results in delivering combinations of social services with housing at their core.

Scholars have also drawn attention to integrated care as a needed response to specifically address the fragmentation that characterizes the current U.S. healthcare system.⁴

The implementation of integrated primary and behavioral health care (PBHC) programs in community mental health (CMH) settings is a recent healthcare service delivery transformation that represents a shift to a more patient-centered and recovery-oriented system of care for persons with serious mental illness (SMI). Providers of integrated PBHC are developing and testing new approaches for delivering collaborative, interdisciplinary team-based care.

Finding Home, Hope, and a Future documents Harbor Care’s years spent in pioneering its system of integrated social services, which began by assisting persons with serious mental illness and within a few years expanded to include other marginalized people.

This book supplements recent studies by deeply engaging with a single organization to explore how integrated care, social services, and housing work together in practice. My focus on talking with a wide range of individuals involved with Harbor Care, including staff, clients, administrators, and Board members, allowed me to explore how interconnected services work on many levels. Readers will learn how the integrated approach works at Harbor Care, and not just because it guides Board members’ decisions or pushes social services staff to think about how they can collaborate to best meet client needs. It reaches deep down as staff and clients in combination develop the latter’s capacities to live lives as fully as they can.

Two Harbor Care personnel put the organization’s contribution to providing effective care, supportive services, and housing in their own way. The first, a staff member since the 1980s, referred to the early work of Harbor Homes, Harbor Care’s first forerunner, by saying, We took on the hardest challenges and created ways for people with persistent mental illnesses to learn to live full lives. Another staff member referred to all the categories of Harbor Care clients by asserting, We became a perpetual conveyor belt of opportunity.

In telling the Harbor Care story this book focuses on the experiences of individuals in the Harbor Care community, including those quoted above. Together their stories explain how the perpetual conveyor belt of opportunity was created and continues to make a difference in people’s lives.

Who I Am

Consistent with this book’s telling the Harbor Care’s story by focusing on the people directly involved, I will include here a few points about me as the researcher and writer. A retired social science academic, in 2013 I began what has become a volunteer career. On my new path I have authored histories of local organizations successfully responding to formidable societal issues. Finding Home, Hope, and a Future fits that format.

Now, more to the point about why Harbor Care became a major project in my new career. A clue becomes glaringly obvious when I mention the name of the person who was Harbor Homes’ first hire in 1982 and remained at the helm of the nonprofit until retiring the end of October 2022—Peter Kelleher. I, Ann Kelleher, am his former sister-in-law. Although a job opportunity had lured me to the State of Washington in 1980, in 2007 I became reacquainted with the Kelleher family as recounted in Chapter 5. Our reconnecting happened at the dedication ceremony of a new Harbor Care residence building. So learning more about the nonprofit, what made its success and expansion possible, flowed logically from my new volunteer career’s objective.

As a final point in this Introduction’s endeavor to provide readers with useful information, the following timeline summarizes major events in Harbor Care’s history. It can help sort them out as the nonprofit’s story unfolds.

Harbor Homes/Partnership for Successful Living/Harbor Care Timeline

The following lists major events in the development of the nonprofit today known as Harbor Care.

1980 Harbor Homes established as a nonprofit to provide social services for people with persistent mental illnesses.

1982 The house at 3 Winter Street purchased and renovated. Peter Kelleher hired as director and nine clients began occupancy.

1984 Harbor Homes granted contracting authority by Community Council Mental Health Center of Nashua.

1985 The Gathering Place opened at 33 Main Street.

1987 Independent Living Complex opened at 30 Allds Street.

1988 Residences opened at 156 Chestnut Street and 8-16 Maple Street. In March a major fire occurred at the Maple Street facility.

1989 The Maple Street building reopened and, in addition to supervised apartments, it offered respite housing and an emergency shelter for homeless people.

1991 Client apartments and Harbor Homes headquarters established at 12 Amherst Street. Five condos purchased and opened as client residences.

1992 Milford Regional Counseling Services merged with Harbor Homes.

1997 Healthy at Home and Welcoming Light, Harbor Homes spinoffs established as nonprofits.

2003 Greater Nashua Council on Alcoholism/Keystone Hall merged with Harbor Homes.

2004 Veterans FIRST programs began with transitional housing for homeless veterans in a leased facility.

2005 Amherst Street Administrative Staff and the Gathering Place moved to 78 Main Street.

2006 Southern New Hampshire HIV/AIDS Task Force merged with Harbor Homes.

2007 Buckingham Place opened at 46 Spring Street providing transitional housing for veterans and their families.

2008 Harbor Homes and Affiliates became the Partnership for Successful Living.

2009 Harbor Care Health and Wellness Center opened at 45 High Street.

2010 Dalianis House opened at 59 Factory Street providing transitional housing for veterans. Keystone Hall moved to 615 Amherst Street.

2013 BAE Systems Independence Hall opened in Manchester NH providing transitional housing for veterans.

2017 Partnership for Successful Living administrative center opened at 77 Northeastern Blvd. Veteran homelessness in greater Nashua effectively ended.

2019 Boulder Point Veterans Housing opened in Plymouth NH providing permanent supportive housing for veterans.

2020 Partnership for Successful Living became Harbor Care.

1

. Harbor Care

2021

Annual Report.

2

. Fraser, Integrated Primary Care and Social Work: A Systematic Review,

176

.

3

. Weinstein, Health Care Integration,

72

.

4

. Lemieux, Integrated Primary and Behavioral Health Care,

557

,

559

.

1

Launching Harbor Homes

The Interview

He had applied for the Manager job at Harbor Homes, a newly minted nonprofit. What exactly the title Manager meant Peter Kelleher was not sure, yet here he was driving north to Nashua New Hampshire for the interview in sluggish rush hour traffic. The air was dense and stifling on this early July afternoon with both temperature and humidity in the mid-

90

s.

While having a rethink about why he had decided to try for another job, his aging but only slightly decrepit twelve-year-old Chevy Nova began bumping along the road. The thumps got worse with every rotation of the back right wheel. No choice but to pull over and change the tire. For a moment he wondered if going on to the interview would turn out to be a good idea as he scrambled out the car door and opened the trunk.

It was

1982

and Kelleher, as a

27

-year-old with a wife and a young child, a MSW from Simmons College, and experience working with people suffering from persistent mental illness, reckoned he was ready for a work upgrade. He felt compelled by an as yet vaguely defined sense of purpose, or was it a hope, that chronically mentally ill individuals should be encouraged to develop their capabilities. With appropriate assistance many such people could learn and live fuller lives. Peter Kelleher had an impression that, as a brand-new nonprofit, Harbor Homes might provide an environment for innovative social services.

Literally dripping in sweat Kelleher got back in his car. He arrived at the Community Council Mental Health Facility of Nashua over a half an hour late. Entering a small office he stood facing three women seated around a table. Though not usually intimidated, in this case he was acutely aware of his wilted appearance—sweaty brown hair plastered to his head and a somewhat soggy rumpled blue suit. After introductions, and a brief explanation for his lack of punctuality, Kelleher was heartened when the interviewers suggested he take a few more minutes to clean up a bit. He was hopeful that they would not judge him too harshly for being late. Sometimes people think of being on time as a measure of a person’s capacity to take responsibility seriously.

Although beginning the interview on the back foot Peter Kelleher greeted each of the three women. Betty Hall was a member of the New Hampshire House of Representatives, Sister Lorraine Arsenault chaired the department of social work at Rivier College in Nashua, and Lee Page was Housing Director at the Community Council Mental Health Center. Kelleher was their last of ten interviewees, distilled down from the potential pool of over

100

applicants.

Kelleher’s response to their first question caused each of three interviewers to realize they were talking to the probable frontrunner. He demonstrated knowledge of social work in general, intensive knowledge of the mental health field in particular, and in depth thinking of how best to work with clients as individuals in assisting them to realize their potential. Several more minutes of conversation convinced the four people in the room that they shared a common sentiment. They thought the current crisis brought on by deinstitutionalizing people suffering from chronic mental illnesses could be turned into opportunity, a chance to demonstrate that such marginalized people could develop their own skills by being provided with ground breaking social services.

None of the four ever forgot their shared Interview Day.

Peter Kelleher began work on July 13, 1982 as Harbor Homes’ first employee. There was no time to lose. By September 7, 1982 the empty house owned by Harbor Homes Inc. on 3 Winter Street in Nashua would become home to nine people of varying ages, with a variety of persistent mental illnesses, and no experience in living cooperatively with others. He launched into action propelled not only by the hope in his heart but by pressing necessity.

Start Up

What seems so natural now, over 40 years later, was in fact a risk taken together by the Harbor Homes founders and their first employee. Hindsight suggests that establishing Harbor Homes Inc. as an ongoing operation happened because of the fortuitus combination of at least three factors. First, the national trend to deinstitutionalize people with persistent mental illnesses created the need to provide them with housing and community-based support services. Second, the exceptional group of able and dedicated professionals, spending months of their personal time, accomplished the heavy lifting needed to bring the new nonprofit into being. Third, the fortuitous choice of Peter Kelleher as the agency’s managing director turned possibility into reality. His soon-to-be demonstrated exceptional capabilities surprised even himself.

1. Deinstitutionalization as Public Policy

Community-based approaches to providing assistance for the chronically mentally ill were advocated as early as the 1950s. They were to replace housing people in institutions providing 24-hour care, and by the late 1970s they had become dominant. Such a major shift in social service provision became possible because it had been adopted as policy by the US government.

The federal Community Mental Health Act, passed in 1963, authorized an alternative to large-scale mental health institutions, often called asylums at the time. According to President Kennedy who signed the act into law, it offered a new bold approach in shifting funding away from large institutions to community-based mental health treatment programs. By 1980 the inpatient population at public psychiatric hospitals had declined by 75%.¹

An analysis of the deinstitutionalization trend asserted it was produced by at least three factors. First, psychiatric drugs were developed for treating mental illnesses. Second, specialist and public opinion moved from a lock them away response to thinking that when possible mentally ill people should be treated and integrated into society. Third, federal funding shifted to community mental health care centers. For example, Medicaid and Medicare reimbursements were designated for community mental health centers instead of mental hospitals.² Also The Supplemental Security Income disability benefits program provided direct financial support for eligible individuals with mental illness living in the local community.³

The publication of Ken Kesey’s book One Flew Over the Cuckoo’s Nest in 1962 generated support for deinstitutionalization from the general public. The plot line’s message took off as a major media event when it came out as a film in 1975. Jack Nicholson won an Oscar for his portrayal of a man seriously mistreated in a fictionalized mental health institution. The fact that the book’s author had been a nurse’s aide in the psychiatric wing of a California veteran’s hospital accorded the story a convincing air of authenticity.⁴

A positive case can be made for deinstitutionalization because it provided the context for granting legal rights to the mentally ill and opened up avenues for their social integration. However opponents of deinstitutionalization pointed out that many of the people released were severe cases who suddenly had to live on their own with little support. These critics asserted that often community mental health centers were insufficiently funded.⁵ Many providing services for people with persistent mental illness would agree. According to online information from the nonprofit Young Minds Advocacy, Despite progress, public mental health systems largely failed to develop sufficient resources and staffing adequate to treat and support individuals in home and community-based settings.⁶

The national trend directly affected events at the local level. They help explain why in the early 1980s a group of people in Nashua New Hampshire saw the need to take action by creating Harbor Homes. Law suits in the state had accused mental health professionals of warehousing people instead of working with them to achieve their potential. At about the same time the NH state legislature cut its budget for mental health programs. As a result mental health centers were discharging people with persistent mental illnesses. Some of them had no support system and nowhere to go.⁷

2. Forging a New