Dimitrinka Pesheva (left), a home care aide, comforts 101-year-old Ida Kachanov in Kachanov's apartment in Brookline, Massachusetts, on December. 2, 2016. Kachanov has been receiving services through Springwell since 1983. Pesheva works at one of Springwell's vendor agencies and spends her shifts with Kachanov doing anything she might need, including cooking, feeding, cleaning, bathing, dressing, or simply providing comfort and companionship. She has been working with Kachanov for the past three years. When Pesheva first started working with Kachanov, Kachanov was able to get around using a walker and could feed herself. Now, Kachanov is bed-ridden and needs 24-hour care. She is often confused and frustrated, and refers to Pesheva as "Mama," calling for Pesheva many times throughout her shift to come to her side and hold her hand. Kachanov is originally from Moscow where she was an English professor. She moved to the United States in 1978. #

Hillary Tarr, a Community Transitions Case Manager at Springwell, drives to a meeting at Wingate, a nursing and assisted living facility in Needham, Massachusetts, on October 14, 2016. Tarr has been an employee at Springwell for just over two years and focuses on helping seniors transition out of nursing facilities and back into their homes, or into a new home. Many of the elders she works with are low-income or homeless, making the transition particularly complicated. Tarr also helps her clients find and apply for housing and purchase necessary household items they cannot otherwise afford. With a caseload of 84 elders, Tarr spends much of her day outside of the office visiting and checking in with each one. #

Lilia Mantsur (left) takes a memory test while meeting with Marius Zakarauskas, a senior Care Advisor at Springwell, in her apartment in the Casselman House, an affordable housing building in Newton, Massachusetts, on October 20, 2016. The test, which Mantsur passed, is done once a year to evaluate each client and a letter is sent to his or her physician if declining memory is determined. Mantsur's husband passed away two months ago, and now Zakarauskas is helping her manage life alone. "Marius is very caring and attentive. I can call him always," she said. Mantsur receives services 18 hours per week for help with homemaking and personal care. Her walking is unstable and her hands shake a lot, which makes performance of simple daily tasks challenging. #

Lilia Mantsur reads a poem she has translated from English to Russian to Marius Zakarauskas in her apartment in Newton, Massachusetts, on October 20, 2016. Mantsur, who is originally from Crimea, moved to the United States in 1999 to be with her daughter. She was a literature teacher back home, and continues to surround herself with books, including those by her favorite poet, Alexander Pushkin. #

Community Transitions Case Manager at Springwell Hillary Tarr (center) meets with 83-year-old Nadia Supin (left), social worker Julia Lilley (right), Supin's son Boris, and nurse Emily Monahan (not pictured) at a nursing and assisted living facility in Needham, Massachusetts, on October 14, 2016. The group discusses the obstacles Supin faces upon being discharged from Wingate and how they can address them. #

Physical therapist Barbara Duffy (right) asks 83-year-old Nadia Supin to shuffle to her right to test her balance during a physical therapy session in Supin's apartment in Newton, Massachusetts, on December 2, 2016. Supin was discharged from Wingate, a nursing and assisted living facility in Needham 20 days ago, and is now working to regain her independence at home. #

Physical therapist Barbara Duffy asks 83-year-old Nadia Supin to raise her left leg to test her balance during a physical therapy session in Supin's apartment on December 2, 2016. Supin was admitted to Wingate, a nursing and assisted living facility in Needham, in August after suffering from a stroke, and now that she is living on her own again, she is at risk of falling and injuring herself with no one there to help her. To assist with her transition, Supin receives 18 hours of care per day including bathing, dressing, cleaning, homemaking, and grocery shopping. #

Liubov Nedzelscaia (right), a home care aide, cuts 83-year-old Nadia Supin's chicken for her in Supin's apartment on December 2, 2016. Before retiring, Supin was a computer analyst. She moved to the United States from Moscow with her family in 1989. #

Marius Zakarauskas, a senior Care Advisor at Springwell, drives to Newton, Massachusetts, to visit two of his clients on October 20, 2016. Zakarauskas is responsible for working with 70 elders, determining their eligibility for home care programs, creating care plans and overseeing their implementation. In the office, he is available to all of the elders he serves by phone. Sometimes they call to ask a question, voice a concern about services they receive, or ask for more help. Other times, they just want to talk. He also communicates with local vendors contracted by Springwell to coordinate care and services for his clients. This includes laundry, cooking, cleaning, bathing, dressing, locomotion, eating, medication reminders, transportation, and other tasks. Zakarauskas spends part of his workday outside the office doing home visits with clients. He has been working at Springwell for six years. “It can be a very stressful job, but also very rewarding,” he said. #

Rafael Rubinov, 86, in the lobby of the Casselman House, an affordable housing building in Newton, Massachusetts, on October 20, 2016. Rubinov started receiving services through Springwell in 2006, and is currently being cared for 24/7. Rubinov broke his hip two years ago and has not walked since. Rubinov also suffers from advanced dementia. "Sometimes he thinks he's living in Israel. The other day, he told me it was his 100th birthday. Some days, his memory seems normal, and then the next, he's forgotten everything." Zakarauskas said. "He always recognizes me, but forgets why I am visiting him every two months." #

Marius Zakarauskas (center), meets with 86-year-old Rafael Rubinov (right) and his worker, Vlavo Jovic (left), in the lobby of the Casselman House on October 20, 2016. #

Trudy Day, 88, reacts after hearing good news from Hillary Tarr (not pictured), a Community Transitions Case Manager at Springwell, during a visit at Marist Hill nursing and rehabilitation center in Waltham, Massachusetts, on October 14, 2016. Day was admitted to Marist Hill in 2013. Now healthy, she is able to take care of herself and is working with Tarr to move back into the community. After being admitted at Marist Hill, Day was placed under the care of a court-appointed guardian. Day was living in an apartment before entering the nursing facility, and has since lost the apartment and does not know what happened to her furniture and belongings. After weeks of trying to get in touch with Day's guardian, Tarr was finally able to speak with him to find out what happened to Day's belongings. He agreed to meet with Tarr to bring her what was left. During Tarr's visit to Marist Hill, she let Day know she would be able to get some of her belongings back. "I had a brand new winter coat and boots. I want them back. It's cold in here!" Day told Tarr. Still, Day is upset over all that was lost. "Every time I visit she talks about her things, all the stuff she had. It's not just material things, they're sentimental." Tarr said. When Tarr finally met with Day’s former guardian, Trudy’s passport and social security card were among the belongings she was able to retrieve. #

Hillary Tarr sorts through clothing and household items at the Springwell offices in Waltham, Massachusetts, on October 14, 2016. The boxes contain t-shirts, socks, bedding, a razor, a broom, and other necessities for one of her clients who will be going home for the first time in a couple of weeks. #

Hillary Tarr (right), visits with Trudy Day at Marist Hill nursing and rehabilitation center on October 14, 2016. Day was admitted to Marist Hill in 2013. Now healthy, she is able to take care of herself, and is working with Tarr to move back into the community. #

Trudy Day reacts after hearing good news from Hillary Tarr during a visit at Marist Hill nursing and rehabilitation center on October 14, 2016. "Trudy is content, but doesn't need to be in a nursing facility," Tarr said. #

65-year-old Robert Bryan meets with Hillary Tarr (not pictured), in his apartment in Newton, Massachusetts, on November 10, 2016. Bryan became a quadriplegic when he was 43 after receiving a gunshot wound through the top of his skull. Bryan was at a club in Rhode Island when a man opened fire, allegedly trying to target the club's owner and hitting Bryan instead. Bryan's wife could not provide the care he needed after the shooting, so he was placed in a nursing home, but fought to get out and move into his own place. "I just say you gotta keep pushin", Bryan said. Now, he is back in his own apartment where he has been for three days, despite advice from doctors that he remain in a nursing home. #

Hillary Tarr (left), a Community Transitions Case Manager at Springwell, meets with 65-year-old Robert Bryan in his apartment in Newton on November 10, 2016. He receives 32 hours per day of home health aid support (sometimes there are two workers with him at once), but has had difficulty keeping the same workers due to his specific needs and requirements. "My house is a wreck. I can't get my hair combed, a shave, I feel like a ghost," Bryan said. He explained to Tarr that there is no continuity between workers and he feels that many of them are not trained to do tasks the way he wants them done, such as changing his colostomy bag. "I've told him that if he can't keep a worker around, then he'll be without services. And if he doesn't have services, he's putting himself in a dangerous situation and at a great risk of something happening to him," Tarr said. "But going home is his choice to make." #

89-year-old Lia Khasina meets with Marius Zakarauskas in her apartment in the Coleman House, an affordable housing building in Newton, Massachusetts on October 27, 2016. Khasina has been working with Zakarauskas for about a year and receives 14 hours of homemaking and personal care weekly. #

A cane hangs from the door inside 89-year-old Lia Khasina's apartment during a meeting with Marius Zakarauskas in her apartment in the Coleman House on October 27, 2016. #

Lia Khasina laughs while meeting with Marius Zakarauskas in her apartment in the Coleman House, an affordable housing building in Newton, on October 27, 2016. During their visit they spoke about her health issues, doctor visits, and the services that she is receiving. She also told Zakarauskas how lucky she was to have a worker who always does what she asks her to do and sometimes even knows what needs to be done without asking. She explained that walking is sometimes very difficult for her, but she thinks that physical therapy would not help her at her age. #

On on October 13, 2016, Marius Zakarauskas meets with Schantel Wilchcombe (left) and Jennifer Morris (right) at the Springwell offices in Waltham to discuss a particular case they are collaborating on. The daughter of one of the elders Zakarauskas works with called the office concerned about her father’s worker and worried that her father was not receiving the services he needed. Springwell staff often work to facilitate communication between vendor agencies, vendor workers, and families. #

Marius Zakarauskas meets with 93-year-old Nathan Schiller (center), who is the primary caregiver for his wife, Victoria Schiller (right), 85, in their home in Newton, on November 3, 2016. In addition to a number of health issues, Victoria has dementia, and receives 12 hours of home health aid through Springwell every day. #

From left: Marius Zakarauskas, Nathan Schiller, Nathan's wife, Victoria Schiller, and home care aide Agnes Stanek, in the Schiller's home in Newton on November 3, 2016. Nathan is Victoria's primary caregiver, a role that has become a full-time job for Nathan. When he first began caring for her, she often yelled at him and refused to take her medication. During their visit, Nathan told Zakarauskas that Victoria usually does not remember his name or that he is her husband, and calls him "Dad," but recently she said, "Thank you, Nathan." "He's the best caregiver I've ever seen," Zakarauskas said of Nathan. Originally from Moscow, the Schiller's moved to the United States in 1973 with their children. Nathan was a filmmaker and screenwriter back in Russia, making educational scientific films. Before retiring here in the U.S., he owned a store in Harvard Square in Cambridge, Mass. called "Little Russia," selling jewelry and items from Russian culture. Victoria was a high school teacher in Russia and was teaching Russian Culture at Harvard University. #

Hillary Tarr helps 76-year-old Lawrence Clark shop for a desk online in his apartment in Waltham on November 3, 2016. Tarr has been working with Clark for about a year, and has helped him furnish his home and purchase everyday necessities through the Money Follows the Person program, a federal demonstration project that assists elders and people with disabilities who want to move from facility-based care to the community. "Hillary has done wonders for me. My apartment was empty and she got me all of these things," Clark said. #

Hillary Tarr helps Lawrence Clark shop for winter boots online in his apartment in Waltham on November 3, 2016. When Hillary first started working with Clark, she was unaware of his living situation. "I started crying after walking into his apartment for the first time and seeing the way he was living," Tarr said. All Clark had was on an old mattress on the floor with holes in it. He has no family and lives alone. When Clark suffered from a recent stroke, the maintenance man in his building was the person who found him and made sure he got help. Now, Clark, a former janitor from South Boston, is doing well. He has not had any recent falls or hospitalizations, and is transitioning out of Tarr's program. #

Marius Zakarauskas meets with Hanna Tseytlina, 92, at her apartment in the Parker House, a subsidized senior living facility in Newton, on October 13, 2016. Zakarauskas is Lithuanian himself and moved to the U.S. 11 years ago. Along with Lithuanian and English, Zakarauskas speaks Russian and therefore works primarily with the Russian community. It is Zakarauskas' job to determine his clients’ eligibility for home care programs, creating care plans, overseeing their implementation, and contacting agencies and vendors to coordinate care for the elders he serves. In Tseytlina's case, that means nearly 24 hours of care seven days a week, as she suffers from a number of debilitating health issues. #

A photo of Hanna Tseytlina, 92, and her husband, Leonid, who passed away forty years ago, sits on a shelf in her apartment in the Parker House in Newton on October 13, 2016. Tseytlina is one of the elders Marius Zakarauskas serves. As a Care Advisor at Springwell, Zakarauskas is working with 70 elders, and is responsible for determination of elders’ eligibility for home care programs, creation of their care plans and oversight of their implementation. In the office, he is available to all of the elders he serves by phone. Sometimes they call to ask a question, voice a concern about services they receive, or ask for more help. Other times, they just want to talk. Zakarauskas also communicates with local vendors contracted by Springwell to coordinate services for his clients. Springwell’s vendor workers then assist elders with laundry, cooking, cleaning, bathing, dressing, locomotion, eating, medication reminders, transportation, and other tasks. Zakarauskas has been working at Springwell for six years and moved to the U.S. from Lithuania 11 years ago. Along with Lithuanian and English, Zakarauskas speaks Russian and therefore works primarily with the Russian community. Tseytlina uses a walker to help her get around, and some days are better than others. Today, she told Zakarauskas she was tired but happy to see him. "He is the best man," she said. "I thank God for Springwell and their services." #

Marius Zakarauskas says goodbye to Hanna Tseytlina, after visiting her at her apartment in the Parker House, a subsidized senior living facility in Newton, on October 13, 2016. #

Anne Dinatale, 60, in her room at Wingate nursing facility in Needham, on October 28, 2016. Dinatale was admitted to Wingate in March of 2015 after being transferred from another nursing facility where she was participating in rehab after a fall in September 2014 in which she fractured the humerus bone in her left arm. Dinatale is battling a number of medical issues, and she needs knee replacements and a right hip replacement. "The list is endless, really," Dinatale said. #

Hillary Tarr holds housing applications for Anne Dinatale, during a visit at Wingate nursing facility on October 28, 2016. Dinatale was Tarr's first case when she started working in the Community Transitions program. During their meeting she and Tarr discuss goals for Dinatale to improve her health in order to leave the nursing facility and live on her own in an apartment. Because Dinatale spends all day in bed, she has lost much of the muscle needed to get out on her own. Tarr explains to Dinatale that she must be able to stand and pivot from her bed into a wheelchair and commode, at the very least, in order to live on her own. Once she is able to do that, she will have a better chance of being discharged. #

Anne Dinatale, in her room at Wingate nursing facility. Tarr also helps Dinatale with housing applications and has placed her on a waiting list for several locations. "Unfortunately, the typical wait time is two to ten years," Tarr said. Dinatale currently has nowhere to go if she is discharged from Wingate. "“My ex-husband divorced me after almost 40 years. In the beginning it was mind-boggling. He was abusive, so thank God. He sold my house that I grew up in. So I’ve got nowhere to go. I thank God for Hillary. She truly cares. She’s not just going through the motions. She’ll call me if something comes up, she’ll swing by. I don’t know what I would’ve done without her. She just keeps me rolling. Like I say, picture yourself laying in this bed, ya know?" Dinatale said. The walls in Dinatale’s room are filled with various paintings, drawings, and inspirational quotes gifted to her by one of the nighttime supervisors at Wingate who saved the artwork from being thrown out. “I dream of going shopping, setting up my apartment. I dream of nobody coming in in the middle of the night sticking you and moving you. I’ve been waiting so long. And I know it’s a wait, as Hillary prepares me every step of the way. But oh my god, how can you look at these walls for so long? That’s why I started the pictures. I’m much better when I’m looking at a picture and I’m like, “Oh, I’m in the jungle or wherever the picture is,” Dinatale said. #

Anne Dinatale becomes emotional while talking with Hillary Tarr about what it would mean to her to leave Wingate nursing facility on October 28, 2016. "It would mean the world. The universe. I can’t even put it into words," she said. #

Marius Zakarauskas meets with 101-year-old Ida Kachanov in her apartment in Brookline, on October 20, 2016. Kachanov became bed-ridden after a fall and requires 24/7 care. Zakarauskas' job is to make sure Kachanov’s care needs are met; to achieve this, Zakarauskas communicates with Kachanov directly, her son, and agencies that provide care for her. Some days, Kachanov is disoriented and struggles to understand what is going on. Others, she can remember and recite poems from her childhood, Zakarauskas' says. "Today, she is confused. You can see it in her eyes when she's confused," he said. #

Marius Zakarauskas says goodbye to Ida Kachanov after meeting with her in Kachanov's apartment in Brookline on October 20, 2016. Kachanov has been receiving services through Springwell since 1983, and was one of Zakarauskas' first cases. When he first met Kachanov, she did not like him. "She would call and complain to my supervisor that I was too young and inexperienced, but after a few months, she told me I was like a son to her." Zakarauskas said. #