Aging In The Right Place With Sarah Canham, PhD
Original Article from: McMaster Institute of Health Equity
Cynthia, we have got a brand-new podcast. What are we talking about?
We’re going to talk about the tents in a way. Have you seen the tents, Robbie? Do you know what I’m talking about?
I have seen tents in my Facebook feed, but I’m not seeing tents in my community.
That’s probably a little bit of a difference about where we each live because of course, like so much of our country, we are both working from home. I’m in an urban setting and you are in a more suburban setting. When I go for a walk, there are tents at the dog park, at the kids’ play park, and on the sidewalk where I was waiting to get my COVID vaccine. A lot of folks have moved out of the shelter system with the fear of COVID is spreading and they’ve set up tents all over urban centers in Canada, which I’m sure you are well aware of. Of course, you’re also aware that homelessness in Canada is not a new problem. It’s something that we’ve been dealing with for ages.
I’m a fifteen-minute drive down the road from you. I’m in Burlington and you’re in Hamilton. It’s a different story. I walked down to the park and there are no tents. It doesn’t mean there’s no homelessness. I see somebody up out of the little row that runs behind a set of houses and I think, “I wonder where that person is sleeping tonight.” It’s less visible and in this day-to-day working from home, it’s not something that I see on a daily basis, unlike the experience that you described. Do you know what we’re both seeing that’s not quite as dramatic?
What’s that?
We’re both seeing our cities get older.
That’s what we’re going to talk about. We are talking with an incredible researcher who is in charge of a huge research project about sites all across Canada called Aging in the Right Place. She’s an Associate Professor at the College of Social Work and in the Department of City and Metropolitan Planning in the College of Architecture and Planning at the University of Utah. She’s an adjunct professor at Simon Fraser University and an all-around great person. We are going to talk to Sarah Canham.
—
Sarah, can you tell us about the problem that your work addresses and what it’s trying to help solve?
The work I am involved in relates to thinking about how we have traditionally supported older adults who are experiencing homelessness. With this demographic, it’s those who are aged 50 and older when we think about older adults. Welcome, everybody to the older age that I’m talking about. Thinking about how we have supported older adults who have experiences or past experiences of homelessness, how we can help them age in place and age in the right place. A place that meets their diverse needs, their unique and individualized life circumstances where they find themselves in this moment. You can think of it as a continuum. We look at several different shelters from transitional housing to supported and supportive housing locations. It’s to determine which ones of those locations can help older adults who are experiencing homelessness age the best that they can in a place that most supports what their needs are.
You identified two pathways in older adults who had their first experience of homelessness in older age and those who had longer-term chronic episodic homelessness and have continued with experiences of homelessness or have been housed in older age. What similarities and differences do you see between those groups? What has that meant for the potential supports in place?
Canada has a federal definition for homelessness. This would include those who we might most readily see who was staying on the street or in some other unsheltered location. Maybe they are in a location that’s not intended for humans to be inhabiting. There are those who are staying in our emergency homeless shelters, so those who are in the system. They’re accessing the homelessness system. There are those who are what we call provisionally accommodated, so they’re living temporarily with others. You might see people couch surfing.
Oftentimes, you see women, in particular, in later life using their social supports and their social network and are higher among that couch-surfing population. The Canadian definition of homelessness even includes those who are at risk for homelessness. Those who are living in precarity or substandard housing locations. The indigenous definition of homelessness also suggests that when we lack our family or home, that contributes to homelessness. This is the work of Jesse Thistle. It’s beyond the lack of a physical structure. It’s the lack of family and social support for individuals.
Yes, we have the chronic people who have had these chronic or episodic experiences of homelessness, but we also have those who are newly homeless in late life. Even within those two groups, you also have all these different variations, whether they are unsheltered or couch surfing or what have you. When we look at the populations, and we are seeing this a lot more, particularly with COVID, the eviction moratoriums are ending in a lot of the cities. You are seeing more people being evicted and oftentimes, being evicted or homeless for the first time because maybe they lost their job or maybe they have some other situation where they can no longer work.
More people who are entering later life are going to experience this first-time homelessness because of the economic situations that we are seeing. There is not enough affordable housing to support the growing numbers of people who are losing their job or have had low wages for their life course. That group of individuals, that newly homeless, if you think about perhaps hadn’t had an opportunity to work in a job where they accumulated resources or accumulated wealth. Now, they are finding themselves homeless for the first time.
If we can hook them into family networks or family resources, perhaps we can divert them from ever experiencing homelessness. There are lots of diversion efforts for that group. The chronically or episodically group is traditionally what you would see are perhaps higher levels of untreated mental illness or higher levels of substance use, more entrenchment in the experience of homelessness. It’s a larger part of what their whole life history is. There are distinct and unique experiences across these two groups.
It brings to light something that I enjoyed, a real light bulb moment that I had when I was reading your published paper. There’s a lot of talk about aging in place. We have got to let people age and let people age where they want to. This idea that as you get older, you automatically have a consistent place to live. It’s guaranteed to be there and you have to decide to stay there and if that place is suitable and it will meet your needs.
This paper also shines a light on the fact that there’s a wealth of research on homelessness and younger populations. It’s this paradox. We know that there’s a lot of people experiencing homelessness in earlier life and yet when we look to older adults and how older adults are going to age and where they are going to age, they have to stay in place. There’s not research there on what if there is no right place for that to happen?
Even if the place isn’t the right place, maybe they are living in a situation where perhaps their health has declined and they now need different disability accommodations, but they are not able to afford a ramp or grab bars or all these different elements that you add to your home to make it more accessible. If people don’t have the financial resources to pay for that, how can they stay in that place healthfully? How can the age well there?
Maybe the neighborhood has changed and they are stuck in place or they can’t keep up with the cost of living in that neighborhood. If they have a mortgage and they’ve paid it off but then they have this huge tax bill because the assessed cost of their house has gone up too much, they have to decide between paying their tax bill or having the right medication or healthy food. That’s those who have a mortgage versus those who are still renting and have never had the opportunity to own a home. Is it the right place? Lots of people say, “I want to age in place. I want to stay in place.” The majority of people, 85% to 90% of people say that when you survey them. When you get down to the limitations that our environments put on our lives, it becomes a different story for people.
You talked a little bit about the spectrum of housing supports that are provided to older people with experiences with homelessness. You broke those into several groups. What were those tranches?
This also goes back to what we were talking about this diversity of need, the uniqueness of need, and the need to individualize the locations and the supports that we are providing to individuals. What we did is we looked at trying to come up with categories that provide either physical structure or services and supports to individuals. At the highest level of healthcare and social support, we have this for the general population older adults and general populations as well but long-term care. It provides a shelter for someone as well as high-level complex health and social care needs.
A step down from that in terms of need is having permanent supportive housing. We are still having support on-site, so you can bring medical care professionals on-site as needed. There is also, oftentimes, maybe a case manager or a worker on-site to help people manage their finances, manage their medications, ensure that their homes are clean or their apartments are clean. All those day-to-day activities of daily living that people need to have at home are all on-site. That’s a great model for people who are finding themselves in need of additional support and not being able to live independently anymore. A little bit less support than that but still provision of housing is instead of supportive housing, they call it supported housing. This is where you might have a worker on-site, but all of the resources that an individual would access are off-site supports. You might coordinate them to come on-site, but it’s not an integrated model of supportive housing there.
A little bit further down from that, we can think of our transitional or emergency shelters. Transitional spaces are a great option and we don’t have enough of these. Let’s say that a person was on the street or an emergency shelter and they had to go to the hospital for healthcare needs. They don’t have somewhere to go to recover, rest and convalesce after they get out of the hospital. They need a transitional space where they can get on their feet again or get in a wheelchair again or whatever it may be so that they’re now able to transition into a permanent supportive housing or supported housing location. People need that stability and need to be provided that support. Oftentimes, people need this to move into a place where they can be more independent.
At the lowest level, there is no housing or there is no shelter provided is that of case management. If we have more case managers and outreach workers, if nothing else, if we can’t have enough housing, which it seems we don’t have, we need more case managers. We need more people on the ground supporting the coordination of services and supports and helping people navigate the healthcare housing systems, which are complex. If you don’t have a lot of background knowledge about how to navigate these systems, it is overwhelming. If you don’t have access to technology, it’s complicated. Having people on the ground is a no-brainer. We need more people who are out there helping people access and coordinate their services. Those are our categories across that spectrum that provide different levels of either housing shelter or services and supports.
In 2020, we would have all said, “This would be great,” but has COVID made it seem more urgent?
Case management in particular? Outreach in particular or any of this?
Across the spectrum, it’s been a special problem. To me, the public language around aging isn’t there. We hear about homelessness and the problems with transmission in a homeless population. We don’t hear about how that multiplied when you have something like aging into the equation.
I could go on several different tangents here and different directions, but I will pick up on one thread of what I’m thinking as it relates specifically to older adults. What I’m hearing is the increase in social isolation. People are encouraged if they have the ability to stay in their homes, avoid other people, and be mindful about their interactions, how often you go outside, and who you interact with. Particularly the impact that COVID has on older adults. The transmission among our older population has had a particular impact on the willingness, comfort level, and safety that people feel in leaving their homes if they have one.
That is something I’m hearing from community partners as it relates to all older adults, not necessarily just those experiencing homelessness. When we think about those experiencing homelessness, we can think about our shelter settings. They are not designed to have individual spaces where people can isolate from other individuals. These are, oftentimes, large spaces where people are sleeping in the same rooms together.
We are needing to figure out a way to better adapt the models that we have to allow people to isolate and at the same time, not feel socially connected. We have to do a lot better with that. I don’t think we have answered that. That is on the minds of a lot of people when I’m talking with them. Maybe it is technology. I’m in Vancouver and when it’s rainy, people aren’t going outside. Can we do socially distant outdoor activities? What are the things we can do to continue to make people feel part of a community that doesn’t put them at unnecessary risk? I’m not sure I answered your question at all.
You did. That idea of people sleeping together in large, open spaces also speaks to a modicum of dignity and privacy. These are things that aren’t afforded to people who are finding themselves experiencing homelessness.
When we think about aging in the right place, that dignity and that privacy is key. If people aren’t able to feel that dignity or privacy, I would argue that they are probably not aging in the right place.
In your paper, you review several studies looking at different interventions across this spectrum and you explicitly state that you are not going to evaluate the quality of the evidence. I won’t grill you too far on this. You do present some of the findings of those studies. In the read-through you’ve done, what are the elements that jumped out to you as appearing as robust findings of these interventions? What have you learned about the changes that different interventions make at different scales on how they are done?
Going back to the first point, which is we didn’t assess the quality because there haven’t been enough randomized control trials done in this topic area. We will generally either fund housing research or health research. I know that there are new initiatives through CIHR to merge the two but, traditionally, they have been quite separate. There hasn’t been a ton of randomized control trials. What there has been an amazing trial done of is the housing first model through the at-home swap project. We found many models that borrow from or use housing first at their core to support those.
That is the most robust model that we are working with. That housing first tells us that housing is the best medicine for people. Once people have stable housing and a stable base, then we can start building other goals from there. Do they have a goal to, for instance, reconnect with family members that they have been disconnected from? Do they have a goal to start working on their finances and managing their finances differently or better or even opportunities for employment or education? Maybe they want to do volunteer work.
Ultimately, that brings me to the models we identified that are those permanent supportive housing. You have housing as your first step, and then you have staff support workers, whether it’s social support for social connection or financial support, employment, education, health, physical health, mental health. Income is key to all of this. Do we have permanent supportive housing locations that are low-barrier that are accepting of people who choose to drink, smoke and use cannabis or heroin?
Lots of locations have created these barriers and these ways to keep people out. How can we create communities and places where we are lowering the barriers to housing? Thinking about ensuring that we have the fewest number of barriers to get people into housing. Once they are in housing, wrapping support around them so that they can stay housed and they can age in the right way, right place that best meets their needs.
I like the idea of not holding people who are experiencing homelessness up to a higher standard than we hold other people. If I decide to drink, no one comes and takes away my home because I shouldn’t have a safe place to live if I get drunk or if I use a drug. That’s not a standard I’m held to, so why should anybody else be held to that standard?
This is where complex care and health needs are being looked after. You receive health care and support from us or you get to continue drinking alcohol. You can’t have both. “You can’t drink here, so out the door.” These are not places that are supporting people that best meet their needs and are individualized to what their needs are. It’s a medical model that says, “This is the only way that the world works. If you don’t fit within that, good luck.” That’s not how the world works. That’s why many people fall through the cracks and there are many gaps in these services. In many cases, we are not meeting the need of how people are truly living their lives. We are assuming things.
What this reminded me of is we were talking about barriers to access to housing that people in the LGBTQ+ community experience. I was wondering, in doing your survey of previous studies, if you encountered anything that looks at aging in the LGBTQ community, or is that another gap?
It’s an amazingly huge gap. The challenge with the work that we did, one of the limitations of that work is that we looked at any research that had been published with outcomes. Did they report on whether or not this housing model improved or decreased health or improved housing outcomes? I do know models that work to serve older LGBTQ residents, but there is no research evidence on it yet. Doctoral students, PhD students, or whatever, let’s get to work. Let’s do it because there’s such a need. It’s so important. It gets back to the need to individualize the supports for a quite diverse older adult. There is limited research on indigenous models that are supporting elders. A lot of work there is needed as well. We see a gap in immigrant and refugee populations as well. There is a lot of work to do.
Jacqueline Gahagan at Dalhousie has started some of that work on the LGBTQ-focused housing for seniors among others. You have identified that we’ve got a bunch of gaps and services aren’t meeting people where they’re at. What’s the takeaway for policymakers? What’s the takeaway for housing providers?
For the purposes of this study, what we were aiming to do is get a baseline so we could understand what’s out there and what is the world of models look like. We have a Vancouver site, a Montreal site, and a Calgary site. What we’re doing is we are looking at examples from each of these and we’re doing a deep dive. We are collecting a ton of data about what we’re calling promising practices. We are looking at one transitional housing site and two permanent supportive housing sites. We are asking the question, do these models allow people to age in the right place? What are the elements that contribute to the “right place” for older adults who have lived or living experiences of homelessness?
In practice, we could offer this as a template for communities to use as they are saying, “Where are the gaps in our housing continuum? Do we have enough low-barrier long-term care sites for our population, which undoubtedly is increasing in age throughout all of Canada? Do we have enough permanent supportive housing sites in our municipality? Do we have enough case managers? Are we advocating for more funding for case managers to support those who have that need?”
There’s also an important place for city planners and for people who are working in city government to say, “Have we zoned our neighborhoods in the right way so that we are not completely focused on single-family homes? Can we allow for multiunit and multi-housing types within our communities because Canada is diverse? Can we break up or undo some of the zonings that are embedded within our cities to build and permit for these different housing types and these different shelter types?” Without that, we will be more restricted in where we’re able to build new housing. There are lots of takeaways for folks and there’s always a need to build more housing and shelter for people. It’s all of those things.
I’m wondering what the obstacles are to making these things happen?
Do we have enough political will? Do we have people out there saying, “Not only is it going to be something that I advocate while I’m running for a position or a political office, but then am I going to implement my ideas once I’m in office? Am I going to work with city staff to rezone our communities to allow for diverse or more densely sited areas so that we can diversify those neighborhoods?”
Not only political will but community will. Oftentimes, we have these negative stereotypes of what happens when people have experiences of homelessness or look a certain way. As a society, if we have decided that certain people are less worthy of housing, we’re not going to make it anywhere. This goes back to something you said, Cynthia. This is a moral issue as well. We need to decide, is Canada a place where we’re okay with some of our neighbors living on the street, or do we want our governments and our communities to do something about it?
It’s a mixture of this preconception or discrimination we have and changing that so that we can vote people in that are going to do something about it, provide more funding for this, and take away some of the behind-the-scenes barriers that we don’t even know about. Of course, there’s always the Not In My Back Yard-ers. There is no evidence that when you build a new affordable housing site in a community that there are negative outcomes. It’s a lot of perception of, “What is this going to do to my home values?” There’s little evidence to suggest that those negative attitudes are borne out in any reality.
Your comment about political will immediately have me thinking about the YIMBYs, the Yes, In My Back Yard movement, and the ability to implement often depends on how much trust is being kicked up in opposition or support. What would you say to those people who are reading this who maybe aren’t themselves a policymaker or aren’t a housing provider, and what steps could they take?
If you are a citizen, you have the ability to vote. You have the ability to go to your city council and sit in, listen, and give your voice. You’re not voiceless. You might not know the mechanism yet. You can go online and see when the city council meetings are, then you can go and share your voice. When you see in the media that there are the NIMBYs, the Not In My Back Yard-ers, they often will have community consultation sessions that the planners will have. You can go to those events and say, “I am an advocate for bringing diverse housing types into my community and I want to support people to be able to afford to live in their home. I don’t want my neighbors to be living on the street or to be living in a place that doesn’t meet their needs. I want them to have a nice home. Yes, I’m in support of this.”
You can write op-eds if you’re for it. You see someone write a NIMBY or an op-ed in the paper. Come on this podcast. You can do all sorts of things. You just have to get your voice out there. If you truly believe that housing is a right and healthcare is a right and these are things that everybody should have access to, amplify your voice and amplify the voice of those who agree with you. There are lots of avenues for that.
One more technical question. I’m curious about whether you have any evidence on this or not. The prevalence of experience with homelessness among older adults. When I was working for Homeward Trust in Edmonton, we had our statistics on who we found as experiencing homelessness. Usually, either if you’re homeless count or through interaction with one of the services we fund with it, the shelters in the city, what we saw was a sharp decline in homelessness. We were not including at risk of homelessness, but a sharp decline in homelessness that we saw after age 65. That ties in both to questions of financial stability with the availability of the OAS and GIS and reduced lifespans for people who have long experiences of homelessness. I’m curious, with my policy hat on, what scale are we talking about? How many people do not have the support to age in the right place, given the experience of homelessness?
I can probably best speak to the Vancouver context. That’s where I’m most familiar with the statistics. We had the 2020 point in time count and as compared to the 2017 point in time count, there wasn’t a huge difference in absolute numbers. From the 2014 time count, they happen every three years, we saw rates of older adults experiencing homelessness. Those who are 55 and older in that study are increasing while we saw youth decreasing.
I was trained as a gerontologist and this wasn’t something even on my radar until it started emerging as an increasing trend within Vancouver. The answer of who’s not aging in the right place is larger. It’s harder to get at. Traditionally, all the point in time counts is an underestimation because we are trying to get at the numbers who we can either find in a shelter or who are willing to talk to us when we go out on the street and look for people. It’s an undercount. We are seeing that those numbers in the last decade or so have been increasing.
The number cruncher in me immediately asks is that in parallel with the expected aging in the population that’s happening more broadly or is that beyond the rate of aging within the population?
I bet the folks who crunched the numbers for the point in time count would appreciate your additional expertise in sifting through that data. That’s a good question because we are seeing the trend overall. We are at 23% of the homeless population aged 55 and older who’s experiencing homelessness.
In Vancouver?
Yeah.
That’s a big number.
It is 55 and older, not 65 and older. There are those numbers to be mindful of.
Regardless of whether or not it’s tracking at the same percentage as the population in general, it’s aging. It doesn’t matter. At the end of the day, we still have older adults needing a safe, affordable place to live than we did previously. We don’t have the mechanisms in place to make that happen.
That is likely what’s happening, too. The people that we are not counting at that point in time count are those people who are couch surfing and living in this at-risk of homelessness group that we consider as from the federal definition as experiencing homelessness. We are not even counting those folks. Those numbers don’t exist. We don’t know what that group is. We only see them once they are in our systems or we can find them on the street. This is what I do and think about every day, my estimation is much higher.
I wanted to mention, too. The other thing you can do is think about, this could be you, your parents or your grandparents at any time. We don’t even recognize that until it happens to us. Especially in that cohort of people who it’s their first-time experiencing homelessness, I don’t think people even necessarily thought that they were on that pathway until they were there. That became a shock to them. We can go to policymakers and all those other things, too, but we can also think about ways to support family members and those who we see educate people and help people with finances. Can we advocate for more financial management education earlier on in life so that we can have some of those things in place? That’s a side tangent. This can happen to many people and it’s not on their radar until they are a bit too far down the line. How can we do something a little bit earlier on to prevent that downstream effect?
Housing is the best medicine. What is preventative medicine?
Keeping people housed.
What’s beautifully in the other half of this podcast, income security.
Income security is such a key part of this. You can’t maintain housing unless you are income secure. Once you are income secure, then you are going to have more stable housing. They are completely linked and completely tied. Some of these supportive housing sites, one of their key features is helping people with their finances. Maybe you’re an older woman and your husband always manages your finances and you have no idea how to do it, then he passes away and you’re stuck. You don’t pay your taxes because you didn’t even know you’re supposed to. Now, you need somebody to help you with that. Learn how to do that process. It can be a sad pathway, but it happens.
Is there anything else you want us to know beyond the questions that we’ve asked?
Oftentimes, one of the things I always say to people is we’re all aging. If we are lucky enough, we’ll be older one day. For those who are already older and already in a difficult situation, think about it as your future self and try to put supports and services in place in the broader community to help your future self. If you’re not thinking about your neighbor and you don’t have the, “I want to help somebody else,” mentality and you’re self-interested, it’s still going to benefit you if your full community is feeling supported and housed.
It is less expensive to house our community members than to have them living on the street accessing healthcare supports and emergency supports. It’s much more expensive to homelessness than it is for housing. Housing is a right. Beyond that, we all have to come together and decide that this is not the world we want. We don’t want to see people living on the street. We don’t want to see people who are not aging in the right place. What are we going to do about it? What are we going to do to contribute to the solution?
I like that takeaway. I like the idea that housing is a right and it’s also the cheapest option. Why are we choosing something that is a harder path forward that is a societal choice and why is it the one being made? That’s a great place to end. Are you good?
I’m good.
Unless you want to start talking about numbers, dollars, and cents. We could work through that.
I have to do some more research on that.
I like this conversation. Thank you.
Thank you both.
It’s great to have you on.
I’m sad that we have to have this conversation.
It’s great that we have a platform to talk about it.
—
That was some fascinating stuff. This is the exact kind of evidence we wanted with this show to make some positive change in the world, to have evidence that can start to change the way the policymakers are doing things.
There were multiple takeaways from what Sarah brought to the table and there will be more going into the future. There was one part of that where Sarah and I were talking past each other. We were talking about what had happened with the older homeless population in Vancouver and Edmonton. I was talking about a change in homeless levels across ages that once you hit age 65, you didn’t see as many homeless people in homeless counts. Sarah was talking about a change overtime where there were increasing rates of 55 plus people experiencing homelessness.
I pulled up the data. It turns out we’re both right. In Vancouver, the share of older adults 55 plus in their homeless counts went from 18% to 24% from 2014 to 2020. That greatly exceeds their increase in the share in the general population. In Edmonton, it was also increasing though you can only see the 2014 to 2016 window there because of the way they did their reporting from 2018. At the same time, that is driven heavily by the 55 to 64-year-olds. In both cities, you see that there are 3 to 6 times as many 55 to 64-year-olds being counted as homeless in homeless counts. There are 65 plus so that fits with what I was talking about where we don’t know if that’s because of the greater income security programs or just because people die when they are at a much earlier age when they are homeless. We have pretty good data on that.
This is an interesting stuff. I hope that it gets into the right people’s ears so that we can start making decisions that are based around these facts and figures. I can’t wait to hear more about what our upcoming guests have to say.
Who’s up next?
The next time we have is the Montreal Site lead for the Aging in the Right Place Project. She’s going to talk us through what happens when you are an older Canadian and you just can’t stay where you are. Many folks who are experiencing homelessness end up in hospitals and then where do they go? They end up in long-term care. She’s going to talk us through what are the characteristics of a good transition into a new living situation for people who need that demographic and also what kind of policy elements that can either support this being a positive move or hinder it. Some of the things that she reveals in this conversation are painful.
I’m looking forward to hearing more about that. We’re focused on Aging in the Right Place led by Sarah Canham in the first couple of episodes. We’re going to pivot to talking about income security in the next two. Cynthia, what other housing topics do we have to look forward to in the future?
I have the absolute pleasure of working with some of the best housing researchers in this country and I dare say the world. We’ve got Community Housing Canada, which is led by Damian Collins. We’ve got At Home in the North led by Julia Christiansen, People Policy Prospects led by Katherine Leventon, Breed and Balance Housing led by Penny Gurstein. We have a whole lot of other topics that we’re going to be addressing coming up and people are not going to want to miss this stuff. It’s groundbreaking.
If somebody is reading this and says, “My ministry is working on such and such a topic in housing. I’d love to hear about the evidence behind this topic.” What should they do?
They should send me an e-mail, a note Cynthia@CHEC-CCRL.ca. We could do a podcast, a rapid evidence business report. We could put you in touch with the right researcher to help you find the answers that you need.
It’s valuable that service out there for policymakers across the country.
Sarah Canham – LinkedIn
Jacqueline Gahagan – LinkedIn
F T I