From living in social isolation to dying alone, the COVID-19 pandemic has given the general population a glimpse into what homeless people go through every day, said James O’Connell, MD, FACP, president of the Boston Health Care for the Homeless Program.
“As one homeless person told me the other day, ‘The only good thing about COVID is now everybody in the country gets to see the isolation we've lived in,’” he said.
When the pandemic hit, people experiencing homelessness were already in a terrible public health situation, Dr. O’Connell said. For instance, mitigation measures like physical distancing, frequent hand washing, quarantining those exposed, and isolating those infected are simply not feasible in crowded shelters, he said.
“From a perspective of viral transmission, shelters are similar to prisons, nursing homes, and cruise ships. When people live so closely together, the virus will spread with alarming efficiency,” Dr. O’Connell said. “With the frequency of co-occurring medical and psychiatric vulnerabilities in our homeless population, we knew coronavirus would be a very devastating disease for our folks.”
Now, six months after the country's first lockdown orders, health care systems are finding innovative solutions for their patients experiencing homelessness, as well as unexpected challenges. Primary care physicians across the country shared their experiences reaching this population during the COVID-19 pandemic, from securing temporary housing to adapting clinical care.
Hotels for the homeless
Many communities have found ways to protect their homeless residents from crowded shelter conditions during the pandemic, albeit temporarily.
When COVID-19 started to hit California, organizations across the state secured housing for those without stable living situations. The resulting initiative, called Project Roomkey, used Federal Emergency Management Agency (FEMA) funding to allow homeless individuals at heightened risk of complications or death from COVID-19 to stay in hotel and motel rooms.
After three months, the project served an estimated 14,200 at-risk individuals experiencing homelessness, Gov. Gavin Newsom's office reported on June 30. As of July, nearly 1,000 individuals in Santa Clara County had been placed in motels through the project, said Cheryl Ho, MD, a primary care physician at the Valley Homeless Healthcare Program in San Jose.
Many of her patients have been grateful for and amazed at the opportunity, she said. Some have even seen drastic improvements in their health conditions, such as one patient whose former place of residence was the all-night bus. “When he finally got a place to stay that was stable, where he could take a shower and go to the bathroom, his chronic lower-extremity edema resolved,” said Dr. Ho. “He no longer had that issue because he had a place to put his feet up.”
In a similar fashion, New York City was able to relocate more than 16,000 single adults from dormitory-style, single-adult shelters into hotels, said Regina M. Olasin, DO, FACP, chief medical officer of Health Care for the Homeless in New York City. In addition, before testing became widely available, the organization and the city's Department of Homeless Services proactively isolated high-risk individuals with clinically presumptive COVID-19 infection, she said at the Virtual Summit on Health System Recovery from the COVID-19 Pandemic, an online conference held in June by Global Health Care.
“The early removal of clinically at-risk shelter residents to isolation sites made individuals more isolated,” Dr. Olasin noted. “However, it does appear to have had a positive impact on not having widespread dissemination of COVID among the shelter population.”
Baltimore also secured hotel space early on in the pandemic for its most vulnerable residents experiencing homelessness, said Adrienne Trustman, MD, chief medical officer for Health Care for the Homeless in Baltimore. “Many of those people, but I think not all, were pulled out of shelters and into hotels, where they got their own hotel room with their own bed, their own bathroom, with three meals a day being delivered, and they have stayed there,” she said. “I was just speaking with one of my primary care patients who's been in a hotel since the middle of March.”
Patients in Baltimore have had varying reactions to hotel life, said Dr. Trustman. “Depending on the individual's perspective, some people are really happy to be alone in a hotel room and it's such a relief,” she said. “And then I think it starts to get a little bit lonely, or for some people it's lonely to begin with.”
In addition, many patients experiencing homelessness who've been temporarily housed in California are afraid of what might happen next, said Dr. Ho. “People are scared because they don't know how long this will last for, and we don't know because it's dependent on the FEMA funding, and we don't know when that is going to dry up,” she said.
The next phase in California, called Homekey, dedicated $600 million in grant funding to purchase and rehabilitate various housing facilities, such as hotels and vacant apartment buildings, which will serve as permanent housing for people experiencing or at risk of experiencing homelessness. For Dr. Ho, this goal of long-term housing is vital, especially for the vulnerable elderly individuals who cannot care for themselves.
“Nobody can fathom that they were on the street, and now that we see them in front of our very eyes, we can't imagine putting them back out on the street ever again,” she said.
One city's testing tale
Not every city has had access to hotel housing for its homeless population.
When the pandemic hit Boston in March, the Health Care for the Homeless Program screened everyone going into the city's shelters for symptoms of the virus (e.g., fever, shortness of breath, or cough), Dr. O’Connell said. In lieu of hotels, the program and its partners across the city constructed two tents where shelter residents could go if needed, he said.
“We had a tent for quarantining, and then we had a really sophisticated tent for isolating symptomatic people awaiting test results,” said Dr. O’Connell. “We had negative pressure in the tent, everybody had their own toilet, there was six feet of separation, each room was walled off by very thick canvases, and people had privacy.”
If someone screened positive at the shelter, he or she was sent to the hospital for testing. “It was about two to three days, sometimes four days before the results came back, so we would bring those people to the tent and isolate them rather than [having them] remain in the shelters while waiting for the results,” Dr. O’Connell said.
Through mid-March, the team, as well as other clinicians serving the homeless across the country, were surprised to see almost no cases in a population that was expected to be devastated by COVID-19, he said. “Then, on March 20, we saw the first few people turn positive, and we realized all were clustered around our largest shelter, which is called Pine Street Inn.”
So in early April, with the blessing of the shelter and the public health department, the team tested everyone in the shelter in addition to conducting the usual screening process. While one person had a fever and about 10% had mild symptoms, none of the 408 people screened met the formal screening criteria to qualify for COVID-19 testing at the time, Dr. O’Connell said.
But when the test results came back, 148 (36%) were positive.
“We thought maybe 10 or 15 people might turn positive. We weren't expecting 148. … Then we had this stark realization that this was essentially spread by people who at the time of testing had no symptoms or, at the most, minimal symptoms,” said Dr. O’Connell, adding that one-third of the shelter staff also tested positive.
They weren't sick enough to be in the hospital, but the shelter residents who tested positive needed to be isolated from the rest of the community. One option was the program's longstanding medical respite care facilities, where one floor was converted into a 52-bed COVID-19 unit, Dr. O’Connell said. In addition, Mayor Marty Walsh secured an empty 85-bed hospital that was about to be converted into condominiums, and he joined Gov. Charlie Baker and the Mass General Brigham system in creating Boston Hope, a field hospital in the Boston Convention and Exhibition Center with 1,000 beds, including 500 beds for COVID-positive homeless and poor people that were staffed by the Boston Health Care for the Homeless Program.
Then it was time to test the residents at other homeless shelters. “All of the large shelters we tested over the next two weeks had 30% to 40% positive rates, and virtually everybody, as in Pine Street, was without symptoms,” said Dr. O’Connell. “This underscored our alarming realization that this virus is being spread fast by people who don't even know they're infected.”
Ultimately, only a handful of people ended up being hospitalized or ventilated, he said. “This has been surprising and unexpected, and we don't yet understand why. Could this be a different strain of the virus? Are unknown factors somehow protecting the shelter population? We simply don't know,” said Dr. O’Connell.
As of July, the team was doing universal testing of all shelter residents every two weeks, with promising results, he said. “Right now, the positive test rate is down to 1% to 4%, low enough to do effective isolation and contact tracing and other key public health measures.”
In ordinary times, shelters are life-preserving. Those living on Boston's streets are three times more likely to die than those living in shelters, according to a study published in September 2018 by JAMA Internal Medicine. But in times of communicable diseases, crowded shelters can serve as unwitting Petri dishes, said Dr. O’Connell.
“Interestingly, we have yet to have any of our street folks turn positive unless they had spent time in a hospital or nursing home,” he said. “But to be sure, safe housing is the best way to minimize spread of the virus, not living on the streets.”
Clinical care consequences
From a clinical perspective, the pandemic has affected nearly every aspect of care for homeless patients.
In general, COVID-19 is more difficult to identify in this population because they already suffer from chronic and acute diseases, said Dr. Trustman. “It's really tricky because I estimate that probably a third of my primary care patients have a cough at any given time,” she said. “You're in a shelter and you're constantly being exposed to other viruses, so having a cough is kind of a way of life almost.”
The homeless population also faces challenges in accessing primary care, and even more so during a time when that care has transitioned away from in-person visits, said Dr. Olasin. “There's a disparity in significant bandwidth equity and lack of smartphone access to facilitate virtual encounters,” she said.
When it came time to shift to virtual primary care visits, it became apparent that some patients had no telephone access at all, said Tracey Henry, MD, MPH, MS, FACP, assistant health director of the Primary Care Center at Grady Memorial Hospital, a safety-net hospital in Atlanta.
“The issue we saw was that when we limited in-person clinic visits to more urgent cases or patients with high-risk conditions, there were a lot of patients that we couldn't contact to tell them the clinic was limiting visits. Many of those patients continued to come in,” she said, adding that the clinic remained open for these patients.
Even for patients who do have phones, prepaid plans with limited minutes can mean precious little time for a telemedicine visit, said Dr. Henry. “They're using a lot of their data for the 20- to 30-minute phone visit, so that is a disparity as well,” she said.
For Dr. Ho, one benefit to having patients temporarily housed in hotel and motel rooms was that age-old amenity: the landline telephone. “We created a separate telehealth program with the help of providers from our larger health care system to reach out and do phone calls with nearly 2,000 clients,” including those in both motel and congregate settings, she said. “Because some of our patients don't have regular access to a telephone, we were actually able to use the room phone in the motels to reach them.”
In effect, the patients had access to a primary care system where doctors could refill medications with a phone call, and pharmacy partners could then provide contactless delivery, said Dr. Ho. If a COVID-19 swab or an in-person visit was needed, the street medicine team that usually provided care at homeless encampments went to the motels and hotels instead.
“As the shelter in place lifted a little bit, we have now been directing folks back to their primary care sites,” she said, “but a large percentage of those folks did not have primary care doctors, so we've been offering them to join our homeless health care team for primary care.”
The phone calls have worked well in a pinch, especially for long-term patients, but Dr. Ho said she misses seeing patients' faces, as most don't have the technology to do video visits. “For the new patients that I am seeing, I think it's harder to establish that trust and rapport without seeing that person in person,” she said.
Dr. O’Connell agreed, noting that the utility of telemedicine comes at the expense of less human touch. “We have a lot of homeless people on our board of directors, and we were talking to them about what they think of telemedicine,” he said. “They said in a time of crisis, it's been a great way to keep in touch with everybody, but they miss the touch, they miss the visits, they miss the human contact.”