As COVID-19 ravages the United States, 42 states and Washington, D.C., have issued stay-at-home orders to prevent the virus’ spread. But what happens when you don’t have a place to call home?

Essential hospitals nationwide care for 360,000 patients who struggle with homelessness. They live in close-quartered shelters and outdoor encampments with poor access to hygiene facilities, leaving them at increased risk of contracting COVID-19. Their high rates of chronic illnesses and untreated medical conditions means a higher likelihood they will experience the virus’ most severe consequences.

In an April 8 webinar, association staff experts joined Margot Kushel, MD, professor of medicine at University of California San Francisco (UCSF), to explore resources for association members treating homeless people during the COVID-19 pandemic. Kushel directs the UCSF Center for Vulnerable Populations at association member Zuckerberg San Francisco General Hospital and Trauma Center and the UCSF Benioff Homelessness and Housing Initiative.

Housing-Insecure Patients Pose Challenges

Besides facing increased risk for COVID-19, high-acuity patients who face housing insecurity pose challenges to caregivers at essential hospitals. These patients often have comorbid mental health and substance misuse conditions and frequently lack advance care planning and surrogate decision-makers. Without options for safe discharge, hospitals are forced to admit patients who might not otherwise meet admission criteria, including patients with minor symptoms and patients under investigation, which could pose problems for crowded hospitals.

“None of this will work without the coordination of the health care sector, particularly the safety-net health care sector, and local public health departments, with the homeless services sector. Neither can act appropriately without the other,” Kushel said. She advised that medically trained professionals, such as registered nurses, prepare to coordinate these efforts.

Screening and Processing Protocols

“We need hospitals to make sure they are screening for homelessness,” Kushel said. She suggested The National Association of Community Health Centers PRAPARE Tool and the Centers for Medicare & Medicaid Services’ Accountable Health Communities Health-Related Social Needs Screening Tool as helpful screening methods.

Kushel and the Benioff Institute developed a framework for processing homeless patients based on Centers for Disease Control and Prevention guidelines and her own experience. Health care providers should discharge homeless patients who are infected, presumed infective, or under investigation based on their risk level to group settings with shelter and medical services, hotels, motels, dormitories, or trailers.

With support from the Federal Emergency Management Agency (FEMA), California launched Project Roomkey, an initiative to provide hotel and motel rooms to homeless individuals during the COVID-19 pandemic. Project Roomkey aims to secure up to 15,000 rooms, and has placed 869 individuals as of April 3. Each hotel includes wraparound services, including custodial, laundry, security, and support staff; select hotels will partner with José Andrés’s World Central Kitchen to provide meals. FEMA will cover 75 percent of the costs.

Forming Community Partnerships

Forming partnerships in a pandemic can be difficult, but it’s not impossible. Leveraging pre-existing relationships is key, and hospitals looking to initiate partnerships can consult their local health departments as a first step. Still, Kushel said, “I have seen absolutely amazing partnerships happen nearly overnight.”

For example, essential hospital Alameda Health System, in Oakland, partnered with Abode, a supportive housing and homeless services provider, and other community partners to launch two housing initiatives. Operation Comfort provides isolation housing for symptomatic or COVID-19-infected people experiencing homelessness, and Operation Safer Ground provides safe housing for high-risk people experiencing homelessness.

“Making these isolation and quarantine systems work really demands more than simply caring for COVID,” Kushel said. “I can’t emphasize enough how much taking into account a population that has been deeply traumatized, and, because of that, experiences high rates of behavioral health conditions and mistrust with the health system, needs to be [considered].” Alameda Health System’s initiatives serve behavioral health needs by providing smoking cessation, opioid replacement, and alcohol withdrawal management services.

Despite the challenges the COVID-19 pandemic presents, it has propelled essential hospitals to work toward community-integrated health care. “As much of a tragedy as it is, we would be really remiss not to take advantage of this crisis to move people into housing as we move forward from here,” Kushel said. “We really know how to house people, we know what housing-first policies work, and I think what they are hoping is we can use this moment to get people access to what they need.”

Watch the webinar on-demand or join us for the next webinar in our COVID-19 series.

Visit the America’s Essential Hospitals coronavirus resource page for more information about the outbreak.