COVID-19 is far from the only crisis affecting New York City. With more than 70,000 people without a home on any given night, “We were in a major homeless and housing crisis to begin with,” said ACP Member Amanda Ramsdell, MD, a hospitalist at Weill Cornell Medicine. She works at the main Cornell tertiary care center, but also at a satellite community hospital, where she said up to 20% of inpatients are documented to be homeless at time of admission.
When the pandemic began, bed availability was top of mind, and thus so was the problem of patients not having stable housing, said Dr. Ramsdell.
“Were they going to be delayed in the hospital and take up isolation rooms? . . . The rapid nature in which everything was unfolding, we were concerned that any delay in [disposition] would really have a huge impact in the transition out of the hospital and making room for all the patients we knew were coming in,” she said.
Working on the general medicine wards throughout the pandemic, Dr. Ramsdell has cared for a number of homeless patients with COVID-19.
“I think that what struck me the most about the patients I saw was rapid physical deconditioning,” she said. “That was the toughest because . . . you have to be fairly independent and without certain medical conditions in order to be in the shelter, so a lot of these patients were newly recommended for [subacute rehab], whereas they had previously been functional prior to COVID.”
Compared to the general population, homeless individuals infected by COVID-19 were estimated to be two times more likely to be hospitalized, two to four times more likely to require critical care, and two to three times more likely to die, according to a report published in March 2020 by the National Alliance to End Homelessness.
Thankfully, at least some cities have not yet seen such dire consequences. As of July, only small numbers of Boston's homeless people had been hospitalized or ventilated due to COVID-19, and of almost 900 who tested positive in the shelters, only 12 deaths had been documented, mostly among older persons with end-stage cancer or liver disease, said James O’Connell, MD, FACP, president of the Boston Health Care for the Homeless Program.
“The relative lack of severity of COVID-19 in our shelter population has been surprising and baffling,” he said. “We don't know why, to this moment, and we are awaiting genomic studies to determine if this could possibly be a strain of the virus that is highly transmissible but with milder illness. Or are there unknown factors that somehow are protective of homeless persons?”
While COVID-19's impact on the homeless has varied by community, hospitalists across the country are working both inside and outside their hospital walls to ensure the best possible outcomes for this vulnerable population.
Discharge to . . . hotel?
Denver has good and bad news.
Some good news: COVID-19 hospitalizations in the homeless population were on the decline through mid-summer after surging in April, said ACP Member Sarah Stella, MD, hospitalist at Denver Health, a safety-net hospital affiliated with the University of Colorado School of Medicine. “That gives us more time to strategize and prepare for a second wave.”
The bad news: The city simultaneously has had an overall increase in people experiencing homelessness, especially those camping in tents or living on the street. “We're seeing a pandemic within a pandemic—a large number of people that are newly homeless—who were working, lost their jobs, were unable to pay their rent, and now they're living on the streets or in their car,” said Dr. Stella.
This has translated into an increase in hospital admissions at Denver Health. “We're seeing a lot more people being hospitalized, but not as much COVID at the moment, although those numbers are looking like they may start to go up again,” Dr. Stella, also an associate professor of medicine at the University of Colorado, said in July.
Denver and some other cities have secured hotels and motels as temporary housing for their most at-risk people experiencing homelessness, including both those with COVID-19 and those who are older or have chronic health conditions and would otherwise risk exposure to the virus on the streets or in shelters. For Dr. Stella, who is also the lead physician on Denver Health's complex-patient flow initiative, having hundreds of these respite beds across the city has been crucial for homeless patients with COVID-19 who don't need to be in a hospital.
“Having a place for them to be safe and isolate and recover from COVID with some additional support has really been key for our hospital not having capacity issues,” she said.
Hospitals and clinicians without such resources can face real problems when patients are well enough to leave, noted Dr. O’Connell. “When they don't have a place for that person to go afterwards, it's a real dilemma for the hospitalist. When you discharge somebody with COVID to the streets or the shelters, it runs counter to the core of our profession,” he said.
Being familiar with available resources for homeless patients in your community is key, said Tracey Henry, MD, MPH, MS, FACP, an inpatient and outpatient attending at Grady Memorial Hospital, a safety-net hospital in Atlanta affiliated with the Emory University School of Medicine.
Before the pandemic, homeless patients with funding could be discharged to a personal care home, but this was less of an option for COVID-positive patients because these homes have multiple people living in them and would not allow for appropriate physical distancing, she said.
“If they were ready for discharge but COVID-positive, sending patients to a homeless shelter or personal care home was not an option. The question became, is it OK for them to be potentially discharged back to the street?” said Dr. Henry, also an assistant professor of medicine at Emory. “But then it becomes this moral conundrum. Can they physical distance and can they stay away from others? Luckily, we had other options like Georgia World Congress Center.”
Part of the Georgia World Congress Center was converted to a 200-bed care facility for patients with mild to moderate COVID-19 when the pandemic first began. Although the facility closed at the end of May, it reopened in July after the state experienced an increase in cases and hospitalizations. Atlanta also secured hotel rooms for its homeless patients who were ages 65 years or older or who had underlying health conditions that made them vulnerable to the virus.
For patients hospitalized at Grady with COVID-19 who had no place to go when they were recovered, clinicians coordinated with the social work team to make more informed discharge decisions, said Dr. Henry. “This is the time to really make sure you have a team of social workers, case managers, and others who are aware of all the resources in your community,” she said. “If you have a COVID hotel or a place where you can send them to go . . . then obviously that's an option.”
While securing temporary housing for people who would otherwise be discharged to shelters has been helpful in New York City, it's also posed some care issues, said Dr. Ramsdell, also an assistant professor of clinical medicine at Weill Cornell Medical College.
Patients who are homeless generally experience geriatric syndromes and physical deconditioning much earlier in life, she noted. “From a functional status standpoint, sometimes going to a hotel where you're pretty isolated and on your own isn't the safest situation,” said Dr. Ramsdell.
Even if patients with COVID-19 are ready to leave the hospital, the disease may have caused severe deconditioning and orthostatic hypertension, limiting their independent function in an isolated setting like a hotel.
“It was really challenging in the early days because people were discharged from hospitals thinking that they were going back to their shelter, and they were actually going to a hotel room where they didn't have their medications, where they didn't have the support system they did have in their original shelter,” said Dr. Ramsdell.
Levels of support for patients varied from hotel to hotel. While the city's Department of Homeless Services tried to establish a structure for nurses to check on patients, “It was really hard to predict and to know what services were available when you were trying to send patients,” Dr. Ramsdell said.
Similarly, at an isolation hotel for people experiencing homelessness in Providence, R.I., National Guard members provided residents with meals, medications, and care packages. But the hotel staff had no consistent system for addressing gaps in medical care, according to a report published online in July by the New England Journal of Medicine.
In response, attendings, trainees, and medical students from Warren Alpert Medical School of Brown University volunteered to evaluate residents' medical needs over the phone. They arranged for primary care telemedicine visits, as well as made careful decisions to have cigarettes and alcohol delivered to those with dependence. In addition, the phone call “interviews led to several people being redirected to more appropriate care settings, including hospitals, psychiatric units, and nursing homes,” the report authors wrote.
How hospitalists can help
Hospitalists can optimize care for patients experiencing homelessness at admission, during hospitalization, and at discharge, experts said.
When patients experiencing homelessness are admitted, it's key to be aware that many will already feel stigmatized and may not trust the health care system, said Dr. O’Connell.
“They're going to be scared to death,” he said. “So treating them like everybody else really helps in this situation because the isolation is only going to exacerbate their feeling of being stigmatized.”
In addition, contacting a homeless patient's primary care clinician at admission is an easy way for hospitalists to improve continuity of care, Dr. O’Connell said, although he noted that outpatient health care for the homeless is limited in many communities. “Most of our homeless people have a primary care nurse practitioner or [physician assistant] or doctor, and that helps a lot because they usually will know the people that that person cares about.”
Patients experiencing homelessness may have prolonged hospitalizations, but this can be an opportunity as well, said Dr. Henry. “Some of our patients were eligible for [CMS coverage] but have never filled out paperwork or didn't know how to fill out paperwork,” she said. “So while they're in the hospital for a whole month, for instance, why not get that paperwork started so that perhaps by the end, we will be able to help them have money and funding for placement [after discharge]?”
Discharge disposition will depend on which resources are available in the local community.
For example, hospitalists in some communities can discharge patients without homes to a medical respite facility. “It's a place where people can go who are still sick and the hospital is not going to keep them any longer, but they don't have a safe place to go other than the shelter or the streets,” said Dr. O’Connell, who helped create the Boston Health Care for the Homeless Program's medical respite program in 1985.
The National Health Care for the Homeless Council reported in a June webinar that its Respite Care Providers' Network has more than 1,500 members. Still, respite care services aren't widely available everywhere, such as New York City, “which is really unfortunate,” said Dr. Ramsdell.
However, the city does have a unique right-to-shelter mandate that provides every person in the city with a legal right to shelter if desired. While the mandate sets the city apart from others across the country, she advised hospitalists not to discharge shelter-seeking people to the streets if at all possible. “I would advise people to really exhaust all resources in your hospital to understand where they can go,” Dr. Ramsdell said.
Keep in mind that the patient's family may turn out to be such a resource, especially during a pandemic when people's hearts may be more open than usual, said Dr. Henry.
“Some people that were homeless were proud and didn't want to burden their families,” she said. “We've had a few cases actually where just reaching out to family members, they were definitely willing to take them in and actually had a place where they could social distance in the home.”
Discharge to a family member is an optimal immediate solution if available, but for many unhoused patients, that's not an option. Ultimately, long-term partnerships and new resources are needed to improve an imperfect system that poses significant barriers to people getting into shelters or housing, said Dr. Stella.
That's another point where hospitalists can play an important role—by advocating for the right resources to meet their communities' needs, she said. “Although I've spent a lot of my time inside the hospital walls, I am more convinced that we really need active engagement of hospitalists outside the hospital walls to make things better,” said Dr. Stella.
One target would be partnering with community organizations. “My advice would be to reach out to get to know who the partners are in your community who are seeing the other side of these patients,” she said.
At Denver Health, existing partnerships between the hospital and such organizations as the Colorado Coalition for the Homeless, shelter providers, and the local public health agency have been crucial to the COVID-19 response, Dr. Stella said. Those partnerships led to the formation of a city-wide task force to quickly coordinate COVID-19 strategy for people experiencing homelessness, which included municipal and public health leaders.
“I'm one of the few clinical voices on the task force, but I feel like people value my perspective as a practicing physician who is engaged with hospitalized patients, who understands those challenges really well,” she said, adding that members of such groups are typically happy to see interest from clinicians on the hospital side.
While homelessness remains a difficult problem, Dr. Stella said sustained relationships between the hospital and the community are key to potential solutions. “This is a really important, very vulnerable group of patients. We can't address COVID-19 without addressing homelessness,” she said. “My work with the community has made me actually more optimistic that eventually we'll find a way to address these challenges together.”