Managing the COVID-19 outbreak has been a challenge on all fronts for health care organizations. Operationally and financially, hospital and medical facility managers have faced an uphill battle as they work to contain the virus and stay afloat. There is one situation in particular that has the potential to both devastate an entire population and dramatically impact the financial health of hospitals around the country: the spread of COVID-19 among homeless populations in the United States.
According to the National Alliance to End Homelessness, there are about 567,715 homeless people in the U.S. right now. Though many homeless individuals live in temporary facilities such as shelters and sober-living houses, many also frequent extended-stay motels, live under bridge overpasses, or inhabit tent cities erected along rarely used streets. Additionally, housing evictions and foreclosures have been legally stalled throughout this outbreak. However, once this health crisis is over, experts believe months of unpaid rent and mortgages will usher in a new wave of unsheltered individuals and families. The hidden impact of this pandemic could cause an already struggling health care system to collapse under the weight of newly unemployed, unsheltered, and uninsured Americans.
Why is the homeless population especially vulnerable during this time? These individuals are generally unable to practice proper social distancing and proper hand washing, and they are likely unable to acquire masks and cleaning supplies to keep them safe. Additionally, medical testing and treatment are more difficult to access for this population, in a country where these things are already under extreme pressure.
There are several factors associated with this population that health care leaders must consider during this outbreak, including:
- The rapid spread of COVID-19 among homeless individuals.
- The risk factors that make COVID-19 especially dangerous for homeless populations.
- The growth of the homeless population following the COVID-19 outbreak.
- The financial impacts of treating homeless individuals for COVID-19.
Homelessness - A Health Crisis Within a Health Crisis
The following statistics for the year 2019-2020 were curated by the National Alliance to End Homelessness:
- 84% of unsheltered people self-report physical health problems vs. 19% of sheltered people.
- 78% of unsheltered people are diagnosed with mental health challenges vs. 50% of sheltered people.
- 75% of unsheltered people suffer from substance abuse vs. 13% of sheltered people.
Even more tragic are the number of homeless individuals diagnosed with co-occurring physical health, mental health, and substance abuse challenges or co-morbidities: 50% of unsheltered people vs 2% of sheltered people. This population of older adults with preexisting health problems and unsanitary living conditions puts homeless individuals at a higher risk for infectious disease exposure and death.
Addressing COVID-19 Patient Care Among the Homeless
While the CDC has published safety guidance for shelters and other service providers to the homeless, it has proven nearly impossible to accommodate the unprecedented need for bed space that would adhere to those social distancing protocols, testing, and quarantine rules.
According to the National Alliance to End Homelessness, an estimated 107,194 individuals over the age of 45 were living unsheltered on a single night in 2019. 400,000 new shelter beds are needed to accommodate everyone who is unsheltered and to ensure appropriate social distancing. This demonstrates the massive undertaking that would have been needed during early 2020 to limit spread among the homeless.
Needless to say, the responsibility of care transfers to the health care system that has reported an over-representation of COVID-19 patients that are mainly of color, over 40 years of age, and the homeless.
Homeless Patient Safety
For example, early April saw a COVID-19 outbreak at three homeless shelters located in King County, Washington. Quick interventions - including testing and isolation – were necessary to reduce transmission. Some asymptomatic individuals with COVID-19 were identified and isolated, helping to prevent spread to other individuals outside of the shelter. This situation revealed the difficulties of stopping the spread within communal living spaces, as well as the need to dispatch shelter staff and street outreach teams to assess and treat those who are most vulnerable and ill - before they reached communal living spaces.
Predictive modeling in California suggests that "60,000 of the state's 150,000 homeless could contract COVID-19." These types of numbers dictate the need for a different response from health care providers - one that includes a "coordinated effort among civic leaders, health systems, homeless service providers, and private organizations, to limit spread, reduce stigma and ensure everyone is cared for with dignity and respect."
What’s Next?
Patient safety as a whole is a critical concern for health care administrators. Health care leaders may be tasked with planning and supervising departmental medical services, including coordination of schedules to meet the rise in COVID-19 patients. Additionally, as CDC guidelines have changed - sometimes from day to day, health administrators must ensure on-going compliance with state laws and federal regulations.
With patient and staff safety as a guiding principle during the current pandemic, health care teams have had to quickly come up with practical responses and operating procedures to cover all the following areas of patient care:
- Cleaning, sanitizing, and the distribution of PPE.
- Screening of staff and walk-in patients for COVID-19 symptoms.
- Testing and notification of suspected COVID patients.
- Visitor restrictions and mandates for masks, hand washing, and distancing.
- Transitioning from in-person appointments to telemedicine platforms.
- Eliminating or reducing elective surgeries to benefit ICU capacity.
With every patient that comes through the door, a number of decisions concerning patient care and safety must be made - above and beyond the normal operating procedures. When it comes to the homeless population, there are additional challenges to consider. This population may be unable to quarantine, unable to maintain hand washing and other hygiene-related tasks, and unable to keep a supply of protective equipment. This puts the homeless population at much greater risk of infection and other complications.
Some health care organizations are employing the following methods for mitigating these risks:
- Re-deploying existing senior community centers to serve as medical centers for the homeless.
- Removing any time restrictions or other shelter policies that would limit people's ability to access shelter resources.
- Re-organizing motels and hotels to create additional housing capacity for non-sick homeless populations.
- Screening all visitors and staff before admission into homeless service provider locations.
One solution that could relieve the pressure on health care systems if put into place: medical respite care being established in the cities with the largest homeless populations. According to the National Health Care for the Homeless Council, “medical respite care“ is a short term residential care solution that allows homeless individuals a place to rest, get medical care and gain access to other support services as well.
There are a number of significant issues that have surfaced during the COVID-19 outbreak, with caring for the homeless population being just one. Though this population has always faced public health concerns, the challenges of reaching and treating this population have added a sense of urgency to the fight against homelessness.
If you are interested in the role a health care administrator can play in solving this problem, consider a career as a health care administrator. The first step: an executive MHA.
Sources
https://endhomelessness.org/wp-content/uploads/2020/03/Covid-Fact-Sheet-3.25.2020-2.pdf