When Covid-19 hit, San Francisco Community Health Center decided to keep its doors open.
Although many appointments moved to telehealth, the health center was still a place where unsheltered patients could pick up a hot meal, grab their medications, and see a case manager. It was much more than many organizations could do – and, said Director of Clinic Operations Kate Franza, it still wasn’t enough.
Mental health needs shot up. Spaces in treatment programs for substance use disorders became increasingly rare. Concerns about vaccines kept some patients away.
“Based on what we had known pre-Covid, folks within the homeless community…require a street-based level of care,” Franza explained.
Staff members – many of them multilingual, none of them in lab coats – began going out into San Francisco’s Tenderloin district in teams, passing out hygiene kits, providing wound care and other immediate medical services, and assessing patients who might need additional care. When vaccines became available, teams began circulating to distribute them.
But CEO Lance Toma explained that the coronavirus itself wasn’t the primary problem. “San Francisco, on the whole, we’ve done pretty remarkably with respect to Covid,” he said. “Overdose deaths have far exceeded our Covid deaths. [Substance use disorder] is actually, in some ways, more of the crisis at this point.”
According to Bobby Watts, CEO of the National Health Care for the Homeless Council, there’s no question that people who are unsheltered have been hit harder by Covid-19 itself. “When we do have data, it showed that people experiencing homelessness died at higher rates than the general population,” he said. “From a health point of view, it’s been really hard and bad.”
People living in conventional shelters are less able to socially distance, and living in an encampment makes handwashing much harder, Watts said. People without stable housing are less able to rest when they need it. All of these factors make it harder to keep healthy, and harder to recover when someone comes down with Covid-19.
But the pandemic has caused additional problems, including the closing of soup kitchens and substance use disorder treatment programs, the movement of medical appointments to telehealth, and an increase in mental strain. The general population has felt the impacts of all of these, but for unsheltered individuals, the toll may be particularly high.
For example, Watts explained that many people experiencing homelessness do have cell phones, but they may not have a way to charge them – especially with the closures of libraries and other community spaces – or any minutes in their data plan. That can severely affect an individual’s ability to access medical care via telehealth. That lack of access, in turn, can lead to the worsening of an existing health condition.
At the ground level
These issues, and their consequences, are playing out for the patients of safety net providers across the country.
At Camillus Health Concern in Miami, “using the telehealth to reach this segment of the population was challenging,” said CEO Francis Afram-Gyening. Some patients were resistant to the technology and preferred to see their providers in person.
In addition, “if they’re here, it’s a one-stop shop” where patients can receive mental health care, have their chronic conditions monitored, and even pick up their medication. When that wasn’t available, “there was significant clinical impact,” particularly where conditions like diabetes and hypertension were concerned. Patients had less access to their behavioral health medications as well.
Afram-Gyening’s staff delivered medications to patients at shelters, and the pharmacy remained open. Still, he said, “if there wasn’t a pandemic, they would have come in.”
Ryan Kelly, a physician at Community-University Health Care Center in Minneapolis, a professor of medicine at the University of Minnesota, and a hospitalist at the university’s facility, said that the pandemic “opened my eyes to all the things that need to go right in a person’s life just to get to a single clinic appointment on a single day,” from having adequate rest to accessing transportation. “All of that was mind-blowingly exacerbated by the pandemic.”
Patients were less likely to see their providers, whether for preventative care or acute issues, leading to increased hospitalizations, Kelly said. The screening protocols for patients who do come into the health center may feel invasive for an unstably housed population.
And for patients with substance use disorders – as at San Francisco Community Health Center – the problems are exacerbated. At the hospital, Kelly has seen worsening mental health lead to higher levels of alcohol use, with related liver damage. “We’ve lost patients we care about,” he said.
Patients with diabetes or substance use disorders had a harder time finding bathrooms – and thus washing their hands – before taking their insulin or suboxone, a medication for opioid use disorder. Kelly said he’s seen patients admitted to the hospital for injection-related infections “uncountable times.”
And for a homeless population, safely storing medications – or even keeping them close – is a serious challenge. “We get a lot of calls about lost medications, stolen medications,” said Ana Enriquez, a health care coordinator at Community-University.
Like other safety net providers, Community-University Health Care Center has focused on workarounds “All of the suboxone patients get my cell phone number and can text me,” Enriquez said.
Patients who are experiencing homelessness may text her from a friend’s phone, telling her they’ll be available at that number for one day only. “That’s how we roll with the suboxone program. It’s high intensity at all times, because there’s such a high risk of relapse and overdose,” she explained.
And the phone can be an effective way to treat patients. Kelly recalled an unsheltered patient who was trying to overcome a fentanyl addiction but found the withdrawal symptoms difficult to work through. Through telemedicine, Kelly and the patient worked out a successful treatment regime. “The patient was really able to stay focused,” he said.
A new way to shelter
Despite the difficulties, there have been some silver linings.
For one, Watts said, both the Centers for Disease Control and Prevention and the Department of Housing and Urban Development developed guidelines for people living in shelters and encampments, helping to reduce confusion. “We were really pleased that they contacted us and asked for our input,” he added.
In turn, “that led to some cities, many cities, saying, ‘We have to protect the health of people experiencing homelessness,’” Watts said. In part, that translated into arranging for unsheltered individuals and families to stay in hotels and similar non-congregate settings to keep them safe during the pandemic.
Santa Clara County’s Valley Homeless Healthcare Program, which encompasses California’s Silicon Valley, is one such example. Even before the first shelter-in-place orders were given, Medical Director Dr. Cheryl Ho and her colleagues began having conversations about how best to care for their homeless patients. Within two days of the first orders, the program began moving unsheltered individuals into hotels.
“They didn’t have anywhere to go, and they didn’t have anywhere to play it safe,” Ho said. “We just felt like our homeless neighbors were being forgotten.”
Because there wasn’t enough room for everyone, the program focused on people who were 70 or older, or who had three or more health conditions that would put them at increased risk. People who tested positive for Covid were housed in hotels through a separate program. At one point, there were 1,000 people staying in Santa Clara County hotels.
Retired doctors were called upon to provide telehealth services, medications were delivered directly to rooms, and the program brought its medical mobile unit.
For Ho, housing people experiencing homelessness during the pandemic was about doing the right thing. “There’s a tale of two cities in every community in the United States, but I think it’s especially striking in Silicon Valley,” she said. “We cannot let our neighbors die of Covid when we have the resources in place.”
This temporary housing proved to have another benefit: It was easier to provide services, from health care to more permanent housing opportunities, to people in shelters. Afram-Gyening, Franza, and Ho all reported significant numbers of people who went into permanent housing after spending time in shelter-in-place hotels.
“It really made a dent in [the number of] unsheltered homeless. The ability to house them and surround them with support structure really kept them away from the streets,” Afram-Gyening said. “That was the beauty of it.”
Since the pandemic began, Direct Relief has supported safety net providers and other organizations serving people experiencing homelessness across the United States. In particular, the organization provided $487,000 in medical support to Camillus Health Concern and $36,000 to Community-University Health Care Center, and served as a sponsor for the National Health Care for the Homeless Council’s 2021 Conference and Policy Symposium.