ACEP COVID-19 Field Guide

Authors: Margarita Popova, MD; and Aisha T. Terry, MD, MPH, FACEP

Background

Homelessness is associated with health inequality, including higher morbidity and mortality rates and greater use of acute hospital services. Homelessness often results from accumulated adverse socioeconomic conditions, and homelessness itself is a key driver of poor health.¹

According to the latest estimates, on any given night, there are approximately 570,000 people experiencing homelessness across the US.² This population is disproportionately older and has higher levels of comorbidities, resulting in higher risk for contracting and suffering complications of COVID-19.³

Furthermore, people experiencing homelessness live in environments that are conducive to the spread of disease, as they often live in communal living settings (from shelters and halfway houses to encampments), making adherence to current social distancing recommendations and stay-at-home orders difficult, if not impossible. In addition, people experiencing homelessness may not have regular access to basic hygiene supplies or showering facilities, further facilitating virus transmission. Lastly, homeless populations are often more transient and geographically mobile, which makes it difficult to track these populations, treat those who need care, and follow up with patients who are discharged.⁴

One recent paper estimated that according to the lower end of projections, the current pandemic is likely to cause approximately 21,000 hospitalizations and 3,400 deaths among people experiencing homelessness in the US.⁵ There is also concern that the current record-high unemployment claims will be followed by additional housing instability and homelessness, which will further stretch an already taxed homelessness assistance system, increasing the impact of COVID-19 on this vulnerable population.⁵

Clinical management

Management of patients who are experiencing homelessness and present to the emergency department with symptoms concerning for COVID-19 does not differ from management of any other adult. However, if a patient is deemed clinically stable and well enough for discharge, special care must be taken to ensure a safe discharge plan for this population. For discharge to be safe for the patient and the community, it is important to understand the local public health system and available resources, which vary greatly in different parts of the country.

Systematic response

Reaching or protecting patients who are homeless requires collaborative effort by homeless outreach teams, health departments, health care facilities, and housing authorities. Clinicians who wish to help protect people experiencing homelessness from the spread of COVID-19 can look to the CDC’s guidance on “People Experiencing Homelessness and COVID-19” for information and resources. The National Low Income Housing Coalition also has useful information on “COVID-19: Coronavirus and Housing/Homelessness,” which includes state and local news in terms of policy that affects this population.

The National Health Care for the Homeless Council recently published a brief “COVID-19 & the HCH Community: Needed Actions From Public Health and Emergency Response Systems,” which outlines the types of system-wide actions needed to protect homeless patients during the COVID-19 pandemic. These actions range from establishing isolation and quarantine spaces for multiple groups of people with varying symptomatology and stages of testing to assisting shelters with screening, ensuring continuity of usual care, and quarantining.

The federal government has taken steps to assist homeless populations. The CARES Act, for example, includes $4 billion in funding and protections for homeless Americans and more than $150 billion in other funding to be utilized for homeless services, housing and rental assistance, and frontline organizations. The details around how these funds will specifically be appropriated and accessed are currently being discussed and are thus evolving.⁶

Assisting homeless populations during the COVID-19 pandemic is an enormous challenge that, unfortunately, does not have easy answers. From the federal to the state and local levels, new measures for the public are being announced daily. It is critical that this vulnerable community not be overlooked in the response to this public health crisis.

Resources

1. Stafford A, Wood L. Tackling health disparities for people who are homeless? Start with social determinants. Int J Environ Res Public Health. 2017;14(12):1535. Published 2017 Dec 8. doi:10.3390/ijerph14121535
2. Henry M, Watt R, Mahathey A, Ouellette J, and Sitler A. The 2019 Annual Homeless Assessment Report (AHAR) to Congress. The U.S. Department of Housing and Urban Development website. Published 2020 Jan.
3. Culhane D, Doran K, Schretzman M, et al. The emerging crisis of aged homelessness in the US: could cost avoidance in health care fund housing solutions? Int J Popul Data Sci. 2019 Nov 8;4(3).
4. Tsai J, Wilson M. COVID-19: a potential public health problem for homeless populations. Lancet Public Health. 2020;5(4):e186-e187. doi:10.1016/S2468-2667(20)30053-0
5. Culhane DP, Treglia D, Steif K, Kuhn R, Byrne T. Estimated emergency and observational/quarantine capacity need for the US homeless population related to COVID-19 exposure by county; projected hospitalizations, intensive care units and mortality. National Alliance to End Homelessness website. Published 2020 Mar 20. 
6. Letona C. CARES act provides some COVID-19 protections for homeless populations, but there is more to do. National Law Center on Homelessness & Poverty website. Published 2020 Mar 30.