It’s a cliche that holds true now more than ever – the emergency department really is the front door to the medical system. Despite many health and social services shuttering or moving to virtual care during the COVID-19 pandemic, the emergency department remains open 24/7. Our EDs are still committed to seeing anyone who shows up, in communities of all sizes from coast-to-coast. And while we try to keep people at home during the COVID-19 pandemic, the reality is that this approach only works if you have a home. This pandemic has shone a light on all of our systemic problems, including the ways that people are marginalized and forgotten about. What about the estimated 35 000 people in Canada who are homeless on any given night? We are seeing them in our emergency departments, for COVID-19 symptoms, and for the myriad of other acute medical problems they experience. So how can we meet their needs in the context of the COVID-19 pandemic?
Pearls and Considerations
- Elevated pre-test probability for COVID-19: congregate settings are hotbeds for COVID-19 transmission. People living in homeless shelters or sleeping rough who are unable to practice physical distancing and hand hygiene are more likely to acquire COVID-19 in the community.
- Increased risk of severe COVID-19: the homeless population has a high prevalence of underlying medical conditions, like COPD and diabetes, placing them at higher risk for a complicated COVID-19 illness.
- Increased risk of transmitting COVID-19: if a COVID-19 infection is missed, a patient is more likely to transmit the infection if they are returning to a congregate living situation and/or unable to practice physical distancing and hand hygiene. This is why it is really important to have a clear plan for swabbing, awaiting test results, and discharge for anyone who is experiencing homelessness.
- A changing social and health service landscape: many services have closed or gone virtual during the pandemic. This is a major problem for people who are homeless, who may not be able to access meals, transportation, shelter, washrooms, showers, laundry, or healthcare. Many people do not have access to the internet or a telephone, which exacerbates the problem of accessing services right now.
- Try to have an updated list of services and work with the social worker to put plans for accessing services into place before discharge.
- Loss of income: many people who are homeless rely on “binning” (collecting bottles to return), panhandling, sex work, and other activities to generate income. In many places bottle return is stopped, fewer people are out in public, and demand for sex work has gone down. Consider this when you think about discharge planning, acquiring prescriptions, and transportation. If possible, identify relevant income supports and help people to access these supports. This is also relevant for patients who are at risk of becoming homeless.
- Increased risk of experiencing harms associated with drug use: while not all people who are homeless use drugs, some do. The restricted movement of people and goods locally and around the globe is changing the cost and toxicity of street drugs, and some supervised consumption sites and harm reduction supply distribution sites have closed. This combines to create more risk of harm, including overdose death, for people who use drugs. Provide take home naloxone, harm reduction supplies for drug use, information on responding to overdoses during COVID-19, and refer to local services that are still operating. Consider prescribing substances to lessen the harm from the toxic drug supply – for details and guidance see Risk Mitigation in the Context of Dual Public Health Emergencies issued by the British Columbia Centre on Substance Use and endorsed by the BC Ministry of Health and College of Physicians and Surgeons of BC.
- Experiences of stigma: many people who are homeless have had stigmatizing experiences in the healthcare system – because of stigma towards people who are homeless, and also because of other types of stigma. A warm, empathetic interaction from the triage nurse, emergency room physician, and other allied health goes a long way!
- Education: the volume of COVID-19 related information is overwhelming even for healthcare providers. Without reliable internet and other information, people who are homeless may not know current best practices for preventing and managing COVID-19 infection. Have health education materials available to give patients that are tailored to the unique circumstances and needs of people who are homeless.
- Resiliency: one of the peer workers we know reminded us that people who are homeless have always fought to survive in a world that isn’t built for them. The patients you see have incredible survival skills – and they can tell you what they need right now!
- Whole community approach: The challenges facing people who are homeless and unsheltered or living in shelters require collaboration between the health system, social service providers, government, emergency services, people with lived experience, and more. If it’s not already happening, bring together key partners to establish a whole community approach.
COVID-19 screening in Homeless patients:
Our homeless patients are at high risk for contracting this virus. Barriers to safe social distancing due to crowding in shelters and lack of health literacy are only some of the many roadblocks to preventing this virus from spreading in this population. The ER is a prime location for health care workers to advocate and reduce the spread of this virus amongst our homeless populations.
Strongly consider screening for any patient exhibiting classic symptoms of viral infection (cough, fever, shortness of breath, etc.). Additionally, ED physicians should have a very low threshold to test these patients as incidence of asymptomatic carriers of this virus may be high. Having a local lead and the ability to directly contact the shelters for these patients to plan for discharge (especially in instances where the tests are positive) will be immensely helpful to reduce spread. Additionally, admission for homeless patients who have COVID-19 (even though they may have mild symptoms) may be necessary to reduce community transmission. Keep in mind, some of these patients may also be experiencing addiction or other harms associated with substance use. Due to changing resources in the community to treat these medical conditions during the pandemic, they are at higher risk from complications of withdrawal. Be vigilant about screening for these concurrent comorbidities.
If you are discharging a patient back to a shelter after taking all precautions, educating patients about the COVID-19 pandemic will be helpful to prevent transmission. Handing out information sheets about the virus and local resources such as contact numbers for safe injection sites, dental services, addiction and harm reduction services, shelters, and mental health/social work services that are available (during the pandemic) will be crucial to providing the best comprehensive care for our patients.
Hamilton’s Emergency Departments have partnered with the Hamilton Shelter Health Network (https://shelterhealthnetwork.ca/), to create a protocol to help EDs navigate which patients to screen for and what are the safest plans for discharge amongst this vulnerable group. Please refer to the infographic for an example protocol:
It’s even more important now to start disposition planning early. Consider and plan for 4 scenarios: positive COVID-19 swab; negative swab but high clinical suspicion of COVID-19; awaiting COVID-19 swab results; unlikely COVID-19. Ideally, you will have a pathway for each of these scenarios that has been developed in partnership between the hospital and the local shelters or other services for people who are homeless. If there isn’t a pathway, we recommend not discharging anyone until their swab result is back; trying to have people return to the shelter or location they came from, if applicable; calling a shelter to confirm intake prior to discharging someone; and ensuring that anyone who fits one of the first 3 scenarios has a place to self-isolate to prevent further transmission. People may also be living rough (i.e. camping outdoors) and should not be forced into a shelter or other facility. Some municipalities have arranged for hotel and motel rooms for people who are homeless to use for self-isolation. Research and understand your local resources and plans.
We’re In This Together
Despite the challenges, healthcare providers, social services, government, and community members have come together across the country to ensure people who are homeless aren’t left behind during COVID-19. There is broad-based coalition work in Victoria, BC with the health authority at the table, exemplifying the community wide approach. Cities like London, ON are providing hotel rooms to people who are homeless. Healthcare providers are advocating for improved services and better infection prevention and control practices in shelters. Here in Hamilton, ON we’ve seen family doctors who work at shelters, infectious disease doctors, and emergency medicine physicians come together to create pathways from the community to the ED and back again. And amidst constantly changing evidence and recommendations, one thing is clear: homelessness has worsened the impact of COVID-19. When the dust settles, we can draw on our newly forged relationships and work together to end homelessness in our communities.
5 printable pdfs authored by the CDC and tailored for people who are homeless on COVID-19 and what to do when sick; social distancing; symptoms; how to help take care of someone who is sick; and how to protect yourself.
CAEP statement on COVID-19 and Persons Experiencing Homelessness or Vulnerable Housing.
Canadian Alliance to End Homelessness: https://caeh.ca/
For more information, please contact the authors below. Thanks again to Dr. Tim O’Shea for his dedication to our homeless patients in Hamilton, Ontario.
Claire Bodkin MD (PGY-1 Family Medicine)
Kevin Junghwan Dong MD CCFP-EM
Reviewed by Dr. Tim O’Shea MD FRCPC (Internal Medicine)
All resources in this article are from Free Open Access Medical Education (FOAM).
Mosites E. Assessment of SARS-CoV-2 Infection Prevalence in Homeless Shelters—Four US Cities, March 27–April 15, 2020. MMWR. Morbidity and Mortality Weekly Report. 2020;69.
Tobolowsky FA. COVID-19 Outbreak Among Three Affiliated Homeless Service Sites—King County, Washington, 2020. MMWR. Morbidity and Mortality Weekly Report. 2020;69.
Tsai J, Wilson M. COVID-19: a potential public health problem for homeless populations. The Lancet Public Health. 2020 Apr 1;5(4):e186-7.
US CDC. Interim Guidance for Homeless Service Providers to Plan and Respond to Coronavirus Disease 2019 (COVID-19). 22 Apr 2020.
This post was copy-edited by @alexsenger.