Figure 1. Figure 1. Design of the Covid-19 Response System for the Homeless Population.

The Covid-19 response system for the homeless population has three main domains: planning and coordination, creation of alternative care sites, and case identification. The core capabilities for each domain are shown, along with adaptations that have been necessary as the number of Covid-19 cases among homeless people has risen in Boston and the response to the pandemic has shifted from containment to mitigation.

Dr. Jessie M. Gaeta: The Covid-19 epidemic is an unprecedented disruption to the social fabric and health care system in the United States. At the time of this writing, Covid-19 has caused more than 110,000 deaths in the United States thus far3 and has been projected to cause more than 125,000 deaths in total.4 Although initial reports suggested that the infection results in symptoms ranging from mild cough and dyspnea to respiratory failure and sepsis, we now know that people with the infection can be asymptomatic.5 Because of this, there are concerns that asymptomatic people will unknowingly spread the virus. This possibility has implications for the general population and especially for certain vulnerable populations, including those in congregate settings such as homeless shelters. In addition, homeless people are known to have a high burden of chronic heart disease,6 chronic lung disease,7 and accelerated aging,8 all of which are risk factors for severe Covid-19.1 The BHCHP, a nonprofit Federally Qualified Health Center that provides health care to homeless people at more than 40 sites across Boston, proactively developed a Covid-19 response system for the homeless population (Figure 1). This response system features several core capabilities for containing and mitigating the spread of SARS-CoV-2.9 The response system was launched in partnership with city and state public health entities, Boston homeless shelters, Boston Medical Center, and other community stakeholders, even before the first case of Covid-19 in a homeless person was identified in Boston.10

Planning and Coordination

The first domain of the response system is focused on careful planning and coordination, with a centralized approach to decision making and resource deployment. This domain includes the following core capabilities: establishment of an internal team and framework for the response; engagement in cross-sector collaboration and transparent, frequent communication; use of a case-tracking database and adherence to procedures for data collection; organization of a shift away from standard clinical services; promotion of an early increase in infection-control practices within shelters; and development of a PPE prioritization strategy that would inform PPE conservation and use during periods of constrained supply.

Creation of Alternative Care Sites

Figure 2. Figure 2. Alternative Care Sites.

During the Covid-19 pandemic, the Boston Health Care for the Homeless Program worked with local design and construction companies and government to create temporary structures that would serve as alternative care sites for the quarantine and isolation of homeless patients (Panel A). The tents have a separate entrance for patients, as well as designated space for the staff to put on and take off personal protective equipment. Patients are separated into “pods,” which are rooms that allow patients to stay 6 ft apart and are built with floor-to-ceiling dividers made of heavy plastic, a material that can be easily cleaned between patient stays (Panel B). Each pod has a bed, storage space, an electrical outlet, a garbage pail, and a vital-sign monitoring station, which can be seen hanging in a basket (Panel C).

The second domain of the response system is centered on the rapid development of alternative care sites for the isolation and quarantine of people who are homeless or cannot isolate safely at home. Locations were secured and developed in partnership with Boston Medical Center and the City of Boston, as well as with a local construction company and design firm. Simultaneously with the creation of the Covid-19 ward at the Barbara McInnis House, two large medical tents (Figure 2) were constructed over the course of 1 week in a parking lot abutting a local homeless shelter: one tent has served as an isolation site for symptomatic people who are awaiting test results, and the other tent has served as a quarantine site for asymptomatic people with known or suspected exposure to the virus.

Case Identification

The third domain of the response system is the identification of people who have been exposed to and possibly infected by the virus. In the first weeks of the pandemic, efforts were focused on screening shelter guests at the front door for exposure and symptoms, testing symptomatic people, and performing contact investigations. The BHCHP two-item screening tool has been used to assess shelter guests for cough and shortness of breath. If a guest indicates that either of these symptoms is present, the body temperature is taken. Those who have a temperature of 37.8°C or higher are referred to a BHCHP pop-up testing site; several of these sites have been developed in areas with a high density of homeless services. The BHCHP has conducted contact investigations to identify additional people to be referred for isolation or quarantine. A “mission control” team was established to coordinate referrals to and placements at an increasing number of alternative care sites, to facilitate transportation to such sites, and to coordinate care and discharge planning with local hospitals. The BHCHP has continuously improved its data management and tracking system and refined its PPE prioritization strategy as supplies have waxed and waned and cases have continued to mount.

Adaptations

Three additional sites have been identified for further expansion of Covid-19 services in Boston. In collaboration with the Commonwealth of Massachusetts, Boston Medical Center undertook renovation, staffing, and infection control at the decommissioned hospital East Newton Pavilion, and the building has since been used as an isolation site for homeless people with Covid-19. Simultaneously, the City of Boston undertook renovation at another decommissioned hospital with the intention of using the building to supplement the capacity at tent locations. Finally, the City of Boston secured the Boston Convention and Exhibition Center to serve as an isolation site called “Boston Hope,” providing 500 beds dedicated for patients with Covid-19 who are either homeless or unable to isolate safely at home. As the focus of the BHCHP progressed from containment to mitigation and pandemic management, the program phased out quarantine sites for asymptomatic people who had been exposed to the virus and expanded isolation sites for infected people. In turn, local homeless shelters have used nearby university dormitories to decongest crowded facilities.

Perhaps the most notable adaptation to the BHCHP response system was the introduction of universal testing of shelter guests for Covid-19.11 Approximately 2 weeks into the pandemic, the BHCHP identified a cluster of Covid-19 cases from a single large shelter. In partnership with shelter leadership, the BHCHP conducted testing of more than 400 guests in 2 days, identifying nearly 150 new Covid-19 cases; most of these cases were not associated with symptoms. The identification of widespread transmission and exposure among asymptomatic shelter guests resulted in a decrease in contact investigations in this setting. In addition, it became apparent that the front-door screening tool was also not effective in detecting asymptomatic infections. In the subsequent days and weeks, symptom screening was continued when possible to identify people who needed expedited testing, but it was done with an awareness of its limitations and was deprioritized in the overall care model. In the case under discussion, it was indeed universal testing — not symptom screening — that led to the diagnosis of Covid-19. In the months that followed, the BHCHP implemented universal testing approximately every 2 weeks at a number of large congregate shelters for adults.

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