Exploring published literature of emerging practice as a response to challenges due to COVID-19
3 July 2020
The summaries below are of articles that might help thinking about what has been learned from the COVID-19 experience so far, along with suggestions on how this might be used to support improvement in future.
This week, all the featured articles are about how COVID-19 is affecting people experiencing homelessness. We look at how systems in Scotland and internationally have responded to support people and examine evidence on how this is being experienced. The topics below include:
- previous pandemics and international responses to COVID-19
- mitigating the impact in Scotland, and
- maintaining changes.
Overview
At the outset of the COVID-19 crisis there were major concerns about how health and social care services would be able to support homeless people through the crisis. Homeless people are considered a particularly at risk group in terms of health outcomes generally, as many homeless people have mental health and/or addiction comorbidities. These and/or other physical comorbidities put them at greater risk of being immunocompromised and vulnerable to disease.
To add to this this issue, they may also have diminished ability to adhere to guidance that prevents/mitigates disease (for example hand washing or self-isolation) or be less aware of the disease risks. In addition they may face inequities of access in terms of their receipt of health and social care services. People experiencing homelessness may also be at greater risk of either not seeking or adhering to help from services.
Summaries
Lessons from previous pandemics and international responses mitigating COVID-19 impact
Experiences from previous pandemics have shown that any infectious disease will disproportionately render those without housing more vulnerable and at risk of poor outcomes compared to the housed population. It is also well understood that homeless shelters are likely to be venues where respiratory diseases could spread rapidly.
Homelessness and the Response to Emerging Infectious Disease Outbreaks: Lessons from SARS
This is an article by Leung et al on the study of the impact of SARS and challenges specific to the homeless population in the areas of communication, infection control, isolation and quarantine, and resource allocation. The study is based on interviews with homeless service providers and public health officials in Canada, where although the outbreak was contained and no homeless person was infected with SARS, the need for a planning framework specific to the homeless population for the future was recognised.
Among other things, this learning from SARS had indicated that shelter closures might be needed as many homeless services had considered scaling back or eliminating services out of fear that large gatherings of people might increase the risk of disease spread. Ultimately, this was not needed for the outbreak in Toronto that prompted this research.
Interrupting COVID-19 transmission in homeless shelters is challenging, requires enforcement of quarantine, testing (for residents and staff members) and prompt isolation residents with confirmed disease.
Mitigating the impact of COVID-19
Continuing support
From where we are now, it is clear a great deal of effort and funding has gone into mitigating the COVID-19 crisis for homeless people to ensure that required support continues to be provided.
Edinburgh Access Practice
The Faculty for Homeless and Inclusion Health newsletters highlighted the work being done by the Edinburgh Access Practice to ensure they are able to provide support to people, safely in a new setting. An outreach clinic at the covid hub hotel, which includes Saturday mornings and weekend and night cover, is the focus for over 30 new patients using:
- opiate substitution
- student-supported methadone delivery service
- 3-4 alcohol detoxes, and
- a new functioning intermediate care unit taking step up and step down cases (in an underused HIV unit).
There are also plans for a residential managed alcohol consumption unit (based on Canadian research and with Stirling University support).
Govan Law Centre
The Govan Law Centre, which offers advice and legal support to people experiencing homelessness, are continuing their services by offering a free and confidential advice service. This is provided through WhatsApp, Facebook messenger, email and a free call back telephone service for people who are feeling worried about work, money, debt, housing, or access to public services. They also have a new freephone contact for people either living or working in Glasgow.
Get Digital Scotland – Get Connected
As more services are moved online, there is an access challenge for people experiencing homelessness who might not have access to the internet or the skills to engage digitally.
The Get Connected project was designed to provide digital devices to people and build their digital literacy. They provided 36 digital devices with unlimited texts, calls and data. Alongside this, support was provided by 'digital champions' who helped with the essentials for someone getting started on a new device such as unboxing their device, setting up the sim card, registering with a Google account and installing essential apps. They were also trained in delivering digital skills at a distance.
Reflections from people using the devices were positive. People reported being able to reconnect with friends and family, being able to access more support and being able to develop their skills further. There were also benefits in people being able to access news and information along with entertainment.
Housing rough sleepers
Another strand of the response to COVID-19 for people experiencing homelessness was the efforts to house people sleeping rough. In Glasgow, the difficult decision to close the night shelter was made after the first confirmed case of COVID-19. This response centred on new funding being made available to charities and local authorities.
The Scottish Government is providing £50 million to help charities and others who require additional capacity to support those at risk of being worst affected by the crisis including homeless people. A £20 million Third Sector Resilience Fund will also support the continued viability of third sector organisations involved in the response to COVID-19 if they are affected by cash flow and other problems.
The Simon Community was provided with £300,000 funding to house people in hotel accommodation.
In addition to this, the Wheatley Group has provided empty properties to the four local authorities it has a strategic agreement with (Glasgow, Edinburgh, West Dunbartonshire and West Lothian).
Challenges for this response
Several UK-wide studies have noted that the quality of temporary accommodation provided to homeless people can be unsuitable for self-isolation. This is due to having to share kitchens and bathrooms. However, the choice to move service users to, potentially, more suitable accommodation in the middle of a pandemic is problematic because it risks them losing support networks they may have had which can be vital if there is a need to self-isolate.
St Ann's Hospice: coronavirus and hostel living
This blog outlines some of the challenges and successes of supporting people in hotels and hostels while maintaining strict hygiene standards and social distancing.
There are challenges for staff in knowing the latest guidance on safe practice, as well as difficulties accessing PPE. Similarly, finding ways that people can avoid communal areas has been challenging.
The blog notes that there are examples of how some hostels have managed to support residents at this time through, for example, providing all service users with a kettle and tea/coffee making facilities to restrict the need to access shared kitchens. Other interventions to support people from taking risks is for staff shopping for those self-isolating and delivering medications.
Maintaining changes
People are keen to ensure that people who have been housed are not pushed back into rough sleeping.
Homelessness and Rough Sleeping Action Group
The Homelessness and Rough Sleeping Action Group (HARSAG) has been reconvened for the first time since 2018. They will be reconsidering homelessness and rough sleeping within the new context of COVID-19 and the work that has been done to support people at this time. A key focus will be on efforts to accelerate the implementation of the recommendation, from their previously published, Action Plan on Ending Homelessness and Rough Sleeping, that councils will not be allowed to house homeless people in hotels and bed and breakfasts for more than seven days after the lockdown is over.
Housing Cost Calculator
To facilitate the planning of moving people out of hotel and hostel accommodation, the Centre for Homelessness Impact has developed a Housing Cost Calculator. This will enable health and social care partnerships to roughly estimate the cost of keeping people from going back to rough sleeping and model different scenarios in how to implement this.
'Everyone Home': 19 charities call for 'triple-lock' to end rough sleeping after COVID-19
(Sourced from the Homelessness Network COVID-19 updates and briefings)
Civil society groups have come together behind the Everyone Home framework under the banner 'Everyone Home' to call on the Scottish Government to take steps to end homelessness. Using the experiences and lessons from the COVID-19 pandemic, a collective of independent bodies have put together a suggested plan on how to sustain the current momentum for addressing homelessness.
The plan outlines three priorities:
- More good homes: building housing capacity.
- No return to rough sleeping: those being housed as part of the COVID-19 response should remain housed.
- No evictions into homelessness: protections should be introduced to stop evictions into homelessness.
Crucially, the plan also outlines how the charities involved in developing the plan can support authorities to deliver including co-producing frameworks for translating learning from the COVID-19 response into 'rapid rehousing transition plans' and working with landlords and housing associations to create more capacity and support better allocation planning.
Sources
Kar SK, Arafat SMY, Marthoenis M, Kabir R. Homeless mentally ill people and COVID-19 pandemic: The two-way sword for LMICs [published online ahead of print, 2020 Apr 10]. Asian J Psychiatr. 2020;51:102067. doi:10.1016/j.ajp.2020.10206 https://doi.org/10.1016/j.ajp.2020.10206
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 https://doi.org/10.1016/S2468-2667(20)30053-0
Kirby T. Efforts escalate to protect homeless people from COVID-19 in UK. Lancet Respir Med. 2020;8(5):447-449. doi:10.1016/S2213-2600(20)30160-0 https://doi.org/10.1016/S2213-2600(20)30160-0
Lima NNR, de Souza RI, Feitosa PWG, Moreira JLS, da Silva CGL, Neto MLR. People experiencing homelessness: Their potential exposure to COVID-19. Psychiatry Res. 2020;288:112945. doi:10.1016/j.psychres.2020.112945 https://doi.org/10.1016/j.psychres.2020.112945
Mosites E, Parker EM, Clarke KEN, et al. Assessment of SARS-CoV-2 Infection Prevalence in Homeless Shelters - Four U.S. Cities, March 27-April 15, 2020. MMWR Morb Mortal Wkly Rep. 2020;69(17):521-522. Published 2020 May 1. doi:10.15585/mmwr.mm6917e1 https://doi.org/10.15585/mmwr.mm6917e1
Wood LJ, Davies AP, Khan Z. COVID-19 precautions: easier said than done when patients are homeless. Med J Aust. 2020;212(8):384-384.e1. doi:10.5694/mja2.50571 https://doi.org/10.5694/mja2.50571
Leung CS, Ho MM, Kiss A, Gundlapalli AV, Hwang SW. Homelessness and the response to emerging infectious disease outbreaks: lessons from SARS. J Urban Health. 2008;85(3):402-410. doi:10.1007/s11524-008-9270-2 https://doi.org/10.1007/s11524-008-9270-2
Aidala AA, Sumartojo E. Why housing?. AIDS Behav. 2007;11(6 Suppl):1-6. doi:10.1007/s10461-007-9302-z https://doi.org/10.1007/s10461-007-9302-z
Thiberville SD, Salez N, Benkouiten S, Badiaga S, Charrel R, Brouqui P. Respiratory viruses within homeless shelters in Marseille, France. BMC Res Notes. 2014;7:81. Published 2014 Feb 5. doi:10.1186/1756-0500-7-81 https://doi.org/10.1186/1756-0500-7-81
Baggett TP, Keyes H, Sporn N, Gaeta JM. Prevalence of SARS-CoV-2 Infection in Residents of a Large Homeless Shelter in Boston [published online ahead of print, 2020 Apr 27]. JAMA. 2020;323(21):2191-2192. doi:10.1001/jama.2020.6887 https://doi.org/10.1001/jama.2020.6887
Dorney-Smith S, Williams J, Gladstone C. Health visiting with homeless families during the COVID-19 pandemic. Journal of Health Visiting. 2020; 8(5):190-193. doi:10.12968/johv.2020.8.5.190 https://doi.org/10.12968/johv.2020.8.5.190