Persons experiencing homelessness (PEH) who were at high risk of severe COVID-19 were 2.5 times less likely to contract SARS-CoV-2 if they were provided with individual hotel rooms and medical and social support compared to citywide rates in homeless shelters, according to new research from the University of Chicago Medicine, Lawndale Christian Health Center, and the Chicago Department of Public Health (CDPH).
Additionally, PEH who participated in this housing intervention also saw improvements in certain health measures such as blood pressure, and more than half of them moved on to longer-term housing after the intervention. The results were published on December 13 in JAMA Network Open.
The findings provide hard data demonstrating these types of interventions can be highly effective for improving stability for PEH and that increasing healthcare and social support access can drive better health outcomes and improve health equity.
Initially, the team did not set out to conduct a research study; instead, their focus was simply to minimize the impact of COVID-19 on an extremely vulnerable population.
As we started learning about the coronavirus wreaking havoc in nursing homes, we thought about folks living in congregate shelter settings in Chicago, where in some settings, 300 to 400 people are living together in open rooms, and we realized this virus could be a real threat to this population."
Wayne Detmer, MD, Chief Clinical Officer of Operations at Lawndale
Thomas Huggett, MD, a family medicine physician at Lawndale, said positivity rates were spiking at the shelters within weeks of Illinois Governor JB Pritzker's lockdown announcement in March 2020.
"On March 20, 2020, Governor Pritzker said, 'Stay at home.' But where are people who are experiencing homelessness going to stay?" said Huggett. "By the beginning of April, up to 60% of the tests we were conducting in the shelters were positive, and we realized we couldn't test and isolate our way out of this. But we had some very vulnerable folks over the age of 60 with chronic conditions, and Dr. Detmer had the idea -; rather than isolating folks who were positive for the virus, why not protect people before they got it?"
The city of Chicago offered an entire hotel -; almost 200 rooms -; for the intervention, and the first guests arrived on April 2, 2020. The healthcare team conducted screenings in shelters to identify high-risk individuals meeting at least one of the following criteria: at least 60 years old, at least 55 years old with any underlying health condition, or under 55 years old with any health condition known to substantially increase COVID-19 risk (e.g., HIV/AIDS). Those who met the criteria were offered the option to move from the shelter to an individual hotel room with extensive supportive services, where they were able to stay as long as needed, up to the full five-month length of the intervention.
"The city really wanted to do something to address the inequities in how COVID-19 was affecting Chicagoans, and our team was able to work with the city of Chicago and other partners to bring this whole package together to provide care within the hotel, where a person would have their own room and bathroom and be given that space away from other people so they would not get COVID-19," said Huggett. "We felt being proximate to the guests was important, so we had 24/7 coverage at the hotel. We realized we could provide a lot of care that people needed to stabilize their health. We could make sure that people were getting the medicines they needed, we could treat mental illnesses and substance use disorders, we could provide wound care. We weren't running a hospital but were providing protective housing with the wraparound health and social supports to maintain people's safety during the pandemic."
After the intervention ended in September 2020, the outcomes were clear: providing people experiencing homelessness with individual hotel rooms and wraparound care led to a dramatic reduction in COVID-19 rates and improvements in other health measures, including lower blood pressure and improvements in glycemic control. Also, over half of the individuals who spent time in the hotel went on to more permanent housing.
"We saw that people in this intervention were 2.5 times less likely to contract the virus compared to rates among people experiencing homelessness in shelters across the city," said Elizabeth Tung, MD, Assistant Professor of Medicine at UChicago Medicine, who help analyze the study data. "It shows that the basic intervention of moving people out of congregate settings worked to lower COVID-19 rates. But the other takeaway here is that this was an opportunity to pilot a model of temporary stabilization housing for people with high-risk health conditions -; we saw dramatic improvements in hypertension and diabetes control and stabilization of mental health and substance-use disorders. Over half of these patients went on to more permanent housing.
"All of this has public health implications. When you think about how much time and money is spent every time someone ends up in the ER because they're experiencing homelessness and can't take care of their medical needs -; it's more expensive, it's worse for the patient, and you end up with terrible outcomes. These data show us that a medical housing approach could help."
Tung hopes to conduct additional research to determine the costs and benefits of such an approach outside of a pandemic context, but the team is certain that this kind of hands-on intervention is key to helping the most vulnerable people get back on their feet.
"The collaborative work between the Chicago Department of Public Health, the Department of Family & Support Services, Lawndale Christian Health Center, homeless service providers and other community partners has been a real strength of our city's response to COVID-19 among people experiencing homelessness," said Isaac Ghinai, MBBS, medical director of testing and laboratory-based surveillance at CDPH. "While people experiencing homelessness remain at increased risk of COVID-19 and a host of other infectious and non-infectious health conditions, the collaborations forged by this pandemic response that are detailed in this manuscript demonstrate Chicago's ability to come together to enact impactful, lasting change."
Huggett added that upstream factors such as living conditions can impact health inequities.
"Housing is healthcare and an issue of racial equity," he said. "When we provide housing, people's health improves. There are fewer hospitalizations, fewer emergency room visits, and life span increases. This intervention is part of that -; providing people with not just the housing but also the wraparound supports they needed, both medically and socially."
Huggett, T.D., et al. (2021) Assessment of a Hotel-Based Protective Housing Program for Incidence of SARS-CoV-2 Infection and Management of Chronic Illness Among Persons Experiencing Homelessness. JAMA Network Open. doi.org/10.1001/jamanetworkopen.2021.38464.