COVID-19 & Homelessness: An Interview with Dr. Bill Soares
Bill Soares, MD, MS is an Assistant Professor in the Department of Emergency Medicine at at UMMS - Baystate in Springfield, MA.
Regina Royan, MD, MPH is a third year Emergency Medicine Resident at the University of Chicago
What is your specific area of interest within social emergency medicine?
Addressing the needs of at-risk populations who present to the emergency department, primarily those with substance use disorder and other social determinants (homelessness, uninsured, food insecurity, transportation issues) that make the bridge to outpatient care challenging.
How has COVID-19 affected the way ED providers should be thinking about homelessness in the ED?
My hope is that COVID-19 has served to highlight the extreme disparities in health and care for homeless populations. For a variety of reasons, including mistrust, bias, and frequent utilization, homeless and at-risk populations have historically been treated differently than our other ED patients. Many ED providers approach homeless and at-risk populations with a sense of hopelessness ("I can't make a difference in this person's life") or just world bias ("This person deserves the problems they have"). COVID-19 has forced us to think more broadly about homelessness - if for no other reason than wanting to limit the spread of the disease. Many of us have, because of COVID-19, been offered a glimpse into the life and hardships of the homeless and at-risk populations. For some, we have begun to understand the structural barriers that negatively impact the health and wellbeing of these populations.
How has COVID-19 affected homeless patients’ interest or ability to seek care in the ED or elsewhere?
Like all other patients, homeless and at-risk patients have been scared to come into the hospital, for fear of COVID-19 transmission. This has likely had a profound negative impact, as the rates of untreated chronic medical conditions, substance use disorder and mental health issues have all increased. Unfortunately, we will likely not know the true impact of COVID-19 for many years, as the data on morbidity and mortality due to causes outside of COVID-19 continues to be delayed.
How has your community worked to address the needs of homeless patients who are suspected or confirmed to have COVID-19?
In Springfield, MA we have two large shelters that we knew would not have the capacity to accommodate isolation for homeless patients with COVID-19. We had conversations early with our city, local primary care providers who were familiar with the homeless population, and the department of health to find a solution. We ended up erecting quarantine tents with partitions where COVID positive patients, PUIs (Patients Under Investigation), and known contacts were able to stay through their isolation period. The Health Services for the Homeless were instrumental in providing 24/7 NP and APP coverage for the tents with MDs rounding twice a day. Patient cooperation was quite good and we were able to provide monitored ETOH treatment to prevent withdrawal as well as obtain extended courses of take home methadone from patients’ typical treatment sites. We were also able to provide social services resources and mental telehealth visits. Overall, I think the effort was successful because we were able to meet patients “at their level”, without judgement, and supported their needs to encourage compliance with isolation recommendations.
Are there unique questions that we should consider when making decisions about which homeless patients to test for COVID-19?
I believe that universal testing is important for all patients in the COVID-19 pandemic, as the presentation of patients with transmissible disease ranges from asymptomatic to near death. Homeless and at-risk populations present unique risks to others in the population due to communal or fluctuating living situations (i.e. couchsurfing), in addition to often being surrounded by others with chronic medical conditions. In short, my threshold to test a patient who is homeless or at-risk is very low.
Are there unique questions that we should consider when making decisions about how to disposition homeless patients with COVID-19?
As emergency providers, it is our responsibility in this pandemic to ensure that we are not only protecting the health of the individual, but also of the larger community. Disposition of homeless patients is, unfortunately, different from county to county, depending on the resources available. Establishing communication with community homeless providers (shelters, social workers, DPH) and creating plans for both COVID 19 positive patients and PUI patients as early as possible is critical, in order to avoid not having a plan when caring for the homeless PUI patient on Saturday at 2AM.
Additionally, please remember that, due to COVID-19, many patients that don't consider themselves homeless are at-risk of being homeless. They may be sleeping on a friend’s couch or moving from place to place. Having an honest discussion with all COVID-19 and PUI patients about their housing situation is critical to the health and wellbeing of the patient and the community.
What do you think are the most important research questions that need to be answered with regard to homeless patients and COVID-19?
I believe the true impact of COVID-19 on homeless and at-risk populations has not been realized. The so-called Death Gap - the unexplained increase in non-COVID related mortality during the pandemic, continues to increase, and is likely due to disruption of normal healthcare as well as added stressors associated with the pandemic. Exploring the true impact of the pandemic on homeless and at-risk populations is crucial to help us develop safety measures to continue to support our patients.
Are there any new policy measures, be they local or national, related to homelessness and COVID-19 that you are excited about?
COVID-19 has loosened restrictions on treatment for substance use disorder. The increased use of telehealth, specifically to initiate medication for opioid use disorder (MOUD), the renewed focus on harm reduction, the increase in take home methadone and, the willingness to explore novel treatment methods, including monitored alcohol therapy (MAT) are all exciting opportunities to help our patients.
If you could implement one policy measure related to homelessness and COVID-19, what would it be?
Addressing the social determinants that continue to hamper the health and wellbeing of homeless populations is critical during COVID-19. A measure that automatically enrolls patients into insurance programs such as Medicaid is feasible and would remove a barrier to treatment for many homeless and at-risk populations. During this time of the pandemic, no one should be denied treatment, both for COVID, but also for their chronic medical conditions, due to a lack of insurance.
Anything else we should be thinking about?
Your homeless and at-risk patients are just as scared about COVID-19 and the impact on their life as others. Take a bit of time to have an honest discussion, work to find ways that you might be able to help - maybe it is refilling medications, maybe offering transportation or additional food, maybe a few extra phone calls to establish follow up care. Your effort and understanding will not only help to meet the physical needs of your patient, it will also go a long way in helping to rebuild trust in our healthcare system for homeless and at-risk populations.
Are there any resources that you would recommend if people are interested in learning more about this topic?
HUD has a catalog of resources focused on the care of COVID-19 in homeless populations.
Also, now is the perfect time to apply for your DEA-X waiver to prescribe buprenorphine, as many of our patients with opioid use disorder may have had interruptions to their regular treatment. Free 8 hour training can be found here, once training is complete, apply for your DEA-X waiver here (it is all free if you have a full DEA).
Bill Soares, MD, MS is an Assistant Professor in the Department of Emergency Medicine at at UMMS - Baystate in Springfield, MA.
Regina Royan, MD, MPH is a third year Emergency Medicine Resident at the University of Chicago