How Chicago doctors work to limit COVID-19 spread among homeless

For people experiencing homelessness, the calls to stay home are impossible to meet. Because this population is disproportionately affected by COVID-19, Rush University Medical Center created a workgroup dedicated to blunting the impact of the pandemic on the homeless population and Chicago’s most vulnerable citizens.

On March 13, six people from Rush and the Franciscan Shelter in Chicago joined to start this workgroup that quickly expanded to include more than 50 people from 10 shelters, as well as congregate living facilities, hospitals, city agencies, advocacy groups and others.

“I gathered a call of about five people who were volunteers, attending physicians and the director of the shelter that we’ve been working at to begin thinking about what we’re going to do to respond to this crisis in particular because the shelter environment was pretty packed,” said Steven Rothschild, MD, professor and chair of family medicine at Rush University Medical Center in Chicago. “It was obvious early on that this was the group that was going to get hit pretty hard because everybody is sleeping about two feet from each other.”

Early goals of the workgroup consisted of reducing the spread, providing support and sustaining basic medical services for the homeless population on Chicago’s West Side during the COVID-19 outbreak. It has since expanded to containment. Teams work together to isolate persons with symptoms or confirmed cases of COVID-19, obtain cultures quickly when outbreaks occur, support agencies that care for these vulnerable populations, and serve as a clearinghouse for information.

“The homeless population is a group that has a disproportionate amount of medical problems. ... They’re more likely to get exposed to the virus, they’re more likely to get sick from the virus, and more likely to die from the virus,” said Daniel Dunham, MD, an internist and professor of internal medicine at Rush Medical College in Chicago. “You have a high-risk patient population because of close proximity, and if somebody at the shelter does have COVID-19, depending on how the shelter is constructed, there’s a really good chance that multiple people are going to get it.”

Together, the team of health professionals has launched several initiatives to help Chicago’s homeless population.

The teams meet twice a day, seven days a week to discuss ongoing efforts for the homeless population. At 8 a.m., stakeholders meet to problem solve and address issues that are seen in the field. Then at the 3 p.m. call, physicians and other health professionals call in to further discuss the ongoing operations.

One effort has been finding alternative housing for those experiencing homelessness. The team worked with the Department of Public Health to establish a level 1 quarantine unit in Hotel One Sixty-Six, a boutique hotel located in Chicago’s Gold Coast. Homeless people at highest risk can be tested, receive food and basic services, and receive wraparound mental health and medical services provided by Lawndale Christian and the Chicago Department of Public Health.

“Initially, we were going to use the hotel to quarantine individuals who had symptoms of COVID-19, but we didn’t have test results yet,” said Dr. Rothschild. “Now we’re using it to house individuals from the shelters where there have been known cases and we’re using it to shelter the individuals who are at the highest risk of complications,” which includes people with chronic illness and anyone 60 or older, he said.

When there is a case of COVID-19, the workgroup works together to identify and perform sweeping cultures through the facilities followed by education.

“It's a lot of education for the people who are serving food, such as what they can do to protect the residents of the shelter and other important medical information,” said Dr. Dunham

“One thing we’re seeing is that when the city and our team gets involved early—when there’s only one or two cases—we’re able to come create isolation on site and really reduce the spread,” said Dr. Rothschild. “We’ve been fairly effective in putting the brakes on.”

Additionally, the team has been able to “get people to environments when they have the infection where they’re more closely monitored than in other locations,” he said. “This expands the capacity to care for these patients. When there are too many people with COVID-19 to move, we can educate staff, and get them personal protective equipment [PPE]?”

Shelters are not usually run by doctors and nurses, which means there is a need for intensive education. The teams work with shelters to provide PPE, show them how to don and doff PPE, how to isolate people and how to manage those patients.

“We're seeing closer partnerships develop out of this between shelters and clinical entities,” said Dr. Rothschild. “We're working to expand it now through both the city and the state departments of public health to pair up shelters that don't have medical care with federally qualified health centers who can be that backup.”

If an individual experiencing homelessness has tested positive for COVID-19, that means shelters are off limits. For those patients, the team created an isolation unit, which the team prefers to call a “medical respite unit” on the West Side of Chicago that is run by nurse practitioners with backup from several physicians.

“A Safe Haven is a non-profit that has worked with the vulnerably housed community for over two decades,” said Dr. Rothschild. “Over a two-week period they converted office space into our medical respite unit, providing a safe space where people could recover and receive daily medical monitoring.”

“The unit also allows for psychiatric backup because the problems are medical but are also frequently mental health,” he said. “About 25% to 30% of our homeless population has significant mental illness, with additional ones having ongoing substance-use disorders.”

“We’re now actually moving into a mode where we’re problem solving the transportation of people to and from the shelters, but also working with safe-housing advocates to begin to bring online more assisted living for vulnerable homeless so that we’re moving out of shelters into safe apartment-like spaces to reduce spread,” said Dr. Rothschild. “That is advocacy work that we’re doing with the Coalition for the Homeless and All Chicago—the parent organization for the Continuum of Care, which provides care for the homeless.”

While Hotel One Sixty-Six and A Safe Haven resources have been helpful, there still needed to be quarantine and isolation work on site at the shelter.

“For us to screen with them, we need to physically go on site to take a look and say, ‘This is high risk. Can you try doing these things?’” said Dr. Dunham. “It’s really a multifactorial approach, but you need to be on site and interact with them.”

“One of the first places we investigated that really had a major outbreak very early on was Pacific Garden [Mission] on the West Side,” said Dr. Rothschild. “The strategy was initially to move folks out, but now because of the way that building was laid out, we can isolate on site.”

Under the oversight of Evelyn Figueroa, MD, professor of family medicine at the University of Illinois at Chicago School of Medicine, they were able to create an isolation unit for men and women who were COVID-19 positive at the Pacific Garden shelter.

“This was critical because we see more and more people come up COVID-positive,” said Dr. Rothschild. “We would not have the capacity to just take everybody to the Safe Haven or Hotel One Sixty-Six.”

Residents of the shelter are screened through questionnaires and temperature measurements. If patients are identified as being high risk, they will be moved to another area. When patients test positive for COVID-19, they are treated and isolated.

One of the real successes of this outreach to the homeless population is that 10 shelters in Chicago have been able to work together.

For example, if one shelter can sequester people who have been infected, then they will take those patients. The other shelter will then house those who do not have COVID-19, which can “roughly limit the exposure to half as opposed to assuming that everybody’s going to get it,” said Dr. Dunham. “There’s a way to come together. These are all people who are idealistic and likeminded, but a lot of times they’re not always communicating with other likeminded people.”

“But now it has forced us to think more globally and try to share resources,” he said. “All these relationships have been built because of this crisis.”

“At the end of the day, as physicians we’re charged with not just treating disease but keeping people healthy,” said Dr. Rothschild. “As we have dived into this as a group of physicians from across the city, it really has become more obvious and urgent that we see housing as a form of medical care.”

The AMA continues to compile critical COVID-19 health equity resources to shine a light on the structural issues that contribute to and could exacerbate already existing inequities. Physicians can also access the AMA’s COVID-19 FAQs about health equity in a pandemic.

Stay up to speed on the fast-moving pandemic with the AMA's COVID-19 resource center, which offers a library of the most up-to-date resources from JAMA Network™, the Centers for Disease Control and Prevention, and the World Health Organization. Also check out the JAMA Network COVID-19 resource center.