Homeless patients with COVID-19 often go back to life on the streets after hospital care, but there's a better way

Union Square in Manhattan where many homeless people in New York live. Noam Galai via Getty Images
In 2019 there were approximately 567,715 homeless people in the United States. While that number has steadily declined since 2007, it has increased over the past two years. For New York City, 2020 was a record year for homelessness even before COVID-19. When the lockdown began in mid-March, the 60,923 homeless people who were in the city's protection system were disproportionately affected by the pandemic.
Not all of the city's homeless, of course. The over 60,000 do not include the homeless hiding in patient lists and waiting rooms in the emergency room. In 2019, there were more than 300 homeless people in hospitals in the city annually who are patients or who use the hospital as emergency shelter.
As a naturopath, educator, and researcher in the field of public health and social epidemiology working in the city, I am fully aware of the challenges and the tragedies I have already experienced. As of May 31, the New York Department of Homeless Services had reported 926 confirmed COVID-19 cases in 179 emergency shelters and 86 confirmed COVID-19 deaths. In April alone, the DHS reported 58 homeless deaths from COVID-19, 1.6 times the overall rate for cities. While there is no reliable analog data for other cities, what happens in New York can teach others a lesson.
A protest against the homeless who temporarily live in New York's Lucerne Hotel on the Upper West Side. Steven Ferdman via Getty Images
Homeless shelters are vulnerable
The vulnerability of the homeless population to COVID-19 is not unique to New York City. Homeless shelters are particularly vulnerable to disease transmission almost everywhere. Shelters tend to be unequipped, busy, and generally unable to provide safe care, especially for those recovering from surgery, wounds, or illness.
Add to this the inability to isolate, quarantine, or physically distance the homeless during COVID-19. New York City then used almost 20% of its hotels as emergency shelters with one or two customers per room. That helped, but it was hardly a perfect situation.
So the question is: where do homeless patients go when they are released from acute medical care, especially in the post-COVID-19 era?
Homeless patients who have been discharged from hospitals or clinics and then moved to shelters, shelters, or the streets sometimes do not fully recover from their illnesses. Some inevitably end up in the hospital again. The result is an adverse and costly cycle for both patients and the healthcare system.
And the situation continues to deteriorate: between July 2018 and June 2019, 404 homeless people died in the city - 40% more than last year and the largest increase in a decade compared to the previous year. No data has been available since the outbreak began, but initial evidence suggests that the death toll is higher between June 2019 and June 2020.
A former Radisson Hotel in New York City has been converted into a homeless shelter. John Nacion / SOPA Images / LightRocket via Getty Images
Medical rest: one possible solution
Medical rest is short-term home care for the homeless who are too sick or frail to recover on the street but not sick enough to be in a hospital. It provides a secure environment for recovery and access to follow-up management and other social services. Medical follow-up care can be offered in free-standing facilities, shelters for the homeless, nursing homes and temporary accommodation.
Medical rest has worked in communities across the United States. Health outcomes for patients have improved, and hospitals and insurers, particularly Medicaid, have saved money. But these programs are few and far between. In 2016 there were 78 programs in 28 states. Most programs are small, 45% have fewer than 20 beds.
Care models vary, but essentially provide beds in one room dedicated to recovery, assistance with follow-up appointments, medication management, medically appropriate meals, and access to social services such as home navigation and welfare. Some programs offer on-site clinical care.
Research shows that homeless patients in New York City stay in hospital 36% longer and cost an average of $ 2,414 more per stay than patients with stable housing. By discharging patients to relief programs, hospitals reduced the number of emergency visits after discharge by 45% and readmission by 35%. New York Legal Assistance Group, which conducted a cost-benefit analysis, found savings of nearly $ 3,000 per stay (provider saved $ 1,575, payers saved $ 1,254) from shorter hospital readmissions and less length of stay.
Studies outside of New York also show improved health outcomes in a number of ways. One found that 78% of patients were released from breathing space “for health reasons”. Patients showed a 15% to 19% increase in primary care-related care after discharge on medical rest. In addition, at least 10% and up to 55% of discharged patients who were discharged went into permanent or improved living arrangements.
Next Steps
While there are agreed national standards for medical rest, the program models can adapt to the needs of a particular community. There are already dozens of recreational models across the country, both in large cities and in small towns. One complication, however, is the sheer breadth of the medical rest approach. Given that it is housing, homelessness and health care, medical rest does not fit exactly into a single system and would require the collaboration and agreement of multiple city and state authorities.
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Yet more and more communities are seeking medical rest to fill this gap. Chicago is working with providers to provide health care to the homeless. This includes providing temporary living facilities and clinics to mitigate the effects of COVID-19.
There is an urgent need to help the homeless with both housing and health care. Medical rest is one possible solution. It has successfully provided recreational housing and medical care during a pandemic. Why shouldn't it become an integral part of our service system?
Andrew Lin, developer of a supportive housing program at BronxWorks, a nonprofit group that provides homeless and housing support services in the Bronx, contributed to this article.
This article was republished by The Conversation, a non-profit news site dedicated to sharing ideas from academic experts. It is written by: J. Robin Moon, City University of New York.
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J. Robin Moon does not work for any company or organization that would benefit from this article, does not consult any stocks or companies that would benefit from this article, and has not disclosed any relevant affiliations beyond her academic appointment.

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