(photo: John McCarten/City Council)
What happens when a historic pandemic collides with an unprecedented housing crisis? The inextricable link between housing and health is now more apparent than ever as doctors both care for critically ill patients with the novel coronavirus, COVID-19, and simultaneously scramble to make plans for the most vulnerable in our society who simply have no place to isolate.
Only a few weeks into this crisis, we have seen numerous patients recuperating from COVID-19 who linger for days in the hospital because of their need for medically-appropriate shelter. This highlights the immediate need to establish “medical respite” opportunities. Medical respite facilities are settings that “provide a safe and humane alternative when discharge to home is not possible for people without home,” in the words of the National Healthcare for the Homeless Council. These should be available for any New Yorker in need.
In hospital and emergency medicine, providers are familiar with the idea of a ‘social admission,’ meaning that a patient may enter or remain in the hospital because he or she has no place to safely care for him- or her-self. Reasons range from needing intravenous antibiotics or oxygen supplementation, to simply “aging out” of the ability to care for oneself. Such social admissions often stay in the hospital for weeks or even months longer than would a medically-similar patient with more secure housing and social support.
Today, facilities around the country are keeping homeless patients with the novel coronavirus in hospital beds, sometimes for days, because they lack a secure non-hospital setting in which to isolate. This week in New York has clearly demonstrated that a hospital bed is a dangerously scarce, life-saving resource for critically ill people coming into the hospital in the midst of a worldwide pandemic.
Based on guidelines from the Centers for Disease Control, if a person develops fever and symptoms of a cold and is concerned about having the novel coronavirus, hospitals are generally recommending: Stay home, keep a safe distance from others, regularly wash your hands thoroughly with soap and water (or hand sanitizer), avoid public transportation, and call your doctor before reporting to one of the already-overcrowded emergency rooms, where people are equally at risk of spreading or contracting the virus. Clearly this is incredibly challenging for any person in the shelter system, living on the street, or living in an overcrowded space. For those who are homeless but avoiding the shelter system, preferring to remain on the street, protecting themselves from close contact with others, even washing their hands, may be next to impossible.
In just the first few weeks of this crisis, in a small swath of the city, COVID-19 has crudely unearthed every failing of our society when discharging patients back to the community: living 6-8 people in a studio, couch surfing after recent layoffs, and needing to avoid domestic violence. Housing is clearly complex, and the numbers reflected in the official shelter census just scratch the surface of those in our city who may have a need for respite locations.
Clearly, our society is only as resilient as the structures in place to care for the most vulnerable during a time of pandemic. We need rapid, effective access to isolation facilities for homeless and unstably-housed people who are sick but not requiring inpatient care, whether or not they have previously stayed in the shelter system.
The system must be streamlined, with the referral process clearly communicated to hospitals to facilitate expedited transfer from either hospital discharge or outpatient clinics to isolation settings. We need immediate access to individual rooms for people becoming homeless in the wake of the pandemic, having been pushed out of unstable housing or discharged from various institutions. People need the ability to come off the streets with access to individual rooms where they can safely isolate for their safety and that of others.
Every hour and every open hospital bed will count in our management of this crisis to support our inundated healthcare system as we provide life-saving care to the most vulnerable in our city, and all New Yorkers.
By Amanda Ramsdell, MD; William Levine, MD; Aarti Patel, PA-C; Nell Eisenberg, MD; Laura Kolbe, MD; Yinan Lan, MD; Todd Cutler, MD; David Scales, MD, MPhil, PhD; and Lucy Willis, MD. On Twitter @ARamsdell3, @aarthiparthi, @nellbell_e, @laurakolbemd, @todd_cutler, @DavidAScales, @LucyWillisMD