key: cord-0954305-k8ap8emc authors: Landgraf, Rita; Holloway, Susan; Beaman, Renee; Fitzgerald, Ray title: Delaware COVID-19 Homeless Community Outreach Partnership 2020 date: 2020-07-01 journal: Dela J Public Health DOI: 10.32481/djph.2020.07.023 sha: eccc9693b86e3deade506c1a1df9e42796bdccad doc_id: 954305 cord_uid: k8ap8emc nan The disproportionate impact of the COVID-19 pandemic on individuals in poverty, individuals with substance use and mental health diagnoses and communities of color has been well documented. 1 A recent report from Johns Hopkins Bloomberg School of Public Health illustrated the relationship between health disparities among vulnerable populations and the spread of COVID-19. 2 The following factors play an important role in COVID-19 disparities among individuals experiencing poverty, individuals suffering from substance use and mental health disorders and communities of color: 1) Higher rates of underlying health conditions and decreased access to medical care; 2) Employment in essential jobs with high levels of public interaction; 3) Structural issues such as concentrated poverty, living conditions and lack of paid sick leave; In addition, the Centers for Disease Control and Prevention (CDC) identified early on that persons experiencing homelessness are at high risk for COVID 19. 3 Homeless services are often provided in congregate settings, which could facilitate the spread of infection. Because many people who are homeless are older adults or have underlying medical conditions, they may also be at higher risk for severe disease. The CDC emphasized that health departments and healthcare facilities should be aware that people who are homeless are a particularly vulnerable group and recommended that if possible, identifying non-congregate settings where those at highest risk can stay may help protect them from COVID-19. 4 On March 24, 2020 the COVID-19 Homeless Community Outreach Partnership was established by Delaware Department of Health and Social Services (DHSS) and charged with identifying and engaging individuals experiencing homeless to 1) Identify if COVID-19 viral activity was present among the homeless, especially in night shelters remaining open, and those living on the streets, many of whom would continue to congregate outside of day shelters that were closed in light of the State's restrictions. 2) Triage and place in shelter (largely motels and hotels throughout the state) those homeless who were extremely vulnerable to the acuity of COVID-19 if exposed to the virus. The triage was largely implemented based on CDC guidelines, and included those testing positive for COVID-19 and or exposed to someone positive, those 65 and older, and those with chronic medical conditions Specifically, the outreach team engaged homeless individuals, conducted 2,528 screenings for COVID-19 symptoms, and other concerning vital signs. Our approach evolved as the availability of testing increased and we were thankful to many of the health care providers and the Division of Public Health for donating testing supplies to our teams. In addition, all on the ground team members were in full Personal Protection Equipment (PPE), which was also donated. Since this was primarily a COVID-19 outreach activation, centralized housing to safely isolate and/or selfquarantine is a critical component of a holistic outreach model to mitigate the spread of COVID-19 among vulnerable individuals, particularly those who screen presumptive positive during outreach. It is important to note that regardless of whether the individual was COVID-19 positive or negative, the addition of this essential housing resource for protection and self-quarantine for vulnerable populations statewide was strategically established early in the activation to help mitigate viral spread and positively impact health outcomes for all Delawareans. The University of Delaware, Partnership for Healthy Communities (PHC) was invited by DHSS to lead the strategic operational plan for this specialized outreach activation. The mission of the PHC is to align and strengthen University of Delaware research, educational, and service capabilities to improve the health and well-being of Delaware communities and beyond through effective partnerships. The PHC is engaged in over 40 strategic initiatives with various degrees of involvement, ranging from alignment via board and committee memberships, to engagement in campus-community partnerships around multi-sector, coordinated efforts to impact social and environmental factors that promote optimal health and well-being and advance equity. Rita Landgraf as the Director of the PHC and as former Cabinet Secretary of DHSS was requested to be the lead managerial partner. DHSS/Division of Substance Abuse and Mental Health (DSAMH) was invited to join as the colead in strategic management as well as developing the social support teams to be integrated with a medical team in the field. DSAMH is committed to managing the impact of COVID-19 across the behavioral health system, by continuing to monitor the well-being of its population in order to reduce future incidents and deaths of despair. Prior to COVID-19, the percentage of DSAMH clients who rated themselves as "suffering" in a standardized Well-Being Assessment was greater than that of the general population and in other populations with mental health and addictions disorders (15% vs. 3%). Additionally, since the onset of the COVID-19 pandemic, DSAMH has monitored weekly DTRN data and noted increased rates of alcohol use, overdose and homelessness. Susan Holloway, associate deputy director of health, integration and social determinants serves as co-lead. Lieutenant Governor Bethany Hall Long served as an advisor to the managerial strategic team and provided hands on support as a public health nurse and professor to the medical team. In advancing the integrated delivery model, all services delivered were in accordance with all applicable Federal, State, and Local laws, regulations, and DHSS approved program guidelines and certifications. Services included the following: 1. Intensive infection prevention efforts on those most likely to develop severe complications from COVID-19, including people who are currently in shelters and people who are currently unsheltered. A commitment to expand the category of those receiving intensive infection prevention efforts as resources permitted. The primary strategy for intensive infection prevention efforts was to provide single occupancy housing, while separating people with symptoms quickly, creating isolation units (i.e. hotels, motels) for persons under investigation (PUI), and bringing into shelter those must vulnerable to acuity if impacted by viral activity. The COVID 19 Homeless Community Outreach Partnership co-leads created clear lines of communication relative to the importance of the process, so that homeless service providers and health (physical and behavioral) systems had easy access to appropriate isolation and/or quarantine resources to decrease the chance that potentially COVID + individuals spend extended time among the general population experiencing homelessness. 2. Screening and referral were conducted by a team approach consisting of a medical team integrated with a social service team, inclusive of behavioral health specialists. Two teams were established to support the statewide activation. Dr. Sandy Gibney was the medical lead and established the medical protocols initiated inclusive of screening for symptoms. When testing became more readily available, Dr. GIbney administered the PCR test and was responsible for the follow up and monitoring of those housed in hotels. Dr. Gibney established a medical team to assist her in the activations for New Castle and Kent Counties. Dr. Rama Peri was recruited to lead the Sussex County medical team and was trained and provided initial guidance by Dr. Gibney, following the same established recognized protocols inclusive of follow up relative to testing results and recruiting additional medical team members. Both teams continue to recirculate with the homeless as the state restrictions continue to be lifted. The Social Service Teams were integrated with Medical teams and consisted of DSS, DSSC, and DSAMH personnel, some on the ground and some behind the scenes coordinating appropriate hotel/motel referrals. In addition, behavioral health providers from Aquila, RI International, and Peace by Piece supported teams. These teams provided food at the screening sites, personal hygiene items, clothing and naloxone. When individuals were deemed eligible for placement in hotel/motel based on the CDC guideline criteria, the social service team would provide the transport and representatives from the team would support providing meals or securing support from organizations for meal and medication distribution dependent upon placements. • If an individual was presumed positive, the medical team referred that individual to the social service team for placement and medical follow up relative to isolation and or quarantine in a COVID-19 + hotel. • If an individual screened negative and is at high risk for medical complications, social service teams would arrange for placement in non Covid-19 +hotel/motel/shelter. • If an individual screened negative and was at low risk of medical complications, the individual remained in the shelter or non-sheltered with appropriate social distancing, cleaning and re-screening. The CDC recommended that individuals not be forcibly "swept" from their current location. It is appropriate to provide the individual with an option to remain where they are, if appropriate social distancing and hygiene needs can be addressed, or to enter an appropriate shelter opportunity where appropriate social distancing, cleaning and screening measures can be met, if available. Individuals meeting the DSAMH criteria of serious persistent mental illness and/or substance use disorder, along with the COVID-19 triage criteria, were supported by the behavioral health provider in one of three designated sites throughout the state, with the intent to establish a behavioral health discharge plan and connect these individuals to appropriate level of care when restrictions are lifted and safely transition individuals into care. Table 1 provides information regarding the managing agency, eligibility criteria, program details and funding sources related to hotel/motel placements for each identified vulnerable population. Mental Health Services, is to provide federal funds to support outreach and mainstream service linkage to persons with serious mental illness who are experiencing homelessness or at imminent risk for homelessness. The target population also includes persons experiencing homelessness who have co-occurring diagnoses of mental illness and substance use disorder. The outcomes of this effort were to build upon the systems that have been established to meet the needs of individuals, especially during the COVID 19 activation timeline (March 24 -June 15, 2020). This activation was not a solution for homelessness, but has highlighted processes that can be extended into the work many continue to advance in ending homelessness. In addition, the intersection between clinical support and social support provides a holistic approach in enhancing stability and overall wellbeing. The three hotels that DSAMH supported were considered temporary behavioral health programs during the restrictions of short-term lodging enacted by the Governor. The hotel/motel restrictions were phased out beginning June 1 and efforts were underway to connect the 332 individuals placed into the next level of care, inclusive of housing supports. All of the 332 individuals placed during the COVID-19 activation timeline were included in a planning process to support them to the next level of care, 185 accepted the plan and have moved into the next level of care. The total number of individuals refusing services was 114; however, efforts remain underway to continue to engage with these individuals in hopes of advancing treatment in the future. During this timeframe, two individuals died and cause of death appears to be of natural causes. Unfortunately, 31 individuals are currently lost to the system due to the transient nature of the population but outreach efforts remain. The transitional housing strategy includes several types of housing (see Table 2 ). Table 2 . Transitional housing types in the traditional housing strategy Housing Type Description Emergency Placement Single occupancy housing in a hotel/motel setting for individuals experiencing behavioral health distress; identified as homeless, high risk, and assessed as Covid +, Covid-, or Person under investigation who could be safely isolated. Provide a healthy living environment for individuals to initiate and sustain recovery, defined as abstinence from alcohol and other nonprescribed drug use and to gain improvement in their physical, mental, spiritual, and social wellbeing. In addition, these residences act as transitional housing according to NAAR Level IV standards that provides a setting for individuals awaiting inpatient treatment post withdrawal management from residential treatment in a recoveryoriented, safe, drug and alcohol-free environment. A statewide apartment program for persons working toward the goal to live independently and who need some additional daytime, evening, overnight and weekend supervision. Provide a transition for those individuals who have no permanent residence and have needs that require short-term stabilization beyond traditional housing programs after exiting the hospital or If they have any ongoing psychiatric care need. Cost-effective, community-based housing alternatives for adults living with severe psychiatric disorders, who are unable to live fully independently and can benefit from intensive supportive and rehabilitative services in the home. A housing program for adults with serious and persistent mental illness (SPMI) who can benefit from round-the-clock oversight and lowintensity support from onsite, unlicensed staff members. Its goal is to increase resident stability, promote hope, wellness and resiliency, and foster greater independence through providing rehabilitative services in a home-like environment. DSAMH is committed to increasing access to care and treatment for individuals living with substance use disorder (SUD) and opioid use disorder (OUD). This effort further supports the START Initiative, a system-wide, quality improvement process that will increase connectivity, improve referral and data sharing, and ensure wrap-around services across the State of Delaware through the implementation of evidence-based programs and practices. The system includes stakeholders from public safety, education, criminal justice, social service, transportation, public health, hospitals, and primary care providers, as well as other providers and entities. DSAMH will utilize a coordinated approach to enable individuals to move from transitional housing to a long-term housing option. Further, the client will be afforded the option to remain with their current provider of choice and the flexibility to transition to a different level of care when needs dictate a change in services. The approach is also intended to allow individuals to access coordinated services from providers that may be funded by different state agencies that occupy a role in the life of the consumer. DSAMH will address the long term housing needs of individuals through various programs inclusive of the • State Rental Assistance Program. Affordable voucher-based program in partnership with Delaware State Housing Authority (DSHA). The Delaware State Rental Assistance Program is designed to assist low-income households who are eligible to receive continuing supportive services and require affordable housing to live safely in the community. The program will utilize SRAP vouchers administered by the DSHA for households referred by the Department of Health and Social Services (DHSS) and the Department of Services for Children, Youth, and their Families (DSCYF). DHSS and DSCYF will leverage existing funds to provide supportive services to SRAP applicants during the program application, screening, and housing selection processes. After a SRAP applicant is approved and moves into the SRAP-assisted unit, DHSS, DSCYF, or an approved service provider will continue to make appropriate supportive services available to the participant throughout their participation in the Program. Participation in supportive services is voluntary and is not a condition of participation in SRAP. • The Section 811 Program. The Section 811 program allows persons with disabilities to live as independently as possible in the community by subsidizing rentalhousing opportunities, which provide access to appropriate supportive services. • Tax Credit Properties. Apartment complexes that participate in the federal lowincome housing credit program. The individuals sheltered in DSSC/DSS monitored hotels/motels are on a different timeline since this program has been in existence prior to COVID-19 and, due to COVID-19, the time allowed for motel/hotel shelter has been extended. In partnership with New Castle County, DHSA, Delaware Housing Alliance, and Family Promise, a pilot program has been initiated to focus on families with children placed in motels/hotels and transitioning these families utilizing programs such as rapid re-housing, housing first and/or supportive housing or some level of permanent housing through the leveraging of a variety of federal funds. The focus is to extend this statewide to achieve housing stability opportunities for homeless families. The unduplicated number of individuals placed in motels/hotels during this timeframe (ending June 11) is 1,427. The total number of households with children is 260 and the total number of children is 476. In addition, 28 individuals placed are over the age of 65. In closing, this ongoing effort, relative to homelessness, will be strengthened by focusing on cultural competence to ensure effective interaction with priority populations. By continuing to build on a framework that was developed through stakeholder feedback, statewide consortiums, and national experts, Delaware can ensure a systematic approach to addressing gaps, streamlining and leveraging resources and applying data-driven practices to improve housing access, treatment, and wraparound supports that are essential to the long-term success. COVID-19 exacerbating inequalities in the US How health disparities are shaping the impact of COVID-19 People who are at higher risk for severe illness Interim guidance on unsheltered and coronavirus disease 2019 (COVID19) for homeless providers and local officials Delaware Academy of Medicine / Delaware Public Health Association. This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License The effort of this activation was supported by many throughout our state, inclusive of a variety of elected officials, state personnel, individuals, advocates and organizations. This work could never have been accomplished without this level of engagement. We are extremely grateful to all who provided guidance and support during this activation.