[Skip to Content]
[Skip to Content Landing]

Assessment of a Hotel-Based COVID-19 Isolation and Quarantine Strategy for Persons Experiencing Homelessness

Educational Objective
To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  Can persons experiencing homelessness with confirmed or suspected coronavirus disease 2019 (COVID-19) and mild to moderate symptoms be safely monitored in designated isolation and quarantine (I/Q) hotels?

Findings  In this cohort study among 1009 I/Q hotel guests referred from hospitals, outpatient settings, and public health surveillance, 81% completed their recommended I/Q course, and only 4% of those transferred from the county hospital required readmission for COVID-19 progression.

Meaning  This study suggests that, during the COVID-19 pandemic, a hotel-based I/Q strategy that delivers integrated medical and behavioral health support to people experiencing homelessness can be done safely outside the hospital setting.


Importance  Several jurisdictions in the United States have secured hotels to temporarily house people experiencing homelessness who require isolation or quarantine for confirmed or suspected coronavirus disease 2019 (COVID-19). To our knowledge, little is known about how these programs serve this vulnerable population outside the hospital setting.

Objective  To assess the safety of a hotel-based isolation and quarantine (I/Q) care system and its association with inpatient hospital capacity.

Design, Setting, and Participants  This retrospective cohort study of a hotel-based I/Q care system for homeless and unstably housed individuals in San Francisco, California, was conducted from March 19 to May 31, 2020. Individuals unable to safely isolate or quarantine at home with mild to moderate COVID-19, persons under investigation, or close contacts were referred from hospitals, outpatient settings, and public health surveillance to 5 I/Q hotels. Of 1009 I/Q hotel guests, 346 were transferred from a large county public hospital serving patients experiencing homelessness.

Exposure  A physician-supervised team of nurses and health workers provided around-the-clock support, including symptom monitoring, wellness checks, meals, harm-reduction services, and medications for opioid use disorder.

Main Outcomes and Measures  Characteristics of I/Q hotel guests, program retention, county hospital readmissions, and mean length of stay.

Results  Overall, the 1009 I/Q hotel guests had a median age of 44 years (interquartile range, 33-55 years), 756 (75%) were men, 454 (45%) were Latinx, and 501 (50%) were persons experiencing sheltered (n = 295) or unsheltered (n = 206) homelessness. Overall, 463 (46%) received a diagnosis of COVID-19; 303 of 907 (33%) had comorbid medical disorders, 225 of 907 (25%) had comorbid mental health disorders, and 236 of 907 (26%) had comorbid substance use disorders. A total of 776 of 955 guests (81%) completed their I/Q hotel stay; factors most strongly associated with premature discontinuation were unsheltered homelessness (adjusted odds ratio, 4.5; 95% CI, 2.3-8.6; P < .001) and quarantine status (adjusted odds ratio, 2.6; 95% CI, 1.5-4.6; P = .001). In total, 346 of 549 patients (63%) were transferred from the county hospital; of 113 ineligible referrals, 48 patients (42%) had behavioral health needs exceeding I/Q hotel capabilities. Thirteen of the 346 patients transferred from the county hospital (4%) were readmitted for worsening COVID-19. Overall, direct transfers to I/Q hotels from emergency and outpatient departments were associated with averting many hospital admissions. There was a nonsignificant decrease in the mean hospital length of stay for inpatients with confirmed or suspected COVID-19 from 5.5 to 2.7 days from March to May 2020 (P = .11).

Conclusions and Relevance  To support persons experiencing homelessness during the COVID-19 pandemic, San Francisco rapidly and safely scaled a hotel-based model of I/Q that was associated with reduced strain on inpatient capacity. Strategies to improve guest retention and address behavioral health needs not met in hotel settings are intervention priorities.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 Credit(s)™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: January 11, 2021.

Published: March 2, 2021. doi:10.1001/jamanetworkopen.2021.0490

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Fuchs JD et al. JAMA Network Open.

Corresponding Author: Jonathan D. Fuchs, MD, MPH, San Francisco Department of Public Health, 25 Van Ness Ave, Ste 500, San Francisco, CA 94102 (jonathan.fuchs@sfdph.org).

Author Contributions: Drs Fuchs and Kanzaria had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Fuchs, Evans, Imbert, Bloome, Fann, Skotnes, Sears, Moughamian, Reed, Rosenthal, Bobba, Kushel, Kanzaria.

Acquisition, analysis, or interpretation of data: Fuchs, Carter, Evans, Graham-Squire, Fann, Sears, Pfeifer-Rosenblum, Eveland, Borne, Lee, Jain, Kushel, Kanzaria.

Drafting of the manuscript: Fuchs, Carter, Evans, Graham-Squire, Fann, Pfeifer-Rosenblum, Reed, Rosenthal, Kanzaria.

Critical revision of the manuscript for important intellectual content: Fuchs, Graham-Squire, Imbert, Bloome, Fann, Skotnes, Sears, Pfeifer-Rosenblum, Moughamian, Eveland, Borne, Lee, Rosenthal, Jain, Bobba, Kushel, Kanzaria.

Statistical analysis: Fuchs, Carter, Evans, Graham-Squire, Fann, Pfeifer-Rosenblum.

Obtained funding: Kushel.

Administrative, technical, or material support: Fuchs, Bloome, Fann, Sears, Pfeifer-Rosenblum, Moughamian, Eveland, Kushel, Kanzaria.

Supervision: Fuchs, Fann, Bobba, Kushel, Kanzaria.

Conflict of Interest Disclosures: Dr Fuchs reported receiving grants from the Centers for Disease Control and Prevention outside the submitted work. Dr Jain reported receiving grants from the Centers for Disease Control and Prevention and President’s Emergency Plan for AIDS Relief outside the submitted work. Dr Kanzaria reported serving as an unpaid clinical advisory board member for Collective Medical and has received reimbursement for travel and accommodation-related expenses outside the submitted work. No other disclosures were reported.

Funding/Support: The analysis of the work described was supported by the Benioff Homelessness and Housing Initiative at the University of California, San Francisco.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The views expressed herein do not necessarily reflect the official policies of the City and County of San Francisco nor does mention of trade names, commercial products, or organizations imply endorsement.

Additional Contributions: We thank Jessica Knaster Wasse, MPH, Public Health–Seattle & King County for her early insights as we launched our San Francisco isolation and quarantine hotel model, and Erin Hartman, MS, University of California, San Francisco Benioff Homelessness and Housing Initiative for her editorial assistance with this manuscript. They were not compensated for their contributions. We would like to acknowledge the tireless efforts of the San Francisco Health Services Administration, Department of Homelessness and Supportive Housing, and Department of Public Health Containment Branch staff, including teams of nurses, behavioral health specialists, and disaster service workers who established and maintained San Francisco’s isolation and quarantine hotel system of care: Trent Rhorer, MPP; Daniel Kaplan, MPA; Noelle Simmons, MPP; Dariush Kayhan, MA; Kira Barrera, BA; Robert Walsh, MPA; Doris Barone, MPA, CEM; Abigail Stewart-Kahn, MS; Scott Walton, BA; Kelly Hiramoto, LCSW; Spencer Williams, BA; Saba Shahid, PsyD; Rafaella Wilson, RN; Jason Albertson, LCSW; Sarah Strieff, BSN, RN; Jose Luis Guzman, BS; and John Trinidad, MSW; they were not compensated for their contributions to this article. We also thank San Francisco Department of Public Health leaders Ayanna Bennett, MD; Tomas Aragon, MD, DrPH; and Grant Colfax, MD, and Mayor London Breed for their unwavering support; they were not compensated for their contributions to this article.

Zhang  XM , Zhou  HE , Zhang  WW ,  et al.  Assessment of coronavirus disease 2019 community containment strategies in Shenzhen, China.   JAMA Netw Open. 2020;3(6):e2012934. doi:10.1001/jamanetworkopen.2020.12934 PubMedGoogle Scholar
Ferguson  NM , Laydon  D , Nedjata-Gilani  G ,  et al.  Impact of Non-pharmaceutical Interventions (NPIs) to Reduce COVID-19 Mortality and Healthcare Demand. Imperial College London. 2020.
Hellewell  J , Abbott  S , Gimma  A ,  et al; Centre for the Mathematical Modelling of Infectious Diseases COVID-19 Working Group.  Feasibility of controlling COVID-19 outbreaks by isolation of cases and contacts.   Lancet Glob Health. 2020;8(4):e488-e496. doi:10.1016/S2214-109X(20)30074-7 PubMedGoogle ScholarCrossref
Sehgal  AR , Himmelstein  DU , Woolhandler  S .  Feasibility of separate rooms for home isolation and quarantine for COVID-19 in the United States.   Ann Intern Med. 2021;174(1):127-129. doi:10.7326/M20-4331PubMedGoogle Scholar
Henry  M , Watt  R , Mahathey  A , Ouellette  J , Sitler  A.   The 2019 Annual Homeless Assessment (AHAR) Report. US Department of Housing and Urban Development; 2020.
Imbert  E , Kinley  PM , Scarborough  A ,  et al. Coronavirus disease 2019 (COVID-19) outbreak in a San Francisco homeless shelter.  Clin Infect Dis. Published online August 3, 2020. doi:10.1093/cid/ciaa1071
Mosites  E , Parker  EM , Clarke  KEN ,  et al; COVID-19 Homelessness Team.  Assessment of SARS-CoV-2 infection prevalence in homeless shelters—four U.S. cities, March 27-April 15, 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(17):521-522. doi:10.15585/mmwr.mm6917e1 PubMedGoogle ScholarCrossref
MacKenzie  OW , Trimbur  MC , Vanjani  R .  An isolation hotel for people experiencing homelessness.   N Engl J Med. 2020;383(6):e41. doi:10.1056/NEJMc2022860 PubMedGoogle Scholar
United States Interagency Council on Homelessness. Webinar: COVID-19 planning and response: isolation and quarantine: lessons learned from King County. Published March 24, 2020. Accessed September 27, 2020. https://www.usich.gov/tools-for-action/webinar-covid-19-planning-and-response-isolation-and-quarantine-lessons-learned-from-king-county
Grasselli  G , Pesenti  A , Cecconi  M .  Critical care utilization for the COVID-19 outbreak in Lombardy, Italy: early experience and forecast during an emergency response.   JAMA. 2020;323(16):1545-1546. doi:10.1001/jama.2020.4031 PubMedGoogle ScholarCrossref
New York City Department of Health and Mental Hygiene (DOHMH) COVID-19 Response Team.  Preliminary estimate of excess mortality during the COVID-19 outbreak—New York City, March 11-May 2, 2020.   MMWR Morb Mortal Wkly Rep. 2020;69(19):603-605. doi:10.15585/mmwr.mm6919e5 PubMedGoogle ScholarCrossref
Office of the Mayor, City and County of San Francisco. San Francisco issues new public health order requiring residents stay at home except for essential needs. Published March 16, 2020. Accessed September 27, 2020. https://sfmayor.org/article/san-francisco-issues-new-public-health-order-requiring-residents-stay-home-except-essential
Achenbach J, Weiner R. Experts project autumn surge in coronavirus cases, with a peak after Election Day. Washington Post. September 5, 2020. Accessed September 27, 2020. https://www.washingtonpost.com/health/coronavirus-fall-projections-second-wave/2020/09/04/6edb3392-ed61-11ea-99a1-71343d03bc29_story.html
San Francisco Department of Public Health. Covid-19 alternative housing program. Updated January 25, 2021. Accessed September 27, 2020. https://data.sfgov.org/stories/s/COVID-19-Alternative-Housing/4nah-suat/
Centers for Disease Control and Prevention. Duration of isolation and precautions for adults with COVID-19. Updated October 19, 2020. Accessed October 29, 2020. https://www.cdc.gov/coronavirus/2019-ncov/hcp/duration-isolation.html
Centers for Disease Control and Prevention. When to quarantine. Updated December 10, 2020. Accessed October 29, 2020. https://www.cdc.gov/coronavirus/2019-ncov/if-you-are-sick/quarantine.html
World Health Organization. Home care for patients with suspected or confirmed COVID-19 and management of their contacts. Published August 13, 2020. Accessed September 25, 2020. https://www.who.int/publications/i/item/home-care-for-patients-with-suspected-novel-coronavirus-(ncov)-infection-presenting-with-mild-symptoms-and-management-of-contacts
Mehtani  N , Ristau  J , Snyder  H , Knight  K. COVID-19: a catalyst for change in telehealth service delivery for opioid use disorder management. Abstract presented at: The Association for Multidisciplinary Education and Research in Substance Use and Addiction; October 7, 2020.
Mehtani  NJ , Ristau  JT , Eveland  J .  COVID-19: broadening the horizons of U.S. harm reduction practices through managed alcohol programs.   J Subst Abuse Treat. Published online December 3, 2020. doi:10.1016/j.sat.2020.108225PubMedGoogle Scholar
Centers for Disease Control and Prevention. People at increased risk. Updated January 4, 2021. Accessed October 23, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/index.html
Kanzaria  HK , Niedzwiecki  M , Cawley  CL ,  et al.  Frequent emergency department users: focusing solely on medical utilization misses the whole person.   Health Aff (Millwood). 2019;38(11):1866-1875. doi:10.1377/hlthaff.2019.00082 PubMedGoogle ScholarCrossref
Elixhauser  A , Steiner  C , Harris  DR , Coffey  RM .  Comorbidity measures for use with administrative data.   Med Care. 1998;36(1):8-27. doi:10.1097/00005650-199801000-00004 PubMedGoogle ScholarCrossref
Cowan J. San Francisco’s homeless population is much bigger than thought, city data suggests. New York Times. November 19, 2019. Accessed September 27, 2020. https://www.nytimes.com/2019/11/19/us/san-francisco-homeless-count.html
San Francisco Department of Public Health. Single room occupancy hotels in San Francisco: a health impact assessment. Published Spring 2016. Accessed September 27, 2020. https://www.pewtrusts.org/-/media/assets/external-sites/health-impact-project/sfdph-2016-sroh-report.pdf
Saunders  M. 55 Test positive for coronavirus at San Diego convention center shelter. abc10 News San Diego. December 5, 2020. Accessed December 9, 2020. https://www.10news.com/news/local-news/san-diego-news/55-test-positive-for-coronavirus-at-san-diego-convention-center-shelter
Baggett  TP , Racine  MW , Lewis  E ,  et al.  Addressing COVID-19 among people experiencing homelessness: description, adaptation, and early findings of a multiagency response in Boston.   Public Health Rep. 2020;135(4):435-441. doi:10.1177/0033354920936227 PubMedGoogle ScholarCrossref
Kendall M. Newsom seeks more money for novel homeless housing program. Mercury News. Updated September 29, 2020. Accessed December 9, 2020. https://www.mercurynews.com/2020/09/28/newsom-seeks-more-money-for-novel-homeless-housing-program
Smith  LE , Amlôt  R , Lambert  H ,  et al.  Factors associated with adherence to self-isolation and lockdown measures in the UK: a cross-sectional survey.   Public Health. 2020;187:41-52. doi:10.1016/j.puhe.2020.07.024 PubMedGoogle ScholarCrossref
Brooks  SK , Webster  RK , Smith  LE ,  et al.  The psychological impact of quarantine and how to reduce it: rapid review of the evidence.   Lancet. 2020;395(10227):912-920. doi:10.1016/S0140-6736(20)30460-8 PubMedGoogle ScholarCrossref
Kryda  AD , Compton  MT .  Mistrust of outreach workers and lack of confidence in available services among individuals who are chronically street homeless.   Community Ment Health J. 2009;45(2):144-150. doi:10.1007/s10597-008-9163-6 PubMedGoogle ScholarCrossref
Why some homeless choose the streets over shelters. Transcript. Talk of the Nation. National Public Radio. December 6, 2012. Accessed December 10, 2020. https://www.npr.org/2012/12/06/166666265/why-some-homeless-choose-the-streets-over-shelters
Leung  CS , Ho  MM , Kiss  A , Gundlapalli  AV , Hwang  SW .  Homelessness and the response to emerging infectious disease outbreaks: lessons from SARS.   J Urban Health. 2008;85(3):402-410. doi:10.1007/s11524-008-9270-2 PubMedGoogle ScholarCrossref
Gaeta  JM , De Las Nueces  D , Munson  DG , Barocas  JA , Walsh  KE .  Case 21-2020: a 66-year-old homeless man with COVID-19.   N Engl J Med. 2020;383(2):170-178. doi:10.1056/NEJMcpc2002421 PubMedGoogle ScholarCrossref
Perri  M , Dosani  N , Hwang  SW .  COVID-19 and people experiencing homelessness: challenges and mitigation strategies.   CMAJ. 2020;192(26):E716-E719. doi:10.1503/cmaj.200834 PubMedGoogle ScholarCrossref
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
Want full access to the AMA Ed Hub?
After you sign up for AMA Membership, make sure you sign in or create a Physician account with the AMA in order to access all learning activities on the AMA Ed Hub
Buy this activity
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right

Name Your Search

Save Search
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience

Lookup An Activity


My Saved Searches

You currently have no searches saved.


My Saved Courses

You currently have no courses saved.