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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.

Abstract

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.

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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.

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