Association of Shelter-in-Place Hotels With Health Services Use Among People Experiencing Homelessness During the COVID-19 Pandemic | Emergency Medicine | JN Learning | AMA Ed Hub [Skip to Content]
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Association of Shelter-in-Place Hotels With Health Services Use Among People Experiencing Homelessness During the COVID-19 Pandemic

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

Question  Was placement in a shelter-in-place (SIP) hotel during the COVID-19 pandemic associated with health system utilization among people experiencing homelessness with a history of high use of acute health services?

Findings  In this cohort study of 686 high users of acute county services experiencing homelessness, those who received a SIP hotel placement had significantly fewer emergency department visits, hospital admissions, inpatient days, and psychiatric emergency department visits compared with matched controls without a placement.

Meaning  These findings suggest that provision of noncongregate shelter with supportive services in SIP hotels during the COVID-19 pandemic was associated with reduced use of acute health services among people with prior high use.


Importance  Some jurisdictions used hotels to provide emergency noncongregate shelter and support services to reduce the risk of COVID-19 infection among people experiencing homelessness (PEH). A subset of these shelter-in-place (SIP) hotel guests were high users of acute health services, and the association of hotel placement with their service use remains unknown.

Objective  To evaluate the association of SIP hotel placements with health services use among a subset of PEH with prior high acute health service use.

Design, Setting, and Participants  This study used a matched retrospective cohort design comparing health services use between PEH with prior high service use who did and did not receive a SIP hotel placement, from April 2020 to April 2021. The setting was 25 SIP hotels in San Francisco, California, with a daily capacity of 2500 people. Participants included PEH who were among the top 10% high users of acute medical, mental health, and substance use services and who had 3 or more emergency department (ED) visits in the 9 months before the implementation of the SIP hotel program. Data analysis for this study was performed from February 2021 to May 2022.

Exposures  SIP hotel placement with on-site supportive services.

Main Outcomes and Measures  The primary outcomes were ED visits, hospitalizations and bed days, psychiatric emergency visits, psychiatric hospitalizations, outpatient mental health and substance use visits, and outpatient medical visits.

Results  Of 2524 SIP guests with a minimum of 90-day stays, 343 (13.6%) met criteria for high service use. Of 686 participants with high service use (343 SIP group; 343 control), the median (IQR) age was 54 (43-61) years, 485 (70.7%) were male, 283 (41.3%) were Black, and 337 (49.1%) were homeless for more than 10 years. The mean number of ED visits decreased significantly in the high-user SIP group (1.84 visits [95% CI, 1.52-2.17 visits] in the 90 days before SIP placement to 0.82 visits [95% CI, 0.66-0.99 visits] in the 90 days after SIP placement) compared with high-user controls (decrease from 1.33 visits [95% CI, 1.39-1.58 visits] to 1.00 visits [95% CI, 0.80-1.20 visits]) (incidence rate ratio [IRR], 0.60; 95% CI, 0.47-0.75; P < .001). The mean number of hospitalizations decreased significantly from 0.41 (95% CI, 0.30-0.51) to 0.14 (95% CI, 0.09-0.19) for SIP guests vs 0.27 (95% CI, 0.19-0.34) to 0.22 (95% CI, 0.15-0.29) for controls (IRR, 0.41; 95% CI, 0.27-063; P < .001). Inpatient hospital days decreased significantly from a mean of 4.00 (95% CI, 2.44-5.56) to 0.81 (95% CI, 0.40-1.23) for SIP guests vs 2.27 (95% CI, 1.27-3.27) to 1.85 (95% CI, 1.06-2.65) for controls (IRR, 0.25; 95% CI, 0.12-0.54; P < .001), as did psychiatric emergency visits, from a mean of 0.03 (95% CI, 0.01-0.05) to 0.01 (95% CI, 0.00-0.01) visits for SIP guests vs no change in the control group (IRR, 0.25; 95% CI, 0.11-0.51; P < .001).

Conclusions and Relevance  These findings suggest that in a population of PEH with high use of acute health services, SIP hotel placement was associated with significantly reduced acute care use compared with high users without a placement.

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Article Information

Accepted for Publication: May 18, 2022.

Published: July 27, 2022. doi:10.1001/jamanetworkopen.2022.23891

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Fleming MD et al. JAMA Network Open.

Corresponding Author: Mark D. Fleming, PhD, MS, School of Public Health, University of California, Berkeley, 2121 Berkeley Way West, Berkeley, CA 94720 (

Author Contributions: Ms Evans and Dr Graham-Squire 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: Fleming, Evans, Graham-Squire, Kanzaria, Kushel, Raven.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Fleming, Evans, Raven.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Evans, Graham-Squire, Cawley.

Obtained funding: Kushel.

Administrative, technical, or material support: Kanzaria, Kushel.

Supervision: Raven.

Conflict of Interest Disclosures: Dr Kanzaria reported being a consultant for Amae Health, Inc outside the submitted work. Dr Kushel reported receiving a donation from the Marc and Lynne Benioff Foundation Philanthropic and grants from National Institute of Aging during the conduct of the study and reported serving on the board of Housing California. No other disclosures were reported.

Funding/Support: This work was supported by grant K01HS027648 from the Agency for Healthcare Research and Quality. Dr Kanzaria’s and Dr Raven’s salaries were supported by a grant from the Benioff Homelessness and Housing Initiative at the University of California, San Francisco.

Role of the Funder/Sponsor: The funders 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 content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.

Additional Contributions: We thank the San Francisco Department of Public Health and the partnering San Francisco County agencies for their leadership and implementation of the work described in this article.

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