Lessons from the COVID Response for People Experiencing Homelessness - An Acute Care Perspective

By: Sahil Gupta
Sahil Gupta is an emergency room doctor at St. Michael's Hospital of Unity Health Toronto.


Many care providers feared what would happen when COVID-19 made its way to crowded shelters and drop-in centres. People experiencing homelessness face a high burden of chronic disease, including diabetes and Chronic Obstructive Pulmonary Disease (COPD), and often lack the ability to safely isolate and shelter in place. Early in the pandemic, options for these individuals narrowed as shelters limited the number of people they could take in. Having no other place to turn to, hospitals often became the default place to care for patients experiencing homelessness until a respite space became available. In Toronto, respite isolation sites were created for people who tested positive or who needed a space to isolate. However, these spaces took time to mobilize, and there was limited capacity to care for people with mobility needs or active substance use.

People experiencing COVID-like symptoms needed to be tested before they could return to shelter spaces. Lab turnaround times of three to five days delayed the safe discharge of many people. By mid-April, a pattern emerged where possible outbreaks in shelters started to manifest their presence in the emergency department (ED). At St. Michael's Hospital of Unity Health Toronto, the ED cared for more than 950 people experiencing homelessness through the course of the pandemic. Often times, these patients did not require acute care.

Without a centralized command structure or strategy to deal with the surge of patients, people experiencing homelessness often had few options. In the absence of such a structure which requires adequate resources to lead a truly coordinated response, profound efforts among an entire team of health care providers – hospitals, social and community service workers, labs, public health and others – were needed in order to develop a coordinated plan to respond to patients' needs. Furthermore, testing, contact tracing and isolation – all key tenets of an effective containment strategy – are extremely challenging for people experiencing homelessness because of unaddressed social determinants like having no identification or safe housing.

Mobilizing a collective response: How a group of providers stepped in to support this vulnerable population

Despite limited resources, collaborative efforts between community agencies, ED leadership, inpatient teams, laboratory services, and public health emerged to respond to this crisis. This led to improved care for this vulnerable community. 

These initiatives included new ways to identify outbreaks happening in shelters. These early warning systems helped trigger mass testing within shelter sites and tracing and isolation strategies in a timely fashion. Building contacts with local shelters helped to inform when there would be a large number of patients that would be sent for testing. There was also improved care for patients in isolation using social supports, and measures to address substance withdrawal.

At St. Michael's, the COVID Assessment Centre (CAC) expanded the screening criteria for COVID testing for people experiencing homelessness and shelter staff. The CAC also worked with shelters and the Family Health Teams at the hospital to carry out testing and coordinate post-testing care within the shelters. The hospital's ED chief, Dr. Carolyn Snider, worked with LKS-CHART, a healthcare data analytics team, to develop a Homelessness Dashboard which incorporates many lessons from the early days of the pandemic. It monitors recent swab results for patients, helps ensure a smooth pathway through their ED visit, and links the ED visits from the same shelter that might be happening to allow for coordinated contact tracing. 

A call to action: The vital need for a centralized approach in wave 2

Ongoing challenges exist and need to be addressed. Many patients have increased transiency and instability created by the pandemic, while others don't have identification or a valid health card, making tracing and following up on results challenging.  At times, care falls to hospitals that end up admitting patients even though they do not require this level of care simply because they don't have anywhere else to go.

As preparations for a second wave ramp up, we must have a proactive response that incorporates these lessons and continue to collaborate to fill the gaps of our health system. A centralized leadership structure is urgently needed. It requires a key command lead together with a multidisciplinary team of leaders from municipal and provincial public health, the city, the shelter system, community providers and acute care hospitals working collaboratively to effectively align efforts around testing, isolation and acute care capacity, and improved housing for prevention. During the first wave, we directly witnessed shelters' vulnerability to COVID-19 outbreaks, even though they are often the only alternative for people sleeping on the streets. They deserve safe options.

With hospitals now taking steps to address the surgical backlog, while also providing services for growing numbers of people seeking care in the ED, they cannot continue to serve as the stopgap in caring for patients experiencing homelessness. Hospitals also face ongoing and significant capacity pressures that have begun to mount once again due to limited long-term care space stemming from COVID-19 and rising numbers of alternate-level-of-care patients. This means reduced availability in hospital to provide isolation for patients during the pandemic. We also cannot run the risk of overwhelming our hospitals – we have seen the consequences of this in other jurisdictions. Recognizing and working with the needs of the community, supported by the leadership of a central command structure, will allow for a dignified response that fits within a public health strategy and improve care.

Learn more:

People experiencing homelessness were among the vulnerable, high-risk populations that needed unique health and social supports during the first wave of the pandemic. They will also continue to require a coordinated strategy during wave 2 and beyond. To learn more about this important topic, we have compiled a number of useful resources for further reading:

  • On August 3, 2020, the CBC's Front Burner broadcast an episode on Homeless encampments, COVID-19, and Canada's housing crisis, which featured an interview with Leilani Farha, former UN Special Rapporteur on the Right to Housing and Global Director of the housing advocacy organization, The Shift, along with experiences shared by a few residents who live in encampments in Toronto. While the entire podcast is of value, of key interest to this topic is segment: 5:14-9:32. Mentioned in the interview is Finland's example, which is the only country in the world that has reduced homelessness and is on track to reducing it by 2027. Complementary background by World Economic Forum (Feb. 3, 2018): WEForum- Here's How Finland Solved its Homelessness Problem.
  • In a St. Michael's Foundation COVID-19 podcast, Stephen Hwang, Director, MAP Centre for UrbanHealth Solutions at St. Michael's Hospital talks about research being done at MAP in response to COVID-19 and vulnerable populations. While the entire podcast is of value, of key interest to this topic is segment: 14:37-17:28. .