The homeless are among one of the most vulnerable groups of people impacted by COVID-19. Street homeless tend to fall under the higher risk category for severe COVID-19 disease, because they are more likely to be older male smokers, with many medical comorbidities, and — under pre-COVID-19 conditions — were 10 times more likely to die than the general population.
That means providing care to the homeless is even more vital amid a pandemic. To meet that need, Emma Lo, MD, Assistant Professor of Psychiatry and attending physician for the Street Psychiatry program at the Connecticut Mental Health Center (CMHC), has been continuing her work even in the face of challenges presented by the statewide stay-at-home order and social distancing.
Street Psychiatry is the mental health component of street medicine, and providers conduct outreach to unsheltered homeless people who live on the streets, in parks, under bridges, and in encampments, Lo explained. The goal is to improve access to mental health care, as well as engage those who are unlikely or unable to engage through traditional systems due to a variety of structural barriers, she said. The Street Psychiatry team at CMHC also brings therapy, medications, and even groups to people sleeping on the streets, and connects people with social services for basic needs.
But the COVID-19 pandemic has forced Lo and her team to change the ways they approach their work.
“Every patient encounter or situation has a flavor of COVID-19,” Lo said. “The pandemic has affected all aspects of care — from the way in which care is delivered, to the services available, to the medications available, to the decision-making behind sending someone to the hospital. Our patients are deeply affected by this crisis, both because of their inherent vulnerabilities and because of the services that have changed.”
Homeless patients are unable to follow the recommendations set forth by the Centers of Disease Control and Prevention, Lo said, because it’s nearly impossible to remain 6 feet apart in shelters or other public spaces. There is poor access to handwashing or hygiene. With no home to stay at, they can’t isolate at home, and they do not have access to face masks.
“Our patients are not only stressed about contracting the virus, but they bear the burden of the shutdowns very immediately and personally,” Lo said. “The anxiety of this uncertain future and threat to their very beings only begins to describe the emotional turmoil experienced by many of our clients, and we have already seen exacerbations of mental illness related to these devastating societal side effects of COVID-19.”
Providing Care to the Homeless During a Pandemic
When CMHC’s Street Psychiatry team has deployed over the last several weeks, patients have been approached from 6 feet away. Team members first explain the precautions they need to take, “which lies counter to the fairly intimate connections we try to build with people during normal times,” Lo said.
The team then screens a patient for symptoms before beginning conversations, and there’s a protocol in place for in the event someone screens positive. They distribute hygiene kits made by students containing homemade alcohol wipes and flyers that illustrate ways to prevent the virus and what to do if an individual has symptoms.
Additionally, the team’s outreach hours have been reduced from five to seven times each week, to once a week for two hours. That makes it difficult to find people they’re typically in regular contact with — especially because the majority of them do not have phones.
“We are taking the stance that we need to be public health ambassadors — especially now — and prevent our high-risk population from contracting the virus, which would be devastating,” Lo said. “Meanwhile, we recognize that mental health problems do not just pause during a pandemic, and may, in fact, be exacerbated during these difficult times. We ultimately know that our friends on the street are extremely vulnerable to the physical, social, and economic impact of the pandemic, and we need to protect them by modifying our outreach, but above all else, making sure that we do not abandon them during the times in which they likely need us most.”
Lo acknowledged the Street Psychiatry team's partners, including Cornell Scott-Hill Health Center’s Homeless Health Team, which provides primary care, urgent care, and mobile COVID-19 testing for homeless people, as well as the Outreach and Engagement Team, which handles case management and housing services for people experiencing homelessness. Both programs are still operating during the pandemic with adjusted services.
In addition to working both on and off site at CMHC, Lo is providing consultation to ShelterOne, a medical respite for homeless people who test positive for COVID-19 and don’t have a safe place to recover and isolate. Lo said the shelter has a capacity to serve up to 40 patients.
She helped design the organization’s behavioral health protocols, which aim to prepare the respite center for potential behavioral health emergencies, “as well as create the unique opportunity for folks to get connected to mental health treatment if they were not already,” she said.
“In designing this protocol, we noted a need for a psychiatrist, so I volunteered to serve as their psychiatric consultant along with the other psychiatrists on our team,” Lo said. “After that, our licensed clinical social worker and program manager became heavily involved in assisting the team with discharge planning and care coordination.”
Since ShelterOne opened, Lo has provided telehealth consultations to patients staying there, via donated tablets. Lo said while there hasn’t been a large demand for consultations, she’s found it helpful to have a video platform to know what the patient looks like in case CMHC’s Street Psychiatry team encounters them again in the future . Yale Psychiatry residents and Public Psychiatry Fellows have volunteered to help with the consultations, as well, Lo said.
“Patients at ShelterOne are certainly feeling marginalized and are being denied treatment, jobs, and shelter as a result of a history of COVID-19, even if they are now medically cleared,” Lo said.
COVID-19 Exacerbates Discrimination Against the Homeless
Lo said such patterns of discrimination against homeless people are, sadly, not unusual, but “it is only magnified during times like these when the poor do not have the luxury or choice of protecting themselves during ‘stay-at-home’ orders, and it makes me incredibly angry and sad for our society.”
One such instance was occurred at New Haven’s Union Station, a location where homeless people used to be able to sit during the day, and most of the night. Under the statewide shelter-in-place order, the train station quickly became one of the only public locations available to the homeless. Lo said while normally incredibly cooperative, the train station recently reduced its hours and have refused entry to anyone except ticketed passengers.
“This leaves homeless people with absolutely no place to go for even temporary shelter, during rain or cold, which is heartless and tragic in a time where the homeless are at their most vulnerable,” Lo said. “Having a place to sit inside is very little to ask during these trying times.”
“I have seen a lot of fear and disgust coming from the public viewing homeless people as dangerous and contaminated, which is not only unempathetic and false, but also counterproductive to the mission of keeping everyone safe,” Lo said.
Lo said while she and her colleagues are advocating and collaborating with the city of New Haven to devise alternatives, such as a makeshift drop-in center and hotels for the unsheltered homeless, “the solutions will not come fast enough to prevent people from having to sleep unprepared outdoors in rain and cold.”