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Surveying Tenants of Permanent Supportive Housing in Skid Row about COVID-19

By: Ben Henwood, PhD

We analyzed survey results collected from 532 Permanent Supportive Housing (PSH) tenants in Los Angeles, California during the 4th week of March in 2020. Results show that nearly all tenants were aware of COVID-19 and 65% considered it to be a very serious health threat, which was a strong predictor of taking protective measures (i.e. hand washing and social distancing).

Living in shelters or on the streets makes protective measures including social distancing and handwashing difficult and high rates of underlying health conditions, including obstructive lung disease, increases vulnerability. In 2019, the United States had more than 369,000 PSH units that can provide an opportunity for social distancing. Older units such as single-room occupancy (SRO) with shared bathroom facilities, however, may make social distancing more challenging.

In our study, staff members from one of the largest providers of PSH in Los Angeles conducted phone surveys with tenants who lived in either a studio apartment or an SRO with shared bathroom facilities. Tenant responses were inputted to a survey tool and analyzed to guide programmatic response to tenant needs. Our findings indicate that targeted outreach may be needed further to reduce risk. For example, we found that male tenants had lower odds of perceiving COVID-19 as a serious health threat, which is consistent with prior literature. We also found that tenants with a mental health diagnosis, in particular, had lower odds of washing their hands consistently, which may speak to the need for increased mental health support and interventions that target daily functioning.

Our paper recognizes, while lack of capacity may result in symptom-triggered testing approaches in PSH, recent reports from shelter settings demonstrates that universal testing would be required to identify the high proportion of mild, pre-symptomatic, and asymptomatic cases, which are suspected to play a major role in COVID-19 transmission. The fact that PSH tenants exhibit premature aging, early onset of geriatric conditions, and require in-home supports suggests that risk within PSH may be elevated, particularly in single-site programs where all tenants in the same building receive support services, as opposed to scatter-site programs where units are located in the community by private landlords. Yet single-site may PSH may also facilitate access to healthcare and COVID-19 information. Our team has designed a study to examine the comparative effectiveness of single- versus scatter-site PSH in reducing COVID-19 risk behaviors and transmission.

Benjamin Henwood, PhD, LCSW, is a recognized expert in health and housing services research whose work connects clinical interventions with social policy. Dr. Henwood has specific expertise in improving care for adults experiencing homelessness and serious mental illness, as well as in the integration of primary and behavioral health care.

Being a Social Worker in a Time of Social Distancing

By: Tara Ryan-DeDominicis, LCSW 

With 3,446,291 confirmed cases of COVID-19 worldwide and 1,092,815 confirmed cases in the United States, I do not think any of us would have believed the statistics we are seeing now even one month ago (Center for Disease Control,  2020). There are currently 123,717 confirmed cases in my home state of New Jersey where I am a social worker in the field of homelessness (CDC, 2020). There are currently 8,864 people in the state of New Jersey who are considered homeless (NJ211, 2020).  Considering the difficulties accessing this population, that number is considered a low estimate by many of us who work in this field. Persons who are homeless are already at greater risk than their non homeless peers for significant health issues including pulmonary disease, respiratory infections, tuberculosis, and HIV (Hwang, 2001). Additionally, before this pandemic, persons who are homeless experience hospitalization five times more than the general community (Hwang, 2001). These medical disparities and lack of general wellness including lack of access to nutritious meals, insufficient sleep and inability to properly social distance (National Alliance to End Homelessness, 2020) make for a very at risk population during the time of COVID-19. Even those who are in homeless shelters during this time are unable to properly remain socially distant due to shelter overcrowding and with bunk beds, in many cases less than two feet apart (Jan & Johnson, 2020). In this post I hope to share my first hand perspective as a social worker in homeless services during the time of COVID. 

I am in the field of homelessness and am often a resource to answer questions specifically about unemployment, health insurance and health care, housing assistance etc. Although sometimes difficult, I could always find an answer. Currently, finding answers has become increasingly difficult. Myself and many social workers are facing questions we do not know how to respond to and have been introduced to a problem so large it has changed the systems we once knew how to navigate. “All the shelters are closing their doors, where do I go?” “ I cannot get through to unemployment on the phone, what do I do now?” “ How do I socially distance myself in a tent city?”. These are but a few examples of how the homeless population is struggling with an already limited amount of resources in the face of the pandemic. 

 While I spend my days trying to get my guests the best and most honest answers I can to their questions, I keep glancing at the sticky note I placed on my laptop: “Physically distant. NOT emotionally distant. NOT spiritually distance, NOT compassionately distant.”  In this time of unprecedented uncertainty, I put all my efforts into what I can control for myself and for guests. I am no longer able to offer the warmth and safety of our large dining room, where guests can charge their phones, wash up in the restroom or escape the rain. I am no longer able to offer interactions between our guests and our staff and volunteers who are a source of comfort and socialization while they enjoy a hot meal. During this time of social distancing we are able to provide bagged lunches and groceries to the line of socially distanced individuals standing six feet apart outside our door, as new restrictions prevent guests from entering our facility. My agency was often a place where guests were able to have a hot meal, socialize, and most importantly were offered a break from the elements of living outside–this shift has been an adjustment for our guests, but also the social workers and how we work with them. We are able to provide the meals in white paper bags instead of large blue plates and we are still providing social services via text message or phone call instead of sitting side by side. Both provider and guest have acknowledged that this is not the same. However, despite not being able to be near them, it does not mean we cannot remain close to them.

I am trying to do whatever can be done to maintain connection with my population during this time of crisis–a population already facing loneliness and isolation (Dej, 2016). For me that has ranged from FaceTiming a guest to make sure they are taking their medicine to praying the rosary with a scared guest over the phone. Showing I am still here by putting a cupcake in a guest’s lunch because she is turning thirty years old today with no one to celebrate with and using petty cash to send dog food to a guest who is unable to go to the store for her pet. These attempts to remain connected to my guests on an individual level are in addition to efforts on a larger scale between my agency, the county and other community resources. We all have the same goal  to access testing for the homeless population, locate any available shelter or motel beds and ensure anyone living outside has the supplies they need. In an effort to remain as consistent as possible with services already available to this population, the state of New Jersey has taken measures such as extending all emergency assistance through April 30th, working with shelters to enhance cleaning policies recommended by the CDC and covering all COVID- 19 related services and testing through NJ FamilyCare/Medicaid (N.J.Department of Human Services, 2020).

These times are uncertain and I cannot promise my guests as much as I would like. I am unable to provide our individual mindfulness counseling to our guests who struggle with trauma or our music therapy that so many of our guests look forward to. It takes me longer to navigate the systems that are put in place to assist this population such as benefit enrollment and direct service connection.  I am still searching, researching, and sitting with many questions I hope to be able to answer for them. What I can promise them is that I will be there, I will answer the text, I will pray with them, cry with them, and laugh with them until we are together again. I will advocate to the local government and community for their needs and spend hours on the phone adjusting our systems to allow for easier access and more complete services for all our vulnerable guests. What I can promise is in this time of social distancing, is I will still be there.  

References: 

Center for Disease Control and Prevention. Cases of coronavirus disease (COVID-19) in the U.S. (2020). Cases in the U.S. Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html

Dej, E. (2016). Psychocentrism and homelessness: The pathologization / responsibilization paradox. Mental Health & Distress as a Social Justice Issue, 10(1), 1-19. https://doi.org/10.26522/ssj.v10i1.1349 

Hwang,S.W. (2001) Homelessness and health. Canadian Medical Association Journal, 164 (2), 229-233. Retrieved from www.cmaj.ca/content/cmaj/164/2/229.full.pdf

Jan, T., & Johnson, J. (2020, April 14). Hotels sit vacant during the pandemic. But some locals don’t want homeless people moving in. The Washington Post. Retrieved from https://www.washingtonpost.com/business/2020/04/14/homeless-hotels-coronavirus/

National Alliance to End Homlessness. (2020). Population At- Risk:Homelessness and the COVID-19 Crisis. Retrieved from https://endhomelessness.org/resource/fact-sheet-population-at-rick-homelessness-and-the-covid-19-crisis/

New Jersey Department of Human Services. Press Releases. (2020). NJ Human Services Works to Protect & Help Maintain Continued Benefits for Residents Amid COVID-19 Outbreak. Retrieved from https://www.state.nj.us/humanservices/news/press/2020/approved/20200318b.html 

NJ211. (2020). Homeless in New Jersey. Retrieved from  https://www.nj211.org/homeless-new-jersey

Bio: 

Tara Ryan- DeDominicis is a LCSW in New Jersey and a DSW student at Rutgers University.  Tara is the Director of Programs and Services at nourish.NJ and serves on the social work advisory councils for Sacred Heart University and the College of Saint Elizabeth.

Recent Publication: Ryan-DeDominicis, T. A Case Study Using Shame Resilience Theory: Walking Each Other Home. Clin Soc Work J (2020) doi:10.1007/s10615-019-00745-9

Collaborative, Proactive Approaches to Mitigating the Spread of COVID-19 among Individuals Experiencing Homelessness – An Example from the Field

By Courtney Conley, P.h.D.

One of the most feared eventualities of COVID-19 recently became a reality when San Francisco reported on April 11 the novel coronavirus had begun to spread through its homeless population. The institutional living environments which characterize most emergency shelters mean that containing the spread, in the absence of widespread testing, is particularly challenging. Moreover, individuals who are experiencing homelessness maybe some of those at greatest risk of death due to the novel coronavirus as they often have multiple co-morbidities, such as Type II diabetes, hypertension, respiratory illnesses, and obesity and malnutrition, all which compromise the immune system. 

Homeless service providers have long mitigated the risk of infectious diseases in emergency shelter environments through rigorous testing procedures that control the spread of viral infections such as tuberculosis, HIV/AIDS, and hepatitis A and C. In the absence of adequate supplies of testing for COVID-19, however, homeless service providers in communities throughout the US were caught scrambling to respond. In further irony, the strategy of social distancing means that individuals experiencing homelessness have nearly nowhere to go and their access to opportunities, already limited, have been nearly eliminated. For many, unresolved trauma could mean that the social isolation and psychological stress of the pandemic could further weaken the immune system and physical resilience. In sum, homeless service providers are tasked with flattening the curve in the homeless population, before it even begins.

The City of Knoxville in East Tennessee has demonstrated impressive success in facing these challenges. Responding proactively and in a coordinated manner, Knoxville funded The Guest House in early April as an 18-room COVID-19-dedicated shelter for individuals experiencing homelessness who may test positive for COVID-19. The coordinated, city-wide approach has meant that individuals shelters are not duplicating efforts, and the community is maximizing the efficiency of its housing and funding resources. Moreover, HUD has issued clear guidelines on how to utilize homeless management information systems (HMIS) proactively to track cases, while maintaining client privacy.  The Knoxville-Knox County CoC has long partnered with the Social Work Office of Research and Public Service at the University of Tennessee to operate a robust HMIS with nearly 100% participation among service providers. This proactive coordination enabled the KnoxHMIS staff to swiftly adapt the system as a tool for communication and collaboration among area emergency shelter, street outreach, and healthcare workers to communicate symptomology and testing specific to persons who are experiencing homelessness and may be eligible for The Guest House.  Basic demographic and testing status information are included in the program’s data set.  Along with limited demographic information, there is basic reporting that aids in daily communication of discharge status. This program has locked visibility in KnoxHMIS and is only shared with emergency shelter, street outreach, and participating partner healthcare facilities.  

The nature of public health is that the most successful efforts are often invisible – it’s hard to prove what didn’t happen. Still, if local communities like Knoxville continue their proactive and collaborative efforts, we can limit the spread of COVID-19 in our most vulnerable populations. 

As for homeless research, the time is now for more scenario planning, as well as how to mitigate social isolation among already marginalized communities in the context of a pandemic and widespread social distancing. COVID-19 has revealed just how interconnected humans are across the globe, and how supporting all members of our communities makes us all more resilient, physically, psychologically, and emotionally. 

Author Biography: Dr. Courtney Cronley is an Associate Professor at the University of Tennessee, Knoxville College of Social Work. Her research centers on the impact of trauma in the lives of women experiencing homelessness, health disparities, and changing the built environment to promote better outcomes for individuals experiencing homelessness. She teaches graduate research methods courses and statistics, as well as health policy and social justice.  

Social Workers, COVID-19, and Homelessness

by Stephanie Duncan, LCSW and Jordan Dyett

As Social Workers, we were certainly given one of the most significant tests during Social Work Month worldwide. As we know a pandemic, known as Coronavirus (COVID-19) has hit the streets. While witnessing our streets empty, worldwide Social Workers and others in the helping professions are challenged with serving those who are sick while also keeping in mind our own safety. Social workers generally rely on human contact in order to provide service and assist the most vulnerable population groups – and working remotely is not always an option for all of us.

The media and new federal restrictions of staying indoors may cause fears in many of our clients, particularly children, older adults, people who are homeless,  people with chronic disease and with mental illness. COVID-19 primarily affects older adults and those who have compounding disabilities — characteristics included among the homeless population. Moreover, many individuals who are homeless live in large housing facilities such as congregate shelters, while others live on the streets, making not only this group of people vulnerable to COVID-19, but also others who may be working with or encounter them. Homeless providers worldwide are faced with a unique opportunity to protect the health of this vulnerable population and advocate for all possible measures to do so. 

Preparing for this major outbreak is on the minds of many providers whether they work primarily with people experiencing homelessness who are in a homeless service agency or are within the other larger systems such as hospitals, mental health agencies and substance use clinics. Calculations by the CDC suggest that 2.4 million to 21 million  people worldwide could require hospitalization, with only 925,000 beds available and one tenth for the critically ill (Fink 2020). Large cities in the United States such as Phoenix, Portland, Washington D.C. cities across California, and New York City all have significantly high homeless populations, all of whom are vulnerable to an outbreak (Fuller 2020). In addition, bad health and significant respiratory problems are major factors in contracting COVID-19. Prior to the outbreak, the homeless experienced higher rates of death compared to the general population, in part because of lack of access to sanitation, overcrowded shelters, and chronic illness or respiratory problems  (Boonyaratanakornkit et al, 2019). With such large numbers anticipated of those who will become infected, many providers are not only concerned with the welfare of their clients but also their own. Worldwide, we hear the recommendation of “social distancing” and “work from home.” Yet, it is not always feasible. People experiencing homelessness by definition have nowhere to go, and currently the greater population has been instructed to social distance and stay indoors (Fuller 2020). The other challenge we face as providers is when someone tests positive and has nowhere to go, and hospitals are filling up – -what do we do and where do we send people? 

While our media concentrates on what is unraveling as infections of COVID-19 increase, our national policy has yet to foster another narrative regarding the homeless. In the recent $8.3 billion bill passed by Congress, there were no funds specifically allotted to homelessness — communities may not be able to expand shelter space nor pay for more service providers without additional resources (Kim, 2020).  The homeless have so many competing, unmet needs, making it more difficult for them to contend with this pandemic (Morse, 2020). Alison Eisinger, Executive Director at the Seattle-King County Coalition on Homelessness stated the most pressing issue has always been housing, and this pandemic is shedding light on how this is still the most important need for the homeless. (Morse, 2020). We know prejudices already exist against those experiencing homelessness, and the federal government demonstrates this prejudice by largely ignoring their existence and offering no additional assistance to people living without stable housing. 

As social workers and faculty our jobs are to think outside the box and help those who may need assistance even if we are social distancing while doing so. It is recommended that in larger settings employees work in shifts to decrease the amount of workers when possible or offer remote work. Please continue to educate others surrounding the topic of homelessness and help shift the discourse surrounding this population towards helping the most vulnerable rather than blaming. Please also find a letter in the resources section below from the Coalition of Human Needs to our Senate — this is an example of how to shed positive light and advocate for people experiencing homelessness. Consider being a positive voice on behalf of the homeless, whether it’s sending a letter to the Senate, blog posting or stimulating positive discussion about the needs of people who are homeless in your own community.

Resources (Many of these links contain a long list of resources and materials on the Coronavirus and homelessness for providers):

The Disaster Housing Recovery Coalition will lead recurring national calls on Coronavirus and Homelessness/Housing every Monday at 2:30pmET until Congress includes housing and homelessness resources in the COVID-19 stimulus package. 

National Alliance to End Homelessness is providing resources and updating as they come available on their website: https://endhomelessness.org/coronavirus-and-homelessness/

Yale School of Medicine has created a guide for clinicians working in opioid treatment programs: https://drive.google.com/file/d/1ONbz6AFb5KSjrfhSudRb4-9nPZHBh1RT/view

The Coalition on Human Needs has written a letter to the Senate addressing this topic: https://www.chn.org/wp-content/uploads/2020/03/CHN-print-version-COVID-19-senate-letter-3-13-20.pdf

Novogradic Consulting has a new blog post with policies from state allocating agencies.

Org Code has posted a blog post to stimulate discussion in your local community about COVID-19 and the homeless: https://www.orgcode.com/pandemic_planning_and_services_that_support_people_who_are_homeless

References

Boonyaratanakornkit, J., Ekici, S., Magaret, A., Gustafson, K., Scott, E., Haglund, M., Kuypers, J., Pergamit, R., Lynch, J., & Chu, H. Y. (2019). Respiratory Syncytial Virus Infection in Homeless Populations, Washington, USA. Emerging infectious diseases, 25(7), 1408–1411. https://doi.org/10.3201/eid2507.181261

Fink, S. (2020, March 13). The Worst-Case Estimate for U.S. Coronavirus Deaths. Retrieved from https://www.nytimes.com/2020/03/13/us/coronavirus-deaths-estimate.html

Fuller, T. (March 10, 2020). Coronavirus outbreak has America’s homeless at risk of a disaster. The new york times.  

Kim, C. (2020, March 18). During the Covid-19 pandemic, nowhere is safe for homeless people. Retrieved from https://www.vox.com/2020/3/18/21183812/covid-19-coronavirus-homeless

Morse, I. (March, 2020). Homeless amid the coronavirus outbreak. Aljazeera news. retrieved from https://www.aljazeera.com/news/2020/03/homeless-coronavirus-outbreak-200311121536154.html 

Stephanie Duncan serves as the National Center’s Project Coordinator, Please find a more detailed bio in the Meet our Staff section. She has worked for several years in program evaluation and research, and as well as working as a clinician in homeless service agencies. 

Helping Homeless Through Business Improvement Districts

By Wonhyung Lee, PhD


There are more than 1,000 business improvement districts across the U.S., and the number continues to grow. Business improvement districts, or BIDs, are formed when property or business owners agree to pay and make collective efforts to take care of the area by themselves.

Each BID makes its own decision about how to manage the area through services like street cleaning, security, and marketing. As a result, many cities are now divided up by the boundaries of BIDs and maintained at a district level.

My recent research focused on how BIDs approach homeless populations. Because BIDs typically represent the interests of the business community, BIDs are often understood as forces behind anti-homeless policies.

However, I found that the approaches that BIDs take to deal with homelessness could vastly differ from district to district. In my study in Washington, D.C., I focused on the BIDs that have sought collaborative, long-term approaches toward homelessness, which I categorize into three dimensions.

First, BIDs make excellent advocates for the housing-first policy from an economic and investment point of view for the city. Second, BIDs are naturally positioned to mediate the private and public interests where business owners, residents, activists, and law enforcement officers could share information and work together. Third, BIDs are capable of providing direct services such as street outreach, service referrals, and even job opportunities for homeless populations. These examples show that BIDs can play a different role in addressing homelessness and improve the relationship between the business community and homeless populations

This content is also available in the recent academic minute (1/9/2020). An expanded discussion was aired through UAlbany Podcast: The Changing Role of Business Improvement Districts. The actual study is available in her article (2018): “Downtown Management and Homelessness: The Versatile Roles of Business Improvement Districts.” Journal of Place Management and Development 11 (4): 411-427. 

–Dr. Wonhyung Lee is a Professor at one of our partner schools, the School of Social Welfare at the State University of New York at Albany. She holds a Ph.D. in Urban and Regional Planning and an MSW in Social Work. With these, she takes an interdisciplinary approach to her research. Dr. Lee’s research centers around community development and engagement, with a specific interest in the process of neighborhood revitalization in disadvantaged communities.   Dr. Lee is currently co-leading an NSF-funded project on Smart and Connected Communities with a goal of developing a technology that can improve the communication between service-seekers and service-providers.