The Florida Department of Health in Pinellas County (DOH-Pinellas) serves one of Florida's largest counties with a population of more than 920,000 residents (73.7% White Non-Hispanic, 9.9% Black, 7.5% White Hispanic; median age 48, 13% poverty rate). Open since 1936, it now has six locations and five school-based clinics staffed by 700 employees with services that range from controlling infectious diseases and ensuring safe drinking water to disaster preparedness and child care licensing, to primary care, dental services and more. In March 2020, Pinellas identified the need for a process for non-congregate sheltering of homeless individuals and families to mitigate the spread of COVID-19. A collaborative project was developed for hospitals and test sites to refer positive cases, contacts, and those pending results to hotels for isolation and quarantine with central intake by the Homeless Leadership Alliance, transportation, case management and behavioral health by Directions for Living, monitoring, medical care, investigations and surveillance by DOH-Pinellas and overall coordination and funding (via FEMA, HRSA, and food pantry donations) by Pinellas County Human Services. The goal of this project was to create a process to identify COVID-19 patients needing safe place to isolate or quarantine due to homelessness, assist in meeting their needs during isolation and quarantine, connect them to ongoing health care services, and discharge them to a safe place. Additionally, the County funded a shelter liaison position to complement this process with a goal to reduce the incidence and spread of COVID-19 within shelter settings for individuals who have been identified as homeless. The position incorporated in person infection control assessments and continued guidance to shelter coordinators across the county. By providing facility coordinators and staff with the appropriate guidance on identifying cases, conducting contact tracing and implementing hygiene recommendations such as hand washing, social distancing, and mask wearing, homeless shelters and facilities have been able to reduce the spread and transmission of COVID-19. The practice also provided the opportunity to coordinate and facilitate infection control guidance within settings where there is an elevated number of individuals experiencing homelessness outside of the shelter setting. This includes drug/rehab and behavioral health centers as well as correctional facilities. The project had a strong public health impact, with no major COVID-19 outbreaks at any homeless shelters in Pinellas County nor any documented secondary transmission among identified COVID-19 cases in shelter residents. The project also has the added benefit of addressing health inequities by connecting individuals to ongoing health care and housing. To date the project has served 136 homeless individuals via referrals from hospitals and DOH-Pinellas with 53 individuals that were not currently connected to health services at time of referral enrolled in the County’s Health Care for the Homeless Program and 30 individuals that were street homeless at time of referral were discharged to a shelter or housing. The key to this project’s success was collaboration and community partnerships along with continual efforts to improve the process. All partners meet via telephone three times per week for updates, planning, and QI efforts.
Our innovative practice is new to the field of public health because it was a new collaborative between nontraditional public health partners to mitigate the spread of an emerging infectious disease in homeless shelters through pooled community resouces and funding. Sheltering for COVID-19 looked very different and quickly exceed previously planned targeted sheltering of infectious disease outbreaks among small groups of individuals. Additionally, the project addressed new problem of ongoing hospital capcity limits and gave hospitals a safe option for discharging homeless clients needing a non congregate setting to isolate or quarantine. It also provided unique opportunity for shelter coordinators and staff to be educated and assisted in the implementation of COVID-19 infection control guidelines within their facility. At the beginning of the COVID-19 pandemic there were multiple concerns for the continuation of services within homeless shelters. One major concern was the high- risk nature of the population these shelters serve. Individuals experiencing homelessness may be elderly adults or have a variety of underlying health conditions that can put them at increased risk for illness if they contract COVID-19. This population is also considered underserved because of their low socioeconomic status and lack of access to resources. In addition, the congregate living setting of homeless shelters can potentially increase the risk of COVID-19 transmission. Many shelters expressed concern about having to close their doors to guests or greatly reduce the capacity at which they were providing services in order to mitigate the spread of COVID-19. There was also a lack of clear guidance for navigating and implementing the recommendations and guidelines within these unique settings. For instance, for an individual who lives at home, the CDC and state departments recommending quarantining or isolating within a room in the house to prevent infecting other household members. Within homeless shelters this may not be an option for residents depending on the layout and space available in each facility. This practice created mitigation strategies that provide direct support and guidance from the DOH for homeless shelter coordinators and service providers to reduce the transmission and spread of COVID-19 within their facilities. The community liaison position that was developed within this practice is new to the field of public health because it provides a direct line of contact between homeless shelters and the department of health for infection control strategies to improve health outcomes related to COVID-19. Currently in other counties within the state of Florida there are no other positions that provide this type of support or service to this population. Homeless services continue to be a priority for DOH-Pinellas. This practice quickly and creatively adapted to the emergency of COVID-19 in the homeless community by creating a position that was based off the epidemiology skills of COVID-19 investigators and contact tracing staff and developed a unique set of skills applicable to homeless shelter settings . Many of the assessments were conducted prior to report of any case of COVID-19 in the shelters with the intention of educating staff on prevention rather than control. However, if a case was identified at a shelter, the community liaison was able to provide quick and concise guidance for strategies to isolate the case and prevent an outbreak.
This practice utilizes a variety of existing tools and resources to provide personalized infection control recommendations to each participating shelter. The infection control assessment tool utilized by the community liaison is the COVID-19 Infection Control Inventory and Planning (ICIP) Tool for Homeless service providers. See attachments for Tools utilized. Homeless shelter providers were provided with a copy of the assessment and given the opportunity to meet directly with the community liaison for in-person walk through of the facility and follow up COVID-19 guidance based on the capacity and services provided. At the conclusion of each assessment shelter coordinators were also provided with electronic and physical copies of DOH and CDC resources related to their facility including informative wall hangings, screening guidelines, and detailed directions on how to complete quarantine or isolation within the facility if the spacing was appropriate. In addition, the community liaison worked directly with DOH and homeless leadership throughout the county to provide a safe place for identified cases or close contacts to a case to complete isolation or quarantine if the shelter they were residing at could not provide an adequate living space for them while also protecting non-infected residents.
A collaborative project was developed for hospitals and DOH-Pinellas test sites to refer positive cases, contacts, and those pending results to hotels for isolation and quarantine. Key partners were directly involved in the planning process and implementation and continue to meet several times per week for ongoing planning and quality improvement. Central intake of referrals to the hotel is done by the Homeless Leadership Alliance, the Pinellas Continuum of Care Lead Agency. Transportation, case management and behavioral health is provided by Directions for Living, a community mental health agency who is homeless street outreach provider and contracted to provided behavioral health services for the County's Health Care for the Homeless Program. Client monitoring, medical care and enrollment into Health Care for the Homeless Program, investigations and surveillance is done by us at DOH-Pinellas; we are also Pinellas County's contracted medical provider for the Health Care for the Homeless Program. Overall coordination and funding of project is done by Pinellas County Human Services. Human Services has been able to secure funing for hotel via FEMA, for health, case management, and behavioral health services through HRSA, and food via food pantry donations. See attached homeless flow document to see how all partners work together to ensure goal or project is met. The goal of this project being to create a process to identify COVID-19 patients needing a safe place to isolate or quarantine due to homelessness, assist in meeting their needs during isolation and quarantine, connect them to ongoing health care services, and discharge them to a safe place. These goals have been achieved through collaborative partnerships outlined. The project was able to successfully address health inequities by connecting individuals to ongoing health care and housing during and post isolation and quarantine as DOH-Pinellas and Directions for Living are services providers for the County's Health Care for the Homeless Program. Collaboration was fostered through ongoing communication with partners.
Additionally, the County funded a shelter liaison position for DOH-Pinellas via HRSA grant to complement this process with a goal to reduce the incidence and spread of COVID-19 within shelter and group settings for individuals who have been identified as homeless or transient. The position worked to foster collaboration with community stakeholder by incorporating in person infection control assessments and continued virtual guidance to shelter coordinators across the county. By providing facility coordinators and staff with the appropriate guidance on identifying cases, conducting contact tracing and implementing hygiene recommendations such as hand washing, social distancing, and mask wearing, homeless shelters and facilities have been able to reduce the spread and transmission of COVID-19. The practice also provided the opportunity to coordinate and facilitate infection control guidance within settings where there is an elevated number of individuals experiencing homelessness outside of the shelter setting. This includes drug/rehab and behavioral health centers as well as correctional facilties.
This project was continually adapted to meet the needs of the homeless population in Pinellas County throughout COVID-19. All key project partners meet via telephone three times per week for individual client updates, planning, and QI efforts. Additionally, DOH-Pinellas meets with all shelter providers routinely to keep them up to date on COVID-19 including changes to state and national guidelines. For example, in the early stages of COVID-19 the CDC recommended requiring two consecutive negative test results for individuals to return to group settings. As research progressed and resulted in a changed in the recommendations for testing, the way homeless shelters could accept new guests back from hotel also evolved. However, prior to communication with the shelter liaison, many shelter coordinators were unaware or unsure of how to implement new guidance into their daily procedures. The community liaison provided shelter coordinators with recommendations and guidelines that were specific to how their current procedures could be adapted and updated to safely continue to provide services.
In addition, many individuals who are homeless do not have a reliable form of communication or stable housing. The recommendations for isolation and quarantine for the general population typically rely on a case having a house to quarantine or isolate in and a phone to communicate guidance from investigator to the case. The presence of the shelter liaison creates an COVID case investigator who focuses specifically on this population and develops relationships with shelter coordinators to maintain communication with cases, conduct timely investigations for contact tracing and connects cases with community partners for safe housing to complete quarantine or isolation.
Throughout this program we have learned the importance of communication between community partners and the health department. With the help of this program quickly identifying and guiding isolation practices as well as the community resources that provided testing, housing, and health care there have not been any recorded outbreaks within shelter settings in Pinellas County. By providing a direct contact, the shelter liaison, shelters were able to effectively notify DOH-Pinellas when they had a confirmed or probable case and either receive guidance or incorporate the procedures previously discussed to isolate and prevent further spread within the shelter without hesitation. Additionally, the project had the added benefit of connecting individuals to ongoing health care and housing. To date the project has provided hotel for isolation and quarantine for 136 homeless individuals via referrals from hospitals and DOH-Pinellas with 53 individuals that were not currently connected to health services at time of referral enrolled in the County’s Health Care for the Homeless Program and 30 individuals that were street homeless at time of referral were discharged to a shelter or housing.
Infectious Disease Prevention and Control
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