San Diego County is a region that spans 4,500 square miles and has a diverse population of 3.3 million residents. According to the annual Point in Time Homeless Count, there are 7,658 people experiencing homelessness living in San Diego County in 2020; 3,971 of those individuals are living unsheltered. In recent years, County of San Diego Health and Human Services Agency (HHSA) Regional Operations have been expanding homeless outreach services and building collaborations with various partners across the county. When it comes to homeless services, collaboration is the key to successful outcomes. HHSA has long-standing partnerships with various jurisdictions, law enforcement agencies, internal County departments, community organizations and health agencies that serve people experiencing homelessness. These partnerships, which existed long before COVID-19, have been strengthened during the pandemic. In early March 2020, the County and its partners were able to mobilize quickly to develop comprehensive plans to prevent the spread of COVID-19 among people experiencing homelessness. The development and implementation of these plans occurred prior to the first cases of coronavirus arriving in San Diego County. Early interventions included COVID-19 screenings in the local emergency shelters, deploying County public health nurses with local homeless outreach teams, securing hotel rooms for quarantine and isolation, and more. These interventions resulted in low numbers of infection among individuals experiencing homelessness across the County during the pandemic. County of San Diego developed and activated various Sectors as part of the initial Emergency Response to the COVID-19 pandemic. One of the Sectors was the COVID-19 Homeless Sector, which was tasked with dispersing COVID-19 information to organizations and partners serving the homeless, as well as directly to people experiencing homelessness. Critical information and best practices were shared via Homeless Sector public telebriefings, Sector e-blasts, County printed materials, County news channels, social media, press conferences, and more. 

The County of San Diego COVID-19 Homeless Sector was tasked with dispersing COVID-19 information to organizations and partners serving the homeless, as well as to people experiencing homelessness. Critical information and best practices were shared via Homeless Sector public telebriefings, Sector e-blasts, County printed materials, County news channels, social media, press conferences, and more.

To support individuals experiencing homelessness and prevent the spread of COVID-19, the Homeless Sector identified locations around the San Diego County region where handwashing stations and portable toilets were installed near known encampments. Additionally, in early March, the Homeless Sector team identified a need in the homeless community for COVID-19 Prevention Hygiene Kits. Some kit supplies are purchased by the County and some are donated. The kits initially included a COVID-19 informational post card in English and Spanish, face coverings, hand sanitizer, antiseptic wipes, soap, water, and band-aids. As the pandemic evolved, additional needs were identified by Homeless Sector stakeholders, and the kits were expanded to meet those needs. New items included: information on HHSA Behavioral Health Services and COVID-19 Testing and Flu Clinics. As the pandemic continues to evolve, the COVID-19 Prevention Hygiene Kits will continue to expand, for example, as more information is shared about the COVID-19 vaccine, new kits will include this information. 

The Homeless Sector partnered with the HHSA Regional Homeless Services teams to assemble the hygiene kits. Once the kits were assembled and transported to County facilities and partner organizations across the region, they were given to unsheltered individuals by the County’s street outreach teams, the County’s Public Health Nurses, or by other community organizations conducting street outreach to people experiencing homelessness. The County partnered with 66 community organizations (homeless services providers, homeless outreach staff, non-profits, charity, and faith-based organizations) to help distribute the COVID-19 prevention hygiene kits in all areas of the County. The team from HHSA Central & South Regions Homeless Services continues to lead the efforts in assembly and delivery of kits with the help of staff from the County’s COVID-19 Homeless Sector.

Since March 2020, over 20,000 COVID-19 Prevention Hygiene Kits have been distributed to unsheltered individuals across the region.

By reaching one of San Diego County’s most vulnerable populations, these hygiene kits have been a useful education and outreach tool for unsheltered individuals and the response from the recipients has been overwhelmingly positive. This effort has been very well received by community partners that serve people experiencing homelessness; 94% of participants on a November 2020 Homeless Sector telebriefing indicated in an anonymous poll that they wanted the program to continue. Outreach staff have come to rely on the hygiene kits to fight the spread of the virus within this vulnerable population, and the kits also serve as an engagement tool to start the conversation with someone who is living on the streets.

In March 2020, during the early days of the pandemic, County staff had been reassigned to support roles in the COVID-19 Homeless Sector to bolster communication efforts between homeless service providers, HHSA staff, city administrators, and homeless outreach workers on the ground. The Homeless Sector began holding weekly public telebriefings through the Zoom videoconferencing platform that provided a collaborative space for key stakeholders to share best practices, discuss challenges they were facing, ask questions, and innovate together about how to adapt service delivery to fit within the new COVID-19 regulations. The weekly telebriefings and e-blasts reach over 500 recipients, and were the primary methods used to coordinate the initial hygiene kit distribution network. Feedback provided to HHSA during these telebriefings resulted in the inclusion of feminine hygiene products to support females experiencing homelessness and power banks so that clients could charge their phones and keep in contact with outreach workers. Power banks were an essential item to incorporate into the kits because libraries were no longer open to charge devices or to use as meeting places to conduct outreach appointments. These hygiene kits served a dual purpose, they provided the clients with resources to sanitize, and also established trust with the outreach workers.

Streamlining the process and centralizing the distribution of kits helped to reduce unnecessary interactions and possible exposures among staff and volunteers. To accomplish a streamlined approach, the Homeless Sector partnered with a local charitable organization who donates meals for the unsheltered and are located in key sites around the county. They offered their two distribution sites for outreach staff to pick up hygiene kits.

The Centers for Disease Control and Prevention has recommended the use of facial coverings and hand washing as often as possible to reduce the spread of COVID-19. By providing these products to the homeless population along with COVID-19 informational post cards in the COVID-19 prevention kits on a consistent and regular basis, people experiencing homelessness are provided the tools to use evidence-based precautions in lowering the risk of contracting or spreading the virus.

County of San Diego COVID-19 Homeless Sector brings together a diverse group of community leaders, stakeholders, and residents who are representative of a community that is engaged in efforts to: help educate and mobilize communities, develop and address their priority needs, identify resources,  plan actions to improve the health of the community, and improve outcomes for our neighbors without homes. Members represent diverse generations and community groups, Cities and government agencies, community and nonprofit organizations, health centers, schools, and advocacy groups that all serve unsheltered individuals. Community partners have been instrumental in the planning, assembly, and distribution of COVID-19 prevention hygiene kits throughout the county. The idea was developed early in the pandemic with the help of community stakeholders involved in the Homeless Sector. It was developed in response to the increasing risk of the COVID-19 virus and the need to act prioritize prevention. The items included in the hygiene kits were identified and discussed during the community telebriefings that took place each week where anyone working with the homeless population was able to access decision makers and request to be included in the distribution process. Early on the Homeless Sector learned that providers who typically distribute feminine hygiene products to unhoused individuals, had limited availability amidst the pandemic. Based on this need, feminine hygiene products were added to the kits, including sanitary pads and tampons. One outreach worker described an experience where they were working with an unsheltered woman who was not accessing shelter services. The outreach worker handed her a hygiene kit and prepared to leave. The woman embraced the kit, held it close to her chest, and started to cry in gratitude. These interactions allow the outreach teams to build rapport with their clients and increase the likelihood that they might be able to refer them to additional services when the client is ready. As the number of hygiene kits being distributed has continued to grow, community partners are engaged to streamline the distribution process while staff work to optimize the assembly process and bring down costs. A San Diego State University Public Health Undergraduate Intern helped the Homeless Sector in conducting a cost analysis of the hygiene kits from inception through December 2020 which helped with cost analysis and budget planning  This document is now being used internally for tracking supplies and costs of the kits and has replaced previous tracking methods.

County of San Diego COVID-19 Homeless Sector holds regular public telebriefings, provides a weekly e-blast to over 500 recipients that connect stakeholders to COVID-19 resources including: best practices, recent health orders, funding opportunities, local news, opportunities to make requests for hygiene kits, and for collaboration in serving the homeless population in San Diego County. New challenges or successes are highlighted and shared with the sector and discussed so that barriers can be addressed, and plans can be implemented. Frequently asked questions are noted and catalogued on the local County website and referenced in all communication channels, which are updated regularly. These open platforms have led to new items being included in hygiene kits, additional distribution channels, and an increased reach as more partners are able to access County resources.

Organizations that have connected via the Homeless Sector’s online platforms have gone on to create new partnerships that allow a more coordinated service delivery system. Meal distributions programs now include hygiene kits in their meal delivery, mobile shower programs have shelters they can refer to, and homeless outreach teams partner with law enforcement to bring people directly to temporary lodging resources. The County partnership with SDSU School of Public Health to offer internships to students who now serve essential roles in supporting COVID-19 related efforts throughout the sectors. In Homeless Sector, the internship project has brought learning opportunities and in the case of the hygiene kits, a dedicated intern to support analysis of the project staffing and material costs.

All efforts to address people experiencing homelessness also address health equity. Extensive work has been done via hygiene kits and many other interventions to educate and protect this vulnerable population, to engage them and provide referrals to housing and other services. The example provided about the woman who received a female specific hygiene kit is but one illustration. The impacts to social determinants of health are at the forefront of all work done in the Sector.

As COVID-19 regulations have changed throughout the pandemic, so have the hygiene kits. Items have been added or removed based on the feedback received from the community, as well as the requirements in stopping the spread of the virus. When the California Governor made facial coverings a requirement to wear in public, face coverings were added to the hygiene kits and distributed to organizations that had regular contact with people experiencing homelessness. When libraries closed and clients could no longer charge their phones or access the internet in those facilities, the Homeless Sector advocated to purchase power banks so that clients could recharge their phones and stay connected to their service providers. Providing female hygiene kits is another response to the need of females experiencing homelessness. Sector staff would also update information cards depicting the latest guidelines in accordance with the public health orders. As the pandemic surged in November and December, the production of kits increased accordingly. In December alone, as cases grew significantly, over 3,000 kits were distributed via 66 outreach agencies to unsheltered in all areas of the County.

Supplies for the kits were purchased using County funds set aside for COVID-19-related expenses. Procedures that have been adapted to maintain the program include the coordination of staff and volunteers to assemble an average of 2,000 hygiene kits per month. Some items for the hygiene kits are provided from the State, other through donations to the County and other resources. Together, these partnerships and resources have enabled an increased number of produced kits.  

Lessons learned from this program include recognizing the value in creating a collaborative space for community partners to share best practices and discuss solutions to challenges that they are facing. Providing these platforms allows for new partnerships to form as organizations draw upon each other’s strengths to deliver the best possible outcomes for their clients. The 20,000 hygiene kits distributed to date have helped keep cases low within the homeless population and has kept valuable ICU beds open for other patients. The COVID-19 Prevention Hygiene Kit Distribution program has provided cleanliness, compassion, and dignity to people during a time when other services were interrupted. There is a current evaluation project underway to conduct focus groups with people experiencing homelessness that will include asking about the hygiene kits and what items are the most useful. As of 12/18/2020, COVID-19 numbers among persons experiencing homelessness have remained relatively low given their risk, with a total of 665 cases and 7 deaths (data as of 12/18/2020).

Our practice implemented quality improvement since the beginning of this effort. As public health orders and rules changed, we adapted our kits and information to align with those. We asked our partners for feedback and implemented new items as recommended. We implemented cost savings based on analysis. We use poll questions regularly in our telebriefings to poll participants and utilize data to guide our practice. We have started focus groups with persons experiencing homelessness to gather feedback on our interventions and help guide future ones.