Sheltering people experiencing homelessness in a pandemic: Lessons learned
More than 1,000 people experiencing homelessness have been given a dignified place to stay in these last few months. How can we keep it going – and growing – post pandemic? These are three takeaways are shared by Health Commons Solutions Lab in collaboration with Dr. Gillian Kolla from a project launched by a group of Toronto healthcare, municipal and community partners – including Inner City Health Associates, Parkdale Queen West Community Health Centre and University Health Network – to establish COVID recovery sites for people experiencing homelessness who had tested positive for COVID-19.
The COVID-19 pandemic has created enormous risks for people experiencing homelessness.
To deal with the issue, several community consultations were held in April to surface ideas on the design and operation of recovery sites for people experiencing homelessness who test positive for COVID-19.
The initial concept was for a large congregate “field hospital” model. While potentially effective, efficient and risk-averse from a medical perspective, through consultations we heard from frontline workers, housing experts and harm reduction teams that this approach felt akin to “warehousing the homeless.” A congregate approach lacked the dignity that could only be gained from the provision of private space that would encourage people to remain at the site for the duration of their recovery.
After listening to community input, the ICHA leadership shifted its vision from a “field hospital” model to using hotels, where each person could have a private room and bathroom. Medical, nursing, community and harm reduction workers and peer workers would be onsite to meet potential needs of clients. Community partners said this model offered a more dignified way to provide housing, social services and health care.
Three hotels with almost 400 rooms using this model are now operational across Toronto to provide isolation and recovery sites for people experiencing homelessness who have been diagnosed with COVID-19 or have been in close contact with someone who has.
These hotel recovery programs are part of a broader effort across the city that has repurposed over a dozen hotels to provide shelter an additional 1,200 people experiencing homelessness. These additional sites have allowed greater physical distancing than is possible in existing shelters to reduce the risk of COVID-19 transmission.
We share three observations from the early success of the COVID recovery site program to inform broader conversations regarding the long-term housing needs of the more than 7,000 people experiencing homelessness in Toronto.
1. Large scale solutions to housing are possible
A few months ago, the idea that governments could rapidly re-house more than 1,200 people experiencing homelessness would have been almost unthinkable. Now, in the midst of a global pandemic, it has happened, making it clear that it is possible to house people quickly and with dignity. Even in Toronto, with its rental affordability crisis and low vacancy rate, creative solutions to liberate housing stock exist and are practical.
At this moment, some people who experienced homelessness in March have the dignity of a door that they can close and some rest from the relentless grind of a life with precarious housing.
Prior to the pandemic, the lack of urgency to address homelessness held us back from the implementation of concrete solutions. This moment can help demonstrate “what is possible” in ending homelessness.
2. Support all forms of care
The team at the recovery site is a mix of clinical staff, community and harm reduction workers and peer support workers. In the early days of planning the recovery site, images of Italy and Wuhan and the unknowns about the impact on the health of this community of clients – who often have other comorbidities – were the dominant point of reference, pushing the focus to a heavily medicalized model.
As the Toronto experience has progressed, it has become clear that most people at the recovery sites have subacute or asymptomatic COVID-19. This means that the most logical intervention is housing with social supports to help people stay in place, not a field hospital that treats critically ill patients.
Identifying housing as the intervention shifts the model of care. The role of community and harm reduction teams, and peer support workers in particular, can and must be elevated. The non-medical side effects – addressing boredom, uncertainty, anxiety and providing for basic needs – became the focus of care.
Peer workers epitomize the concept of non-medicalized and non-institutionalized support. They have the unique ability to understand peoples’ experiences and empathize in a way that clinical care providers cannot. In an integrated model, the seamless and complementary approaches give people options to receive the support they need.
Historically, peer workers have been undervalued in the healthcare and housing systems. This devaluing of their work makes them vulnerable, particularly when they are shouldering the greater share of direct client care. At the recovery sites, access to a living wage, supports, personal protective equipment and stable employment ensures that peers have what they need to do this important work.
3. Keep your hands on the wheel, eyes on the horizon
The healthcare community brings deep expertise in diagnosis and managing illness that has been useful in confronting COVID-19. Clinical teams are onsite to provide medical care for people at the recovery sites.
Interestingly, in our consultations with clients at the recovery sites, it was notable how infrequently they mentioned having COVID-19 as their primary concern. The people we spoke to didn’t focus on being sick with a potentially fatal illness, they worried instead about their precarious housing situation once their 14-day stay came to an end.
The recovery sites show what comprehensive, team-based care within housing might look like, particularly a model that privileges low threshold provision of care by peers, with more specialized supports available where needed. It exemplifies a reconfiguring of our assets to form a fit-for-purpose solution. But even as we lean into the difficult work of creating new interdisciplinary models of care, we must keep our eyes fixed on the long-term, stable solution: housing that builds or maintains community networks.
The most illuminating part of this experience is not what the system is capable of when we push past the excuses and reasons for inaction but how it has brought us so much closer to fulfilling our aspirations for a future without homelessness.
In the Toronto program, repurposing emptied hotels has created the possibility of shelter for people experiencing homelessness. Focusing on dignity, creating a culture of saying “yes” to people to help them meet their needs and expanding the stock of housing available to people experiencing homelessness has the potential to teach us lessons on addressing what has seemed to be an intractable problem.
This is a powerful moment to learn from and a model to advance post-COVID-19.