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Community Outreach to Individuals Experiencing Homelessness During COVID-19


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Community Outreach to Individuals Experiencing Homelessness During COVID-19

  1. 1. Community Outreach to Individuals Experiencing Homelessness During COVID-19 November 18, 2020
  2. 2. CME Credit • Bridgeport Hospital Yale New Haven Health is accredited by the Connecticut State Medical Society to sponsor continuing medical education for physicians. The Bridgeport Hospital Yale New Haven Health designates this live activity for a maximum of one (1) AMA PRA Category 1 CreditsTM. Physicians should claim only credits commensurate with the extent of their participation in the various activities. • This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Bridgeport Hospital Yale New Haven Health and the Weitzman Institute. Bridgeport Hospital Yale New Haven Health is accredited by the Connecticut State Medical Society to provide continuing medical education for physicians. • The content of this activity is not related to products or services of an ACCME-defined commercial interest; therefore, no one in control of content has a relevant financial relationship to disclose and there is no potential for conflicts of interest.
  3. 3. Community Outreach to Individuals Experiencing Homelessness During COVID-19 18 Nov 2020
  4. 4. COVID-19 in the United States 11,344,154 cases on 11/17/20 up from 10,392,702 cases on 11/11/20 248,555 deaths
  5. 5.
  6. 6. 1 week ago: National trends – continue to worsen
  7. 7. News headlines Moderna’s Covid-19 vaccine (mRNA-1273) is strongly effective, early look at data show -reduced the risk of Covid-19 infection by 94.5% -approximately 30,000-patient study -no participants receiving vaccine had severe disease vs 11 in placebo Dr. Fauci: “very impressive” -no significant safety concerns Side effects: fatigue and muscle pain, headache and achiness -Pfizer vaccine last week: -more than 90% effective in preventing COVID-19 -no serious safety concerns have been observed -Safety and additional efficacy data continue to be collected - Submission for Emergency Use Authorization to the FDA planned ~ third week of November
  8. 8. News headlines • Bamlanivimab – Emergency Use Authorization – neutralizing IgG1 monoclonal antibody that binds to the receptor binding domain of the spike protein of SARS-CoV-2 • Only for mild to moderate COVID-19 in adults and pediatric patients 12 years who are at high risk for progressing to severe COVID-19 and/or hospitalization
  9. 9. Resources • Nuvance health 1600+ articles reviewed: • CDC: • WHO: • Johns Hopkins: • Others
  11. 11. SLIDE 13 BACKGROUND The disproportionate impact of COVID-19 among individuals experiencing poverty, individuals suffering from substance use and mental health disorders and communities of color has been well-documented. COVID-19 Disparities Underlying Health Conditions Decreased Access to Healthcare Employment in Essential Jobs = High Levels of Public Interaction Structural Issues Concentrated Poverty Cultural Beliefs and Values
  12. 12. SLIDE 14 DELAWARE ACTIVATION Covid-19 Homeless Community Outreach Partnership DHSS DSAMH Providers UD PHC University of Delaware, Partnership for Healthy Communities (PHC) • Directed the strategic operational plan for specialized outreach activation DHSS/Division of Substance Abuse and Mental Health (DSAMH) • Served as Co-lead in strategic management as well as developed the social support teams and facilitated social service integration with medical field teams DHSS/Division of State Service Centers (DSSC) and Division of Social Services (DSS) • Provided Emergency Assistance funds for hotel vouchers, rent, utilities and emergency shelter Core Strategic Entities
  13. 13. SLIDE 15 INTEGRATED DELIVERY MODEL Covid-19 Healthcare Organization Partnership Established Homeless Outreach Medical & Social Service Screenings Engagement in care services and addressing identified needs related to the Social Determinants of Health Transitional Housing Strategy Development Implementation Continued Treatment Seamless Access Strategy Long-term Housing & Support Services
  14. 14. SLIDE 16 SCREENING APPROACH Outreach team engaged 2,528 homeless individuals to: 1. Identify if viral activity was present among the homeless 2. Screen for social determinants of health needs 3. Triage and shelter those homeless who were extremely vulnerably to the acuity of COVID-19 if exposed to the virus
  15. 15. SLIDE 17 Screening Presumed Negative High Risk Social Services Team non-COVID-19 hotel/motel/shelter Low Risk Social distancing, cleaning and re- screening Presumed Positive Social Services Referral Medical Follow-up COVID+ Hotel SCREENING AND DIAGNOSIS
  16. 16. SLIDE 18 SERVICE FUNCTIONS  Infection Prevention and Treatment  Shelter / Hotel/ Housing  Social Services & Supports Infection Prevention & Treatment Shelter/ Hotel/ Housing Social Services & Supports Integrated Transitional Housing Components
  17. 17. SLIDE 19 TRANSITIONAL HOUSING STRATEGY Hotel-based Program Locations • Allowed for single room occupancy as well as on- site wraparound services to address social determinants of health needs identified during screening. • Each individual was supported by provider staff in establishing a behavioral health discharge plan inclusive of housing to transition to the next level of care. • DSAMH placed 332 individuals in the hotel-based program. Of the 332 individuals, 185 accepted the next level of care, inclusive of housing. Jennifer Corbett, Delaware News Journal
  18. 18. SLIDE 20 OPERATIONS • The Social Services Teams were integrated with medical teams and consisted of DSS, DSSC, and DSAMH personnel, some on the ground and some behind the scenes coordinating appropriate hotel/motel referrals. • Behavioral health providers from Aquila, RI International, and Peace by Piece provided transportation, food at the screening sites, personal hygiene items, clothing and naloxone, and secured support from organizations for meal and medication distribution dependent upon placements.  Individuals enrolled in the hotel-based program received daily services including: clinical assessments, prepared meals, clothing and laundry services, referrals to long-term supports and other identified service needs.
  19. 19. SLIDE 21  The Delaware State Opioid Response (SOR) Grant addresses gaps in Delaware’s system and increase access to quality treatment, refine transitions to care, and complement existing efforts. This funding allows Delaware to engage vulnerable individuals, build sustainable capacity and infrastructure for treatment, housing and other social determinants of health.  The purpose of the Projects for Assistance in the Transition from Homelessness (PATH) Formula Grant, administered by the U.S. Department of Health and Human Services, Center for Mental Health Services, is to provide federal funds to support outreach and mainstream service linkage to persons with serious mental illness who are experiencing homelessness or at imminent risk for homelessness. The target population also includes persons experiencing homelessness who have co-occurring diagnoses of mental illness and substance use disorder. FUNDING
  20. 20. SLIDE 22 CASE STUDIES DEMONSTRATED PROGRAM SUCCESS Joshua was experiencing homelessness and struggling with an alcohol addiction as well. The transitional plan was for him to move to New Castle County into one of the men's transitional houses. To date, Mr. Pitts is doing well and maintaining his sobriety. He has also taken on a part-time job at Goodwill and continues to focus on his success. Claire was experiencing homelessness and was jobless. By the end of the program, she found a job at Appleby's in Rehoboth Beach and was able to save enough money to find herself a rental close to the beach and work. Eric was experiencing homelessness and was unemployed. He previously spent his time panhandling in Wilmington. Now, he resides in Peace by Piece transitional housing and works full-time at the New Castle recycling plant in a position he was referred to through the program.
  21. 21. SLIDE 23 LONG-TERM HOUSING STRATEGY DSAMH- Utilized existing resources, including access to coordinated services from community providers, social services resources from sister agencies, housing vouchers, section 811 program resources and tax credits. This program design: • enabled individuals to move from transitional housing to a long-term housing option; • Afforded the client the option to remain with their current provider of choice and • the flexibility to transition to a different level of care, as needed. DSSC- Program existed prior to COVID-19 and allowed for extended motel/hotel shelter  Partnership with New Castle County, DHSA, Delaware Housing Alliance and Family Promise  Utilizes various programs including rapid re-housing, housing first/supportive housing, and permanent housing
  22. 22. SLIDE 24 OUTCOMES  The unduplicated number of individuals placed in motels/hotels during this timeframe (ending June 11) is 1,427. The total number of households with children is 260 and the total number of children is 476. In addition, 28 individuals placed are over the age of 65.  Collaboration- across Delaware agencies, geographies, and providers was key to success
  23. 23. SLIDE 25 ACKNOWLEDGEMENTS The efforts of this activation were supported by many throughout the state of Delaware, inclusive of a variety of elected officials, members of the University of Delaware’s academic community, state personnel, advocates and social service organizations. This work could never have been accomplished without this level of engagement and support. We are extremely grateful to all who provided guidance and support during this activation.
  24. 24. PRESENTER INFORMATION Alexia Wolf Chief of Social Determinants and Recovery Support Services (302)
  25. 25. SLIDE 27
  26. 26. Thank You! To learn more about The Path Forward series To view previous COVID-19 sessions: