Addressing COVID-19 Among People Experiencing Homelessness: Description, Adaptation, and Early Findings of a Multiagency Response in Boston.

People experiencing homelessness are at high risk for coronavirus disease 2019 (COVID-19). In March 2020, Boston Health Care for the Homeless Program, in partnership with city and state public health agencies, municipal leaders, and homeless service providers, developed and implemented a citywide COVID-19 care model for this vulnerable population. Components included symptom screening at shelter front doors, expedited testing at pop-up sites, isolation and management venues for symptomatic people under investigation and for people with confirmed disease, quarantine venues for asymptomatic exposed people, and contact investigation and tracing. Real-time disease surveillance efforts in a large shelter outbreak of COVID-19 during the third week of operations illustrated the need for several adaptations to the care model to better respond to the local epidemiology of illness among people experiencing homelessness. Symptom screening was de-emphasized given the high number of asymptomatic or minimally symptomatic infections discovered during mass testing; contact tracing and quarantining were phased out under the assumption of universal exposure among the sheltered population; and isolation and management venues were rapidly expanded to accommodate a surge in people with newly diagnosed COVID-19. During the first 6 weeks of operation, 429 of 1297 (33.1%) tested people were positive for COVID-19; of these, 395 people were experiencing homelessness at the time of testing, representing about 10% of the homeless adult population in Boston. Universal testing, as resources permit, is a focal point of ongoing efforts to mitigate the effect of COVID-19 on this vulnerable group of people.

Health Care Spending And Use Among People Experiencing Unstable Housing In The Era Of Accountable Care Organizations.

Provider organizations are increasingly held accountable for health care spending in vulnerable populations. Longitudinal data on health care spending and use among people experiencing episodes of homelessness could inform the design of alternative payment models. We used Medicaid claims data to analyze spending and use among 402 people who were continuously enrolled in the Boston Health Care for the Homeless Program (BHCHP) from 2013 through 2015, compared to spending and use among 18,638 people who were continuously enrolled in Massachusetts Medicaid with no evidence of experiencing homelessness. The BHCHP population averaged $18,764 per person per year in spending-2.5 times more than spending among the comparison Medicaid population ($7,561). In unadjusted analyses this difference was explained by greater spending in the BHCHP population on outpatient care, including emergency department care, as well as on inpatient care and prescription drugs. After adjustment for covariates and multiple hypothesis testing, the difference was largely driven by outpatient spending. Differences were sensitive to adjustments for risk score, which suggests that housing instability and health risk are meaningfully correlated. This longitudinal analysis improves understanding of health care use and resource needs among people who are homeless or have unstable housing, and it could inform the design of alternative payment models for vulnerable populations.

Changes in public order after the opening of an overdose monitoring facility for people who inject drugs.

BACKGROUND: In the face of an increasingly fatal opioid crisis, Boston Health Care for the Homeless Program (BHCHP) opened the Supportive Place for Observation and Treatment (SPOT), a unique low-threshold harm reduction program for monitoring people who have injected drugs and are at imminent risk of overdose. This study examines the impact of the opening of the SPOT program on measures of injection drug-related public order in the neighborhood surrounding the facility. METHODS: Data was collected at 10 weeks prior and 12 weeks post SPOT implementation on: number of over-sedated individuals in public, publicly discarded syringes, publicly discarded injection-related litter, and instances of active injection drug use or exchange of drugs. Changes were evaluated using Poisson log-linear regression models. Potential confounders such as weather and police presence were measured and controlled for. RESULTS: The average number of over-sedated individuals observed in public significantly decreased by 28% (4.3 [95% Confidence Interval (CI) 2.7-6.9] v 3.1 [CI 1.4-6.8]) after SPOT opened. The opening of SPOT did not have a significant effect on the other measures of public order. The daily average number of publicly discarded syringes (28.5 [CI 24.5-33.1] v 28.4 [CI 22.0-36.5]), pieces of publicly discarded injection-related litter (376.3 [CI 358.6-394.8] v 375.0 [CI 345.8-406.6]), and observed instances of active use or exchange of drugs (0.2 [CI 0.1-0.9] v 0.1 [CI 0.0-0.1]) were not statistically significantly different after the opening of SPOT. CONCLUSIONS: The opening of SPOT was associated with a significant decrease in observed over-sedated individuals. Other measures of injection-drug related public order did not improve or worsen with the opening of SPOT, however, they have been shown to improve with the implementation of a supervised injection facility.

The willingness of people who inject drugs in Boston to use a supervised injection facility.

BACKGROUND: In Massachusetts, the number of opioid-related deaths has increased 350% since 2000. In the setting of increasing overdose deaths, one potential intervention is supervised injection facilities (SIFs). This study explores willingness of people who inject drugs in Boston to use a SIF and examines factors associated with willingness. METHODS: A cross-sectional survey of a convenience sample of 237 people who inject drugs and utilize Boston's needle exchange program (NEP). The drop-in NEP provides myriad harm reduction services and referrals to addiction treatment. The survey was mostly self-administered (92%). RESULTS: Results showed positive willingness to use a SIF was independently associated with use of heroin as main substance (odds ratio [OR]: 5.47; 95% confidence interval [CI]: 1.9-15.4; P = .0004), public injection (OR: 5.09; 95% CI: 1.8-14.3; P = .002), history of seeking substance use disorder (SUD) treatment (OR: 4.99; 95% CI: 1.2-21.1; P = .05), having heard of SIF (OR: 4.80; 95% CI: 1.6-14.8; P = .004), Hispanic ethnicity (OR: 4.22; 95% CI: 0.9-18.8; P = .04), frequent NEP use (OR: 4.18; 95% CI: 1.2-14.7; P = .02), current desire for SUD treatment (OR: 4.15; 95% CI: 1.2-14.7; P = .03), hepatitis C diagnosis (OR: 3.68; 95% CI: 1.2-10.1; P = .02), posttraumatic stress disorder (PTSD) diagnosis (OR: 3.27; 95% CI: 1.3-8.4; P = .01), report of at least 1 chronic medical diagnosis (hepatitis C, human immunodeficiency virus [HIV], hypertension, or diabetes) (OR: 3.27; 95% CI: 1.2-8.9; P = .02), and comorbid medical and mental health diagnoses (OR: 2.93; 95% CI: 1.2-7.4; P = .02). CONCLUSIONS: Most respondents (91.4%) reported willingness to use a SIF. Respondents with substance use behavior reflecting high risk for overdose were significantly more likely to be willing to use a SIF. Respondents with behaviors that contribute to public health burden of injection drug use were also significantly more likely to be willing to use a SIF. Results indicate that this intervention would be well utilized by individuals who could most benefit from the model. As part of a broader public health approach, SIFs should be considered to reduce opioid overdose mortality, decrease public health burden of the opioid crisis, and promote access to addiction treatment and medical care.