In March 2020, when COVID-19 and the subsequent shelter-in-place order hit San Francisco, nurses at the Department of Public Health faced an unprecedented challenge. In addition to operating out of pop-up clinics in shelters and navigation centers, they were tasked with treating thousands of unhoused people across more than two dozen hotels citywide in the midst of a deadly pandemic. But in the months that the operation started, little has been released about the work occurring behind hotel doors.
The original goal of moving people experiencing homelessness into shelter-in-place hotels (nicknamed “SIP hotels”) was to create safe spaces for people to quarantine, thereby limiting the spread of COVID. The Centers for Disease Control and Prevention released guidelines in April, stating that “sleeping outdoors often does not provide protection from the environment, adequate access to hygiene and sanitation facilities, or connection to services and health care.” Many of those who were moved inside were deemed at high risk due to age or pre-existing health issues like asthma.
Each SIP hotel site operates slightly differently. The city of San Francisco has leased everything from tall, tower-style luxury hotels to smaller, motel-style facilities with doors that lead directly outdoors. Smaller sites may only have two half-day clinics per week, while the larger sites have as many as eight nurses on site five days a week. There is an emphasis on building trust and relationship with the guests; because of this, an effort is made to keep nurses on the same rotations.
All told, 20 nurses are currently on staff across 25 hotel sites. This includes both the existing shelter health nursing staff, as well as registered nurses who were deployed as disaster service workers.
On site, what the nurses are faced with goes far beyond simply preventing the spread of the virus. Kate Shuton, the city’s director of shelter health, oversees 19 SIP hotels. She says that “COVID is a piece of it, but it’s really just a piece, because these folks have so many complex medical needs and substance use disorder issues, and mental health issues. The reality is folks are in need of medical care for many other things.”
One of the first obstacles nurses faced was not being able to operate out of a central clinic, in order to mitigate infection risk. Instead, they set up base camps with supplies in empty hotel rooms, and went room-to-room to treat patients directly.
“We tried to stabilize people as best we could with that model,” Shuton explains. “We have been able to help people with managing their chronic diseases, making sure they have their meds, conducting preventative testing, and doing wound care. We try to get people into primary care when we’re able. And most of our providers can prescribe meds for substance use disorder. We’re really working collaboratively to keep people out of the hospital.”
But the shift into private rooms hasn’t come without challenges. In contrast to the congregate design of The City’s large shelters, small rooms with a closed door can prevent nurses from responding to life-threatening situations like drug overdoses.
Tia Paneet, a charge nurse, oversees seven SIP hotels. She’s been instrumental in bringing a harm reduction approach into two of those, partnering with the AIDS Foundation and The Drug Overdose Prevention and Education Project to make sure nurses and shelter staff have the overdose reversal drug Narcan on hand — and that they know how to use it.
That alone has been a new experience. “I’ve been working with librarians, and people from the department of elections, and engineers, and other people I would never have had the opportunity to work with,” Paneet says. “Some of these people don’t have a lot of experience working with people experiencing homelessness, or people who use drugs. It’s shone a light on the work that’s needed, and the work that we are continuing to do.”
Additionally, while at the hotels, many people began ongoing care that can have positive, longlasting impacts. “We can test you for COVID, for sexually-transmitted diseases, for hepatitis C, we can draw your blood, we can get you in-home care,” says Paneet. “It’s easier to bring services to people when you know where to find people.”
Back into the system
As was announced late last month, several of the SIP hotels are now slated for closure. In response, nurses are preparing to transition folks to shelters or safe sleeping villages — when possible. Details on which hotels are closing and when have not been made public, and repeated requests to The City for clarification on this and the budget for running the hotels went unanswered. As of this week there are only 2,300 shelter and navigation beds available, but more than 1,300 people are already on the wait list.
“In terms of folks going back to the shelter system and navigation centers, we’re ready for them,” says Shuton of her shelter health staff. “We know most of them, we’ve worked with them. They will land well. But, of course there’s not enough beds in those sites.”
The lack of beds could mean that many hotel residents may end up back on the street during the pandemic and the rainy season, which could create a public health crisis the city spent millions to avoid.
Paneet hopes that if nothing else, the folks who will eventually be required to leave the hotel rooms they’ve called home for several months will be better equipped to survive, regardless of if they end up in a shelter, a permanent home, or on the streets.
“We helped people get benefits, signed up for health insurance, access general assistance, veterans’ benefits, CalFresh, and assessed for housing through coordinated entry,” she says.
Records of the treatment hotel residents got during their stay will travel with them through The City’s health records system. “We all collaborate using electronic medical records so people can be followed, and we know who saw who,” Shuton says. “We also continually communicate verbally through secure email about specific clients.
“I wish I had as good care through my primary care with my health insurance that a lot of folks get through us,” she adds. “Our core team is truly the Navy Seals of nurses.”
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