How community paramedics are helping San Diego protect its homeless population from COVID-19
“Community paramedics hold a unique skill set to address the overlapping mental, medical and social conditions that homeless individuals may be presenting”
Reprinted with permission from the California Health Care Foundation 2020.
By Padma Nagappan
If you walk into the cavernous lower level of the San Diego Convention Center, you’ll find more than 1,300 people, but they aren’t there for a conference. All are experiencing homelessness in California’s second-most-populous county – and during the COVID-19 pandemic, they are being sheltered in the facility by local government agencies.
“We have one of the largest homeless populations under one roof in the U.S., so it’s a shelter but on a much larger scale,” said Chris Heiser, deputy chief of San Diego Fire Rescue and the incident commander at the center. “It’s not easy to describe how many resources needed to be in place to bring in this number of people under one roof.”
People sleep on cots lined up in orderly rows on a vast concrete floor with socially distanced spacing. Their belongings are neatly stacked next to their beds. Community paramedics and staff from multiple agencies walk the floor, checking on clients and helping reinforce good choices to stay safe and healthy. Rows of tables make up the dining area, which serves hot food delivered daily.
On-site clinics with nurses and physicians address the varying and complex medical needs of this group of people. Many have chronic medical and mental health conditions.
Periodic testing has identified six positive cases at the center. Those individuals have been moved to hotel rooms for isolation. Countywide, about 105 have tested positive out of the more than 7,500 people experiencing homelessness, and there have been no deaths. A total of 11,961 infections were identified as of June 24 in the county of 3.3 million people.
This is in stark contrast to the 2017 hepatitis A outbreak, which spread rapidly through San Diego County’s homeless population, sickening nearly 600 and claiming 20 lives. Unsanitary conditions in encampments led to the outbreak, and officials weren’t prepared. They scrambled to contain it and deployed public health workers to educate and vaccinate, washed streets, sanitized surfaces in transit systems, and installed portable toilets and hand-washing stations. It took nearly two years before the hepatitis A outbreak subsided, an experience that highlighted systemic flaws in the response of local authorities and the need for alternative housing options, along with proactive communication, planning, and coordination of resources and logistics among multiple stakeholders.
Lessons learned from 2017
“One of the big lessons of hepatitis A was that there was a communications breakdown between the city and county,” said Heiser. In the aftermath, “we created a memorandum of understanding so we can be on the same page no matter the complexity and urgency for any outbreak.”
Fast-forward to 2020. The city, county, the Regional Task Force on the Homeless, and the San Diego Housing Commission, along with multiple agencies and nonprofits, have implemented a proactive, coordinated plan. The plan set up a central location at the convention center for clients and the local response, called Operation Shelter to Home. Each partner has clearly defined roles, and early preventive action defines their approach. In all, there are 800 staff and volunteers supporting the effort.
“San Diego has dramatically changed its approach to homelessness over the past few years,” said San Diego Mayor Kevin Faulconer in a written statement. “We no longer wait for consensus on where and when we add more services and shelter.”
In February and March, when the pandemic was gaining momentum in other places, San Diego sent public health workers out to encampments and temporary shelters to educate the community about COVID-19 and offered people the opportunity to move into the center.
San Diego County counted 7,619 people experiencing homelessness in January, down 6% from 2019, with about half sheltered and half unsheltered.
Starting on Apr. 1, 2020, the city began moving people into the convention center and arranged for three nonprofits – Father Joe’s Villages, Alpha Project, and Veterans Village – to provide services and monitoring.
Incoming people get screened and assigned to the service provider that best suits their needs, and that organization monitors them with daily temperature checks and offers behavioral health and medical services. Heiser said safety officers circulate through the facility and that the clients generally respect rules requiring face masks, social distancing, and good hygiene.
“We see them daily, so we’re getting to know them personally,” Heiser said. “We don’t dictate to them. We work with them.”
Cheryl Mesa, 61, moved into the convention center on April 8 and is under the care of Father Joe’s Villages. The experience of the past two months has changed her so much that she said she is determined not to return to the streets. “I’ve been homeless pretty much all my life, since I was 25 years old,” Mesa said. “I don’t want to ever go back out there again. This is a once-in-a-lifetime blessing that came upon us. Oh, my God! What this did for us is awesome.”
Before moving into the convention center, she lived at a long-term shelter run by Father Joe’s Villages, which wasn’t able to allow for social distancing. Mesa has four sons and three daughters ranging in age from 20 to 36. She lost custody of her children because of chronic substance use but has been drug-free for six years, she said, and now is in touch with most of her children.
She worried that fights would break out among convention center residents, as often happens in conventional shelters, but she was relieved to see that managers there have kept things under control. “You used to have to keep your eye on your stuff so it’s not stolen,” Mesa said. “But it’s working out real well.”
She has stayed mostly indoors, worried that she might catch something and bring it back to the center if she ventures out. But within the convention center, she said, the daily temperature checks and prompt interventions with clients showing symptoms make her feel safe from COVID-19.
Community paramedics: Conduits to help
Community paramedics have been key players at the convention center. The city began training community paramedics six years ago as a resource to reduce the number of 911 calls made by people who frequently used emergency rooms and to help them get to the services they need. Community paramedics serve as the eyes and ears of the operation, giving feedback to Heiser, who shares it at his meetings with partner agencies each day. They then adapt the program to solve the problems.
Amanda Keating, who has been a community paramedic for four years, spends three days a week working the floor at the convention center, assessing individual needs and making referrals to specialized services. Many clients have substance use issues, and others have chronic medical conditions. Community paramedics serve as conduits connecting them to providers.
Some clients may be experiencing physical pain, depression, or a behavioral crisis.
“We’re there to step in, and we have a heightened awareness when there’s something going on that others might miss,” Keating said. “Sometimes it’s just knowing a complaint has been heard and acknowledged or alleviated, and sometimes it’s a whole lot more.”
The mood among residents runs the gamut from those who are coping well to those who have never used shelters before and are struggling to adapt. Some of those who are homeless were recently discharged from hospital stays and require more help than is available on the floor daily. Keating and her colleagues find and refer them to services.
“Community paramedics hold a unique skill set to address the overlapping mental, medical, and social conditions that homeless individuals may be presenting simultaneously and can prioritize accordingly,” Mayor Faulconer said. “It’s what they are trained to do, and during this pandemic they have been even more important to aid clients at the shelter so as to not impact the general emergency-response system.”
Organizing a complex response
Jeffrey Norris, MD, a family medicine physician, is medical director at Father Joe’s Villages and oversees care of about 470 clients at the convention center. With the hepatitis A outbreak, he said the challenge was in figuring out what resources were available where and who could deploy them best – not an easy task.
“We learned from those woes,” he said. “We need to all sit down at the same table. If not, we will waste resources and people will die.”
Norris said he is surprised that there have been so few COVID-19 infections in the homeless community at a time when substantial community transmission is happening.
“When we saw what was happening in places like San Francisco, we jumped on it quickly,” Norris said. “Anyone with symptoms of any kind was quickly isolated and placed in hotel rooms – coughs, runny nose – we don’t know at that moment what their lab results are going to be, so we err on the side of caution.”
Before the pandemic, there were many shelters that had long waiting lists. But the convention center provided a sharp increase in capacity, enabling Father Joe’s to get people admitted on the same day they agree to accept the help. Such speed was practically unheard of before this year.
City workers such as library and recreation staff were assigned to process paperwork quickly. The city makes parking lots available 24/7 to people living in their cars and offered access to storage facilities for their belongings. Hand-washing stations were provided in hot spots and shelters.
Norris’ team of nurse practitioners, physician assistants, doctors, and medical assistants provides primary care four half-days a week. They also offer medication-assisted treatment on site for those with substance use disorder or opioid use disorder. And they join the multiagency daily meetings to assess and regroup.
“It’s a deliberate effort for continuous process improvement,” Norris said. “What we’ve done is the best we’ve done as a community in a short time.”
The region’s leaders are determined not to allow history to repeat itself, Faulconer said. “We’ve also maintained a consistent posture when it comes to public safety and public health on our streets, so we never revert back to the unsanitary conditions” that led to the hepatitis A outbreak.
Local agencies are working on plans to find longterm housing for clients they move out of the convention center after the pandemic ends. Acquiring hotels is one of several ideas under consideration.
For Mesa, the experience at the convention center has opened her mind to different options. When the pandemic ends, she plans to find longterm housing.
“We’re all getting matched with places,” Mesa said. “I’ve never had my own place, so I just want to get a part-time job, keep myself busy, maybe even volunteer at St. Vincent’s, which rescued me so many times and helped save my life.”
For more photos, visit The California Health Care Foundation
About the author
Padma Nagappan is a journalist who covers health, environment and agriculture. Within the health beat, she focuses on public health issues, health impacts of environmental issues, medical advances and medical research. She has reported on substance abuse and the opioid crisis, health disparities, cancer, mental health and drug interactions. Her stories have been published in media outlets in the U.S. and U.K., including Everyday Health, “Dermatology Times,” “New Scientist,” TakePart, MedShadow, “Ag Alert,” SugarOnline, “San Diego Union-Tribune,” and KPBS TV and Radio. Padma earned a master’s degree in business administration from Madurai Kamaraj University in India. She is based in San Diego.