William Doak1,2 and Neha G. Reddy, MPH1,2
1 The Rhode Island Medical Navigator Partnership, Providence, RI 02903, USA
2 Warren Alpert Medical School of Brown University, Providence, RI 02903, USA
Correspondence concerning this article and requests for reprints should be addressed to William Doak (william_doak@brown.edu)
ABSTRACT
COVID-19 continues to pose a threat to the wellbeing of communities across the country, including communities experiencing homelessness. In an effort to support unhoused and underhoused community members in Rhode Island, the Rhode Island Medical Navigators Partnership (RIMNP), a collaboration of medical students, social workers, healthcare practitioners, and housing-insecure community members, has sought to expand its scope in response to acute needs presented during the pandemic. Since March of 2020, RIMNP has increased collaboration with House of Hope—an organization of advocates working to prevent and end homelessness in Rhode Island, coordinated weekly grocery and meal deliveries to families experiencing food insecurity, helped community members fill out economic impact forms for stimulus checks and to apply for government-subsidized cellular phones, and advocated for a “housing first model” to better support the immediate needs of unhoused communities. The lessons learned during this pandemic highlight the increasing need for national conversations about housing insecurity as a fundamental structural determinant of health.
The Rhode Island Medical Navigator Partnership (RIMNP) is an interdisciplinary program that seeks to address inequities affecting people experiencing homelessness in Rhode Island. Teams of housing-insecure community members, social workers, medical students, and physicians form the core units of the organization, engaging in street outreach, health-systems navigation, and social support [1]. While a majority of RIMNP’s work occurs by way of in-person encounters among team members, COVID-19 physical distancing restrictions have hindered much of this interaction. In an attempt to continue its structurally-informed approach to reducing health inequities associated with homelessness, RIMNP has adjusted its focus towards addressing food and economic insecurity experienced by community members as well as continuing advocacy in support of social housing, a term used in this essay to evoke social justice principles when referring to public measures that attempt to house and support those experiencing housing insecurity. In the era of COVID-19 and physical distancing, RIMNP strives to mitigate the social burden of the current moment on those experiencing homelessness.
Community members experiencing homelessness continue to encounter challenges arising in part from institutional and governmental attempts to limit the spread of COVID-19. As journalists and social critics have already noted, stay-at-home orders take on a different meaning when stable housing is not in the picture [2-4]. For some folks, housing might look like a nook that fits a mattress behind a barbershop’s back alley, and -- when the weather gets really rough -- the floor of a neighborhood friend; for some, it’s a shelter; for others, it may take the form of an extended-stay motel or “transition housing” in-between benefit applications [5,6]. Even for those in the community with housing, reduced bus schedules and shuttering of state offices have rendered the systems that once helped secure food and other social services inaccessible. Less formal means of support have also evaporated: stay-at-home orders marked the closure of many meal sites, and fewer cars on the road means less money given to people who panhandle to make ends meet.
The depth of the health consequences associated with housing insecurity already indicated a need for interdisciplinary health-system navigation and structural reforms both locally and nationwide; COVID-19 has further confirmed the urgency of this need. While the logistical challenges that come along with physical distancing have certainly shifted the trajectory of RIMNP’s endeavors, these shifts have resulted in more collaboration with agencies outside of RIMNP’s immediate circle of affiliates. Amidst calls to eliminate all face-to-face contact, RIMNP leadership decided that shrinking operations would ultimately counter the organization’s mission and responsibility to the community.
In response, RIMNP began to partner more closely with House of Hope (HoH), a Rhode Island-based organization with a mission to prevent and end homelessness in the state and to end the personal and social trauma of homelessness. HoH’s team of outreach workers and case managers has continued to provide essential services throughout the pandemic. A core aspect of the organization’s work is conducting street outreach, during which outreach workers engage unsheltered persons, offering support and linkage to services. This work continues with COVID-19 modifications like wearing masks and badges to show essential-worker status and disseminating hand sanitizer and other basic needs to members of the community. Furthermore, HoH staff members have played a key role in supporting community members sheltering in hotels during COVID-19 in order to contain the spread of disease and deconcentrate shelters.
In conversations with HoH, folks experiencing homelessness, and those who have been recently housed, it became clear that food insecurity has cast an ever-broadening shadow during this pandemic due to skyrocketing unemployment rates, overburdened food banks and meal sites, and quarantining guidelines that make it challenging for people with chronic medical conditions to purchase food [7]. In partnership with HoH, RIMNP began a project to purchase, organize, and distribute bags of groceries and frozen meals to folks who are currently housed by the state or who have underlying medical conditions and are unable to go grocery shopping. These “weekly meal subscriptions” have been made possible by community donations, and, in total, 18 individuals have found alimentary support through RIMNP.
In addition to food insecurity, accessing government stimulus payments has also proved burdensome. Those who did not file taxes in 2018/2019 or who do not receive SSI or SSDI benefits must fill out a form on the IRS website in order to be eligible to receive a check. This process represents a major barrier for people who have difficulty using or accessing smartphones and computers. Therefore, RIMNP volunteers have been helping fill out economic impact payment forms over the phone; however, the reality that many individuals in the RIMNP network do not have reliable access to a phone constrain simple, tangible efforts to connect community members to resources--a sizeable hurdle given that adherence to physical distancing measures depend heavily on phone communication. In response, a few RIMNP teams purchased government-subsidized phones to facilitate social support or care-coordination. As the pandemic continues to evolve, RIMNP’s role and place as an organization will as well, reflective of the cumbersome landscape unhoused communities must continue to navigate. These changes further reinforce RIMNP’s foundational priority around combating high rates of social isolation through meaningful, longitudinal relationship building.
Certain innovations implemented during COVID-19 give a taste of what life could look like after the worst of this pandemic subsides. By revamping access to alternative shelter options and supplying more sanitary fixtures to individuals living in “tent cities” or other alternative dwellings, cities across the country have demonstrated the capacity to adapt systems to fit the immediate needs and daily realities of the homeless community. Advocates have also noticed advancement towards a “housing-first model” in which housing systems accommodate in-need community members without traditionally requisite “means testing” or other bureaucratic hurdles. Country-wide, there is increasing support for these measures outside of the housing-advocacy community, notably amongst healthcare workers concerned for housing-insecure patients recovering from hospitalization. As governments continue to wrestle with the socio-economic fallout of COVID-19, they have the opportunity to continue the push towards social housing to better address the needs of community members experiencing chronic homelessness beyond the scope of the pandemic [8].
These proposed solutions are not without their own share of questions. How can we ensure that folks who may be eligible for social housing maintain their autonomy in the decision-making process? How can we work to decommodify the housing market under the principle of housing as a basic right in an effort to avoid positioning social housing as means of removing the “eyesore” of homelessness? How can we support the economic stability of folks who are housing-insecure? Most fundamentally, how do we rebuild systems to center the voices of those most marginalized as valued and integral members of our communities?
The lessons learned during COVID-19, including the importance of inter-agency collaboration, the willingness to dynamically reimagine organizational scope while staying true to purpose, and the focus on community accessibility, will inform RIMNP’s efforts ahead. Ultimately, COVID-19 has shown the need for an ongoing, robust national conversation about housing insecurity as a structural determinant of health beyond hindering the spread of novel coronavirus. Whether and how these efforts will continue prove among the most pressing questions to come of the current moment’s revitalized emphasis on collectivism.
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