By Miriam Komaromy, MD
Mr. J.W. was in the sitting room of the COVID Recuperation Unit in Boston Medical Center (BMC) when I met him. He was a restaurant worker who had lost his job when the surge of COVID infections hit Boston last spring. The friends who rented him a room had asked him to leave because of fear of contagion from non-family members. Homeless for the first time in his life, he had been living on the street and sleeping in shelters when he began to cough and feel feverish. “I thought I was going to die and I was afraid of making other people sick. I came to BMC because I needed help.”
Boston is among the U.S. cities that were hit early and hard by COVID. Boston Medical Center is the region’s largest safety-net hospital and has served Boston’s most disadvantaged, vulnerable residents since 1855. As news of the impending coronavirus pandemic worsened, clinical and administrative leaders from BMC grew increasingly concerned about the plight of people who were unhoused—how would they escape infection, and what would they do if they became infected? We had daily phone calls with leaders of local organizations who provided services for people experiencing homelessness—the Boston Public Health Commission, Boston Health Care for the Homeless Program, harm reduction organizations, shelter directors, and others—and worked to come up with a plan.
Real estate in Boston is notoriously expensive. Hotels seemed like a possible option for housing people experiencing homelessness, since so many hotels were sitting empty once the COVID surge began, but one hotel owner after another declined to allow their facility to be used for this purpose, whether people were infected or not. Testing at shelters revealed rising rates of COVID infection, even among asymptomatic people. BMC’s inpatient units and ICU began to treat increasing numbers of seriously ill patients.
With no other solution on the horizon, BMC leadership approached the Commonwealth of Massachusetts about loaning a decommissioned hospital building which was undergoing remodeling, adjacent to the BMC campus. After a few rounds of discussion, we obtained permission to open a COVID Recuperation Unit (CRU) on two floors of the building and began a frantic two-week period during which we prepared the facility, recruited staff, and developed a clinical model.
On April 9, we opened the doors of the CRU and admitted 15 patients on the first night. Our patients were all experiencing homelessness and COVID-infected. They were well enough to avoid hospitalization but in need of isolation and clinical care. The next eight weeks were a blur of providing care as best we could and solving problems as they arose. Sarah Arbelaez, Vice President of Clinical Services at BMC, who oversaw the implementation of the CRU, described it as “disaster medicine.”
As the Medical Director for the program, I often imagined changing the tires while we were driving the proverbial bus. Whatever the appropriate image, it was a frightening, inspiring, and stressful time. We did not know much yet about COVID-19, and had no idea how bad things would get before they started to get better. We also did not know how ill our patients might become, and what types of problems we needed to prepare for.
By the time the CRU closed eight weeks later, as cases of infection waned dramatically, we had cared for 226 patients for an average stay of more than a week per person. We had recognized and adapted our care to respond to the fact that half of our patients were actively using substances at the time of admission, and nearly four out of five patients had a behavioral health diagnosis. No one died in the CRU, but we reversed seven overdoses. Although it is impossible to say how many infections we averted by providing a safe place for people to isolate, the vast majority of patients stayed in the CRU until they had completed the recommended period of isolation. We also provided a critical “escape valve” for the overwhelmed inpatient services at BMC, avoiding the need for BMC to turn away patients for lack of beds.
Other models of care for similar patients have sprung up around the country, many situated in hotels. There are distinct advantages of a hotel-based model, and we might well have tried it ourselves if a hotel had been available. As it was, we had an opportunity to develop a model of care in a hospital setting.
We share with you the details of our successes and challenges in a white paper, “Development and Implementation of a COVID Recuperation Unit at Boston Medical Center for People Experiencing Homelessness.” The development of this paper was generously supported by RIZE Massachusetts, with a goal of providing a “how-to” manual if such services need to be implemented again, during this or future pandemics.
Dr. Miriam Komaromy is the Medical Director of the Grayken Center for Addiction at Boston Medical Center.