State of California
Recommended Strategic Approaches for COVID-19 Response for Individuals
Experiencing Homelessness
March 2020
Developed in partnership with Margot Kushel, MD and the UCSF Benioff Homelessness and Housing Initiative

Critical Elements of Our Recommendations
1. Focus intensive infection prevention efforts on those most likely to develop severe complications from
COVID-19, including people who are currently in shelters and people who are currently unsheltered.
Expand the category of those receiving intensive infection prevention efforts if resources permit. The
primary strategy for intensive infection prevention efforts is providing single occupancy housing.
2. For the sheltered population experiencing homelessness, general risk reduction should be done through
decreasing density of group shelters, which may require creating additional or auxiliary spaces to sustain
bed numbers, increasing cleaning, and screening guests for symptoms.
3. Separate people with symptoms quickly and ensure they wear facemasks. Create isolation units (i.e.
hotels, motels, trailers) for people under investigation (PUI).
4. Cohort COVID + individuals in group settings with appropriate healthcare personnel or place COVID + in
individual isolation units (i.e. hotel, motel, trailer) for duration of quarantine.
5. Communities should prioritize individual housing units (e.g. hotels, motels, and trailers) for unsheltered
and sheltered individuals experiencing homelessness who are either (1) people under investigation or
(2) at high risk of medical complications, as defined below.
6. Consistent with CDC recommendations, unless individual housing units are available (i.e. hotel rooms)
communities should not be clearing encampments and dispersing people throughout the community. If
a community is unable to provide a hotel room or other single occupancy housing and client is
asymptomatic, provide outreach services (screening, food, hygiene) and ensure that recommended
social distancing is maintained where individual is located, or determine if there is an available shelter
opportunity with appropriate social distancing, cleaning and screening procedures that the person
would like to access.
7. Create clear lines of communication so that homeless service providers and health systems have easy
access to appropriate quarantine resources to decrease the chance that potentially COVID + individuals
spend extended time among the general population experiencing homelessness. Ensure that health care
providers are screening for homelessness to avoid placing people who are experiencing homelessness
and potentially COVID + (or known COVID +) with COVID-19 negative.

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 8. For every step of this process, para transit should be made available wherever transport is needed,
Durable Medical Equipment should be made available where needed at each site, and ADA compliant
hotel rooms must be kept for those who require these accommodations.

Definitions
High Risk of Medical Complication Individual: Individual with high risk of POOR OUTCOMES if they were to
become COVID +. Specific populations include individuals who are 60 years of age or older and people of any age
with preexisting lung disease, heart disease, cancer, diabetes, HIV, or other major medical conditions (if further
health screening is possible).
Low(er) Risk of Medical Complication individual: Individual who would be at lower risk for severe
consequences were they to become COVID +.
Independent: Individual that can do activities of daily living (ADLs), and can manage (e.g. no significant
behavioral health needs) in a hotel, motel, or trailer setting.
Higher Need: Individual that requires assistance with ADLs or is medically frail OR has high behavioral health
needs that cannot be accommodated in a hotel, motel, or trailer setting.
COVID +: Individual that has tested positive for COVID-19. This will include people who are confirmed COVID +
but do not require hospitalization (at this point) AND people who have completed hospital stays and no longer
require hospitalization but who are still potentially infectious.
Person Under Investigation (PUI): Medical term for an individual with positive symptom screen or, if possible, a
positive secondary screen (meaning a Registered Nurse (RN) or other medical professional, as referred to by
outreach or shelter staff, has screened the individual and considers the individual at high risk of infection).
Presumed COVID-19 negative (not COVID + or PUI): These individuals are currently not showing symptoms but
may still be or could become COVID +. All efforts should be taken to try to reduce risk (e.g. deep cleaning, hand
washing, separate beds at least 3 feet apart and 6 feet where possible, head to foot bed arrangements, and
screens between beds if possible).
Alternative Care Settings: Group facility (i.e. shelter) where individuals who are COVID + can be grouped
together and receive basic medical care and observation.
Quarantine Hotel/Motel/Trailer: Single room occupancy facility for those who are a PUI. These sites could also
be used for those who are confirmed COVID +.
Hotel/Motel/Trailer for High Risk Persons: Single room occupancy facility for those who are presumed COVID19 negative but at high risk for complications were they to become COVID +. Ideally, these should be a separate
facility from the quarantine hotels/motels/trailers.

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 Recommended Sites
For PUI:
1. Quarantine hotel/motel/trailer or other place where individuals can be isolated from others during
investigation. (Quarantine Hotel)
2. Alternative care settings: group facilities (i.e. shelters) separated from presumed COVID-19 negative
individuals and staffed by healthcare professionals where individuals who are PUI can receive
healthcare and assessments to see if they require higher level of care (i.e. transfer to emergency
department or inpatient).

For COVID +
1. Alternative care settings: group facilities (i.e. shelters) separated from presumed COVID-19 negative
individuals and staffed by healthcare professionals where individuals who are COVID + can receive
healthcare and assessments to see if they require higher level of care (i.e. transfer to emergency
department or inpatient).
2. Quarantine hotel/motel/trailers for those who could be safely isolated (e.g. those who are
independent) and do not require extensive healthcare while contagious.

For Presumed COVID-19 negative:
1. Hotels/motels/trailers for High Risk Persons [to prevent infection for individuals at high risk of
medical complications],
2. Shelters with appropriate social distancing, or
3. Remain unsheltered with appropriate outreach and social distancing.

Local Coordination Essential
This recommended system will work best if managed and filtered through a centralized coordinated system with
the county public health department, emergency services office and local continuum of care and homeless
providers.
Additionally, we recommend that the county institute a hotline or identify specific medical personnel (e.g. an
RN) who could take intakes and assess individuals as:
1. High versus Low Risk of medical complications (based on age, or medical co-morbidities)
2. Presumed COVID-19 negative versus PUI versus COVID +
3. In need of further medical assessment (i.e. referral to Emergency Department, urgent care clinic, or
other) prior to decision

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 Screening and Referrals
For shelter staff → screen all guests for symptoms (see recommended triage questions
below):
1. If a guest answers yes to triage questions, staff should contact the coordination system/identified
medical personnel for a decision as to whether the person requires further medical evaluation
and/or should be considered a PUI. Depending on the prevalence of infection and judgement of
local authorities, localities may suggest different thresholds to trigger referral to the coordinating
center. For example, some may ask that any positive response to any questions or a fever greater
than 100.4 degrees requires referral to coordinating center. It may be reasonable to set a different
threshold (e.g. either a fever OR yes to two questions). This recommendation may change over time
as we learn more. The coordination system will assist in determining whether the person is clear to
stay at the shelter, requires immediate medical attention or should be transported (with a mask and
appropriate social distancing precautions) to a quarantine hotel/motel/trailer.
a. If person needs to be placed at a site for PUI → place mask on them and transport to
identified place for PUI. Ideally, should be a hotel to decrease risk of exposure to others.
2. If a guest screens negative and is a client at high risk for medical complications (as defined above),
staff should arrange for placement in a high-risk hotel/motel/shelter. Localities should determine
the best strategy to make these referrals and whether individuals require medical screening prior to
placement.
3. If a guest screens negative and is at low risk of medical complications, the guest can stay in shelter
with appropriate social distancing, cleaning and screening.

For unsheltered outreach staff→ screen all individuals that are outreached to for symptoms
(see recommended triage questions):
1. If an individual answers yes to triage questions, staff should contact coordination system or
identified medical personnel for decision as to whether the person requires further medical
evaluation and/or can be considered PUI. The coordination system/identified medical personnel will
assist in determining whether the person is clear to stay where they are currently located or enter
an appropriate shelter environment, requires immediate medical attention, or should be
transported (with a mask) to a quarantine hotel/motel/trailer. Note, protocols, including screening
criteria, can be adapted locally and should be similar for those used in sheltered population.
2. If an individual screens negative and is at high risk for medical complications, as defined above, staff
should arrange for hotel placement for high-risk persons.
3. If an individual screens negative and is at low risk for medical complications, CDC recommends that
the person not be forcibly “swept” from their current location, but it would still be appropriate to
provide people with options to remain where they are, if appropriate social distancing and hygiene

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 needs can be addressed, or to enter an appropriate shelter opportunity where appropriate social
distancing, cleaning and screening measures can be met, if available.

Key recommendations from the CDC for encampments include:
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Unless individual housing units are available, do not clear encampments during community
spread of COVID-19. Clearing encampments can cause people to disperse throughout the
community and break connections with service providers. This increases the potential for
infectious disease spread.
Encourage people staying in encampments to set up their tents or sleeping quarters with at
least 12 feet x 12 feet of space per individual.
Ensure nearby restroom facilities have functional water taps, are stocked with hand hygiene
materials (soap, drying materials) and bath tissue, and remain open to people experiencing
homelessness 24 hours per day.
If toilets or handwashing facilities are not available nearby, provide access to portable latrines
with handwashing facilities for encampments of more than 10 people.

For Hospitals/Emergency Departments/Clinics:
1. When discharging a person who is confirmed COVID + who requires further quarantine but does not
require hospital level care, health care staff should contact the coordination system for
determination on whether the client should go to an alternative care setting versus a quarantine
hotel. NOTE: hospitals and EDs should assess housing status before discharging a PUI or COVID+
person.
2. When discharging someone who is a PUI, staff should arrange for placement in a quarantine hotel
for PUI. Once result is confirmed, staff should contact the coordination system to convey the results
of the test.
3. If person is determined to NOT be a PUI, healthcare system should ensure they are returning or
going to a location in which they can engage in appropriate social distancing and hygiene activities.
Staff would contact the coordination system to let them know person is not considered a PUI.

Potential Pathways for
Coordinated System Decision-maker
1. Client is given option of staying where they are or of entering an appropriate shelter environment, if
available (presumed COVID-19 negative, and not at high risk of medical complications)
2. Client is at high risk of medical complications, is assessed and is likely COVID-19 negative →
transport to a hotel/motel/trailer for population at high risk of medical complications.
3. Client considered a PUI → client should be given a mask, separated from the general population,
and transported to a quarantine hotel/motel/trailer, or alternative care center if necessary.

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 Recommended Triage Screening Steps
For shelter staff and outreach workers, below is the recommended triage screening steps to take with shelter
residents and homeless outreach clients:
1. Ask the individual:
a. Do you have a cough?
b. Are you feeling feverish?
c. Do you have difficulty breathing (worse than usual)?
2. Take temperature—if higher than 100.4 degrees, client screens positive.
Note: In shelters, ask guests these questions daily. In unsheltered settings, screening should be performed by
outreach workers as feasible.

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