The Role of Alternate Care Sites in Health System Responsiveness to COVID-19

The COVID-19 pandemic has altered life and upended health and the economy for millions of Americans, highlighting fault lines that sharply divide our population along racial/ethnic and socioeconomic status. These determinants predict life expectancy, food and housing security, health care access, and educational and economic opportunities.

In Baltimore, Maryland, a city of segregated neighborhoods, life expectancy varies by up to 16 years and the infant mortality rate can vary by a factor of 20 across communities separated by just a few miles.¹ These differences traverse many health and socioeconomic indicators that befall the largely Black neighborhoods and are marked by years of civic neglect, inadequate housing policies, and gross underinvestment.

The cruelty of COVID-19 is not only its high transmission potential and its mortality rate. It is also the disproportionate ill effects on the most vulnerable and marginalized populations, who are already far more likely to experience underlying chronic health conditions; have limited or no access to healthy foods; reside in group homes, homeless shelters, or prisons; and have lower health care access.^2,3 Although few population-based COVID-19 studies have been published, initial research and reporting clearly indicate that Black, Latinx, and Native American populations are disproportionately affected by COVID-19.^2–4 Higher rates of being uninsured or underinsured, receiving discriminatory treatment, and subsequently mistrusting the health system among racial/ethnic minorities affects care and will result in suppressed estimates of COVID-19 incidence, prevalence, and mortality in these communities.⁵ Our own surveillance data, from three primary care practices in Baltimore, reveal that Black and Latinx patients are more than twice as likely as are White patients to test positive (19%, 26%, and 7%, respectively).

THE BALTIMORE ALTERNATE CARE SITE HOTEL MODEL

Pandemic responses vary widely across state borders, driven by the need for large-scale isolation facilities and a rapid expansion of health care spaces. Around the United States, alternate care sites (ACSs) are used as part of local or Federal Emergency Management Agency–led emergency response plans to address pandemics and natural disasters when health care facilities are unable to accommodate the surging demand for resources.

The concern for inadequate hospital capacity combined with an anticipated need for isolation space led a local health system to collaborate with the state of Maryland to open an ACS in a 400-bed Baltimore hotel. As in other cities, the process of locating a suitable, available, and willing hotel was difficult given the concerns of owners regarding financial guarantees, potential property damage, reputation, and restoration requirements. The state provided financial backing. Plans called for this hotel to serve as an isolation dormitory at no cost to admitted residents and to accommodate individuals no longer requiring in-patient care but with limited housing options owing to unstable living situations or a high risk of household exposures (box on p. 1363 lists admission criteria). In addition, patients staying at this ACS were to be connected to transitional care services to facilitate a safer return to the community.

BOX 1. Admission Criteria to Hotel Alternate Care Sites (ACSs).

Is 18 years old or older with diagnosed or suspected COVID-19

Is willing to cease smoking or accept nicotine-replacement alternatives

Is able to independently perform most activities of daily living (e.g., transfers, communicating, eating, maintaining continence, and dressing)

Does not require continuous cardiopulmonary monitoring, mechanical ventilation, blood products, or close inpatient-level medical supervision

Has no unstable behavioral health concerns or need for sitter

Does not require scheduled respiratory therapy using nebulizer, bilevel positive airway pressure ventilator, or continuous positive airway pressure ventilator

If on scheduled hemodialysis, needs established hemodialysis center and established transportation to and from the ACS

The hotel infrastructure proved well suited to providing safe and comfortable isolation space, in-room refrigerators and safes to store personal medication and valuables, food services, security, conference space converted into a command center, Wi-Fi, ability to maintain hot and cold zones, and in-room climate control. Stations for donning and doffing were built into each occupied floor with modest architectural modifications.

This model uses telehealth technologies with purchased tablets and patients’ own smart phones to connect with providers for chronic care management, behavioral counseling, social work, pharmacotherapy, and specialist consultation. This augments a small number of onsite staff, including nurses, nonclinical support staff, providers, social workers, and pharmacists.

Clinical documentation was integrated with the same electronic health record used by the health system and built as its own ambulatory department to achieve rapid deployment. Additionally, a transportation system was organized for routine and emergent transport of patients to and from the medical center, hemodialysis, and radiology. A dedicated advanced life support ambulance crew was stationed at the hotel. Centers for Medicare and Medicaid Services waivers allowed the conversion of the hotel into an ACS as an extension of the medical center. This model still requires compliance with patient and employee safety standards and quality and performance improvement regulatory requirements. Stakeholders and subject experts developed site- and context-appropriate documentation standards and internal emergency response plans and compiled them into a comprehensive operation manual.

As the COVID-19 pandemic evolves, this health system is finding the demand for health care utilization ever more focused on critical care capacity. Within a month of testing in homeless shelters and group homes, rates of COVID-19 varied from 15% to just over 50% in some facilities. Close quarters, congregate meals, and the need to access social services means social distancing, quarantine, and isolation are difficult to achieve. Therefore, this hotel ACS was able to respond to this crisis by pivoting its mission to temporarily housing hundreds of the city’s residents experiencing homelessness suspected or confirmed to have COVID-19. In this partnership, our health system is providing clinical support and the health department is addressing residents’ case management and social service needs.

OTHER ALTERNATE CARE SITE MODELS

In China, a novel approach was implemented to meet the crushing demand for isolation facilities with basic medical assistance. The rapid construction of 16 Fangcang hospitals with 16 000 beds allowed provincial health systems to provide five essential functions during this emergency: triage, isolation, basic medical care, frequent monitoring with rapid referral to higher level care, and essential living and social spaces.⁶ Unlike previous field hospitals, these facilities separated patients by severity, provided high quality and safety controls, and incorporated electronic health record systems that allowed closer integration with the main hospitals.

In Chicago, Illinois, city officials partnered with local hotels to provide several thousand beds for temporary housing of unsheltered individuals recovering from COVID-19. Patients are monitored by the department of public health and other contracted health workers. Additional rooms are allocated to frontline workers and first responders. Los Angeles, California, embarked on a similar model to provide 20 000 hotel rooms for people with COVID-19 who are experiencing homelessness, are health care workers, are victims of domestic violence, or are elderly. These efforts are expected to continue to slow the spread of infection by providing dignified shelter space and continued medical supervision.

CONCLUSIONS

In the face of this pandemic, addressing the needs of marginalized groups is paramount. If not now, then when? The ACS hotel concept may provide a viable approach to addressing the immediate recovery needs of those in crowded or unstable living conditions with harm-reduction strategies that also minimize risk to others. Using hotels as ACSs has inherent benefits given their existing infrastructure, ability to provide comfortable and dignified living quarters, and aptness to undergo rapid conversion into health care spaces in as little as two weeks. At this early stage, such facilities appear to do well with public–private partnership for financing, equipping, and staffing along with implementation of technology and strong infection-control and -prevention plans.

Still, ACSs require further scrutiny to better plan and understand the types of model most appropriate and efficient for the population density, existing health disparities, prevailing social determinants, epidemiological factors of the infection, and the local health and commercial infrastructure. As the first wave of COVID-19 moves through the population, such assessments are urgently needed to proceed with further refinements using evidence-based practices.