Community Outreach to Individuals Experiencing Homelessness During COVID-19
Community Outreach to Individuals
Experiencing Homelessness During COVID-19
November 18, 2020
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Community Outreach to Individuals
Experiencing Homelessness During COVID-19
18 Nov 2020
COVID-19 in the United States
11,344,154 cases on 11/17/20 up from 10,392,702 cases on 11/11/20
248,555 deaths https://coronavirus.jhu.edu/map.html
1 week ago:
National trends – continue to worsen
Moderna’s Covid-19 vaccine (mRNA-1273) is strongly effective, early look at
-reduced the risk of Covid-19 infection by 94.5%
-approximately 30,000-patient study
-no participants receiving vaccine had severe disease vs 11 in placebo
Dr. Fauci: “very impressive”
-no significant safety concerns
Side effects: fatigue and muscle pain, headache and achiness
-Pfizer vaccine last week:
-more than 90% effective in preventing COVID-19
-no serious safety concerns have been observed
-Safety and additional efficacy data continue to be collected - Submission for Emergency Use Authorization to
the FDA planned ~ third week of November
• Bamlanivimab – Emergency Use Authorization
– neutralizing IgG1 monoclonal antibody that binds to the receptor
binding domain of the spike protein of SARS-CoV-2
• Only for mild to moderate COVID-19 in adults and pediatric
patients 12 years who are at high risk for progressing to severe
COVID-19 and/or hospitalization
Wednesday, November 18, 2020
COVID-19 HOMELESS COMMUNITY OUTREACH PARTNERSHIP 2020
PROGRAMS FOR ASSISTANCE IN TRANSITION FROM HOMELESSNESS
impact of COVID-19
individuals suffering from
substance use and mental
health disorders and
communities of color has
Essential Jobs =
High Levels of
University of Delaware, Partnership for Healthy Communities (PHC)
• Directed the strategic operational plan for specialized outreach
DHSS/Division of Substance Abuse and Mental Health (DSAMH)
• Served as Co-lead in strategic management as well as
developed the social support teams and facilitated social
service integration with medical field teams
DHSS/Division of State Service Centers (DSSC) and Division of Social
• Provided Emergency Assistance funds for hotel vouchers, rent, utilities
and emergency shelter
Core Strategic Entities
INTEGRATED DELIVERY MODEL
Engagement in care
related to the
Outreach team engaged 2,528 homeless
1. Identify if viral activity was present among
2. Screen for social determinants of health
3. Triage and shelter those homeless who
were extremely vulnerably to the acuity of
COVID-19 if exposed to the virus
Social Services Team
cleaning and re-
SCREENING AND DIAGNOSIS
Infection Prevention and Treatment
Shelter / Hotel/ Housing
Social Services & Supports
Integrated Transitional Housing Components
TRANSITIONAL HOUSING STRATEGY
Hotel-based Program Locations
• Allowed for single room occupancy as well as on-
site wraparound services to address social
determinants of health needs identified during
• Each individual was supported by provider staff in
establishing a behavioral health discharge plan
inclusive of housing to transition to the next level of
• DSAMH placed 332 individuals in the hotel-based
program. Of the 332 individuals, 185 accepted the
next level of care, inclusive of housing. Jennifer Corbett, Delaware News Journal
• The Social Services Teams were integrated with medical teams
and consisted of DSS, DSSC, and DSAMH personnel, some on
the ground and some behind the scenes coordinating
appropriate hotel/motel referrals.
• Behavioral health providers from Aquila, RI International, and
Peace by Piece provided transportation, food at the screening
sites, personal hygiene items, clothing and naloxone, and
secured support from organizations for meal and medication
distribution dependent upon placements.
Individuals enrolled in the hotel-based program received daily
services including: clinical assessments, prepared meals, clothing
and laundry services, referrals to long-term supports and other
identified service needs.
The Delaware State Opioid Response (SOR) Grant addresses gaps in
Delaware’s system and increase access to quality treatment, refine
transitions to care, and complement existing efforts. This funding allows
Delaware to engage vulnerable individuals, build sustainable capacity
and infrastructure for treatment, housing and other social determinants
The purpose of the Projects for Assistance in the Transition from
Homelessness (PATH) Formula Grant, administered by the U.S.
Department of Health and Human Services, Center for Mental Health
Services, is to provide federal funds to support outreach and
mainstream service linkage to persons with serious mental illness who
are experiencing homelessness or at imminent risk for homelessness.
The target population also includes persons experiencing homelessness
who have co-occurring diagnoses of mental illness and substance use
DEMONSTRATED PROGRAM SUCCESS
Joshua was experiencing homelessness and struggling with an alcohol addiction as
well. The transitional plan was for him to move to New Castle County into one of the
men's transitional houses. To date, Mr. Pitts is doing well and maintaining his sobriety.
He has also taken on a part-time job at Goodwill and continues to focus on his
Claire was experiencing homelessness and was jobless. By the end of the
program, she found a job at Appleby's in Rehoboth Beach and was able to
save enough money to find herself a rental close to the beach and work.
Eric was experiencing homelessness and was unemployed. He previously spent his time panhandling in
Wilmington. Now, he resides in Peace by Piece transitional housing and works full-time at the New Castle
recycling plant in a position he was referred to through the program.
LONG-TERM HOUSING STRATEGY
DSAMH- Utilized existing resources, including access to coordinated services from
community providers, social services resources from sister agencies, housing vouchers,
section 811 program resources and tax credits. This program design:
• enabled individuals to move from transitional housing to a long-term housing option;
• Afforded the client the option to remain with their current provider of choice and
• the flexibility to transition to a different level of care, as needed.
DSSC- Program existed prior to COVID-19 and allowed for extended motel/hotel shelter
Partnership with New Castle County, DHSA, Delaware Housing Alliance and Family
Utilizes various programs including rapid re-housing, housing first/supportive housing,
and permanent housing
The unduplicated number of individuals placed in motels/hotels during this
timeframe (ending June 11) is 1,427. The total number of households with
children is 260 and the total number of children is 476. In addition, 28
individuals placed are over the age of 65.
Collaboration- across Delaware agencies, geographies, and providers was key
The efforts of this activation were supported by many
throughout the state of Delaware, inclusive of a variety
of elected officials, members of the University of Delaware’s
academic community, state personnel, advocates and social
service organizations. This work could never have been
accomplished without this level of engagement and support.
We are extremely grateful to all who provided guidance and
support during this activation.
Chief of Social Determinants and Recovery Support Services
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