For San Francisco public health officials, it was a potential nightmare scenario.
On May 7, a man experiencing homelessness tested positive for COVID-19. He had just visited the city’s Sobering Center, a facility in the South of Market district where intoxicated people can recover safely without being transported to overcrowded hospital emergency rooms.
Before anyone realized the man had COVID-19, he had exposed 17 other people he had been with at the sobering center. These exposed individuals spent their days interacting with the public — panhandling, entering stores, visiting hospital emergency rooms, and spending time on the streets. Without prompt action to get them off the streets, they might have become coronavirus “superspreaders” — people who infect a disproportionate number of other people.
Finding people without shelter and with substance use disorders who mistrust authorities, and then persuading them to enter a quarantine site was no easy task. Only one group of emergency responders in San Francisco was primed to handle such a job — the Fire Department’s Emergency Medical Services EMS-6 team.
We’ve been versatile, and we’ve been able to stretch in order to fulfill other roles that nobody else could.
—Simon Pang, section chief of EMS-6
“We know these people so well, it wasn’t terribly difficult to find them,” said April Sloan, the unit’s senior captain. “A lot of them have established spots — liquor stores they frequent, corners they hang out on, bus stops they’re at. And they trust us. We work hard to establish rapport with them.”
EMS-6 is a team of more than a dozen paramedics participating in a California pilot program called community paramedicine run by 14 local EMS agencies. Each jurisdiction tailors its community paramedicine efforts to local needs. In San Francisco, EMS-6 community paramedics are trained to do more than respond to 911 calls and take patients to the hospital. They get to know the frequent users of emergency services, most of them people experiencing homelessness and people suffering from substance use and mental health disorders. The paramedics know how to talk with these individuals with challenging lives, assess their medical and social needs, and direct them to services that are more suitable for their needs than a hospital emergency room, including the sobering center or a mental health clinic.
Staffing a Quarantine Site
Now, as the city labors to control the COVID-19 pandemic, EMS-6 paramedics are adapting their skills to the evolving crisis. They’re finding people living outdoors who are suspected of having COVID-19, bringing those people to quarantine sites, partnering with San Francisco’s street medicine team to have people tested for the disease, and making contingency plans to divert patients from emergency departments and assist field hospitals and nursing homes if cases surge.
“We’ve really added a whole number of things to our repertoire,” said Simon Pang, section chief of EMS-6. “We’ve been versatile, and we’ve been able to stretch in order to fulfill other roles that nobody else could.”
One critical function taken on by EMS-6 paramedics was staffing a quarantine site (similar to Project Roomkey) for people exposed to COVID-19 in the Sobering Center outbreak. These clients had severe alcohol use disorder and could not stay safely at one of the many hotels set up to handle suspected and confirmed coronavirus patients. They needed two crucial forms of help — controlled access to alcohol so they would avoid going into sudden withdrawal, and supervision by people trained to manage medical and mental health crises.
Four community paramedics partnered with staff from the Sobering Center to run the site, referred to simply as “Site 16” to protect the privacy of the residents staying there. In the weeks that followed, the paramedics assessed the residents every few hours, checked for symptoms of alcohol withdrawal and COVID-19, handled behavioral outbursts, and artfully negotiated with anyone who tried to leave.
These people brought me back to health. I’m so calm, I’m healthier, I’ve gained weight. . . . I’ve never met such nice people in my life.
—Lisa Aragon, who moved into a quarantine hotel
after being exposed to COVID-19
Nurses from the Sobering Center administered measured alcohol doses for the clients under established protocols. As the clients’ mental and physical health stabilized, the paramedics began talking to them about their challenges and goals, identifying resources to help them. Residents continued to stay at the site and receive help with achieving the goals they’d set for themselves, even after it became clear none of them had contracted COVID-19.
One patient, Lisa Aragon, 58, had experienced homelessness for more than two decades. Addicted to alcohol and crystal meth, she said she suffered from depression, anxiety, severe arthritis, and nerve damage. When she arrived at Site 16, she felt agitated and ill, she said. Now, after a month at the site, she’s stopped taking crystal meth, lowered her alcohol intake, visited a doctor to get treated for her health problems, and is looking to qualify for subsidized housing.
“These people brought me back to health,” said Aragon. “I’m so calm, I’m healthier, I’ve gained weight. . . . I’ve never met such nice people in my life.”
Other residents stopped drinking altogether and went to detox facilities, Pang said. Some have been enrolled in health plans and connected with primary care. Two were found eligible for priority housing, one for veteran services, Pang said. Given these residents’ frequent use of 911 services when on the street, Site 16 likely averted hundreds of calls to emergency services, he said.
“These are people who live extremely chaotic lives, who were in and out of the hospital, often found prone on the sidewalk,” he said. “We’re giving them a sense of security and stability that they haven’t had in years.”
Mobile Testing, Surge Plan Preparations
For the past three months, community paramedic captain Eddy Bird has been riding with a nurse practitioner from the San Francisco Department of Public Health street medicine team. The pair screen people experiencing homelessness for COVID-19 and evaluate those with medical complaints who are staying at the more than 30 shelter-in-place hotels and quarantine sites located throughout the city. They also respond to 911 calls from people with nonemergency needs, some of whom call only because they feel isolated and stressed by the pandemic, Bird said.
“We’ve assisted with wound care, things like abdominal pain, nontraumatic back pain,” Bird said. “If somebody needs mental health services and is not suicidal, we can call a mental health professional. If somebody’s run out of medications, the nurse practitioner can prescribe medications. Sometimes we pick up medications for them and drop them off at their home.”
Bird and other members of EMS-6 have also staffed a COVID-19 testing site in the Tenderloin neighborhood, providing people with information on what to expect during the test and what to do if they test positive.
Versatility of Community Paramedicine
Meanwhile, Pang has been working with other city emergency officials on contingency plans in case of a coronavirus surge. Depending on the level of emergency, community paramedics could be asked to handle nonemergency coronavirus-related calls to keep people from going to overwhelmed hospitals, lead triage at an overflow field hospital, and take charge of nursing homes if staff become overwhelmed.
“I think this shows the versatility of our unit — that we’re able to fulfill that role if we needed to,” he said. “We’re selected to do it because we can. We’re available, we’re mobile, we work from 6 AM to 2 AM. There’s no one else that is suited to this role.”
Some of the tasks contemplated for San Francisco’s paramedics in the case of a surge in COVID-19 cases are possible due to the March 4 proclamation issued by Governor Gavin Newsom. He authorized the state’s Emergency Medical Services Authority (EMSA) to allow local agencies to let paramedics aid in the prevention of the spread of the virus. EMSA Director Dave Duncan, MD, has embraced that flexibility.
San Francisco’s community paramedicine team’s response to the pandemic is exemplary, said Janet Coffman, a professor at UCSF and independent evaluator of California’s community paramedicine pilot project.
Now that we’ve seen [the shelter-in-place, stabilization] model, and we’ve seen how successful it’s been, it’s really worth fighting for.
—Christine Couch, San Francisco
Fire Department community paramedic
Since it began in 2014, a total of 14 municipalities in California have piloted community paramedicine programs under the project. The most successful programs are ones that divert people, when appropriate, to mental health crisis centers and sobering centers. These have resulted in a dramatic drop in the numbers of people with mental health and substance use problems being taken to emergency rooms, the UCSF evaluation found.
Out of all the programs in California, San Francisco appears to have adapted most effectively to deal with the demands of COVID-19, Coffman said. She attributed this in part to the city’s leaders recognizing the value of community paramedicine, and strong collaboration between the paramedics and other city departments.
“I think what they’re doing is impressive,” she said. “I think part of the reason they’re able to be impressive is they had a strong foundation.”
Reducing Pressure on Emergency Departments
Overall, the community paramedicine pilot has demonstrated that expanding paramedics’ job capacities can meaningfully reduce pressure on emergency department services, Coffman said.
In recent weeks, Pang’s team has moved Site 16 to a bigger building, known as Site 42, and has continued to care for people experiencing chronic homelessness and substance use disorders who need somewhere to shelter in place. Most of the original clients have now moved on to detox facilities or regular shelter-in-place hotels. The Sobering Center has temporarily relocated to Site 42 because it has rooms where clients can be isolated during the pandemic, and the center staff is providing nursing care and case management.
Earlier this month, two clients at Site 42 and several staff members, including two community paramedics, tested positive for COVID-19. The Sobering Center had to close again but is due to reopen shortly, Pang said.
Christina Couch, a paramedic at Site 16 and now Site 42, said she hopes the shelter-in-place, stabilization portion of the operation can become a permanent part of the team’s strategy for helping those experiencing homelessness who are the hardest to help.
“Now that we’ve seen that model and we’ve seen how successful it’s been, it’s really worth fighting for,” she said. “They’re housed, they have meals, and they have medical checks. We can provide for their needs. I’d love to see that continue.”
Aragon, the resident gaining stability at Site 16, said if the paramedics hadn’t taken her there she’d be dead — if not from COVID-19, then from alcohol, drugs, or street violence. These days she tends to houseplants in her room, watches TV, showers every day, and makes plans for a better life.
“I ain’t got nothing to worry about over here,” she said as she sat with one of the paramedics on a recent afternoon. “It’s wonderful. I’m so happy. I thank God every day.”
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