Study design, setting and population

The present qualitative study is a sub-study embedded within the “Toronto At Home/Chez Soi: Qualitative follow-up study” (TORONTO AH/CS-QUALI STUDY) (https://maphealth.ca/ahcs-quali-study/) carried out from April 2020 to October 2020. The TORONTO AH/CS-QUALI STUDY aims to explore service user and provider perspectives on the circumstances, challenges, experiences, and unmet needs that may have prevented HF clients from achieving better social, health, and other recovery-oriented outcomes while receiving long-term HF services through the Toronto site of the At Home/Chez Soi study carried out during 2009–2017 [31]. This COVID-19-focused sub-study explores provider perspectives during the first wave of the pandemic, as the implementation of the Toronto AH/CS-quali study coincided with the beginning of the COVID-19 pandemic in Canada. We amended the TORONTO AH/CS-QUALI STUDY protocol to include the COVID-19 sub-study and received approval from the Research Ethics Board (REB) at Unity Health Toronto, Toronto, Canada. The qualitative methodology can offer a valuable perspective to explore the impacts of the challenges, opportunities and lessons learned in providing support and response services to underserved or socio-economically excluded populations during the COVID-19 pandemic [32].

For the purpose of the sub-study, we recruited 20 HF clients and nine HF frontline workers in Toronto. The recruitment and main COVID-19 findings from HF clients have been published elsewhere [33]. For the present study focused on the perspectives and experiences of HF frontline workers, we targeted and recruited a purposive sample of nine HF frontline workers from the three first and largest HF programs (run by three community-based organizations: Across Boundaries (AB), COTA Health and Toronto North Support Services (TNSS)) that implemented HF services for people with lived experiences of chronic homelessness and severe mental disorders in Toronto, Canada, back in 2009 under the implementation of At Home/Chez Soi study in Toronto [31, 34]. The target sample (N = 9) included three HF frontline workers Case Managers(CMs) for each of the three HF agencies was decided prior to the study based upon the following factors.

First, although the three agencies deliver HF services, there are differences between them based on the type of clients served and the core HF services approach they deliver. AB provides HF with Intensive Case Management (ICM) with specific services oriented toward ethno-racial populations with moderate needs level (MN) for mental health services; TNSS provides HF with ICM for clients with MN for mental health services regardless of their ethno-racial background; COTA provides HF services with Assertive Case Management (ACT) for clients with high need level (HN) for mental health services.

Second, HF Case managers (our study populations) provide frontline HF services in a client/Case Manager ratio of 20:1 for HF with ICM and 10:1 for HF with ACT. More detailed information on HF-specific services (ICM and ACT) delivery by the targeted sample and the three agencies can be found in a previous publication by Hwang et al [34].

Third, we were interested in having frontline workers with a longer-term history (between 3 and 10 years) of working as CMs within the three HF programs to better answer the objectives of the TORONTO AH/CS-QUALI STUDY, which go beyond the COVID-19 pandemic. Considering all this, three CMs from each HF program (N = 9) was sufficient to answer our study objectives and to observe potential differential and common perspectives, experiences, challenges and strategies to help us have more comprehensive and generalizable findings on the studied topics.

Our study sample was recruited using a written invitation letter containing the rationale, goals, objectives, methodology, benefits and potential harms, principal investigators’ contact details, and the ethical approvals of the study. Letters were circulated by email through HF program managers, as well as by asking the first interviewed participants to be free to invite their colleagues to participate in our study (snowball sampling). Interested individuals contacted the study co-principal investigator and lead author (CPI: CML) or the study’s peer research assistant (PRA, GD). The PRA or the CPI subsequently contacted all HF frontline workers who expressed their willingness to participate to confirm their participation in the study and in the virtual semi-structured audio-recorded interview.

Study’s ethics

The TORONTO AH/CS-QUALI STUDY, including the COVID-19 sub-study, received ethics approval from the REB at Unity Health Toronto, St. Michael’s Hospital, Toronto (Canada). All participants received a written consent form containing information regarding the study rationale and objectives, methodology, type of data to be collected, and potential benefits and harms of the study. Participants could provide oral or written consent to participate in the study, have their interviews audio-recorded and transcribed, and use de-identified interview quotations in public or academic knowledge translation outputs. The oral consent process was documented in writing by the PRA on the consent form just prior to the virtual interview. All participants received an electronic gift card with a value of CAD 40 for their participation in the study despite being frontline workers in the midst of the pandemic.

Data collection

The qualitative semi-structured interviews were conducted virtually using Zoom for Healthcare [35], the virtual platform approved by the Unity Health Toronto REB to conduct research interviews. We used a flexible interview guide comprised of semi-structured-COVID-19 related questions to address the study’s COVID-19 objectives. After each interview, the two facilitators had a debriefing session to discuss salient topics, identify discourse saturation, or examine new areas that needed further in-depth exploration in subsequent interviews. The interview guide is presented in S1 Table in S1 File. The individual interviews lasted between 35 to 45 minutes. To further enhance the privacy and security of the data collected, we recorded interviews using an external audio-recording device rather than using the internal audio-record feature of the Zoom platform. The collection of rich and comprehensive narrative data at each interview was facilitated by two experienced study team members: PRA (a self-identified man with lived expertise in social exclusion, injustice, mental illness and housing instability) and either the CPI (a mixed-raced scientist self-identified as a woman) or study’s co-investigator (a scientist self-identified as a man from black ethno-racial background). Both scientists had expertise in homelessness and health, socio-economic determinants of health, and health inequities/inequalities.

Data analysis

We conducted the data analysis process manually (an Excel file was used to organize and facilitate the coding process), but using an interactive, dynamic and participatory approach to enhance the trustworthiness, validity, and reliability of the data analysis process and derived findings [36]. Our analysis was guided by the Analytical Framework (AF) method for multidisciplinary-qualitative studies [37] and thematic analyses [38].

First, if needed, we de-identified (removed any name that may have led to participants’ or their close colleagues or clients’ identification) audio-recorded data collected from participant interviews. Second, the de-identified audio-recorded data were transcribed into text format by an experienced external transcribing service and verified by at least one study team member. Third, all transcribed text data were carefully read line-by-line by the study’s lead author and CPI (who also participated as a co-facilitator in most interviews) for a first in-depth familiarization with the data.

Fourth, from the nine interview transcripts, a sample of three transcripts was identified as having richer information by the lead author and PRA. The three selected transcripts were read in-depth by three members of the research team (including the team members who facilitated the interviews) to identify common codes and develop a coding and themes framework. The framework follows a tree-style and is composed of third-, second and first-grade themes as identified from the coding process. The third-level themes (or third-level categories) were the lower or basic themes yielded from the identification and analyses of a cluster of identical or similar coding keywords (e.g. challenges in supporting the social and health needs of clients in-house, in-person services resulting from suspension of the residential or in-person mental or social support services codes). The second-level themes were derived from the identification and analyses of cluster or alike third-level themes (e.g. challenges in delivery in-person support services, derived from the challenges in supporting the social and health needs of clients in-house, in-person services themes). The main or first-level themes were derived from the further identification and analyses of alike main relevant second-level themes that linked to the study objectives (e.g., Challenges that HF frontline providers faced in serving HF program clients’ theme were informed by the second-level themes: challenges in delivery in-person support services, challenges in delivery in -agency-related services, or provide appropriate virtual support services).

Fifth, after each of the three members independently coded and categorized the data of the three-interview transcript sample, the CPI reviewed the resulting preliminary coding to confirm common codes or add new codes and themes, therefore completing the core code/theme AF. Sixth, this initial AF was further validated in an interactive working session by four members of the research team, including the lead author, the two members who participated in the initial coding and categorization of the three-interview transcripts, and one of the researchers who did not participate in the initial coding. Seventh, the validated AF was then applied to the remaining six interview transcripts by three research team members (each member applied the AF to two interviews). During this process, each member could identify and add new codes or second and first themes that were not presented in the existing AF.

Once the coding and theme identification process was finalized, the CPI read the remaining six interview transcripts and validated the inclusion of newly identified themes and categories in the AF (very few additional second-and-third themes emerged), completing, therefore, the final AF, which included salient quotations and preliminary interpretations made by the coding team. Finally, we analyzed and interpreted the coded and themed data, guided by a mix of inductive and deductive approaches [39] using the thematic analyses [38] and social-ecological model (particularly the updated motives and influence: proximal processes sub-model) [40, 41] and critical theory [42] as references. The CPI conducted the first analysis and interpretation of the AF, followed by a validation process by three other members of the team and critical revision and further validation by the rest of the paper’s co-authors.

The challenges faced (Objective 1)

With the sudden onset of the COVID-19 pandemic and implementation of strict public health measures (lockdowns, mandatory quarantines, physical and social distancing), the HF programs and in particular the HF frontline workers, found themselves facing several interrelated challenges in providing the habitual and urgent HF supports to their clients, as they were not prepared to provide a quickly appropriate and effective response. The challenges that were experienced were grouped into the following two main categories.

Challenges in meeting HF client’s health and social well-being needs

During the pre-pandemic, HF workers regularly checked HF clients’ health, social status, and needs in person, either in the HF agencies facilities, at the client’s home, or in community settings (e.g., coffee shops and parks). Furthermore, HF clients also had the option to actively participate in group-based social activities (e.g., social dining, healthy social talks, physical and psychological wellness activities, and social networking events). However, at the beginning pandemic, all of these activities abruptly stopped and quick changes needed to be implemented, such as transitioning to virtual support formats (video or phone-based) usually from the home of the HF frontline workers; therefore, suspension of all non-urgent in-person encounters between HF personnel and clients were implemented.

“It is a challenge. We’re so used to the face-to-face contact and you know talking to them and then you know when you visit them, they might say, can we go for a coffee and we take them for a coffee you know; there’s a lot of things that you can’t do. They can’t even come into the office as a drop-in. We can’t do that anymore.”

[B0006]

These changes and intersecting critical issues, such as limitations in the availability and access to technology and communication resources (e.g., not all clients had access to mobile or computer devices and phone or internet services, see more on the below theme), personal protective equipment (PPE), personnel resources (e.g., not enough personnel to attend to clients’ urgent needs in person) and clients’ health issues triggered several barriers for HF workers to respond to their client’s needs in an appropriate and timely way.

HF frontline workers expressed challenges in assessing the coping capacity of their clients and changes or exacerbation in their mental or physical health issues, particularly among those with severe mental illness, substance use, mobility limitations, risk of food insecurity, as well as clients with very limited or non-social ties outside of those they had developed as a result of their involvement in HF programs. This made HF frontline workers feel powerless regarding the amount, quality and frequency of the support they could provide to meet such clients’ needs.

“We’re doing on phone calls and also sometimes WhatsApp, usually once a week so we can see if there is a mental health concern. If you know the person is okay with the video and because not everybody is okay with the video, it is a challenge”

[B0001C].

Adding to this, especially during the first months of the pandemic, HF workers also had difficulty assisting clients with non-COVID-19 health issues to connect with healthcare services, as the health system was overwhelmed and many health services were suspended or shifted to virtual visits.

“The reality is, is it is, everything is very limited. Everything is taking a lot longer-you know, doctors’ appointments. As you know, [it is] hard to get things done. It has become quite a bit different. Everyone is trying to do things virtually, and that is a problem for our clients/”

[B0003C].

Similarly, in the first months of the pandemic, HF frontline workers had a hard time assessing the housing needs or housing status of some of their clients, mainly those with limited access to a phone or other communication device/service and those living in non-shared or single residential units. They were unable to contact them by phone or in-person.

“I would say the biggest challenges are kind of our social activities and community visit. We do face-to-face visits in the community. Those are very much limited at this time. I can’t do a home visit; right, that’s like the most core part of my job ‘cause that’s why I’m hired; right.”

[B0008]

This increased their worries about the lack of clients’ ability to maintain healthy and safe home environments, address housing issues (e.g., water leaks or appliance repairs, air-conditioning malfunctioning) and adhere to residential unit rules (e.g. reduced noise) which could impact their housing tenure. Furthermore, HF programs needed to suspend the housing relocation services for clients, as in-person visits to rental units were suspended and there were not many rental housing options available.

Challenges in the transition to a virtual support format

The shift to implementing a virtually-based HF support approach to ensure HF clients continued to receive some amount and type of HF services/support during the first wave of the pandemic brought different challenges for HF frontline workers. Among such challenges was the limitation in delivering appropriate phone or video-call-based services/support to their clients, as many of their clients did not have smartphones and PCs or access to internet and phone services in their residential units.

“I had to call my clients. Some of them didn’t have phones, some of them didn’t have Wi-Fi. I had to you know do a virtual visit. So, no technology, no phones, no Wi-Fi. I think technology and Wi-Fi, Internet, these two have been very, very important, you know like problems”

[B0009]

Another challenge experienced by HF frontline workers was that some clients were unwilling to establish a trustful, interactive and informative communication process via phone or video, which eroded the existing active and interactive communication relationship they had built with their clients before the pandemic.

“It’s not the kind of relationship building that we have usually in the past; and our clients, they’re experiencing it, they’re not really voicing it but you can tell they’re reacting differently to the way we are right now.”

[B0003C]

Furthermore, even when some clients started to access and use virtual support services/activities, the HF frontline workers noticed that their clients reacted differently or interacted little on the phone or during virtual support sessions compared to during in-person active or collaborative interactions they had before the pandemic.

“I think it’s a bit harder to build rapport and that trust when it’s just, if you’re, you know, calling them over the phone or just seeing them over a screen.”

[B0008]

Thus, HF frontline workers were concerned that these challenges were reducing the continuity of the support process, undermining the social, health and housing progress and improvements that some clients had accomplished before the pandemic.

Strategies to support health and social well-being needs

HF frontline workers knew some of their clients could experience an onset or exacerbation of their mental and physical health problems due to mandatory lockdowns, quarantines, and isolation/social distancing, as well as the stopping or significant reduction in existing social and health support services within and outside HF programs; therefore, they came up with several strategies, which seemed to work well. For example, HF frontline workers implemented more frequent and longer phone checks (sometimes daily or two or three times a week) with their clients, especially those they knew had severe or complex mental or physical disorders(including substance additions) and were or not in treatment before the pandemic, as well as with those clients, they were able to identify evident changes or decline in their mental or psychological status.

“We do make a lot of phone calls to our clients and try and speak to them and ask them how things are going. Sometimes, it’s difficult to talk about certain things on the phone. I think having them see us would be a lot better, but we just can’t at this point in time; right.”

[B0003C]

Also, they identified available and easily accessible outpatient healthcare services (e.g., family doctors or nurses, psychiatrists), and liaised and advocated with local pharmacies and supportive hospital staff (i.e., hospital-based social workers) to coordinate and connect care services for their clients with need for non-COVID-19 care or treatment. Nevertheless, such care was delivered in its majority virtually. In-person care was only available for severe health issues or clients with assisted treatment (e.g., IV pharmacotherapy).

“I know some of the GPs have done like over-the-phone appointments at this time, so we will support them as well with that. The loaner phones had been helpful for that because we can provide a phone for them to connect with their GP and have an assessment done that way. I have collaborated with the management in trying to phone the person[client] and then the doctor.”

[B0008]

Furthermore, HF frontline workers updated their clients’ residential, personal and medical history. They also closely revised treatment adherence and doses of those clients with the evident onset or exacerbation of mental disorders. Frontline workers followed up with HF program health providers (psychiatrists, nurses, physicians) or primary care physicians to assess and implement treatment adjustments if required. This strategy seems to improve clients’ health and assist HF frontline staff in planning continual supports for those with greater health needs.

“We are trying to advocate and say actually he is not doing well doctor and set up and advocate for medications. It’s very important. We talk to them [physician] so they [clients] can get the medication.”

[B0001C]

As HF frontline workers observed an exacerbation or worsening of mental health problems (including substance use including alcohol) among some HF clients, they were able to increase some support services via phone or virtually, such as harm reduction education, connecting to in-program counselling specialists, and referrals to external (in-person or virtual) harm reduction services to which their clients could turn to if needed.

“We’re doing a lot of addiction kind of you know support and connections. And we are doing more harm reduction education and support [resources] for that. We are able to access crisis, Gerstein crisis centre, and we are also connected and work with CAMH [Centre for Addiction and Mental Health]. We collaborate with them very well. So, that is the access that we provide and refer them to

[B0001C]

After the first three months of the pandemic, some of the HF programs and the HF frontline workers also started virtual health-related stress/uncertainty relief and socializing sessions (e.g. peer-led conversations about welfare, medication, and health issues, weekly virtual yoga and mindfulness sessions) to further support the social and health issues experienced by their clients.

“Peer support is actually a separate program online now. Conversations, issues about medical, medication, health issues, so you have peer support and discussion in groups, we’re doing that now.”

[B0001C]

HF frontline workers reported that although such virtual activities started with few clients, they observed that more clients were connecting or interested in such activities.

Furthermore, since many social support services that provide food and meals to their HF clients were closed as a result of the COVID-19 pandemic, putting some of their clients at high risk of food insecurity, as many clients continued to live in poverty or had reduced financial capacity to meet their food needs. Thus, HF programs organized small food baskets and grocery gift cards for clients with greater food needs. Items were delivered to clients either by HF frontline workers (for clients with physical mobility issues or limited transportation services) or by clients picking it up at HF program facilities.

“We’re always making sure that they have food and if they don’t, we get it for them, or we ask for it. My manager goes out and buys them some stuff sometimes as well.”

[B0006]

HF frontline workers also updated their clients regularly on the very few free meal programs and food services available in their neighbourhoods, which mainly provided takeaway options. However, many services that continued to operate were far away from the client’s home, thereby limiting access for many clients.

“There were a few places where a person could get a meal, and we would direct them to those places, but they were very far from where most of our clients live.”

[B003C]

Strategies to enhance the transition to the virtual support approach

HF programs and frontline workers set up several strategies to enhance the adaptation to the sudden shift from in-person to virtual support due to the pandemic. Among such strategies, there was a partnership with a local telephone service provider to give free smartphone devices and provisional internet and phone connection services to HF clients who did not have access to electronic devices or internet services.

“Some of them [clients] didn’t have a phone, some of them didn’t have Wi-Fi. I had to you know, do a virtual visit. So, no technology, no phones, no Wi-Fi. So, the program, you know, [we] tried to resolve this, and we gave our clients phones which is great.”

[B0009]

Nevertheless, such a digital and communication initiative was challenging to implement as some clients lacked knowledge of the functioning of virtual systems or smart devices, and others did not want to use them. Thus, HF frontline workers provided in-person or phone help/guidance on the basic functioning of the given phones, set up email accounts and explained how to navigate the virtual services HF programs and other support platforms provided.

“Now the challenge is with the phones. It’s too short-sighted to just give somebody a phone that’s never used a smartphone. They just do not [the phone functioning), so what I try to do is sit down with them for an hour and go over like hey, this is your emergency contacts, and like this is how you pick up a phone call, keep it simple.”

[B0007].

Despite the above, most workers reported that giving phones and access to the internet and phone services was very beneficial, as it helped them to reach and support more clients virtually. In addition, many clients could also engage in virtual services offered within and outside HF programs and connect with friends, relatives and acquaintance-based social networks.

Strategies to support housing needs

Though the majority of their HF clients were stably housed (have independent or assisted place to live), HF frontline workers put in place various housing-related strategies to prevent the loss of accommodation, enhance housing stability, and resolve housing issues arising during the pandemic lockdowns or stay-at-home orders. For example, for clients with videophone services, HF frontline workers regularly performed wellness checks to ensure the state, cleaning and maintenance of their clients’ accommodation. HF frontline workers also regularly asked their clients about any housing issues (either physically or administrative such as renewal of renting contracts) that needed to be fixed and either arranged assistance through the HF program or landlords. These strategies were reported to work well.

“I say, I just want to check if you’re doing okay, and I just see, you know, If the landlord is taking care of fixing anything broken. I just want to see the unit, how they’re doing: can I have you on video? Then I tend to just look at that [residential unit].”

[B0001C]

As the ongoing pandemic and strict public health response measures in Toronto continued over the summer of 2020, the lack of air conditioning was an important issue for many HF clients who did not have access to air conditioning services in their home due to limited financial resources. In addition, they could not access most public spaces with air conditioning that they used to do over the summer previous to the pandemic (e.g., libraries, coffee shops, malls) as they were closed or had very restricted access. Thus, HF frontline workers requested financial support from the HF program or a medical prescription for air conditioning, particularly for clients with underlying health problems, as a physician could prescribe air conditioning as part of a patient’s treatment plan. Hence, clients could apply for financial support to deliver and install a cooling device such as an air conditioner or fan as part of their treatment coverage. However, HF frontline workers highlighted that it was not a smooth process and required time, as it implies a lot of bureaucratic steps. Also, not all physicians knew or were willing to prescribe air conditioning as part of a treatment plan.

“If you have a doctor that can write really well [the need for air conditioning] for you, then you can get the air conditioning. If he doesn’t, if it’s not good, then you don’t get it. That’s how it has been and it’s still a challenge.”

[B0001C]

Finally, secure and affordable housing became much harder to obtain during the COVID-19 pandemic. If private market housing could not be obtained for new clients or those who had scheduled a housing change or end of their housing lease, as well as clients who required COVID-19 mandatory quarantine but were living in congregate settings (e.g., boarding home or rooming house), HF programs would house such clients in temporary shelters or hotels funded by the local government during the pandemic until a new home was found or the clients completed the mandatory quarantine period.

“We are now getting temporary housing which could, in the form of some hotel rooms, basic hotel rooms, but they’re available for our clients. If there’s a situation where our client has to leave their place, or they get taken into our team and they have to find a place we’re putting them up in some hotels for a little while. We are accepting new clients, but most of those people will probably be placed in a hotel until things cool down for a bit and those hotel rooms are supplied by mostly the government or, you know, funders of our agency as well.”

[B0003C]

Psychological well-being effects

A great amount of fear and worry of being exposed to COVID-19 was a commonly manifested psychological effect among HF frontline workers, especially those engaged in providing in-person support to their clients. Although they used PPE, they felt vulnerable to contracting the COVID-19 virus because some clients did not entirely adhere to social distancing and stay-at-home orders (mainly due to mental impairment) or could not afford PPE (e.g., masks and hand sanitation due to lack of financial resources or supply shortages).

“As a case manager, I think we are facing with a lot of problems, fear, because I don’t know, where these clients, you know, have gone [around] and which people they meet. Some of my clients really like you know to see or their friends and go everywhere.”

[B0009]

High psychological stress and anxiety were identified as other frequent psychological issues experienced by HF frontline workers. However, participants recognized that such effects were mostly related to their feelings of powerless and inability to appropriately assist those clients with more health and social support needs (e.g., clients whose mental health worsened or who were at high risk of overdose, self-harm, and suicidality) and the new scenario where they found working alone and finding solutions to meet their client’s needs.

“I would say not being able to see your co-workers, mentally it’s affecting me [more stress and anxiety], but also [not] being able to consult them, just having people on-hand at the office [where] I can say, hey, I need your help with this new scenario or with this thing popped up.”

[C0007

Many of the HF workers frequently questioned their supportive role and felt unprepared, undertrained, and under-resourced to provide an effective and timely response to clients with complex intersecting needs and those with less ability to adapt to the new virtual way of providing support services.

“I was trying to help my client as much as I could so, and like some of them, they didn’t have phones, no technology, no like Wi-Fi. Then, you know, I heard this news [client’s death from overdose], so it was very difficult for me to put you know, everything in place, put myself together and you know, deal with this like tragic news.”

[C0009]

Work well-being effects

The increased workload was a frequent issue, negatively impacting HF frontline workers. Adapting to working remotely from home and pivoting to a virtual environment increased the overall hours that HF frontline workers spent providing support to clients. It also challenged their ability to plan meaningful support activities virtually but also organize and deliver safe in-field support services for clients in most need. Further, working from home was affecting their capacity to have a positive balance between work and family obligations, as work was taking priority over personal or family activities/obligations (e.g., parenting and schooling children).

“Working from home, unfortunately, is much harder in the sense that there is no downtime. I’m working seven hours straight at home; it’s a lot. You’re doing a lot more in that time. 9:00 to 5:00 is like the expectation, but now during COVID, we’re allowed to work from 8:00 to 8:00, so there’s a little bit of flexibility we have, but sometimes I do leave my phone on a little bit later and I keep [working] on.”

[C0007]

Other work-related effects included the feeling of increased work and financial insecurity that some HF frontline workers were experiencing, as they feared that they might lose their job due to agency closures or a reduction in the many support services implemented due to the pandemic.

“I could see many stressors, right? Like my son, he’s four years old, and his daycare was closed, I had him at home. And I didn’t know, you know, what happened with my job, so [if] we continue with this agency or we have to go on like government support programs and things like that. So, I feel somehow it [insecure and worry].”

[C0009]

Recommendations for the way of delivering support services

HF frontline workers believed that some public health and social measures implemented to contain the COVID-19 pandemic should be maintained during the post-pandemic period. Among the first group of measures recommended are those related to health protection, such as having fewer clients within shelters or supportive programs’ facilities, having access to PPE equipment for staff and clients, and reducing the frequency of in-person encounters between clients and support workers in indoor or confined spaces. In addition, some HF frontline workers considered that these measures could contribute to reducing the spread of other infectious diseases among support workers, clients and local communities.

“You know it’s going to be better practice the social and public health measures for us to always maintain a good healthy distance from people.”

[B0003C]

Maintaining a virtual approach to support services was highly recommended by almost all participants. This allows workers to reach more clients in need of housing, social, and health support and help the workforce be more efficient in allocating services and tailored activities according to their client’s needs, including facilitating access to a speedy referral within and across social, health, and housing systems. Nevertheless, participants recognized that this approach could lead to more isolation and loneliness among some clients, which may add to other significant support services disparities. Some clients face financial barriers that leave them without access to PCs/smartphones or internet or phone services.

“Technology; offering the free phones, stuff like that. You know more mental health supports virtually, and more virtual programs are all free. I would hope that these continue because they have pretty immense success but do I think it will continue after? No, I think a lot of it will be halted. Maybe there might be a hybrid or lessening of it, but, I believe some of the virtual programs will always remain but a lot of other services might be completely gone later.”

[B0007]

Recommendations for strengthening housing services

HF frontline workers believed that COVID-19-related measures implemented within the supportive housing and shelter system should be maintained and strengthened beyond the ongoing pandemic. Among such measures are improved safety and sanitized conditions, reduced dormitory capacity and increased spacing within shelter clients.

Moreover, some HF frontline workers suggested that effective and long-term strategies to reduce the usage burden of drop-in services by people who moved to safe independent or supportive housing units without the need to do so should be implemented and monitored. This would allow other people without access to stable housing and supports to get a bed/room in the shelter system and optimize limited housing resources.

“It will definitely have permanent changes to how we deliver with clients because we know that our clients sometimes use the shelter system even though they have housing; right! And we have some issues, some people who are like that and who are you know, want to be near their friends, so their friends may be in a shelter, and they’ll go and see [stay with] them.”

[B0003C]

Finally, all HF frontline workers called for local, provincial and federal governments and associated stakeholders to increase resources and access to affordable, safe and sustainable housing solutions paired with robust social and mental health(including access to food) support for people experiencing homelessness/housing instability, as doing so would reduce other socioeconomic and public health concerns such as poverty and crime.

“You know, I believe everyone needs access to the very basic needs. It doesn’t matter, I don’t care about barriers, you just got to get people a place to sleep that’s safe and to eat. If you don’t have those two things, you’re going to have crime, you’re going to have poverty, you’re going to have these overlapping barriers that people can’t get through. It’s just the basic human, human right and need, I believe that you need access to food, housing.”

[B0007]

Recommendations for health-related services

HF frontline workers highlighted that the pandemic exposed the lack of adequate nurse and physician resources in the community to cope with the complex physical and mental health needs of underserved or socially excluded populations during the pandemic times and beyond. Therefore, they asked for increasing or mobilizing robust financial investment and resources to expand and retain healthcare personnel supporting these populations.

“Nurses and doctors worked hard, really super hard and it shouldn’t be that way. We should have those services you know. So, taking care of your healthcare is a preventive measure, so you need to have more hospitals, more facilities, more trained staff, more doctors, more nurses.”

[B0005]

Also, HF frontline workers recommended increasing access to more personalized, appropriate, timely, integrated and sustainable healthcare services during and beyond public health emergencies. Among such suggestions is the implementation of and facilitating access to specialized and intensive mental health services to appropriately meet the mental care needs of people experiencing homelessness, as many of the existing support services do not cover such needs. As many emphasized that such population groups frequently experience complex and intersecting mental health and social needs that require interdisciplinary and person-based supports and treatments to better enhance their health recovery and overall well-being.

“I think also just more availability for mental health services like different therapies because, I mean you know, we can provide this, you know a limited amount of counselling and the medication piece; but also, I think a lot of people out there have [mental disorders], you know, they need more intensive therapy.”

[B0008]

Recommendations for response preparedness

Despite social support programs showing a remarkable capacity for problem-solving and prioritizing some essential services during the first wave of the COVID-19 pandemic, HF frontline workers found multiple gaps that should be addressed in order to build or strengthen the preparedness to better provide timely and coordinated (social, economic, health, food, and communication) support services for clients of HF and alike support programs and for people experiencing homelessness without having supportive services.

Among such strategies, there is a need to strengthen the planning, coordination and effectiveness of response management and procedures; mobilize more financial and human resources at all levels of the supportive social and health systems (e.g., housing/shelter, mental and additional support services, food support services, technological and social connection services, skills development or training, and social networking connections, and internet and phone services).

“Also, just economically[support], like maybe more employment programs generated towards the people that have mental health or addictions issues, more activities, more you know, social opportunities-so many things, yeah.”

[B0008].

Another strategy that was suggested was to provide more efforts and mechanisms to collect, integrate and facilitate access to information on individuals’ housing, health, family, financial benefits, and social networking status across supportive services need to be implemented. This would increase opportunities to deliver timely, appropriate and coordinated care for people in most need during public health emergencies and beyond. Furthermore, it would reduce the bureaucracy and the need for clients to share personal information with service providers, thus ensuring the continuity and personalization of care and social support.

“Any type of support you need immediately can be delayed significantly, and we learned that. For instance, it’s much harder to reach ODSP. People are most vulnerable; unfortunately, they can’t manage some aspects of their lives. I am [cheeked] who are my contacts, I have their right phone number or the right pharmacy phone number. So, I’m realizing the importance of having these set up. I think our organization did a good job in the sense of like well we need to update our [clients] profiles, in full. Especially during this pandemic because we need to know how to best serve them in any type of emergency situation.”

[B0007]

Finally, some HF frontline workers suggested that any potential policies that seek to restrain access to public spaces (e.g., use of libraries, malls, and community centres) should be carefully considered and assessed, even during public health emergencies. Many of these public spaces constitute the only areas where underserved and socio-economically excluded people can break their isolation and loneliness, satisfy heating and cooling needs, and access much-needed resources.

“Yeah, the world is going to be very small for our clients. Libraries, parks, community centres, malls. All these things are gone. And that’s another thing too like say, you were going to the malls and people will be rushing them out now more because of stigma or you know, all kinds [things]. I definitely think they’re going to change, definitely, they’re going to be feeling more isolated and things are going to be less available to them.”

[B003C]

Limitations

Despite being one of the few studies assessing the impact of COVID-19 on the delivery of HF services to people with lived experience of homelessness in a large, urban and high-income country, the present study has the following limitations. The data collection was done during the first wave of the COVID-19 pandemic (April to July 2020); thus, it is likely that HF programs have implemented further strategies and responses to support their clients with less challenging and more client engagement. It may also be that HF frontline workers have experienced new challenges in the service delivery process as the COVID-19 pandemic and associated public health and social measures continue to be in place in the study setting. Furthermore, the response capability of HF programs to address their client’s needs during the pandemic could have differed from that of other supportive organizations serving underserved population groups, which may have had either more or limited financial, material, and personnel resources. Similarly, this study’s findings might differ from those in other geographical contexts with different socioeconomic conditions and political and emergency response capacities. Therefore, it should be considered when extrapolating or comparing the present study’s findings.

Recommendations for programming, policy practice, and research

In Table 1, we provide key recommendations for strengthening the role of social, health and housing organizations or programs serving underserved populations during and beyond local or global public health emergencies.

Download:

• PPT
  PowerPoint slide
• PNG
  larger image
• TIFF
  original image

Table 1. Recommendations for HF programs, government, community and for research, and practice.

https://doi.org/10.1371/journal.pone.0278459.t001

In conclusion, despite the several work-, programming- and structural-related challenges experienced by HF frontline workers when responding to the needs of their clients during the first wave of the COVID-19 pandemic, they played a critical role in meeting the communication, food, housing and health needs of their clients during the pandemic, even when it negatively affected their well-being. A more coordinated, integrated, innovative, sustainable, effective and well-funded support response is required to meet the intersecting and complex social, housing, health and financial needs of underserved and socio-economically excluded groups during and beyond public health emergencies. Ensuring appropriate work, health and financial support for support services workers will further contribute to appropriately meeting the needs of underserved populations.