Public health agencies can prevent infectious diseases among people experiencing homelessness by strengthening partnerships, improving data systems and identifying the most pressing health needs of this population.

Homelessness and chronic homelessness in the U.S. have steadily increased over the last 6 years, reaching record highs in 2022. Infectious disease rates are also increasing among people experiencing homelessness. Existing challenges accessing public health and clinical care services – like limited transportation, administrative obstacles and prior negative experiences – can delay disease identification, treatment and mitigation. The COVID-19 pandemic made clear that there are ripe opportunities for state and local health departments to identify and respond to infectious disease needs among their unhoused population.

The CDC Foundation and CDC wanted to try an innovative approach: establish Centers of Excellence in Public Health and Homelessness (“Centers”) in 3 health departments. Lessons learned from these Centers are outlined in our JPHMP article, “Strengthening Public Health Capacity to Address Infectious Diseases: Lessons from three Centers of Excellence in Public Health and Homelessness.”

Centers of Excellence in Public Health and Homelessness

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The Centers were located in Seattle-King County, Washington; San Francisco, California; and the state of Minnesota. We selected these sites for their existing successes bridging homeless services and public health.

In Seattle-King County, WA, staff from Public Health Seattle-King County (PHSKC) conducted interviews and focus groups with internal and external partners to learn more about the infectious disease needs of their unhoused communities. These sessions highlighted interest in improving hygiene services, restroom access and air quality, and prioritizing harm reduction strategies and trauma-informed, culturally relevant behavioral health support. PHSKC continues to improve how they integrate housing status into their existing disease surveillance systems to identify, respond and prevent future infectious disease threats to people experiencing homelessness.

In partnership with the University of California, San Francisco, the San Francisco Department of Public Health focused on identifying gaps in disease reporting and treatment for people experiencing homelessness. This Center analyzed their data systems to identify opportunities to link siloed databases between public health and homeless services. They also developed three tools to better serve people experiencing homelessness in their community, including a model for conducting infectious disease-focused health fairs. They used this model to implement a community health fair and later mobilized the Center to guide MPox response for unhoused communities in San Francisco.

The Minnesota Department of Health (MDH) partnered with the Health, Homelessness and Criminal Justice Lab at the Hennepin Healthcare Research Institute to establish their Center. They formed an inclusive Advisory Group to guide their efforts to “promote policies that improve how homelessness programs address public health and how public health departments address homelessness.” MDH utilized their Center as a platform to conduct the state’s first homeless mortality study. This study revealed that people experiencing homelessness in Minnesota die at a rate that is 3 times higher than their housed counterparts. MDH continues to engage with the media and the public about their findings, with hopes that the study can be continued in the future.

The Centers of Excellence project was designed to share evidence-based practices to assist other health departments in their efforts to serve people experiencing homelessness. The Centers submitted dozens of strategies, best practices and lessons learned. We compiled these materials and additional resources from external partners to produce the Centers of Excellence in Public Health and Homelessness Toolkit. We distributed the toolkit to health departments, service providers and other partners. It is available online at https://www.cdcfoundation.org/PHAHToolkit.pdf?inline.

Through this project, we learned:

• Partnerships are critical and take time and effort. Public health agencies value strong partnerships with other agencies, academic institutions and community-based organizations. The Centers wished to better understand the priorities of their partners, improve communication, and collaborate with a wider range of diverse organizations.
• Sustained financial and human resources are needed to do this work. Health departments differ widely in their structures, operations and funding mechanisms. Staffing and resources dedicated to unhoused populations also vary considerably among agencies. Dedicating adequate resources and staff specifically to homelessness can increase an agency’s reach and effectiveness.
• Community buy-in is critical. Gaining support from agency leadership, elected officials and community members is extremely important to health departments operating in this space.

Homelessness in the United States is a public health crisis. We hope that public health and community leaders can appreciate the urgency of building public health capacity to better support unhoused populations. We consider people experiencing homelessness to be a population of focus in health equity efforts and recommend increased population-specific funding for health departments to adequately support the health of their communities.

State and local governments should ensure that health departments have designated health and homelessness staff who are familiar with the unique health needs of people experiencing homelessness. In addition, federal agencies should continue to invest in tools, resources and technical assistance to support public health and homelessness programming.

To learn more, read our article “Strengthening Public Health Capacity to Address Infectious Diseases: Lessons from three Centers of Excellence in Public Health and Homelessness” in the November 2023 issue of the Journal of Public Health Management and Practice.

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During this work, Michael Bien, MPH, served as a Monitoring and Evaluation Manager at the CDC Foundation. Prior to this, he initiated and coordinated a street outreach program in his hometown of Athens, Georgia and six surrounding counties. His work focuses on homelessness, housing and promoting health equity.

Ashley Meehan, MPH, is a PhD student at the Johns Hopkins Bloomberg School of Public Health. Prior to this, she worked at the Centers for Disease Control and Prevention on homelessness and health activities. She earned her MPH from Emory University’s Rollins School of Public Health.