AJPH COVID-19
The Role of Alternate Care Sites in
Health System Responsiveness to
COVID-19
See also the AJPH COVID-19 section, pp. 1344–1375.
The COVID-19 pandemic
has altered life and upended
health and the economy for
millions of Americans, high-
lighting fault lines that sharply
divide our population along ra-
cial/ethnic and socioeconomic
status. These determinants pre-
dict life expectancy, food and
housing security, health care ac-
cess, and educational and eco-
nomic 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 socio-
economic 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 shel-
ters, or prisons; and have lower
health care access.2,3 Although
1362 Editorial Kaysin et al.
few population-based COVID-
19 studies have been published,
initial research and reporting
clearly indicate that Black, Lat-
inx, and Native American pop-
ulations are disproportionately
affected by COVID-19.2–4
Higher rates of being uninsured
or underinsured, receiving dis-
criminatory treatment, and sub-
sequently mistrusting the health
system among racial/ethnic mi-
norities affects care and will
result in suppressed estimates of
COVID-19 incidence, preva-
lence, and mortality in these
communities.5 Our own sur-
veillance data, from three pri-
mary care practices in Baltimore,
reveal that Black and Latinx pa-
tients 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, al-
ternate care sites (ACSs) are
used as part of local or Federal
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.
The hotel infrastructure
proved well suited to providing
safe and comfortable isolation
space, in-room refrigerators and
Emergency Management Agency– safes to store personal medication
led emergency response plans to and valuables, food services, se-
address pandemics and natural curity, conference space con-
disasters when health care facil- verted into a command center,
ities are unable to accommodate Wi-Fi, ability to maintain hot and
the surging demand for resources. cold zones, and in-room climate
The concern for inadequate control. Stations for donning and
hospital capacity combined with doffing were built into each oc-
an anticipated need for isolation cupied floor with modest archi-
space led a local health system to tectural modifications.
collaborate with the state of This model uses telehealth
Maryland to open an ACS in a technologies with purchased
tablets and patients’ own smart
400-bed Baltimore hotel. As in
phones to connect with providers
other cities, the process of lo-
for chronic care management,
cating a suitable, available, and
behavioral counseling, social
willing hotel was difficult given
work, pharmacotherapy, and
the concerns of owners regarding
specialist consultation. This
financial guarantees, potential
augments a small number of
property damage, reputation, and onsite staff, including nurses,
restoration requirements. The nonclinical support staff, pro-
state provided financial backing. viders, social workers, and
Plans called for this hotel to serve pharmacists.
as an isolation dormitory at no Clinical documentation was
cost to admitted residents and to integrated with the same elec-
accommodate individuals no tronic health record used by the
longer requiring in-patient care health system and built as its
but with limited housing op- own ambulatory department to
tions owing to unstable living achieve rapid deployment. Ad-
situations or a high risk of household ditionally, a transportation system
ABOUT THE AUTHORS
Alexander Kaysin and Diana N. Carvajal are with the Department of Family and
Community Medicine, University of Maryland School of Medicine, Baltimore. Charles
W. Callahan is with the University of Maryland Medical Center, Baltimore.
Correspondence should be sent to Alexander Kaysin, Department of Family and Community
Medicine, University of Maryland School of Medicine, 29 S Paca St, Baltimore, MD 20770
(e-mail: akaysin@som.umaryland.edu). Reprints can be ordered at http://www.ajph.org by
clicking the “Reprints” link.
This editorial was accepted June 11, 2020.
doi: 10.2105/AJPH.2020.305838
AJPH September 2020, Vol 110, No. 9
 AJPH COVID-19

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

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 per-
formance improvement regula-
tory 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 fo-
cused 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 tempo-
rarily housing hundreds of the
city’s residents experiencing
homelessness suspected or con-
firmed to have COVID-19. In
this partnership, our health sys-
tem is providing clinical support
and the health department is
addressing residents’ case man-
agement 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 as-
sistance. 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, ba-
sic medical care, frequent moni-
toring 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 incor-
porated electronic health record
systems that allowed closer inte-
gration with the main hospitals.
In Chicago, Illinois, city offi-
cials partnered with local hotels
to provide several thousand
beds for temporary housing of
unsheltered individuals recover-
ing from COVID-19. Patients
are monitored by the department
of public health and other
contracted health workers. Ad-
ditional rooms are allocated to
frontline workers and first re-
sponders. Los Angeles, Cal-
ifornia, embarked on a similar
model to provide 20 000 hotel
rooms for people with COVID-19
who are experiencing homeless-
ness, 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 med-
ical supervision.
CONCLUSIONS
In the face of this pandemic,
addressing the needs of margin-
alized groups is paramount. If not
now, then when? The ACS hotel
concept may provide a viable
approach to addressing the im-
mediate 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 digni-
fied 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 implementa-
tion of technology and strong
infection-control and -preven-
tion plans.
Still, ACSs require further
scrutiny to better plan and un-
derstand the types of model most
appropriate and efficient for the
population density, existing
health disparities, prevailing so-
cial determinants, epidemiologi-
cal 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.
Alexander Kaysin, MD, MPH
Diana N. Carvajal, MD, MPH
Charles W. Callahan, DO
CONTRIBUTORS
A. Kaysin served as the main author of the
editorial and the chief medical officer for
the described project. D. N. Carvajal
contributed to the writing and preparation
of the editorial. C. W. Callahan contrib-
uted to the writing of the editorial and
served as the executive officer for the
project.
ACKNOWLEDGMENTS
We are grateful for the contributions of
Smisha Agarwal to this work.
CONFLICTS OF INTEREST
The authors have no conflicts of interest
to declare.
REFERENCES
1. Baltimore City Health Department.
Neighborhood health profile reports.
2018. Available at: https://health.
baltimorecity.gov/neighborhoods/
neighborhood-health-profile-reports.
Accessed March 5, 2020.

September 2020, Vol 110, No. 9 AJPH Kaysin et al. Editorial 1363
AJPH COVID-19

2. Khunti K, Singh AK, Pareek M, Hanif

W. Is ethnicity linked to incidence or
outcomes of COVID-19? BMJ. 2020;369:
m1548.
3. Brooks RA. African Americans struggle
with disproportionate COVID death
toll. 2020. Available at: https://www.
nationalgeographic.com/history/2020/
04/coronavirus-disproportionately-
impacts-african-americans. Accessed
June 24, 2020.
4. Laurencin CT, McClinton A. The
COVID-19 pandemic: a call to action to
identify and address racial and ethnic
disparities. J Racial Ethn Health Disparities.
2020;7(3):398–402.
5. Casagrande SS, Gary TL, Laveist TA,
Gaskin DJ, Cooper LA. Perceived dis-
crimination and adherence to medical care
in a racially integrated community. J Gen
Intern Med. 2007;22(3):389–395.
6. Chen S, Zhang Z, Yang J, et al.
Fangcang shelter hospitals: a novel con-
cept for responding to public health
emergencies. Lancet. 2020;395(10232):
1305–1314.

1364 Editorial Kaysin et al. AJPH September 2020, Vol 110, No. 9
Reproduced with permission of copyright owner. Further reproduction
prohibited without permission.