Creating "Safer Ground": implementation of a service-rich housing program for people experiencing homelessness during...

Operation Safer Ground (OSG) was created in response to the COVID-19 pandemic. Without safe locations to shelter in place, people experiencing homelessness (PEH) were especially vulnerable to COVID-19. In March 2020, California's Governor signed an executive order that provided local governments with flexible emergency funding to develop "immediate solutions" to mitigate COVID-19 infection risk among PEH. Alameda County Health used those funds to create OSG, a robust and expansive program to address not only COVID-19 risk among PEH, but also the larger health and housing challenges faced by this population.

In this study, we use the Exploration, Preparation, Implementation, and Sustainment (EPIS) framework to explore key phases of the OSG implementation process and better understand facilitators and barriers that arose. We conducted semi-structured interviews with 34 public health officials and staff who were involved in the development and implementation of OSG. We used a hybrid deductive and inductive qualitative analysis approach for data analysis.

Cross-sector collaboration emerged as a critical component across all phases of OSG. Alameda County Health's preparation phase was significantly accelerated by prior work establishing cross-agency partnerships integrating medical, behavioral, and social services for PEH with complex needs, and developing a robust information-sharing infrastructure. This existing foundation positioned the County to effectively leverage emergency COVID-19 funding. Additionally, OSG's nimble and engaged leadership contributed to the swift development and relatively smooth launch of the program. Collapsing bureaucratic hierarchies and empowering key staff and partners to drive decision-making during the preparation phase made people feel included, excited, and recognized for their expertise. During implementation, the presence of leadership on-site allowed for real-time feedback and adaptive problem-solving. However, securing permanent housing for OSG participants remained a persistent challenge. The primary barrier was structural: a critical shortage of affordable housing within the County.

Our findings highlight that when key elements such as cross-sector collaboration, engaged leadership, and flexible funding align, significant progress can be made in providing housing and integrated medical, behavioral, and social services for PEH with complex needs.