Chapter 3. Methodology

Overall Objective

Our main objectives are:

1. Helping the public make informed decisions and care for themselves during health events, thereby alleviating their potential demands on health care delivery systems.
2. Assisting community health call centers with developing such response capabilities by employing strategies and models to provide support in:
   • Health information.
   • Disease surveillance.
   • Triage/decision support.
   • Quarantine and isolation support/monitoring.
   • Outpatient drug info/adverse event reporting.
   • Mental health support/referral.

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Overall Strategy

During any catastrophic event, the health care system will be overwhelmed with both the genuinely sick and the "worried well." Communities need to use all resources available to them in order to prevent a complete breakdown in health care delivery that a large patient surge could precipitate. Community health call centers can serve a vital role in such response efforts if they are provided the appropriate tools and guidance.

The SARS outbreak in Toronto demonstrated how great public concern can be by the demand for information their hotline recorded—316,615 total calls over 3 months and a peak daily volume of 41,789 calls.² Toronto Public Health was able to effectively use recorded information and up to 46 staff at a time for handling almost two-thirds of callers. However, a third of callers were not able to speak to a staffer at the time of their call, though they indicated the need to do so. This demonstrates that, despite the best efforts of a large and well-organized public health response, including a structured hotline capability, there were still challenges in meeting the information demands of the public. This project has produced resources and strategies that can guide health call centers to provide expanded services that can assist public health and health care agencies in an emergency.

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Target Audiences

Target audiences were health call centers selected based on the following criteria determined in the literature review: 1) pre-existing knowledge base/minimal competencies, 2) existing connection to the public health network, 3) experience working within a care team framework, and 4) anticipated availability during a mass casualty event to perform the newly acquired cross-trained duties and competencies.

Health call centers identified as meeting the criteria include:

• Poison control centers.
• Nurse advice lines.
• Drug information centers.
• Health agency hotlines.
• Local/State/Federal public health agencies.

The health call centers identified would likely be familiar with basic physiological responses to particular health threats due to a pre-existing knowledge and skills gained in their area of health care. In addition, the professionals employed by such centers would likely have prior experience in assessing patient status, problem-solving, and working with symptomatic patients over the phone. During any health emergency event, they would continue to provide regular services that help direct the appropriate patients to health care facilities. In addition, they could expand services to provide information and support related to the event, much of which could be handled with nonclinical staff. In this way, they could help with surge capacity and informing the public about health issues so that they can make informed decisions and care for themselves.

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Challenges for Preparedness

The 2004 Redefining Readiness Project from the Center for the Advancement of Collaborative Strategies in Health reported that approximately 60 percent of the public would not heed official instructions to get vaccinated during a smallpox outbreak, and that approximately 40 percent of the public would not heed official instructions to shelter in place during a dirty bomb incident.⁷ These statistics can be alarming to preparedness planners who assume that the public will be compliant with government recommendations. However, it is informative to understand the reasons behind such statistics.

In the case of smallpox vaccination, 55 percent of respondents indicated that they would need more advice or information. They cited lack of worry about catching the disease, serious worries about what government officials would say or do, serious worries about the vaccine, and conflicting worries about catching the disease and getting sick from the vaccine. This is consistent with the actions of health and medical professionals who chose not to get vaccinated in the Centers for Disease Control and Prevention's (CDC) Smallpox Vaccination Program, albeit without the actual presence of smallpox in the world. For those professionals, the risks of vaccination and the potential for adverse effects without a threat of the disease contributed to their reluctance to participate in the program. However, most of these professionals would support targeted vaccinations as a strategy to stop an outbreak of smallpox—information that could help people to decide that they should get vaccinated during an outbreak.

In the case of sheltering in place during a dirty bomb incident, the major reasons for not following instructions involved concern for the safety of others (their children, family members, and pets). Having measures in place to assure the public that these others were being taken care of (school children were also sheltering in place) or were not at risk (pets kept indoors would be safe) would help them in complying with sheltering instructions.

These challenges can, in part, be alleviated by the use of community health call centers that can help provide needed information for people to make good decisions based on their individual concerns and situations. Call centers can not guarantee that everyone will comply with recommendations, but they can help people understand them and the risks or consequences of their choices.

The 2004 Redefining Readiness report further states that in regards to smallpox vaccination, "58 percent of the American people would find it extremely or very helpful if they could talk by telephone at no cost with someone they don't know, who works for their local government, and who has been specially trained by the health department to give people information and advice about what to do in this situation. However, considerably more people (84 percent of the population) say they would find it extremely or very helpful to talk with someone they know well, who they are sure wants what is best for them, and who has been specially trained in advance to give people information and advice about what to do in this situation." This suggests that call centers that are embedded in the community and familiar to the public should be well received when providing support during a health emergency.

Other encouraging findings come from a national survey conducted by the Harvard School of Public Health's Project on the Public and Biological Security. Blendon et al. report that, when faced with a serious outbreak of pandemic flu, a large majority of Americans are willing to make major changes in their lives and cooperate with public health official recommendations. More than three quarters of Americans say they would cooperate if public health officials recommended that they curtail various activities of their daily lives for 1 month during a flu pandemic: 94 percent say that they would stay at home away from other people for 7 to 10 days if they were sick, and 85 percent say that they and all members of their household would stay at home for that period if another member of their household were sick. Therefore, providing support to individuals to enable them to remain at home and care for themselves could be critical.⁸

In addition, helping the public make informed decisions and to care for themselves can alleviate their demands on health care delivery systems. A community health call center can provide general topic and event information, the most current public health messages, and appropriate information on personal and family protection for almost any emergency that has a potential health impact. They can also provide the public with specific State and local health department guidelines, points of contact for referral agencies, and general health decision support and evaluation.

It is precisely this type of support that the public requests during an emergency. In our experiences during the influenza seasons of 2003-2004 and 2004-2005 in Colorado, public concerns centered on the unique challenges of each season. For example, in 2003-2004 there were several pediatric deaths very early in the season that sparked fears in many parents. The most asked questions included "Where can my child get a flu shot?" "Where can I get a flu shot?" and "What are the symptoms of flu?" The most frequent call types during this season were information calls, followed by possible flu reports and calls from health care professionals requesting health department guidance documents.

In the 2004/2005 season, there were concerns of vaccine shortage after a season that elevated influenza awareness in the public's mind. The most asked questions this time included "Where can I get a flu shot?" "What is the status of the vaccine shortage?" and "What is FluMist?" Calls for information were the most frequent; however, calls from health care professionals requesting health department guidance documents and health departments updating our call center on current issues were the next highest. This shows that, as with community needs concerning a seasonal influenza, needs with similar health issues can change and systems need to be ready to handle those challenges.

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Community Emergency Response Challenges

After September 11, 2001 and the release of anthrax letters along the East Coast over the following weeks, our call center experienced a 10 percent increase in call volume related to these events, even though the affected communities were all in the Eastern portion of the country and our call center was in the Western portion. This phenomenon concerned us, because we did not know whether further terrorist attacks were on the horizon or if anthrax letters would surface in the communities that we serve. If such events were to occur, what would be the resultant public concern, and how would that affect our call volume? Would we be able to continue to provide the regularly needed services of poisoning information consultation and nurse triage recommendations? Or would these services be hindered by the public demand for information related to the current events?

We knew that call center responses about medical concerns from the public prevented unnecessary visits to health care facilities and reduced caller panic. The public would seek this type of expertise out if they again felt threatened by exposure to anthrax in their mail or if their environment was somehow contaminated by a terrorist attack.

Poison control centers are the classic resource for parents concerned about a potentially toxic exposure to their child. These centers have trained staff who are adept at calming parents while collecting information to assess an exposure. Most of the time, these exposures are not toxic and do not require further medical evaluation. According to the 2005 annual data from the American Association of Poison Control Centers, 74 percent of calls to poison control centers are successfully managed in the home.⁹ The availability of such resources via telephone prevents approximately 1.8 million visits annually to physician offices and hospitals. As seasonal influenza patient influxes have demonstrated, the current health care delivery system would be challenged to accommodate this number of patients.

Nurse advice lines are another important resource for those who have health concerns and who are looking for guidance on what to do about those concerns. Seventy percent of callers to the Denver Health NurseLine complied with nurse recommendations, though that same percentage of callers had a different plan for health care in mind before calling.¹⁰ The trust that callers have for nurses, the information that nurses provide, and the nurses' review of the patient's options all contribute to this substantial change of behavior.

When planning for emergency responses, it seems wise to build on the expertise, credibility, and infrastructure of community health call centers. Expanding their capabilities to inform, educate, and assist the public with their health concerns can free the health care delivery system to most effectively use limited resources to provide care to those most in need. This approach can especially aid in handling those at low risk for injury or illness, who may have valid fears and concerns that, without a mechanism to get information, could lead them to overtaxed hospitals and health departments.

To begin developing this type of response capability, there community emergency planners and their response partners should consider four questions:

• What would you do to handle a surge in public contacts during a public health emergency?
• Could you adequately predict the potential volume of contacts?
• How would you identify staff, facilities, and other resources for this need?
• If you couldn't handle this demand, who in your community could?

This report will address these issues to provide planners and response agencies with direction in answering these questions in ways that suit their communities' needs.

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Planning for Public Information Needs

According to "Mass Medical Care with Scare Resources: A Community Planning Guide," a 2007 publication by the Agency for Healthcare Research and Quality (AHRQ), the public requires clear messages and communications strategies to inform them about the status of the event and what actions they should take.¹¹ To accomplish this during an event, it is important to have all potential communication partners involved, including public information officers (PIOs) from public safety agencies, public health agencies, hospitals and health care organizations, 911 dispatch centers, special information phone lines (211, 311, health call centers), and the media.

The National Incident Management System (NIMS) guidance outlines the organizational structure for enhancing the public communication effort by formation of a Joint Information System (JIS) to provide the public with timely and accurate incident information and unified public messages.¹² This system employs the Joint Information Center (JIC) to bring communicators such as the PIOs from various agencies together during an incident to develop, coordinate, and deliver unified messages. This helps to ensure that Federal, State, and local Governments are releasing the same information. While NIMS embraces the JIC/JIS concept, it leaves it to community planners to develop the processes, procedures, and systems for communicating timely and accurate public information during emergency situations.

Elements of a comprehensive public information strategy should include the use of:

• Mass media to provide the public with information on preventive measures, home care management, and the appropriate time to seek health care services.
• Community health call centers to reinforce mass messaging and to provide additional and more tailored information to individuals with questions and concerns, as well as to review these issues for their value as potential mass media messages.
• Community health call centers to assist with outpatient (home care) monitoring and support, thereby helping to extend the reach of public health and health care systems into households.
• Information collected by the call centers for situational awareness and disease outbreak management and control.

The CDC requires, in their Cooperative Agreement Guidance for Public Health Emergency Preparedness continuation grants for FY 2006, that communities provide needed health and risk information to the public and key partners during a terrorism event or other emergencies. Target capabilities are to advise the public to be alert for clinical symptoms consistent with an attack agent, to disseminate health and safety information to the public, and to ensure that their public information line can simultaneously handle calls from at least 1 percent of the jurisdiction's population or residences.¹³

So what would that mean for a community trying to meet such target capabilities? Let's begin to address the questions that we posed above for community emergency response planners in context of the CDC target capability goal:

What would you do to handle a surge in public contacts during a public health emergency?

Many State and local health departments are beginning to develop plans and response capabilities for providing public information for pandemic influenza and other health emergencies. A recent thread on a Strategic National Stockpile Listserv indicated that public health agencies are planning a range of responses, including developing protocols and information resources, arranging for augmented staffing and volunteers, making technology/infrastructure improvements, and partnering with established call centers. All of these are important measures and will be needed for developing any response capability.

Public health or public safety agencies should reach out to health call centers in the community to learn about their capabilities and how they could assist in response efforts. Community health call centers should reach out to planners in emergency management or public health to learn about their needs and how they can be of assistance. Hopefully, the tools that we present in this report will be useful to all parties in developing the needed community response capabilities.

Could you adequately predict the potential volume of contacts and how would you identify staff, facilities, and other resources for this need?

The HEALTH Tool Set (http://www.ahrq.gov/research/health) can calculate call volumes given various parameters. For example, given a population of 4 million, the tool set first determines the approximate number of those most able to contact an information line (2.8 million people age 15 years or older). Given a level of public concern at 1 percent and the communication means at 100 percent phone, the tool establishes a target capability goal (based on the CDC public information hotline goal of 1 percent) of 28,000 individuals or 7,000 residences, assuming four people per residence.

Simultaneously serving that many people would require equal numbers of phone lines and staff. Such a capacity would be prohibitively expensive and impractical. Mass media messages and the Emergency Alert System would be better at addressing the most immediate concerns and needs of the public.

However, trying to accommodate that call volume over several days may be more realistic and practical, as people will naturally form questions and concerns over time as they process basic event information from media coverage and experience difficulties related to the event. Setting the event length from 1 to 5 days while keeping the call center operating for 18 hours each day (for example, from 6:00 a.m. to midnight, when most people are likely to call) estimates the staffing and phone lines required for handling the 1 percent call volume. The tool set is limited to assume that calls are equally spread over the duration of the event, but it does identify the relative numbers of staff and phone lines needed over time:

Event Duration (Days)	1	2	3	4	5
Average Calls/Day	28,000	14,000	9,333	7,000	5,600
Staffing (FTE)	354	181	123	93	76
Phone Lines	401	213	148	116	95

*These calculations assume that each caller speaks with an agent for an average call length of 293 seconds, including after-call activities.

Operating such a call center is much more than just people and phone lines. It also takes facilities, technology and management experience for it to operate well. Again, the HEALTH Tool Set can help estimate costs for capital expenses (facilities, furniture, training, etc.) and technology expenses (computers, telephones, phone switches, etc.). If an agency is starting without much infrastructure, the costs to build a call center can be substantial. The agency may find that unless it is going to operate such services continually, investment of such funds may be impractical. The HEALTH Tool Set also has a Surge Options Matrix—a series of questions to help users decide whether to develop a call center capacity or to seek other alternatives.

If a particular agency could not handle this demand, who else in the community could?

There are usually a variety of call centers in any community that provide services such as customer relations and technical support—some may even be health related. These facilities may have the requisite capacity to handle large call volumes during an emergency, but if they are not involved in health services, they may lack staff who can handle health-related calls. It may be possible to develop partnerships with these non-health call centers for the use of their facilities during emergencies; however, staff may need to be supplied. Many other issues would need to be resolved in such arrangements:

• Under what circumstances would the facility be available? Would that access be guaranteed? Would there be any limits on how long the facility could be used for a response (days, weeks, months)?
• Would the facility have all the requisite equipment for the planned response capability? If not, could that equipment be stored onsite for when needed? If equipment is installed before an event, could the facility use it for their operations in the meantime?
• Would there be opportunities for those expected to staff the center during an emergency to practice call handling before an event? Would they have access to that facility for such practice? Could there be periodic exercises to test the ability to mobilize resources and staff the facility?
• Would the facility's employees (since they are familiar with call center operations) be a potential staffing pool for a response? If so, could they be trained beforehand in how to handle health related calls? Would they be paid to participate in the response or would they be volunteers? What are the liability issues for using facility staff in either circumstance?
• Are there any costs for facility "readiness" for a response? What would the costs be for using a facility during an event (direct cost reimbursement or daily usage fee)? For a prolonged response, would there be economic impacts to the facility's business operations, and who would be responsible for those impacts?

This is just a partial list of issues that would have to be resolved. Many of these issues may not be a factor for those considering using community health call centers for providing response capabilities during an event. These call centers can include poison control centers, nurse advice lines, drug information centers, and public health hotlines, among others. Since these community call centers deal with health-related calls every day, it should be easier for them to provide the needed capabilities under contract or in partnership with public health and public safety agencies.

It is likely that established health call centers would need additional resources only in equipment and staffing to provide services that are similar to those that they provide daily. In addition, these call centers have established relationships with the community that could help gain public trust in information from such sources. It is generally easier to expand the breadth of services that a trusted health call center provides normally than to convert a non-health call center to provide services that it normally does not.

The objective of this project is to provide some guidance, strategies, and resources for both community health call centers and the agencies planning for emergency event responses so that each understands how they can successfully develop the capabilities needed to meet the expected public needs for information and support.

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