Chapter 5. Recommendations

In reviewing disaster scenarios for expected community needs, it becomes clear that we must help the public make informed decisions and care for themselves during severe health events. It is only with such strategies that we can hope to alleviate many potential demands on health care delivery systems and to accommodate those most in need. Assisting community health call centers to develop certain response capabilities is a part of that overall strategy. By employing the scenario-specific models and tools in this report, health call centers can increase their ability to support the following areas:

• Health information.
• Disease surveillance.
• Triage/decision support.
• Quarantine and isolation support/monitoring.
• Outpatient drug information/adverse event reporting.
• Mental health support/referral.

As this report has illustrated, four of the Department of Homeland Security National Planning Scenarios afford the best opportunity to involve most of the potential response capabilities for community health call centers:

• Biological attack—aerosol anthrax.
• Biological disease outbreak—pandemic influenza.
• Biological attack—plague.
• Biological attack—food contamination.

This does not imply that health call centers could not play an important role in responses to other scenarios; rather, that developing tools related to the response needs of these four biological scenarios affords the greatest potential for success.

Poison control centers, nurse advice lines, drug information centers, health agency hotlines and local/State/Federal public health agencies were chosen as target audiences for the proposed scenario-specific models and applications because they are familiar with basic physiological responses to particular health threats due to the knowledge and skills gained in their area of health care. The professionals employed by such centers have experience in assessing patient status, problem-solving, and working with symptomatic patients over the phone.

During any health emergency, these centers could continue to provide regular services while expanding services to provide information and support related to the event. Much of the expansion of services could be handled with nonclinical staff. In this way, these centers could help with surge capacity and informing the public about health issues so that they can make informed decisions and care for themselves.

It seems wise to build on the expertise, credibility, and infrastructure of community health call centers when planning for emergency responses. 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 their 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.

This does not guarantee compliance with official recommendations, but it should help the public to understand the risks or consequences of their choices. However, call centers that are embedded in the community and familiar to the public should be well received when providing support during a health emergency.

Call centers attempting to provide the community services described here should do so in cooperation with the public health authority that, by statute, is responsible for coordinating health and medical services in response to public health and medical care needs following a major disaster or emergency, or during a developing potential medical situation. This coordination with the public health authority will help to ensure consistency with other response measures.

The model and tools proposed in this report should be used as part of a comprehensive public information strategy that includes 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.

In an emergency, the public may view hospitals as "safe havens"—places to go for food, shelter, protection, and medical attention. However, particularly in the event of a transmissible infectious disease in which hospitalized patients represent the sickest patients in the community, the concept of hospitals as "safe havens" may not be applicable. It may become more advantageous to manage and support the public in their homes with the assistance of health call centers. Community response planners will need to reinforce the concept of the home as a "safe haven" in their risk communication strategies and develop measures to support this concept in all aspects of their planning efforts. The possibility that some rudimentary degree of medical care will need to be delivered in the home setting should be included in public preparedness and education campaigns.

Integration With Current Programs and Initiatives

The concept of using community health call centers, the proposed model, and the IR applications fits well within programs and initiatives at the State and Federal levels. Such response resources can easily fit within the National Incident Management System (NIMS) that provides a consistent nationwide template to enable all government, private-sector, and nongovernmental organizations to work together during domestic incidents.

By working within the NIMS framework and coordinating with local authorities, health call centers can ensure that the public receives accurate, coordinated information, helping to decrease panic and calls to emergency management. In the same manner, call centers can participate in ongoing operations, such as quarantine and isolation management or Strategic National Stockpile support, as part of the multi-agency coordination system, a combination of facilities, equipment, personnel, procedures, and communications integrated into a common framework for coordinating and supporting incident management.

Federal and State Governments have set forth several requirements to be prepared for a disaster, including pandemic influenza. In Homeland Security Presidential Directive 8: National Preparedness, there are 36 essential capabilities on the Target Capabilities List (TCL) that various levels of government should develop and maintain.³¹

Among those TCLs is the requirement to strengthen medical surge and mass prophylaxis capabilities. Included in the National Preparedness Goal is supporting medical target capabilities for medical surge, such as isolation and quarantine.³² The proposed model and IR applications provide support for these efforts by allowing residents to identify and locate their point of dispensing (POD) location for mass prophylaxis and providing a mechanism to track and monitor patients in isolation and quarantine in order to assist public health agencies.

The State of Colorado, like many others, has a quarantine and isolation component in its pandemic influenza plan. The Pandemic Influenza Annex to the Colorado Department of Public Health and Environment Internal Emergency Response Implementation Plan gives the authority to isolate or quarantine persons, groups of people, or buildings in Colorado, and at the recommendation of the Governor's Expert Emergency Epidemic Response Committee, to limit or close public gatherings and restrict the movement of people.

Containment strategies range from those affecting individuals (e.g., isolation of patients) to measures that affect groups or entire communities (e.g., monitoring of contacts, cancellation of public gatherings). Guided by the current epidemiological data, State and local public health officials will implement the most appropriate of these measures to maximize the impact on influenza transmission and to minimize the impact on individual freedom of movement. The HELP program is included in the plan as a means to gather surveillance data for situational awareness and to support efforts to monitor those individuals placed in isolation or quarantine. Using the proposed IR applications will aid in providing this response capability.

Public Health Communications and Education

The National Association of County and City Health Officials has some timely recommendations to prepare for pandemic influenza. First is to engage the community and bring all stakeholders together in a way that makes sense. An essential piece to preparing any community for a public health emergency is involving stakeholders in the planning. Community members need to be heard, and if they feel that their views are not only being considered but also incorporated into the planning process, they will be more likely to support whatever plan is created. Second is to empower people to do their own planning. Third is to establish excellent lines of communication, the key to education about and awareness of any public health issue. These recommendations support the concept of health call centers and their use of IR technology to communicate with the public:

"Dissemination and sharing of timely and accurate information with the health care community, the media, and the general public will be one of the most important facets of the pandemic response. Advising the public in actions they can take to minimize their risk of exposure or actions to take if they have been exposed, will reduce the spread of the pandemic and may also serve to reduce panic and unnecessary demands on vital services."³³

The National Governors Association also stresses the importance of public communications in order to build a trusted relationship with the response community and enhance the public's understanding of pandemic influenza. Responses to pandemic influenza must provide for effective communication to the public to minimize negative behaviors, accentuate positive actions, and limit the psychosocial and psychological impact of imposing public health measures that include movement restrictions. These messages should be developed and trained and trusted messengers should be selected now.³⁴ For this reason, established and community-embedded health call centers are a good fit to partner with public health agencies to provide such communications.

A major goal of public health education messages is to ensure that the public has the knowledge to protect itself. Prevention and infection control are the first line of defense, but there are other education topics as well. Dispelling rumors keeps the public properly informed and less prone to panic because of misinformation. Public health authorities have the responsibility to explain the rationale behind disease control measures, to explain why these measures are necessary, and to ensure that information is current and that messages do not contradict one another.³⁵  Health call centers can partner with public health agencies to relay such information to the public in a consistent, accurate, and up-to-date manner.

In "Components of Effective Disaster Public Education and Information," (December 2005) a working group of the Emergency Management Accreditation Program emphasizes the correlation between effective public education and coordinated, effective disaster response and recovery outcomes. The report outlines steps for creating comprehensive and understandable public education messages so that residents can be better informed and better prepared. The report notes that, "Federal and State Governments must support local capabilities to provide effective public education and information through continuity of authority, emphasis, message, and language, as local and State public education and information have a direct impact on successful outcomes in a disaster."³⁶ It is such local capabilities that health call centers have to offer the governments and communities they serve.

Blendon et al. reported that most Americans favor the use of quarantine as a weapon against contagious diseases like SARS and pandemic influenza but are far less comfortable with strict enforcement and monitoring measures. While 76 percent of Americans surveyed said that they favor quarantining those potentially exposed to serious contagious diseases, only 42 percent supported a compulsory quarantine under which those who refused to comply could be arrested. However, 75 percent of those surveyed would favor periodic telephone calls to monitor those in quarantine.²⁴ This suggests that a quarantine strategy using a health call center and a tool such as the QI Monitoring Application would be favorable to most Americans and likely to experience good compliance.

The HELP model, which has become established in the community and is used on a daily basis, can be a resource for times of disaster, giving people the risk-based messages that include how to care for themselves and their families in order to mitigate a threat. The various call flows are designed to give reassurance as well as direction and information on the appropriate response measures. Such information can substantially change the behavior of the caller.

Our report on the Denver Health NurseLine demonstrated that 70 percent of patients complied with nurse advice line recommendations, though the same percentage had a different plan for their health care prior to calling.¹⁰ Patients who called were already aware of a need for information and were receptive to changing their behavior based on the information they received. It is not unlikely that the same behavioral changes would be seen in an emergency situation with persons contacting a health call center and perhaps even those receiving information via an IR system.

Special Needs Populations

Special needs populations will need customized forms of contact during an emergency. The proposed IR applications take into consideration some special needs communities, in particular the Spanish-speaking population. By developing most of the IR applications to accommodate both English and Spanish, a majority of callers will have the option to use such strategies to get information on the disaster. Depending on a community's demographics, it may want to offer additional language options for callers.

Planners will need to determine if there will be sufficient demand to have announcements recorded in a particular language or to have those callers speak with a staff person using a translation service. The vision impaired will also likely find it easy to retrieve information via their telephone rather than from printed materials or the Internet. Many call centers have relied on TTY/TDD technology to communicate with the hearing impaired, though text messaging and e-mail communications are becoming more prevalent. The IR applications do not support TTY/TDD, and those callers would need to interact with a staff person to get information. The use of toll-free numbers should enable those without a phone in their home, a cell phone, or without even their own residence to call from any public phone at no cost.

Volunteer Use in Call Centers

Volunteers can assist health call centers in responding to public inquiry. The volunteers would need to have a vested interested in the community and be able to think on their feet, work under pressure, and answer the questions. To find these individuals, a call center can look to established volunteer groups, church organizations, or recognized nongovernment organizations like the Salvation Army or the American Red Cross. Planners who choose to use health care workers to staff a call center may want to look for volunteers through the Health Resources Services Administration (HRSA) Emergency Systems for Advance Registration of Volunteer Health Professionals program that each State is developing. An important caveat made by HRSA is that these individuals will need to identify themselves to callers as volunteers helping the State.³⁷

When using volunteers in a call center, it is best to be aware of the legal implications of volunteer use in a disaster situation. Good Samaritan statutes are laws enacted by various States that protect health care providers and other rescuers from being sued when they are giving emergency help to a victim. The rescuer has to use reasonable, prudent guidelines for care during the response. Under such laws, the assistance must be voluntary, the person receiving the help must not object to being helped, and the rescuer's actions must be a good-faith effort to help.³⁸

The Federal Volunteer Protection Act provides that no volunteer of a nonprofit organization or governmental entity shall be liable for harm caused by an act or omission of the volunteer on behalf of the organization or entity if the volunteer meets certain requirements.³⁹ It is very important to note that this Federal law preempts State laws to the extent that such laws are inconsistent, except that it does not preempt any State law that provides additional protection from liability relating to volunteers or to any category of volunteers in the performance of services for a nonprofit organization or government entity. Health call centers that use volunteers should contact their legal counsel to ensure that their use is in compliance with applicable laws, that volunteers are covered under their liability insurance for such use, and that volunteers are properly trained for such activities.

Public Information Partnerships

Public information partnerships between health call centers and public health agencies prove that together they can meet the expected needs of communities during health emergencies including: improving information support and surge capacity, expanding surveillance signals, and collecting data for situational awareness. These partnerships help meet the new demands on public health agencies, increasing their response capabilities and access outside of the 9:00 a.m. to 5:00 p.m. work day, handling rapidly evolving information while maintaining control, and enabling members of the public to care for themselves and their families by supplying the information to help them make decisions.

The need for such partnerships will remain constant or potentially increase, since public health events will continue to occur. These events will require effective, structured, and coordinated systems for providing public information and support as part of the response. The HELP model has been proven to be a cost-effective, efficient, reliable, and adaptable component of Colorado's readiness response model for any public health emergency. The HELP model offers the promise for similar response capabilities for other community health call centers working in partnership with their public health agencies. These community resources will likely have robust infrastructure to serve as strong platforms that can incorporate the proposed tools and adapt them as needed.

Model Utility and Adaptability

This model and the IR applications were applied locally and statewide, but they could potentially be adapted for interstate and Federal use. There may be legal risk implications for clinical personnel using decision support and triage strategies across State lines. The National Council of State Boards of Nursing (www.ncsbn.org) is working to secure mutual recognition of nurse licensure across States that may help with this issue. However, a larger issue concerns the coordination of messages across various levels of government to ensure consistency and public trust. It may be difficult for public health and safety agencies across all levels of government to agree on specific strategies and develop unified messages. It may be easier to develop response resources such as the HELP model and IR applications on a statewide or smaller scale to avoid the difficulties in regional and national coordination. Planners at various levels of government should consider this challenge in their planned application of such resources.

The model and applications that we have developed are largely informational in nature and can be delivered easily with trained nonclinicians or can be automated. However, the applications should all be employed with sufficient back-up support such as the HELP platform so that users can always get the proper assistance.

In our experience, it has been valuable to have systems and processes that can be adjusted to the changing needs of emerging public health events. This has included the ability to:

• Rapidly change FAQ content and public health messages.
• Handle surge responses through a variety of mechanisms
  • Using recordings/announcements
  • Using an interactive response system with interactive response applications
  • Partnering with media to deliver information
  • Having trained ancillary staff.
• Learn from experiences.

Some of the lessons learned from more than 3 years of operating the HELP program include:

• Call volume is driven by the event and media attention—anticipate call volume surges related to morning, afternoon, and evening news broadcasts.
• Media organizations are willing to assist with disseminating information, including hotline numbers regularly displayed in television news crawlers.
• Adaptation to include the latest local and State health department messages is necessary to meet both public health and public needs.
• Surveillance, though not an intended purpose of the program, became an important function due to the utility of structured data collection (situational awareness) and the ability to identify emerging issues (sentinel event detection).

Operating a public informational resource requires the ongoing need to adapt, reassess, and improve. There always will be further challenges to address:

• Testing the IR applications in various community groups (non-English speakers, seniors) and determining if there are any issues with their use.
• Improving public messages and FAQ information content.
• Determining other information and tools for meeting the needs of health emergency events.

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References

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³⁴  Preparing for a pandemic influenza: a primer for governors and senior State officials. National Governor's Association Center for Best Practices, 2006. Available at: http://www.nga.org/Files/pdf/0607PANDEMICPRIMER.PDF.

³⁵  Web site. University of Michigan Medical School, Center for the History of Medicine. The 1918-1920 influenza pandemic escape community digital document archive. Available at: http://www.med.umich.edu/medschool/chm/influenza/index.htm.

³⁶  Components of effective disaster public education and information working group report, December 2005 (interim document) The Emergency Management Accreditation Program (EMAP). Available at: http://www.emaponline.org/?232.

³⁷  Health Resources Services Administration. Emergency system for advance registration of volunteer health professionals: interim technical and policy guidelines, standards, and definitions, version 2 June 2005. Available at: http://www.hrsa.gov/esarvhp/guidelines/default.htm.

³⁸  Good Samaritan, Charitable Care Statutes, and Specific Provisions Related to Disaster Relief Efforts. American Medical Association. 2005. http://www.ama-assn.org/ama1/pub/upload/mm/395/goodsamaritansurvey.doc.

³⁹  Federal Volunteer Protection Act of 1997 from The National Archives and Records Administration GPO Access Web site. Available at: http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=105_cong_public_laws&docid=f:publ19.105.pdf [PDF Help].

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