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Center for Public Health Preparedness


University at Albany Center for Public Health Preparedness

Addressing At-Risk Populations in Emergency Preparedness Planning

Original Satellite Broadcast: 5/8/2008


Moderator: Good Morning and welcome to the University at Albany, Center for Public Health Preparedness Grand Round Series. I am Kris Smith and I will be your moderator today. Before we start we would like to ask you, to please fill out your evaluations online. Continuing Education credits are available after completing the post test and your feedback is valuable to the development of our future programs. We’ve got a packed show today, but if there is time we’ll be sharing a toll free number, for you to call-in with your questions. You may send your written questions at anytime by fax to 518-426-0696 or by e-mail to the address on your screen. We’ve gathered an impressive group here today to speak on the subject of Addressing At-Risk Populations in Emergency Preparedness Planning. From the Association of State and Territorial Health Officials we have Jim Blumenstock, Chief Program Officer of Public Health Practice, Welcome Jim.

Jim: Thank you Kris, Good Morning.

Moderator: Thank you. From the Seattle and King County Advanced Practice Center, we welcome Carina Elsenboss, and last but not least, Kay Abby from the Montgomery County Maryland Advance Practice Center. Sincere thanks as well to each of you for joining us today, and also to NACCHO, The National Association of County and City Health Officials for their generous sponsorship of this broadcast. Again welcome all, I think we’ve got a great show, so lets jump right into it Jim. Why don’t we go to the heart of the matter and talk about why some people are considered more at risk than others?

Jim: Sure. You know we talk about at-risk or vulnerable populations in the context of a pandemic, we're really talking about those folks that really will suffer the consequence of a pandemic—those that truly need some special care and attention because of the many consequences that society as a whole we will suffer if and when a pandemic hits our

Moderator: Jim What kind of consequences are you talking about? Is isn’t realistic to
Assume that pretty much everybody's lives will be disrupted in a pandemic?

Jim: Oh, absolutely. I think we, as a society, are all at risk of becoming exposed or infected with the illness. We're also all vulnerable to the consequences in varying degree. What our focus is, is on that segment of the population that are really in the category above and beyond the general population that really needs special care and attention because of their circumstances. You know, the fact that they may have some economic challenges, some communications difficulties, no support group, whether it be in a family setting or in a community setting. People just need basic help in maintaining their own independence and quality of life.

Moderator: We found that the Center for Public Health Preparedness recently cosponsored a series of public engagement meetings here in New York State and a lot of the participants with special needs, said that some of the expectations such as, that they'll be able to stock pile food or care for a family member at home are just not realistic to their circumstances, so I understand what you're saying

Jim: Absolutely. I mean, normal operations or society as we normally would appreciate and benefit, will be disrupted. Again, that's all a major theme of our planning efforts, not only for the population as a whole but also for those who are really at risk, or considered more vulnerable than others.

Moderator: We use a number of different terms to talk about vulnerable populations: I’ve heard them at risk, special needs or disconnected. Who are we talking about when we talk about disconnected populations, does it go beyond the rural and homeless?

Jim: Oh certainly, the rural residents and the homeless, are clearly the two major categories that we often refer to first. But there are others, when you really look at our community, other examples that I would like to use, would be, those that are possibly house-bound, that really need that societal support because of their circumstances. Other examples, would be those that are really just removed from their normal family or their home environment. Travelers, whether it be business men and women who are just away from their community and need to stay where their place of employment is, that just are not linked into society or community support. Students are another example that we really need to consider, those away from their home and away from their home towns.

Moderator: Let’s take your example of the home-bound, I mean what are—what’s the practical method that you can reach them?

Jim: Well, one of our approaches is certainly to identify networks and systems that are already in place that do an outstanding job for their defined purpose. So when you talk about those that are home-bound, you look at the “Meals on Wheels Program” as a classic example. They provide great services with their defined purpose. But by expanding and involving them in our at-risk population’s preparedness activities, they provide great outlets. They can communicate, they can deliver services, they give feedback to the public health and medical communities if some of their clients are suffering unduly. So that is just one great example of how we're trying to use the country's existing networks to build sort of a network of networks.

Moderator: Our program last month, had a wonderful guest, Anna Marie Jones of CARD and she mentioned something that I think we need to consider, is that even people who are not normally vulnerable may become vulnerable as circumstances change.

Jim: Absolutely. You look at-- you evaluate yourself and your family members. You know, many of us are blessed with good health, good family support. But those things change. So you know, people may not be vulnerable, at-risk today, but three or four months from now, whether it be it is a change in their health status, their economic status or just—I use the example of the traveler— put in an environment that they're not comfortable with. So we all need to be cognizant of that. Sort of address our own preparedness planning efforts. But more importantly, the governmental and the private sector planning efforts need to factor those elements into their overall planning activities to address the obvious and the not so obvious, who may— who are or soon will become vulnerable.

Moderator: Doesn't that system overload issue seem particularly daunting.

Jim: Well I think you've identified the one, major, or THE major challenge that public health planners are currently addressing. You know, what is our surge and the depth of our ability to address everyone's needs, appropriately and efficiently.

Moderator: Let's turn now to the important project that you are actively involved with, with ASTHO’s, as Chief Program Officer of Public Health Practice. Let’s start by explaining, what is ASTHO, and what its mission.

Jim: ASTHO, The Association of State & Territorial Health Officials, is a national organization that represents the 57 health agencies of our states, the District of Columbia and the Caribbean and pacific territories. Our role basically is to support our members and to help really shape and form national public health policy and practice to enable them to do their very best to protect the health of their community.

Moderator: We see on the screen that you’ve developed a guidance for special needs populations. What was the reason behind development of this guidance?

Jim: Well, I think it was clear recognition that all state, local and territory health agencies are doing a laudable job in addressing the needs of the community in preparedness planning. But we realized there was an effort necessary to sort of harness this knowledge and experience, and share it amongst each other and also to try to identify gaps and fill in those gaps and holes in planning and preparedness. And again, at risk or vulnerable populations do represent some special challenges for the governmental public health community just because of their special needs. So that was the primary purpose of our project and we were so glad to be part of it, and lead it.

Moderator: Well Jim what other agencies were involved?

Jim: Well before that I would like to mention at this time, certainly The Centers for Disease Control and Prevention. We really appreciate their support and their confidence in us as an Association, and as a practice community to lead this effort. Other major partners were the University of Minnesota, The Center for Infectious Disease Policy and Research (CIDRAP)—they really did an outstanding effort in doing much of the legwork around this project. We use the efforts of Keystone, on some of our public engagement issues, which we'll talk about shortly as well.
And of course NACCHO. As ASTHO is to State Public Health, NACCHO is to City and County Health Departments, and so we often partner with them to make sure the full public health community is involved and their interests are addressed.

Moderator: I probably should have mentioned, I will give you a chance to mention— that you are looking for input on the guidance from members of the public, is that correct?

Jim: Oh, absolutely. In a few moments we will talk about the guidance but the key here is, while we've done our very best to outline, some, what we believe excellent recommendations and approaches to planning for— to address the at-risk population, the key here is that we need as much input as possible. Not only from the community that we're trying to protect, and help but also other sectors of our communities such as government leaders, emergency managers, even private industry. Anyone that has a stake in this public health effort and the insights that could help us refine this guidance document so it really is as usable and effective as it can and should be.

Moderator: And of course this guidance document emerged from your public engagement project. What states were involved and how did you select them?

Jim: Well, in a perfect world we certainly would have wanted to have these public engagements in many more states, if not all of them. We were pleased to sort of work with Kansas City and Boston as two states that were identified, principally for giving us a little bit of demographic and geographic diversity. But more importantly because they already had an infrastructure and reputation for public contact and community engagement so we wanted to tap right into their resource and capabilities.

Moderator: What was the organization that gave you so much help with recruitment and planning in Kansas City, One KC Voice I believe it is called?

Jim: Absolutely. They are a non-profit, non-partisan organization that exists basically to help shape and form regional policy recommendations. That was exactly what we were looking for. They were grassroots. They had connections and contacts and they were trusted agents. A lot of the sectors, segments of their community that really wanted to benefit from it. We were so pleased that they and so many others assisted us in the process.

Moderator: Well, since you talked about the process and our audience members no doubt want to emulate it, maybe you can take us through the development steps.

Jim: Sure. To sort of showcase three or four of the major features, like every other organization that takes this type of activity, we did convene an advisory panel.

Moderator: First step.

Jim: For first step of typical bureaucratic reaction. But all kidding aside, we were so pleased with their contributions. I mean, they were the anchor and the guiding light in our activities. 19 individuals shared by Commissioner Auerbauch from the state of Massachusetts, representing so many other sectors of society that really served as a steering committee to really help us shape and form and point us in the right direction. Really what the planning guidance needed to address. Then from there we identified and convened five work groups representing in excess of 60 to 70 individuals that really did most of the work. The steering committee was outstanding but clearly the 19 individuals could not do the amount of research and the deliberations as these work groups did. They came together and really worked hard over the last four or five months. Certainly this is a very participatory process as well. As we were doing environmental scanning, researching, trying to identify those practices and procedures that worked well in the community, we also wanted to reach out and touch the population that we were—we are trying to protect. So we had, as we talked about, two public engagement sessions. We also held a national stakeholders meeting and as we'll soon discuss, the opportunity for everyone to really look at and weigh in on our draft items.

Moderator: Beyond the two colleagues joining us on the panel today, who else was on the advisory committee?

Jim: Well, within the 19, there are several I would like to highlight, just to try to give you a sense of the diversity. We were so pleased that the Department of Homeland Security was able to able to participate. Again, because pandemic influenza while a public health concern, certainly has an impact on national security as well. The American Red Cross, as another example. Of course, many of the local and county agencies that are so beneficial including mental health and substance abuse services.

Moderator: Because the public engagement part of it is becoming so prominent, talk about how you actively seek input from the individuals who are most affected by this planning.

Jim: Sure. The aspect of a public engagement is basically to identify those individuals that are—that are the stakeholder or that would most benefit from the services that we're trying to create. Really get a sense from them of what their needs are, what their expectations are, what their values are. Because while we can use the best science and professional judgment. It still falls short if we don't reach out and really have a dialogue and learn from what public—what the public wants or expects from us and what their needs are. So that really is the beauty and the heart of a public engagement process.

Moderator: As a result of this process in its entirety you must have just tons of data and findings. Who's going to sort through all of that?

Jim: Right, well the public engagement process helped us shape the draft items. Now, as we've released the guidance to the greater community for comment, my staff, which is extremely talented and dedicated and I owe so much to them for this level of effort, we will review those comments, summarize them and decide how best to react. Couple of courses of action would certainly be going back to the advisory committee, Centers for Disease Control and Prevention, possibly the five work groups that helped develop them to see if there are any adjustments, refinements and we do expect to see a lot of reinforcement of a lot of the good points that were raised. That in itself will also be extremely valuable to know what we hit and scored a ten on, versus—as well as those that need work. Certainly, we're committed to taking those comments and refining the product before it's released within the next month or so.

Moderator: Well I don’t want to put you on the spot, and I know it hasn't been released yet, but could you share any key findings or gaps that our audience members might want—be interested in.

Jim: Sure. The guidance document is a fairly lengthy product in the sense that it contains dozens of recommendations, tips, resources, best practices. So it’s an outstanding resource. Certainly within that document there are a series of recommendations. The four that I would like to highlight quite frankly, really foundational in this process is number one, in all of your public health planning— engage the community you're trying to protect.

Moderator: Common sense.

Jim: The collaboration and the engagement is key. Another aspect is at the end of the day, you know, also involve them in evaluating your process. Because they will be the ultimate judge of exactly how well we've performed. Of course in between those two is the guidance provides suggestions of data sources where public health planners can really use information to help identify and locate the average population they're trying to serve.
So those are sort of the three main ones I would like to highlight in this point in time

Moderator: And Jim you mentioned earlier, you don’t reinvent the wheel, if there are systems in place, use them.

Jim: Absolutely.

Moderator: Well I am going to give a plug to your guidance and encourage our viewers to jump online, review that guidance and share your feedback, it has to happen by next Thursday May 15th and we will share this information again at the end of the program. Please, do look at that and give us your thoughts.

Jim: Absolutely. We welcome any and all comments. It would be very helpful to the process, so thank you.

Moderator: Thank you. Well you mentioned reviewing state and local plans and collecting promising practices, the perfect segue to introduce our other panelist members, both program managers from advanced practice centers, happen to be from either end of the United States. Welcome again Carina and Kay. Were going to start with Carina, and you hail from Seattle. Could you share with us first a brief overview of what advanced practice centers are, how they're funded, what is their mission, what do we need to know about advance practice centers?

Carina: Advanced practice centers are funded through the National Association of County and City Health Officials with use of Centers for Disease Control funding. The goal really is to help local public health departments build their preparedness planning capability and it really is an opportunity for locals to help locals. There are eight advanced practice centers around the country, eight—Kay and I represent two of them. We are really doing the work that other locals are struggling with in terms of the public health preparedness planning and taking our lessons learned and creating tools and resources for others to use.

Moderator: Based on all the work you've done, what do you consider to be the key elements for planning?

Carina: The key elements for our vulnerable populations planning really are two— as Jim’s talked about— work collaboratively with community based organizations, utilize those existing networks that are already in place. We've also found that it's important that in identifying those community-based organizations. They have—there are those trusted leaders— they have a sense of what would work in the communities we're trying to reach. It's important that we reach out to them, build relationships, maintain trust and also be flexible learning from what their needs are.

Moderator: Not to be the voice of doom and gloom, but when you define special needs, at-risk populations, you have a large universe and is it really realistic to expect that all will be impacted to the same degree during a public health crisis?

Carina: Well you know we find out that outcomes aren't going to be equal but really the opportunities should be and everyone should have the opportunity to have public health preparedness tools and resources.

Moderator: Well, I don't think anyone would disagree that your goal of reaching those most vulnerable populations is admirable but I imagine incredibly challenging so how do our audience members go about achieving that goal?

Carina: Well Jim’s talked about a couple of findings of the ASTO document and I think that will be a great place for people to start. We've been fortunate that we back in 2006 started doing some planning in this area and it's really important to-- again, in the absence of a level playing field that we create different buffers and by working with the community-based organization we have an opportunity to learn about the community and do outreach. Part of one of the things that's very central to our work in this area is communication. It’s woven throughout. We find time and time again in emergencies and disasters that communication failures rise to the top in the lessons learned and what needs to –changes that need to take place in planning to prepare for future events. So we really want to work through communication and support the communities so they're better able to respond.

Moderator: Okay, and when you assess where you begin, how do you go through that?

Carina: You know, again, Jim took us through some of the findings in terms of that definition. You know, find out who are the most vulnerable in your community. There is also a CDC workbook that helps take local health departments through this exercise as well, but define them. Understand your department's role in reaching them. Again, public health is one piece of the puzzle in reaching vulnerable populations. There are other government, non-governmental organizations that play a key role. And so understanding what is public health bringing to the table. Many times public health has extensive experience working with these communities and utilize the existing knowledge that exists in your health department to make those connections to the preparedness work.

Moderator: Right—think outside the realm of emergency preparedness to what services do vulnerable populations already receive—and how can you piggyback perhaps?

Carina: Right. It also goes to that sustainability issue. Money comes and goes and you want to make those connections and increase awareness and so as a program is going out and working on obesity issues it's also a perfect opportunity to let them know about you know, emergency preparedness kits or different personal preparedness tools that they could be working on.

Moderator: Carina, you mentioned that everyone can be vulnerable but I know that you've identified certain groups in particular that we will need to plan and advocate for. What populations fall into these groups?

Carina: You know, when we first started looking at defining our community, it was quite daunting and I think it's daunting for many health departments. So we tried to look at those groups that we would be more-- we would have a more direct training and planning role with versus those we would advocate for. In the advocacy realm for example, there are seniors and in our county there's several different programs, governmental programs and—that are working with seniors and so we decided that we needed to work with those systems that are in place and hope that they're advocating for their clients. In terms of the direct planning, Jim mentioned homeless and we have quite active healthcare for the homeless network in our community and we realize that in a pandemic (especially), they'd be very vulnerable and we needed to do more direct planning and training so those are a couple of examples.

Moderator: And children of course as well.

Carina: Yes.

Moderator: We might not immediately think of them as vulnerable but depending on the circumstances—

Carina: Right, limited English proficient, hearing impaired, deaf, blind, hard of hearing, those are some of the key groups that we’ve been working with.

Moderator: Have you used mapping to try to identify vulnerable populations?

Carina: You know, we have and it's very simple using census data which as we get further and further away from the census it becomes less relevant. But earlier on it was helpful for us to look at some of those key areas like children, individuals over 75, limited English proficient and find out where they're living. And this was an opportunity for us—you can see we did look at limited English proficient and we were able to use this map actually in a response where we were having power outages as a result of a tremendous windstorm. The power outages came on the heel, we had very cold temperatures, and so we were seeing an increase in our emergency departments of carbon monoxide poisonings, particularly among immigrant and refugee communities. And so we went back to this map that we had done months earlier and said well we need to get out there with messages with carbon monoxide prevention messages. Where do we need to target them as the power outages continue to go on? We did a very crude comparison and then reached out to community organizations in those areas and so it was one example. Where we had taken our planning work and transitioned into a response.

Moderator: Carina, you mentioned community-based organizations and I think Jim alluded to this as well. They seem to be a linchpin in using the systems that are already in place. But how do ensure that those community-based organizations are in a position to continue to provide services when they're apt to be impacted as well.

Carina: When we we’re in our planning phase we had this idea of a model of working with community-based organizations and again, communication was central and so we really wanted to utilize them as communication conduits in an event of an emergency. How are we getting the messages out there quickly and rapidly and efficiently? And so we went to community—several community-based organizations and surveyed them. And asked them—you know, we have this idea that you're an incredible resource and we’d like to you have your communication conduits in an event of an emergency, what would you need in order to help us work on this? Does this make sense? Also, that first question, does this make sense? And they said yeah, we could help with that, but we need more information about preparedness and we also realize that as a health department it was important that they have the tool to be able to stay open so they would be open in emergencies so they could or immediately after and so we took that information of talking with the community-based organizations, looked at what the barriers were: time, money, training, and then came up with a training program where we talk with them using the CARD model. We were very fortunate, early on to discover, Anna Marie, one of your previous guest and her organization CARD, down in California. And they have some great tools that I think she mentioned and they really breakdown some of these jargon-y, very complicated things, into very basic and manageable and approachable tools. So personal preparedness, business continuity planning. Some, you know, what does it mean to have a call-down list? Some of these things that we talk about with them, give them overview of some preparedness topics and also provide an opportunity for CVO’S to talk to CVO’S that’s very important that they have an opportunity to learn from each other some community based organizations are very far ahead in this area and have done great work. Others, not so far ahead, have encountered other barriers and by talking to another CVO it provides them an opportunity to learn from them and be able to advance their planning.

Moderator: Tell us again what CARD stands for.

Carina: Community Agencies Responding to Disasters out of Oakland, California. Their resources, I think there's going be a link at the end of this program and of course the past webcast are a great source of information about how to really engage with community- based organizations. And it goes to that idea of why reinvent the wheel. I mean as Advanced Practice Center’s we're trying to create things that don't exist so other people don't have to reinvent the wheel. And CARD was a good opportunity to go to an organization that has many years of experience and utilize their resources.

Moderator: A lot of common sense approach in that and we tend to think top down and we are starting a little to think bottom up and we also need to think sideways so that we can all—it has to be an integrated approach. You spoke of the Community Communications Network. Is that a national effort or one unique to King's county?

Carina: You know Community Communications Networks are all over in some form or another. The CDC workbook talks about this concept but what we did— we, again, what does it mean to have people as communication conduits in the event of an emergency. And we again looked around and found one in Kentucky. State of Kentucky has KOIN, K-O-I-N, and was a great model for us to look at. What does this mean to have— to work with partners in this way. We took that model, modified it slightly. We have a form that people fill out, talk about roles and responsibilities, people can receive alerts from the health department as health advisories or health alerts. Advisories are more low level, don't need to take immediate action. We use those for West Nile virus messaging. We were doing mass dispensing clinics, an opportunity for people to come and people receive flu vaccine. An alert is more—there is life at stake, life and safety messages. We used that in our windstorm when we were seeing people, you know coming to our emergency
departments with carbon monoxide poisoning. And really we had just launched this and we had some key after-hour contacts for the immigrant and refugee community, calling people on their home cell phones on a Saturday really helped us get ahead and get messages out there in a way that the health department wouldn’t of been able to, because they are the trusted leaders in the community.

Moderator: I have to ask the obvious question though—we have wonderful ways of reaching people but when the power is out, and the cellular service is out what happens then?

Carina: You know, it's a challenge. What it is, is we've been trying to work with our community leaders to find those places where people gather that we can go out-- if we can get people on the ground, either health department staff or other partners, get messages posted and—

Moderator: That happened in the windstorm.

Carina: Right, and so we had some pictorial messaging in multiple languages that we put up on flyers in communities, and so were trying to identify some of those areas

Moderator: You also worked with a local newspaper.

Carina: We did. It was fortunate that the Seattle Times came to us saying we see that there is this huge need to get information out there in multiple languages. They offered as a public service, above the fold, multiple translations and yes, many of the people that we were trying to reach might not read the Seattle Times, (an English mainstream paper) on a daily basis but they would see it in the news stands and we had stories, anecdotal stories of people seeing Korean on the front-page of the Seattle Times, and stopping to learn more. And also, we had an opportunity for business to post that in their stores so that they were able to take part and get messages out there.

Moderator: Were—did you have an approach for people who were illiterate or is there one you could suggest?

Carina: You know, we find pictorial messaging is very important and we've been trying to work on this, it’s quite a challenge because it’s very resource intensive and pretesting. But whenever possible we use graphic novels (were working on one right now) or just simple icon’s to help get information out.

Moderator: So basically think about every alternative way you can to get that message out there and simplified.

Carina: Yes. It's critical and then also getting an opportunity to get some information back from the community. Emergency response very much focuses on the structural impacts in a disaster. We're also very interested in the communication-back. That relationship with these key leaders to get information back about the human impact and what's going on.

Moderator: You've shared a great deal of information already but I know you have more. What do you think is most important in communicating effectively with vulnerable populations, what lessons have you learned?

Carina: You know we’ve learned that to work through trusted leaders, to have simple messages—I mean this is true for anyone in a response your literacy goes way down. Very simple messages, visual messages. It's important to get to know the audience and you know we've talked—we’ve done some audience research and focus groups to get better information. I mean the risk-communication principles don’t really change. You know—be first, be right and be credible. There are other ways to get information out through non-mainstream media, through these trusted leaders that we've been working on.

Moderator: Questions been asked before but what have we learned from events like Katrina?

Carina: You know we’ve learned several things from—and I think that's where a lot of this planning has come from. I know in our jurisdiction it was a wake-up call to us that you know, we— some of the traditional mechanisms we were using for the general public were not going to be reaching all of our audiences.

Moderator: You did some research.

Carina: We did. Going back to pandemic flu, an area that public health is the lead on, we realized that pan flu messages are going to be some of the most difficult that a health department would ever have to deliver. Then put that on top delivering to all segments of our community—it’s particularly challenging.

Moderator: Did you find out that some segments of the community were going to be a harder sell than others?

Carina: Oh, yes. We did focus groups with three different communities: Vietnamese immigrants, Mexican immigrants, and African American communities. We took them through, gave them a very high level overview of pan flu 101, because we realize this might be the first encounter people are having with this information. As good as that as we’ve done in getting that information out there it hasn't reached everyone.

Moderator: As hard as we've tried.

Carina: As hard as we’ve tried, yes, good clarification. It was important to provide an overview. Then we take them through an exercise where they have some key messages. Again, we had talked with community based organizations had done some in-depth interviews and from those interviews, came up with some key messages such as, you know, the— the protection of holidays and private celebrations, how important is that to you knowing that with social distancing measure we were going to have to—some of those things might be curtailed. We had a bunch of different messages people rated from least important to most important. It was an opportunity for people to think about what is important to them. Then we did you know, the traditional focus group interview questions. And then had an opportunity for people to talk with each other and then finished that with a preparedness brainstorming because we were—we thought we were—and had heard that receiving this information can be very overwhelming, can be very troubling to people and so we wanted them to leave with some messages about what they could do when they left to be more prepared.

Moderator: What did you learn about use of hotlines? Because I think that's something we've all integrated into our planning.

Carina: Hotlines—well its kind of a funny story in that we—the hotline stories, actually one of a translation gone bad and so it was an opportunity where we had asked someone—a vendor to translate and it really translated a line that is hot. This was a lesson learned about translation improvement and we've taken great steps as an organization—very quickly because of this. But we also have another initiative underway in our community, an equity and social justice initiative that this dovetails to, of really looking at quality improvement, making sure the messages that are simple, that are going to be translated, who's the audience for that message and we’re hoping to have a repository, internally about translated messages so that in an emergency we can get messages out there quickly. And that’s actually—it's great that the department is starting to move in that direction for all of it is programming, not just preparedness.

Moderator: This is great advice because I think we feel we've got it translated its fine. But then I think back, was it the Vega—the translator—Spanish, no-go. If you're telling somebody call a line that's hot, you may not have them calling your health department.

Carina: Right.

Moderator: That’s great to know. And you’ve put some of these lessons learned into a toolkit that I understand will be available to us very soon.

Carina: Yes, under our—as an advanced practice center with the support of NACCHO and CDC, it is that collection of some our lessons learned and some of these tools. So I’ve talked about the focus group guides and how we’ve worked with community based organizations to run and facilitate those focus groups. We have information there; the interview guides; some of the trainings. Of course, referencing the CARD materials and the assessment tools of our conversations with community based organizations and those are going to be in an online form, released in June.

Moderator: We'll be looking for those. Thank you for that information. You know, let's go to Kay who's been waiting patiently to share some great information and I know that your organization, your advanced practice center has developed some extremely valuable tools. Talk about some of what you have to offer.

Kay: Well thank you, Kris. Thank you again for the opportunity for us to be able to share our tools and our advanced practice centers. The tools I’d like to share with you today all can be downloaded from our county website, also with NACHO’s toolbox. The first tool that I am going to speak about is our campaign, plan to be safe campaign materials. Again, these are the tools that are in our toolbox and our plan to be safe campaign is actually a campaign that we used initially with our senior residents in our community. What we've found is that when we went out to do educational sessions with our seniors, we showed them how to put a disaster kit together and we gave them just plentiful information about emergency preparedness but it was almost stifling to them and the fact that they just don’t know how to take that first step. So we sat down with them and said what type of messages do you want? They said we want something simple, something that we can do. So we came up with our plan to be safe campaign which is a—there are three components to the campaign. There is a poster that lists the nine essential items. There is a packet that inserts into the poster, as well as an everybody ready brochure that has three steps. The three steps are, start a conversation, make a plan, make a kit. This campaign has actually expanded into other at risk populations. We’ve used this with women that are pregnant, women with children and in addition we used it with people that are limited with their English proficiency.

Moderator: Well I am glad you said that because we actually have a video clip here that demonstrates how this campaign has been presented to folks who have limited English proficiency, so let's take a look.

Video: In the event of an emergency Plan 9 helps you shelter in place. Put together a kit with these items: water, food, clothes, medications, flashlight, can opener, radio, hygiene items, first aid and you're done. Remember, plan to be safe.

Moderator: That about sums it up.

Kay: I kind of think the beauty of this, just like Carina and Jim said, there are actual icons, pictures and again its one word. People understand what we're trying to have them do. So again, this campaign has taken off like wildfire.

Moderator: Glad to hear that. I actually was privileged to see it being rolled out at the Public Health Preparedness Summit a couple of years ago and it was very impressive.

Carina: Oh thank you.

Moderator: So where else have you presented and where can people see it?

Kay: Again this campaign we presented at different conferences. Again it’s available on our website and again other people throughout the United States have used this campaign. Some people have taken this and put it on billboards. Some people have even been very creative and put it on plastic bags in super markets. So I think you might see it more often than you think.

Moderator: Obviously impressive looking materials. But we talked about barriers to communication and disconnected populations. I can’t imagine that any agency, be it local, public health, Red Cross or a community-based agency, has the staffing power to actually distribute this great information as broadly as we’d want.

Kay: You're so right and that's one of our problems with public health. We really want to start to integrate within public health and also our community organizations, it’s really important. Our response to emergency is a community response. Every individual, every organization has actually the ability to respond and have the responsibility to respond. So were really trying to push these materials outside our public health arena.

Moderator: And when you talk about practical toolkit, I know these materials get right down to the nitty-gritty. For instance if I need to disinfect my water, how do I do that?

Carina: Yes and another component of our plan to be safe campaign is actually a teaching chart, it’s a flip chart that we developed because the need was there when other people started to use our information they wanted more. So this flip chart is actually a template of our plan to be safe campaign. It has a picture of water on the front and you would sit this on a table and the people would see the water but it has speaking notes behind it. Such as how many drops does it require of chlorine bleach to disinfect water? 16 drops. So it has the speaking notes— talking points, so people can present this campaign very easily.

Moderator: So you're reinforcing the information and leaving it with them—

Kay: That's correct.

Moderator: In a method that they can understand. How do you decide what languages these get translated into?

Kay: Very good question. In Montgomery County, in our public school systems we have over a 128 languages spoken. So when we took this material, we took our first nine top languages to be able to have these developed. And if the need arises we have the capability to put them into other languages.

Moderator: Again, keeping in mind basic literacy issues—is that the reason for the great pictures?

Kay: It is. Another example also with our—we have conversation clubs in our county that are held at schools and it’s for people who are trying to learn the English language. They’ve actually taken this plan to be safe materials and used it because of simplification and it has two-fold it teaches in the language and also emergency preparedness.

Moderator: And you’ve obviously talked a great deal about making information accessible to individuals with limited English proficiency. And it’s something that people might not think about—it’s not just people who aren't able to read or cannot use the language but people who can not hear. And we do have a video clip that shows in it presentation style a means of communicating with people who have hearing loss.

Video: How will this help in a disaster? Well Maryland Relay is a service provided by the state of Maryland for individuals who are deaf, hard of hearing and speech disabled. We're open 24/7, 365. If there was an emergency situation that would appear in the state of Maryland, our calls can be routed to other states to be handled.

Moderator: So once again, you're reinforcing the messages. We had the closed-captioning and I know there can be problems with that closed-captioning when there's an emergency and the news stations send information at the bottom of the screen. But you also have the individual with the American Sign Language, so we’re making sure that message gets out there.

Kay: Yes, we’re really trying hard, definitely.

Moderator: And I know that you just keep coming up with innovations and one that we talked about earlier and I just love; Martta the planner, talk about Martta

Kay: Martta the planner is actually a community health nurse that works in emergency preparedness and again she came up with this costume, again like “Bob the Builder.” When we went out to do our trainings on the plan 9 material plan to be safe materials, we really wanted the training to be fun, interactive and to keep away the fear factor. So Martta actually has the tool belt and hard hat and she has all the nine essential items in that tool belt.

Moderator: And are checklists part of nine essential items?

Kay: Definitely, the checklist is incorporated into that.

Moderator: In addition to checklists, do share ways for various groups or facilities to actually practice what they learned?

Kay: Well one of the checklists that we developed was with our nursing home, assisted living and group homes. And this is a checklist for facilities to be prepared. An example, we had this with our license and regulatory service of public health who expect nursing homes for certification through our quality assurance survey we incorporated this checklist into the nursing home’s plans. During Isabel, in 2003 it actually struck the east coast because these plans were in place we were able to call over 400 nursing homes facilities to make sure that they had electricity, they had the generators and they had a three day supply needed to be able to be self sustained.

Moderator: One of the materials you talked about was a case management material. Can you—can you take us through that because I think that really helps.

Kay: The case management piece was actually for aging and disability and this is another service that we have in our county and this is home care services. It comprises of a team of a case manager and also a certified nursing assistant. The type of the service they give in the homes is services for activities such as bathing, light housekeeping, bathing and what they did, they went into the home to focus on the plan nine essential items. On the baseline we found most of our clients had 50% of five or more of items and after three months it went up to 90%. Show it shows the trusted member who somebody knows and somebody who has the caring approach to go in there can make a difference.

Moderator: And who would you suggest would be other trusted members of the community that our audience should be working with?

Kay: Well, again I think any agency that people have any connection with that people have to know that they trust is a source of information. So it can be your faith communities, it can be churches; it can be different civic organizations.

Moderator: There's a lot of talk about the role of faith based organizations now as trusted leaders and are we using them enough? How can work better with them? Because obviously many faith organizations have limited resources and would need some help to be involved.

Kay: Again, its all about community engagement. When we started to work with our faith communities, we really focused on faith community nurses, many people know them as
parish nurses. What we did, we came together at the table to talk about emergency preparedness. We did some focus groups with the faith community nurses and trying to figure out what they define as an emergency. What we found out is somebody who might be in a service, might have a heart attack and if you need to call 911, and start CPR. But we really wanted to expand their scope. And traditionally their practice is more the spiritual and educational so they were a really good avenue to be able to get emergency preparedness in. So we held a conference, we developed a toolkit for faith communities which has a wealth of source of information and it even has an assessment piece for nurses to be able to identify what at risk populations they have in their congregations.

Moderator: And oftentimes faith based organizations representatives are doing home visits, they're trusted. So they are a perfect adjunct to our efforts. But their resources again might be strained so we have to make it easy for them to work with us.

Kay: It is. And also to is keep them engaged. We came to the table three years ago and we put the information out to them through our website and many times we'd have like little tips for emergency preparedness, we’ll pass that on to them to put into different their bulletins and different ways to get communication out to the residents.

Moderator: I think a lot of studies have shown as well as the faith based impact that children's issues are particularly important when we're planning. Have you worked with childcare networks or other systems to make this happen?

Kay: That’s an interesting question because just a few minutes ago we were talking more about the senior residents, so now we’re working on the other side of the spectrum. And what we’ve learned during SARS especially in Canada, our critical service workers, hospital workers, were put to task, many of them were working beyond their 8 or 12-hour day. Childcare for long-term became a huge issue. So we started these conversations to sit down with our childcare networks in our community, asking them if there was a public health emergency which tend to be biological emergencies that tend to last longer than fire or other type of emergencies. If children needed to be placed into sometime of a safe environment, would they be willing to volunteer to almost start their own network for childcare providers. This is how we are starting to approach this. It’s very important that public health starts collaborating with the childcare providers because children can be very vulnerable during emergencies.

Moderator: And has Montgomery County developed a toolkit for childcare providers as well?

Kay: Yes, we have, and the toolkit that we have developed is a train the trainer toolkit. And it is a very extensive toolkit, it has over 140 different pages but again, it's not meant to be in one setting--take parts of it to be able to train. Currently we have 500 of our childcare providers in our county trained on this toolkit. Currently we are putting it into a Spanish version because a lot of our child care providers are Latino so they do provide a lot of information, but they need the information in Spanish.

Moderator: I want to talk about risk communication because it’s just a subject that obviously all of the planners now are trying to integrate into their preparedness. Have you done that? What have you learned through use of risk communication with Montgomery County audiences?

Kay: Well, it’s interesting, we started to target our different groups in our county and one of the groups that we've worked is our Latino Health Initiative. They have other initiatives in the county as well and what we learned about risk communications was is that when we did several focus groups, we did eight focus group and we were really targeting Latinos that are new to our county within the last five years that came to United States and low income. And through this focus group what we found was that there wasn't any information available in their language or information they could understand. So the result of that focus group we developed a curriculum for Latino health promoters who are lay people in the community. These are women who actually have jobs during the daytime but they volunteer to become health promoters to bring education out to the Latino cultures and they go into health fairs, they go into the neighborhoods. They'll sit at the kitchen table to talk about health issues such as heart disease, cancers, etc. We really tapped into the health promoters. Just recently we did three pilots in our county. Where we brought people out to training sessions and what we found traditionally women would only come to these sessions but men were showing up to the sessions after the second session because they really felt that the head of the household, this is the responsibility to know about emergency preparedness and what they need to do to protect the family. Through these sessions there were four things that we felt that were very valuable. When we asked these people to sessions we needed to provide child care. Childcare is very critical again, were looking at low income we wanted people to come to these sessions, so childcare was provided. We held these sessions at schools second of all, we needed food. Any time you have groups together, it’s important to feed them. Again, it was like snacks. Wasn’t any elaborate dinner or lunch but it was very important to keep the atmosphere friendly and easy going. And third, we had what we call stipends or incentives. I'm not talking about money. I'm talking about little flashlights, first aid kits, anything to jump start that disaster kit. And fourth a trusted member to deliver and that was the lay health promoter—to be able to give that message.

Moderator: How important is that component of it do you think?

Kay: Extremely important. Again, people have to really know that this person is telling you this to prepare there has to be some importance to it.

Moderator: An in their planning I think they’ve talked—I know risk communication concept is third party verification. So if it’s coming from a government source to an audience that isn’t necessarily trust government—you better have someone who is trusted to echo what you’re saying.

Kay: Yes and there have been several studies on that also that recognizes that.

Moderator: It didn't seem to have to be someone with for instance a lot of academic credentials.

Kay: No. With our curriculum, we did provide training—they went through an extensive training. So they felt empowered to go out into the community. We're developing a tool kit in English and Spanish as well. This can be used not just with health promoters because I realize a lot of people don’t have health promoters in the community but any organization that has outreach into the Latino population.

Moderator: And that curriculum will be available soon?

Kay: Yes we are hoping by June. They can actually go into our county website or the NACCHO website toolbox to be able to download this. What I wanted to say about our tools and resources, we have developed all these tools where somebody can take and put their own logo. It’s really important so they can bran their own document so it doesn't say Montgomery county of Maryland on that. All of our tools are accessible for that.

Moderator: You are really hitting the streets with this.

Kay: Oh definitely.

Moderator: Are you working with the CERT teams, Community Emergency Response Teams?

Kay: Yes. We just started a neighborhood imitative, this just happened in the last two weeks and we piloted three neighborhood groups, homeowners association and the CERT team is really valuable because they are looking for projects to do so they actually go into neighborhoods to start training about emergency preparedness. And what we're really looking for is targeting neighbors in our— who might need special needs during an emergency and to help to identify those needs. Because during an emergency the first people we turn to is our neighbors, people that we look to. The message that we're really putting out there, within 72 hours you're on your own, you better have a plan. In this toolkit that we're developing to, there's even cards that says help, okay, so people can put these into their windows.

Moderator: What you said was really interesting to me about the neighborhood toolkit. We talked a little bit earlier about how the Center for Public Health Preparedness co-sponsored community engagement meetings in New York and we don't have those findings final but we do know some of what we learned and there was an immense interest in having a neighborhood response. It was really the first I had seen that. Obviously you now have tools that are at the ready to make that happen.

Kay: Yes

Moderator: Very, very impressive.

Kay: Thank you.

Moderator: So take it down from the neighborhood response to what an individual should do. I know there are checklists for individuals but a lot of them out there are lengthy and maybe are not as basic as we need them.

Kay: Another tool that we actually develop was a stay at home tool kit and this is for individuals, families to be able to use and initially this toolkit was designed for pandemic influenza because our charge was to be able to keep our hospitals, our community clinics alive, up and running and we really wanted someone to know how you take care for someone during the flu. And it has very simple information; how to take a temperature, how to disinfect a surface. Again this is one-page information so people can use.

Moderator: Timely too, I would imagine given the triage document that came out just a few days ago that talks very seriously about the limitation of your normal healthcare resources, how people are going to are to try to help each other and themselves. I understand you've got yet another toolkit that will be coming out of the end of May. Why don’t you tell us what that is.

Kay: You know its so interesting, Kris, when I started to look at these tools, the ones I am discussing –there are nine tool kits—plan nine, go figure.

Moderator: Go figure.

Kay: Another toolkit that we're looking is stop the spread toolkit and this is really designed for medical offices and community clinics. It's on infection control, which is so important during any type of outbreak. It has really basic information; it has a power point presentation with a voice-over. It can be broken into segments for ten minutes of training for office staff. It has different components of the plan., even has a little sticker in there that staff can use that says ask me if I washed my hands. This sticker is important for patients to empower them—it's okay to ask your health provider if they washed their hands before they do the examination.

Moderator: And it reminds the healthcare provider, oh I have to wash my hands.
Kay: Right, it puts them on the spot.

Moderator: These are such valuable resources. What does a community do if they don't have an advanced practice center and they can't develop these types of tools?

Kay: This is why advance practice centers were actually created by CDC and NACCHO for us to be able to a take that charge and to develop tools and resources for local public health agencies. All of our tools can be downloaded at the NACCHO toolbox and also the APC’S all have their websites and I would ask people to go to this websites and the information at the end of this presentation

Moderator: Ok because we will want to give folk a chance to learn how to access that. And by the, good news we do have time to take some of your calls. Probably only a few so call quickly. You can reach us toll free 800-452-0662. We do hope that you will do that because we've covered a lot of information, we’ve got more to cover but there may be specific questions out there that people want to ask. We want to give them a chance. Contact information if we were to get this—these toolkits if we want them can you take us through how we get those you said there are several websites, how do they reach you.

Kay: My name and my direct line is on this slide that you're seeing right now. I can be reached at 240-777-1240. My e-mail address is there. To look at our tools you can go to www.montgomerycountymdgov/apc and this will direct you right into our website to see all the tools that we discussed today.

Moderator: In case our viewers can't scribble that fast, I do want to remind everybody this presentation will be available on our web site and the web streaming in a couple of weeks as well. Other communities, are they this far ahead in this type of initiative and these types of materials?

Kay: It really depends on the structure and because I come from Montgomery County, Maryland, we're in the National Capital Region. And when we speak of the National Capital Region it’s almost like a three state, between Virginia, D.C. and Maryland and we do have an urgency to plan because if an emergency is going to happen its really going to happen in the heart of capital in D.C. So we're really moving very quickly and very fast and this is what's so important to take our tools and resources to be able to share with others. Again, its just not for local Public health its for other community organizations, they can use these tools just as well as anybody else.

Moderator: I want to show the contact information for our other guests, Jim and Carina as
well. Then I actually have a question I wanted to ask as well. So we'll get that contact information up before the end of the show. One of the preliminary findings, and I’ll address this to you Jim, and feel free to comment as well Carina and Kay— with our community engagement, when we talk about stockpiling prescription medications, huge red flag. Is anything being done to make that more reasonable and what are we to tell people to do?

Jim: You clearly have identified one of the significant challenges that we have. By challenge I mean we have clearly rules and regulations to protect the consumer against drug misuse and overuse under normal circumstances. But this is a good example of where we really need to change our standard practices and provide those—those opportunities to go into an emergency mode to wave policies and procedures and create a different set for different circumstances so if we are advising the public to stock pile medications but yet their pharmacist or their insurance company or physician is not allowed or is not willing to give them extra supplies, that is a huge issue. So we're working with the lawmakers, the rule makers, the industry to see if there's a way in which we could support that recommendation to make it easier, but yet still safe and not totally compromise the integrity of the system that’s in place to make sure there's not misuse or abuse of medications. But I’m glad you raised that point because that is one of the most significant concerns which almost— almost sort of a— a conflict in messaging that we're advising individuals to stock pile medications but yet they're encountering significant barriers, institutional barriers to get those personal supplies, you know, in large quantities for extended periods of time.

Moderator: I’m sure so glad you raised that point because as a risk communicator it strains credibility when we're asking people to do a series of things. One of which is impossible for them to do, do they then not concluded that about everything we are telling them to do, throw their hands up, it is not going to be achievable.

Jim: Yeah I don't think so. Because to be effective in risk communication the way we normally present it is that we realize that we need to do this and WE need to get you to a point where you can do it. So while we're not— may not be able to achieve it at this point in time because of those barriers that are in place, the trusted message, if you will, is that the government and the system is working as hard as it can to remove those barriers to make it more— make it easier for the general public and the at risk individuals to accomplish and follow the set of guidance.

Moderator: So it's okay to say we don't have this solved but we know that it's a problem and we're working on it.

Jim: Absolutely, it’s easy to identify a problem with the honest, sincere message that we don't have a solution for you yet, but we're working as hard as we can to put it in place— recognizing that's the end point and now all the things we have to do to get us there.

Moderator: Carina and Kay, hearing and addressing those real concerns, that's something that you demonstrated the importance of during your focus groups, correct?

Carina: It’s important that a Health Department be transparent about some of the decisions that are being made that will impact the lives of the residents. Again, making sure that people do have opportunities to access drugs is important and as Jim mentioned we're still figuring out what that looks like but it's important to consider all of the residents in the planning.

Moderator: We had—and anybody can jump in on this, Kay, if you have some thoughts, than we'd love to hear from you. We had a call from a viewer who wants to know: to what extent has breastfeeding been included in planning? Does it need to be—its part of your childcare.

Kay: Right, well that’s an excellent question again because that’s another source of food and is important to really look at that, and to be truthful we had not looked at the issue at this time.

Moderator: Especially nutritional needs.

Kay: That’s very true.

Moderator: There are a number of things—there is always something else to plan for.

Kay: There is always something and it seems like when you go through this hole the hole gets deeper and bigger for sure.

Moderator: But you have to get in there and mix it up. We have a question from Connecticut and they would like our panel to help our viewers make the distinction between special needs populations, vulnerable populations and at-risk populations. What is the term du jour or do we use them all in different contexts?

Jim: They really are interchangeable. But the term of art is at-risk. That is what we're using even though even in our dialogues we've talked about vulnerable and special. So that's probably not a direct answer. But again, we would consider the at-risk population sort of the larger group that really we are planning and focusing on.

Moderator: Carina, anything to add on that?

Carina: Yea, we use the term vulnerable because that’s what we—we went back and forth in the early stages and we have a vulnerable population’s action team and that’s kind of how we’ve defined our work. But really we do— (as has been mentioned) all people can be vulnerable in the event of an emergency. But it really is those individuals who do not have access to communication to the resources in a way that someone else who can do other things—you know, pay for a hotel room. It’s those individuals we're particularly concerned about so we do use the term vulnerable in our work because of how our work was started but at-risk and special could also be used.

Moderator: Kay, what do you think?

Kay: It’s very interesting because we have changed those terms so many times with our
own groups. We started with people with special needs, vulnerable populations, and special populations and currently we are trying to use the term at-risk. And again you really have to look at that time event and what the impact of the event is on the individuals. Just because an individual might have a handicap, that person might have all the resources so they would not fall in that category.

Jim: You know if I could add to that— we really are getting away from the labeling and we're looking at factors that really help define a person's status, whether they be at risk or vulnerable or special. So I think to sort of refrain the question, I think that's the bigger issue is looking at the new way and probably the more appropriate way of really trying to define, identify and locate those that we're really trying to protect.

Moderator: That's really solid logic. I worked with a group at CDC that was trying to define special needs in term of communication. I think we came up with something that—it helps me. Special needs or vulnerable or at-risk populations in terms of communication would be those who cannot receive the message for whatever reason; cannot understand the message for whatever reason and can not or will not act upon it
for whatever reason. So it really gets into the practical matters of it. We have a question and they want to know: how do you reach out to those community based agencies, it’s obviously a great idea but how do you make that initial contact and keep on with it?

Carina: Well again, we looked at relationships we already had with community based organizations. We had done some work with CBO’s during our isolation and quarantine planning. And had gone to them asking them to help us support individuals who may need additional support while they were in isolation or quarantine. We went back to those individuals and said you know we want to look at this idea of a communication conduit. So it was really starting a conversation, you know looking at the existing resources— they had some capacity, had some awareness about preparedness and starting that conversation.

Moderator: I want to go over the contact information for Carina and Jim before we have to close our broadcast. I am assuming that both of you are very willing to answer e-mails and tell people so here's the contact information for Carina who is out in King County in Washington and again, this will be available on our web site. And for Jim, Association of State and Territorial Health Officials also known has ASTHO. We want to give—we got probably ten seconds, take-home message? Kay I am going to give you the last word here.

Kay: Oh, my goodness. I just really wanted to say there are so much resources out there and I think it's important to start somewhere. And again, that’s where you really have to start for preparedness to take that first step

Moderator: Well you did it I think it probably was about 10 seconds. What a great conversation today. If people didn't take away a lot of important information today then they just weren't listening but I’m sure that they’ll be able to follow up. I want to thank you their in the audience very much for joining us today. Please complete the online evaluation; continuing education credits are available after completing the post-test. Your feedback is always helpful to the development of our future programs. This program, as I said will be available via web streaming within two weeks, please see our website for more details. We hope you join us for the final program of this season on June 12th when doctors Christine Gebbie and Kathleen White join us to speak on Adapting Standards of Care Under Extreme Conditions, a very topical issue. Please see the University at Albany Center for Public Health Preparedness website for more details. I'm Kris Smith and I'll see you next time on the University of Albany Center for Public Health Preparedness Grand Rounds




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