Developing Community Level Strategies for Healthcare Delivery During

Mass Illness EventsDeborah Levy, PhD, MPH

CAPT, USPHSDivision of Healthcare Quality Promotion

Centers for Disease Control and PreventionMarch 4, 2010

Overview • Community workshops for pandemic

influenza and lessons learned

• Stakeholder meetings and lessons learned

• Ongoing activities and supporting tools in development

• Key points for surge planning

The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers for Disease Control and

Prevention/the Agency for Toxic Substances and Disease Registry

Delivery of Care

Long Term Care/ Assisted Living

EMS“Pre-hospital” “Hospitals”

Alternate Healthcare

Sites

Community Clinics*

Private Providers

Dialysis Centers

Elective Surgical Sites

Homes Emergency rooms/ Hospital facilities

Call Centers 911 + I&Rs

*Community clinics refers to a spectrum of outpatient/private provider, rural health centers, urgent care centers, federally qualified health centers (FQHC) and FQHC-like entities

Community Workshops for Healthcare Delivery in an Influenza Pandemic

• Develop coordinated strategies for delivering healthcare to those at home, in the community, and up to and including the emergency room

• Identify preparedness needs related to healthcare delivery among community planners and other stakeholders

• Outcome of the workshops– Develop a “Community Model of Healthcare Delivery” for an influenza

pandemic (2 workshops in 2008)– Determine strategies for standing up “Alternate Care Systems” (ACS)

in the community (1 workshop in 2008)

Community Workshops for Healthcare Delivery in an Influenza Pandemic

2008 Activities• Models of Healthcare Delivery

– Mid-sized metropolitan area– Multi-county rural region

• Development of an Alternative Care System – Mid-sized metropolitan area

2009-2010 Activities• Follow-up workshops planned for 2010, large

urban area and regional alternate care system

• Continuing to develop tools/templates for community planners and other stakeholders

Workshop Participating Sectors• 911 and other call centers

• Emergency medical services

• Emergency departments

• Hospital administrators

• Primary care providers

• Urgent care centers and other outpatient clinics

• Home health

• Long term care

• Palliative care

• Pharmacists

• VA medical centers

• Public health

• Emergency management

• Local government

• Mortuary services

• Faith-based organizations

• Schools/school nurses

• Legal

• Public safety

• Non-profit organizations

“Pan Flu Scramble” Activity

• Bring healthcare partners and supporting organizations to the same table

• Visualize surge in ill patients that will likely accompany a moderate to severe influenza pandemic

• Identify community’s issues and chokepoints associated with patient care

Diagram of Healthcare Delivery Model

• From where do they receive patients?

• To where do they send patients?

• Where are the chokepoints in patient flow?

• What are the alternatives?

• At what points can they assist other critical sectors?

Selection of Best Strategies for ACS

• Reviewed 8 strategies for standing up alternate care systems

• Discussed advantages and disadvantages

• Listed available resources and those that would have to be developed

• Selected strategies with the understanding that an implementation plan would be needed

ACS Options• At home independent care• Patient isolation/quarantine and alternative to

home care• Expanded ambulatory care• Care for recovering non-influenza patients• Limited supportive care for non-critical patients• Primary triage and rapid patient screening• Overflow hospital providing full range of care• Mobile hospital

Workshop Lessons Learned• Sectors did not know of each other’s plans and made

incorrect assumptions about the plans

• Hospital leadership had not grasped the complexity of the issues and the need to integrate their planning with the community

• Local government was not aware of the types of issues it would have to deal with

• Role of public health in healthcare delivery was not clear to themselves and to the other sectors

• Most effective communities included public health, healthcare, and emergency management in their planning efforts – lead did not matter

• Call Centers– Workbook to coordinate call

centers– Short version posted as

guidance in spring 2009, full version posted 12/2009

• Primary Care Providers– Template of a plan for primary

care offices (posted 2/2010)– “Pan Flu Organizer” (in

development)

Stakeholder Meetings

Pediatric Stakeholder Meeting• Group 1 – Develop an operational plan for

3 sizes of medical offices (posted 2/2010)

• Group 2 – Develop a vaccination implementation and administration plan (posted 10/2009)

• Group 3 – Develop a communications plan for information needs and public message topics (posted 2/2010)

• Group 4 – Identify and prioritize hospital issues, and address high risk pediatric patients (in clearance)

Stakeholder Meetings Lessons Learned

• Coordination of multiple call centers had not been addressed

• Primary care providers (PCPs) did not have plans for dealing with a pandemic and were not integrated into their communities’ emergency response planning

• Pediatric hospitals’ surge plans were not coordinated with other acute care facilities

Pediatric Mass Critical Care Project• Convene pediatric experts (including bioethics,

critical care, disaster preparedness, EMS, infectious diseases, law, nursing, pharmacy, respiratory care, etc.)

• Propose a framework or system for hospital- based mass critical care in pediatrics to include a triage protocol for prioritizing access to critical care resources

• Publish as a series of manuscripts

• Subgroups/focus areas– Family-centered care– Education and communication tools for enabling care– Regionalized systems of neonatal and pediatric care– Supplies/equipment/infrastructure– Triage/treatment/resource allocation– Limiting unnecessary use of hospital resources– Ethical and legal dilemmas and decision making– International considerations

• In-person working group meeting (10/2009)

• Broader stakeholder meeting (3/2010)

Pediatric Mass Critical Care Project

ESI-Based Suite of Triage Tools• Resources for healthcare facilities to use only for

triage of patients who have suspected or potential exposure to influenza, only during a pandemic– Adult and pediatric patients

• Designed for face to face encounters with patients who present to emergency departments, urgent care centers, primary and long term care, clinics and home health, public health or other healthcare facilities

• Manage patient surge in a variety of healthcare settings from a community perspective– Sort patients to the appropriate place, for the appropriate care, at

the appropriate time– Determine patient acuity (level 1-5) and estimate patient

resource needs

• Includes a User Guide, Brief Guide, and Pocket Guide for health professionals– Triage algorithms, site of care algorithm, and checklist of

community resource availability

• Train the trainer session (10/2009) and community tabletop exercise (12/2009)

ESI-Based Suite of Triage Tools

Delivery of Essential Healthcare Services

• Collaborative planning with 10 recipient activities– Defining priority services, ethical and legal

ramifications, border issues, resource requirements and sharing, public health’s role, phone triage, pre- hospital issues, and home health

• Nine awardees – GA, IL, IN, MI, MN, NH, NYC, OR, VA

• Start date of 9/30/2008 for 1 year, all except VA requested a no-cost extension

• Conference in Atlanta to show products and explore options for next steps (3/2010)

Community Preparedness Tools• Community Assessment Tool

• Community Planning Tool

• Pan Flu Scramble Activity and Guide

• Pan Flu Discussion Guides

• Guide on establishing a community model of healthcare delivery

• Guide on establishing a community-based alternate care system

Key Points for Surge Planning• Healthcare, public health, and emergency management need to plan

together and exercise together

• Planning together for pandemic surge results in improved response to other activities and incidents, and more efficient use of resources

• Healthcare components other than hospitals are equally valuable community assets and need to be integrated into planning

• Pediatric and neonatal populations are inadequately addressed

• EMS should communicate regularly with healthcare and public health for patient movement/distribution and public response

• Plans, protocols, algorithms must be operational, implementable, and integrated/coordinated

Healthcare Preparedness Team• CDC/DHQP

– Adeyelu Asekun– Kelly Dickinson– Kathy John– Sherline Lee– Jean Randolph– Alcia Williams– Lecia Winn

• ORISE– Will Artley– Ron Edmond– Freddy Gray– Linda Hodges– Michael Outler– Jennifer Reynolds– Annette Skoczylas– Betsy Smither– Amber Tayman– Casey Thomas– Kelly Williams