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2014 Model PracticesApplication Name: 2014 Model Practices : LA County Department of Public Health - Emergency Preparedness and Response Program : Community led Responses in Emergency Response Applicant Name: Mr. Sinan Khan, MPH, MA Community led Responses in Emergency Response
Submitting LHD/Agency/Organization:
Los Angeles County Department of Public Health
Street Address: 600 S. Commonwealth Avenue, Suite 700
Submitting LHD/Agency/Organization/Practice website:
www.lapublichealth.org/eprp Practice Contact Job Title: Director, Medical Countermeasures Head of LHD/Agency/Organization: Dr. Alonzo Plough Provide a brief summary of the practice in this section. Your summary must address all the questions below.
Size of LHD jurisdiction (select one):
3,000,000
In the boxes provided below, please answer the following:
1)Where is LHD located? 2)Describe public health issue 3)Goals and objectives of proposed practice 4)How was practice implemented / activities 5)Results/ Outcomes (list process milestones and intended/actual outcomes and impacts. 6)Were all of the objectives met? 7)What specific factors led to the success of this practice? 8) What is the Public Health impact of the practice?
Emergency planners at local health departments (LHDs) continue to develop mass prophylaxis plans to prophylax entire populations within forty eight hours in order to reduce mortality after a bioterrorist attack. Although, Points of Dispensing (PODs) serve as cornerstones for mass prophylaxis many LHDs find it extremely difficult to prophylax their entire population within forty eight hours using only their PODs because of staffing. Given the spate of recent budget cuts at the local and state level LHDs barely have the staff to perform day to day functions, let alone emergency POD operations that is staffing resource intensive.
Los Angeles County (LAC) spans across 4,752 square miles with eighty-eight incorporated cities and several unincorporated areas. The population of the county of 10 million people is extremely diverse due to a high rate of immigration, with people representing more than a 140 nations and speaking over 100 languages. In addition, the County has several high priority terrorist targets, is a large tourist destination, neighbors a larger tourist destination, has a large daytime population influx, and also has a large sheltered-in population. The Los Angeles County Department of Public Health (LACDPH) must therefore plan to mass prophylax up to 12 million people within 48 hours of a bioterrorist attack to prevent loss of lives and reduce widespread panic. Los Angeles County would be required to simultaneously operate 208 PODs and maintain a client throughput of 1,500 people per hour per site in order to meet their goal. LACDPH would require a total staffing of approximately 15,000 people per 12 hour shift for POD operations alone to meet this goal. Given this massive strain on LACDPH staffing resources The Emergency Preparedness and Response Program began looking at volunteer resources from the community.
Starting in 2009 LACDPH began focusing heavily on recruiting community volunteers through its Medical Reserve Corp (for clinical staff) as well as organizing community organizations such as CERTs, community volunteer coalitions as a part of its Public Health Emergency Volunteer (PHEV) network for non clinical staff. Volunteers were required to participate in regular seminars, conferences and POD exercises organized by LACDPH (funded by the Public Health Emergency Preparedness grant). The long term goal was to eventually organize a POD staffed completely by volunteers from the community with Health Department staff providing minimal staff as a part of the incident command system. The community organizations would be responsible for organizing the POD, Site set up, clinical operations, non clinical functions as well as public messaging. Since H1N1 LACDPH has worked integrated community organizations in its POD Operations, however, in 2012 LACDPH organized it's first POD using community resources. This was repeated with great success in 2013. LACDPH would provide staffing for four key ICS positions, the Incident Commander, the Safety Officer, the Planning Section Chief and the Operations Sections Chief. Thus making it a volunteer run POD with minimal supervision from LACDPH. The POD was heavily evaluated by LACDPH personnel for its client throughput and long term feasibility. The POD was a success and lay to rest all questions related to an all volunteer run POD. Supplemental materials:
You may provide no more than two supplement materials to support your application. These may include but are not limited to graphs, images, photos, newspaper articles etc. (Please use one of the following: pdf; txt; doc; docx; xls; xlsx; html; htm)
Model Practice(s) must be responsive to a particular local public health problem or concern. An innovative practice must be 1. new to the field of public health (and not just new to your health department) OR 2. a creative use of an existing tool or practice, including but not limited to use of an Advanced Practice Centers (APC) development tool, The Guide to Community Preventive Services, Healthy People 2020 (HP 2020), Mobilizing for Action through Planning and Partnerships (MAPP), Protocol for Assessing Community Excellence in Environmental Health (PACE EH). Examples of an inventive use of an existing tool or practice are: tailoring to meet the needs of a specific population, adapting from a different discipline, or improving the content.
In the boxes provided below, please answer the following:
1)Brief description of LHD – location, jurisdiction size, type of population served 2)Statement of the problem/public health issue 3)What target population is affected by problem (please include relevant demographics) 3a)What is target population size? 3b)What percentage did you reach? 4)What has been done in the past to address the problem?5)Why is current/proposed practice better? 6)Is current practice innovative? How so/explain? 6a)New to the field of public health OR 6b)Creative use of existing tool or practice 6b.1)What tool or practice did you use in an original way to create your practice? (e.g., APC development tool, The Guide to Community Preventive Services, HP 2020, MAPP, PACE EH, a tool from NACCHO’s Toolbox etc.) 7)Is current practice evidence-based? If yes, provide references (Examples of evidence-based guidelines include the Guide to Community Preventive Services, MMWR Recommendations and Reports, National Guideline Clearinghouses, and the USPSTF Recommendations.)
Emergency planners at local health departments (LHDs) continue to develop mass prophylaxis plans to prophylax entire populations within forty eight hours in order to reduce mortality after a bioterrorist attack. Although, Points of Dispensing (PODs) serve as cornerstones for mass prophylaxis many LHDs find it extremely difficult to prophylax their entire population within forty eight hours using only their PODs because of staffing concerns.
Given the spate of recent budget cuts at the local and state level LHDs barely have the staff to perform day to day functions, let alone emergency POD operations that is staffing resource intensive. Given that disease modeling and Federal Emergency Management Agency (FEMA) bioterrorism scenario models show that each additional day LACDPH misses it’s mass prophylaxis target – thousands of individuals could die – LACDPH emergency planners began exploring the possibility of using other staffing resources to supplement their LHD staff and possibly add additional sites to add fail safes to its mass prophylaxis operations. The most important resource to find solutions related to POD staffing models being considered or tested by other jurisdictions has been the SNS List Serve, an online discussion forum where individuals working closely with SNS issues post their thoughts and comments as well as questions. There several formally written literatures on POD models that discuss workforce efficiency and staffing models. However, there was nothing concrete available regarding conducting an all volunteer POD. The largest barrier sited with use of volunteers were that their poor training was reflected in their POD operations. LACDPH therefore spent several years training its volunteer resources through seminars, conferences and actual field experience in PODs. Most jurisdictions list in their After Action Reports on PODs that they included volunteers to supplement their LHD staff at PODs – something LACDPH also did to prepare it’s volunteer workforce for the all Volunteer POD.
Prior to the application and success of this approach LACDPH staff would have been solely responsible for staffing all 208 PODs in Los Angeles County. Given that LACDPH would require a staffing of over 15,000 staff per 12 hour shift – it would be very burdensome on LACDPH to fill its POD staffing roster. However, this approach significantly reduces the burden on the County to be the sole agency providing staffing for mass prophylaxis. This approach allows LACDPH to tap into staffing resources from the community itself. Given that all volunteers are pretrained through seminars, conferences and active participation at PODs in conjunction with County staff provides them with the right skill sets to work in a POD setting with minimal County supervision. This approach thus allows LACDPH to organize all volunteer PODs with only key ICS positions filled by County staff – thereby significantly reducing the burden on LACDPH.
Given that the staffing constraints faced by LACDPH during an event requiring mass prophylaxis is also faced by all other agencies – LACDPH personnel conducted a literature review to understand how other agencies tackled this issue. These issues can be broken down into two categories: a.) Staff Procurement and b.) Staff Training.
Due to state and local budget constraints most LHDs are understaffed to run their daily functions (Flynn, 2004). In addition, exactly how many staff are needed is unknown, as demand at each site is variable and unpredictable. Models suggest large staffing requirements, making the process extremely burdensome on LHDs (Trust for America’s Health, 2005; Los Angeles County, 2006).
a. POD Staff Procurement
The forty-eight-hour deadline to prophylax the entire general population puts a heavy burden on PODs, especially when LHDs estimate they would require several hours to contact and recruit their POD staff and set up POD operations and security. This puts great constraint on the Overflow Responsiveness - 1 time available to procure volunteers. The POD staffing resources consist of volunteers and staff from various departments within the local agency as well as other partner agencies. For example, a county will use its own staff as well as staff from cities within its boundaries; this in itself could lead to staffing complications unless there is marked delineation of duties between cities and the county, which is rare (Los Angeles County Operation Chimera, 2005a). Nevertheless, a large percentage of PODs would be volunteer-driven and getting a workforce large enough to staff PODs for two twelve-hour shifts per day could become challenging. Spontaneous volunteers arriving at PODs would add to the traffic congestion and would negatively influence POD operations. LACDPH addressed this problem by avoiding spontaneity of volunteers and requiring them to be preregistered through the Medical Reserve Corp for Clinical Staff and the Public Health Emergency Volunteer (PHEV) Network for non clinical volunteers.
Most LHDs concede that they will not be able to set up and operate all PODs at once and
PODs would be opened based on availability of staffing and security resources. This would once again put great strain on PODs already open as people from neighboring and distant cities may pour in to obtain prophylaxis. In addition, in an area as large as Los Angeles County this process would be extremely chaotic. LACDPH would therefore prefer an all hands on deck approach where all 208 PODs would go active at the same time. In addition, this is the only way LACDPH would meet the 48 hour mass prophylaxis timeline.
b. POD Staff Training
POD volunteers would require “just-in-time” training in communication, ICS and the POD process. Training staff on the use of radios and understanding ICS takes time, but not doing so would lead to a breakdown in communication (Los Angeles County Emergency Preparedness and Response Program, 2006). A lack of familiarity among volunteers with the chain of command established under ICS can lead to delays, as they do not understand how to report problems through proper channels and how to order supplies (Los Angeles County Operation Chimera, 2005c). A breakdown in communication can result in duplication of efforts; resource requests and gaps in operations affect the efficiency of PODs, resulting in a slower throughput (Los Angeles County Operation Chimera, 2005b). Since POD staff receives only just-in-time training for the POD process, misunderstood instructions can lead to disruption of POD operations. However, increasing the time spent on such training can result in delayed opening of PODs. The CDC-developed algorithm used during triage is complicated and requires time to properly understand it and be able to implement it. Computer-based systems like the inventory management system or patient tracking systems require advance training.
LACDPH therefore requires volunteers to regularly participate in seminars, conferences and hands on exercises so they have a clear understanding of ICS and POD operations. This preplanning enabled LACDPH to prepare a volunteer workforce that can run an all Volunteer POD with LACDPH staff only providing staffing for key ICS positions.
Overflow Responsiveness - 2 Although several LHDs have incorporated volunteers into their POD staffing model – LACDPH took this approach one step further. LACDPH created a trained volunteer workforce for POD operations that can successfully operate a POD with an all volunteer staffing model. LACDPH would only provide four staff members for key ICS positions. This model will serve as a new benchmark for future POD operations and is now a part of LACDPH’s mass prophylaxis strategy. Overflow Responsiveness - 3 The LHD should have a role in the practice’s development and/or implementation. Additionally, the practice should demonstrate broad-based involvement and participation of community partners (e.g., government, local residents, business, healthcare, and academia). If the practice is internal to the LHD, it should demonstrate cooperation and participation within the agency (i.e., other LHD staff) and other outside entities, if relevant. An effective implementation strategy includes outlined, actionable steps that are taken to complete the goals and objectives and put the practice into action within the community.
In the boxes provided below, please answer the following:
1)Goal(s) and objectives of practice 2)What did you do to achieve the goals and objectives? 2a)Steps taken to implement the program 3)Any criteria for who was selected to receive the practice (if applicable)? 4)What was the timeframe for the practice 5)Were other stakeholders involved? What was their role in the planning and implementation process? 5a)What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s) 6)Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Else, provide an estimate of start-up costs/ budget breakdown.
The Los Angeles County Department of Public Health’s (LACDPH) Emergency Preparedness Program (EPRP) operates as a first line of defense to prevent, protect against, quickly respond to, and recover from health emergencies, including natural, biological, chemical and radiological incidents. EPRP also provides strategic direction, support, and coordination for LACDPH preparedness and emergency response activities. As a part of its emergency planning, EPRP is responsible for mass prophylaxis planning and would therefore be required to prophylax up to 12 million people within 48 hours of a biological attack. Given the geographic size of the County, the number of PODs required, the number of staff and security requirements EPRP choose to explore various possibilities of supplementing it’s staffing during a Public Health Emergency requiring mass prophylaxis. EPRP thus became the primary facilitator of the development of an all volunteer POD staffing model.
The major stakeholders in this practice are community based organizations, faith based organizations, non governmental organizations, local CERT teams, and community coalitions. LACDPH has organized several such organizations as a part of its Public Health Emergency Volunteer network. During the planning phase their volunteers are required to actively participate in seminars, conferences and hands on POD exercises. During the implementation their volunteers that have completed the trainings are deployed to staff the all volunteer POD.
Given that Los Angeles County has experienced numerous emergencies/disasters, ranging from earthquakes and fires to civil unrest, and more recently the Pandemic H1N1. The Emergency Preparedness and Response Program (EPRP) was established to ensure that the county is sufficiently prepared to prevent and mitigate the public health consequences of natural or manmade emergencies for Los Angeles County residents through threat assessment, planning, improved operational readiness, and timely response. With over 10.1 million residents in a county that is 4,089 square miles, the Department of Public Health needs the assistance of the community to prepare and respond to public health emergencies.
The Department of Public Health sponsors MRC Los Angeles, a local unit registered with the Office of Civilian Volunteers Medical Reserve Corps under the Office of the Surgeon General. Under the direction and coordination of the Emergency Preparedness and Response Program, MRC Los Angeles is comprised of medical, health, dental, mental health, and other skilled professionals, organized and trained to assist during public health emergencies. MRC Los Angeles is a member of the Los Angeles County Disaster Healthcare Volunteers (LAC DHV) Collaborative, which is co-chaired by the Department of Public Health and LA County Emergency Medical Services Agency. Members of the LAC DHV Collaborative synergistically works together to uphold and integrate federal standards of National ESAR-VHP and MRC to effectively manage, train, and deploy a volunteer workforce to augment existing local medical and public health systems in response to disasters or public health emergencies.
The purpose of PHEV Network is to increase the coordination and collaboration with established community volunteer units that are willing to assist the Department of Public Health in responding to public health emergencies by creating a system to engage, train, and deploy these groups. The PHEV Network values coordinating efficiently, nurturing collaboration, communicating effectively, and respecting the autonomy of community volunteer units.
Evaluation assesses the value of the practice and the potential worth it has to other LHDs and the populations they serve. It is also an effective means to assess the credibility of the practice. Evaluation helps public health practice maintain standards and improves practice.
Two types of evaluation are process and outcome. Process evaluation assesses the effectiveness of the steps taken to achieve the desired practice outcomes. Outcome evaluation summarizes the results of the practice efforts. Results may be long-term, such as an improvement in health status, or short-term, such as an improvement in knowledge/awareness, a policy change, an increase in numbers reached, etc. Results may be quantitative (empirical data such as percentages or numerical counts) and/or qualitative (e.g., focus group results, in-depth interviews, or anecdotal evidence).
In the boxes provided below, please answer the following:
1)What did you find out? To what extent were your objectives achieved? Please re-state your objectives from the methodology section. 2)Did you evaluate your practice? 2a)List any primary data sources, who collected the data, and how (if applicable) 2b)List any secondary data sources used (if applicable) 2c)List performance measures used. Include process and outcome measures as appropriate. 2d)Describe how results were analyzed 2e)Were any modifications made to the practice as a result of the data findings?
Objective 1. Develop a volunteer workforce to assist LACDPH during a Public Health Emergency Given that Los Angeles County has experienced numerous emergencies/disasters, ranging from earthquakes and fires to civil unrest, and more recently the Pandemic H1N1. The Emergency
Preparedness and Response Program (EPRP) was established to ensure that the county is sufficiently prepared to prevent and mitigate the public health consequences of natural or manmade emergencies for Los Angeles County residents through threat assessment, planning, improved emergencies for Los Angeles County residents through threat assessment, planning, improved operational readiness, and timely response. With over 10.1 million residents in a county that is 4,089
square miles, the Department of Public Health needs the assistance of the community to prepare and respond to public health emergencies. LACDPH therefore sponsored the MRC Los Angeles, a local unit registered with the Office of Civilian Volunteers Medical Reserve Corps under the Office of the Surgeon General. Under the direction and coordination of the Emergency Preparedness and Response Program, MRC Los Angeles is comprised of medical, health, dental, mental health, and other skilled professionals, organized and trained to assist during public health emergencies. In addition, LACDPH also developed the PHEV Network to increase the coordination and collaboration with established community volunteer units that are willing to assist the Department of Public Health in responding to public health emergencies by creating a system to engage, train, and deploy these groups. The PHEV Network values coordinating efficiently, nurturing collaboration, communicating effectively, and respecting the autonomy of community volunteer units. LACDPH believes that there is sufficient stakeholder commitment to sustain the practice of an using an all volunteer POD model. LACDPH currently has 1,407 active volunteers through the Los Angeles Medical Reserve Corp to serve as clinical staff at the POD and 1,600 active volunteers through the Public Health Emergency Volunteer Network to serve as non-clinical staff at the POD. During H1N1, LACDPH operated a 109 PODS over a six week period. Volunteer staffing made up a large component of the staffing at these PODs. In addition, most volunteers recruited by the LAMRC and PHEV actively participate in seminars and conferences hosted by LACDPH. The active participation of volunteers in all events hosted by LACDPH fosters a sense of shared responsibility.
Objective 2. Conduct a POD exercise using an all Volunteer POD Model Starting in 2009 LACDPH began focusing heavily on its Medical Reserve Corp (for clinical staff) as well as the Public Health Emergency Volunteer (PHEV) Network in order to train staff in POD operations. Volunteers were required to participate in regular seminars, conferences and POD exercises organized by LACDPH (funded by the Public Health Emergency Preparedness grant). The long term goal was to eventually organize a POD staffed completely by volunteers from the community and answer one question – can a well trained volunteer force conduct POD operations with minimal supervision? Starting in November 2012, LACDPH has regularly and successfully tested its community volunteer run PODs. Objective 3. Sustain the practice of using an all volunteer POD staffing model as a part of standard operations during a Public Health emergency. LACDPH will continue to recruit volunteers through the
Los Angeles County Medical Reserve Corp (LAMRC) and the Public Health Emergency Volunteer (PHEV) Network. LACDPH will continue to host seminars and conferences to ensure the competence of it’s current volunteer workforce. Finally, LACDPH, like all other Public Health Emergency Preparedness Grantees, must conduct POD exercises on a yearly basis to ensure competence. LACDPH will therefore continue to host influenza PODs using an all volunteer workforce model to
sustain the practice over a period of time.
Sustainability is determined by the availability of adequate resources. In addition, the practice should be designed so that stakeholders are invested in its maintenance and to ensure it is sustained after initial development. (NACCHO acknowledges fiscal crisis may limit the feasibility of a practice’s continuation.)
In the boxes provided below, please answer the following:
1)Lessons learned in relation to practice 2)Lessons learned in relation to partner collaboration (if applicable) 3)Is this practice better than what has been done before? 4)Did you do a cost/benefit analysis? If so, describe 5)Sustainability – is there sufficient stakeholder commitment to sustain the practice? 5a)Describe sustainability plans
LACDPH believes that there is sufficient stakeholder commitment to sustain the practice of an using an all volunteer POD model. LACDPH currently has 3,000 active community volunteers through its MRC and PHEV programs.
During H1N1, LACDPH operated a 109 PODS over a six week period. Volunteer staffing made up a large component of the staffing at these PODs. In addition, most volunteers recruited by the LAMRC and PHEV actively participate in seminars and conferences hosted by LACDPH. Finally, given the success of the LACDPH all volunteer PODs using community volunteers starting in 2012 - LACDPH believes that there is sufficient stakeholder commitment.
The active participation of volunteers in all events hosted by LACDPH fosters a sense of shared responsibility.
Continue to recruit, update skills and finally conduct all volunteer POD exercises regularly.
LACDPH will continue to recruit volunteers through the Los Angeles County Medical Reserve Corp (LAMRC) and the Public Health Emergency Volunteer (PHEV) Network. LACDPH, like all other Public Health Emergency Preparedness Grantees, must conduct POD exercises on a yearly basis to ensure competence. LACDPH will therefore continue to host influenza PODs using an all volunteer workforce model to sustain the practice over a period of time.
In addition, LACDPH is expanding the role of community organizations, as a recruitment tool in themselves. In addition, LACDPH has used volunteer community organizations as a public messaging tool. LACDPH also provides these organizations with liability coverage under declared disasters and exercises.
Please identify the topic area(s) the practice addresses. You may choose up to three public health areas:
Practice Category One:
Emergency Preparedness NACCHO website Model Practices brochure E-Mail from NACCHO I am a previous Model Practices applicant Colleague in my LHD Colleague from another public health agency Conference Are you a previous applicant?:
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