Emergency Management Strategies for Identifying and Integrating Community Resources to Expand Medical Surge Capacity: Role for Health Call Centers

Gregory M Bogdan, PhD - Research Director & Medical Toxicology Coordinator Rocky Mountain Poison & Drug Center – Denver Health - Associate Professor, Dept. Pharmaceutical Sciences University of Colorado Health Sciences Center

Challenges For Healthcare

• Lack of surge capacity in healthcare systems • Information and triage needs of “worried well” and “walking wounded” • Quarantine and isolation to halt spread of disease • Mass prophylaxis or immunization of communities • Pandemic or severe seasonal influenza

Estimates of Influenza Impact

Demands for health resources during a severe influenza outbreak may cripple healthcare systems

Health Outcomes

Fatalities

15% Gross Attack Rate*

87,000

35% Gross Attack Rate*

207,000 Hospitalizations Outpatients Visit 314,400 733,800 18.1 million 42.2 million Self-care Ill 21.3 million 49.7 million * % US population with a clinical case of influenza

Challenges for Preparedness

• 2004 Redefining Readiness Project* – 60% of public would not heed official instructions to get vaccinated during smallpox outbreak – 40% of public would not heed official instructions to shelter in place during a dirty bomb incident • Its not disregard for authority, but the need to obtain additional information from a trusted source that would limit public compliance with these directives

Need to educate, inform and support what the public should do in an emergency

*R. Lasker, Center for the Advancement of Collaborative Strategies in Health

Public Does Rely Upon Call Centers in Emergencies

25 20

Toronto lines received >300,000 calls with daily peak of 47,567 calls (using >200 PH nurses)

15 10 5 0 Florida Meningitis Toronto SARS Trenton Anthrax NYC - WNV Colorado - WNV Certain events (bioterrorism, child-targeted, new emerging disease) will effect the amount of public concern and numbers of people having information or others needs.

How Can Call Centers Help?

Public Health/Safety agencies announce health emergency

Uncontrolled Messages Controlled Messages

Information partners relay accurate, up-to-date, consistent messages and collect data from public Public will initially receive information from the mass media Poison Center Nurse Line Health Hot Line Perhaps up to 25% of the public will have questions which call centers can help with 1 2 3 “Tools” for Call Center Responses

Health Call Centers Reduce Hospital Surges Everyday

• United States Poison Control Centers – Of 2.4 million contacts about potential toxic exposures each year, 1.8 million (75%) are managed outside of health care facilities • Denver Health NurseLine – Manages 40% of callers at home – Study: 70% of callers change their plans after calling (most seek lower intensity of care than originally planned: home > clinic > ED)

Health Emergency Line for the Public (HELP) Model

• • Standardized, prepared response to public health events:  Providing consistent, accurate information  Collecting and maintaining structured data to characterize events and responses (for both sentinel events and situational awareness)  Capability and capacity to adapt to other public health emergencies (using technology & tools) Operating daily since 2003 (7a-10p) and has responded to several major health events in Colorado  Used in annual WNV & influenza responses (>80,000 calls)  Collects data used for situational awareness (influenza, dead animal, emerging disease reports)  Model of poison center/public health partnership

H EALTH E MERGENCY L INE F OR THE P UBLIC GOAL: “Preventing” Patient Surges to Overwhelmed Healthcare Agencies

Hospitals & Healthcare Facilities

Medical Evaluation & Treatment General Public Health Professionals Info Request H E L P Info Delivery Referral of Screened Patients For Triage & Evaluation Health Information Triage & Decision Support Disease Surveillance Quarantine & Isolation Support Outpatient Drug Info & Adverse Events Real-Time Reporting of Collected Epidemiologic Information GOAL: “Redirection” of Contacts from Overwhelmed Health Agencies

Local & State Public Health Agencies

Epidemiologic Surveillance, Investigation & Control Measures, Prophylaxis (Operational Model From an AHRQ Task Order)

HELP’s First Test - 2003

Jul 22: Colorado (4.4 million) confirms 1 st human WNV case, HELP launched just two hours prior • HELP received 12,150 calls (Jul 22 - Oct 11) including >2,500 dead bird reports (5 information providers) • 60% of callers serviced with upfront messaging • As of Oct 30: 47 deaths and 2,543 confirmed cases [Toronto (4.6 million) SARS experience - 44 deaths and 438 SARS cases]

70% 60% 50% 40% 30% 20% 10% 0% Smallpox Flu/Pneumonia West Nile Virus Mold Hantavirus Tuberculosis

Our Experience Shows

• Need for and importance of providing information and support to public (trust) • Surveillance - not the original purpose of line, became an important function (data) • Structured hotline capabilities are an important response component (capacity) • Health call centers can and do serve a vital role in response efforts (ready or not) – Need tools and guidance for large events

Latest AHRQ Task Order

• Develop, implement and test a model to adapt community health call centers to support home management and shelter in-place approaches in certain mass casualty or health emergency events • Determined best DHS scenarios for such strategies

DHS National Planning Scenarios

• • • • • Strategies and tools were developed specifically for 4 of the 15 scenarios: Biological Attack – Aerosol Anthrax Biological Disease Outbreak – Pandemic Influenza Biological Attack – Plague Biological Attack – Food Contamination *Tools have wider applicability and can be modified for other scenarios *Dept of Transportation (EMS/911) and CDC exploring call centers’ roles in pandemics

Response Model & Tools

• HELP Model (strategies & blueprint for structured call center emergency response) • Interactive Response (IR) Tools – Quarantine & Isolation Monitoring (outbound) – Zip Code Specific Messaging (inbound) – Pill Identification/Information (inbound) – FAQ Library (inbound)

Why Quarantine Monitoring?

• Taiwan - 131,132 people in quarantine for SARS (10 to 14 days) • Quarantine included limited travel and health monitoring (primarily with in person home visits, some phone calls) • 99% of those in quarantine did not develop SARS and only needed monitoring • Call center • Periodic checks • Referral to other sources if symptoms develop.

Give info per FAQ’s COHELP Patient list, contact numbers provided by Health Dept IVR System Quarantine Patients Call is answered

Press 1 for English

YES

Press 2 for Spanish

This is the Colorado Help Line. If you need assistance and would like to speak to someone, press 0. If you do not need assistance, press 1 1 0 Thank you. If you need assistance in the future, please call….

Information Provider answers call. How may I help you?

Calls are delivered at random times each day x2 NO First Unsuccessful Attempt Second Unsuccessful Attempt Public Health Notified Request for information Request for assistance or requested information not in FAQ We will call you back in ….

Request goes to Public Health or other appropriate resource per protocols

But Will It Be Acceptable in US?

Harvard School of Public Health Survey revealed that: • 76% favor quarantine of people suspected of having been exposed to a serious contagious disease  29% no longer favor if people are arrested for refusing • 75% favor use of periodic telephone calls to monitor quarantined people (84% favor daily visits)  43% guards, 40% e-bracelets, 31% periodic video screening • 70% prefer they or family member be quarantined at home These factors suggest quarantine monitoring by call centers is good strategy for disease control/containment Blendon RJ et al. Attitudes Toward The Use Of Quarantine In A Public Health Emergency In Four Countries. Health Affairs 2006; 25:w15-w25.

Why this response capability?

   Public health events will continue to occur and will require coordinated responses to protect our healthcare systems Need structured, integrated responses that are:  Cost-effective     Efficient (use of staff and technology) Accurate Consistent Adaptable Health call centers can fill a vital role in providing information, collecting surveillance data and monitoring/supporting home care strategies

Summary

• Health call centers already exist within communities and should be considered/integrated as part of emergency response strategies  Health Call Centers can:  Improve information support for public and providers    Assist with surge capacity Provide surveillance signals, situational data Realize the new Public Health environment  Increase visibility (extend response capabilities outside of Mon to Fri 8 am to 5 pm period, improve access)  Handle evolving info while maintaining control (assist with info management, improve dissemination)  Aid decision support (assist with healthcare utilization)

Further Information

For inquiries regarding presentation: Gregory M. Bogdan, PhD Rocky Mountain Poison & Drug Center – Denver Health 777 Bannock St, Mail Code 0180 Denver CO 80204 303-739-1239 [email protected]

For additional info on AHRQ task orders: “Health Emergency Assistance Line and Triage Hub (HEALTH) Model” www.ahrq.gov/research/health/ “Adapting Community Call Centers for Crisis Support: A Model for Home Based Care and Monitoring” www.ahrq.gov/prep/callcenters/