Community Health Centers and Emergency Preparedness: An ...

J Community Health (2008) 33:241–247 DOI 10.1007/s10900-008-9093-9

ORIGINAL PAPER

Community Health Centers and Emergency Preparedness: An Assessment of Competencies and Training Needs Elizabeth Ablah Æ Annie M. Tinius Æ Leslie Horn Æ Chris Williams Æ Kristine M. Gebbie

Published online: 1 April 2008 Springer Science+Business Media, LLC 2008

Abstract Community health centers (CHCs) provide care to a large number of medically underserved Americans. As primary care providers and trusted members of their communities, CHCs need to be prepared to respond to emergency and disaster situations, as they may be relied upon for medical care and other support services. Focus groups were conducted with CHC medical directors and administrators from New York City. Participants discussed previous emergency preparedness training, future training needs, applicability of competencies, and usefulness of two training programs. Participants indicated that they had more experience with preparedness training than many of their colleagues, although participants still reported further training needs. In particular, emergency roles and responsibilities, decontamination and containment, and personal preparedness were given as needed training topics for staff. The training resources were reported to be useful and beneficial. Participants also reported that most of the competencies were appropriate for CHC clinicians. During an emergency, people want to receive care from their normal provider, and for many, that provider is a CHC. This and other research suggests that the emergency E. Ablah (&) A. M. Tinius Department of Preventive Medicine and Public Health, University of Kansas School of Medicine—Wichita, 1010 N. Kansas, Wichita, KS 67214, USA e-mail: [email protected] L. Horn K. M. Gebbie Center for Health Policy, Columbia University School of Nursing, 630 West 168th Street, MB6, New York, NY 10032, USA C. Williams Community Health Care Association of New York State, 90 State Street, Suite 805, Albany, NY 12207, USA

preparedness needs facing CHCs are significant and should be addressed. Keywords Community health centers Emergency preparedness Competency Online training

Introduction Community health centers (CHCs) serve an estimated 16,000,000 patients at 5,000 locations throughout the United States, and are a critical part of both ongoing care and emergency response [1–5]. These centers were begun in 1965 as a part of the Johnson administration’s ‘‘War on Poverty,’’ with the goal of providing care to medically underserved populations [1]. Health centers have undergone many changes since then, but the primary purpose remains the same: CHCs provide care for underserved, uninsured, minority, migrant, and low-income populations. In a disaster or crisis situation, most people seek care from their usual healthcare provider, and for many people, that provider is a CHC [6, 7]. After Hurricane Katrina in 2005, CHCs treated thousands of displaced residents from the Gulf region [8]. If CHCs are not prepared for emergencies, they may become unable to provide services to a population in need of help [9]. CHC leadership and staff need to receive effective training in order to be adequately prepared for a wide-variety of situations. However, there is currently very little literature that assesses CHC training needs and examines CHC perceptions of emergency preparedness competencies. This paper discusses the findings from two focus groups with CHC leadership personnel to determine emergency preparedness readiness of CHCs and identify what preparedness needs could be met with training.

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J Community Health (2008) 33:241–247

Methods

Emergency Preparedness Training

Focus group sessions were used to explore the perceptions of community health center leaders about emergency preparedness training. The specific purpose was to discover participants’: (1) previous emergency preparedness training experiences, (2) challenges faced during training and additional training needed, and (3) response to online training modules and clinician competencies. Two focus groups were conducted approximately a year apart; the second focus group was conducted with many of the same participants in order to gather additional details about previously discussed topics. The reported results integrate findings from the two focus groups.

Regarding emergency preparedness training, participants reported they had ‘‘a good deal’’ of training. The training they had received was based on a ‘‘collaborative learning model,’’ a 6-month intensive training program that offered guidance in developing a comprehensive emergency preparedness plan. Participants explained:

Participants The first focus group consisted of eight participants and the second, seven participants, all of whom were either administrators or medical directors at community health centers in New York State. Participants were recruited through the Community Health Care Association of New York State (CHCANYS) and were members of the CHCANYS Emergency Preparedness Advisory Committee. Instruments and Procedures Focus group scripts, based on literature reviews and training needs assessment templates, were developed to direct the conversation. In addition, at key points during the discussion, participants were provided with documents describing competencies in emergency preparedness and available preparedness courses, as a stimulus to identifying perceptions about training needs and resources. These documents are described below with the discussion results. The groups were conducted by a facilitator from the University of Kansas School of Medicine—Wichita (KUSM-W). Focus groups were held in New York City in 2006 and 2007. The focus group sessions were audiorecorded, transcribed, and reviewed for key themes that emerged from participants’ responses. The project was approved by the Human Subjects Committee at KUSM-W.

Results Demographics Focus group participants reported being employed in administrative healthcare roles, but some also had active patient practices. Most had at least several years of service at a CHC, and all had clinical experience. Most participants represented large, urban CHCs.

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‘‘[The collaborative training] went step by step, developing an emergency plan, from doing your hazardous vulnerability assessment to making sure you know how to handle bomb threats..., making this plan fit your organization, fit your community… What do you do if a bomb explodes inside your building? What if it floods? Every ‘what if’ that you could possibly imagine based on your hazardous vulnerability assessment.’’ One participant reported having an immediate need for the skills gained from the emergency preparedness training. During the first week of the 6-month training, an explosion occurred outside of his building and caused the center to lose electricity. The participant had been grateful for the training, reporting that the experience highlighted the necessity of emergency preparedness planning and identified areas for improvement. Despite their considerable emergency preparedness training, participants indicated that the amount of emergency preparedness training received by their New York colleagues based outside of Manhattan varied considerably. Participants believed that their own amount of training was unusually sophisticated, and reported that most community health centers across the country did not have preparedness plans and very few of the CHC leaders had gone through similar intensive training courses. Challenges and Needs for Training Staff Following the collaborative training, participants established preparedness plans within their organizations and began training their staff accordingly. Focus group participants reported that the staff training process had been ‘‘overwhelming’’ and ‘‘time-consuming,’’ requiring implementation in multiple segments. Furthermore, many participants reported that many of their staff had not had previous hospital experience, limiting their comfort with emergency response: ‘‘Community health center staff didn’t have the hospital background, so the instinct for emergency is not there and that’s what we’re finding...When you don’t have the instinct, you have to teach that along with the [emergency preparedness] information.’’


To overcome this, participants reported needing to repeat training until the procedures seemed more natural to the staff. Focus group participants discussed the need for emergency preparedness training for contract employees who perform necessary functions for CHCs: ‘‘This [training] is not just for frontline [employees], but you need security and you need the facilities [staff].’’ Participants reported that having trained security guards and cleaning personnel would be necessary in several different emergency situations, such as bomb threats or contamination by a hazardous or infectious agent. However, training these workers presented additional challenges due to their varying levels of education and experience; additionally, these workers tended to be employed by other agencies, and were not actually CHC staff. Participants discussed previously utilized methods of staff training. Interactive drills were reportedly important and useful. Although it takes time to create them, games and prizes ‘‘work really well to motivate people.’’ Creativity and development of a culture of personal responsibility were cited as important elements of training. Further, participants reported that CHCANYS was developing a flipchart or ‘‘cheat sheet’’ for quick access to phone numbers and information, and participants considered this to be a valuable resource for all CHC staff training. The flipchart would have replaceable cards, a pocket for a resource CD, and would possibly include ‘‘memory sticks’’ containing information retrievable on a personal data assistant (PDA), which participants reported would be useful in a power outage. Needed Training Topics Participants identified topics that CHC staff emergency preparedness training must include. Topics included: CHC and individuals’ roles and responsibilities, decontamination and containment, and personal preparedness. First, participants agreed that all CHC staff must understand what their roles are in emergencies: ‘‘[Knowing one’s role] is so key... That is what folks really care about, what is my role in an emergency, what do I need to know.’’ While a person’s role may be particular to their specific CHC, participants suggested that the training curriculum could ‘‘describe possible roles’’ and ‘‘bring awareness to the person to find out ‘what is my role.’’’ Emphasizing the relevance of the topic, participants indicated that staff may not know they have a role and would not inquire about it if not discussed in training.

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Another training topic important to participants was decontamination: ‘‘Once you identified an infected patient and has been so diagnosed, how do you clean the environment so that the next person that is in the examination room is not at risk for that infection?’’ Another participant pointed out that decontamination of the environment is not limited to the examination room, and this fact needs to be addressed in training: ‘‘Not just the room, everything, following the path of the patient… move their way through, use the bathroom, use the water fountain, touch all the doorknobs, you know, and make some effort to see exactly where he could go.’’ Closely related to the issue of decontamination was recognition and isolation of possibly infected and contagious patients, or as stated by one participant, ‘‘How to identify a potential infectious patient coming into the center, how to properly give the patient a mask, and also put a mask on you if you come in contact with the patient.’’ Participants acknowledged that certain patients must be isolated, but often this does not occur early enough. Participants suggested that training receptionists or security teams to recognize certain symptoms would allow for patients to be isolated more quickly and possibly limit the spread of infection. Further, participants discussed the importance of personal preparedness, or ‘‘how to protect yourself and your family in an emergency.’’ Participants believed that every CHC staff member needed to have a home preparedness plan and a go-bag with items that may be necessary in a disaster, such as extra cash, bottled water, non-perishable food, a battery-operated radio, and a first aid kit. One participant reported that this topic has been addressed in staff training, but with limited success: ‘‘Our staff is afraid to be prepared. They don’t want to think about it.’’ Response to Emergency Preparedness Competencies Focus group participants were given a list of competencies developed for all clinicians who treat, triage, or communicate with patients, and were asked to identify which of these competencies were applicable to CHC clinicians. This list of competencies was developed by the Association for Prevention Teaching and Research (formerly the Association of Teachers of Preventive Medicine) in collaboration with the Center for Health Policy at Columbia University School of Nursing and consists of 11 tasks that a

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competent clinician would be able to perform in an emergency response situation [10]. Participants indicated that most of the emergency preparedness competencies for clinicians may be adapted or applied to CHC staff who treat or triage patients. Some competencies were seen to be particularly important; for example, the first competency, ‘‘Describe one’s expected role in emergency response as a part of the institution or community response,’’ was perceived to be: ‘‘So key. I mean, to me [this competency] is like the number one importance. That is what the folks really care about—what is my role in an emergency, what do I need to know.’’ However, participants indicated that competencies 8, 9, and 11 were not as likely to be necessary in the CHC setting, and these three competencies could be omitted from a list prepared specifically for CHC staff. Regarding competency 11, ‘‘Participate in post-event feedback and assessment of response with the local public health system and take needed steps to improve future response,’’ one participant indicated, ‘‘I haven’t seen that one implemented in any way.’’ Additionally, participants also indicated that competencies 2 and 6, which refer to responding to emergency events and initiating patient care, were somewhat broad and needed to be limited to an individual’s own health center and scope of practice. The participants’ updated list of competencies targeted specifically for CHC staff can be found in Table 1.

Response to Online Training Materials Participants were provided paper copies of online, interactive emergency preparedness training modules available online through the New York Consortium for Emergency Preparedness Continuing Education (NYCEPCE) and the State University of New York (SUNY) Albany School of Public Health [11, 12]. The six modules address: the basics, biological incidents, chemical incidents, radiological incidents, explosive incidents, and incidents affecting children. The modules are interactive and provide feedback on the appropriateness of the user’s answers. Participants were also shown preliminary models of an interactive simulation program, Hospital Emergency Response Exercises (HERE), which depicts emergency scenarios and is available on DVD from NYCEPCE. The HERE simulation is adapted according to the discipline chosen by the user, including physician, physician assistant, nurse, nurse leader, dentist, or pharmacist. The simulation provides immediate feedback to users through a ‘‘decision meter,’’ which changes colors according to the appropriateness of the user’s choices, and also through written explanations given after every user response. Focus group participants were asked to discuss the usefulness of these training tools. In general, they liked the instant interactive nature of both the modules and the HERE simulation. The ‘‘decision meter’’ used in the simulation was viewed positively because it provided immediate feedback and added interest, increasing staff

Table 1 Participants’ adaptation of competencies for CHC workers A clinician in an initial assessment and decision-making role must be able to do the following: 1.

Describe your expected role in emergency response in the specific practice setting as part of the institution or community response.

2.

Respond to an emergency event within the incident or emergency management system of the practice.

3.

Recognize an illness or injury as potentially resulting from exposure to a biologic, chemical or radiologic agent possibly associated with a terrorist event.

a.

Recognize uncommon presentations of common diseases and distinguish these from common presentations of uncommon diseases that may be related to a terrorist event or emerging infectious disease.

b.

Recognize emerging patterns or clusters of unusual presentations.

4.

Institute appropriate steps to limit spread, including infection control measures, decontamination techniques, and use of appropriate personal protective equipment.

5.

Report identified cases or events to the public health system to facilitate surveillance and investigation using the established institutional or local communication protocol.

6.

Initiate patient care within your professional scope of practice.

7.

Use reliable information sources (e.g., infection control department, state or local public health agency, Centers for Disease Control and Prevention) for current referral and management guidelines.

8.

[Participants rejected.]

9.

[Participants rejected.]

10. Identify and manage the expected stress/anxiety associated with emergency events, making referrals for mental health services if needed. 11. [Participants rejected.]

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buy-in. Participants said they could use the modules and the simulation for new staff orientation, as a permanent resource in the staff training center, or at the beginning of training sessions as staff arrive. Participants said this training was needed and could be used with several types of staff positions within the community health center. Additional topics for training that could be provided online were discussed. Examples included topics such as whom to contact in an emergency, how to recognize diseases and when to report them, recognition of one’s personal limitations and when to ask for help, and whether an emergency calls for evacuation. One participant elaborated: ‘‘I think the one thing that is missing here is being able to identify people or sources of information, being able to collaborate. ... ‘‘[It is important] that they know what to do when they are out of their league. I think one of the biggest things is that people panic, and people think they can do it all.’’ Although most feedback was positive, some participants also expressed concerns about the format of the modules. One reported concern was that online testing does not allow for human interaction or feedback. Another concern was that online testing may be unfair to trainees who understand and can apply the material, but do not test well. Participants agreed that the online modules must not replace drills or the types of hands-on experiences that create the ‘‘reflexes and pathways’’ necessary to respond to real patients. One participant commented that using the modules for training and as a way to measure competence ‘‘would save us a lot of time,’’ while acknowledging ‘‘that there is value in the human interaction and observation’’ even though it is ‘‘more time-consuming.’’ The consensus opinion was that online exercises and live drills are both valuable and need to be used to supplement each other. Post-tests and evaluations are available to users who wish to receive continuing education credit, or the module can be completed alone or can simply be used a resource. Participants also wanted a way to obtain certification after completion of the module, or a way to measure attainment of a competency. One participant referred to Advanced Cardiac Life Support testing, which began online recertification within the past year, as a model. Participants reported that the modules would save time and would standardize training and certification, especially regarding clinical competencies: ‘‘I think what you’re building here... is a standardized way of assessing competency, which is what we’re lacking... Clinical competency is really hard to assess. We rely on testimonials of competency in the medical field, but this [module format] is very clear. You could use it.’’

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Discussion During a disaster or emergency, people seek care where they have received care before. When given a choice about where to receive information or care following a bioterrorism event, the majority of patients prefer to contact their own physician over an emergency room [6, 7]. CHCs serve as primary care providers for an increasing number of Americans, and as such, may also be expected by those people to perform vital services in emergency and disaster situations. Focus group participants recognized this, saying that in an emergency, ‘‘People are going to go to where they get their health care, to where they feel comfortable... They are going to run to their practitioner first as opposed to going to a hospital.’’ Focus group participants also believed that CHCs are seen as ‘‘resources for information…[and] a communication area too,’’ yet many CHCs are not well prepared for emergencies or well connected to their local health department. A survey of Florida CHC administrators revealed that very few administrators (36%) had addressed issues such as decontamination of patients exposed to biological or chemical agents, and even fewer (31%) had addressed involvement of law enforcement or security in an emergency involving the centers’ facilities [7]. Furthermore, the Florida survey also found that the greatest need facing centers is in training personnel, with 80% of responding administrators reporting this need as their highest priority [7]. These survey responses support the results of these focus groups, which also indicated that staff training is an extremely important, although potentially time-consuming, task. Even among the focus group participants, who indicated that they have had an unusually high level of preparedness training, personnel training, decontamination of patients, and utilization of security were seen as vital training needs. This suggests that the needs among less-prepared CHCs may be even greater. In order to further the emergency preparedness of CHCs, identification of competencies and development of useful training resources are crucial. Having an accepted list of emergency response competencies will aid in developing and evaluating standardized training programs for CHC staff [13, 14]. Although emergency preparedness competencies for healthcare workers exist, CHC-specific competencies aid in meeting and evaluating individual performance expectations [15–17]. Emergency preparedness competencies have been developed for many other specific health professionals, such as nurses and public health workers, but institutionally oriented CHC emergency preparedness competencies have often been overlooked [18]. Because CHCs respond to disasters and

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emergencies, clarification of applicable competencies (and if need be, addition of new competencies) is an important step in emergency preparedness for this response group. Innovative training methods such as the online modules and HERE simulation specifically address needed issues and may be helpful in relieving the burden of training for less-prepared CHCs. For example, participants indicated that staff training could be overwhelming, and developing an interesting and interactive curriculum required a considerable amount of time. However, the modules and simulation were perceived to be engaging and easy to use. Participants also requested a means of assessing individuals’ competence, and several participants reported the modules could be utilized for that purpose. Participants also identified personal preparedness as a needed training topic. Other studies have found that in some disaster situations, significant percentages of healthcare workers may not report for work, primarily due to care-giving conflicts or concern about the safety of their families [19, 20]. Providing training regarding personal preparedness, including preparing alternative child or elder care, is an important aspect of overall preparedness for CHC. The Basics module and the HERE simulation both present information on this topic and could be used to introduce the importance of personal preparedness to CHC staff.


welcome. In particular, participants responded positively to online, interactive training modules and indicated that these modules could be valuable and time-saving, supplementing hands-on drills and exercises. Furthermore, participants identified areas in which more training would be beneficial, including explaining staff and CHC roles and responsibilities, decontamination and containment, and personal, at-home preparedness. Increased emergency preparedness training for CHCs is necessary to protect the millions of Americans who receive their healthcare from a CHC, as well as those CHC employees, both clinical and otherwise, who are dedicated to providing affordable care services, including emergency and disaster response services, to medically underserved populations. However, very little literature examines the topic of CHC emergency preparedness. Due to the paucity of research, this study serves as a first step in understanding the needs of this overlooked emergency response group. In light of the role that CHCs played in the response to Hurricane Katrina, and considering the current trend to better incorporate public health and healthcare providers into the national first response capability overall, it is clear that CHCs must be better prepared to serve as frontline emergency responders in the fields of public health and healthcare.

Limitations References Although this study was limited by number of participants, the participants were representative of typical New York City community health centers, and were not markedly different from administrators and directors at other centers. The results of the focus groups might be limited to CHCs in New York State, with an emphasis on New York City, and might not precisely reflect needs of other areas. Although CHC leadership in New York City had already received considerable training, they found these modules to be incredibly needed, time-efficient and innovative, suggesting that less-prepared and less-trained CHCs could benefit from the emergency preparedness training modules and simulation as well.

Conclusions Focus group participants reported having received emergency preparedness training but suggested that their experiences were not typical of community health center leaders, especially outside of New York City. Furthermore, the responsibility of training their health center staff had required a considerable amount of leaderships’ time and creativity, so focus group participants indicated that easy-to-use training modules and simulations would be

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