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Jefferson County Health Just in Time Closed POD Protocol

State: CO Type: Promising Practice Year: 2019

Brief description of LHD- location, demographics of population served in your community.

Jefferson County is located near the center of the state along the Front Range of the Rocky Mountains, adjacent to the state capital of Denver. U.S. census estimates in 2017 identify the population of Jefferson County at 574,613, making it the fourth-most populous county in Colorado. The population includes 25.30% under the age of 18, 8.10% from 18 to 24, 32.10% from 25 to 44, 24.90% from 45 to 64, and 9.60% who were 65 years of age or older. The median income for a family was $67,310. About 3.40% of families and 5.20% of the population were below the poverty line, including 5.80% of those under age 18 and 5.10% of those age 65 or over. 

Describe public health issue:

During a public health emergency requiring large scale dispensing of prophylactic medication or vaccine to prevent illness, JCPH would open public PODs, which are locations where people impacted by the emergency could receive the needed medication or vaccine.  The public health issue addressed by this model practice is providing access to the medication/vaccine for community members who may have a difficult time getting to or navigating the POD environment, as well as the staff of organizations that provide critical services.  

Goals and objectives of the proposed practice: 

To provide access to prophylactic medication/vaccine during a public health emergency to people living in long term care or nursing home environments and people who might have a difficult time accessing needed medication/vaccine at public PODs.

To provide a system for the staff of organizations responsible for critical infrastructure, emergency response, and healthcare services to receive medication/vaccine at their facility during a public health emergency.

How was the practice implemented/activities:

Because this Protocol was developed for use during large scale public health emergencies, and Jefferson County has not experienced such an event since this Protocol was developed, implementation of this practice has been through exercises and trainings established to test the effectiveness and ease of use of the JIT Closed POD Protocol.  The Protocol was tested in an assisted living environment, at an organization that provides critical infrastructure support, at a national Public Health conference, at a statewide Public Health and Healthcare Coalition meeting, and in a JCPH emergency response staff training. 

Results/Outcomes (list process milestones and intended/actual outcomes and impacts):

  • A critical public health need was identified - to provide medication/vaccine to all impacted populations during an emergency event requiring the dispensing of medication/vaccine to prevent illness.
  • A gap in the planning/provision process was identified - the difficulty of certain community members to access those resources at public POD locations.
  • A draft Protocol was developed to address the identified gap.
  • The Protocol was tested in multiple environments.

Were all of the objectives met:

The objective of providing access to prophylactic medication/vaccine during a public health emergency to people living in long term care or nursing home environments, and people who might have a difficult time accessing this medication/vaccine at public PODs, was effectively tested and met the goals of the Protocol. 

The goal of developing a system for organizations responsible for critical infrastructure and healthcare services to receive prophylactic medication/vaccine at their facility during a public health emergency, and to provide that medication/vaccine to their staff, their staff's family members, and their clients, residents, or patients, was also effectively tested and met the goals of the Protocol.

What specific factors led to the success of this practice:

The development of a Protocol that could be activated when an event happens, and includes the documentation, messaging, resource lists, job action sheets, signage, training resources, and instructions needed to quickly implement the dispensing process.

A Protocol that provides for community members who may have difficulty accessing emergency medication/vaccine during a public health emergency to be able to access those resources in a convenient and familiar location, without having to transport to and wait in line at public PODs.

A Protocol that provides a process for maintaining the staff of organizations which provide critical services on the job and providing those services, rather than leaving work to stand in line at a public POD to receive medication/vaccine during a public health emergency. 

Public Health impact of practice.

Because of this model practice, community members, who may have in the past had a difficult time accessing medication/vaccine during a public health emergency, will have the option of accessing those resources directly from facility/staff where they receive other services.

The Protocol will also provide the opportunity for the staff of organizations providing critical services to receive medication/vaccine during a public health emergency, at their place of employment, resulting in those staff members remaining at work and on the job, rather than leaving work to receive medication/vaccine at an open POD.

Website for your program, or LHD:

https://www.jeffco.us/public-health

The JCPH JIT Closed POD Protocol is a practice that is new to the field of public health. 

Statement of the problem/public health issue. 

The Protocol was developed in response to a public health issue involving access to medication/vaccine during a public health emergency by community members who may not be able to get to or navigate a public POD location, as well as the staff working in organizations that provide critical services. 

What target population is affected by problem? What is the target population size?  (please include relevant demographics).

The JIT Closed POD Protocol is a tool that could be used by any organization wanting to provide medication/vaccine directly to their staff, staff's family members, and clients/patients, rather than having their staff leave work to wait in line at an open POD or having their patients/clients unable to access the medication/vaccine because they are unable to wait in line.  Some of the organizations that could benefit from this Protocol in Jefferson County are:

  • Long Term Care facilities/Nursing Home facilities/Residential Care/Home Health agencies - (The number provided below is the number of licensed facilities, there are many more unlicensed.  This resource would benefit both licensed and unlicensed facilities):  215 licensed plus additional unlicensed
  • EMS/Ambulance providers/Hospitals:  14 EMS/Ambulance, 4 Hospitals
  • Municipal agencies (Law Enforcement, Emergency Management, emergency response and critical service agencies, etc.):  12 municipalities
  • Any agency that provides critical services and/or that would be impacted by their staff leaving work to wait in line to receive medication/vaccine (long term care, hospitals, adult day centers, emergency response agencies, detention centers, rehab centers, hospice and dialysis providers, utility services, home health agencies, residential care facilities, etc.).  Or organizations that would prefer to provide medication/vaccine directly to their staff, staff's family members, and clients at their place of employment, this could include colleges and universities, K-12 schools, day care centers, organizations, etc. 

What percentage did you reach? What has been done in the past to address the problem?

Prior to the development of the JIT Closed POD Protocol, JCPH Emergency Preparedness and Response staff met with numerous long-term care and assisted living facilities in Jefferson County to provide the opportunity for those facilities to receive medication/vaccine directly at their facility during a public health emergency requiring the dispensing of prophylaxis to prevent illness.  Although all the facilities expressed interest in the direct receipt/closed POD process, facility staff had limited time to fill out the documentation and receive the needed training, especially when there was no actual emergency currently taking place.  Facility staff emphasized that they would want to receive medication directly at their facility during a public health emergency, though.

Why is the current/proposed practice better? Is current practice innovative? How so/explain?

In response to the interest shown, combined with the time constraints often experienced by healthcare facilities and critical infrastructure organizations, JCPH developed a Protocol that could be activated and implemented when a public health emergency happens, eliminating the need for facilities to invest time prior to an event to fill out paperwork and participate in training.  The Protocol includes all of the information needed for a facility to quickly register to receive medication/vaccine directly at their facility or organization (or for the facility/organization to pick up the medication), and to set up the dispensing area where the facility will provide the medication/vaccine to their staff, their staff's family members, and the facility's clients.  The Protocol provides the information needed to train the staff who will be dispensing/administering the medication/vaccine, it includes the documentation and paperwork needed to receive, track, and return any unused medication, it provides a list of suggested supplies needed, and includes a communication process for asking questions or to request additional supplies/resources.

During a public health emergency requiring the dispensing/administration of medication/vaccine to prevent illness, JCPH is confident that many of the long-term care, nursing home, and other medical and critical infrastructure organizations in Jefferson County will prefer to receive prophylaxis at their place of business rather than waiting in line at a public POD.  The Jefferson County JIT Closed POD Protocol is an innovative practice that provides the resources needed for that process to take place quickly and effectively during a public health emergency. 

The Jefferson County JIT Closed POD Protocol provides numerous improved and innovative benefits including: 

  • It enables health facilities and businesses to register to receive medication/vaccine directly at their place of business when a public health emergency happens, eliminating the need to complete a registration and training process ahead of time;
  • It enables community members who may have a difficult time getting to or navigating a public POD location to receive medication/vaccine quickly and easily at a safe and familiar location;
  • It allows the staff of organizations that provide critical services to remain at work and to receive medication/vaccine needed to prevent illness for themselves and their family members, rather than leaving work to wait in line at a public POD location, potentially resulting in staffing shortages at these critical organizations;
  • By providing a system through which facilities and organizations can provide medication/vaccine directly to their staff, their staff's family members, and their clients/patients, the community members represented by these staff members, family members, and client/patients will receive their medication/vaccine at their facility/place of business rather than at a public POD site, thereby reducing the number of community members accessing medication/vaccine at public PODs, allowing local Public Health agencies to provide emergency medication/vaccine more quickly using fewer resources. 

Is it new to the field of public health?

The Protocol developed by JCPH enabling organizations to register to receive medication/vaccine when a public health emergency happens, and to train their staff, set up their site, track needed data, administer medication/vaccine, and communicate with their local Public Health agency (LPHA) is a unique process and Protocol. 

Is it a creative use of existing tool or practice?

The JCPH JIT Closed POD Protocol builds upon various closed POD principles involving the establishment of Closed POD Agreements with organizations within an LPHA's jurisdiction.  These organizations would receive medication/vaccine from the LPHA during a public health emergency that required the dispensing/administration of medication/vaccine to prevent illness, and these organizations would dispense/administer the medication/vaccine directly to their staff, their staff's family members, and their clients/patients.

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.) 

While the JCPH JIT Closed POD Protocol was developed without intentional use of recognized tools or practices, it is based on years of exercises and plans reviewed by the CDC through the Cities Readiness Initiative. There are several tools in the NACCHO toolkit that contain pieces of information that can be found in the JCPH JIT Closed POD Protocol.

Is the 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.)

While the exact JCPH JIT Closed POD Protocol is not evidence-based on the guidance provided above, similar to most emergency mass dispensing activities, the Protocol is based on evidence from past exercises. As stated in a 2014 article from Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science (Rebmann, 2014), The only existing published literature on closed PODs includes case studies and lessons learned from past exercises.” It was also stated in the same article that, Those with 1 or more closed PODs were more likely to believe

their jurisdiction could distribute medical countermeasures within 48 hours compared to those without a closed POD (78.5% vs 21.5%; X2 = 10.8, p = .001).” Thus, Closed POD planning will allow for JCPH to reach the 48-hour dispensing benchmark set by the CDC and the Rand Corporation.

Goal(s) and objectives of practice

To provide access to prophylactic medication/vaccine during a public health emergency to people living in assisted living or nursing home environments and people who might have a difficult time accessing needed medication/vaccine at public PODs.

To provide a system for the staff of organizations responsible for critical infrastructure and healthcare services to receive medication/vaccine at their facility during a public health emergency.

What did you do to achieve the goals and objectives?  Steps taken to implement the program.  

Because this Protocol was developed for use during large scale public health emergencies, and Jefferson County has not experienced such an event since this Protocol was developed, implementation of this practice has been through exercises and trainings established to test the effectiveness and ease of use of the JIT Closed POD Protocol.  The Protocol was tested in an assisted living environment, at an organization that provides critical infrastructure support, at a national Public Health conference, at a statewide Public Health and Healthcare Coalition meeting, and in a JCPH emergency response staff training.

JCPH will continue to run drills, exercises, and trainings to test and improve the JIT Closed POD Protocol, so that when/if a large scale public health event happens in Jefferson County requiring the dispensing of medication/vaccine to prevent illness, JCPH will be able to quickly and effectively implement the JIT Closed POD Protocol.

Any criteria for who was selected to receive the practice (if applicable)?

The Protocol/practice was first tested in an assisted living community in Jefferson County.  This location was selected because of the community they serve (residents requiring some assistance with activities of daily living and who would likely have difficulty attending an open POD), the commitment of the facility staff to emergency preparedness and response, and because the facility had expressed interest in receiving medication/vaccine during a public health emergency at their facility to administer to their staff, their staff's family members, and their residents.

What was the timeframe for the practice and were other stakeholders involved?

The JCPH Closed POD Protocol was developed in 2016/2017, and continues to be tested and improved through drills, trainings, and exercises.  Through this planning and improvement process, numerous stakeholders have been involved, including assisted living staff and residents, critical infrastructure organizations, local, regional, and state Public Health staff, Healthcare Coalition partners, and JCPH/Jefferson County emergency preparedness and response staff.

What was their role in the planning and implementation process?

For the initial stages of planning and implementation, the primary stakeholders were JCPH LPHA staff and assisted living facility staff and residents, whose roles were to participate in the development of the Protocol, as well as assist with drills, exercises, and trainings to test, evaluate, and refine the parameters of the Protocol.   As the Protocol developed, additional stakeholders were involved in the testing and evaluation process, including critical infrastructure/emergency response partners, local, regional, and state Public Health staff, Healthcare Coalition partners, and JCPH/Jefferson County emergency preparedness and response staff. 

What does the LHD do to foster collaboration with community stakeholders? Describe the relationship(s) and how it furthers the practice goal(s).

JCPH fosters collaboration with community stakeholders through the Metro Foothills and the North Central Region Healthcare Coalitions, through local, regional, state, and national meetings, trainings, and conferences, and through collaborating with response partners and agencies in Jefferson County and the North Central Region on emergency preparedness and response drills, trainings, exercises, and real events.  

Any start up or in-kind costs and funding services associated with this practice? Please provide actual data, if possible. Otherwise, provide an estimate of start-up costs/ budget breakdown.

Estimated costs to the start-up and practice of this project for JCPH would be 0.5 FTE for 6 months. At an average salary, the total cost invested for this project is approximately $25,000 (to include development, training, drills, exercises, and on-going revisions as needed).

What did you find out?

During the pilot test of the Protocol (at an assisted living facility), the development team anticipated the assisted living facility staff and residents to experience some difficulty with understanding and implementing the process, training staff, managing resources and inventory, effectively using and tracking documentation and supplies, and communicating with LPHA staff.  During the evaluation meeting following the pilot test, though, the facility staff and residents said they felt confident setting up and running their POD using only the information provided in the JCPH JIT Closed POD Protocol.  JCPH staff observed the assisted living facility staff setting up their POD, training their staff, receiving and managing inventory, supplies, and documentation, running their POD, and demobilizing the POD and POD staff.  The process took place in an organized, efficient, and professional manner, with no input from JCPH staff who were evaluating the process.

The same results were identified, experienced, and communicated through the evaluation process at additional drills, exercises, and trainings related to the JCPH JIT Closed POD Protocol with regional, state, and Healthcare Coalition partners, with critical infrastructure agency staff, with participants at a national Public Health conference, and with JCPH emergency response staff.

To what extent were your objectives achieved?

The objective of providing access to prophylactic medication/vaccine during a public health emergency to people living in long term care or nursing home environments, and people who might have a difficult time accessing this medication/vaccine at public PODs, was effectively tested and met the goals of the Protocol. 

The goal of developing a system for organizations responsible for critical infrastructure and healthcare services to receive prophylactic medication/vaccine at their facility during a public health emergency, and to provide that medication/vaccine to their staff, their staff's family members, and their clients, residents, or patients, was also effectively tested and met the goals of the Protocol.

Please re-state your objectives.

To provide access to prophylactic medication/vaccine during a public health emergency to people living in long term care or nursing home environments and people who might have a difficult time accessing needed medication/vaccine at public PODs.

To provide a system for the staff of organizations responsible for critical infrastructure and healthcare services to receive medication/vaccine at their facility during a public health emergency.

Did you evaluate your practice?

The JCPH JIT Closed POD Protocol has been tested through multiple drills, exercises, and trainings, all of which were evaluated through a ‘Hot Wash' process, which is the immediate "after-action" discussion and evaluation following a drill, exercise, training, or response to a real event.  A written evaluation form was also disseminated during two of the exercises/trainings, the information collected was reviewed, and the data and recommendations were incorporated into the Protocol revision process.

The questions on the evaluation form were:

  1. Please rate your overall experience running a JCPH Closed POD.
  2. What areas of the JCPH Closed POD Instruction Manual were most helpful?
  3. Were there gaps in the information contained in the Manual that would have helped you to be more successful?
  4. Other than the Manual, were there other processes, tools, or resources that were helpful?  Are there any other processes, tools, or resources that could have been beneficial to have?
  5. Were the forms and documentation you were provided adequate and effective?  Are there any other forms or documentation that would have been beneficial to have? 
  6. Was the communication process between your organization and JCPH effective?  Are there any recommendations you would make to improve the communication process?
  7. Was the process of picking up and returning medication and/or supplies to JCPH effective?  Are there any recommendations you would make to improve this process? 
  8. Are there any other recommendations you would offer to help improve the JCPH Closed POD process in the future?

List any primary data sources, who collected the data, and how? (if applicable)

Data collected during exercises included time of receipt of initial notification email, time to return enrollment form, time to set-up Closed POD location for dispensing, and through-put rates. This data was collected through the HSEEP exercise evaluation process.

List any secondary data sources used. (if applicable)

N/A

List performance measures used. Include process and outcome measures as appropriate.

The CDC has outlined benchmarks for dispensing through the Medical Counter Measures' Operational Readiness Review (MCM ORR) process. These metrics were used as the baseline for comparison of actual numbers obtained.

Describe how results were analyzed.

Results were compared against the benchmark for Open PODs. There was also a qualitative analysis of the comments and feedback obtained through the after-action process.

Were any modifications made to the practice as a result of the data findings?

As a result of the data findings, revisions were made to the JCPH JIT Closed POD Protocol, documentation used for running the POD, Job Action Sheets for the POD staff, the Quick Reference Guides used for training on the Head of Household screening and dispensing process, the supply request process, the Head of Household and medication instruction forms, the Frequently Asked Questions document, and the training Power Point.

Lessons learned in relation to practice.

What we learned in relation to practice is that the Protocol is easy to use, works well, meets the objectives, and fills a response gap for population groups that would generally have a more difficult time waiting in line at an open POD to pick up medication or receive vaccine during a public health emergency (residents in assisted living and nursing home environments and health facilities and the employees of organizations that provide critical services, including law enforcement, medical care providers, fire responders, etc.).

We also learned that people unfamiliar with the Protocol or mass medication dispensing are able to understand the Protocol, order needed supplies, train their staff to fill POD positions, set up the POD site, use the paperwork, track resources, complete the dispensing process, demobilize their POD and staff, and communicate effectively with their LPHA in the process.

Lessons learned in relation to partner collaboration. (if applicable).

While developing and testing the Protocol process, JCPH collaborated with internal, local, regional, state, and national partners to exercise and train on the JCPH JIT Closed POD Protocol.  We learned that this Protocol is a process that many Public Health partners are interested in implementing in their own jurisdictions, and many have requested a copy of the Protocol for use in their agency. 

We learned that the concern during public health emergencies regarding how to meet the needs of residents in assisted living and medical facilities and the staff in organizations that provide critical services, as well as reducing the number of community members seeking medication/vaccine at open PODs, is a common concern among LPHA, and an important planning consideration regarding mass medication/vaccine dispensing.  The partners who have participated in drills, trainings, and exercises testing the Protocol have expressed a desire to implement a similar Protocol in their jurisdiction. 

Did you do a cost/benefit analysis? If so, describe.

JCPH did not perform a cost-benefit analysis for this project.

Is there sufficient stakeholder commitment to sustain the practice?

Yes, JCPH has had great interest from the groups targeted for the JIT Closed POD Protocol. Utilizing the Protocol, we have engaged numerous healthcare coalition partners in discussions on medical counter measure dispensing. The feedback on exercises has been outstanding.

Describe sustainability plans.

JCPH will continue to present the JIT Closed POD Protocol to our partners within the jurisdiction. The Protocol has been added to the annual plan review list and is built into the JCPH Medical Counter Measures' Incident Command System Organization chart. This position will be exercised in 2021 during the state-wide full-scale exercise.

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