A Public Health Hazard Mitigation Planning Process Jennifer M. Griffith, DrPH, MPH; S. Kay Carpender, BS; Jill Artzberger Crouch, MPH; Barbara J. Quiram, PhD rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr
Introduction: The Texas A&M Health Science Center School of Rural Public Health, a member of the Training and Education Collaborative System Preparedness and Emergency Response Learning Center (TECS-PERLC)*, has long-standing partnerships with 2 Health Service Regions (Regions) in Texas. TECS-PERLC was contracted by these Regions to address 2 challenges identified in meeting requirements outlined by the Risk-Based Funding Project. First, within Metropolitan Statistical Areas, there is not a formal authoritative structure. Second, preexisting tools and processes did not adequately satisfy requirements to assess public health, medical, and mental health needs and link mitigation strategies to the Public Health Preparedness Capabilities, which provide guidance to prepare for, respond to, and recover from public health incidents. Methods: TECS-PERLC, with its partners, developed a framework to interpret and apply results from the Texas Public Health Risk Assessment Tool (TxPHRAT). The 3-phase community engagement-based TxPHRAT Mitigation Planning Process (Mitigation Planning Process) and associated tools facilitated the development of mitigation plans. Tools included (1) profiles interpreting TxPHRAT results and identifying, ranking, and prioritizing hazards and capability gaps; (2) a catalog of intervention strategies and activities linked to hazards and capabilities; and (3) a template to plan, evaluate, and report mitigation planning efforts. Outcomes: The Mitigation Planning Process provided a framework for Regions to successfully address all funding requirements. TECS-PERLC developed more than 60 profiles, cataloged and linked 195 intervention strategies, and developed a template resulting in 20 submitted mitigation plans. Discussion: A public health–focused, community engagement–based mitigation planning process was
J Public Health Management Practice, 2014, 20(5), S69–S75 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
developed by TECS-PERLC and successfully implemented by the Regions. The outcomes met all requirements and reinforce the effectiveness of academic practice partnerships and importance of community engagement in mitigation planning. Next Steps: Additional funding has been approved to expand the Mitigation Planning Process to all counties in Texas with local health departments.
Author Affiliations: Training and Education Collaborative System Preparedness and Emergency Response Learning Center (Drs Griffith and Quiram and Mss Carpender and Crouch), Office of Special Programs (Drs Griffith and Quiram), and Department of Health Policy and Management (Drs Griffith and Quiram and Ms Crouch), Texas A&M Health Science Center School of Rural Public Health, College Station. This work was supported, in part, by a Preparedness and Emergency Response Learning Center grant from the Centers for Disease Control and Prevention (CDC), under FOA CDC-RFA-TP10-1001, to the Texas A&M Health Science Center School of Rural Public Health, grant U90TP000408, and contracts with the Texas Department of State Health Services Health Service Region 2/3 and Health Service Region 6/5S, contracts 2012-040772 and 2012-041926, respectively. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or Texas Department of State Health Services Health Service Regions 2/3 and 6/5S. TECS-PERLC acknowledges its partners at the state, regional, and local levels for their contributions during the course of work with the Texas Public Health Risk Assessment Tool: Bruce Clements, MPH, Director, Community Preparedness Section, Texas Department of State Health Services, Division of Regional and Local Health Services; Michael Felan, Program Specialist, Texas Department of State Health Services Health Service Region 2/3, Community Preparedness Section; Jennifer Kiger, MPH, Regional Public Health Preparedness Manager, Texas Department of State Health Services Health Service Region 6/5S; John Fleming, Senior Planner with the Bureau of Public Health Preparedness, Office of Surveillance and Public Health Preparedness, Houston Department of Health and Human Services. The authors declare no conflicts of interest. Correspondence: Jennifer M. Griffith, DrPH, MPH, Office of Special Programs, School of Rural Public Health, Texas A&M Health Science Center, MS 1266, 302 Administration Bldg, College Station, TX 77843 ([email protected]). DOI: 10.1097/PHH.0000000000000064 *The PERLC program is designed to address the preparedness and response training and education needs of the public health workforce. Supported by Federal funding (2010 to date), the program includes 14 centers in Council on Education for Public Health accredited Schools of Public Health. For additional information, see www.cdc.gov/phpr/perlc factsheet.htm.
S69 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S70 ❘ Journal of Public Health Management and Practice KEY WORDS: hazard risk, mitigation planning, public health, risk
assessment
The Training and Education Collaborative System Preparedness and Emergency Response Learning Center (TECS-PERLC) is a collaboration of the 3 schools of public health in Texas. The common goal is to increase capacity for community resilience through community engagement by providing planning, training, and exercise assistance to the public health workforce. The Texas A&M Health Science Center School of Rural Public Health serves as the PERLC grantee and collaborates with its partners in South Dakota and Texas. In Texas, counties are permitted, but not required, to provide public health services. If counties do not elect to perform public health functions, the Texas Department of State Health Services (DSHS) fills these service gaps. The DSHS divides the 254 counties in Texas into 8 geographic regions; 59 of the 254 counties have local health departments (LHDs) operating under a Local Public Health Contract with the DSHS. These LHDs provide preventive, protective, regulatory, and preparedness functions to 82% of the Texas population. For the remaining counties and population, DSHS Health Service Regions (Regions) fill the role of an LHD, providing essential public health services, including preparing for, responding to, and recovering from a public health emergency.1,2 Texas DSHS Regions 2/3 and 6/5S were awarded Risk-Based Funding as part of the 2011 Centers for Disease Control and Prevention (CDC) Public Health Preparedness Cooperative Agreement.3 Both regions had existing partnerships with the Texas A&M Health Science Center School of Rural Public Health. These existing partnerships allowed TECS-PERLC to serve in multiple capacities for both Regions, as well as engage TECS-PERLC resources and expertise to respond to state-level requests during the course of the 2-year Risk-Based Funding Project.
● Background The Division of State and Local Readiness at the CDC awarded funds for the Risk-Based Funding Project to systematically identify hazard risks and engage in mitigation planning activities at the Metropolitan Statistical Area (MSA) level.3 Metropolitan Statistical Areas are geographical areas defined by the US Office of Management and Budget and used for statistical purposes.4 Funded pilot sites were required to
develop risk mitigation plans to specifically address the public health, medical, and mental health needs of the community, including vulnerable populations; develop a matrix that describes and ranks/prioritizes the public health threats and risks within the jurisdiction; identify the specific public health threats and risks that will be addressed with this funding; and propose strategies and activities designed to reduce/mitigate the threats and risks.3(p62)
The principal goal of Risk-Based Funding was to link mitigation strategies to the 15 Public Health Preparedness Capabilities (Capabilities) released by the CDC in March 2011 and more specifically the Community Preparedness Capability.3 These Capabilities were developed to assist state, regional, and LHDs address preparedness challenges related to identifying public health preparedness priorities and serve as national standards and guidance “to better organize their work, plan their priorities, and decide which capabilities they have resources to build or sustain.”5(¶3) The Texas A&M component of TECS-PERLC was asked to participate in the development and testing of a Texas-specific public health risk assessment tool. In addition, Regions 2/3 and 6/5S, representing Dallas and Houston, respectively, contracted with Texas A&M to develop translational materials to assist state, regional, and LHDs and local jurisdictions with public health mitigation planning.
Tool development committee Preexisting tools and processes did not meet project requirements to assess public health, medical, and mental health needs and to link strategies to the Capabilities. To address these requirements, a team of stakeholders from state, regional, and local public health; emergency management; homeland security; health care systems; mental health services; and academia worked in partnership to develop an assessment tool. This tool was designed to efficiently and effectively function for small, medium, and large jurisdictions; assess and rank 41 hazards; account for mitigation factors based on the Capabilities; specify the impact of hazards; and be used for public health preparedness strategic planning. The Texas DSHS developed and released version 1.1 of the Texas Public Health Risk Assessment Tool (TxPHRAT) in March 2012, providing a system for gathering data elements required to meet Risk-Based Funding Project requirements. TECS-PERLC participated in the TxPHRAT development process by providing feedback on interface, data entry, results, and outputs. To ensure data entered into TxPHRAT yielded the expected results, it was necessary to have a clear understanding of formulas and calculations used in the tool. TECS-PERLC partnered with tool developers to create a guide that explained
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A Public Health Hazard Mitigation Planning Process
the formulas and calculations in the tool. The resulting Color-Coded Guide to Formulas and Computations in the Texas Public Health Risk Assessment Tool6 provided transparency for results calculated by TxPHRAT and addressed the need to translate results to broader stakeholder groups.
Addressing requirements of Risk-Based Funding While TxPHRAT was being developed at the state level, TECS-PERLC met with partners in the Dallas and Houston MSAs to discuss Risk-Based Funding Project goals, objectives, and deliverables at the regional level. The results from TxPHRAT were the initial step in the broader planning process, with the overall goal to improve the ability for communities to prepare for, respond to, and recover from public health incidents through increased public health awareness and community engagement, that is, mitigation planning. Two challenges were identified in achieving this goal. First, a formal authoritative structure did not exist within an MSA. With no responsible or decisionmaking entity to guide and approve planning efforts, LHD representatives within each MSA identified and selected their Regions as project lead to address this challenge. To broaden the mitigation planning process, additional counties within the Regions, but not part of the MSA, were included in the planning process by using discretionary funding awarded by the state. The second challenge was the lack of a formal public health mitigation planning process using TxPHRAT results. To address this challenge, TECS-PERLC adapted Federal Emergency Management Agency’s Local Mitigation Plan Review Guide’s Regulation Checklist to create an overall community engagement–based process to develop public health risk mitigation plans. Elements adapted for use included the planning process, hazard identification and risk assessment, mitigation strategy, and implementation.7 The adaptation process resulted in the TxPHRAT Mitigation Planning Process (Mitigation Planning Process), including County Profiles, the Intervention Strategies and Activities Document (Strategies Document), and the Mitigation Planning and Reporting Template. These tools were developed to facilitate the interpretation and application of TxPHRAT results to initiate mitigation planning through community engagement and are described in the “Methods” section.
● Methods More than 60 counties were engaged in this project, including counties without LHDs. All counties assessed the 64 functions aligned with the 15 Capabilities and
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the availability of resources required to respond to each of 41 hazards included in the tool. Each county or region entered assessment data into the tool to generate county-level TxPHRAT results. TxPHRAT results identified top public health hazards on the basis of hazard and residual risk scores, capability gaps, and resource gaps for each county. However, LHDs needed assistance engaging broader stakeholder groups, such as county judges, emergency managers, law enforcement, and hospital representatives, in mitigation planning efforts. As an academic practice partner, TECS-PERLC collaborated with the 2 Regions to develop the Mitigation Planning Process. The logic model for the Mitigation Planning Process (Figure), created using the CDC Program Evaluation Logic Model Framework (CDC Framework),8 illustrates the interrelated phases of the process and their connection to the long-term, overall goal of improving community ability to prepare for, respond to, and recover from public health incidents. The Mitigation Planning Process logic model demonstrates how this community engagement–based process moves beyond assessment into mitigation and relies on outcomes from each phase to address Risk-Based Funding Project requirements.
Phase 1 The first phase of the Mitigation Planning Process used TxPHRAT results and stakeholder feedback to create County and Regional Profiles. These Profiles included 4 primary outputs of TxPHRAT: hazard risk scores; residual risk scores; capability gaps; and resource gaps. The Profiles also ranked and prioritized risk scores, capability gaps, and resource gaps. To meet preferences of various stakeholders in using and applying results, a combination of narrative, tables, and figures were used to present outputs. Regions were required to identify top hazards and capability gaps at the regional level. TxPHRAT results were generated at the county level, and there was concern that averaging scores would mask differences at the county level. TECS-PERLC developed a ranking strategy to identify top hazards and capability gaps at the regional level to address this concern. County and Regional Profiles were the short-term outcome of the first phase of the Mitigation Planning Process (Figure). This outcome initiated phase 2 of the process by identifying specific hazards and capability gaps for mitigation planning efforts.
Phase 2 The second phase of the Mitigation Planning Process linked Profile results to intervention strategies
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S72 ❘ Journal of Public Health Management and Practice FIGURE ● TxPHRAT Mitigation Planning Process Logic Model
qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Abbreviation: TxPHRAT, Texas Public Health Risk Assessment Tool.
designed to mitigate hazards and address capability gaps. Public health and emergency management mitigation strategies were collected and reviewed for their applicability to all the Capabilities and hazards. Strategies included approaches to mitigation activities that would supplement the use of traditional public health response assets, equipment, and supplies. Sources included, but were not limited to, academic practice partners, professional organizations, nonprofit organizations, state health departments, regional health departments, LHDs, local jurisdictions, federal agencies, and peer-reviewed literature. All cataloged strategies could be linked directly to the Community Preparedness Capability. Strategies were also assessed for attributes linking them directly to supporting functions of the remaining 14 Capabilities. If a strategy supported the functions of 1 or more of the additional Capabilities, it was linked to the corresponding Capability or Capabilities. Strategies were then assessed for applicability to each hazard on the basis of the original intent and potential for expansion to other hazards. Applicable strategies were compiled into the Strategies Document. The Strategies Document served as a single resource for stakeholders to use in the mitigation planning
process. This resource allowed clickable search and navigation based on a hazard or a capability. The user-friendly format provided stakeholders a tool to easily search for strategies based on prioritized hazards or capability gaps. Once strategies were identified, stakeholders began tailoring them to target hazards or capabilities in preparation for implementation, initiating phase 3 of the Mitigation Planning Process.
Phase 3 The final phase of the Mitigation Planning Process included a template to document details of the select strategy: description; goals and outcomes; objectives; partners; needed resources, including anticipated and actual costs; funding sources; action steps; evidence of completion; applicable capabilities; applicable hazards; notes and considerations; barriers and challenges encountered; and best practices. A logic model, based on the CDC Framework,8 was also provided as part of the template and included instructions on which details from the narrative should be transposed to the visual framework. A completed template provided a single document to plan, implement, evaluate, and report on an activity.
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A Public Health Hazard Mitigation Planning Process
TxPHRAT Mitigation Planning Process training TECS-PERLC conducted 2 face-to-face trainings, one in each Region, to introduce the Mitigation Planning Process and train stakeholders on the use and application of the tools. Each session introduced stakeholders to their County Profile and TxPHRAT results, demonstrated the use of the Strategies Document, and engaged county stakeholder groups in the use of the logic model section of the Mitigation Planning and Reporting Template. Training objectives included the following: describe Profile components; identify relationships of data Profiles to TxPHRAT; translate the meaning of different graphs, tables, and figures in Profiles; explain layout and function of the Strategies Document; apply search process to identify strategies for prioritized hazards and capability gaps using the Strategies Document; and create a draft logic model for a selected strategy. An online version of the training was also developed to provide stakeholders continued access and guidance on the Mitigation Planning Process and appropriate use of the tools.
● Outcomes The Regions contracted with TECS-PERLC to develop a public health–focused mitigation planning process. TECS-PERLC, in collaboration with its state and regional partners, developed a systematic framework to meet requirements of the Risk-Based Funding Project. Using proven community engagement strategies,9-12 stakeholders from MSA counties were able to select leadership and establish project charters. Groups were able to partner effectively to use resources, reach consensus, and receive local approval to implement regional activities. Furthermore, the Mitigation Planning Process included a framework and tools to move beyond assessment into planning and implementation of mitigation efforts. Each step of the Mitigation Planning Process and the accompanying tools directly linked to and addressed requirements of the Risk-Based Funding Project. To address the requirement of identifying, ranking, and prioritizing hazards and risks, TECS-PERLC created more than 60 County Profiles, using output from TxPHRAT. In addition, variations of regional profiles were created to report outputs for groups of counties representing each of the Regions and MSAs. TECS-PERLC cataloged 195 strategies; of these, 99 were linked to all 41 hazards and 23 were linked to a single hazard. In addition, most strategies were linked to a single capability (63%) (Table). The Strategies Document provided a bridge between County/Regional
TABLE ● Capabilities and TxPHRAT Hazards and Number of Linked Strategies qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Capability/Hazard Community preparedness Community recovery Emergency operations coordination Emergency public information and warning Fatality management Information sharing Mass care Medical countermeasure dispensing Medical materiel management and distribution Medical surge Nonpharmaceutical interventions Public health laboratory testing Public health surveillance and epidemiologic investigation Responder safety and health Volunteer management Agricultural disease outbreak Agro terrorism Air quality Biological disease outbreak Biological terrorism—communicable agents (including A, B, and C agents) Biological terrorism—noncommunicable agents (including A, B, and C agents) Chemical terrorism Civil disorder Communications failure Conventional terrorism Cyber/technical incident Dam failure Drought Dust storms Extreme cold Extreme heat Earthquake Fires—large scale (not wildfire) Flood Food borne disease Hailstorm Hazardous materials incident—fixed facility Hazardous materials incident—transportation Hurricane/tropical storm Lightning Mass casualty incidents Mass population surge Nuclear attack Pandemic influenza Power failure Radiological incident—fixed facility
No. Linked ISAs 97 11 9 34 12 13 19 23 10 10 9 0 8 22 5 139 140 105 156 151 144 117 105 105 114 106 106 108 105 107 109 115 110 118 139 106 116 115 119 107 108 106 113 159 107 117 (continues)
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S74 ❘ Journal of Public Health Management and Practice TABLE ● Capabilities and TxPHRAT Hazards and Number of Linked Strategies (Continued) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Capability/Hazard
No. Linked ISAs
Radiological incident—transportation Radiological terrorism Severe winter storm Sewer failure Storm surge Supply disruption (water, food, pharmaceuticals) Tornado Water supply contamination Wildfire Windstorm
116 119 110 105 108 107 115 137 109 108
Abbreviations: TxPHRAT, Texas Public Health Risk Assessment Tool.
Profiles and strategies designed to mitigate hazards and risks. To assist counties and Regions in meeting the RiskBased Funding Project requirement of developing mitigation plans, TECS-PERLC created the Mitigation Planning and Reporting Template. The comprehensive nature of the template allowed it to be used in planning, implementation, evaluation, and reporting. At the time of publication, Regions reported 20 Mitigation Planning and Reporting Templates have been completed.
geographically and also faces its own personnel and resource constraints. These challenges suggest a need to foster local community engagement efforts at the county level using the Mitigation Planning Process. Community engagement, while known to be important and effective,9-12 is costly to develop and maintain. By centering the Mitigation Planning Process within the county jurisdiction, ownership and buy-in are fostered at the grassroots level, while allowing the Region to provide support of locally designed mitigation plans.
● Next Steps To build upon and improve the mitigation process, TECS-PERLC recently completed After Action Reviews and content reviews of completed Mitigation Planning and Reporting Templates. On the basis of findings from these activities and from experiences documented throughout the past 2 years, modifications will be made to the tools to better meet the needs of the broader group of stakeholders involved in the Mitigation Planning Process. In addition, the Texas DSHS has approved funding for TECS-PERLC to expand this project to all counties in Texas with LHDs. REFERENCES
● Discussion Successful mitigation requires a process that engages stakeholders and a mechanism to formally approve and implement plans. Public health community engagement efforts, by definition,13 should include diverse audiences and stakeholder groups. Stakeholders should be engaged in all phases of the Mitigation Planning Process, including participation in the assessment process, the potential use and prioritization of strategies and activities to address specific hazards and capabilities, and the subsequent evaluation of the effectiveness of the plan. To facilitate an effective mitigation planning process, tools should be available to and adapted for various stakeholder groups. The absence of these tools impedes the ability of communities to prepare for, respond to, and recover from public health threats. Counties with infrastructures, such as LHDs, that support and sustain long-term relationships within a network of local stakeholder groups appear to be more successful in the Mitigation Planning Process. Preparedness efforts in counties without LHDs may be hindered because of isolation and lack of time, resources, and personnel. In counties where there is no local public health infrastructure, public health services are provided by a regional office that is separated
1. Texas Department of State Health Services. Public Health Funding and Policy Committee Annual Report. Austin, TX: Texas Department of State Health Services. https://www.dshs .state.tx.us/phfpcommittee/docs/PHFPCAnnualReport 0313/. Published 2013. Accessed December 7, 2013. 2. Texas Department of State Health Services. Regional and Local Health Services hold state’s public health system together. http://www.dshs.state.tx.us/rls/RLHS042211.shtm. Updated March 2012. Accessed December 7, 2013. 3. US Department of Health and Human Services Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response. Public Health Emergency Preparedness Cooperative Agreement: CDC-RFA-TP11-1101cont11. Atlanta, GA: Centers for Disease Control and Prevention; 2011. 4. Nussle J. Update of Statistical Area Definitions and Guidance on Their Uses. Washington, DC: Office of Budget and Management Executive Office of the President; 2008. 5. US Department of Health and Human Services Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response. Funding, guidance, and technical assistance to states, localities, and territories. http:// www.cdc.gov/phpr/capabilities. Published 2011. Accessed September 5, 2013. 6. Griffith JM, Fleming J, Dawson B. Color-Coded Guide to Formulas and Computations in the Texas Public Health Risk Assessment Tool: Teaching and Education Collaborative System. Preparedness and Emergency Response Learning Center, Texas A&M Health Science Center School of Rural Public Health and Houston Department of Health and Human Services; 2012.
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A Public Health Hazard Mitigation Planning Process
7. US Department of Homeland Security, Federal Emergency Management Agency. Local Mitigation Plan Review Guide. Washington, DC: Federal Emergency Management Agency; 2011. 8. US Department of Health and Human Services Centers for Disease Control and Prevention, Office of Strategy and Innovation. Introduction to Program Evaluation for Public Health Programs: A Self-study Guide. Atlanta, GA: Centers for Disease Control and Prevention; 2005. 9. Ahmed SM, Palermo AG. Community engagement in research: frameworks for education and peer review. Am J Public Health. 2010;100(8):1380-1387. 10. Minkler M, Wallerstein N. The growing support for CBPR. In: Minkler M, Wallerstein N, eds. Community-Based Participatory
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Research for Health: From Process to Outcomes. 2nd ed. San Francisco, CA: Jossey-Bass; 2008:544. 11. Schoch-Spana M, Sell TK, Morhard R. Local health department capacity for community engagement and its implications for disaster resilience. Biosecur Bioterror. 2013;11(2):118129. 12. Wells KB, Tang J, Lizaola E, et al. Applying community engagement to disaster planning: developing the vision and design for the Los Angeles County Community Disaster Resilience initiative. Am J Public Health. 2013;103(7):11721180. 13. Thompson B, Kinne S. Social change theory: applications to community health. In: Bracht N, ed. Health Promotion at the Community Level. Newbury Park, CA: Sage; 1990:45-65.
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Introduction: The Texas A&M Health Science Center School of Rural Public Health, a member of the Training and Education Collaborative System Preparedness and Emergency Response Learning Center (TECS-PERLC)*, has long-standing partnerships with 2 Health Service Regions (Regions) in Texas. TECS-PERLC was contracted by these Regions to address 2 challenges identified in meeting requirements outlined by the Risk-Based Funding Project. First, within Metropolitan Statistical Areas, there is not a formal authoritative structure. Second, preexisting tools and processes did not adequately satisfy requirements to assess public health, medical, and mental health needs and link mitigation strategies to the Public Health Preparedness Capabilities, which provide guidance to prepare for, respond to, and recover from public health incidents. Methods: TECS-PERLC, with its partners, developed a framework to interpret and apply results from the Texas Public Health Risk Assessment Tool (TxPHRAT). The 3-phase community engagement-based TxPHRAT Mitigation Planning Process (Mitigation Planning Process) and associated tools facilitated the development of mitigation plans. Tools included (1) profiles interpreting TxPHRAT results and identifying, ranking, and prioritizing hazards and capability gaps; (2) a catalog of intervention strategies and activities linked to hazards and capabilities; and (3) a template to plan, evaluate, and report mitigation planning efforts. Outcomes: The Mitigation Planning Process provided a framework for Regions to successfully address all funding requirements. TECS-PERLC developed more than 60 profiles, cataloged and linked 195 intervention strategies, and developed a template resulting in 20 submitted mitigation plans. Discussion: A public health–focused, community engagement–based mitigation planning process was
J Public Health Management Practice, 2014, 20(5), S69–S75 C 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright
developed by TECS-PERLC and successfully implemented by the Regions. The outcomes met all requirements and reinforce the effectiveness of academic practice partnerships and importance of community engagement in mitigation planning. Next Steps: Additional funding has been approved to expand the Mitigation Planning Process to all counties in Texas with local health departments.
Author Affiliations: Training and Education Collaborative System Preparedness and Emergency Response Learning Center (Drs Griffith and Quiram and Mss Carpender and Crouch), Office of Special Programs (Drs Griffith and Quiram), and Department of Health Policy and Management (Drs Griffith and Quiram and Ms Crouch), Texas A&M Health Science Center School of Rural Public Health, College Station. This work was supported, in part, by a Preparedness and Emergency Response Learning Center grant from the Centers for Disease Control and Prevention (CDC), under FOA CDC-RFA-TP10-1001, to the Texas A&M Health Science Center School of Rural Public Health, grant U90TP000408, and contracts with the Texas Department of State Health Services Health Service Region 2/3 and Health Service Region 6/5S, contracts 2012-040772 and 2012-041926, respectively. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the CDC or Texas Department of State Health Services Health Service Regions 2/3 and 6/5S. TECS-PERLC acknowledges its partners at the state, regional, and local levels for their contributions during the course of work with the Texas Public Health Risk Assessment Tool: Bruce Clements, MPH, Director, Community Preparedness Section, Texas Department of State Health Services, Division of Regional and Local Health Services; Michael Felan, Program Specialist, Texas Department of State Health Services Health Service Region 2/3, Community Preparedness Section; Jennifer Kiger, MPH, Regional Public Health Preparedness Manager, Texas Department of State Health Services Health Service Region 6/5S; John Fleming, Senior Planner with the Bureau of Public Health Preparedness, Office of Surveillance and Public Health Preparedness, Houston Department of Health and Human Services. The authors declare no conflicts of interest. Correspondence: Jennifer M. Griffith, DrPH, MPH, Office of Special Programs, School of Rural Public Health, Texas A&M Health Science Center, MS 1266, 302 Administration Bldg, College Station, TX 77843 ([email protected]). DOI: 10.1097/PHH.0000000000000064 *The PERLC program is designed to address the preparedness and response training and education needs of the public health workforce. Supported by Federal funding (2010 to date), the program includes 14 centers in Council on Education for Public Health accredited Schools of Public Health. For additional information, see www.cdc.gov/phpr/perlc factsheet.htm.
S69 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
S70 ❘ Journal of Public Health Management and Practice KEY WORDS: hazard risk, mitigation planning, public health, risk
assessment
The Training and Education Collaborative System Preparedness and Emergency Response Learning Center (TECS-PERLC) is a collaboration of the 3 schools of public health in Texas. The common goal is to increase capacity for community resilience through community engagement by providing planning, training, and exercise assistance to the public health workforce. The Texas A&M Health Science Center School of Rural Public Health serves as the PERLC grantee and collaborates with its partners in South Dakota and Texas. In Texas, counties are permitted, but not required, to provide public health services. If counties do not elect to perform public health functions, the Texas Department of State Health Services (DSHS) fills these service gaps. The DSHS divides the 254 counties in Texas into 8 geographic regions; 59 of the 254 counties have local health departments (LHDs) operating under a Local Public Health Contract with the DSHS. These LHDs provide preventive, protective, regulatory, and preparedness functions to 82% of the Texas population. For the remaining counties and population, DSHS Health Service Regions (Regions) fill the role of an LHD, providing essential public health services, including preparing for, responding to, and recovering from a public health emergency.1,2 Texas DSHS Regions 2/3 and 6/5S were awarded Risk-Based Funding as part of the 2011 Centers for Disease Control and Prevention (CDC) Public Health Preparedness Cooperative Agreement.3 Both regions had existing partnerships with the Texas A&M Health Science Center School of Rural Public Health. These existing partnerships allowed TECS-PERLC to serve in multiple capacities for both Regions, as well as engage TECS-PERLC resources and expertise to respond to state-level requests during the course of the 2-year Risk-Based Funding Project.
● Background The Division of State and Local Readiness at the CDC awarded funds for the Risk-Based Funding Project to systematically identify hazard risks and engage in mitigation planning activities at the Metropolitan Statistical Area (MSA) level.3 Metropolitan Statistical Areas are geographical areas defined by the US Office of Management and Budget and used for statistical purposes.4 Funded pilot sites were required to
develop risk mitigation plans to specifically address the public health, medical, and mental health needs of the community, including vulnerable populations; develop a matrix that describes and ranks/prioritizes the public health threats and risks within the jurisdiction; identify the specific public health threats and risks that will be addressed with this funding; and propose strategies and activities designed to reduce/mitigate the threats and risks.3(p62)
The principal goal of Risk-Based Funding was to link mitigation strategies to the 15 Public Health Preparedness Capabilities (Capabilities) released by the CDC in March 2011 and more specifically the Community Preparedness Capability.3 These Capabilities were developed to assist state, regional, and LHDs address preparedness challenges related to identifying public health preparedness priorities and serve as national standards and guidance “to better organize their work, plan their priorities, and decide which capabilities they have resources to build or sustain.”5(¶3) The Texas A&M component of TECS-PERLC was asked to participate in the development and testing of a Texas-specific public health risk assessment tool. In addition, Regions 2/3 and 6/5S, representing Dallas and Houston, respectively, contracted with Texas A&M to develop translational materials to assist state, regional, and LHDs and local jurisdictions with public health mitigation planning.
Tool development committee Preexisting tools and processes did not meet project requirements to assess public health, medical, and mental health needs and to link strategies to the Capabilities. To address these requirements, a team of stakeholders from state, regional, and local public health; emergency management; homeland security; health care systems; mental health services; and academia worked in partnership to develop an assessment tool. This tool was designed to efficiently and effectively function for small, medium, and large jurisdictions; assess and rank 41 hazards; account for mitigation factors based on the Capabilities; specify the impact of hazards; and be used for public health preparedness strategic planning. The Texas DSHS developed and released version 1.1 of the Texas Public Health Risk Assessment Tool (TxPHRAT) in March 2012, providing a system for gathering data elements required to meet Risk-Based Funding Project requirements. TECS-PERLC participated in the TxPHRAT development process by providing feedback on interface, data entry, results, and outputs. To ensure data entered into TxPHRAT yielded the expected results, it was necessary to have a clear understanding of formulas and calculations used in the tool. TECS-PERLC partnered with tool developers to create a guide that explained
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
A Public Health Hazard Mitigation Planning Process
the formulas and calculations in the tool. The resulting Color-Coded Guide to Formulas and Computations in the Texas Public Health Risk Assessment Tool6 provided transparency for results calculated by TxPHRAT and addressed the need to translate results to broader stakeholder groups.
Addressing requirements of Risk-Based Funding While TxPHRAT was being developed at the state level, TECS-PERLC met with partners in the Dallas and Houston MSAs to discuss Risk-Based Funding Project goals, objectives, and deliverables at the regional level. The results from TxPHRAT were the initial step in the broader planning process, with the overall goal to improve the ability for communities to prepare for, respond to, and recover from public health incidents through increased public health awareness and community engagement, that is, mitigation planning. Two challenges were identified in achieving this goal. First, a formal authoritative structure did not exist within an MSA. With no responsible or decisionmaking entity to guide and approve planning efforts, LHD representatives within each MSA identified and selected their Regions as project lead to address this challenge. To broaden the mitigation planning process, additional counties within the Regions, but not part of the MSA, were included in the planning process by using discretionary funding awarded by the state. The second challenge was the lack of a formal public health mitigation planning process using TxPHRAT results. To address this challenge, TECS-PERLC adapted Federal Emergency Management Agency’s Local Mitigation Plan Review Guide’s Regulation Checklist to create an overall community engagement–based process to develop public health risk mitigation plans. Elements adapted for use included the planning process, hazard identification and risk assessment, mitigation strategy, and implementation.7 The adaptation process resulted in the TxPHRAT Mitigation Planning Process (Mitigation Planning Process), including County Profiles, the Intervention Strategies and Activities Document (Strategies Document), and the Mitigation Planning and Reporting Template. These tools were developed to facilitate the interpretation and application of TxPHRAT results to initiate mitigation planning through community engagement and are described in the “Methods” section.
● Methods More than 60 counties were engaged in this project, including counties without LHDs. All counties assessed the 64 functions aligned with the 15 Capabilities and
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the availability of resources required to respond to each of 41 hazards included in the tool. Each county or region entered assessment data into the tool to generate county-level TxPHRAT results. TxPHRAT results identified top public health hazards on the basis of hazard and residual risk scores, capability gaps, and resource gaps for each county. However, LHDs needed assistance engaging broader stakeholder groups, such as county judges, emergency managers, law enforcement, and hospital representatives, in mitigation planning efforts. As an academic practice partner, TECS-PERLC collaborated with the 2 Regions to develop the Mitigation Planning Process. The logic model for the Mitigation Planning Process (Figure), created using the CDC Program Evaluation Logic Model Framework (CDC Framework),8 illustrates the interrelated phases of the process and their connection to the long-term, overall goal of improving community ability to prepare for, respond to, and recover from public health incidents. The Mitigation Planning Process logic model demonstrates how this community engagement–based process moves beyond assessment into mitigation and relies on outcomes from each phase to address Risk-Based Funding Project requirements.
Phase 1 The first phase of the Mitigation Planning Process used TxPHRAT results and stakeholder feedback to create County and Regional Profiles. These Profiles included 4 primary outputs of TxPHRAT: hazard risk scores; residual risk scores; capability gaps; and resource gaps. The Profiles also ranked and prioritized risk scores, capability gaps, and resource gaps. To meet preferences of various stakeholders in using and applying results, a combination of narrative, tables, and figures were used to present outputs. Regions were required to identify top hazards and capability gaps at the regional level. TxPHRAT results were generated at the county level, and there was concern that averaging scores would mask differences at the county level. TECS-PERLC developed a ranking strategy to identify top hazards and capability gaps at the regional level to address this concern. County and Regional Profiles were the short-term outcome of the first phase of the Mitigation Planning Process (Figure). This outcome initiated phase 2 of the process by identifying specific hazards and capability gaps for mitigation planning efforts.
Phase 2 The second phase of the Mitigation Planning Process linked Profile results to intervention strategies
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S72 ❘ Journal of Public Health Management and Practice FIGURE ● TxPHRAT Mitigation Planning Process Logic Model
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Abbreviation: TxPHRAT, Texas Public Health Risk Assessment Tool.
designed to mitigate hazards and address capability gaps. Public health and emergency management mitigation strategies were collected and reviewed for their applicability to all the Capabilities and hazards. Strategies included approaches to mitigation activities that would supplement the use of traditional public health response assets, equipment, and supplies. Sources included, but were not limited to, academic practice partners, professional organizations, nonprofit organizations, state health departments, regional health departments, LHDs, local jurisdictions, federal agencies, and peer-reviewed literature. All cataloged strategies could be linked directly to the Community Preparedness Capability. Strategies were also assessed for attributes linking them directly to supporting functions of the remaining 14 Capabilities. If a strategy supported the functions of 1 or more of the additional Capabilities, it was linked to the corresponding Capability or Capabilities. Strategies were then assessed for applicability to each hazard on the basis of the original intent and potential for expansion to other hazards. Applicable strategies were compiled into the Strategies Document. The Strategies Document served as a single resource for stakeholders to use in the mitigation planning
process. This resource allowed clickable search and navigation based on a hazard or a capability. The user-friendly format provided stakeholders a tool to easily search for strategies based on prioritized hazards or capability gaps. Once strategies were identified, stakeholders began tailoring them to target hazards or capabilities in preparation for implementation, initiating phase 3 of the Mitigation Planning Process.
Phase 3 The final phase of the Mitigation Planning Process included a template to document details of the select strategy: description; goals and outcomes; objectives; partners; needed resources, including anticipated and actual costs; funding sources; action steps; evidence of completion; applicable capabilities; applicable hazards; notes and considerations; barriers and challenges encountered; and best practices. A logic model, based on the CDC Framework,8 was also provided as part of the template and included instructions on which details from the narrative should be transposed to the visual framework. A completed template provided a single document to plan, implement, evaluate, and report on an activity.
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A Public Health Hazard Mitigation Planning Process
TxPHRAT Mitigation Planning Process training TECS-PERLC conducted 2 face-to-face trainings, one in each Region, to introduce the Mitigation Planning Process and train stakeholders on the use and application of the tools. Each session introduced stakeholders to their County Profile and TxPHRAT results, demonstrated the use of the Strategies Document, and engaged county stakeholder groups in the use of the logic model section of the Mitigation Planning and Reporting Template. Training objectives included the following: describe Profile components; identify relationships of data Profiles to TxPHRAT; translate the meaning of different graphs, tables, and figures in Profiles; explain layout and function of the Strategies Document; apply search process to identify strategies for prioritized hazards and capability gaps using the Strategies Document; and create a draft logic model for a selected strategy. An online version of the training was also developed to provide stakeholders continued access and guidance on the Mitigation Planning Process and appropriate use of the tools.
● Outcomes The Regions contracted with TECS-PERLC to develop a public health–focused mitigation planning process. TECS-PERLC, in collaboration with its state and regional partners, developed a systematic framework to meet requirements of the Risk-Based Funding Project. Using proven community engagement strategies,9-12 stakeholders from MSA counties were able to select leadership and establish project charters. Groups were able to partner effectively to use resources, reach consensus, and receive local approval to implement regional activities. Furthermore, the Mitigation Planning Process included a framework and tools to move beyond assessment into planning and implementation of mitigation efforts. Each step of the Mitigation Planning Process and the accompanying tools directly linked to and addressed requirements of the Risk-Based Funding Project. To address the requirement of identifying, ranking, and prioritizing hazards and risks, TECS-PERLC created more than 60 County Profiles, using output from TxPHRAT. In addition, variations of regional profiles were created to report outputs for groups of counties representing each of the Regions and MSAs. TECS-PERLC cataloged 195 strategies; of these, 99 were linked to all 41 hazards and 23 were linked to a single hazard. In addition, most strategies were linked to a single capability (63%) (Table). The Strategies Document provided a bridge between County/Regional
TABLE ● Capabilities and TxPHRAT Hazards and Number of Linked Strategies qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Capability/Hazard Community preparedness Community recovery Emergency operations coordination Emergency public information and warning Fatality management Information sharing Mass care Medical countermeasure dispensing Medical materiel management and distribution Medical surge Nonpharmaceutical interventions Public health laboratory testing Public health surveillance and epidemiologic investigation Responder safety and health Volunteer management Agricultural disease outbreak Agro terrorism Air quality Biological disease outbreak Biological terrorism—communicable agents (including A, B, and C agents) Biological terrorism—noncommunicable agents (including A, B, and C agents) Chemical terrorism Civil disorder Communications failure Conventional terrorism Cyber/technical incident Dam failure Drought Dust storms Extreme cold Extreme heat Earthquake Fires—large scale (not wildfire) Flood Food borne disease Hailstorm Hazardous materials incident—fixed facility Hazardous materials incident—transportation Hurricane/tropical storm Lightning Mass casualty incidents Mass population surge Nuclear attack Pandemic influenza Power failure Radiological incident—fixed facility
No. Linked ISAs 97 11 9 34 12 13 19 23 10 10 9 0 8 22 5 139 140 105 156 151 144 117 105 105 114 106 106 108 105 107 109 115 110 118 139 106 116 115 119 107 108 106 113 159 107 117 (continues)
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S74 ❘ Journal of Public Health Management and Practice TABLE ● Capabilities and TxPHRAT Hazards and Number of Linked Strategies (Continued) qqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqqq
Capability/Hazard
No. Linked ISAs
Radiological incident—transportation Radiological terrorism Severe winter storm Sewer failure Storm surge Supply disruption (water, food, pharmaceuticals) Tornado Water supply contamination Wildfire Windstorm
116 119 110 105 108 107 115 137 109 108
Abbreviations: TxPHRAT, Texas Public Health Risk Assessment Tool.
Profiles and strategies designed to mitigate hazards and risks. To assist counties and Regions in meeting the RiskBased Funding Project requirement of developing mitigation plans, TECS-PERLC created the Mitigation Planning and Reporting Template. The comprehensive nature of the template allowed it to be used in planning, implementation, evaluation, and reporting. At the time of publication, Regions reported 20 Mitigation Planning and Reporting Templates have been completed.
geographically and also faces its own personnel and resource constraints. These challenges suggest a need to foster local community engagement efforts at the county level using the Mitigation Planning Process. Community engagement, while known to be important and effective,9-12 is costly to develop and maintain. By centering the Mitigation Planning Process within the county jurisdiction, ownership and buy-in are fostered at the grassroots level, while allowing the Region to provide support of locally designed mitigation plans.
● Next Steps To build upon and improve the mitigation process, TECS-PERLC recently completed After Action Reviews and content reviews of completed Mitigation Planning and Reporting Templates. On the basis of findings from these activities and from experiences documented throughout the past 2 years, modifications will be made to the tools to better meet the needs of the broader group of stakeholders involved in the Mitigation Planning Process. In addition, the Texas DSHS has approved funding for TECS-PERLC to expand this project to all counties in Texas with LHDs. REFERENCES
● Discussion Successful mitigation requires a process that engages stakeholders and a mechanism to formally approve and implement plans. Public health community engagement efforts, by definition,13 should include diverse audiences and stakeholder groups. Stakeholders should be engaged in all phases of the Mitigation Planning Process, including participation in the assessment process, the potential use and prioritization of strategies and activities to address specific hazards and capabilities, and the subsequent evaluation of the effectiveness of the plan. To facilitate an effective mitigation planning process, tools should be available to and adapted for various stakeholder groups. The absence of these tools impedes the ability of communities to prepare for, respond to, and recover from public health threats. Counties with infrastructures, such as LHDs, that support and sustain long-term relationships within a network of local stakeholder groups appear to be more successful in the Mitigation Planning Process. Preparedness efforts in counties without LHDs may be hindered because of isolation and lack of time, resources, and personnel. In counties where there is no local public health infrastructure, public health services are provided by a regional office that is separated
1. Texas Department of State Health Services. Public Health Funding and Policy Committee Annual Report. Austin, TX: Texas Department of State Health Services. https://www.dshs .state.tx.us/phfpcommittee/docs/PHFPCAnnualReport 0313/. Published 2013. Accessed December 7, 2013. 2. Texas Department of State Health Services. Regional and Local Health Services hold state’s public health system together. http://www.dshs.state.tx.us/rls/RLHS042211.shtm. Updated March 2012. Accessed December 7, 2013. 3. US Department of Health and Human Services Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response. Public Health Emergency Preparedness Cooperative Agreement: CDC-RFA-TP11-1101cont11. Atlanta, GA: Centers for Disease Control and Prevention; 2011. 4. Nussle J. Update of Statistical Area Definitions and Guidance on Their Uses. Washington, DC: Office of Budget and Management Executive Office of the President; 2008. 5. US Department of Health and Human Services Centers for Disease Control and Prevention, Office of Public Health Preparedness and Response. Funding, guidance, and technical assistance to states, localities, and territories. http:// www.cdc.gov/phpr/capabilities. Published 2011. Accessed September 5, 2013. 6. Griffith JM, Fleming J, Dawson B. Color-Coded Guide to Formulas and Computations in the Texas Public Health Risk Assessment Tool: Teaching and Education Collaborative System. Preparedness and Emergency Response Learning Center, Texas A&M Health Science Center School of Rural Public Health and Houston Department of Health and Human Services; 2012.
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A Public Health Hazard Mitigation Planning Process
7. US Department of Homeland Security, Federal Emergency Management Agency. Local Mitigation Plan Review Guide. Washington, DC: Federal Emergency Management Agency; 2011. 8. US Department of Health and Human Services Centers for Disease Control and Prevention, Office of Strategy and Innovation. Introduction to Program Evaluation for Public Health Programs: A Self-study Guide. Atlanta, GA: Centers for Disease Control and Prevention; 2005. 9. Ahmed SM, Palermo AG. Community engagement in research: frameworks for education and peer review. Am J Public Health. 2010;100(8):1380-1387. 10. Minkler M, Wallerstein N. The growing support for CBPR. In: Minkler M, Wallerstein N, eds. Community-Based Participatory
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Research for Health: From Process to Outcomes. 2nd ed. San Francisco, CA: Jossey-Bass; 2008:544. 11. Schoch-Spana M, Sell TK, Morhard R. Local health department capacity for community engagement and its implications for disaster resilience. Biosecur Bioterror. 2013;11(2):118129. 12. Wells KB, Tang J, Lizaola E, et al. Applying community engagement to disaster planning: developing the vision and design for the Los Angeles County Community Disaster Resilience initiative. Am J Public Health. 2013;103(7):11721180. 13. Thompson B, Kinne S. Social change theory: applications to community health. In: Bracht N, ed. Health Promotion at the Community Level. Newbury Park, CA: Sage; 1990:45-65.
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