NW Oregon Health Preparedness Organization CDC Pandemic Influenza Collaborative Planning for Delivery of Essential Health Care Services: Portland Oregon Metro Area and SW Washington Project Evaluation Report Prepared for The Centers for Disease Control and Prevention and Northwest Oregon Health Preparedness Organization Prepared by Gary Oxman, MD, MPH Christine Sorvari, MS June 2010 CDC Pandemic Influenza Collaborative Planning for Delivery of Essential Health Care Services Portland Oregon Metro Area and SW Washington Project Staff Gary Oxman, MD, MPH, Principal Investigator Christine Bernsten, BA, Program Manager; Contributing Author Victoria Cross, BA, Senior Office Assistant Beth McGinnis, MPH, Project Coordinator Kathryn Richer, MA, Program Manager; Contributing Author Christine Sorvari, MS, Senior Evaluation/Research Analyst Aron Stephens, MPH, Program Development Specialist Project Contributors/Consultants Barry Anderson, PhD Portland State University Linda Dodge, MA Organizational Quality Associates Mike Edrington, BS Organizational Quality Associates Jeff Fletcher PhD Portland State University Michael Garland, D.Sc.Rel. Portland State University Katrina Grant, MD Oregon Health and Science University Sandy Johnson, PhD Multnomah County Health Department Safina Koreishi, MD Oregon Health and Science University Lisa Kulkarni, MBA Multnomah County Health Department Richard Leman, MD Oregon Public Health Division Paul Lewis, MD Washington County Health Department John McConnell PhD Oregon Health and Science University Cynthia Mills, DMV, MPH Multnomah County Health Department Roy Montgomery, BS Organizational Quality Associates Zumana Rios, MHA Multnomah County Health Department Rajiv Sharma PhD Portland State University Robert Stenger, MD, MPH Oregon Health and Science University Amy Sullivan, PhD, MPH Multnomah County Health Department Jessica Sosso-Vorpahl, MD, MPH Oregon Health and Science University And the NW Oregon Health Preparedness Organization Steering Committee MULTNOMAH COUNTY HEALTH DEPARTMENT, HEALTH OFFICER AND HEALTH ASSESSMENT AND EVALUATION CDC PANDEMIC INFLUENZA COLLABORATIVE PLANNING FOR DELIVERY OF ESSENTIAL HEALTH CARE SERVICES For more information contact: Gary Oxman, MD, MPH Tri County Health Officer Multnomah County Health Department [email protected] 503.988.3674 Ext 22640 Kathryn Richer, MA Region 1 Coordinator NW Oregon Health Preparedness Organization Multnomah County Health Department [email protected] 503.988.3674 Ext 24223 This document is 100% funded by the U.S. Department of Health and Human Services Centers for Disease Control and Prevention Essential Health Care Services Project (Award: 1U90TP000129) The findings and conclusions in this report are those of the project participants and do not necessarily represent the official position of the Centers for Disease Control and Prevention. MULTNOMAH COUNTY HEALTH DEPARTMENT, HEALTH OFFICER AND HEALTH ASSESSMENT AND EVALUATION CDC PANDEMIC INFLUENZA COLLABORATIVE PLANNING FOR DELIVERY OF ESSENTIAL HEALTH CARE SERVICES CDC Pandemic Influenza Collaborative Planning for Delivery of Essential Health Care Services: Portland Oregon Metro Area and SW Washington EXECUTIVE SUMMARY Purpose of Project The purpose of this grant was to develop, exercise, and evaluate a coordinated approach to health care delivery in the face of a Severity Index Category 5 influenza pandemic. Specifically, the approach to coordination developed for this project was modeled after the well-established Multi-Agency Coordination (MAC) Group. The MAC Group is a component of the National Incident Management System (NIMS) and has been used for decades as a decision-making tool in natural disasters. The adaptation of a traditional MAC Group to address health and medical emergencies is relatively new and had not been attempted in our region prior to this project. The Health/Medical MAC Group was comprised of local hospitals, public health, and a representative of the physician community. The group’s charge was to make decisions about scarce resource allocation and develop policy recommendations affecting the system of care for patients with influenza and those with other significant medical needs during a severe influenza event. Understanding that the health care response to a severe pandemic will present extraordinary operational and ethical challenges, we committed to explicitly integrate the use of an ethics framework into the Health/Medical MAC Group’s decisions that would affect care delivery and health care system coordination The entire project was undertaken with the intent that resulting products could be disseminated and adapted by other communities. Given this intent, the project utilized NIMS-compliant approaches, along with public health and academic resources typically available in midsized urban areas. Project Implementation The project was carried out in three phases. The first phase focused on developing a proposed system of care based on an assessment of the local health care system’s current capacities and on the projected demands for influenza and non-influenza care during a 1918-like influenza pandemic. During the second phase, the coordination approach, (i.e., the Health/Medical MAC Group) was developed and refined. The third phase focused on evaluating the effectiveness and community’s acceptance of the approaches to health care delivery and coordination. Initially, phase two was to include an iterative series of functional community level decision- making exercises anchored in scenarios that represented various points in the evolution of a 10- week wave of a severe influenza pandemic. The exercise series began according to this plan. However, the autumn wave of the 2009 H1N1 pandemic came to dominate the attention of both local public health and local health care delivery providers. As a result, the planned exercise series shifted to a series of real-time, Health/Medical MAC Group meetings. MULTNOMAH COUNTY HEALTH DEPARTMENT, HEALTH OFFICER AND HEALTH ASSESSMENT AND EVALUATION CDC PANDEMIC INFLUENZA COLLABORATIVE PLANNING FOR DELIVERY OF ESSENTIAL HEALTH CARE SERVICES Successes and Learning We believe that this shift from a planned exercise series to real-time coordination activities improved community engagement, and resulted in practical and meaningful learning. The following list highlights significant successes and learning we had in the course of this project. We were hopeful that we could develop an approach to prioritize and coordinate care based on objective data on system capacity, available resources, and likely health outcomes. As the project progressed, we learned that there were major barriers to using an approach deeply rooted in quantitative measures of capacity and health outcomes. As a result, the project evolved to have an emphasis on practical, real-time, ethically-based decision making at the community level. We developed an effective approach to quantitatively analyze local hospital inpatient care delivery capacity. This resulted in useful information for developing approaches to 1) defining essential services, 2) planning for deferral of inpatient care (e.g., delaying elective surgery), and 3) planning for the reengineering of certain types of care so that they could be provided in venues other than hospitals. We developed an epidemiologic model of influenza incidence and health care delivery impacts at the local community level. This model proved useful in estimating demand for care, taking into account the influence of high-risk medical conditions and the impacts of available 21st-century ambulatory care treatments such as antibiotics and antiviral drugs. We developed, implemented, tested, and evaluated a NIMS-compliant approach to community-level decision making to support health care system coordination. The majority of the Health/Medical MAC Group implementation was carried out in the context of real- time decision making around H1N1 issues requiring a coordinated regional health care delivery approach. Despite the transition from the planned exercise series to a series of actual decision-making meetings, we were able to retain the community observation and evaluation components included in the exercise plan. Key successes specific to the Health/Medical MAC Group include: - Integration of an explicit ethics framework into decision-making processes. - Wide participation and on-going commitment of local hospitals, public health, and a representative of the physician community as decision-makers. - Development of efficient and effective approaches to providing staff support, facilitation, as well as effective integration into the local emergency management structure. - General acceptance of the decision-making processes by a diverse group of community stakeholders. - Identified opportunities for improving decision making and coordination processes, from stakeholders representing diverse community and organizational perspectives. MULTNOMAH COUNTY HEALTH DEPARTMENT, HEALTH OFFICER AND HEALTH ASSESSMENT AND EVALUATION CDC PANDEMIC INFLUENZA COLLABORATIVE PLANNING FOR DELIVERY OF ESSENTIAL HEALTH CARE SERVICES CDC Pandemic Influenza Collaborative Planning for Delivery of Essential Health Care Services: Portland Oregon Metro Area and SW Washington Table of Contents I. INTRODUCTION 1 II. BACKGROUND 3 III. PROJECT DESIGN 7 IV. PROJECT ACTIVITIES AND FINDINGS 10 Section 1 Analysis of Current Hospital Care Utilization and Projected Pandemic Influenza Prevalence and Hospital Demand Utilization of Health