Strengthening Hospitals and Healthcare Disaster Response Capability by Addressing Vulnerable Populations

1. Strengthening Hospitals and Healthcare Disaster Response Capability by Addressing Vulnerable Populations Debra Kreisberg, Deborah Thomas, Comilla Sasson, and Morgan Valley Department of Emergency Medicine University of Colorado Denver Quality Health Care for Culturally Diverse Populations October 21, 2010

2. Barriers to a Culture of Preparedness NATIONAL GOAL: A CULTURE OF PREPAREDNESS Individuals, communities, private industry, nonprofit entities, and all levels of government share responsibility and play a crucial role in preparing for disasters and emergencies. PRIMARY BARRIER The United States suffers from extensive Health Disparities perpetuating service delivery structures in which too many Americans cannot get adequate healthcare, with underlying vulnerabilities often linked to geographical, economic, cultural, and racial factors.

3. Vulnerable Populations & Health Disparity • Individuals, groups, and/or communities who cannot respond in similar ways as the general population throughout all emergency management phases • Examples: age, physical, mental, emotional or cognitive status, culture, ethnicity, religion, language, etc. • Multifaceted and often interacting • Comprehensive health of a community pre-disaster directly correlated to the magnitude of the health crisis during and after the event • Underlying health inequities & barriers to healthcare access do not disappear in disaster; instead they become intensified

4. Hospitals’ Link to Vulnerability • Hospitals are critical infrastructure • Essential resources for communities • BUT, around the nation they struggle to meet the daily needs of their communities in non-disaster times • Quandary of baseline health inequities and barriers to access intersecting with hospital as a critical resource • Creates an incredible challenge to meet the needs of all effectively in face of disaster • Must directly address vulnerable populations & baseline experiences with healthcare system in hospital disaster plans

5. Need for Innovative Approaches in Hospital Disaster Preparedness Planning • Currently, Hazard Vulnerability Analysis (HVA) determine impacts and potential system failure • focus on the facility • but, do not address diverse groups in these approaches • New approaches emphasize impact on systems • organizational and the community level • integrate an understanding of CLAS standards appropriate to an altered standard of care situation

6. Focus Groups Latino Communities Statewide Vulnerability Assessment Interview of Hospital Administrators Pilot Project • Three interrelated phases that inform incorporating diverse populations explicitly into hospital preparedness planning Informing Hospital Preparedness Planning Incorporating Diverse Populations

7. To the best of your ability, please rate the linguistic/cultural diversity of your hospital’s service area population? 16.5% 35.4% 32.9% 10.1% 16.5% 8.9% 31.6% 3.8% 6.3% 22.8% 10.1% 5.1% 1 Extremely Diverse (3.8%) 2 3 Moderately Diverse (31.6%) 4 Somewhat Diverse (35.4%) 5 6 Very Little Diversity (8.9%) 1 Extremely Concerned (6.3%) 2 3 Moderately Concerned (22.8%) 4 Somewhat Concerned (32.9%) 5 6 Very Little Concerned (16.5% Interviews: Hospital Perspective • Specific to four areas of emergency planning for culturally diverse and Limited English Population (LEP) communities • Estimation of service community’s cultural and linguistic diversity, as well as of administrative support for culturally competent care measures • 153 emergency planners at hospitals throughout Colorado, of which 91 responded, with 80 survey completions and 11 partial completions To what degree has your senior administration identified cultural/linguistic competence as a concern?

8. Statewide Vulnerability Assessment • Basis for a more robust hospital-based approach • Identification of the most vulnerable populations, their locations, and the number of people • Mechanism for identifying and prioritizing communities to select for conducting a series of focus groups • Garner more detailed information on access to health facilities before, during and after a disaster • Based on the literature, fifteen variables were compiled from the U.S. Census, individually evaluated, and then statistically combined to identify communities where characteristics converge

9. Statewide Vulnerability Assessment Colorado Front Range Denver Denver • Coalescence around combination of poverty, no high school diploma, linguistic isolation, Hispanic, and low median household income • While informative, masks specific pressures, constraints, opportunities, and views that exist within a particular community and so more detailed analyses in these areas is warranted. • Identification of 8 communities for conducting focus groups, of which 5 complete

10. Focus Groups • 5 focus group sites, a series of five 2-hour focus groups held in rural and urban communities • Communities with high representation of Hispanic limited-English-speaking populations, in Leadville, Alamosa, Greeley Aurora and Denver • Participants were asked about their perceptions and anticipated expectations of emergency health services in disaster events • Approved by Colorado Multi-Institutional Review Board (COMIRB)

11. Amplification of Baseline During Disaster • Requires defining baseline first • Premise for conducting the focus groups “We’re a really small community with few economic resources, and it’s well known that the community hospital isn’t equipped for most things. And they can’t handle most situations, and I think that in a disaster there really isn’t much they could do.”

12. Schools Churches Clinics Police Station Fire Station Gymnasium Red Cross Center Emergency Room Hospital Other cities Shelter Neighbor’s house Accessing Services: Baseline • Places have different meaning • Hospital is but one place listed; increased in importance in some disaster scenarios

13. Amplification of Baseline During Disaster • Vulnerabilities are not the same across the entire group • Hierarchies exist and diversity within group • Spectrum of vulnerability exists Insurance Status “What I noticed, is that they assist you if you have insurance in a matter of seconds, when you have insurance it’s a few seconds, just like that. It’s not fair, no, it’s not.” Language Barriers “With me, when they notice I speak English, that I understand, they treat me differently. I feel like they help me more. They don’t ignore me.”

14. Level of Trust “…. I personally think that our community would not be ready in the event of an emergency and the community hospital would not be ready to assist even one fourth of the people. …. people who are used to going to other counties to see their doctors wouldn’t be able to do it. And then, what happens? They wouldn’t get medical treatment.” “The hospital is like a horrible game of roulette because you don’t know what you are going to get.”

15. “Yes, they ignore you. But if you speak up, “I want to talk to the manager”. And then they’ll say, “oh… OK” So then they’ll see you. But you have to do it yourself because if don’t speak up no one is going to speak for you.” “… a community with scarce economic resources, so even people who are trained, and even if they wanted to live here, it’s not good for them because they’re not offered a good salary. So we don’t have stable doctors. We don’t have paramedics, stable nurses, and they’re always coming and going.” Agency and Structural Considerations

16. “So I'm not willing to go by myself, you need someone to come along; you need someone to come with you.” “I would take my family, like I said before, because of safety reasons so that we can be all together. You know that we Latinos have very tight-knit families. No matter what happens we are always together.” Collectivism & Individualism

17. Not All Disasters Are Alike “I believe that family members would all get together in the house that is farthest from the chemical spill…. If one or two start to feel bad, then one of the adults could take them to the hospital.” “I think you have to weigh the situation and analyze whether the people going with you are in danger by going to the hospital with the injured person, or to see if it’s better to keep them home, so that they’ll stay there.”

18. Next Steps • Align these findings with CLAS standards and document explicit implications for hospitals with recommendations • Need to know the service area community and the role of GIS • Many of the themes that emerged likely relate to other groups, but important to understand how • Development of a tool for the hospital administrators, not just facility based, but linked with the community • Recommendations for interfacing with the community Overarching Goal: No matter who ends up on the hospital doorstep in a disaster, the best care possible can be delivered with cultural sensitivity to varied populations in all types of disasters