Reaching Vulnerable Populations During a Public Health Emergency National Prevention Summit October

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Reaching Vulnerable Populations During a Public
Health EmergencyNational Prevention
SummitOctober 27, 2006

• Karen B. DeSalvo, MD, MPH, MSc
• Tulane University
• University Presidential Advisor for Public
  Medical Services
  
• Executive Director, Tulane Community Health
  Center at Covenant House

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Overview

• What happened in New Orleans after Katrina
  regarding the care of vulnerable populations?
  
• What are lessons learned from that experience and
  recommendations?

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Pre-Storm Vulnerable Population

• As seen on TV
• 49th or 50th on UnitedHealthFoundation rankings
  for the past 6 years
  
• 20 of the population uninsured
• 250,000 vulnerable

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Safety Net Pre-Storm

• Centralized Charity Hospital System
• State run
• Hospital based clinics
• Staffed by Tulane and LSU faculty and residents
• Antiquated systems without patient linkage to
  primary care physicians and without EHR

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Defining Vulnerable

• Traditional
• Poor
• Women-headed households
• Elderly
• Homeless
• Severely mentally ill
• Immigrants

Morrow, Disasters, 1999
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Special Issues

• Burden of chronic illness
• Poor control
• Multiple medications
• Lower literacy
• Social support weaker
• Less financial reserves
• Lack of medical home

Centers for Disease Control and Prevention.
Health alert network http//www.phppo.cdc.gov/HAN
/ArchiveSys/ViewMsgV.asp?AlertNum00233
DeSalvo, JGIM, 2005 www.statehealthfacts.org
Greenough, NEJM, 2005
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Post-Storm Reality

• Doctors without hospitals or clinics
• Patients without doctors
• Public resources focused on shelters and the
  displaced
  
• In the city
• First responders
• Citizens who stayed behind
• Vulnerable populations
• Day-trippers

Niyogi, et al, AJMS, 2006 in press
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Reality

• In a disaster, everyone is vulnerable
• 200,000 homes destroyed
• Loss of social networks
• Unemployment and loss of insurance
• All providers become the safety net

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Providing Care

• On the fly
• Uncoordinated silos
• Unavailable medical information
• Broad scope of needs
• Urgent
• Chronic disease
• Mental health
• Educational

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Solution

• Flexibility
• Makeshift system
• Borrowed resources
• Private
• Local governmental
• Federal
• Ask forgiveness not permission

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9 oclock Meeting
DeSalvo, et al, Health Affairs, 2006
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USNS Comfort-Temporary Charity
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Temporary Ambulatory Settings
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Considerations for a Makeshift System

• Safety
• Site
• Staff
• Supplies
• Storage
• Scope of services
• Standard of care

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DeSalvo, Annals, 2005
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Goals in a Natural Disaster

• Mitigate disease, suffering, and death
• Sustain infrastructure, the economy, and societal
  functioning
  

Homeland Security Council National Strategy for
Pandemic Influenza. http//www.whitehouse.gov/hom
eland/nspi/pdf.
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Lesson Learned

• Exposed
• Weakness in our public health infrastructure
• Problems with a centralized health care system
• Complications of fragmented health system
• Lack of systems to coordinate and communicate
  with clinicians
  
• Need for regional coordination for persons with
  chronic disease

Greenough, NEJM, 2005 DeSalvo, ASIM, 2006
Redliner, Pediatrics, 2006
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Changed Strategy

• All Hazards Planning
• Communication, redundancy, systems
• Worst case scenario
• Public private partnerships
• Legal documents in place to allow partnerships
• Partnerships between medical and social services
  sectors
  
• Regional care networks

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Flexible Delivery
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Local Providers