1. North Carolina Preparedness & Emergency Response Research Center (NCPERRC) Structural Capacity of North Carolina’s Public Health Regional Surveillance Teams (PHRSTs)

2. North Carolina Preparedness & Emergency Response Research Center (NCPERRC) This research is a part of the North Carolina Preparedness and Emergency Response Research Center (NCPERRC) which is located at the University of North Carolina at Chapel Hill’s Gillings School of Global Public Health and was supported by the Centers for Disease Control and Prevention (CDC) Grant 1PO1 TP 000296-02. The contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC.

3. Authors 1Milissa Markiewicz, MPH, MIA 1 Jessica Sage, MPH 1 Jennifer Horney, PhD, MA, MPH, CPH 1,2 1Jennifer Hegle, MPH 1 1Allison George, MPH 1 3Anne-Marie Meyer, PhD 3 Pia MacDonald, PhD, MPH, CPH 1,2 1: North Carolina Institute for Public Health, Gillings School of Global Public Health, University of North Carolina (UNC) 2: Department of Epidemiology, Gillings School of Global Public Health, UNC 3: Cecil. G. Sheps Center for Health Services Research, UNC

4. Background Many states have developed regional structures to better coordinate preparedness and response efforts, consolidate services, and supplement local government agencies In 2001, NC established 7 PHRSTs to build local capacity to prevent, prepare for, respond to, and recover from public health events

5. Who are the PHRSTs? PHRSTs were originally designed to include a physician/epidemiologist, an industrial hygienist, a nurse/epidemiologist, and an administrative support technician; 3 pharmacists are shared by the 7 teams PHRSTs are located at a host local health department (LHD) in their designated region They provide support and services to an average of 12 LHDs (range, 7 – 17)

6. What do PHRSTs do? PHRST provide support and services in the following areas: –Preparedness planning –Epidemiology and surveillance –Consultation and technical assistance –Communication and liaison assistance –Training –Exercises –Public health event response

7. Research Goal The overall goal of the study is to develop a better understanding of the impact of regionalizing public health workforce assets by: Assessing the structural capacity of the 7 PHRST teams Identifying variation in structural capacity between PHRSTs Exploring the implications of any observed variations

8. What is Structural Capacity? Structural capacity is defined as “program inputs” and includes 5 types of resources: –Human –Fiscal –Informational –Physical –Organizational In order to effectively support LHDs and provide needed services, PHRSTs must have adequate and appropriate structural capacity

9. Methods Extensive literature review of public health systems and services research (PHSSR) methods Review of capacity measures from related disciplines Development of constructs to measure each of the 5 types of resources that comprise structural capacity Paper-based surveys and face-to-face interviews with each PHRST to gather data on each team’s structural capacity

10. Structural Capacity Dimensions and Sample Measures DimensionSample Measures HumanTeam composition, experience, academic and other training FiscalBudget, sources of funds InformationalNumber and diversity of partners, communication mechanisms PhysicalEquipment, space OrganizationalDirectives, accountability

11. Selected Findings: Human Resources PHRST composition now varies; the only full- time position common to all teams is an administrative support technician Average team size is 3.75 full-time equivalent (FTE) employees (range: 3.05 – 4.25)

12. Selected Findings: Human Resources Physician/Epidemiologist –5 of the 7 teams are led by a physician –Some teams felt a physician afforded their team credibility with LHDs and other partners –Other teams felt LHDs already have sufficient access to a physician Nurse/Epidemiologist –6 of the 7 teams have a nurse –1 team replaced this position with an epidemiologist as LHDs employ nurses but don’t generally have an epidemiologist, and therefore lack this expertise

13. Selected Findings: Human Resources Industrial Hygienist/Environmental Specialist –Teams were most divided over the need for industrial hygienist or environmental specialist –Some teams felt LHDs do not have staff with expertise in industrial hygiene (IH), and that an individual with academic training in IH provided a unique and important skill set to LHDs –Others felt that there was more work for an environmental health specialist, and that training in environmental health would enable an individual to fill the industrial hygienist role as well

14. Selected Findings: Fiscal Resources Team budgets averaged $418,162 (range: $348,872 - $481,432) for fiscal year July 1, 2008 – June 30, 2009 All teams reporting receiving in-kind support from their host LHD in the form of information technology resources, training, finance personnel/assistance, and meeting space

15. Selected Findings: Informational Resources The average number of preparedness and response partners per team was 61 (range: 47-71) 30 groups were listed as partners by all 7 teams Teams universally expressed the importance of working with partners in order to accomplish their mission 6 of the 7 teams reported common barriers to electronic communication with LHDs and other partners; the most common problem reported was limited email in-box space, both on the part of PHRSTs and their partners

16. Selected Findings: Physical Resources There were few differences in the equipment owned by PHRSTs, which included: –Basic office equipment –IT and communications equipment –Vehicles

17. Selected Findings: Organizational Resources PHRSTs reported receiving directives from: –Office of Public Health Preparedness and Response (PHP&R) at the North Carolina Department of Public Health (NCDPH) –Their host LHD –LHDs in the region –Communicable Disease Branch at NCDPH –Emergency Management –NC Department of Environment and Natural Resources

18. Selected Findings: Organizational Resources 4 teams prioritized directives received from their host LHD 3 teams gave priority to directives received from PHP&R All teams listed PHP&R, their host LHD, and the LHDs in their region as the 3 groups to which they felt most accountable; however, the order varied by team

19. Conclusions Significant variation between PHRSTs cannot be explained by demographic or geographic variables. Two areas of PHRST structural capacity stand out as potentially needing attention: –Human resources –Organizational resources

20. Conclusions: Human Resources PHRSTs offered varying rationales for why each position was important to carrying out their team’s mission (e.g., some teams believe they can best enhance local capacity by providing LHDs with expertise they lack) It may be useful to reevaluate team composition based on the support and services PHRSTs provide: –What types of support and services are most critical to LHD response capacity? –Are PHRSTs appropriately configured to provide these services? –How much flexibility in team composition is necessary/desirable to meet varying local needs?

21. Conclusions: Organizational Resources PHRSTs are in the challenging position of receiving directives from, and being accountable to, a variety of entities at the local, regional, and state level This situation seems to have contributed to a lack of clarity regarding the role of PHRSTs on the part of PHRSTs themselves, as well as their host and regional LHDs It may be useful to examine the factors causing differences in perceived accountability so that the role of PHRSTs is more clearly defined

22. Related and Current Research A companion study examined the support and services PHRSTs provide to LHDs, and variation in services provided by different teams Current research is underway to examine whether variation in PHRST structural capacity and the services they provide to LHDs is associated with variation in LHD preparedness capability

23. Questions? Contact Information Jennifer Horney, PhD, MA, MPH, CPH Research Assistant Professor, Department of Epidemiology Deputy Director, UNC Center for Public Health Preparedness North Carolina Institute for Global Public Health’ University of North Carolina CB 8165 Chapel Hill, NC 27599 jen.horney@unc.edu