COVID-19 has heightened public awareness of the importance of public health in various healthcare settings, revealed critical opportunities to improve infection prevention and control (IPC), and illuminated the ripple effects that gaps in IPC can have in healthcare facilities and communities. Local health departments (LHDs) have a growing role in infection prevention and control and many have seen their relationships with facilities evolve from one tied to mandatory reporting of outbreaks to a collaborative partnership for prevention.

NACCHO, with support from the Centers for Disease Control and Prevention (CDC) Division of Healthcare Quality and Promotion, is providing funding and technical assistance to 25 Building Local Operational Capacity for COVID-19 (BLOC COVID-19) demonstration sites to prevent and respond to COVID-19.

NACCHO spoke with Bill Dart Assistant Director of Public Health from Sangamon County, Illinois as well as Greg Danyluk, PhD, MPH, MS Epidemiology Program Manager and Bernie Kloppenburg, MPH, CPH, Lead Epidemiologist, Long-Term Care Facilities Response Team from Polk County, Florida, two of the participating local health departments from NACCHO’s BLOC COVID-19 demonstration sites, to learn more about how they have built, grown, and maintained relationships with high-risk facilities in their communities in order to support infection prevention and control efforts.

Could you describe how you established your partnerships with facilities in your region and how you built trust with them?

Sangamon: We let facilities in our jurisdiction know that the local health department is here and ready to consult with them. We let them know that we would be working with them on their cases and that we were also a resource for personal protective equipment (PPE)and testing supplies.

Being in touch with them, answering their questions, connecting them with resources they needed, and helping them to interpret state and federal guidance helped us to build those relationships.

Polk: We have gradually built partnerships with our long-term care facilities (LTCFs) mostly by staying in contact with them through regular email communications on infectious disease topics such as flu, respiratory syncytial virus, Legionnaires disease, norovirus, rotaviruses, and scabies and by working with the facilities when they have outbreaks of infectious diseases. We also participate in have a local emergency health and medical coalition meeting to give updates to LTCFs and emergency preparedness groups. We knew that LTCFs would present a special challenge during our response efforts, so we restructured our operations and accordingly, dedicating a core team of epidemiologists that communicated with our LTCFs experiencing active outbreaks and provided guidance and resources to prevent transmission. Especially as facilities have transitions in leadership, we continually engage and update them on the ever-changing guidance with our staff available seven days a week and a dedicated person assigned to each facility outbreak.

What lessons learned or successful strategies related to building facility partnerships have you gained from this experience?

Polk: Building partnerships with our LTCFs during the pandemic was critical. Part of our strategy to do this was to maintain constant communication with our facility contacts, like the Director of Nursing (DON) and the executive directors. We were able to help facilities that were struggling through the sea of ever-changing guidance, not just from CDC, but from the regulatory authority.

When we introduce ourselves, we establish a clear purpose of what our role is for them. We are not regulatory. We are there to provide education, guidance, and resource assistance for them.

One challenge we faced with our LTCFs was a high turnover rate among the local facility leadership, particularly the DON and the executive director. It often takes months to build these partnerships and establish trust with these local contacts. So, when someone new is on board, we have to begin building that relationship all over again. When we introduce ourselves, we establish a clear purpose of what our role is for them. We are not regulatory. We are there to provide education, guidance, and resource assistance for them. We set a tone and expectations early for what it’s like to work with us and go over how to report cases and outbreaks. We also provided consultation on testing and infection prevention strategies.

What are your plans to maintain relationships with facilities beyond COVID?

Polk: We have had relationships with facilities in Polk County prior to COVID-19 because we provide them with guidance and work with them through outbreaks such as flu or norovirus. We send regular email communications to LTCFs, including COVID-19 weekly surveillance reports, which show the trend of COVID cases, percent positivity, emergency department visits, hospitalizations and deaths over time to show them how the data we collect is used. We wanted to be transparent and establish a rapport. Additionally, the healthcare-associated infection (HAI) program in the state of Florida will occasionally conduct trainings or webinars on various organisms of concern and we make sure to share opportunities like this to our LTCFs. We also hold regular meetings with our local health, medical staff, and health medical coalition. We encourage LTCFs in our area are to join the local health coalition chapter.

Is there one lesson learned that you’ve experienced when it comes to building relationships with facilities to support IPC particularly with the COVID-19 response?

Polk: We are building trust by acknowledging the current issues that our LTCFs are experiencing and aligning with them by establishing a culture of “we are in this together.” We emphasize that they are not alone in this by demonstrating that we are facing similar issues, assuring that we are partners in this effort, and working on forming a resolution together.

Sangamon: A main lesson learned for us was being clear that we are non-regulatory and then checking in with them through regular email communications and phone calls, letting them know that we are there for support.

Do you have any overall advice that you would offer to other local health departments who may be struggling with facility relationships?

Sangamon: Do not be discouraged by some facilities not wanting to be partners immediately. That can be frustrating, but you have to proceed with the ones that are willing and not be discouraged or disgruntled by not having all of the facilities on board. Some facilities may just not come along right away.

Polk: Know your community and your health department’s level of experience with facilities in the past. When you introduce yourself, define what your role will be. Build trust and have routine communication with them before outbreaks happen. To support relationship building with facilities we created a standard operating procedure for our LTCF team, to ensure consistency with communication and general policies and procedures for outbreak management. We have a document that new staff can read and get a general idea of our operations. It has made training and onboarding much more efficient.

If you are having trouble with facilities that are part of a larger corporate structure, we found that presenting yourself to the local facility staff as a resource and not as an antagonistic relationship was more likely to lead to interactions with us. They still answer to a corporate office, but the local staff trust us to be a partner.

And leveraging regulatory agencies is an important part of this relationship. We do contact the regulatory agency if we are getting facility leadership that is clearly not being cooperative and might be endangering residents, but we try not to jump straight to the regulatory agency or corporate offices. We have a designated contact for our region and when we conduct an infection control assessment (ICAR), we share that information with the regulatory agency. We keep them informed of any disease patterns emerging in the community and any issues facilities are facing, while advocating for the facilities. We are protective of reporting negative things to the regulatory agency if a facility is struggling to meet an obligation but are working to meet standards. We explain to the agency the challenges the facility is facing and what they are doing well. Maintaining that transparency and communication helps prevent miscommunications between the regulatory agency, the facility, and the health department. It’s a triad of communication.

Has COVID impacted the perceptions that facilities have of the local health department?

Sangamon: Before COVID-19, we were just here when they had infections they needed to report. Since the pandemic, they really see us also as a source of comfort, someone they can go to for certain needs, commiserate about their situation, and troubleshoot their issues with cohorting and things like that. I think they appreciate us more certainly now.

Early on they may have felt they were going to be fine through the pandemic and then the guidance changed rapidly week to week, and they really needed someone to be a beacon or a guiding light to get them through it.

Polk: We have had a similar experience. Our level of communication has grown stronger since the pandemic. Prior to COVID-19, our relationship was based on data sharing through a regulatory obligation and now it is much more than that. Facilities reach out to us with general questions and for general support, like help to set up a vaccine program to help boost uptake among staff. We are more of a resource to them. Early on they may have felt they were going to be fine through the pandemic and then the guidance changed rapidly week to week, and they really needed someone to be a beacon or a guiding light to get them through it. And now that I think we have proven our worth to them, they are more receptive to using us as a routine or regular resource.

More about BLOC COVID-19

NACCHO’s Building Local Operational Capacity for COVID-19 (BLOC COVID-19) demonstration site project is designed to enhance local capacity to prevent and respond to COVID-19 by building health department capacity in infection prevention and control (IPC), supporting identified high-risk facilities by conducting in-person or virtual IPC assessments, and expanding collaboration and coordination between health departments and community infection prevention partners.