Isolation and Support Nurse Help Line

The County of San Diego (COSD) is a county in the southwestern corner of the U.S. state of California. As of the 2021 census, the population was 3,286,069 making it California's second-most populous county and the fifth-most populous in the United States. The County has five supervisorial districts. The Department of Public Health Services is one department in the COSD Health and Human Services Agency, and it serves all of San Diego County. According to the 2021 census, the County's demographics are 43.8% White (not Hispanic/Latino), 34.8% Hispanic/Latino, 12.9% Asian, 5.6% Black/African American, 4.9% two or more races, 1.4% American Indian/Alaska Native, and 0.6% Native Hawaiian/Pacific Islander (United States Census Bureau, 2021). Eighty-eight point three percent of residents have at least a high school degree or higher, and 40.3% have a bachelor's degree or higher (United States Census Bureau, 2021). Median household income is $83,454; and 10.7% of residents live under the poverty threshold (United States Census Bureau, 2021). Six point three percent of residents under 65 years have a disability, and 8.2% of residents under 65 years are uninsured (United States Census Bureau, 2021).

The first COVID-19 case recorded in a San Diego County resident was on March 9, 2020 (Alverez, 2020). When COVID-19 was declared a national emergency on March 13, 2020 (Biden Jr., J. R., 2022), cases increased to 55 cases (SanDiegoCounty.Gov, 2022). By March 30, 2020, there were 72 total cases (SanDiegoCounty.Gov, 2022). Testing was limited during this time. The first testing data available reports 123 tests for March 11, 2020; by March 31, 2020, 11,343 tests were reported (County of San Diego, Health and Human Services Agency, Public Health Services, Epidemiology and Immunization Services Branch, 2020). By April 8, 2020, COSD reported a total of 36 cumulative deaths from COVID-19. Of the 36 individuals, 10 (28%) were Hispanic/Latino, 15 (42%) were White, and two (6%) were Asian (CBS 8 San Diego, 2020). Demographic information was not available for the remaining nine cases.

County residents were increasingly concerned about contracting COVID-19. The low access to testing supplies increased County residents' concerns. COSD worked tirelessly to communicate with the public throughout the pandemic and planned its COVID-19 response interventions with a health equity focus.

On March 23, 2020, the County created a dedicated phone line for residents to call and be connected to a Public Health Nurse to address COVID-19 questions. Initially called the Nurse Triage Line, the County eventually renamed the phone line to the Isolation and Support Nurse Help Line (ISNHL). The County temporarily reassigned more than 30 Public Health Nurses to staff the line and utilized an existing partnership with 211 San Diego to establish the phone line using 211 San Diego's call center infrastructure. The ISNHL answered incoming calls from residents and expanded to make outgoing calls to residents that tested positive for COVID-19 at County-operated test sites. The goal of ISNHL was to provide wraparound services to populations disproportionately impacted by COVID-19, with a special focus on those needing to quarantine or remain in isolation. The ISNHL nurses provided resources and referrals to residents to ensure they had adequate resources while in quarantine and/or isolation. Core responsibilities of the ISNHL staff nurses are to:

1.      Respond to all live calls.

2.      Respond to off-hour voicemails.

3.      Provide education about COVID-19 and how to safely quarantine/isolate.

4.      Help schedule testing appointments as necessary and when available.

5.      Remind callers of testing options, including State and County-run testing sites.

6.      Document all caller(s) information using appropriate forms.

7.      Communicate positive and inconclusive test results to individuals via phone and email and assist individuals with receiving copies of their results via email if needed.

8.      Refer callers to various resources depending on needs (e.g., housing or food).

In October 2021, the ISNHL was integrated into one of the core activities of the Centers for Disease Control and Prevention (CDC) grant OT21-2103, the National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities. The ISNHL continues to call and reach positive COVID-19 cases and direct people to needed services. The process objectives and milestones for the ISNHL as part of this grant include the following:

1.      Maintain existing staff and/or hire additional staff to continue providing helpline services.

2.      Coordinate with entities (e.g., health care providers, testing sites, and community organizations) to refer individuals to the ISNHL.

3.      Contract/partner with agencies providing lodging, food, transportation, and medical care to ensure individuals have comprehensive services to meet their needs while in isolation.

From March 23, 2020 to September 30, 2022, the ISNHL received 116,493 incoming calls and answered over 115,000 calls from the public. In addition, between November 1, 2020 and September 30, 2022, the ISNHL made more than 170,000 outgoing calls to speak with residents who tested positive at a COVID-19 test site operated by the County of San Diego.

ADDITIONAL LINKS

·         Main COSD COVID-19 site: https://www.sandiegocounty.gov/coronavirus.html

·         COSD testing site:  https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/community_epidemiology/dc/2019-nCoV/testing.html

·         211 San Diego: https://2-1-1sandiego.org/

References

Álvarez, J. A. (2020, March 10). San Diego County's first positive COVID-19 case reported. San Diego County News Center. Retrieved December 26, 2022, from https://www.countynewscenter.com/san-diego-countys-first-positive-covid-19-case-reported/  

Biden Jr., J. R. (2022, February 18). Notice on the continuation of the national emergency concerning the Coronavirus Disease 2019 (covid-19) pandemic. The White House. Retrieved December 13, 2022, from https://www.whitehouse.gov/briefing-room/presidential-actions/2022/02/18/notice-on-the-continuation-of-the-national-emergency-concerning-the-coronavirus-disease-2019-covid-19-pandemic-2/#:~:text=On%20March%2013%2C%202020%2C%20by,and%20safety%20of%20the%20Nation 

CBS 8 San Diego. (2019, April 8). San Diego County officials provide daily coronavirus update - April 8, 2020. [Video]. YouTube. https://www.youtube.com/watch?v=2skkHiBFAEg

County of San Diego, Health and Human Services Agency, Public Health Services, Epidemiology and Immunization Services Branch. (2022, December 8). County of San Diego - Coronavirus Disease 2019 (COVID-19). ArcGIS dashboards. Retrieved December 13, 2022, ‌‌‌‌‌from https://www.arcgis.com/apps/dashboards/96feda77f12f46638b984fcb1d17bd24      

SanDiegoCounty.Gov. (2022, December 8). Cases, hospitalizations, and deaths by Demographics. Coronavirus Disease 2019. Retrieved December 13, 2022, from https://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/community_epidemiology/dc/2019-nCoV/status/COVID19_Cases_Hospitalizations_Deaths_by_Demographics.html  

United States Census Bureau. (2021, July 1). U.S. Census Bureau QuickFacts: San Diego County, California. QuickFacts. Retrieved December 13, 2022, from https://www.census.gov/quickfacts/fact/table/sandiegocountycalifornia/PST045221

The ISNHL is a unique service created for a novel issue—COVID-19 quarantine and isolation on a countywide scale. Because no similar circumstances existed on a large scale before the pandemic, there was no existing service in place to address this incident. The ISNHL was created to fill the need of bridging individuals to testing services, offering recommendations on quarantine and isolation procedures, and supporting those in quarantine/isolation with links to needed services. The ISNHL further demonstrates innovation in practice by addressing the disparities that minority and low-income populations face by having a pool of connected resources at their disposal. It used a call center model in answering live calls as well as providing outgoing calls to individuals, and also actively providing outreach to individuals via emails, whom could not be reached via phone.

PRIORITY POPULATION

The priority population for ISNHL is high-risk and underserved individuals, including racial and ethnic minority groups, and people living in rural communities. Racial and ethnic minority populations in San Diego include the following population estimates from the 2015-2019 American Community Survey 5-Year Estimates:

·         American Indian and Alaska Native (Non-Hispanic): 12,500 residents;

·         Black or African American (Non-Hispanic): 156,100 residents;

·         Native Hawaiian and Other Pacific Islander (Non-Hispanic): 12,800 residents;

·         Asian (Non-Hispanic): 394,700 residents; and

·         Hispanic or Latino (of any race): 1,117,500 residents.

Additional populations of focus included: Rural populations: 515,400 residents in unincorporated areas (San Diego Association of Governments 2019) and persons experiencing homelessness: 7,600 (Regional Taskforce for the Homeless). The cumulative priority population size is approximately 2,216,600 individuals. The specific priority populations for the ISNHL are individuals in the priority population, and individuals who tested positive for COVID-19 and/or called the ISNHL to seek COVID-19 resources and support. 

The total number of outgoing and incoming calls from March 23, 2020 to September 30, 2022 is 289,049 calls. This number includes the 116,493 calls that the ISNHL answered between March 23, 2020 and September 30, 2022, and 172,556 outgoing calls the ISNHL made between November 1, 2020 and September 30, 2022. The outgoing calls were to individuals who tested positive for COVID-19 at a test site operated by the County of San Diego. Information on how many of the calls were with duplicate individuals is not available.

HEALTH EQUITY

The priority populations were identified because health inequities for racial and ethnic minority groups persist in San Diego County. For example, American Indian/Alaska Native and Hispanic residents had the lowest health insurance status in 2019 (Community Health Statistics Unit, 2022). In addition, 1 in 5 Black/African residents reported unfair treatment when receiving medical care resulting in an increase of chronic diseases and delays in diagnosis/treatment (Community Health Statistics Unit, 2022).

Self-isolation and distancing are difficult to achieve for individuals living in congested household conditions and persons experiencing homelessness. The populations most at risk of living in overcrowded housing are Hispanic/Latino, Native Hawaiian/Pacific Islander, and African-American populations. This issue is very new and unique since quarantining was not commonly practiced on a large scale pre-COVID-19. The ISNHL was the first intervention of its kind to address this issue since the start of the pandemic.

Health equity was at the forefront of designing every action for COSD's COVID-19 response, including the ISNHL. The ISNHL coordinated with several health care providers, testing sites, and community organizations to refer individuals back to the line. They also formed a partnership with 211 San Diego, a contract/partner agency of COSD to provide lodging, food, transportation, and medical services to ensure vulnerable individuals have comprehensive services to meet their needs while in quarantine/isolation.

The second most spoken language in San Diego County is Spanish. To accommodate reaching out to all persons who tested positive and being mindful of the large Hispanic/Latino population, especially during surges, the ISNHL nurses sent emails to positive cases in both English and Spanish. In addition, callers may request any language while calling the ISNHL and an interpreter of their chosen language is able to join the call and provide live interpretation. To ensure that the priority populations knew of this resource and were able to access it, the ISNHL was promoted through the COSD press briefings, Live Well San Diego sector telebriefings, and newsletters. Examples of Live Well San Diego sectors include the business sector, community and faith-based sector, rural sector, and education sector.

EVIDENCE-BASED PRACTICE

The ISNHL followed evidence-based practices in its design and implementation. The County Nurses were trained in maintaining the line. While it initially used the 211 San Diego service, which is a long-time County contractor, patients calling to inquire about COVID-19 symptoms and testing options were routed to an internal centralized County phone number that was managed by County Nurses. According to Kappa et al. (2020), using an internal centralized call center lowered operating costs by 7.7% and provided higher operation efficiency. Surveys conducted in this study showed the importance of staff training with feedback, simplified work algorithms, and expanded clinical roles (Kappa et al., 2020). Mayfield et al. (2021) also found that calling using a messaging campaign that contacted members of priority populations using text and voice messages increased the population's odds of seeking COVID-19 testing and scheduling health care appointments overall. They also showed that messaging campaigns may reduce disparities in minority populations, though some existing barriers may persist (Mayfield et al., 2021).

References

Community Health Statistics Unit. (2022, January). Racial Equity: Framework & Outcomes Brief. County of San Diego, Health and Human Services Agency, Public Health Services. https://www.sandiegocounty.gov/content/dam/sdc/hhsa/programs/phs/CHS/Racial%20Equity%20Framework%20and%20Outcomes%20Brief%2C%20Data%20Guide.pdf

Kappa, S. F., McClain, C., Wallace, K., Cinquina, P., Lawson, D., Smith, M. M., Walz, E., Edwards, B., & Kirsh, G. M. (2020). Implementation of a Centralized, Cost-effective Call Center in a Large Urology Community Practice. Reviews in urology, 22(2), 67–74.

Mayfield, C. A., Sparling, A., Hardeman, G., de Hernandez, B. U., Pasupuleti, N., Carr, J., Coltman, K., & Neuwirth, Z. (2021). Development, Implementation, and Results from a COVID-19 Messaging Campaign to Promote Health Care Seeking Behaviors Among Community Clinic Patients. Journal of community health, 46(4), 728–739. https://doi.org/10.1007/s10900-020-00939-0

COSD initiated the ISNHL, in March 2020, with an existing community partner, 211 San Diego. 211 San Diego is a resource line for San Diego County. The ISNHL used 211 San Diego's infrastructure. Individuals would call 2-1-1 to connect to a Public Health Nurse staffed on the ISNHL. In November 2021, nurses began to call positive cases with a separate County of San Diego phone number. During the initial testing shortage, people called the ISNHL to talk about their symptoms in order to be approved to receive a COVID-19 test. Once there were enough testing supplies for everyone who wanted a test, the ISNHL would assist individuals to receive their test results. ISNHL nurses also proactively called people who tested positive for COVID-19 to provide support and referrals to appropriate resources.

COLLABORATION

There was no collaboration with the priority population when the ISNHL was initiated as the COSD needed to act swiftly during the pandemic and ensure that it took all necessary actions to mitigate existing disparities and prevent further exacerbation. The ISNHL was promoted through the COSD press briefings, Live Well San Diego sector telebriefings, and newsletters. Examples of Live Well San Diego sector include the business sector, community and faith-based sector, rural sector, and education sector. Starting in early 2021 the ISNHL was no longer part of 211 San Diego's service. However, 211 San Diego remained an active partner; the ISNHL referred callers in need of services to 211 San Diego's pool of resources. This shift was relatively easy to make because 211 San Diego has been an existing partner of COSD well before COVID-19. 

LHD ROLE IN PLANNING AND IMPLEMENTATION

The County of San Diego helped to establish and maintain the ISNHL since its beginning. The ISNHL's goal is to support families that are disproportionately impacted by COVID-19 by reducing barriers of isolation such as households living in close quarters, limited income, and/or potential loss of employment. The ISNHL provides case management services to persons who are isolating due to being positive for COVID-19. The nurse and support specialists assess the persons' needs to safely isolate and then connect them to needed services such as temporary lodging, general relief, food, transportation, and medical services. These services help decrease the spread of COVID-19 and improve health outcomes through provision of health/social service resources to families.

Some of the initial and evolving duties of the staff who work on the ISNHL include:

·         Participate in trainings so all Nurses ensure standardized service;

·         Staff the ISNHL from 8:00 am to 8:00 pm every day to answer live calls;

·         Document all caller(s) information using appropriate forms;

·         Schedule test appointments when appropriate and available;

·         Receive verbal consent for patients that are scheduled at Drive Up Testing Sites;

·         Remind callers about additional testing options, including testing sites managed by the State, and provide appropriate contact information;

·         Communicate positive and inconclusive test results to individuals; and

·         Refer callers to various resources depending on needs (such as housing or food).

STAFFING AND BUDGET

When the ISNHL first formed, several COSD staff members were reassigned to ensure the line was successful. Initial staffing for ISNHL included 30 Public Health Nurses, four (4) Public Health Nurse Supervisors, and four (4) Health Promotion Specialists to operate the ISNHL 12 hours a day, seven days a week. The cost of the ISNHL came from COSD's general funds. Over time, the ISNHL reduced staff and hours, as need and call volume changed. In June 2021, the ISNHL became fully funded by the CDC 2103 grant, with a budget of approximately $1.2 million for 2 years.

The ISNHL has been successful in implementing this intervention due to the high level of coordination between staff, County organizers, and 211 San Diego. 211 San Diego has a broad range of resources that the ISNHL was able to access through the ongoing partnership. This streamlined connecting individuals in need of support with required resources, enabling access through one source for all services rather than multiple sources for various needs. All nursing staff maintaining the helpline were trained in managing the line. The intervention had clearly outlined objectives that were documented in a reference guide for all nurses to reference when needed. The ISNHL's dedication to internal collaboration contributed to the team's successes. They facilitated coordination to triage calls during periods of high call volume which occurred during the several COVID-19 surges. This ensured responses were provided to all COVID-19 cases and callers.

From March 23, 2020 to September 30, 2022, the ISNHL answered over 115,000 calls from the public. In addition, between November 1, 2020 and September 30, 2022, the ISNHL made more than 170,000 outgoing calls to speak with residents who tested positive at a COVID-19 test site operated by the County of San Diego.

The ISNHL managers reviewed call logs in order to identify trends in calls and call volume, to prepare resources, and to staff appropriately. For example, from March 2020 to May 2020, about 10% of calls on the ISNHL were conducted in Spanish, so a minimum of one Spanish-speaking Public Health Nurse was always staffed on the line.

In October 2021, the ISNHL was integrated into one of the core activities of the Centers for Disease Control and Prevention (CDC) grant OT21-2103, the National Initiative to Address COVID-19 Health Disparities Among Populations at High-Risk and Underserved, Including Racial and Ethnic Minority Populations and Rural Communities. The process objectives and milestones for the ISNHL as part of this grant include the following:

1.      Maintain existing staff and/or hire additional staff to continue providing helpline services.

2.      Coordinate with entities (e.g., health care providers, testing sites, and community organizations) to refer individuals to the ISNHL.

3.      Contract/partner with agencies providing lodging, food, transportation, and medical care to ensure individuals have comprehensive services to meet their needs while in isolation.

The objectives of the ISNHL were met. The ISNHL maintains existing staff and hired additional staff as needed. It coordinated with entities such as the Live Well San Diego sectors and their pool of community organizations to refer individuals to the ISNHL. It partnered with 211 San Diego to provide lodging, food, transportation, and medical care to ensure individuals have comprehensive services to meet their needs while in isolation. It also provided all positive cases it called and/or received calls from with the following services:

·         Basic needs: 55.3%

·         Income support and employment: 18.3%

·         Target populations: 15.8%

·         Organization/community/international services: 7.3%

·         Health care: 1.1%

·         Mental health and substance use disorder: 0.9%

·         Individual and family life: 0.8%

·         Consumer services: 0.2%

·         Criminal justice and legal services: 0.2%

·         Environment and public health safety: 0.1%

This practice was intended to serve San Diego County residents' needs arising due to COVID-19 disparities during quarantine and isolation. This practice will end at the end of the CDC 2103 grant's end, in June 2023. No further plans were made to maintain the ISNHL especially as COVID-19 cases and disease burden are decreasing, although information will be available online, and residents will receive steps to access their test results. 211 San Diego will continue to connect people with community, health and disaster services 24/7/365.

COSD developed the infrastructure to receive calls and software to log call notes with COSD's Information Technology department. In addition, staff wrote an Operations Manual for the ISNHL that includes descriptions of activities and workflows, in case the ISNHL needs to be re-established for another public health emergency.