Doing Good by Playing Well with Others: Exploring Local Collaboration for Emergency Preparedness and Response

Abstract

Increasingly frequent and costly disasters in the US have prompted the need for greater collaboration at the local level among healthcare facilities, public health agencies, emergency medical services, and emergency management agencies. We conducted a multiphase, mixed-method, qualitative study to uncover the extent and quality of existing collaborations, identify what factors impede or facilitate the integration of the preparedness community, and propose measures to strengthen collaboration. Our study involved a comprehensive literature review, 55 semistructured key-informant interviews, and a working group meeting. Using thematic analysis, we identified 6 key findings that will inform the development of tools to help coalitions better assess and improve their own preparedness community integration.

Increasingly frequent and costly disasters in the US have prompted the need for greater collaboration at the local level among healthcare facilities, public health agencies, emergency medical services, and emergency management agencies. The authors conducted a multiphase, mixed-method, qualitative study to uncover the extent and quality of existing collaborations, identify what factors impede or facilitate the integration of the preparedness community, and propose measures to strengthen collaboration. The study involved a comprehensive literature review, 55 semistructured key-informant interviews, and a working group meeting.

In recent years, disasters have increased in their frequency and impact.¹ Changing climate conditions are engendering more extreme weather events, and more people are living in risky environments because of population, migration, and development pressures.² These trends are not likely to change in the foreseeable future. At the same time, the health consequences of disasters often exceed the capacity of a single hospital or response agency. In the US, the disconnect between disaster consequences and institutional capacities has triggered the need for greater collaboration at the local level among healthcare facilities, public health agencies, emergency medical services, and emergency management agencies. Enhanced integration of these entities is proving fundamental to the nation's strategy for building healthcare resilience to disasters. We conducted a multiphase study to uncover the extent and quality of existing collaborations, identify what factors impede or facilitate the integration of the preparedness community, and propose measures to strengthen collaboration. This research is part of a larger project funded by the US Centers for Disease Control and Prevention (CDC) to find ways to promote collaboration at the local level.

Background

Government grant requirements, guidance documents, and scholarly analyses have emphasized the critical role of collaboration in managing disasters and their health consequences (see Table 1). Historically, federal funds have played an influential role in facilitating collaboration among the various sectors involved in preparing for and responding to public health emergencies. Sources of federal funding streams reflect the inherently multidisciplinary nature of healthcare preparedness. These streams originate from several agencies in the Department of Health and Human Services (HHS) and the Department of Homeland Security (DHS). Notable HHS funding programs include the Healthcare Preparedness Program (HPP) in the Office of the Assistant Secretary for Preparedness and Response (ASPR) and the Public Health Emergency Preparedness (PHEP) cooperative agreements and the Cities Readiness Initiative (CRI), administered by CDC. Key DHS programs, administered through the Federal Emergency Management Agency (FEMA), have included the Urban Area Security Initiative (UASI) and the Metropolitan Medical Response System (MMRS) program, which is no longer funded.

Table 1.

Recent Texts Promoting Collaboration in the Management of Disasters and Their Health Consequences

Document	Emphasis on Collaboration
The Joint Commission's Emergency Management standards	Requires accredited hospitals to plan and exercise in collaboration with community partners' exercise activities and to promote partnerships to address incident management capabilities³
Department of Health and Human Services (HHS), Office of the Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program (HPP) guidance	Requires recipients of HPP cooperative agreements to “develop or refine healthcare coalitions”⁴
CDC, Office of Public Health Preparedness and Response (OPHPR)'s Public Health Emergency Preparedness program (PHEP) guidance	Program guidance stipulates that “the healthcare system role in community preparedness involves coordination with emergency management, public health, mental/behavioral health providers, community and faith-based partners, state, local, and territorial governments …”⁵
Homeland Security Presidential Directive 5	“The Federal Government recognizes the role that the private and nongovernmental sectors play in preventing, preparing for, responding to, and recovering from terrorist attacks, major disasters, and other emergencies. The Secretary [of DHS] will coordinate with the private and nongovernmental sectors to ensure adequate planning, equipment, training, and exercise activities and to promote partnerships to address incident management capabilities.”⁶
Homeland Security Presidential Directive 21	Refers to “vertical and horizontal coordination across levels of government, jurisdictions, and disciplines; a regional approach to health preparedness; engagement of the private sector, academia, and other nongovernmental entities in preparedness and response efforts.”⁷
Presidential Policy Directive 8	Directs that “[t]he national preparedness system shall be designed to help guide the domestic efforts of all levels of government, the private and nonprofit sectors, and the public to build and sustain the capabilities outlined in the national preparedness goal.”⁸
National Health Security Strategy (NHSS)	“It is the responsibility of local, state, territorial, tribal, and federal governments to provide guidance and facilitate collaboration and coordination among individuals, families, and communities, including the private sector, to implement strategies to prevent, protect against, respond to, and recover from an incident.”⁹
HHS handbook on Medical Surge Capacity and Capability	Describes the concept of a healthcare coalition for emergency preparedness and response as comprising “healthcare organizations and other assets … that form a single functional entity to maximize medical surge capacity and capability in a defined geographic area. It coordinates the mitigation, preparedness, response, and recovery actions of medical and healthcare providers, facilitates mutual aid support, and serves as a unified platform for medical input to jurisdictional authorities.”¹⁰
UPMC Center for Health Security's evaluation report on the US Hospital Preparedness Program	Noted the rapid development of coalitions across the country. Every working group participant indicated that some sort of coalition of healthcare facilities and preparedness and response agencies in their community has developed.¹¹

Collaboration among public health agencies, hospitals and clinics, allied health organizations, emergency management offices, and emergency medical services agencies takes many forms. Healthcare coalitions represent one model of collaboration between these entities and are defined by the US government as “single functional entities of healthcare facilities and other healthcare assets to organize and implement the mitigation, preparedness, response, and recovery actions of medical and healthcare providers in a jurisdiction's healthcare system.”¹²^(p138) However, collaboration for healthcare preparedness is not always so structured. Indeed, many jurisdictions in the US rely on less-formal relationships between sectors to carry out preparedness and response activities.

The creation of healthcare coalitions for emergency preparedness and response is now mandated for federal funding through the HPP and encouraged through the PHEP program.^4,5,13 The literature shows that coalitions are now ubiquitous, with over 90% of hospitals reporting that they participate in a coalition¹⁴ and that they collaborate with community partners.¹⁵ In addition to mandating the establishment of healthcare coalitions, ASPR has released guidance to facilitate member preparedness, including most recently its Checklist for Healthcare Coalitions for Ebola Preparedness.¹⁶

Anecdotal evidence suggests that coalitions have improved responses to real disasters (eg, the Virginia Tech shooting, the Minnesota bridge collapse, the 2009 H1N1 influenza pandemic, the Joplin, Missouri, tornado).¹¹ Despite these experiences, it remains unclear how capable many of these coalitions are. Some federal, state, and local officials have said in private conversation that some coalitions may look better on paper than in reality.

Coalition leaders have stated publicly that strengthening local collaboration and building coalitions is not easy, especially without additional funding. Many of the most successful coalitions received special funding—in some cases, over $1 million.¹⁷ Whether the success of these coalitions can be replicated among other coalitions without this extra funding is not clear.

In qualitative research previously conducted with coalition leaders across the country,^11,18 it was a common refrain among some (but not all) that they experienced limited engagement by one or more of the essential partners. Similar rationales for the reluctance to engage are conveyed from different sectors: From public health, it is argued that disaster preparedness is not in their core mission; emergency management agencies are said to argue that disaster preparedness and response is their exclusive turf; and hospital executives are said to point out that their cost/benefit analysis of disaster preparedness indicates that preparedness is not the best use of limited financial resources.

Finding ways to address these arguments and overcome this reluctance to collaborate could help to promote emergency preparedness. In doing so, it is important to understand that every community is unique and every effort at local collaboration looks different. They have distinctive structures, origins, histories, and politics.¹¹ Thus, it is likely that a range of strategies will be necessary to strengthen collaboration. At the same time, coalition leaders have expressed a real hunger to learn from each other and to share best practices. Facilitating such exchanges, sharing lessons learned, and identifying opportunities to improve collaboration should lead to greater community integration of local preparedness.

Methods

We conducted a multiphase investigation with 3 goals in mind: to examine the extent and quality of existing collaborations for healthcare preparedness, to identify significant facilitators and barriers to integration of the preparedness community, and to propose specific measures that could strengthen collaboration for healthcare readiness and response. The research was deemed exempt by the University of Pittsburgh Institutional Review Board.

Phase 1

We conducted a systematic PubMed literature review to identify issues, barriers, and solutions related to community-based integration of public and private entities for health emergency preparedness. The publication time frame was January 1, 1995, through August 1, 2013. Search terms were: healthcare coalitions, healthcare emergency preparedness, community emergency preparedness, emergency management collaboration, hospital preparedness coalitions, hospital preparedness collaboration, public health emergency preparedness coalitions, public health emergency preparedness collaboration, and community preparedness and response. Our initial search generated 298 publications, and the abstracts were screened for relevance.

Ninety-nine articles met the following inclusion criteria and were reviewed in depth: pertaining to the US context; addressing local or state-level collaboration for healthcare preparedness OR other disaster-related purpose; and an example of peer-reviewed research, guidance from an authoritative body, OR an expert consensus statement. Commentaries, letters, opinions, and editorials were excluded. From this review we distilled 4 major themes:

• Healthcare preparedness collaborations have diverse origins and degrees of formality;

• They often lack clear governance structures, limiting effectiveness;

• Their joint activities vary in scope and focus, limiting generalizability about key functions; and

• Coalitions often neglect to engage other stakeholders important for broad healthcare preparedness.

These themes were used to guide interviews in phase 2.

Phase 2

We conducted 55 semistructured interviews to elicit stakeholder views on how cross-sector collaboration has enhanced healthcare preparedness, which factors promote and/or inhibit collaboration, whether current national programs in healthcare preparedness are working, and what measures could further integrate diverse practitioner communities to benefit healthcare readiness and response. Interviews were typically 30 minutes in length and conducted by telephone. Interviewees were recruited from an initial convenience sample of known key informants. Additional interviewees were added by snowball sampling.

Interviewees included practitioners from public health, healthcare, emergency management, and emergency medical services; authorities in these fields at federal, state, and local levels of government; and leaders of relevant national professional organizations. We also interviewed healthcare practitioners from geographically diverse disaster-affected communities under the literature- and interviewee-derived assumption that professionals discovered collaboration's benefits under the stress of real events. Although we sought diversity with respect to geography and the types of disasters experienced by the interviewees, there was no attempt to seek diversity based on specific characteristics of the coalition in their community.

A summary report for each interview was prepared, synthesizing the audiotaped conversation and the records of a dedicated note taker. Audiotapes were consulted to clarify and refine the contemporaneous typed notes and to confirm verbatim quotes. The project team, including senior researchers with a long engagement with the topics of healthcare preparedness and coalition formation, participated in an iterative process of thematic analysis. Developed on the basis of the literature review, certain a priori themes were embedded in the interview protocol. Additional themes and subthemes were induced during periodic team discussion of the summary reports and a comparison among the reports. These debriefing and analytic sessions were used to generate an initial coding schema that was then applied to the summary reports as a whole using NVivo software (version 10). Continuous monitoring of the coding confirmed that thematic saturation was achieved.

Phase 3

On September 15, 2014, a 1-day working group meeting was convened in Baltimore, MD, to explore the US healthcare preparedness landscape, to discuss the findings from the previous phases of the study, and to consider what new practical tools, if any, could strengthen collaborations to minimize the health impacts of disasters. Meeting participants consisted largely of a subset of interviewees from phase 1. (See Figure 1 for institutional affiliations of interviewees and meeting participants.) The meeting program consisted of presentations of the phase 1 and phase 2 research findings followed by facilitated discussion among all the attendees. The meeting proceedings were conducted with an understanding that no statements would be attributed to a specific individual or institution.

Figure 1.

Institutional Affiliations of Participants in Interviews and/or Working Group Meeting

Findings

The following were the predominant themes arising from the working group meeting. They represent an iterative consideration of phase 1 and phase 2 findings, meeting participant confirmation of these findings, reflections on their significance, and practical next steps. Table 2 lists all the themes discovered in the research.

Table 2.

Themes That Emerged from Interviews and Working Group Meeting

Common Attributes of Coalitions
Stakeholder composition	Coalition members include diverse entities representing different sectors.
Continuum of formality in coalition structure	There are varying degrees of formalized relationships among coalition members, ranging from “gentlemen's agreements” to codified rules and regulations.
Diverse origins	Catalyzing events are often responsible for spurring coalition formation and growth.
Common vision	Coalition members have a shared mission around which to rally and organize activities.
Obligatory or voluntary participation	Certain entities are obligated (sometimes legally) by their missions to participate in coalitions, while others may add value even if they are not formal participants.
Value Added by Coalitions
Collective action	Coalition members are better equipped to work together in unison.
Relationships	Coalition members develop relationships that foster increased understanding between entities and their capabilities.
Operational efficiency	Coalitions are able to execute enhanced responses to public health and/or healthcare emergencies.
Patient management	Coalition activities result in reductions in morbidity and mortality, improved patient care, and more positive patient outcomes.
Greater preparedness	Coalitions are better prepared to respond to public health and/or healthcare emergencies.
Facilitators of Coalition Building
Disaster response experience	Practical experiences with disasters illustrate the need to collaborate and the cost(s) of not collaborating.
Forums and exercises	Coalitions engage in coordinated meetings that convene diverse member stakeholders to address specific issues.
Routine, face-to-face meetings	Regular interactions and meetings among diverse coalition members improve the quality of collaboration.
Direct funding	Direct monetary support from the government enables healthcare facilities to participate in coalitions.
Coordinating entities	Outside entities coordinate linkages among emergency management agencies, EMS agencies, healthcare facilities, and public health agencies.
Grant alignment	There is synergy between the demands of funding streams originating from CDC, DHS, and HHS.
Healthcare executive involvement	Coalitions have the support of hospital executives in carrying out activities.
Impediments to Coalition Building
Monetary issues	Coalitions lack funding (or funding mechanisms) to finance their activities.
Organizational cultures	There is friction between the diverse members of a coalition (ie, different perceptions of how to do things).
Grant alignment	Coalitions must contend with competing priorities as dictated by grant guidelines.
Leadership	Leaders of stakeholder groups are uninterested or have competing priorities.
Poor information flow	Coalition members do not communicate with each other and thus do not understand one another's activities and capabilities.

1. Local preparedness community integration is diverse in structure and function.

Healthcare coalitions are only one mechanism for collaboration among the healthcare, emergency medical services, public health, and emergency management sectors. Coalition and collaboration-building is a multiphased, nonlinear process. Not all communities have established formal healthcare coalitions, and not all coalitions are similar in structure, membership, function, or focus. One participant noted, “If you have seen one coalition, then you've seen one coalition.”

Some healthcare coalitions have formal memoranda of understanding (MOUs), while others have informal verbal agreements. Some coalitions have established structures such as nonprofit organizational status, while others are informal networks. Healthcare coalitions have been shaped by real-world events; the scope and magnitude of disasters have determined their capabilities. Additionally, some institutions are part of multiple and overlapping coalitions or other collaborative efforts.

Given the variety in structure, function, and capabilities of local collaborations, participants raised concern that there is a lack of clarity around how coalitions are—or should be—defined. The rise of integrated hospital networks has further blurred the definition and role of coalitions and has led to actual or potential conflicts between collaborations with network partners versus coalition members. Participants questioned how to reconcile the apparent conflict between geographic coalitions and integrated health networks, as well as whether it is effective to have multiple overlapping collaborative bodies. Despite ambiguity around the nature and scope of coalitions and the existence of multiple overlapping collaborations, participants posited that trying to force collaborative efforts into a uniform structure would not benefit healthcare preparedness efforts throughout the nation.

2. Grant funding and requirements often determine coalition activities and capabilities.

Several participants described funding as an important catalyst of intersectoral collaboration. One participant pointed out that coalitions that invest money in personnel and coordination efforts at the regional level (as opposed to just buying equipment) typically enjoy enhanced emergency response capacities. However, recent cuts to the HPP and PHEP programs have diminished coalitions' ability to operate, sustain intersectoral collaborations, and continue evolving. Another participant expressed concern that healthcare coalitions would be forced to seek additional preparedness funding from their member institutions if there are continued reductions in federal monies. Participants expressed skepticism that requests to fund their extramural coalition activities would be approved.

Despite the benefits of federal dollars, another participant pointed out that the architecture of the federal funding enterprise can limit preparedness and response capabilities at the local level. In some jurisdictions, for example, emergency planning in coalitions is often driven by grant timelines rather than a solutions-based approach to enhancing emergency response capabilities. Similarly, certain grant provisions prevent coalitions from prioritizing intersectoral collaboration or focusing their efforts on other critical aspects of emergency response, such as recovery and rebuilding. Others pointed out that while funding is critical, it often has the unintended effect of creating disciplinary silos, a problem that may be rectified by redirecting funds toward collaborative activities, or by petitioning federal authorities to further increase alignment between different funding streams.

Nearly all participants expressed concern about decreases in HHP and PHEP funding and the impact it is already having on efforts at local collaboration. They were especially concerned about the loss of coalition coordinators who are in many cases largely funded out of grant dollars. It was frequently stated that these coordinators are the glue that holds these coalitions together. It was also often stated that the amount of money now available to hospitals through the HPP is insufficient to motivate hospitals to continue to participate. For coalitions that span large geographic areas, as is often the case in the western half of the country, even sending representatives to a monthly meeting can be a significant cost to small healthcare facilities.

3. Turf, silos, culture, and competition are common barriers.

Many participants spoke about differences in cultural norms (eg, behaviors, terminology, work speed, hierarchy) among the various disciplines involved in coalitions. These differences at times lead to misunderstanding, frustration, and a lack of trust among members. Local and state bureaucratic silos were also frequently mentioned as a barrier. This can create communication breakdowns and misaligned or redundant work products. Turf battles, especially related to money (funding and budgets), were another common problem, especially in coalitions that encompass more than one jurisdiction. Business competition among hospitals and integrated healthcare networks remains an obstacle for many coalitions, although there was a sense that this issue is not as much of a problem as it was several years ago.

It was noted by some that these issues are barriers primarily to collaboration in preparedness activities. During the actual response to incidents, particularly large or acute events, these barriers largely go away, and the various entities do in fact collaborate well. Some participants noted that the amount of warning prior to an emergency is a key variable—especially for healthcare entities—in that, with more time to respond, healthcare facilities are more likely to attend to their own business interests (eg, retaining patients in their own network).

4. Buy-in from healthcare and government leaders is beneficial to coalition sustainability.

Emergency management often is not a top priority for hospital administrators and other healthcare executives (as well as public health officials), who have many other competing priorities. Participants discussed how to better engage healthcare executives and politicians in emergency preparedness, as well as whether such efforts were worthwhile. Some participants felt that attempting to further engage healthcare executives was futile. They argued that we cannot expect healthcare executives to be advocates for emergency preparedness. One participant said, “The best you can hope for is that the c-suite does not stand in the way of a staff person doing their job. …” Other participants felt that support or “buy-in” from healthcare executives is essential to the success and sustainability of coalitions and to the ability to successfully prepare for and respond to health threats. Moreover, some participants suggested that not only does executive leadership need to be engaged in preparedness but that they should be filling a leadership role during emergency response. One participant remarked, “Every time I saw my command center stood up, one of those individuals from the c-suite was at the head of the table … occupying the role of the incident commander—it was never the emergency manager.… There is great vulnerability not being at the head of the table if a bad decision is made.”

Participants suggested that one mechanism for ensuring that healthcare executives view preparedness as a priority, and as such empower their emergency managers and allocate adequate resources, is to make the business case for emergency preparedness. Continuity of operations, they said, should be the main driver of engagement. Healthcare executives need to be convinced that disasters pose a real threat to their operations and that there is a significant and real return on investment in preparedness planning. Participants recommended that emergency managers try to build support for their efforts from revenue-generating departments in the organization whose operations could be interrupted in a disaster. It may also be more productive to focus engagement efforts on chief operating officers, chief financial officers, and chief risk officers, whose responsibilities revolve around ensuring organization success and mitigating threats to operations. Another option for motivating hospitals and other healthcare entities to join coalitions may be to require their participation (eg, the pending rule from the Centers for Medicare & Medicaid Services, entitled “Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers”).¹⁹

5. Every incident is a learning opportunity.

Communities with robust coalitions have described disasters and public health emergencies as having catalyzed greater collaboration among the public health, emergency management, and healthcare sectors. Many participants also affirmed that connecting coalition activities back to real-world events helps prevent preparedness fatigue. One participant suggested that relatively frequent small-scale events present communities with “valuable experiences that really test the surge capacities of coalitions.” Several participants from New York City concurred and described how Hurricane Sandy encouraged their city's health authorities to consider critical aspects of emergency response and recovery, including evacuation strategies, healthcare facility closure, and sheltering.³

Participants noted that past disasters shape communities' collective perceptions of and responses to future threats in other ways. One participant, for example, noted that the impact of disasters on intersectoral collaboration varies: An acute weather emergency requiring involvement from multiple sectors is more likely to break down institutional barriers than a sustained public health emergency such as an infectious disease outbreak. Other participants commented that communities are “always fighting the last war,” citing seemingly unnecessary hospital evacuations during Hurricane Irene as a reason for delayed decision making around hospital evacuations during Hurricane Sandy.

Whether past disasters elucidate or limit understanding of current and future emergencies, participants agreed that communities in the US face no shortage of opportunities to exercise their preparedness and response capabilities. Rather, the problem lies in ensuring that these opportunities result in sustained knowledge and improved response. One participant noted that the preparedness community at large has yet to understand how learning truly occurs and how lessons learned by an individual or a single community that directly experience a disaster can be translated into broad knowledge. Debriefings and after-action meetings may be effective for ensuring that those directly involved in a response learn from their experience, but they have not translated to improved preparedness nationally.

6. Metrics are needed.

Participants generally agreed that outcomes research on intersectoral collaboration and emergency preparedness and response is difficult, if not impossible, to conduct. While they stressed the desire for metrics to evaluate the effectiveness of collaborative, intersectoral relationships, they acknowledged that outcomes research in the field is hampered by the fact that the desired outcomes of healthcare preparedness collaboration have yet to be articulated. One participant pointed out that an abundance of information on the importance of collaboration already exists, as well as models for building and sustaining model coalitions. Nevertheless, the preparedness community still lacks criteria for measuring collaborative successes at the federal, state, and local levels. Others suggested that quantitative measures are insufficient for measuring preparedness and that qualitative measures are probably better suited to do so. Another participant commented that it is often difficult to translate academic or theoretical models of collaboration into operational coalitions in the community.

Despite these inherent challenges in outcomes research, participants identified several quantitative proxies for measuring levels of preparedness, including financial returns on investment, avoidable hospitalizations, and averted deaths. A key qualitative measure of preparedness was performance during real-life disasters. Additionally, one participant, a coalition leader, underscored the importance of developing a mission or common vision around which to design, implement, and evaluate preparedness activities. Another participant suggested that emergency preparedness leaders should periodically ask hospital personnel to whom they would turn for help in the event of a disaster, to better gauge levels of collaboration within and between individual institutions.

Limitations

This research has several important limitations. Although geographic and sectoral diversity was sought among the participants, no attempt was made to survey a representative sample of coalitions across the country; therefore, the views expressed by the participants may not accurately reflect the views of the average coalition and may not reflect the range of views of diverse coalitions (eg, rural versus urban, public health–led versus hospital-led, etc) and the views of entities engaged in other collaborative efforts. Furthermore, the interviews and meeting discussion were all based on the individuals' personal viewpoints, which may not accurately reflect the views of others in their coalitions. Despite these limitations, we judge that, given the size and diversity of the participant pool and the fact that we achieved thematic saturation with respect to the literature review, interviews, and meeting, this study allowed us to discover most of the key issues related to local preparedness community integration.

Conclusion

The findings of the literature review, interviews, and working group meeting are all quite consistent and, therefore, likely to be valid reflections of the state of local preparedness community integration that exists. Collaboration is happening everywhere, but the extent and quality of the collaborations vary. It differs between different localities, and it varies within a given locality depending on the particular activity and the partners involved. Since each coalition is an island with a limited view of peer coalitions, and since there are few metrics by which to compare preparedness community integration across coalitions, it is hard for coalitions to assess how they are doing in this regard.

The consistency of the research findings also indicates that there is a shared sense of the common facilitators of and barriers to local preparedness community integration. This suggests that it may be possible to create tools to promote better collaboration that would be applicable to many different coalitions. The next phase of this larger project will be to develop tools to help coalitions better assess and improve their own preparedness community integration. Such tools, if successfully adopted, might provide the basis for further research into practical solutions to overcome some of the barriers identified in this project.

Footnotes

Acknowledgments

The authors wish to thank David Sugerman, MD; Dahna Batts, MD; and Deborah Levy, PhD, from the CDC for their unwavering support and guidance. We also wish to thank Kimberley Shoaf, DrPH, from the University of Utah School of Medicine for her insights, support, and collaboration in convening the working group meeting. This research was funded by a Cooperative Agreement (number CE002353-02) from the CDC. The research, analysis, and findings are solely those of the authors and do not necessarily represent the official view of the CDC or HHS.

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