Approaches,Successes,and Challenges in Recruiting Closed Points of Dispensing Sites: A Qualitative Study

Data Analysis

Transcript data were analyzed using content analysis to identify, code, and categorize participants' responses to the interview questions. Major themes were also identified and categorized. Participant quotes were reported to help deepen the understanding of major themes. Words in parentheses within the quotes were added by the research team to give context to or clarify the respondents' quotes. Quantitative data from the participants' demographic survey were analyzed using the IBM SPSS Statistics for Windows version 26.0 (IBM Corp, Armonk, NY).

Selection of Closed POD Sites

Participating public health officials identified multiple criteria and approaches they used to identify and select possible closed POD sites. Although many disaster planners noted they would like to recruit any willing agency, they were restricted by resource issues that required them to prioritize which organizations to approach for recruitment. As a public health official explained:

I think [recruiting] as many as possible would be ideal but keeping in mind that also takes staff time and resources to dedicate to them, which would then be detracted from our open POD, and we don't have a lot of staff. That's a challenge for us.

One of the most frequently mentioned criteria for site selection was size. Multiple disaster planners indicated that larger businesses are advantageous, because fewer individuals would need to go to open PODs. In addition, smaller sites require as much work for the jurisdiction to set up and manage as larger sites, but with less burden relieved from open POD sites. Disaster planners noted that recruiting 1 or 2 very large sites is less work than 5 or 6 smaller sites, even if they result in the same number of community members covered by those closed PODs. This is due to the number of meetings, conversations, trainings, planning, and coordination needed to recruit each site. Because the actual deployment of the POD is usually handled by the site itself, the impact of size on logistics and staffing does not generally alter the workload of the disaster planner. As disaster planners noted:

We have found that going after too small a company is really counterproductive because it's as hard to deal with a smaller company as it is for the larger company in terms of the setup and maintaining contacts. So it doesn't make a whole lot sense for us to go after a company of say, 50 employees, as opposed to a company with 5,000 employees.

If it's a small business that needs our help to develop plans or to take over their training or to run their operation, that doesn't help us. We would just rather have those people visit the points of dispensing we're already establishing. So, we want there to be a large business that's big enough that can sustain their own closed POD program, instead of us having to just do the exact same thing at another location.

Very large private businesses and colleges and universities were frequently mentioned as ideal closed POD sites due to their size. As a disaster planner said, “we have tackled all of the extremely large employers.” Another explained: “we kind of looked at our highest employers within our county and tried to [recruit] the top 5 of those employers.” The preferred minimum size of a site for recruitment varied by jurisdiction. For some, a site with 100 employees was sufficiently large to recruit, whereas others aimed for businesses and agencies with a few hundred staff or more. As a public health official noted, however, the total number of community members covered under that closed POD site is much more than just the number of employees—closed PODs also provide MCMs to staff family and household members. Therefore, “even if it does seem like a very small company, when you start factoring in [the employees'] families, it can end up being more than you think initially.”

Another frequently mentioned criterion for closed POD site selection was vulnerable or confined populations in relation to individuals who lack access to or the ability to get through open POD sites. Groups or sites that fell under this category included homeless individuals, agencies that provide services to those who are homebound, long-term care facilities, those with functional needs, and corrections agencies. As a disaster planner noted, “we do try to coordinate with the prison or jail system that we have…because those are populations that are not going to be able to come to an open POD site.” As another explained, recruiting corrections populations is “a no-brainer because they actually cannot leave to come get their medication.”

One public health official noted that long-term care facilities are a priority to recruit because “those populations already have medical care programs in place, and so it's just better [to have a closed POD] serve those, instead of reinventing the wheel.” Another disaster planner described long-term care facilities as a recruitment priority because:

They [long-term care facilities] already have the resources to assist certain populations on a daily basis…they have the trust of that population. So it makes more sense to work with that organization to provide the medicine to those populations so they don't have to go through the stress of going through the open POD. So that would probably be our top priority.

Another important group to approach for closed POD site recruitment is critical infrastructure agencies. Critical infrastructure groups, such as utility companies and first responder agencies, are essential to keeping a community functioning during a disaster. As a disaster planner explained, “All of our first responder agencies are in the [closed POD] plan…because we need them on the street actually working and so they can't be sick.” Another explained: “we want to make sure that [critical infrastructure and first responder staff] can still continue their duties and continue providing whatever resources or services that they provide to the public.” However, public health officials noted multiple challenges in recruiting critical infrastructure groups, for example:

We should start focusing on critical infrastructure, you know, people that supply the power, the water, things that everybody else relies on to run their lives. But some of those entities are not all solely located in county X, which makes it difficult because maybe their headquarters are in the city, but they have big facilities in the county, or maybe there's one across the river in [the neighboring state]. So getting them on board and getting it all sorted out because they have to run it through their office of council, have their lawyers look at it and what have you, takes a long time. So, we haven't really done a good job with that, with critical infrastructure.

For some public health agencies, a limiting criterion for selecting a closed POD site is whether that group has a licensed medical staff. Having a licensed medical staff employed by the site is a preference for some, but for others it may be a state requirement due to laws governing the administration of MCMs. One disaster planner who works for a state with restricted laws explained, “we have a specific dispensing regulation in the state that only [licensed medical providers] can actually truly dispense medications.” Another public health official noted that the sites “need to have an employee health program and at least someone who can be a vaccinator, or a team of vaccinators…typically an employee health program will have a nurse or someone who can vaccinate.” Another stated, “we have legislation in place that supports the ability for a lay person with a small amount of training to give…after using an algorithm or a certain degree of screening…to give somebody else a bottle of pills.” Disaster planners who work for a state that does not require a licensed medical staff described the advantage of partnering with an agency that has a medical provider as follows:

We make sure that they have medical staff. We do want them to have a medical type person on staff that knows about what kind of vaccines or drugs might be given. So that way, if there are questions that come up during an actual event, they would have somebody that they could refer to.

[We approach] any organizations that have medical staff because we won't staff it for them. We give them medical supplies, the information, but then they are expected to go to their facility and do all the dispensing, so they need to have medical staff on board. They need to have a standing order to cover their staff so they need some sort of physician at some point in the process.

Recruitment Process

Most of the participants spoke about their recruitment process as a multistep operation that involves making some type of initial contact, followed up by a face-to-face meeting. For some, initial contact occurs through existing relationships and community partnerships, such as presenting about closed PODs at a healthcare coalition, a long-term care facility association, a preparedness conference, or elsewhere. This can save time, as one public health official explained: “I would reach out and see if there's any large meetings where you can hit multiple organizations at once.” Multiple disaster planners noted the benefit of having working relationships with some prospective sites due to other collaborations they have had with the health department, saying:

If we already have some relationship with them, that makes it a lot easier. So if…maybe they have food service establishment as part of their business…we might be able to use a hook from our [food] inspection side of the health department and utilize those connections.

One of the things that is really effective in our area, because it's rural, is that we know folks and our health department staff know folks, and in every county, we have relationships with businesses and organizations and key stakeholders.

Using those partnerships that you have with people that are actually in the community are very helpful. When we did our invited closed POD training in one of our counties, we had the county nurse manager invite people. We put her name up [in the training announcement] because everyone knew who she was and we knew that they were going to show up. If we put my name, nobody was going to show up. So just using those community people to reach out to those organizations and kind of be the face until you go there and present is very helpful.

When a point of contact is not known, initiating the recruitment process can be more challenging, because it often involves some form of trying to identify the right person at the organization. As one public health official noted, “a lot of it is cold calling or sending out information. It's finding the right person to talk to, to bring them in [to explain the program].” Many public health officials noted that the cold-calling process requires a lot of patience and persistence, because they often get passed from one individual to the next in order to reach the right person in the organization. As one planner noted, “finding the right person to talk to is huge. You can call and get transferred to so many different people. That's always a challenge.” For other public health officials, cold calling has been completely ineffective, even when they are persistent. As another planner commented, “we run into situations where identifying a single point of contact can be impossible. We leave messages for who we think is a point of contact or trying to get that information, but they never call back.” Four disaster planners said they used email or letters to reach out to prospective closed POD partners, but several emphasized that phone calls were a more effective method of communication:

I have found that the calls are much more effective. It's probably not a big surprise. I mean we definitely get responses with emails, but the percentage isn't great that respond back. We've done both, but I've found more success with phone calls.

The types of contacts that disaster planners are trying to reach within an organization varies greatly. Some disaster planners mentioned asking for the organization's health and safety manager, occupational health manager, or anyone who may have a medical background. Another disaster planner said, “I feel like HR [human resources] is always a good place to start.” Another mentioned that, “business continuity people are very good because they spend their lives thinking about ‘what if?’ and ‘how if?’ so we would approach them [for recruitment].” However, the point of contact changes based on the type of organization, as a public health official said:

We do try to track down if they have a position like an emergency manager or a safety manager, or an emergency coordinator, or somebody of that ilk. If they don't, or even somebody who's medically oriented, like a staff nurse or some type of medical staff employed, we usually try to go to them. But we'll work with anybody all the way from CEO [chief executive officer] all the way on down to a section manager. So it depends on the entity and what kind of resources we think they have.

Several planners emphasized the need to prioritize establishing a member of management or leadership as a point of contact during recruitment. One planner stated, “I start with a preparedness team or security team…if not, I just go to management.” Another individual stated simply, “we try to identify the decision makers at the site.” Making contact with decision makers is important for this process, as making contact with someone who is not in a leadership or management role can lead to getting passed on up the chain repeatedly, resulting in losing contact with the prospective site altogether or being rejected by leadership after time was already invested to recruit a new site. A disaster planner offers this caution when speaking with prospective closed POD contacts who are not in leadership roles themselves:

You're going to want to have buy-in from their leadership, whether that's the CEO, other people in HR, legal, any operations managers, or anything like that. Make sure that they are part of that next meeting because I found through trial and error that if the buy-in isn't there with the leadership team, then it's kind of, I don't want to say it's a waste of time, but it delays the whole process of becoming a closed POD.

Frequently mentioned by disaster planners and public health officials was the importance of having a face-to-face meeting. Several planners referred to the face-to-face meeting as an opportunity to make their “sales pitch” for why a site should become a closed POD. As one public health official explained, the pitch depends on the perceived willingness of that site to participate in the closed POD program:

If the initial phone call goes well, then we bring training materials, some example medication containers, and we basically do the hard sell of, “This is what it takes to dispense. Are you willing to participate?” If they're not quite sure and they would like to link in a few more people, maybe the decision makers of the business, then we go in with a little bit softer approach, and it's just more of a discussion… [such as,] “This is the situation.”

Paperwork to Establish a Closed POD Site

Many of the participating public health officials stated that they use a memorandum of understanding (MOU) or memorandum of agreement (MOA) as paperwork to establish a closed POD site. Several of those interviewed explained that having an MOU or MOA was a straightforward way to engage with closed POD partners about their responsibilities as a site and the responsibilities of the local public health agency. One disaster planner noted:

We currently establish an MOU with each of the POD sites. It looks good documentation-wise, and it's a good tool for the administration to feel comfortable about what they are agreeing to for their business and then what they're not agreeing to for their business…and it just kind of spells it out without any questions or gray areas.

A majority of those using MOUs or MOAs have the same paperwork template for all of their sites, but a few mentioned having a customized MOU for specific types of facilities. These customized MOUs seemed to be based on a potential closed POD site's resources and abilities, particularly in distributing and administering MCMs. One disaster planner compared the needs of a distribution site with those of a long-term care facility: “With the distribution site…we asked them to provide more material handling equipment. We didn't need to do that with the long-term care facility.” The types of sites that were most frequently mentioned as needing customized MOUs or MOAs were hospitals and long-term care facilities.

In terms of maintaining MOUs and MOAs, several disaster planners said they revisit their MOU with a site every 3 to 5 years. They do this to check in with the site according to state requirements for the MOU or MOA, or because the MOU has a set expiration date between 3 and 5 years. When asked why this expiration and renewal process is used, one planner explained:

It kind of forces the county to go back and revisit [the MOU] in 5 years. And remind them [closed POD site contact person or leader] that [they have] MOUs and remind them that they're a closed POD. And it encourages the county to maintain a relationship with them. Plus, some lawyers won't allow a company to sign a document that doesn't have an expiration date on it.

The setting of an expiration date on MOUs is useful for both maintaining relationships and creating an MOU that is more acceptable from a legal standpoint for the closed POD partners.

Some participating public health officials said they do not use MOUs or MOAs due to legal concerns from prospective closed POD partners. Instead, they require sites to sign a closed POD enrollment form, application, or medication survey. As a participant explained, “we don't use an MOU. We use a closed POD enrollment form, because we've found that having MOUs scared a lot of organizations.” Jurisdictions that use a closed POD enrollment form or application have found these informal approaches to be successful in recruiting sites. As a disaster planner said, “folks at the closed POD sites have been really agreeable to having quite informal agreements without needing a legal review process.” Some sites use a survey to determine how many doses of medication would be needed by the site if they were to deploy; this document is updated regularly to account for changes at the site. As a disaster planner explained:

We send out that [contact form] every year to get updated and then every other year we send out the medication survey again for them to update it so that if they have any changes. For nursing homes and home health, stuff like that…staffing can change so much, so can residents, so we say, “What is your maximum staffing that you can have, and what is the maximum number of beds?”

In addition to MOUs, MOAs, and closed POD enrollment forms, many closed POD sites are required to submit a contact form that outlines names, phone numbers, addresses, and emails for primary and secondary points of contact at the sites. The contact forms are updated anywhere from every 6 months to every 2 years.

Some disaster planners require a site to complete a closed POD workbook, template plan, or checklist as part of their process of becoming a closed POD site. The documents are reviewed with the disaster planner as part of the enrollment process. These workbooks and template plans aid sites in readiness to deploy by providing a starting place for the site. They can also be used by the disaster planner to “hone in a little bit on how much handholding the health department would need to do with [the site], if any,” and gauge the needs of a closed POD partner.

Commitment From Public Health and Sites in Closed POD Agreements

In addition to needing a written plan, other commitments made within the enrollment paperwork hold both parties—public health planners and closed POD sites—accountable to their partnership. Almost every participating public health official stated that their organizations committed to training closed POD staff through education and POD exercises and drills. Sites were not asked to commit to attend or participate in training. The training was offered as a benefit of joining as a way of helping the site prepare for deployment.

In addition to trainings, other commitments made during MOU agreements typically relate to the availability and supply of physical resources to the closed POD site. Most disaster planners explicitly stated that the closed POD is required to provide their own space and staff for operations. As a disaster planner explained, “they have to identify a space that will accommodate for enough, you know, their throughput basically.” Others explained:

It's not important what type of room it is, if it's a large room where they can set up the different stations, and then they can figure out where they are going to enter, where they are going to exit, and depending on the number, how many you have, how many staff do you need.

The agreement between the 2 of us is that we work together. They furnish the space. They furnish the people to keep things in line. We furnish the vaccinators if they don't have enough, and then that's the agreement that we have.

In addition to space, some closed POD sites offered to provide all of the supplies needed to run the POD, except the MCMs. Examples of supplies offered by public health officials included signage templates, POD forms, job action sheets, screening forms, and other office supplies. Other public health departments required closed POD sites to provide everything except the MCMs. As a disaster planner explained:

If they are a closed POD site, basically we will be supplying the medications or the vaccine and any kind of, especially if it's a vaccine, needles and those types of supplies that would need to come with it. But, and we do tell them up front, that they would be expected to provide their own staff to run their own POD; and the paper supplies, office supplies, those kinds of things, they would also have to provide for themselves.

Another planner explained, “we furnish all the supplies for the POD, so they don't really have to spend anything for anything outside of personnel.” It was noted by a public health official that the distribution of supplies was determined based on the closed POD site's routine activities and that those specific commitments are outlined in the MOU or MOA. For example, a medical site, such as a long-term care facility, would likely need fewer supplies than a site that does not routinely provide medical care.

The final commitment frequently made by disaster planners to their closed POD sites is what many of them referred to as a “POD-in-a-box.” Although the content of the kit varies between disaster planners, all kits consist of supplies above and beyond the MCMs that would be provided to any closed POD. Kit supplies range from just the paperwork required to run the closed POD to including all office supplies and crowd control measures. One disaster planner explained:

[POD-in-a-box] has a list of the things that the organization should provide on its own and then there are things that the county will provide, free of charge and we'll deliver to them…. It's a la carte. They can select, “We don't need the big orange traffic cones, oh but we need some wire file baskets, yeah that's good.” And they can pick and choose, and then we will deliver it to them.

Another disaster planner said they use the POD-in-a-box to thank the sites for signing up to become a closed POD. Their kit comes in a reusable tote and is full of “basic office supplies and first aid kit, hand sanitizer. Things that [the closed POD] might need to operate their POD.” They give the kits away after training meetings or while working on developing the closed POD plan, to make sure the POD knows how much they are appreciated.

Just-In-Time Closed POD Recruitment Model

One site discussed a “just-in-time” recruitment model, in which sites are recruited mid-event when the sense of urgency is greatest. The site plans to implement this model with their smaller sites—most of which are long-term care facilities—during an event. They already have a professional relationship with these sites and have informed them about the closed POD program. Because the sites are small, however, they lack the infrastructure to develop and maintain a full closed POD program continuously. Instead, the public health official's plan is to reach out to those sites when an event occurs and ask them if they would like to be a closed POD site. The health department is prepared to deliver medications to these closed POD sites and allow the site to distribute the medication to their patients, employees, and their family members. Because the sites are healthcare agencies, they already have the medical infrastructure and processes in place to administer medication. In addition, the health department has developed protocols for just-in-time training for these sites to quickly teach them how to be a closed POD. As the public health official explained:

We several times have made really hard pushes to get long-term care facilities to be closed POD sites, and they have always been a challenge. The people who run long-term care facilities seem to, there doesn't seem to be a whole lot of longevity with those people. There's a lot of turnover there. So it's often hard to find the right person to talk to. They also frequently have 3 other jobs and they're not really in a position to take a day off or half a day off to come listen to our [POD] presentation, and they just, quite frankly, aren't particularly interested in it. But one of the solutions we came up with to resolve that was that we created a program called an “instant POD.” If the POD network is activated, [the long-term care facility staff] can come to the distribution center and provide information about confirming who they are, which long-term care facility they represent, and sign the MOU on the spot, and become a closed POD on the spot, and take medications back with them for their employees and their residents.

Challenges to Recruiting Closed POD Sites

One challenge identified was convincing sites that pre-event closed POD planning is necessary. As some public health officials stated:

Schools are difficult [to recruit] in the sense that it's a lot of kids, a lot of kids' families, a lot of parents, a lot of teachers, a lot of teachers' families. And so by the time you get everything put together, you have to, in a way, to convince them that it's worth their effort.

The largest challenge that we have faced is not really understanding what a POD is, why they would need to be involved if there's all these other emergencies, what's a biological hazard, what's the chance that it will happen here?

Multiple disaster planners mentioned that legal issues often pose a challenge in setting up a new closed POD site. As a public health official stated, “[the sites] are always concerned with the liability statement [in the MOU].” Disaster planners noted other legal challenges:

Legal issues can sometimes be more difficult, and it's more of a “we [the site] want to do this but it's just not possible. At the time of an event, however, we're interested.” And so it's difficult to sometimes have those conversations and the legal considerations with some of those entities, and it's just not practical to pursue the closed POD MOU without the drive of an impending event or one that's already occurred to help make that policy effective.

I just need both legal [groups] to sit down in a meeting together and answer each other's questions, because we'll send out our MOU template and say, “if you have any comments, you know, feel free to send them back,” and then we'll get it back and it's all marked up in red. We're like, oh, this is something that can't be changed.

I would say there's a lot of legal barriers, as far as their concerns with medical malpractice, if they're not a healthcare agency and dispensing medications during an emergency. It's up to us as a health department to educate them on what is a declared emergency, what is listed as far as legal statutes, and stuff like that. So legal barriers are huge, probably the main thing that stalls the MOU from getting signed.

There is fear around the liability of being responsible for any kind of adverse events related to the MCMs. I think that is the biggest fear that people have.

Multiple public health officials discussed the challenges of preparing a closed POD site to deploy if mass vaccination is needed. Having staff who could deliver vaccine was one of the most frequently mentioned challenges to recruiting a closed POD site. As a disaster planner explained, “[we check] whether they have nurses that can provide the vaccine, since we wouldn't be providing staffing for them, because they would have to train their staff ahead of time.” Disaster planners explained other challenges in recruiting a closed POD site for mass vaccination:

One main concern with space requirements is that some closed PODs will be required to maintain cold chain for vaccinations. This requirement can put restrictions on the space available for the closed POD use, but many public health officials stated willingness to work with the closed PODs on this point to make sure it is both safe and effective for their operations.

It's [dispensing] vaccine that concerns me with POD planning, because a lot of the organizations may have 1 or 2 occupational health individuals on staff, but that doesn't necessarily mean that they are a medical professional or registered nurse, so they would have issues administering vaccines if it were a vaccine POD.

We can't say whether or not our health department will be able to actually provide them with additional needles, alcohol, or any other type of ancillary supplies that are going to not necessarily come with the vaccine. In a pan[demic] flu scenario, the vaccine is not going to come through the traditional [Strategic National Stockpile] shipment, it's going to come more through a third-party vendor and it's not going to come with, you know, the syringes or the needles if it's not already in individually prefilled syringes.

I would bet that there's going to be a lot of closed PODs that are currently signed that are not going to be able to actually fulfill the vaccination component. [Mass vaccination is] multi-months long, potentially years long, and you've got to vaccinate at least twice in a short period of time. So there's definitely a lot more unique challenges for the mass [vaccination] campaigns.

The dispensing law will be lifted [during an event] for pills only. Vaccines get a little mucky. They will have to use the credentialed folks, the certified and licensed folks, to do the vaccine administration. That will make it challenging for some sites that don't [employ] those individuals.

The disaster planners discussed the challenges in trying to recruit a large national organization or business, or an agency that is part of a larger network or healthcare system. As a disaster planner explained, “when you have a large corporation, they might want to [be a closed POD], but then they might hit the brakes with their national agency, saying ‘no, no, no, we're not going to do this.’” Another planner described similar challenges with long-term care facilities that are part of a healthcare system, saying, “Some nursing homes, if they are part of a larger network of nursing homes, sometimes the larger network will not allow them to join in [become a closed POD] even though they see the need at the local level and would like to.” Sometimes the disaster planner had the opposite issue: an agency that was part of a larger network was a closed POD and then the corporate office wanted all of the sites to join, even when that was not feasible. As a public health official explained:

We have a utilities company within our jurisdiction that have signed on [to be a closed POD] and they have been part of our plan for years. But once their corporate [office] caught wind of what we were doing and how good it was working; they then wanted that person to get [closed PODs] in all counties that have a site. Now they are having a lot of trouble because, you know, every county runs their closed PODs differently. So what we are doing in one county doesn't necessarily mean the same in [their other sites]. So it is hard for corporations to come on board when you can't take [all of their sites].

Recommended Practices Related to Recruiting Closed POD Sites

Multiple public health officials recommended leveraging existing partnerships, hosting disaster exercises, and using educational programs to raise awareness when developing a closed POD network. As a public health official said, “Well, if I was to personally know people at that company, I might go to them first because I would be able to get in to the right people sooner.” Another public health official explained, “if they've approached us or if they have some interest based on their circumstances, then we take that into consideration.” And another said, “in every county we have relationships with businesses and organizations and key stakeholders, and one of our workers spends a lot of time on the ground, showing and talking with folks. So it's part of that relationship where the sales pitch [for becoming a closed POD site] happens, and they trust him and trust us because we have these relationships.” Similarly, multiple disaster planners mentioned the importance of being able to explain why closed PODs are vital to a community. As the disaster planners explained:

I would say the disaster planner needs to understand the benefit and understand the whole public health response around closed PODs and why it's beneficial for the county. That will allow for them to come across to the potential closed POD partners as knowledgeable and enthusiastic. Because if the enthusiasm isn't there, then the buy-in won't be there. Yeah, I think buy-in is so important.

Just be persuasive. I didn't think getting into public health that I would have to be persuasive with educating people on the benefits of mass prophylaxis, but it's important if you're trying to get your numbers together for response within 48 hours, the worst-case scenario. So yeah, I would say that is really important. Can't be shy.

Many disaster planners also discussed leveraging educational programs or disaster exercises to create interest in closed PODs. As public health officials described:

When you are at a conference and maybe there is a discussion about the POD program in general, the POD plans, and you say something that gets somebody's attention, they come up and give you a card and say, “I'd be really interested to know more about this,” and you can, you know, make the pitch to them, recruit them. And maybe they tell someone else in an affiliated organization, “Hey, this is good stuff. You should get on board with this.”

We had a full-scale exercise a year ago last November with long-term care centers, and in that particular [exercise] we used anthrax and getting the Strategic National Stockpile in. And so when we approached them [about becoming a closed POD site], they were willing to go along with it.

For jurisdictions that have a healthcare coalition, it was recommended to leverage that relationship to help recruit closed POD sites. One public health official described their approach: “We did a presentation to all of our attendees, who are part of the coalition, on what a closed POD is and why they should become one.” As another described, “we have funds to host coalition meetings and work more closely with them and get them interested because we can provide them benefits.” Another advantage to approaching healthcare coalition partners was that it provides broader geographical coverage areas. As a disaster planner explained, “if we target our coalition, which hits 4 counties, we will likely cover our residents that live here as well as outlying areas, which increases our [POD coverage] number.”

Many disaster planners mentioned the importance of letting the agency know that becoming a closed POD site means their staff would get early or first access to MCMs during an event. As one planner explained, during the recruitment pitch they tell the site, “You get [the MCMs] first and that to them is like, ‘Okay, then that means something to us.’” As another noted: “being able to provide [the POD site staff] and their families with medications beforehand and not have to come to the open POD, sometimes that's enough [to convince them to become a closed POD].” One planner developed a 1-page document on the benefits of becoming a closed POD. As the planner described, “I have this piece of paper that has the benefits of becoming a closed POD and it's things like, the medicine is sent directly to them, free of charge, and they don't have to stand in line with 50,000 other people at an open POD to get it.” Multiple disaster planners also emphasized the importance of consistently following through after an initial contact has been made. As one planner noted, “You have to be persistent and you have to have that follow-up, and if you lose traction on it, you almost have to go back and start over.” One public health official emphasized the importance of building a partnership with your health department's general counsel office to help manage the legal challenges.