HCPH Mobile Program: Bringing Public Health to the Public

Harris County Public Health (HCPH) is a large LHD that surrounds and includes Houston, Texas, the fourth largest city in the United States. In 2010, Harris County/Houston surpassed New York City and its surrounding area to become the most diverse place in America (Link to May 9, 2017 Los Angeles Times Article - http://www.latimes.com/nation/la-na-houston-diversity-2017-htmlstory.html). Racial demographics of the 4.54 million Harris County residents are as follows (per U.S. Census Bureau): 42% Hispanic or Latino 30% White 18% African American 6% Asian 2% Two or More Races Below 1% Native American Below 1% Native Hawaiian Pacific Islander Below 1% Other Races Geographically, Harris County covers over 1,770 square miles of mixed urban, suburban and rural areas. Data USA analysis shows a median age of 33.1 years, median household income of $56,629, median property value of $156,000 and a poverty rate of 16.7%. One of the major public health issues in serving such a diverse community spread across such a large geographic area is transportation. The population of unincorporated Harris County (those areas outside the city limits of Houston) is greater than the population inside the city proper. Yet unincorporated Harris County has virtually no public transportation. Getting residents to brick and mortar HCPH facilities is a significant challenge to providing services to the community. HCPH's model practice in response to this problem is to bring a holistic approach to mobile outreach. The primary goal of the HCPH mobile program is to mobilize as many of the full spectrum of public health services as possible. This means the traditional use of assets such as mobile medical and dental clinics or pet adoptions, but also moving beyond traditional thinking. HCPH has additionally mobilized nutrition outreach, vector-borne disease education, and environmental health. We even incorporated virtual reality into a specialty vehicle that addresses healthy lifestyle education plus preparedness/response. HCPH's mobile program is best summed up as, Bringing Public Health to the Public”. Activities surrounding implementation of this model practice began with literally a blank page. HCPH's Innovation and Engagement (I&E) Team custom designed, engineered and project managed seven vehicles simultaneously to specifically address the seven primary areas of service HCPH provides. Working directly with each of the Divisions within the Department, the concept of operations was developed to create integrated public health fairs using the seven mobile vehicles. These events enable HCPH to provide essentially its full range of services at pop-up” locations anywhere in Harris County. The results and outcomes of this practice have exceeded the expectations of HCPH. This was illustrated by its success in response to the Hurricane Harvey disaster. Originally HCPH planned a public rollout of its mobile program in partnership with the Harris County Public Library (HCPL) system for September 19, 2017. HCPL facilities are an educational and services resource for many of HCPH's target population. This partnership is a perfect collaboration for the mobile program. However, the HCPH plan for this soft roll-out” of the mobile program was derailed by Hurricane Harvey on August 24, 2017. The HCPH mobile fleet and its concept of operations for bringing public health to the public experienced a trial by fire” in response to the needs of Harris County residents suffering from Hurricane Harvey flooding. The results and outcomes met (and continue to meet) the objectives. The impact of this practice immediately following Hurricane Harvey was significant. The HCPH Mobile Outreach Team partnered with local grocery stores, faith-based organizations, schools and community centers. Among the many school partners, HCPH worked with the Sheldon Independent School District (ISD) to provide vital services to children and their families. Sheldon ISD worked with HCPH staff multiple times during the hurricane relief period, and helped the planning team spread the word about mobile outreach services being provided. Partnerships with supermarket chains included Walmart, Kroger, and Home Depot, all of which provided food donations, cleaning supplies, and incentives for the public. Over 32 days of its post-Harvey operations, HCPH's Mobile Outreach Team served 923 patients for childhood vaccinations, adult and child tetanus, plus adult and child flu shots. They provided nutrition education to 3,133 patients, dental education to 3,694 patients, food safety information to 2,240 individuals and mosquito/vector-borne disease education to 5,160 individuals. The team enrolled 501 individuals for WIC benefits, and 2,232 families received food supplies from the HCPH mobile pantry. The team also provided pet vaccinations, microchipping, food and flea medications to 1,436 animals. The Harris County Public Health website is accessible at this link: http://publichealth.harriscountytx.gov/

Transportation in a county that is larger than the State of Rhode Island, yet has essentially no public transit system, is a major problem for public health. The target population for public health services frequently lacks the time and resources to travel to existing Harris County Public Health (HCPH) facilities. Simultaneously, HCPH cannot afford to build and staff enough brick and mortar facilities to cover every neighborhood in its 1,770 square miles of responsibility. With a total county population of 4.54 million, approximately 2.3 million residents live in unincorporated Harris County and are the public health responsibility of HCPH. The county has a poverty rate of 16.7%. While public health impacts all citizens (not just those living in poverty), it is conservative to say that at least 384,100 people (16.7% of 2.3 million) are most in need of direct public health services in unincorporated Harris County. The real number is even higher. Within just 32 days following Hurricane Harvey, the HCPH Mobile Outreach Team reached nearly 5% of the most vulnerable members of the target population. The HCPH mobile program continues to operate and expand that reach. Many LHD's and other health organizations operate mobile units to provide medical, dental or even pet adoption services. In the past these have proven effective at addressing some portion of the public health concerns. The innovation HCPH has implemented in its practice, to be responsive to the particular local public health problem of transportation, is to mobilize the fullest possible spectrum of services. This practice improves upon previous approaches by holistically bringing public health to the public, versus certain limited components. HCPH's approach to developing this practice is highly innovative. From collaborating with non-public health organizations that bring fresh perspectives, to integrating cutting edge technologies never before employed for public health, HCPH has established a model practice for overcoming transportation barriers to health equity. One of the key ways this practice is innovative is its improvement over previous content. A prime example is HCPH's approach to vector-borne disease education/outreach. Being the largest U.S. population center located in the climate zone classified as humid subtropical”, mosquito and other vector-borne diseases are a significant public health concern for Harris County. To improve its education/outreach content for vector-borne diseases, HCPH's Innovation and Engagement (I&E) Team designed a vehicle to function as a mobile museum. HCPH then partnered with the Houston Museum of Natural Science to fabric the exhibits inside the vehicle at truly museum-quality level. The result is an experiential practice in educating the public about the risks of vector-borne diseases and the techniques they can use to mitigate those risks. Another way in which this practice is responsive and innovative is its adaptation of methods and technologies from different disciplines. This is best illustrated by HCPH's vehicle known as the Virtual Health & Response Unit (VHRU). The I&E Team was particularly innovative in creating the VHRU to respond to multiple public health needs/problems/concerns. HCPH's Preparedness and Response Division has need of a mobile information and command post during emergency situations such as Hurricane Harvey. However the vast majority of the time when no emergency is present, such a vehicle would remain unused. Simultaneously, HCPH was looking to create an innovative practice to combat the effects of sedentary lifestyle. The I&E Team considered these problems and designed the VHRU to function in dual modes, depending on the need. The VHRU incorporates the new technology of virtual reality (VR) into two onboard rooms, controlled from a third room. HCPH uses the VR rooms to engage the adult public in active experiences such as underwater exploration, painting in 3-dimensions and climbing Mount Everest. The engagement supports the messaging of HCPH's, Sitting is the New Smoking”, campaign to educate the public about the risks of being sedentary and practical techniques on how to minimize the effects. Further innovation onboard the VHRU is the use of Xbox active gaming to engage the younger public regarding sedentary lifestyle. Three, 75-inch screens are mounted along the driver's side of the VHRU and connected to Xbox consoles inside the VHRU control room. Participants outside the vehicle engage in active, motion-capture gaming that also supports the messaging of HCPH's, Sitting is the New Smoking”, campaign. Perhaps the most innovative practice integrated into the VHRU is its ability to convert from its health education role and become a mobile information and command unit to respond in emergencies. HCPH demonstrated this innovation when it activated the VHRU for the very first time during Hurricane Harvey. The VHRU was so new when Harvey struck the Harris County/Houston area that it had never been used publicly. HCPH activated the VHRU to be on station at the 250-bed patient area HCPH established during the hurricane at NRG Stadium Park. One of the lessons HCPH learned when it created the refugee center in the Astrodome for Hurricane Katrina victims was that people feel isolated and out of touch once they enter evacuation centers. Debuting the VHRU in its response mode allowed HCPH to keep both evacuees and its own workers informed about what was happening with the disaster. The vehicle was positioned between the patient area and HCPH's command area. The three, 75-inch screens on one side of the VHRU were facing the patient area, while the other two, 75-inch screens and entrance to the vehicle were facing the HCPH command area. Instead of Xbox active gaming, the VHRU functioned as a mobile information center by streaming live news coverage on all five screens using the vehicle's onboard LTE/WiFi system. HCPH set up tables and chairs around the VHRU to create separate areas for both patients and workers to congregate and stay informed. In addition to the two units detailed above, the HCPH mobile program includes the following five vehicles: medical clinic, dental clinic, pet adoption/care, nutrition and environmental health. The nutrition and environmental vehicles are also innovative examples of responsiveness to public health needs. The nutrition unit provides a farmers market” setting for food distribution and healthy eating education. The environmental unit combines food safety/restaurant inspection, nuisance neighborhood, lead poisoning, swimming pool and drinking water education all in one vehicle. HCPH's practice of mobilizing public health by acknowledging that its parts are intimately interconnected and addressable only by reference to the whole is innovative and responsive to the needs of a population challenged by transportation.

Food Safety|Nutrition, Physical Activity, and Obesity

Harris County Public Health's new fleet of Mobile Units is the ultimate outreach, engagement and partnership tool to take public health to the public. Individual mobile units address specific health issues, so each has potential and value to specific populations and agencies. Collectively, the sum is greater than its parts and when events feature all HCPH mobile units, the community is provided a wide array of preventative health services, resources and education. The Harris County and City of Houston Public Library Systems were the first collaborative partners HCPH sought. The City and County represent large, diverse populations in all socio-economic groups. The libraries are located in diverse communities and reflect the needs of their residents. Many offer English, citizenship and computer classes. This collaboration is for mobile events that are co-branded with HCPH and the libraries to meet specific community needs such as health and nutrition, mosquito education and responsible pet ownership. The libraries will extend HCPH's educational reach by curating materials from their information resources that support the public health messaging. During the events the libraries will also provide special programs and activities to support the topic. The libraries and HCPH will promote the events in advance. Community Centers throughout Harris County have been excellent partners for mobile events. Many offer senior activities and exercise classes, perfect populations for many of the units. In the weeks following Hurricane Harvey, the HCPH Mobile Outreach Team held a number of its integrated public health events at Community Centers. Since pets have universal appeal, the Mobile Adoption Unit is in great demand at community centers, dog parks, pet food stores, pet-friendly bars and restaurants and community events. In addition to adoptions, services often include vaccinations, microchipping and education on responsible pet ownership. The HCPH Mobile program is still in its infancy, but plans for future partnerships include engaging academic institutions to offer internships, service learning and volunteer opportunities. Women's and family shelters, grocery stores and public housing also offer HCPH future opportunities for reaching residents in need of services and education. The mobile units can be requested for community events. Fully implementing all the planned partnerships for the HCPH mobile program was slowed in late summer 2017 due to Hurricane Harvey. Although the mobile units had been built when Harvey hit, they had not yet been rolled out operationally. Never the less, HCPH made the decision to immediately deploy the units to provide critically needed services to flood ravaged communities. Hurricane Harvey devastated large portions of Harris County, turning neighborhoods into lakes and flooding thousands of single family homes, apartments and businesses. While many evacuees stayed in shelters for weeks, some flood victims never left their. HCPH's Mobile Outreach Team brought needed services and resources to strategically selected communities. The Office of Emergency Management identified the most storm-damaged neighborhoods and HCPH used its health equity data to determine locations where residents would need the most help to recover. Most people in these communities were low-income and had no flood insurance. Using existing partnerships and quickly developing new ones, allowed HCPH the flexibility to respond to areas where there were the greatest needs. There is little public transportation in unincorporated Harris County, many people lost their cars in the flood and gas was in short supply, so HCPH chose locations close to impacted residential areas and nearby businesses people would be frequenting. Through collaborations across the entire community, dozens of parking lots at grocery stores, home improvement stores, shopping centers, community centers and schools (closed due to flooding) became pop-up mobile resource centers, offering help and hope to distraught, weary disaster victims. Residents came for food, water, health screenings, vaccinations and disaster recovery information. An unexpected benefit was that the events became a gathering place for residents struggling to survive and recover. Neighbors shared harrowing stories and compared damage. Children played and reconnected with their friends. While the mobile events brought desperately needed supplies and services, they also helped people feel less alone and served as a catalyst for collective healing. In addition to the many one-day events, the mobile units were also incorporated into two CASPER events, door-to-door surveys of flood damaged communities. Mobile units were located close to the areas being surveyed and that information was conveyed to residents by survey teams. Advance notice of the surveys and mobile services was provided by community centers, school districts, management districts, news media and community newspapers. The communication team also reached out to new partners to help inform the community in advance.

This section addresses evaluation of both the process (qualitative data) and the outcome (quantitative data). The process being addressed is the way in which HCPH implemented its model practice to mobilize the maximum number of public health elements possible, while simultaneously integrating methods and technologies from other disciplines. The outcome being addressed is the impact of this model practice on the community HCPH serves. The objectives of the HCPH mobile program include mobilizing as many public health services as possible and overcoming transportation barriers by bringing those services directly to the public in highly innovative ways. Process: The process HCPH employed in creating both the vehicles and their concept of operations (conops) was adapted from Agile Development methodologies originally founded for software development. The iterative approach of Agile Development was best suited to the extremely tight timeline mandated by the project because it allows for incremental changes mid-process. The HCPH mobile program was on such a tight timeline in order to meet fiscal funding requirements. The average time to design, engineer and project manage construction of a single specialty vehicle is 18 months. This was the time required to create the first of HCPH's seven vehicles, which was done singularly. The remaining six vehicles were developed simultaneously, with all design, engineering and project management of construction completed in only 8 months. Agile Development enabled this aggressive timeline. Evaluation of the process occurred throughout the project by way of in-depth interviews with both internal and external customers. This included all levels of HCPH personnel, from end-users in the field, to Subject Matter Experts (SME's) and Executive Management (internal customers), as well as clients who receive HCPH services (external customers). Operational, functional and fiscal requirements of all stakeholders were incorporated into development of the vehicles and their conops. Performance metrics used in evaluating this process included adherence to the development/delivery timeline, feasibility of the conops and satisfaction of the needs of stakeholders. Results across all metrics were positive. The vehicles were successfully designed, engineered and manufactured on time and on budget to meet the fiscal requirements. Feasibility of the conops were proven during real-time deployment of the mobile fleet in response to Hurricane Harvey and successfully provided services to thousands of citizens. Feedback from all stakeholders (internal and external) has been universally positive. Outcome: Even though the HCPH model practice of full-spectrum mobilization of public health services using techniques and technologies from other industries is quite new, quantitative outcome results are available due to Hurricane Harvey. Recovery efforts since the flood have slowed HCPH's roll-out of its mobile program for general purposes. However, HCPH deployed its mobile fleet for the first time to provide relief to the hardest-hit areas of Harris County following the storm. Results from this deployment indicate the efficacy of this model practice. The HCPH Mobile Outreach Team began Harvey recovery operations on September 5, 2017. The team remained operational for 32 days, providing vital health services to rural and adversely impacted areas within Harris County. Medical and dental mobile units, vehicles fully equipped to provide clinical services in the field, were critical for post-Harvey relief activities. The mobile medical unit served as a medical clinic on wheels where staff provided immunizations and wellness screenings. The unit is equipped with two fully functional private exam rooms. The similarly outfitted mobile dental unit was used for the same purpose, which allowed teams to see four patients at the same time. The Youth Dental team provided strategies to practice good dental hygiene and proper tooth brushing techniques to children and their parents. The mobile vector unit served as a museum showcasing the growth of mosquitos and their role as infectious agents. It also supplied the public with mosquito repellents (donated through the HCPH partnership with Johnson & Johnson), information about proper netting and dunks, prevention tips regarding mosquito-borne illnesses and the harmful effects of stagnant flood water. The nutrition mobile unit distributed food items donated by our Houston Food Bank partners and provided nutrition education and consultations. Services also included an extension of the Women, Infant and Child (WIC) services to sign up individuals to receive September and October WIC benefits. The veterinary mobile unit provided pet immunizations, microchipping, flea prevention medications, pet food and animal care information. The environmental vehicle distributed cleaning supplies and provided safety information for food and water. The virtual health/response unit provided healthy lifestyle education. Children could take part in the Play Zone to engage in and learn about the benefits of physical activity. As part of its ongoing Hurricane Harvey response, HCPH established partnerships with organizations that provided the Mobile Outreach Team with resources and locations to access individuals. The Mobile Outreach Team partnered with local grocery stores, faith-based organizations, schools and community centers. These partnerships included Walmart, Kroger and Home Depot, all of which provided food donations, cleaning supplies, and incentives for the public. Among its many school partners, HCPH worked with the Sheldon Independent School District (located in one of the hardest hit areas) to provide vital services to children and their families. Sheldon ISD worked with HCPH staff multiple times during the hurricane relief period, and helped the planning team spread the word about mobile outreach services being provided. In recognition for their partnership, the HCPH Mobile Outreach Team received the Sheldon ISD's Harvey Relief Recognition Award. The HCPH Mobile Response Team impacted more than 19,000 individuals in the first 32 days following Hurricane Harvey. The team served 923 patients for childhood vaccinations, adult and child tetanus, plus adult and child flu shots. They provided nutrition education to 3,133 patients, dental education to 3,694 patients, food safety information to 2,240 individuals and mosquito/vector-borne disease education to 5,160 individuals. The team enrolled 501 individuals for WIC benefits, and 2,232 families received food supplies from the HCPH mobile pantry. The team also provided pet vaccinations, microchipping, food and flea medications to 1,436 animals. Community residents responded with enthusiasm, stating that the Mobile Outreach Team was a resource that the public should, Take advantage of.” County employees were deeply humbled by the experience and expressed their gratitude declaring how, Every drop of sweat was worth it.” Many members of the community stated their belief this mobile health practice was, and will continue to be, A great idea!”

Success sustainment of the HCPH mobile program is based on on-going capacity-building, resource development and sustainability planning. Currently, much of the direct expenditures for the program are covered by county/DSRIP funds. To ensure adequate resources and to maximize our investment, sustainability for our program is being addressed on several levels including: Assessing the efficacy of mobile versus traditional, existing HCPH health programs. Implementing those services via mobile program where return on investment merits. Continuing to actively seek diverse funding sources for the program including local charities and foundations, federal and state grants and individual donors. We have already secured a grant for $50,000 for spay/neuter coupons to be distributed to pet owners at community events. Leveraging current partnerships and continuing to build additional ones for product donations. In the aftermath of Hurricane Harvey, we received mosquito repellent from Johnson & Johnson and pet vaccines from Banfield Foundation. Cleaning supplies and food donations came from a variety of sources including Kroger, Walmart and Home Depot and were distributed to the hardest hit areas of Harris County. HCPH's mobile program continues to serve as a food distribution site for the Houston Food Bank, reaching underserved and storm ravaged areas for the county. Continuing to utilize internal HCPH resources. o The DSRIP outreach team will continue to provide operational support of this project, focusing on community engagement and interventions. o Continuing to effectively market the program through our Office of Communication, Education and Engagement. o Another area of internal support will come from the Office of Policy and Planning (OPP). OPP is responsible for coordinating comprehensive assessment, planning, evaluation and policy development activities across the HCPH organization. o This project will also be supported by other department divisions or offices to include in house legal counsel, financial analysis, logistic support and executive leadership.

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