Oswego County is a large, rural county located on the southeast shore of Lake Ontario in upstate New York. Its size is slightly larger than the State of Rhode Island. Its rurality is reflected in the percentage of residents who access public transportation (0.7% in Oswego vs. 26.6% as state average). It has a population of 121,594, 61% of them in rural areas. As with most rural areas in the country, Oswego County has experienced economic hardship in recent decades and seen an acceleration of the total population reduced while the proportion of residents aged 65 and above increased in recent years. Over the past several years, the community has been striving to collaborate to address health inequity caused by inadequate education outcomes, high unemployment rates, lack of transportation, depressed real property values, low health literacy, and generational poverty.

When it started to plan the COVID-19 response, Oswego County Health Department (OCHD) realized that the limited high-speed internet access in many remote towns and villages of the County posted a new challenge to health equity. Despite the shortage of resources, as most rural local health departments face in the nation. OCHD decided to set up a phone bank (uploaded File One) to address health inequity because landline and cellular phones are more accessible than the internet to the county residents. The objectives of the phone bank include:

·       ensuring COVID-19 information available to all residents and overcome barriers due to lack of internet access;

·       creating a two-way conversation channel and allowing residents to talk with live, trained staff to deliver COVID-19 information and promote health literacy; and

·       building partnerships by engaging community members and stakeholders to overcome resource shortages and sustain and enhance the phone bank's operation and functions.

To ensure the phone bank is readily accessible to all county residents, OCHD distributed more than 1,500 posters (uploaded File Two) about the phone bank number with the COVID-19 prevention information throughout the County in less than two weeks in early March 2020. In the first month, the phone bank received more than 2,200 calls (uploaded File Three) after the phone number was publicized.

The phone bank has innovatively targeted the community’s critical needs and attracted many health equity-minded individuals and agencies’ support. Since it started in the middle of March 2020, the phone bank has not only reached the populations it intended to reach but also created partnerships to address broad health inequity caused by lack of internet access and identified opportunities to ease individual’s struggles due to rural poverty. Based on the community’s needs, the phone bank flexes its operation hours and the staff level to use limited community resources wisely and enhance collaborations as well. The phone bank has also provided feedback from the community to the countywide COVID-19 response, especially in communication about the disease on websites, social media, and daily updates. Well-trained and information timely-updated phone bank staff ensures a high quality of services.    

Phone bank (or call center) is a centralized office staffed with a trained team for receiving and transmitting a large volume of inquiries by telephone. It is documented that phone banks have been used to control infectious disease outbreaks and chronic conditions. But no report exists that taking phone banks as a tool to address health inequity in the community. For the preparation of this application, we searched “phone bank” or “call center” combining with “health inequity” in Google Scholar, PubMed, and MMER but did not find any research reports about using phone bank to address health inequities. We checked NACCHO’s public health practice tool kits by keying “phone bank” or “call center,” the website indicated “0” results for both searches.

OCHD’s innovative use of phone bank include:

·       a complement to websites, social media, and press releases to deliver COVID-19 information in rural communities lacking internet access;

·       two-way communication to reach residents in a vast rural area for promoting health information and health literacy about COVID-19 prevention; and

·       an “anchor” for community partnerships to address rural health inequities in local COVID-19 response.

A nation report claimed that 24% of rural adults without access to high-speed internet. As of October 2020, 20% or more households have no internet or have dial-up only in a third of the County’s territories, includes the third populous area of the County. Even in some areas with high-speed internet, many residents rely on local public libraries to access the internet. Many lost their access to the high-speed internet with public libraries’ closure due to the COVID-19 pandemic. In addition to websites, social media, and daily press releases, OCHD set up a phone bank at the beginning of March 2020. By mid-November, it answered more than 11,000 calls, not including calls to other lines in OCHD then forwarded to the phone bank and out-going calls by phone bank staff. The phone bank has been an important channel to educate the public about the disease and reach out to broader residents that the internet could not. The phone bank also acts as an “antenna” for OCHD, keeping aware of the community’s questions and concerns, and even some individual’s needs in COVID-19 response. Many community individuals and agencies witnessed the power of the phone bank’s connections to residents in this geographically large county and formed partnerships surrounding the phone bank as well.

In the COVID-19 pandemic, accurate and timely information to citizens is the key to building the community’s trust, support, and collaboration. During the early weeks of the pandemic, residents found comfort in having a live person to ask questions and discuss the disease, prevention measures, and regulations to contain the disease. The phone bank has filled the gap of lacking access to the internet for many county residents and provide all residents with easy access to trained and information-updated live persons to discuss their concerns. In the first four weeks, the phone bank received more than 2,200 calls.

The first large, unexpected partnership came shortly after the phone bank was set up. The Office for Aging, with a small staff, noticed the phone bank’s outreach capacity and asked the phone bank to contact several hundred seniors to check these seniors' status and educate them about the disease in a short time. The phone bank took this collaboration opportunity to establish itself as a new and active community response player and made several hundred calls. Within a week, the phone bank reached everyone over 70 years old who resided in the County, gave them educations about COVID-19 prevention, and checked each of the senior’s needs.

In mid-May, the phone bank sensed the testing capacity shortage in the County from many calls asking for testing sites and requests for free testing because of lack of health insurance. OCHD reached out to a regional medical center for a new partnership bringing in testing capacities into the County. A mobile van equipped with testing devices could deliver testing to different locations throughout the county, but the mobile service required pre-registration online for efficient operation. Many rural residents were not able to access the internet. To keep the partnership and serve remote rural residents, the phone bank staff took personal information over the phone and registered those without the internet. The mobile testing came to the County and collected close to 1,000 samples for the residents; among them, 25% were assisted by the phone bank for the pre-registration online.

Another example of innovatively using the phone bank came from an elementary school situation. After schools opened in the fall semester, school surges created a tremendous amount of work for OCHD to contact students' parents and guardians to inform them of quarantine and isolation orders and educate them about in-household preventive measures. The phone bank took over some of the tasks to help disease investigators and school specialists’ workloads. The phone bank persistently tried to identify and reach out to vulnerable families. In one case, after four days’ trying, there was still no responses from the family even with help from the school, the phone bank suggested having a field visit to the family. The field visitation of the family found that it was an illiterate, single father family. His limited monthly minutes on his cellular phone were used up, and he planned to go to his mother’s house to use her landline phone to call OCHD. On the site, the nurse explained the disease to the father, delivered the quarantine order, advised the father to watch his child and himself for symptoms, and checked their needs in the quarantine period. This family received services as all other affected families in the County received.

Like many rural government health departments, OCHD provides local public health, including preventive and clinical services, environmental health, and early interventions with limited staff and other resources. Collaboration and partnership become critical for OCHD’s success in COVID-19 response. In the meantime, the versatility of the phone bank provided new opportunities to establish new partnerships in the community against COVID-19, and these partnerships creatively addressed health inequity in the County.

Staffing the phone bank has been a partnership since it started. One of the earliest challenges was to staff the phone bank. Besides getting county employees from other departments, OCHD reached out and sought collaborations from retired nurses and other healthcare professionals in the community. Later, to serve the minority Spanish-speaking community, OCHD set up a collaborative arrangement for accessing a bilingual county employee in another department. As phone bank needs increasing, eventually, OCHD persuaded the department leader and this bilingual caseworker to staff the phone bank regularly.

An unexpected partnership came quickly shortly after the phone bank was up. At the beginning of the pandemic, the state DOH implemented strict testing criteria. The only community hospital in the County gathered the personnel for the testing but was short of staff for screening and scheduling the test as the hospital tried to keep its clinical service operation as usual. Then the phone bank stepped up to screen and schedule for the hospital. The partnership expanded the phone bank's functions, assisted the hospital’s operation, and ensure limited healthcare resources reasonably and equitably distributed in the community.

Another unexpected partnership happened in late May when the COVID-19 virus spread communitywide. There are four nursing homes and many assisted senior living facilities in the County. As the virus spread, the phone bank received many concerned calls and inquired about protecting the seniors there from the residents and their families. The community concerns expressed to the phone bank quickly got OCHD’s attention. To protect senior citizens in these facilities, OCHD collaborated with the New York State Department of Health (the state DOH), because nursing homes and assisted living facilities are under the state DOH’s regulation in New York State and provided drive-through tests for nursing home staff in the County. This testing service built a strong foundation for the continuous partnership between OCHD and nursing homes in the County. In the following months, OCHD and nursing homes closely worked together on disease control and reporting for the nursing homes and the community.

The new partnership did not just connect OCHD with local and regional service providers but also with the clients that OCHD intended to serve. Considering that many farms would hire seasonal migrant workers and many of these workers come from countries where outbreaks surged, the phone bank reached out to more than three dozen farms to seek partnership with farms to test farm employees, including migrant workers. Based on mutual agreements, OCHD delivered testing to farms and identified and isolated positive workers timely. This partnership protected the migrant farmworkers and prevented the virus from further spreading to county communities. Later, when a farm had a case surge, the farm’s owners and operators collaboratively worked with the county and state authorities and successfully limited the virus within the farm and prevented a likely community outbreak.

These unexpected partnerships brought OCHD, the hospital, nursing homes, assisted living facilities, and farms to set good examples and provided experience in building partnerships with colleges and schools when the new academic year started in September 2020. In the beginning, the phone bank was a channel for OCHD connecting with the college health center and school nurses. Later, the phone bank brought college administration and school education administrators together to the County. With the college and all school districts’ support, the County was able to prioritize resources for COVID-19 control and timely inform county residents of the disease activities. The whole county benefited from the collaboration that started with and built on phone bank activities.

Continuous quality improvement is one of the operation principles of OCHD. In the planning stage, the department set quality improvement measures of the phone bank operations, as the center of information for all county residents and partners, in:

·       Accuracy and timeliness of the information provided; and

·       Accessibility and responsiveness to the information.

To ensure the phone bank services' quality, everyone who works at the phone bank undergoes initial training. For accurately and timely delivering the ever-updating federal and state guidance and local disease information, phone bank workers also get updated training. The training contents are updated as the pandemic evolves, information and procedures renew, and the community’s inquiries change. The phone bank gradually became the information center for COVID-19 response and kept exploring opportunities for building partnerships and expanding its services. Because of quality improvement and control measures, in the first eight month’s operation that this application covers, the phone bank services were well received by the County residents, and it never received any complaints.

The phone bank has been staffed with heterogeneous sources of OCHD workers, community volunteers, and other county employees from half a dozen departments. Many times, the phone bank staff comes and goes in flowing. To assure the service's quality, the phone bank workers usually get the information updated earliest, and two phone bank leaders are included in the department’s leadership team meetings on COVID-19 response. These actions helped the phone bank train newcomers and update existing members on the latest guidance and information. The phone bank also uses two large whiteboards to highlight the most recent call’s topics and key points for answering these topics.

As the phone bank took the information center's role with high workloads, OCHD kept the model of “planning, acting, monitoring, re-assessing, and responding (and planning again)” cycle to continuously maintain and improve the quality of services by the phone bank. The phone bank leaders were original members in the COVID-19 response planning, and they have participated in all COVID-19 related meetings in the department since then. In daily interactions with other components of the response operation and at the scheduled meetings, the phone bank shared the information about the whole process. It provided insights from the community to facilitate many response actions. The leaders monitored messages from County communities for tailoring the county’s messages in websites, social media, and daily press releases to the public during the pandemic. The leaders monitored call volumes to adjust operation hours and the staff level. They assessed the outcomes of their actions as the feedback for planning the next phase of action/operation.

Evolving the pandemic trends, regulations and guidelines about traveler information, quarantine and isolation guidance, disease control recommendations have been issued continuously and updated. For accurate and updated information, the phone bank developed Frequently Asked Question (FAQs) sheets and continually updated them as the pandemic evolved. Retrospectively early questions centered around signs and symptoms and transmission and preventive measures.  Then testing, isolation, and quarantine questions followed.  After that, complaints became a popular theme and continue to come in.  Not long ago, travel-related questions and business reopening guidelines were frequent.  A few months ago, school and college reopening and planning were dominant. And now vaccination questions and concerns are the focus. 

Because the phone bank is a two-way communication channel, sometimes, it serves as an “early warning system” to OCHD to sense the health inequity and be prepared to provide services to break down the barriers for equitable health outcomes. The County’s first outbreak event happened in a food processing facility. Most of the employees there spoke Spanish and Karen. The phone bank became aware of it and set up online translation services ahead of joint samples collection to test all employees between the state DOH and OCHD. This pre-event readiness greatly facilitated the testing sessions for over 160 facility employees.

As the phone bank plays a vital role in the COVID-19 response operation, the phone bank also tried to identify opportunities for addressing health inequity through partnerships. When the phone bank has reached everyone, who was going to be quarantined or isolated, it does not merely deliver the orders but also check their living conditions. In checking people’s living conditions, the phone bank was able to identify those in need of supplies, food, and daily necessities. To fulfill these individual’s needs while maintaining phone bank staff, the phone bank collaborated with the Environmental Health Division (EH). It used EH staff to go to the field to deliver these legal orders because their sanitarians travel throughout the County to inspect county regulated entities and are familiar with the county routes and streets. This collaboration has helped many families and individuals in the pandemic.