Seminole County is in East Central Florida just north of Orlando. With an estimated population of 473,408 (as of July 1, 2019), according to the U.S. Census Bureau. Seminole County is also the most densely populated county in Central Florida with a total land area of 309.5 square miles. The county is comprised of seven cities and six unincorporated areas represented by 26 zip codes and 86 census tracts as of the 2010 Decennial Census. 52% of the population is female, 80% Caucasian and 78% non-Hispanic.

The Florida Department of Health in Seminole County (DOH-Seminole) serves the community with a mission to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts. DOH-Seminole, and its community partners, have worked collaboratively to address the needs of county residents who are most impacted by the COVID-19 pandemic. 

Due to the COVID-19 pandemic, the need for community testing to target specific populations was identified and existing testing locations were insufficient to meet the demand. Per Centers for Disease Control (CDC) guidelines racial or minority groups, people experiencing homelessness, people with disabilities among other populations are considered as “Other People who Need Extra Precautions.” Additionally, COVID-19 early data showed a disproportionate number of Hispanic individuals were dying from COVID-19 and initial testing locations did not address this disparity. As of May 8, 2020, 50% of the individuals who died due to COVID-10 in Seminole County were Hispanic. This was greatly disproportionate to the percentage of Hispanic residents in Seminole County. DOH-Seminole’s Community Integrated Mobile Health Services (CIMHS) team quickly mobilized to address this concern.

A root cause analysis identified a variety of barriers inhibiting a large portion of the Hispanic community from being tested. Barriers included lack of transportation, translation and language difficulties, availability of testing sites during non-work hours and lack of understanding of the unique impact of COVID-19 in the Hispanic community. Planning for outreach events to offer testing to the Hispanic community quickly revealed a need to collaborate with community partners to fully address the disparity. CIMHS connected with Hispanic faith-based organizations and business to secure physical locations to offer testing in the areas where Hispanic residents live and work. Partnering with the business or faith-based leader in each of the designated sites also afforded the opportunity to quickly disseminate information regarding COVID-19 and the dates, times and locations of the testing events. With the locations secured, CIMHS enlisted assistance from other community partners including Seminole County Government and the Seminole County Sheriff’s Office who aided with logistics and traffic control.

Over the course of the next several months, CIMHS led thirty testing events and tested nearly 2700 individuals in the chosen locations. Cloth masks and educational information regarding social distancing, handwashing and other COVID-19 information was shared at each event. As of November 7, 2020, the percentage of Hispanic individuals who died from COVID-19 lowered to 12%.

DOH-Seminole’s CIMHS program is unique and innovative in its approach to serve the community, in the community, and bring needed services to targeted geographic locations to reduce barriers and promote optimal health. The CIMHS team is immersed in the community and well positioned to engage residents through well-established, trusting relationships. Through these relationships, CIMHS was able to mobilize quickly to address the identified issue facing the Hispanic community in Seminole County. While only 22% of Seminole County residents are Hispanic, in early March, Hispanics encompassed 50% of the deaths due to COVID-19 in Seminole County. The emergence of COVID-19 necessitated cessation of many scheduled outreach events and activities normally performed by CIMHS. While social distancing and stay at home recommendations/orders impeded traditional outreach activities, DOH-Seminole quickly recognized the need to target COVID-19 testing and resource distribution to the Hispanic community. CIMHS utilized DOH-Seminole’s Innovation Lab to develop a strategic plan to tackle the problem and implement a streamlined service delivery approach. The DOH-Seminole Innovation Lab (Inno Lab) is a recent enhancement to DOH-Seminole’s “Journey to a Culture of Innovation.” The Inno Lab offers a safe space for staff and the community to collaboratively create and test innovative ideas. During the second quarter of 2019, several tasks were completed in the development of the Inno Lab. Key informant interviews and field visits aided in the development of theoretical and logical framework which resulted in the creation of the Inno Lab space. Through a partnership with AdventHealth, approximately a dozen DOH-Seminole staff were training in Design Thinking. Design Thinking is a methodology for creative problem solving that involves innovation and strategic leadership. The five phases of Design Thinking are gathering empathy, defining the problem, creating ideas or brainstorming, developing a prototype or plan of action and finally testing the prototype or plan of action. At the onset of the COVID-19 pandemic, implementation of the Inno Lab had just begun.

The COVID-19 pandemic impacted every aspect of public health service delivery in Seminole County. DOH-Seminole programs worked hard to implement strategies to continue essential public health services while adhering to social distancing and community stay at home orders/recommendations. The extra burden to continue services during a pandemic limited the number of DOH-Seminole staff able to assist with the Hispanic community testing events. However, understanding the need, DOH-Seminole staff, especially Spanish speaking staff, stepped up to work after hours and on the weekends. Utilizing the Inno Lab, the team met to develop the framework for initiating a quick and effective response to the identified issue – a higher and disproportionate percentage of COVID-19 deaths seen in the Hispanic population. Drawing on the cultural experiences of DOH-Seminole Hispanic staff, the team conducted brainstorming sessions to identify the best means of reaching the Hispanic community and providing culturally appropriate education aimed at mitigating the spread of the virus in the community and reducing the number of COVID-19 deaths in the Hispanic community.

The CIMHS team connected with businesses and faith-based organizations in Hispanic communities to garner additional information regarding barriers in the Hispanic community preventing individuals from being tested for COVID-19. The information obtained revealed that transportation and language barriers and lack of knowledge regarding transmission of the virus were contributing to a reduced number of Hispanic individuals being tested for COVID-19 and engaging in behaviors that could potentially spread COVID-19. Armed with the information from internal focus groups and community stakeholder interviews, the team met in the Inno Lab to discuss what was learned and develop a plan to address the issue.

The CIMHS community testing events were innovative in that they quickly addressed a community problem through implementation of a new service with the aim of improving health outcomes for a targeted community group. Several Inno Lab sessions were held. First, sessions focused on brainstorming, focus groups and key stakeholder interviews to identify possible barriers to the Hispanic community receiving COVID-19 testing. Second, incorporating information gathered from brainstorming sessions, focus groups and key stakeholder interviews, the team identified strategies to address the barriers identified. Third, the team developed a structured implementation plan to deliver COVID-19 testing services in targeted locations, in collaboration with community partners. To augment testing services, education and resources were also identified as a needed component to the testing events.

Several challenges were quickly identified, including feasibility of testing sites that could accommodate large crowds and not impose traffic difficulties on major roadways. This challenge was resolved through strategic geographic planning which ensured smooth traffic flow. Language barriers were resolved through the recruitment of DOH-Seminole Spanish speaking staff to be placed in key positions which interfaced with the individuals being tested. This ensured informed consent and efficient education regarding essential COVID-19 community mitigation topics. Additionally, the need for partner collaboration was paramount in planning for the Hispanic community testing events.

Understanding the extent of the endeavor being planned, DOH-Seminole involved several community partners to ensure the testing events were well planned and addressed the needs of the community. Planning meetings were held with several organizations including Seminole County Government and Seminole County Sheriff’s Office. Seminole County Government provided logistical support including use of the mobile command vehicle, staff for set up of the events, electricity for refrigeration of the collected specimens and other needs as they were identified. The Seminole County Sheriff’s Office aided with traffic flow planning and provided deputies at each event for traffic control. Another need that was identified was the need for many qualified clinicians to perform the specimen collection. CIMHS engaged the assistance of Bueno Pharmacy, a local full-service pharmacy staffed with bilingual clinicians, and the American Community Clinic, a free community clinic with numerous clinical volunteers. Collaboration with these community partners was an essential component to the success of this effort. 

In addition to the partners identified above, CIMHS communicated with several Hispanic businesses and faith-based organizations including Iglesia Christiana Hispana, Iglesia Presbiteriana El Redentor, St. Mary Magdalen, Bueno Pharmacy and St. Lukes Lutheran Church. These locations were specifically chosen due to their robust Hispanic congregation and feasibility of the physical site to accommodate a large number of attendees without impeding local traffic. Additionally, the locations of the sites provided geographic coverage across the county.

Once the key players were identified, an Inno Lab session was held to develop a process flow for the event. See attached PDF – ‘Process Flow Chart.’ Identifying each role and the associated duties assigned provided clarity and ensured a seamless delivery of services. The roles identified were as follows: registration staff, clinical assistant, clinician, driver, and epi/data team. Training to orient staff to each position was held and staff were fully informed of their role and responsibilities. Additionally, just in time training was provided before the onset of each event to remind staff of their role and associated responsibilities. Before each event, CIMHS worked with the partners to develop an individualized traffic flow pattern including an onsite visit and discussion and resolution of any potential barriers at each site. See attached PDF – ‘Traffic Flow Example.’

To avoid an influx of calls and confusion from individuals being tested, flyers were developed, in both English and Spanish, to provided education regarding COVID-19 (importance of hand washing, social distancing, etc.) and how to obtain test results. In partnership with the labs being used at the time, Labcorp and Quest, flyers were customized with clear instructions on how to obtain test results via the on-line portal. Depending on the test kits available for each event, the corresponding test result flyer would be provided to each individual being tested.

The partnerships developed during this project have further enhanced the services of DOH-Seminole by fostering trust in the community, educating the community about COVID-19 and other services offered at DOH-Seminole. In addition to information disseminated during events, individuals were also provided with cloth masks to further contain the spread of COVID-19 in the community. Collaborative partnerships created during these testing events resulted in opportunities for vaccination sites which will be explored as vaccination initiatives develop.

DOH-Seminole was able to quickly and creatively adapt to an identified issue utilizing the Plan Do Check Act (PDCA) cycle and incorporating Design Thinking methodology in the Inno Lab. The PDCA cycle is a four-step problem solving iterative process used to develop a cohesive process or improve functionality of a process. Using these methodologies allowed DOH-Seminole to quickly and effectively address a serious disparity in our community.  

The initial problem statement read COVID-19 pandemic, the need for community testing to target specific populations was identified and existing testing locations were insufficient to meet the demand. Per CDC guidelines racial or minority groups, people experiencing homelessness, people with disabilities among other populations are considered as “Other People who Need Extra Precautions.” Additionally, COVID-19 early data showed a disproportionate number of Hispanic individuals were dying from COVID-19 and testing locations were initially concentrated in a limited area of the county.’  The following AIM statement was created: ‘An opportunity exists to improve the COVID-19 testing response among underserved or at-risk Seminole County residents. Success will be measured by the increase of COVID-19 testing where at least one of the identified underserved or at-risk Seminole County residents is represented.’

Initial data showed a disparity in the percentage of deaths due to COVID-19 in the Hispanic community in Seminole County. As of May 8, 2020, 50% of Seminole County residents who died due to COVID-19 were Hispanic. The Hispanic testing initiative resulted in numerous testing sites with over 2700 individuals being tested. As of November 6, 2020, the percentage of Seminole County COVID-19 deaths in the Hispanic community reduced to 12%.

Focus groups and key stakeholder interviews revealed several root causes, including transportation and language barriers and the cost of testing. Internal factors impacting extensive testing included a limited workforce to conduct testing and process specimens and limited operational logistics to conduct large testing sites. Countermeasures included the following: identification of viable testing sites and workforce, collaboration with community partners including local government agencies and clinical organizations and measured and detailed process mapping.

During the process, CIMHS was able to adapt to meet the needs of the community and address issues quickly. For example, transportation of the specimens, and accompanying paperwork, to DOH-Seminole for specimen and lab requisition processing was creating a bottleneck and impeding expeditious handling. To improve the process, DOH-Seminole explored the use of Eventbrite to pre-register individuals for the event. The individual entered their information in the system and a spreadsheet was generated containing all of the necessary information. This information was used to proactively prepare documents and expedite specimen processing. This system has been adopted in subsequent events including early COVID-19 vaccination events.

Several lessons were learned during the course of the seven-month initiative. Staff were adaptable and supportive of one another. The process was modified when necessary. Continual analysis of data was essential to determine subsequent locations and steps. And, above all community collaboration and partner engagement was vital to provide a robust and expeditious response.

Another enhancement developed during the Hispanic testing initiative was the adaptation of the testing event to reach other populations such as the homeless, refugee and migrant individuals, residents of domestic violence shelters, facilities with individuals with special needs, etc. Through replication of the Hispanic initiative events, several other populations were able to be seamlessly provided COVID-19 testing services and education. One of the early challenges that was addressed was the allocation of manpower. DOH-Services continued, some without interruption, causing a hardship on departments to allocate staff to assist with the Hispanic initiative. However, adhering to the fundamental philosophy of serving the community, allowances were made, and staff worked together to ensure all core DOH-Seminole services continued throughout the initiative. The initiative was shared at the Central Performance Management and Quality Improvement Consortia.

The success of the Hispanic testing initiative was due to collaborative planning, teamwork and partner engagement. The initiative served to address a significant disparity in the community while providing the framework for future events. The CIMHS Hispanic testing initiative Inno Lab project served as an example for future Inno Lab projects. Utilizing lessons learned during DOH-Seminole’s first Inno Lab project has created a meaningful public health impact and enhanced services and practice at DOH-Seminole. Several subsequent Inno Lab projects have been initiated and will follow the framework established during DOH-Seminole’s initial project.