Plan for Preventing the Spread of COVID-19 in San Mateo County and Reducing Disparate Impacts: Summary and Selected Metrics
|Ethnicity/Race||SMC Covid+ 9/24/20||SMC Census est 2019||HPSM Medi-Cal 5/2020||HPSM ACE 5/2020|
Asian + PI
|Pacific Islander||2.4%||1.5%||See above|
The impacts of the pandemic have been significant: 20,000 low-wage workers have lost their jobs; 21,815 immigrant households have applied for $1,000 financial assistance through the Immigrant Relief Fund; 3,924 households have applied for rental assistance; there has been a 250% increase in pounds of food distributed by Second Harvest every month; 4,411 school children lack Wi-Fi tools for distance learning; and over 600 small businesses have applied for financial assistance.
As the SMC Recovery Initiative has highlighted, it will take the collective capacity of the entire community to build a more equitable, healthy and connected San Mateo County. Given the deep systemic challenges the pandemic has exacerbated, the public health strategies to respond to the pandemic are one part of a broader array of countywide efforts. There have already been substantial County-led efforts to expand investments in housing, rental assistance, financial relief, childcare, food insecurity, Wi-Fi access, and economic recovery and the SMC Recovery Initiative has identified the need for even more. There will have to be sustained long-term focus to achieve meaningful impact.
Thus, although COVID-19 poses health risks to all our residents, we know that some of our communities are at elevated risk for COVID-19 and are shouldering a greater burden of the impacts of COVID-19. San Mateo County Health’s plan to contain the spread of the virus is designed to account for the specific conditions, risk factors, and demographics of these communities so that all of our residents receive the support they need to protect their health.
Two strategies address immediate drivers of spread
While the roots of the disparate impacts of the COVID-19 are deep, the focus of this Plan is two strategies (Strategy 1: Expand and improve communication to encourage adoption of protective behaviors and build trust and engagement in Public Health protection efforts and Strategy 2: Enhance culturally competent mitigation strategies for preventing spread (testing, contact tracing, isolation support, healthcare and supportive services) and related actions we can take to address the immediate drivers of the spread in at-risk communities: (1) Continued focus on adoption of the protective behaviors that most prevent the spread (face coverings, hygiene, social distance, no gatherings); (2) Lack of trust in government and engagement in Public Health protection efforts (3) Lack of testing among certain communities with high positivity rates; (4) Inability for frontline and low wage earners to safely isolate due to economic impacts.
Meet overarching metrics
Counties across the state are challenged with the same problems. The California Department of Public Health has developed an Equity Metric aimed at reducing the inequitable burden of COVID-19 on populations of color and low-income residents. This is the overarching metric for our plan. The State metric incorporates a focus on reducing disparities in the COVID-19 impacts in the census tracts identified through application of a multi-dimension index, the California Healthy Places Index (CHPI) https://healthyplacesindex.org/about/. This is highly aligned with the SMC Social Progress Index work and the equity lens we are applying to our response.
Metric: Percentage COVID-19 positivity (7-day average, 7 days lagged) for the lowest quartile HPI census tracts.
Goal: must be <5.25% to move to the orange tier; <2.2% to move to the yellow tier.
Milestone: We have appointed a new Public Health Equity Officer to coordinate our public engagement related to this plan as of November 15; continued learning from targeted focus groups with people who have lived experience of the virus; and monitoring of our progress using the metrics associated with these strategies; in coordination with other local partners and the Bay Area counties.
Strategy 1: Expand and improve communication to encourage adoption of protective behaviors and build trust and engagement in Public Health protection efforts
We are prioritizing four Strategy 1 actions (A-D) below to respond to the following drivers of the spread of the virus in our most vulnerable communities: (1) Continued focus on adoption of the protective behaviors that most prevent the spread (face coverings, hygiene, social distance, no gatherings); (2) Lack of trust in government and engagement in Public Health protection efforts.
A. Expand targeted, culturally competent communications and public information through the Office of Community Affairs and trusted emissaries to reinforce core messaging and to promote (1) Continued focus on adoption of the protective behaviors that most prevent the spread (face coverings, hygiene, social distance, no gatherings)
All our residents deserve timely, reliable, and relevant health information in languages and formats that meet their needs and explain the behaviors and resources that protect their health. In addition to the countywide Our Comeback Depends on All of Us campaign, a partnership with the Office of Community Affairs and Communications leverages the infrastructure in place for Census 2020 including partnerships with community-based organizations and layers public health messages into tailored communications. The focus has been on culturally competent in-language messages using traditional, print, digital and social media about protective behaviors such as face covering and avoiding gatherings, acceptance of testing, what to expect if positive and contact tracing. Targeted communications aim to bring these messages to at-risk populations, including Latina/o/x, Filipino, Pacific Islander, African American communities, farmworkers, homeless individuals, LGBTQ+, younger (20-39) populations, older adults, all low-income communities. We aim to continuously update and target messaging guided by epidemiological data regarding the populations and geographic areas impacted by spread of the virus: for example, epidemiological information to-date emphasizes the need for targeted messaging to Latina/o/x and Pacific Islander populations within East Palo Alto and Redwood City; Latina/o/x, Pacific Islander and multi-race populations within San Mateo; Latina/o/x, Asian and multi-race populations within Daly City and farmworkers in the South Coast. Similarly, young adults ages 20-24 in East Palo Alto, Redwood City, and Half Moon Bay are indicated for targeted messaging that will align with testing in these communities. There is a Bay Area regional campaign, Crushing the Curve, targeting youth. (See exhibit for examples.) Trusted messengers have been critical for in-person and media outreach: pediatrician/MD, public health nurse, faith community leaders, local leaders, CBOs. Milestone: Responses due September 18 to the Office of Community Affairs RFP for community partners to assist in outreach and education in their communities as our community-based organizations are led by and serve those most impacted and are closest to their voices. These partners will survey community members regarding their beliefs about behaviors that spread the virus and then goals will be set to increase understanding over time. In addition, the following metrics will be tracked: # canvassing events per month; # of media impressions in target communities per month; # visitors to COVID resource webpage; # Masks distributed via Mask Mobile deployments per month.
B. Maintain public dashboards and in-language resource information to promote (1) Continued focus on adoption of the protective behaviors that most prevent the spread (face coverings, hygiene, social distance, no gatherings) and respond to (2) Lack of trust in government and engagement in Public Health protection efforts.
Timely, accurate and accessible information and locally created in-language resources 211, 211211 (text), call centers, websites, and social media. Maintain County Health baseline metric: 163,000 monthly visitors to website; 22,000 followers on Facebook and 5,300 followers on Twitter.
C. Centering the voices of those most impacted: provide information and support and enlist ongoing feedback from most impacted communities through town halls and focus groups for continuous improvement to promote (1) Continued focus on adoption of the protective behaviors that most prevent the spread (face coverings, hygiene, social distance, no gatherings) and respond to (2) Lack of trust in government and engagement in Public Health protection efforts.
These interactive activities include forums, town halls, focus groups, streaming social media events targeting communities most at-risk. Leveraging the partnerships that already exist between the Office of Diversity and Equity, Diversity and Equity Council, each of the Health Equity Initiatives and other partners, the Public Health Equity Officer will share information about the public health response and help us learn and improve the public health and countywide response with regular feedback from participants in these community focused events. Milestone: Given the overwhelming impact on the Latina/o/x community, the Public Health Equity Officer will convene a Latina/o/x advisory committee to review the learnings and offer input to the continued public health response. Metric: # activities. Goal: 6+ interactive activities by December 31.
- Two Race and COVID-19 Town Hall events were held to build solidarity with and learn from communities of color and low-income communities most impacted by COVID-19 and racial injustice. Baseline metrics: 125 /231 participants during two 1.5 hour events; 55% respondents to surveys/feedback/posting of materials. Goal: 1+ by December 31.
- 4 livestream events, 4 in Spanish and 1 in English providing education, parent support, trauma-informed coping and resiliency building skills, and resources targeting Latina/o/x and Coastside Latina/o/x communities and virtual parent cafes led by family partners. Goals: 3 focus groups with people who have lived experience of the virus by December 31. Support at least 1 livestream event per month targeting a vulnerable target community through trusted in-language messengers by December 31.
- School presentations on the impact of COVID-19, resources and trauma informed coping skills for staff and parents.
- Faith community: The Health Officer held a virtual dialogue with faith leaders to enlist them as trusted messengers to many impacted residents. Now posted to web. Milestones: 50 participants Zoom event late May; Regional Pacific Islander Task Force convening of Pacific Islander faith leaders upcoming October 17.
- Monthly virtual peer-led support events organized by Health partners such as Health Equity Initiatives, Heart and Soul, One EPA, CA ClubHouse to build community and collective support.
- City-facing presentations to City Equity/other committees representing impacted communities; 5 to date, more as requested.
D. Rely on partnerships and trusted intermediaries SAMCEDA, the County Office of Education, First5, and the Health Plan of San Mateo to reach key sectors to promote core behaviors (1) Continued focus on adoption of the protective behaviors that most prevent the spread (face coverings, hygiene, social distance, no gatherings) and respond to (2) Lack of trust in government and engagement in Public Health protection efforts.
Work with trusted intermediaries to prioritize health equity when collaborating with stakeholders as they make decisions, develop communication plans, and build mitigation strategies.
- Partner with SAMCEDA and business community to increase education regarding how to prevent the spread. Improve safety for essential most at-risk workers in construction, food service, and custodial/maintenance.
- Milestones: Virtual education session for 190 businesses on July 23; for 150 SFO vendors August 13; and for 33 cities/economic development offices/Chambers of Commerce on September 2.
- Milestone: Translation and distribution of this event into Spanish and Chinese and posted to website by September 23.
- Milestone: Targeted information campaign using multi-channel ethnic media, social media and direct mailings, enlisted respected business leaders and targeting minority owned businesses in high risk sectors, commencing by October with first milestones completed by November 30.
- Partner with the County Office of Education to continue to provide technical assistance and support implementation of the Pandemic Recovery Framework as well as message directly to the school communities. Milestones: # K-6 Waivers approved; # schools open for in-person learning after SMC becomes eligible under State tier.
- Partner with First5 and Child Care Coordinating Council to support outreach and technical assistance to childcare providers. Milestones: Maintain clear information sharing and escalation pathways for issues/questions from childcare providers.
- Partner with the Health Plan of San Mateo to monitor COVID impacts on and coordinated messaging to their low income Medi-Cal and ACE memberships who are 18% of San Mateo County residents (numbering 141,048 8/1/20). Also focus on older adults in congregate care facilities who have been 58% of San Mateo County deaths and the staff and caregivers who work in these settings.
Strategy 2: Enhance culturally competent mitigation strategies for preventing spread (testing, contact tracing, isolation support, healthcare and supportive services)
If our efforts as part of Strategy 1 are successful to expand and improve communication, Strategy 2 will be more successful. We are prioritizing the four Strategy 2 actions below (A-D) to respond to the following drivers of the spread of the virus in our most vulnerable communities: (2) Lack of trust in government and engagement in Public Health protection efforts (3) Lack of testing among certain communities with high positivity rates; and (4) Inability for frontline and low wage earners to safely isolate due to economic impacts.
A. Ensure low barrier access to testing for at-risk populations by expansion of neighborhood-level testing sites supported by local trusted partners and combined with outreach for at-risk populations. Addresses (2) Lack of trust in government and engagement in Public Health protection efforts (3) Lack of testing among certain communities with high positivity rates.
Access to convenient, no-cost testing helps residents protect their health and aids public health in the identification of positive cases. Feedback from the town halls has already led to improved registration processes for people with technology barriers and walk ups, community rotations, access for children, and improved in-language materials regarding what to expect. The three keys of this strategy that are described fully in the separate Testing Plan with associated metrics (overarching is to achieve 308 tests/100,000 population by October 12, 2020) are (1) ensure sufficient testing capacity to meet the need for timely testing in connection with comprehensive case and contact investigation; (2) invest in strategic community testing of our at-risk and vulnerable populations; and (3) ensure equitable access to testing. In addition to supporting broad access to testing in different geographic areas of the County, the Plan describes how we are aligning our communications and working with local partners to create targeted neighborhood testing sites that serve at-risk, vulnerable neighborhoods, as identified through the local epidemiology and demographic information, that are offered at flexible times to meet community needs. Populations such as farmworkers and older adult residents and staff of congregate care facilities who are high risk are also addressed in the Testing Plan. Baseline: Ten neighborhood testing events over approximately 6 weeks. Goal: By October 19, average at least four neighborhood testing events per week.
B. Ensure timely and responsive, culturally competent contact tracing and case investigation to overcome (2) Lack of trust in government and engagement in Public Health protection efforts.
Early identification of cases, contact tracing, and isolation of positive residents is the key strategy to contain the spread of the virus. Spanish and other language capacity is critical for successful engagement. State metric and goal expected soon.
- Maintain sufficient staffing to ensure a caseload of no more than 2 new cases/day for contact tracers. Currently have sufficient staffing but they are not yet taking 2 new cases per day as they are training up.
- Milestone: Provide cultural humility training to contact tracers by December 1, 2020.
- Ensure at least 40 % of contact tracers have bilingual language competency. Current: 40% (34) Spanish speakers, 3% (2) Tongan, 3% (2) Tagalog, 1.5% (1) Chinese (of the staff currently trained up and taking cases).
C. Provide culturally competent wrap around services COVID+ who need support to isolate through Mental Health Association Public Health Support Program and referrals to meet needs for housing, food security, economic support and coverage. Addresses (2) Lack of trust in government and engagement in Public Health protection efforts; and (4) Inability for frontline and low wage earners to safely isolate due to economic impacts.
95% of the referrals to date have bilingual Spanish engagement. Metrics: # bilingual case managers; # referrals per month. Baseline: 3 bilingual case managers; from 08/18/2020 to 09/17/2020, there were 263 referrals representing more than 600 benefited. Goal is to continue to exceed 250 per month.
- Housing: Health partners with Housing and Human Services to continue to inform the development of both the immediate housing alternatives for COVID+ individuals and families as well as the longer-term development of permanent housing resources. The number housed through this effort is reported daily and is currently 25. Capacity is flexible, the number may go down if the need declines, and the number may go up if the need increases.
- Food: Second Harvest has been provided 4.1 M pounds of food a month, a 250% increase from before the pandemic. Great Plates Delivered initiative to address food insecurity among older adults while supporting economic recovery. Daily metrics # of older adults served, # restaurants serving, $ back into the economy. 9/15/20: 2600 served, by 68 restaurants putting $11.5M back into the economy.
- Health Coverage is pathway to medical and behavioral health care: Health Coverage Unit implemented and extended policy change to keep ACE clients enrolled in health coverage – reaches almost 20,000 Latin-X residents with incomes below $25K for a single adult. County Health and Human Services work together to get and keep eligible residents on Medi-Cal. Metric: # of low-income residents enrolled in ACE (22,992). % bilingual staff (100% bilingual; 88% Spanish); demographics of client satisfaction surveys (77% completed in Spanish).
- Other County support: The County and private entities have supported Rental Assistance, Landlord Assistance, and the Immigrant Relief fund as well as childcare.
D. Continue safety net healthcare and supportive services provided by Health and local providers to heal and prevent spread.
In parallel to these public health strategies, Health continues to provide and contract for the culturally competent healthcare and supportive services that can assess and treat the illnesses affecting the lowest income residents including those who have been hospitalized for COVID-19 and are more likely to have underlying health conditions such as asthma and heart disease. Partner with all local hospitals to monitor the potential for surge demands and coordinate regarding use of alternate care resources. Metric: Hospital capacity to meet surge of 35% of baseline average daily census. Met consistently since the beginning of the pandemic. https://www.smchealth.org/data-dashboard/hospital-data
Notes & Sources
Health Inequities in the Bay Area BARHII (9/22/20) https://bd74492d-1deb-4c41-8765-52b2e1753891.filesusr.com/ugd/43f9bc_f79cccc60ed7424faea668cc75d5736f.pdf
Centers for Disease Control (9/22/20) https://www.cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html
California Dept of Public Health (9/22/20) https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/Immunization/ncov2019.aspx
Berkowitz et al. Cities Health Structurally Vulnerable Neighbourhood Environments and racial ethnic COVID-19 inequities. (7/29/20) https://www.tandfonline.com/doi/full/10.1080/23748834.2020.1792069
Center for Health Care Strategies (6/2017) https://www.traumainformedcare.chcs.org/wp-content/uploads/2018/11/Fact-Sheet-Understanding-Effects-of-Trauma.pdf
San Mateo County specific dashboards for demographic, housing and economic data: http://www.gethealthysmc.org/data
San Mateo County dashboard tracks cases: https://www.smchealth.org/data-dashboard/county-data-dashboard
Haro et al. California Initiative for Health Equity &Action Health Policy Report (9/20) https://healthequity.berkeley.edu/sites/default/files/covid_essentialworkers.pdf
We expect the State metric to incorporate a focus on reducing disparities in the COVID-19 impacts in the census tracts identified through application of a multi-dimension index, the California Healthy Places Index (CHPI) https://healthyplacesindex.org/about/This metric incorporates 25 community characteristics that affect equitable access to health and well-being. This is a similar approach to the San Mateo County Board of Supervisors innovative development of the Social Progress Index at the census tract level. Dialogue with the State to date suggests the metric will focus on closing gaps of COVID-19’s impact on lower-income residents and residents of color. The State has suggested that it may expect Counties to achieve improvement within timeframes as short as six weeks.