Adapting ICS Structure to Build Community Resilience and Preparedness for Long-Term Disease Response

State: TX Type: Promising Practice Year: 2023

Harris County, Texas encompasses 1,777 square miles of sprawling urban and suburban landscape and is home to over 4.7 million people, making it the third largest county based on population size in the country. Harris County Public Health (HCPH) provides a variety of public health services to residents across the county, which includes the 2.3 million residents that reside within the City of Houston. HCPH primarily services the areas of Harris County outside of Houston city limits, including 33 municipalities and the unincorporated areas of Harris County. Harris County is racially and ethnically diverse with 43.7% Hispanic or Latino, 20.0% African American, and 7.3% Asian populations due to its size and internationally recognized industries. Within the county's expansive population, there are several vulnerable groups whose needs have not been fully addressed by traditional service providers and may experience barriers to accessing standard resources offered during preparedness, response, and recovery efforts.

The outbreak of an acute respiratory disease, COVID-19, in December 2019 in Wuhan, China evolved into a public health crisis globally in 2020. HCPH responded to the first case of COVID-19 in the county in early March of 2020. On March 4th, 2020, Harris County activated the Incident Command System (ICS) to respond to the COVID-19 pandemic and, on March 11th, a Local State of Disaster was declared for the county. The scale of the threat called for significant expansion of the formal ICS structure to successfully address the public health needs of the community. Mass testing, and later mass vaccination, called for hundreds of clinical and support staff. Efficient epidemiological surveillance called for hundreds of epidemiologists, contact tracers, case investigators, and data entry staff. Communication, outreach, and health equity efforts called for hundreds of health communication and health promotion staff. Additionally, emergency management, human resources, data analytics, logistics, strategic planning, and financial management needs also grew. Eighteen months into the response, 579 employees were activated within the ICS structure, of which 136 were full-time employees (FTEs) and 443 were temporary employees. Of the 136 FTEs, nearly 70% (92 FTEs) had primary public health functions that supported non-COVID-19 duties. Within the 18 months, FTEs reported roughly 215,000 overtime hours, equivalent to 138 FTEs and $16.6 million in personnel cost. Working overtime within this state of emergency for an extended length of time led to significant employee burnout and rising rates of employee turnover. Employee turnover placed further burden on remaining staff to complete critical functions, fueling a cycle of unsustainable workload and poor staff retention.

The COVID-19 emergency response presented a unique challenge in which ICS activation was maintained long-term and multiple participants across different sections collaborated to provide support. These circumstances called for altered emergency response practices that were specific to local public health departments and addressed the unique challenges they face the inability to forecast the occurrence and magnitude of emerging disease threats, staffing shortages, a large variety of required roles and responsibilities, and balancing other essential public health services. An adapted ICS staffing model that was sustainable long-term and readily adaptable in the case of future threats was critically needed. This would allow the health department to remain flexible amongst the shifting priorities within infectious disease emergency responses while supporting continuity of operations to maximize the county's emergency preparedness and resilience.

This challenge drove HCPH to change its staffing and operational model by creating a new and separate COVID-19 Division within the health department that maintained ICS compliance as it relates to FEMA. This shift allowed dedicated staff to continue focusing on reducing the spread of COVID-19, increasing COVID-19 vaccine uptake, increasing data-driven systems change, promoting recovery and resilience, and implementing health equity strategies to better address the needs of disproportionally impacted populations. This adapted staffing model reduced strain on the rest of the agency's FTEs, allowing those who were activated from other critical areas, such as veterinary public health, mosquito and vector control, and environmental public health, to return to their original functions outside of the emergency response. This ability further supported long-term recovery through restoring pre-pandemic core public health service offerings.

The short-term objectives of this practice were quickly actualized through the creation of COVID-19 division and its dedicated teams focusing on specific objectives. HCPH significantly increased the capacity and efficiency of its infectious disease surveillance by forming an epidemiology operations branch that developed a prioritization system for effective case investigation and contact tracing and actively monitored potential outbreaks in high-priority congregate facilities across the county. The outreach branch formed several taskforces of community health workers to provide targeted outreach to demographics with low vaccination rates, such as the Homeless, Immunocompromised, Disabled, Disadvantaged, and Elderly Navigation (HIDDEN) taskforce. With help from the data analytics branch, the field operations branch provided COVID-19 testing and vaccination services in the most socially vulnerable zip codes with the highest case rates and lowest vaccination rates. Plans to build and maintain community engagement throughout long-term COVID-19 recovery efforts were created and executed through dedicated health equity and community resilience staff within the planning section.

The long-term impact of this practice is the enhanced ability to quickly adapt and use existing infrastructure to respond to other emerging disease threats. When the first local mpox case was identified in June 2022, HCPH was prepared to act on this threat immediately by utilizing the existing COVID-19 division personnel and infrastructure. As the threat increased, HCPH provided mpox testing, vaccination, and outreach to the community without compromising daily COVID-19 operations. Personnel, already familiar with their emergency response functions for COVID-19, had the core skills and tools necessary to adapt their efforts to mitigate the new threat. Existing COVID-19 vaccination sites were key in providing pop-up mpox vaccination sites across the county by co-locating these vaccinations. Through the groundwork done to develop a sustainable ICS-based emerging disease response team, HCPH and the county remained resilient in the face of a new infectious disease threat and a local public health emergency declaration was avoided.

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A community's ability to withstand and recover from disasters impacts all members of the community. High levels of community resilience benefit all community members; however, it can particularly benefit those who are most vulnerable to the negative impacts of disasters. Historically, Harris County has experienced several natural disasters that severely impacted residents, including Hurricane Katrina (2005), Hurricane Ike (2008), Hurricane Harvey (2017), Tropical Storm Imelda (2019), and Winter Storm Uri (2021). Additionally, several infectious disease threats occurred through the same period, including the H1N1 influenza pandemic (2009-2010), West Nile virus (2012), Ebola (2014-2015), two rabies cases: the death of a resident and a rabies infected dog (2008 and 2015), Zika virus (2016-2017), a measles resurgence (2019), the COVID-19 pandemic (2020- present), and mpox (2022- present). Facing new disasters while not fully recovered from previous disasters places the most vulnerable residents in a continuous state of rebuilding – a state that significantly hinders the community's ability to fully recover from past disasters and remain resilient against future disasters.

Harris County's population is highly socially vulnerable (SVI of 0.895 out of a maximum score of 1) based on CDC's Social Vulnerability Index (SVI) which considers the population's socioeconomic status, household characteristics, racial and ethnic minority status, and housing and transportation conditions. Based on 2020 census data, over 20% of Harris County residents under the age of 65 do not have health insurance. Additionally, a Harris Cares survey conducted in 2018 found that approximately 15% of residents reported delaying or avoiding care due to being underinsured. HCPH aims to reduce the impacts of these systemic barriers to care by providing accessible preventative care and connecting residents to various resources through its daily operations. Local disease outbreaks severely threaten the progress made towards a healthier community as continuity of operations is interrupted to support emergency response functions during a time when essential services are needed most.

The current proposed practice of creating a COVID-19 Division is an innovative model that improved HCPH's ability to respond to the emergency. This practice is new to public health as traditionally health departments used the ICS structure. HCPH was able to creatively adapt the traditional ICS structure and develop the division with specific teams dedicated to emerging disease emergency response. This division incorporates traditional ICS characteristics, such as the standardized core functional groups and clear chains of command and would incorporate new functions that supported the longevity of response and future preparedness. Extended response conditions further affect recovery efforts, as entering the post-disaster recovery phase is delayed. The sustained nature and frequency of emerging disease threats called for a new approach to local health department infectious disease response and preparedness.

The Incident Command System is an evidence-based practice that was developed to improve interoperability in incident management. Since its inception in the 1970s, ICS has proven to be an extremely effective all-risk, all-hazard approach of managing emergency responses and is used nationwide by many different types of organizations and across many different types of disasters and events. By design, ICS is meant to exist within the confines of an incident or event and, thus, be temporary. The intended impermanence of the ICS structure has frequently been challenged by infectious and natural disaster threats, as a response could span many months, and even years. The severity of an infectious disease threat can ebb and flow, making it difficult to define the end point” of these types of disasters.

The concept of this practice aimed to provide additional support to the most vulnerable communities by lessening the disease burden and proactively supporting recovery to build community resilience. With long-term goals in mind, new branches and taskforces were created within the adapted ICS structure to address inequalities. HCPH created a Race and Ethnicity Taskforce, which implemented an Equitable Testing Strategy and then an Equitable Vaccination Strategy. This taskforce was comprised of key members in HCPH's Resilience and Equity Branch (REB). REB supported the taskforce in many ways like providing HCPH's COVID-19 trend data analysis that revealed an over-representation of infection and hospitalization rates amongst Blacks and an alarming increase amongst Hispanics communities. These insights guided HCPH's plans to emphasize the need to incorporate upstream solutions” utilizing equity approaches to advance population health and community resilience. Within the new team, HCPH regularly conducts county-wide data analyses on infection rates, testing and vaccination to ensure equity and inform strategies. COVID-19 infection, testing and vaccination trends are coupled with social vulnerability (SVI) and historical knowledge of the county to identify communities impacted to allow the emerging disease response team to increase accessibility to information, tests, and vaccines in the right places. The team also developed a Pandemic Equity Strategy to mitigate risks, reduce COVID-19 disproportionality, collect key COVID-19 health and related social data. Other methods used to embed equity principles came through hosting community listening sessions and focus groups. The team also created incentivized vaccination programs for communities burdened by COVID-19 and expanded HCPH's reach within houses of worship and community-based organizations, aligning with one of the goals of REB to increase access to vital health services.

To build the community's capacity to respond to and recover from infectious diseases, HCPH created a dedicated, COVID-19 Division with teams focused on responding to COVID-19 and subsequently other emerging disease threats in September 2021. The emerging disease response team played a key role in creating a scalable strategic plan to ensure continued mitigation of emerging diseases while reducing the costs to the county. Poor health outcomes can be linked to social and structural barriers like years of neighborhood underinvestment; structural racism, economic, and social systems; dense housing; exposure on the job for front-line workers; and transportation. Therefore, health equity was a focus among each of the goals and objectives.

Four main goals drove the establishment and operations within the new emerging disease response team: 

Goal 1. Planning and Readiness focuses on readiness planning for future potential variants and corresponding waves of COVID-19 infection, as well as other emerging infectious diseases. 

Goal 2. Education and Information provides data-driven recommendations and guidance for the community based on the current levels of transmission in the area. 

Goal 3. Surveillance and Analysis supports emerging infectious disease surveillance and data gathering operations such as case investigations focusing on congregate settings such as schools, long-term care settings, and businesses. 

Goal 4. Services and Resources aims to provide infectious disease mitigation resources and services to the community at no charge, focusing on the communities with little to no access and higher disease risk. This includes linking residents with other resources and services to improve their health and quality of life.  

To support these goals, each team within the COVID-19 Division was tasked with objectives that aligned with their expertise. Within Goal 1: Planning and Readiness, the emergency management branch developed emerging disease response standard operation guides and procedures, lead after action reviews and hotwashes, and planned infectious disease response trainings for internal staff and local partners.  The grants and strategy branch supported these objectives by identifying and addressing areas of improvement to provide strategic guidance.  

The communications, outreach, and emergency management branches worked closely with county elected officials and other county and community partners to promote engagement and awareness around COVID-19 within Harris County since January 2020. Specifically for Goal 2: Education and Information, these efforts were expanded within the emerging disease response team structure. To date, HCPH has developed hundreds of partnerships within the community to reach individuals most impacted by COVID-19 and mpox. In collaboration with various partners, workshops and townhalls were developed with specific community sectors that represented where residents live, learn, work, worship, and play. Workshops and townhalls support bidirectional dialogue between subject matter experts at HCPH and community sectors to inform and coordinate on effective approaches to respond to and recover from infectious disease emergencies. This coordinated approach has included various community-based organizations including housing partners, faith-based partners, FQHCs, schools, providers, and more. Creating and maintaining local partnerships is critical to meet the needs of the community, as partners are aware of the barriers for accessing information and services that their community members face and HCPH can begin to adapt to better serve those communities. 

To work towards achieving Goal 3: Surveillance and Analysis, the epidemiology operations and data analytics branches work collaboratively to gather and analyze data to identify signs of increases in disease transmission and adapt guidance to notify and protect the community. In addition to monitoring and responding to immediate threats, the epidemiology operations team has been able to research local long-term impacts (health, behavioral/mental, societal) of emerging disease threats and how they relate to sociodemographic factors to better link marginalized populations to adequate services. These insights further translate into innovative interventions for the community in preparation for case surges and novel infectious diseases. 

Providing the most critical resources to those who needed them most was the focus in Goal 4: Services and Resources. The operations section has provided equitable access to testing and vaccinations throughout the COVID-19 response, and successfully incorporated additional offerings during the mpox outbreak. In effort to continue providing services and reach those who need it most, the grants and strategy branch develops strategies that are flexible and adaptable to changes in local epidemiological trends, population dynamics, and available resources. Additionally, the grants and strategy branch frequently monitor avenues to secure additional funding opportunities and utilizes existing grant funding to maximize the services and resources HCPH can provide to the community. 

HCPH applied to and received grant funding that was used to create and sustain this new program. The various grants totaled to approximately 76 million dollars. Hiring full-time employees was the priority, many of these employees held previous experience as they were activated to respond to the COVID-19 emergency via the ICS since 2020. To date, over 50 full time employees have been onboarded in various sections, such as Emergency Management, Epidemiology, Grants and Strategy, and Operations. The grants also support employees who assist with database management and analysis, technology, logistics, and finance. In addition to these employees, over 150 temporary employees are also supported with these grants. Temporary employees assist in meeting an immediate need and can onboard quickly, and like full-time employees many of the temporary employees onboarded have experience working at HCPH and responding to the COVID-19 emergency. These grants support more than just employees, for example equipment like refrigerators for vaccines and generators to support field staff in case of power outages have also been purchased. Major contracts with academic institutions such as the University of Texas Health Science Center at Houston School of Public Health who provide weekly data analysis of COVID-19 trends and focus on breakthrough infections, vaccine efficacy, and testing patterns. The ability to implement a new wastewater surveillance system that will monitor viral loads throughout the county as testing demand continues to decrease. Supporting training and travel for employees to conferences to share best practices and learn how to continue advancing HCPH's services to the community.  

However, HCPH is aware that grant funds are temporary, and many of these grants are set to expire by 2024. We continue to review staffing needs and has developed scalability plans that allow us to quickly decrease/increase staff as needed. Scaling down staff and services allows the program to stretch the budget longer and take every opportunity to extend grants, such as by requesting no cost extensions. This provides HCPH with more time to spend down funds without requesting additional funds. As mentioned previously, as new emerging disease threats arise, like mpox and more recently Ebola, using the existing team that has been built to respond provides cost saving opportunities by eliminating the need to request for money from the county. As always, HCPH continues to monitor federal, state, and local funding opportunities.

Through the adapted ICS model utilized to create the COVID-19 Division, HCPH has been able to successfully respond to several recent emerging disease threats, including COVID-19, mpox, and the Sudan Ebola virus, while continuing to provide other essential public health services. Outcome evaluation data was collected internally to measure the scope of services and outreach that HCPH has been able to provide to the community. To date, the COVID-19 Division has: 

Provided 11,299,366 COVID-19 PCR tests

Administered 798,607 doses of Pfizer, Moderna, J&J, and Novavax COVID-19 vaccines  

Includes 771 doses provided to 539 homes for residents who are home-bound and their caretakers 

Assembled and distributed 308,440 COVID-19 care kits which include masks and easy-to-understand information on COVID-19 prevention, vaccines, and resources available including assistance with food, childcare, legal inquiries, and more 

Distributed 806,953 masks 

Administered 6,399 doses of JYNNEOS vaccines for protection against mpox 

Engaged directly with 1,911,459 residents via outreach 

Served 620,624 people at community-based events 

Served 90,482 through community canvassing 

Canvassed 1,003 apartment complexes, serving 202,169 units 

Submitted 2,692 resource navigation program applications to connect Harris County residents with various community resources through collaboration with state public benefit programs 

Made 53,907 phone calls to local organization to raise awareness of nearby HCPH services 


In the past year, several other milestone accomplishments were achieved, such as: 

Accomplishment #1: Utilizing the existing COVID-19 vaccine site structure to provide other types of vaccines. The ability for HCPH to quickly adapt to provide other types of vaccines for flu, mpox, and all FDA authorized COVID-19 vaccine formulations is a significant achievement. This highlights how, as a team, operations were successfully expanded to meet the needs of the community served.  

The COVID-19 division's operations section focused on COVID-19 vaccine administration throughout 2022, specifically rolling out new COVID-19 booster doses. Every new vaccine rollout included internal offices and divisions, the Local Health Authority (LHA), and Legal Counsel. Through communication, coordination, and cooperation, HCPH has successfully rolled out new vaccines within 1-2 weeks of approval by the FDA, CDC, and DSHS. To date, the following booster doses have been administered:  

959 Moderna 2nd booster doses from 3/31 to 9/2 (before bivalent boosters were approved) 

1412 Pfizer 2nd booster doses from 3/31 to 9/2 (before bivalent boosters were approved) 

1024 Moderna bivalent booster doses through 12/1/22 

1346 Pfizer bivalent booster doses through 12/1/22 

Since August 15th, 2022 the operations section has incorporated JYNNEOS vaccines that offer protection against mpox into daily operations to serve high-risk populations, including the LGBTQIA+ and Black and Hispanic communities and administered over 6,500 doses. Approximately 40 staff members were oriented with a new electronic medical record (EMR) software, conducting several just-in-time training (JITT) sessions for field staff and call center agents, developing new policies and procedures, and creating a workflow that minimized risk and emphasized safety. Within the emerging disease response team, several branches across different sections worked together, including the Vaccine Operations, Site Scheduling, Clinical Oversight, Call Center, Grants and Strategy, and Emergency Management branches, to ensure the quick turnaround was successful. Internal communication, coordination, and cooperation led to the successful vaccine rollout, increased vaccine awareness, and helped reduce misinformation and stigma related to the disease. The call center branch answered over 3,500 related calls and scheduled appointments across multiple sites. Additionally, HCPH was able to partner with over 90 unique organizations during this time to administer the JYNNEOS vaccine. 

Since October 17th, 2022, Vaccine Dispensing Units (VDUs) within the vaccination branch began incorporating administering the influenza vaccine into daily operations. The implementation was completed quickly by conducting multiple just-in-time training (JITT) sessions and ensuring proper supply procurement and delivery to begin administering before peak flu season. Various branches within the adapted ICS structure worked together to coordinate sites with partners, adjust workflows to maximize operational efficiency, and collect and retain operational data. Externally, this increased HCPH's partner reach and community access to the flu vaccine. Site location and partnership selection focused on serving vulnerable populations, strengthening the community's capacity to recover from disease threats, and maximizing resources by utilizing partnerships, preexisting resources, and coordinating internally. Since implementation, the emerging disease response team's operations section has administered a total of 1,031 doses of flu vaccine while also providing COVID-19 and mpox vaccines at various locations across the county. 

As a result of the implementation, HCPH has improved access and reduced barriers, resulting in thousands of vaccines being provided to the community at no cost to residents.  

Accomplishments #2: Prioritizing health equity through specialized teams to focus on vulnerable populations. A specialized team was formed to vaccinate and test special populations, including those in nursing homes, long-term care facilities, and group homes. Additionally, the team provides at-home services to individuals who are bed-bound and immobile. This Congregate/At-Home Team has serviced 38 congregate facilities from January through November 2022. During this time, they have also traveled to 138 homes and provided 185 COVID-19 vaccines. Success is attributed to excellent coordination, communication, and flexibility within the team and Operations Unit. The Congregate/At-Home Team has increased access and removed barriers to care for vulnerable populations. The team has identified and mitigated health disparities, responded to disease threats, and maximized resources by strengthening HCPH's relationship with congregate facilities and servicing vulnerable populations. 

Accomplishment #3: Creation of a new flu portal platform for schools within Harris County to report cases of flu and ILI. The flu portal helps strengthen flu surveillance in the county by monitoring flu trends through the reporting of daily absenteeism due to influenza-like illness (ILI). It allows schools to report baseline information as well as potential increases in ILI reports; this information is helpful when determining if a particular school is experiencing an outbreak. Since October 20, 2022, when the flu portal went live for schools to register and report, 217 schools have reported ILI data electronically. 

Since the flu portal was created in October 2022, public, private, and charter schools in Harris County were recruited on a rolling basis, with plans to recruit a wider number of private and charter schools and child-care facilities in the future. Detecting flu outbreaks in schools can facilitate the development and implementation of timely public health recommendations to prevent the spread of disease to high-risk populations. ILI data can also provide more targeted outreach and resources more appropriately. Through the utilization of the flu portal, epidemiologists were able to conduct active surveillance for several ILI outbreaks at schools and school nurses can electronically report daily numbers at their convenience and view previous ILI trends for their district or school. The implementation of the flu portal and the data collected complements existing influenza and ILI data to better monitor trends in the community which allows for outreach activities and vaccination events to be better targeted if a certain area or school is experiencing an outbreak.  

Through the various dedicated teams, HCPH reached new levels of engagement within the community that would not have otherwise been possible. The engagement and partnership management accomplished through this team was an invaluable asset in the health department's readiness. The partnerships that the emerging infectious disease team developed mirrored the community's diverse residents. Thus, HCPH was able to reach specific target populations that were the most vulnerable against the respective infectious disease threat. Established Ryan White HIV/AIDS Program partners and partnerships with organizations serving the LGBTQ+ community played a crucial part in reaching communities disproportionately impacted by the recent mpox outbreak when stigma presented as a significant barrier. When the 2022 outbreak of the Sudan ebolavirus in Uganda was identified as a potential threat, the emerging infectious disease team was able to reach out the local Ugandan community directly to promote situational awareness about the threat and provide information on precautions taken to limit risk of transmission, such as the travel screening requirements. Additionally in 2023, further initiatives are planned that will continue to make this program a success by creating and implementing a more robust capability to monitor and track current and emerging diseases. Implementing enhancements for data monitoring and reporting will significantly improve disease surveillance including the agency's ability to operationalize critical resources to the community. 

Building a COVID-19 Division, adapted from the Incident Command System (ICS) structure for long-term emerging disease response was designed to serve as a sustainable solution for responding to emerging disease threats in Harris County. Supporting and responding to these types of emergencies frequently spans several months and places significant burden on the local health department, its staff, and the community which it serves. Functioning in a continuous state of emergency long-term is unsustainable. Lessons learned from the COVID-19 response have shined a light on the burnout and pandemic fatigue that can occur when an infectious disease remains a significant threat to the community for an extended period. This practice aimed to be beneficial to all stakeholders involved, including community members who do not directly take advantage of the services which HCPH provides. The community resilience built with this practice will continue to have a positive ripple effect in the community, reducing the upfront costs associated with future infectious disease emergency response and readiness activities, lessening the risk of future local hospital bed shortages, and building a strong local public health workforce.

The success and fiscal sustainability of this practice has been made possible using grant funding. As previously mentioned, about 76 million dollars of grants have been and are currently used to support this new adapted model focusing on utilizing an experienced team and infrastructure to respond to threats. In effort to support the long-term sustainability of this practice, in November 2022, the COVID-19 Division has been integrated into HCPH's newly created Office of Epidemiology, Surveillance, and Emerging Disease (OESED) to support further knowledge share and recovery support functions amongst various epidemiology functions. Additionally, existing grant funds are being utilized to provide workshops, trainings, and other resources to employees, so they are better equipped to respond to emerging disease threats.

Through continuously monitoring and applying for available funding opportunities, HCPH was recently awarded a 5-year 30-million-dollar award through the Centers for Disease Control and Prevention infrastructure grant. This grant will allow the health department to continue to sustain the crucial team and initiatives that have been created in the past few years. Additionally, the health department also secured a 5-million-dollar approved but unfunded Crisis Cooperative Agreement grant which allows the state to funnel necessary funding when public health emergencies are declared. Through this grant, $150,000 are available to use in 2023 to support the mpox response, and while cases are trending down there are still many resources that can be obtained to sustain this emerging disease program.

From the lessons learned within the practice, maintaining situational awareness during blue sky days, days when daily operations are executed outside of an emergency, was identified as a crucial preparedness function. To date, the original COVID-19-focued adapted ICS team has expanded their research and reporting to include situational awareness updates on several infectious disease outbreaks occurring within the U.S. and globally, such as influenza, RSV, group A strep, measles, Ebola, cholera, and others. Additionally, managing local partnerships in Blue Sky Days was identified as a crucial recovery and preparedness function. Significant portions of the work done within this practice has been completed alongside community partners across the county. Maintaining great relationships with existing partners continues to build engagement and trust within these communities. Developing new partnerships, with focus on connecting with partners who serve vulnerable communities, continues to build awareness around the resources and services that HCPH can offer both in and out of emergency response functions. Through these functions, the practice continues to support sustainable recovery.