Changing the model for case and contact management in public health

By Linda Dempster

Fraser Health Authority is the second largest health authority in Canada. We are responsible for the delivery of hospital and community-based health services to over 1.8 million people in 20 diverse communities from Burnaby to Fraser Canyon on the traditional territories of the Coast Salish peoples.

Our team of nearly 40,000 staff, medical staff and volunteers is dedicated to serving our patients, families and communities to deliver on our vision: Better health, best in health care.

One team that is particularly important for our COVID-19 response is the Population and Public Health Team. This team comprises experts in public health such as Medical Health Officers, Public Health Nurses, Communicable Disease Nurses and Environmental Health Officers, just to name a few.  As our cases of COVID-19 across the Fraser Health Region began to rise our Public Health team had to quickly redirect resources from their regular daily functions to focus on case and contact management.

When an individual tests positive for COVID-19, it’s vital that quick and thorough follow-up on close contacts is carried out.  This is done by public health as case and contact management plays a key role in preventing the spread of the virus. Public health staff help stop the spread of COVID-19 in the community by investigating where an individual may have acquired the virus and preventing further spread. They also investigate clusters of cases to identify potential worksites or businesses that are at higher risk for spread of the virus.  That is where the Environmental Health Officers working with community partners such as by-law or local law enforcement to enforce COVID safety plans is key.

Traditional case and contact management can be very time consuming and requires expertise in case investigation.  With significant increases in our case counts in the fall we had to quickly re-evaluate how we were managing case and contact management. Clearly we did not want to compromise the value given the importance of reducing the risk of transmission during this pandemic so we had to develop alternative strategies.  The overall strategy focused on some key areas:

  1. Streamlining case assessments using a risk-based approach
  2. Development of a team model for case and contact assessment and notification
  3. Leveraging technology

The previous model for case assessments was very detailed and required significant time for case interviews.  Upon reviewing the data it was determined that approximately 75 per cent of cases were low risk and would be able to self-isolate and follow public health instructions.  We were confident they would abide by the instructions. Based on this assessment we recommended the development of a Contact Tracing Aide role.  This role would do the initial case and contact notification as well as the assessment for low risk cases.  We also streamlined the case and contact investigation tools.  Approximately 25 per cent of the cases and/or contacts were more vulnerable and we were less confident they would be able to successfully follow public health guidelines without more intense support.  These higher risk cases would be referred to an expert hub for more intense case management as well as cluster identification and follow-up. Based on the number of daily cases we developed an algorithm for staffing requirements for contact tracing aides as well as public health expert roles.  Starting in mid-September to date we have hired and trained 364 contact tracing aides.

The team model for the contact tracing aide role is that they are supervised by a public health nurse.  Initially the ratio is approximately one nurse to five contact tracing aides but once the aides became more proficient and comfortable in the role we increased the ratio to one to 10.  This has been highly successful and we are keeping up with case and contact management in addition to being more efficient without losing quality of the assessments.

Finally, we looked at how we could leverage technology to streamline our systems and provide better support to the public.  This included an on-line form for the positive cases to input their contacts so the contact tracers had the information as soon as the positive case received their test results.  The positive test result was texted to the case with a link to the on-line form.  Further use of technology is being explored such as auto-texting cases on isolation when isolation is complete.

Although not the only initiatives we put in place to better manage our case and contact management these are a few of the changes we made in a very short period of time that increased our efficiency while not compromising the quality or integrity of the case and contact management process in public health.

Linda Dempster, RN, BScN, MA is Vice-President, Patient Experience and Pandemic Response at Fraser Health Authority in British Columbia.