How to build and scale a contact tracing program—lessons from the disaster recovery field

Parallels in disaster recovery

On the surface, a hurricane and the COVID-19 pandemic are two very different threats, but they impact individuals, families, communities, and companies in similar ways. Businesses close. Schools shutter. Homes and lives are lost. And, similar to the contact tracing workforce needs, the scale and speed needed to respond to disasters far outpaces the available service delivery capacities.

When the State of Louisiana brought us on to help with Hurricane Katrina recovery efforts, we mobilized quickly—hiring and training 2,300 people and standing up nine housing assistance centers within months. And we did this work in an intense post-hurricane environment with massive infrastructure challenges. Following Hurricanes Maria and Irma, ICF stood up the largest public infrastructure recovery program in U.S. history obligating more in the first year (~$1.4 billion) than any other disaster and $17 billion to date to help Puerto Rico repair public infrastructure and mitigate against future disaster impacts. Within 10 days after contract award, 82 staff were mobilized and ICF ultimately hired 352 staff of which 320 (91%) are local staff.

From our work on these projects and other quick program ramp-ups, we have learned what it takes to create and scale an effective program in a challenging environment.

Look for similar skill sets to find the right workforce

To contain the spread of coronavirus and safely reopen the economy, the U.S. needs to hire tens of thousands of contact tracers in short order. But you’re not going to find an untapped army of 500 people in your community who have public health degrees, so how do you screen and recruit candidates appropriately? What are the specific knowledge, skills, and abilities of a contact tracer and what are the gaps between where your applicant base is and what’s needed to do the job?

The CDC has published guidance on the basic knowledge and skills that contact tracers need to do their jobs effectively. Chief among the requirements are excellent interpersonal skills and cultural sensitivity. You want people who can build trust and rapport, and who demonstrate empathy and cultural competency appropriate to the local community.

Given the economic downturn, many workers are un- or under-employed right now. The hospitality industry, for example, has been particularly hard hit and may provide you with a reliable pool of candidates, due to the strong interpersonal skills required for front-of-house hotel and restaurant roles. While they will require comprehensive training, many of these out-of-work individuals are likely eager to learn new skills and get back to work.

Of course, there are different tiers of contact tracer roles that you will need to fill within your program, and each has its own set of requirements. For example, experienced public health tracers may assume supervisory roles, while entry-level workers may start with the lowest-impact cases and work their way up from there. By creating an organizational structure that allows for proper oversight and professional development opportunities—with experienced disease intervention specialists distributed throughout the workforce—you will establish a continuum of capability within your operation.

Once you have your workforce, you will need to train them quickly and effectively. There are many basic (and free) training tools, such as ASTHO's entry-level contact tracer course, that can get you started. From there, you will need to layer on your state- and local-specific training materials, which you can do through the development of protocols.

Develop detailed protocols—and prepare to evolve them

Before you can train your new contact tracers on your specific jurisdictional needs, you will need to develop a detailed set of protocols for them to follow. Get specific and document everything in writing, including confidentiality practices and available resources for referral. Protocols will need to address HIPAA privacy regulations and instruct contact tracers on how to set up their remote workspaces to respect the confidentiality needs of patients and their contacts. Protocols will also need to establish an effective referral process. Since many patients and contacts will have multiple and significant social service needs, the protocols must outline all available resources and make it clear to contact tracers (1) how to recognize a social service need through verbal cues, (2) what the referral options are for a range of needs, and (3) when to make those recommendations. Understanding boundaries is critical, as you don’t want your contact tracers to become caseworkers by default or due to a lack of alternatives. 

Even the best program designs will anticipate only 60-80% of the issues you’ll encounter on the job. Once your program is up and running, you will need to evolve your protocols to address unforeseen issues and needs. To do this in a nimble way, you must have a mechanism in place that allows you to (1) identify new patterns and developments in the field quickly, (2) revise your protocols accordingly, and then (3) do check-up trainings for your staff to put the new protocols to work.

Effective protocol development requires a heavy upfront investment, but it’s well worth the effort. You will start on steady ground with a training program that’s specific to your community context, and you’ll have the tools in place that will allow you to revise and expand your protocols and training as the program evolves.

As you design your contact tracing training program, keep in mind some training best practices:

• Use a mix of training strategies to deliver the best results and appeal to all learning styles. In a remote context, training channels can include engaging learners through e-learning, mobile learning, virtual instructor-led training, online job aids, role-plays, coaching/mentoring, training videos, and games.

• Understanding training needs is key. Doing some amount of analysis up front helps to ensure that you are addressing the correct gaps in skills and knowledge by asking “What do staff need to know, do better, or do differently?” This step can be as simple as a discussion with a program leader or subject matter expert, or more involved, by collecting data through surveys, interviews, or focus groups. Once you identify gaps, you can design your training to close them.

• Learning by doing promotes retention. Without special tactics to retain knowledge, learners quickly forget a significant amount of what they are taught—roughly 70% within the first 24 hours. While concerning, this gap in retention does not have to be a foregone conclusion. You can increase knowledge retention for your learners by implementing techniques to engage and encourage them to apply what they are learning as they are learning it—for example, by using role-plays to practice case interviewing.

• Assess results. Using performance metrics, pre- and post- assessments, surveys, or other tools, you can determine what did or did not work well, and how to improve the training in the future.

Lean on technology to analyze data, spot trends, and strengthen operations

The technology you use will play a central role in your contact tracing operation, so it’s essential to choose a Management Information System (MIS) that is powerful and intuitive enough to organize and track the work of this vastly expanded workforce. The contact tracing application is important, and there are plenty of options, but beyond that, you must also consider how your system will facilitate workload management and call management across your expanded team. When a person calls back to complete their interview or provide additional details, interactive voice response (IVR) can help route them to the tracer they started working with, which allows you to maintain the relationship and trust already started. We know from our work in communities impacted by disaster that building trusted relationships with a dedicated POC—in this case, the contact tracer—is critical to helping individuals navigate the process successfully.

The people are just as important as the MIS. Strong managers will use the MIS data for internal purposes—helping balance cases across the team of contact tracers, identifying ways the protocols need to be adjusted, assigning complex cases to experienced tracers, and conducting quality assurance. You also need a strong analytics team that can use the MIS to identify patterns and pinpoint hotspots, outbreaks, and clusters. This will help you to quickly mobilize resources into the community to provide services to those that need them and prevent further spread.

You may be able to tap into your local education workforce to fill some of these roles. Teachers and educators who have been impacted by the economic downturn likely possess many of the skills required for quality assurance and data analytics to support effective contact tracing.

Getting back to work

While this crisis is new, you likely have a strong public health infrastructure in place that you can build on to create and scale your contact tracing program. By following the guidance outlined above, you will be able to put a qualified army of “disease detectives” on the job and get your community back to work.