Emergency preparedness for health professionals has become a national concern. In 2003, the Health Resources Services Administration (HRSA), through its Bureau of Health Professions (BHPr), awarded $26.6 million in grants for the Bioterrorism Training and Curriculum Development Program (BTCDP). The purpose of this national program (in 2007 relocated to the Office of the Assistant Secretary for Preparedness and Response) is “to develop a comprehensive health workforce that possesses the knowledge, skills and abilities to recognize indications of a terrorist event or other public health emergency; meet the acute care needs of patients including pediatrics and other vulnerable populations in a safe and appropriate manner; rapidly and effectively alert the public health system of such an event at the community, state, and national levels; and participate in a coordinated, multidisciplinary response.”1 Two types of grant awards were made simultaneously: 13 projects for curriculum development in health professions schools for preprofessional training and 19 projects for continuing professional education. The intention of the BHPr in awarding both types of grants was to stimulate curriculum development for both undergraduate and practicing health professionals.
The Area Health Education Centers (AHEC) program, also located in HRSA, was established by the federal government in the late 1970s to address the maldistribution of health professionals.2 In 2006, 46 states had AHEC programs where one or more medical schools collaborated with one or more community-based agencies—AHECs—in planning and conducting health professions education based on health workforce needs in medically underserved areas. The AHECs traditionally have had a variety of funding sources and typically expand their services to conduct community education as well as programs for health professionals.3
The University of California (UC)–San Francisco Statewide AHEC Program, established in 1979, was among the recipients receiving a BTCDP two-year award to conduct continuing education for the state's health professionals, and one of three projects nationwide conducting the initiative through an AHEC program. The grant established the California Emergency Preparedness Program (cal-PEN) with four objectives:
▪ to connect existing and new linkages and partnerships to form a statewide emergency educational network,
▪ to recruit and train multidisciplinary teams to offer continuing education to health professionals serving populations from medically underserved communities,
▪ to conduct educational activities with a minimum of 2,500 health professionals in the first year, and
▪ to enhance linkages between AHECs and the public health system.
We review here the organization, process, and outcomes of cal-PEN's first two years of experience in 2003 through 2005 and discuss implications for the future. We report these first two years partly because in subsequent years, when renewed but reduced federal funding allowed the program to continue, the focus and partnerships changed somewhat.
The cal-PEN program
Six of California's 10 AHECs requested to participate in cal-PEN, which from the beginning has been administered through the statewide AHEC office, based in Fresno. The AHECs were located in different geographic areas of the state: San Diego Border AHEC, San Diego; Central Coast AHEC, Santa Cruz; South Bay AHEC, San Jose; Harbor AHEC, Los Angeles; Multicultural AHEC, East Los Angeles; and Shasta Community AHEC, Redding. Each AHEC hired a coordinator to organize and conduct local educational activities and recruit and train local faculty. The California Poison Control System (CPCS) based at UC–San Francisco School of Pharmacy partnered with cal-PEN initially with the intention of having its staff of pharmacists serve as regional faculty to conduct the education. (Financial problems altered this plan, as explained later.) The well-established mission of CPCS is to provide free, immediate, expert treatment advice via telephone about poisonous, hazardous, and toxic substances to both consumers and medical professionals throughout California through four regional centers located in San Diego, Fresno, San Francisco, and Sacramento. The program director (J.B.) of cal-PEN (also the director of the statewide AHEC program); the AHEC associate director (H.A.); cal-PEN's program manager, program evaluator (V.F.), and medical director; the CPCS director; and a community AHEC director and coordinator formed an executive committee to oversee planning and management. The program benefited from the input of two medical directors, both at UC–Davis School of Medicine (UC–Davis). After the first year, one left the program. All program staff, including local coordinators and AHEC directors, met as a network quarterly to plan, evaluate progress and solve problems. Contracts with AHECs and other partners were performance based and cost reimbursed so that incentives would align with program responsibilities.
Our program director established partnerships with statewide organizations by forming a statewide advisory committee. These partnerships were (and continue to be) with the California Department of Health Services (DHS), Emergency Management Services Authority (EMSA), California Academy of Family Physicians (CAFP), California Primary Care Association (the state organization of community clinic consortia), California Rural Health Association, UC Office of the President, UC Television (UCTV), and UC–Davis. The CAFP and UCTV engaged in delivering the educational modules to reach areas of the state beyond the target regions of the AHECs. The CAFP offered cal-PEN's educational activities to 39 family medicine residencies distributed throughout California, many of which were sponsored by county institutions serving vulnerable populations. UCTV and UC–Davis produced four of the educational modules for distance learning. These one-hour modules were recorded in commercial quality, broadcast via cable and satellite to a North American audience of potentially 15 million, and archived on the Web for asynchronous viewing by health professionals. These modules were accredited by UC–Davis. All faculty presentations were accredited by the American Academy of Family Physicians.
Mission and target audiences
The cal-PEN network developed a mission statement: “To prepare California's health professionals caring for the state's multicultural, underserved populations, to respond to bioterrorism and other public health emergencies.” A Web site described the program. Because both BHPr and AHEC programs typically train health professionals for underserved areas, cal-PEN target audiences during the first two years—and, in most cases, to the present—were physicians, nurses, nurse practitioners, physician assistants, pharmacists, mental health providers, public health providers, dentists, first responders, and health administrators, all of whom worked in sites caring for medically underserved populations. Typically, these sites were community health centers, county clinics, and family medicine residency clinics where primary care physicians and other practitioners practice with these populations. These practitioners are those most likely to be unable to participate in other disaster-preparedness educational activities offered in hospitals or other venues. The CAFP partnership provided immediate access to family medicine residencies in underserved sites. HRSA provided hospitals with grant funds for disaster-preparedness programs that also were available to other physicians and health professionals.
The directors of the participating AHECs conducted an educational needs assessment in each of their respective service areas with a total of 58 health professionals to learn how the future cal-PEN curriculum could be responsive to local community needs and interests. Respondents indicated preferences in two subject areas: (1) clinical information about emergent conditions and diseases, and (2) information about their roles and responsibilities in a disaster. Respondents preferred a one-hour lecture presentation at their clinical sites on weekdays rather than a presentation at a professional meeting, Internet, Web cast, or satellite venues, or on weekends or evenings. The statewide advisory committee and program staff agreed that the curriculum content should prepare health professionals for any public health emergency.
Curriculum and faculty
We developed the curriculum guided by the needs assessment, the commitment to a focus on preparedness for all hazards, the guidelines for core competencies established by the U.S. Centers for Disease Control and Prevention with Columbia School of Nursing Center for Health Policy, national guidelines from the National Incident Management System, the expertise of cal-PEN's medical directors and of other colleagues with expertise in infectious disease and emergency preparedness, and the program director and evaluator, who had academic experience in medical education.4–6 The cal-PEN program's medical director (C.S.), a faculty member at UC–Davis with background in infectious disease and public health, had key roles with state partners as medical advisor to the CPCS and EMSA and as a member of the Joint Advisory Committee for the Administration of the National Center for Disease Control (CDC) and HRSA grants in emergency preparedness. He therefore advised these agencies about their emergency planning and assured that the cal-PEN curriculum conformed with both national and state developing standards for disaster preparedness. Because the HRSA grants were awarded simultaneously, there were few curriculum resources to draw upon initially, and the opportunity for the cal-PEN program to collaborate with other programs came only after the first year when most had developed their own approaches for disaster preparedness. The cal-PEN curriculum content, however, developed in collaboration with experts from state agencies concerned with emergency preparedness; at the same time, they were developing their own standards for training in hospitals and community health centers.
The curriculum consisted of four one-hour modules each with objectives and slides designed to address the aforementioned HRSA program goals to prepare health professionals to assess local risk, recognize the indications of an emergency, respond to immediate needs of patients, communicate appropriately, and participate in an organized response. The modules were General Preparedness, Chemical and Radiological Events, Bioterrorism, and Emergent Infections. UCTV produced the modules in both English and Spanish. Case studies were added to make sessions more interactive, and slides about recent or local disasters added relevance for presentations in local communities. All of the modules were reviewed and updated periodically by the medical director with input from the coordinators, faculty and advisors. Two weeks after Hurricane Katrina a new module, entitled Infectious Diseases Following a Disaster, was developed by the medical director (C.S.), taped, and broadcast through the UCTV network and the CDC's public health learning network. In response to numerous requests for information about avian flu, another module was developed and broadcast similarly. The face-to-face educational sessions were arranged by the AHEC coordinators and CAFP and delivered by trained faculty in community health centers, hospitals, public health departments, family medicine residencies, and AHEC offices.
A multidisciplinary group of faculty was trained to conduct the educational sessions. We originally had intended that some of the faculty would be pharmacists from the CPCS who would travel to nearby clinical sites identified by AHECs in their respective areas. In addition, AHECs identified their own local faculty with interest or expertise in the curriculum topics. The faculty were vetted by the program director and medical director and trained by the medical director during five sessions held in different geographic areas of the state. The 15 CPCS faculty were 10 pharmacists, three physicians, and two administrators. Eight of these participated in cal-PEN activities; however, only a few were consistently active. The AHECs identified and trained 41 local health professionals as faculty: 18 physicians, seven nurses, one pharmacist, and 15 professionals from other disciplines. The CAFP recruited 33 faculty, most of whom were family physicians with the residency programs. Each faculty member received an honorarium for each session presented.
At the program's inception, the evaluator (V.F.) guided constituents in a formative process to develop an evaluation plan that would establish a common statement of mission, objectives, and activities; provide evidence of accomplishments relevant to the cal-PEN mission and intended outcomes defined by HRSA; and focus on what participants agreed was most important to evaluate. The ensuing cal-PEN evaluation plan included measures to assess educational activities, training sites, geographic areas, and organizational changes. The evaluator collected baseline information from the AHEC directors about their expectations of the program and their preexisting partnerships and educational activities. Evaluation tools were designed to elicit self-reported data from learners about their backgrounds, the types and locations of their practice sites, their patient populations, the relevance of the educational material, and the quality of the content and presenter. Learners received continuing education credits contingent on completion of these evaluation tools. Evaluation forms were collected locally by AHEC coordinators and by coordinators for CAFP and UCTV and submitted to the central program office for entry into a database. Data analysis included an assessment of learners' practice sites and the degree to which they represented medically underserved populations as defined by the California Office of Statewide Health Planning and Development. Qualitative data about the patient populations within learners' practice sites were used as proxy measures to assess other features of underserved populations at those sites.
Our evaluation included a plan to assess the capacity of AHECs as organizations to deliver this type of information, and potentially to deliver other information of vital national importance. Towards the end of the first two years, we conducted an accreditation-like self-study process to encourage AHECs to reflect on their productivity and capacities. AHECs were asked to identify their strengths, areas needing improvement and plans for each of the HRSA and cal-PEN program objectives using data from the aforementioned evaluation tools and their quarterly progress reports.
Information from all sources of the evaluation was reviewed and discussed regularly by the executive committee and program network to guide the rapid and complex developments of the program. AHECs received periodic data summaries about activities sponsored by their individual sites and cumulative data about program outcomes.
Outcomes of the Training
During the two years of cal-PEN that we are reporting in this article, cal-PEN reached a wide range of health professionals mostly from underserved practice sites. Descriptions about the types of practitioners, sites, faculty, and educational sessions along with learners' feedback and the AHECs' self-study follow.
Health professionals trained
A total of 9,537 health professionals attended one or more of the educational module presentations during the two-year period reported here. Of these, 7,895 (83%) submitted the evaluation forms. Table 1 shows the numbers and types of health professionals who participated. Of these, one third (34%) were physicians. Others included nurses (842; 11%), nurse practitioners (280; 4%), physician assistants (235; 3%), medical assistants (558; 7%), and first responders, including emergency medical technicians (456; 6%). Health administrators (956; 12%) were often part of the group participating at community health centers or other clinics. (The total number of health professionals trained as of April, 2007 is 19,421. An additional 22,000 individuals have viewed one or more modules through UCTV, and 90 county or state health departments have downloaded one or more.) Of 7,272 health professionals reporting their ethnicities, 4,989 (69%) were from minority groups with the largest group being Hispanic (2,189; 44%).
Table 2 depicts the types of practice sites of the health professionals. Of the 6,999 reporting practice sites, 5,739 (82%) were from sites that typically care for the medically underserved. These sites were community health centers, rural health centers, mental health centers, Indian Health Services, clinics for the homeless, and state and local health departments. As another way to assess the program's effectiveness in reaching underserved populations, participants were asked to estimate the percentage of heir patients during their last week of practice who were uninsured, funded by Medicaid, ethnic minorities, or non-English speaking. Of the 4,979 participants responding, over 90% estimated that more than 25% of their patients were in these categories of vulnerable populations. (The numbers were a bit different for each category, but all were over 90%.) Of the 39 family medicine residencies in California, 26 participated, and 15 (58%) were in underserved sites, specifically county institutions.
The five educational modules were delivered both individually and in combination during 462 presentations by the six AHECs, CAFP, and UCTV. Most (334; 72%) were sponsored by the AHECs. CAFP sponsored 95 (21%) of the presentations in family medicine residencies which accounted for 1,094 (41%) of the physician participants. UCTV conducted 33 (7%) of the sessions but had joined the project late in the second year. (This number grew rapidly in subsequent years.) The sessions were delivered for the most part in target sites (e.g., community health centers and residency programs) and at times when most personnel could be available.
Learners rated aspects of the presentations for the four modules from 1 (poor) to 5 (excellent), including the relevance of the information, the quality of speakers, and the overall quality of the program. With over 6,000 participants rating the four modules (numbers varied slightly according to areas and modules rated), 95% or more rated these areas as good to excellent. Qualitative feedback from learners about each of the modules was especially useful. Learners were asked how they would incorporate what they learned from the educational sessions into their practices. Although not a rigorous analysis, their many comments were reviewed and organized into like areas. Certain themes emerged from the comments about each module.
▪ Module 1 (general preparedness) reinforced for learners the need for emergency plans, i.e., starting a plan, examining existing agency plans, or developing a family plan. Comments from community health center officials suggested that the program directed their staff's attention to clinic preparedness plans that were required by the state health department. One coordinator commented, “The module presentations heightened consciousness about disaster planning, and personnel began to examine more carefully the emergency plans in their sites.”
▪ Module 2 (bioterrorism) enhanced learner awareness of possible unusual clinical presentations, or “zebras,” that don't fit into common and typical diagnostic patterns.
▪ Module 3 (chemical and radiological agents) was noted to provide useful approaches to decontamination.
▪ Learners indicated that module 4 (emerging infectious diseases) enhanced their consciousness about infection control. A coordinator commented, “personnel became more conscientious about hand washing.”
▪ Data about module 5 (infectious diseases after disasters) were incomplete, because this module was developed at the end of the two-year project period.
AHEC partnership outcomes
From the perspectives of independent community agencies or programs that partnered with each other and the statewide AHEC program office to implement the cal-PEN program, the AHECs' self-study process provided information about the effectiveness of the program and their own strengths and challenges in meeting program objectives. Only one of the AHECs was conducting continuing professional education before cal-PEN. Typically, depending on their host agencies or existing partnerships and funding, the AHECs were engaged in various educational activities in the community. With cal-PEN funding, each AHEC developed promptly a plan to add this new focus and recruited local staff. The cal-PEN program was also the first truly statewide collaboration in which participating AHECs each conducted the same programmatic activities since 1983, when federal “core” funding for the statewide AHEC program expired. Noteworthy was the fact that none of the AHECs had formal partnerships with public health departments beforecal-PEN, and each engaged immediately in collaborative emergency planning and training for public health nurses.
Five of the six AHECs participated in the self-assessment process. One did not have the capacity to continue for financial reasons and terminated its participation in cal-PEN close to the end of the two years. The AHECs' collective assessments about their strengths and unmet needs in meeting federal and cal-PEN program goals can be summarized as follows. Strengths reported were
▪ participation in local committees and in task forces with counties, community health center consortia, the American Red Cross, the Joint Advisory Council, public health departments, and local EMSAs;
▪ linkages with local family medicine residencies;
▪ training of large numbers and types of health professionals from broad geographic areas;
▪ increased capacity to assist community health centers in implementing their mandates for emergency preparedness;
▪ ability to market cal-PEN successfully;
▪ creation of partnerships with public health departments; and
▪ diversity of both trainees and faculty.
The unmet needs were
▪ expansion of the training to first responders;
▪ expansion of linkages, training, and recruitment of new faculty to all of California's 58 counties;
▪ a statewide marketing plan with an updated Web site;
▪ increased distance learning opportunities;
▪ focus on special populations; and
▪ enhancement of faculty skills.
What We Learned
During the two-year period reported here, the cal-PEN program objectives and mission (stated earlier) were accomplished successfully and exceeded expectations, as reflected in the numbers and types of trainees and other outcomes reported above. We discuss below some of the strategies and challenges that affected these results and our ability to meet these objectives, along with implications for the future.
Our partnerships and linkages with public health
The partnerships at both state and local levels provided a statewide educational delivery system with a uniform approach to teaching emergency preparedness among the partner organizations. The state DHS, part of the advisory committee, required community health centers to develop emergency plans coincident with the beginning of cal-PEN. Thus, in some instances AHECs served as the educational vehicle for the community health centers to carry out their state mandated clinic emergency plans. The AHECs, with their inherent orientation to underserved communities, were able to engage rapidly in identifying local resources for training and strategies to capture the interests of health professionals with California's most needy populations. As they typically do when developing a new program, the AHECs gravitated to community partners that had complementary missions in emergency preparedness and with underserved populations. Not surprising, then, were the instant collaborations with community health centers and public health departments. The linkage of the cal-PEN medical director to state and national public health was an important part of the success in collaborative planning in emergency preparedness between education (AHEC) and service (DHS, clinics) sectors.
When the CPCS was unable to participate fully, new partners were sought to engage actively in the administration of the curriculum. The CAFP and the UCTV offered immediate venues for widespread dissemination of the curriculum to family physicians and other health professionals. Some AHEC leaders were concerned that these activities might become parallel projects and drain resources from the AHECs or discourage the involvement of other AHECs in the future. In response, program leadership encouraged AHECs to link locally with these new partners, particularly the residencies. Those that did (four AHECs) strengthened their relationships with these programs by assisting with training.
Because CAFP's participation did not occur until midway into the program, numerous residency programs were unable to participate but reported that they planned to do so in subsequent years. This interest was particularly important for future planning, because most of the physician participants, both faculty and residents, came from the residencies, and in our experience busy physicians who are safety net providers find it difficult to attend traditional continuing education during clinic hours. Similarly, UCTV, although joining late in the project period, became a resource to reach health professions viewers nationwide. Both CAFP and UCTV were important for future planning to reach all areas of the state. The residency network and the distance learning provided by UCTV enabled the program to distribute information beyond the AHEC regions.
We found that designing an evaluation plan with staff and partner organizations, the “stakeholders,” was important. The process itself clarified the program objectives, engaged consensus about how to achieve and measure these, and focused on the expected outcomes. Program data reviewed at quarterly intervals by the network pointed to strengths and weaknesses in our progress and allowed the program director to address any performance issues among the AHECs or other partners. The early commitment to the evaluation plan enhanced the coordinators' conscientiousness about collecting the evaluation forms and most likely contributed to the high return reported above. The monitoring of progress and results also positioned the program well for future funding.
Recruiting and training our faculty and learners
With the diminished role of the CPCS, the AHEC coordinators began identifying their own local faculty to administer the program in a timely manner and were very successful in doing so. More important, in retrospect this approach broadened the capacity of the local AHECs and built sustained teaching resources in their communities.
We found that the all-hazards approach to disaster-preparedness education was important to the success of the program and marketing it to health professionals in a state that has experience with earthquakes, fires, floods, and even volcanic eruptions. This orientation also equipped the program to respond in a timely manner to emergent educational needs, as occurred with the module about infectious diseases after a disaster. The capacity to produce, broadcast, and Web archive this new educational module immediately after Hurricane Katrina demonstrates how an AHEC program and its partners in academia, the media, and public health can respond rapidly with information and disseminate it widely. New modules were planned to respond to other emerging needs (i.e., avian flu, mental health after disasters, and special needs of older populations).
The role of AHEC coordinators and the CAFP who marketed and provided training on site at target clinics and residencies at convenient times for the clinicians, enhanced attendance by safety net providers who may have found it difficult to attend more traditional continuing medical education. The ability of coordinators and their local faculty to adapt presentations by requesting the preferred module topics and supplementing them with interactive case studies of local interest contributed further to participation.
Strengthening the AHECs
Our AHEC program increased its capacity to function as an extended grassroots network for information dissemination. The funding provided by cal-PEN for local staff (coordinators) and faculty established the participating AHECs as a resource for emergency preparedness in their respective communities. The AHECs were revitalized by the resources, local interest, and the increased capacity to do continuing professional education. As reported, this was the first time the AHEC program had conducted one focused activity with several AHECs. Because California has not had a state-funded AHEC program for a specific educational activity, unlike the arrangement in many other states, each of the AHECs has conducted its own different educational programs responding to needs in their respective regions. The success of cal-PEN as a demonstration of an educational delivery system suggests the potential for AHEC programs to sponsor other educational activities of interest to state or national agencies. The AHECs strengthened their ties to community health centers and, at least in respect to emergency preparedness, became an educational asset for the centers. The AHECs' self-study to identify strengths and needs guided the cal-PEN's future plans to extend the education to new areas and sites, to conduct interdisciplinary tabletop exercises, and to develop new education focusing on special populations.
The diminished role of the CPCS, the uncertainties within the funding agency, and the daunting task of reaching widespread areas of the state with the educational activities were continuing challenges. The CPCS, originally envisioned to be the principal partner for faculty, had experienced a funding crisis the year before the cal-PEN inception and consequently suffered substantial losses of trained pharmacists. Although they recovered funding, there was an inadequate reserve of pharmacists, which limited scheduling flexibility. Furthermore, the CPCS and the California AHEC program experienced quickly the difficulties in combining two large systems with different missions: CPCS to deliver services and the AHEC to deliver new and extensive education. Pharmacists found it difficult to prioritize cal-PEN needs and were unavailable to meet the local training needs of the AHECs. The design of the program did not take into account the scheduling needs of community health centers and other potential participant institutions with those of pharmacists staffing the CPCS. Compounding these difficulties was the lack of financial incentives for the pharmacists to participate. The CPCS is administered through UC, where regulations for employees prohibited giving honoraria to the pharmacists. As a result, these unanticipated scheduling problems, lack of economic incentives, and low availability of faculty resources delayed the delivery of the educational program.
Another difficulty was HRSA's changing organization and policies affected by the drastic reduction in Title VII health professions funding. This created uncertainties about future funding, shifts in priorities about what would be funded, and barriers for projects being able to mutually inform each other. As it continued, the cal-PEN program was flexible enough to respond to changing federal needs and resources by adding skills-based learning to the curriculum and investing the limited resources in the most capable and productive AHECs.
Finally, a continuing challenge with implications for the renewed funding of cal-PEN was developing strategies to reach all areas of the state. In response, the AHECs expanded their service areas beyond their traditional target regions. AHECs were encouraged to collaborate with family medicine residencies that had not participated previously. Other strategies included broadening access to UCTV and developing new partnerships, for instance, with local Medical Reserve Corps. Future plans for curriculum development recognized the need to complement the knowledge-based learning described here with skills building exercises, such as tabletops and drills. (A tabletop is a discussion-based exercise with an actual or assumed real-life situation in which participants play roles in the scenario and evaluate the process and outcomes. A drill refers to a coordinated and supervised operations-based exercise to test an agency's or organization's emergency plan.)7
During its first two years, the statewide AHEC program's cal-PEN mission was accomplished successfully with the broad representation of health professionals trained in communities throughout California and the high numbers working with underserved populations. New partnerships, a well-received curriculum, a trained community-based faculty, and the increased capacity of the AHECs themselves to do continuing professional education in emergency preparedness established a network of organized and accessible resources which still continues. Among the more recent developments are tabletop exercises in community health centers about pandemic influenza, a new module on avian influenza, annual faculty development programs, and a collaborative program with the California DHS on disaster surge planning (surge refers to unanticipated numbers of patients that overwhelm the capacity of a hospital or clinic).
The linkage of local AHECs with public health departments and community health centers is an excellent example of a useful way to bridge the traditional gap between primary care and public health in planning and delivering health services.
We believe that cal-PEN has demonstrated its capacity to distribute important information to California's safety net providers in widespread geographical areas. The program has also increased the expertise within the local and, in turn, the statewide AHEC program to conduct programs of vital interest to communities.
The ultimate impact of this and other programs with similar missions about emergency preparedness will be assessed by learners recognizing that increases in their knowledge, skills and experiences gained from educational interventions actually made a difference in their performances in an emergency or disaster. Future evaluation methods should capture systematically these scenarios in a descriptive manner. Such data, collected and collated from those health professionals who have participated in disasters, will elicit which educational activities improved their abilities to perform and thus be of great value to the nation's disaster planning agencies.
The authors want to acknowledge the contributions of Brenda Mitchell, program analyst for the California AHEC and cal-PEN programs, for her management of the cal-PEN database. The authors also thank the AHEC coordinators and faculty who made these results possible.
This work was funded through HRSA, BHPR grant #T01HP1405, now housed in the Office of the Assistant Secretary for Preparedness and Response (ASPR). This administrative move was made recently to improve the coordination between preparedness and response programs.