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Adapting Community Call Centers for Crisis Support

Public Health Emergency Preparedness

This resource was part of AHRQ's Public Health Emergency Preparedness program, which was discontinued on June 30, 2011, in a realignment of Federal efforts.

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Appendix 3. (continued)

Multipurpose/Multifunction Support Services

It is also important to know the scope of the services that the call center will provide. A hotline can be constructed that addresses only a single topic/incident or one that could handle multiple topics. It may be best to begin providing services for a few topic areas and then to gradually increase topic areas over time (see figure below for an example of expanded services).

Figure presents an example of the scope of expanded services to be provided by a call center. For details, go to [D] Text Description.

[D] Select for Text Description

An example of a more detailed call handling flow for West Nile Virus calls is shown below. The expected needs for both the public and public health professionals were accounted for and appropriate information resources or referrals were put in place.

Flowchart depicts the handling of calls about West Nile virus. For details, go to [D] Text Description.

[D] Select for Text Description

Summary: A single hotline can be configured to provide information and support for a variety of events. It may be better to establish one emergency hotline that can be customized to various events and gain support from the public and health care professionals than to try to promote a new hotline for every new event.

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Use of Recordings and Other Information Resources

Once service levels, scope of services, service providers, and call flows are determined, it becomes important to consider ways to help handle anticipated call volumes. In non-emergency events it may be easy to have staff answer every call. However, in any type of health event that generates some public concern, call volumes may rapidly increase, especially if media organizations become engaged; it becomes difficult to staff so that every call is answered and there are no call queues.

Up-front messages can provide the most requested information of the day to satisfy the greatest number of callers with a fixed complement of staff. Be careful to keep the length of upfront messages acceptable to callers (generally no more than 1 minute), or they get frustrated with the inability to speak to someone in a timely manner.

We have tracked call times to make sure that the majority of callers do listen to messages and then hang up (indicating to us that they received answers to their questions) instead of waiting in queue (indicating they still have unanswered questions). For those that opt to remain in queue, we cycle other frequently requested information after 1 minute to try to answer their questions before reaching the staff. That ensures that the staff is really assisting those who could not be helped easily by other means. Callers also can be referred to other information sources (such as the Internet) that they may opt to explore instead of waiting in queue or to investigate first before calling back. It is important that Web addresses are easy for the caller to jot down from the message (i.e., Internet resources with more complicated addresses can then be accessed from the supplied Web address via links. This avoids difficulty with trying to capture complex Web addresses (i.e.,

Messages and recordings provide many advantages:

  • Insure consistent, accurate information delivery on every call.
  • Deliver the most urgent public health messages.
  • Allow for customized messages to address most frequent concerns and issues.
  • Reduce the need to speak with a staff person.
  • Assist with call volume surges.
  • Direct callers to Internet resources for information.

Summary: Remember that every call that can be handled by a recorded message or referred to the Internet reduces the need for staffing during peak call volumes.

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Use of Call Center Technology

Call center technology can improve call handling efficiency and assist with call volume surges. Examples of such technology are:

  • Automatic Call Distribution (ACD) functionality, which insures that calls are evenly distributed among available call handling staff and reduces any delays in answering calls.
  • Call management software, which can be used to monitor call length times, queues and wait times, abandonment rates, and other call metrics (these metrics are important for both understanding what callers are experiencing and to help manage staff in the call center).
  • Interactive Response (IR) technology to allow callers to access information using their touch tone phones or even voice commands and thereby increase their ability to self-service their needs. This is used extensively in banking and airline industries. Examples of four such applications that we have developed for addressing anticipated needs in certain public health emergencies are detailed in Appendix 4, Developing an Interactive Response Tool.

Summary: In operating a call center, it is important to consider available technology for increasing call handling efficiencies and understanding call metrics.

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Information Topics and Content

It is important to determine the specific topic areas on which information will be provided. We have worked in partnership with public health agencies to determine these topic areas and have required that an epidemiologist approve all information content before using it. This helps to ensure consistency with broader public health response messages and efforts. Topic areas could include:

  • Smallpox.
  • West Nile Virus.
  • Influenza/Pneumonia.
  • Anthrax.
  • Tuberculosis.
  • Hantavirus.
  • Ricin.
  • Mold.
  • Avian Flu.
  • White Powder.
  • SARS.

Besides determining the topics, it is also important to determine the information subtypes to be offered, such as:

  • General information.
  • Public health messages (personal/family protection, health department messages and points of contact).
  • Provider guidelines and treatment information.

The process of determining these subtypes helps anticipate specific questions for which the public may need answers. Developing information resources in the format of FAQs and their answers works very well (go to Appendix 3-A at the end of this appendix for an example). The FAQs can be assigned key words so they can be quickly referenced during a call. We have also found that having a process for "Information Not Available" is important. For such calls it is important to have a notification protocol to alert the appropriate health department contact so they can evaluate whether a FAQ or other resource is needed with the expectation of an answer within 72 hours.

Referral protocols can also be important information resources. Since the HELP program is staffed with information providers, they are instructed to refer callers with certain health issues to other resources: callers requiring symptom management are referred to their health care provider or a nurse advice line, and callers reporting a potentially toxic exposure are referred to a poison control center.

Summary: Determine information topics to be addressed and then what information content is needed. Consider having all content approved first by appropriate public health agencies. Be prepared to add additional information as the situation and need dictates. Develop the appropriate referral protocols to direct callers to other resources, as needed.

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Staff Training and Quality Control

It is important to provide call center staff with the appropriate tools and training for them to deliver the expected service level. The skill profile for staff depends on the actual level of service they are required to provide and may also depend on the nature of the event.

In our experience, Level 1 service can be provided with Information Providers (those with some familiarity of health concepts, such as teachers, paramedics, veterinary technicians, medical/nursing students). Level 2 service would require licensed clinicians (such as nurses, pharmacists, physicians), who would be expected to provide health care assessment and advice.

We suggest developing a standardized training program for staff that includes the following three components:

  • Customer service/communication skills—to prepare staff for answering calls from people who have different abilities for processing information, a range of emotions regarding health concerns, and special needs (such as translation services for non-English speakers and TDD/TTY services for the hearing impaired). Important skills to teach are active listening to help callers identify their specific concerns while demonstrating empathy and respect. Crisis listening skills may be needed to help staff identify callers with signs of mental distress who could benefit from counseling resources and referrals.
  • Technology skills—to teach staff to operate telephones and information management software. Utilizing software that guides staff through a call in a standardized manner, prompting them for required information, will help to simplify training in this area.
  • Content education—to prepare staff to provide the appropriate information in a conversational manner and at a level that the caller can comprehend. Requiring staff to first listen to live calls and to have them role play as callers can help their training.

We developed a training program that includes 3 hours of didactic and 3 hours of practical call handling for all new personnel. The 6-hour time frame seemed reasonable for circumstances that would require a quick staffing ramp up to address an emergency. We have pre-trained certain individuals (such as existing administrative personnel) and provided them limited call handling experience to give us a resource for potential surges in call volume. We have also had staff attend Web casts and in-person trainings related to specific health topics for their continued training. Affording staff the opportunity to promote the HELP program to the public and professional groups at conferences has resulted in increased staff satisfaction.

It is important to have active quality assurance/quality control (QA/QC) procedures in place both to monitor the services being provided and to provide feedback to staff. Such procedures can help to quickly identify if calls are not being handled properly and staff need further training. QA/QC procedures can include recorded call reviews (or "listening in" to live calls), peer review of call documentation, and mechanisms for staff to provide feedback and suggest improvements.

Summary: Develop a staff training program that is consistent with expectations for service delivery and can be used to accommodate staffing ramp ups related to emergencies. Training should include components for communication skills, technology skills, and content education. An active QA/QC program helps to assure consistent service delivery and to provide staff feedback for ongoing improvement.

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Data Collection and Reporting

As important as it is to provide information to the public and health care providers, it is equally important to provide data related to an event, including the most common concerns, the origin of calls, and the specific information that callers are reporting. This data can help in the overall management of a health emergency and may be useful to public health agencies. They may be used to create additional or clearer messages for public information campaigns through various media outlets or to better understand whether disease control measures are effective (i.e., situational awareness).

For call data to be useful, it must be collected in a structured manner and then be reported in a consistent and reliable manner. The first step is to choose a commercial software application that has the ability to accommodate data entry and management requirements, preferably in a structured manner that leads staff step-wise through call data collection. In our experience, important call data elements include but are not limited to:

  • Call volumes (calls per hour, day, week).
  • Number of callers who listened to recorded information only.
  • Number of calls handled by a live agent.
  • Calls abandoned (caller hung up without listening to recorded information).
  • Caller demographics (zip code, county, city).
  • Caller contact info (phone number or E-mail, if needed to provide followup).
  • Call type (WNV, influenza, other topics).
  • Call reason (information, report case, provider information).
  • Health info provider (listing of FAQs used).
  • Surveys (dead bird reports, vaccine adverse events reporting system).

Ideally, the software should be able to assist in information resource management (such as maintaining and quickly accessing FAQ libraries or State/local health department notification and referral protocols). As stated previously, we established an "Information Not Available" protocol which requires that the appropriate health department contact is notified and our software application accommodates this notification automatically.

The software should also be able to generate reports and export data files for transmission to the appropriate agencies or clients. An example of the components of reports generated for our public health partners include:

  • Call metrics (call volume, call times, call disposition).
  • Caller demographics (zip code, county, city).
  • Call types (WNV, influenza and other topics).
  • Information delivered (specific FAQs and counts of requests).
  • Customizations ("Information Not Available" requests, out-of-state calls).
  • Surveillance signals (based on call center experiences).
    • Sentinel alerts (such as any "white powder" calls or health topics not covered).
    • Trends in public concerns (comparisons to previous reporting periods).

We have found it extremely useful to export and transmit survey data (such as dead bird reports or self-reported illness of influenza/pneumonia that can be geo-coded) to a recipient for conversion to maps for use in situational awareness and disease control strategies. A few sample data reports items and graphs from typical reports are presented in Appendix 3-B at the end of this appendix.

Summary: We do not endorse any specific software application but urge call centers to choose a solution that affords them the data entry, information resource management, and reporting capabilities they require. Agreed upon reporting schedules and processes should be developed with expected report recipients to ensure timely and useful information exchange.

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Adaptability and Utility

In our experience, it has been valuable to have systems and processes that can be adjusted to the changing needs of emerging public health events. This has included the ability to:

  • Rapidly change FAQ content and public health messages.
  • Handle surge responses through a variety of mechanisms:
    • Use of recordings/announcements.
    • Partnering with media to deliver information.
    • Having trained ancillary staff.
  • Learn from experiences.

Some of the lessons learned from more than 3 years of operating the HELP program include:

  • Call volume is driven by the event and media attention—anticipate call volume surges related to morning, afternoon, and evening news broadcasts.
  • Media organizations are willing to assist with disseminating information; for example, regularly including hotline numbers in television news crawlers.
  • Adaptation to include the latest local and State health department messages are necessary to meet both public health and public needs.
  • Surveillance, though not an intended purpose of the program, became an important function due to the utility of structured data collection (situational awareness) and ability to identify emerging issues (sentinel event detection).

Such partnerships between community health call centers and public health agencies prove that together we can meet the expected needs of communities during health emergencies, including: improving information support, improving surge capacity, expanding surveillance signals, and data collection for situational awareness. These partnerships help realize the new demands on public health agencies—increasing their response capabilities and access outside of the 9 a.m. to 5 p.m. work day, handling rapidly evolving information while maintaining control, and enabling the public to care for themselves and their families by supplying the information for them to make decisions.

Summary: The need for such partnerships will remain constant and potentially increase since public health events will continue to occur. These events will require effective, structured, and coordinated systems for providing public information and support as a component of a cost-effective, efficient, reliable, and adaptable response.

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