Hospital Systems Serving Health Disparity Populations (HSSHDPs) deliver needed services to racial and ethnic minorities and other underserved communities. HSSHDPs may experience long-term effects of natural and man-made disasters that in turn could affect health outcomes for the populations they serve. The COVID- 19 pandemic has affected virtually every US healthcare system and, therefore, provides a unique opportunity to study the effects of large-scale and long-term stressors on under-resourced systems serving vulnerable patient populations. Using the framework of the disaster management cycle (mitigation, preparedness, response, and recovery), this project proposes to conduct a mixed methods study of the long-term effects of COVID-19 on US hospitals across four critical domains (quality, workforce, finances, and innovation), with a special focus on HSSHDPs and on the health disparity populations they serve. This project will be the first major national investigation of the effects of a national disaster on HSSHDPs. This rigorous mixed methods study will be significant in identifying HSSDHPS most and least affected by the COVID-19 pandemic and will deepen the understanding of the contributing factors that led to successes and challenges. The study will identify actionable best practices and challenges to HSSHDPs' operations before, during and after the COVID-19 pandemic. The specific aims of this study are: Aim 1. Describe the long-term effects of COVID-19 on hospitals and the perceived usefulness of disaster management planning activities (including interactions with Coalitions). In partnership with the American Hospital Association and America's Essential Hospitals a nationally representative survey of 2000 hospitals will be conducted to examine variation by HSSHDP status and other characteristics. Aim 2. Analyze changes (before, during, and after the COVID-19 pandemic, 2018-2023) in hospital- level quality, service levels, and finances, and in patient-level outcomes. Using secondary data sources, the study will focus on differences among HSSHDPs, and for context, compare HSSHDPs with non-HSSHDPs. Aim 3. Explore the challenges faced by HSSHDPs during the pandemic and the strategies pursued to overcome them. The study will include 12 in-depth case studies, using purposive sampling to select HSSHDPs and non-HSSHDPs with and without major effects due to COVID-19. Semi-structured interviews with stakeholders will be used to more fully understand existing structures, challenges, interactions with Coalitions, and other disaster management strategies. Aim 4. Develop prioritized policy recommendations to enhance resilience of our most critical public health systems for future disasters to protect the health of our most vulnerable populations and the facilities that serve them. A national Delphi consensus panel in conjunction with the National Academy of Science Engineering and Medicine will be conducted.

This project aims to understand the long-term impacts of disasters on Hospital Systems Serving Health Disparities Populations (HSSHDPs), and in turn contribute insightful recommendations for improvements in disaster preparedness. HSSHDPs are embedded within their communities and understand the myriad challenges faced by the people they serve and play a pivotal role in reducing health disparities resulting from disasters. In the long-term, by implementing recommendations that address concerns of such hospital systems, the populations will be better served, thereby, positively impacting overall public health.