Guidance for Implementing the Opening Up America Again Framework

Guidance for Implementing the Opening Up America Again Framework

This implementation guidance provides tools and resources to assist decision makers to implement the Guidelines for Opening Up America Againexternal icon framework. Guidance is provided to monitor local conditions (transmission, public health, and healthcare system capacity) and adjust mitigation strategies over time to effectively contain outbreaks and minimize negative side effects of more significant restrictions on commerce and education.

It begins with steps that all Americans need to take in every community.  From there, it outlines core capacities needed in communities to respond to and manage COVID-19 cases as well as delineates key metrics to monitor community mitigation efforts.  All of the guidance is anchored to the phases of the Opening Up America Again framework.

The appendices contain more detailed tools for communities such as indicators to better track and adjust mitigation efforts as well as comprehensive mitigation guidance organized by phase and by setting.  Finally, there are user-friendly decision trees to help leaders make informed decisions about reopening. A companion community leader’s guide to further enable implementation activities accompanies this resource.

Steps for All Americans in Every Community

All jurisdictions should continue to promote individual and workplace practices that reduce the risk of transmission as people move through the community.

Individuals should:

  • continue to wash their hands often
  • cover their coughs and sneezes
  • avoid close contact with others
  • disinfect frequently-used items and surfaces
  • stay home when they feel sick
  • use cloth face coverings when out in public

Employers should:

  • Notify and work with state and local public health officials if an employee tests positive for COVID-19
  • Develop and implement appropriate policies, in accordance with Federal, State, and local regulations and guidance and informed by industry best practices, regarding:
    • social distancing
    • personal protective equipment
    • health checks like temperature screening
    • isolating and sending home those who are sick
    • not allowing employees positive for COVID-19 to physically return to work until cleared by a medical provider, or according to the guidance for discontinuing home isolation for COVID+ cases managed at home
    • notifying local health officials and individuals who may have been exposed when someone is confirmed, or presumed to be positive for COVID-19
    • sanitization, cleaning and disinfection
    • business travel

Preparing– Establishing Core Capacity

All jurisdictions need to build and maintain a core capacity to respond to and manage COVID-19 cases. Leaders should convene a broad set of stakeholders across sectors to:

  • Communicate data about local transmission, public health and healthcare system capacity, risk to vulnerable populations, and economic considerations;
  • Share local status of gating criteria (as described by Opening America Up Againexternal icon framework, and below); and
  • Develop coordinated re-opening plans and guidance

The framework for Opening America up Again outlines core preparedness plans every jurisdiction needs before beginning the process of “gating” or reducing mitigation strategies.  This is especially important in a jurisdiction that has experienced significant transmission and healthcare system strain.  Assistance is available, including staffing, to support states, tribes, localities, and territories to establish and maintain this capacity.

Plans should be updated throughout the response to ensure lessons learned are rapidly assimilated into practice and at a minimum address the following components:

Testing and Contact Tracing

  • Ability to quickly set up safe and efficient screening and testing sites for symptomatic individuals, and to trace contacts of COVID-19+ cases
  • Ability to test syndromic/Influenza-Like Illness (ILI)-indicated persons for COVID-19 and trace contacts of COVID-19+ cases
  • Ability to test at sentinel surveillance sites for asymptomatic cases, and trace contacts of COVID-19+ cases

Healthcare System Capacity

  • Ability to quickly and independently ensure adequate staff and provide critical medical equipment and supplies (e.g. personal protective equipment (PPE)) to meet unexpected surge demands
  • Ability to surge ICU capacity

Develop Plans Specific to Community Needs

  • Protect the health and safety of workers in all settings
  • Protect the health and safety of vulnerable populations and those living and working in high-risk settings (e.g., senior care facilities, correctional facilities)
  • Protect employees and users of mass transit
  • Implement strategies to promote social distancing and use of cloth face coverings
  • Monitor local transmission and public health and healthcare system capacity
  • Immediately take steps to limit any rebounds in transmission, or outbreaks, by increasing mitigation strategies to address a specific outbreak (e.g., returning to an earlier phase as outlined in the Opening America Up Againexternal icon framework, depending on severity).

Monitoring Community Conditions and Gating Criteria

Once the core capacity is in place, monitoring community transmission, public health, and healthcare system capacity will help jurisdictions assess readiness for moving between phases for lifting mitigation strategies.  The Opening Up America Again framework outlines gating criteria for states and localities to use in determining when and how to decrease or increase community mitigation strategies over time as the risk of transmission for COVID-19 changes.

These gating criteria are anchored to time-bound, population-level metrics of COVID-19 burden (newly identified cases, emergency department or outpatient visits associated with the disease, and percentage of COVID-19 positive tests) as well as measures of the public health and health-system capacity to address current circumstances (robust testing and contact tracing capabilities, hospital inpatient and ICU beds, and access to PPE).

Communities with significant or uncontrolled community transmission are considered in pre-gating or Phase 0.  Jurisdictions need to meet all the gating criteria prior to removing any shelter in place order or entering Phase 1.  These metrics and how to utilize them to inform decision-making are described in Appendix 1.

Once the gating criteria are met, jurisdictions enter Phase 1 and proceed to move between three phases, altering the level of community mitigation recommended as they pass through each gate.  Phase 1 corresponds to areas with the highest disease burden and ongoing community transmission, with the most significant mitigation strategies in place.  At the other end, Phase 3 corresponds to areas with lower disease burden and less frequent community transmission with the least significant community mitigation strategies deployed.

Each phase outlines necessary mitigation strategies to protect public health.  Until a vaccine is widely available and/or medications are broadly accessible to manage COVID-19 symptoms, individuals need to follow good personal hygiene practices, stay at home when sick, and practice some amount of physical distancing to lower the risk of disease spread.  These precautions are needed regardless of the phase a community is in.

It is also critical to identify when transmission begins to place the public health and healthcare system at risk, so appropriate actions can be taken.  A gating indicators dashboardexternal icon has been created as a tool to help pull relevant data streams into one platform to support decision making and regional planning and coordination.  It can be accessed by jurisdiction officials through GeoHealth.  Again, indicators and thresholds can be found in Appendix 1.

Community Mitigation Across the Phases

Protecting public health is at the center of the Opening Up America Again framework. However, jurisdictions are also addressing the economic and social consequences of COVID-19.  Mitigation strategies should be implemented in a manner that is sufficient to contain transmission and allow sectors to plan for and minimize the negative impacts of the mitigation. The earliest signs of a cluster of new cases or a reemergence of broader community transmission should result in a re-evaluation of community mitigation strategies and a decision on whether they should be strengthened. Increasing mitigation should be tailored and measured, specific to any increase observed.

For example, an outbreak in a high risk setting such as a nursing home or correctional facility would result in strict mitigation, contact tracing and isolation of cases for all individuals entering that setting, but may not necessitate implementing strict community-wide measures such as a shelter-in-place order if the outbreak can be effectively contained.  Assessing the appropriate mitigation approach and only implementing the strategies appropriate to the observed transmission will help minimize the societal and economic impacts of mitigation.

The following framework categorizes jurisdictions based on the level of transmission and community capacity to contain the transmission.  The categories align with the phases in the Opening Up America Again plan to assist with transitions between the gates and phases.

Community Mitigation by Re-Opening Phases
Community Mitigation by Re-Opening Phases
Opening Up America Again Phase Pre-Gating or Zero Phase Phase One Phase Two Phase Three
Transmission Characteristics Significant or Uncontrolled Transmission Significant or Controlled Transmission Moderate, Controlled Transmission Low, Controlled Transmission
Community Description Emerging and Current Hot Spots

Public health and health system capacity exceeded

Previous hot spots where transmission has met thresholds and public health and health care systems can manage level of transmission Moderate transmission that is within capacity of public health and health systems Limited Transmission (rural, low density areas)
Mitigation Needs Shelter in Place Significant Mitigation Moderate Mitigation Low Mitigation
Thresholds for Gating & Mitigating Adjustments Thresholds for gating not met: maintain or initiate significant, or implement additional mitigation if not currently in place Thresholds for gating met/maintained: reduce mitigation to Phase 1 then maintain until next gating thresholds are met

OR

Moderate Transmission community where public health or health system capacity thresholds are no longer met: increase mitigation across all setting to Phase 1 level

Thresholds for gating met/maintained: reduce mitigation to Phase 2 then maintain until next gating thresholds are met

OR

Low Transmission community where public health or health system capacity thresholds are no longer met: increase mitigation across all setting to Phase 2 level

Thresholds for gating not necessary if community never experienced transmission that exceeded public health or healthcare system capacity: apply Guidelines for all Phases

OR

Moderate Transmission community where thresholds for gating met/maintained: reduce mitigation across all settings to Phase 3

Travel patterns within and between jurisdictions will impact efforts to reduce community transmission too.  Coordination across state and local jurisdictions is critical – especially between jurisdictions with different mitigation needs. Considerations for employers and employees are outlined in Appendix 2.  Refer to the latest  CDC travel guidance for additional information.

Decision-Making for Community Mitigation

State, local, tribal, and territorial officials are best positioned to determine which phase their jurisdiction falls within.  Decisions about moving to a different phase will be made at the state, local, tribal and territorial level.

Appendices 3-5 contain more detailed tools and resources to help officials make decisions about the appropriate level of community mitigation by phase and setting.  Appendix 6 contains the development and pre-production concepts for a community leader’s guide toolkit