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Climate Change AND Health Equity​

Interim Guide to Health Equity-Centered Local Heat Planning 

Interim Guide ​Released September 29, 2023​

*Note: This is an Interim Guide. The California Department of Public Health looks forward to feedback from local jurisdictions and other stakeholders on this guide. We will continue to incorporate input and anticipate releasing an updated guide for summer 2024.​ To submit feedback or questions about this guide, email climatechange@cdph.ca.gov​.

Contents:

This document is intended to assist local jurisdictions with incorporating health equity​ into new or existing heat action and planning efforts. Creation of heat plans and use of this document are not mandatory but are recommended. This guide can be used by land use planning and community development agencies, emergency management planners, public health partners including local health jurisdictions and Tribal governments, as well as community members and advocates supporting or engaged in these efforts. Strategies or elements from this document can comprise a new or updated stand-alone heat plan, or be incorporated into Local Hazard Mitigation Plan updates, Climate Action & Adaptation Plans, General Plan Safety Elements, or Public Health Emergency Preparedness Plans. 

This guide was developed based on a review of more than 40 local and regional extreme heat plans, guides for creating heat plans, and other best practices for creating plans and strategies that center or work to address health equity. A selected bibliography is included in Appendix 1​ (PDF) for reference. 

This guide is intended as a resource for local jurisdictions to help with protecting the entire community from extreme heat regardless of residents’ background and access to resources, and in particular those with the least opportunity for good health. This resource can help facilitate partnerships between local health departments, offices of emergency services, and other local agencies.​​

It is recommended that this document be reviewed in full prior to initiating any planning efforts, in order to incorporate a health equity approach throughout the entire process. However, if planning has already begun, you may review the recommendations that apply to your specific phase of planning and seek opportunities to incorporate strategies that may have been missed in previous steps of the planning process where feasible.

Organization

This guide is organized according to steps, then categories, and finally phases:

Steps: The steps indicated below outline eac​h stage of a process for developing or updating a health-equity centered local heat plan​:

  1. Engage with priority populations and partner organizations in jurisdiction

  2. Identify heat risks to priority populations

  3. Set thresholds for declaring an extreme heat event

  4. Select heat plan actions

  5. Finalize plan for implementation

  6. Evaluate success of the plan


Categories: Step 4 (“Select Heat Plan Actions”) allows you to ​​select from a number of categories of actions—actions grouped together according to a specific topic. Categories can be thought of as areas in which to intervene to protect health. The categories are as follows:

  • Category 1: Communications and Engagement

  • Category 2: Data, Surveillance and Situational Awareness

  • Category 3: Cooling Centers and Other Cool Spaces

  • Category 4: Homes

  • Category 5: Workplaces

  • Category 6: Schools and Childcare Facilities

  • Category 7: Built and Natural Environment

  • Category 8: Transit

  • Category 9: Assisted Living and Skilled Nursing Facilities

  • Category 10: Local Detention Facilities

  • Category 11: Shelters and Encampments

  • Category 12: Ensuring Continuous Power and Affordable Energy

  • Category 13: Institutionalizing Extreme Heat Work

​​
Phases: Within each c​​​ategory, actions are organized by phases of implementation:

  • Long-term planning and policy actions to reduce exposure to heat and build resilience

  • Heat season (pre, during, and post)

  • Heat event (pre, during, and post)

II. Heat in ​​the Co​ntext of Climat​e Change

Climate change is considered the greatest public health threat of this century.1 ​The health impacts of the climate crisis are already being felt by Californians, with negative health effects projected to only worsen in the coming years.2​ Many populations in California also currently face health inequities, unfair and unjust health differences between population groups that are systemic and avoidable.3 People facing the greatest health inequities include populations with low income, older adults, children, communities of color, people with disabilities, people experiencing homelessness, immigrants, Tribal communities, and people who have been marginalized or discriminated against based on gender, race/ethnicity, or sexual orientation.4 Climate change disproportionately impacts these same populations.5

The Health Impacts of Heat 

Heat is already the deadliest of all types of weather events in the United States, and with climate change, increasing heat across California is projected to cause two to three times more heat-related deaths by mid-century. Exposure to high temperatures can cause negative health impacts, such as heat-related illnesses, which include heat cramps, heat rashes, heat exhaustion, heatstroke, and death. Other health impacts include:

  • Worsening of existing medical conditions: Heat events are associated with increases in emergency department visits for acute renal failure, kidney disease, diabetes, and cardiovascular diseases. 

  • Adverse birth outcomes as a result of extreme heat exposure during pregnancy, including increased risk of congenital heart disease, pre-term delivery, low birthweight, and stillbirth. 

  • Mental health impacts, with research showing a link between higher temperatures and suicide rates. 

  • Indirect health impacts, such as through

    • increases in work-related injuries such as falls;

    • health harms from disruption of life-sustaining medical equipment during public safety power shutoffs, rolling blackouts, or electrical outages;

    • disruption or delay in medical services due to many people needing care at the same time when it’s hot;

    • drowning or injury while swimming in bodies of water to cool off; and

    • ​injury or death due to increased interpersonal violence and aggression. 

Heat Has Inequitable Health Impacts

While higher average temperatures and more frequent and severe heatwaves are and will continue to be experienced across all of California, the negative health impacts of heat are not distributed equitably across all populations. Numerous communities and populations face a disproportionate risk of experiencing heat-related health impacts because of greater exposure to heat, greater sensitivity to higher temperatures, and/or reduced adaptive capacity (the ability, through resources such as financial, political, and social capital, to reduce or avoid the negative impacts of climate change) resulting from historic and continuing systemic marginalization. For example, workers outdoors or in non-air-conditioned spaces, people currently unhoused, people who are incarcerated, and people living within an urban heat island experience above average, continuous, or prolonged exposure to heat, increasing their risk of health impacts. Additionally, communities with low income, low social cohesion, or that have been historically and presently marginalized and underinvested in may face worse living conditions, have limited access to decision-making processes, power, and resources, in turn limiting adaptive capacity prior to, during, and after an extreme heat event. Finally, older adults, children, people who are pregnant, people with pre-existing health conditions, and people taking prescription medications or substances are more sensitive to changes in temperature and heat, increasing their susceptibility to heat-related health impacts.

​Compounding Impac​​ts​

​​Factors creating disproportionate risk may overlap with each other, as well as with other existing health, social, economic, or environmental injustices creating a compound or cumulative impact within a population or community, further exacerbating risk of experiencin​g heat-related health impacts. For example, outdoor workers may experience direct exposure to heat during the workday and may not be able to afford to turn on air conditioning at home due to costs (or may not have access to air conditioning at all), extending their exposure to heat and eliminating any opportunity for reprieve and recuperation, thus increasing their risk of heat illness. Fear of job loss, eviction, deportation, or incarceration may also hinder community memb​​​ers from accessing government-funded support programs, such as weatherization or utility bill subsidies. This same community may have low tree canopy coverage, or may be located in a rural, unincorporated area with limited access to resources, limiting collective adaptive capacity.


The Importance of an E​​quity Focus in Heat Planning

Given the inequitable distribution of heat-related health impacts, local heat mitigation, adaptation, response, and recovery efforts must apply a health equity lens when developing, implementing, evaluating, and prioritizing strategies. A health equity frame for heat planning and action is necessary to ensure that those experiencing limited adaptive capacity and the greatest exposure, sensitivity, and impact are prioritized and benefit from focused efforts to achieve positive health outcomes in the face of heat events.

​Con​​sidering Concurrent Events

​​Extreme heat can lead to worsening air pollution, wildfires (and wildfire smoke), and drought. In recent years, jurisdictions across California have experienced concurrent record-breaking extreme heat events at the same time as major smoke events due to wildfires. These concurrent events can challenge preparedness and response activities. For example, recommendations to cope with extreme heat (such as opening windows at night to bring in cooler air) conflict with recommendations to protect from poor air quality (to keep doors and windows closed). Efforts to prepare and respond, therefore, cannot be siloed, and must account for the likelihood of concurrent climate-related emergencies.

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​​III. A Health Equ​ity-C​​enter​​ed Local Heat Plan​

We recommend following the below steps in developing or updating your jurisdiction’s health equity-centered heat plan.

​​Steps

  1. Engage with priority populations and partner organizations in jurisdiction

  2. Identify heat risks to priority populations

  3. Set thresholds for declaring an extreme heat event

  4. Select heat plan actions

  5. Finalize plan for implementation

  6. Evaluate plan​

​​Step 1: Engage with priority ​populations and partn​​​​​er organizations in jurisdiction

Extreme heat disproportionately affects certain populations and key to developing or updating a heat plan is identifying priority populations who may be most impacted by extreme heat events and engaging with these populations and the organizations that serve them. It is critical to engage with community members and partner organizations throughout the process of developing the plan and as your jurisdiction implements the plan to protect the public from the health impacts of heat. 

​​​​​​​Key Term Definition: Priorit​​y Populations
We use the term “priority populations” here to indicate groups of people who are disproportionately impacted by extreme heat.

  1. Identify priority populations. We recommend considering the following groups or individuals as priority populations:

    • Renters

    • Unh​oused populations

    • Incarcerated individuals

    • Older adults

    • Women, children, pregnant people

    • Individuals taking medications or using substances

    • Low-income individuals and households

    • People living in urban heat islands (UHI)

    • People with health conditions such as respiratory or cardiovascular diseases, or diabetes

    • People with mental health conditions

    • People with mental or physical disability

    • People with electricity-dependent medical equipment

    • Socially or geographically isolated populations

    • Some racial and ethnic groups, particularly Black or African American, American Indian or Alaska Native, and Latine/x

    • Outdoor workers and workers in non-air-conditioned environments

    • People who are active outdoors

    • Overburdened and under-resourced populations (see definition below​​)

    • Immigrants and refugees

    • Individuals who are limited English proficient (LEP)

    • Emergency responders

      Key Term Definitio​n: Overburdened and under-resourced populations

      Overburdened and under-resourced populations include people or communities that experience disparate exposure, risk, or negative outcomes, such as environmental injustices resulting in health inequities, due to systematic oppression through discriminatory policies, plans, and procedures, including limiting access to cash, capital or other financial resources. These populations may overlap with or include many of the other populations or groups listed, as well as additional populations; this is intentional to encourage the use of an intersectional approach (PDF) to identify prio​rity populations within your jurisdiction.


  2. Identify partner organizations and establish roles and responsibilities. Consider including both traditional and non-traditional planning and community development partner organizations, with a focus on any and all internal and external partners that engage with and serve priority populations. Examples include:

    • Public Officials (e.g., Mayor’s Office, Board of Supervisors, appointed committee members)

    • Emergency Management Agencies

    • Healthcare Providers and Facilities

    • Agencies Operating Cooling Center & Other Cool Spaces (e.g., parks and libraries)

    • Agencies Serving At-Risk Populations (e.g., serving unhoused people, older adults, etc.)

    • Agencies that Support Critical Resources (e.g., food banks, water utilities, energy utilities, nonprofits that provide utility assistance)

    • Planning and Public Works Agencies

    • National Weather Service (PDF)

    • Tribal Governments

    • Community-Based Organizations

    • Mutual Aid Groups (in which groups of community members work together voluntarily to meet vital community needs such as food, housing, or disaster relief)

    • Occupational Safety and Health Organizations

    • Schools and School Districts

    • Academic Institutions

    • Businesses

    • Voluntary Organizations (such as Voluntary Organizations Active in Disaster)

  3. Participate in engagement activities and needs assessment with community members and partner organizations regarding extreme heat planning, particularly with respect to priority populations. For more information on how to conduct meaningful community engagement, refer to the resources provided in Appendix 1 ​(PDF) under the “Community Engagement section.

  4. Collaborate with community-based organizations (CBOs) and partner organizations to involve them in plan development, implementation, and evaluation.

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Step 2: Identify heat risks to priority populations​

After identifying and engaging with priority populations and organizations that serve them, it is critical to gain a better understanding of where priority populations reside in your jurisdiction and what factors increase their risk to extreme heat. We recommend using the following tools to identify heat risks to priority populations:

​See Appendix 2​ (PDF) for detailed step-by-step instructions on how to use these tools to complete the above steps.​

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Step 3: Es​tablish thresholds for declaring heat events and taking actions

In different jurisdictions, different agencies (such as the local health department or the local office of emergency services) may be responsible for determining when to declare a heat event locally. Local emergency managers may already have these protocols established. The California Department of Public Health recommends utilizing the National Weather Service (NWS) HeatRisk Tool as part of this process. The NWS itself issues advisories, watches, and warnings based on this tool as interpreted by their staff’s experience and expertise. Local jurisdictions may choose to adopt and amplify warnings from the NWS, and plan ahead what actions will be taken at which alert level from the NWS. We recommend the NWS Heat Risk Tool because it incorporates health data into its calculations to forecast risk of heat-related impacts to occur over a 24-hour period. More information on interpreting HeatRisk Levels can be found in CDPH’s HeatRisk Grid (PDF).

Pursuant to AB 2238 (Rivas, Chapter 264 of the Public Resources Code, Statutes of 2022), on or before January 1, 2025, the California Environmental Protection Agency, in coordination with the Integrated Climate Adaptation and Resiliency Program (ICARP), the State Department of Public Health, and the Department of Insurance, will develop a statewide extreme heat ranking system to be based upon, but not limited to, all of the following:

  1. Available meteorological data from government and academic sources, including maximum temperature, minimum temperature, and duration of extreme heat events.

  2. Information and data on health impacts of heat established through best available science or data from past heat and extreme heat events, including available mortality and morbidity information.

  3. Measures of extreme heat severity, including the severity of the outcome of extreme heat on human health.

  4. Locally relevant information, such as urban heat island effects, or cooling effects from urban tree canopies or other cooling measures.

  5. Comments and suggestions obtained from public input received at a minimum of one public workshop, as appropriate.

Once the extreme heat ranking system is implemented, local jurisdictions will be recommended to use this system.​

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Step 4: Select Extreme Heat Plan Actions​

Once you have worked to identify and engage priority populations and partner organizations, understand the risks to priority populations, and set thresholds for declaring an extreme​ heat event and taking actions, the next step is to select actions to include in your jurisdiction’s heat plan. Ensure that you are centering the priority populations and partner organizations in decision-making around how to prioritize actions and which actions to select.

Actions are organized according to 13 categories. Within each, there are long-term planning and policy actions, actions to implement before, during, and after each heat season, and actions to implement before, during, and after a heat event. ​

Use the below list to jump to any category:

    • Category 13: Institutionalizing Extreme Heat Work​

Category 1: Commu​​​nications and Engagement​

Communic​​​ating about the upcoming heat season and more specifically about an imminent extreme heat event is vital. Communications should provide priority populations with information about who is most likely to suffer from heat-related health impacts, how to recognize heat-related illness, individual behaviors that can reduce risk, and resources available to help reduce risk (such as cooling centers and energy assistance and weatherization programs.) Heat is an underrecognized threat, with many people feeling that they have already experienced extreme heat and are not at risk. Incorporating climate change into your messaging can signal to community members that the frequency, severity, and duration of heat waves is increasing due to climate change, along with the risk of heat-related health impacts.

It is critical to collaborate with community organizations and other partner agencies and organizations (as identified in Step 1) to co-develop, test, and distribute messaging that is culturally and linguistically appropriate.

Many factors affecting exposure to heat, sensitivity to heat, and capacity to adapt to heat are outside of the control of the individuals at risk. For example, a person with low income living on the top floor of an affordable apartment may not be able to afford air conditioning or a different apartment; policymakers have a role in providing high-quality affordable housing, accessible weatherization services, code enforcement, setting maximum indoor heat standards, or providing transportation to cool areas. Make sure messaging addresses policymakers and others who can address risk factors through actions such as land use and transportation planning, housing policies, workplace protections, tree planting and shading, and other cooling mechanisms, as well as heat-focused response and recovery policies. Protecting people from heat is a community responsibility; all the onus should not be on people facing disproportionate heat risk to protect themselves, when they already face so many daily challenges. Don’t forget that reducing greenhouse gas emissions at a societal level prevents the heat illnesses and deaths of the future and is an essential part of health communications for policymakers.


​Long-term planni​​​ng and policy: communications and engagement

Long-term planning and policy actions​

Develop messages directed at advancing policies to reduce climate pollution, prepare for impacts, and advance health and equity. Rather than requiring onerous personal protective actions on the part of people facing inequities, keep the focus on our collective responsibility to “create the conditions in whic​​h people ​can be healthy, (the Institute of Medicine definition of public health​), and to lessen exposure and sensitivity to heat. The American Public Health Association (4 MB PDF, starting on page 234) recommends that climate and health communications “establish […] an ‘environmental [policy] frame’ that the places people live, work, and play affect their health; “state your values to allow people to connect your message with shared values such as fairness, opportunity, efficiency, […] equality; “state the problem and solution clearly so that your audience understands the need for unified societal action, and specifically what you want them to do. In sum: “Environmental [Policy/Societal] Trigger + Solution + Values = Public Health Message.

Develop messages to have rea​​dy ahead of heat season. Briefly link increasing heat to climate change, eg., “climate change is making extreme heat more frequent, more severe, and longer-lasting…​ See examples on pages 248–9 of APHA’s “Climate Change, Health, & Equity: A Guide for Local Health Departments. (4MB PDF)

Develop communications materials with input from partner organizations and community members. These can include but are not limited to webpages; social media posts; information provided to 3-1-1 and 2-1-1 operators; signage at transit stops, public transit, cooling centers, park entrances and trailheads, and elsewhere.

  • Provide messaging i​​n different languages; co-develop messaging with priority populations and organizations that serve them; include resources available to improve living conditions long-term, not just recommendations for behaviors; evaluate the reach and effectiveness of the messaging.

Develop key actions for disseminating communications with community-based organizations, local health departments and priority populations and incorporate into the​​ overall heat plan. For instance, consider developing a Partner Relay Network such as that implemented in the County of San Diego to work with community-based organizations, faith-based organizations, and refugee resettlement organizations to translate and disseminate emergency information to those with limited English proficiency (LEP).

Develop plans and seek funding for programs that improve social cohesion and increase the number of hard-to-reach priority populations who receive messaging and check-ins by leveraging volunteers (a model includes “Be A Buddy, implemented in New York City) or existing home visiting programs (Meals on Wheels, In Home Supportive Services, ​​Black Infant Health programs, asthma programs, etc.) to conduct outreach during a heat event.

Train existing volunteer emerge​​ncy organizations in your jurisdiction to conduct outreach to priority populations during a heat event.

Develop a community trai​​ning on heat-related health risks to train residents to provide information to their peers before or during a heat event.

In all action planning​ and community engagement, respect diverse cultural practices related to extreme heat and cooling strategies.


Heat season: communications and engagement
Pre​​ heat season​ During heat season​​​​​​​​​​​​​​​​​​​​ Post heat season
  1. Post information to website and social media about who is most likely to suffer from heat-related health impacts, how to recognize heat-related illness, individual behaviors that can reduce risk, and resources ava​​ilable to help reduce risk.
  2. Engage CBOs and agencie​​s serving at-risk populations to distribute messaging. ​
  3. Work with partners and the local community to emphasize the importance of mental health support during an extreme heat​​ event and provide guidance on managing stress and anxiety (ensure language accessibility and ADA compliance). Promote Disaster Distress Helpline resources. ​
  4. 3-1-1 and 2-1-1: Provide messaging to operators and plan for po​tential surge staffing during heat waves, when calls for government services increase.
  5. Launch program that leverages volunteers or home visitors to check on priority populations during extreme heat events (​​New York City’s “Be a Buddy” program provides an excellent model).
  1. Re-post and update website and social media messaging.
  2. ​Continue engaging messaging partners.
  3. Reinforce mental health messages.
  4. Post messaging at transit stops and in other public s​​​paces emphasizing protective actions and resources available for priority populations.
  5. Post messaging at ​​park entrances and trailheads discouraging over-exertion during extreme heat and how to recognize and treat signs of heat-related illness.

  1. ​​​Evaluate reac​h of messaging to the extent possible, particularly success at reaching prior​​ity populations. ​ ​ ​ ​



Heat event: communications and engagement
Immediately pre heat event During heat event
  1. Post information to website and social media about who is most likely to suffer from heat-related health impacts, how to rec​ognize heat-related illness, individu​​al behaviors that can​​ reduce risk, and resources available to help reduce risk. ​
  2. Activate CBOs and agencies serving at​​​-risk populations to distribute messaging.
  3. 3-1-1 and 2-1-1: Activate potential surge staffing t​​o ensure adequate coverage.​
  4. Activate program that leverages volunteers​​ and home visitors to check on priority populations during extreme heat events. ​
  5. Activate Partner​​ Relay. ​
  6. Direct in-pers​​on and/or telephone-based outreach to difficult-to-reach at-risk persons, such as people experiencing homelessness and people who are medically vulnerable. 
  7. Direct messaging to w​orkers in and employers of high-risk occupations about rights and obligations, and recognizing heat-related illness, in partnership with Cal/OSHA, unions, workplaces. ​​

  1. Re-post and update website and social media messaging.​
  2. Continue engaging messaging mpartners.
  3. Monitor 3-1-1 and 2-1-1 staffing needs.
  4. Monitor and support home visiting programs.
  5. Continue engaging Partner Relay with updated messaging.
  6. Monitor and support outreach programs.
  7. Reinforce messaging to high-risk workers and their employers.




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Category 2: Data, Surveillance and Situational Awareness​

Maintaining situational awareness of the human impacts of heat is critical. Residents, community-based organizations, partner agencies, and the media often look to local jurisdictions to provide an understanding of the impacts of a recent heat wave. However, jurisdictions currently vary in their capacity to collect, analyze, and disseminate data on local heat-related health impacts. CDPH looks forward to supporting local jurisdictions in this effort as it initiates Climate Change and Health Surveillance to provide near real-time notification for public health departments, first responders, and the community for emerging or intensified climate-sensitive diseases. This will allow interventions to reduce and prevent further illness. Surveillance will provide early warnings of heat-related illness cases. Local jurisdictions should maintain awareness of these efforts as they unfold.


Long-term pla​​nning and policy​: data, surveillance, and situational awareness

Long-term planning and policy actions

Identify sta​​ff to ta​​ke on heat surveillance and data analysis responsibilities.

Identify all available data sources that can be used to track heat-related health outcomes (e.g., emergency department visits, 911 calls, death data).

If data sources are not available for near-real-time surveillance of ​heat-related outcomes, work with partners (e.g., health systems, CDPH, coroner’s offices, emergency services) to begin developing systems for reporting and accessing data (e.g., BioSense).

Set up agreements with necess​​ary partners to access data on an ongoing basis.

Train staff on the use of relevant data systems.

Determine what data you can share with the public, and how you will do so.

Develop templates for methods of disseminating data to partners (e.g., dashboards or template reports)​.


Heat season: data, surveillance, and situational awareness

Pre heat season​ During heat season Post heat season
  1. Develop data analysis plans, queries, and systems for tracking ​​data during the heat season.

  1. If your jurisdiction currently has capacity, track heat-related em​ergency calls and emergency department visits.
  2. If your jurisdiction currently has capacity, provide real time surveillance data to community-based organizations, local health departments, and priority populations related to heat illness and response activities, such as through a regularly updated dashboard or weekly distributed Heat Report.

  1. Analyze not just overall trends in heat-related emergency calls and emergency department visits, but trends among race/ethnicity, in different age groups, by geography, housing status, etc. to focus future interventions.​​
  2. Disseminate data related to heat season.


Heat event: data, surveillance, and situational awareness

Immediately pre heat event​ During heat event Post heat event
  1. ​​Test out systems for creating situational reports that summ​​arize heat-related data.

  1. ​Distri​bute internal agency weekly situation reports including summaries of health impact and weather data, bar​​riers, and needs.
  1. ​Conduct post-heat wave rapid analysis of heat emergency calls​, ED vis​​its, and other impacts.

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Category 3​​: Cooling Centers and Other Cool Spaces

Cooling centers and other cool spaces are important options for people who do not have air conditioning in their homes or may have lost power in their homes. Developing an overall cooling center plan prior to a heat season can ensure that your jurisdiction has cooling centers in locations that are accessible to priority populations. Because many different agencies are often responsible for operating cooling centers and cool spaces, collaborating with partner agencies to develop these actions is crucial. The actions described below highlight steps to ensure health equity when incorporating cooling centers and other cool spaces to a heat action plan. Jurisdictions should also review CDPH’s Cooling Centers Guidance (updated July 2023) for general considerations for cooling centers.

People prefer going to cooling centers that have other activities going on, preferably in a location already used by many members of the community, rather than a stand-alone cooling center without other resources, services, or activities.

Cooling centers are one essential component of heat illness prevention, response, and resilience. There are many barriers to cooling center usage. Cooling centers are important safety nets, but more equitable solutions enable people to stay in their homes or other safe places without having to relocate to stay healthy.

More information on cooling centers including lessons learned from cooling center implementation: “The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation.  ​


Long-term planning and policy: cooling centers and other cool spaces

Long-term planning and policy actions

Adopt a policy to set cooling center locations in proximity to identified priority communities in both urban and rural locations (see Steps 1 and 2). Ensure that coolin​g centers and other cool spaces are ADA compliant and accessible.

Allocate a funding ​​source for cooling centers, pools, and splash pads to remain open late during extreme heat events.

Engage with a diverse group of partners to assist in implementation of multi-functional cooling centers and cool spaces.6 Potential partners can include but are not limited to: 

  • ​​City/county government agencies (e.g., health departments, libraries, community centers, cultural centers, senior services, emergency management agencies)

  • Transit agencies

  • Nonprofits (e.g., Red Cross)

  • Food access and distribution groups (e.g., Meals on Wheels)

  • Area Agency on Aging or other local older adult organizations

  • School systems

  • Energy/Utility companies

  • Religious​​ organizations and community organizations

  • Local businesses​​

Develop public-privat​e partnerships to expand the accessibility and attractiveness of public cool spaces (e.g., malls, movie theaters, museums).

Develop partnerships to ​explore implementation of resilience hubs, with the potential to use them as cooling centers during extreme heat events.

Develop a cooling center and other cool spaces communication plan that works both internally between partners and implementers as well as externally for public education and awareness.

  • Include in messaging what cooling centers are, who should consider using cooling centers, and whether additional resources are available (e.g., food, water, heat health information, accessibility for companion animals as well as allergen-free spaces, social services, children’s activities, or other identified resources).

Determine at what thresholds to open cooling centers, e.g., all heat season (May through September – a best practice in hot climates), or when the HeatRisk category is predicted to be yellow (1/minor), or orang​​e (2/moderate), or when the National Weather Service issues an advisory, watch, and/or warning. Determine who will make this decision and how it will be communicated for implementation.


Heat seas​​on: cooling centers and other cool spaces

Pre heat season During heat season Post heat season
  1. Ensure cooling centers and other publicly accessible cool spaces (e.g., parks, pools, splash pads) are planned and located in proximity to identified priority​​ communities (See Step 1​); include both urban and rural locations.
  2. Include up-to-date informatio​n on cooling centers and other cool spaces on a public webpage (ensure ADA compliance and l​​anguage accessibility).
  3. Train cooling center staff to recognize the signs and symptoms of heat-related illness, and to take action to cool the ​​person quickly and call for help. Have ice and cold water ready to quickly lower body temperature.
  4. Identify local resources and subject matter experts to train cooling center staff to identify and address any behavioral health needs th​​at may arise in the cooling center. Train cooling center staff on safety and security procedures specific to the location being used as a cooling center.

  1. ​Provide (free if possible)​ transportation to and from cooling centers and other cool spaces especially for​​ older adults and those lacking public transportation access.
  2. Update posted cooling center information as needed.
  3. Continue ongoing training for cooling center staff.
  4. Monitor safety and behavioral health needs at cooling centers.


  1. Develop report on attendance and demographics of attendees at cooling center centers utilizing survey administered at cooling center.
  2. Identify and document lessons learned from each heat season and incorporate changes into future​​ heat planning.
  3. Evaluate ov​​erall effectiveness of cooling centers and other cool spaces.


Heat event: cooling centers and other cool spaces

Immediately pre heat event​ During heat event
  1. Distribute cooling center locations and hours widely to the public through various media and in multiple languages. Advertise cool spaces (radio, social media, newspape​​r, calling home care agencies, engaging with organizations, etc.) and provide education and awareness to priority populations (ensure ADA compliance and language accessibility). ​
  2. Ensure that cooling centers are open an​​d available to all population groups, including unhoused individuals, LGBTQ+ community and immigrants. Immigration documentation should never be requested or discussed in connection with cooling c​enter services, and it should be made clear that all are welcome. Include messaging that all people are welcome at cool spaces in public-facing announcements and information and ensure messaging is reaching priority populations (ensure ADA compliance a​​nd language accessibility).
  3. Distribute and hang up adequate and clearly visible signage (ensure ADA compliance and​ language accessibility) indicating the existence of a cooling center, including hours of operation.
  4. Gather additional resources (e.g., food, water, ice, heat health information, or any othe​r identified resources) to be available for cooling center attendees.
  5. Ensure adequate staffing is read​​​y and available for cooling centers and other cool spaces.
  6. Plan for programming at cooling centers.

  1. ​Continue publicizing cooling center locations and hours.
  2. Continue ensuring access to cooling centers.
  3. Track attendance at cooling centers and incorporate attendee survey, wh​​en possible, to understand demographics and the ways in which attendees access information and access cooling centers.
  4. For more extreme heat events—particularly those during which temperatures remain elevated overnight—consider extended hours for cooling centers, po​​ols, and splash pads at least until 7:00pm, due to the increased risk of health impacts when temperatures remain elevated overnight, particularly indoors.
  5. Provide transportation to and from cool spaces especially for older adu​​​lts and those lacking public transportation access.
  6. Increase the attractiveness of cooling centers by providing educational and entertainment program​​ming (research indicates that barriers to accessing cooling centers include people worrying that they will have nothing to do).

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Category 4: Homes​

Properly weatherized homes with energy efficient air conditioning can serve as a protective factor against heat-related health impacts. However, due to aging infrastructure and historic and continued disinvestment in Black, Indigenous, Latinx, and other communities of color and low-income neighborhoods, many people live in homes that are not properly weatherized and do not have sufficient active or passive cooling systems in place. Providing people with the opportunity to stay safely in their homes during a heat wave is important because research indicates that many people are reluctant to leave their homes to go to a cooling center during a heat wave. Jurisdictions should partner with priority populations (identified in Step 1), housing authorities, tenants’ rights organizations, community-based housing organizations, landlords, and homeowner’s associations to identify and prioritize neighborhoods and/or multi-unit buildings in need of cooling units, passive cooling systems, and other tenant protections or supportive resources that can bolster residents’ ability to remain safe in their homes during a heat event. The actions described below highlight steps to ensure health equity when incorporating homes into a heat action plan.

Long-term planning and policy: homes

Long-term planning and policy actions​

Assess how many homes in your jur​​isdiction have air conditioning; consider also assessing more broadly homes with vulnerabilities such as poor housing quality.

Seek funding and develop plans to distribute cooling units to those who do not have them in their homes, with a focus on priority populations. Consider coordinating with energy assistance efforts​​ (listed below). The LIHEAP (Low-Income Home Energy Assistance) Program can provide cooling to eligible low income customers on a health care provider’s order.

Finance other cooling strategies for homes, s​​uch as cool roofs and walls, window films, trees, and other forms of shade, and home weatherization. (See also Category 7: Built and Natural Environment.)

Adopt and enforce an ordinance setting safe maximum indoor temperature thresholds for housing, and ensure the ordinance provides an avenue for complaint-based in​​spections and enforcement.

Update building codes (adop​​​t cool roof, green roof, etc.) and incentives to encourage the use of passive cooling systems (window films, shade structures, building orientation, etc.). (See also Category 7: Built and Natural Environment​.)

Develop and adopt poli​cies to protect against energy price increases, to cease all residential power and water shutoffs during heat season, and ensure that residents can keep air conditioning running during heat events.

Build relationships and partnerships with tenants’ rights organizations, landlord associations, homeowners associations, and community-based housing organizati​​ons to assist in implementation and communications of heat actions.

Work with utility compani​​es to ensure continuous power for people who use electricity and battery dependent assistive technology and medical devices. The federal HHS emPower platform prov​ides datasets and resources to local jurisdictions to identify and protect the health of at-risk Medicare beneficiaries who rely on electricity-dependent durable medical and assistive equipment and devices.

Connect at-risk residents with weatherization services, such as the State Department of Community Service and Developmen’s (CSD) Energy Efficiency and Weatherization Programs or the Cal​ifornia Public Utility Commission’s (CPUC) Energy Savings Assistance Program:

  • Work with healthcare providers to identify high-risk patients.
  • Assist residents with understanding the process and completing applications.

Connect at-risk residents with energy assist​​ance, such as CSD’s Low Income Home Energy Assistance Program.

  • Work with healthcare providers to identify high-risk patients.
  • Assist residents with understanding the process and completing applications.

Coordinate with tenants’​ rights organizations and priority population residents to monitor and evaluate the impact of long- and short-term strategies on housing costs, gentrification, a​​​nd displacement.


Heat season: homes

Pre heat season During heat season Post heat season
  1. ​​Distribute cooling units (e.g., fans, electric heat pumps, portable air conditioners) to homeowners, renters, and other dwe​​llings, with a focus on identified priority populations. (See Appendix 1​ (PDF) for example program implemented in New York City.) ​

  2. Ensure system to report housing complaints is up-to-date (as well ​​as ADA compliant and in accessible language(s)) and inspection teams are adequately staffed.
  3. Partner with tenants’ rights organizations to distribute information or provide trainings that are ADA compliant and in accessible​ language(s) to priority populations on housing complaint reporting process and ​​relevant tenants’​ rights and protections.

  1. ​​Continue cooling unit distribution.
  2. Ensure appropriate staffing is available to support a he​​at event response. Expedite enforcement of housing complaints related to rental housing being too hot.
  3. Reinforce tenant protection measures.
  1. Conduct post-distribution surveys to understand coolin​g unit use and effectiveness among receiving populati​​ons.



Heat event: homes

Immediately pre heat event During heat event
  1. Distribute cooling units (e.g., fans, portable air conditioners) to homeowners, renters, and other dwellings especially to priority populations with identified lack of these syst​​ems in their ho​​mes. The CA Energy Commission’s Equity Building Decarbonization Program provides efficient he​at pump air conditioning installation to low-income residents. Also see energy efficiency and weatherization resources above. ​
  2. Expedite enforcement​​ of housing complaints related to rental housing being too hot and evaluate response. ​

  1. ​Continue distributing cooling units.
  2. Monitor enforcement of housing complaints.

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Category 5: Workplaces​

Outdoor workers and people who work in facilities without air-conditioning are at risk for heat-related health impacts and may not be aware of either the health risks or their rights. The California Division of Occupational Safety and Health (Cal/OSHA) has a heat illness prevention standard for employers of most outdoor workers, as well as proposed standards for indoor workers, but gaps in compliance, enforcement, and covered workplaces remain. All employers in Cal/OSHA’s jurisdiction are required under current standards to correct unsafe conditions for workers created by heat. It will be important to update any workplace safety guidance in a heat action plan based on new California or federal standard and changes to existing standards to ensure employer compliance and workers’ awareness of rights. The actions described below highlight steps to promote health equity when incorporating workplaces into a heat action plan.

Long-term planning and policy: workplaces

Long-term planning and policy actions​

Partner with employers, labor unions, and community-based workers’ rights organizations to develop heat warning messages that are culturally and linguistically a​​ppropriate, tailored to those in high-exposure jobs, including outdoor workers and those working in non-air-conditioned indoor workplaces (e.g., warehouses).

Develop a mechan​​ism of communication between the jurisdiction and employer​​s to provide notifications and information regarding heat risk, exposure, and compliance with heat illness prevention standards including high-heat procedures throughout the heat season and extreme heat events (ensure language accessibility).

Collect and analyze data on workplace exposure to extreme heat, in partnership with CDPH, Cal/OSHA, labor unions, and community-based workers’ rights organizations. Work with​ listed partners and employers in industries with higher risk of extreme heat exposure to recommend or provide additional worker health protections and resources.


Heat season: workplaces

Pre heat season During heat season Post heat season
  1. ​​​Create a campaign tailored to heat-exposed workers to amplify messages about health risks and workers’ ri​ghts related to rest breaks, water,​ and other heat illness prevention strategies. ​​​​​​​​Consider using 99 calor mate​​rials.

  2. ​Partner with labor unio​​ns, community-based workers’ rights organizations, and employers to secure funding for or locate resources for workers such as home cooling units, wide-brimmed hats, and light-colored breathable clothing to augment protections mandated by Cal/OSHA.
  3. Communicate information to employers about their responsibilities under the heat illness prevention standard as well as under the Injury​ and Illness Prevention Program standard​ (PDF). Refer employers to Cal/OSHA Co​​nsultation Services for further information and assistance. 
  1. ​Continue running heart risk campaign for workers.
  2. Reinforce and expand partnerships to locate resources for workers.
  3. Continue employer-focused communications.
  1. Gather data related to extreme h​​​eat exposure for outdoor workers and workers in facilities without air conditioning.
  2. Evaluate messaging campaign; identify lessons learne​​d and areas of improvement.
  3. Conduct meetings or surveys with employers and heat-exposed workers to understand success​​​es and barriers from most recent heat season.


Heat event: workplaces

Immediately pre heat event​ During heat event
  1. Coordinate the delivery of information to employers, outdoor worke​​rs, and those who work in facilities w​​ithout air conditioning.
  2. Coordinate provision of additional cooling resources (e.g., home weatherization or utility bill assistance, home cooling units, wide-brimmed hats, light-colored breathable clothing) to outdoor workers and tho​​se who work in facilities without air conditioning.

  1. ​Continue and expand information delivery.
  2. Continue coordination of cooling resource provision.​

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Category 6: Schools and Childcare Facilities​​

Infants and children are priority populations that are particularly susceptible to negative health impacts from heat. Schools and childcare facilities are places where children spend a lot of time, making them important components of any heat plan. Due to historic and continuing systematic disinvestment in schools and businesses, including childcare facilities, in Black, Indigenous, Latinx and other communities of color as well as low-income communities, these facilities more frequently lack or cannot afford to run air conditioning throughout the facility, and are surrounded by heat-absorbing hard, dark-colored surfaces such as asphalt, further increasing the risk of children in attendance experiencing heat-related health impacts. With climate change extending the duration of the heat season, heat waves are more likely to occur during the school year as well. The actions described below highlight steps to ensure health equity when incorporating schools and childcare facilities into a heat action plan.

Long-term planning and policy: schools and childcare facilities

Long-term planning and policy actions​

Support schools and distr​​icts to engage with the California Schoolyard Forest System to increase tree canopy and reduce heat at schools. Develop plans to apply for CAL FIRE Green Schoolyard Grants.

Distribute information regarding child providers’ legal responsibility to maintain childcare facilities at safe temperatures and how to report violations to the CA Departme​​nt of Social Services Child Care Licensing Program.

Support training for school workers and child care workforce to better understand the signs and symptoms of heat-related illness; ensure that adequate staff outside of teaching staff ​​are equipped to monitor and understand the signs and symptoms. Work with the California Department of Social Services’ new Facility Impact Climate Section once established.

Encourage schools or school districts to develop their own heat or adverse weather emergency action plans (EAPs), to include

  • The need for lower intensity physical activity and for providing enough fluids during any activity
  • Plans for dealing with a hea​​t-related illness should one occur

  • If early dismissal or school is cancelled, a response plan to ensure students are adequately supported once they leave school or childcare grounds (including information on where families can find cooling centers)

Work with schools and school districts to develop communications and engagement activities that provide information to parents and caregivers on how to ke​​ep children safe, resources that are available, and information on understanding the signs and symptoms as well as what to do when you believe a child may be suffering from a heat-related illness.

Work with schools and school districts that serve the priority populations identified in Step 1 to conduct a needs assessment that identifies schools and childcare facilities t​​hat do not have adequate cooling, whether school buses have air conditioning, and where schools and childcare facilities may have inadequate shaded areas. Use Green Schoolyards America’s California Tree Canopy Equity Map when complete. Work with schools, school districts, and priority population parents, students, and teachers and staff to prioritize projects and secure funding to implement community-identified cooling strategies.

Engage and partner with the local school boards, parent teacher associations, teachers, parents, students, Child Care Licensing, Department of Social Services, or other relevant par​​tners to solicit feedback and support on actions related to extreme heat.

Incorporate schools and childc​​​are facilities into greening or tree planting plans in your jurisdiction.

Work with schools and school districts to pr​​ovide or secure funding to implement temporary or pilot cooling projects that were prioritized and co-designed with parents, students, teachers, and other facility staff.


Heat season: schools and childcare facilities

Pre heat season​ During heat season Post heat season
  1. Distribute and prov​​ide training when needed on the CDPH Interim Health Guidance for Schools on Sports and Strenuous Outdoor Activities during Extreme Heat (ensure ADA compliance and language accessibility). ​
  2. Communicate with schools, school boards, parent teacher associations, teachers, and parents around heat season​​. See examples from the California Department of Public Health, the Center for Disease Control and Prevention (CDC), and the Arizona Department of Health Services.
  3. Assist schools and childcare facilities in educating students on heat related illness in an age-appropriate manner​​​ (lesson plans, hand-outs, ​​media, in-person lessons, etc.).
  4. Implement temporary or pilot cooling projects (e.g., fans, temporary shade​ structures/sails, misting machines, etc.) at schools that serve prio​​rity populations.

  1. ​Reinforce training about sports and other outdoor activities.
  2. Continue communicating with schools, school boards, parent teacher associations, teachers, and parents.
  3. Support schools and childcare facilities in educating students​.
  4. Monitor cooling projects.​
  1. Evaluate sch​​​ool response to extreme heat events and incorporate lessons learned into heat action planning.
  2. Gather data on how many students received education/information and conduct surveys with teache​​​rs and/or parents to understand ways in which information was used or not.
  3. Review pilot project effectiveness by collecting feedback from students, te​​achers, and staff on utility or opportunities for improve implemented measures.



Heat event: schools and childcare facilities

Immediately pre heat even​t During heat event
  1. ​Distribute and provide training when needed on the CDPH Interim Health Guidance for Schools on Sports and Strenuous Outdoor Activities during Extreme Hea​​t (ensure ADA compliance and language accessibility). ​
  2. Deliver up-to-date information on an extreme heat event to schools, child care facilities, school boards, parent teacher associations, teachers, and parents (e​​nsure ADA compliance and language accessibility). ​
  3. For childcare facilities, please refer to PIN 23-09-CCP Extreme Heat Hazard Awareness Focusing on Infants and Young Children and PIN 23-12-CCLD Preparation for Extreme Heat, Public Safety Power Shutoffs, and W​ildfire Emergencies.

  1. ​​​​​Reinforce training about sports and other outdoor activities.

  2. Continue updating schools, school boards, parent teacher associations, teachers, and parents.
  3. Reinforce guidance to childcare facilities.

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Category 7: Built and Natural Environment​

Depending on how it is developed and managed, our built and natural environment can either contribute to hotter temperatures through concentration of hard, dark, heat-absorbing surfaces, narrow streets, tall buildings, and limited tree canopy or green space, or alleviate temperatures through trees, green space, passive solar siting and designs, shading, and cool surfaces. Public outdoor spaces serve as an important place to disseminate information, resources, as well as maintain social cohesion and connectedness throughout the year, but also during an acute extreme heat event. However, due to the legacy of racist housing policies and historic and continuing disinvestment in low-income neighborhoods and communities of color, many communities are in urban heat islands and do not have safe, accessible, or appealing outdoor spaces nearby that provide sufficient protection from extreme heat, such as shaded seating or play areas, water features, and more. Reducing the urban heat island and providing a safe, heat-adapted outdoor environment are critical efforts that every jurisdiction can undertake.

Long-term planning and policy: built and natural environment

Long-term planning and policy actions​

Conduct a shade assessment to determine locations with existi​​ng sufficient, or insufficient shade from trees, buildings, or other structures. Prioritize tree planting or outdoor shade structure installation based on areas with insufficient shade that serve priority populations identified in Step 1. Engage community members to determine exact locations (e.g., parks, paths, routes, etc.) to be prioritized for shade within their community. For census tract maps of shade, see US Forest Service’s Urban Tree Canopy in California tool. NatureScore provides parcel-level assessments of natural elements, while Cal Poly’s Urban Tree Detector maps individual trees and tree density.

Secure funds to implement temporary or pilot c​​​ooling projects at community-prioritized outdoor spaces.

Secure funds for permanent cooling strategies and solutions, including tree planting and maintenance, in areas with majority priority populations (identified in Step 1).​​

Building Code Updates: Adopt cool roof, green roof, or other ​​passive cooling ordinances and incentives.

Pavements: Convert existing pavements to permeable or cool pavements during significant renovations or repair projects; require new pavements to be cool or permeable, particularly in places such as parkin​​g lots. The California Emissions Estimator Model (CalEEMod) can help quantify the health, climate, and economic benefits of such project strategies, as well as advancing environmental approvals.

Urban forestry: Develop an urban forestry management plan; do t​​ree planning and maintenance. See California Releaf’s resources for guidance.

Planning: Integrate heat as a key consideration in planning processes, utilizing the Plan Integration for Resilience Scorecard for Heat (PIRS for Heat) to spatially evaluate networks of plans to reduc​e vulnerability to heat.

 Assess walkable or cyclable access to ADA-compliant and accessible green space, water sources (splash pad, pool, natural water source, potable water fountain), or shaded walk and cycle paths. Secur​​​e funds to implement community-led projects to increase green space and water sources accessible by walking, cycling, and rolling.

Conduct community-engaged assessment of land use policies and zoning and identify additional opportunities to change policies to promote nature-based solutions and heat-resilient community pla​​nning and development.

Consider planning for and developing long-term funding streams f​​or urban cooling investments such as stormwater fee, water bill or business improvement district (BID) fee.


Heat season: built and natural environment

Pre heat season D​uring heat season Post heat season
  1. ​Confirm partners or sites for temporary or pilot outdoor cooling projects. Secure and distribute resources as needed​​.

  1. ​Implement temporary or pilot outdoor cooling projects (e.g., tents, canopies, umbrella shades, mist​​ing machines, dr​inking water, fans, etc.) in prioritized communities (identified in Ste​p 1).
  1. Review utiliza​tion of pilot projects; collect community feedback o​​n utility or opportunities for improve implemented measures.


Heat event: built and natural environment

Immediately pre heat event During h​eat event Post heat event
  1. Based on threshold for activation (see Step 2​), post messaging about heat event, health-related risks, and war​ning signs at park and trail entrances, and ​other public outdoor spaces. ​
  2. Implement temporary or pilot outdoor cooling projects (e.g., tents, canopies, umbrella shades, misting machines, drinking water, fans, etc.) in prioritized communities (identified in St​ep 1). ​

  1. ​​Update heat messaging as needed.
  2. Monitor outdoor cooling projects.
  1. ​​​Rev​​iew utilization of pilot projects; collect community feedback on utility or opportunities for improve implemented measures. ​

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Category 8: Transit

Historic and current zoning, land use and transportation planning, and funding prioritization for transportation projects or services that support single-occupancy vehicles has made public transit unsafe, inaccessible, inconvenient, and unaffordable for many communities across California. Nonetheless, many people living in urban areas, people with low-income, older adults, people with disabilities, people who are unhoused, and more rely on public transit to access essential goods and services, such as food, jobs, health care providers, and school. Public transit is an essential service during extreme heat events that provides people with the opportunity to access cooling centers and other cool spaces; however, due to historic disinvestment in public transit, transit stops frequently lack shade structures, trees, or other cooling strategies. Ensuring transportation options are affordable, convenient, accessible, and safe for priority populations can bolster community resilience in the face of extreme heat events.

Long-term planning and policy: transit

Long-term planning and policy actions​
Conduct a needs assessment and plan to develop shade structures and/or nature-based solutions at transit stops and along walking and cycling facilities providing access to transit stops, foc​​using on transit stops serving neighborhoods with priority populations; secure funding and construct shade structures and/or nature-based solutions at transit stops and walking and cycling facilities.
Assess or review transit improvement plans with priority populations and community members to allow for community to prioritize essential investments or improvements in infrastructure, routes, or frequency to improve access to essential resources and services year-round.
Assess air conditioning of buses and other public transit vehicles, buildings or infrastructure.
Secure funding to implement community-prioritized improvements to transit stops, services, and transit-related walking and cycling facilities.
Secure funding to expand services or implement pilot programs during heat season (e.g., free rides to cool public spaces, temporary shade structures, misting machines, access to free drinking water, or other cooling strategies at key transit stops, etc.).
Explore with local transit providers the feasibility of providing free transit during declared heat warnings as a respite from the heat.


Heat season: transit

Pre heat season​ During heat season Post heat season
  1. Reconvene and confirm new and existing partnership and collaborators. Dist​ribute resources and information as neede​d.

  1. Incorporate ​​heat-related messaging in transit advertisements (at stations, on vehicles, etc.).

  1. Gather community feedback and assess utilizati​​on of expanded services or pilot projects. Identify opportunities for improvement or expansion based on community feedback.​​


Heat event: transit

Immediately pre heat event​ During heat event
  1. Distribute resources to set up pop-up cooling measures at transit stops and other locations.​​​​​
  2. Initiate communications and engagement strategies informing community of expanded se​​rvices and pop-up locations.
  1. Provide free rides on air-conditioned public transit, including to and from cooling centers a​​nd other cool spaces, prioritizing services for and in communities with majority priority populations.
  2. Implement pop-up cooling measures at transit stops (e.g., free drinking water, temporary s​​hade structures, misting machines, etc.).​

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​Category 9: Assisted Living and Skilled Nursing Facilities​​

Residents of assisted living and skilled nursing facilities may include community members with greater sensitivity to temperature changes, such as older adults, people on medications or using substances, people with pre-existing conditions, and people with disabilities or access and functional needs. While these facilities are largely monitored and regulated by the State and Federal government, given the high concentration of community members with greater sensitivity to temperature changes, it is imperative that residents and facility staff are engaged and integrated in local extreme heat planning efforts as well.

Long-term planning and policy: assisted living and skilled nursing facilities

Long-term planning and policy actions​

Establish partnerships with regional or district offices of the CDSS Community Care Licensing and CDPH Licensing & Certification Programs to track or monitor facilities’ compli​​​ance with temperature regulation requirements.

Engage assisted living and skilled nursing facilities and residents in localized planning for increasing access to shade, green space, and other cooling measures in public sp​​aces directly surrounding or in close proximity to facilities.

Assess or support assiste​​​d living and skilled nursing facilities in updating or reviewing disaster plans to incorporate extreme heat considerations.

Coordinate alongside ​​the long-term care Ombudsman through the California Department of Ag​​ing to set up system of reporting and addressing heat-related complaints associated with older adults in long-term care facilities.

Include proposals to supp​ly long-term care facilities with energy-efficient cooling (such as heat pumps) in applications for federal funding such as disaster mitigation, Inflation Reduction Act, or the Infrastructure Investment and Jobs Act.


Heat season: assisted living and skilled nursing facilities

Pre heat season​ During heat season
  1. Work with regional or district offices of the CDSS Community Care Licensing and CDPH Licensing & Certification Programs to remind facilities of their legal obligation to m​​aintain facilities at safe temperatures, and promote or encourage local f​acilities to train/re-train staff on heat-related health impacts, warning signs, prevention measures, temperature requirements and related complaint submittal process. ​
  2. ​​​Support or work with existing community-based organizations or community advocates to train residents and residents’ families and friends on how to submit complaints of non-compliance with temperature requirements.

  1. ​Support monitoring facility conditions and staff knowledge.
  2. Continue supporting advocates for facility residents.​​


Heat event: assisted living and skilled nursing facilities

Immediately pre heat event​ During heat event
  1. Issue heat advisory and ensure facilities are prepared to implement heat management and response strate​​​​gies.

  1. Facility staff should monitor indoor temperature, look for warning signs of heat-illness, and ​provide additional cooling strategies as needed (e.g., water, ice, cooling towels, loose clothing, etc.).​

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Category 10:  Local Detention Facilities​

People who are incarcerated in local and tribal detention facilities are at disproportionate risk of heat-related health impacts due to greater exposure to extreme temperatures and, importantly, the inability to personally control exposure and take adaptive measures, such as drinking water and taking cool showers.7,8 People who are incarcerated also have higher rates of pre-existing conditions and may be taking medications that increase their sensitivity to heat. Consequently, it is essential that heat planning efforts incorporate considerations, strategies, and engagement of people who are currently incarcerated to reduce the risk of harm from heat-related health impacts for this population. In the long term, the primary means to prevent heat illness for people who are incarcerated is reducing the number of people incarcerated or involved in the justice system altogether, through policy and system changes.9,10

Long-term planning and policy: local detention facilities​

Long-term planning and policy actions​

Review or assess the number of local and tribal detention facilities that have and utilize air conditioning throughout, as well as the number of facilities that have emergency prepare​​dness and evacuation plans and the quality of those plans.

Establish and enforce ma​​ximum indoor temperature thresholds for all local detention facilities (in the local jurisdiction control) in common spaces as well as each individual housing unit or holding facility.

Coordinate response to hea​​t and support to tribal detention centers an​​d jails when possible.

Assure that incarcerated people and their families are provided information about heat illness, how to recognize signs, what actions to take in the heat, and how to seek re​​dress if conditions are unsafe.


Heat season: local detention facilities

Pre heat season During heat season Post heat season
  1. Conduct a rapid assessment of facilities that do not have sufficient air conditioning or cooling​ measures.
  2. Secure funding and ensure all people who are incarcerated have adequate access to clean drinking water and other cooling measures (e.g.,  fans, ice packs, cool cloths, cold showers, misting machines, cold showers​​, br​eathable clothing, etc.).
  3. Provide trainings to staf​f and residents on warning signs of heat illness and other heat-related health impacts, and steps to take if heat-related illness is suspected.
  4. Ensure adequate medical staff capacity to support response to increased demand for emergency response an​​d medical care as needed.

  1. Monitor temperature indoors and outdoors at faciliti​​es; adjust outdoor recreation or work hours based on thresholds established in Step 2​.
  2. Monitor acccess to drinking water and cooling measures.
  3. Reinforce knowledge for staff and residents.
  4. Monitor medical staffing needs.

  1. ​​Assess rates of heat-related illness or related health outcomes at facilities; disaggregate based on population demographics, as well as facility structure (e.​g., with​​ or without functioning HVAC).


Heat event: local detention facilities

Immediately pre heat event​​ During heat event
  1. Provide rapid refresher training on heat-related health warning signs; distribute intermediary solutions to ​​staff and residents.
  2. Issue heat advisory and​​ activate heat man​​agement and response plans.
  1. Adjust o​utdoor recreation hours based on thresholds established in Step 2.​​​
  2. Deploy additio​​nal medical staff and distribute intermediary cooling solutions (e.g., fans, ice packs, cool cloths, cold showers, misting machines, cold showers, breathable clothing, etc.).

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Category 11: Shelters and Encampments

People who are currently unhoused face a disproportionate risk of experiencing heat-related health impacts due to their prolonged exposure to heat, frequently with little respite or reprieve during a heat event. People who are currently unhoused may also be older or have a pre-existing health condition or disability, further increasing their sensitivity and risk of experiencing heat-related health impacts. However, there are existing solutions that local government, advocates, and service providers can implement in collaboration to increase protections for people who are currently unhoused during a heat event, as well as long-term planning solutions that can address current housing inequities to reduce and eliminate disparate impacts experienced by people who are unhoused.

Long-term planning and policy: shelters and encampments

Long-term planning and policy actions​

Work with people currently unhoused and related community-based organizations to develop plans and seek funding to increase shelter capacity or other emergency h​​ousing, rapid re-housing strategies, and protections during extreme heat events.

Work with people currently unhoused and related community-based organizations to develop comprehensive plans and secure resources to provide mor​​e stable, affordable, safe, permanent (and s​​upportive for those who need it) housing as well as intermediary solutions, such as safe, stable, and resourced encampment sites.

Develop and ​adopt an ordinance to cease any activity that results in encampment relocation or dismantling extreme heat events.


Heat season: shelters and encampments

Pre heat season​ During heat season
  1. Establish or reconvene partners working with people currently unhoused. Distribute or se​​cure resources an​d information as needed to support collaborative extreme heat response efforts.
  2. Train municipal staff on ​​ordinance (if adopted) to​ halt all activity that results in encampment relocation or dismantling during extreme heat.
  3. Establish partnership, m​​echanisms for activation, and resources needed to increase shelter capacity, additional temporary housing strategies or rapid re-housing support during heat event activation. 
  4. Work with people who are unhoused and related CBOs to identify key routes to provide free transit/transportation services as a respite from heat, and to public cooling centers or other publicly accessible cool spaces.

  1. Procure resources (e.g., water, shade structures, misting machines, sanitation services, showers, etc.) to be distributed at established encampments, shelt​ers, rapid re-housing locations, etc.
  2. Reinforce staff training.
  3. Monitor shelter capacity and other housing strategies.
  4. Support ongoing transportation and access to cooling centers.


Heat event: shelters and encampments

Immediately pre heat event​ During heat event
  1. ​​Activate emergency temporary housing strate​​gies (e.g., i​ncreased shelter capacity, Project Roomkey, rapid re-housing). ​

  1. ​Support ongoing temporary housing efforts.
  2. Provide water​​, misting machines, shade structures, and other cooling strategies to established encampments.
  3. Provide free tran​​sit/transportation as a respite from heat, and to and from public cooling centers or other publicly accessible cool spaces.

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Category 12: Ensuring Continuous Power and Affordable Energy​

During heat waves, the California Independent System Operator (CAISO), can call for rotating outages statewide to protect the stability of the state’s electric grid, as increased demand from active cooling mechanisms such as HVAC systems strain capacity. Additionally, during heat and wildfire season, utilities may turn off power to specific areas when fire hazard levels are high, typically during periods that are dry with high wind and high temperatures. Rotating outages and public safety power shutoffs can occur during the heat season or an extreme heat event, with rotating outages lasting 1–2 hours while public safety power shutoffs average 1–2 days in length. Both pose a serious risk to health and well-being of impacted communities, particularly those who utilize electric or battery dependent assistive technologies or medical devices, older adults, and others with greater sensitivity to changes in temperature or limited access to resources to support their adaptive capacity.

Long-term planning and policy: ensuring continuous power and affordable energy

Long-term planning and policy actions

Work with local energy utilities to establish agreement to postpone or disallow residential water and energy shutoffs due to nonpayment during heat season. Connect househ​olds at risk of energy shutoff due to nonpayment with CSD’s Low Income Home Energy Assistance Program and CPUC’s Energy Savings Assistance Program.​​​​

Analyze or determine which communities are at greater risk of experiencing public safety power shutoffs (e.g., in high fire risk area). The PSE Healthy Energy Californ​​ia Public Safety Power Shutoff Interactive Map shows frequency and duration of past PSPS events, and population characteristics of communities experiencing them.

Work with utilities and communities to identify strategies to reduce or eliminate the need for PSPS events (e.g., establish community microgrid, etc.).​​

Identify opportunities to establish or expand ordinances, building codes, incentives, or grant programs to implement energy efficiency, weatherization, dec​arbonization and/or passive cooling strategies in all public and private owned commercial and residential buildings.


Heat season: ensuring continuous power and affordable energy

Pre heat season​ During heat season
  1. ​​Plan and activate utility representatives or home visitors to check on people who use electricity and battery dependent assistive technology and medical devices have sufficient back-up continuous power sources. As a resource, the federal HHS emPower platform​ provides datasets and resources to local jurisdictions to ​​​identify and protect the health of at-risk Medicare beneficiaries who rely on electricity-dependent durable medical and assistive equipment and devices. ​

  1. ​​Continue to support protection of at-risk people.


Heat event: ensuring continuous power and affordable energy

Immediately pre heat event D​uring heat event ​Post heat event
  1. Activate utility representatives or other home visitors to check on people who use electricity and battery dependent assistive technology and medical devices to assure bac​k-up power systems are fully operable. Provi​​de assistance to relocate individuals to spaces with a continuous, reliable power source (e.g., community cooling center).
  2. Work with your local health jurisdiction to develop and share information regardin​​g risk of refrigerated food spoilage during power outages, and how to reduce risk of related health impacts.

  1. ​Continue to support pr​otection and/or relocation of at-risk people.
  2. Reinforce messaging about food spoilage. 
  3. Work with local health jurisdictions, food banks, social services, Tribal, or emergency response organizations to emergency non-perishable food to households ​​impacted, in prioritized communities (identified in Step 1​).
  1. ​Work with local health jurisdictions, food banks, s​ocial services, emergenc​​​y response, Tribal, and low-income food assistance programs to ensure access to sufficient replacement of food lost during power outage or PSPS events.

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Category 13: Institutionalizing Extreme Heat Work​

Implementing and sustaining a comprehensive set of policy and preparedness interventions that reduce health risks from extreme heat requires creating a governmental agency infrastructure that supports efficient, effective heat work. A number of jurisdictions—such as the City of Los Angeles, Phoenix, and Miami-Dade County, have designated a “Heat Officer responsible for coordinating their jurisdictions communications, policy work, preparedness, and response to extreme heat.

Long-term planning and policy: institutionalizing extreme heat work

Long-term planning and policy a​ctions

Appoint a Heat Officer with the responsibility for coordinating your jurisdiction’s communications, policy work, preparedness, and response to extreme heat. The ​​Heat Officer should be at a sufficiently high level of government to allow them the authority to unify your jurisdiction’s work on extreme heat.

Create a local governm​ent interagency heat task force led by the Heat Officer, to implement and update the heat action plan and coordinate local response.

Develop and adopt gui​​delines for procurement of goods and services government agencies that promote cooling or minimize generation of heat.​

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Step 5: Finalize plan for implementation​

Once your jurisdiction, partner organizations, priority populations and community members have selected the heat actions to include in your jurisdiction’s heat plan, collaboration should continue as you work to clarify operational details and establish a clear path to move towards implementation of heat actions. Implementation details regarding roles and responsibilities, timelines, costs, funding, and prioritization of actions should be included within your heat plan, or as a publicly accessible supplementary document, to ensure transparency and accountability.

Define Roles & Responsibilities

Your jurisdiction and partner organizations should review the heat actions included in your heat plan and determine which entity will take the lead in implementing each action and which entities will provide support or will need to be engaged throughout implementation. The lead organization will take primary responsibility for coordinating further development of the action, as well as activation, implementation, and monitoring the heat action impacts. Lead organization roles may align with the mandated responsibilities and related jurisdiction of a specific department, agency, office, or organization. Additionally, you will need to consider which populations, neighborhoods, or communities will be most impacted by heat actions and include community-based organizations as well as other priority population representatives in lead or supporting roles for relevant heat actions to ensure implementation is community-driven. Establishing and integrating roles and responsibilities for partner organizations, departments or offices within your jurisdiction, and specific community groups within your heat plan will provide clarity, focus, and transparency for implementing entities as well as the community at large.

Timeline for Implementation

A timeline for implementation of heat actions should be developed and incorporated into your heat plan. Lead and supporting entities should work together to approximate the time they will need to conduct additional planning, analysis and community engagement; secure funds; and operationalize each heat action across your jurisdiction or within specific priority communities (based on populations identified in Step 1). Implementation timelines should be developed for near- and long-term heat actions to ensure immediate relief is provided to community members who need it most, while also committing to implementation of actions that provide policy, systemic, or environmental changes which can relieve heat-related health disparities and inequities overall. Integrating a timeline for implementation within your heat plan will allow for greater transparency, accountability, and collective understanding of the time it will take to achieve near- and long-term goals. Include timelines to share updates on progress, challenges, and roadblocks, as well as create opportunities for community members to provide feedback on progress made or changes and improvements that are needed.

Cost Estimates & Funding Sources

Finally, estimated cost and potential funding sources should be calculated, identified, and listed for each heat action within your heat plan. Costs such as new staff, resources, training, equipment, and fees should be factored in, as well as the scale of implementation (e.g., pilot project vs. county-wide implementation). Proposed or potential funding sources should be listed as well; consider collaborating with partner organizations and community members to identify potential funding constraints as well as innovative solutions. Incorporating associated costs and opportunities for funding within your heat plan will allow for transparency on the scope and scale of each heat action, as well as around current financial constraints and barriers. It will also allow community to track progress in applying for or securing funding and identify or share additional opportunities for potential funding. Additionally, it may allow community members and organizations to garner community support and overcome existing financial constraints by advocating for organizations or agencies to allocate funds for implementation of community-driven heat actions. Funding and financing ideas and resources can be found on the Arsht-Rockefeller Foundation Resilience Center’s Heat Action Platform. Additional funding resources can be found in Appendix 1 (PDF). ​​

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Step 6: Evaluate plan

A critical component of any plan is continual monitoring and evaluation to ensure planned actions achieve their intended impact and have not resulted in unintended consequences. In order to successfully track the progress and impact of your heat action plan, monitoring and evaluation activities should be integrated within your plan and aligned with heat action steps, so your jurisdiction and implementation partners have the tools, resources, and capacity to collect data and feedback before, during, and/or immediately following implementation of a heat action strategy. Recommended monitoring and evaluation strategies have been incorporated throughout each category in the guide to demonstrate key points when data, feedback, or other information can be collected and analyzed to evaluate the results and impact of your heat action plan. If feasible, set aside a portion of the budget for evaluation.

On a regular basis, your jurisdiction, implementation partners, and community members should review heat plan activities and related outputs (e.g., the number of people served) and outcomes (e.g., changes in heat-related health outcomes or community perceptions and experiences) to determine what worked, what didn’t, what lessons were learned, and what changes are needed to improve the utility and impact of your heat actions. This process should be community-driven and fully integrate the voice, perspective, and experiences of priority populations within the community to ensure that heat actions are benefiting these populations and advancing health equity as intended. Upon completing an evaluation, priority populations within the community should also be informed of evaluation results to ensure that your jurisdiction’s interpretation of community input and feedback is accurate and representative of community members’ lived experience, as well as to maintain transparency and knowledge sharing. Finally, community should also be engaged in the process of revising heat actions to ensure that the updated actions meet the needs of the community members most impacted. Iterative, community-engaged monitoring and evaluation will enable your jurisdiction, implementation partners, and community members to track, assess, course correct as needed, and eventually demonstrate the progress that has been made towards equitable heat resilience, response, preparedness, and recovery as a result of heat action plan implementation.

Further guidance and resources can be found within the Center for Disease Control and Prevention’s (CDC) Enhanced Evaluation Framework. Additionally, your local health jurisdiction, academic institution, or other public health entities within your community or region may be able to provide guidance and support on monitoring and evaluation best practices and/or assist in establishing a clear monitoring and evaluation plan for your heat action plan.

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References​ 

  1. Romanello M, McGushin A, Napoli CD, et al. The 2021 report of the Lancet Countdown on health and climate change: code red for a healthy future. The Lancet. 2021;398(10311). (doi.org/10.1016/S0140-6736(21)01787-6)

  2. U.S. Global Change Research Program. Fourth National Climate Assessment. 2017;2(4):1-470. (nca2018.globalchange.gov/  

  3. Whitehead M. The concepts and principles of equity and health. International journal of health services : planning, administration, evaluation. 1992;22(3):429-445. (doi.org/10.2190/986L-LHQ6-2VTE-YRRN) 

  4. California Department of Public Health - Office of Health Equity. Portrait of Promise: The California Statewide Plan to Promote Health and Mental Health Equity (PDF). A Report to the Legislature and the People of California by the Office of Health Equity. 2015. (www.cdph.ca.gov/Programs/OHE/CDPH%20Document%20Library/Accessible-CDPH_OHE_Disparity_Report_Race_Equity.pdf)

  5. Romanello M, Napoli CD, Drummond P, et al. The 2022 report of the Lancet Countdown on health and climate change: health at the mercy of fossil fuels. The Lancet. 2022;400(10363):1619-1654. (doi.org/10.1016/S0140-6736(22)01540-9)

  6. Widerynski S, Schramm P, Conlon K, et al. The Use of Cooling Centers to Prevent Heat-Related Illness: Summary of Evidence and Strategies for Implementation Climate and Health Technical Report Series Climate and Health Program (PDF), Centers for Disease Control and Prevention. N.d. (www.cdc.gov/climateandhealth/docs/UseOfCoolingCenters.pdf)

  7. Lee J, Blaeser J, and Small C. Extreme heat will take an unequal toll on tribal jails. Grist. (grist.org/indigenous/tribal-jail-climate-change-extreme-heat/). Published May 10, 2023.

  8. Skarha J, Peterson M, Rich JD, Dosa D. An Overlooked Crisis: Extreme Temperature Exposures in Incarceration Settings. American Journal of Public Health. 2020;110(S1):S41-S42. (doi.org/10.2105/ajph.2019.305453)

  9. American Public Health Association. Advancing Public Health Interventions to Address the Harms of the Carceral System​. www.apha.org. 2021;202117. (www.apha.org/Policies-and-Advocacy/Public-Health-Policy-Statements/Policy-Database/2022/01/07/Advancing-Public-Health-Interventions-to-Address-the-Harms-of-the-Carceral-System)

  10. Holt DWE. Heat in US Prisons and Jails: Corrections and the Challenge of Climate Change. SSRN Electronic Journal. Published online 2015. (doi.org/10.2139/ssrn.2667260)

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