Emergency Preparedness and Community Coalitions: Opportunities and Challenges

Emergency Preparedness and Community Coalitions: Opportunities and Challenges

HSC Research Brief No. 24
November 2012
Emily Carrier, Tracy Yee, Dori A. Cross, Divya R. Samuel

Readying local health systems for natural disasters, disease outbreaks, or other large-scale emergencies that produce surges of sick or injured people -- all while sustaining routine operations -- presents an enormous challenge. Effective emergency preparedness demands coordination among diverse entities at the community, regional, and national levels. Given the range of stakeholders involved, the fragmented nature of local health care delivery, and constrained resources, forming and maintaining broad community coalitions devoted to emergency preparedness is inherently difficult. While certain participants, such as hospitals and local emergency medical services, regularly collaborate, other crucial groups -- including primary care physicians and long-term care facilities -- generally remain outside these preparedness coalitions, according to a qualitative investigation of 10 U.S. communities conducted by the Center for Studying Health System Change (HSC).

Obstacles to building and sustaining community coalitions include the competing priorities of different organizations, limited funding for preparedness relative to direct health care delivery, turnover among coalition leadership, and the difficulty of maintaining engagement in between actual emergencies. The study also found that the 2009 H1N1 influenza pandemic provided a real-world test that in some communities strengthened coalition relationships and revealed weaknesses in others. Although the federal Hospital Preparedness Program (HPP) has been a catalyst for coalition formation, participants expressed concern that recent and potential future funding reductions could weaken collaborative efforts.

Preparing for Disasters

Following the September 11, 2001, terrorist attacks, the federal government established the Hospital Preparedness Program (HPP) within the Health Resources and Services Administration, later transferring it to the HHS Office of the Assistant Secretary for Preparedness and Response (ASPR). HPP provides cooperative agreement funding to states and eligible municipalities to improve the ability of health care systems to prepare for and respond to public health emergencies. Over the past decade, the program has distributed billions of dollars to hospitals and other health care providers to build surge capacity, stockpile medical supplies, and improve communication systems.

The degree to which health care providers participate in community-level emergency preparedness beyond minimum regulatory requirements -- such as those mandated by the Joint Commission and the Centers for Medicare and Medicaid Services (CMS) -- varies widely. A few organizations have invested extensively in developing emergency management capabilities, but many community providers have more limited involvement.

Both providers and policy makers have increasingly recognized that no single hospital or health care organization can manage a major public health emergency independently. This recognition has spurred interest in healthcare coalitions -- voluntary collaborations among hospitals, health departments, emergency management agencies, and other community organizations that work together to prepare for and respond to emergencies.

Community-based emergency-preparedness coalitions in the 10 study communities typically included hospitals, public health departments, emergency medical services (EMS), and emergency management agencies. Coalition structures ranged from informal networking arrangements to more formally organized entities with governance structures, regular meeting schedules, and dedicated staff. In several communities, the local hospital association served as the coalition's organizational hub.

Through the lens of the 2009 H1N1 influenza pandemic, the study explores how coalitions developed, their strengths and limitations, and the policy factors that shape their effectiveness.

The H1N1 Experience

The initial U.S. case of H1N1 influenza was confirmed in April 2009, and within months the virus spread across the country. The subsequent vaccination campaign -- the largest since the 1976 swine flu effort -- required coordination among hospitals, public health agencies, physician practices, pharmacies, schools, and other community organizations. The H1N1 pandemic tested many communities' preparedness coalitions in ways that tabletop exercises and drills cannot fully replicate.

Throughout this period, the Centers for Disease Control and Prevention (CDC) issued guidance on prioritizing vaccine distribution, antiviral use, infection control, and community mitigation strategies. State and local public health departments served as the primary conduit for CDC recommendations and bore the responsibility for distributing vaccine to providers.

Challenges to Preparedness

Organizations engaged in community-level health care preparedness encountered numerous challenges in building and sustaining broad, inclusive coalitions. Even well-established coalitions with strong hospital and public health participation struggled to engage certain types of providers and community organizations.

Multiple federal, state, and local organizations play roles in health care emergency preparedness, sometimes leading to fragmented or overlapping efforts. The two primary federal preparedness programs -- HHS's Hospital Preparedness Program and the CDC's Public Health Emergency Preparedness (PHEP) cooperative agreement -- fund different aspects of community preparedness and channel resources through different state and local agencies. In communities where these funding streams supported separate coalitions or planning activities, respondents described duplication of effort and occasional tension between hospital-focused and public health-focused preparedness initiatives.

In contrast, considerably less attention has been paid to engaging long-term care facilities, community physicians, and other outpatient providers in preparedness coalitions. These providers play essential roles during large-scale public health events -- for example, physician offices typically administer the majority of routine vaccinations and would be expected to vaccinate priority populations during a pandemic. Yet, most coalitions had only minimal contact with independent physician practices, and nursing homes or other post-acute care facilities were rarely at the table.

Although hospitals and public health departments have generally developed strong working relationships, often forged through years of collaboration on preparedness and augmented by HPP and PHEP funding, engaging other organizations has proven more difficult. Coalition leaders cited several reasons for this difficulty, including the sheer number and diversity of potential participants, resource constraints that limited outreach, and the challenge of demonstrating the tangible benefits of participation to providers who view preparedness as a secondary concern.

Insufficient collaboration among stakeholders during the H1N1 pandemic highlighted the consequences of narrow coalition membership. In several communities, confusion arose over which providers would administer vaccine, in what order priority groups would be served, and how vaccine distribution logistics would work. Some physician practices reported learning about vaccine availability through the media rather than through official channels, undermining trust in the preparedness process.

When engaging nontraditional partners, coalitions often encountered the challenge that health care organizations' primary focus is on clinical care delivery, not emergency management. As one hospital preparedness coordinator noted, "Emergency preparedness competes with everything else that the hospital has to do on a daily basis." Smaller organizations, such as independent physician practices and home health agencies, typically lack dedicated staff for emergency planning and have little capacity to devote to coalition activities.

However, stakeholders such as schools and businesses may bring fresh perspectives and unexpected resources to emergency preparedness. In one community, school officials became effective partners in the H1N1 vaccination campaign, opening their facilities as mass vaccination sites and helping communicate health information to families.

Independent Physician Practices on the Fringe

Hospital-employed physicians reported effective integration into their institutions' preparedness plans, including participation in drills and clear expectations during emergencies. In contrast, independent physicians had little involvement in or awareness of community coalitions. Most community-based physicians reported that their emergency preparedness planning was limited to their own offices and did not extend to broader community coordination.

Small, independent physician practices were particularly difficult to engage in community preparedness efforts. These practices often had limited administrative resources and found it impractical to participate in coalition meetings, exercises, or planning sessions. Their involvement in the H1N1 response was generally limited to administering vaccines to patients who came to their offices for routine care. Although a few physician respondents expressed interest in more formal preparedness roles, most indicated they lacked the time and capacity to participate in coalitions.

Both hospital and community practice respondents generally felt that primary care physicians should have a defined role in emergency preparedness but disagreed on the specifics. Some hospital-based respondents felt that primary care physicians should be integrated into hospital response plans, while independent physicians were concerned about maintaining autonomy and flexibility in a crisis.

Most primary care respondents concurred that during the H1N1 pandemic, vaccine distribution to their practices was delayed and communication from public health authorities was inconsistent. In at least one community, the public health department prioritized vaccine distribution to schools and public clinics over private physician offices, frustrating physicians who viewed themselves as the appropriate vaccination providers for their patients.

Market Influences on Coalitions

Respondents observed that certain features of local health care markets influenced both the formation and function of preparedness coalitions. In several communities, competitive tensions among hospitals complicated collaborative preparedness efforts, as organizations were reluctant to share detailed information about their capacities, vulnerabilities, or operations with competitors.

A handful of respondents acknowledged that market competition sometimes inhibited preparedness discussions. For example, one hospital might be reluctant to share its surge capacity with a competitor for fear of revealing strategic information. Several coalition leaders mentioned that building trust was a critical but time-consuming prerequisite for effective collaboration, especially in markets with intense hospital competition.

During the H1N1 pandemic, some coalitions encountered tensions over vaccine distribution, with hospitals and physician practices jockeying for priority access to limited supplies. These competitive dynamics reinforced the importance of having clear, pre-negotiated protocols for resource allocation during emergencies.

Ultimately, nearly all respondents agreed that preparedness coalitions produced tangible benefits -- including improved communication, shared training opportunities, and coordinated response plans -- that outweighed competitive concerns. The challenge was sustaining engagement over time, especially as the urgency of a particular threat faded.

Nearly all hospitals working with both emergency-management and hospital-based coalitions found value in both, despite the potential for overlap. Hospital-focused coalitions offered a peer-to-peer environment in which clinical and logistical issues could be discussed openly, while broader emergency-management coalitions connected hospitals to fire, police, and public health partners.

Given the generally collegial nature of the hospital-to-hospital relationships fostered through years of preparedness work, some respondents questioned whether hospitals' competitive behavior during a crisis would actually undermine the collaborative response. Most believed that in a true disaster, the imperative to care for patients would override competitive considerations.

Rural Communities: Unique Challenges and Strengths

While all providers felt the strain of constrained preparedness resources, rural communities confronted particular difficulties. Rural areas typically had fewer hospitals, fewer physicians, and more limited public health infrastructure than urban or suburban communities. At the same time, geographic distances complicated communication and coordination, and rural hospitals often lacked the staffing to dedicate personnel to preparedness planning.

Some rural providers showed creativity in addressing these challenges. In one community, the critical access hospital served as the de facto hub for the entire community's emergency preparedness, coordinating among the local EMS squad, volunteer fire department, and county health department. The smaller scale of rural communities sometimes facilitated closer working relationships among providers, even if the formal coalition infrastructure was less developed.

Respondents did note that local partnerships in rural communities tended to rely heavily on personal relationships rather than institutional structures, making them vulnerable to disruption when key individuals moved on.

Policy Implications

Recent studies, including an Institute of Medicine report and a Government Accountability Office review, have highlighted the importance of community-based coalitions for health care emergency preparedness. ASPR's 2012 HPP funding guidance explicitly requires states and municipalities to use HPP funds to establish and strengthen health care coalitions. The agency defines a health care coalition as a collaboration of health care and response organizations that serves as a multi-agency coordinating group for health care preparedness and response activities.

Across sites, respondents consistently raised concerns about the sustainability of federal funding for community preparedness. HPP funding has declined from its peak and faces the prospect of additional reductions. Respondents noted that even current funding levels were insufficient to support the full range of preparedness activities needed, and that further cuts could undermine hard-won coalition structures and relationships. Several respondents argued that sustained, predictable funding is essential because building trust and operational capacity among diverse organizations requires years of effort that would be lost if funding disappeared.

Policy makers could consider two general strategies for engaging broader participation in health care preparedness coalitions: creating incentives for participation, or embedding preparedness into activities that providers already perform.

Creating incentives to participate in training and exercises is one approach, but such incentives would need to be substantial enough to offset the opportunity cost for practices that lose revenue when clinicians are away from patients. Some respondents suggested that CMS could incorporate emergency preparedness requirements into hospital and physician quality programs, thereby creating a financial incentive for broader participation.

Some community-based physicians and clinic leaders questioned whether the current coalition model -- built around meetings, drills, and exercises -- was the most effective way to engage small practices. Alternative approaches might include web-based training modules, streamlined communication systems that operate through existing platforms such as electronic health records, or simply building preparedness contacts into physician practice management.

For small primary care practices in fragmented markets, health information exchanges (HIEs) or electronic health record systems could potentially serve as communication platforms during emergencies, enabling public health departments to share timely information with physicians and receive surveillance data in return.

Consider embedding preparedness into activities that organizations already conduct. For example, CMS conditions of participation already require hospitals to develop emergency preparedness plans. Strengthening these requirements to include demonstrated community coalition participation could encourage engagement without requiring additional dedicated funding for coalition activities.

One option would be integrating preparedness planning into community benefit requirements for tax-exempt hospitals. As these hospitals conduct community health needs assessments, they could incorporate an assessment of emergency preparedness infrastructure and identify gaps in coalition participation.

Additional opportunities might include incorporating emergency preparedness into graduate medical education and continuing medical education requirements, thus building awareness and competence among physicians early in their careers and maintaining it over time.

If collaborative preparedness efforts lead to stronger provider networks that improve everyday care coordination -- not just emergency response -- the value proposition for participating organizations improves significantly. Some coalition leaders observed that the communication channels and relationships built through preparedness work had already begun to facilitate everyday clinical coordination among providers.

For example, nursing homes owned by or contracting with hospital systems may already be integrated into the system's preparedness plans. But independent nursing homes and assisted living facilities remain largely disconnected from community coalitions. Given the vulnerability of long-term care populations during emergencies -- including challenges with evacuation, medication supply, and continuity of care -- incorporating these facilities into coalitions is a pressing priority.

Given the diverse characteristics of health care markets -- including the degree of provider competition, the extent of hospital consolidation, and the level of public health infrastructure -- no single coalition model will be suitable for all communities. Rather, effective policy should support flexible approaches that allow communities to build on their existing strengths while addressing specific gaps in preparedness capacity.

At this point, it is difficult to determine the optimal level of federal investment in health care preparedness coalitions, partly because the return on that investment is inherently hard to quantify. However, the alternative -- underinvesting in community preparedness and discovering critical weaknesses during an actual disaster -- carries risks that extend well beyond the health care system.

Data Source and Funding Acknowledgement

This investigation examined emergency-preparedness coalition activities in 10 communities. Eight were drawn from HSC's Community Tracking Study sites: Boston; Cleveland; Greenville, S.C.; Indianapolis; Lansing, Mich.; Little Rock, Ark.; Miami; and Orange County, Calif. Two additional communities were selected for their rural characteristics: Appalachian Ohio and rural South Carolina. In total, 65 semi-structured interviews were conducted between March 2010 and February 2011 with hospital emergency preparedness coordinators, public health officials, EMS directors, community physicians, nursing home administrators, and other stakeholders.

This research was funded by the Centers for Disease Control and Prevention (CDC). This document was supported by Cooperative Agreement Number 5U38HM000528 from the CDC. Its contents are solely the responsibility of the authors and do not represent the official views of the CDC.

Sources and Further Reading

CDC: Public Health Emergency Preparedness (PHEP) Cooperative Agreement — Federal funding and guidance for state and local public health emergency preparedness capabilities, which support the coalitions examined in this research.

HHS ASPR: Healthcare Coalition Overview — The Office of the Assistant Secretary for Preparedness and Response outlines the role of healthcare coalitions in coordinating emergency response among hospitals, public health agencies, and emergency management.

ASPR TRACIE: Healthcare Coalition Resources — Technical resources and implementation guides for healthcare coalition development, addressing many of the coordination challenges discussed in this study.

CMS: Emergency Preparedness Requirements for Medicare and Medicaid Providers — Federal emergency preparedness conditions of participation that Medicare-certified hospitals and healthcare facilities must meet.

Robert Wood Johnson Foundation: Health System Preparedness Research — RWJF-funded research on community health system resilience and emergency preparedness infrastructure relevant to coalition development.