Healthy, Resilient, and Sustainable Communities After Disasters: Strategies, Opportunities, and Planning for Recovery (2015)

6

Health Care

Recovery planning and post-event recovery activities for the health care sector—which includes prehospital resources, hospital-based care, and out-of-hospital care delivery systems—are ideally focused on a continuum of community needs, ranging from short-term early recovery needs to decisions about long-term healthy community goals. If developed properly, these latter goals can help communities not only recover from a disaster but also address chronic community health concerns such as access to health care services. In the early recovery period, health care recovery planning should be initiated with assessment of residual health care sector capacities and challenges and, for long-term planning, acknowledgment of current and planned changes in health care delivery and financing systems. For example, as of the writing of this report, planning for long-term community health needs might include consideration of possible expanded access to preventive services stemming from the Patient Protection and Affordable Care Act¹ (ACA). The committee urges local health systems to continue or initiate proactive recovery-focused planning to build health care sector resilience. This planning will facilitate actions that (1) stabilize, strengthen, and integrate existing resources; (2) identify resources that should be rebuilt or replaced; and (3) identify de novo preventive and health care delivery approaches that are sustainable and affordable and will lead to improved health and public health outcomes in the community.

To accelerate the recovery of the health care sector in the event of a disaster, the community must assess the health care services currently in place and develop an agreed-upon comprehensive community disaster response and recovery plan prior to a disaster. This planning process should leverage data derived from health information systems and solicit input and feedback from a variety of stakeholders and sectors invested in building and sustaining a strong and robust health care infrastructure within the community. During short- and intermediate-term recovery, the health care sector should identify both patient and system gaps that occurred during the response that could be improved upon should another disaster occur. During long-term recovery, identified patient and system gaps should be addressed and goals set for an improved healthy community.

Disasters often cause health systems to adjust the way health care services are delivered, moving care delivery out of hospitals and into the community and using team-based strategies to meet multifaceted needs of survivors (DeSalvo, 2013). In many ways, these adjustments better meet patient needs and are

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¹ Patient Protection and Affordable Care Act, 42 U.S.C. § 18001. Aug. 25, 2010.

consistent with contemporary policies such as those of the ACA. As a community addresses disaster-related impacts during recovery, it needs to think about opportunities to leverage disaster experiences, relationships, and recovery resources to shift to these new models of care.

This chapter presents the committee’s assessment of major health care sector resources and operational processes that are mobilized along the continuum from pre-disaster planning to post-disaster recovery, and its guidance for enhancing and supporting the optimal use of these assets to create healthier communities after disasters. The chapter addresses four key strategies that drive the success of recovery for the health care sector and ultimately the building of a healthier community:

• Use multidisciplinary team-based care strategies to meet multifaceted health care needs.
• Ensure continuity of access to health care services.
• Use health information technology to drive decision making for individual and community health, and to inform future planning.
• Leverage health care coalitions and other relationships with local care providers for health services strategic decision making and alignment of clinical resources.

The chapter concludes with a checklist of key activities that the health care sector needs to perform during each of the three phases of recovery: pre-event, short-term recovery, and intermediate- to long-term recovery.

HEALTH CARE IN THE CONTEXT OF A HEALTHY COMMUNITY

The degree of integration of health care services with each other and across the continuum of public health, behavioral health, and social services contributes significantly to overall community health and, relatedly, the community’s resilience to withstand the impacts of a disaster. This comprehensive and integrated vision of health has been incorporated into major influential initiatives that continuously assess the health of the nation, including America’s Health Rankings, the Commonwealth Fund’s Scorecard, and the Robert Wood Johnson Foundation’s County Health Rankings (County Health Rankings, 2014; Radley et al., 2014; United Health Foundation, 2013).

Unfortunately, given the importance of the health care system to realizing maximally healthy and resilient communities, it has long been known that America as a whole, and most of its communities in particular, experiences suboptimal quality in health care delivery (IOM, 2000, 2001, 2013a). As discussed in Chapter 1, the United States has the highest per capita health care costs but poorer health relative to its peer nations. In an effort to address this disparity, the Institute for Healthcare Improvement developed the Triple Aim—better experience of care at lower cost and improved population health—which serves as the foundation for organizations and communities to transition from a focus on health care to a focus on optimizing health for individuals and populations (IHI, 2007). Key strategies for the Triple Aim include

• “Innovative financing approaches;
• New models of primary care, such as patient-centered medical homes” to meet comprehensive needs of individuals (see Box 6-1 for characteristics of optimal coordinated care systems);
• “Sanctions for avoidable events, such as hospital readmissions or infections; and
• Integration of information technology”—advancing data and knowledge sharing (IHI, 2007).

As communities conduct planning to enhance the resiliency and sustainability of their health care infrastructure, prepare for rapid response to crises, and engage in the activities necessary to recover from a disaster, the logic of the Triple Aim and its underlying conceptual foundations outlined above provide a useful and aligned strategic model to focus the efforts of the multiple stakeholders with a voice in health care activities relevant to disaster planning. At the same time, the disaster management cycle, along the continuum from pre-disaster planning to immediate- and long-term recovery, provides currently under-

leveraged opportunities for the infusion of new resources that can facilitate the reorganization of health care infrastructures to support the broader goal of realizing maximally healthy communities.

In addition, as communities engage in the spectrum of health care activities related to disaster preparedness, response, and recovery, they should take advantage of prevailing shifts in the delivery and funding of medical care. Two relevant and related movements are occurring synergistically. First, the recommendations contained in the landmark Institute of Medicine (IOM) report Crossing the Quality Chasm: A New Health System for the 21st Century (IOM, 2001) introduced new concepts in “comprehensive patient-centered care” that continue to guide the care delivery system toward reorganization that meets the needs of patients more effectively through enhanced cooperation and continuity of healing relationships across clinical disciplines and settings of care. Advances in data and knowledge sharing via new health information technology and data infrastructures are essential to implementing this vision. Second, the concept of “population health”—proposed by Kindig and Stoddart (2003, p. 380) as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group”—that focuses on the patterns of health determinants and the policies and interventions that result in health outcomes has now migrated from the public health community to become an emphasis of the health care delivery system, driven by pressures for greater value being exerted by the purchasers of care. “Value,” generally defined as the relationship between outcomes of care and the cost of providing that care, entails a focus not only on the care of individual patients but also on the total population of patients treated by care delivery systems. The evolution of reimbursement away from a fee-for-service model toward models based on value provides financial fuel for a shift in focus favoring prevention (e.g., preventing hospital admissions and re-admissions). Of particular interest in the present context, this population-based approach for the health care system now begins to mirror the traditional population perspective typically associated with public health and provides a useful bridge for integrating health care delivery more effectively into the comprehensive effort of creating or rebuilding healthier communities. It also provides incentives for developing collaborative relationships among local care delivery organizations, which are key to building resilience.

Two related efforts provide guidance and opportunities relevant to the ongoing task of strengthening and integrating communities’ clinical care and prevention systems. First, the IOM produced a report in 2012 entitled Primary Care and Public Health: Exploring Integration to Improve Population Health (IOM,

2012b). That report observes that, although both of these fields “share a common goal, historically they have operated independently of each other. However, new opportunities are emerging that could bring the two sectors together in ways that will yield substantial and lasting improvements in the health of individuals, communities, and populations” (IOM, 2013c). The report describes the interactions between the two sectors as so varied that no single specific model or template for integration can be prescribed for all communities. However, it does identify the following set of principles reflecting the components essential to successful integration efforts, which the committee endorses as key to integrating health into broader disaster recovery efforts:

• having a shared goal of improving population health;
• involving the community in defining and addressing its needs;
• strong leadership that bridges programs, disciplines, and jurisdictions;
• sustainability; and
• the collaborative use of data and analysis (IOM, 2012b).

The second effort, convened by the Association of State and Territorial Health Officials (ASTHO)—the ASTHO-Supported Primary Care and Public Health Collaborative²—arose from the above IOM report and aims to “inform, align, and support the implementation of integrated efforts that improve population health and lower healthcare costs” (ASTHO, 2014). Given the need to maximally leverage existing resources, the committee urges ASTHO and its partners in this effort to include disaster planning and preparedness as an explicit activity.

DISASTER-RELATED HEALTH CARE CHALLENGES

Disasters are often accompanied by significant threats to the immediate- and long-term physical health of individuals living in affected communities and by disruptions of the health care delivery infrastructure. Health status can be affected by injury associated with the disaster; exposure to toxins and environmental contaminants; and exacerbation of preexisting risk factors and clinical conditions due to stress, lack of access to health care and social support resources, and disruption of continuity of care. Health care delivery infrastructure can be compromised by loss of facilities; migration of health professionals away from the impacted area; and disruption of critical supports such as information and data technology, medical supplies and pharmaceuticals, transportation, and medically necessary social services (a more detailed description of disaster impacts on health is presented in Box 1-1 in Chapter 1). The obvious paradox is that at a time when medical care is urgently needed, its capacity is often diminished. These effects are especially pronounced among already vulnerable populations and individuals who have little ability to withstand health insults or further erosion in previously overburdened care delivery systems. For medically vulnerable individuals, disaster-related disruption in primary care can create a secondary surge of increased demand for medical services during recovery due to a rise in chronic health issues exacerbated by the disaster (Runkle et al., 2012). In the long term, the disaster’s impact on the social vulnerability of the population can have a ripple effect that further strains the health care delivery system. Shifts in patient demographics featuring disaster-related increases in numbers of indigent patients can create significant burdens for weakened health systems (Colias, 2005). Such effects are felt not just by hospitals but also by the entire spectrum of care delivery providers (public, private, and nonprofit). A healthy community

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² More than 50 organizations participated within this collaborative including, but not limited to, “ASTHO, the National Association of County and City Health Officials, Trust for America’s Health, Association of Public Health Nurses, and Association of Schools and Programs of Public Health. Primary care is represented by lead medical societies including the American Medical Association, American Academy of Family Physicians, American Academy of Pediatrics, and American College of Preventive Medicine. Health insurer partners include the National Association of Medicaid Directors, America’s Health Insurance Plans, and Alliance of Community Health Plans. Federal partners include HRSA, CDC, CMS, CMMI, and AHRQ” (ASTHO, 2014).

approach to recovery focused on reducing post-disaster social vulnerabilities by addressing the social determinants of health may ameliorate these detrimental impacts.

HEALTH CARE SECTOR ORGANIZATION AND RESOURCES

A 2012 IOM report emphasizes that preparedness, crisis standards of care, response, and recovery require a systems approach to planning “to integrate all of the values and response capabilities necessary to achieve the best outcomes for the community as a whole” (IOM, 2012a, p. 3). The report states further that

A complex mosaic of federal, state, and local resources is available for health care–related pre-disaster planning and disaster response and recovery. The roles of stakeholders at each of these different levels, along with resources available to support them in their activities, are discussed briefly below.

Federal Level³

Under the structure of the National Disaster Recovery Framework (NDRF; described in more detail in Chapter 3), health care falls within the Health and Social Services Recovery Support Function (RSF) (see Box 6-2), which is coordinated by the Assistant Secretary for Preparedness and Response (ASPR) within

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³ A broader synopsis of legislation and federal policy related to disaster recovery and health security can be found in Appendix A.

the U.S. Department of Health and Human Services (HHS) on behalf of the HHS Secretary. The NDRF supports a “whole-community” approach to recovery planning and operations. Thus, the audience for its guidance is specifically intended to include a broad range of stakeholders, including the health care delivery system.

The primary source of federal funding to support health care system preparedness, including pre-event planning for health care system recovery, is the Hospital Preparedness Program (HPP), established in 2002 and administered by ASPR. The original goal of the HPP was to enhance the ability of hospitals to prepare for and respond to bioterrorism attacks on the United States, as well as other public health emergencies, such as influenza pandemics and natural disasters. Today, the HPP is a crucial element of community resilience and enhances the response and recovery capabilities of the nation’s health care system. Recognizing that a resilient health care system requires the engagement of all the system’s components, ASPR has shifted the focus of the program from hospitals to health care coalitions (health care coalitions are described in Box 6-3). This shift reflects the recognition that, as demonstrated by such events as Hurricanes Katrina and Sandy and the H1N1 influenza pandemic, hospitals cannot be successful in response and recovery without the support and cooperation of a variety of critical community partners (ASPR, 2012). State HPP grantees, who are responsible for disseminating HPP funds to health care coalitions, are expected to encourage representation from the full spectrum of health care services in the building and sustaining of these regional coalitions—a goal the committee suggests warrants continued emphasis by federal and state leadership.

Currently, all 50 states, as well as the District of Columbia, eight U.S. territories and freely associated states, and the nation’s three largest municipalities (Chicago, Los Angeles, and New York City), receive HPP funding. A core element of the contemporary version of the HPP is the capabilities-based framework developed in January 2012 titled Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness (ASPR, 2012). This guidance document lays out the eight health care system preparedness capabilities, one of which is Healthcare System Recovery. Importantly, these eight capabilities align with the Public Health Emergency Preparedness (PHEP) capabilities outlined in the Centers for Disease Control and Prevention’s (CDC’s) Public Health Preparedness Capabilities: National Standards for State and Local Planning (CDC, 2011), supporting the coordinated use of preparedness grant funds (see Chapter 5). Although only one of the HPP capabilities focuses specifically on recovery, the premise is that building and sustaining these eight core capabilities will provide the requisite infrastructure for short- and long-term disaster response and recovery.

According to the HPP guidance, “healthcare system recovery involves the collaboration with Emer-

gency Management and other community partners (e.g., public health, business, and education) to develop efficient processes and advocate for the rebuilding of public health, medical, and mental/behavioral health systems to at least a level of functioning comparable to pre-incident levels and improved levels where possible. The focus is an effective and efficient return to normalcy or a new standard of normalcy for the provision of healthcare delivery to the community” (ASPR, 2012, p. 12). HPP staff report to the committee that 36 of the 50 state public health department HPP awardees have allocated funds for the Healthcare System Recovery capability and its two functions (see Box 6-4). The majority have focused on establishing a designated lead for recovery work, performing health care risk assessments, and engaging in the development of a recovery plan and process for hospitals and other facilities. Additional funded recovery activities include conducting trainings and workshops on building recovery and continuity of operations (COOP) processes.⁴

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⁴ E-mail communication, R. Dugas, HPP, to A. Downey, Institute of Medicine, regarding HPP funds, August 26, 2014.

The committee notes that the HPP cooperative agreement guidance document includes limited discussion of recovery planning beyond the early recovery phase. It is the committee’s view that planning aimed only at achieving a preexisting and likely suboptimal state fails to exploit an opportunity to achieve more desirable longer-term goals of maximally healthy communities through improvements in care delivery and health care access. Thus, the committee strongly urges ASPR to take leadership in working with its fellow agency partners to expand the vision that informs its efforts. The HPP guidance would then be updated to articulate that the goal of health care sector recovery should not be simply to return to the pre-disaster state but to strengthen the sector so that the community will emerge from recovery healthier, more resilient, and sustainable. The checklist at the end of this chapter can be used to review and update this guidance accordingly. Further, the recovery functions identified in the updated HPP cooperative agreement should be aligned with similar changes to other federal grant programs, including the CDC’s PHEP cooperative agreement and the preparedness grants of the Federal Emergency Management Agency (FEMA) (see Recommendation 1 in Chapter 3).

Although health care system recovery is a key ASPR programmatic area, it is important to note that many other departments within HHS and across the federal government (e.g., the U.S. Department of Veterans Affairs [VA]) have important roles in defining and expanding the role of health care in a healthy community. The Centers for Medicare & Medicaid Services (CMS), for example, has great influence as a result of its authority to determine the services that can be covered by Medicare and Medicaid. For instance, effective January 1, 2014, a change in the federal rule on essential health benefits allows Medicaid reimbursement for preventive services delivered by nonlicensed providers as long as those services have been recommended by a physician or another licensed provider (ASTHO, 2015). This rule change has important implications in terms of transitioning to community-based models of care (e.g., utilization of community health workers), as described later in this chapter. Other agencies whose efforts need to be integrated into the recovery planning process include the Health Resources and Services Administration, which provides support for federally qualified health centers, and the Agency for Healthcare Research and Quality.

Federal Legislation Relevant to Health Care Sector Preparedness and Recovery

Waivers and Authorizations Waivers of certain federal regulatory requirements are available following presidentially declared disasters and emergency declarations to ensure that health care systems and providers have the flexibility necessary to provide care when their infrastructure has been impacted by the disaster. Often these waivers are issued during the initial stages of disaster response, but they may be extended during the short-term recovery period as warranted. Waivers and their justification are subject to congressional notification.

Under Section 1135 of the Social Security Act, the Secretary of HHS may waive requirements under Medicare and Medicaid upon declaring a public health emergency.⁵ Such waivers allow, for example, bed capacity increases, cessation of all but emergency survey activities, relaxed length-of-stay requirements in skilled nursing facilities, and relaxed supervision requirements for staff in home health and hospice agencies. The waiver authority may also be used to enable health care professionals who hold out-of-state licenses to operate legally and obtain reimbursement in the state experiencing the emergency. Waivers may be retroactive to the beginning of the emergency. Also under Section 1135 of the Social Security Act, the Secretary of HHS may waive sanctions for hospitals engaging in inappropriate transfer or relocation of patients for medical evaluation under federally declared disaster conditions. Under normal conditions, the Emergency Medical Treatment and Active Labor Act (EMTALA) of 1986 requires hospitals to offer emergency screening and stabilization to all comers irrespective of citizenship, legal status, or ability to pay.⁶ They may not transfer or discharge individuals with an emergency medical condition unless the

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⁵ Social Security Act § 1135, Aug. 14, 1935.

⁶ Examination and Treatment for Emergency Medical Conditions and Women in Labor. 42 U.S.C. § 1395dd. 2005.

patient has stabilized or given informed consent, or if their condition necessitates transfer to a hospital better equipped to provide needed care. The Secretary’s waiver applies only to relief from sanctions under EMTALA; it does not apply to actions brought by individuals or hospitals alleging harms owing to violations of EMTALA. Those individuals or hospitals may still sue for damages. Waivers from EMTALA sanctions were utilized during Hurricanes Katrina, Rita, Gustav, and Ike, among others.

Should the President declare an emergency or disaster and the Secretary of HHS also declare a public health emergency, the Secretary has the authority to waive sanctions against hospitals that fail to comply with specific provisions requirements of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule (ASPR, 2013):

• the requirement to obtain a patient’s consent to disclose protected health information to a family member or close personal friend involved in the patient’s care (45 CFR 164.510(b));
• the requirement to honor an objection to being included in the facility directory (45 CFR 164.510(a));
• an individual’s right to a notice of privacy practices for protected health information (45 CFR 164.520);
• an individual’s right to request privacy restrictions (45 CFR 164.522(a)); and
• an individual’s right to request confidential communications (45 CFR 164.522(b)).

When a waiver is issued, it pertains only to the region and timeframe described in the public health emergency declaration. Moreover, it pertains only to hospitals that have instituted a disaster protocol, and it lasts only up to 72 hours from the time the hospital begins to invoke its disaster protocol. When the presidential or secretarial declaration ends, a hospital must resume compliance with all HIPAA requirements for all patients under its care, irrespective of whether 72 hours has elapsed since its disaster protocol was invoked. In the absence of an emergency waiver, HIPAA rules still allow certain disclosures to disaster relief organizations and for treatment purposes (ASPR, 2013). For example, HIPAA regulations allow hospitals to disclose protected health information to the American Red Cross so it can inform family members of a patient’s whereabouts (45 CFR 164.510(b)(4)).

CMS Proposed Rule On December 27, 2013, CMS filed a Federal Register notice regarding the Proposed Rule for Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers (still pending as of publication of this report). The rationale for this rule is that “disasters can disrupt the environment of health care and change the demand for health care services. This makes it essential that health care providers and suppliers ensure that emergency management is integrated into their daily functions and values.”⁷ CMS believes that the fragmented collection of current federal, state, and local laws and guidelines and accrediting organization emergency preparedness standards is inadequate for ensuring that health care providers and suppliers are prepared for a disaster. This assertion is based on extensive analysis of the literature and ongoing dialogue with various stakeholders and representatives of local, state, and federal entities.⁸ Consistent with the point made earlier in this chapter that building a comprehensive and integrated care delivery system is fundamental to creating maximally healthy and resilient communities, the committee was pleased to note that this proposed rule is aligned with and in fact cites the program guidance for emergency preparedness grants from HHS.

The proposed rule addresses what most experts cite as the key elements of preparedness necessary to ensure that health care is available during response to and recovery from an emergency: “safeguarding

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⁷ 78 F.R. 79084, Dec. 27, 2013.

⁸ The proposed rule reflects the guidance and input of key stakeholders in health care delivery infrastructure, including other federal agencies; the American College of Healthcare Executives (policy guidance); the American Osteopathic Association (standards for disaster preparedness); The Joint Commission (standards for emergency preparedness); the National Fire Protection Association (disaster and emergency management standards); and certain states, including California and Maryland, with salient state-level requirements.

human resources, ensuring business continuity, and protecting physical resources.”⁹ To these ends, the proposed rule focuses on four key functions for different categories of care providers and suppliers:

• risk assessment and planning utilizing an “all-hazards” approach, which means evaluating the full range of potential hazards and vulnerabilities;
• “develop[ing] and implement[ing] policies and procedures based on the emergency plan and risk assessment”;
• developing and maintaining an emergency preparedness communication plan to facilitate well-coordinated patient care “within the facility, across health care providers, and with state and local public health departments and emergency systems”; and
• “develop[ing] and maintain[ing] an emergency preparedness training and testing program.”¹⁰

The Patient Protection and Affordable Care Act In 2013, the Institute of Medicine (IOM) organized a workshop that examined the impacts of the ACA on preparedness (IOM, 2014a). While the ACA does not include many specific provisions that directly address preparedness, response, or recovery, a number of the provisions will have an impact on strengthening the resilience and health of a community and should be taken into consideration during disaster recovery. Examples include

• the impact of coverage expansion, changing reimbursement systems and new incentives on preparedness activities;
• the use of health information technology to strengthen preparedness, response, and recovery;
• the use of existing resources for improving daily operations and emergency response;
• workforce training needs;
• opportunities for building relationships and coalitions among health care delivery systems that may not previously have been involved in preparedness activities; and
• an emerging model for care delivery referred to as community paramedicine or mobile integrated health care practice (see Box 6-5) (IOM, 2014a, p. 37).

Many of the ACA provisions with more immediate impacts on improving community resilience and health are highlighted in Table 6-1.

Regional, State, and Local Levels

The highly decentralized health care delivery system encompasses a wide range of for-profit, nonprofit, and governmental (regional, state, and local) entities. Community health care is delivered through the interaction of hospitals, networks of outpatient providers, long-term care facilities, home health care and hospice, emergency medical services, behavioral health services, community and large chain pharmacies, and walk-in health services. A complex, sophisticated support system of financial, diagnostics, and logistics (e.g., supply chain, transportation) providers are less well understood facilitators of care. Technology, in particular health information technology, has an ever-increasing role in connecting patients to providers and structuring that connection in powerful ways. Planning, coordination, and financial support by regional, state, and local public health entities also are important elements of a community’s health care system. Health care coalitions, described earlier, are key mechanisms for supporting a coordinated approach to planning at the regional level.

The goal of incident management in events entailing mass casualties or the catastrophic failure of crucial infrastructure is “to get the right resources to the right place at the right time.” These same goals should also help guide recovery. As noted by the IOM,

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⁹ 78 F.R. 79085, Dec. 27, 2013.

¹⁰ 78 F.R. 79085, Dec. 27, 2013.

Health care systems and hospitals are well recognized as crucial partners in community health planning because of their organizational capacity, specialized workforce, health analytic capabilities, and significant stakeholder status in their communities. Often undervalued and overlooked as healthy community partners, however, are local outpatient providers and clinics, group homes, long-term care facilities, and home health providers, which can play key roles in surge response and recovery efforts (IOM, 2012a). The vast majority (approximately 89 percent) of health care encounters occur in these outpatient settings (Hall et al., 2010; Schappert and Rechtsteiner, 2011), and the increasing focus on preventive care is leading to an even greater role for outpatient care facilities and providers. Therefore, it is imperative that outpatient care assets be integrated as the systems framework for disaster prepared-

TABLE 6-1 ACA Provisions That Could Potentially Affect Medical and Public Health Preparedness Activities^a

^a The information presented in this table was compiled by the rapporteurs of a 2014 IOM workshop (IOM, 2014a) based on presentations made by workshop speakers. Each potential impact has been referenced to the workshop speaker(s) who discussed the relevant topic as follows: ¹Lisa Tofil, ²Norman Miller, ³Gregg Margolis, ⁴Georges Benjamin, ⁵Charles Cairns, ⁶Ellen Embrey, ⁷Karen DeSalvo, ⁸Justin Barnes, ⁹Nicole Lurie, ¹⁰Gus Birkhead, ¹¹Nathaniel Hupert, ¹²Brandon Dean, ¹³Kevin Larsen, ¹⁴Roland Gamache, ¹⁵Connie Chan, ¹⁶Xiaoyi Huang, and ¹⁷Jack Ebeler.

^b Summary items garnered from https://www.govtrack.us/congress/bills/111/hr3590/text# (accessed June 8, 2014). SOURCE: IOM, 2014a, p. 4-7.

ness, response, and recovery is developed. However, the committee recognizes that health care providers based outside of hospitals, particularly private providers, have limited and sometimes no funding for participating in a comprehensive disaster planning effort. Greater attention to incentivizing the participation of the full spectrum of health care providers is needed to actualize a systems approach to disaster preparedness and recovery.

PRE-DISASTER HEALTH CARE SECTOR PRIORITIES

The speed and success of the health care system’s post-disaster recovery depend to a large extent on pre-disaster planning both within the health care sector and across sectors. A robust pre-disaster planning process also is key to capitalizing on the opportunities presented by a disaster to improve the health care system during the recovery process because it prepares the community to make the needed improvements.

In the pre-disaster preparedness stage, specific attention is devoted to planning for the transitions from response to recovery and then back to steady state. The planning includes

• identifying and developing relationships with key local and regional partners;
• identifying [and strengthening] programs and systems that could be leveraged after a disaster; and
• building an understanding of current program and system resources, capabilities, and needs (FEMA, 2014a.

This section identifies several key activities that should be undertaken prior to a disaster to increase the capacity of the health care sector to respond to the surge in health needs that may occur in the early recovery phase as well as to the long-term community health care needs that may arise later during the recovery period. These activities include

• assessing the capacity and vulnerability of the health care system,
• establishing, sustaining, and exercising health care coalitions and other coordinating groups,
• developing continuity of operations (COOP) and recovery plans, and
• establishing a resilient health information technology system.

As indicated earlier in this chapter, a variety of federal, state, and local funding resources may be available to aid in these activities.

Assessing the Capacity and Vulnerability of the Health Care System

The success of the recovery of any community’s health care sector is informed by an assessment of the community’s health status and the strengths and weaknesses of its health and social service systems and resources prior to disaster. It is imperative that recovery planning for the health care sector be informed by an assessment of the community’s overall risks, threats, and vulnerabilities, such as those that could impact community infrastructure (buildings), transportation (roadways, bridges, tunnels), utility services (water/sewage treatment, electricity), and its vulnerable populations. Such assessments also should include a vision of what post-disaster recovery should look like for that community from the health care and health systems perspectives.

Community Health Needs Assessment

Under the provisions of the ACA, nonprofit hospitals are now required to conduct a community health needs assessment.¹¹ A community health needs assessment (CHNA)¹² is:

To avoid a tax penalty, nonprofit hospitals conducting CHNAs must demonstrate a community benefit. One such benefit that could stem from CHNAs and associated implementation plans is community health resilience. By providing information on vulnerable populations in the community, preparing to meet the

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¹¹ 26 U.S.C. § 501(r).

¹² The term “community health needs assessment” is often used interchangeably with the term “community health assessment.”

needs of those populations, and increasing public awareness regarding the threat of social vulnerability, nonprofit hospitals can help build a more prepared community (IOM, 2014a). To this end, Internal Revenue Service (IRS)-required CHNAs should be conducted in collaboration with the regional, state, or local department of health (NACCHO, 2012) and, where possible, utilize data from existing health information technology systems, which are discussed later in this chapter.

Hazard Vulnerability Analysis

Recovery planning for the health care sector should also be informed by a health care facility assessment that includes a hazard vulnerability analysis (HVA). HVA is defined as “a systematic approach to identifying all hazards that may affect an organization, assessing the risk (probability of hazard occurrence and the consequence for the organization) associated with each hazard and analyzing findings to create a prioritized comparison of hazard vulnerabilities. The consequence, or vulnerability, is related to both the impact on organizational function and the likely service demands created by hazard impact” (HHS, 2007).

An HVA examines physical infrastructure risks based on environmental (e.g., wind, fire, storm, flood) and other vulnerabilities (e.g., insufficient quantities of medical equipment and pharmaceuticals, food, water, limitations of insurance coverage). This assessment helps identify facilities or systems for which more robust advance planning is necessary to ensure continuity of operations after a disaster (Knowlton and Rotkin-Ellman, 2014). Typically, an HVA is required as part of the Joint Commission’s accreditation process, and it is a requirement under CMS’s proposed emergency preparedness rule discussed above.

As mentioned earlier, a facility’s HVA should also be informed by overall community risks and vulnerabilities. Most local emergency management planners routinely conduct a threat and hazard identification and risk assessment (THIRA)¹³ based on their jurisdiction and region; health care facility planners should collaborate with their local emergency management agency in the development of their facility/ health system HVA.

In addition to collaboration with local public health and emergency management agencies, both a pre-disaster CHNA and an HVA must be informed by a broad range of public- and private-sector perspectives that encompasses citizens, community- and faith-based organizations, health care providers and other nearby health care systems, government and elected officials, insurers, and representatives of the business community. Representation of these groups in recovery planning for the health care sector is critical to identifying what capabilities the health care system and its partners may need to bring to bear during the response to and recovery from a disaster.

Establishing, Sustaining, and Exercising Health Care Coalitions and Other Coordinating Groups

ASPR’s HPP emphasizes the importance of communities building and sustaining health care coalitions, as discussed previously in this chapter. To aid in these efforts, ASPR’s HPP cooperative agreement supports the establishment of these coalitions and provides guidance on how they can strengthen a jurisdiction’s medical surge and other health care preparedness capabilities. As highlighted in the 2012 IOM report Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response, health care coalitions have two key functions:

• “Develop strategies and tactics to support emergency preparedness, response, and recovery activities of substate regional health care systems involving member organizations; and
• Provide multiagency coordination for the interface with the appropriate level of emergency

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¹³ A THIRA is a four-step process that assists the entire community, including individuals, businesses, faith-based organizations, nonprofit groups, schools, and governments, in determining and comprehending its risks and estimating capability requirements (FEMA, 2014b).

The multistakeholder composition of health care coalitions is important not only in preparedness planning and response but also in bringing together the relevant multisector expertise during short- and long-term recovery (see Box 6-6). The coalition can serve as a primary mechanism for local and regional coordination (for planning and operations) among care providers, as well as in public health and emergency management. If coalitions are to serve these functions, however, they must participate in state and local recovery planning and be integrated into the organizational structures of the RSFs specified in the NDRF. Relationships with the public health and emergency management sectors can facilitate this integration.

Historically, many health care coalitions have limited their membership to representatives of hospitals, public health, and emergency management. Given the complex health care needs of a community during recovery from a disaster, however, coalition membership needs to expand beyond those sectors (see Table 6-2).

Efforts to expand representation on health care coalitions to reflect the full complement of stakeholders presented in Table 6-2 may face considerable challenges. For example, private outpatient providers care for the majority of the population (including most patients on Medicaid [O’Shea, 2007; Paradise, 2015]) but generally have little incentive to participate in recovery planning or health care coalitions. Outpatient providers (including behavioral health care providers) are decentralized, mainly privately owned businesses that have increasingly limited regular contact with hospitals (because of an increase in hospital-based providers who handle inpatient duties) and may see little value in participating in such organizations and planning efforts. Professional organizations (particularly those specific to specialties such as pediatrics) may be helpful in facilitating efforts to engage nonhospital providers in the recovery planning process.¹⁴

Task forces and workgroups may be formed before and after disasters to address specific needs related to health care recovery and may require the participation of health care providers. For example, pediatricians should participate in children and youth task forces, as discussed in Chapter 8. Other examples include behavioral health workgroups and workgroups formed to meet the needs of frail elderly persons (e.g., those in nursing homes) (Hillsborough County Government, 2010).

Developing Continuity of Operations and Recovery Plans

COOP is “an effort within individual organizations to ensure they can continue to perform their essential functions during a wide range of emergencies, including localized acts of nature, accidents, and technological or attack-related emergencies” (DHS, 2012, p. P-3). Because health care systems provide a critical array of services after a disaster, they must develop a COOP plan as part of their overall disaster recovery plan (DHS, 2012). ASPR’s Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness emphasizes that health care facilities must develop a COOP plan as part of achieving the Healthcare System Recovery capability (ASPR, 2012). This guidance document identifies four important tasks associated with the implementation of COOP:

• “Identify the healthcare essential services that must be continued to maintain healthcare delivery following a disaster;
• Encourage healthcare organizations to identify the components of a fully functional COOP and develop corresponding plans for implementation;
• If a disaster notice can be provided, alert healthcare organizations within communities threatened by disaster and if requested and feasible, assist them with the activation of COOP such that healthcare delivery to the community is minimally impacted; [and]

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¹⁴ E-mail communication, S. Needle, Healthcare Network of Southwest Florida, to A. Downey, Institute of Medicine, regarding experience with disaster recovery, August 23, 2014.

• Develop coordinated healthcare strategies to assist healthcare organizations transition from COOP operations to normalcy or the new norm for healthcare operations” (ASPR, 2012, p. 14).

In addition, the Joint Commission identifies four elements of performance related to recovery that it uses to accredit and certify hospitals:

• “EM 02.01.01 EP4—The hospital develops and maintains a written Emergency Operations Plan that describes the recovery strategies and actions designed to help restore the systems that are critical to providing care, treatment, and services after an emergency;
• EM 02.01.01 EP5—The Emergency Operations Plan describes the processes for initiating and terminating the hospital’s response and recovery phases of the emergency, including under what circumstances these phases are activated;
• EM 02.02.03 EP2—[EOP describes the following] How the hospital will obtain and replenish medical supplies that will be required throughout the response and recovery phases of an emergency, including personal protective equipment where required; and

TABLE 6-2 Potential Members of Health Care Coalitions to Address Recovery Considerations

SOURCE: ASPR, 2012, p. 2.

• EM 02.02.03 EP3—[EOP describes the following] How the hospital will obtain and replenish non-medical supplies that will be required throughout the response and recovery phases of an emergency.” (The Joint Commission, 2013)

COOP plans should also guide a health care facility or system on “how key resources from governmental, nongovernmental, and private sector agencies can be used to support the sustainment and reestablishment of essential services for healthcare organizations. This coordination assists healthcare organizations to maintain their functional capabilities during and after an all hazards incident and enables a rapid and more effective recovery” (ASPR, 2012, p. 13).

In developing COOP and recovery plans, health care sector planners need to extend beyond surge scenarios to include major infrastructure loss contingencies. Planning for infrastructure loss requires the identification of potential temporary sites and facilities, as well as measures to ensure continuity of supply chain operations. The following considerations apply to supply chain continuity planning¹⁵:

• Administrators should have a plan in place for sourcing post-disaster supplies, including a supply list (e.g., based on a disaster formulary or records of past orders) with anticipated quantities, binding contracts with suppliers and pre-authorization for placing orders. Special consideration should be given to assessing whether a supplier is providing products or services to other facilities and determining the prioritization of those products/services.

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¹⁵ Personal communication, G. Kirtser, ROi, to A. Downey, Institute of Medicine, regarding lessons learned from Mercy Health Joplin Experience, July 16, 2014.

• Disaster recovery plans, operating procedures, and supply lists need to be documented and available in digital and paper forms, and multiple staff members need to be aware of them.
• Large distribution companies (which most health facilities use) have planned extensively for disaster scenarios and can be a good resource. Distributors may not share disaster plans as a matter of course, but facility administrators can request this information to help with their own plans.

Just as important as establishing a COOP plan is establishing a plan for the transition from continuity of operations to normal operations following disaster recovery (ASPR, 2012).

Finally, much of the emphasis in disaster drills and exercises focuses on preparing for disaster response, with little attention given to testing a facility’s COOP and recovery plans. Failure to conduct such testing could impact the availability essential services of a health care facility or system following a disaster.

Establishing a Resilient Health Information Technology System

The nation is advancing toward the widespread adoption of personal health records and electronic health records, which facilitate the collection of patient-specific medical information that can be shared among providers to help maintain continuity of care. Federal legislation—most notably the ACA and the Health Information Technology for Economic and Clinical Health Act,¹⁶ included in the American Recovery and Reinvestment Act of 2009—encourages the use and spread of health information technology. These two acts include specific provisions aimed at increasing the use of electronic health records throughout the health care sector, as well as the implementation of meaningful use guidelines with which to monitor and reward health care providers and organizations using the technology (ONC, 2012). Additionally, efforts at the state and local levels to create health information exchanges are facilitating the flow of clinical information across centers of care.

The emergence of information technology in health care has presented both opportunities and challenges for its use in disaster scenarios. Concerns remain about privacy and information and data sharing, as well as costs associated with new technology. Nonetheless, experience from past disasters has shown that health information technology tools (e.g., electronic medical records, health information exchanges) are valuable assets in addressing many of the challenges associated with the interruption of health care relationships that occurs as patients relocate temporarily or permanently away from their regular providers, thereby losing the benefit of their providers’ records (see Box 6-7). Because access to health information and other vital records is imperative during recovery, health systems need to be more proactive in planning for continuing access to these resources following a disaster (Horahan et al., 2014). Electronic records that can be accessed from cloud-based storage, for example, ensure access to critical health information if physical records are destroyed. Health systems also should consider storing copies of electronic health records on a local physical server to ensure access in the event of a disruption in Internet service. In addition, personal health records are increasingly available through consumer-mediated exchange initiatives, such as the Blue Button initiative (Health IT, 2014), and mobile personal health apps such as Microsoft’s HealthVault (HealthVault, 2015). These technologies can empower individuals and families to be prepared for all kinds of emergencies, increase health literacy, and reduce some of the post-disaster challenges related to lack of access to critical health information. Differences in the responses to Hurricanes Katrina and Sandy demonstrate the benefits of health information technology for preparedness, planning, response, and recovery (IOM, 2014a).

In addition to facilitating individual care, health data also can be used to develop a better understanding of the community (e.g., through baseline data) and to evaluate program effectiveness as health protection and promotion measures are implemented. The expansion of coverage through the ACA has increased participation in the health care system. As a result, more people are now visible to the system and more data are available with which to understand a community’s potential vulnerabilities, to plan for

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¹⁶ 42 U.S.C. § 300jj et seq.; § 17901 et seq.

individuals with specific or complex health needs, and to foster resiliency. Likewise, data from electronic health records, syndromic surveillance, and other sources can facilitate modeling, predictive analytics, and real-time situational awareness that informs pre-disaster planning and provides decision support during and after an event (IOM, 2014a).

Health information technology also is expanding beyond health care to enable better integration of different kinds of care providers, a capability that could be of great value after a disaster when people need to reconnect with their entire care support network. For example, Parkland Center for Clinical Innovation (PCCI), a nonprofit organization in Dallas, Texas, has developed an information exchange portal that captures social health components important to public health preparedness and response (PCCI, 2014). The aim is to include more than 400 community organizations that provide a range of social services, including shelter, food and nutrition assistance, transportation assistance, housing assistance, and financial support (IOM, 2014a). A goal is to connect health care organizations and providers in the region, as well as behavioral health professionals and first responders, through the information portal. Thus, the portal can serve to provide coordination of care for patients whose care involves various health and social services providers, enabling the sharing of information about medications and medical history and facilitating the identification of patients with mobility needs who may require additional assistance, especially during a disaster.

Many of the benefits of health information technology, including information exchange portals, are useful during daily operations but can provide extra benefit during and after disasters or emergencies (see Table 6-3). For example, health information technology makes it possible to develop a unified patient, victim, materiel, and fatality tracking system. Having a single unified tracking system that conforms to a consistent set of standards reduces unnecessary redundancy and improves interoperability, facilitating efforts to address the challenges encountered during all facets of disaster response and recovery as well as throughout the provision of care, from prehospital settings through rehabilitation facilities.

TABLE 6-3 Potential Applications of an Information Exchange Portal in a Disaster

SOURCE: Chan, 2013.

EARLY POST-DISASTER HEALTH CARE RECOVERY PRIORITIES

As noted by FEMA (2014a, C-6), “Disaster response and recovery operations are interdependent, overlapping, and often conducted concurrently.” The assessment of community health and social service needs and of the recovery resources available to meet those needs may occur while response operations are ongoing. Further, health system recovery happens in phases, entailing a gradual/staged reintroduction of services. As the community progresses to intermediate- and long-term recovery, ongoing evaluation of resources and the changing needs of individuals is essential. In the post-disaster environment, for example, the number of people who are newly homebound and in need of home care may increase.

Conducting Post-Disaster Assessments

Immediately following a disaster and throughout the recovery period, assets must be aligned with the identified on-the-ground requirements of the community. To ensure that the needs of the impacted population are being met, not only infrastructure assessments but also community health assessments and assessments of supplies are required. However, a standardized tool for rapid, simplified needs and impact assessment is currently unavailable. ASPR, working with other relevant agencies from within HHS and other federal departments—including FEMA, the U.S. Department of Transportation (DOT), and the National Institutes of Health (NIH) (National Library of Medicine)—is well positioned to establish a standardized assessment tool that can be used by state and local officials to assess the impact of a disaster on the health system both immediately following the event and during recovery. Any such tool should be based on the common principles outlined in the Post-Disaster Needs Assessment developed by the European Commission, the United Nations Development Group, and the World Bank (GFDRR, 2013).

Restoring Care Delivery Infrastructure and Services

In the short term following a disaster, recovery of the health care system should be focused first on ensuring that the immediate medical needs of the population are being met. Meeting those needs requires ensuring the accessibility of urgent care centers and shelters with appropriate supports for at-risk individuals, as well as functioning supply chains for acquiring medicines and needed medical supplies. As short-term recovery continues, the focus should shift to restoring not only emergency health care services (inpatient and outpatient) but also the health care delivery infrastructure necessary for reestablishing primary care (Runkle et al., 2012). This is especially critical for medically vulnerable populations, such as those requiring ongoing care for chronic diseases. If primary care is not restored in a timely manner, a secondary surge in disaster casualties could result from exacerbation of preexisting conditions.

Consistent with the principles laid out in the IOM reports on crisis standards of care, it may not be feasible immediately to provide the same level of care as that previously available; however, providing some level of care is a moral and legal imperative (IOM, 2009, 2012a, 2013b). To this end, it may be necessary to allocate scarce resources or conserve, adapt, and/or substitute some supplies to ensure that functionally equivalent or crisis care is provided, depending on the situation. In the event of significant damage to health care infrastructure, it may be necessary to adapt facilities or to use temporary facilities to ensure continuity of care. Such strategies may include the following:

• Tent facilities may be used to meet immediate emergent care needs in the impacted community. Such facilities and guidance on operating within them may need to be sought from external parties such as the disaster medical assistance team (DMAT), the National Guard, or other military units.
• Mobile clinics may be operated both by governmental (see Box 6-8) and by nongovernmental (including faith-based) organizations, but coordination between these two sectors is needed.
• If permanent reconstruction of hospitals and other medical facilities will require an extended period of time, temporary modular buildings can be used in the interim. Such facilities must be able to accommodate auxiliary services to support staff. Important partners include state emergency management to help with permits and regulations, as well as utility companies to set up water, power, and communications infrastructure (e.g., to support access to electronic health records).
• Rented office spaces may serve as temporary physician offices, but attention to accessibility is necessary for those with limited transportation options.

Given that much of the health care delivery system is privately owned (and often runs on thin margins), funding support for restoring infrastructure can be a significant challenge, particularly when organizations are underinsured (ASTHO, 2007). Lost revenue due to disruption of services adds to this challenge. In many communities, the private health care industry is a major part of the economy, so that delays in recovery of the health care sector translate into delays in recovery for the community as a whole. Consequently, special attention should be paid during pre- and post-event planning to mechanisms that can expedite financial aid for these critical services. The private sector is not eligible for FEMA Public Assistance funds that are provided for nonprofit health care systems and facilities after a major disaster to fund the reconstruction of damaged infrastructure (see Chapter 4). In the event of a supplemental appropriation, funds from a Community Development Block Grant for Disaster Recovery (CDBG-DR) can be applied to reconstruction of privately owned facilities but will not be available immediately, and there will be many competing priorities for these funds. Low-interest loans from the Small Business Administration and Federal Housing Administration (FHA)-insured loans for health care facilities may be important mechanisms for handling costs not covered by insurance.

Ensuring Availability of the Required Medical Workforce

Retaining a damaged health care facility’s workforce following a disaster is critical to ensure that skilled workers will be available when the facility is again fully operational (see Box 6-9 for one health system’s approach to workforce retention after a disaster). Guaranteeing pay and jobs provides employees with needed financial security, the opportunity to maintain their clinical skills, and enhanced psychological recovery through a sense of being useful to the community. Additionally, other local health care facilities that remain operational will likely experience a surge in people seeking care as a result of the community’s reduced capacity. Temporary transfer of displaced medical staff to such facilities can help alleviate this burden.

As part of COOP plans, specific consideration should be given to ensuring that the needs of the health care workforce are met. Otherwise, the permanent migration of providers away from the impacted community, as occurred following Hurricane Katrina, will have a direct impact on the quality of care provided to a population in the short and long term (Berggren and Curiel, 2006; Rudowitz et al., 2006). Following a disaster, however, the needs of a community may change. Therefore, accurate assessments are critical to ensuring that the appropriate workforce is available to meet post-disaster needs. Determination of how many and what types of providers will be required during recovery requires assessment of the disaster’s impact on local populations, and these needs may change as the recovery progresses. Strategies that may be used to help retain the health care workforce include the following:

• In the immediate post-disaster period, health system employers can assist staff and their families with personal recovery priorities (e.g., housing, child care, rental cars, cash advances to meet basic needs).
• Health systems and governments can help offset the costs of or provide temporary offices for physicians.
• Temporary care facilities can be provided, with flexibility to use them either within or outside of the employing health system.

Although retention of existing providers is critical after a disaster, needs assessments may reveal the need to recruit personnel with additional skills and expertise. Following Hurricane Katrina, for example, loan forgiveness programs and other incentives were used for this purpose (DeSalvo, 2011). Local medical education institutions also can help recruit medical professionals. In recruiting efforts, consideration should be given to long-term needs that may be associated with contemporary changes in health care policy. For example, increased numbers of insured patients as a result of the ACA may create a need for more primary care physicians.

Coordinating Volunteers and Other Medical Professionals from Outside the Community

Depending on the nature and scope of a disaster, local health care organizations may be bolstered by additional personnel with medical expertise (e.g., through the Emergency Management Assistance Compact and other mutual aid agreements). Acute care facilities typically serve as hubs for disaster-related

medical care, but additional staff and interim facilities may be required to supplement local capacity or replace it if it has been destroyed. U.S. Department of Defense personnel, Medical Reserve Corps (MRC) personnel, disaster relief organizations, emergency management agencies, and/or staff and resources from other localities may be involved, depending on the disaster’s scope. While the MRC is a national program administered by ASPR, these units comprise local volunteers positioned to meet the disaster-related needs of the communities in which they live and serve. Each local unit is required to uphold minimal national standards to be officially recognized by ASPR, but the mission and training of MRC personnel are determined largely by the local unit leadership and the organization in which they are housed. There are currently around 1,000 local MRC units across the country and in U.S. territories (MRC, 2015).

The influx of providers that may occur primarily during the response phase may extend into the recovery period to address ongoing critical gaps; therefore, both preparedness and recovery plans need to take into account the challenges associated with the use of volunteer providers. Increasing the number of available paid and volunteer personnel alone does not constitute a successful response if these human resources lack the skills, training, and expertise necessary to meet the needs of a community struck by a disaster. After-action reports following some of the nation’s largest and even smallest disasters have suggested that identifying, mobilizing, and integrating health care and other workers into a disaster response is one of the most significant challenges.

Mechanisms for addressing the legal issues surrounding licensing and credentialing of out-of-state medical providers include both state-enacted legislation and federally sponsored registries. The Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP), a federal program administered by ASPR, was created to establish a standardized volunteer registration process for disasters and public health and medical emergencies. The program is managed at the state or territorial level in collaboration with local agencies and organizations; however, ASPR’s national ESAR-VHP program staff provide guidance and technical assistance in the development of these registration systems. The ESAR-VHP program provides an efficient and coordinated process for verifying the identities, licenses, credentials, accreditations, and hospital privileges of health care volunteers, a process which saves vital time during emergencies (ASPR, 2015). The Uniform Emergency Volunteer Health Practitioners Act is a model bill that, if enacted by a state, recognizes the licensure of health care providers in other states during an emergency or disaster if those providers are registered with a public or private registration system, including ESAR-VHP. More than a dozen states have enacted this legislation (ACS, 2015).

In addition to the issues surrounding volunteer credentialing and liability, free services provided by volunteers can have unintended consequences if allowed to operate for too long. Free clinics may be critical sources of care during the early days or even weeks after a disaster; during the recovery period, however, these facilities can place further financial strain on private providers who would otherwise be receiving payment to care for those patients (IOM, 2014b). Thus, it is important that decisions on both deploying and demobilizing volunteer services be based on continual assessment of the capacity of the local health care infrastructure, including private providers, to deliver care to the community after a disaster.

INTERMEDIATE- TO LONG-TERM RECOVERY: OPPORTUNITIES TO ADVANCE HEALTHIER AND MORE RESILIENT AND SUSTAINABLE COMMUNITIES

Rebuilding Health Care Facilities After Disasters for Increased Resilience and Sustainability

Health systems and services must be able to ensure continuous operation in disaster situations, particularly in light of the expected increase in the number and severity of disasters as a result of climate change. However, health systems themselves may contribute to climate change through high energy usage, carbon emissions, and use of chemical materials. Thus, the health sector must become resilient to the impacts of climate change and be environmentally friendly. The health sector can help ameliorate climate change by reducing its carbon footprint through efficient energy use and by reducing water consumption and contamination. Two recent demonstration projects carried out by the Pan American Health Organization

demonstrate that it is feasible and economically beneficial to implement interventions that are both safe and green in health facilities (PAHO, 2014).

During the long-term recovery period, the rebuilding of health care facilities gives a community the opportunity to establish environmentally friendly permanent facilities in which previous vulnerabilities have been addressed, making the facility—and thus, the community—more resilient and sustainable. The American Meteorological Society has identified three approaches—a combination of structural, nonstructural, and functional interventions—to addressing vulnerabilities while bolstering resilience and sustainability:

• Structural hardening—the use of construction elements (e.g., impact-resistant glass; waterproofing measures; backup systems for critical utilities such as electricity, heating, ventilation, and air-conditioning [HVAC], plumbing) that maximize resiliency.
• Incremental adaptation—an approach to addressing operational vulnerabilities that could cause loss of function. For example, critical systems (HVAC, electricity) can be moved out of basement/ lower-level floors in flood-prone areas, and some hospitals are locating emergency departments on the second floor and parking and/or administrative offices on the ground floor. In addition, critical systems can be made redundant (e.g., multiple emergency power generators).
• Innovative practice—means of increasing resilience by transforming the role of health care in communities. For example, facilities can be relocated to improve community access, and health services can be expanded beyond acute care to encompass health and wellness. A network of providers outside of hospitals can be leveraged to fill this latter role, allowing hospitals to focus on acute care. This type of systemic change benefits communities during day-to-day operations as well as during disaster recovery. Improving access and quality of care is discussed further in the next section (American Meteorological Society, 2014).

Further, as part of the President’s 2013 Climate Action Plan for preparing communities for the impacts of climate change, HHS established a Sustainable and Climate Resilient Health Care Facilities Initiative to help health care facilities increase their resilience (White House Office of the Press Secretary, 2014). To assist in this effort, a best practices toolkit was created to help all stakeholders enable continuity of care in the face of extreme weather events and other disasters. This toolkit identifies the current status of the resilience of health care infrastructure to extreme weather risks and best practices that health care organizations can adopt to improve their climate readiness (White House Office of the Press Secretary, 2014).¹⁷

These resilience and sustainability principles have been applied in both large metropolitan and smaller suburban and rural facilities. Rebuilding and renovation also provide an opportunity to improve facility design features that can impact patient care and experiences (e.g., locating the emergency room, operating rooms, and radiology in proximity to one another). Newer, more effective technologies that would otherwise have been too costly to install may also be integrated into facilities. This process should involve input from the community, which can help identify current and future needs. Additionally, assessments should be conducted to ensure that renovations and upgrades are based on a full understanding of the current health care system, community populations, their chronic health issues, and the behaviors that influence medical care (Hillsborough County Government, 2010). The examples described in Box 6-10 highlight these opportunities.

Improving Health Care System Access and Quality of Care

Reducing the social and economic costs of health care services through actions taken during recovery can contribute to a healthier and more resilient and sustainable community. Viewed through the lens of

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¹⁷ The Best Practices Toolkit for Sustainable and Climate Resilient Health Care Facilities can be found at http://toolkit.climate.gov/sites/default/files/SCRHCFI%20Best%20Practices%20Report%20final2%202014%20Web.pdf (accessed April 8, 2015).

creating optimally healthy post-disaster communities, maximizing the accessibility, quality, and effectiveness of medical care should be an obvious and defining requirement. Nonhospital settings—including ambulatory clinics, medical and dental offices, nursing homes, rehabilitative and assisted living centers, hospices, pharmacies, urgent and emergency services, and home health care services—are essential to realizing maximally health communities. As noted earlier, moreover, the degree of integration of these services with each other and across the continuum of public health, prevention, behavioral health, and social services significantly determines overall community health and, relatedly, the resilience of the community.

After a disaster, communities have an opportunity to evolve their health systems beyond the typical high-cost, low-quality care that is prevalent throughout the country today. The cost of avoidable health care utilization is high. For example, the top 5 percent of health care utilizers generate half of all health care spending (Cohen and Uberoi, 2013), and one county found that the cost of poverty in its jurisdiction was an annual $2.5 billion, consisting largely of costs for emergency room visits ($663.5 million) and hospitalizations ($1.5 billion) (Pinellas County, 2013). During the long-term recovery of health systems, communities can address unsustainable costs by improving health care infrastructure and resources to prevent emergency room visits and hospital admissions (see Box 6-11).

As highlighted in Box 6-12, following hurricanes Katrina and Rita, HHS supported the establishment of the Louisiana Health Care Redesign Collaborative, which developed and oversaw the implementation of a practical guide for an evidence-based, quality-driven health care system for New Orleans (HHS, 2006).

Four key principles guided the long-term recovery of the health care sector, and the committee supports these as guiding principles for any community:

• Delivery redesign—All stakeholders—including health care organizations, professional groups, public and private purchasers, and other health system participants—focused on reducing the burden of disease and improving health through primary care and prevention. They exploited opportunities to leverage the work of other sectors—for example, by working with community development organizations that fund community health centers.
• Improved quality—The plan established a team-based care and medical home model, and incorporated an all-hazards approach for effective emergency preparedness.
• Tools—The system emphasized the creation and use of provider tools, such as standardized and interoperable health information technology to improve safety and effectiveness.
• Realignment of incentives—Coverage was expanded through realignment of incentives, including the use of innovative payment models to support team-based care and the integration of behavioral health into primary care (HHS, 2006).

Importantly, many of the approaches used by a community to address entrenched health disparities and high health care costs (such as those described in Box 6-11) are similar to those used to meet post-

disaster health care needs. Sustaining these approaches beyond the response and early recovery phases of a disaster is one way to improve long-term access to care. Examples of such complementary approaches include but are not limited to the following:

• Community-based care, such as mobile clinics and the emerging community paramedicine model described earlier in this chapter (see Box 6-5).
• Employment of community health workers to better link community members to needed health services. Community health workers can facilitate the integration of health and human services partners (including health care, public health, social services, and housing) and have been shown to improve patient compliance with chronic disease management (see Box 6-13).
• Collocation and integration of clinical services with other types of services (e.g., social services) using a team-based care approach. These integrated care models follow naturally from the care that is provided immediately following a disaster, when case managers and health professionals work in a collaborative and coordinated manner to meet the comprehensive needs of survivors (see Box 6-14).

RESEARCH NEEDS

In the process of developing its guidance and recommendation specific to the health care sector, the committee noted that further research is needed to address the following questions:

• How can team-based and community-based care approaches that emerge after a disaster be sustained?
• What is the effect of the Affordable Care Act on health care system recovery approaches?
• How can health care coalitions be optimally leveraged to better integrate health care leadership into recovery planning and operations?
• What are the long-term impacts on health when access to care is disrupted?

SUMMARY OF FINDINGS AND RECOMMENDATION

While emergency responses that provide essential life-sustaining interventions in the immediate aftermath of a disaster take obvious priority at such times, preparing the health care delivery system for resilience before a disaster, restoring and preferably enhancing the health care infrastructure after a disaster, and engaging this rebuilt infrastructure more successfully in realizing healthier communities overall warrant increased attention and priority. The ultimate goal of planning and rebuilding toward a comprehensively defined healthy community often is not a vision or priority for recovery efforts. In fact, much of the language in disaster recovery guidance focuses on restoring the community to a “normal or new normal” status. Active participation by the health sector is essential in defining a community’s “new normal” and using the tragedy of the disaster experience as an opportunity to rebuild to achieve optimal health, resilience, and sustainability—in short, a healthy community capable of withstanding such events in the future.

Through its research and testimony provided for this study, the committee learned how important, and how difficult, it is for health care leaders to understand the many sources of available support and to participate in decision-making forums with local, state, and federal leaders at every stage in the process. The complexity of the various bureaucratic processes and the jargon that is often used can be daunting to anyone who is not an emergency manager or other disaster management specialist. A community’s health care leaders and executives are especially likely to be unfamiliar with their roles and responsibilities during a disaster. As a result, disaster planning and operations leaders at the federal, state, and local levels need to reach out to clinical leaders as they conduct their activities, with the specific intent of engaging them in the collaborative work necessary to envision and strive toward a maximally healthy community and to build a more resilient health care system. At the same time, however, the responsibility for ensuring that health care is integrated into a multisector effort does not lie solely with governmental planners. Health care leaders themselves need to be sensitized to the importance of engaging proactively in community preparedness efforts that extend to planning not only for response but also for recovery. Health care

coalitions provide an important mechanism for this multistakeholder, multisector approach and should be supported in expanding this role. Guidance and training for health care sector grantees under the HPP (see Recommendation 4 in Chapter 3) should bring greater awareness of this responsibility.

“Organized information is key to resiliency” (Coastal Recovery Commission of Alabama, 2010, p. 6.06). The ability of the health care sector to meet the medical needs of a disaster-impacted population and monitor health outcomes as the community progresses through the recovery process toward a healthier and more resilient and sustainable future will depend on a robust health information technology infrastructure. According to the Office of the National Coordinator for Health Information Technology, “The best way to ensure that health information can be accessed during an emergency is to ensure that it can be accessed during routine care” (ONC, 2012, p. ES-1). Despite the clear advantages noted earlier in this chapter of advancing the nation’s clinical and health data and related analytic competencies, progress has been suboptimal for many reasons. Common barriers to the adoption of electronic health records by physicians include cost (initial purchase and maintenance), training requirements, and concerns regarding lost productivity (HHS, 2014b). The threat of disaster provides one more motivating factor for overcoming these barriers and establishing a robust health information technology infrastructure. In the event that such systems are not in place before a disaster, however, the recovery process should be leveraged as an opportunity to advance both this infrastructure and plans for utilizing it to ensure continuity of care and to facilitate a learning system approach to recovery in the context of health.

Concrete steps that can be taken to implement this recommendation at the state and local levels include the following recommendations from a recent report by the Office of the National Coordinator for Health Information Technology (ONC, 2012), written for public and private organizations interested in sharing health information during and after a disaster:

• “Understand the State’s disaster response policies and align with the State agency designated for Emergency Support Function #8 (Public Health and Medical Services) before a disaster occurs.
• Develop standard procedures approved by relevant public and private stakeholders to share electronic health information across State lines before a disaster occurs.
• Consider enacting the Mutual Aid Memorandum of Understanding to establish a waiver of liability for the release of records when an emergency is declared and to default state privacy and security laws to existing Health Insurance Portability and Accountability Act (HIPAA) rules in a disaster. States should also consider using the Data Use and Reciprocal Support Agreement in order to address and/or expedite patient privacy, security, and health data-sharing concerns.

• Assess the State’s availability of public and private health information sources and the ability to electronically share the data using HIE(s) [health information exchanges] and other health data-sharing entities.
• Consider a phased approach to establishing interstate electronic health information-sharing capabilities” (ONC, 2012, p. ES-3).

In addition, emergency management and health sectors (including public health and health care) should work together to undertake public education/outreach efforts that promote the use of mobile applications for transporting personal health records to increase individual readiness.

HEALTH CARE SECTOR RECOVERY CHECKLIST

The committee has identified four pre-event and nine post-disaster critical recovery priorities for the health care sector that are inextricably linked to strengthening the health, resilience, and sustainability of a community. Action steps for each of these priorities are provided in the following checklist. Health care sector leaders will need to adapt these actions to local context, but this guidance provides an indicative set of concerns to be taken into consideration during recovery. The checklist illustrates how the following 4 key recovery strategies, identified as recurring themes at the beginning of this chapter, apply to individual priority areas:

• Use multidisciplinary team-based care strategies to meet multifaceted health care needs;
• Ensure continuity of access to health care services;
• Use health information technology to drive decision making for individual and community health, and to inform future planning;
• Leverage health care coalitions and other relationships with local care providers for health services strategic decision making and alignment of clinical resources.

Pre-Event

Priority: Assess Capacity and Vulnerability of the Health Care System

Primary Actors¹: Health and Medical System Partners, State/Local Health Departments²

Key Partners: Emergency Management Agencies, Social Services Agencies, Community- and Faith-Based Organizations

Key Recovery Strategies:

• Use health information technology to drive decision making for individual and community health and to inform future planning.
• Leverage health care coalitions and other relationships with local care providers for health services strategic decision making and alignment of clinical resources.

Activities include but are not limited to:

Conduct a community health needs assessment (CHNA), ensuring hospital-conducted assessments are coordinated with public health agencies.

• – Use CHNA data to derive information on vulnerable populations that will need to be considered in recovery planning at facility and community levels.

Conduct a health system hazard vulnerability assessment.

• – Develop scenario-based vulnerability assessments to determine potential vulnerabilities to the health sector infrastructure (inpatient and outpatient facilities).
• – Coordinate vulnerability assessments with state and/or local emergency management and, when possible, incorporate information from the community Threat and Hazard Identification and Risk Assessment (THIRA).

Plan to meet recovery needs of at-risk populations, including those with special medical needs.

• – Develop a registry of community members with special medical needs.
• – Use data from health information technology, CMS, and other relevant sources to help pre-identify individual and community health vulnerabilities and to inform potential recovery plans.

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Priority: Establish, Sustain, and Exercise Health Care Coalitions and Other Coordinating Groups

Primary Actors: Health and Medical System Partners, State/Local Health Departments

Key Partners: Emergency Management Agencies

Key Recovery Strategy:

• Leverage health care coalitions and other multisector partnerships among local care providers for health services strategic decision making, alignment of clinical resources, and coordination with public health and emergency management sectors.

________________

¹ See Appendix F for further description of terms used to describe Primary Actors and Key Partners in this checklist.

² Throughout this checklist, “State/Local” is used for the purposes of brevity but should be inferred to include tribal and territorial as well.

Pre-Event

Activities include but are not limited to:

If not already established, form health care coalition with clear governance structure and responsibilities to serve as a regional (substate) planning and coordination group for disaster preparedness, response, and recovery.

Ensure health care coalition membership encompasses, to the degree possible, all essential partners specified in ASPR’s Healthcare Preparedness Capabilities: National Guidance for Healthcare System Preparedness.

Identify and seek alignment with other area health coalitions and collaboratives.

Ensure that health care coalition plans and exercises address recovery activities.

Consider the need for task forces/workgroups to address specific health care issues (e.g., behavioral health) or the needs of special populations (e.g., children and youth).

Establish pathways for integrating the health care coalition into state, regional, or local coordinating structures under the NDRF.

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Priority: Develop Continuity of Operations (COOP) and Recovery Plans

Primary Actors: Health and Medical System Partners, State/Local Health Departments

Key Partners: Emergency Management Agencies, Private Sector Suppliers and Distributors

Key Recovery Strategies:

• Ensure continuity of access to clinical care services.
• Use health information technology to drive decision making for individual and community health and to inform future iterations of planning.
• Leverage health care coalitions and other relationships among local care providers for health services strategic decision making, alignment of clinical resources, and coordination with public health and emergency management sectors.

Activities include but are not limited to:

Proactively engage in discussions with emergency management with regards to disaster recovery planning and community organizational structures aligned with the NDRF, including recovery coordinators and local recovery managers.

Ensure alignment of planning occurring through all relevant federal grants and cooperative agreements (public health and emergency management).

Identify essential health care services and develop contingency plans for continuity of operations based on health care facility vulnerability assessments.

Pre-identify shelters and facilities where specialized care will be provided.

Include major medical infrastructure loss and supply chain interruptions in scenario-based planning and continuity of operations plan.

• Ensure that contracts with supply vendors and pre-authorization are in place.

Understand array of resources for recovery assistance and requirements and processes for reimbursement.

Exercise and drill continuity of operations and recovery plans on a regular basis.

Pre-Event

Priority: Establish a Resilient Health Information Technology System

Primary Actors: Health and Medical System Partners, State/Local Health Departments

Key Partners: Health Insurers, Private-Sector Information Technology (IT) Innovators and Vendors

Key Recovery Strategies:

• Ensure continuity of access to clinical care services.
• Use health information technology to drive decision making for individual and community health and to inform future planning.

Activities include but are not limited to:

Support the establishment of a health IT infrastructure (interconnected data systems and analytic capacity) that is essential to the continuity of health care and social services delivery across the continuum of disaster response and recovery.

• – Promote and support the adoption of electronic health records.
• – Include social vulnerability risk factors as standard data elements.
• – Establish data sharing agreements to support intra- and interstate electronic health information sharing capabilities.
• – Ensure capacity to protect privacy while transferring personal health information.
• – Employ system redundancies to improve resilience of health IT infrastructure.

Promote the use of personal health records as a critical aspect of individual/family preparedness.

Short-Term Recovery

Priority: Conduct Post-Disaster Assessment

Primary Actors: Health and Medical System Partners, State/Local Health Departments

Key Partners: Emergency Management Agencies

Key Recovery Strategies:

• Leverage health care coalitions and other relationships among local care providers for health services strategic decision making, alignment of clinical resources, and coordination with public health and emergency management sectors.
• Use health information technology (IT) to drive decision making for individual and community health and to inform future iterations of planning.

Activities include but are not limited to:

Integrate health care coalition leadership within the public health incident command system.

Establish capacity of local hospitals, outpatient facilities, emergency physician networks, etc. to deliver care.

• – Determine disaster impact on health system infrastructure (facilities, supply chain, and health IT systems), medical workforce capacity, and critical services.
• – Estimate magnitude of surge.

Assess damages and estimate reconstruction costs.

Identify urgent disaster-related risks to community health.

Identify the most vulnerable populations that will require assistance/consideration.

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Priority: Restore Care Delivery Infrastructure and Services

Primary Actors: Health and Medical System Partners, State/Local Health Departments

Key Partners: Behavioral Health Authorities, Social Services Agencies

Key Recovery Strategies:

• Leverage health care coalitions and other relationships among local care providers for health services strategic decision making, alignment of clinical resources, and coordination with public health and emergency management sectors.
• Use multidisciplinary team-based care strategies to meet multifaceted health care needs.
• Ensure continuity of access to clinical care services.

Activities include but are not limited to:

Utilize local staff to establish fusion ambulatory and urgent care site.

Ensure accessible community-based emergency department with follow-up and hospital transfer relations.

Reestablish essential primary care clinics and ensure coordination with other components of the health system.

Secure damaged facilities to prevent access and subsequent injury/exposure and salvage working equipment if possible. Store damaged equipment for FEMA/insurance claims.

Track activity and cost for FEMA/insurance reimbursement.

Short-Term Recovery

Request expedited medical facility plan reviews and surveys of facilities ready to reopen to the public. Reopen minimally damaged facilities.

Identify community resources available for intermediate facility arrangements until health facilities are recovered.

Restore access to vital records.

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Priority: Ensure Availability of the Required Medical Workforce

Primary Actors: Health and Medical System Partners, State/Local Health Departments

Key Partners: Federal Agencies (including ASPR), Behavioral Health Authorities

Key Recovery Strategies:

• Leverage health care coalitions and other relationships among local care providers for health services strategic decision making, alignment of clinical resources, and coordination with public health and emergency management sectors.
• Ensure continuity of access to clinical care services.

Activities include but are not limited to:

If needed, implement strategies (e.g., incentives) designed to retain a health and medical services workforce in the affected area.

Mobilize and deploy Medical Reserve Corps or ESAR-VHP volunteers to support efforts.

Engage in a process for wellness checks and monitor behavioral health needs of medical workforce.

Coordinate health (including behavioral health), medical resources, and volunteers responding to the area.

Ensure transition of medical system partners and/or health care coalition members from ESF-8 response efforts to health and social services RSF recovery efforts.

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Priority: Locate and Meet Needs of At-Risk Community Members with Special Medical Needs

Primary Actors: State/Local Health Departments

Key Partners: Health and Medical System Partners, Emergency Management Agencies, Community- and Faith-based Organizations

Key Recovery Strategies:

• Use team-based care strategies to meet multifaceted clinical care needs.
• Use health information technology to drive decision making for individual and community health and to inform future iterations of planning.
• Ensure continuity of access to clinical care services.

Short-Term Recovery

Activities include but are not limited to:

Utilize registries if available or other electronic health information to locate at-risk community members.

Track vulnerable patients transferred from long-term care facilities and other institutions.

Ensure access to and availability of pharmaceuticals, including psychotropics, and critical medical equipment for those with special medical needs.

Utilize mobile services to meet needs of community members without access to transportation.

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Priority: Coordinate Provision of Clinical Services

Primary Actors: Health and Medical System Partners

Key Partners: State/Local Health Departments, Social Services Agencies, Behavioral Health Authorities, Emergency Management Agencies

Key Recovery Strategies:

• Leverage health care coalitions and other relationships among local care providers for health services strategic decision making, alignment of clinical resources, and coordination with public health and emergency management sectors.
• Use team-based care strategies to meet multifaceted clinical care needs.

Activities include but are not limited to:

Engage social services and community health workers to ensure comprehensive care needs of survivors are met.

Identify opportunities for collocating health care services with behavioral health and social services.

Intermediate- to Long-Term Recovery

Priority: Monitor Ongoing Health and Medical Needs of Post-Disaster Population

Primary Actors: State/Local Health Departments

Key Partners: Social Services Agencies, Health and Medical System Partners

Key Recovery Strategy:

• Use health assessments and health information technology to drive decision making for individual and community health and to inform future iterations of planning.

Activities include but are not limited to:

Conduct community health needs assessments.

Utilize aggregate data from health IT systems to evaluate ongoing clinical care needs and changes to patient demographics.

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Priority: Rebuild Health Care Facilities After Disasters for Increased Resilience and Sustainability

Primary Actors: Health and Medical System Partners, State/Local Health Departments

Key Partners: Emergency Management Agencies

Key Recovery Strategies:

• Leverage health care coalitions and other relationships among local care providers for health services strategic decision making, alignment of clinical resources, and coordination with public health and emergency management sectors.
• Ensure continuity of access to clinical care services.

Activities include but are not limited to:

Adopt construction standards and practices that ensure safety and continued functionality in the event of a disaster.

Rebuild and strengthen health care infrastructure through such methods as:

• – Structural hardening—use of construction elements (impact-resistant glass, waterproofing measures, backup systems for critical utilities like electricity, HVAC, plumbing) that maximize resiliency.
• – Incremental adaptation—address operational vulnerabilities that could cause loss of function. Ex. Relocating critical systems (HVAC, electricity) out of basement/lower level floors or redundancy for critical systems (multiple emergency power generators).
• – Innovative practice—increase resilience by transforming role of health care in communities and functionality. Ex. Relocating facilities to improve community access and expanding health services beyond acute care to health and wellness. Leverage network of providers outside hospitals for this role to allow hospitals to focus on acute care. Benefits communities during blue sky times and after disasters. Improving access and quality of care is discussed further in section below.

When necessary and feasible, rebuild significantly damaged medical facilities outside of known hazard areas.

Consider opportunities to improve sustainability of health care facilities (e.g., reduced carbon footprint, reduced water waste).

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Priority: Improve Health Care System Access and Quality of Care

Primary Actors: Health and Medical System Partners, State/Local Health Departments

Key Partners: Emergency Management Agencies, Urban and Regional Planning Agencies, Community Development Organizations

Key Recovery Strategies:

• Leverage health care coalitions and other relationships among local care providers for health services strategic decision making, alignment of clinical resources, and coordination with public health and emergency management sectors.
• Use team-based care strategies to meet multifaceted clinical care needs.

Activities include but are not limited to:

Ensure that all stakeholders—health care organizations, professional groups, public and private purchasers, and other health system participants—are focused on reducing the burden of disease and improving health through primary care and prevention.

Engage community leaders early in the process to express interest in participating in broader community redevelopment processes.

Improve quality by identifying opportunities to improve type of care, configuration and location of services to best meet the needs of the community.

• – Consider opportunities and benefits to adopting team-based and community-based care models (patient-centered medical homes, community paramedicine).
• – Identify opportunities to integrate health services with other assistance for vulnerable populations (e.g., public housing, senior housing).
• – Incorporate an all-hazards approach for effective emergency preparedness into the health care system.

Expand coverage in part through realignment of incentives.

Evaluate opportunities to fill preexisting gaps in health care capacity (e.g., primary care, behavioral health capacity).

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Priority: Update Planning Documents and Share Lessons Learned with Other Communities to Improve Post-Disaster Recovery Planning

Primary Actors: Health and Medical System Partners

Key Partners: Emergency Management Agencies, State/Local Health Departments

Intermediate- to Long-Term Recovery

Key Recovery Strategies:

• Leverage health care coalitions and other relationships among local care providers for health services strategic decision making, alignment of clinical resources, and coordination with public health and emergency management sectors.
• Use health assessments and health information technology to drive decision making for individual and community health and to inform future iterations of planning.

Activities include but are not limited to:

Update COOP plans based on lessons learned.

Participate in after-action process, including analysis of lessons learned and identification of opportunities for improvement.

Utilize state, regional, and national conferences, workshops, and discipline-specific professional meetings to share lessons learned and opportunities for improvement so that other jurisdictions can benefit from their recovery experiences.

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