This is called when an emergency occurs WITHIN the Medical Center that interferes with our ability to care for patients. Being prepared for a natural disaster, infectious disease outbreak or other emergency where many injured or ill people need medical care while maintaining ongoing operations is a significant challenge for local health systems. Both hospital and community practice respondents acknowledged a sense of alienation from each other, noting that the smaller the practice, the more difficult it is to participate and have a voice in community collaborations.
During the H1N1 pandemic, for example, some coalitions developed plans to distribute supplies in advance.
Across sites, respondents consistently reported that hospitals and hospital-owned physician practices typically are much more involved in emergency-preparedness coalitions than other stakeholders, reflecting both the federal financial support hospitals receive for preparedness activities and their size, structure and resources.
There are two general approaches policy makers could consider to broaden participation in emergency-preparedness coalitions: providing incentives for more stakeholders to join existing preparedness coalitions or building preparedness into activities providers already are pursuing. Other opportunities might include incorporating community-level preparedness activities into care-coordination activities that can count toward patient-centered medical home certification or encouraging electronic health record vendors to include features that facilitate electronic submission of important data to local, state and federal authorities during a disaster. If collaborative preparedness activities leveraged existing affiliations and activities among stakeholders, the resulting coalitions might look very different from community to community. HackensackUMC has developed a model emergency response plan integrated with local, regional, military and federal entities. 11, 2001, terrorist attacks, many health care providers have adopted emergency-preparedness plans, including participation in such activities as community-wide drills and tabletop exercises, to strengthen their ability to respond to a disaster.
First, preparedness activities, such as planning, training and participating in drills, do not generate revenue for health care providers but have costs in staff time and materials. Nonmedical stakeholders, such as police, fire, coroners, school systems and employers, have varying degrees of involvement in medical emergency planning collaboration. In some hospital systems, the system’s preparedness plan directly encompassed physician practices owned by the hospital system. Rural respondents reported depending on buy in from a smaller pool of institutional leaders, and these leaders did not always perceive value in allocating limited funding and staff time for emergency management and participation in coalitions. However, most attention has focused on population-level management of obesity or chronic illness rather than disaster preparedness and response. Other stakeholders, particularly smaller and independent primary care practices, could potentially contribute to preparedness efforts, but there are significant barriers to involving them in traditional coalitions in a sustainable way. For example, programs that offer extra payment to primary care practices to coordinate care of patients with specific chronic conditions might also encourage and reward coordination related to emergency preparedness or the creation of business continuity plans. Similarly, hospitals and physician practices using a common electronic health record platform may find it easier to share real-time information about utilization and to prepare jointly for surges.
Given the low probability of certain events, stockpiling supplies and committing staff to emergency preparedness often are not high institutional priorities.4 In addition, community coalitions require competitors to work collaboratively. Regional or specialty-based medical societies may maintain similar lists and can provide basic training in disaster planning through continuing medical education.
However, respondents across all sites generally agreed that providers put normal competitive dynamics aside for preparedness efforts and meet and share information on capacity and supply chains when needed.
As one respondent said, “Rural hospitals are facing huge budgetary issues right now. As a prolonged, low-mortality event, H1N1 tested community preparedness, clarified the challenges different stakeholders face, and pointed to ways to broaden and strengthen local collaboration. Hospital staff in nearly all sites reported challenges with fit-testing disposable protective face masks because of the staff time required and because fit-testing alone consumed a substantial proportion of their inventory.


Physicians and other clinicians employed by hospitals or working in community-based practices owned by hospitals usually fall under the umbrella of hospital preparedness activities. Even in a disaster where victims seek care at hospitals, community-based clinicians can play a role.
Maintaining adequate supplies, particularly of masks, was a challenge when hospitals in a community, as well as public agencies, were competing for the same products. We are just about a week into National Preparedness Month and already a number of informative articles, social media posts, and even contests have been published providing many great ideas and resources for building, or updating, your preparedness plan.
Challenges to developing and sustaining community coalitions may reflect the structure of preparedness activities, which are typically administered by designated staff in hospitals or large medical practices.
In contrast, much less attention and funding have focused on involving other health care providers, such as independent physician practices, ambulatory care centers, specialty care centers and long-term care facilities, in community-based preparedness activities.
Consider building preparedness into activities providers already are pursuing.An alternative approach to traditional preparedness coalitions would be to leverage activities providers already are pursuing unrelated to preparedness activities. Maintaining preparedness is a daunting task, given that emergencies can spring up at a national, regional or local level and take forms as varied as a global pandemic, a regional hurricane or a local outbreak of food-borne illness.
While there is limited funding for preparedness activities, hospitals are not subsidized to keep beds empty and supplies stockpiled for a disaster, and it is impractical for trained staff to sit idle until a disaster strikes. Each of these factors may affect how planning responsibilities, staff and information are most efficiently shared in preparation for and during a disaster. The focus on hospitals reflects their historic importance in providing staff, space for planning and response, and treatment of emergency victims, including such specialized services as decontamination or burn care. This study’s findings suggest that preparedness work could be integrated with broader care delivery, with possible implications for how to evaluate coalitions. High levels of physician participation in those markets were attributed to hospital systems setting the expectation that physicians would participate and paying them for their efforts, and, in some cases, even allotting them administrative time to participate in preparedness or other system-level work.
A few respondents reported that competition did affect preparedness collaborations, particularly when hospital leaders are guarded about sharing capabilities and needs with peers at other institutions. Employment of physicians is only one of the ways markets vary—hospitals may be independent or tightly affiliated with one another, nursing homes may be closely linked to local hospitals or to national chains, and health information may be shared widely or not at all. For example, in a disaster, hospitals generally try to discharge as many inpatients as possible, and community-based providers could help by seeing or contacting discharged patients to ensure they are receiving needed follow-up care. Other respondents reported frequent communication among competing hospitals on shared pandemic plans and hospital policies for emergencies. Most primary care respondents agreed that physicians are focused mainly on their patients’ day-to-day needs and do not see preparedness as part of their mission. Nearly all hospitals working with both hospital-employed physicians and independent community-based physicians reported that hospital-employed physicians are easier to engage, suggesting that markets with larger physician groups and more hospital employment of physicians would be better positioned to build integrated surge-capacity plans. For example, nursing homes owned by or closely affiliated with hospitals may use the hospitals’ preparedness staff, making it easy to develop collaborative approaches to preparedness.
Emergency preparedness requires coordination of diverse entities at the local, regional and national levels. For example, outside Seattle, three small rural hospitals pooled funds to hire a shared emergency manager across the facilities. Policy makers could encourage groups whose participation is currently limited in most communities, such as independent physician practices, to join traditional preparedness coalitions that meet regularly to develop joint plans or coordinate responses. Given the diversity of stakeholders, fragmentation of local health care systems and limited resources, developing and sustaining broad community coalitions focused on emergency preparedness is difficult.


A hospital respondent in another community coalition cited reluctance to work with nursing homes because of the perception that they are primarily looking for a place to offload patients in an emergency.
At the same time, public health preparedness experts have sought to develop methods to evaluate community coalitions. And, unlike other events that health care organizations must prepare for, such as Joint Commission inspections, there are no predictable, short-term consequences for failing to engage in collaborative, community-level disaster planning. Some health systems did expect employed physicians in community practices to work collaboratively in disaster planning.
In some cases, this reflected a commitment at the highest levels of organizations, but, in other cases, it reflected rapport among preparedness staff.
Two additional sites were added: New York City because of significant investment in preparedness and Chicago to increase Midwestern representation. Providers and policy makers alike increasingly have recognized the value of collaboration through community-based preparedness initiatives to minimize the amount of redundant capacity each provider must maintain. One option would be to incorporate preparedness activities into existing incentive programs aimed at underrepresented stakeholders, including independent physicians and nursing homes. The H1N1 influenza pandemic was the most recent national event that required large-scale preparedness and response. No rural respondents described working with their state office of rural health on emergency preparedness. While hospitals and public health departments participated in all emergency-preparedness coalitions in the communities studied, involvement of nonhospital providers and other stakeholders varied significantly across the communities (see Table 1). That’s the mentality at small as well as big hospitals, [but] you can multiply that by 100 for small [rural] hospitals. Sixty-seven telephone interviews were conducted between June 2011 and May 2012 with representatives of state and local emergency management agencies and health departments, emergency-preparedness coalitions, hospital emergency preparedness coordinators, primary care practices and other organizations working on emergency preparedness and response. Because of the generally collegial approach to preparedness activities, respondents reported that tighter hospital affiliations in consolidated markets had little impact.
There are two general approaches policy makers could consider to broaden participation in emergency-preparedness coalitions: providing incentives for more stakeholders to join existing coalitions or building preparedness into activities providers already are pursuing. Some offer on-site health care, which may serve as an alternate source of care that is not always coordinated with hospitals or independent practices, and others may require documentation from a clinician before potentially affected people can return to school or work. Changes in local market structures, such as increased hospital employment of physicians, also may diminish barriers in some communities. A number of different federal, state and local organizations work with health care providers individually and collectively to promote collaboration in preparedness activities.
Likewise, hospital efforts to work with physician practices and long-term care facilities to prevent avoidable readmissions might incorporate preparedness activities. We spent 100+ hours planning, researching, and gathering emergency supplies to share ideas with others. While all providers felt the strain of competing demands in allocating resources for emergency preparedness, rural providers were particularly strapped.



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