Chapter 4: Integration of the Healthcare Coalition into Overall Emergency Response and Recovery

In Section 2.1.1, candidate incident response and recovery objectives were presented for the Healthcare Coalition. If these objectives are adopted by a Coalition, then the strategies used to achieve them can be grouped according to the following categories:

• Promote situational awareness and consistent response actions among Coalition member organizations by facilitating information sharing.^[39]
• Represent the collective interests of the Coalition member organizations in addressing issues with incident command and jurisdictional authorities (Tier 3).
• Facilitate resource support to Coalition organizations through mutual aid and other assistance mechanisms.
• Enhance support to Coalition member organizations from the Jurisdictional Agency (Tier 3) directly or from other entities (e.g., State or Federal government) through the Jurisdictional Agency.

Examples of response strategies that a Healthcare Coalition may incorporate into its EOP are provided below.

Promoting situational awareness and consistent response actions among Healthcare Coalition member organizations

The information processing function of the HCRT plays a key role in providing situational awareness among Coalition members. As an extension of this strategy, the HCRT can also promote consistency in response actions among its member organizations without impinging on their independent decision-making authority. The Coalition can achieve this support through the following actions:

• Collecting, compiling, and reporting situation updates and other data from Coalition members. Reported data may include how the hazard has affected each healthcare organization in terms of patient volume, patient types, or direct impact on the healthcare organization itself. Information collected and disseminated can also include how Coalition members are responding.
• Facilitating patient tracking for Coalition member organizations and providing this information back to healthcare organizations so they can assist families searching for loved ones.
• Collecting, compiling, and reporting information about each Coalition member’s response strategy.
• Collecting (from Public Health authorities or subject matter experts) and disseminating recommendations related to specific response actions for unusual patient cases. These recommendations could include information related to changes in the understanding of a disease or injury pattern or protocols for the evaluation or treatment of incident patients. These efforts require close coordination with Public Health authorities.^[40]
• Promoting consistent public messaging for Coalition member organizations. This can be achieved, in part, by disseminating public information guidance from the Jurisdictional Agency (Tier 3), which has lead responsibility for public information. As discussed in Chapter 3, it may entail convening individuals from member organizations to promote consistency of public messages. The Coalition may also monitor the media for erroneous or alarming messages that could impact the public perception of the healthcare response.

Representing the collective interests of Coalition members to the Jurisdictional Agency (Tier 3)

The HCRT can represent Coalition members in their interactions with the Jurisdictional Agency (Tier 3) during response and recovery. Examples of activities the Coalition could engage in include:

Addressing public sector actions that might adversely impact healthcare organizations: Public safety, public health, and other agencies may implement response tactics that inadvertently compromise operations at healthcare organizations. For example, roadblocks used to secure an area during a mass gathering can hinder healthcare personnel from reporting to their workstations. The HCRT can bring these types of issues to the attention of the jurisdictional authorities in an effort to resolve them.

Promoting financial support to healthcare organizations for response services and expenses: Because of the fiscal environment in which many healthcare organizations operate, they are especially vulnerable to interruptions in reimbursement for services, increased expenses related to medical surge, or other service obligations, such as mass decontamination. These activities often do not have a clear mechanism to recoup expenses, especially when the specific patient population is not insured. The Healthcare Coalition, working with its members and jurisdictional authorities, can facilitate solutions in conjunction with third party payers and government funding sources. Potential issues that the Coalition may address include:

• Payment for emergency response services that do not have a billing code. As noted above, some emergency actions may not have assigned billing codes, but may generate significant costs for the Coalition member organizations (e.g., decontamination, preparations for a large security event). The HCRT can facilitate meetings between Coalition member organizations and the appropriate authorities to promote fair reimbursement for these services.
• Payment for services provided in “non-participating” and “non-traditional” healthcare settings. Third party payers may have contracts for services that are provided only at certain preferred (“participating”) healthcare organizations, or facilities with a designated level of service (e.g., pediatric care at a hospital licensed and accredited for pediatric services). During emergency response and recovery, it may be helpful to modify these restrictions when the healthcare system is severely challenged. The HCRT can facilitate meetings to bring this issue to the attention of the appropriate authorities to seek resolution.

Addressing uneven patient distribution: Given the likely influx of victim “walk-ins” during a mass casualty incident and the potential for a direct hazard impact on healthcare delivery, strategies for patient distribution may need to be adjusted in real-time. The HCRT can assist with this by collating data (status reports) from individual healthcare organizations and transmitting the data to EMS or other authorities managing patient distribution. In addition, returning the aggregate data to Coalition member organizations enables them to anticipate response actions and develop contingency plans.

Facilitating mutual aid and other resource support between Coalition member organizations

As noted earlier, Healthcare Coalitions can serve an important role in facilitating mutual aid and other resource support between healthcare organizations. Key roles for the Coalition are described below.

Facilitating requests for and offers of assistance: The HCRT can receive and disseminate requests for assistance; receive offers of assistance from all legitimate sources (other Coalition members, jurisdictional authorities, etc.) and convey them to the impacted organization; connect the organizations offering assistance to the requesting organization; assist the requesting organization with determining which resources are best suited to fulfill the need;^[41] and transmit all mutual aid requests and related actions to the relevant Jurisdictional Agency(s) (Tier 3). In some instances, the most important assistance may be to screen the deluge of assistance offers (at the request of the impacted organizations) and convey only those offers relevant to the described needs, thus lightening the burden on facility managers at the impacted organizations.

The process for requesting and offering assistance should be based on a written instrument that is adopted by all Coalition members during preparedness planning (see Section 7.3). This enables the HCRT to assist with the resource sharing process while avoiding any command decision-making role.

Trouble-shooting issues related to mutual aid: Despite the best intentions, conflicts related to resource support may arise between Coalition members. The Coalition may establish procedures for resolving these conflicts. In some situations, the Coalition’s Senior Policy Group may become involved. However, the Coalition only facilitates the interface between the involved parties; it typically has no authority to be the arbiter or determine a resolution.

Facilitating resource support from jurisdictional authorities

The HCRT may facilitate external resource requests and assistance for its member organizations when mutual aid from within the Coalition is unavailable or insufficient. Much of this is conducted through a process similar to the facilitation of mutual aid between Coalition members. Specific concepts for consideration are described below.

Coordination of resource requests:When resources are needed by multiple healthcare organizations simultaneously, the requests can be processed more efficiently if they are received by the Jurisdictional Agency(s) (Tier 3) through one source (i.e., the HCRT). The HCRT can provide a “needs picture” to the Jurisdictional Agency(s). The HCRT can also standardize the format and wording of requests to improve the accuracy of their interpretation by the Jurisdictional Agency (Tier 3) or by State (Tier 4) or Federal officials (Tier 6) who receive requests through the Jurisdictional Agency.

Distribution of resource assistance: The Healthcare Coalition can promote a “level playing field” for its members by facilitating how resources are best distributed to meet patient need. For example, the HCRT might hold a teleconference between organizations that are requesting the same scarce resource (e.g., ventilators) from a medical equipment cache. The HCRT can help the requesting organizations reach an agreement on the most appropriate way to distribute the scarce resource. The Senior Policy Group may be asked to assist with any particularly contentious or controversial allocation decisions.

Emergency patient transfer out of the area: If patient transfers are required outside of the Coalition’s geographic area, the Healthcare Coalition may support its member organizations through direct interface with the Jurisdictional Agency (Tier 3). The HCRT may serve as a coordinating point in conjunction with the Jurisdictional Agency as it prioritizes and allocates these transfers.

Potential response strategies for the Healthcare Coalition in relation to jurisdictional authorities include:

• Promote a common operating picture (situational awareness) between Coalition member organizations and the community response^[43]
• Supplement, but not supplant, the ability of the Jurisdictional Agency to execute its incident management responsibilities (i.e., support the interests of the Jurisdiction in relation to relevant healthcare organization response activities)
• Facilitate the delivery of external support by the Jurisdictional Agency to Healthcare Coalition member organizations.

The Healthcare Coalition’s activities benefit jurisdictional authorities (Tier 3) by providing an efficient conduit for the jurisdiction’s authorities to disseminate guidance, acquire information, and coordinate activities between public health and the private healthcare sector.

Promote a common operating picture between healthcare organizations (Tier 1) and the community response (Tier 3)

The information processing function of the HCRT may be critical in helping the Jurisdictional Agency establish a common operating picture for the community response. Much of the data that a Coalition collects and disseminates is useful to Jurisdictional Agencies. Similar to activities listed in 4.1.1, the Coalition might select the following strategies:

• Collect, compile, and report situation updates and other data from Coalition members to the relevant Jurisdiction Agency(s) to enhance situational awareness. Reported data can include how the hazard has impacted Coalition member organizations.
• Facilitate the tracking of incident patients treated by Coalition organizations to maintain accountability for patients and facilitate family reunification efforts by Jurisdictional Agencies.
• Collect, compile, and report elements of Coalition members’ response strategies, which may vary across organizations. This could help shape recommendations given by the jurisdiction.
• Provide an outlet for recommendations from the Jurisdictional Agency(s) to Coalition members (e.g., treatment protocols).

Supplementing, not supplanting, jurisdictional incident command

Many of the Healthcare Coalition’s information processing activities can assist the overall management of the incident by the relevant Jurisdictional Agency(s) if the products are appropriately disseminated to these agencies. Exhibit 4-1 provides one example.

Exhibit 4-1. Assistance with rapid epidemiological investigation

Public health authorities often have the difficult task of developing an accurate and complete epidemiological picture of an incident. This may require them to rapidly collect data and information from many disparate sources.^[44] The ability of the HCRT to acquire, aggregate, and transmit epidemiological data from its member organizations can markedly assist with this task and be mutually beneficial.

It is important that the Healthcare Coalition is not perceived as competing with or intruding on the incident management responsibilities of jurisdictional authorities (Tier 3). The Healthcare Coalition should make every effort to prevent this perception by ensuring the following:,/p.

• Timely notification to jurisdictional authorities (Tier 3). The Notification Center Technician or Duty Officer may be the first to receive a report that a potential incident is occurring. There must be a reporting mechanism in place to rapidly notify jurisdictional authorities (Tier 3).
• Participation in Incident Action Planning conducted by the relevant Jurisdictional Agency(s). The response of the HCRT and Coalition member organizations should be consistent with the overarching response objectives, strategy, and tactics of the Jurisdictional Agency. This coordination may require, at the request of the Jurisdictional Agency, the participation of the HCRT or select personnel from Coalition member organizations in local Incident Action Planning activities. HCRT personnel should be available to participate in planning meetings or operations briefings with the Jurisdictional Agency.
• Availability of medical and other advice to the Jurisdictional Agency. Even if not participating in the Jurisdictional Agency’s Incident Action Planning, the HCRT may be asked to provide expert advice related to medical issues. This could include identifying subject matter experts from Coalition members to provide advice to jurisdictional authorities on issues such as protective measures and other safety issues for responders encountering an unusual infectious agent.
• Adjusting to the strengths and weaknesses of the Jurisdictional Agency. Some Healthcare Coalitions may reside in areas with robust public health and medical resources in the public sector. This does not obviate the need for the Healthcare Coalition; it merely reshapes its operational focus. For example, a jurisdiction may already have an efficient process to collect response data from local healthcare organizations. The HCRT might still enhance response coordination between Coalition members by providing a forum for direct information exchange. Alternatively, if few public health and medical resources reside in the local public sector, the Healthcare Coalition, through the HCRT, may develop more robust processes to support the public sector’s incident management responsibilities. This should be defined in collaboration with local public agencies during preparedness activities.

Facilitating support from Jurisdictional Agencies to Coalition partners and from the Coalition to the jurisdictional response

When resource support is requested through mutual aid within the Healthcare Coalition, the relevant Jurisdictional Agency(s) managing the overall response should be informed. The Coalition can also facilitate the provision of support from Jurisdictional Agencies to healthcare organizations by facilitating equitable assistance based on actual need. Jurisdictional Agencies may provide the following types of assistance to Coalition members during incident response:

• Medical equipment and supplies
• Medical personnel (including solicited volunteers)
• Facilities (e.g., public facilities to address surge capacity)
• Assistance with infrastructure support, such as utilities
• Requesting, from appropriate authorities, modification of day-to-day healthcare regulations to fit the needs of the specific incident (e.g., temporarily modifying the permissible number of licensed beds in a residential healthcare facility)
• Emergency funding for unusual services (e.g., decontamination) or an unusual level of service delivery (e.g., increasing staffing for a mass demonstration or other type of planned event)
• Police augmentation of healthcare organization security departments and traffic control
• Strategic and tactical guidance to healthcare organizations on such issues as victim evaluation or treatment (e.g., conveying new protocols for assessing patient exposure as additional risk information is obtained from a chemical release site)
• Morgue resources and guidance for mass fatality incidents.

Response strategies for the Healthcare Coalition with regard to other Healthcare Coalitions include the following:

• Coordinate information sharing with other regional Healthcare Coalitions to enhance situational awareness about an incident and promote a common operating picture regarding the regional healthcare response.
• Facilitate assistance through regional mutual aid so that all healthcare organizations can optimally contribute to or benefit from available regional, State, and Federal response assistance.
• Promote consistent and effective healthcare response actions between Healthcare Coalitions across the affected region(s).

Each of these response strategies, and the major actions required to accomplish them, are described below.

Coordinate information sharing between Healthcare Coalitions

A common operating picture of the regional response to a healthcare emergency may be achieved by exchanging incident related information between Healthcare Coalitions. This may include aggregate data that has been collected by the HCRT from its member organizations, as well as information provided by the Jurisdictional Agency(s). Protocols for how this information will be shared between Healthcare Coalitions should be established during preparedness.

Facilitate regional resource support

The resource pool available for meeting requests for assistance may be expanded if there is good coordination between regional Coalitions. This ideally should be established through preparedness initiatives and addressed using instruments and processes described in Chapter 6.

Mutual aid and cooperative assistance between Healthcare Coalitions may include more than just physical resources. For example, experienced HCRT personnel from one Coalition may assist with the emergency response of another Coalition.^[46] This type of assistance may help beyond the actual incident by promoting future relationships and advancing preparedness initiatives. In addition, newer Coalitions may benefit greatly from sharing tools and SOPs from a well-established Coalition.

Promote effective and consistent regional healthcare response

Regional coordination of healthcare response objectives, strategy, and major tactics can promote consistency in the healthcare response across the region and enhance public cooperation. This may occur by sharing action plans between Tier 2 Coalitions or exchanging other pertinent information, such as patient evaluation and treatment protocols. These actions can help promote and maintain consistency even as incident information and follow-on directives evolve.