Integrating Health System Preparedness and Community Resilience: Using the CMS Preparedness Rule as a Focusing Event

The CMS Emergency Preparedness Rule

The final emergency preparedness rule enacted by CMS requires 17 different types of health facilities to meet particular requirements in order to receive federal Medicare dollars. The rule is divided into 4 “elements” of preparedness (planning and risk assessment, policies and procedures, communication, and training and testing), and under each element there are provisions that each institution must meet. The rule requires collaboration in areas of training among different health facilities. Also, its broader requirements should strongly motivate healthcare facilities to reach out to community partners to make sure critical needs can be met in an emergency. ⁴ This was, in fact, made explicit in the final rule:

In addition, providers and suppliers should leverage resources through their memberships with professional associations and nongovernment agencies, such as the Red Cross. Many nongovernment organizations and both national and local professional associations provide vetted emergency preparedness resources, materials and trainings.^5(p64011)

The rule is also premised on the value of all-hazards preparedness. Previous research has found that features associated with all-hazards preparedness, such as standard operating procedures and training of personnel, were important across a range of scenarios. ⁶

While some may question the degree to which CMS will actually issue sanctions against hospitals and other healthcare organizations, including ambulatory surgery centers, dialysis centers, and hospices, for not meeting preparedness requirements under the rule, at the very least, the issuing of the emergency preparedness rule should serve as a focusing event to encourage collective community action around healthcare preparedness. Coalitions could serve an important role in promoting such action.

Potential Role for Healthcare Coalitions

Healthcare coalitions are entities funded through the Hospital Preparedness Program administered by the Assistant Secretary for Preparedness and Response (ASPR) in the US Department of Health and Human Services (HHS). These coalitions have historically been based around particular institutions, usually hospitals, that serve to bring other providers and community resources into the coalition. However, in 2012, HHS issued guidance in an attempt to change this model. Perhaps the most fundamental change to result from this guidance was the shift to a capabilities-based model for healthcare coalitions. These capabilities serve as performance measures to evaluate how well healthcare coalitions are performing in regard to “preparing for, responding to, or recovering from disasters and emergencies.”^7(p5) These capabilities are: providing a foundation for healthcare and medical readiness, coordinating healthcare and medical response, providing for continuity of healthcare service delivery, and preparing for medical surge. ⁷ The federal government has recognized for some time that these capabilities can be achieved through a variety of different coalition models. ⁸ The previous February, ASPR issued a grant directive authorizing the use of funds from the Hospital Preparedness Program to establish nonprofit coalitions.^9,10

Healthcare coalitions have demonstrated considerable effectiveness, not only in terms of planning and preparedness, but also participating in response activities. Researchers have noted the value of the coalition approach to past response efforts. Adalja et al noted that previous coalition building efforts in New York may have helped to build relationships between hospital emergency managers, which led them to contact each other first during Hurricane Sandy. ¹¹ This same article notes the Greater New York Hospital Association helped New York hospitals to function as a coalition when identifying available bed space and personnel in the midst of the emergency. Coalitions have been credited with similar success in directing patients to particular hospitals and preventing the system from becoming overwhelmed following the Boston Marathon bombing and the Amtrak train crash in Philadelphia. ¹² While Toner argued that healthcare coalitions have improved preparedness among hospitals and public health agencies as well as improving collaboration among diverse preparedness stakeholders that has proven valuable in disasters, he acknowledged that challenges persist. ¹³ Many coalitions remain underdeveloped, and inadequate funding can make it challenging to carry out essential functions. A 2015 report published by the American College of Emergency Physicians questioned the efficacy of coalitions in establishing adequate emergency preparedness and suggested that for-profit or not-for-profit healthcare systems should be allowed to function as coalitions as opposed to using the geography-based approach. ¹⁴

SETRAC, one of the largest coalitions in the United States, has worked with the Texas Department of State Health Services to ensure that hospitals receiving patient transfers during hurricanes were not in harm's way of the hurricane themselves. ¹⁵ The coalition has facilitated medical coordination during emergencies using software that allows the data of evacuated patients and of hospitals receiving evacuated patients to be compiled quickly and with a high degree of accuracy. This software was used to evacuate 2,400 patients during Hurricane Rita. ¹⁶ The coalition has also partnered with local groups such as the Cypress Creek Emergency Medical Services to offer its first bleeding control class to the general public, which was successful and has led to additional courses being offered. ¹⁷ Texas has been ahead of the curve, as they have a model based on the state's trauma system infrastructure going back to the passage of the Omnibus Rural Health Care Rescue Act in 1989. ¹⁸

During the response to Hurricane Harvey in 2017, SETRAC demonstrated its operational capacity. The coalition facilitated the transportation of a man with a life-threatening head injury from one hospital to another hospital with a Level I trauma center through coordination with the US Coast Guard. For the duration of the storm, SETRAC's Catastrophic Medical Operations Center served as a hub for information management, providing supplies and other types of assistance, maintaining situational awareness, and facilitating the transportation of patients in extremely hazardous conditions. ¹⁹

SETRAC has been cited for its success in fostering independence through collaboration with healthcare, public health, and emergency medicine stakeholders, as well as community partners such as civic and faith-based organizations. ¹⁹ Coalitions have been noted for several years as helping to address issues such as medical surge by promoting immediate bed availability in their jurisdictions. The Southwest Utah Preparedness Coalition, working with the local health department, regularly exercises its ability to update information regarding beds and other resources using the Utah Healthcare Resource Management System. It has also helped to develop relationships with organizations such as schools, churches, and sports teams to use their facilities to house less injured individuals in the event of an emergency. And the coalition has sought partnerships with mental health providers and faith-based organizations to provide psychological and spiritual support in the aftermath of an emergency. ²⁰

Such collaboration was evident in the response to the Chimney wildfire, which occurred in San Luis Obispo County in California in August 2016, just prior to the passage of the final rule. The area healthcare coalition was responsible for coordinating the healthcare response to the fire, which included coordinating with the Medical Reserve Corps and Red Cross to address physical and behavioral health needs in shelters and working with human services agencies to meet the needs of displaced people. The coalition also provided health surveillance, updated situational awareness, and helped oversee clean-up activities. ²¹ Such a response demonstrates the value of having well-trained and well-resourced healthcare coalitions ready to provide the kind of all-hazards preparedness the rule is designed to address. While this response and the work of the coalition in Utah predate the final approval of the CMS rule, they demonstrate how healthcare coalitions were already moving in the direction of drawing on a wide range of partners to collaborate on all-hazards preparedness and how the CMS rule can serve as a spark to promote such work in other organizations. ²⁰

The CMS preparedness rule has spurred notable responses in a number of other states as well. The Central Florida Disaster Medical Coalition, which consists of representatives from hospitals, long-term care facilities, federally qualified health centers, dialysis centers, and behavioral health facilities, developed a strategic plan for 2016-2018 that addressed the key major components of the rule. The plan addressed communication by setting a goal of developing an algorithm for updating and communicating coalition plans to stakeholders. In regard to policies and procedures, the plan set a goal of promoting medical surge capacity by better integrating policies, procedures, protocols, and regulations into the overall functions and planning of providers in the region. A number of items in the plan, including making sure that the coalition's plans aligned with existing plans to serve vulnerable populations, were to be tested with drills and exercises. Another objective of the strategic plan was to reevaluate their active assailant plan. ²² While this strategic plan was finalized prior to the passage of the final rule, there is much evidence that the national discussion on emergency preparedness strongly influenced it.

The Santa Clara Valley (CA) Emergency Preparedness Healthcare Coalition has also laid out a convincing roadmap for using healthcare coalitions to realize the benefits of the CMS preparedness rule. The coalition includes members representing providers such as hospitals, dialysis centers, EMS, skilled nursing facilities, community health centers, and surgical centers. In a presentation to the California Hospital Association, the coalition expressly described the CMS rule as the “seed for the coalition framework.”^23(p6) The coalition described an outreach and recruitment strategy to bring more community partners into the fold through a process of initial outreach (including cold calls), engaging with different committees, and sharing information at a variety of conferences. The coalition notes that the CMS rule brought more people to the coalition and that the planning and training program are modeled after the CMS rule. ²³

While many grant recipients were slow to initiate such collaborations, the recent implementation of the emergency preparedness rule by the CMS has spurred more action on the issue. Its broader requirements necessitate healthcare facilities reaching out to community partners to make sure critical needs can be met in an emergency. ⁴ Healthcare coalitions have already been working toward better implementation of the emergency preparedness rule by coordinating workshops and seminars provided by the Center for Domestic Preparedness. ²⁴ ASPR has also made available a wealth of educational resources, including reference documents and webinars, through the Technical Resources, Assistance Center, and Information Exchange. ⁸ Having well-functioning, independent healthcare coalitions may not only be beneficial to satisfying the rule, it may be essential. However, coalitions need not take on this work alone if they can integrate their preparedness efforts into a broader community resilience agenda.

Focusing on Resilience Instead of Preparedness

Taking advantage of money from multiple funding streams, community resilience coalitions have been sprouting in different areas around the United States and the world. An example of a global effort to promote community resilience is the 100 Resilient Cities Initiative. ²⁵ The website describes the organization as supporting “the incorporation and adoption of a view of resilience that includes not just shocks—earthquakes, fires, floods, etc.—but also the stresses that weaken the fabric of a city on a day-to-day or cyclical basis.” ²⁵ Resilience challenges addressed by US cities include “inadequate transportation and the connected risk of infrastructure” (Atlanta), “improving water management while fostering social cohesion and equity” (Boston), “identifying and integrating the needs of … vulnerable populations, building community cohesion, and reducing crime” (Chicago), preparing “for potential threats from rail accidents and climate change” (Minneapolis), and preparing for “risks from sea level rise” (New York City). While the cities noted and other US cities involved in the initiative are approaching the challenge of community resilience in part from a perspective of preparing for future emergencies, many are also addressing daily challenges like transportation and water quality, as well as social concerns such as community cohesion and integration. ²⁵ This initiative, which involves a range of partners from the public, private, and nonprofit sectors, suggests a larger framework into which issues such as healthcare emergency preparedness could be integrated. ²⁵

Schneider describes how emergency managers can become integrated into larger community sustainability initiatives and the importance of doing so: Emergency managers “must develop a role for themselves as a participant in the local consensus building effort” and “perceive themselves as working on a common agenda with other community institutions and leaders.”^26(p76) Emergency managers must also come to view “each phase of the [emergency management] function (risk assessment, mitigation, preparedness, response, and recovery) as a part of a holistic system.”^26(p76) Technical components, policies, and programs related to emergency management must be integrated into larger community planning and development efforts, making it an “essential or necessary component” of such efforts.^26(p76) Finally, “[t]he end product of emergency management must be understood as being fundamentally connected to all facets of community life in a coordinated effort to promote sustainability.”^26(p77)

The Near Southwest Preparedness Alliance (NSPA) serves the region around Roanoke, Virginia. ²⁷ Craig Camidge, executive director of NSPA, views healthcare preparedness as being strongly tied to community resilience.

“A poorly prepared facility represents a vulnerability for the community that may require resources and personnel if emergency response is needed—diverting those material and human resources away from other important areas of the community,” Camidge wrote. “A well-prepared facility, however, is an asset to a community for the very fact that they are not likely to consume emergency response resources immediately following a community-wide disaster. Their resiliency ensures response assets are in play for other areas of the community” (Camidge, email communication, February 2, 2018).

Smaller-scale initiatives at the local level also show how healthcare preparedness can be integrated with other areas of emergency management and community resilience in general. In Ohio, the Columbus CARE Coalition engages a variety of community stakeholders, including mental health providers, community organizations, city government, and community activists, to “identify and intervene when trauma occurs to promote healing and resiliency.” ²⁸ The coalition employs a 4-pronged approach of community outreach, developing a community trauma response team, networking with other organizations involved in trauma response, and providing trauma training to members of the general public. In regard to community outreach, the coalition provides workshops, training, and materials in advance of traumatic events, as well as support efforts after an event has occurred. ²⁸ The coalition has also identified a particular trauma certification program to guide training efforts moving forward. ²⁸ While one could view this as preparing for a catastrophic event likely to result in wide-scale trauma, one could also view this as better equipping members of the community to deal with the traumas that can affect them, their families, friends, or neighbors on a daily basis. In reaching out to different segments of the community, it is possible to get to know them and identify those areas most affected or most likely to be affected by trauma and meet those needs on an ongoing basis. While this coalition is more concerned with psychological and emotional trauma than the kind of physical jeopardy more commonly associated with healthcare coalitions, examples of the work of healthcare coalitions noted the need to partner with mental health partners and faith-based organizations to tend to emotional and psychological wounds after a crisis.

The Putnam County (NY) Community Resilience Coalition is funded through the Resilient Children/Resilient Communities Initiative led by Columbia University's National Center for Disaster Preparedness and Save the Children, with funding provided by GlaxoSmithKline. The goal of the overall project is to develop a model of resilience focused on children that can be employed in communities throughout the United States. Putnam County's approach involves stakeholders including emergency management, public health, schools, foster care, first responders, and other community organizations. The Putnam County Coalition also has 4 goals: build resilience among community organizations that promote resilience among children, improve the area's ability to meet the psychological and psychosocial needs of children, build networks and improve coordination of emergency plans, and increase awareness of efforts to protect children amid disaster.

Putnam County has reported progress in regard to meeting these goals, including carrying out a community needs assessment, creating “best practices” checklists for emergency shelters, coordinating a county-wide table-top exercise and after-action report, and increasing the ability of response and community organizations to deliver messages directly to families and children. ²⁹ This effort again incorporates significant aspects of emergency preparedness, but also incorporates elements to improve the lives of children on a daily basis, such as strengthening the organizations they depend on and seeing that their psychological and psychosocial needs are met on an ongoing basis. While again focusing on emotional and psychological trauma, this is another example of a community coalition that healthcare coalitions can easily find common cause with, not only because of their shared interests in attending to harm in the community after a catastrophic event, but also in regard to their aim to improve daily life in the community.

The Los Angeles County Community Disaster Resilience (LACCDR) Project works to develop improved strategies for engaging community stakeholders, such as faith-based organizations, in community resilience efforts before a public health emergency occurs. It was established by the city department of health in cooperation with the RAND Corporation, the UCLA Center for Health Services and Society, and the Emergency Network of Los Angeles. ³⁰ Community organizations involved include the American Red Cross, City Youth and Family Services, community mental health providers, the school system, and the local chamber of commerce. ³¹ In a review of the project, the majority of project participants were found to be engaged in public health education efforts, maintaining ongoing communication with community partners, and engaging in outreach to vulnerable or at-risk members of the community, although lack of training on how to build community partnerships was identified as a barrier. ³²

While some of these coalitions created as part of the project may be in a more nascent stage, more developed community resilience coalitions have been able to demonstrate measurable benefits from their activity. Chandra et al report that in a table-top exercise, the resilience coalition performed as well as or better than strictly preparedness coalitions in regard to self-sufficiency and partnership, although both types of coalitions were lacking in educational materials to address relevant topics. ³³ It is important to note that the creation of the LACCDR is part of a study coordinated through multiple community stakeholders and funded with a Public Health Emergency Preparedness grant, money from the National Institutes of Mental Health, and support from the Robert Wood Johnson Foundation. The purpose of the study is to evaluate the level of resilience in the communities before the coalitions are established as well as after. ³⁴

Each of these community resilience coalitions has a specific focus, whether on intervening to provide assistance after a community trauma, protecting children, or improving health outcomes. These larger community resilience efforts that seek to regularly engage with the community could easily find many ways to integrate the work of healthcare coalitions and help meet the requirements of the CMS rule. This would not only benefit the healthcare coalitions in regard to increased visibility and resources and the healthcare facilities in regard to improved preparedness, but it would also advance the missions of these respective groups. Lack of functioning healthcare facilities during an emergency will delay care for trauma victims and make their situation worse. More children will be put at risk if healthcare institutions in the community are not functioning and working in coordination with each other. In the case that public health emergencies, such as those which are the focus of the LACCDR, reach a critical mass, the healthcare sector will need to have the capacity to deal with those who are harmed. Conversely, efforts to build capacity in the healthcare sector can help to prevent large-scale emergencies, particularly if they contribute to improved planning, collaboration, and communication.

The LACCDR is the community resilience coalition most comparable to healthcare coalitions, as they are expressly focused on natural and public health emergencies. That model can offer insight into how efforts to make healthcare coalitions more sustainable can be accomplished within a resilience framework and also how that framework can allow communities to use the CMS rule as a focusing event to rally stakeholders around health system preparedness.

The importance of focusing events is an important component of Baumgartner and Jones's punctuated equilibrium theory. ³⁵ This theory holds that policy tends to remain stable over time until a punctuating event occurs that disrupts that stability. After the disruption has passed, a new state of equilibrium sets in, although it will be a different state of equilibrium than what existed before. The approval of the CMS emergency preparedness rule has led to a disruption in the US healthcare community because it has forced some providers who have not previously been engaged with preparedness issues, such as ambulatory surgery centers, to address such issues. Whether or not the financial penalties associated with the rule are rigorously enforced, the training sessions, conferences, and relationships developed as a result of the rule, as well as the manner in which it elevated organizations' consciousness regarding preparedness issues, is likely to have important long-term benefits. The expense for developing these relations is largely limited to time, but these relationships are likely to have the most durable effects in improving preparedness.

A paper by Williams et al evaluated the performance of the LACCDR in achieving its goals by comparing community resilience coalitions to more traditional public health preparedness coalitions. ³⁶ Resilience coalitions were found to be larger and to have more varied partners, perhaps due to specialized training regarding how to expand their coalition. The resilience coalitions provided more community training with more of a focus on vulnerable populations. Additionally, the training activities engaged in by resilience coalitions were geared toward allowing people to disseminate information to others, as opposed to preparedness coalitions engaging in more standard exercises to test preparedness plans. The study also found that, while there was a statistically significant difference in levels of trust between resilience and preparedness coalitions in the first year, resilience coalitions improved the level of trust in the second year so that it was no longer significant. The authors speculate that since more organizations were involved in the resilience coalitions, the process was disruptive at first, but as partnerships were developed the disruption eased and the larger coalitions were able to engage in a larger number of and more diverse activities. ³⁶

From Resilience to Sustainability

Whereas ASPR previously gave a lot of latitude to the states, the office is now requiring that states fund healthcare coalitions and stop direct facility—that is, direct hospital—funding within 2 years. Thirty times in the new rule, CMS states that it “strongly recommended” that healthcare providers and suppliers seek the counsel and assistance of their healthcare coalitions to reduce their administrative burdens and implementation costs. On November 15, 2017, the rule became enforceable, and institutions are scrambling to find their healthcare coalitions—which, too often, are not ready to help them.

This is a critical juncture for healthcare preparedness. Congress does not appear to be pressing for a change to the rule, and CMS appears to have worked with ASPR to link the Public Health Emergency Preparedness cooperative agreement with the preparedness rule. Meanwhile, healthcare coalitions must show engagement with what ASPR calls the “core four”—hospitals, emergency management agencies, public health departments, and emergency medical services—and if not, the state must withhold funding. The bottom line is that ASPR has implemented grant requirements, funding restrictions, reporting metrics, and oversight mechanisms that drive the necessity of effective, neutral organizations.

One could argue that there is not as much pressure on the health preparedness sector as it first appears, based on previous evidence that (1) the federal government is unlikely to carry out a threat to withhold funding, and (2) if health facilities will not really be held to higher preparedness standards, it reduces the need for sustainable healthcare coalitions. Even if one accepts both of these premises to be true, the finalizing of the CMS rule and the guidance on healthcare coalitions represent an opportunity to break down the barriers between public health emergency preparedness and community resilience efforts. The federal government requiring healthcare facilities to enter into partnerships and memoranda of understanding with outside entities to demonstrate that they can continue to provide an adequate standard of care in an emergency creates an opportunity for healthcare institutions to become more engaged in broader community resilience efforts, such as those to assist individuals who have been victims of traumatic violence or helping children to be better prepared for extreme weather events.

In terms of developing sustainable healthcare coalitions, there are a number of examples of coalitions excelling by going beyond the “core four” and incorporating a broader diversity of community partners. Doing so allows healthcare coalitions to better demonstrate their capacity to deal with everyday struggles as well as major catastrophes that may strike in the future. By becoming better integrated into efforts under the banner of community resilience, healthcare coalitions have an opportunity to show that they are not just about preparing for disasters that may come in the future, but about being a partner in dealing with today's challenges. Preparedness may be seen as being stronger tomorrow, but resilience is seen as being stronger today.

Conclusion

The federal government has communicated through the issuance of the CMS Hospital Emergency Preparedness Rule that healthcare preparedness should be more highly prioritized by health facilities. At the same time, the federal government has communicated through guidance regarding the Hospital Preparedness Program that coalitions should be prepared to be more entrepreneurial in achieving their goals and objectives in the coming years. Incorporating health system preparedness and healthcare coalitions into a broader framework of community resilience is an approach to achieving those goals. If hospitals and other facilities are willing to contribute time, attention, and resources to initiatives like improving environmental quality, repairing infrastructure, and improving the quality of life for vulnerable populations in communities in ways that improve the daily life in a community, then more businesses, nonprofits, and other organizations in the community will have incentive to participate in healthcare security planning when the time comes. Coalition participation in this work will also help to emphasize how interconnected public health is with all of these issues.

As noted by Manna in reference to No Child Left Behind, even if federal policy seeking to employ sanctions is not an effective “stick” to accomplish goals, such efforts can still emphasize important issues, promote the setting of goals, encourage redistribution of resources, and induce behavior changes. ¹ Behaviors induced could include emergency managers working on a common agenda with other community leaders; integrating technical components, programs, and policies with larger community sustainability efforts; and linking all community policies to the concept of sustainability. ²⁶

Many people see healthcare emergency preparedness as planning for tomorrow as opposed to meeting the challenges of today, whereas resilience is seen by many as getting strong today to meet both current and future challenges. By becoming more involved in larger community resilience efforts, healthcare coalitions can better demonstrate the value of emergency preparedness today and in the future. Whether the CMS rule proves to be an effective stick in pressing health system preparedness, it can serve as a focusing event to get healthcare coalitions more fully integrated into the communities they serve.