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Workshop Summary
INTRODUCTION
As part of its ongoing mission to foster dialogue among stakeholders
and to confront the challenges inherent in ensuring the nation’s health
security, the Institute of Medicine (IOM) Forum on Medical and Public
Health Preparedness for Catastrophic Events sponsored a town hall
session at the 2012 Public Health Preparedness Summit, held February
21-24 in Anaheim, California.1 The session was facilitated by Lynne
Kidder, president of the Bipartisan WMD Terrorism Research Center and
co-chair of the IOM Forum.
As summarized by Kidder, other sessions of the 2012 Summit
discussed the value of regional capacity building; the importance of
interagency, intergovernmental, and public-private collaboration; and the
significant role that health care coalitions can play in ensuring resilient
communities and national health security. In this session sponsored by
the IOM, the focus of discussion was sustaining health care delivery
beyond the initial response to a disaster and facilitating the full long-term
recovery of the local health care delivery systems. The following text
serves as a summary of only the IOM-sponsored session.
As part of the critical infrastructure of any community, health
systems and assets are vital not only for the safety and well-being of its
citizens, but also for the economic vitality, quality of life, and livelihood
1
The planning committee’s role was limited to planning the town hall session, i.e.,
workshop. The summary has been prepared by the workshop rapporteurs as a factual
summary of what occurred at the workshop. Statements, recommendations, and opinions
expressed are those of individual presenters and participants, and are not necessarily en-
dorsed or verified by the IOM, and they should not be construed as reflecting any group
consensus.
1
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2 POST-INCIDENT RECOVERY CONSIDERATIONS
of the entire community. Many elements required for recovery are also
fundamental to the day-to-day operations of these systems (e.g.,
information sharing, identifying and leveraging existing capabilities of
medical providers in a community, developing trusted relationships).
Investing in improved health care delivery systems, both financially and
through collaborative capacity building, can enhance economic devel-
opment and growth before a disaster, and also prove instrumental in
sustaining services and recovering after a disaster.
While the impacted local communities are the first responders and
the drivers of long-term recovery, this session also discussed the
important supportive roles played by the federal government, the private
sector, nongovernmental organizations (NGOs), and state officials.
Specifically, the session was designed to engage representatives from
federal, state, and local governments, and the nonprofit and private
sectors to do the following:
Identify services necessary to maintain or improve the affected
health care service delivery infrastructure to ensure it meets the
long-term physical and behavioral health needs of affected
populations.
Discuss the roles and functions of the relevant Recovery Support
Functions in facilitating long-term recovery of the health care
service delivery infrastructure.
Highlight lessons learned from previous disasters, and identify
priorities for pre-incident operational plans, with a specific focus
on opportunities to leverage programs and activities across the
public, private, and nonprofit sectors that support long-term
recovery and mass casualty care.
This report summarizes the presentations and commentary by the
invited panelists.2
2
The complete statement of task can be found in Appendix A.
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3
WORKSHOP SUMMARY
THE FEDERAL GOVERNMENT: COORDINATOR AND
FACILITATOR
The National Disaster Recovery Framework
The National Disaster Recovery Framework (NDRF) was released in
September 2011 by the Federal Emergency Management Administration
(FEMA), in collaboration with other federal partners, following a series
of information-gathering public meetings across the country. Deborah
Ingram, assistant administrator for the Recovery Directorate of FEMA,
explained that the NDRF is one of a series of integrated national plan-
ning frameworks covering prevention, protection, mitigation, response,
and recovery that are required under Presidential Policy Directive-8 on
national preparedness.
The NDRF establishes a powerful mechanism to support recovery
problem solving, improve access to resources, and foster coordination
among state, tribal, territorial, and federal agencies and nongovernmental
organization (NGO) partners and stakeholders. This represents a new
way of thinking about managing disasters, Ingram said. Although much
focus has been on response, those initial activities that are critical to
saving lives and property, even more work needs to be done beyond that.
The NDRF provides common language and concepts to foster full
community-based recovery. “Whole community,” Ingram explained,
includes all levels of government, the private sector, nonprofit and faith-
based organizations, and others in the community, working together to
help support the recovery process. The NDRF is a national framework in
the sense that it is national in scope and community-based; it is not a
federal framework (i.e., for how the federal government will manage
recovery). Decisions need to be made at the community level about how
best to move forward for each community. As FEMA looks at recovery,
it is going beyond FEMA, Ingram said. The framework is not about new
authorities and new funding—it is about leveraging existing resources
and understanding how to deploy them more effectively.
The NDRF defines roles and responsibilities and promotes
establishment of post-disaster organizations to support recovery. It is
scalable and flexible, and provides for a deliberate and transparent
process.
The three key elements of the NDRF are
Planning—both pre- and post-disaster recovery planning.
Leadership—at the local, state, tribal, and federal levels.
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4 POST-INCIDENT RECOVERY CONSIDERATIONS
Recovery Support Functions—working with federal partners to
provide structure for communities, states, and tribes to use in
pre- and post-disaster planning and recovery efforts. The six
functional areas of assistance are described in Box 1.
BOX 1
Recovery Support Functions (Lead Coordinating Agency)
Community Planning and Capacity Building (FEMA)
Helping the community bring its stakeholders together to establish
the vision, priorities, goals, and milestones for that community.
Economic (U.S. Department of Commerce)
Fostering the ability to sustain the community through the workforce
(e.g., having a tax base in the community that supports community
services, having places for people to buy food so that they will stay
in the community).
Health and Social Services (U.S. Department of Health and Human
Services)
Focused on the restoration of health and social services.
Housing (U.S. Department of Housing and Urban Development)
Supporting a state-led housing task force to address housing needs,
particularly rebuilding post-disaster.
Infrastructure (U.S. Army Corps of Engineers)
Recovery of systems such as roads, bridges, power, and trans-
portation. Minimizing disruption, ensuring access to health facilities
and other necessary functions.
Natural and Cultural Resources (U.S. Department of Interior)
Minimizing the harm to and facilitating the recovery of resources
that are vital to the identity of communities (e.g., wetlands, parks,
historic monuments, properties).
SOURCE: Ingram presentation (February 23, 2012).
Playing a key role to support the NDRF are the Federal Disaster
Recovery Coordinators. Coordinators are responsible for working with
the state, tribe, or local community to identify its recovery needs and
convene the necessary recovery support functions. Ingram noted that
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5
WORKSHOP SUMMARY
FEMA is currently hiring for these positions and is planning to have one
coordinator in each of the 10 FEMA regional offices to support pre-
disaster planning in the states.
Using the Health and Social Services Recovery Support Function as
an example, Ingram illustrated how the functions work together to
promote optimally coordinated assistance. Other functions that may be
critical to the success of the Health and Social Services function are the
Infrastructure function, which helps to provide timely and well-
prioritized access to hospitals; the Economic function, which may be
instrumental in the rebuilding of private health care facilities; the Com-
munity Planning and Capacity Building function, which brings the
whole-community view to comprehensive recovery planning and sup-
ports the identification of priorities; and the Housing function, which
informs where residential areas might be established, or where health
care needs can be anticipated.
Effective coordination is essential for effective disaster assistance,
for the health care sector as well as all sectors, Ingram concluded. The
NDRF provides the necessary planning, coordination, leadership, and
structure to allow that to happen. It is early in the process, Ingram noted,
but as the NDRF moves ahead, we will start to see communities thinking
more about the recovery process, bringing in partners, building networks
in advance, and working together in a pre-disaster setting to plan how
best to manage post-disaster needs.
Office of the Assistant Secretary for Preparedness
and Response—Portal to the Full Spectrum of Department of Health
and Human Services (HHS) Resources
In addition to the partnership with FEMA on the NDRF described by
Ingram, HHS collaborates with the Department of Defense, the
Department of Homeland Security, the Department of Veterans Affairs,
the Department of Commerce, and a host of other interagency partners
on recovery activities, said Kevin Yeskey, Deputy Assistant Secretary
for Preparedness and Response and director of the Office of
Preparedness and Emergency Operations in the HHS Office of the
Assistant Secretary for Preparedness and Response (ASPR).
As one example of a response and recovery planning program at
ASPR, Yeskey described the Hospital Preparedness Program (HPP). One
aspect of the program is the development of health care service resilience
through hospital coalitions. If a hospital becomes incapacitated or
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6 POST-INCIDENT RECOVERY CONSIDERATIONS
destroyed (e.g., as happened in Joplin, Missouri, in May 2011 as the
result of an EF-5 tornado) there will be other hospitals in that community
that are prepared to assist with pre-established Memorandums of
Understanding (MOUs) and agreements that facilitate the sharing of
resources and care of patients. The HPP also supports hospital and
medical facilities in the development of continuity-of-operations plans. It
is much easier for facilities to shelter-in-place if they can than to
evacuate and move patients, Yeskey said. Administratively, it is easier to
keep operational at some level than it is to shut down and reopen at a
later time. Another focus of HPP is medical surge capabilities, for
example, the availability of mobile facilities.
With regard to disaster response, the resources of the entire HHS
department are engaged and committed, including, for example, the
Centers for Disease Control and Prevention (CDC), Food and Drug
Administration, National Institutes of Health (NIH), Health Resources
and Services Administration, Substance Abuse and Mental Health
Services Administration, Centers for Medicare & Medicaid Services
(CMS), Administration for Children and Families, and ASPR. It is not
just ASPR and the National Disaster Medical System involved in
response, Yeskey stressed, but the entire HHS department. When it
comes to recovery, HHS also wants to have the entire department
applying its existing authorities, regulations, and resources to assist in the
recovery effort, he said. For both response and recovery, ASPR provides
“one-stop shopping” for communities in need to muster the resources of
the entire HHS department.
Some of the most common questions, and also some of the most
complex, that ASPR receives concern hospital and health care facility
reimbursement under disaster conditions. Can we bill for care that was
provided in a tent? Or bill for services provided in a modular facility we
built that is licensed by the state? Answers to these complex and nuanced
questions vary somewhat from situation to situation, and addressing them
is a part of continuity-of-operations planning. In the past 4 or 5 years,
Yeskey noted, CMS has become very engaged in response and recovery
and has been proactive in trying to address these needs through its
regional offices. For example, CMS has posted answers to “frequently
asked questions” about reimbursement issues on its website, and makes
staff available to assist with issues and waivers.
Another important resource is the authority of the Secretary of HHS
to declare a public health emergency, commented Yeskey. This allows
the Secretary to take certain actions and waive certain requirements or
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7
WORKSHOP SUMMARY
sanctions. When the President has also declared an emergency or
disaster, the Secretary may apply certain waivers under section 1135 of
the Social Security Act. For example, the Secretary can waive certain
sanctions or penalties for not adhering to certain provisions of laws, such
as the Health Insurance Portability and Accountability Act (HIPAA) or
the Emergency Medical Treatment and Labor Act (EMTALA), during
the declared emergency and for a specified period of time. This gives
facilities some flexibility and reduces their administrative burden, so that
patients can be taken care of in a timely fashion.
Yeskey reiterated Ingram’s comments that as the lead agency for the
Health and Social Services Recovery Support Function, the whole of
HHS is engaged to support locally led recovery efforts and restoration of
public health, health care, and social services. This also includes
behavioral health, environmental health, food safety, school impacts, and
long-term health of responders.
HHS is working to make response and recovery a seamless
transition, and Yeskey encouraged participants to get to know their own
regional emergency coordinators, who work in every HHS region
throughout the country.
THE PRIVATE SECTOR: BUILDING RESILIENT
COMMUNITIES
The private sector has an important role to play in preparing for and
responding to public health emergencies and in building resilient
communities. Joshua Riff, chief medical officer at Target Corporation,
explained how Target is actively involved in building public–private
relationships to improve community preparedness and public health
response.
Sharing Our Strengths
Target is a Fortune 30 company employing 360,000 team members.
More than 25 million guests visit every week, generating $62 billion in
annual sales. Headquartered in Minnesota with international offices in
over 20 countries, Target is the fifth-largest U.S. retailer, with more than
1,740 stores and 38 distribution centers in 49 states. Riff stressed that
Target is more than simply a merchandiser (i.e., involved in sales and
promotion of products). Target Corporation is also a retailer (i.e., buys
goods in large quantities and maintains a robust supply chain), as well as
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8 POST-INCIDENT RECOVERY CONSIDERATIONS
food supplier, pharmacy, bank, credit card issuer, health care provider,
and employer. The company needs to protect all of these businesses in
the same way that others in the community need to protect their busi-
nesses. By partnering together, Riff said, we can share our stories and
our strengths.
Target is committed to the health and well-being of communities,
both every day and in response to public health emergencies, and is an
active partner with many health-related agencies throughout the country.
Disaster preparedness, relief, and recovery are top priorities for the
company as they work to protect Target team members, guests, and
businesses, as well as contributing to the resiliencies of communities.
Riff added that Target looks at these public partnerships as a public
good, not as a competitive advantage. The company is able to respond
when asked for drug distribution or immunizations because it has such a
large U.S. presence, but Walgreens, CVS, Wal-Mart, or other
competitors complement Target’s footprint, he said, and Target will
bring them to the table as well.
As an example of Target’s commitment to public well-being, Riff
described the company’s comprehensive global crisis management
program, which, he noted, is somewhat unique to Target. A key focus of
the program is preparedness, including practice drills for emergency
scenarios. A 24/7 Corporate Command Center at the headquarters in
Minnesota, the “C3,” tracks natural disasters around the world and alerts
team members, partners, and vendors to developing situations and
potential needs. There is also a global security program, and Target has
extensive public safety partnerships with law enforcement, emergency
management, and the public health sector as well as structures in place to
respond to any major crisis affecting the company’s businesses
throughout the world. These partnerships are essential for Target’s
planning and preparedness, Riff said.
The Power of Planning Together
Riff emphasized that a response is much more robust when we
prepare, plan, and exercise with our partners. For example, every year
before hurricane season Target prepares its distribution centers by
moving goods or services generally needed in hurricanes for easy
mobilization. When a natural disaster is emerging as a threat to an area,
the company ships all the supplies the local Target will need to protect its
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9
WORKSHOP SUMMARY
guests and team members and their communities, and to supply the
public health partners in the area.
In 2011 during Hurricane Irene, 222 Target stores and distribution
centers and many team members were in the path of the storm. In
preparation for the storm, 117 stores closed. Of those, 109 stores and 3
distribution centers were impacted. Through multiple preparation calls,
the Corporate Command Center advised stores on how to prepare their
buildings, how to partner with local agencies, and most importantly, how
to protect their team members and allow their team members to protect
their homes and those of their friends and family (i.e., the community).
The Corporate Command Center also helped to ensure that local
management teams could get the support they needed.
Throughout a crisis, the Corporate Command Center keeps Target
teams informed and safe, donates funds, and participates in the recovery
efforts. After Hurricane Irene, Target donated over a quarter of a million
dollars to the Red Cross, Salvation Army, and other local organizations,
as well as in-kind donations of relief kits to victims and rescuers. The
company also sent team members to volunteer in the impacted
communities. Team members, Riff said, are actually some of the
company’s greatest assets in recovery and relief, volunteering out of the
kindness of their hearts and lending tremendous support.
Pre-established relationships and joint planning are the key to
successful public-private relationships, Riff said. For example, in 2009,
Target signed an MOU to formalize the relationship between Target and
the California Emergency Management Agency so that the company can
be fully integrated into California’s state planning efforts. This provides
the state with direct access to Target’s thought leaders and decision
makers, who can assist with resources or logistical support. It also allows
the company to be better prepared to deliver needed supplies such as
water and relief kits. In addition to California, Target has MOUs with
Maryland and New Jersey. The MOU establishes that Target will be part
of the planning process and that there will be two-way information
sharing before, during, and after a crisis.
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10 POST-INCIDENT RECOVERY CONSIDERATIONS
NONGOVERNMENTAL ORGANIZATIONS:
PROVIDING SUPPORT AND RELIEF
The American Red Cross
The American Red Cross is a volunteer-led humanitarian organiza-
tion that provides relief to victims of disaster and helps people prevent,
prepare, and respond to emergencies. The relationship of the American
Red Cross and the federal government is unique, said Linda MacIntyre,
chair of the Red Cross National Nursing Committee and assistant clinical
professor at the University of California, San Francisco. The Red Cross
is both an independent, nonprofit, charitable organization and a
congressionally chartered organization. Under the charter, the Red Cross
is expected to carry out certain responsibilities, including, for example,
supporting the provisions of the Geneva Convention, providing family
communications and other supports to the U.S. military, and maintaining
a system of domestic and international disaster relief under the National
Response Plan, which is coordinated by FEMA. Despite this close
relationship with the federal government, the Red Cross is not a
governmental agency and does not receive federal funding on a regular
basis to carry out its services and programs.
Health is crucial in community resilience and response in a disaster,
MacIntyre said. The Red Cross is in the community before, during, and
after a disaster. Public health and emergency services that the Red Cross
provides include, for example, general population shelters (serving
individuals with chronic illness, functional and access needs, and many
others), emergency aid stations, supportive counseling, assistance in
reunification with families and friends, and outreach and condolence
visits. The Red Cross also works to link families and caregivers with
resources. Long after the emergency shelter is gone, the Red Cross is
there to provide long-term individual and family services. This may
include client case management, assistance with unmet needs, and health
and human services provided directly and through other agencies and
partnerships.
For disaster health services, Red Cross has an MOU with CDC to
provide morbidity and mortality data. While this is a somewhat unusual
obligation, MacIntyre noted, this health information is essential in terms
of planning and responding. Other services include assisting the
community in providing health care education, implementing preven-
tative measures such as vaccination, and supporting public health
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WORKSHOP SUMMARY
departments with surveillance. Mental health recovery and resilience
information tools and resources can be provided to school personnel,
community members, mental health providers, community service
providers, and other key stakeholders. In addition, psychological first aid
and other resilience training can be provided to community members,
and post-deployment support and training can be provided to disaster
responders. Red Cross Biomedical Services provides blood and blood
products as needed, working with the American Association of Blood
Banks.
As a partner in response and recovery, the Red Cross offers
scalability of operational response, from a single-family fire to flood
damage or a series of hurricanes or tornadoes. Scalability is key, and
operations move from local to regional to nationwide deployment as
needed, and then back again to the chapter level for recovery. Because
the Red Cross is part of the community, MacIntyre said, it is also part of
the recovery.
Reaffirming the comments by the other panelists, MacIntyre said that
whole-community planning and preparedness as well as partnerships are
the critical components of success in long-term recovery of health
services. In fulfilling its mission the Red Cross works closely with other
NGOs, partnering with countless local and national organizations.
MacIntyre shared one example of planning and partnership success.
Shortly after 9/11, a severe ice storm hit the Kansas City area. The Red
Cross had difficulty gathering volunteers to support the response because
most of them were in New York City dealing with the aftermath of the
terrorist attacks. Despite this and other challenges, agencies worked
together afterward to problem-solve and coordinate services. As a result,
after Hurricane Katrina, approximately 3,000 evacuees were served at a
“one-stop shop” that included public health, faith-based organizations,
nonprofit organizations, hospital personnel, pharmacists, and nurses.
Nurses, for example, helped to coordinate complex health care needs
such as ensuring people were able to receive their chemotherapy or
dialysis.
In closing, MacIntyre shared that one of her goals as chair of the
National Nursing Committee is to better represent the communities that
the Red Cross serves through increased diversity, both internally with
volunteer and paid staff and externally with partnerships. Research has
shown, she said, that when we better represent the communities that we
serve, better health outcomes result.
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12 POST-INCIDENT RECOVERY CONSIDERATIONS
LOCAL AND STATE ROLES: THE COMMUNITY
AS THE LEAD
The new National Disaster Recovery Framework is helpful because
it articulates things that have been needed at the state and local levels for
quite some time, said James Craig, director of the Office of Health
Protection at the Mississippi State Department of Health. The most
effective, efficient, timely response to any disaster is the local response.
Therefore, Craig said, the most effective long-term recovery of any
community is that which is planned and managed at the local level by the
impacted community. This is supported in the NDRF (see Box 2), which
stresses that federal, state, or other disaster recovery organizations
recognize that communities have the lead role in planning for and
managing their recovery. Craig noted, however, that in their efforts to
“vigorously support local, state, and tribal governments,” these agencies
and organizations can sometimes provide too much help that may not be
consistent with the impacted community’s direction.
The NDRF also acknowledges the notion that you cannot, or perhaps
should not, always rebuild in exactly the same way as before the disaster.
The framework states that successful recovery may involve relocation of
some or all of the community’s assets (see Box 2).
BOX 2
National Disaster Recovery Framework Excerpts
Leadership and Local Primacy
“Successful recovery requires informed and coordinated leadership throughout
all levels of government, sectors of society, and phases of the recovery process.
It recognizes that local, State and Tribal governments have primary
responsibility for the recovery of their communities and play the lead role in
planning for and managing all aspects of community recovery. This is a basic,
underlying principle that should not be overlooked by State, Federal and other
disaster recovery managers. States act in support of their communities, evaluate
their capabilities, and provide a means of support for overwhelmed local
governments. The Federal Government is a partner and facilitator in recovery,
prepared to enlarge its role when the disaster impacts relate to areas where
Federal jurisdiction is primary or affects national security. The Federal
Government, while acknowledging the primary role of local, State and Tribal
governments, is prepared to vigorously support local, State and Tribal
governments in a large-scale disaster or catastrophic incident.” (FEMA, 2011,
pp. 9-10 [emphasis added])
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WORKSHOP SUMMARY
Achieving Disaster Recovery
“Recovery is more than the community’s return to pre-disaster circumstances,
especially when the community determines that these circumstances are no
longer sustainable, competitive or functional as shown by the community’s post-
disaster condition. A successful recovery in this case may include a decision to
relocate all or some portion of the community assets and restoration of the
affected area to a more natural environment. In these circumstances, the
community recovery decision making is informed by evaluating all alternatives
and options and avoiding simple rebuilding or reconstructing of an area that
continues to be vulnerable.” (FEMA, 2011, p. 13 [emphasis added])
SOURCE: Craig presentation (February 23, 2012) citing FEMA (2011).
Planning for the Unexpected
As an example of the importance of thorough long-term recovery
planning, Craig shared his experiences as the incident manager for the
health and medical state responses for Hurricane Katrina in Mississippi.
The Gulf Coast Medical Center in Biloxi, Mississippi, was a 189-bed
hospital directly across the street from the beach. Destroyed by the
hurricane, the hospital reopened with limited services in 2006. Inpatient
services dropped by 40 percent, and the hospital closed again on January
1, 2008. Much of the surrounding population had moved north, Craig
explained, and few were left to accommodate with health services in that
location. In other words, the hospital did not close in 2008 as a direct
result of the storm, but closed because planning was probably inadequate
at the community level to foresee that the community would relocate and
that the hospital, rebuilt in place, would no longer be central to its users.
The current plan is for the hospital to relocate north to follow the
population shift. Other components of the health care system, such as
pharmacies and physician offices, also moved north to where the people
now live, and there is no reason to have a hospital where there are no
doctors, patients, or pharmacies.
Another item that was misjudged in the planning was the capacity of
the mental health component that would be needed. Around 40 percent of
Mississippians in the lower part of the three counties on the coast had
either signed up for, were currently in, or had recently completed mental
health services, but this was not sufficiently planned. Moving forward,
plans need to address the ability to maintain capacity of critical mental
health services for effected populations.
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14 POST-INCIDENT RECOVERY CONSIDERATIONS
In addition, following the hurricane the population density shifted so
that more individuals are now living inland. Therefore, the active
recovery effort is having to focus on developing a new regional water
and wastewater infrastructure further inland to provide service to the
relocated population. Overall, the relocation of the population to a less-
vulnerable area was a critical factor in recovery, but was unplanned.
Craig stressed that everyone, including local businesses, should have
long-term recovery planning. As an example, he described a current
challenge facing the recovery efforts following the EF-5 tornado in
Smithville, Michigan, in 2011. More than 150 homes, nearly all of the
businesses, all of the city government, the funeral home, and the Piggly
Wiggly were destroyed. The Piggly Wiggly was the only grocery store in
Smithville. The parent company is concerned about rebuilding in
Smithville because it does not know if the people will come back. In
turn, people are hesitant to come back until they find out if the Piggly
Wiggly is reopening.
The last example Craig shared related to the historic flood impacting
14 counties in Mississippi in 2011, displacing thousands of residents and
destroying thousands of acres of farmland, with an estimated crop loss of
around $800 million. During the response phase, the state created a
health care flood impact taskforce of interested parties from the health
care systems in those 14 counties (e.g., pharmacies, physician groups, the
state medical association, the hospital association, long-term care,
hospice, home health care). The taskforce composed of local impacted
communities continued through the short-term recovery and worked
together to assist in planning for the long term. This became a best
practice. The next step is to form official regional health care coalitions
out of the taskforce, and possibly a multiagency coordinating system.
Emergency plans for many hazards in this particular event were
insufficient, Craig said, and through this coalition there is now a better
opportunity to coordinate and plan locally.
Depth and Breadth of Local Recovery Planning and
Priority Setting
A participant commented that from a community perspective,
engaging in recovery planning can look very daunting. There are
ancillary services that are critical for health care, such as public and
private emergency medical service (EMS) units, contracted hospital linen
services, water, power, and a host of other suppliers. Such services also
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WORKSHOP SUMMARY
cross local or state borders, so planning may involve multiple states,
commonwealths, or jurisdictions. How necessary is it, for example, to
find out the details of one specific hospital relying on one set of specific
suppliers and another hospital relying on other entities?
The HHS Hospital Preparedness Program emphasizes the
development of coalitions both in and outside hospitals, including EMS,
individual providers, long-term skilled nursing facilities, and other
community members, Yeskey responded. He noted that hospitals are
likely to be competitors on a day-to-day basis, so bringing them together
to work cooperatively and discuss their systems with competitors can be
challenging. It is important to share protocols and work out the details in
advance regarding resources and staff. For example, if one hospital loans
nurses to another, who will pay their salary? If a ventilator is loaned out
and ends up getting transferred out of the state due to patient transfer,
who is covering the reimbursement? Eventually one needs to work down
to this level of detail, Yeskey said, but it does not all have to be done in 1
day.
Priorities in any response situation, Yeskey said, are to save lives,
protect the public’s health, protect responders, protect infrastructure, and
maintain situational awareness. Each community needs to determine its
own priorities for recovery, for example, the order of priority for
recovery of public utilities, debris removal, law enforcement, health care,
or education. Making this determination in advance will help significantly
with preparedness, response, and recovery of the community.
Craig added that the people and the partnerships are almost as
important as the plan. In his experience, strong leadership in the
development of the vision for where the long-term recovery is going and
inclusion of all key stakeholders is what leads to success. Without that
leadership and without all of the right people, what looks like a perfect
solution very quickly falls apart.
BARRIERS AND CHALLENGES TO RECOVERY
A key challenge to response and recovery is creating national
policies and making national decisions that translate well to the local
levels. For a private-sector partner, a major challenge when dealing with
a national public health response is having corporate solutions that can
be applied across the country. A national and global retailer such as
Target needs national and global strategies, Riff said. In response to the
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16 POST-INCIDENT RECOVERY CONSIDERATIONS
H1N1 influenza pandemic, for example, 1,744 Target locations had
vaccine available for the healthy public. The company has one standing
protocol for how to give vaccinations. What Riff found, however, was
that in dealing with state and county health departments, there were
about 1,500 vaccination protocols and communication campaigns, which
made it challenging to execute on the company’s national strategy.
Another challenge Riff highlighted is getting communities to partner
with the private sector ahead of time to participate in planning, instead of
calling for supplies after the disaster. Craig concurred that, at the local
and state levels, planning efforts are not engaging the private sector to
the extent needed. There is a general hesitancy to leverage and use both
the private sector and NGOs. But the government does not have enough
resources to handle disasters alone, and may not be the most efficient in
response, commented Craig. Private industry can often mobilize much
faster than government, sometimes delivering supplies within hours,
while a government response may take days.
Situational awareness and “rumor control” are also challenges.
Information changes over the course of time, impacting decision making,
Yeskey said. When a policy changes due to new information, sometimes
it is viewed as indecision. For example, when a case of H1N1 influenza
shuts down a school, and it is then learned that the situation is not as
severe as initially thought, so the policy changes and the school reopens,
it is difficult to convey to the public that we know what we are doing, he
said. Based on what is known at the time, the best protective decisions
and policies are put forth, and are likely to change based on new
information. Communicating this is a significant challenge.
Ingram noted that a challenge for FEMA is getting local
communities to pay attention to the NDRF pre-disaster. Communities are
already overwhelmed, and there is some denial that they need to prepare.
Post-disaster, there is much interest in planning for the next time, but we
need to convey the importance of pre-disaster planning, and to find those
champions in the communities that can help the process. Working
together before a disaster is challenging, MacIntyre agreed, especially as
public health positions continue to be cut and finding the time to forge
the needed relationships becomes very difficult.
An obstacle to planning, Craig added, is that some states have a
certificate-of-need process. Health care planners at the state level must
be convinced that resources are needed in different places before capital
projects can be approved.
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WORKSHOP SUMMARY
FINAL REMARKS
Each long-term recovery is different and unique, and planning for all
of the variables of a recovery is very difficult, Craig noted. At the federal
level, FEMA and HHS have key coordination and support roles, bringing
money and people to recovery operations. State government helps to
ensure that the local government and community get the support they
need for their long-term recovery. The local community has the lead role
in planning for and managing all aspects of community recovery. State
and local governments need to ensure that their plan works for their
community and engages the private sector and all of the parts of the
health care system.
REFERENCE
FEMA (Federal Emergency Management Administration). 2011. National Disaster
Recovery Framework. http://www.fema.gov/pdf/recoveryframework/ndrfpdf
(accessed April 13, 2012).
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