All disasters are inherently local and require a coordinated response at the lowest jurisdictional level within an impacted area.1 In the case of public health emergencies, such a response effort spans across local public health and emergency management to also include emergency medical services (EMS), hospitals and health care coalitions, community health centers (CHCs), and other nongovernmental and private sector partners. Recent disasters have highlighted not only the benefits of partnership but also the need to further develop and jointly exercise with partners prior to an emergency. Hurricane Sandy left more than 100 dead and millions without power across much of the northeast, and as far west as Michigan, last October, further highlighting the importance of public health engagement and involvement in the emergency management process.
These themes were reinforced at the Public Health Preparedness Summit in Atlanta, March 12-15, where a diverse panel shared the story of how first responders, hospital staff, and public health worked to evacuate hundreds of patients from New York University Langone Medical Center after a hospital generator failed. All evacuees were transported safely to other facilities, largely due to staff preparedness training and coordination among agencies. First responders, hospital staff, and public health worked together to evacuate patients, distribute and track transferred patients, onboard additional medical staff, and resolve professional credentialing issues. The success of the coordinated response will inform the future of hospital preparedness and shows the value of developing partnerships long before disaster strikes.
As the response at New York University Langone Medical Center demonstrates, strong partnerships across organizations are essential to ensure effective response to emergencies. Recent studies have shown that partnerships yield a modest success rate of 50%, yet many partnerships fail due to insufficient organizational investment, leadership, and dedicated resources.2 Public health, EMS, hospital preparedness, and emergency management efforts are all crucial elements to disaster preparedness and response, but they are more effective when planned and coordinated jointly.
The George Washington University Homeland Security Policy Institute's Preparedness, Response, and Resilience Task Force released a report in June 2012. The report highlighted past successes of public health and emergency management response efforts that have become more interconnected, from 9/11 to Hurricane Katrina to the 2009 H1N1 pandemic, but underscored that more still must be done to reach levels of preparedness required to achieve community resilience.3 While the George Washington University report highlights gaps and offers policy recommendations to enhance the nation's resilience, it does not include specific recommendations for forging such partnerships at the local level. Recognizing the need, the National Association of County & City Health Officials, in coordination with their Public Health Emergency Management Workgroup, developed guidelines to encourage collaborative partnerships at the local level to better prepare for public health emergencies.
Public health preparedness is often characterized narrowly to include disease outbreaks, bioterrorism, and emerging health threats but, in practice, actually addresses a broader scope of natural and manmade disasters, consistent with emergency management's “all-hazards” approach to planning.3 Through their daily work and the duties performed in support of Emergency Support Function 8, the local health department (LHD) workforce is at the center of the public health emergency preparedness system. As such, it is incumbent upon LHD officials to proactively engage key community stakeholders before, during, and after a response.
Developing partnerships prior to emergencies allows for candid discussions about resources, limitations, and operational realities. In addition, this allows time to become familiar with the culture and management styles of each organization. Unfortunately, the political nature of some local and state offices may mean high staff turnover, especially after an election. As successful partnerships rely on personal relationships, government officials may find themselves establishing and maintaining new relationships on an ongoing basis. Jurisdictions should develop mechanisms to institutionalize partnerships to ensure that the collaboration continues across organizations even amidst personnel turnover.
In addition to traditional emergency management partnerships, local health officials should consider establishing partnerships with their local EMS and their CHCs. Both EMS and CHCs are frontline medical providers that can directly attest to the health of a particular community. Furthermore, as safety-net organizations, EMS and CHC staff members are often knowledgeable about the vulnerable and at-risk populations that they serve. In times of disaster, these 2 organizations serve a valuable role and augment community resilience.
EMS providers are currently located throughout every community in the United States. On a daily basis, these providers deliver on-demand, in-home medical care at a moment's notice. In addition to the traditional role of emergency response, EMS throughout the world are evolving into a viable mechanism to increase the delivery and availability of preventative services and primary care within communities. The primary purpose of EMS is to provide patient care for acute or emergency events. However, studies show that 30% to 40% of ambulance service responses are for nonemergency events.4 Many times, patients who lack access to primary care use EMS to access emergency departments for routine health care services (ambulance transports account for 16.2 million, or roughly 15%, of all emergency department visits).4 Of these visits, approximately 40% of patients are admitted for further treatment.4
Currently, EMS providers are paid when they transport a patient to a limited set of destinations, including hospitals and critical access hospitals. When EMS providers do not transport, they are not paid for the services provided. The current reimbursement structure thus incentivizes patient transport to an emergency department instead of providing individualized care with transport to an appropriate facility. The current structure neither incentivizes nor takes patient outcomes into consideration. While many patients could be more appropriately cared for in primary care settings, alternate locations, or in their own homes, current reimbursement mechanisms do not provide payment for treatment in, nor transport to, these settings.
The shift in EMS utilization offers tremendous potential for improving care coordination, increasing quality, and enhancing the overall efficiency of the health care system. It has been demonstrated in other countries that nontraditional utilization of EMS also helps reduce hospital crowding, prevent avoidable readmissions, decrease avoidable expenditures, and increase access to medical care.
Some of the most prominent and successful programs are found in Canada, Australia, and Europe.5 The providers trained in these programs are used as community-based providers and offer a variety of services at low cost to the system (such as intravenous antibiotic administration, wound care, phlebotomy, diabetes care and management, medication adherence, fall assessment and prevention, congestive heart failure follow-ups, influenza vaccinations, vitamin B12 injections, and tetanus immunizations); the great majority of these services are within the current paramedic scope of practice in the United States.
Countries that have embraced community paramedicine are reaping the benefits of using EMS in more than just an emergency or disaster context. These countries have actively embraced community paramedics as health care providers that offer basic services to enhance and facilitate primary care delivery. For example, the nurse practitioner-community paramedic model in Nova Scotia has produced several statistically significant cost savings for both the patient and the health care system. Direct annual health care costs diminished from $2380 to $1375 per person over the 3 years of the study. At the same time, total visits to a general practitioner (who are not on the Nova Scotia islands) decreased 28%, from 5214 to 3759, during the 3-year study period. The reduction in general practitioner visits was associated with significant travel expense savings and reductions in prescription medication costs. In addition, a 40% reduction in emergency department visits was realized during the 3-year study period.6
In the United States, community paramedicine is being explored and implemented in several communities. In 2009, the Western Eagle County Health Services District joined with the Eagle County Public Health Agency, local physicians, and the International Roundtable on Community Paramedicine to plan and implement a community paramedicine program in Eagle County, Colorado. This rural resort community, located in the Rocky Mountains, is home to approximately 54 000 residents, 30% of whom are uninsured (as are 54% of ambulance patients). As a result of the closure of the local home health agency, and other service gaps in the county, EMS personnel have become the de facto health care providers of last resort. Now in its third year, the program aims to improve health outcomes among medically vulnerable populations and to save health care dollars by preventing unnecessary ambulance transports, emergency department visits, and hospital readmissions. In addition to EMS, CHCs also serve as a safety net on a daily basis and during emergencies.
Operating in more than 8500 locations throughout the country, CHCs are essential members of the public health community. Each year, CHCs provide critical access to primary care services for more than 20 million patients.7 During emergencies, CHCs can supplement surge capacity by serving as alternate care sites or triage, offering mental health support to first responders and community members, and reaching out to vulnerable populations with public health services, as they are most susceptible to adverse health impacts.8 Given the extent of services offered and their reach into communities, CHCs are well suited to provide critical information and medical care during a disaster.
The potential of leveraging CHCs as partners in emergency response has not yet been fully realized. A 2006 national survey conducted by the National Association of County & City Health Officials supported that assertion. In the survey, 75% of LHD respondents reported that CHCs should participate in preparedness planning and response yet only 22% reported an existing partnership with their local CHCs.8 Both CHCs and LHDs share the common goal of providing care to underserved communities, and the collaboration offers a direct benefit not only to these organizations but also to their communities that as a result receive better provision of health care.
A 2010 study found that of 1265 LHDs and CHCs (797 LHDs and 468 CHCs), 53% of LHDs and 60% of CHCs reported having previously partnered for public health preparedness activities. Of those who partnered, 93% categorized those collaborative opportunities as positive experiences.8 Regardless of their previous experience with partnership, 97% of respondents expressed a willingness to collaborate with their neighboring CHC or LHD for emergency preparedness and response activities in the future.8 While these relationships have not been fully realized, the data show potential for LHDs to more fully integrate CHCs into their emergency preparedness planning and response efforts.
This article highlights just 2 of the many partner organizations LHDs should reach out to on a broader scale for public health preparedness planning and response activities. While much progress has been made in recent years to leverage community resources and existing systems to bolster community resilience, more still can be done to improve these efforts. LHDs are well positioned to reach out to community organizations and begin the process to develop personal relationships that are the foundation of all partnerships. Developing strong and sustainable partnerships is not easy, but the public health community should continue to foster relationships with a wide array of organizations to best prepare for the next community response.
2. Centers for Disease Control and Prevention. A Structured Approach to Effective Partnering: Lessons Learned From Public and Private Sector Leaders. Atlanta, GA: Centers for Disease Control and Prevention; 2013.
3. Barishansky R, Bourne M, Darnell D, et al. Public Health and Emergency Management: Challenges and Opportunities. Washington, DC: The George Washington University, Preparedness, Response, and Resilience Task Force, Homeland Security Policy Institute; 2012. http://www.gwumc.edu/hspi/policy/taskforce_resilience_PublicHealth.cfm
. Accessed April 12, 2013.
8. Ablah E, Konda K, Konda K, Melbourne M, Ingoglia J, Gebbie K. Emergency preparedness training and response among community health centers and local health departments: results from a multi-state survey. J Community Health. 2010;35:285–293. http://www.ncbi.nlm.nih.gov/pubmed/20379843
. Accessed April 12, 2013.