The Role of Public Health and Health Systems, Facilities, and Providers in Emergency Preparedness and Response
The rural healthcare delivery system provides access to healthcare services, including primary care, mental and
behavioral health, emergency care, and public health services. The rural healthcare delivery system consists of
rural hospitals, Critical Access Hospitals (CAHs), Federally Qualified Health Centers (FQHCs), Rural Health
Clinics (RHCs), long-term care facilities, public health agencies, home health agencies, emergency medical
services (EMS), and dental practices, among others. The unique public health and healthcare system challenges
experienced in rural communities, including provider shortages, weakened rural health infrastructure, and
financial limitations of rural hospitals and health systems, are further heightened during public health
leadership in rural healthcare systems can support effective and innovative response efforts and drive
health equity. Planning and coordination between public health and healthcare systems, facilities, and providers
are essential for emergency planning, response, and recovery.
Surge capacity is a critical component of healthcare preparedness. The U.S. Department of Health and Human
Services Administration for Strategic Preparedness and Response defines
surge capacity as:
“Medical surge describes the ability to provide adequate medical evaluation and care during events
that exceed the limits of the normal medical infrastructure of an affected community. It encompasses the ability
of health care organizations to survive a hazard impact and maintain or rapidly recover operations that were
compromised (a concept known as medical system resiliency).”
When there is a surge of patients, healthcare facilities are stretched beyond their normal operative capacity.
When needed, the U.S. Department of Veteran's Affairs (VA) can provide surge assistance to local communities.
Referred to as the VA's Fourth
Mission, the VA supports national, state, and local preparedness in response to emergencies and
disasters. The VA will fill service and support gaps during emergencies, as it is the “primary medical
back-up system” for the Department of Defense.
Depending on the emergency, healthcare providers may be unable to provide the usual standard of care. Rather,
they may shift to a “sufficiency-of-care mode” with a focus on saving as many lives as possible.
This may involve triaging patients as an approach to identifying whom to care for and when, based on their
medical needs and the available resources. In some instances, healthcare facilities may identify patients who
need to be transferred to other nearby healthcare facilities to best serve them.
When there is a patient surge during a response, healthcare systems must care for an influx of patients and meet
the increased demand for medical services. Some considerations for surge capacity include ensuring adequate:
Medical personnel – A surge will often require a greater number of medical and
healthcare personnel to deliver care and coordinate services. In addition, specific types of emergencies or
disasters may increase demand on certain specialist providers. For example, surgeons may be especially in
demand following an explosion.
Physical space and beds – Hospital beds and availability of rooms can be limiting
factors during an emergency. Hospitals can establish plans for using both clinical space, such as outpatient
rooms, and non-clinical space, such as hallways, to house patients. Discharging patients who are not in need
of immediate attention can free up space for patients with more urgent needs. Alternate
care sites can also accommodate the surge of patients and can be created in areas more easily
accessible to incoming responders.
Supplies and equipment – During a surge, additional supplies and equipment may be
needed to serve the influx of patients. Depending on the type of emergency or disaster, needs may include
specialized equipment, including technology, for delivering medical care as well as communications and
Partners are essential in supporting surge capacity. Communities can develop plans for engaging partners, such
as EMS personnel, healthcare facilities, and other community organizations, to
support the increased demand for medical personnel, physical space, and supplies and equipment.
Critical Access Hospital Helps Lead Response to Mass Casualty Incident
After a bus crash, multiple international patients
— many with severe injuries — were transported to a local Critical Access Hospital (CAH). The
hospital accommodated the patient surge by identifying additional space for treating patients, using
assistive technology to communicate with patients who were not proficient in English, and working with
partners to bring in trailers and other equipment and supplies for the response.
Also, during an emergency, residents from urban areas may evacuate to or through rural areas. This can put added
strain on available resources and hospital bed capacity. Rural communities should consider this possibility, as
well as potential numbers and characteristics of urban evacuees, in their planning efforts.
The HHS Administration for Strategic Preparedness and Response Technical Resources, Assistance Center, and
Information Exchange (ASPR TRACIE) provides resources
highlighting lessons learned and promising practices for planning and responding during surge capacity.
Critical Access Hospital Responds Under Challenging Circumstances
Alaska activated crisis standards of care (CSC) guidelines for 20 medical facilities in the fall of 2021,
including the Borough of Petersburg, located on Mitkof Island in southeastern Alaska. The island's sole
healthcare provider, Petersburg Medical Center, provided a strong response despite numerous challenges.
If a surge response can no longer maintain typical levels of care, rural hospitals and healthcare systems may
shift to crisis
standards of care (CSC). The goal of CSC is to achieve the best outcome for groups of patients,
rather than individuals. It balances and adjusts resources in response to demand.
After an emergency, communities can use data from surveillance measures of the health system's performance
the response to inform efforts to improve the health system's surge capacity for future disasters. It is also
important to consider secondary surge capacity during the recovery phase. The specific healthcare needs of
populations affected by the emergency or disaster may differ between the response and recovery phase.
Continuity of Care
Ensuring continuity of care for patients with chronic diseases can be challenging during and after an emergency
as people evacuate and may be unable to easily access their providers.
There are several preparedness and recovery strategies that can help mitigate gaps in care for patients during a
public health emergency.
Patient education and preparedness – It is important to educate patients about healthcare
options, make patients aware of potential shelter locations, and ensure patients are stocked and knowledgeable
about their medication needs.
Healthcare provider and organization preparedness – This includes establishing
communication processes; backing up medical records; acquiring a surplus of supplies and equipment; and building
relationships with other local institutions and organizations, like pharmacies and social service agencies.
Provider-patient communication – Depending on the type of emergency, means of
communication between providers and patients may be severely altered or limited. However, when possible,
healthcare providers can communicate essential information to patients and the public when other means of
communication may be disrupted. For patients with caregivers, provider-caregiver communication during an
emergency may be critical for ensuring the patient's needs are met if access to their provider is limited.
During an emergency, health systems and providers may need to be innovative to ensure that critical health
information is communicated to patients. For example, the COVID-19 pandemic has emphasized the importance
of telehealth and telemedicine for reaching patients at home in rural areas. Hurricane Katrina
illustrated the need for providers to preemptively document emergency contact information and ask patients to
share their disaster plans: for example, where they would evacuate to, in case of an emergency. Providers should
also be prepared to disseminate medical information at shelters or temporary clinics, if needed.
Patient safety – The following are strategies for keeping patients safe and secure during
an emergency response:
- Putting in place a security team
- Monitoring incoming and outgoing patients and visitors
- Establishing quarantine, decontamination, and isolation areas
- Ensuring emergency access and exit routes are clear and accessible
- Maintaining functioning critical systems such as electricity and water supply
Volunteer and donation management – During a response, healthcare providers and local
volunteers may be responsible for managing the acquisition and distribution of donated medical supplies,
including medications and personal protective equipment.
Hospital visits for ambulatory care sensitive (ACS) conditions is one metric for identifying groups that did not
receive adequate and timely access to care during the emergency response. By monitoring health service
utilization for ACS conditions, health systems can assess who may have experienced lapses in care during an
emergency and can ensure these subgroups receive the care they need during the recovery phase. During the
recovery phase, documenting strategies and procedures that supported successful continuity of care during the
emergency can improve continuity of care for patients during the next disaster.
The COVID-19 pandemic has forced the United States to seriously examine the country's capacity to produce,
distribute, and deliver immunizations during an emergency. The U.S. Department of Health and Human Services
(HHS) developed the Operation Warp
Speed Strategy for Distributing a COVID-19 Vaccine. The strategy outlined several priority activities to
distribute vaccines to all Americans:
Engaging with state, tribal, territorial, and local partners and other stakeholders to promote vaccine
Utilizing a centralized and phased approach for distributing vaccines via health departments, federal
entities, and commercial partners like pharmacies
Ensuring distribution sites can store, handle, and safely administer vaccines
Collecting and monitoring data on distribution and administration of vaccines
Vaccine production uses materials (for example: glass vials, stabilizing agents) that require a stable supply
chain and a trained workforce to manufacture the vaccine. By anticipating potential bottlenecks in the supply
chain and, if possible, forecasting the demand in advance of an emergency, rural communities may be able to
avoid vaccine shortages in the future.
Distribution – Vaccine distribution to rural healthcare systems is heavily dependent on
the national approach. During the COVID-19 pandemic, the United States government used a centralized approach to
distribute COVID vaccines to attempt to maintain full visibility and tracking of the process across the country.
A contracted distributor then supplied the vaccines allocated by the government to state, tribal, and local
jurisdictions and authorized partners for delivery. Rural health systems can prepare for receiving vaccines by
ensuring their infrastructure, storage capabilities, and other logistics are in place. Tapping into existing
networks and engaging partners to ensure that a community receives necessary vaccines are action items to ensure
better healthcare for the community.
Delivery – The following strategies can be used to improve vaccine delivery and
deployment in rural areas during an emergency:
Set up mass vaccination sites to increase patient load and minimize management issues across smaller
Partner with pharmacies and long-term care facilities to leverage existing infrastructure and aid in
scheduling appointments, reaching out to community members, storing vaccines, and other logistics
Partner with the National Guard to administer vaccines and train others in vaccine administration
Create mobile vaccination clinics to improve access to vaccinations, especially in remote rural
Use community-based settings, such as schools, churches, and fire departments, to administer vaccines,
improve access for hard-to-reach communities, and improve vaccine confidence
Our resource, COVID-19 Vaccination in Rural Areas, provides
information, guidance, tools, and more to support COVID-19 vaccination strategies in rural communities.
During the COVID-19 pandemic, rural communities identified innovative
strategies to vaccinate community members against COVID-19. For example, in rural Alaska, tribal
healthcare providers delivered COVID-19 vaccines to community members via small airplanes, water taxis, and
Lessons learned from vaccine implementation during an emergency response can improve vaccine distribution and
delivery strategies to prevent future infectious disease outbreaks. For example, during the COVID-19 pandemic
response, rural communities experienced challenges that impeded immunization efforts. These challenges included
limited vaccine confidence, access, and uptake in rural areas. The National Governors Association Center for
Best Practices (NGA Center) recommends the following strategies
for rural communities:
Build vaccine confidence by delivering transparent and effective communication and messaging campaigns in
Ensure access to vaccines for rural populations by adopting approaches that address common rural challenges
related to infrastructure, travel distance, and workforce
Develop equitable and sustainable vaccine allocation and distribution systems for rural communities
During the recovery phase, organizations and agencies like the World Health Organization and the Centers for
Disease Control and Prevention may update their vaccine implementation guidance based on lessons learned from
the response to ultimately inform future planning efforts. It is important that rural communities consider and
include any changes in such guidance in local preparedness planning.
Resources to Learn More
Hospital-Based Emergency Care: At the
Discusses the impact of limited resources and increased patient volume on hospital-based emergency and trauma
care during disasters. Topics cover workforce across various disciplines, patient safety, quality and efficiency
of emergency care services, information technology, and challenges of providing emergency care in rural
Organization(s): National Academies of Sciences, Engineering, and Medicine
Emergency Response Checklist: An All-Hazards Tool for Hospital Administrators and Emergency Managers
Provides information and checklists on key factors necessary to help hospital administrators and emergency
managers respond to disaster events. Covers coordination of hospital operations, internal and external
communication, safety and security, triage, surge capacity, continuity of essential services, and post-disaster
Organization(s): World Health Organization (WHO)
Rural Healthcare Surge
Resources for rural healthcare systems preparing for and responding to a COVID-19 surge. Includes resources for
emergency medical services, inpatient and hospital care, ambulatory care, and long-term care settings. Addresses
a wide range of topics including healthcare operations, space, supplies, funding, and more.
Organization(s): COVID-19 Healthcare Resilience Working Group
Health Care Delivery System Assessment Tool
Offers rural healthcare leaders with a systematic approach for assessing their healthcare system's emergency
preparedness and response. Topic areas for assessing efficiency and effectiveness include governance and
leadership, community engagement, financial health, clinical care, and emergency resilience.
Organization(s): Colorado Hospital Association (CHA), Eugene S. Farley, Jr. Health Policy Center
Strategies to Increase COVID-19 Vaccine Uptake in Rural Communities
Outlines strategies and considerations to increase vaccine uptake particularly in rural communities including
improving access, leveraging trusted messengers, and creating sustainable structures for vaccine delivery.
Organization(s): National Governors Association
to Rural Evacuation: Planning for Rural Population Surge
Reports findings from a study assessing the likelihood of urban evacuation to rural areas in response to a
disaster or public health emergency and provides considerations for rural planning and response.
Author(s): Meit, M., Briggs, T., & Kennedy, A.
Organization(s): NORC Walsh Center for Rural Health Analysis