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Healthcare Coalitions Don’t Have Response Role? Really?

Healthcare Coalitions Don’t Have Response Role? Really?

In a well known LifeLock commercial, bank robbers storm into a bank yelling, "Everybody on the floor." As customers hit the floor, a man in a security uniform is chilled out when one of the customer’s whispers, "Do something!" He replies, "Oh, I'm not a security guard. I'm a security monitor. I only notify people if there is a robbery." After a brief glance around the customer passively says, "There's a robbery." The narrator then says, "Why monitor a problem if you don't fix it?" Well, the same applies to healthcare coalitions.

But, many coalition leaders argue that they have no 'response' role, that they are not 'operational.' Really? Maybe this is just a misunderstanding about definitions, or lack thereof. Let's come back to that.

rant

I got all fired up about this issue, because eight people died unnecessarily in a nursing home days after Hurricane Irma departed to the North. And it came to a head a few days ago.

This past week I ended up in an uncomfortable debate with a consultant on LinkedIn over the role of the Broward County (Florida) Healthcare Coalition during Hurricane Irma. Specifically we were debating the deaths at Hollywood Hills Rehabilitation Center in Broward County, and the responsibilities of the Broward County Healthcare Coalition (BCHC). I stated:

"...As for the Broward County Healthcare Coalition, the blame does not lie with them. But, they better be able to show (document) that they had been in touch with the facility before, during, and after the storm; that they had been invited to participate in training opportunities and exercises; they need to be able to show that they've been using their HPP grant in an effective, efficient manner, not just to hold meetings and buy stuff. If they cannot, then they need to ask themselves some tough questions."

The consultant, who works for a firm I respect, responded with:

"...The Broward County HCC is not a response agency and has no responsibility to 'check on' healthcare facilities in the middle of a disaster response."

He later stated more generally, as if every healthcare coalition across the Nation is the same:

"...As for HCCs, again, I said they do not have a response role during emergencies."

His confidence irked me.

To much fault of my own, the conversation digressed from there. Some have said, "You sound angry, frustrated, Karl." Yes I am. I cannot swallow that eight people died from heat related illnesses in a nursing home days after the storm passed. It should not have happened. The resources– state, federal, local, and private sector– were there, but no one connected the dots. And that's the healthcare coalition's sweet spot.

We are 15 years into funding for healthcare preparedness; we are in year-six of the shift from hospital facility preparedness to healthcare system preparedness; we are in year-six of the shift to multi-discipline, multi-sector, multi-jurisdictional healthcare coalitions. Florida is not some low-funded state with minimal financial resources- they are the third highest funded state in the nation. They are a state that 'gets' disaster preparedness and response.

And Florida's long-term care providers have seen enough to know they can't go it alone, But until the CMS rule was published final, they had little to no interest in their healthcare coalitions. The number one frustration voiced to me by coalition leaders has been, "We cannot get long-term care to the table." Now, everyone is scrambling, and too few coalitions have the organizational maturity keep up with requests.

I digress, forgive me.

Florida

Let me be clear, I am not placing the blame for the deaths at the Hollywood Hills Rehabilitation Center on the Broward County Healthcare Coalition. But, it is fair– we have a duty– to question what steps they took before, during, and after the disaster to ensure the County's healthcare providers had what they need to reduce human suffering and loss of life.

So you ask, "why do you keep saying the 'Broward County Healthcare Coalition.' I thought healthcare coalitions are regional in scope." I'm glad you asked. You see, unlike the Tampa Bay Health and Medical Preparedness Coalition and Central Florida Disaster Medical Coalition, which serve the Tampa and Orlando regions, the Florida Department of Health (FDOH) has yielded to politics and turf battles to allow the South Florida counties of Dade, Broward, Palm Beach, Collier, Lee, and Monroe to each have their own healthcare coalition. Anyone who knows the political landscape down there will tell you, "no duh, those guys always go it alone."

Did you know the Florida Keys are in Monroe County, which is served by the Keys Health Ready Coalition, but you cannot get to the Keys from the Monroe County mainland without going through Dade County, served by the Miami-Dade County Healthcare Preparedness Coalition? Really? And that's a problem I'm pretty sure the FDOH recognizes. Notice that on the map above, the Keys are transparent like they are in no man's land. Why are they not orange like Monroe County? Hmm...

You see, unlike they've done with Tampa and Orlando, which tend to work well regionally on many issues, in South Florida the FDOH has enabled jurisdictional silos, duplication of effort, redundant expenses, and exponential administrative burden. So, if the Broward County Healthcare Coalition lacks the financial resources and horsepower it needs to deliver in a 'response' role, we now know why.

'Response' role. We'll get back to that.

To the contrary, The Texas Department of Health Services, which has built one of the most effective hospital preparedness programs in the Nation, funds one fiduciary, The SouthEast Texas Regional Advisory Council (SETRAC), for the entire Houston region. Through it's 'corridors,' SETRAC coordinates the healthcare preparedness, response, and recovery efforts for 25 counties and a population of roughly nine million people. And in 'response' they do it through a sophisticated, well staffed Catastrophic Medical 'Operations' Center (CMOC). Hmm... So SETRAC activates the CMOC during 'response?' Is that a 'response' role, a role in the 'operations' chain? 

Note that, in Texas, healthcare coalitions have another role in 'response.' That is, they deploy boots on the ground 'responders,' medical and logistics professionals. Hmm... Maybe one could say that when boots are on the ground those 'responding' are in a 'response' role carrying out strategies determined within the 'operations' section– as tacticians, triaging, treating, and transporting victims.

Remember, the decision to have their healthcare coalitions serve a tactical role in Texas is choice made by State, not a mandate from ASPR.

Operations, Response, Tactics

As questions are asked and answered during the State's and County's after action process it is my hope the aforementioned consultant– and coalition leadership across the Nation– have just been confusing terminology. I hope everyone is just confused by what the Assistant Secretary for Preparedness and Response (ASPR) means when they state in the Health Care Preparedness and Response Capabilities and the Cooperative Agreement that healthcare coalitions must 'operationalize,' plans and be prepared to 'respond?'

I hope that the Broward County Healthcare Coalition had a 'response' role. Based on the timeline released by the Hollywood Hills Rehabilitation Center, there's reason to question, as the timeline only shows one call to the coalition and no calls from the coalition to the facility.

  • The building has two FP&L (Florida Power & Light) transformers that provide electrical power. One powers life safety systems and the second one only powers the AC chiller.
  • At 3 p.m., electrical power in the building flickered and came back without generator assistance. The electrical power to the AC chiller went down and did not come back.
  • We made our first call to FP&L at 3:49 p.m. and created an emergency service ticket number.
  • Before the storm, we put our protocols into place (approved by ACHA) for disaster situations and on our own initiative, added ten spot coolers (with temperature gauges)  and fans which were distributed evenly on the first and second floors.
  • FP&L told administrators they were coming in the morning to fix the electrical power for the AC Chiller. Then FP&L said they would arrive in the afternoon. FP&L did not show throughout the day.  Care continued to be provided to all residents according to protocol.
  • At 5:36 pm, Natasha Anderson (VP at Larkin) contacted the Florida Emergency Information Line to report the A/C transformer issue. A representative gave her an emergency number in Tallahassee to call to report.
  • At 5:39 p.m., Anderson contacted the number provided, The Florida Department of Emergency Management Private Sector Hotline, and spoke to someone named Jorge. She explained the situation and asked that we be made a priority as we were a hospital and nursing home with 162 patients. Jorge said the matter would be escalated.
  • At 6:57 p.m., Anderson called Jorge back to see if there any updates to her emergency call. She was told there were not, and reassured our situation had been reported and escalated.
  • At 7:29 pm Monday, Anderson received a call from the Florida Department of Health in Tallahassee informing her it was working on our emergency.
  • At 9:24 p.m., Anderson contacted the DOH emergency line again to say she had received no updates.
  • At 9:57 p.m., Anderson received a call from the DOH emergency line informing her that they were working on our request but had no updates. She again expressed the urgency of getting FP&L out to reset the A/C chiller transformer.
  • It’s important to note that through Monday, the building was still cool and the spot coolers were in place maintaining required temperatures..
  • FP&L told administrators they would be coming to fix the transformer Tuesday morning. FP&L did not show up. FP&L later said they would arrive at the center Tuesday afternoon to fix the transformer. FP&L did not show up.  Care continued to be provided to all residents according to protocol.
  • At 9:58 am, Anderson contacted the Tallahassee DOH emergency line to inquire about the status of her calls for help. She was told there were many hospitals and healthcare facilities with FP&L problems due to the storm. Anderson again asked to be made a priority due to the frail and elderly resident population.
  • At 12:53 pm we reached out to Memorial Regional Hospital and asked for additional spot coolers to help keep the center’s temperature maintained. These spot coolers were received and put in place at 3:15 p.m.
  • At 1:18 pm, we reached out to the Broward coalition and the coalition offered to send a mass email to all members to see if additional coolers could be provided. The email went out at 1:21 pm
  • At 4:41 pm, Anderson received a call from AHCA on behalf of the EOC. AHCA was informed of all our efforts to obtain help and keep the building cool. AHCA said they would inform emergency response teams we still needed assistance.
  • Throughout the day, the center’s administrator (Jorge Carballo) and engineer (James Williams) called FP&L to try to get assistance.
  • Between 6 pm and 11 pm , a physician’s assistant rounded on patients to check that the patients were stable in light of the current conditions. Jorge C. was constantly rounding as the administrator (as a non-medical person) during this time frame.
  • At 1:30 am the first patient (1) had tachycardia. 911 rescue was called by the Facility. The patient was stabilized and transferred to the hospital
  • At 2:30 am 911 rescue was called by the Facility when a second patient (2) had respiratory distress. The patient was stabilized and transported to the hospital.
  • At 4:30 am, 911 rescue was called by the Facility as a third patient (3) went into cardiac arrest. Resuscitation measures were provided. Patient was pronounced dead at the center by 911 rescue.
  • At 4:30 am, while 911 rescue still there, a fourth (4) patient had cardiac arrest. However, the patient was on “do not resuscitate orders” and was not resuscitated.  This patient died.
  • At 4:45 am, while 911 rescue still there, a fifth patient (5) had cardiac arrest, rescue 911 resuscitated the patient but the patient later died at the hospital.
  • At 5 am, our Director of Nurses was informed of the incidents. She recommended moving patients from the second floor to the first floor where it was cooler. Jorge Carballo was also contacted.
  • The evacuation of patients occurred in conjunction with local authorities and Memorial Regional staff, around 6:30 am
  • FP&L arrived at our center to fix the transformer on Wednesday morning, hours after our residents began having health emergencies.   Up to and through the evacuation, protocol was followed.

Is a 'role in response' different from 'responding?' Does operational mean putting boots on the ground assisting with evacuation of patients and starting IVs, or is that really tactics? Could 'operations' really be 'coordination?'

To be fair to all, ASPR does not define the terms response, responding, operations or operationalize within the HPP Cooperative Agreement or the Healthcare Preparedness and Response Capabilities. Maybe it'd be a good idea for them to put some definitions on the table.

They do, however, define the term Emergency 'Operation's' Center (EOC) in the Health Care Preparedness and Response Capabilities, which helps shed some light.

"The physical location at which the coordination of information and resources to support incident management (on-scene operations) activities normally takes place. An EOC may be a temporary facility or may be located in a more central or permanently established facility, perhaps at a higher level of organization within a jurisdiction. EOCs may be organized by major functional disciplines (e.g., fire, law enforcement, medical services), by jurisdiction (e.g., federal, state, regional, tribal, city, county), or by some combination thereof." 

Hmm... 

Maybe ‘operations’ does not mean boots on the ground. Maybe it does not mean that the healthcare coalition must get trucks with flashing lights and deploy to evacuate a nursing home. 

Here's a few other tidbits from the HPP Cooperative Agreement and the Health Care Preparedness and Response Capabilities.

Cooperative Agreement

For the purposes of this FOA, ASPR defines a health care coalition (HCC) as a coordinating body that incentivizes diverse and often competitive health care organizations and other community partners with differing priorities and objectives and reach to community members to work together to prepare for, respond to, and recover from emergencies and other incidents that impact the public’s health. HCCs should coordinate with their HCC members to facilitate:

  • Strategic planning
  • Identification of gaps and mitigation strategies
  • Operational planning and response
  • Information sharing for improved situational awareness
  • Resource coordination and management

HCC's In Response

HCCs serve a communication and coordination role within their respective jurisdictions. This coordination ensures the integration of health care delivery into the broader community’s incident planning objectives and strategy development. It also ensures that resource needs that cannot be managed within the HCC itself are rapidly passed along to the ESF-8 lead agency. HCC coordination may occur at its own coordination center, the local EOC, or by virtual means – all of which are intended to interface with the ESF-8 lead agency. 

Coordination between the HCC and the ESF-8 lead agency can occur in a number of ways. Some HCCs serve as the ESF-8 lead agency for their jurisdictions. Others integrate with their ESF-8 lead agency through an identified designee at the jurisdiction’s EOC who represents HCC issues and needs and provides timely, efficient, and bidirectional information flow to support situational awareness. Regardless, HCCs connect the medical response elements and provide the coordination mechanism among health care organizations, including hospitals and EMS, emergency management organizations, and public health agencies

HPP awardees must ensure by the end of Budget Period 2 that their HCCs are engaged when an emergency with the potential to impact the public’s health occurs within their boundaries. The HCC and its members must, at a minimum, define and share essential elements of information (EEIs) to include elements of electronic health record and resource needs and availability. In particular, awardees must ensure the HCC is engaged when one or more health care organizations have lost capacity or ability to provide patient care or when a disruption to a health care organization requires evacuation. 

Healthcare Capabilities

A group of individual health care and response organizations (e.g., hospitals, emergency medical services (EMS), emergency management organizations, public health agencies, etc.) in a defined geographic location. HCCs play a critical role in developing health care delivery system preparedness and response capabilities. HCCs serve as multiagency coordinating groups that support and integrate with ESF-8 activities in the context of incident command system (ICS) responsibilities.

 

So, what's the takeaway?

  1. Healthcare coalitions have a role in 'response'
  2. Healthcare coalitions have a role in 'operations'
  3. Healthcare coalitions have the choice to put boots on the ground in 'tactical' roles, if authorized by their state
  4. No role in response, no funding
Karl Schmitt, MPA

Karl Schmitt, MPA


Karl is the Passionate Founder & CEO of bParati. He is on a mission to build a national network of effective, sustainable healthcare coalitions. More...

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In all we do, we seek to reduce human suffering and loss of life caused by disasters.

We get it done by connecting the preparedness efforts of healthcare organizations, emergency management agencies, and public health departments through effective, financially self-sustaining healthcare coalitions.

Yes, we believe healthcare coalitions are the path forward.

Karl Schmitt, Passionate Founder & CEO, bParati

Karl SchmittPassionate Founder & CEO

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