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H H S Department of Health and Human Services
Health Resources and Services Administration
Primary Care: The Health Center Program

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Health Center Emergency Management Program Expectations

Policy Information Notice 2007-15

EXPECTATIONS

Health centers must have risk management policies and procedures in place that proactively and continually identify and plan for potential and actual risks to the health center in terms of its facilities, staff, clients/patients, financial, clinical, and organizational well-being. Plans and procedures for emergency management must be integrated into a health center’s risk management approach to assure that suitable guidelines are established and followed so that it can respond effectively and appropriately to an emergency. Health centers should also be aware that other entities (i.e., accrediting organizations, State and/or local health departments) may also have requirements related to emergency management activities.

Health centers are diverse organizations. Therefore, each health center will require an emergency management approach that considers the center’s size, location, resources, as well as current State, local, or community/regional plans. Location and size of the facility, the number of staff, and the type of operations are key factors to consider in developing an appropriate emergency management strategy. Small health centers might have relatively basic emergency management strategies whereas centers with multiple sites, greater variability in operations, or large numbers of staff may develop more complex approaches.

The emergency management expectations for health centers addressed in this guidance are as follows:

A. Emergency management planning—health centers should be engaged in an ongoing, continuous process to ensure that emergency management plans (EMP) are appropriate.

B. Linkages and collaborations—health centers should maximize their linkages and collaborations.

C. Communications and information sharing—health centers should have policies and procedures for communicating and sharing information with internal and external stakeholders.

D. Maintaining financial and operational stability—health centers’ business plans should address financial viability in the event of an emergency.

A. Emergency Management Planning

Emergencies can disrupt care provided to health center patients by significantly increasing demand for services or severely impacting current operations. An emergency management plan or EMP (also known as an emergency operations plan or disaster plan) is essential to minimize the disruption of services for patients, assure the health center’s ongoing financial and organizational well-being, and link the health center to the local community response.

The purpose of the EMP is to ensure predictable staff behavior during a crisis, provide specific guidelines and procedures to follow, and define specific roles and responsibilities. The EMP should address the four phases of emergency management—mitigation, preparedness, response, and recovery:

  • Mitigation activities lessen the severity and impact a potential disaster or emergency might have on a health center’s operation;
  • Preparedness activities build capacity and identify resources that may be used should a disaster or emergency occur;
  • Response refers to the actual emergency and controls the negative effects of emergency situations; and
  • Recovery actions begin almost concurrently with response activities and are directed at restoring essential services and resuming normal operations. Recovery planning is a critical aspect to sustaining the long-term viability of the health center.

It is essential that the EMP be developed with an interdisciplinary approach involving all departments within the organization as the entire organization will be affected and play a role in an emergency. The Governing Board, senior management, and the clinical staff should have a lead role in the development of the EMP, and the Governing Board should approve the final EMP and any revisions to it.

Health centers should initiate emergency management planning by conducting a risk assessment such as a Hazard Vulnerability Analysis. The risk assessment should identify potential emergencies and the direct and indirect effects these emergencies may have on the health center’s operations and the demand for services. The risks identified in the risk assessment should be prioritized based on the likelihood of occurrence and severity and addressed in the EMP. There are many risk assessment tools available and health centers are encouraged to use the tools that best meets their specific needs.

Health centers are encouraged to participate in community level risk assessments and integrate their own risk assessment with the local community. Many States and communities may have already completed a risk assessment for their area, and health centers are encouraged to use these assessments as a starting point for their own assessment.

In developing the EMP, health centers should describe their approach to responding to emergencies that would suddenly and significantly affect the demand for the organization’s services or its ability to provide those services. The EMP should take an all-hazards approach—meaning that the health center has considered and has developed an EMP that is simple and flexible enough to respond to all of the identified emergencies. These could include a sudden and abrupt event such as an explosion or a sustained event over a longer period of time such as pandemic influenza.

Many State and/or local EMPs are already in place and, to the extent possible, a health center’s EMP should be aligned and integrated with these emergency plans. The role of the health center in these plans should be clearly established and reflected in both the health center’s internal EMP as well as in the State and/or local EMPs. To maximize integration, health centers are encouraged to connect with any ongoing efforts in these areas before developing and implementing their EMP. Health centers may also want to explore developing mutual aid agreements with other community health care providers such as other health centers, hospitals, and rural health clinics for resources such as personnel, equipment, and supplies. To find out if there is an established community and/or regional EMP, health centers should contact their local county government.

The EMP is necessary to ensure the continuity of patient care in the event of an emergency. It should describe under what circumstances and how, when, and by whom the EMP is activated, procedures for notifying staff when it has been initiated, and the roles and responsibilities of all personnel responding to the emergency. Health centers should appropriately include components in their plan that reflect the unique characteristics of the health center—size, location, resources, environment, populations served, and the role it plays within its community. For many health centers, the EMP can be a basic plan; for others, the EMP will need to reflect the complex nature of its operations and capacities. A health center’s EMP should address the following components as appropriate, considering the role of the health center in the local and/or State plans and what is most appropriate and necessary for the health center to respond to an emergency:

  • Continuity of operations;
  • Command and control;
  • Staffing;
  • Surge patients;
  • Medical and non-medical supplies;
  • Pharmaceuticals;
  • Security;
  • Evacuation;
  • Decontamination;
  • Isolation;
  • Power supply;
  • Transportation;
  • Water/Sanitation;
  • Communications; and
  • Medical records security and access.

Individuals impacted by emergencies often experience significant emotional stress. The health center’s EMP should address the behavioral needs of both patients and staff and identify additional resources for providing those services. The plan should also help staff prepare their families for emergencies—if staff are prepared at home, they are more likely to carry out vital responsibilities and duties at work in the health center. For additional information on personal preparedness, visit the Department of Homeland Security’s Web site.

The EMP should describe if and how health centers will continue to provide primary health care services to current and surge patients to the extent possible during an emergency, including consideration for continuity of services for contracted services as well as those services that are directly provided by the health center. The EMP should evaluate a health center’s ability to maintain normal operations and describe the circumstances that must be met for the health center to discontinue non-emergency primary care services or cease operations for a period of time, especially if staffing levels decrease. Provision of primary health care services should be consistent and aligned with the health center’s role, as determined in consultation with the local community. If applicable, the EMP should also address how the health center will utilize mobile vans during an emergency and how services to patients served by the van will be continued should access be impeded, or if it were damaged or destroyed.

Health centers should plan for assuring access for special populations, such as migrant and seasonal farm workers, homeless people, and residents of public housing. Many times these populations need additional assistance and communication (such as culturally and linguistically appropriate messages and outreach). In developing the EMP, health centers are encouraged to also consider other populations such as non-English speaking individuals, children including those with special needs and those served at school-based health centers, individuals living with HIV disease, and disabled and elderly individuals.

Health centers should provide ongoing training on emergency management and the implementation of the EMP to employees at all levels of the organization. Health center employees may be eligible to participate in State and local trainings on emergency management and health centers are encouraged to use these available resources. Appropriate planning and adequate education and training are critical to ensure staff are prepared to deal with an emergency when confronted with one.

Health centers should continually test and evaluate the effectiveness of their EMP and make adjustments as necessary. Exercises reveal what works, what does not, and what is needed to enhance the effectiveness of the EMP. The objectives of testing EMPs through exercises are to minimize confusion and mistakes that may occur during an actual emergency. The frequency and methods of testing and evaluation (table top drills, functional exercises, etc.) should be determined by the organization, but should be at least on an annual basis. Health centers are also encouraged to test their plan in a community-wide and regional setting by participating in local, regional, or national disaster drills or exercises, if possible and as appropriate. Health centers’ EMPs should be updated and revised based on any lessons learned from participation in drills, exercises, or actual emergencies.

B. Linkages and Collaborations

Normal operations can become overwhelmed during an emergency, and health centers may have to rely on other community organizations for assistance and, possibly, for assuming some aspects of patient care. Established linkages and collaborations are critical for an effective EMP. Coordinated efforts are necessary to provide comprehensive care during this time and integration into the local community response can increase the health center’s ability to obtain needed resources for continuing care.

In developing their EMP, health centers should integrate with the emergency management system at the State, local, and community levels. Health centers should collaborate with State and local emergency management agencies, professional volunteer registries housed in State Departments of Health, emergency medical services systems, public health departments, hospitals, mental health agencies, national organizations, PCAs, and Primary Care Organizations (PCO). Health centers should also be prepared to work with organizations that may not be part of their usual primary health care delivery network. These may include local businesses, law enforcement, fire services, local military installations, schools, and faith-based organizations

Health centers should define their role within their local community prior to an emergency and be proactive in engaging community leaders, identifying key organizations, and developing ongoing relationships. Well in advance of an emergency, health centers should establish relationships with key decision makers to assist in effectively navigating State and local systems to obtain needed resources before, during and after an emergency. Participating in State, local, and community emergency/disaster exercises will aid in initiating and developing linkages with these individuals and organizations.

C. Communications and Information Sharing

During an emergency, standard communication systems are often overwhelmed or destroyed and health centers will likely have difficulty accessing critical information. A well-defined communications plan is an important component of an effective EMP. The EMP should identify the health center’s policies and procedures for communicating with internal (staff, patients, special populations, Governing Board) and external (appropriate Federal, State, local, and Tribal agencies) stakeholders as well as with the public during emergencies.

Health centers should also develop policies and procedures that describe who will be responsible for communicating important information and which agencies or groups should receive communication, the process for how the communication will take place, and what general information should be communicated.

As part of the EMP, the health center should develop strategies for communicating with patients during an emergency including procedures to make patients aware of any alternative primary care service arrangements that may be available in the event the health center is closed. Health centers are encouraged to work with their State and/or local public health department in developing appropriate communication messages for patients. Local radio and television may be useful for communicating such messages. All educational materials and other emergency information should be culturally and linguistically appropriate and developed at reading levels appropriate for the population being served.

The health center’s EMP should identify backup (also referred to as redundant) communication systems in the event that standard communication systems are unavailable and include these in its EMP. Example of redundant communication systems include: two-way radios, mobile/cell phones, and wireless messaging. The health center’s communication policies, procedures, command structure, and backup communication systems should be tested in conjunction with the EMP at least on an annual basis or more frequently, as appropriate. Health centers’ communications systems should be integrated into the local health care and community systems and be tested in conjunction with these systems.

Health centers should have an all-hazards command structure within the organization, such as a standard ICS, that links with the community’s command structure for emergencies. As a component of the NIMS, many communities have established an ICS for use during an emergency—the ICS provides a unified, organized, and structured method for cooperation and coordination as well as to facilitate decision making and response. The health center’s ICS should also include procedures for communicating with staff and other key stakeholders during an emergency. These policies and procedures should be integrated with the health center’s EMP.

The quality of key decisions made during emergencies is critically dependent on the availability of current, accessible, accurate, and relevant information. Data reporting assists decision makers in assessing the current situation and identifies critical needs, such as supplies and staffing, that are essential to continuing the provision of care prior to, during and after an emergency. Data reporting can assist local communities in positioning resources and facilitate access to these resources for health centers.

To maximize access to resources, health centers are encouraged to have systems in place which accurately collect and organize data for anticipated requested/required reporting. Health centers should collaborate with State and local agencies, such as PCAs, PCOs, and local public health departments to develop standard reporting protocols. The reporting protocols should be integrated into the communication section of the health center’s EMP.

In the event of an emergency, health centers (both Health Center Program grantees and FQHC Look-Alikes) will be required to submit data to their HRSA Project Officer (PO). Depending on the circumstances, HRSA may initiate procedures before, during and after emergency events that include asking for information from each affected health center such as the status of health center operations, patient capacity and/or staffing/resource/infrastructure needs.

D. Maintaining Financial and Operational Stability 

Health centers can face significant obstacles in regaining financial stability after an emergency and may spend several months or even years in the recovery phase. Physical or property losses sustained from emergencies can cause interruption or discontinuation of services for patients and disrupt the community health care infrastructure. Adequate planning for recovery in the assessment, planning, and response process will shorten the time it takes a health center to become fully operational.

The ability to adequately respond to an emergency can help preserve the financial viability of the health center. Health centers’ business plans should address the financial response to an emergency including goals for maintaining cash reserves and plans related to managing and insuring against business interruptions, equipment, facilities, and property loss. The purpose of incorporating emergency management considerations in the business plan is to reduce and/or minimize potential adverse impacts brought about by an emergency. As part of these plans, health centers should annually review their insurance coverage to ensure that it is current and that the coverage is adequate.

Preserving vital operational records and documents is critical to a quick resumption of operations. Health centers should have backup information technology systems to ensure that electronic financial and medical records2 are available during and after an emergency. Consideration should be given to the feasibility of obtaining off-site storage for these electronic records with emphasis on electronic access and retrieval during or after an emergency. In advance of an anticipated event, health centers are encouraged to secure facilities to the extent possible, and may want to consider off-site or safe storage for their equipment and data.

Business plans should address strategies for resuming key functions that would enable health centers to fully conduct operations, such as ensuring that billing systems are in place for obtaining payment and reimbursement as soon as possible. Health centers are encouraged to have a backup billing system in place to track charges and sustain the flow of reimbursement needed to maintain the financial viability of the health center during any response and recovery. They should have a system to track patients being treated as a result of an emergency (i.e., surge patients) that is independent of normal operations which can be used in obtaining any supplemental funding should it become available.

In the event of an emergency, Health Center Program grantees can use grant funds to provide services consistent with their approved scope of project and the terms of their grant award. Generally, all costs charged to Federal grant awards must be consistent with Federal cost policy guidelines, program regulations, and the terms of the award. Health centers should contact their Grants Management Specialist if they have grants administration questions related to emergencies. Both Health Center Program grantees and FQHC Look-Alikes should make every attempt to collect reimbursement for services from appropriate public and private coverage.

CONCLUSION

Health centers have demonstrated exceptional expertise in delivering comprehensive, culturally competent, quality primary health care services to vulnerable and underserved populations. This may prove even more crucial in the event of an emergency. A successful emergency response may largely depend on the ability of health centers to communicate with appropriate stakeholders, whether staff, patients, or other entities. Health centers are encouraged to be proactive in engaging community leaders, identifying key partner organizations, and developing ongoing relationships. The ability to adequately respond to an emergency can help safeguard the operational and financial viability of the health center.

The expectations outlined in this guidance are intended to be broad to ensure applicability to the diverse range of health centers and ease in integrating them into what health centers are already doing related to emergency and risk management. In addition to developing, implementing, and maintaining an EMP, health centers should continually look for opportunities to enhance awareness, educate and train boards and staff, evaluate and test procedures, and integrate emergency management into what the health center does on a daily basis. A well-developed and appropriate emergency management strategy which reflects the unique characteristics, circumstances, and environment for the health center, will assure that it will be able to recover quickly and continue to provide essential services in their community.

KEY DEFINITIONS

Emergency Management: The process of planning, developing, implementing, and executing a comprehensive system of principles, policies, procedures, methods, and activities designed to ensure an organization’s effective response to natural and manmade disasters affecting its environment and business operations. Emergency management is a comprehensive system, which includes planning, mitigation, preparedness, response, and recovery activities. Health center emergency management entails developing a plan based on the hazard vulnerabilities likely to affect the health center, conducting exercises and drills to assure sound response and recovery activities, and includes annual reassessments and updates to recognize any new threats or vulnerabilities to improve on emergency management procedures and activities.

Emergency Management Plan (EMP): A document describing the comprehensive system of principles, policies, procedures, methods, and activities to be applied in response to natural and manmade disasters to ensure patient and employee safety, to mobilize resources, to maintain health center business operations, and to assist in providing mutual aid in a community-wide response requiring medical services.

Homeland Security Presidential Directives: Homeland Security Presidential Directives (HSPDs) are issued by the President of the United States on matters pertaining to Homeland Security. Two key HSPDs were created to establish national initiatives that develop a common approach to domestic incident management and include the National Response Plan (NRP), the National Preparedness Goal, the National Incident Management System (NIMS), the Universal Task List (UTL), and the Targeted Capability List (TCL). These are HPSD-5: Management of Domestic Incidents and HSDP-8: National Preparedness.

Incident Command System (ICS): A system for managing resources from other organizations during an emergency. The ICS is a standardized on-the-scene emergency management system that is used nationwide. It is specifically designed for an integrated multi-organizational structure and is scalable to handle the complexity and demands of a single or multiple incidents without being hindered by jurisdictional boundaries. The ICS manages and coordinates facilities, equipment, supplies, procedures, and communications within a common and defined organizational structure, to effectively accomplish stated objectives pertinent to an incident.

Jurisdiction: A range or sphere of authority. Public agencies have jurisdiction at an incident related to their legal responsibilities and authority. Jurisdictional authority at an incident can be political or geographical (e.g., city, county, tribal, State, or Federal boundary lines) or functional (e.g., law enforcement, public health).

National Incident Management System (NIMS): A system mandated by HSPD-5 that provides a consistent nationwide approach for Federal, State, local, and tribal governments; the private-sector, and nongovernmental organizations to work effectively and efficiently together to prepare for, respond to, and recover from domestic incidents, regardless of cause, size, or complexity. To provide for interoperability and compatibility among Federal, State, local, and tribal capabilities, the NIMS includes a core set of concepts, principles, and terminology. HSPD-5 identifies these as the ICS; multiagency coordination systems; training; identification and management of resources (including systems for classifying types of resources); qualification and certification; and the collection, tracking, and reporting of incident information and incident resources.

National Preparedness Goal (NPG): The NPG will guide Federal departments and agencies, State, territorial, local and tribal officials, the private sector, non-government organizations and the public in determining how to most effectively and efficiently strengthen preparedness for terrorist attacks, major disasters, and other emergencies. The NPG also includes seven national priorities. The national priorities are: Implement the National Incident Management System (NIMS) and the National Response Plan (NRP), Expanded Regional Collaboration, Implement the Interim National Infrastructure Protection Plan, Strengthen Information Sharing and Collaboration Capabilities, Strengthen Interoperable Communications Capabilities, Strengthen Chemical/Biological/Radiological/ Nuclear/Explosives Detection, Response and Decontamination Capabilities, and Strengthen Medical Surge and Mass Prophylaxis Capabilities. Focusing on these priorities will ensure adequate infrastructure that is prepared—at the Federal, State, local, and regional levels—through shared priorities, goals, and objectives.

National Response Plan (NRP): A plan mandated by HSPD-5 that integrates Federal domestic prevention, preparedness, response, and recovery plans into one all-discipline, all-hazards plan.

Targeted Capability List (TCL): The identification of target levels of capabilities that Federal, State, local, and tribal entities must achieve to perform critical tasks for homeland security missions. Capabilities are combinations of resources that provide the means to achieve a measurable outcome resulting from performance of one or more critical tasks, under specified conditions and performance standards. The TCL identifies 37 capabilities integral to nationwide all-hazards preparedness, including terrorism. 

Universal Task List (UTL): The UTL was developed in close consultation with Federal, State, local, and Tribal entities and national associations to help the homeland security community implement the capabilities-based planning process established under HSPD-8. The UTL is a "living" document that will continue to be refined and expanded as it is put into practice.

RESOURCES

There are a wide range of resources available to assist health centers in support of emergency management activities. Technical assistance related to emergency management also may be available from PCAs that have been engaged in emergency management planning activities in their State and health centers that have already developed EMPs. Listed below are a number of Federal references health centers may find helpful.

Department of Health and Human Services

Health Resources and Services Administration

Centers for Disease Control and Prevention—Emergency Preparedness & Response

Food and Drug Administration—Bioterrorism/Counterterrorism

Substance Abuse and Mental Health Services Administration—Disaster Response

National Institute for Occupational Safety and Health—Business Emergency Management

Department of Labor, Occupational Safety and Health Administration—Emergency Preparedness and Response

State Offices and Agencies of Emergency Management—Contact Information

Department of Homeland Security

Footnotes

2 For information on HIPAA privacy and disclosures in the event of an emergency, please visit the HHS Web site.