Study Examines Barriers to Broader Community Collaboration to Prepare for Disasters

While hospitals and first responders consistently work together to prepare for natural disasters, infectious disease outbreaks and other emergencies likely to result in many injured or ill people, other important groups — primary care clinicians and nursing homes, for example — typically do not participate in local emergency-preparedness coalitions, according to a new qualitative study of 10 U.S. communities by the Center for Studying Health System Change (HSC).

Emergency preparedness requires coordination of diverse entities at the local, regional and national levels. Community-based coalitions are intended to foster local preparedness and minimize the need for federal intervention, according to the study funded by the U.S. Centers for Disease Control and Prevention.

Given the diversity of stakeholders, fragmentation of local health care systems and limited resources, developing and sustaining broad community coalitions focused on emergency preparedness is difficult, the study found.

"Health care providers' focus on emergency-preparedness activities waxes and wanes, reflecting the many pressures and competing demands they face. While maintaining normal operations, they must prepare for low-probability, high-impact events that can sharply increase demand for care and stress capacity to the breaking point," said HSC Senior Researcher Emily Carrier, M.D., coauthor of the study with HSC Researcher Tracy Yee; Dori Cross, HSC research assistant; and Divya Samuel, former HSC research assistant.

Using the lens of the 2009 H1N1 influenza pandemic, the study examined emergency-preparedness coalitions in 10 U.S. communities: Boston; Chicago; Greenville, S.C.; Indianapolis; Miami; New York City; Phoenix; Orange County, Calif.; Seattle; and Syracuse, N.Y.; and included rural communities adjacent to the Greenville, Phoenix and Seattle markets.

The study findings are detailed in a new HSC Research Brief, "Emergency Preparedness and Community Coalitions: Opportunities and Challenges," available online at

Key findings include:

  • Most preparedness efforts and funding focus on hospitals, reflecting their historic importance in providing staff, space for planning and response, and treatment of emergency victims, including such specialized services as decontamination or burn care.
  • Physicians and other clinicians employed by hospitals or working in community-based practices owned by hospitals usually fall under the umbrella of hospital-preparedness activities. Likewise, first responders — police, fire and emergency medical services — typically work closely with hospitals.
  • Much less attention and funding for community-based preparedness activities have focused on involving other health care providers, such as independent physician practices, ambulatory care centers, specialty care centers and long-term care facilities. Few communities involve independent practitioners other than maintaining a list of those willing to volunteer in the event of a disaster.
  • A lack of collaboration among stakeholders reportedly has contributed to problems. For example, respondents in four communities—Boston, Chicago, Greenville and Indianapolis—reported challenges working with local school systems, citing coordination and communication difficulties during the H1N1 pandemic. According to a Chicago respondent, "Some schools told people that kids couldn't come back to school without a doctor's note. Hundreds of people went to ERs for a doctor's note."
  • When working with nontraditional partners, health care preparedness coalitions reported difficulty in aligning goals and securing buy in from those who view emergency management as outside their scope of responsibility. For example, one community coalition reported contacting long-term care facilities to offer funding to stockpile antiviral medication but found no takers. A hospital respondent in another community coalition cited reluctance to work with nursing homes because of the perception that they are primarily looking for a place to offload patients in an emergency.

The study identified two general approaches that policymakers could consider to broaden participation in emergency-preparedness coalitions: providing incentives for more stakeholders to join existing preparedness coalitions or building preparedness into activities providers already are pursuing.

One approach could be to provide funding aimed directly at supporting independent physicians' and other underrepresented stakeholders' participation. However, lack of funding—while an important problem—is not the only barrier to these groups' involvement. Lack of time, training and sometimes simply awareness that they have a role in disaster response also are important factors.

Another option would be to incorporate preparedness activities into existing incentive programs aimed at underrepresented stakeholders. For example, programs that offer extra payment to primary care practices to coordinate care of patients with specific chronic conditions might also encourage and reward coordination related to emergency preparedness or the creation of business continuity plans. Likewise, hospital efforts to work with physician practices and long-term care facilities to prevent avoidable readmissions might incorporate joint preparedness activities.