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U.S. Department of Health and Human Services

Integration With Other Tiers

Management of the State response (Tier 4) requires effective integration of State public health and medical assets with jurisdictional incident management (Tier 3). This function may be provided under the guidance of State public health using the infrastructure capability (e.g., manpower, computing resources, communications equipment) of the State EOC.[9] In this way, State emergency management personnel collect and analyze public health and medical data generated by jurisdictional (Tier 3) unified command teams, as well as investigative findings from law enforcement and other agencies. The ability to examine these data, in real time, and rapidly return aggregate information to jurisdictions facilitates incident planning and promotes a consistent multijurisdictional strategy. It also enables the State to maintain accurate and updated records of resource availability—a crucial factor in coordinating mutual aid support.

A challenging aspect of the State response is coordinating the efforts of multiple jurisdictions without infringing on their responsibility in incident management. This is best accomplished by establishing key information requirements for all State jurisdictions through the Planning Section of the State incident management team or the MACC (i.e., State EOC). Standardized procedures should be developed for reporting medical and public health data (i.e., what, when, where, and how) and for requesting mutual aid. Reports should include strategies and tactics being used by local jurisdictions through their jurisdictional IAPs. This integrates the State with jurisdictional incident management (Tier 3) and facilitates coordination between affected jurisdictions. It also reduces the chance that conflicting strategies between jurisdictions may occur, causing anxiety and weakening public confidence in the response. A well-defined information management function enables local medical and public healthcare providers to access guidelines for patient evaluation and treatment from State public health authorities. This capability can be critical in a rapidly evolving infectious disease outbreak.

The State (Tier 4) also provides the interface between jurisdictional incident management (Tier 3) and Federal public health and medical assistance (Tier 6). For example, the State Governor makes the formal request to HHS for the Strategic National Stockpile (SNS) if the need for SNS assets is identified. If the SNS is deployed, State officials work closely with SNS coordinators and jurisdictional managers to coordinate its distribution to affected jurisdictions. The information management (i.e., knowing what support is needed) and incident management (i.e., working with local incident managers) facilitates this process.

How a State organizes its emergency services to promote integration will depend on many factors, including its geography, population distribution, and historical hazard experience. Some States favor a decentralized approach with the expectation that most hazards will be managed by relatively sovereign local jurisdictions. Other States have established detailed State-driven management procedures that are outlined in extensive regulations. The Standardized Emergency Management System (SEMS) in California provides an excellent example of the latter situation and is briefly described here.

California established SEMS in the early 1990s as a Statewide management system for use by public safety personnel (e.g., firefighters, police) and other emergency responders. State agencies are required by law to use SEMS for incidents involving multiple agencies or multiple jurisdictions. In addition, local governments must use SEMS in multiagency or multijurisdiction response to be eligible for State reimbursement for response-related personnel costs.[10] SEMS is flexible to meet the demands of all hazards, and it is based on ICS functions (Command, Operations, etc.) and a five-level organization of response.

Figure 5-1. Generic SEMS Management Structure

Figure 5-1 shows the generic Standardized Emergency Management System (SEMS) structure. The structure is a 5 level hierarchy starting from the ground up. The ground level is the “Field Response”, emergency responders carrying out tactical decisions and activities in direct response to a threat. The Field Response requires the use of ICS functions. Above the Field Response is the “Local Government”. Local Government includes cities, counties, and special districts and manages and coordinates overall emergency response and recovery activities in their jurisdictions. Above local government is the “Operational Area” which encompasses the county and all political subdivisions in the county, including special districts. The Operational area manages and coordinates information, resources and priorities among local governments and serves as the coordination and communications link between local and regional levels. Above the operational area is the “Regional Level” which manages and coordinates resources among operational areas. The Region Level also coordinates information sharing between operational areas and the State level and oversees State support for emergency response activates in the region. Last, at the top of the hierarchy, is the “State Level” which manages State resources to meet emergency needs of other levels and coordinates mutual aid among regions and between regional and State levels. Finally, the State Level serves as communication link between the State and the Federal response system.

Information abstracted from Standardized Emergency Management System (SEMS) Guidelines for Special Districts.

Although SEMS provides a well-developed organization for public safety emergency services, it does not comprehensively address the incorporation of public health or private medical assets as the primary responders and incident managers. In addition, SEMS generally assumes a defined incident scene and relies on this to organize the initial response structure (this is understandable given the major hazard risks in California). However, because a defined scene is much less likely in a public health emergency, additional organizational guidance may prove helpful. The MSCC Management System was written to provide such guidance.

The Metropolitan Medical Response System (MMRS), described in more detail in chapter 4, is a Federal Department of Homeland Security (DHS) program that provides guidance for metropolitan areas to coordinate medical response across local jurisdictional borders.[11]


  1. If the State is serving as the primary incident command authority, then its ICS Planning Section would provide this service.
  2. Office of Emergency Services, California. Standardized Emergency Management System (SEMS) Guidelines for Special Districts (1999)
  3. Information on the MMRS program is available at:

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  • This page last reviewed: February 14, 2012