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U.S. Department of Health and Human Services

5.1 Developing the Healthcare Coalition

The preceding chapters described potential roles for the Healthcare Coalition during an emergency to support its member organizations and promote integration of their efforts with the jurisdictional response (Tier 3). Achieving this desired capability requires specific developmental and preparedness efforts. The organizational structure and processes used to prepare the Coalition for an emergency will vary from the structure and processes used by the Coalition during emergency response.

The remaining chapters of this handbook examine strategies and actions that the preparedness element of the Healthcare Coalition can use to prepare the Coalition for effective emergency response.[1]

5.1.1 Coalition Development Strategies

The initial steps in Coalition development should focus on defining the Coalition’s intended function during emergency response.[2] The authors of this handbook recommend that planners who are developing a Healthcare Coalition or enhancing an existing one first describe the response objectives for the Coalition (see Section 2.1.2). A new Coalition with limited resources may decide to limit its initial response objectives to the following:

  • Provide initial and ongoing notifications regarding incident activity to relevant Coalition member organizations.
  • Provide a structured[3] ability to teleconference the liaisons from Coalition member organizations to share information.

In designing the Healthcare Coalition, it is important to consider the workload and expense that establishing and maintaining a Coalition places on its member organizations. The following characteristics for the Coalition are intended to minimize this burden while not compromising the Coalition’s effectiveness during emergencies.

  • Simplicity: The preparedness and response configurations of the Coalition should be constructed as simply as possible to meet the Coalition’s objectives. This might mean limiting the number and types of healthcare organizations included in a single Healthcare Coalition. Other Coalitions could then be established to cover the non-participating healthcare organizations.
  • Cost-effective: Development and maintenance costs should be controlled as much as possible. The Healthcare Coalition should be designed to be financially viable without depending heavily on short-term financial streams, such as grants. Cost-effective processes could include distributing preparedness assignments among the member organizations rather than having a large number of fulltime, dedicated preparedness positions within the Coalition. Use of existing facilities and personnel from member organizations for both preparedness and response will provide cost savings by limiting bureaucracy and personnel expenses.
  • Sustainable: Following initial development, some level of effort is required to sustain and improve the Coalition’s capabilities over time, including training personnel, conducting exercises, and implementing corrective actions. However, maintenance activities should be designed so they are not overly burdensome to Coalition members. Sustainability can be promoted by factoring in maintenance and replacement costs for equipment and supplies purchased by the Coalition. Doing this prior to any major equipment or supply purchase promotes the optimal long-term investment of resources and funding.

5.1.2 Determining the Geographic Boundaries

An important early step in developing the Coalition is determining the geographic boundaries for the Healthcare Coalition. Factors to be considered include local government boundaries, physical impediments to coordination (rivers, mountains, etc.), as well as the number and type of potential member organizations. Other factors to consider include contractual obligations, integrated healthcare system relationships, and patient referral patterns. The critical point is that there is often no one controlling factor for defining the boundaries of the Coalition. The most important considerations should be those that have the greatest effect on the Coalition’s ability to effectively respond under emergency conditions.

The following options can be used to help determine the geographic boundaries of a Healthcare Coalition.

  • Bounding the Healthcare Coalition within a single political jurisdiction. For example, healthcare organizations in a medium-sized city may decide to form a Coalition to support their needs during response.
  • Creating geographic subdivisions within a single jurisdiction due to the number of organizations and inherent complexities of the area. The number and types of potential Coalition members in a large metropolitan area may preclude the use of a single Healthcare Coalition response organization. Multiple Coalitions in any single jurisdiction should coordinate with each other and may consider joint preparedness activities (committee meetings, document development) for efficiency.
  • Creating functional divisions within a jurisdiction. In a large, complex jurisdiction, Healthcare Coalitions may form along functional lines: one for hospitals, one for health centers and other outpatient treatment facilities, and so on. Again, these Coalitions must coordinate with each other closely during both preparedness and emergency response.
  • Including healthcare organizations from multiple jurisdictions to form a regional Healthcare Coalition. Some Coalitions may have boundaries that stretch across two or more local governments. For example, a group of hospitals may be closely situated in neighboring counties or cities. Healthcare organizations that participate in an inter-jurisdictional Coalition must maintain their relationship with their respective Jurisdictional Agencies (Tier 3) and in some instances, they may form relationships directly with the State (Tier 4) if no Tier 3 entities exist.
  • Bounding the Coalition in a large, sparsely populated region to provide a network of remotely located healthcare organizations. In some sparsely populated regions, a Healthcare Coalition may be established to support healthcare organizations across many jurisdictional boundaries. In this scenario, the distinction between MSCC tiers could be much less prominent. For example, many rural jurisdictions have little public health or other medical representation at the local government level and, therefore, little command and control authority in this sector. In these situations, a single collocated arrangement may be preferred in which local jurisdictional authorities (Tier 3) and the Healthcare Coalition (Tier 2) work together as a single healthcare MAC System to address emergency response issues.[4] The newly formed MAC System may also have a direct relationship with the State (Tier 4) through regional entities.

Issues that healthcare planners may consider in determining the size and scope of the Healthcare Coalition include the following:

  • The more jurisdictional boundaries crossed by the Healthcare Coalition, the more complex and difficult it can be to maintain.
  • The complexity of managing the Coalition typically increases with the number and diversity of participating organizations.
  • A politically-defined jurisdiction (city, county, etc.) is responsible for the health and well being of its citizens. Aligning the Coalition within that area of responsibility may be beneficial in terms of receiving funding and other support. In addition, municipal, public safety, and other emergency services are often situated along these same political divisions.
  • The Coalition may be defined by the pre-selected sponsoring organization. These administrative bodies may already have a select set of participants. For example, a hospital association that exists within or across jurisdictional boundaries may serve as the administrative body for the Coalition (see Section 5.3.1).
  • Coalition planners should be mindful of geographic boundaries that have been established for preparedness purposes rather than specifically for emergency response. For example, many States have created sub-divisions to distribute preparedness funding (e.g., Hospital Preparedness Program, Urban Area Security Initiative, Metropolitan Medical Response System). While these subdivisions can help bring healthcare planners into contact with other stakeholders, they may conflict with how healthcare organizations actually interact during emergency response (e.g., patient referral patterns). Their value in shaping the structure of the Coalition must be evaluated on an individual basis.

5.1.3 Determining the Participating Organizations

The following principles can be used to guide decisions on which organizations should be included as official members with decision-making (i.e., voting) authority of the Healthcare Coalition:

  • Participation may involve a variety of organizations, but each should have a primary role in medical care delivery (or some element thereof) during incident response.
  • Participants must be able and willing to commit the necessary preparedness resources and establish the response requirements to fully participate during incident response.
  • Participant organizations may be day-to-day business competitors, but must agree that fair representation should be assured for all Coalition member organizations.
  • Participation in the Healthcare Coalition must be voluntary.

Using these criteria, the following types of healthcare organizations could potentially participate in the Healthcare Coalition:

  • Hospitals, integrated healthcare systems, managed care groups that deliver healthcare services, community health centers, outpatient clinics, specialty healthcare services such as dialysis and surgery centers, and other point of service healthcare organizations.
  • Specialty hospitals that provide services in a geographic area (e.g., a “Woman’s Hospital” that focuses on obstetrics and gynecology can provide support services during an emergency, such as offering to accept transfer of stable hospitalized female patients from impacted healthcare organizations).
  • Federal medical facilities that operate in a geographic area, including Department of Defense and Veterans Administration (VA) medical centers, as well as Federally-funded community health centers, clinics, or other facilities (Exhibit 5-2).

Exhibit 5-2. Participation of Federal healthcare assets in the Healthcare Coalition

Although Federal healthcare assets have demonstrated a willingness to participate in Healthcare Coalitions based on their geographic area, they have unique restrictions compared to private healthcare organizations. Potential issues include the following:

  • Participation cannot compromise their Federal mission(s). For example, VA Medical Centers have a primary responsibility for providing healthcare to veterans, plus they have secondary Federal missions during disasters (e.g., to the National Disaster Medical System (NDMS) and to the Department of Defense).
  • Participation is at the discretion of the Commanding Officer or executive leader of the organization.
  • Participation can occur during both Federally-declared and non-declared disasters, but it is subject to specific legislation and/or agency specific rules or standards. For example, VA Medical Center Directors are authorized under Title 38, U.S.C., Section 1711(b) to provide emergency care in mass casualty situations; however, patients must be charged for these services at rates established by the Secretary of Veterans Affairs.*

The mutual benefit of participation by Federal facilities has been demonstrated in many incidents. After Hurricane Katrina’s landfall in 2005, the Biloxi, MS VA Hospital received veterans as well as private citizens needing healthcare. During a power failure in the primary and backup electrical systems at Walter Reed Army Medical Center in 2001, intensive care unit and medical-surgical beds were rapidly committed by other hospitals in Washington D.C. when Walter Reed was considering whether to evacuate critical care patients. Ultimately, backup power was restored and the transfer beds were never needed.

* Barbera JA, Macintyre AG, Shaw G, et al, Emergency Management Principles and Practices for Healthcare Systems, Glossary (2006); Available at:

  • Long-term care facilities, including skilled nursing and assisted living facilities, rehabilitation centers, chronic and hospice care, and others, should be considered for inclusion in the Healthcare Coalition. These organizations can serve as important resources to assist the more traditional healthcare organizations, and promoting
    their resiliency to avoid the need for evacuation is in the best interest of hospitals. The information processed by the Healthcare Coalition and other support during emergencies (such as facilitating mutual aid and other resource assistance) can be valuable for these
    organizations as well.
  • Healthcare assets that provide outpatient services, including community health clinics, private practitioner offices, and home healthcare organizations, could all be contributing members of a Coalition. While these entities may not have the infrastructure or personnel available to develop complex procedures for incident response, they should be considered for inclusion for the following reasons:
    • During an emergency, patients will seek care in the most familiar settings.
    • Hospitals may become severely challenged or crowded, leading patients to seek care in other settings.
    • Some patients may have treatment needs that can be adequately managed by outpatient-oriented assets, thus relieving the burden on hospitals.
    • Hazards that impact these organizations may lead to patients presenting to similarly impacted hospitals.

The approach to incorporating these resources into the Coalition’s preparedness and response can be relatively simple. They may elect to integrate with the Healthcare Coalition in one of two ways:

  • Associate within a larger organizational structure that represents them in the Coalition. Mechanisms for this coordination can be established through the Coalition. For example, individual practitioners or a small group practice could organize under the umbrella of a(n):
    • Hospital
    • Integrated healthcare system
    • Large outpatient facility where they have professional privileges
    • Professional society or association (e.g., local Medical Society), if practitioners within the society provide the representation.

The organizing body for these assets must be able to conduct Coalition preparedness activities, such as attending meetings and keeping member organizations informed. It must also be able to perform emergency response services, such as collecting and disseminating information to the organizations that it represents.

  • Participate only in the Coalition’s situational awareness activities. In lieu of the arrangement described in the preceding bullet, individual providers or group practices may benefit primarily by participating in the information exchange function of the HCRT.

Exhibit 5-3. Participation of smaller healthcare assets in the Healthcare Coalition

The emergency response planning that is conducted by an individual practitioner’s office may be limited. Procedures that most effectively allow a private practitioner to integrate into the jurisdictional response focus on information issues, such as:

Obtaining information:

  • Obtaining incident-specific guidance on personal protection and other safety measures for practitioners, their staff, and other patients (e.g., appropriate Personal Protective Equipment for an infectious agent).
  • Obtaining information on the specific medical evaluation of incident cases, such as the availability of confirmatory lab tests and the specific limitations of these tests.
  • Obtaining pertinent information on population risk (e.g., for a biological exposure, understanding the community-wide approach to risk stratification for potentially exposed patients).
  • Obtaining reliable incident information on medical needs such as unusual patient treatment requirements.

Reporting information:

  • Knowing where to report and what information to transmit on patients who have been evaluated or treated at the practitioner’s location (to help the jurisdiction authorities define the size and scope of the affected population).
  • Knowing whether public health emergency powers have been invoked (e.g., allowing release of private patient information).

In some jurisdictions, these issues may already be addressed by an effective public health response system (e.g., advisory for the providers in the jurisdiction). This does not negate the utility of a Coalition, which can facilitate delivery of messages or collect responses for the public health system.

  • Other potential participants in the Healthcare Coalition include specific public sector assets that provide direct medical care (e.g., medical care units in non-medical agencies) and home health organizations. As an example, the Washington, D.C. Healthcare Coalition includes the Office of the Attending Physician at the U.S. Capitol. Although this office has few resources that can be shared with other Coalition members, it actively participates in information exchange. This is important since this office provides medical services and recommendations to the Capitol Hill workforce in the D.C. area.

In addition, other organizations that do not typically provide “point of service” medical care may be considered for inclusion in a Healthcare Coalition. For example, the King County Healthcare Coalition in the State of Washington includes Airlift Northwest (an air medical transport service), Puget Sound Blood Center, American Red Cross, Washington Poison Center, and many other entities.[5] Other organizations, such as local public health departments, have different primary responsibilities and may report directly to State (Tier 4) authorities. They also have statutory “command and control” authorities that would be restricted in a Tier 2 Healthcare Coalition. Therefore, these entities may best relate to the Healthcare Coalition through interface at the jurisdictional level (Tier 3), but still provide advice and support to Coalition preparedness activities.

It may be helpful to establish requirements for participation in the Healthcare Coalition at the outset of Coalition development. Defining requirements that are too prescriptive, however, can inadvertently leave some vital partners out. For example, not all participants may be able or willing to enter into a Mutual Aid commitment to share resources, yet they can still play an important role by sharing information. The lack of potentially available resources for sharing should not preclude participation in the Healthcare Coalition.

The following are two reasonable requirements for participation in the Coalition:

  • Participants must be able to commit personnel time to Coalition preparedness meetings. For many healthcare assets, this could mean simply having a representative present for the Coalition’s preparedness meetings. Smaller assets may be represented by an umbrella organization. They maintain awareness by reviewing and commenting on the proceedings of the Coalition’s preparedness efforts.
  • Participants must be willing to share information (strategic and tactical) related to their activities during emergency response. It is up to the HCRT to establish the format and methods for sharing this information. The requirements may be as simple as reporting bed availability or more complex, such as reporting patient evaluation strategies. This will depend on the complexity of the Coalition and the incident.

In some situations, organizations deemed “highly valuable” to the Healthcare Coalition may decline participation. Though ultimately their prerogative, it is important to clearly explain the benefits of Coalition participation and address their specific concerns. The following concepts should be conveyed to potential participants to demonstrate the value of participating in the Healthcare Coalition.

  • Participation does not deter from or change the participant’s inherent and autonomous decision-making authority.
  • Participation may enhance the organization’s emergency preparedness efforts through a collaborative Hazard Vulnerability Analysis (HVA) and by sharing strategies for mitigation and preparedness.
  • Participation may improve the organization’s performance during emergencies because information shared between Coalition organizations promotes situational awareness for responding healthcare organizations.
  • Participation may facilitate access to resources through mutual aid arrangements that otherwise could take more time to access if pursued through other channels.
  • Participation may assist in meeting standards and regulations (e.g., The Joint Commission accreditation standards and others) related to community preparedness and integration into emergency response.

  1. While the structure and processes differ, healthcare planners may consider using specific response procedures during preparedness to enhance familiarity with response methods. For example, notifications for Coalition preparedness meetings may be conveyed via the notification messaging procedures used for response, but with a lower level of assigned urgency.
  2. Defining what the Healthcare Coalition will do during emergency response will help guide preparedness efforts. This is the primary reason why the initial chapters of this handbook focus on the Coalition response organization.
  3. “Structured” refers to supporting with an agenda, facilitation, and minute taking.
  4. It is important to distinguish this Tier 2 Coalition arrangement from a jurisdictional Tier 3 organization that carries local government authority to operate as command and control, or as area command. The Tier 3 local authority or Tier 4 regional organization (i.e., with State command authority) may set incident objectives and specify resource priorities. This is common in many areas of the U.S. and appears to work well, and may be the primary interface for the Tier 2 Healthcare Coalition.
  5. King County Healthcare Coalition, Members, Partners, and Staff: Accessed February 9, 2009 at: staff.aspx.

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  • This page last reviewed: February 14, 2012