Emergency Support Function #8: Current Challenges and Future Directions

InterAgency BoardOctober Board Meeting

Milwaukee, WIOct 17, 2012

Kevin Yeskey, MDSenior Advisor

MDB, Inc

ESF#8 has provided a mostly successful framework for recent domestic disasters◦ A fragmented public health and medical response system

functions within acceptable limits for “routine” disasters A national health and medical preparedness and

response system can be developed only when administrative and legislative barriers are removed◦ Incentives need to be provided to volunteers and private

industry for their participation ESF#8 should to shift to capabilities-based core

functions to better align with the public health and medical preparedness cooperative agreements

Take Home Points

Core functions of ESF #8 under the NRF

Agricultural safety and security* Public Health technical assistance

and support* Behavioral health+ Public health and medical

information* Vector control* Potable water/wastewater and

solid waste disposal* Mass fatality management, victim

identification, and decontaminating remains+

Veterinary medical support+

Assessment of public health/medical needs*

Health Surveillance* Medical care personnel+ Health/medical/veterinary

equipment and supplies Patient Evacuation+ Patient Care+ Safety and security of drugs,

biologics, and medical devices* Blood and Blood Products Food Safety and Security*

+ NDMS* PH function

“Uncomplicated” disasters◦ Single event, small geographic area, few

jurisdictions, limited duration, natural cause Disasters we have recent experience with

◦ Hurricanes, Tornados, Floods “Notice” events DomesticThe typical Stafford Act incident

*No standard metrics to support this claim

In 15+ Years of Preparedness Efforts, What We Do Well*:

Hurricane ‘saac

Complicated Disasters◦ Large geographic area,

long-term event, multiple jurisdictions Catastrophic events

◦ Novel Not recently seen, beyond the

imagination

◦ No-notice events◦ International/Multi-

national◦ Engaging all potential

resources

*No standard metrics to support this claim

What We Struggle With:

SARS

DWH

H1N1

Earthquake

Organizational structure is different and sometimes untested/unrehearsed◦ Who was in charge of the pandemic response?◦ When was the last time we responded to something like Haiti?◦ The leadership bench is thin◦ Management by CNN

Complex jurisdictional issues◦ Situational awareness is difficult◦ Uneven levels of preparedness across jurisdictions◦ Different places do things differently◦ Prioritization is harder and timelines are different

Scarce resources◦ Competing demands for the same limited resources

50 DMATs and more can’t be rapidly manufactured Complex events are harder by nature and expectations aren’t well managed

◦ Japan earthquake, tsunami, nuclear PP meltdown◦ Haven’t linked ESF#8 core functions to public health and medical preparedness

capabilities as defined by PHEP and HPP preparedness grants No real measures of success Many other factors

◦ Funding

Why We Struggle

What are the fundamental challenges

with responding to catastrophic health events and ESF#8?

Federal resources cannot be used locally and local resources cannot be used nationally

What are the fundamental challenges with catastrophic

health events and ESF#8?

Federal System Can’t be Used Locally◦ NDMS is federal asset

No access to resources by State or local jurisdictions Homeland Security Act

Federalized all NDMS members No protections unless federalized Cannot deploy for free Can use federal caches but have to reimburse

Reimbursement goes to the US Treasury and not Program

NDMS is expensive to deploy: $1000/person/day◦ USPHS requires SG Activation◦ VA and others require reimbursement to activate◦ DSNS is centrally controlled

Local Resources Cannot be Used Nationally◦ Local licensed medical volunteers from MRC,

ESAR-VHP, ARC cannot cross State lines unless federalized or Gubernatorial declaration waiving licensure requirements EMAC doesn’t generally apply to medical/nursing Don’t have benefits without federalization

USERRA, FTCA, WC, Pay To federalize takes weeks

Application process is tortuous Background checks Credentialing

Make NDMS a local asset Return 501(c) 3 status to teams Permit teams to use federal caches for local missions

Manage local op tempo so national readiness is not compromised

Fund teams accordingly Continue to recruit medical/surgical subspecialties

Make the application process less cumbersome

What are the Solutions?

Make local assets available nationally◦ Enact model volunteer laws in all states/territories/tribes

in order to protect victims, providers, and hospitals◦ Eliminate burdensome federalization requirements◦ Establish a national disaster credential (license) that

enables holders to practice across state borders when requested and in times of emergency, not just a bad day.

◦ Incentivize locals to participate Incentivized reimbursement rates for prepared providers

and facilities Provide workers comp, FCTA, job protection

Engage the outpatient sector and private sector

What are the Solutions?

National Guard Model◦ State asset that can be federalized when

necessary to address national crisis Can be used in EMAC scenarios Regional support of states without teams

◦ State receives funding and cache Must meet/exceed federally determined readiness

standards ◦ Teams can still fund raise for team purposes

Future Medical Preparedness

Federal resources cannot be used locally and local resources cannot be used nationally

Ask private institutions/providers to perform “inherently governmental” functions

What are the fundamental challenges with catastrophic

health events and ESF#8?

Private sector involvement◦ Given the standards, why can’t private sector

provide medical and public health assets? Requirements

Admin/legal relief-liability, licensure, workers’ comp Demonstrated daily utility Performance standards

Training/Exercises Readiness Testing

Reimbursement for preparedness

Preparedness is Everyone’s Responsibility

Federal resources cannot be used locally and local resources cannot be used nationally

Ask private institutions/providers to perform “inherently governmental functions”

Disconnect between preparedness and response

What are the fundamental challenges with catastrophic

health events and ESF#8?

Community Preparedness (Healthcare System Preparedness) Community Recovery (Healthcare System Recovery) Emergency Operations Coordination Emergency Public Information and Warning Fatality Management Information Sharing Mass Care MCM dispensing Medical Material Management and Distribution Medical Surge Non-pharmaceutical intervention Public Health laboratory testing Public Health Surveillance and Epidemiological investigation Responder Safety and Health Volunteer Management

* Over $1 Billion awarded annually for the past 11 years

Public Health and Medical Capabilities in the HHS Preparedness Grants*

ESF #8 Core Functions are not linked to Grant Capabilities

Agricultural safety and security* Public Health technical assistance

and support* Behavioral health+ Public health and medical

information* Vector control* Potable water/wastewater and

solid waste disposal* Mass fatality management, victim

identification, and decontaminating remains+

Veterinary medical support+

Assessment of public health/medical needs*

Health Surveillance* Medical care personnel+ Health/medical/veterinary

equipment and supplies Patient Evacuation+ Patient Care+ Safety and security of drugs,

biologics, and medical devices* Blood and Blood Products Food Safety and Security*

+ NDMS* PH function

Federal resources cannot be used locally and local resources cannot be used nationally

Ask private institutions/providers to perform “inherently governmental” functions

Disconnect between preparedness and response

Absence of substantial regional preparedness

What are the fundamental challenges with catastrophic

health events and ESF#8?

Template for ESF#8 Regional Preparedness

Medical Surge Capability and Capacity Handbook

Planning◦ Joint planning with State and locals

Hurricanes-Gulf Coast plans resulted in FEMA ambulance contract

Floods-plans with ND resulted in no requests for federal assistance in 2010 floods

Earthquake-Multi-state New Madrid planning NSSE’s-close coordination with host sites better defined

needs; improved plans; and better federal support◦ Regional planning

Federal support for regional planning resulted in public health support moving across state lines for several disasters

Integration With All Levels

Federal resources cannot be used locally and local resources cannot be used nationally

Ask private institutions/providers to perform “inherently governmental” functions

Disconnect between preparedness and response

Absence of substantial regional preparedness

Absence of science-based decision making

What are the fundamental challenges with catastrophic health events and ESF#8?

◦ Integration with other public services◦ EMS ◦ Fatalities management◦ Patient movement◦ Force protection◦ International deployment◦ Funding

What are examples of ESF#8 responsibilities that require a re-look?

Law enforcement Issues: perishable information, duplication of efforts, operational security and info sharing Solutions:

Joint investigations with public health PH officials are provided security clearance and pilot testing getting them secure commo

equipment Still haven’t included providers/hospitals

◦ EMS: ◦ Issue: Not fully integrated into the health and ◦ medical strategy

Solutions Expanded scope of practice in disasters Treat and release should be reimbursable Transport options-reimburse for taking patient to other than hospital Specific federal funding for EMS preparedness Support FICEMS

Integration with other Sectors

ESF # 8 Missions◦ Fatalities Management

Issue: fatalities management lacks a comprehensive national strategy

Solutions:Need to work past the jurisdictional laws for ME/coroners

Incorporate fatalities management into a comprehensive missing persons strategy HHS performs victim identification Assign body recovery to an agency

or to private industry

◦ Patient movementIssue: critical care patient transport lacks operational capacity for large eventSolutions Shelter in place strategy Coalitions/regional planning

Dead

Missing

Hospitalized

Force Protection◦ Issues: Teams, equipment and facilities need

protection during transport and deployment.◦ Solutions

Arm teams-very bad idea DoD/NGB-cannot reliably perform these functions ESF#13 Support

Don’t always understand ESF#8 mission, operations MOU

Currently have an MOU with USPP (with special deputization) to provide initial assessment and liaison for deploying teams

◦ What to do on the international front?

Future of ESF#8

International Deployments◦ Issues

No license to practice medicine in foreign countries Some countries malpractice is a criminal not civil offense

Logistics support is very difficult Force protection is a show stopper for HHSSolutions

????????

Future of ESF#8Non-Stafford Act Incidents

Budget-federal PH and medical preparedness funding decreased by 38% between FY’05 and FY’12◦ 40 States and DC have cut

PH budgets in the past year/15 States have cut for 2 years

◦ Personnel Since 2008, 49,000 PH jobs lost

(15K State/34K local)

◦ Equipment/Supplies/Facilities States unable to sustain

inventories on current budgets

◦ Training One of the first items to be

eliminated during shortfalls

Funding Gap

2002

2005

2008

2011

0

500

1000

1500

SNSPHEPHPP

Questions

Kyeskey@michaeldbaker.comwww.michaeldbaker.com