The probability of certain public health threats, the costs and funding related to such threats, and the “silo” effect of the public health sector all contribute to the preparedness gap between public health and other sectors. It is time to bridge this gap and update preparedness efforts to better prepare for 21st Century threats.
The U.S. disaster and disease health preparedness infrastructure has historically focused on a few key pillars including:
Strong national public health presence from the Department of Health and Human Services (HHS) Assistant Secretary for Preparedness and Response (ASPR), and from the Centers for Disease Control (CDC);
Community-level preparedness by state and local public health departments; hospital system preparedness and healthcare coalitions; and
Varying levels of engagement and support from emergency management.
Although these pillars have prepared the United States better than ever before, it is not enough to meet the evolving threats that are now facing the nation.
Reasons Behind the Public Health Preparedness Gap First, “disaster dissonance” widens the gap. Health preparedness has historically focused on readiness for catastrophic events. The challenge is that many people do not think they will ever be affected by a catastrophic event. The likelihood of a low-probability, high-impact hurricane like Katrina or Sandy seems small, so the level of preparedness needed for these events may not feel necessary. Thus, people recognize there is a threat, but many choose not to prepare.
Second, health preparedness is expensive and time-consuming, and funding is being continually reduced. The Public Health Emergency Preparedness (PHEP) cooperative agreement is the only major source of funding for state and local health departments, and it has significantly declined over the past 10 years. As a result, when unforeseen threats like Zika occur, funding is shifted from existing priorities, and there is not enough political will to raise the money to bolster capabilities, which leaves the nation’s long-term preparedness weaker.
Third, health preparedness, like many fields, is siloed. Healthcare coalitions are an ideal example. Federal funding from ASPR’s Hospital Preparedness Program (HPP) is meant to create a noncompetitive space for different parts of healthcare to plan, exercise, and coordinate for public health emergencies. Unfortunately, coalitions have struggled to breach the siloes within healthcare and bring more than just hospital systems to the table. This failure restricts the ability to assist patients with chronic care needs that would be best served in an outpatient setting like a pharmacy or a dialysis center. Ultimately, this harms the whole community because these other parts of healthcare tend to be less resilient, take longer to recover, or never reopen, which dampens economic recovery.
Moving Toward 21st Century Preparedness Whether it is the term used or not, resilience – not response – should be the major focus going forward. Resilience looks much more broadly at how to create strong, cohesive communities with the goal that the stronger communities are, the better they will bounce back when faced with trauma. Although resilience is built by many different programs, a key component and first step forward should focus on incorporating the changes happening in healthcare such as: expanded coverage options; value-based medicine; Accountable Care Organizations (ACOs); and the development of electronic health records.
U.S. healthcare reform has led to highest number of insured American’s ever. Access to insurance supports and coincides with the growth of traditional provider networks and the development of new modalities such as convenient care clinics in pharmacies and the ability of pharmacists to provide immunizations. By their very nature, these new care delivery centers spread care away from a centralize location and increase resilience. Most importantly, there is a shift toward value-based medicine, which changes how healthcare systems approach patient engagement. Previously, revenue was directly connected to the amount of services provided; now it is shifting to how successful these services are. This is the goal of the newly created ACOs, which coordinate patient care to enhance wellness, avoid duplication of services, and better manage chronic illnesses. ACOs are resilience in action. They project into the community because they are designed to be concerned with patients’ health outside the hospital’s walls or a doctor’s waiting room.
ACOs also help to answer a critically unanswered question in preparedness, “Who is responsible for a patient?” Traditionally, when an outbreak or disaster occurs, if a patient with chronic illness is not hospitalized or in a healthcare facility, there is no one responsible for ensuring that he or she has the life-sustaining healthcare required. Whether medicine, oxygen, or supportive care, patients are left to try to fill the gaps themselves or call emergency services. Efforts like ASPR’s emPOWER map, which identifies vulnerable Medicare patients who use electric powered medical equipment, are extremely helpful to identify and assist these patients after an event occurs, but need to be better incorporated into day-to-day care. If the healthcare preparedness community begins to increase focus on collaborating with ACOs and other community-based organizations, it will significantly increase the resilience of communities.
Likewise, the adoption of electronic health records and the expansion of Health Information Exchanges are vital tools for ensuring resilience. With their use, patients can continue to receive the correct care they need by any provider in any region that can access the patient’s records. Working to make these systems interoperable and protected by backups in other locations directly influences the level of care patients receive. None of this is easy, but it is critical for protecting patients.
Lastly, because healthcare in the United States is owned mostly by companies, it requires a type of partnership that can feel uncomfortable at first, but public/private partnerships is critical to protect patients. The first step to encourage public health to collaborate with other organizations is by thinking like a business to understand the motivations and limitations of what private healthcare can do. If traditional public health worked to understand these motivations and to prioritize lifting restrictions and assisting healthcare to continue its operations, private sector healthcare companies would be more receptive to working alongside its public partners. The result would be more resilient communities thanks to joint private and public resources being deployed effectively.
Protecting and building the resilience of communities’ health is a long-term and incredibly difficult endeavor. It requires agility and the ability to capitalize on rapidly changing healthcare landscape, but it is possible if traditional views on what it takes to be ready can adapt and if funding has sufficient flexibility.