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Alternate Care Sites (including shelter medical care)
Topic Collection
December 19, 2023

Topic Collection: Alternate Care Sites (including shelter medical care)

In the event of a disaster or public health emergency, Alternate Care Sites (ACS) may be created to enable healthcare providers to provide medical care for injured or sick patients or continue care for chronic conditions in non-traditional environments. These ACS may include locations that need to be converted (e.g., schools and stadiums) or they may include facilities like mobile field hospitals. While ACS and systems are designed to accommodate a surge in those seeking care for acute conditions, medical shelter operations are designed to support chronic condition care. The scope of this collection includes both ACS and medical shelter operations during a disaster. The resources in this Topic Collection highlight recent case studies, lessons learned, tools, and promising practices for developing and activating ACS. It is important to note that while the listed plans incorporate best practices, all ACS plans must take into account and comply with the Americans with Disabilities Act (ADA) which requires all care environments to be able to accommodate those with disabilities. Some resources listed do not adequately account for these requirement or refer to ”special needs” shelters based on disabilities, and not medical conditions, which is not acceptable under ADA.

Planners may wish to access several other related ASPR TRACIE Topic Collections. The Access and Functional Needs Topic Collection highlights recent case studies, lessons learned, tools, and promising practices for working with individuals with disabilities and others with access and functional needs. For information on planning for and treating patients at a large pre-planned event, access the Mass Gatherings/Special Events Topic Collection. For alternate care areas within a hospital, access the Hospital Surge Capacity and Immediate Bed Availability Topic Collection. The Healthcare-Related Disaster Legal/ Regulatory/ Federal Policy Collection includes links to resources on select laws, key issues, lessons learned, tools, and promising practices that can help healthcare professionals better understand the environment in which they will be asked to respond during large-scale emergencies.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

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Must Reads

ASPR TRACIE. (2018). Medical Surge and the Role of Health Clinics.
Because of their extensive geographic coverage, strong community ties, and potential to reach medically underserved areas, health clinics play a key stakeholder role in emergency and disaster preparedness and response. ASPR TRACIE conducted this exploratory study to learn more about the scope and level of implementation of emergency management activities among health clinics, including activities that some clinics may have initiated in response to the CMS Final Rule. (Access the report summary: https://files.asprtracie.hhs.gov/documents/aspr-tracie-medical-surge-and-the-role-of-health-clinics-summary.pdf.)
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ASPR TRACIE. (2022). Considerations for the Use of Temporary Care Surge Sites for Managing Seasonal Patient Surge. U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response.
This document describes the major considerations healthcare facility emergency planners must account for when determining patient surge management solutions for longer-duration events, such as weeks to months of managing seasonal illness surge. The term "surge site" is used to describe a non-patient care area either inside the walls of the facility or a site immediately adjacent such as a tent, trailer, or other mobile and temporary facility.
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Cantrill, S.V., Pons, P.T., Bonnett, C.J., et al. (2009). Disaster Alternate Care Facilities: Selection and Operation. Agency for Healthcare Research and Quality.
The authors conducted a literature review and collected responses to a questionnaire that featured items related to the establishment and operation of alternate care facilities (ACF) during several U.S. mass casualty events. They used results to develop and describe the ACF selection tool, operations template, and staffing recommendations; a hospital patient selection tool that can help select patients eligible for transfer to an ACF; and ACF equipment and supply options.
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Crum, B., Hill, J., Jepsen, D., et al. (2007). Pandemic Influenza Response: Ketchikan's Alternate Care Site Exercise. (Slides only.)
In October of 2006, the community of Ketchikan, Alaska held an emergency preparedness exercise that included two Alternate Care Site scenarios. Speakers in this webinar describe the planning process associated with supplying and staffing a rural Alternate Care Site, and discuss the staffing challenges and lessons learned from this exercise.
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Florida Department of Health. (n.d.). Alternate Care Site Tabletop Exercises. (Accessed 9/11/2023.)
This webpage lists alternate care site tabletop exercises for rural and urban settings; contact the Florida Department of Health’s Training and Exercise Section at TandE@flhealth.gov for copies.
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Institute of Medicine. (2012). Crisis Standards of Care. A Systems Framework for Catastrophic Disaster Response. Volume 5: Alternate Care Systems. National Academies Press.
This chapter provides an overview of the role of Alternate Care Sites, the related roles and responsibilities of providers, and operational considerations. This comprehensive overview of the spectrum of alternate care systems includes helpful figures, diagrams, and recommendations. Also included is a table (8-3) that lists the response by incident type (anthrax terror attack, catastrophic earthquake, detonation of improvised nuclear device, and pandemic).
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Millin, M.G., Jenkins, J.L., and Kirsch, T. (2006). A Comparative Analysis of Two External Health Care Disaster Responses Following Hurricane Katrina. (Abstract only.) Prehospital Emergency Care. 10(4): 451-456.
The authors analyzed data from two disaster temporary healthcare clinic sites (one in Louisiana, staffed by out-of-state volunteers and the other in Mississippi, with a federal Disaster Medical Assistance Team) to better understand the needs and medical conditions of the 500 patients seen over two days of operation. The majority of visits were for chronic diseases, primary health care, vaccinations, and to obtain medications that patients did not have with them. The authors noted the need for improvements in primary care disaster planning, including for pediatric patients, for social services, and for pharmaceuticals to treat acute and chronic conditions.
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Summit County Health District, Summit County Emergency Management Agency, Akron Regional Hospital Association. (2008). Development of an Alternative Care System: A Workbook for Community Planners Preparing for Medical Surge.
Rather than identifying individual Alternate Care Sites (ACS), Summit County chose to develop a comprehensive system. This document provides an overview of the ACS strategies and approach and provides step-by-step guidance for others interested in similar approaches.
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Thomas, T. and Loehr, M. (2011). Alternate Care Facilities: Developing Medical Surge Capability in King County. Seattle and King County Public Health.
This presentation describes Seattle and King County’s alternate care site plans, including when to activate, scope of care, staffing, equipment and supplies, site selection, and challenges and opportunities related to their use to support medical surge. This resource also includes a presentation on the agency’s plans to provide medical support to mass care shelters.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary of Preparedness and Response. (2016). Federal Medical Station.
This factsheet defines Federal Medical Stations (FMS) and explains how state, local, tribal, and territorial authorities can request FMS (i.e., the FMS cache alone, the cache with federal staffing, or federal staffing alone).
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Education and Training

California Department of Public Health. (2008). Government-Authorized Alternate Care Site Training Guide.
This training course can be used as a tool for local health departments and other healthcare providers interested in developing alternate care sites. The materials were designed to be customized to fit a variety of jurisdictions.
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Crum, B., Hill, J., Jepsen, D., et al. (2007). Pandemic Influenza Response: Ketchikan's Alternate Care Site Exercise. (Slides only.)
In October of 2006, the community of Ketchikan, Alaska held an emergency preparedness exercise that included two Alternate Care Site scenarios. Speakers in this webinar describe the planning process associated with supplying and staffing a rural Alternate Care Site, and discuss the staffing challenges and lessons learned from this exercise.
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Minnesota Department of Health. (2013). Minnesota’s Mobile Medical Resources Training Aid: Alternate Care Sites.
This 2-minute video (hosted on YouTube) shows how mobile medical team members set up and work inside of an alternate care site. This video is designed to enhance instructor-led classroom training.
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* New Jersey Department of Health. (2016). Medical Needs Shelters (MNS) in New Jersey and the Role of the MRC (Medical Reserve Corps) in Medical Needs Shelters.
This 59-minute webinar discusses medical needs sheltering, meeting the needs of the whole community, and medical needs shelter templates. Though focused on New Jersey’s plans, information may be adapted by other jurisdictions.
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* Stanford, C. (2010). Post-Earthquake Medicine in Haiti: Disaster Relief at a Field Hospital. University of Washington, Northwest Center for Public Health Practice.
This one-hour webinar showcases the lessons learned and operations of a field hospital set up in the aftermath of the 2010 Haiti Earthquake. Dr. Christopher Sanford served as a medical officer on a U.S. Federal disaster response team deployed to the field hospital.
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* Thomas, T. and Loehr, M. (2011). Alternate Care Facilities: Developing Medical Surge Capability in King County. Seattle and King County Public Health.
This presentation describes Seattle and King County’s alternate care site plans, including when to activate, scope of care, staffing, equipment and supplies, site selection, and challenges and opportunities related to their use to support medical surge. This resource also includes a presentation on the agency’s plans to provide medical support to mass care shelters.
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Federal Medical Stations

Knickerbocker, D.. (2014). Federal Medical Station (FMS). (Please request document from ASPR TRACIE: askasprtracie@hhs.gov.) U.S. Department of Health and Human Services. Office of the Assistant Secretary for Preparedness and Response.
This document provides an overview of the Federal Medical Station (FMS), including what is included in the FMS cache and examples of how they have been deployed during events. Also included are a fact sheet and staffing model for the 50-bed FMS, a FMS Wrap Around Checklist, and FMS Site Survey Checklist. Please note that the descriptions provided in this resource are specific to federal FMS operations only.
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Rackard, J. and Vitale, J. (2012). Federal Medical Resource Support for a Natural Disaster: Federal Medical Station and Strategic National Stockpile. Centers for Disease Control and Prevention, Division of Strategic National Stockpile.
The speakers in this presentation provide an overview of the Strategic National Stockpile and Federal Medical Station (FMS) concept, mission, and capabilities. An FMS timeline and deployment organizational chart are also included.
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U.S. Department of Health and Human Services, Office of the Assistant Secretary of Preparedness and Response. (2016). Federal Medical Station.
This factsheet defines Federal Medical Stations (FMS) and explains how state, local, tribal, and territorial authorities can request FMS (i.e., the FMS cache alone, the cache with federal staffing, or federal staffing alone).
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Guidance

Agency for Healthcare Research and Quality. (2004). Rocky Mountain Regional Care Model for Bioterrorist Events: Locate Alternate Care Sites During an Emergency.
Chapter 4 of this document describes processes associated with selecting, validating, supplying, and staffing alternate care sites.
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ASPR TRACIE. (2018). Medical Surge and the Role of Health Clinics.
Because of their extensive geographic coverage, strong community ties, and potential to reach medically underserved areas, health clinics play a key stakeholder role in emergency and disaster preparedness and response. ASPR TRACIE conducted this exploratory study to learn more about the scope and level of implementation of emergency management activities among health clinics, including activities that some clinics may have initiated in response to the CMS Final Rule. (Access the report summary: https://files.asprtracie.hhs.gov/documents/aspr-tracie-medical-surge-and-the-role-of-health-clinics-summary.pdf.)
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ASPR TRACIE. (2018). Medical Surge and the Role of Urgent Care Centers.
This report summarizes findings from interviews ASPR TRACIE conducted with urgent care physicians and center administrators in 44 states to collect their feedback on the role their facilities could play in the nation’s healthcare preparedness and response activities. (Access the summary here: https://files.asprtracie.hhs.gov/documents/aspr-tracie-medical-surge-and-the-role-of-urgent-care-centers-summary.pdf.)
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* ASPR TRACIE. (2022). Considerations for the Use of Temporary Care Surge Sites for Managing Seasonal Patient Surge. U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response.
This document describes the major considerations healthcare facility emergency planners must account for when determining patient surge management solutions for longer-duration events, such as weeks to months of managing seasonal illness surge. The term "surge site" is used to describe a non-patient care area either inside the walls of the facility or a site immediately adjacent such as a tent, trailer, or other mobile and temporary facility.
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California Department of Public Health. (2010). CDPH Guidance: Approval for Health Care Facility Use of Surge Tents.
Though California-specific, this guidance describes the requirements of the state fire marshal, local fire departments, and the Office of Statewide Health Planning and Development relative to establishing tents to accommodate healthcare surge. The guidance may be helpful in identifying safety and logistics issues.
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Cantrill, S.V., Pons, P.T., Bonnett, C.J., at al. (2009). Disaster Alternate Care Facilities: Selection and Operation: Chapter 2- Background. Agency for Healthcare Research and Quality.
A discussion of the role and objectives of non-hospital alternate care site facilities stresses the need for clear operational definitions for what can and cannot be accommodated appropriately in terms of care, service, and acuity level. Planning to utilize the spectrum of healthcare delivery facilities including ambulatory care sites can assist with managing the surge of lower acuity patients to preserve hospitals for high-acuity cases. The focus on bioterrorism can be extended to other mass casualty events.
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Centers for Disease Control and Prevention. (2015). Community Planning Framework for Healthcare Preparedness.
This document includes information to help planners enhance and/or develop a community's medical surge plans. It is organized into chapters, such as: Building Planning Teams and Coalitions; Models of Healthcare Delivery; Alternate Care Systems (ACS); Essential Healthcare Services; and Crisis Standards of Care. Chapter 5 includes a review of ACS plans in the community and offers some strategies for ACS planning.
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* Centers for Disease Control and Prevention. (2017). Information for Disaster Evacuation Centers.
This webpage contains links to evacuation center-related resources such as: infection control, medical management and patient advisement, guidelines for play areas, and animals in public evacuation centers.
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Centers for Medicare and Medicaid Service. (2009). Emergency Medical Treatment and Labor Act (EMTALA) Requirements and Options for Hospitals During a Disaster.
This memorandum and associated fact sheet (from 2009) describes EMTALA requirements and flexibility for an appropriate Medical Screening Examination and options for hospitals experiencing an exceptional patient surge. Alternate screening sites on a hospital’s campus, referral to a hospital-controlled off-campus site, and referral to a community screening site are addressed in terms of an EMTALA obligation.
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Centers for Medicare and Medicaid Services. (2017). Temporary Hospitals Established in Response to Catastrophic Damage from Hurricanes.
This document addresses the CMS requirements regarding the temporary hospitals that have been established in the U.S. Virgin Islands and Puerto Rico due to hospital closures impacted by Hurricanes Irma and Maria. It also provides information on payment and billing issues.
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Hassol, A. and Zane, R. (2006). Reopening Shuttered Hospitals to Expand Surge Capacity. Agency for Healthcare Research and Quality.
This guidance document provides tools and recommendations to help planners determine if and how to utilize an abandoned or shuttered hospital for surge capacity needs during a mass casualty or other similar event. It provides staffing requirements, safety checklists, supplies and equipment needs, and regulatory/legal issues to consider.
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Institute of Medicine. (2012). Crisis Standards of Care. A Systems Framework for Catastrophic Disaster Response. Volume 5: Alternate Care Systems. National Academies Press.
This chapter provides an overview of the role of Alternate Care Sites, the related roles and responsibilities of providers, and operational considerations. This comprehensive overview of the spectrum of alternate care systems includes helpful figures, diagrams, and recommendations. Also included is a table (8-3) that lists the response by incident type (anthrax terror attack, catastrophic earthquake, detonation of improvised nuclear device, and pandemic).
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Phillips, S.J., Knebel, A., and Johnson, K.. (2007). Mass Medical Care with Scarce Resources: A Community Planning Guide.
Chapter VI of this guide provides an overview of the issues surrounding non-federal, non-hospital-based alternative care sites (ACS). Different types of ACS are described, and factors associated with decision making during mass casualty events are highlighted. Sample case studies are also included including several from Hurricane Katrina.
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* Summit County Health District, Summit County Emergency Management Agency, Akron Regional Hospital Association. (2008). Development of an Alternative Care System: A Workbook for Community Planners Preparing for Medical Surge.
Rather than identifying individual Alternate Care Sites (ACS), Summit County chose to develop a comprehensive system. This document provides an overview of the ACS strategies and approach and provides step-by-step guidance for others interested in similar approaches.
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The Joint Commission. (2006). Surge Hospitals: Providing Safe Care in Emergencies.
This document provides an overview of different types of surge hospitals, and discusses how they are managed and operated. Surge hospitals can include mobile medical facilities and portable facilities. Case studies from real events are also included.
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U.S. Department of Health and Human Services, Health Resources & Services Administration. (2020). Requesting a Change in Scope to Add Temporary Service Sites in Response to Emergency Events.
This Program Assistance Letter provides an update to the process for requesting a change in scope to the federal scope of project to add temporary locations in response to emergency events.
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Lessons Learned

* ASPR TRACIE. (2022). Considerations for the Use of Temporary Care Surge Sites for Managing Seasonal Patient Surge. U.S. Department of Health and Human Services, Administration for Strategic Preparedness and Response.
This document describes the major considerations healthcare facility emergency planners must account for when determining patient surge management solutions for longer-duration events, such as weeks to months of managing seasonal illness surge. The term "surge site" is used to describe a non-patient care area either inside the walls of the facility or a site immediately adjacent such as a tent, trailer, or other mobile and temporary facility.
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Blackwell, T. and Bosse, M. (2007). Use of an Innovative Design Mobile Hospital in the Medical Response to Hurricane Katrina. (Abstract only.) Annals of Emergency Medicine. 49(5): 580-588.
This article summarizes the deployment of a mobile hospital following hurricane-related damage to Mississippi’s acute care infrastructure. The authors describe how Carolinas MED-1, a mobile hospital, provided emergency care, diagnostics, surgical capabilities, general and critical care while healthcare infrastructure repairs occurred in the impact areas.
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Cage, J. (2013). Joplin Pays it Forward: Community Leaders Share Our Recovery Lessons.
This document compiles stories of those that were part of the response and recovery efforts after the Joplin tornado in 2011. The firsthand accounts include lessons learned from the operation of surge medical clinic and volunteer coordination points; coordination of thousands of volunteers; and health care service relocation and other recovery efforts. NOTE: Lessons learned from healthcare facilities are addressed in pages 55-73.
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Cantrill, S.V., Pons, P.T., Bonnett, C.J., et al. (2009). Disaster Alternate Care Facilities: Selection and Operation. Agency for Healthcare Research and Quality.
The authors conducted a literature review and collected responses to a questionnaire that featured items related to the establishment and operation of alternate care facilities (ACF) during several U.S. mass casualty events. They used results to develop and describe the ACF selection tool, operations template, and staffing recommendations; a hospital patient selection tool that can help select patients eligible for transfer to an ACF; and ACF equipment and supply options.
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Carmichael, J. (2016). Alumnus Heads Innovative Mobile Disaster Hospital for FEMA. Virginia Commonwealth University (VCU) News.
This article addresses the mobile hospital that was set up in Louisville, MO after a tornado damaged the local hospital. It will remain operational until 2018 when construction of a new hospital is planned to be complete. It provides lessons learned from nurses and other staff managing the temporary hospital (e.g., showers should be wheelchair accessible, patients need more private rooms, and doctors require improved access to electronic medical records).
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Caspers, C., Smith, S., Seth, R., et al. (2016). Observation Services Linked with an Urgent Care Center in the Absence of an Emergency Department: An Innovative Mechanism to Initiate Efficient Health Care Delivery in the Aftermath of a Natural Disaster. (Abstract only.) Disaster Medicine and Public Health Preparedness. 10(3):405-10.
This article demonstrates the usefulness and diverse population base that can be cared for by an emergency department (ED) Observation Unit. The authors examine what happened in the absence of an ED through a retrospective review of such a model created after the destruction of the NYU Langone Medical Center ED during Hurricane Sandy.
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Deal, B.J., Fountain, R.A., Russell-Broaddus, C.A., and Stanley-Hermanns, M. (2006). Challenges and Opportunities of Nursing Care in Special-Needs Shelters. (Abstract only.) Disaster Management and Response. 4(4): 100-5.
This article discusses lessons learned and challenges that were encountered by nurses volunteering in special-needs shelters during Hurricanes Katrina and Rita, including issues related to human and physical resources, patient care, and confidentiality. Evacuee patients included residents with special needs, and residents of nursing homes and group homes for mentally and physically disabled persons. Similar issues may occur in alternate care and shelter site congregate environments.
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Eastman, A., Rinnert, K., Nemeth, I., et al. (2007). Alternate Site Surge Capacity in Times of Public Health Disaster Maintains Trauma Center and Emergency Department Integrity: Hurricane Katrina. (Abstract only.) The Journal of Trauma. 63(2):253-7.
After Hurricane Katrina, the Dallas Convention Center Medical Unit was established to meet the increased demand for medical care. The authors examined data for 10,367 patients who sought emergent or urgent healthcare at the alternate care site and found the care not only safe and effective, but it also allowed care in urban trauma centers and emergency departments to continue.
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Hamilton, D., Gavagan, T., Smart, K., et al. (2009). Houston's Medical Disaster Response to Hurricane Katrina: Part 2: Transitioning from Emergency Evacuee Care to Community Health Care. National Center for Biotechnology Information, U.S. National Library of Medicine.
The authors explain how alternate care sites were set up in Houston to provide medical care for Hurricane Katrina evacuees. Topics covered include elements of the regional disaster response (e.g., regional coordination, triage and emergency medical service transfers into the region's medical centers, medical care in population shelters, and community health challenges).
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Kearns, R.D., Skarote, M.B., Peterson, J., et al. (2014). Deployable, Portable, and Temporary Hospitals; One State's Experiences through the Years. (Abstract only.) American Journal of Disaster Medicine, 9(3):195-210.
The authors review the use of temporary hospitals to augment the healthcare system as a solution for dealing with a surge of patients for various disasters. They highlight experiences from North Carolina including after the 9/11 attacks.
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Liu, L., Kiger, J., Rankin, D., and Kendrick, K. (2019). Preventing and Monitoring Infectious Disease Risks in Post-Disaster Shelters. National Association of County and City Health Officials (NACCHO).
The speakers in this webinar share lessons learned from the 2017 hurricane season specific to public health surveillance activities in a large evacuation shelter, communication between state and local health department staff, and identifying and controlling infectious disease outbreaks in shelters. Links to the “Cot-to-Cot” survey, a surveillance form, and supplemental questions and answers are also provided.
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Merin, O., Nachman, A., Levy, G., et al. (2010). The Israeli Field Hospital in Haiti — Ethical Dilemmas in Early Disaster Response. The New England Journal of Medicine. 362(e38).
The authors share experiences with field hospital issues in an austere environment and how healthcare practitioners addressed resource dilemmas. They describe their triage protocols and how they managed ethical dilemmas.
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Millin, M.G., Jenkins, J.L., and Kirsch, T. (2006). A Comparative Analysis of Two External Health Care Disaster Responses Following Hurricane Katrina. (Abstract only.) Prehospital Emergency Care. 10(4): 451-456.
The authors analyzed data from two disaster temporary healthcare clinic sites (one in Louisiana, staffed by out-of-state volunteers and the other in Mississippi, with a federal Disaster Medical Assistance Team) to better understand the needs and medical conditions of the 500 patients seen over two days of operation. The majority of visits were for chronic diseases, primary health care, vaccinations, and to obtain medications that patients did not have with them. The authors noted the need for improvements in primary care disaster planning, including for pediatric patients, for social services, and for pharmaceuticals to treat acute and chronic conditions.
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* Provincial Health Services Authority. (2021). British Columbia's Mobile Medical Unit.
This website provides an overview of the mobile medical unit for British Columbia (Canada) and how it is used during real events. It includes links to information on lessons learned, roles during disaster response/ recovery, and deployment criteria.
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* Stanford, C. (2010). Post-Earthquake Medicine in Haiti: Disaster Relief at a Field Hospital. University of Washington, Northwest Center for Public Health Practice.
This one-hour webinar showcases the lessons learned and operations of a field hospital set up in the aftermath of the 2010 Haiti Earthquake. Dr. Christopher Sanford served as a medical officer on a U.S. Federal disaster response team deployed to the field hospital.
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* Taylor, M., Stokes, W., Bajuscak, R., and Shekar, S. (2016). Mobilizing Mobile Medical Units for Hurricane Relief: The United States Public Health Service and Broward County Health Department Response to Hurricane Wilma, Broward County, Florida. Journal of Public Health Management and Practice. 13(5):447-52.
This article describes the lessons learned from the nine mobile medical vans deployed during Hurricane Wilma. It includes data from the type of medical evaluations provided, other services (e.g., syndromic surveillance), and common presenting complaints by patients. Of particular interest may be the types of treatment services provided and a list of key lessons learned such as using the Incident Command System (ICS), using redundant communications, developing a protocol for credentialing prior to deployment, and the different responders in addition to medical providers involved.
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The Joint Commission. (2006). Surge Hospitals: Providing Safe Care in Emergencies.
This document provides an overview of different types of surge hospitals, and discusses how they are managed and operated. Surge hospitals can include mobile medical facilities and portable facilities. Case studies from real events are included.
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Lessons Learned: Infectious Disease

ASPR TRACIE. (2020). Baltimore Convention Center Field Hospital: One State's Experience during COVID-19.
ASPR TRACIE met with the joint leadership team from the Baltimore (MD) Convention Center Field Hospital (BCCFH), a joint effort to establish an alternate care site (ACS) created to help manage the patient surge from the COVID-19 pandemic. This case study highlights their experiences standing up and maintaining this ACS and includes challenges and considerations by category in the hopes that the information can be helpful to stakeholders engaged in similar planning and response efforts.
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ASPR TRACIE. (2023). Augmenting Rural Hospital Capacity in California: Lessons Learned from COVID-19.
The COVID-19 pandemic challenged all aspects of health care, and rural areas were hit particularly hard. Many rural hospitals do not have the capacity to accommodate patient surge, may not have the on-site capabilities to treat very ill patients, and may be challenged with providing care in place versus transferring patients, especially during a pandemic. ASPR TRACIE met with subject matter experts from California who helped manage the response to the pandemic across the state to learn more about how they worked with hospital staff particularly in Imperial County (a rural area bordered by San Diego, Riverside, and Yuma [Arizona] counties, and Mexico) to augment capacity and accommodate patient surge.
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Centers for Medicare & Medicaid Services. (2009). Hospital Alternative Care Sites during H1N1 Public Health Emergency.
A summary sheet provides responses to questions of payment, conditions of participation and standards of care associated with hospital alternative care sites established to support the H1N1 patient medical surge. It includes a discussion of EMTALA issues and Social Security Act section 1135 waiver compliance alternatives to hospitals.
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Chung, S., Monteiro, S., Hogencamp, T., et al. (2011). Pediatric Alternate Site of Care during the 2009 H1N1 Pandemic. (Abstract only.) Pediatric Emergency Care. 27(6): 519-26.
The authors describe the design, implementation, and performance of an alternate site of care for non-urgent pediatric patients with influenza-like illnesses (ILI) during the 2009 H1N1 pandemic. They found that select non-urgent patients with ILI were treated safely and efficiently with a high level of family satisfaction in these non-traditional settings.
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Cruz, A.T., Tittle, K.O., Smith, E.R., and Sirbaugh, P.E.. (2012). Increasing Out-of-Hospital Regional Surge Capacity for H1N1 2009 Influenza A Through Existing Community Pediatrician Offices: A Qualitative Description of Quality Improvement Strategies. (Abstract only.) Disaster Medicine and Public Health Preparedness. 6(2):113-116.
This article discusses communication, interventions and coordination of community resources for low-acuity pediatric patients and their families as a mechanism to increase community surge capacity during the H1N1 pandemic and for future disease outbreaks. Strategies to support access to primary medical home practitioners that include increasing clinical staffing, longer office hours and identifying additional office space can help to mitigate surge on local emergency centers.
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Lam, C., Walhorn, R., Toner, E., et al. (2006). The Prospect of Using Alternative Medical Care Facilities in an Influenza Pandemic. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science. 4(4): 384-390.
The authors reviewed literature on federal and state pandemic plans and categorized models for alternate care facilities. The team then analyzed how these models applied to an influenza pandemic, including how they could function as primary triage sites, provide supportive care, offer isolation locations to patients, and serve as recovery clinics to facilitate patient discharge from hospitals.
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U.S. Department of Health and Human Services (2009). Requesting an 1135 Wavier.
When the HHS Secretary declares a public health emergency under Section 319 of the Public Health Service Act, s/he may temporarily waive or modify certain requirements to ensure that there are enough health care resources and services available to meet the needs of the public’s health. This document highlights examples of waivers and other related information.
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Mobile Medical Units

Minnesota Department of Health. (2013). Minnesota’s Mobile Medical Resources: About the Mobile Medical Unit (MMU).
This 4-minute video (hosted on YouTube) provides an overview of a Mobile Medical Unit, how it is set up, used, and managed.
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* Provincial Health Services Authority. (2021). British Columbia's Mobile Medical Unit.
This website provides an overview of the mobile medical unit for British Columbia (Canada) and how it is used during real events. It includes links to information on lessons learned, roles during disaster response/ recovery, and deployment criteria.
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* Taylor, M., Stokes, W., Bajuscak, R., and Shekar, S. (2016). Mobilizing Mobile Medical Units for Hurricane Relief: The United States Public Health Service and Broward County Health Department Response to Hurricane Wilma, Broward County, Florida. Journal of Public Health Management and Practice. 13(5):447-52.
This article describes the lessons learned from the nine mobile medical vans deployed during Hurricane Wilma. It includes data from the type of medical evaluations provided, other services (e.g., syndromic surveillance), and common presenting complaints by patients. Of particular interest may be the types of treatment services provided and a list of key lessons learned such as using the Incident Command System (ICS), using redundant communications, developing a protocol for credentialing prior to deployment, and the different responders in addition to medical providers involved.
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Plans, Tools, and Templates

Big South Fork Medical Center (TN) and Oneida High School. (2017). Memorandum of Understanding (MOU) for Alternate Care Site.
This document describes the understanding between a hospital and a school in Tennessee for the establishment and operation of an alternate care site.
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California Department of Public Health. (2008). Government-Authorized Alternate Care Site Operational Tools Manual.
This resource includes templates and checklists to support the operation of an alternate care site.
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Centers for Disease Control and Prevention. (2017). MedCon: Pre-Event.
This tool helps estimate the need for medical care in displaced populations after a disaster based on baseline population characteristics. It does not account for disaster-related injuries but can be helpful to estimate the needs for shelter-based and other medical services.
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Centers for Disease Control and Prevention. (2019). CDC Disaster Shelter Assessment.
This form and accompanying guidance can help practitioners carry out a quick assessment of emergency shelters. The form can be tailored and covers 10 general areas, from basic food safety and water quality to companion animal.
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District of Columbia Department of Health, Heath Emergency Preparedness and Response Administration. (2010). Alternate Care Site Pandemic Surge Optimization Plan. Braintree Solution Consulting, Inc.
This template was developed to help the D.C. Department of Health develop a comprehensive and prescriptive response plan. It includes guidance for site selection, operations, staffing, low acuity care CONOPS, community-focused ambulatory care clinic CONOPS, and primary triage point CONOPS. Appendices include sample emergency legislative orders, alternate care site admission orders, and site selection matrix.
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East-West Gateway Council of Governments. (2016). East-West Gateway Council of Governments Regional Alternate Care Site Plan.
This plan contains documents that fully detail the St. Louis Area Regional Response System (STARRS) approach to Alternate Care Sites (ACS). It highlights how ACS can be used to alleviate the burden caused by a surge of patients entering the healthcare system.
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Florida Department of Health. (n.d.). Alternate Care Site Tabletop Exercises. (Accessed 9/11/2023.)
This webpage lists alternate care site tabletop exercises for rural and urban settings; contact the Florida Department of Health’s Training and Exercise Section at TandE@flhealth.gov for copies.
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Illinois Medical Emergency Response Team. (2012). Alternate Care Site Planning Temporary Medical Treatment Station Planning.
This site provides tools, planning considerations, and supply and equipment information for temporary medical treatment stations. Though not specific to temporary hospitals, this guidance may provide some useful information regarding sample pharmaceutical caches, medical supplies and equipment, site selection, and the like.
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Mercy Hospital Joplin. (2018). Temporary Hospital Buildout and Design: Floorplans.
These floorplans can help healthcare facility planners and builders erect temporary, hard-sided facilities to replace buildings damaged by disasters.
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New Jersey Department of Health. (2013). Alternate Care Site/Expanded Treatment Area Planning Template.
This resource includes considerations for selection, operations, communication, human resource management, logistics, and legal and regulatory issues related to alternate care sites.
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North Carolina Department of Health & Human Services, Office of Emergency Medical Services. (n.d.). National Mobile Disaster Hospital Factsheet. (Accessed 1/3/2019.)
This one-page factsheet provides an overview of the North Carolina Mobile Disaster Hospital. It includes information on deployment capability and site requirements.
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Salt Lake, Summit, and Tooele County Healthcare Preparedness Coalition. (2014). SST Regional Mass Surge & Alternate Care Plan.
This comprehensive plan explains how alternate care facilities will be used in the Salt Lake, Summit, and Tooele County (UT) Region to help increase the capacities and capabilities of public health and healthcare facilities in the event of a mass casualty incident that leads to a surge in patients.
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Spectrum Health and Grand Valley State University. (2012). Alternate Care Site Implementation Plan for the Cook-DeVos Health Sciences Building.
This alternate care site (ACS) plan includes sections on: roles for various directors (e.g., communication, security/safety, finance, logistics); ACS design (e.g., patient flow, standing orders, and nursing subunits); and staffing requirements. Sample job action sheets are included; all appendices are available upon request from ASPR TRACIE (1-844-5-TRACIE [587-2243] or askasprtracie@hhs.gov).
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* Summit County Health District, Summit County Emergency Management Agency, Akron Regional Hospital Association. (2008). Development of an Alternative Care System: A Workbook for Community Planners Preparing for Medical Surge.
Rather than identifying individual Alternate Care Sites (ACS), Summit County chose to develop a comprehensive system. This document provides an overview of the ACS strategies and approach and provides step-by-step guidance for others interested in similar approaches.
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U.S. Department of Justice, Civil Rights Division. (2009). The ADA and Emergency Shelters: Access for All in Emergencies and Disasters.
This Addendum highlights several issues that emergency managers and shelter operators need to consider to ensure compliance with the Americans with Disabilities Act when planning for and providing shelter during emergencies and disasters. These issues can also apply to volunteers and employees with disabilities.
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Research

Krumperman, K., Weiss, S., and Fullerton, L.. (2015). Two Types of Prehospital Systems Interventions that Triage Low-Acuity Patients to Alternative Sites of Care. Southern Medical Journal. 108(7): 381-386.
While not disaster-specific, this study of low-acuity 9-1-1 callers noted that they were receptive to being transferred to a call center staffed by nurses with referrals to an urgent care center or primary physician provider or being treated on scene by paramedics and referred either to an urgent care center or primary physician.
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Shelter Medical Care/Medical Needs Sheltering

BCFS Health and Human Services Emergency Management Division. (n.d.). ESF-6/ESF-8 Emergency Sheltering: Best Practices for Emergency Managers. (Accessed 2/15/2019.)
This presentation reviews the differences between general and medical needs shelters, and includes data on United States aging trends and medical conditions, and describes care needs of “individuals requiring monitoring or management by a credentialed medical professional to manage their condition” that may be seen at a medical shelter.
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California Office of Emergency Services. (2022). Designating Shelters.
This webpage provides guidance for ensuring that individuals with access and functional needs can be sheltered in a timely, inclusive and dignified manner during a disaster.
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* Centers for Disease Control and Prevention. (2017). Information for Disaster Evacuation Centers.
This webpage contains links to evacuation center-related resources such as: infection control, medical management and patient advisement, guidelines for play areas, and animals in public evacuation centers.
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Centers for Disease Control and Prevention, National Center for Environmental Health. (2015). A Guide to Operating Public Shelters in a Radiation Emergency.
This document can assist emergency managers with planning and response efforts related to shelter operations in a radiation emergency. The guide includes information on screening for radioactive contamination, decontamination, radiation monitoring, registration, health surveillance, and communications consistent with Centers for Disease Control and Prevention Community Reception Center guidance. Chapter Three of this guidance document shares strategies for screening and decontamination (of people, service animals, pets, possessions, and vehicles) in shelters. Quick guides on decontamination are provided as appendices.
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Federal Emergency Management Agency. (2010). Guidance on Planning for Integration of Functional Needs Support Services in General Population Shelters.
This guidance document redefines the requirements for inclusion in general population shelters and provides new direction for the approach formerly known as “special needs shelters.” This document describes the national standard for shelter operations that integrate people with disabilities and others with access and functional needs into general population shelters.
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Florida Department of Health. (2015). SpNS Job Action Sheets.
These Job Action Sheets for Special Needs Shelters in Florida may be adapted by other jurisdictions for use in their plans.
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* New Jersey Department of Health. (2016). Medical Needs Shelters (MNS) in New Jersey and the Role of the MRC (Medical Reserve Corps) in Medical Needs Shelters.
This 59-minute webinar discusses medical needs sheltering, meeting the needs of the whole community, and medical needs shelter templates. Though focused on New Jersey’s plans, information may be adapted by other jurisdictions.
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Risoe, P., Schlegelmilch, J., and Paturas, J. (2013). Evacuation and Sheltering of People with Medical Dependencies Knowledge Gaps and Barriers to National Preparedness. Homeland Security Affairs 9, Article 2.
The authors discuss the gaps in knowledge related to disaster preparedness and people with medical dependencies and propose solutions to fill those gaps (e.g., establishing registries, estimating resource needs).
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* Thomas, T. and Loehr, M. (2011). Alternate Care Facilities: Developing Medical Surge Capability in King County. Seattle and King County Public Health.
This presentation describes Seattle and King County’s alternate care site plans, including when to activate, scope of care, staffing, equipment and supplies, site selection, and challenges and opportunities related to their use to support medical surge. This resource also includes a presentation on the agency’s plans to provide medical support to mass care shelters.
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Agencies and Organizations

U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. NDMS Teams.
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U.S. Department of Health and Human Services. Office of the Assistant Secretary for Preparedness and Response. 1135 Waivers.
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This ASPR TRACIE Topic Collection was refreshed and comprehensively reviewed in January 2019 by the following subject matter experts (listed alphabetically):

Eric R. Alberts, CEM, FPEM, FPEM-HC, CHPP, CHEP, SEM, Corporate Manager, Emergency Preparedness, Orlando Health, Inc. (Hospital System); Jim Bolen, MS, Planning Section Chief, Butler County / State of Ohio AHIMT; Nicholas V. Cagliuso, Sr., PhD, MPH, Senior Assistant Vice President for Emergency Management, Office of the President & CEO, NYC Health + Hospitals; Dee Grimm, RN, JD, Director of Business and Program Development, BCFS Health and Human Services, Emergency Management Division; John Hick, MD, HHS ASPR and Hennepin County Medical Center; Michael Melton, MPA, MA, MEP, Emergency Logistics Coordinator, Los Angeles County Department of Public Health; and Mary Russell, EdD MSN, Healthcare Emergency Response Coalition Palm Beach County Florida.

 

It was comprehensively reviewed in November and December 2016 by the following subject matter experts (listed alphabetically):

Eric R. Alberts, CEM, CHS-V, FPEM, FPEM-HC, CDP-1, CHPP, CHEP, SEM, CFRP, FABCHS, Manager, Emergency Preparedness, Orlando Health, Inc. (Hospital System); James Bolen, MS, Planning and Operations Manager, Butler County (Ohio) Emergency Management Agency; Tracy L. Buchman, DHA, CHPA, CHSP, Assistant Professor, Department of Occupational & Environmental Safety & Health, University of Wisconsin-Whitewater; Julie Bulson, MPA, BSN, RN, NE-BC, Director, Emergency Preparedness, Spectrum Health; Dee Grimm, RN, JD, Director of Business and Program Development, BCFS Health and Human Services, Emergency Management Division; John Hick, MD, HHS ASPR and Hennepin County Medical Center; Dave Nichols, CEM, Public Health Seattle & King County Washington; and Mary Russell, EdD, MSN, Emergency Services, Boca Raton Regional Hospital. 

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