Relief Healthcare Facilities (RHFs): Established licensed healthcare facilities (e.g., hospitals, long-term acute care hospitals, long-term care facilities, and other licensed inpatient healthcare facilities) that accept patient transfers or share extra resources to extend conventional standards of care to as many people as possible during a crisis and therefore minimize the use of crisis standards of care.
Crisis Standards of Care: Standards of care that reflect a substantial change in usual healthcare operations and the level of care that healthcare providers are capable of delivering during a crisis. When a state government formally declares the need for crisis standards of care, this formal declaration enables specific legal/regulatory powers and protections for healthcare providers as they perform the necessary tasks of allocating and using scarce medical resources and adopting alternate healthcare operations during a crisis.
Medical Operations Coordination Cell (MOCC): A cell (group of medical operations experts) within emergency operations centers (EOCs) at the sub-state regional, state-wide, and federal regional levels that can assist in the transferring of patients between healthcare facilities. A MOCC makes data-and stakeholder-informed decisions to balance patient load and ensure high-quality care. MOCC decisions direct the movement of patients and resources from one facility to another or re-direct referrals of patients who would usually go to an overwhelmed facility or system to one that has the capacity to care for those patients.
Many COVID-19 cases are geographically localized and can overwhelm local healthcare facilities. This means that healthcare systems typically have uneven distribution of COVID-19 cases, with some regions’ healthcare systems experiencing patient surges while others have excess capacity for patient care. When healthcare facilities reach or exceed patient capacity, crisis standards of careexternal icon are often implemented. Healthcare systems entering crisis standards of care are faced with the tremendous challenge of providing high-quality care while allocating scarce resources.
This guidance is for state and local emergency medical planners and all healthcare facilities, especially facilities in rural areas. This guidance outlines considerations around the transfer of patients, staff, and supplies between healthcare facilities to optimize patient care, balance resources, and minimize use of crisis care standards. One strategy is to identify relief healthcare facilities and either establish a federal, state, or regional Medical Operation Coordination Cell (MOCC) or coordinate with an existing MOCC. This guidance offers considerations for jurisdictions around patient safety and relief healthcare facility operations. Specific guidance related to the implementation of the elements highlighted in this guidance can be found in the Federal MOCC Toolkitpdf iconexternal icon.
Many states and regions have drawn upon years of experience responding to past public health emergencies as they coordinate healthcare, public health, and emergency medical systems in response to COVID-19. One advantage of a coordinated approach is monitoring for resource-straining surges of patients and identifying facilities with available beds, staff, and supplies.
To optimize care for patients, some states designate facilities with available beds and staff as relief healthcare facilities (RHFs). RHFs are established licensed healthcare facilities (e.g., hospitals, long-term acute care hospitals, long-term care facilities, and other licensed inpatient healthcare facilities) that accept patient transfers or share extra resources to extend conventional standards of care to as many people as possible during a crisis and therefore minimize the use of crisis standards of care.
The Federal Medical Operations Coordination Cells (MOCCs) Toolkitpdf iconexternal icon offers flexible guidance to help regional, state, local, tribal, and territorial governments improve surge capacity and resource allocation across the healthcare delivery system during the COVID-19 pandemic.1,2> The toolkit provides a framework for states or local jurisdictions to establish RHFs. The primary goals for states identifying RHFs are:
- Providing the appropriate level of medical care.
- Protecting healthcare personnel and non-COVID-19 patients from infection.
- Preparing for a potential surge in patients with respiratory infection.
- Preparing for shortages of personal protective equipment (PPE) and staffing.
The following guidance is for state and local emergency medical planners and all healthcare facilities, especially facilities in rural areas, planning to identify RHFs, establish a MOCC, or coordinate with an existing MOCC. Guidance, tools, and resources for many of these factors can be found in the MOCC toolkitpdf iconexternal icon.
- Centralized decision-making must occur at the regional, state, or health system level.
- Work with MOCCspdf iconexternal icon,1,2 local and state public health organizations, healthcare coalitions, and other local partners to understand the impact and spread of the COVID-19 outbreak in your area and any modifications in ongoing initiatives being implemented.
- Ensure that emergency medical service (EMS) agency licensure and resource capabilities are included in local and regional planning efforts. Identify ground and aeromedical transport assets to support patient transfers and develop processes for interfacility transport.
- If RHFs are to be used across state lines, the healthcare systems and both states should be engaged for joint planning.
- Develop plans to ensure closed healthcare facilities near RHFs can rapidly and safely re-open if there is a patient surge in surrounding areas.
- Patients suitable for transfer should have their information entered into a central, secure database for tracking, triage, and placement.
- Communicate information about patients to appropriate personnel before transferring them to another healthcare facility.
- MOCCs and coordinating healthcare facilities should ensure healthcare expenditures will be appropriately covered before transferring patients.3,4,5,6
- Accepting facilities should review and accept patients based on:
- the RHF’s ability to provide appropriate standards of care;
- distance from the patient’s current healthcare facility; and
- the patient’s level of clinical stability.
- PPE and personnel should be tracked in a centralized system:
- Centralized decision makers should review daily data from the National Healthcare Safety Network (NHSN), which now includes acute care and long-term care facility COVID-19 modules (showing percentage use of ventilators and beds above and below average across the state’s facilities), and other data sources to ensure that patients and ventilators are placed appropriately and that accepting facilities can manage increases in patient volume.
- Ensure that RHFs have all legal documentation and infrastructural requirement needed to rapidly re-open, if closed.
- Ensure that RHFs have an adequate number of trained healthcare professionals, sufficient space to accommodate additional patients, appropriate PPE, and other equipment and supplies to care for these patients.
- RHFs must be able to accept transfers from highly impacted hospitals and other healthcare facilities without compromising their ability to respond to surges in their own communities.
- Relief hospitals must be able to provide:
- a critical care bed for a patient with COVID-19 requiring critical care, including mechanical ventilation;
- a critical care bed for a patient without COVID-19 requiring critical care, including mechanical ventilation;
- a non-critical care bed for a patient with COVID-19;
- a non-critical care bed for a patient without COVID-19; and
- a swing bed for long-term recovery, if relief hospitals lack critical care capacity.
- Some rural facilities may have limited capacity to accommodate clinically complex patients and may be more appropriate for non-critical patient care or care of patients without COVID-19. Relief hospitals must be able to provide critical care capability on site if they are accepting patients with a high risk of decompensation who may need to be transferred to higher levels of care if their condition deteriorates quickly.1
- Relief skilled nursing homes should declare their willingness to accept both patients with and without COVID-19 and their willingness to accept stable patients requiring long-term mechanical ventilation and considered appropriate for skilled nursing home level of care.2,3
- Relief long-term care facilities should be willing to accept stable patients requiring mechanical ventilation considered appropriate for long-term care.
- Ensure RHFs use strategies to ensure workers’ safety and support, including healthcare personnel monitoring and operational planning.
- Ensure healthcare facilities, including RHFs and other facilities treating patients with COVID-19, submit data on ventilator and bed use, PPE stock, healthcare personnel staffing, and burden of COVID-19 into the National Health Safety Network (NHSN).
- Consider if cohorting patients and healthcare personnel may be feasible or useful (i.e., entire facilities or units for patients with COVID-19 or non-COVID-19), including post-discharge planning for patients who are going from hospitals to long-term care or other types of healthcare facilities.
- Ensure all RHFs are prepared to safely triage and manage patients with respiratory illness, including COVID-19. Ensure they become familiar with infection prevention and control guidance for managing patients with COVID-19 and preparation steps.
- Ensure RHFs plan to optimize the supply of PPE in the event of shortages and identify flexible mechanisms to procure additional supplies when needed.
- All planning efforts for RHFs should adhere to regulations and standards for informed consentexternal icon regarding patient transfers between facilities. The MOCC toolkit provides informed consent form templates.
- Consider whether and what legal documentation may be necessary to facilitate patient transfers.
- Ensure communication between healthcare professionals at the transferring and receiving facilities, with an accurate clinical description of the patients and with clear acceptance by the RHF.
- Telehealth consults with the RHFs should be considered, as needed, for patient management. 10
- The receiving facility’s policies on visitors should be communicated to family members and healthcare powers of attorney.
Texas used the existing regional trauma system as a stable framework for responding to the COVID-19 pandemic. Texas further strengthened this framework and response efforts by linking existing public health, acute healthcare, and disaster management systems to MOCCs. The state’s experience demonstrates the benefits of having established systems for public health and disaster response.
Texas’s system enabled and facilitated timely action by:
- Structuring cooperation across the state.
- Supporting robust and redundant communications.
- Delivering actionable data.
Building on this existing response framework, Texas implemented performance improvement processes to adapt the system to the response and achieve the best patient outcomes.
The Role of Regional MOCCs
The Regional MOCC bolstered the framework created by Texas’s trauma system by:
- Providing situational awareness.
- Supporting integration of public health, acute health care, and disaster management functions.
- Providing actionable data from consolidating public health and acute health care data sources.
- Coordinating healthcare delivery in hot spots.
- Managing drive-through testing.
- Balancing staff workload across health systems and organizations.
- Ensuring safe and high-quality patient care by transferring within the system where care was optimal.
In mid-March, Michigan began to experience a significant spread of COVID-19 in the southeast region and metropolitan Detroit area – with peak hospitalizations of greater than 4,400. The Michigan Healthcare Preparedness Program quickly put into place a surge strategy that optimized the use of healthcare resources to save lives. A key piece of this strategy was using relief hospitals to extend healthcare to residents in need. Although Michigan encountered staff recruitment challenges for hospitals in minimally impacted regions, willingness of these hospitals to accept patients improved following requests from senior state leadership to hospital chief executive officers. The state’s experience demonstrates the importance of monitoring statewide hospital status and facilitating direct connections between hospitals.
Extending Conventional Standards of Care
Michigan was able to implement the relief hospital concept using the following effective strategies:
During a 20-day period (April 1–20, 2020), nearly 1,000 patients were transferred between hospitals. About 85% of these patients were transferred through direct interhospital contact, and about 30% were transferred within healthcare systems.
The Role of Regional and State MOCCs
Michigan prioritized a facilitative role by establishing and supporting:
- A state MOCC operated by experienced paramedics in an EMS dispatch control center.
- Physician resources for consultation, problem-solving, and medical leadership.
- A statewide hospital status application, was an invaluable tool for identifying relief hospitals and facilitating transfers.
1Medical Operations Coordination Cells Toolkitpdf iconexternal icon
2HHS’s Office of the Assistant Secretary for Preparedness and Response (ASPR) Hospital Preparedness Program (HPP) annual cooperative agreement recipients (62 states, select localities, territories, and freely associated states) and subrecipients (e.g., healthcare coalitions) may utilize this funding to operationalize a MOCC.external icon
3Health Resources & Services Administration COVID-19 Claims Reimbursement to Health Care Providers and Facilities for Testing and Treatment of the Uninsuredexternal icon
4Centers for Medicare & Medicaid Services Coronavirus Waivers & Flexibilitiesexternal icon
5CARES Act Provider Relief Fundexternal icon
6American Society of Clinical Oncology resourcesexternal icon
7Hospitals: CMS Flexibilities to Fight COVID-19pdf iconexternal icon
8Long Term Care Facilities (Skilled Nursing Facilities and/or Nursing Facilities): CMS Flexibilities to Fight COVID-19pdf iconexternal icon
9COVID-19 Long-Term Care Facility Guidance April 2, 2020pdf iconexternal icon
10CDC’s guidance on Using Telehealth Services