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5 Reaching the Last Mile: Potential Opportunities to Improve Coordination and Communication Among Local, State, and Federal Agencies
Pages 55-84

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From page 55...
... site for the state and is set to receive countermeasures, which are then shipped by ground or air to 45 local distribution nodes and to hospitals, with roughly 225 to 245 different shipment locations. Dispensing is a local function, with local health departments responsible for transporting the assets to dispensing locations (hospitals run alternate care facilities with support from emergency management and the health departments)
From page 56...
... Figure 5-1 SOURCE: Lixey Terrill presentation, February 5, 2016. R03033 raster -- not editable
From page 57...
... It can take 9 to 10 hours to ship countermeasures from state-identified warehouses to the most northwestern portions of the upper peninsula, even with favorable weather conditions. Another set of major challenges in Michigan pertains to the feasibility and acceptability of POD operations, Lixey Terrill explained.
From page 58...
... As part of the health care coalition, the organization is one of the largest closed POD partners that has unique access to that community. Muskegon, Michigan, has a mass dispensing plan that includes using all the physician offices in the county as closed PODs that works well for its jurisdiction, but is not a "one-stop shop" -- they also have other open PODs in federally qualified health centers that participate in the health care coalitions.
From page 59...
... Some of the smaller closed PODs, such as nursing homes, depend on local health departments to set up an alpha POD to facilitate distribution (usually by pick up)
From page 60...
... . RE-PLAN is a modeling software that can be used for dispensing operations, identifying POD locations, and helping RSS sites to increase their number of direct deliveries.
From page 61...
... See Box 5-1 for a description of the differences between rural and urban MCM planning in Texas after distribution is completed at the state level. New York City MCM Planning David Starr is the director of the Countermeasures Response Unit, which is situated within the Office of Emergency Preparedness at the New York City Department of Health and Mental Hygiene.
From page 62...
... It is an exclusively medical model with alternate dispensing modalities, including closed PODs, door-to-door,a and drive-thru alpha PODs. She pointed to the local request and activation/mobilization process as suc cessful in both settings, in terms of the transition from an impacted municipality through the county and state levels.
From page 63...
... The Countermeasures Response Unit relies primarily on a network of public PODs and has built a robust capacity to support them; the overarching objective of the exercise was to verify the ability to mobilize for citywide dispensing operations consisting of the immediate mobilization of 30 POD sites citywide. It was a no-notice exercise for all involved parties (field staff, warehouse, trans portation vendors,a etc.)
From page 64...
... Leadership staff (in particular) are preassigned to the 165 POD sites around the city, ­ which are distributed according to models of population density.
From page 65...
... This was difficult, even though the city incident management system mandates this as a core competency for the unit to be able to execute these operations. Assignment of staff had not become a focal issue until shelter understaffing proved a problem during Hurricanes Irene and Sandy, and the commissioner ordered health department staff to respond to that (not their core mission)
From page 66...
... Starr outlined further last-mile successes with regard to emergency medical logistics planning on the dispensing side.3 The Countermeasures Response Unit recently finalized pre-scripted mission requests (PSMRs) that detail the various elements of the SNS request,4 which are now on file at the City Office of Emergency Management Watch Command so that when leadership chooses a Phase I response, the appropriate request on file can be pulled immediately.
From page 67...
... , focused on CDC strategies for ensuring preparedness at the "last mile"; specifically, she explored what CDC is doing to ensure operational readiness at the state and local levels to improve capabilities within state and local public health departments (see Box 5-3)
From page 68...
... First, since 9/11, the PHEP Program has created the new domain of "­ ublic p health emergency management" experts, which differs from traditional emergency management in that it views emergency management through a public health lens. The second key message is to support the public health capabilities that are necessary for state and local public health by framing those into a doctrine of 15 public health preparedness capabilities published in 2012 (see Box 5-4)
From page 69...
... They are prepared and they can do it." Development of the CDC Medical Countermeasures Readiness Review Process and Tool Kosmos explained that DSLR has worked closely and productively with DSNS from the beginning in efforts to build capabilities for state and local readiness for MCM planning; today, the DSLR continues to work with the DSNS to advance the work of state and local public health. Moving forward will require the flexibility to adapt to the changes of the ever-evolving
From page 70...
... By the end of 2016, they will have evaluated more than 400 states, directly funded cities, and local jurisdictions, providing a useful snapshot of the levels of capability within state and local public health. To date, more than $300 million has been invested in MCM planning since the beginning of the project.
From page 71...
... Time and space are also barriers, due to the size of the state and the amount of storage needed. Poole noted that local SNS program staff turnover continues to be a challenge; there is a 10-35 percent turnover rate for SNS coordinators in Texas' 45 local health jurisdictions (due to promotion or transfers out)
From page 72...
... A related issue raised by Starr is the discovery that SNS would not be able to fulfill exact requests being made, due to a decision made years ago by the Public Health Emergency Medical Countermeasures Enterprise (PHEMCE) regarding the ratio of antibiotics held in the SNS stockpile.
From page 73...
... POTENTIAL OPPORTUNITY FOR ALTERNATIVE DISTRIBUTION AND DISPENSING MODELS Sosin remarked that identifying unique approaches to distribution and dispensing models that leverage existing resources is important, but reminded the group that the work involved is more than just, for example, a suggestion to do user-managed inventory. Strains of the volume of material that can be held in the stockpile should be taken into account.
From page 74...
... See Box 5-5 for another example of collaboration between pharmacies and state health officials. With state health departments still hampered by recession and reduced capacity, Loehr suggested turning to large private-sector health care systems9 9  Oneof these systems touches 10 percent of the entire state population, 700,000 people, between members and employees.
From page 75...
... Commitment does not necessarily mean that they will sign a Memoran dum of Understanding (MOU) : Michigan does not require that MOUs be signed with pharmacies, closed PODs, or any other dispensing partner facility; some form of a written agreement suffices (e.g., letter of support or commitment let ter)
From page 76...
... He cited two reasons for this. First, public PODs in some states and local jurisdictions do not provide sufficient capacity and are a strategy geared toward specific populations who cannot get medications in any other way; Loehr predicted that many states will recognize the need to involve the private sector in this part of dispensing.
From page 77...
... For example, she suggested the possibility of providing a more generic agreement than jurisdiction-level MOUs that would still allow employers to be covered under the PREP Act for their liability. Sherman replied that the declaration so far has covered two different scenarios: situations that involve any type of federal agreement and situations involving emergency response mass dispensing.
From page 78...
... It is another illustration of the brilliance and the complexity of the federal–state arrangement that is the United States of America when it comes to health authorities." POTENTIAL OPPORTUNITY FOR IMPROVING TRANSPARENCY AND COORDINATION AMONG LOCAL, STATE, AND FEDERAL AGENCIES From the local perspective, Gore suggested several ways to move forward with the SNS. The first is exercising the whole SNS process from beginning to end: from identification of a bioterrorism threat that triggers
From page 79...
... framework idea would be ideal, especially if it were tied into a mechanism among local jurisdictions as well as between the local, state, and federal levels. Starr also called for increasing visibility into the SNS at the local level: Smoothing that interface when it comes so that not only do we know what is in it, but they know what we want and we know what is on its way.
From page 80...
... Burhans emphasized the importance of including state and local stakeholders in the requirementsetting process for PHEMCE, because decisions on CONOPS and on the formulary have profound impacts on the last mile. Specifically, he advised that as CONOPS are developed, they should be shared with state and local health departments to make sure they understand the assumptions from PHEMCE's side.
From page 81...
... , including pharmacies and multiple forms of PODs (closed PODs; public PODs, drive thru)
From page 82...
... He noted that while there are myriad existing innovations that could be applied, not everyone has had access to innovation about how to have industry rotate products, for example. Gore suggested that utilizing federal buying power for local responses could benefit local jurisdictions that have purchased their own caches for first responders because they could not dispense to them fast enough with SNS assets.
From page 83...
... Lixey Terrill applied this concern to the time frame for dispensing, noting that it could take up to 12 hours for the state to receive the product, plus additional time to move it from the state to the local levels (which still have to dispense to first responders before the general public)


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