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------=_NextPart_01C7237E.7A29CE00 Content-Location: file:///C:/2B494E34/GovernorsVolunteers1204_files/pres.xml Content-Transfer-Encoding: quoted-printable Content-Type: text/xml; charset="utf-8" ------=_NextPart_01C7237E.7A29CE00 Content-Location: file:///C:/2B494E34/GovernorsVolunteers1204_files/slide0083.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" The Ws of Q? Quarantine in Alabama
ADPH 2006
1
Of Dragons, Disasters
and Don Quixote
Governor’s Volunteer Conference December 13, 2006
By  John R. Wible
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Quarantine in Alabama
ADPH 2006
2
Prologue
•Don Quixote de La Mancha was= on a Quest looking for dragons to slay, wrongs to right and damsels to rescue.
•And, he found them, but sometimes they were but windmills.
•So it is with us, our quest = is to rescue to the fair damsel and gamin.
•Sometimes we find dragons= 3;
– but sometimes windmills.
Don Quixote de La Mancha was on a Quest looking for dragons to slay, wrongs to right and damsels to rescue.
And, he found them, but sometimes they were but windmills.
So it is with us, our quest is to rescue to the fair damsel and gamin.
Sometimes we find dragons -  but sometimes windmills.
In their book, Getting to Yes, Roger Fisher and William Ury teach the reader how to negotiate without compromise. In this business however, compromise= is the name of the game.
-- But so is “getting to yes.”
Sometimes getting to “yes” pits us against dragons – but sometimes windmills.
------=_NextPart_01C7237E.7A29CE00 Content-Location: file:///C:/2B494E34/GovernorsVolunteers1204_files/slide0119.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" The Ws of Q? Quarantine in Alabama
ADPH 2006
3
Government Authority to Act in Emergenc= ies: Model
<= span style=3D'visibility:hidden'>•
•Legal auth= ority is at its peak at the emergency’s peak&= #13;•As crisis comes under control, legal authority is subject to greater legal constraints •And attention shifts to  <= /span>responsibility for costs and damages/losses
<= span style=3D'font-size:86%;visibility:hidden'>•
Governmental Authority Model -
At height of emergency – authority is at its peak.  Broad discretion exists under both st= ate and federal laws for the executive – including police and public health officials – to take actions deemed necessary to reduce imminent threats to life, property, and public health and safety

When the crisis is brought under control – when there are no longer imminent threa= ts to life, property, and public health and safety requiring immediate actio= n, the scope of authority is reduced – as need to protect other values and individual rights, resume normal roles.

Further, once immediate threats to life and to public health, safety, and property= are addressed, all those involved in a response will necessarily be faced with the challenge of paying for the loss and damage that has been sustained.<= /font>

Legal issues are still very important even at the height of a crisis – and choi= ces made during crisis moments can have a substantial impact on how losses and damages are paid for after the event.
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Quarantine in Alabama
ADPH 2006
4
= We are Not Alone-
Federal Public Hea= lth Partners
•
•Department of Health & H= uman Services
–CDC, FDA, NIH and health oth= er agencies
–US Public Health Service Commissioned Corps
–Strategic National Stockpile (SNS)
•Indian Health Service (IHS)&= #13;
•Department of Homeland Security
–National Disaster Medical Sys= tem (NDMS)
–= 3;
–AND IN CATASTROP= HIC HEALTH EMERGENCIES—
•Departments of Defense, Vete= rans Affairs
We are not alone. There are federal partners in the emergency.

HHS/CDC - SNS (Strategic National Stockpile).  Caches of equipment, medical supplies and pharmaceuticals, staged = for rapid deployment to anywhere in the county on 12-24 hours notice, in the event of a major health care emergency. It is sent at the Governor’s requ= est on recommendation from the State Health Officer. The “Push-pack” was sent= to NY in 9/11 and to MS/LA in Katrina.

HHS includes many public health agencies including
•CDC - The Commissioned Corps.
•National Institutes of Health (NIH)
•Indian Health Service (IHS)
•Substance Abuse and Mental Health Servi= ces Administration (SAMHSA)
•Agency for Healthcare Research and Qual= ity (AHRQ)
•Agency for Toxic Substances and Disease Registry (ATSDR)
•Food and Drug Administration (FDA)
•Health Resources and Services Administr= ation (HRSA) – Supplies major grants

DHS/ FEMA includes the following key public health resources to be deployed in= the event of an emergency involving health care & Public health:

NDMS (National Disaster Medical System) Specially trained medical, veterinary = and mortuary teams to provide emergency surge capacity in the event of a large scale emergency. The “medical National Guard.”

DoD – Military units a be requested by state authorities to assist with virtual= ly everything except “police work.”  But even this can be “euphamised.” Peach keeping is prohibited by the “Posse Commitatus Act” except to suppress and insurrection under “the Insurrecti= on Act,” a Reconstruction-Era Act.

VA - The VA manages patients evacuations including evacuation resources under NDMS when local capability is exceeded. We are working with VA and they have agreed  to use our AIMS system.

Homeland Security Presidential Directive-5 (HSPD-5) directs Homeland Security Secretary to develop and administer: National Incident Management System (NIMS) and National Response Plan (NRP) to ensure effective management of large-scale emergencies

While the secretary of Homeland Security is responsible for developing and Administering NIMS and the NRP, HSPD 5 indicates that it is to apply to A= LL federal resources and all resources paid for by Federal Funds, before, du= ring and after an emergency.

These are now another integral part of public health in emergencies. This was unheard of just a few years ago.
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ADPH 2006
5
State Partners
•Emergency Management Agency         (AEMA)
•State Troopers
•National Guard
•Department of Public Heal= th
•Agriculture and Industries&#= 13;
•Dept. of Human Resources = ;
•Medicaid Agency
•State Dept. of Education
•Dept. of Environmental Management
•Conservation and Natural Resources
As a local incident grows in scale – local governments will ask for assistance from state.
•State partners:  State Troopers
•National Guard
•Department of Public Health
•Emergency Management Agency (AEMA)
•Agriculture and Industries
•Dept. of Human Resources
•Medicaid Agency
•State Dept. of Education
•Dept. of Environmental Management
•Conservation and Natural Resources
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text/html; charset="windows-1252" The Ws of Q? Quarantine in Alabama
ADPH 2006
6
State Emergency Operations <= /span>Plan - EOP
•Divides disaster responsibilities among the various state agencies in numbered “Emergency Support Functions “ESFs” =
•<= /span>Public Health responsible for
–= ESF # 8 coordination of all medical resources
–ESF # 6 assistance in mass shelters and management of “Medical Ne= eds Shelters”
•<= /span>Annexes – Biological and Radiological
The Act Divides disaster responsibilities among the various state agencies in numbered “Emergency Support Functions “ESFs”
Public Health responsible for
ESF # 8 coordination of all medical resources
ESF # 6 assistance in mass shelters and management of “Medical Needs Shelters.”  There are several proposed acts deali= ng with “Medical needs shelters.” In the last two storms, we spent a great d= eal of time and effort in these two functions.
Annexes – Biological and Radiological
The new plan has just been released. See:
http://ema.alabama.gov/Misc/Alabama%20EOP%202006.pdf
------=_NextPart_01C7237E.7A29CE00 Content-Location: file:///C:/2B494E34/GovernorsVolunteers1204_files/slide0124.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" The Ws of Q? Quarantine in Alabama
ADPH 2006
7

Declarations and Proclamations
• What are Declarations and Pr= oclamations?
•Public announcements
•Legal determinations
–Made by an authorized govern= ment official
–Triggering special emergency powers
–Allowing expenditure of emergency funds
Declaring a disaster or emergency is a public announcement – a statement or declara= tion that the government recognizes that emergency situation exists and, presumably, intends to do something about it.

A Declaration in the context of this course is a legal determination=
made by an authorized official, in accordance with criteria specified by law
Which has the particular effect specified in the governing law: A declaration m= ay
•trigger special emergency powers=
•Allow expenditure of emergency funds, or expenditure of funds in advance of appropriation or in lieu of appropriat= ion
•Waives or modifies normal legal require= ments

They have significant legal impact and import.
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c7ra3Iiib+9zya7WvLrRcTR4GAGHH416fmqgEkcpY6oLjSLETWFpIUtY0DEPkgKB/epxksz10qz/ APH/AP4qiinZGd2N/wBB/wCgTZ/+P/8AxVA+wj/mE2f/AJE/+KooqrIfM+W1w/0EOH/siz3Dofn/ APiqf5tpn/kE2f5P/wDFUUU5LYSbEMlmf+YTZ/k//wAVQJbMf8wmz/J//iqKKmyHdh5tmeuk2X5P /wDFUmbH/oEWX5P/APFUUUJILsT/AED/AKBFl+T/APxVIV089dHsv/In/wAVRRVWQrsTy9O/6A1l /wCRP/iqULp4/wCYNZflJ/8AFUUU7CuyRJLJCCuj2IIORw//AMVU3/CUXX/Pra/98t/8VRRQkDbP /9n= ------=_NextPart_01C7237E.7A29CE00 Content-Location: file:///C:/2B494E34/GovernorsVolunteers1204_files/slide0125.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" The Ws of Q? Quarantine in Alabama
ADPH 2006
8
The Stafford Act
(42 U. S. C. 5121 et seq.)
•= Stafford Act is the principal discretionary federal authority to assist= state and local governments in responding to catastrophic events of any type =
•= Activated by presidential declaration of a “major disaster” or an “emerg= ency”
•= The Stafford Act provides for federal authorities = and funds to:
–= Plan and provision pre-event
–= Send equipment and FEMA manpower in-event
–= Send the Army in a catastrophic event                              (82nd Airborne to Super Dome)
–= Back pay post-event
The Stafford Act is the broadest and most well known of the federal governmen= t's emergency programs. After virtually every hurricane, earthquake, or major tornado, the media reports that the Governor of an affected state has ask= ed the President to declare a major disaster.
•This is THE principal discretionary aut= hority that Congress has provided the President to respond to and recover from catastrophic events of virtually any type.
•It is a particularly useful statute bec= ause it provides both authority and appropriated funds to act
•Although every disaster or emergency im= pacts public health, the Stafford Act has only rarely been used to address incidents that primarily involve health:
• Emergencies were declared in several s= tates in 1999-2000 time frame to provide funding for mosquito spraying to combat W= est Nile Virus/encephalitis
• But note: no declaration was made for = anthrax incidents in 2001 or SARS
•FEMA cannot provide any significant dir= ect funding without a declaration
•FEMA can position resources w/o a decla= ration in anticipation of that declaration
•“Robert T. Stafford Disaster Relief and Emergency Assistance Act, as amended, is codified at 42 USC 5121 – 5206.<= span style=3D'mso-spacerun:yes'>  Principal provisions governing major disasters are found in Title IV; Principal provisions governing emergenci= es are in Title V.  Implementing regulations at 44 CFR, and particularly Part 206 thereof.
Stafford Act is the principal discretionary federal authority to assist state and local governments in responding to catastrophic events of any type=
Activated by presidential declaration of a “major disaster” or an “emergency”
The Stafford Act provides for federal authorities and funds to:
Plan and provision pre-event
Send equipment and FEMA manpower in-event
Send the Army is a catastrophic event (82nd Airborne to Super Dome)
Back pay post-event
------=_NextPart_01C7237E.7A29CE00 Content-Location: file:///C:/2B494E34/GovernorsVolunteers1204_files/slide0126.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" The Ws of Q? Quarantine in Alabama
ADPH 2006
9
Alabama Emergency Proclamations
•Under the Emergency Management Law             = Code of Ala. 1975, §§ 31-9-2, et seq.= :
•Governor proclaims an “emergency” defined as:
•Enemy attack, sabotage or “other hostile action;”
•Fire, flood and “other natural causes.”
•Definition covers B/T incidents or naturally occurring events like hurricanes and tornadoes.
Under Code of Ala.1975, § 31-9-2:
Governor proclaims an “emergency” defined as:
Enemy attack, sabotage or “other hostile action;”
Fire, flood and “other natural causes.”
Definition is broad enough to cover B/T incidents or naturally occurring events like hurricanes and tornadoes.
Under newly passed HB 107, “Public health emergency,” is defined as:
“an occurrence or imminent threat of an illness or health condition, caused by Bioterrorism, epidemic or pandemic disease, or novel and highly fatal infectious agent or biological toxin, that poses a substantial risk of a significant number of human fatalities or incidents of permanent or long-= term disability. Such illness or health condition includes, but is not limited= to, an illness or health condition resulting from a national disaster.”
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Quarantine in Alabama
ADPH 2006
10
Governor’s Powers Under
Section 31-9-1, et seq.
•= To execute the State’s EOP
•= To issue orders, rules and regulations;
•= To control or compel citizen’s movements and activities;
•= To command all state employees; =
•= To call the legislature into special session; =
•= To procure, purchase or condemn; and supplies, property, materiel and facilities paying adequate = = compensation.
•= To enter in EMACs
To execute the State’s EOP.
To issue orders, rules and regulations;
To control or compel citizen’s movements and activities;
To command all state employees;
To call the legislature into special session;
To procure, purchase or condemn; and supplies, property, materiel and facili= ties paying adequate compensation.
To enter in EMACs
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Quarantine in Alabama
ADPH 2006
11
Hegel Studies the Problem
•Wilhelm Hegel stated that logical problems      = = could be resolved by rehearsing the         formula: Thesis, Antithesis, Synthesis.
•<= /span>Thesis – Alabama needs a network of individual = volunteers, hospitals,  other health care providers, by mutual agreement can freely transfer patients, per= sonnel and equipment across the state= and even state lines in the ev= ent of an emergency.
•= Antithesis – There are “Dragons” which impeded th= e satisfying of this need.
•= Synthesis – By identifying, slaying or living with= the Dragons, the truth will be found.
Wilhelm Hegel stated that logical problems could be resolved by rehearsing the formula: Thesis, Antithesis, Synthesis.
Thesis – Alabama needs a network of individual volunteers, hospitals, other health care providers that, by mutual agreement can freely transfer patie= nts, personnel and equipment across the state and even state lines in the even= t of an emergency.
Antithesis – There are “Dragons” which impeded the satisfying of this nee= d.
Synthesis – By identifying, slaying or living with the Dragons, the truth will be found.
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Quarantine in Alabama
ADPH 2006
12
The Dragons
•Dragons
<= span style=3D'font-size:114%'>•HIPAA
•Public Health k= udos or aid and some con= cerns
•Transportation,= EMS and transfer agreement issues
<= span style=3D'font-size:114%'>•Liability issues
•Credentialing i= ssues
Here are some issues that could be dragons if we don’t make them into windmills:
•HIPAA
•Public Health and State government conc= erns or aid
•Transportation, EMS  and transfer agreement issues<= br>
•Liability concerns and
•Credentialing issues
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Quarantine in Alabama
ADPH 2006
13
 Prologue Cont= inues
•In their book, Getting to= Yes, Roger Fisher and William Ury teach the reader how to = negotiate without compromise.
•In this business however,          compromise is the name                           of the game.
•-- But so is “getting to yes.”
•Sometimes getting to “yes” p= its us against dragons – but sometimes windmills.
In their book, Getting to Yes, Roger Fisher and William Ury teach the reader how to negotiate without compromise.
In this business however, compromise is the name of the game.
-- But so is “getting to yes.”
Sometimes getting to “yes” pits us against dragons – but sometimes windmills.
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Quarantine in Alabama
ADPH 2006
14
But, Are They Dragons
-or Windmills?
And, how do you tell the difference?
But, Are They Dragons -or Windmills?

And, how do you tell the difference?

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file:///C:/2B494E34/GovernorsVolunteers1204_files/slide0093.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" The Ws of Q? Quarantine in Alabama
ADPH 2006
15
Painting the Dragon Red
=
The Spring 1998 issue of “Leadership Journal” refers to the process of “Paint= ing the Dragon Red.” That is – identify what is a real dragon and clearly mar= k it so you know how to deal with it.
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Quarantine in Alabama
ADPH 2006
16
1. HIPAA
•45 C.F.R. Parts 160 and 164 provide that “covered entities” may use or disclo= se protected health information (PHI) without the patient’s authorization for treatment, payment and operations (TPO)
•Why wou= ld a disaster be any different from a normal transfer of information for TPO purposes?
•Subject= to “minimum necessary” concept, Public Health, Law Enforcement and National Security agencies may= be informed under specific exceptions to HIPAA under = Part 164.
–A windm= ill? Maybe, maybe not
45 C.F.R. Parts 160 and 164 provide that “covered entities” may use or discl= ose (PHI) w/O the patient’s authorization for: Treatment , Payment , and Operations .
Why would a disaster be any different from a normal transfer  of information for TPO purposes?
Public Health, Law Enforcement and National Security agencies may be informed  for subject to the “minimum necessary” policy for:
•preventing or controlling disease, inju= ry, or disability, including, the reporting of disease, injury, vital events suc= h as birth or death, and the conduct of public health surveillance, public hea= lth investigations, and public health interventions;
•An appropriate authority authorized by = law to receive reports of child abuse or neglect;
•A person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spread= ing a disease or condition and is authorized by law to be notified as necessa= ry in the conduct of a public health intervention or investigation.
Likewise, disclosures may be made:
To “emergency officials”
To judicial authorities
To Law Enforcement (for location and ID)
To avert threat to public health or safety
To National Security (50 USC § 401) or
“Otherwise required by law” –IE. “mandatory” public health surveillance reporting is permitted by HIPAA .   A windm= ill? Maybe, maybe not.

DHHS has opined that Agencies will need to get PHI to respond to emergencies;
•Communications in such times is difficu= lt at best;
•Therefore even a “covered entity” can d= isclose PHI in such an event.
See 45 CFR 164.512(b) public health activities. See also OCR Bulletin 9/2/200= and 9/9/2005 “Hurricane Katrina Bulletin: HIPAA Privacy and Disclosures.”=
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file:///C:/2B494E34/GovernorsVolunteers1204_files/slide0104.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" The Ws of Q? Quarantine in Alabama
ADPH 2006
17
2. Public Health
and State  Assistance
•The State and P= ublic Health offer:
•The Hospital Ba= sed Mutual Aid      Compact (MOU)
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Public Health’s= AIMS System
•The State’s ESA= R-VP system – Public Health’s Learning Content Management System (LCMS)
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Emergency Decla= rations
The State of Alabama and Department of Public Health in Alabama offer as assistance:
The Hospital Based Mutual Aid Compact, the MOU;
Public Health’s AIMS system, the executive of the MOU; and
A Governor’s emergency declaration. “Washing” the scenario through public health adds a layer of immunity for facilities and personnel in a Title 31 Governor’s declared “emergency.” We’ll see more about this later.<= br>

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file:///C:/2B494E34/GovernorsVolunteers1204_files/slide0202.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" The Ws of Q? Quarantine in Alabama
ADPH 2006
18
The Hospital Based Mutual Aid      Compact (MOU)
•This MOU is designed to work along with        = AIMS to facilitate and account for:
<= span style=3D'font-size:88%'>•Transfer and recapture of patients
•Loan or donation of equipment (DMEs) and supplies •Loan and redeployment of professional, facility-= based personnel = •Payment and consideration for payment from = assisting parties, the State and FEMA <= /span>
<= span style=3D'font-size:88%;visibility:hidden'>•
This MOU is designed to work along with AIMS to facilitate and account for:=
Transfer and recapture of patients
Loan or donation of equipment (DMEs) and consumable supplies
Loan and redeployment of professional, facility-based personnel
Payment and consideration for payment from assisting parties, the State and FEMA<= /font>

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Quarantine in Alabama
ADPH 2006
19
AIMS
•AIMS is an on-line system = of hospitals, nursing homes, mental health facilities, = FQHCs and others designed to be the executive force behind the MOU •AIMS was developed in cooperation with ADPH by University of Sou= th Alabama
AIMS is an on-line system of hospitals, nursing homes, mental health facilities, FQHCs and others designed to be the executive force behind the MOU=
AIMS was developed in cooperation with ADPH by University of South Alabama<= br>

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dTlp5/8Afc7iPwzj8K1qaOtOroStoeTKXM2zPv8A/Xr/ALv9TRRf/wCvX/d/qaKBFbR9WsV0WxUz 8i2jB+Rv7o9qffXGjalbtbXgjuIj1SSIkfy4oooC7TVjIWzSy40rxLeW0Y+7DPH9oRfpuG4D8aXz dXd8SeKoEjz/AMsdNw2PqSR+lFFTY09rLr+SJLXT9EiuUu7y7n1K6TlZrzc+w/7K42r+AraXV7HH M/8A443+FFFVZIiU5SauL/a9h/z3/wDHG/wo/tiw/wCe/wD443+FFFAihfarZGcYn/h/ut6n2ooo oA//2Q== ------=_NextPart_01C7237E.7A29CE00 Content-Location: file:///C:/2B494E34/GovernorsVolunteers1204_files/slide0204.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="windows-1252" The Ws of Q? 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Learning Content Managemen= t System (LCMS)
•A data base that manages individual volunteers •LCMS grew from the ADPH on= -line satellite-based learning system •The State of Alabama ESAR-VP       system
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•MRCs use the  LCMS
The LCMS is the ADPH data base that manages individual volunteers of various health-care related professions and others
It grew from the ADPH on-line learning system used to account for CMEs, CEUs and other satellite-based training
It is designated as the State of Alabama ESAR-VP system
MRCs would volunteer and be dispatched through the LCMS

(The satellite in the picture is TelStar.)


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quoted-printable Content-Type: text/html; charset="windows-1252" The Ws of Q? Quarantine in Alabama
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3. Transportation and                        EMS Issues
•Out of state ambulances are forbidden to make point to point runs within the state. <= /span>
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Otherwise, stat= e EMS rules
•   allow full use of ambulances                           from out of state into the state.
<= span class=3DBB style=3D'position:absolute;left:-4.43%'>•Several questio= ns to consider
•EMS units would = be parties to the MOU and be deployed through AIMS<= /div>
Out of state ambulances are forbidden to make point to point runs within the sta= te.
Otherwise, state EMS rules  allow full use of ambulances from out of state into the state.
Several other question need to be addressed:
•Would there be enough ambulances in a d= isaster?
•What if all the hospitals have agreemen= ts to use the same ambulance company?
•What vehicles would be used? Would they licensed as “ambulances” by public health?
•What about common carriers and public s= ervice commissions or the ICC?
Under AIMS, we now have the capability to track and place ambulances in coordination with NDMS/VA which has agreed to participate in  AIMS
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Quarantine in Alabama
ADPH 2006
22
Transfer Agreement Issues
•<= /span>Do you have appropriate transfer agreements?
•<= /span>Could they go out of s= tate perhaps?
•<= /span>To what types of facilities
•= Do you have agreements= with carriers?
•<= /span>Are there backups for everything?
•= Could the MOU incorporate cooperation     on “transfer agreement” language and      use of resources?
•<= /span>What about security of personnel and patients?
•= Can records be transferred electronically ?
• <= /div>
•=   
Do you have appropriate transfer agreements?
Could they go out of state perhaps?
To what types of facilities
Do you have agreements with carriers?
Are there backups for everything?
Could the MOU incorporate cooperation on “transfer agreement” language and us= e of resources?
What about security of personnel and patients?
Can records be transferred electronically ?
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