Theme 1: Policy Considerations and Examples in Practice

• • Necessity for Bespoke Solutions Across the Country: The National Incident Management System (NIMS) offers a framework intended to standardize roles between federal, state, and municipal entities and other public/private partners. The situation differs in practice. The unique realities, working history, and interplay between institutions within each state, and sometimes in different localities within a state, drove the need for tailor-made approaches to ACF stand-up and operations.

  • • Example 1, California: Initiated and operated ACFs within the established state Incident Command System (ICS) chain of command at the state, county, and local jurisdictions. California’s recurring use of this system at scale, such as during fire season, made this an expedient and effective solution across the state.

  • • Example 2, Maryland: Chartered its Baltimore Convention Center ACF as a state hospital under the Maryland Department of Health (MDH), led on-site by attached executives/providers from Johns Hopkins and the University of Maryland. Other ACFs functioned as local hospital network leads that partnered with MDH. Maryland Emergency Management Agency led the state’s unified NIMS/ICS integration and execution.

  • • Example 3, Major Municipalities and Rural Localities: Although the examples were too numerous to discuss in detail, participants shared that municipal leaders in major cities were critically important partners in tailoring ACF solutions, while the situation in rural areas varied widely, depending on which public/private institutions were in proximity for partnership and shared effort.

• • Hybrid Governance and Collaborative, Shared Authority in Operation: As one example, the 400-bed ACF at Sacramento Sleep Train Arena operated under the site management of the California Office of Emergency Services, with oversight by local public health authorities. This team also leveraged the facility management experience and plans of the existing arena leadership and staff.

• • Senior Leaders to Champion the Mission: Across the country, agile solutions required active buy-in, guidance, and support (in the form of waivers, temporary operating authorities, etc.) from senior executive leadership across state and local government, hospital networks, and other public/private partners. Symposium participants cited the conundrum of policy and regulatory frameworks that could not have foreseen the required speed, response complexity, and “new normal” practices needed for COVID-19 emergency operations. In some cases, states had to inspect, review, and issue new licensure in days, not months. ACFs stood up with a mixed surge of medical and support staff from hospital networks, out-of-state staffing agencies, the National Guard or other government entities, and local vendors. ACFs had to identify and seek approval for appropriate levels of care given the intended role for each ACF.

• • Community Bridge Builders: Community-based organizations (CBOs) and neighborhood leaders (often faith-based groups) were critical for public messaging, building trust, and organizing resource distribution (e.g., running vaccine clinics in marginalized communities).

• • Unconventional Labor and Logistics: Partners like the National Guard, contracted vendors, and correctional facilities were leveraged for essential nonclinical support functions such as mass laundry services and large-scale food service.

• • The Power of Informal Networks: The rapid resolution of logistical bottlenecks like securing diesel fuel for generators often happened through informal relationships with parallel responders rather than through formal ICS resource requests. One example was the use of National Guard fuel truck support for generator support at one ACF.

Theme 2: Success and Sustainment

• • Cooperative ICS/Hospital Incident Command System (HICS) Blending: Per the above examples, successful ACF operations were incorporated into the host system (state, municipal, etc.) by adopting and blending existing command structures. This ensured that the facility was treated as a functional, integrated entity of the host system. This improved efficiency of resource acquisition for activated ACFs.

• • Leverage Community Partners to Speed Operations: Each region and locality has its own history of working relationships based on recurring need. Florida, with its annual preparation for hurricanes, had preexisting vendor relationships for scaling food, linen, medical waste processing, and other support. Baltimore leveraged preexisting public health cooperation with churches and other faith-based groups to establish a network of testing sites in high-need areas.

Theme 3: Key Challenges and Thoughts on Mitigation

• • Licensing as a Barrier: Securing temporary licensure for facilities or external providers was highly jurisdiction-dependent. In some cases, formal disaster declarations or waivers were required to activate and operate ACFs. Solutions varied widely. Boston used existing hospital licensing, though with limitations for billing and some other functions. Colorado made use of a combination of existing licenses for flu clinics and adapted pharmacy licensing from a local health system.

• • Complexities Emerged When Integrating Disparate Efforts at Scale: In a San Diego example, two different charities each established hotel housing for a surge of migrants arriving from across the border. As COVID-19 worsened, local authorities had to establish a third, nearby hotel for COVID-19 care. In short order, care providers had to stand up California Office of Emergency Services protocol operations while coordinating patient arrival from different charities. This required coordination with Customs and Border Patrol, social services, local law enforcement, and other entities.

• • Data Sharing and Liability: Data sharing remained universally problematic due to Health Insurance Portability and Accountability Act (HIPAA) concerns and due to disparate systems in use across partnering organizations. The high liability associated with disaster medicine meant that legal support and clear workers’ compensation policies were non-negotiable external needs.

Theme 4: Future Focus

• • Relationships are Key: Emergency management relationships work best when forged before the next crisis. They create the foundation of mutual trust that is critical when a crisis moves operations outside the bounds of standard practice and the regulatory framework. These relationships open the communications channels to find agile, often ad hoc solutions when they are most needed.

• • Leverage Existing Exercise Programs or Create New Exercises to Strengthen Existing Relationships and Foster New Ones: The stress test of pre-incident exercises offers a forum to build and maintain these relationships and to open up dialogue among both traditional and nontraditional partners. As one example, the annual Ultimate Caduceus exercise simulates large-scale combat casualties flowing to the US from a major overseas conflict. In 2025, it brought military and interagency partners and more than 20 hospital networks together under the National Disaster Medical System (NDMS). Lessons learned during these training events can have an outsized positive impact in moments of greatest need.

Summary

External partnerships proved essential to ACF success, with effective operations requiring coordination across state agencies, hospital systems, community organizations, and commercial vendors. Symposium participants emphasized that formal command structures alone were insufficient. Success depended on preexisting relationships and informal networks that could bypass bureaucratic obstacles. Regulatory barriers, particularly around licensing and data sharing, posed significant challenges, while unconventional partnerships with community-based organizations and entities like the National Guard provided critical nonmedical support. Mitigation derives from creativity, flexibility, and trust. By definition, no policies or planning efforts can cover every contingency for novel emergencies at scale. Lessons during COVID-19 proved this. The next large-scale emergency will require unanticipated solutions for emerging problems. All partners must work in the spirit of cooperation and trust to find workarounds and new solutions.