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Rural Health Information Hub

Rural Emergency Preparedness and Response

When emergencies happen in rural communities, especially disasters that are severe or prolonged, the demands on local response agencies and healthcare facilities can quickly consume available resources. Disasters have complex effects, whether they are natural or man-made, and can occur without warning.

Rural communities can deal more effectively with large-scale emergencies by planning and preparing for emergencies before they happen. Rural residents, communities, local governments, and others involved in emergency preparedness and response face challenges that can include:

  • Resource limitations, such as equipment and supplies, training, and infrastructure
  • Access to healthcare for higher levels of care
  • Remoteness and geography
  • Low population density
  • Communication issues

As stated in the Federal Office of Rural Health Policy's document Rural Communities and Emergency Preparedness, rural communities preparing for and responding to emergencies depend on assistance from healthcare facilities, local public health departments, law enforcement, fire departments, and emergency medical services (EMS). Some rural areas lack local public health departments and instead rely on state public health agencies. Where rural local public health departments do exist, many operate with small budgets and limited staffing. Similarly, many rural hospitals face their own financial challenges and resource constraints. As a result, rural public health departments and hospitals may lack the capability to respond adequately to emergencies, leaving communities vulnerable. Rural residents can collectively decide to implement a whole community approach to emergency preparedness and assign community members tasks and responsibilities based on knowledge, strengths, and abilities. For more information and resources on rural public health agencies and the challenges they face, see the Rural Public Health Agencies topic guide.

Frequently Asked Questions

What are the purposes of emergency preparedness, emergency response, and recovery?

Emergency preparedness refers to actions performed before an emergency. Examples can include planning and coordination meetings; writing communication or standard operating procedures; training staff, volunteers, and community members; conducting emergency drills and exercises; and ensuring that emergency equipment is available, in good repair, and ready to use.

Emergency response refers to actions taken after an emergency or natural disaster to help minimize the negative effects. Examples can include emergency communications; coordinating first responders and volunteers; providing emergency medical care to the injured; coordinating temporary shelter for evacuated or displaced survivors; and organizing supplies and equipment for those assisting in and affected by the emergency or disaster.

Recovery is a long-term process in which communities, institutions, and facilities attempt to reestablish the systems and infrastructure that were in place prior to the disaster or use the opportunity to put in place improvements. Examples can include re-evaluating goals and priorities, de-escalating response activities, building resilience, and updating systems.

What is the “all-hazards approach” to emergency preparedness?

The Centers for Medicare and Medicaid Services document Emergency Preparedness Regulation offers this definition:

“An all-hazards approach is an integrated approach to emergency preparedness planning that focuses on capacities and capabilities that are critical to preparedness for a full spectrum of emergencies or disasters, including internal emergencies and a man-made emergency (or both) or natural disaster.”

All-hazards planning involves concentrating on the threat scenarios most likely to occur in specific locations and ensuring that appropriate resources will be available. For example, most rural areas in the Midwest are at greater risk of tornadoes than wildfires or earthquakes, and so their emergency preparedness plans would reflect this. Planning could involve steps to be taken in the event of disruptions in electricity or communications, equipment failures, cyberattacks, damage to facilities, and supply chain problems that would result in shortages of food and water. All-hazards planning is not intended to cover every possible emergency, but rather involves risk assessment to find vulnerabilities in local systems and strategies to limit damage to human life, property, business operations, and the environment.

How can rural communities prepare for outbreaks, epidemics, and pandemics?

In order to lessen the severity of possible disasters, communities and public health agencies must plan ahead, so that procedures are in place before they are needed. Counties are required to develop emergency plans, which often are posted online. Partnering to Achieve Rural Emergency Preparedness: A Workbook for Healthcare Providers in Rural Communities offers suggestions to help Rural Health Clinics, Community Health Centers, and rural hospitals create all-hazards emergency plans and strengthen collaboration with response partners. Planning should include:

  • Understanding operations of emergency management systems at the state, regional, and local levels, as most disasters will not have an immediate federal response
  • Preparing to work with agencies outside providers’ usual networks. These can include law enforcement, schools, churches, and local businesses
  • Becoming familiar with the National Incident Management System, which promotes efficiency, coordination, and effective communication during emergencies
  • Conducting drills to address scenarios such as clinic or hospital evacuation, continuity of operations, and expansion of surge capacity
  • Preparing for surveillance and contact tracing to find the sources of infectious disease
  • Developing procedures for infection control and contingency plans for supply chain breakdowns

The U.S. Fire Administration’s March 2020 document Information for First Responders on Maintaining Operational Capabilities During a Pandemic notes that contingency planning on the part of local first responders will help lessen the effects of pandemics on their agencies and communities. Suggestions for planning include:

  • Acquiring personal protective equipment for first responders, so that they can do their jobs more safely
  • Contacting former employees and community members who can serve as volunteers if needed
  • Identifying skills that can be taught quickly to volunteers
  • Teaching people basic techniques for care of ill family members, and explaining the difference between emergency and nonemergency care, so as to lessen reliance on emergency services
  • Reviewing emergency health and operational policies, and modifying if needed
  • Encouraging vaccination for all personnel and their families
  • Defining who is eligible to work remotely, to minimize contagion

What are some challenges in rural emergency management?

Rural emergency preparedness professionals can experience many barriers or challenges related to the work they do, including:

  • Limited funding for rural response agencies, such as EMS, fire departments, or local public health departments, that could affect the availability of staffing, equipment, training, public outreach and education, and other emergency preparedness and response activities
  • Greater geographical coverage areas, which could result in longer response times during an emergency
  • Demographic challenges, such as rural areas with concentrations of elderly, disabled, and poor residents
  • Infrastructure for communication and warning systems may be substandard or non-existent
  • Coordination and cooperation among a complex network of local, state, and federal agencies during an incident

Strong relationships between people and organizations within a community, and a willingness to volunteer, may help compensate for some challenges rural communities experience during emergencies. However, reliance on volunteers for emergency medical services and fire departments may mean that there is greater turnover in staffing and the possibility that there will be inadequate coverage for all shifts. The Institute for Rural Emergency Management (IREM) provides technical assistance to rural communities and can help with training, hosting workshops, and more. IREM conducts research in and shares best practices between rural community and emergency preparedness and response managers and professionals.

For more detailed information, see the Rural Barriers to Emergency Preparedness and Response section of the Emergency Preparedness Toolkit.

Who should be involved in emergency preparedness and response in rural communities?

Many community members and organizations should be involved with emergency preparedness and response for their rural community. Effective emergency preparedness and response planning includes coordination and communication across regions and numerous types of organizations, including healthcare facilities and service organizations.

Rural healthcare providers and organizations should be familiar with local-, regional-, and state-level emergency management systems. Building professional relationships with key personnel in various health-related or civic organizations and government agencies will better position rural healthcare providers to work effectively and efficiently in the event of a disaster. Examples of these groups can include local and state health departments, primary care associations, behavioral health facilities and agencies, clinics, long-term care facilities, correctional facilities, law enforcement officials, first responders, and disaster relief agencies.

The Rural Domestic Preparedness Consortium (RDPC) offers rural-specific training and resources for emergency responders. Free courses are available in-person and online, and are certified by the Department of Homeland Security. You can view the training schedule and course catalog online. RDPC utilizes an all-hazards approach for emergency preparedness and response training to prepare responders for many types of emergencies, threats, disasters, and hazards. The Public Health Foundation coordinates the TRAIN Learning Network, which provides education, training, and resources to professionals at little or no cost. You can narrow your search of available courses by rural, course format, date, selected public health competencies and capabilities, and more.

To be well prepared, it is important to connect with emergency management officials both at the county and state level. To find your state emergency management agency, see the Federal Emergency Management Agency's (FEMA) list of Emergency Management Agencies. Your state agency can direct you to county, tribal, and local emergency management agencies. The FEMA Tribal Affairs page offers emergency preparedness and response information for those living in Indian Country. For more information on Native American health and wellness, see the Rural Tribal Health topic guide.

How can community members be engaged and trained in disaster preparedness, response, and recovery?

Community members can play an important role in a community's ability to plan, respond, and recover from emergencies and disasters. Community members can participate in planning efforts, receive training, and also serve as volunteers who support response and recovery efforts.

FEMA's Community Emergency Response Team (CERT) program offers education and training in disaster response for community volunteers, such as:

  • Basic search and rescue techniques
  • Fire safety
  • Disaster medical operations
  • Procedures for hazardous materials and terrorist incidents

CERT trained volunteers can provide immediate aid and assistance if professional responders are not available. They can also help emergency response agencies by supporting local emergency preparedness projects and planning.

The Medical Reserve Corps (MRC) is a national network of local volunteer groups that engage communities to support public health, reduce vulnerability, build resilience, and improve preparedness, response, and recovery capabilities. MRC volunteers play a large role in building community resilience and preparing for and responding to disasters. MRC training is free, but registration is required. The MRC TRAIN course catalog and deployment readiness guide for new members is available online for community members to prepare and train for disasters.

Another program offering training for community volunteers interested in assisting with emergency preparedness and response is provided through the Department of Homeland Security's website, Ready.gov. This platform provides emergency preparedness and response education and training resources for a variety of emergencies and disasters, such as flooding, power outages, fires, emergency alerts, active shooter situations, and more.

The Center for Food Security and Public Health (CFSPH) at Iowa State University developed and maintains a website, All Hazards: Resources to Help Rural Communities Prepare for Disasters and Other Hazards, that offers guidance, resources, and assistance for agricultural communities to prepare for and recover from disasters and emergency situations, including dangers related to agrochemicals. In 2016, CFSPH published a guide, All-Hazards Preparedness for Rural Communities, for individuals, farmers, and businesses in rural agricultural communities preparing for an all-hazards approach for their communities and commodities.

Some state-level public health departments offer courses in rural emergency preparedness and response. To find yours, see the list of State Health Departments. FEMA maintains a list of state Emergency Management Agencies. These state agencies may provide programs in homeland security, emergency management, emergency operations, conducting preparedness drills and exercises, hazard planning, strategic planning and community preparedness, and disaster recovery.

How do disasters in urban areas affect rural communities? How can rural communities prepare?

Emergency preparedness and response planning tends to focus on the immediate needs of a community. However, rural emergency planners should consider the effect an urban disaster might have on their community. If residents of larger cities evacuate during an emergency or natural disaster, they would likely travel to or through rural areas.

According to Urban to Rural Evacuation: Planning for Rural Population Surge:

  • Urban residents' predicted behavior will depend on the messaging and language used by the media and government to describe the event and make recommendations; urban residents could choose to shelter in place or evacuate to another urban area or a rural community
  • Increased traffic in rural areas will result in a need for additional resources in rural areas, such as food, fuel, water, and sanitation resources
  • Rural healthcare workers providing emergency care will likely be overwhelmed and, as a result, rural residents' routine healthcare needs might not be able to be met

A 2014 NACCHO report, Responding to Medical Surge in Rural Communities: Practices for Immediate Bed Availability, offers guidance for ensuring 20% of hospital beds within a healthcare coalition can promptly be made available for high-needs patients in the aftermath of a disaster.

Rural emergency preparedness planning to address population surge and related issues should include:

  • Estimating the number of evacuees who might arrive during a disaster, including those with special needs, such as children, the elderly, people with pets, people with limited English proficiency, or individuals with medical conditions
  • Mitigating the effects of population surge on the rural healthcare systems, including the potential for further spread of diseases
  • Planning to share resources with urban counterparts
  • Shelter planning for those traveling or unable to find housing
  • Establishing a communication plan with urban emergency preparedness and response agencies
  • Investigating alternative communication methods to inform evacuees about shelter locations and access to healthcare services
  • Mobilization of volunteers and reallocation of resources

The Rural Preparedness Planning Guide: Planning for Population Surge Following Urban Disasters, a rural preparedness guide from the NORC Walsh Center for Rural Health Analysis, offers case studies and worksheets to guide pre-event, event, and post-event population surge planning for rural communities.

What resources are available for communication planning in a rural area?

It is important to identify strategies for communicating and engaging with rural communities during emergency preparedness and response planning. Sharing key information through verbal or written means is important for a planned, coordinated, and appropriate response to an emergency or disaster. The Public Safety and Crisis Communication in an Emergency or Disaster module of the Emergency Preparedness Toolkit contains sections on developing a crisis communication plan, testing communication systems and equipment, ensuring accessible communications, engaging the media, and more.

Other resources for emergency communication include:

How can rural hospitals and other healthcare organizations prepare for disasters and large-scale emergencies?

Rural providers, professionals, and staff members in healthcare facilities and organizations can prepare for disasters and emergencies in a variety of ways, including:

  • Conducting emergency preparedness training, drills, and exercises within the healthcare facility and with its emergency response partners, such as a local public health department, EMS, and law enforcement
  • Reviewing and updating the healthcare facility's emergency response plans
  • Discussing hypothetical challenges and potential solutions, such as security and supply limitations
  • Cross training among employees so that any employee is able to perform support services and knows procedure when responding to an emergency
  • Holding regularly-scheduled regional planning activities with their urban counterparts
  • Assigning tasks and responsibilities to employees during a disaster

Public Health Emergency Preparedness and Response Capabilities: National Standards for State, Local, Tribal, and Territorial Public Health, published in October 2018 by the Centers for Disease Control and Prevention (CDC), describes the capabilities and functions of emergency preparedness and response standards. The report highlights the importance of working with partners and stakeholders when conducting emergency preparedness and response planning, such as hospitals and other healthcare organizations.

A 2016 CDC planning guide, Long-Term, Home Health, and Hospice Care Planning Guide for Public Health Emergencies, discusses the importance of maintaining health information technology (HIT) in healthcare organizations and offers suggestions for preparing for possible service interruptions during and after an emergency:

  • Decide how to maintain computer access and data storage during an emergency
  • Identify backup computer services or alternative HIT services
  • Enable employees to work remotely while performing essential duties
  • Conduct tests of systems and procedures before they are needed

The report offers ideas for ensuring a plan exists in case of damage to infrastructure:

  • Identify areas of the facility at greatest risk of breakdown or in need of repair
  • Designate personnel who will do repairs as needed
  • Find alternate or backup utilities, such as electricity, plumbing, and communication services

Suggestions for developing policies regarding volunteers who may assist and work in a healthcare facility after a disaster include:

  • Review the laws and regulations related to medical and nonmedical volunteers
  • Identify what resources volunteers may need
  • Develop plans for screening and training that can include criminal background checks and infectious disease screenings
  • Understand liability issues and confirm the facility's insurance covers volunteers

Rural hospitals are required to have emergency operation plans (EOPs) per CMS requirements. This is explained further below in What are the emergency preparedness requirements for rural healthcare facilities? More than 90% of hospitals in the United States use some form of the Hospital Incident Command System (HICS). HICS helps hospitals and healthcare professionals prepare for and react to disasters by establishing a clear chain of command. HICS can be used for hospitals of all sizes.

The Missouri Hospital Association's report, Preparedness and Partnerships: Lessons Learned from the Missouri Disasters of 2011, offers guidance to organizations developing emergency preparedness and response plans.

Another option for staff at rural healthcare organizations preparing for disasters and large-scale emergencies is to complete free, online courses from FEMA's Emergency Management Institute (EMI). A list of EMI's independent study courses is available online.

How can rural communities plan for addressing residents' mental health needs after a disaster?

According to a research and policy brief from the Maine Rural Health Research Center, Encouraging Rural Health Clinics to Provide Mental Health Services: What Are the Options?, many rural areas experience shortages in mental health services, and these deficiencies may become more pronounced after a disaster.

A 2014 Public Health Reports article, An Academic-Government-Faith Partnership to Build Disaster Mental Health Preparedness and Community Resilience, notes that most disaster-related injuries and trauma are psychological, not physical. For that reason, it is important that rural communities plan and prepare before a disaster happens, so appropriate mental health services are available after a disaster. Rural healthcare providers may find they must tailor mental health services to the specific type of disaster their patients experienced. A Tale of Two Studies of Two Disasters: Comparing Psychosocial Responses to Disaster among Oklahoma City Bombing Survivors and Hurricane Katrina Evacuees, an article published in Rehabilitation Psychology, found that survivors of a mass casualty event were more likely to suffer from post-traumatic stress disorder, whereas hurricane evacuees tended to need treatment for serious, persistent, preexisting psychiatric disorders. A fact sheet from the Disaster and Community Crisis Center at the University of Missouri, Mental Health Response to Community Disasters: A Fact Sheet for Disaster Mental Health Planners, Responders, and Providers, reviews the mental health implications of disasters and offers recommendations for mental health interventions.

The Medical Reserve Corps and FEMA's Community Emergency Response Team (CERT) can assist rural communities with planning to address mental health needs after a disaster. Another option for some rural communities may be the Red Cross Disaster Services teams, which include independently-licensed mental health professionals who deploy to work at the local level supporting people affected by the disaster, as well as volunteers working as part of the relief operation. These mental health professionals have master's degrees or higher-level graduate degrees and can include:

  • Psychiatrists
  • Psychologists
  • Clinical social workers and counselors
  • Marriage and family therapists
  • Nurses with a psychiatric-mental health nursing certification or other mental health specialty certification
  • School psychologists and counselors

The Substance Abuse and Mental Health Services Administration (SAMHSA) provides resources for emergency preparedness, response, and recovery. In particular, SAMHSA's Disaster Technical Assistance Center (DTAC) helps states, territories, tribes, and local entities prepare to provide effective mental health services. SAMHSA also offers a Crisis Counseling Assistance and Training Program that provides grants and technical assistance to help individuals and communities recover from natural and man-made disasters through community outreach and access to mental health services.

Challenges and Solutions for Disaster Behavioral Health in Rural and Remote Communities, published by SAMHSA in April 2023, explores potential approaches to disaster behavioral health in rural and remote areas. SAMHSA's 2014 publication, Tips for Disaster Responders: Cultural Awareness When Working in Indian Country Post Disaster, offers suggestions for helping Native American disaster victims in a culturally sensitive manner.

Our community has experienced a disaster. Where can we get help?

State emergency management agencies can help communities activate state and federal resources, where appropriate. The How to Request Assistance for Emergency Preparedness and Response section of the Emergency Preparedness Toolkit offers information about steps to be taken after a disaster occurs, and includes links to State Administrative Agency (SAA) contacts and Federal Emergency Management Agency (FEMA) resources.

Volunteer Organizations Active in Disasters (VOADs) helps promote effective delivery of services to communities that have been affected by disasters. The National Volunteer Organizations Active in Disasters offers a list of state and territorial VOADs which includes email and phone contact information.

The American Red Cross can provide disaster relief and recovery services to rural communities that may include:

  • Providing food, temporary shelter, and emergency supplies
  • Conducting outreach and home visits
  • Organizing volunteer processing centers
  • Health and mental health volunteers who can provide first aid or emotional support

Public health departments may be able to provide some assistance after a disaster. To find your public health department or learn about services they can provide after a disaster, contact your state or territorial health department. Additionally, help may be available from the Medical Reserve Corps (MRC). MRC is a national volunteer network established to provide support for recruiting, training, and activating medical professionals, public health workers and officials, and community members, who are willing to volunteer after disasters and emergencies.

FEMA offers the Disaster Survivor Assistance Program, and provides a list of emergency management agencies and offices.

See the Funding & Opportunities section of this topic guide for a list of funding programs related to rural emergency preparedness and response. Capital funding programs related to infrastructure improvements that will help facilities prepare for emergencies can be found in the Funding & Opportunities section of the Capital Funding for Rural Healthcare topic guide.

The National Academies of Sciences, Engineering, and Medicine's 2015 report, Healthy, Resilient, and Sustainable Communities After Disasters: Strategies, Opportunities, and Planning for Recovery, offers guidance to improve infrastructure and delivery systems in a community after a disaster and can assist rural communities with the recovery process.

What disasters are more likely to affect rural areas?

While disease outbreaks and natural disasters can occur anywhere, some risks may be higher in rural areas. Institutions and structures that may be vulnerable to disasters and emergencies, and are typically located in rural areas, include:

  • Power plants, including nuclear facilities
  • Military bases and missile launch facilities
  • Dams
  • Agricultural chemical infrastructure
  • Food production facilities and aquifers
  • Companies and people involved in transportation of hazardous materials
  • Mining, oil and gas drilling, and other natural resource extraction, transportation, storage, and processing activities
  • Railroads and highways
  • Recreational areas, which may bring large numbers of visitors unfamiliar with local hazards

What are the emergency preparedness requirements for rural healthcare facilities?

In 2016, in an effort to ensure healthcare facilities prepare adequately for disasters, the Centers for Medicare and Medicaid Services (CMS) established an emergency preparedness rule: Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. All affected facilities and agencies must be in compliance and meet the requirements. There are 17 types of providers, suppliers, and facilities impacted by the emergency preparedness rule including healthcare facilities found in rural areas, such as:

  • Critical Access Hospitals (CAHs)
  • Rural Health Clinics (RHCs)
  • Federally Qualified Health Centers (FQHCs)
  • Hospice services
  • Long-term care facilities
  • Home health agencies

The March 2023 document Rural Emergency Hospital Requirements: CMS Emergency Preparedness Final Rule includes excerpts from the REH Conditions of Participation regarding emergency preparedness, and covers the development of an emergency plan, related policies and procedures, communications, training, and more.

To fulfill CMS requirements, the emergency preparedness plans must:

  • Document efforts to cooperate and collaborate with emergency preparedness agency officials
  • Define a course of action, rather than list operational guidelines, to address four factors of emergency preparedness, including:
    • Risk assessment and emergency planning
    • Communication plan
    • Policies and procedures
    • Training and testing

Facility representatives must be able to provide documentation of emergency preparedness plan policies and procedures upon request, and be able to show where they are located. CMS requires the emergency preparedness plan is reviewed and updated on an annual basis.

CMS provides emergency preparedness regulation guidance containing checklists and other resources to help surveyors, providers, facilities, and suppliers comply with the new CMS rule. This resource bank includes frequently asked questions (FAQs), names of healthcare coalitions by state, requirements by provider type, and a sample facility transfer agreement.

Last Updated: 1/5/2024
Last Reviewed: 11/13/2023