Alternate Care Facilities Depend on Flexibility Before They Depend on Space
Alternate care facilities, or ACFs, have long been a pressure valve for overwhelmed health systems during public health emergencies. This qualitative study takes a practical look at how those facilities actually functioned across U.S. emergencies, moving past theoretical surge models and into the operational decisions that determine whether a temporary site helps or hinders care delivery. The central message is straightforward: physical beds alone do not create capacity. Staffing, command structure, supply chains, and linkage to a parent health system often decide whether an ACF becomes a usable clinical asset or an underperforming emergency workaround.
The analysis drew from two complementary sources: a literature review of U.S.-based publications spanning 1946 through 2024, and semistructured group interviews with subject matter experts who had direct experience planning or operating ACFs. Those experts came from clinical, administrative, and emergency management backgrounds, giving the project a broad operational view rather than a single-discipline account. The study focused on common successes, recurring failures, and the practical features that deserve a place in national guidance.
One sentence captures the operational reality: an ACF without clear leadership and resource support is vulnerable from the start.
Experience From 19 Facilities Showed the Same Operational Friction Points
The literature review identified 34 publications covering 19 ACFs across 14 states. The interview component added perspective from 16 participating experts out of 30 invited, including 11 men and 5 women. Rather than looking for a single universal blueprint, the investigators used rapid qualitative methods and matrix-based thematic synthesis to find repeated patterns across sites and emergency scenarios.
Five themes emerged with unusual consistency. Flexibility and adaptability sat at the center of successful implementation, because emergency demand shifts quickly and rarely matches the original facility plan. Strong partnerships with health care systems, emergency management, and public health agencies repeatedly shaped whether the ACF had supplies, staff, authority, and a clear patient flow. Resource availability remained a persistent challenge, especially when equipment, medications, logistics support, and personnel had to be assembled quickly in a strained environment. Executive leadership support also mattered, not as a symbolic gesture, but as the mechanism that unlocked decisions, funding, and system-wide coordination. Clear leadership structures completed the picture, because uncertain command relationships can stall triage, transfer, admissions, and closure decisions at the very moment they need to move quickly.
These themes are clinically important because they map directly onto patient throughput and safety. In a surge setting, delayed decisions can back up emergency departments, create bottlenecks in admissions, and leave patients in inappropriate care settings longer than necessary. The operational design of the ACF therefore becomes part of the clinical intervention itself.
Parent Health System Affiliation Improved Performance and Community Impact
Some ACFs performed better than others because they were built into existing health system infrastructure rather than standing apart from it. Facilities that affiliated with parent health systems, used flexible operational models, or adopted warm closure strategies showed better performance and greater community impact. Warm closure, in this context, means preserving the physical footprint and keeping the site ready for reactivation rather than dismantling it completely after activation ends. In a region where another emergency can follow quickly, that approach reduces the lag between demand and redeployment.
Flexible operational models likely worked because they reduced the mismatch between the site’s original design and the changing needs of the emergency. A rigid facility may be efficient on paper, but emergencies rarely follow a stable script. Patient volumes rise and fall, staffing changes, clinical acuity shifts, and transfer patterns evolve. ACFs that could adapt to those changes were better positioned to remain useful across the full course of an emergency response.
National Guidance Misses Several Operational Needs That Frontline Teams Repeatedly Face
The study also measured experience against current national ACF resources and found clear gaps. Existing guidance does not fully reflect the recurrent operational needs described by experts and the published literature. The missing pieces are not abstract. They include the practical demands of flexibility, reliable partnership structures, resource readiness, executive support, and site-level leadership.
This matters because planning documents often describe what an ACF should be in principle, while frontline responders must decide what it can do in practice. Guidance that does not account for leadership handoffs, supply procurement, activation timing, and post-activation maintenance can leave response teams with a polished plan that does not survive first contact with an actual emergency. The study argues for incorporating experiential lessons into future national resources so that planning reflects the conditions under which ACFs are truly built and operated.
The gap is especially relevant for emergency preparedness leaders who may assume that surge capacity is primarily a bed-count problem. It is not. ACF readiness depends on governance, logistics, and institutional trust as much as it depends on physical infrastructure.
Surge Capacity Begins With Coordination, Not Construction
The most actionable lesson from this study is the need to treat ACFs as networked operations rather than isolated facilities. Health systems, emergency managers, and public health agencies each control different pieces of the response, and the absence of any one partner can compromise the entire structure. Executive leadership support gives the project legitimacy and speed. Site leadership gives it day-to-day coherence. Resource readiness gives it functioning clinical capacity.
For hospitals and emergency planners, the implications are immediate. ACF planning should include durable partnership agreements, defined command structures, and mechanisms for maintaining readiness between activations. Facilities should also be designed or adapted with enough flexibility to shift function as circumstances change. Warm closure strategies may be particularly valuable where repeated surges are plausible and rapid reactivation is more useful than permanent demobilization.
The study does not claim that every ACF model should look the same, and it does not attempt to measure patient-level outcomes. Its strength lies elsewhere: it distills what operators and published reports repeatedly identified as the factors that make ACFs workable during real emergencies. For future public health preparedness, the main challenge is no longer whether ACFs can exist. It is whether national guidance will finally reflect the operational lessons that have already been learned in the field.