Alternate care facilities exposed the limits of static emergency planning
Alternate care facilities, or ACFs, were built to absorb patient surges during public health emergencies. In practice, they have had to function inside fast-moving crises, uneven infrastructure, and fragmented command systems. A qualitative study published in JAMA Network Open examined how those sites actually operated across the United States and found that the recurring problems were not confined to beds, supplies, or staffing alone. The deeper issue was organizational fit: whether an ACF could adapt to the emergency around it while remaining connected to a larger health system and a clear leadership structure.
The study combined a broad literature review with semistructured group interviews of subject matter experts who had direct experience planning or operating ACFs. Publications spanning nearly eight decades were screened, and 34 publications representing 19 ACFs in 14 states were identified. Sixteen clinicians and administrators participated in interviews after 30 experts were invited. Their perspectives, paired with the published record, converged on the same operational themes. Flexibility mattered. So did partnership. So did the ability to close, reopen, and sustain the site without having to start from zero each time.
Flexibility was the common thread across successful sites
Five themes emerged from the synthesis: flexibility and adaptability, strong partnerships with health care systems and public health partners, resource availability, executive leadership support, and clear leadership structures. Those themes fit the realities of emergency care, where demand can change faster than a facility can be assembled. ACFs that used flexible operational models performed better than rigid designs, especially when patient volume, supply access, or staffing patterns shifted unexpectedly. Warm closure strategies, which kept the physical footprint intact for possible reactivation, also appeared to improve community impact.
A rigid facility plan can fail long before patient care begins.
The operational logic is straightforward. A surge site is not a standard ward transplanted into a new building; it is a temporary clinical system that must absorb uncertainty in patient flow, staffing, infection control, transport, and supply logistics. During emergencies, the distance between planning assumptions and bedside reality can be wide. Flexible models reduced that gap by allowing sites to adjust their footprint, workflow, and activation status without dismantling core infrastructure after each wave of demand.
Partnerships determined whether an ACF could function as part of a system
ACFs that affiliated with parent health systems stood out in the study as stronger performers. That connection likely provided more than administrative convenience. It created access to clinical oversight, referral pathways, staffing support, supply chains, and a shared sense of mission with surrounding hospitals and public health agencies. In emergency response, an isolated site can easily become operationally stranded. A facility embedded within a broader system can move faster, coordinate transfers more efficiently, and avoid duplicating functions that already exist elsewhere.
Partnerships with emergency management and public health were equally important. ACFs are rarely activated in a vacuum; they are part of a regional response that depends on transport, bed management, communications, and triage decisions made across multiple institutions. When those relationships are established before a crisis, they become an operational asset rather than an improvised fix. The study’s findings suggest that partnership should be treated as infrastructure, not diplomacy.
Resource shortages shaped performance as much as patient volume
Resource availability emerged as one of the most persistent challenges. That category can include equipment, staffing, logistics, and the operational materials required to convert a physical space into a functioning care environment. Emergency planners often focus first on square footage and bed count, but an ACF without reliable resources can quickly become symbolic rather than functional. The study’s synthesis showed that resource constraints were not isolated inconveniences; they were central determinants of whether the site could sustain care at all.
Executive leadership support influenced that equation in a direct way. Senior backing can unlock decisions about funding, personnel, policy waivers, supply allocation, and interagency coordination. Without visible leadership commitment, ACFs may struggle to obtain the authority needed to move quickly. In a crisis, delay compounds every shortage. A site that lacks executive support may also lack the institutional protection required to maintain staffing and continuity over time.
Clear leadership structures reduced confusion during activation
A recurring lesson from the qualitative analysis was the need for explicit leadership. Emergency care operations deteriorate when no one knows who owns key decisions. Clear command structures help define responsibility for clinical oversight, logistics, staffing, escalation pathways, and communication with partner agencies. That kind of clarity becomes especially important when an ACF is activated rapidly or operates alongside hospitals with different protocols and priorities.
The interviews and literature review pointed in the same direction: leadership ambiguity is not a minor administrative flaw. It can slow supply deployment, blur accountability, and create avoidable friction between clinical teams and emergency managers. ACF planning benefits when leadership roles are defined before activation, not improvised under pressure. In the middle of a public health emergency, decision latency can translate into missed capacity.
National guidance still trails the operational lessons from the field
The study’s central contribution is not simply that it cataloged problems. It showed that the operational needs of ACFs extend beyond what current national guidance fully captures. Flexibility, partnerships, resource readiness, executive support, and site leadership are not abstract planning ideals. They are the conditions that make activation possible and make reactivation realistic after the initial emergency has passed.
Warm closure strategies may deserve particular attention in future guidance. Keeping the site’s footprint intact avoids the inefficiency of total teardown and can shorten the path to reactivation if another surge occurs. In a system where emergencies can arrive in waves, that continuity has obvious utility. The same is true of parent-system affiliation, which appears to strengthen both immediate performance and longer-term community benefit.
This qualitative work does not measure patient outcomes, mortality, or cost savings, and it does not offer a randomized comparison between facility models. Its value lies elsewhere: in identifying the practical design features that repeatedly surfaced across U.S. ACF experiences from 1946 through 2024. Those findings should inform future emergency planning documents, especially because surge capacity depends on more than space alone. When the next crisis arrives, the difference between an ACF that functions and one that stalls may come down to how well planners have anticipated flexibility, partnership, resources, leadership, and reactivation from the start.