NOTE: This information is taken from the National Disaster Medical System: Federal Coordinating Center Guide - June 2000 - Click here to view or download (NOTE: Adobe Acrobat Reader is required).

The NDMS is a partnership between the Department of Health and Human Services (HHS), Department of Defense (DoD), Department of Veterans Affairs (VA), Federal Emergency Management Agency (FEMA), State and local governments, and the private sector. It is best described in the Memorandum of Understanding (MOU) between the Department of Health and Human Services, the Department of Veterans Affairs, the Department of Defense, and the Federal Emergency Management Agency. The MOU is available either through higher headquarters or from the NDMS Headquarters in Rockville, Maryland.

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Objectives

The NDMS is designed to fulfill three main objectives:
- To provide supplemental health and medical assistance in domestic disasters at the request of State and local authorities.
- To evacuate patients who cannot be cared for in the disaster area to designated locations elsewhere in the nation.
- To provide hospitalization in a nationwide network of hospitals to care for the victims of domestic disaster or military contingency that exceeds the medical care capability of the affected local, state, or Federal medical system.

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Operational Concepts

The following major operational concepts form the crux of the NDMS program.

In the event of an emergency or major disaster, the Governor of an affected State may request Federal assistance under the authority of the Disaster Relief Act of 1988, PL 100-707, as amended. The resulting Presidential declaration of an emergency or a major disaster triggers a series of actions coordinated by FEMA, which may include the activation of the NDMS, through the Federal Response Plan (FRP).

The NDMS may also be activated by the Assistant Secretary of Defense for Health Affairs in the event of a military contingency. This is only done when it is expected that DoD and VA medical assets will be overwhelmed by the returning military causalities. DoD will reimburse costs associated with this type of activation.

The NDMS works within the Emergency Support Function (ESF) #8 structure of the FRP. The NDMS includes deployable health care response capability to a disaster site, a patient evacuation system; and pre-identified, NDMS member hospitals providing definitive acute medical care.

At the local level, day-to-day coordination of NDMS planning and operations is accomplished by a NDMS Area Coordinator. Assistance in carrying out local coordination activities is accomplished by NDMS steering committees that include local hospital, medical, public health, public safety, emergency management and emergency medical services (EMS) officials, representatives of voluntary organizations, and elected officials.

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NDMS Organizational Components

The following is not to be construed as a "chain of command." It is merely a hierarchical structure of the organization.

Operational Elements

Medical Response

The primary NDMS resource to provide supplemental medical assistance is the Disaster Medical Assistance Team (DMAT). DMAT members are non-Federal volunteers, and, upon activation of the System for a national emergency, will become temporary Federal employees of the U.S. Public Health Service. The basic DMAT is a volunteer group composed of about 35 to 37 physicians, nurses, technicians, and other allied personnel, coming together and training as a volunteer unit. DMATs are, in the first instance, a community resource for supporting local emergency responders in multiple casualty incidents. Second, DMATs are also assets that may be used for medical response within their home State. Third, DMATs are a national resource that can be called upon to provide interstate aide. There are three levels of DMATs. If a team is considered a level one team, they are capable of deployment to a distant site and will arrive in the area with enough supplies and equipment to be self-sufficient for a limited period of time, at least 72 hours. A level two team is able to deploy as a team, but may not have all the equipment and supplies to be self-sustaining in the field. A level three team is in an "organizational" phase. While the team may not be deployable, individual members of the team may be sent to round out other DMAT teams.

Much of the work of a DMAT at the disaster site will be to provide "triage" and those services necessary for casualty clearing and staging. "Clearing" refers to austere field medical care, and "staging" refers to those medical services required during patient evacuation. While the DMAT is managed by a separate organization, a DMAT in a local NDMS patient reception area may assist in providing medical services associated with receiving patients and assessing their medical needs.

Each team has a sponsoring organization, which could be a major medical center, Public Health agency, or a voluntary organization, such as a local Red Cross Chapter. The DMAT sponsor organizes and recruits the team, pre-enrolls the members, arranges for team training, and coordinates the deployment of the team.

Further information on DMATs is available in the NDMS DMAT Organization Guide, which may be obtained from the NDMS Headquarters Office. In addition, sample DMAT sponsorship agreements, benefit fact sheets, team member enrollment packets, etc., are also available from NDMS Headquarters.

A Step-By-Step Guide to Organizing a Disaster Medical Assistance Team (DMAT)

All About Sponsoring a Disaster Medical Assistance Team (DMAT)

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Patient Evacuation

The second key element of the NDMS is patient evacuation. In the event that the medical systems within a disaster area are overwhelmed, there is a need for a system to move patients to another state that is simple, rapid, and can operate with limited individual patient information. The Aeromedical Evacuation System (AES), administered by the Department of Defense, US Transportation Command (USTRANSCOM), has unique aeromedical evacuation capabilities that are used day-to-day for the transportation of the DoD peacetime patients as well as participating in military an NDMS patient movement exercises. The AES formulates evacuations missions based on patient (casualty) medical and medical equipment requirements, location of care, and availability of aircraft and crews.

Three basic aircraft form the backbone of the AES. The C-9A Nightingale, a modified commercial DC9 passenger jet, can carry up to 40 litter patients, or various combinations of litter and ambulatory patients with an effective range of approximately 2500 miles. It also carries a medical crew of two flight nurses and three medical technicians. This aircraft is used during peacetime to transport eligible beneficiaries between medical facilities in the CONUS and near offshore regions.

The C-141 Starlifter is used primarily to transport military casualties from overseas to CONUS receiving sites. It carries on board equipment for 32 litters, and can be configured to carry a combination of 48 litter and 70 ambulatory patients; or, with additional litter stanchions, it can carry 103 litter patients alone.

The C-130 Hercules can carry approximately 50 to 70 litters. This aircraft has the unique capability of not requiring an improved runway for takeoff or landing. For example, it can land on short stretches of interstate highway, in a desert region, or an open field, weather and soil conditions permitting.

During an overseas military emergency, the Department of Defense, in cooperation with the Department of Transportation and U.S. commercial airlines, can activate the medical component of the Civil Reserve Air Fleet (CRAF). The Boeing 767, the primary airframe of CRAF, can be configured for 111 litters.

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Definitive Medical Care

Definitive medical care begins with the arrival of patients at the FCC reception airfield. It continues through the process of triage both in transition from the aircraft and in the staging area. Next in the process is the assignment to a hospital with the capability to treat the patient, followed by proper and timely ground transportation to the hospital. Finally, and the ultimate goal of the entire process, is admittance and treatment at a member NDMS hospital.

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Hospital Reimbursement

In the case of civilian victims of domestic disaster, the NDMS member hospital will identify whether or not the patient maintains a primary and/or secondary third party payer for medical care, i.e., insurance carrier, Medicare, Medicaid, etc. This information will also be provided to appropriate physicians and care providers. NDMS hospitals, physicians and other care providers, with the exception of transportation associated with casualty reception and distribution, will submit billing for patient care services to the patient's identified third party payer(s) for reimbursement. Uninsured patients will have billed charges submitted to ESF #8 via the US Department of Health and Human Services, Office of Emergency Preparedness for reimbursement from the original patient evacuation tasking order. CIVILIAN CASUALTIES: The NDMS agrees to insure compensation, at 110% of what Medicare would pay (at the time of the disaster) for medically necessary care for disaster-related diagnoses. TRICARE-ELIGIBLE CASUALTIES: The Department of Defense will pay for health care services provided the Military Health System (also referred to as TRICARE) beneficiaries in accordance with the payment rules stated in 32 CFR Part 199. The NDMS member hospital will assume responsibility for coordination of benefits, so that benefits through NDMS will be secondary to any other existing medical coverage (other than Medicaid). NOTE – BY LAW, MEDICAID IS PAYER OF LAST RESORT. If existing medical coverage provides less than the amount noted above, NDMS agrees to pay the difference. NDMS will not compensate for pre-existing conditions except as they directly impact medically necessary care for disaster-related diagnoses. This care would be compensated at 110% of what Medicare would pay (at the time of the disaster). NDMS will not compensate for any deductible.

NDMS member hospitals will submit final bills for payment (after providing for coordination of benefits) to the Fiscal Intermediary/Third Party Administrator (that will be identified by the Office of Emergency Preparedness at the time of the disaster).

In the event the casualties are TRICARE-eligible, NDMS member hospitals will send final bills for payment (after providing for coordination of benefits) to the Fiscal Intermediary/Third Party Administrator who will be identified by the Military Medical Support Office (MMSO). P.O. Box 886999, Great Lakes, IL 60088-6999 (1-888-MHS-MMSO/1-888-647-6676). The FCC will provide liaison for all issues regarding patient care reimbursements.

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Casualty Reception Transportation Reimbursement

The transportation and associated expense of reception activities will be reimbursed under the original patient evacuation tasking order. The FCC, or its designated fiscal authority, will collect appropriate billed charges for ambulance (or other transportation asset) services, medical supplies and equipment, and other support services incurred during casualty reception operations. Charges are to be submitted to ESF #8 via the US Department of Health and Human Services, Office of Emergency Preparedness for reimbursement. In the case of military casualties, billing will be submitted to the Department of Defense, Assistant Secretary (Health Affairs) for coordination through the supplemental care claims processing and payment system. The FCC will provide liaison for all issues regarding patient care reimbursements.

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Return of Patients

The NDMS Area Coordinator is responsible for monitoring the care of NDMS patients placed in facilities associated with their FCC and for coordinating their discharge and their transportation back to their point of origin (or to the nearest site able to provide the opportunity for permanent domicile). Patients requiring continuing care must be returned as soon as appropriate care is available in the area from which they were evacuated and the patient can be transported safely. Transportation will be provided at NDMS expense unless covered by the patient's health care insurer or the patient does not accept transportation arranged by the FCC.

Patients requiring continuing health care or observation must be accepted by a physician at a specific health care facility at their home location prior to being returned. Patients not requiring medical care en route will be provided transportation procured through government sources by the FCC. Civilian patients who are ambulatory and do not require en route care will be issued tickets on the most appropriate commercial carrier.

The FCC will be responsible for arranging the return of the remains of patients who expire during their NDMS-sponsored care to the custody of family or other legally responsible person. Burial arrangements will be made by the FCC at NDMS expense when no legal custodian is identifiable.

Upon discharge of patients from NDMS responsibility, copies of the complete records of patients' care, transportation, and/or disposition of their remains will be sent to NDMS headquarters for permanent, confidential retention.

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