Implementation of Alternate Care Facilities During Public Health Emergencies: A Qualitative Study.

Importance: Alternate care facilities (ACFs) have been used during public health emergencies in the US to expand surge capacity, yet little contemporary evidence synthesizes their operational challenges, successes, and alignment with national guidance. Understanding these experiences is essential to improving ACF planning and implementation. Objectives: To identify common successes, challenges, and best practices in planning and operating ACFs in the US, and to assess how these experiences can enhance national ACF resources. Design, Setting, and Participants: This qualitative study included a literature review of US-based publications (from January 1, 1946, to December 31, 2024) describing ACF implementation during public health emergencies, as well as semistructured group interviews with subject matter experts (SMEs) with experience operationalizing ACFs. SMEs were identified from the literature and national networks and were required to have experience in planning or operating ACFs. Using convenience sampling, SMEs were invited to participate. Participants represented clinical, administrative, and emergency management backgrounds. The literature review and interviews were conducted from June to August 2024 without further follow-up. Data were analyzed using rapid qualitative methods with matrix-based thematic synthesis. Main Outcomes and Measures: The primary outcome was identification of recurrent successes, challenges, and best practices for ACF planning and operations. Secondary outcomes included assessment of gaps in existing national guidance. Results: A total of 30 SMEs were invited to participate; 16 clinicians and administrators accepted, composed of 11 men (68.8%) and 5 women (31.2%). The literature review identified 34 publications representing 19 ACFs across 14 states. Five themes emerged: (1) need for flexibility and adaptability; (2) importance of strong partnerships with health care systems, emergency management, and public health; (3) resource availability challenges; (4) need for executive leadership support; and (5) need for clear leadership structures. ACFs that affiliated with parent health systems, used flexible operational models, or implemented warm closure strategies (ie, allowing ACFs to maintain their footprint and reactivate as needed) demonstrated improved performance and community impact. Conclusions and Relevance: In this qualitative study of ACF experiences, consistent operational needs that extend beyond current national guidance were revealed. These findings suggest that incorporating experiential lessons related to flexibility, partnerships, resource readiness, executive support, and site leadership will strengthen future ACF planning, support more effective activation, and enhance national health care surge capacity during emergencies.