Nursing Homes: Part of the Solution in Community Preparedness

1. Nursing Homes:Part of the Solution in Community Preparedness EM Summit March, 2009 Jocelyn Montgomery, RN, PHN California Association of Health Facilities Disaster Preparedness Program

2. What is Long Term Care?

3. Long Term Care Facility • Refers to any of a range of institutions that provide health care to people who are unable to manage independently in the community • Facilities may provide short and long-term rehabilitative services as well as chronic health care management www.longtermcareliving.com/glossary

4. Wide Range of Facilitiesin Long Term Care • It can consist of: • Care in the home by family members who are assisted with voluntary or employed help • Adult day health care • Care in assisted living facilities • Care in skilled nursing facilities • Care in other types of residential facilities www.longtermcareliving.com/glossary

5. Wide Range of Recipients inLong Term Care • It can include people who are: • Pediatric, elderly, in between • ambulatory • non ambulatory • cognitively intact • cognitively impaired • minimal assistance • completely dependant for all activities of daily living And have special medical and/or behavioral needs

6. Skilled Nursing Facility Defined “Skilled nursing facility" is defined as an institution (or a distinct part of an institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, or rehabilitation services for the rehabilitation of injured, disabled, or sick persons, and is not primarily for the care and treatment of mental diseases; … §§1819(a) and 1919(a) of the Social Security Act

7. Snapshot of Nation’s SNFs • Approximately 16,000 SNFs • 1,730,000 licensed beds • 917,000 nursing staff • 122,400 RNs • 192,100 LPNs • 608,900 CNAs • 12,500 NAs/Orderlies CDC National Center for Health Statistics 2006/2007 data

8. Snapshot of SNF Residents • 1,492,200 living in skilled nursing homes on any given day. • The vast majority of these people are: • 75 or older • Female • White • Stay less than 3 months

9. Snapshot of SNF Residents • Disease prevalence very high • 61% have mental &/or cognitive conditions • 41% do not walk • Only 18% walk without help or supervision Kaiser Commission on Medicaid and the Uninsured 2007

10. SNF Disaster Capabilities • A critical component of the healthcare system • Experts in caring for medically fragile populations • Bed capacity • Back up power • Medications • Emergency Supplies

11. Federal Regulation Requirements • CFR 483.75 (m) disaster and emergency preparedness • F517 (1)the facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents.

12. Federal Regulation Requirements • CFR 483.75 (m) disaster and emergency preparedness • F518 (2) The facility must train all employees in emergency procedures when they begin to work in the facility, periodically review the procedures with existing staff, and carry out unannounced staff drills using those procedures

13. Skilled Nursing Facilities as Resource? YES… BUT…

14. SNF Disaster Challenges • SNFs serve the medically fragile, who may be more severely impacted by disasters • Very little physician presence • High staff turnover • Scare resources for training or equipment • Typically not included in healthcare preparedness community coalitions

15. SNF Disaster Needs • More involvement with local planning efforts • Stronger facility emergency operation plans, particularly from the “walls out” • Assistance to prepare as a partner in response

16. Nursing Homes During Katrina

17. Nursing Homes During Katrina • All studied Gulf State nursing homes (20) met the federal requirements on their most recent state survey • All experienced problems, whether they evacuated or sheltered in place • Plans were often missing several planning elements recommended by experts • Plans were not up to date • Administrators not always familiar with plans

18. Nursing Homes During Katrina Evacuation Issues: • Instructions for evacuating to an alternate site • Guidance for deciding whether to evacuate or shelter in place • Information about the specific needs of residents (to allow staff to modify plans according to residents’ needs) • Plans for reentry of facility

19. Nursing Homes During Katrina Sheltering in Place Issues: • Problems with staffing • Uncertainty of access to community resources • Shortages of supplies narrowly averted • Power disruptions (2 hours—4 weeks) • Generators taxed (A/C in high temperatures; generators only supported lights and fans) • Psychological stress on residents

20. Nursing Homes During Katrina Findings: • Lack of collaboration between state & local emergency entities and nursing homes • Review of plans and prior collaboration can build better plans, and result in better emergency management & access to resources HHS. Nursing Home Emergency Preparedness & Response During Recent Hurricanes. Aug. 2006.

21. Southern California 2007

22. Largest Evacuation (CA History) • Approximately 515, 000 people evacuated • Over 2,200 medical patients evacuated • 14 Skilled Nursing Facilities • 5 Intermediate Care Facilities (MR) • 1 Acute Psychiatric Facility • 3 General Acute Care Hospitals

23. How Did LTC Do? • No structures lost • No disaster – related deaths • Displace residents received excellent care at other facilities and shelters • Staff reported to work Many not knowing whether or not their house were standing

24. Lessons Learned During Fire Storm NEED: • Centralized location to coordinate special needs response operations, patient and bed tracking. • Patient identification bands with critical medical information. • Staff identification that enable them to return to facilities. • LTC evacuation plans that adequately address transport of patients to other facilities. • Criteria for approval to repatriate facility

25. CAHF NEEDS ASSESSMENT • Needs Assessment • Evacuation • Sheltering in place • Pandemic • Power failure • Self-sufficiency and self-reliance

26. Methods • Survey of California LTC facilities • Collected via Survey Monkey, July – October 2008 • Sample size: 115 completed, 134 total responses • Convenience sample, self-reporting • Sample probably represents the “best prepared” facilities

27. Overview of responses • Responses completed by: • Facility administrator (71.8%) • Director of nursing (13.6%) • Director of staff development (12.7%) • Facility size – well distributed

28. Readiness for evacuation • Evacuation includes: • Receiving residents • Sending residents • Agreements with “like” facilities • Within emergency operations plan (EOPs): • 99.1% facilities address evacuation • 87.9% address coordination with “like” facilities • 80.3% included processes for sharing residents’ information with other facilities and external/public agencies • Evacuation planning with local community partners ranked second as a priority for next year

29. Sending residents/patients • Readiness of facilities to evacuate within 1 hour: • Food ready to go: 87.4% • Water ready to go: 82.4% • Essential medical supplies/medication ready to go: 84.9% • Critical health info for residents ready to go: 87.4% • Planned evacuation meals for residents: 74.6% • Planned meals for staff: 44.9%

30. Transportation preparedness • Facilities with transportation vendors or ownership of vehicles for use in an evacuation: 47.9% • Of these, 44.7% have discussed their vendors’ business continuity plan and priority of assistance • 43.7% do not have readily available means to evacuate residents • And are dependent on external emergency agencies

31. Receiving residents/patients • Does the EOP address receiving patients? • 69.7% did • 19.7% did not • 10.6% didn’t know • Specific procedures for accepting residents from like facilities: • 70.9% did • 20.5% did not (8.5% did not know)

32. Managing unsolicited clinical help • Lack preparedness to handle clinical volunteer • Most facilities did not have procedures to manage unsolicited clinical help • Most facilities did not have procedures to request and receive volunteer health professionals from the county:

33. Readiness for sheltering in place • Performance target: > 72 hours’ supplies on hand • Most facilities in survey prepared – in some way – to SIP • However, adequate pharmaceuticals: only 76.7% • Facilities with no water stored: 6% either had no water for staff or residents

34. Sheltering the staff in place • Adequate water (72+ hrs) for staff: 89.0% of facilities • Adequate food for staff: 88.1% • Extra bed linens for staff: 71.8% • Adequate extra cots, mattresses, or roll-away beds for staff: 25.4% • Most facilities have at least some supplies, even if they fall below the 72 hour target • But…this also means 11% don’t have adequate water, 12% don’t have adequate food, etc.

35. Power and utilities • Automatic gas shutoff valves in 49.2%; facilities without gas shutoff values 42.4% (7.6% didn’t know) • Power failure addressed in EOP: 85.3% of facilities • Facilities with stand-by/emergency generator capability 89.8%

36. Services tied to generator power

37. Hours of generator power

38. Alternate forms of communication

39. Internet-connected computers • Most facilities: at least 5 computers • Most facilities (> 94.6%) used their computers for web access and email, facility computers played a key role in clinical care: • Residents had internet access in 18.4% of facilities.

40. Security • Lacking funding, lacking dedicated resources • Most facilities’ staff not required to wear photo identification: • Most facilities (69.9%) did not have security staff • Facilities with procedures for locking down all exterior doors without help from external agencies: 54.7% • Several facilities identified the use of surveillance systems (alarms) and/or security cameras as security mechanisms

41. Emergency operations plans (EOP) • Hazard and Vulnerability Analysis • 22.2% completed HVA within last 5 years • 41% had not • 36.8% didn’t know • EOPs covered: • Evacuation planning - 99.1% • Sheltering in place - 96.6% • Command and control - 95.7% • Triage of casualties - 86.2% • Contingency of power failure - 85.3%

42. Local planning aspects addressed in EOPs

43. Engagement in local planning • Local surge planning • Facilities participating - 48.3% • Not participating - 34.7% • 16.9% didn’t know • Receiving funds or supplies from local health/emergency services agency • Did receive funds/supplies - 6.8% • Did not - 82.9% • 10.3% didn’t know • EOPs reviewed by local emergency planning officials: • 39.1% of facilities • 47% had not been reviewed locally • 13.9% didn’t know

44. Incident command systems

45. Pandemic influenza preparedness • A general lack of preparedness • Isolation/reverse ventilation rooms: • Facilities with: 16% • With out: 82% did not (2% didn’t know) • Infectious disease emergencies addressed in EOPs: • 38.3% addressed quarantine • 37.1% addressed configuration of facility space for isolation or quarantine during an epidemic; and, • 27.4% addressed storage of remains following a mass casualty event

46. Infectious disease preparedness as addressed in EOPs

47. Top 5 ranked priorities for the future • Training staff in emergency procedures • Evacuation planning, particularly with external partners • Implementing an incident command system for use during emergencies • Diagnosis and treatment of residents and staff with potentially infectious diseases • Formalizing MOUs with like facilities; arrangements with vendors/service providers

48. Response Community Working with LTC Providers • Understand the unique position that LTC is in, BOTH as a resource and as a group that may have needs • Actively include LTC in your disaster-related workgroups and planning activities (example: pandemic planning) • Accept invitations from the LTC community to work together (meetings, planning) • Consider the challenges they face

49. California SNFsSome Positive Practices

50. CAHF Disaster Preparedness Program Increase disaster readiness of individual long term care facilities (LTC) Promote integration and collaboration between LTC providers and Other providers Other healthcare partners Emergency response planners State Regional Local levels http://www.cahf.org/public/dpp