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
What is Long Term Care?
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
Wide Range of Facilities It can consist of: in Long Term Care 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
Wide Range of Recipients in Long 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
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
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
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
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
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
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.
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
Skilled Nursing Facilities as Resource? YES BUT
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
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
Nursing Homes During Katrina
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
Nursing Homes During Evacuation Issues: Katrina 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
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
Nursing Homes During Findings: Katrina 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.
Southern California 2007
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
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
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
CAHF NEEDS ASSESSMENT Needs Assessment Evacuation Sheltering in place Pandemic Power failure Self-sufficiency and self-reliance
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 Type of facility 8% 4% 3% SNF 4% Sub Acute 2% Intermediate care facility (ICF) ICF/Developmentally disabled (DD) ICF/DD/Habilitative ICF/DD/Nursing 79%
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 Percent of facilities 40 30 20 10 0 1-6 7-15 16-59 60-99 100-199 200-299 300+ Licensed beds Average daily census Number of beds
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
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%
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
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)
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:
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 Days of potable water stored Percent of facilities 80 60 40 20 0 None 1 2 3 4 5 > 5 Water for residents Water for staff Days
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. Percentage 100 80 60 40 20 0 Supplies for staff to shelter in place for 72 hours Food Potable water Type of supply Bed linens Cots Yes No Some, but not enough Don't know
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%
Services tied to generator power 100 90 80 70 60 50 40 30 20 10 0 Percentage of facilities Lights Red plugs Refrigeration Kitchen Oxygen Computers HVAC Laundry Other
45 40 35 30 25 20 15 10 5 0 Hours of generator power Generator time using circuits identified (see previous graphic) Less than 1 1-4 5-8 9-16 17-24 25-35 36-48 49-72 More than 72 Don't know Hours Percent of facilities
Alternate forms of communication 100 90 80 70 60 50 40 30 20 10 0 Percentage of facilities Cell phone Internet Portable radio Two-way radio Wireless internet Runner system CB radio Ham radio Voice over internet
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. Internet-connected computers Percent of facilities 40 30 20 10 0 None 1-5 6-10 11-20 21-30 > 30 Computers with internet access
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
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%
Local planning aspects addressed in EOPs Yes No Don't know 100 90 80 Percent of facilities 70 60 50 40 30 20 10 0 Hospitals Emergency planners Community or faith based groups "Like" facilities Coordination with local entities
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
Incident command systems Use of HICS for emergency operations Don't know 27% Yes 31% No 42%
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
Infectious disease preparedness as addressed in EOPs 60 Yes No Don't know 50 Percent of facilities 40 30 20 10 0 Isolation of infected patients Quarantine Reconfiguration of space for quarantine
Top 5 ranked priorities for the future 1. Training staff in emergency procedures 2. Evacuation planning, particularly with external partners 3. Implementing an incident command system for use during emergencies 4. Diagnosis and treatment of residents and staff with potentially infectious diseases 5. Formalizing MOUs with like facilities; arrangements with vendors/service providers
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
California SNFs Some Positive Practices
CAHF Disaster Preparedness 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 Program
Pandemic Influenza Workbook for Long Term Care Available on website Released in Sept 2007
WHO Pandemic Stages
Containment Strategies
Non-Pharmaceutical Containment: Self Isolation If you have the flu, or if you think you might have the flu, or if you have been exposed to someone who has the flu PLEASE STAY OUT! If you MUST enter, please!!! wear a mask, wash your hands frequently, avoid coughing/sneezing near anyone else, And leave as soon as possible!!!
Quarantine Within Your Facility If a definite exposure has occurred in a limited part of the facility, these people should be kept apart from the rest of the population as effectively as possible Cohort sick residents Quarantine roommates who would also have been exposed to the infected individuals
Sustainment Strategies Broad impact over geographies, ages, workforces Prolonged over weeks/months Resources will be decreased Demand for care will be increased
PI Annex to Disaster Plan Build on the existing plan: Disasters and Infectious Disease Outbreaks Add sustainability over weeks/months Staffing strategies Plan for higher acuity residents due to an inability to transfer to acute care Management of deceased
Start Stocking Up Now Types of Supplies to Stockpile Disaster supplies for all hazards (including food, water, etc.) Personal Protective Equipment (PPE) Rehydration supplies Infection control supplies Respiratory care supplies Mortuary supplies Simple Oral Rehydration Solution 1 TSP salt 4 TBSP sugar 8 Cups of clean drinking or boiled water and then cooled OTC medications and Rx meds (antivirals) as allowable under the regs
Emergency Staffing Strategies Prepare for worst case 50 % absenteeism Cross Training in essential services Resident Care Food Service Housekeeping Laundry Essential Administrative Procedures Shift to sufficiency of care approach
Facility Security Protection of supplies may be important Consider assigning security personnel during high risk times Control access to facility Control access to supplies Self protection training for staff Deliveries of supplies be protected
Current DPP Projects Advocacy and Collaboration Respiratory Protection Initiative Needs Assessment Planning Summits Education and Outreach Table Top Exercise Tool Website www.cahf.org/public/dpp
San Diego County Collaboration Model Disaster Area Coordinators
San Joaquin County Model Base Control Hospital
Alameda County Model
It takes all the healthcare assets working together
So Lets Work Together! Jocelyn Montgomery RN Director of Clinical Affairs California Health Care Association jmontgomery@cahf.org