All staff members as well as residents and their families must be prepared for the potentially devastating effects of a natural or man-made disaster on a long-term care community.

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reparing our workforce to deal effectively with public health emergencies that may impact long-term care communities represents an immediate need as we face an aging nation. Of more concern is the fact that there is little emphasis in disaster training on age-appropriate care for elderly populations or on special needs of older adults exposed to biological, chemical, or nuclear agents from potential acts of bioterrorism.
       Over the last few years, devastations caused by both man-made and natural disasters have directly impacted long-term care communities. We usually do not consider terrorism events involving long-term care facilities, but on September 11, 2001, St. Margaret’s House, a senior living community of more than 300 residents—900 yards away from the World Trade Center—found itself in the center of such an incident.¹ Fortunately, no residents were injured, thanks to the extensive emergency training of managers and staff. Staff members were able to put their training to good use, as several injured persons fleeing from the devastation sought shelter in the building.
       More recently, the ravages of hurricanes Katrina, Rita, and Wilma clearly showed the inadequacies of government agencies dealing locally with natural disasters, particularly for vulnerable populations like the elderly.² Louisiana’s Department of Health reported that 60% of hurricane Katrina victims were 62 years of age or above, and that the majority of those bodies discovered were in or near nursing homes and hospitals.³ Many of the more than 3,200 persons still missing are from long-term care communities destroyed in the flooding. For the survivors of these life-changing threats, little is understood with regard to how older persons cope with the physical and psychological stressors in the aftermath of such events.
       A report released by the Government Accounting Office (GAO) released in February, entitled, “Disaster Preparedness: Preliminary Observations on the Evacuation of Hospitals and Nursing Homes Due to Hurricanes,” presents some somber evidence regarding both the lack of preparation of long-term care communities and the lack of assistance provided to them by the government in times of disasters.⁴ Although long-term care communities are required to have emergency plans in place, the GAO report found that several barriers make them more vulnerable in disasters, particularly in situations for which evacuation may be necessary. Along with evacuation issues, such as increased health risks to frail elders and lack of availability of shelters and transportation, long-term care administrators face additional challenges. For example, many residents may not have family members who can provide care. In some areas, particularly if devastation impacts a large region, there may be a lack of other settings with the capacity to care for frail elders for potentially long periods of time. Most significant in the GAO report was the finding that the federal National Disaster Medical System, which helps evacuate hospital patients affected by disasters, is not set up to assist in evacuating long-term care communities.

Disaster Preparedness: What is Critical?

       A recent national survey by Mather LifeWays Institute on Aging (Evanston, Ill) found that 9 out of 10 long-term care communities are ill-prepared to deal with public health emergencies due to man-made or natural disasters. Additionally, more than 80% of communities identified a lack of coordination within the emergency and social service networks in their region to provide rapid and comprehensive resources to long-term care communities in times of disasters. Although every state has an emergency management plan in place, more than 80% of communities were either unaware that such a plan existed or did not know how to access state resources for assistance.
       Acute shortages and high turnover of skilled administrators and care providers, as well as the lack of healthcare professionals specializing in geriatrics, complicate the circumstances of future public health emergencies involving long-term care communities. Because the elderly may be more vulnerable and/or show signs and symptoms of bioterrorism attacks or pandemic influenza earlier than adults with healthy immune systems, elders may actually be our sentinels to such an incident.

PREPARE: Addressing the Disaster Readiness Challenges

       PREPARE is a national education program developed specifically for long-term care communities that addresses consequences of bioterrorism, natural disasters, and other public health emergency challenges like influenza pandemics. The program, developed by Mather LifeWays Institute on Aging, is supported through a 3-year cooperative agreement grant awarded by the Department of Health and Human Services’ Health Resources and Services Administration (HRSA).
       PREPARE participants include all levels of managers, direct care providers, and support staff across the senior living continuum—including skilled care nursing centers, retirement communities, assisted living centers, and home healthcare agencies. Participants gain knowledge, skills, and abilities across all key processes of emergency preparedness (ie, surveillance, response, and recovery) through a variety of learning tools and activities including classroom experiences, emergency exercises/drills, and online courses. Communities also receive guidance on ways to integrate this education into quality improvement (QI) programs; build community and volunteer resources; and involve local, state, and federal emergency management systems in their disaster plan and procedures.
       Key topics covered in the PREPARE program include:
• Understanding the effects of man-made and natural disasters on elders
• Demonstrating leadership skills in the long-term care community during and after emergencies
• Activating community linkages and backup strategies for disaster aftermath
• Developing an effective disaster plan for your long-term care community
• Maintaining core competencies through disaster exercises and drills
• Involving residents and families in disaster planning.

Fundamental Components of Disaster Preparedness

       Direct care providers, managers, and all staff in long-term care communities may be called upon to participate in some aspect of disaster preparedness. Therefore, all staff members and managers need to develop knowledge and skills in the fundamental components of disaster preparedness that follow.
       Understanding the effects of man-made and natural disasters on the elderly. We are just beginning to learn how complex the effects of biological or chemical agents common to bioterrorism attacks may be on the aging immune system. In some instances, symptoms in older adults may be ignored because of the perceived unlikelihood of exposure. This was the case in 2002 with a 94-year-old woman living in a rural, isolated area of Connecticut who died of anthrax inhalation. In natural disasters, elders have special challenges that could put them at greater risk for injury, victimization, or further dependency. Some of these factors include sensory loss, functional limitations, memory loss, slow response time, communication barriers, and vulnerability to hyperthermia/hypothermia.
       Demonstrating leadership skills during and after emergencies. During an emergency, staff members or managers may be called upon to take on leadership roles regardless of their positions. Direct care workers often have the greatest knowledge of their residents; in turn, residents often have the greatest trust in their direct caregivers. Therefore, frontline staff has considerable potential to manage situations and provide for resident safety needs.
       Activating community linkages and backup strategies after disasters. Making connections and developing written “mutual aid agreements” with local businesses, volunteer agencies, health systems, religious organizations, and other long-term care communities for essential services and supplies during disasters are important steps in an organization’s disaster preparedness. Fundamental to community linkages is making certain that local and regional emergency management, police, and fire departments (ie, the first responders) know about your long-term care community and residents. This may sound obvious, but in the aftermath of September 11, 2001, New York’s emergency services failed to reach many isolated older adults for days and weeks due to a lack of a coordinated, city-wide communication network to ensure that the location and needs of all elders were known to city services prior to the emergency situation. Finally, long-term care communities need to plan backup strategies—and backups to those plans.
       Developing an effective disaster plan. An effective disaster plan is not one that is reviewed once a year and then placed back on the shelf. On the contrary, a long-term care community’s disaster plan needs to be understood and practiced by staff and managers through regular exercises and drills. Because circumstances may change rapidly as disasters evolve, the most effective disaster plan needs to be dynamic and flexible to address “what ifs.” The “all hazards” model is valuable in developing an effective disaster plan, since it addresses the commonalities occurring in many types of disasters such as the need for emergency warning or evacuation. Understanding the basics can improve staff’s skills and competencies necessary for responding to unexpected events. A disaster-planning checklist (see Table 1) is valuable for reviewing your long-term care community’s current plan.

Table 1

       Maintaining core competencies through disaster exercises and drills. Implementing and evaluating community-wide disaster exercises and drills is essential to ensure that managers and staff members maintain and improve core competencies in emergency preparedness. Integrating these exercises into the continuing QI program assures residents and families that your long-term care community regards resident safety and well being as high priorities. Unlike hospitals, long-term care communities seldom have the opportunity to participate in what is deemed a full-scale disaster exercise. A full-scale exercise simulates a real emergency or disaster as closely as possible to test all aspects of emergency response under stressful conditions and is coordinated with multiple local, state, and federal agencies.
       Other forms of disaster exercises useful to long-term care communities include tabletop and functional exercises. A tabletop exercise involves a team of personnel who discuss a “scenario” disaster and come up with solutions to problems that may arise during the exercise. The disaster scenario is usually written in the form of a script with questions that drive the discussion. The tabletop exercise is a low-cost method to review disaster plans and procedures and is a good starting point to acquaint managers and staff members with potential emergency situations and their roles in such events. Another advantage to the tabletop exercise is that staff may take on different roles and responsibilities to develop their problem-solving skills and better understand how these roles must work together during emergency situations.
       The functional exercise is a simulated, interactive exercise that tests capabilities of staff to respond in emergency circumstances. It is more realistic than a tabletop exercise in that the simulation moves along at a faster pace, and staff members may actually need to participate in an emergency drill as part of the functional exercises (eg, demonstrating proper use of personal protective equipment or conducting a partial evacuation of a building). The “simulators” are in charge of communicating messages to the staff participants about what is happening next during the emergency. To convey realism, simulators often deviate from the disaster script, particularly if it appears that participants are anticipating what is happening next in the scenario.
       Involving residents and families in disaster planning. Including residents and their families is vital to a successful disaster plan. The psychological and emotion impact of disasters may have mixed effects on older adults. For some, a traumatic event may trigger memories of past experiences, resulting in displays of anxiety, grief, fear, depression, and sleep problems. For others, terrorism situations may prompt feelings of patriotism, particularly as many older adults have lived through similar events (eg, the attack at Pearl Harbor).

Table 2

       The long-term care community’s disaster plan should include written guidelines for residents and families that outline the plan, evacuation procedures, and recommended emergency supplies (see Table 2) if residents stay in their facility. For residents with pets, emergency plans for caretaking should be included. The American Red Cross provides several such emergency planning manuals on its website (see “Online Resources”).

Conclusion

       Skilled nursing centers and other long-term care settings are mandated to have written fire and disaster procedures and educate staff on these procedures regularly. Additionally, long-term care communities often include procedures to address emergencies common to natural events in their region (eg, tornadoes, hurricanes, earthquakes, etc.).
       How to deal with uncertainties, such as bioterrorism or catastrophic natural disasters, is a question addressed by very few long-term care communities. The odds of a long-term care community being the target of a terrorist threat are extremely low, but external contamination of air or water supplies from an attack in a particular area may reach one’s long-term care setting. Would your staff understand the danger of such a threat and be prepared to take immediate action to save lives?
       In some areas, there are growing numbers of high-rise long-term care communities being built. If all power was lost due to an act of terrorism that also threatened the building’s integrity, how would you evacuate your residents (many of whom use wheelchairs or walkers)?

Online Resources

       What are some of the situations that your long-term care communities might face in a disaster event? Does your current disaster plan adequately address these scenarios? Does your long-term care community regular educate staff on actions to be taken? These are just some questions for your consideration.
       Disaster preparedness for long-term care communities is an ongoing process that should involve all levels of managers, staff, residents, and families. Being prepared to deal effectively with disasters impacting your long-term care community should be expected; residents and their families must be assured that managers and staff members are ready to meet their special needs.

For More Information
       A 2-day PREPARE “Train-the-Trainer” workshop is the first step toward preparing your community. The federal grant from the Health Resources and Services Administration (HRSA) supports workshop registration and all training materials for 2 participants from each community who gain the necessary skills and tools as PREPARE specialists to train their own managers and staff. The training materials consist of 11 PREPARE learning modules specially designed for experiential learning with all levels of staff, including handouts, PowerPoint slides, case studies, video clips, game simulations, group activities, quizzes, preparedness exercises, course evaluations, and certificates of completion.
       The Institute for the Future of Aging Services, the applied research institute of the American Association of Homes and Services for the Aging (AAHSA), is partnering with Mather LifeWays on PREPARE to conduct an impact evaluation of the program. PREPARE “Train-the-Trainer” Workshops are held monthly in the greater Chicago area and in additional national locations. To learn more about program requirements and to register, contact Cate O’Brien, PREPARE Project Manager, at 847-492-6803 or cobrien@matherlifeways.com.