Comprehensive care for vulnerable elderly veterans during disasters

Archives of Gerontology and Geriatrics 56 (2013) 205–213

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Archives of Gerontology and Geriatrics journal homepage: www.elsevier.com/locate/archger

Comprehensive care for vulnerable elderly veterans during disasters Maria Claver a,*, Aram Dobalian a, Jacqueline J. Fickel b, Karen A. Ricci a, Melanie Horn Mallers c a

Veterans Health Administration Emergency Management Evaluation Center and VAGLAHS HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, 16111 Plummer St. MS-152, Sepulveda, CA 91343, United States b VAGLAHS HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, 16111 Plummer St. MS-152, Sepulveda, CA 91343, United States c California State University, Fullerton, Department of Human Services, P.O. Box 34080, Fullerton, CA 92834-9480, United States

A R T I C L E I N F O

A B S T R A C T

Article history: Received 20 April 2012 Received in revised form 27 June 2012 Accepted 28 July 2012 Available online 16 August 2012

Despite problematic evacuation and sheltering of nursing home residents during Hurricanes Katrina and Rita, an exploration of the experiences of Veterans Health Administration (VHA) nursing homes (VANHs) is necessary for a comprehensive examination of the healthcare community’s response to these disasters. VANH evacuations during these hurricanes have not been widely studied. This exploratory project aimed to provide information about the evacuation experiences and characteristics of vulnerable nursing home residents. Interviews with key informants from VHA facilities with nursing home staff and representatives revealed that physical harm, psychological distress, cognitive decline and increased social isolation were areas that deserved special attention for this vulnerable population. Moreover, physical, psychological and social needs were interconnected in that each influenced the others. Findings contribute to the general conversation about meeting the biopsychosocial needs of nursing home residents in an integrated healthcare delivery system and more broadly, the role of long-term care facilities in general in planning for future disasters. Published by Elsevier Ireland Ltd.

Keywords: Veterans Nursing homes Emergency preparedness Disasters Biopsychosocial model

1. Introduction In contrast to community-dwelling elders, nursing home residents are at greater risk for disaster-related adverse outcomes (Brown, Hyer, & Polivka-West, 2007; Brown, Rothman, & Norris, 2007; Dosa et al., 2012; Laditka et al., 2008). Nursing home residents’ existing biopsychosocial vulnerabilities (Dosa et al., 2008) may cause a disaster to impact this population more significantly than it might affect other populations. These vulnerabilities stem primarily from the effects of chronic diseases and the interplay of biological, psychological and social changes associated with aging. According to the biopsychosocial model of illness and disease, individual well-being is a dynamic interaction between one’s health (such as diseases, disorders, injuries) and larger, contextual factors (Engel, 1977, 1997). Nursing home residents, who are oftentimes frail or disabled, are particularly susceptible to impaired well-being when under physically and psychologically stressful conditions such as those experienced during a disaster (Aldrich & Benson, 2008; Blanchard & Dosa, 2009; Dobalian, Tsao, Putzer, & Menendez, 2007; Fernandez, Byard, Lin, Benson, & Barbera, 2002). VANH residents are especially susceptible to impaired health; they not only meet eligibility requirements

* Corresponding author. Tel.: +1 818 891 7711x2039; fax: +1 818 895 9578. E-mail address: [email protected] (M. Claver). 0167-4943/$ – see front matter . Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.archger.2012.07.010

that necessitate residence in long-term care facilities, but this population has been found to have more comprehensive needs than nursing home residents in the general population (Selim et al., 2004). In 2004, close to 90% of nursing home residents were aged 65 years and older and 45% were over the age of 85 (Jones, Dwyer, Bercovitz, & Strahan, 2009), considered the ‘‘oldest old’’ (He, Sengupta, Velkoff, & DeBarros, 2005). In elderly nursing home residents, the physiological changes associated with aging, particularly loss of skeletal muscle and strength, reduced bone mass, hearing loss, and decreased visual acuity contribute to decreased functional ability and loss of independence (Abrass, 1990; Fernandez et al., 2002; Sieck, 2003; Weinert & Timiras, 2003). Nursing home residents are also likely to have one or more chronic illnesses that affect independent functioning (Dobalian, 2006) and most require assistance with activities of daily living (ADLs), which include eating, walking, transferring, and personal hygiene (Jones et al., 2009). In fact, nearly 80% of nursing home residents over the age of 65 require assistance with four or more ADLs, and greater than half require extensive assistance with bathing, dressing, toileting and transferring (Jones et al., 2009). Residents, particularly those with cognitive impairments are even more unlikely to be able to perform instrumental activities of daily living (IADLs), which involve more complex tasks, such as managing medications and paying bills. Those with cognitive impairments may also require constant supervision to prevent

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injuries and wandering away from the facility. In addition to physical needs that are the result of aging and chronic diseases, nursing home residents also have many psychosocial needs. The veteran nursing home population has unique characteristics that are distinct from the general community nursing home population. The VA nursing home resident population is mostly (96.3%) male (Dobalian et al., 2007). In 2006, the average age was 70.5. VANH residents have high levels of functional dependence; 87% had some ADL limitation. Almost 22% of residents had a diagnosis with serious mental illness, most often schizophrenia. About 16% had a history of alcohol abuse and 32% had dementia (Lemke & Schaefer, 2010). The interrelationship between biological or functional capacity with one’s psychological and social environment creates the foundation for developing effective, comprehensive intervention and support services for older adults. Nursing home residents, who often have overlapping and co-occurring problems, are essentially considered multi-need patients that require a biopsychosocial approach to their care. For example, in addition to challenges due to physical health problems or functional limitations, it is estimated that as many as 50% of nursing home residents suffer from some level of cognitive impairment (Dobalian, 2006; Magaziner et al., 2000), which oftentimes necessitates greater social support and patient care from staff (Ficker, MacNeil, Bank, & Lichtenberg, 2002; Phillips & Hawes, 2005; Schonfeld, 2003). Additionally, two-thirds or more of nursing home residents have symptoms of mental illness (Oriol, 1999). In 2006, 22% of VANH residents had a diagnosis of serious mental illness, 37% suffered from depression, 12% from posttraumatic stress disorder (PTSD), and 25% had a substance use disorder (Lemke & Schaefer, 2010). Socially, nursing home residents tend to suffer from social isolation and have few resources for emotional support, such as friends, family members or formal caregivers (Hicks, 2000). These are the baseline challenges for VANH residents, but such challenges become exacerbated during a disaster. So, a closer examination of disaster response processes becomes salient for future disaster preparation. Fortunately, since Hurricanes Katrina and Rita, more studies have been published examining the evacuation and sheltering experiences of a vulnerable elderly population (Aldrich & Benson, 2008; Henderson, Roberto, & Yoshinori, 2010), many of whom live in institutional settings such as nursing homes (Dosa, Grossman, Wetle, & Mor, 2007; Dosa et al., 2008; Hyer, Brown, Polivka-West, & Berman, 2010; Laditka et al., 2007; Laditka, Laditka, Cornman, Davis, & Richter, 2009). However, specific research on VANH residents during evacuations is sparse. Furthermore, much of the research on disaster preparedness plans has primarily focused on the physical needs of residents, such as the logistical considerations of evacuating a nursing home (e.g., transportation) and securing basic resources and supplies (Eisenman, Cordasco, Asch, Golden, & Glik, 2007; Fernandez et al., 2002; Hyer, Brown, Christensen, & Thomas, 2009; Oriol, 1999; Renne, Sanchez, & Peterson, 2009). While attendance to physical needs, particularly safety and essential medical care, is vital, unmet psychological and social needs can have significant detrimental effects on physical health, and thus, must be addressed with equal concern. Moreover, research has suggested that during the recovery phase, nursing home residents are consistently underserved with regard to psychological intervention (Brown, Hyer, et al., 2007; Brown, Hyer, Schinka, Frazier, & Mando, 2008; Brown, Rothman, et al., 2007). Although a robust body of literature has recently addressed post-disaster psychological intervention, or what is referred to as ‘‘Psychological First Aid’’ (Brown et al., 2009), less is known about how post-disaster psychological needs interact with aging-related biological and social changes.

Follow-up studies of those who survived a disaster such as Hurricane Katrina indicate that the experience and long-term effects of disasters vary by individual; that is, social conditions, especially those related to evacuation care, more than nature itself, predict the extent of the impact of disaster on older adults (Adams, Kaufman, van Hattum, & Moody, 2011). Attempting to understand the various and multiple needs of nursing home residents during disasters, especially as they relate to evacuation experiences, is therefore essential. Best practices, as they relate to evacuation, are multi-dimensional, especially with VANH nursing home residents, who face different risks compared to the general population (Dobalian, Claver, & Fickel, 2010). And while mortality is an important determinant of evacuation success (Dosa et al., 2011), it is important to also address the structures and processes that contribute to effective evacuations, across the continuum from preparedness and response to recovery (Campbell, 2007–2008; Gibson, 2006) that are conducive to more favorable outcomes during a response to a disaster. As noted above, disaster plans for nursing homes generally tend to be limited in scope and often lack guidance about meeting the comprehensive needs of residents. The U.S. Office of Inspector General (2006) found that out of 20 nursing home evacuations reviewed, 15 did not contain adequate information about the needs of nursing residents that would make disaster plan modification possible. Castle (2008) reviewed evacuation plans from 2134 nursing homes and found that only 37% included information about ‘‘specific resident needs.’’ Given the increased risk for morbidity and mortality due to disasters in the nursing home population (Blanchard & Dosa, 2009; Laditka et al., 2009; Oriol, 1999), identifying the biopsychosocial needs of this highly vulnerable population and developing effective plans for meeting those needs during and after a disaster become critical. This exploratory project thus aimed to contribute to the body of literature that exists about evacuation experiences of a particularly vulnerable population – VANH residents – following Hurricanes Katrina and Rita in 2005. A better understanding of the evacuation experience, sheltering in place, and receiving of evacuees due to disaster can further assist nursing homes with strengthening their disaster plans to meet the unique and multi-faceted needs of vulnerable nursing home residents and other special populations. 2. Materials and methods This study employed a qualitative case study design to examine the comprehensive needs of nursing home residents during evacuations and transfers due to Hurricanes Katrina and Rita. In-depth, telephone interviews were conducted in 2007 with key informants from VHA including nursing home administrative and clinical staff and VA Medical Center (VAMC) administrators from four VHA facilities with nursing homes: New Orleans, LA (60 bed nursing home care unit); Gulfport, MS (40 bed Alzheimers care unit and 40 bed in-patient psychiatry care unit); Biloxi, MS (60 bed extended care services unit and 20 bed transitional care unit); and Houston, TX (120 bed nursing home care unit). There were 13 respondents, eight of whom held primarily administrative roles at the time of the hurricanes, two of whom had a clinical role and three of whom characterized their role as both administrative and clinical. An additional two interviews were conducted with regional VA representatives for background and contextual information about the response. The interviews documented respondents’ recollections of nursing home evacuations and sheltering and explored lessons learned from the point of view of providers and administrators from both evacuated and receiving facilities who cared for this vulnerable population. Qualitative research is well-suited to developing an understanding of a complex issue such as evacuation, and is particularly useful for

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exploratory research where important variables of interest are unclear as existing research is limited and events cannot be replicated in an experiment. This study used purposive sampling (Patton, 1990) to select the VAMC-based nursing homes. Purposive sampling allows us to minimize the number of sites required to develop valid insights and makes data collection feasible by maximizing the diversity of the sample and coverage of different types of nursing homes. The size of the purposive sample typically relies on the concept of ‘‘saturation,’’ or the point at which no new information or themes are observed in the data. Qualitative research often substitutes richer data for a more limited sample size. VHA provides direct long-term care to veterans through VANHs, which are now referred to as ‘‘Community Living Centers.’’ VANHs have unique characteristics that distinguish them from other nursing homes: they are staffed by VHA employees and are part of an integrated healthcare delivery system that is present in nearly every community throughout the U.S., and VANHs use electronic medical records, which allow access to any VHA patient’s medical records across the country. Although some VANHs are stand-alone facilities, many are housed within a VAMC sharing physical space with the hospital, as did the four VANHs in this study. In most other regards, however, VANHs have much in common with other nursing homes (Mehr, Fries, & Williams, 1993). Data were collected through 60–90 min, semi-structured key informant interviews conducted by telephone. The semi-structured interview guide (Appendix B) was developed specifically for this study, following well-established methods (Bernard, 2002; Kvale, 1996; McCracken, 1988). Use of an interviewer-administered guide provided opportunities for respondents to raise important issues that the researchers did not consider. Within each topic area of the interview protocol, open-ended questions were asked to allow researchers and respondents to explore new leads and related topics and often generated rich personal narratives. All interviews were conducted by at least two members of the research team, with the second author taking the primary responsibility for leading interviews and the first author (and sometimes third author) taking detailed notes. All interviews were also digitally audiotaped for subsequent transcription. Qualitative analysis provided a contextual snapshot of the evacuation by examining important themes. We used computer software, ATLAS.ti 5.2 (ATLAS.ti Scientific Software Development GmbH), designed specifically for narrative interview and field notes (Fielding & Lee, 1991; Pfaffenberger, 1988) to organize the synthesis and analysis of the transcribed, textual interview data. Analytic tasks included: defining concepts; mapping the range, nature and dynamics of evacuation and attendant phenomena; creating typologies; finding associations; seeing explanations; and developing new ideas, theories, and strategies (Agar & Hobbs, 1985; Glaser & Strauss, 1967; Ryan & Bernard, 2000; Strauss & Corbin, 1990). This research was approved by the VA Institutional Review Board.

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percentage of the resident population, estimated by the study respondents as one-third to one-half, had cognitive impairment. In addition, a segment of this population had a psychological disorder such as PTSD, depression or schizophrenia. Data collected from interviews revealed that the evacuation and transfer of vulnerable nursing home residents due to Hurricanes Katrina and Rita raised unique challenges for administrators and staff in evacuated facilities and in facilities that received evacuated patients, nursing home residents, and older adults that may or may not have been veterans who were rescued from being outdoors (from here forward referred to as ‘‘receiving facilities’’). For the purposes of this paper, evacuation refers to the movement of residents out of harm’s way, and transfer is defined as moving residents to make room for incoming evacuees. Major themes that emerged from the interviews included physical harm, psychological distress, cognitive decline and increased social isolation that can result from evacuation and transfer of frail elders. Although specific challenges reported by respondents from evacuated facilities differed somewhat from those reported by respondents from receiving facilities, these major themes were consistent across all facilities. Appendix A provides information about how many respondents mentioned each of the following themes. 3.1. Physiological frailty Respondents from VA facilities that received evacuees recounted that some of the older adults who arrived at the VAMC had been outside for four to five days and had to be treated for potential exposure to infectious diseases. Many evacuees arrived dehydrated, hungry, severely fatigued, and often confused or unable to speak. Despite the best efforts of staff from evacuated facilities to relay critical patient data, many evacuees arrived without information about next of kin, medical history, or needed medications. Receiving VA facilities were able to access medical records on all evacuated residents through the VA’s electronic medical record system, although some records were unavailable until September 2. Despite the availability of the medical records system, there were cases in which it was difficult to identify whether an evacuee was a veteran or even to determine his or her identity. A nurse practitioner from an extended care unit that received evacuees noted: I also had a gentleman and a lady, and the lady would not talk at all. And the man had had a stroke and was a bilateral amputee. He had a huge pressure ulcer and they had done a flap surgery on that, but it had come all undone in the transport. But those two people could not speak and we didn’t know [anything about them]. Respondents involved in evacuating nursing home residents mentioned that some of the techniques and resources one might successfully use during an evacuation with a non-frail population did not work well with nursing home residents. There was much discussion about one particular patient evacuation-assist device. One long-time VANH nurse manager noted:

3. Results Interviews with administrators and providers from a total of four facilities were included in this study, which represents a 100% response rate. The residents of the VANHs in this study had a skilled nursing need such as wound care or feeding tube maintenance and required assistance with ADLs, such as eating, bathing, or walking, which are common reasons people move to a nursing home (CDC, 2009). Elderly residents that arrived at a VA emergency room were sometimes admitted to the nursing home for a short stay to receive rehabilitation services for conditions acquired due to the hurricanes and/or until appropriate discharge arrangements could be made, most were there long-term. A large

Whatever you do, don’t use the [brand of patient evacuation-assist device] to take the patients down the stairs. We couldn’t use it because the patients wouldn’t get into it. So all of the drills the people had done, nobody had ever put a patient in there, especially somebody with COPD [chronic obstructive pulmonary disease] saying ‘You’re not going to put me in that thing and let it go down the stairwell. I have no intention of going into a [brand of patient evacuation-assist device] and going down the stairwell.’ So, they hand-carried them down the stairs. None of the respondents that mentioned the device recommended its use for this type of evacuation, noting several reasons including that patients would not use it, that the resident had to be in bed

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(not in a wheelchair) for the device to work, that it was designed for limited use and thus became frayed after several uses, and that due to the failure of electricity, it was hot and humid in the facility making wrapping a person up with the device very uncomfortable. In addition, respondents stated that the high incidence of cognitive impairment and/or respiratory illness among frail elders makes this device inappropriate for this population. Selecting nursing home residents that should be evacuated from VA facilities first proved to be challenging. One facility decided to move the sickest residents first, partly because they knew a nearby VANH could take them. Another evacuated the least sick first. A nurse at the latter facility stated, ‘‘. . .first you try to discharge who can be discharged. You wanna make empty beds because you may have to bring some long term care patients that you’re responsible for into the facility. . .’’ One respondent from the facility that evacuated the least sick first mentioned wishing they had evacuated the sickest first because over the course of the disaster, it became necessary to evacuate every patient from the VAMC and by the time the later evacuations occurred, there were complications with securing transportation for medically fragile patients. Many factors impacted how residents would be transported. A physician at a site that had to evacuate a number of residents stated, ‘‘We didn’t want to send people that had behavior problems ‘cause they’re gonna be on a bus for six to eight hours.’’ All agreed that it was important to situate the residents in the transport vehicle to maximize space. This was difficult, however, when transporting residents on ventilators, because these residents had to be manually ‘‘bagged’’ by a healthcare provider. Thus, only two of these residents could be evacuated at one time because of the limited number of providers that could accompany them to provide needed care. For facilities that sheltered in place or accepted evacuees from other sites, the possibility or reality of losing electricity was of considerable concern. Nursing homes tend to house the sickest and frailest. Many residents cannot tolerate extreme heat and would not survive long without air conditioning and some rely on machines needing electricity (e.g., ventilators) to stay alive. Respondents reported that this was of particular concern for residents with spinal cord injuries and those who require suctioning to keep their airway clear. 3.2. Psychological distress Eight of the 13 respondents reported that many residents exhibited symptoms of psychological distress, which was particularly severe for some who had been evacuated. One nurse practitioner described the stress experienced by most of the evacuees by stating, ‘‘Well, you know there was a lot of stress. . . From the patient’s perspective, it’s just not knowing what, you know, what happened to some of their family members. Because you lost everything, you know. They were worried about their dog, their homes.’’ Respondents from VANHs that received evacuees reported that some residents were discharged early and some were transferred to other facilities to make room for incoming evacuees. Although most of the residents that were transferred accepted having to move out of the nursing home to make room for incoming patients, other residents sometimes questioned staff about the decision to move a resident and there was some jealousy among residents regarding whether they would be transferred. In general, residents preferred to remain and not transfer to another facility. Respondents described various approaches used to assist distressed older adults. Many of their existing residents learned about the hurricanes by watching coverage on television and efforts were made to communicate with residents before they saw

the devastating images on the news. Staff provided private rooms for interviewing the adults, had social workers on staff that could provide counseling and support and in very limited cases, used medications in the short-term to address situations in which residents were experiencing severe psychological distress. Overall, the staff felt prepared to handle combative behavior related to a population of psychologically distressed and cognitively impaired residents. Psychological distress persisted after the immediate evacuation was over. Those preparing to return home to Louisiana faced anxiety and worry about going back to a situation that felt out of control. When discussing the impact of the disaster on a man who was rescued from home and recovered in the VA nursing home, a nurse practitioner shared: I did have one patient who, unfortunately, passed away. But he was so nervous. He had had a stroke and his wife was just a delightful person. I did have psychiatry come and talk to him. I feel that he suffered from classic PTSD related to Katrina. He was so nervous about going [home] that I think he willed himself to die so that he wouldn’t have to be put back in that situation because he was so afraid that he would have the same thing happen because he couldn’t walk. They had to put him on a boat and take him out from his house and it was real traumatic for him. She was saying that their house was getting back to order and they were ready to move him back home. He had a heart attack and passed on.

3.3. Protecting residents from cognitive decline As mentioned earlier, up to 50% of the nursing home population in the VANHs affected by Hurricanes Katrina and Rita live with cognitive impairment. In consideration of this, staff took special measures to care for this population, such as using simple language to explain to residents what was happening. Facilities that were to receive evacuees had to provide an appropriate environment for a population of people that might wander, become agitated, and experience confusion, which might have included installing proper lighting, providing extra staff and utilizing alarms on doors to warn staff about wandering patients. Four of the 13 respondents mentioned using an alert system that assisted with resident wandering. A medical administrator from the VAMC in Houston shared how they addressed wandering at one facility: ‘‘You increase your staff visibility. You have to go through and make sure that you got your hallways secure, that maybe you place staff where they can watch, exit doors and things of that nature.’’ The same respondent described preparing their facility to receive nursing home patients: ‘‘You have to [transfer existing residents] a full day before you get to bring nursing home patients over because you have to then go through the [space] and make it safe for the patients that you’re bringing over. But you have to make sure that you’ve cleaned out lockers. . .that you secure doors, that you move things that might be harmful to a nursing home or geriatric or demented patient.’’ Changing a resident’s environment, whether moving to a room down the hall or to another facility hundreds of miles away, may have resulted in temporary episodes of confusion in residents without prior cognitive impairment and may have led to further cognitive decline or aggravated symptoms in those already diagnosed with the condition. Therefore, receiving facilities must be prepared to handle temporary behavioral reactions to the disruption. An administrator of a facility that had to prepare a unit not meant to house patients with cognitive decline shared, ‘‘We recognize the unique needs of the population. I mean, if we’re taking them out of one environment they may be secure with and although it may be the same environment, it may be disruptive and now they’re

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suddenly down. They’re confused.’’ He described an approach they took to minimizing disturbance that might have caused a cognitive decline in residents: ‘‘We try to keep as many people [who are] familiar with the patients with them. . .And then you try to make the environment as friendly as you can with appropriate lighting and activities and things to keep them busy.’’ 3.4. Importance of social support A significant source of stress for veterans who were evacuated from one VANH to another concerned difficulty locating family members or the lack of a social support network for some residents. It was challenging to find next of kin because, as mentioned earlier, many older adults that had been evacuated experienced psychological trauma that temporarily affected memory, while many other residents had dementia or other cognitive impairments. Therefore, they were not reliable sources of information about next of kin including names or phone numbers. A nurse practitioner on the receiving end of evacuees from New Orleans recalled, ‘‘We did have a few patients that had no family and I actually had two patients on my unit that we called Jane Doe and John Doe initially until we were able to get a name.’’ Another shared the story of a woman who would not speak until her family members were located. He said: She wouldn’t talk. She was like mute. So we finally found her son in Illinois and we got in touch with him. He said her daughter lived right next door to her in the New Orleans area and we finally got in touch with her, and she did not know where her mother had ended up. But she was thankful we called her. So I decided I would put the phone. . .I said, ‘I got somebody that wants to talk to you.’ And I put the phone to the lady’s ear and the woman started talking. ‘Cheese and crackers! I’m hungry!’ The American Red Cross website was mentioned as a helpful tool to reunite families in some of these instances, and a social worker remembered that ‘‘there were all kinds of hotlines and I want to say that we used the Internet a lot.’’ Residents with more advanced dementia were the least likely group to have social support networks. In one case, a resident with dementia was under guardianship and his guardian died during the hurricane. As a result, VA staff had to assume guardianship and take over decision-making for the veteran. As an experienced VANH social worker stated, ‘‘Every case was a hard case.’’ While some evacuees could not find or did not have an available social network, others arrived at a receiving VAMC with family members. In these cases, families were not separated even though one of the family members was not a veteran. One nurse practitioner stated that ‘‘when we have families, if we have two people like a husband and wife, we didn’t separate them. . .we can’t separate families.’’ Respondents shared stories about how they provided support to residents who were either sheltering in place or preparing for evacuation. Some of the support was instrumental in nature, such as assisting residents in functioning in their new environment. One physician noted that ‘‘everybody was so needy. . .you know not just sitting and doing things for them, but they just wanted to talk and you know, they’re in a new environment, they needed to be reoriented and ‘how do I use the phone?’ ‘How do I call out?’ you know.’’ Providing emotional support included establishing trust with the residents, which they did by informing residents of what was happening and reassuring them that they would not be left alone. One nurse manager who also provided direct care following the hurricanes said, ‘‘We communicate with the residents. . .in language they could understand, you know, simple. You know. . .we’re here to care for you, you know, kind of reassuring. . .reassuring somebody who is demented, somebody who can’t walk, somebody who’s dependent on, you

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know, oxygen, that we’re going to do our best to take care of you.’’ Another physician mentioned that non-verbal support was important. She describes how she ‘‘looked them in the eye, and hugged them and said, ‘It’s going to be fine.’’’ Perhaps as a result of the intensity of the situation and the extensive support required by the residents, emotional bonds were formed that made resident relocation especially difficult for both residents and staff. Evacuations of nursing home residents were emotionally difficult for both residents and staff due to the residential nature of a long-term care facility. Often, older adults reside in a nursing home for the remainder of their lives and some live in the nursing home for an extended period of time. Thus, relationships form between residents and staff. A nursing administrator commented that relocation of some residents from one VANH to another ‘‘was a heartbreaking thing for some of the staff because some of the patients had been here ten years or something and you know, had become like family to them so it was like waving goodbye to a parent or a good friend or whatever and not knowing if you’d see them again.’’ 4. Discussion Hurricanes Katrina and Rita were collectively among the most devastating urban and regional disasters in the history of the United States. They brought to our attention the grave need for effective planning for evacuation, especially among our most vulnerable population, aged nursing home residents. This exploratory study aimed to identify characteristics of a vulnerable population of nursing home residents that necessitate specialized disaster plans tailored to meet their needs. The VANH response to Hurricanes Katrina and Rita was reviewed through the perspectives of VANH administrators and healthcare providers to find out what techniques worked and what could have been improved to better meet the needs of residents. This study identified four key characteristics of the patient population that was evacuated to VA facilities in response to the two back-to-back hurricanes—physiological frailty, psychological distress, cognitive impairment, and limited social support networks—that together highlight specific biopsychosocial vulnerabilities that may be considered by long-term care facilities in planning for future disasters. The findings partially support prior research regarding the challenges that psychological distress and cognitive impairment present for this population (e.g., Dobalian, 2006; Lemke & Schaefer, 2010; Magaziner et al., 2000). The inclusion of the biopsychosocial framework, one that emphasizes the interconnectedness of various resident needs, highlights the need for more effective responses for co-occurring problems during evacuation, such as cognitive decline and low social support. For example, in this study, the most cognitively impaired residents tended to have the weakest social support networks. Additionally, facilities experienced difficulties reconnecting evacuees with family members due to the fact that psychologically traumatized older adults could not speak and thus were unable to provide information regarding next of kin. Findings also support previous research about the importance of considering the role of social distress among residents (e.g., Hicks, 2000). Many respondents noted the need for a greater number of social workers, psychologists, and psychiatrists to provide care to nursing home residents, in particular for anxiety and stress, during the weeks after the event. Too often, disaster planning fails to adequately address the behavioral and social impacts of the disaster, beginning with the initial preparations and continuing through the response and recovery phases. Our findings thus support a model that connects behavioral and social support needs to the overall greater burden of chronic disease and age-related physical, psychological and social changes associated with nursing home residents compared to hospital patients.

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The importance of psychological distress during nursing home evacuations lends support to prior studies that have suggested that disaster-related mental health services may be of benefit to nursing home residents. For example, Brown et al. asked nursing home directors, administrators and owners to identify residents’ service use and found that although most nursing homes provided some type of mental healthcare during normal operations, disaster-related mental health services were not routinely provided to residents (Brown et al., 2010). Approaches such as Psychological First Aid, an evidence-informed modular approach for assisting people in the aftermath of disasters to reduce distress, show promise for use among nursing home residents (Brown et al., 2009). Although both hospital inpatient and nursing home residents may have special medical needs, our study suggests that approaches that may be appropriate for hospital patients may not be appropriate for nursing home residents. For example, the patient evacuation-assist device described by several respondents may be appropriate for use with the general VA hospital inpatient population, but was less suitable for residents with particular chronic illnesses such as COPD and cognitive impairment. This finding relates to the larger issue of whether the nursing homes we interviewed had their own disaster plan. The nursing homes in our study may have benefited in many ways from being co-located within a VAMC, but VAMC emergency plans at the time often did not include specific guidance for nursing homes located within VAMCs. This created a number of challenges according to respondents. Our participants were aware of the disaster plans for the larger VAMC, but did not have plans specific to the needs of nursing homes and their residents, a finding supported by the results of an analysis of community nursing home disaster plans by Castle (2008). VA’s size and scope as an integrated delivery system afforded it the opportunity to use other facilities within its organization to receive residents and provided access to resources for evacuation and receipt that stand-alone nursing homes may lack. Moreover, facilities in the path of the hurricanes could readily identify facilities that had the necessary personnel and services to meet veterans’ medical needs, such as nutrition and medications, made possible in large part due to VA’s electronic medical record system. Thus, VA’s structure as an integrated healthcare delivery system provided some relative advantages, in comparison to other facilities, in responding to the needs of its residents, but some additional attention to the specific needs of nursing home residents appears warranted even in such systems. Our findings underscore the importance of developing and adapting nursing home disaster preparedness plans to account for specific residents’ needs that render them particularly vulnerable. A ‘‘one-size-fits-all’’ approach to disaster planning is not likely to be adequate for any population with extensive biopsychosocial needs. Disaster plans must meet the specific needs of vulnerable populations such as nursing home residents regardless of whether the decision is to evacuate or shelter in place. Using the biopsychosocial framework as the foundation for evacuation planning will allow administrators to adapt or tailor plans to their populations’ specific combinations of needs and risks. Thus, although the results of this particular study about a special population may not be widely generalizable due to the study design, the emphasis on assessing vulnerability with the biopsychosocial model and designing disaster plans to meet the needs is generalizable to many special needs populations. For example, this approach may be appropriate in addressing the evacuation needs of a community based population of older adults, such as those receiving primary care through home-based programs or to those other populations with psychological disorders.

Another limitation of this study is that respondents’ perceptions may not generalize or may not accurately reflect what occurred. This may be due, in part, to the fact that interviews took place two years after the events, which may affect participants’ ability to recall events. However, Norris and Kaniasty (1992) found that victims of disaster are able to accurately recall their experiences even after some time has passed. One important consideration when considering recall bias is the extensive psychological literature on memory, and in particular, the concept of ‘‘flashbulb memory.’’ Flashbulb memory suggests especially detailed and vivid memory may sometimes be stored and retained for a lifetime. Such memories are associated with important historical or autobiographical events (e.g., the assassination of President Kennedy or 9–11), or important personal events, such as the death of a family member or witnessing an unusual trauma such as a disaster (Brown & Kulik, 1977). Additional research is also needed to better understand how best to encourage nursing home administrators and staff to adopt plans that meet the needs of frail elders and other residents in nursing homes. Moreover, we must address the identified gaps in the scientific literature with respect to assessing the longitudinal impact of evacuation on the health and overall well-being of affected individuals. Information on health outcomes would allow administrators and others to more appropriately weigh the balance of risks and benefits associated with evacuation versus sheltering for different populations. Without this understanding of the relationships between evacuation, sheltering, receiving, and biopsychosocial health outcomes, it is not possible to develop effective response plans that are appropriately tailored to fully meet the specific needs of nursing home residents. For example, future research should focus on how residents fare over the long term after a disaster. Adams et al. (2011) point out that disasters are chronic events that require an understanding of recovery over time. Blanchard and Dosa (2009) found that residents declined post-evacuation as they and the facilities struggled to regain normalcy. Castle (2008) has identified a lack of research about the long-term effect of resident relocation after a disaster. A few studies have attempted to examine the resilience and coping strategies of older adults in the context of evacuation care and stabilization (Bolin, 1999; Greene, 2002). Such studies have made salient the need to examine the person-in-environment; that is, to understand the multitude of needs of nursing home residents within the context of evacuation and recovery. Some people who live through disasters fare much better than others (Tedeschi, Park, & Calhoun, 1998). Future studies would therefore benefit from examining how individual needs of nursing home patients intersect within the context of the nursing home facility and structure, including the delivery of services as well as the organization’s safety culture, both of which are critical components to overall quality of care (Castle, Wagner, Perera, Ferguson, & Handler, 2011; Phillips & Hawes, 2005). VA is well-suited to conduct this type of research because of its access to both micro level (characteristics of residents) and macro-level (structure of delivery, care type) data, as well as due its unique ability to locate and follow veterans receiving care from VA, even if they have been relocated to another VA or VA-contracted community nursing home. Future studies thus will benefit from a greater understanding of VA nursing home residents’ long-term responses to evacuation due to disasters. 4.1. Conclusions Evacuating people out of harm’s way in the face of a disaster is rarely simple. Moreover, all evacuations are not equal and moving vulnerable populations such as nursing home residents from their usual place of care presents additional challenges. Discharge

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planning and response must consider the comprehensive needs of the population, including biological, psychological and social considerations of how a disaster will affect the older adult’s wellbeing and quality of life. The biopsychosocial framework provides a useful tool, and one that is familiar to clinicians, for considering those needs. A nursing home resident’s physical status, including his or her level of frailty, illness, and functional ability, must be considered when deciding whether and how to evacuate a facility. Separation from family and other social support must also be considered, especially for older adults who reside in their place of care.

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3. What were the most common physical health conditions? How functionally impaired were your residents? 4. How cognitively impaired were your residents? a. Approximately what percentage of your residents had psychiatric or mental health disorders not including substance use? b. What were the most common psychiatric or mental health disorders of your residents? Evacuation

Conflict of interest statement

1. When did you first learn that residents might need to be evacuated to/from your facility? How did you learn this? When did the VA contact you about a possible evacuation?

The authors have no competing interests in any organization that may gain or lose financially from the publication of this paper.

2. Were you contacted by federal, state or local agencies (Your parent organization, i.e. VA or owner)? a. How involved were you in the decision whether to evacuate?

Acknowledgments This material is based upon work supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development (Project # RRP 06-134) and the Office of Public Health. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the United States government. Appendix A. Number of respondents that mentioned each theme

3. Were any residents actually evacuated? IF YES: a. When was the decision made to evacuate residents? b. How soon after notification did you start evacuations? c. How many people were evacuated? d. What factors were discussed in order to decide whether to evacuate residents? e. How did you decide who to evacuate? 4. How were residents informed that they would be evacuated?

Theme

# respondents that mentioned theme

Physiological frailty

11

Psychological distress

8

Cognitive impairment

9

Limited social network

9

5. How were residents’ families informed? Or friends/ emergency contacts? 6. Did you get any resistance from residents or their family members about evacuating? If so, how did you deal with this? 7. How much time passed between the evacuation decision and actual evacuation of residents? (When was the first resident evacuated? The last resident?) a. How do you feel about the time that passed? 8. Please describe the actual process of the evacuation.

Appendix B. Discussion guide

a. How long did the evacuation process take? b. Where did your residents go?

Lead in questions 1. What is your position here? What was your position during the time of the hurricane(s)? 2. Is your role clinical, administrative, or both? What are the main types of activities that you are involved in at the nursing home? Is your role different now than before the hurricane(s)?

9. What aspects of the evacuation here were complicated by the residents themselves (e.g., physical, cognitive, behavioral problems)? 10. What about the evacuation process surprised you (e.g., either how well it went or unexpected difficulties that arose)? Receiving evacuees

Pre-hurricane information

1. Who notified you that you might receive evacuees?

1. Please describe the major demographic characteristics of your residents before the hurricane according to:

2. How were you notified?

a. Socio-economic status

3. What preparation did your facility undergo to get ready to receive evacuees?

b. Educational

4. How much did you know about incoming evacuees?

c. Gender d. Age e. Racial/ethnic 2. What percentage of your residents has some condition that significantly affects their ADLs or IADLs?

a. How many evacuees were you expecting? 5. Describe the process of receiving evacuees a. Who did you take in? b. How many evacuees did you actually take? c. Where did evacuees come from?

a. For what percentage of your residents is wandering a problem?

d. Did you have hosting agreements with any facilities that sent evacuees?

b. What percentage of your residents is disoriented?

e. What came with the evacuees?

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