key: cord-0927962-7rrkuje5 authors: Dobbs, Debra; June, Joseph W; Dosa, David M; Peterson, Lindsay J; Hyer, Kathryn title: Protecting Frail Older Adults: Long-Term Care Administrators’ Satisfaction With Public Emergency Management Organizations During Hurricane Irma and COVID-19 date: 2021-09-27 journal: Public Policy Aging Rep DOI: 10.1093/ppar/prab019 sha: 01cf5f57439caca8177299dd8216f6396f5d2aed doc_id: 927962 cord_uid: 7rrkuje5 nan Our friend and colleague, Kathryn (Kathy) Hyer, lost her battle with cancer on January 1, 2021. Beyond her professional accolades as former Gerontological Society of America President and Professor and Director of the Florida Policy Exchange Center on Aging, University of South Florida, School of Aging Studies, Kathy will be remembered for her work in emergency management and disaster preparedness. A highlight of Kathy's career occurred in September 2017 when she was asked by the U.S. Special Committee on Aging to give expert testimony about disaster preparedness. The testimony was solicited shortly after the well-publicized deaths of more than a dozen residents of a Florida nursing home following Hurricane Irma. Kathy used her platform to advocate for the needs of frail older adults who reside in nursing homes (NHs) and assisted living communities (ALCs). Much of Kathy's research focused on hurricane preparedness. Hurricane disasters provide a natural experiment in which the decisions made before and after the storm can severely affect the morbidity and mortality of frail older adults (Jester et al., 2020; Hua et al., 2021) . Kathy's mixed-methods research elucidated which decisions led to better outcomes among older adults residing in NHs and ALCs (June et al., 2020) . Similarly, she strived to understand which decisions had negative consequences and then worked to ensure they would not be repeated. Though hurricane disasters often framed her research, Kathy understood that the lessons of these storms could be applied to other disasters. She repeatedly advocated for the needs of older adults within the all-hazards approach to disasters, whereby disaster planning incorporates principles common to all events and can thus be readily adapted to specific contingencies (Briggs, 2005; Ciottone, 2006) . Much of this knowledge came from her work on a series of National Institutes of Health-funded grants. Before her untimely death, Kathy was Principal Investigator of Strategic Approach to Facilitating Evacuation by Health Assessment of Vulnerable Elderly in Nursing Homes II (SAFEHAVEN II), a National Institute of Aging (NIA)-funded project examining how the decision to evacuate or shelter in place during two major hurricanes in 2017 (Irma and Harvey) affected residents of NHs and ALCs in Florida and Texas. One of the first studies from SAFEHAVEN II found significantly higher rates of mortality and hospitalizations among NH residents during Hurricane Irma compared to those without storm exposure (Dosa et al., 2020a) . Much of the excess morbidity and mortality in NHs for those who have been exposed to a storm remains undocumented, as evidenced by the considerably higher mortality found in NHs compared to the mortality cited by the Centers for Disease Control for the entire state of Florida. Kathy's work with disasters also positioned her as an advocate for institutionalized older adults during the coronavirus disease 2019 (COVID-19) pandemic. In February 2020, Kathy and her SAFEHAVEN II research group closely documented the first reported COVID-19 deaths in a NH and then shortly after in an ALC in Kings County, Washington (McMichael et al., 2020) . The evidence was stark that NHs and ALCs faced a mounting challenge from COVID-19 (Dosa et al., 2020b) and would likely be "ground zero" for the pandemic. In June 2020, Kathy's research team received supplemental funding for SAFEHAVEN II from the NIA to examine COVID-19 in NHs and ALCs. Unfortunately, Kathy's cancer diagnosis and subsequent death precluded her from seeing this work to fruition. This article presents some of Kathy's final work, examining how differences in long-term care (LTC) facility ownership and size may have affected their perceived collaboration with state and local agencies during Hurricane Irma and the more recent COVID-19 pandemic. A critical component during a disaster is collaboration between LTC facilities and the state emergency operation centers (EOCs). Kathy's research queried whether the ownership and regulatory structures of LTC facilities could affect their ability or inclination to collaborate with EOCs. NHs and ALCs vary greatly in their organizational characteristics. NHs are regulated by the federal government, while ALCs are regulated by state governments and differ in the types of care they provide, their staffing levels, and infection control policies Zimmerman et al., 2020) . For example, in NHs universal infection control policies are federally mandated (Volkman et al., 2012) , while only one-fourth of all states mandate infection control policies in their ALCs (Zimmerman et al., 2020) . ALCs also differ greatly by size. Nearly half of the 28,900 licensed ALCs in the United States have between 4 and 10 beds and 15% have between 11 and 25 beds (Harris-Kojetin, 2019; National Center for Assisted Living, 2020). Small ALCs are more likely to care for older adults who receive Medicaid or have a mental illness diagnosis, and they are more likely to be in rural areas with fewer resources (Carder et al., 2015; June et al., 2020) . In Florida, small ALCs licensed to care for persons with a mental illness diagnosis are also more likely to be cited as having more deficiencies and lower quality of care (June et al., 2020) . In turn, most NHs and large, chain-owned and -operated ALCs benefit from economies of scale for resources to meet their residents' needs. These differences in ownership and regulatory structures that are also linked to size could potentially affect the level of collaboration with state and local entities during a disaster. This report highlights findings from SAFEHAVEN II concerning ALC and NH administrators' satisfaction with collaboration with state and local entities during Hurricane Irma in Florida in 2017. Results compare differences among small (<25 beds) ALCs, large (25+ beds) ALCs, and NHs. Other findings compare satisfaction with collaboration with state and local agencies in more detail related to COVID-19 among these same groups of ALCs and NHs. In addition to the descriptive numeric scaled data, a comparison of means was conducted between small and large ALCs and NHs. Finally, a comparative content analysis of open-ended responses from administrators was conducted to understand more about their level of satisfaction. For the Hurricane Irma study, we conducted 61 telephone interviews and six in-person focus groups of 3 to 7 individuals each (n = 28) for a total participant sample of 89. Data were collected between May 2018 and January 2020. Because some administrators reported on more than one site, the data from the 89 participants represented 100 locations (70 ALCs and 30 NHs). There were completed responses on the scaled 1-5 satisfaction item and open-ended responses for 87 sites (Table 1 ). The COVID-19 data were collected between October 2020 and March 2021. The satisfaction and open-ended response data were collected using an online survey distributed to Florida NHs and ALCs via email using Qualtrics software, with distribution facilitated by the LTC membership organizations and administrators with whom we have developed relationships through the SAFEHAVEN II study. A total of 202 participants completed responses on the satisfaction data (Table 1) . In both studies, the objective was to have an equal distribution of small and large ALCs and slightly fewer NHs. In Florida there are 3,154 ALCs and 705 NHs (Agency for Health Care Administration, 2021). The small ALCs (<25 beds) in Florida account for more than two-thirds of all ALC settings (n = 2,084) and 14% of all beds (n = 16,030). Large ALCs (25+ beds) account for one-third of all ALCs and 86% of all available beds (n = 98,267). The scaled 1-5 satisfaction data indicate that small ALCs were the least satisfied (mean [M] = 2.90) with state agency and EOC collaboration during Irma, compared to NHs (M = 3.04) and large ALCs (M = 3.33; Table 1) . A comparison of means test between groups for Hurricane Irma was not significant. Notably, the open-ended responses in the Irma study revealed that small ALCs perceived that they were much less prepared and felt that there was little guidance from state agencies, while many of the NHs and large ALCs felt better prepared and knew which state agencies to turn to for assistance. Below is an exemplar of a resource-rich NH that rated the collaboration a five and had a high level of involvement with their EOC: The EOC coalition has 12 or 13 members, [ours] being one of them. He [head of EOC] met with the group on a couple different occasions, conference calls as well. Being out on the barrier island, we had to move and we understood that. But with that coalition, we had building transportation locations and so forth. So we had places to go to. The following exemplifies an ALC that is part of a large chain that rated collaboration a three, but with an openended response that was positive: Interviewer: How about from state agencies? There were regular calls and things like that. Were those helpful? Respondent: That was very helpful. We were updating every couple of hours the information that's required [on the state site], and then speaking with the local association, calling on the telephone. They were very, very supportive. And then again, the governor's office. I called him three times. And we were one of the first ones to get our lights turned back on. The next example is a small ALC that rated collaboration with state and local agencies a one and explains the lack of coordination to help their facility be prepared in case of a hurricane: Well, after the hurricane, they make all these meetings we need to have … at the end of the year, we need to have gas [for the generator].… Nobody knows how many gas cans you are supposed to have in your facility. Nobody tries to help. You have to fight with everybody for you to do what they say that you are supposed to do. That's why I think they need to [provide us] more help. I want to be prepared because it's best, not for me, for my residents also, but I need help because we are a small facility. We modified the collaboration satisfaction questions for the COVID-19 survey because we learned from the Irma study that satisfaction differed by agency. Therefore, the COVID-19 survey asked about satisfaction with four different agencies: the Governor's office, Agency for Health Care Administration (AHCA), Florida Department of Health (FDOH), and the local EOC (Table 1 ). The one statistically significant finding was that large ALCs were more satisfied with their collaboration with the FDOH compared to small ALCs and NHs (Table 1 ). The mean scores indicated an overall increase in satisfaction with collaboration during COVID-19 compared to Hurricane Irma. The small ALCs were less satisfied with the collaboration with the Governor's office, but this was not statistically significant. In the open-ended responses an administrator of a small, memory care-only ALC believed that it cost lives when the state began vaccinating only NH residents in early December 2020, not offering them to ALCs until January 2021: Opening the ALs to family members has caused an undue burden on the facility. Family members want to According to this administrator, when family members started to visit for the holidays in December, several residents with dementia tested positive with COVID-19 and were hospitalized, and a number of those hospitalized died before they were able to be vaccinated. This same administrator stated, "if my residents were prioritized for vaccination in December when the nursing home residents were, this would not have happened." In contrast to the lower satisfaction rating for the Governor's office, the collaboration with the local EOC for the small ALCs had the highest mean score (M = 4.30) compared to large ALCs (M = 4.29) and NHs (M = 4.11). The results from a comparative content analysis of open-ended responses among small ALCs, large ALCs, and NHs about satisfaction with collaboration suggested that ownership and corporate structures can make a difference in the available resources and ability to respond to a crisis during the pandemic. An administrator from a large ALC stated, "corporate does a nice job in dispersing communications," and a participant from another large ALC said, "corporate policy for all buildings not only met the guidelines but went above and beyond to protect our [residents] ." An NH explains, "emergency management in [county name] has been working with us for years to develop a pandemic plan that was suited to our facility." In some cases, the state regulations for COVID-19 were difficult for a small ALC to meet, as explained by this administrator: "we are a small 14-bed facility and did not have adequate space to quarantine as required, multiple staff to cover the quarantine residents, and PPE" (personal protective equipment). There were clear distinctions in COVID-19 testing between some NHs that were able to successfully test their staff and residents in-house versus ALCs, regardless of size. The latter lacked the structure and resources to do so, as explained in the following quote from an administrator of a large ALC regarding what they perceive the issue to be with AHCA concerning testing guidelines: AHCA issued guidelines stating: Facilities not wishing to apply for a [Center for Disease Control clinical testing waiver] may also partner with an existing lab in your community in order to utilize the test kits provided. However, there is no information on what labs and how to process the testing. We have 30 unused kits. This small ALC administrator voiced frustration with collaboration with two different state agencies: The lack of information and communication between agencies such as AHCA and FDOH. AHCA mandates one thing for ALFs, but countered what FDOH was instructing ALFs. Nobody knew anything or could give ALFs a straight answer. Nobody knew what the rules were anymore and that left ALFs in a dangerous position. This quote from an NH administrator exemplifies the difference a corporate office, chain ownership, and resources can make: Like all NHs, we experienced significant PPE shortages in the early stages of the pandemic, and we had little to no support from the state health department, county emergency management, or federal government. Our company was proactive in going to whatever steps (and in some cases, at whatever cost) necessary to secure the PPE needed to keep our staff and residents safe. Additionally, our company began testing staff and residents several months before it became required, and we continue to test staff weekly and residents at least monthly, depending on staff testing results. While the methods and results of our analyses of collaboration during Hurricane Irma and the COVID-19 crisis differ, they illustrate that different types of disasters can cause severe disruptions in LTC facilities. This demonstrates the importance of an all-hazards approach to disaster planning and response. Our results further demonstrate the need for better collaboration between LTC facilities and the government agencies that regulate them and have a role in protecting vulnerable residents during a disaster, whether it be a hurricane or a pandemic. There is a need for better collaboration between LTC facilities and the government agencies that regulate them and have a role in protecting vulnerable residents during a disaster, whether it be a hurricane or a pandemic. Multiple government agencies are involved in disaster planning and responses in LTC. Not only is there a need for more collaboration between LTC facilities and these agencies, there is a need for collaboration among these agencies to determine the most appropriate role for each in responding to LTC facilities' disaster needs. A mechanism for this exists through the health-care coalitions that operate regionally within each U.S. state to bring together the private and public organizations with emergency response responsibilities. These include health-care providers and public health, safety, and emergency management organizations from their respective regions. Our results suggest that the health-care coalitions across Florida could function more effectively to help meet the needs of LTC residents in an emergency, particularly residents of small ALCs without access to resources that large, corporate, chain ALCs and NHs have at their disposal. The COVID-19 satisfaction results are more telling because we differentiated among the state agencies involved. Here, satisfaction with EOCs was relatively high overall. The one statistically significant finding was that large ALCs were more satisfied with their collaboration with the FDOH compared to small ALCs and NHs during COVID-19. The small ALCs, which were least satisfied with agency collaboration for Hurricane Irma, had higher satisfaction mean scores with agency collaboration during the COVID-19 emergency, except for the state Governor's office, which may be a result of ALCs receiving vaccinations after the NHs. Overall, large ALCs had the highest level of satisfaction with key agencies during Hurricane Irma and the COVID-19 emergency, which likely reflects the influence of organizational differences in LTC. Large ALCs are likely to be part of large, corporate-owned, chain affiliations that offer a higher level of resources and support compared to small, independent ALCs. This may reduce the dependence of the large ALCs on state agency help. Additionally, they may have advantages compared to NHs because they are not subject to the same level of regulation, including infection control, which has led to increased scrutiny of NHs by the AHCA during the pandemic. Further research into infection control requirements of ALCs versus NHs may be needed. These studies suggest that overall, LTC facilities were more satisfied with their collaboration related to COVID-19 than with Hurricane Irma. It is possible that NH and ALC awareness of the importance of working with these agencies, as well as agency awareness of LTC needs, has increased since Hurricane Irma. Another potential explanation is that state agencies reacted with greater urgency to the threat of COVID-19, as did the LTC membership organizations, when the deaths in Washington state became known and federal agencies began to issue warnings and guidelines. It is difficult to compare the two events, but our results do suggest that both events reveal some weaknesses in the critical relationships of NHs and ALCs with the agencies they depend on to manage crises that threaten their residents. These relationships seem to depend on a facility's size and access to corporate resources. Responses and comments from administrators of small ALCs suggest more work is needed to improve their linkages to organizations that can provide support to prepare for and respond to a disaster. A final thought: the role of public health during the COVID-19 pandemic, where residents were rapidly dying, was clear and immediate. During COVID-19 there was a fair amount of coordination between NHs (and, to a lesser extent, ALCs) and hospitals, testing sites, and vaccination sites. In contrast, public health agencies need to play a larger role in hurricane preparedness and response, particularly with small ALCs that do not have a built-in corporate structure like the large, chain-affiliated ALCs and NHs. This could be facilitated through the regional health-care coalitions that bring together public health agencies and providers for disaster planning. In addition, many ALC and NH administrators expressed the need for more bottom-up communication with the state, through which providers give feedback to the Governor's office about the public health needs on the ground, instead of the Governor's office putting in place mandates without more input from providers. With the certainty that there will be more disasters and infectious diseases affecting LTC facilities, more input should be considered from those providing the care, with particular attention to ownership, corporate and regulatory structures, and size in order to protect the smallest among providers in the LTC system. Large ALCs had the highest level of satisfaction with key agencies during Hurricane Irma and the COVID-19 emergency, and this may speak to the influence of organizational differences in LTC. This work was supported by the National Institute on Aging of the National Institutes of Health under award number R01AG060581-01. The sponsors had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript. July 6). 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