Public Health Emergency Preparedness

Summary

The events of September 11th and the devastation caused by Hurricane Katrina demonstrate the impact of such events on the public health infrastructure and the importance of emergency preparedness activities. In addition, the reality of bioterrorism, as exemplified by the anthrax cases reported in the U.S., underscores the importance of preparing for possible bioterrorist attacks. To date, most health care preparedness planning efforts are focused on hospital and first responder preparedness. Nevertheless, we know that the elderly population is particularly vulnerable to bioterrorism and other public health emergencies due to their complex physical, medical and psychological needs. The potential role and question of preparedness on the part of nursing homes has emerged in local and national preparedness discussions. However, we have little understanding of the extent to which nursing homes have planned for and/or been incorporated into regional planning efforts (Saliba, et al., 2004; Dosa, et al., 2003; Helget, et al., 2002).

To address this issue, a series of focus groups were conducted to collect information about disaster and bioterrorism related planning activities among nursing homes in five States—North Carolina, Oregon, Pennsylvania, Washington, and Utah—and Southern California. The aims of the focus groups include:

• Determine if nursing home administrators have prepared and trained staff on disaster plans, including bioterrorism response.
• Assess the special needs of the elderly population in nursing home settings during a public health emergency.
• Determine if nursing homes are able to accommodate patient flows from acute care hospitals or provide other resources.
• Assess the impact of State regulations on the ability of nursing homes to offer support and/or surge capacity.

Focus Group Methods

The focus group discussions included topics such as the level of preparedness activities, special needs of nursing home environments/populations, ability to accept transfers, provide basic medical care and other support, and the influence of State regulations on disaster planning.

Using a convenience sampling strategy, RTI used its Integrated Delivery System Research Network (IDSRN) partners to assemble the focus groups. The IDSRN is a model of field-based research designed by AHRQ to link the Nation's top researchers with some of the largest health care systems to conduct research on cutting-edge issues in health care on an accelerated timetable.

IDSRN partners were asked to recruit staff from three to six nursing home facilities in their respective State(s) to participate in the focus group. Each focus group consisted of between 4 and 10 participants for a total of 49 participants. In selecting participants, IDS partners were asked to identify facilities characterized by:

1. High patient flows to one of their hospital facilities; or
2. A rural location or strategic location in vulnerable communities where hospital capacity or even response planning is low.

Standard focus group techniques were used (Morgan and Kreuger, 1998) to collect and analyze data. Results across all focus groups were compared to identify major themes present in all six States as well as situations unique to one or two States or facilities.

Disaster Preparedness and Planning Activities

While all nursing homes we spoke with engage in some form of disaster planning, the focus, frequency and coordination of these activities varied by facility:

• Nursing homes have plans in place for some public health emergencies, but had not done planning specific to bioterrorism. Disaster plans appear to focus on natural disasters most prevalent in a region (e.g., wild fires, earthquakes, floods, hurricanes).
• All nursing homes conduct quarterly fire drills, staff in-service trainings, and annual or semi-annual disaster drills. The topics addressed in trainings are highly dependent on facility location and State requirements.
• The level of local coordination around disaster planning differs by State. Nursing home representatives, for the most part, reported little involvement in regional coordination efforts.

Special Needs of Nursing Homes

Focus group participants voiced a variety of needs, some of which were unique to nursing homes and some which would be problematic to a variety of health facilities:

• Nursing homes are concerned about caring for special patient populations during an emergency (e.g., Alzheimer's, cognitively impaired, or high fall patients).
• Concerns about staffing in an emergency were universal, since many staff members will want to care for their own families during an emergency.
• Nursing home representatives are concerned about running out of pharmaceutical and other medical supplies in a disaster.
• The adequacy of fuel supplies to power generators is a major concern because power serves a number of important functions in these facilities.
• Nursing homes are concerned about having sufficient food and water supplies.

Potential Roles of Nursing Homes

Focus group participants suggested a number of activities nursing homes could engage in during a public health emergency:

• Nursing homes represented are willing to accept residents from area hospitals but voiced concerns about patient acuity and facility capacity and staffing.
• Nursing homes could provide basic medical care and short term shelter for community residents.
• Nursing home facilities have little excess space and should not be used to store equipment or stockpile drugs.

Influence of State Regulations on Nursing Homes

State regulations did not appear to be a strong factor influencing how nursing homes would respond during a public health emergency:

• Participants were largely unaware of State regulations governing nursing homes during a disaster or public health emergency.
• Nursing homes need formal guidance as well as resources to develop disaster plans.

Two additional themes emerged in several of the focus groups, one related to the role of the Red Cross and the other was motivated by Hurricane Katrina:

• Nursing homes are uncertain about the role of the Red Cross during a public health emergency.
• Hurricane Katrina provoked fears of liability and judgment, decreased confidence that the government will be a source of support in an emergency, and resulted in changes to the duration of time for which nursing homes think they need to be self-sustaining in an emergency.

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1. Introduction

1.1. Background on Nursing Home Disaster Preparedness

The events of September 11th and the devastation caused by hurricane Katrina demonstrate the long-term impact of such events to the public health infrastructure and the importance of emergency preparedness. In addition, the reality of bioterrorism, as exemplified by the anthrax cases reported in the U.S., underscores the importance of preparing for possible bioterrorist attacks. Despite the fact that significant progress has been made in overall preparedness, our ability to detect bioterrorist threats, communicate these in real time to the clinical, public health, and lay communities, and effectively triage and treat afflicted populations continues to raise concern. This is especially true for certain vulnerable populations, such as the elderly, whose unique psychological and medical needs require special attention.

As the U.S. population continues to age, nursing homes have become an increasingly important component of the U.S. health system. The 2004 National Nursing Home Survey estimates that nearly 1.5 million adults are admitted to the Nation's 16,100 nursing homes each year (CDC, 2004). Nearly half of all women and a third of all men are expected to use nursing home care at some point during their lives (Spillman and Lubitz, 2002). Despite their role in serving an increasing proportion of the Nation's population, nursing facilities have been overlooked as health resources and are often not incorporated into larger disaster planning efforts. This may be, in part, because of the difficulties involved in integration and coordination of stakeholders across the health care continuum.

However, this interorganizational collaboration is imperative for effective and coordinated disaster response (IOM, 2002). A complex network of local, State, and Federal government agencies must work together efficiently with community-based providers of care. Federal agencies have endeavored to provide the health care community with relevant information on threats of bioterrorism and other public health emergencies and work with communities in relief efforts following natural and man-made disasters. Nevertheless, only a handful of limited efforts focus on the mechanics of producing viable regional plans and availing surge capacity in times of need.

Most health care preparedness planning efforts are focused on hospital and first responderpreparedness. Nevertheless, the elderly are particularly vulnerable to bioterrorism and other public health emergencies because of their complex physical, social and psychological needs. The potential role and needs of preparedness on the part of nursing homes has emerged in local and national preparedness discussions, especially in the wake of Hurricane Katrina. A recent workgroup sponsored by the Health Resources and Services Administration (HRSA) recommended the development of an interdisciplinary evidence-based curriculum on emergency preparedness that would allow health professionals working with the elderly population to better address the medical needs of their population in an emergency.

However, we have virtually no understanding of the extent to which nursing homes have planned and/or been incorporated into regional planning efforts (Saliba et al., 2004; Dosa et al., 2003; Helget et al., 2002). A pilot study in the Greater Pittsburgh, Pennsylvania area found that nursing home facilities and their medical staffs were largely unprepared to recognize and respond to a bioterrorist event. Lack of personal knowledge and financial resources were cited as two of the most common barriers to preparedness and planning (Dosa et al., 2003). The purpose of this report is to address this gap in knowledge of the role nursing homes could play with respect to regional preparedness.

We hypothesize that nursing homes may strategically contribute to preparedness in their communities, especially in those communities where no hospital facility is located. Ancillary to this report, a model needs assessment tool for determining the readiness of longterm care facilities for public health emergencies is included in Appendix B.

In 2004, The Agency for Healthcare Research and Quality (AHRQ) expanded its Bioterrorism Planning and Response research portfolio to include several projects that focus on surge capacity issues. In doing this, AHRQ recognized the need to better understand two priority areas:

1. Identify ways to augment hospital bed capacity; and
2. Use models to set surge requirements.

In this report, we present the findings of a series of focus groups conducted with nursing home staff in five States—North Carolina, Oregon, Pennsylvania, Washington, and Utah—and Southern California. The purpose of the focus groups was to gauge the level of disaster preparedness and assess the special needs and potential role of nursing homes in the event of bioterrorism or other public health emergencies. The focus groups were used to address the following research questions:

1. Have nursing home administrators prepared and trained staff on disaster plans?
2. Do nursing homes have special needs associated with the elderly population that should be addressed?
3. Are nursing homes able to accommodate patient flows resulting from acute care hospital needs to free beds for surge capacity?
4. How do State regulations influence the ability of nursing homes to offer support and/or surge capacity?
5. In addition to beds, what other surge capacity capabilities might nursing homes offer?

Findings from this report can provide important insight into current nursing home preparedness activities as well as the potential role of nursing homes in larger local or regional preparedness efforts and the special needs experienced by the nursing home population.

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1.2. Organization of this Report

This report is the second report prepared for this project. The first report, The Emergency Preparedness Atlas: U.S. Nursing Home and Hospital Facilities, combines findings from interviews with State disaster coordinators with information obtained through a larger environmental assessment to consider issues of regional planning concordance relevant to preparedness and response of hospitals and nursing homes in disaster situations. In conducting this environmental assessment, we used geographic information systems (GIS) to synthesize and analyze the distribution of nursing home and hospital facilities across the United States and present the results as a series of State- and regional-level maps.

In the remainder of this report, detailed methods and findings of the nursing home focus groups are presented. Section 2 presents an overview of the methods used to compile data for this report. Section 3 presents a synthesis of the focus group results organized into several broad topic areas. Limitations of the study and conclusions about nursing home preparedness and their role in public health emergencies are presented in Section 4.

An ancillary model survey, also prepared for this project, is included at the end of this report in Appendix B: The Long-term Care Preparedness Needs Assessment tool can help regional and State planners and individual longterm care facilities determine their readiness for public health emergencies.

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2. Data and Methods

2.1. Sample Selection

Five States—Washington, Oregon, North Carolina, Utah, and Pennsylvania—and Southern California were selected for focus groups using a convenience sampling strategy. A convenience sample is technically "... any strategy other than simple or stratified random sampling" (Maxwell, 1996: 70). While not preferred, the most feasible approach in some situations is to use a convenience sample. Our main goal for using this approach was to engage all of RTI's IDSRN partners who expressed an interested in studying the project research questions.

Using a convenience sampling strategy, RTI used its Integrated Delivery System Research Network (IDSRN) partners to assemble the focus groups. The IDSRN is a model of field-based research designed by AHRQ to link the Nation's top researchers with some of the largest health care systems to conduct research on cutting-edge issues in health care on an accelerated timetable.

Four IDS partners were involved in this effort: Intermountain Health Care (Utah), Providence Health System (California, Oregon and Washington), UNC Health Care (North Carolina) and UPMC Health System (Pennsylvania). Since IDS partners were asked to identify and recruit staff from affiliated nursing homes, working with motivated IDS partners (rather than attempting to recruit participants using cold calls) resulted in good participation rates for focus groups. RTI's IDSRN consists of a diverse group of hospitals and health systems that adequately capture the heterogeneity of nursing homes across the U.S. Our six-State sample reflects diversity in five dimensions:

• Geographic.
• Level of progress and degree of coordination in both health care delivery and bioterrorism preparedness planning.
• State laws and regulations related to nursing homes services and licensure.
• Supply and demand conditions for nursing home and hospital beds.
• Organizational policies and practices.

In selecting participants, we asked IDS partners to identify facilities characterized by:

• High patient flows to one of their hospital facilities; or
• A rural location or strategic location in vulnerable communities where hospital capacity or event response planning is low.

The purpose for this selection strategy was to identify nursing homes that would be most affected by necessary discharge from the hospital back to the nursing home as well as those nursing homes that are pivotally located and could offer staff/storage/dispensing capabilities to an IDS facility in the event of a public health emergency.

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2.2. Participant Recruiting and Characteristics

For each State, we recruited staff from three to six nursing home facilities to participate in the focus group. Several facilities elected to send two representatives. Each focus group consisted of between 4 and 10 participants. Recruiting was done by IDS partner staff via email inquiries. Once facilities committed to attend the focus group, RTI staff sent a confirmation letter to each attendee explaining the purpose of the focus group and providing logistical information. Participants represented a wide range of roles and expertise ranging from executive directors, administrators, and directors of nursing to quality managers, disaster coordinators, and case managers.

Table 1 lists characteristics of the focus group participants. Each participant was paid $250 as an incentive to travel and participate in the focus group. When possible, we asked facilities to bring a copy of their disaster plan.

Table 1: Characteristics of Focus Group Participants

State	No. Nursing Homes Represented	No. Participants	Participant Titles
California	6	10	1 Executive Director 1 President 4 Administrators 1 Director of Case Management 1 Director of Quality Resources 1 Director of Plant Operations 1 Director of Clinical Services
North Carolina	4	8	3 Administrators 2 Directors of Nursing/Clinical Services 2 Disaster Coordinators 1 Director of Community Contacts/Special Projects
Oregon	9	9	1 Executive Director 3 Administrators 1 Corporate Compliance Officer 2 Staff Development Coordinators 1 Vice President of Risk Management 1 Environmental Services Director
Pennsylvania	4	6	2 Medical Directors 2 Administrators 1 Executive Director 1 Director of Resident Services
Utah	3	4	3 Administrators 1 Director of Nursing
Washington	3	4	2 Administrators 1 Director of Nursing 1 Quality Manager
Total	29	41

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2.3. Protocol Development

The primary purpose of the focus groups was to provide a multi-institutional view of the special needs and potential roles of nursing homes in surge capacity. This allows us to understand the nursing home perspective across diverse conditions and threat scenarios faced in the six States included in our sample. We developed a focus group protocol drawing directly from our stated research questions. The protocol focused the discussions on topics such as the level of preparedness activities; special needs of nursing home environments/populations; ability to accept transfers, provide basic medical care and other support; and the influence of State regulations on disaster planning.

The focus group protocol was pilot tested in North Carolina and minor revisions were made for subsequent focus groups. After the first focus group, several questions were dropped that did not affect comparability of results across the six focus groups. The focus group moderator's guide can be found in Appendix A of this report.

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2.4. Data Collection and Analysis

Each focus group took approximately one and one half hours. Standard focus group techniques (Morgan and Kreuger, 1998) were used to collect and analyze data. Each focus group was run by a two-person focus group team: one facilitator and one note-taker. Senior RTI staff trained in focus group moderation techniques ran each focus group and a junior staff member took notes using a laptop computer. All focus groups were audio-taped. Results from the focus groups were transcribed and analyzed. Results were compared across all focus groups to identify major themes present in all six States as well as situations unique to one or two States or facilities. Personal or facility names are not used in this report in order to preserve the confidentiality of participants.

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2.5. Study Limitations

Focus groups have a number of methodological limitations. First, focus groups gather the perspective of a limited number of participants and are therefore not generalizable to the larger population. While focus groups have high face validity because they rely on comments obtained directly from participants, it is important to keep in mind that results are only representative of the population involved in the focus groups. Second, focus groups require special moderating skills. The use of open ended questions and probes and the understanding of when to focus on a question and when to move on to a new topic area require a certain degree of expertise. Senior staff members responsible for moderating the focus groups have significant experience and training in focus group methodology.

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