Providing Shelter to Nursing Home Evacuees in Disasters:

\ RESEARCH AND PRACllCE

Providing Shelter to Nursing Home Evacuees in Disasters:
Lessons From Hurricane Katrina
ISarah B. Laditka, PhD, James N. Laditka, DA, PhD, Sudha Xirasagar, PhD, MBBS, Carol B. Cornman, BS, PA, RN, Courtney B. Davis, MHA,
and Jane V. E. Richter, DrPH, RN, CHES
During and after disasters, the adequacy of
response by public health agencies, medical
providers, and public safety officials is influenced by the degree to which planning has
addressed needs of special populations, such
as vulnerable older people,I-7 Previous research has found that nursing homes received
notably less support than did hospitals from
federal, state, and local response agencies
during and after disasters. 1
,2 Nearly 2 million
Americans reside in about 18 000 nursing
homes.8 In the coming decades, nursing
homes ,,111 care for many more frail older
people with increasingly complex health
needs7 ,9JO The disaster following Hurricane
Katrina further demonstrated that our nation’s disaster management system does not
respond adequately to the needs of frail older
persons in nursing homes, About 70 nursing
home residents died in 13 nursing homes
during the immediate aftermath of Katrina.l1
In addition to hurricanes, nursing homes are
vulnerable to earthquakes, tornados, chemical
spills from train accidents, and vvidespread
power outages caused by ice storms,
The public health system and nursing homes
need to incorporate the special needs of older
populations into disaster planning, training,
and education,1-7,9,12-14
‘vVe present experiences and perspectives
of administrators and staff at nursing homes
in the Gulf Coast region that sheltered evacuees from Hurricane Katrina’s path, Such
facilities are often called “sheltering” nursing
homes, From their experiences, we sought
to identify needs for preparedness training
in nursing homes that may shelter evacuees
from disaster areas and related practice and
policy needs of the public health system,
METHODS
Sample
We studied all nursing homes that could be
identified 3 weeks after Hurricane Katrina as
Objectives. We examined nursing home preparedness needs by studying the
experiences of nursing homes that sheltered evacuees from Hurricane Katrina.
Methods. Five weeks after Hurricane Katrina, and again 15 weeks later, we conducted interviews with administrators of 14 nursing homes that sheltered 458
evacuees in 4 states. Nine weeks after Katrina, we conducted site visits to 4 nursing homes and interviewed 4 administrators and 38 staff members. We used
grounded theory analysis to identify major themes and thematic analysis to organize content.
Results. Although most sheltering facilities were well prepared for emergency
triage and treatment, we identified some major preparedness shortcomings.
Nursing homes were not included in community planning or recognized as community health care resources. Supplies and medications were inadequate, and
there was insufficient communication and information about evacuees provided
by evacuating nursing homes to sheltering nursing homes. Residents and staff
had notable mental health-related needs after 5 months, and maintaining ade- I
quote staffing was a challenge. . I
Conclusions_ Nursing homes shoud develop and practice procedures to Sh81terJ
and provide long-term access to mental health services following a disaster. Nurs~
ing homes should be integrated into community disaster planning and be classified in an emergency priority category similar to hospitals. (Am J Public Health.
2008;98:1288-1293. doi:10.2105/AJPH,2006.107748)
having sheltered nursing home evacuees; we provide diversity: 2 were urban and 2 rural;
focused on evacuees primarily from affected 2 were closer to the path ofKatrina and 2 were
areas in fl,1ississippi. We contacted the Missis­ more distant; 1 included both a nursing home
sippi Health Care Association and asked for and a rehabilitation center; and the facilities
assistance identifying and contacting all shel~ had numbers of evacuees, from 3 to 50,
tering nursing homes, The association di­ The resources available to us for this rapidrected us to a list of 11 sheltering nursing response research limited us to 4 site visits,
homes on their Web site, We identified 1 additional sheltering nursing home by inter­ Survey Measures and Interview Process
viewing individuals at those listed sites, We Five weeks after Katrina, and again 15
also contacted the Gulf States Association of weeks later, in-<1epth telephone interviews
Homes and Services for the and they were conducted with administrators of the
identified 2 additional sheltering nursing 14 nursing homes, Discussion guides for all
homes in Louisiana, telephone interviews and site visits are
The 14 sheltering nursing homes in OUT shown in Table 1. All telephone interviews
study averaged 108 beds (range= 12-216, were conducted by the same author (c. B, C),
SD=47,5). Twelve were for-profit facilities. At least 1 other author (C.B.D) and anTen were in Mississippi, 2 in Louisiana, 1 in other professional staff member took deOklahoma, and 1 in Arkansas, They re­ tailed notes for all interviews, Notes were
ceived a combined total of 458 evacuees transcribed promptly after each interview
(average=32.7; range =3-38, SD=23.2). and reviewed by 2 of the authors (C. B. C
Four nursing homes in Mississippi were se­ and C. B. D). Corrections were made
lected for site visits, The 4 were selected to promptly, to ensure accurate notes. The
.1288 i Research and Practice I Peer Reviewed I Laditka et at.
American Journal of Public Health 1JUly 2008, Vol 98, No, 7
RESEARCH AND PRACTICE

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TABLE i-Telephone and In-Person Discussion Guides for Administrators and Staff in
Nursing Homes Sheltering Hurricane Katrina Evacuees: Gulf 2005-2006
Type of Interview Discussion Guide
5weeks post-Hurricane Katrina
Phone interviews with administrators (N 14) How did your facility prepare to receive residents evacuated because of
Katrina?
What type of information was received about residents evacuated to your
facility?
How did you contact family members of the evacuated residents?
Based on your experience following Katrina, describe your preparedness
recommendation,
9 weeks post-Hurricane Katrina
In·person inteNiews wtth administrators (N- 4) Describe what happened following Katrina,
Describe strategies that worked well and those that did not work well,
What did you learn because of Katrina?
Describe any new strategies you have incorporated into your plan,
In-person interviews with staff (N = 38) Describe your experiences caring for nursing home evacuees,
What problems did you face caring for evacuees?
What was helpful in caring for evacuees?
What did you learn caring for evacuees?
20 weeks post-Hurricane Katrina
Phone intelViews with administrators (N = 14) Describe status of your facility, staff, evacuees, residents, families of
residents,
Describe any changes to your preparedness plan,
average interview at 5 weeks lasted 25 dietary aides), and 14 support staff (i.e”
minutes (range = 14-47 minutes). The aver­ business, maintenance, and marketing
age interview at 20 weeks lasted 15 min­ managers, medical records and administrautes (range = 8-34 minutes). tive staff, housekeepers). These interviews
Four ofthe authors (S. B. L., S. X., C B. C, ranged from 5 to 20 minutes, with most
C. B. D.l conducted site visits 9 weeks after lasting 8 to 10 minutes,
Katrina; all 4 authors participated in every In addition to interviews with adminissite visit and interviewed a total of 4 ad­ trators and staff, during each site visit we
ministrators and 38 staff members. Admin­ toured the facility, observed the nursing
istrators and staff were asked to describe home’s setting and physical features, and
events after Katrina and to focus on their studied its model (medical or social care),
experiences receiving and caring for evac­ In 3 of the 4 nursing homes, we observed
uees, The lead author (S, B. 1.) conducted and spoke briefly with residents. Immedithe in-depth interview with the administra­ ately after each visit, S, B. L conducted a
tor and took detailed notes. The authors debriefing session with all participating
(S. B. L., S, X., C B. C, C. B. D,) also met indi­ authors and recorded impressions.
vidually v.’ith staff members to conduct interviews. Each researcher took field notes Analytic Procedures
and elaborated on them immediately after Although we used interview guides, our
the visits, The average site visit lasted 2 research was primarily phenomenological; in
hours and 48 minutes (range = 1.25-4 our analysis we used grounded theory to
hours), The average administrator interview identi1Y major themes,15 We also critically
lasted 88 minutes (range = 20 minutes- evaluated the findings of previous stud225 hours). We interviewed 24 direct-care ies,2-7.12-14,16.17 After conducting the interviews
staff (i.e., certified nursing assistants, licensed and site visits and having analyzed the data,
nurses, physical therapists, social workers, we found that the Bioterrotism and Emergency
Preparedness in Aging (BTEPA) study provided a useful conceptual framework for presenting some of the results, The BTEPA
framework was developed using an extensive
evidence review,3
Detailed notes of the telephone interviews
and site visits were transcribed promptly by
tile research team; this provided the qualitative data. We used thematic analysis18 to organize the content and to identifY patterns and
themes in the data 19 Five authors (S.B.L.,
j.N.L, SX, C.B.D., J,VE.R) participated in
the thematic analysis, 11n’ee authors (S,B.L.,
J,N.L., CB.D.) also examined responses in
the telephone interviews conducted at 5 and
20 weeks, to take advantage of the longitudinal study design, Beginning \;,>ith the BTEPA
framework, 3 ofthe authors (S,B.L.,J.N.L.,
SX) developed 8 domains of disaster preparedness for nursing homes, and drafted
their definitions, We used these domains to
organize the presentation of some of our
findings. All authors agreed on representative
examples and quotations for presentation.
RESULTS
Evacuation, Baseline Interview, and
Follow-up Interview
An average of 267.5 miles were driven by
each evacuating nursing home during the
evacuation (SD=50.7), Ten nursing homes
evacuated to elsewhere in Mississippi: 4 from
coastal areas (average travel 141 miles), and 6
from the southwestern portion of the state
(average 192 miles), Remaining nursing
homes evacuated to adjacent states (average
over 700 miles), Two evacuating homes were
in Louisiana (average 78 miles).
Table 2 shows the distribution of evacuees
at the baseline interview and 5 months later,
when 11 facilities were still providing shelter,
The mean number of evacuees at baseline
was 38,7 (range=3-68). Five months later,
the mean number of remaining evacuees was
9.6 (range = 1-28), Although we did not
ask administrators why their facilities continued to shelter evacuees, those at 9 facilities
provided the following reasons (number mentioning each reason in parentheses); evacuees
like it here and want to stay (6); evacuees do
not want to be moved or displaced again (2);
family members of residents have been
July 2008, Vol 98. No, 7 i American Journal of Public Health
Laditka et al. I Peer Reviewed I Research and Practice I 1289
\ REStARtH AND PRACTICE
TABLE 2-Number of Evacuees at Baseline
and 20 Weeks Following Hurricane
Katrina: Gulf Coast, 2005-2006
Evacuees
Facility Evacuees Remaining
Number Sheltered After 5Months
20 a
2 60 16
3 3 3
4 6 0
5 36 2
6 60 9
7 50 28
8 0
9 24 3
10 26 20
11 16 12
12 63 1
13 20 3
14 68 9
evacuated or displaced (2); and evacuating facilities are still being repaired (2). In 6 of the
14 facilities, administrators mentioned at 20
weeks that evacuees had adapted well, In 3
facilities, administrators observed that they
“have seen an increase in depression and
anxiety” or that evacuees were either ”more
demanding” or “miss home.”
Twenty weeks after Katrina, 9 facilities
indicated they were doing well, “everything
is back to normal,” or “things have finally
settled down.” The remaining facilities did
not report such improvements; 2 said that
things were not better or had gotten worse;
2 also said they were coping or adapting to
ehanges; and 1 did not comment on general
status. In the category of preparedness recommendations, there were few notable differences between responses received at
weeks 5 and 20. However, responses about
preparedness had become more specific at
20 weeks, when several administrators
spoke about upgrading contrdcts for gas or
fuel, water, medical supplies, power needs,
and transportation.
At week 20, only 1 administrator said the
facility had made changes to its disaster plan.
Eight others were considering or making
changes to their plans. Of the 6 facilities
that had not made changes and were not
thinking about doing so, 2 said their plan
worked as designed or that they were satisfied, 1 had confirmed arrangements with
community agencies and reviewed its plan,
1 was not aware of changes that needed to
be made, and 2 did not know if changes
had been made.
Results by Preparedness Domain
Our results support 8 preparedness domains (Le., groups of related issues to be considered for understanding preparedness). Six
relevant BTEPA domains3 were revised for
application to nursing home preparedness
(Table 3, domains 3-8). We also extend the
BTEPA framework and identify 2 domains
that address practice and policy needs ofthe
public health preparedness system that are
particularly relevant to nursing homes
(Table 3, domains 1 and 2).
1. Incorporating the needs ofnursing homes
into disaster plans. All 14 administrators and
several staff members provided comments in
this domain. Most administrators said that
local, state, and federal agencies provided little help. One commented, “There were no
other agencies involved. We tried to contact
FEMA and the Red Cross, but they were no
help.” There was considerable evidence that
nursing homes were not included in community preparedness planning. An administrator
in a very rural area emphasized, “We were on
our own! We just have to handle it.”
Many administrators spoke about problems obtaining gasoline from law enforcement officials. Gasoline was needed to run
emergency generators and for daily staff
commutes into work. In a representative
comment, an administrator said, “The gas
stations gave the gas to hospitals but not to
the nursing homes. We asked the sheriff to
help, but the police threatened to arrest our
staff if they took gas.” Three administrators
emphasized that nursing homes have needs
similar to hospitals. One commented, “There
needs to be recognition that nursing homes
need to be high-priority facilities and treated
more like hospitals.”
2. Using nursing hames as a community resource during a disaster. Two administrators
in rural areas emphasized that their facilities
were important community health care resources. In one instance, the administrator
and the director of nursing commented that
their facility had more activity caring for seriously ill individuals who were among the
evacuated residents than did the local hospitals. Another administrator emphasized that
older people in the community sought services in Katrina’s aftermath: “Everybody on
oxygen concentrators started flooding the
nursing home because we were the only
ones with power, They would spend time at
the nursing home then return home and
come back as needed. We set them up and
let them stay for 2 to 3 hours.”
3. Ensuring that core functions are maintained during a disaster. Even before Katrina,
most administrators and staff recognized the
need for stockpiled supplies. However, after
Katrina, most recognized the need to increase their resources in order to be prepared in 3 areas. In the first, they spoke of
the need to increase material supplies, including food, water, medications. personal
hygiene items, intra venous liquids, batteries,
and other items, beyond the recommended
guideline of 3 days-to at least a week. Eight
administrators emphasized the need to increase material supplies to meet needs of
staff of evacuated facilities and their families,
as well as families of their own staff who
sought shelter. In a representative comment.
an administrator said, “Our biggest problem
was that we got more people than we anticipated. We got the residents and their families, and the staff and their families. And we
got dogs, cats, and people who followed the
buses. We ended up with more people to
feed.” Related to supplies, several spoke
about nursing home design issues. For example, a medical records professional said,
“[you need] to have the washer and dryer
hooked up to the generator to keep some
clothes clean, [and you] need emergency
plugs in each [resident’s] room. The kitchen
needs to be hooked up to a generator.” (Facilities had gas for cooking but lacked emergency lighting in their kitchens.)
In the second area, 8 administrators spoke
about the need to call in off-duty staff, ask
staff to work overtime, use agencies to obtain
additional staff, or include staff from evacuated facilities to care for evacuees, In the
third area, 3 adrninistrators emphasized the
need to develop stronger relations with
1290 Research and Practice i Peer Reviewed I Laditka et al.
American Journal of Public Health i July 2008, Vol 98, No, 7
RESEARCH AND PRACTICE

TABLE 3-Eight Domains of Disaster Preparedness for Nursing Homes Based on Discussions With
Administrators and Staff in Nursing Homes Sheltering Hurricane Katrina Evacuees: Gulf 2005-2006
Domain Preparedness
Incorporating the needs of nursing homes into
disaster plans
Using nursing homes as community resources during
adisaster
Ensuring that core functions are maintained in
adisaster
Incorporating care approaches responsive to the
needs of diverse stakeholders
Developing geriatric-specific protocols for managing
across the continuum of care
DeVeloping strategies to maintain mental health
Coordinating and planning for transportation
Ensuring communications
Disaster preparedness coordinators need to include the needs of frail older people who reside in nursing homes in their planning.
Nursing homes should be in an emergency priority categoljl similar to that of hospitals to facilitate having lifelines restored (such
as critical utilities) and access to ambulances and other emergency vehicles for evacuation.
Nursing homes have important resources. including health care professionals, medical resources, end supplies. Thus, they Gon contribute
to community recoveljl after adisaster.
Preparedness requires nursing homes to continue to carry out normal daily operations, with adequate supplies. Training is needed to
maintain adequate stock~iles of supplies and staffing levels. Additional supplies are needed for staff and family members of
the evacuating and sheltering nursing homes. Nursing homes should have back-up vendor arrangements.
Nursing homes will serve an increasingly diverse group of older people in terms of race and ethnicity. Nursing homes should develop
processes to ensure that care is sensitive to residents with diverse backgrounds.
Nursing homes should have established triage and care procedures that address special needs of older people. Nursing homes must
ensure that medical infonmation, medications, and medica: supplies accompany evacuated residents. Nursing homes need plans
to receive evacuees.
Nursing homes need to address mental health needs of residents, evacuees, and staff. Frail older people are more susceptible to
depression following a disaster because of relocation and loss of family. Staff may experience long-term stress aSSOCiated with extra
workload in the facility and also with the need to address personal and family losses frOm the disaster.
Nursing homes need adequate evacuation plans that accommodate Wheelchairs and provide adequate heating, COOling. food, water,
and medications during travel.
Nursing homes must have back-up systems to ccmmunicate with local law authorities and families of residents: land line phones, celi
phones, and Intemet service may be disrupted for several weeks.
Note. Six education and training, clinical practice, pOlicy, and research areas for nursing home preparedness were developed (domains 3-8). Two additional domains (1 and 2) that address practice
and policy needs of the public health preparedness system were identified as being particularly relevant for nursing homes.
Source. Adapted from Johnson A, Howe JL, McBride MR, et al.3
community leaders, local fire and utility departments, and the local preparedness system.
They said strong community relations are
essential to obtaining needed supplies, such
as gasoline. One put it this way: “You need to
work closely with the local people. These are
the people who are going to help you if something happens.”
4. Jncorporating care approaches responsive
to the needs ofdiverse stakeholders. Several administrators and staff noted a need to address
evacuees’ culture. Two commented, “It’s been
a culture shock for us and them.” “They were
used to their lifestyles.” A third put it this
way, “They are looking forward to moving
back home. The weather is much colder
here…. And of course they want red beans
and rice every Monday.” There were no
comments about care differences associated
with race or language.
5. Developing geriatric~specific protocols for
managing across the continuum of care. Most
administrators and staff observed a need to
triage evacuees. Almost all administrators
said their triage worked well. They spoke
about using registered nurses to triage evac~
uees on arrival, immediately assessing their
medical needs (e.g., performing “finger
sticks” for blood sugar levels). Administrators and direct care staff emphasized that
evacuees received proper identification and
chart documents were completed by registered nurses as soon as they were received.
A representative comment by an administrdtor: “When the first group arrived, we set up
a triage, prepared warm baths, and fed
them.” Another administrator commented,
“An assembly line of 7 nurses, administrative clerks, and an activity director was
staffed to complete admissions on each person.” There was considerable evidence that
administrators and staff addressed the special needs of evacuees, ensuring that all
were well hydrated and fed and kept cool,
clean, and reassured.
Responses that identified shortCOmings
of evacuating nursing homes emphasized
the lack of infOImation about evacuees’
medical care, such as charts, care plans, med~
ications, aIld personal medical equipment.
Only 6 administrators said evacuees arrived with their medical charts or a listing
of medications. Only 3 said staff from evac~
uating facilities brought evacuees’ medications. Most administrators and several staff
members said more information should be
sent with evacuees. In a representative remark, an administrator highlighted the
“[need to take] the whole medical chart for
each resident, or at least the last month’s
chart on each resident, rather than just a
transfer sheet.”
Several administrators spoke about the
lack of a formal plan to receive evacuees.
One said, “We have a sheltering agreement
with some other facilities, but not to take resident~ in, only to send them out.” A second
commented, “\Ve had a plan to evacuate our
place but not much of a plan on how to accept people from other facilities.”
6. Developing strategies to maintain mental
health. In 8 nursing homes, staff were managing well at both 5 and 20 weeks after evacuees were received. In 6, however, there was
evidence of stress a<;sociated ,vith staffing,
July 2008. Vol 98. NO.7 i American Journal of Public Health Laditka et al. I Peer Reviewed I Research and Practice i 1291
RESEARCH AND PRACTICE

such as staff shortages. Staff were reported
to be “tired” at both 5 weeks and at 20
weeks; there were reports of inadequate
staffing, staff losses, and staff exhaustion.
Five administrators spoke in the 20-week
interview about longer-tenn concerns, including visits by the l\.1ississippi Department
of Mental Health to help evacuees and staff
“deal with loss and grief” and problems with
fmancial payments associated widl evacuees.
The director of one nursing home resigned,
reportedly because of stress that resulted
from Katrina. Sheltering nursing homes also
had to deal with long-term staff displacement,
such as temporary living in trailers. Four
administrators said their staff members were
continuing to deal with personal losses 5
months after Katrina. One commented, “It
was more traumatic for our staff than we
expected because, in dealing with the losses
and traumas of the sheltered residents, iliey
didn’t get to deal sufficiently with their 0,\111
losses .. such as missing rooftops and
oilier property damage.” Three spoke about
the importance of mentally preparing staff
for a disaster.
Emotional stress was also evident among
evacuees. One administrator commented,
“We’ve seen an increase of depression and
anxiety \-viili ilie evacuees. Some residents
cried about ilie situation because families
can’t come visit like before.”
Z Coordinating and planningfor transportation. Aliliough our focus was on sheltering
nursing homes, all administrators spoke about
the need to improve transportation, boili because poor transportation affected evacuees’
physical and emotional health in sheltering
nursing homes and because half of sheltering
nursing homes transported evacuees iliemselves. Administrators observed iliat vehicles
used for evacuation should be equipped for
the needs of disabled older people and that
staff and supplies need to be adequate for
travel. Most evacuees were transported in
buses wiiliout air conditioning during hot
and humid weather. One administrator commented, “The air conditioning on the bus
had failed. It was at least 120 degrees on
the bus. There was no lift.” Most administrators commented iliat multiple nursing homes
generally identity the same transportation
companies in ilielr evacuation plans.
8. Ensuring communications. All administrators and many staff members mentioned the
need to improve communications \-viili suppliers, law enforcement officials, and families of
residents. Administrators said landline telephones, cell phones, and Internet communications were down or unstable for weeks after
Katrina One commented, “[The food supplier] couldn’t deliver food because food orders were placed on ilie computer.” Administrators in rural areas emphasized that they
were “on ilieir own,” …..iili little contact outside ilieir facilities. Half of the administrators
and many staff members said communicating
wiili evacuees’ families was difficult because
land telephone lines and cell towers were inoperable and because of ilie ma<;sive relocation of families. Several administrators told
us it took them at least a week to contact
families, longer in many instances.
DISCUSSION
Our study of sheltering nursing homes
after Hurricane Katrina provides new insights
in 2 areas: first, nursing homes are community health care resources, and second, they
may already be well prepared for emergency
triage and treatment. Our results underscored
previous research findings showing that following a disaster, nursing homes may need to
address mental health needs and cultural
preferences of evacuees and ilie mental
health needs of residents and staff over long
periods.2
,16.17 There is considerable evidence
iliat nursing home residents have substantial
unmet mental healili needs20-
22 ; iliese needs
exacerbate ilie challenges of providing longterm mental health services to residents following disasters,
As a result of Katrina, most nursing homes
in our sample experienced physical damage
or loss of power and communications that
in many instances lasted several weeks.
Several staff members of ilie sheltering
nursing homes suffered long-term losses to
their homes or other personal property.
The sheltering nursing homes we studied
exemplify extreme conditions that facilities
need to anticipate to prepare adequately
for a disaster. Long-tenn consequences for
sheltering nursing homes following a disaster
can include loss of staff and continuing staff
1292 i Research and Practice Peer Reviewed I Laditka at 131.
shortages. They can also include reduced
productivity associated \-viili fatigue, problems
wiili emotional healili, ilie ongoing need of
staff to address ilieir own housing, transportation, family issues, and other challenges.
Consistent wiili previous studies, our results provide evidence iliat supplies were inadequate to meet ilie needs of residents and
14 evacuees. . ,5.12.13 Our study highlights the
need for additional supplies after a disaster,
such as food for family of staff and for their
pets. Also consistent wiili previous research,
iliere were major shortcomings in transportation and communication.1.2.4-6.12-14 Most nursing homes were unprepared to communicate
wiili vendors and families in ilie absence of
landline phones, cell phones, and ilie Internet.
Loss of all of these communication tools for
a period following a disaster should be anticipated.1
•
2.4-6.12-14 In 2 areas that have received
less attention, evacuating nursing homes did
not send adequate care infonnation wiili
evacuees, and most sheltering nursing homes
did not have fonnal procedures to receive
evacuees. Despite iliese shortcomings, initial
triage worked well; only after triage did
problems arise.
Aliliough ilie Joint Commission on Accreditation of Healilicare Organizations (TCARO)
requires preparedness plans,6,23 only 7% of
US nursing homes are accredited by the
Comrrrission.6 The Centers for Medicare and
Medicaid Semces also requires plans6
•
z3 but
does not specity plan characteristics,6 and
states oversee ilie plans.l.6.14.23 These required plans do not address ilie -wide range
of challenges we found iliat notably affect
ilie ability of sheltering nursing homes to
provide adequate care after a disaster. All
nursing homes should develop fonnal procedures to receive evacuees. Nursing homes
need to plan for enhanced access to mental
health semces for evacuees, residents, and
staff in ilie immediate and longer-tenn aftermaili of a disaster. When evacuating, nursing
homes should have plans to send care information, medications, supplies, staff, and
equipment. Our study results indicate that
disaster planning should be incorporated in
nursing home certification requirements and
in licenSing exams for administrators. Policymakers need to recognize nursing homes as
important healili care resources. Nursing
American Journal of Public Health i July 2008, Vol 98, NO.7
RESEARCH AND PRACTICE

homes should be in an emergency priority
category similar to that of hospitals, integrated into community disaster planning,
and involved with their local emergency
14 management divisions2 •
Given the need for rapid-response research,
budget limitations, and the intense recovery
activity at the time we conducted this study, a
larger survey was not feasible, However, we
were able to collect information about affected individuals’ experiences while the recovery process was continuing, thus, limiting
recall bias, Our findings may not be generalizable to all Gulf Coast states or to the entire
country, Nonetheless, the lessons learned suggest implications for other types of disasters
and other areas of long-term care, The disaster-related problems faced by nursing homes
we studied can occur in the “tornado alley” of
the central and southeastern United States,
earthquake-prone regions of the West Coa~t
and other areas, or anywhere that a railroad
or roadway carrying hazardous materials exists. Fires, power outages, and chemical spills
or explosions can affect large areas, as can ice
storms and heat waves. The need to evacuate
quickly can occur at any time, as can the
need to shelter and be self-sufficient for a period of time. It would be useful to examine
how the findings of this study are transferable
to other types of long-term care faeilities, such
as assisted living facilities, for future research
and policy development. IIlII
About the Authors
partment
Sarah
versity
B,
of
Laditka
South
ofHealth
Carolina.
and
Services
Sudha
Columbia.
Policy
Xirasagar
and
James
Management.
are
N
with
Laditha
the DeUniis
with the Department ofEpidemiology and Biostati.stics,
University ofSouth Carolina. Columbia. Carol B. Cornman
and Courtney B. Davis are with the Qf}ice for the Study of
Aging. University ofSouth Carolina. Columbia, Jane V. E.
Richter is with the Center for Public Health Preparedness,
University ofSouth Carolina, Columbia.
Requests for reprint’ shauld be sent to Sarah B. Laditka,
PhD,
ment,
Department
Arnold Schaal
ofHealth
ofPublic
Services
Health,
Policy
University
and ManageofSouth
Carolina, 800 Sumter St, Columbia, SC 29208 (e-mail:
[email protected]).
This article was occepted April 6, 2007.
Contributors
s.B. Laditka originated the study and its design, conducted
intervi”,,’S. analyzed the data. and drafted the article, J. N.
Laditka contnbuted to the study design, analyzed the data,
and drafted the article. S. Xirasagar conlnbuted to lhe study
design, conducted interviews, helped to analy7.e the data.
and reviewed and contnbuted to the article, C. B. Cornman
contributed to the study design. conducted interviews, and
reviewed and contributed to lhe article. C. B. Davis contributed to the study design. conducted interviews, analyzed lhe data, and reviewed and conlnbuted to lhe article.
J. VE. Richter crmtnbuted to lhe study design. analyzed
lhe data, and reviewed and contributed to lhe article.
Acknowledgments
Funding support fOT this study was provided by lhe
Coastal Resiliency Infonnation Systems Initiative for the
Southeast Rapid Response Research on Social and Environmental Dimensions of Hunicane Katrina, University
of Soulh Carolina
We lhank Marcia J. Lane for her valuable contributions to this research. We are grateful to Dale Morris and
Whitney Wall for their excellent research assistance. \’1e
also thank three anonymous reviewers for constructive
suggestions on earlier versions of this article.
Human Participation Protection
1bis study was approved by the Institutional Review
Board at the University of South Carolina.
References
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