Guide to Emergency Planning for Vulnerable Adults

7/31/2019 Guide to Emergency Planning for Vulnerable Adults

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Identifying Vulnerable Older Adults

and Legal Options for Increasing Their

Protection During All-Hazards Emergencies

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention

A Cross-Sector Guide or States and Communities


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Contact Inormation

Centers or Disease Control and PreventionHealthy Aging Program4770 Buord Highway, N.E.Mailstop F-15Atlanta, GA 30341

elephone: 1-800-CDC-INFO (232-4636); Y: 1-888-232-6348

E-mail: [email protected]: www.cdc.gov/aging/emergency

Suggested Citation

Centers or Disease Control and Prevention. Identiying Vulnerable Older Adults and LegalOptions or Increasing Teir Protection During All-Hazards Emergencies: A Cross-Sector Guide orStates and Communities.Atlanta: U.S. Department o Health and Human Services; 2012.

Disclaimers

Te inormation contained in this document does not constitute legal advice. Use o anyprovision herein should be contemplated only in conjunction with advice rom legal counsel.Provisions may need to be modied, supplemented, or replaced to ensure appropriate citation

to or compliance with relevant local and state laws, to accurately reect the intent o parties to aparticular agreement, or to otherwise address the needs or requirement o a specic jurisdiction.

Web site addresses o nonederal organizations are provided solely as a service to readers.Provision o an address does not constitute an endorsement o this organization by CDCor the ederal government, and none should be inerred. CDC is not responsible or thecontent o other organizations Web pages.


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Identiying Vulnerable Older Adults andLegal Options or Increasing Their

Protection During All-Hazards Emergencies

A Cross-Sector Guide or States and Communities

U.S. Department o Health and Human ServicesCenters or Disease Control and Prevention


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5/56 Contents ii

CONTENTS

Executive Summary................................................................................................... v

Introduction ............................................................................................................. 1

Te Older Adult Population ......................................................................................2Denitions ................................................................................................................3

Vulnerable Populations ..............................................................................................4

Overarching Considerations ..................................................................................... 7

Developing Plans.......................................................................................................7

Identiying and Reviewing Selected Legal Authorities ................................................9

Dening Categories o Emergencies and Hazards ....................................................13

Using Operational Models o Emergency Management ...........................................14

Strategies and Options or Identiying Vulnerable Older Adults ............................. 15

Characterizing the Population .................................................................................15

Using Geographic Inormation Systems (GIS) .........................................................16

Building, Maintaining, and Using Registries ...........................................................18

Using Shelter Intake Procedures to Identiy Vulnerable Older Adults ......................20

Action Options ....................................................................................................... 25

Moving Forward ..................................................................................................... 35

Reerences ............................................................................................................... 37

Appendix A. How Tis Guide Was Developed ........................................................ 39

Work Group Guidance ............................................................................................39

Internet and Database Research ...............................................................................40

Field-Based Research ...............................................................................................40

Appendix B. Glossary ............................................................................................. 43Acknowledgments ............................................................................ Inside back cover


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7/56 Executive Summary v

Executive Summary

IntroductionWe cannot accurately predict which groups o people will be most aected by uture emergencies. However,

recent events have shown that some characteristics o older adults put them at greater risk o illness and deathduring many types o emergencies. For example, older adults may have impaired mobility, diminished sensoryawareness, multiple chronic health conditions, and social and economic limitationsall o which can impairtheir ability to prepare or, respond to, and adapt during emergencies.1 An emergency or disaster also can disruptvital support systems that older adults rely on. For many older adults, independent living is made possible onlywith help rom riends, amily, and in-home services that provide meals, home-based health care, and help withthe activities o daily living.

Events such as Hurricane Katrina in 2005 and the earthquake and tsunami in Japan in 2011 showed howvulnerable older adults can be during emergencies. Unortunately, research conducted or this guide ound threemajor limitations to our ability to plan or and protect older adults:

Many dierent strategies are being used to identiy vulnerable older adults across the country,but none o these strategies have been evaluated.

No consensus exists on the best way to identiy and protect older adults.

Gaps exist in legal mandates to protect older adults.

Tis guide is intended to help close many o the gaps in emergency planning and preparedness or vulnerableolder adults. In particular, it aims to give public health ofcials, the Aging Services Network, emergencymanagement personnel, and essential partners rom other sectors and at all jurisdictional levels (community,regional, tribal, and state) the critical inormation, strategies, and resources they need to improve the planningor and protection o vulnerable, community-dwelling older adults during all types o emergencies (otenreerred to as all-hazards emergencies).

Overarching ConsiderationsSeveral overarching considerations must be taken into account when planning or vulnerable older adults duringemergencies. For example, planning ofcials should

Include older adult issues and needs when developing preparedness plans. Tese plans should identiyessential agencies, organizations, and other stakeholders.

Identiy and review relevant legal authorities.

Dene the dierent categories o emergencies and hazards to better understand how specic emergenciesmay aect older adults in the community.

Use operational models o emergency management to identiy the specic needs o older adults duringeach phase o an emergency.

Strategies and Options or Identiying Vulnerable Older Adultso develop this guide, we conducted research, solicited input rom a cross-sector work group o subject matterexperts, and collected inormation during site visits in dierent parts o the country. We ound that none o themethods currently being used to identiy older adults who may need help in an emergency have been evaluated.


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Tese methods are as ollows:

Characterizing the population: Basic epidemiologic data can be used to guide planning or the delivery oservices, medications, durable medical equipment, and other materials needed to support older adults duringall phases o an emergency.

Using geographic inormation systems (GIS): GIS mapping technology allows ofcials to coordinateinormation about the locations o vulnerable older adult populations, community resources to help older

adults, and potential hazards. Understanding where older adults are located and how they might be adverselyaected by dierent types o emergencies can help local planners and rst responders prepare or how theywill meet the needs o older adults during an emergency.

Building, maintaining, and using registries: Registries can be developed to provide inormation aboutspecic types o helpsuch as medical equipment, transportation, or evacuation assistancethat vulnerableolder adults will need during an emergency. Tey also can serve the broader purpose o identiying olderadults who might need any type o help in an emergency.

Using shelter intake procedures to identiy vulnerable older adults in the community: Tis inormationcan be used to identiy older adults who may need special help.

Action OptionsTis guide outlines specic actions that can be taken at community, regional, tribal, state, and national levels toidentiy vulnerable older adults and plan or their needs during an emergency. Tese action options are organizedinto the ollowing categories:

Develop Plans.

Collaborate with Partners.

Collect and Use Data.

Conduct raining and Exercises.

Build, Maintain, and Use Registries.

Use Law-Based Solutions.

Prepare Older Adults and Caregivers.

Shelter Older Adults.

ake Action at the National Level.

Program Highlights and ResourcesTroughout this guide, we will provide examples rom states, communities, and existing programs that demon-strate practical options or addressing the gaps in preparedness planning. Tese examples will cover topics such asdeveloping plans or rural areas, building community partnerships, leveraging the inuence o area agencies onaging, and using technology to plan or older adults needs. Tese examples also serve as models or action andhighlight existing resources that might be helpul to proessionals working with vulnerable older adults.

Moving ForwardCDC and its work group partners hope this guide can help those involved in emergency preparedness planningat all levels understand the unique needs o older adults. Tis publication is also intended to oer specicstrategies and options or identiying and protecting vulnerable older adults during all-hazards emergencies.

For more inormation, resources, and practical tools, visit our companionWeb site at www.cdc.gov/aging/emergency.


9/56 Introduction 1

1INTRODUCTIONWe cannot accurately predict whichgroups o people will be mostaected by uture emergencies.However, events such as the 2005hurricane season and the 2011earthquake and tsunami in Japanhave shown that some characteristicso older adults put them at greaterrisk o illness and death during many

types o emergencies. For example,older adults may have impairedmobility, diminished sensoryawareness, multiple chronic healthconditions, and social and economiclimitationsall o which can impairtheir ability to prepare or, respondto, and adapt during emergencies.1

Emergencies also can disruptthe support systems that many

older adults rely on. For manyolder adults, independent livingis made possible only with helprom riends, amily, and in-homeservices that provide meals, home-based health care, and help withchores and personal care needs.In act, the majority (93%) oMedicare enrollees aged 65 yearsor older live in the community,rather than in nursing homes or

other congregate settings. Nearlyone-third o this group lives alone.2

In recent years, emergencypreparedness ofcials have begunto recognize the need to addressthe special needs o older adultsand other vulnerable populations.Landmark publications rom

AARP and the American MedicalAssociation, such as We Can DoBetter1 and Recommendations orBest Practices in the Managemento Elderly Disaster Victims,3 high-lighted the devastating eects oHurricane Katrina on older adultsand strengthened the groundworkor more ocused attention on this

population.

Te guidance oered in this publi-cation was developed by a workgroup convened by the Centers orDisease Control and Prevention(CDC). (See Appendix A. HowTis Guide Was Developed.) It isintended to help close many o thegaps in emergency planning andpreparedness or vulnerable older

adults. In particular, this guide

seeks to give public health ofcials,the Aging Services Network,emergency management personnel,and essential partners rom othersectors and at all jurisdictionallevels (community, regional, tribal,and state) the critical inormation,strategies, and resources theyneed to improve the planning

or and protection o vulnerable,community-dwelling older adultsduring all types o emergencies.

Although ofcials also need to planor and protect residents o long-term-care acilities, this guide ocuseson the protection o older adultswho live in community settings.It also uses the term all-hazardsemergenciesto reer broadly to all

types o emergencies.


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Tis guide begins with descriptionso the older adult population andkey denitions, ollowed by sectionson overarching considerations andstrategies or identiying vulnerableolder adults. It concludes bypresenting a set o potential actionoptions that can be taken in advanceto improve identication, planning,preparedness, and response eortsto protect vulnerable older adultsduring emergencies. Te appendicesinclude inormation on how thisguide was developed and a glossaryo terms used throughout the guide.

The Older Adult

PopulationTe older adult population is notcharacterized by age alone. Dierentlaws use dierent parameters todene this population, especiallyin terms o when people becomeeligible or services. For example,although adults are generallyeligible or Medicare coverage atage 65, they also become eligible

or services and protections at age60 under the Older AmericansAct (OAA).4 Te services providedunder the OAA include many types

o assistancesuch as meals, homehealth services, personal care, andtransportationthat help olderadults continue to live in theircommunities. For this guide, wedene older adult as those aged 60years or older. Another actor thatinuences whether older adultsneed help during an emergency iswhether they live in a long-term-care acility or in a community

setting. Community-dwelling olderadults may pose more complexchallenges or planning ofcials thanthose in long-term-care settings

because these acilities may alreadybe governed by specic regulations.o remain in their homes, manycommunity-dwelling adults relyon care rom amily membersor caregivers or rom servicesprovided by area agencies on aging,community organizations, or homehealth agencies.

Interruption o these services duringan emergency can compromise the

sel-reliance and independence ocommunity-dwelling older adults.For these reasons, this guide ocuseson the protection o older adultswho live in their homes in thecommunity.

Older adults are a diverse group interms o their physical and mentalhealth, and vulnerability cannot becharacterized by age alone. Complex

variations in the health status,living environments, and socialsituations o older adults also makeit hard to protect this populationduring emergencies. For example,an independent older adult wholives on the 18th oor o a high-rise building may suddenly becomevulnerable i the electricity goes out

Using Population Proles: Florida

The Florida Department o Health developed a low-tech,

low-cost data collection tool that has proven useul oremergency planning in counties and communities. For each

county, the state provides a description o the population, including

inormation on age, disability status, residency status (e.g., older adultswho live alone), ood stamp receipt, and dialysis use.

This inormation can help counties identiy the specic needs o olderadults and other vulnerable populations in an emergency. State oicials

collect data at the county and zip code level rom human serviceagencies and other sources, such as the U.S. Census Bureau and

the End-Stage Renal Disease Network. Data are given to countiesin a spreadsheet that can be easily shared and accessed during

emergencies.


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during a hurricane, shutting downthe buildings elevators. Older adultsare at increased risk o disease anddeath during emergencies because oactors such as the ollowing:

A higher prevalence o chronic

conditions, physical disability,cognitive impairment, and otherunctional limitations.

Dependence on support systemsor medical care, medication,ood, and other essential needs.

Potential limitations in theirmobility, their access totransportation, or other aspectso unctional autonomy.1,3

In addition to the direct relation-ship between age and the prevalenceo chronic conditions,5 nearly 82%o Medicare beneciaries have atleast one chronic condition, and64% have multiple conditions.6Te treatment o these conditionsmay require daily medications,specialized equipment, or carecoordination.7

I older adults are not able to getthe medications, equipment, orspecial care they need, they can beat increased risk o complicationsand death during an emergency.

DefnitionsEorts to protect older adultscan be complicated by debatesabout the sensitivity and accuracyo methods used to dene thepopulation in need. A variety o

terms have been used to denepopulations considered to bevulnerable or in need o specialattention in an emergency. Tesechallenges reect the need or termsthat are specic enough to includepeople who need special attention,but inclusive enough to encouragethe members o this population toparticipate in the planning process.

Making Communities Stronger: AARP and New Orleans

One way to improve emergency response and recovery eorts is to build strong communities. Ater

Hurricane Katrina in 2005, sta in the AARP oice in Louisiana and residents in the Hollygroveneighborhood o New Orleans came together to nds ways to make sure the needs o older adults

are met in an emergency. Their goal was to increase connections between people, stabilize community groups,and help local residents build their leadership and problem-solving skills.

Local groups Trinity Christian Community, the Carrollton-Hollygrove Community Development Corporation(CHCDC), and Hollygrove Neighbors helped residents rebuild their homes and lives ater Hurricane Katrina. In2007, AARP sta and eight Hollygrove community leaders began working together to improve the neighborhood

and local partnerships.

Training Local LeadersTheir rst project was to create the Livable Communities Academy (cosponsored by AARP and the LouisianaState University Agricultural Center). Twenty-seven residents met or 8 weeks to learn about community issues,

develop priorities or recovery, and learn new leadership and advocacy skil ls. Ater 8 weeks, residents set theollowing priorities: public saety and resident engagement, economic development, health and caregiving, andmobility and transportation. They continued to meet monthly to nd ways to get other residents involved and to

address the issues identied.

The partnership between Hollygrove residents and AARP Louisiana has since received unding rom the AARP

Foundation and the Harrahs Foundation. This unding pays or technical, research, and evaluation support andhelps the group build organizational capacity.

Preparing or EmergenciesTrinity Christian Community and the CHCDC also developed a block captain program and an emergencypreparedness and response guide or residents. Forty-ve residents were chosen to be block captains andlearn how to answer questions about disaster recovery and evacuation. Block captains received manuals withinormation about services such as the Supplemental Nutrition Assistance Program and service providers such

as the American Red Cross and FEMA. The manual also has guidance on how to choose a contractor and howmuch repairs should cost.

Block captains identiy people who need help during evacuations, and they help residents keep track o theirmedications, nancial papers, and amily contact inormation during an emergency.


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Although no consensus has beenreached on the most appropriateand useul terminology, thissection describes several termsthat are common in emergencypreparedness planning.

Vulnerable PopulationsVulnerable populationsare denedby one expert group as ollows:People who cannot comortablyor saely access and use thestandard resources oered indisaster preparedness, relie andrecovery. Tey may include peoplewith sensory impairments (blind,dea, hard-o-hearing); cognitive

disorders; mobility limitations;limited English comprehensionor non-English speaking; as wellas people who are geographicallyor culturally isolated, medicallyor chemically dependent, orhomeless.8

Although no universally acceptedterm exists to dene specicvulnerable populations, this guide

uses the term vulnerable olderadults to describe older adults whomay need additional help duringan emergency.

Communicating with Older Adults in an Emergency

To be able to take action in an emergency, people need inormation they can

understand. Oicials who work in emergency planning must be aware o the needsand limitations o diverse populations, including older adults.11 Age-related limitations

such as cognitive, hearing, and vision impairments can make it hard or some older adults to getand understand health messages or emergency inormation.12 A persons cultural background,language, and literacy level can also aect his or her ability to get, understand, and act on

inormation in an emergency at any age.

When you create health or emergency messages or instructions, keep in mind the needs o

special populations such as older adults, people with sensory impairments, and people withlimited English prociency. At CDCs Health Literacy Web site, you can nd practical inormation,

resources, and tools on how to develop materials or older adults (see www.cdc.gov/healthliteracy/DevelopMaterials/Audiences/OlderAdults/index.html).13

At-Risk PopulationsAt-risk populationswere denedby a pandemic planning advisorypanel to the Association o Stateand erritorial Health Ofcialsas ollows: Tose people most atrisk o severe consequences romthe pandemic, including societal,economic, and health-relatedeects.9

Tey are dened by the Ofceo the Assistant Secretary orPreparedness and Response as

ollows: Some individuals mayhave greater difculty accessingthe public health and medicalservices they require ollowinga disaster or emergency. At-riskindividuals have needs in one ormore o the ollowing unctionalareas: communication, medicalcare, maintaining independence,supervision, and transportation.10

Te unctional areas cited in thisdenition are commonly known bythe acronym CMIS.
http://www.cdc.gov/healthliteracy/DevelopMaterials/Audiences/OlderAdults/index.htmlhttp://www.cdc.gov/healthliteracy/DevelopMaterials/Audiences/OlderAdults/index.htmlhttp://www.cdc.gov/healthliteracy/DevelopMaterials/Audiences/OlderAdults/index.htmlhttp://www.cdc.gov/healthliteracy/DevelopMaterials/Audiences/OlderAdults/index.html


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Special Needs PopulationsTe National Response Frameworkdenes special needs populationsas ollows: Populations whosemembers may have additionalneeds beore, during, and ateran incident in unctional areas,including but not limited to:maintaining independence,communication, transportation,supervision, and medical care.Individuals in need o additionalresponse assistance may includethose who have disabilities; wholive in institutionalized settings;who are elderly; who are children;who are rom diverse cultures; whohave limited English prociency orare non-English speaking; or whoare transportation disadvantaged.14

People RequiringAdditional AssistanceTis term is used by theMassachusetts ask Force onEmergency Preparedness andPeople Requiring AdditionalAssistance.15

Functional Needs SupportServices (FNSS)Te Federal Emergency Manage-ment Agencys (FEMAs) Guidanceon Planning or Integration oFunctional Needs Support Servicesin General Population Sheltersusesa unctional needs rameworkto determine which individualsmight need help in an emergency.FNSS are dened as services thatenable individuals to maintain

their independence in a generalpopulation shelter. Tey includethe ollowing:

Reasonable modicationto policies, practices, andprocedures.

Durable medical equipment.Consumable medical supplies.Personal assistance services.Other goods and services as

needed.16


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15/56 Overarching Considerations 7

2OVERARCHING CONSIDERATIONSEvery jurisdiction (community,regional, tribal, state, and national)aces dierent challenges inpreparing or and protectingvulnerable older adults in anemergency. Many dierent actorsmust be considered, including theexistence (or lack) o relevant legalauthorities, the type o emergency

most likely to happen, and whetherthe jurisdiction is primarily urban orrural. Other relevant actors includethe jurisdictions demographics,geography, and specic environ-mental considerations.

Despite the local nature omany emergencies, events suchas Hurricane Katrina and theterrorist attacks o September 2001

showed that planning and responserequirements or major emergenciesmust go beyond the local levelbecause additional help is otenneeded rom state and ederalagencies. Tis section outlineskey overarching considerationsidentied during the developmento this guide. Tese considerationsmay help ofcials at all levels planand implement measures to protect

vulnerable older adults duringemergencies.

For example, planning ofcialsshould

Include older adult issuesand needs when developingpreparedness plans. Tese

plans should identiy essentialagencies, organizations, andother stakeholders.

Identiy and review relevantlegal authorities.

Dene the dierent categorieso emergencies and hazards tobetter understand how specicemergencies may aect older

adults in the community.Use operational models o

emergency management toidentiy the specic needs oolder adults during each phaseo an emergency.

Developing PlansComprehensive, all-hazardsemergency preparedness requires

the development and maintenanceo emergency operations plans(EOPs) that address the needs

o vulnerable older adults. Teplanning process helps encouragekey organizations and entities toestablish and maintain relationshipessential or community, regional,tribal, and state jurisdictions toeectively respond to emergencies.

Cross-Sector CollaborationCross-sector collaboration betweenall key partners across jurisdictionsis a vital part o preparednessplanning. Planning or special needspopulations, including older adults,may also benet rom includingcommunity members who representspecial needs populations. Basiccross-sector activities should includethe ollowing: identiying vulnerableolder adults and other populations

with special needs beore an emer-gency occurs, developing plans orrisk communication, providing


16/568 Overarching Considerations

shelter, ensuring continuity omedical care, transporting thesegroups to shelter and saety, andreintegrating displaced older adultsback into their communities.

Essential PartnersAgencies and organizations rom avariety o levels will be key in theplanning process. Tese groups mayinclude government entities, AgingServices Network agencies (whichmay or may not be governmental),and community partners.

Government EntitiesGovernment agencies at all levelsare critical partners in emergencyplanning and response and mayinclude the ollowing:

Federal agencies.U.S. Department o Health

and Human Services (HHS)agencies, including CDC,the Administration on Aging,the Centers or Medicare &Medicaid Services, the Ofceo the Assistant Secretary or

Preparedness and Response,

the Indian Health Service, theFood and Drug Administration,and the Health Resources andServices Administration.

U.S. Department o HomelandSecurity agencies, includingFEMA and the Customs andBorder Patrol.

State agencies.State Attorneys General.Medicaid programs.State civil deense.State departments o behavioral

health.State departments o public

health.State emergency management

agencies.State units on aging.

Regional agencies.Metropolitan ransportation

Authorities.Regional governing councils.Regional planning commissions.Local agencies.Aging services providers.Area agencies on aging.Fire departments.Hospital associations.Law enorcement agencies.Local health departments.Local emergency management

ofces.Long-term-care associations.ribal organizations.Bureau o Indian Aairs.Local councils.ribal governments.

Ensuring Workorce Competence: Hawaii

Partners rom many dierent sectors share responsibilityor identiying and protecting vulnerable older adults in

emergencies. Each group has its own training requirements,which may or may not include inormation about older adults. All

emergency responders should have a basic understanding o theunique needs o this population in order to plan and care or them

in an emergency.

The State o Hawaii is a leader in this area. In 2005, the U.S.Department o Health and Human Services unded the PacicEmergency Management, Preparedness, and Response InormationNetwork and Training Services (Pacic EMPRINTS) to provide

continuing education programs or emergency medical personnel andcommunity health providers.17 In 2009, unding was continued by the

U.S. Department o Homeland Security.

Pacic EMPRINTS works to help health proessionals

Recognize terroristic and other emergencies.Meet the acute care needs o the population, including

vulnerable populations.Participate in coordinated, multidisciplinary responses

to emergencies.Rapidly and eectively alert the public health system oan event at the community, state, or national level.

The Pacic EMPRINTS Web site oers ree, online courses and

tutorials, several o which address vulnerable populations. Healthproessionals who work with older adults in Hawaii also have beentrained through the PREPARE program, thanks to a partnership with

Mather LieWays, a nonprot organization based in Illinois (seehttp://matherlieways.com/re_prepare.asp or more inormation).



Aging Services NetworkTe Aging Services Network,created under the authority o theOlder Americans Act (OAA), isresponsible or helping to maintainthe dignity and welare o olderadults.18 It is an essential partnerin preparedness planning orvulnerable older adults. Te AgingServices Network is made up o theAdministration on Aging (AoA),56 state units on aging (SUAs),629 area agencies on aging (AAAs),244 tribal organizations, 2 NativeHawaiian organizations, and themany organizations that provideservices (e.g., home health care ormeal delivery) to older adults.

AAAs may serve a city, county,region, or other planning andservice area, and they may begovernmental, nonprot, orprivate organizations.19 Te OAArequires SUAs and AAAs to createpreparedness plans that includeinormation on how jurisdictionswill coordinate services or olderadults. Te OAA does not speciy

how these requirements should bemet.20,21

Community PartnersCommunity organizations areessential partners in identiyingolder adults and protecting themduring all-hazards emergencies.Examples o communityorganizations that may be involvedin emergency preparedness

planning include the ollowing:

American Red Cross.Community Organizations

Active in Disaster (COADs).Community services organi-

zations such as Meals onWheels.

Faith-based organizations.

Home health care and durablemedical equipment providers.

Legal Aid and other organi-zations that provide legalservices to older adults.

Nonprot social serviceorganizations.

Private-sector companies andbusiness.

Voluntary Organizations Activein Disaster (VOADs).

Identiying andReviewing SelectedLegal AuthoritiesTe ederal legal ramework orall-hazards emergency preparednessand response includes laws,

regulations, and executive orders.Tis section provides a brieoverview o some o the lawsthat may apply to older adults,

Leveraging the Infuence o Area Agencieson Aging: Hawkeye Valley, Iowa

The Hawkeye Valley Area Agency on Aging (HVAAA) inNortheast Iowa has shown that it can maintain servicesto older adults in an emergency such as a blizzard, ice storm, or

food. When older adults call or services, sta members in the Agingand Disability Resource Center assess their situationor example,

whether they need help because o a disaster. They also help callerssign up or the countys Reverse 911 high-speed telephone system

(i available in their area), which county and city oicials use to sendemergency messages.

Ater the initial phone assessment, HVAAA case managers meet withclients to develop personal emergency plans. They also get permissionto release personal inormation as needed during emergencies. They

meet with clients every 3 months to keep inormation up-to-date andidentiy other older adults who may need help.

Planning or EmergenciesTo make sure that people have ood i they are stuck at home duringbad weather, the HVAAA gives rozen and shel-stable meals to clientswho receive home-delivered or congregate meals. When the weatheris very bad, these meals are given out several times during the winter.

To make sure that services can continue in an emergency, HVAAAoicials developed a continuity o operations plan and identied sta

members who can go into aected areas i needed.

Case managers and senior center coordinators also contact clients

during emergencies or inclement weather to nd out i their needshave changed. HVAAA sta members work with service providers and

county emergency management oices to make sure clients get thehelp they need. The HVAAA also is involved in the countys COAD

partnership and long-term recovery committees, and it is a member othe states VOAD (the Iowa Disaster Human Resource Council).

In addition, the HVAAA oers regular training or health proessionals on

disaster and emergency response topics and a program or clients calledDisaster Preparedness 101. This program includes handouts rom the

HVAAA, FEMA, the American Red Cross, and county COADs that casemanagers and senior center coordinators can give to home-bound clients.

TondyourlocalAAA,visithttp://eldercare.gov.



public health, and preparednessand response activities. Individualorganizations and entities shouldconsult their legal counsel orspecic guidance on any legal issuethat may arise in their jurisdiction.

Selected Federal LegalAuthoritiesFederalism is the relationshipbetween individual states and theederal government whereby anypower not expressly granted to theederal government is reserved tothe states or to the people.22 Amongthe powers specically granted tothe ederal government in the U.S.

Directives 5 and 8 (2003); FEMAsNational Response Framework(2008); and the Pandemic andAll-Hazards Preparedness Act(PAHPA) o 2006, which amendedthe Public Health Service (PHS)Act. Although many o theseauthorities address planning orspecial needs or at-risk populations,most do not use an all-hazardsplanning ramework to address thespecic planning and preparednessneeds o vulnerable older adults.PAHPAs provisions, as codiedunder the PHS Act, do specicallyreerence older adults.

Pandemic and All-HazardsPreparedness Act (PAHPA)o 2006Te purpose o PAHPA is toimprove the Nations publichealth and medical preparednessand response capabilities oremergencies, whether deliberate,accidental, or natural.24 o thatend, PAHPA identies the Secretaryo Health and Human Services as

the lead ederal ofcial or publichealth emergency preparedness andresponse and creates the position oAssistant Secretary or Preparednessand Response.

Te act also provides newauthorities or development ocountermeasures and establishesmechanisms and grants to continuestrengthening the public health

security inrastructure at state andlocal levels. O particular relevanceto this guide, the act permits theSecretary o Health and HumanServices to require that entitiesreceiving cooperative agreementawards describe how they willinclude SUAs in their public healthemergency preparedness plans.

Constitution (Article 1, Section 8)are interstate commerce, nationaldeense, and the power to taxand spend or the public welare.Although ederalism empowersgovernment action at local, state,and ederal levels, states have generalpolice power during emergencies.23

Te legal authorities that orm thebasic oundation or preparednessor all-hazards emergencies includethe ollowing: the HomelandSecurity Act o 2002; the Robert. Staord Disaster Relie andEmergency Assistance Act o 1988;Homeland Security Presidential

Building Community Collaborationsin Massachusetts

The Franklin Regional Council o Governments (FRCOG)serves 26 towns in rural Franklin County in WesternMassachusetts. In 2007, the National Association o County and City

Health Oicials unded the FRCOG to implement the Lets Make aPlan project, which is based on a Collaborating Agencies Responding

to Disasters (CARD) program developed in Nor thern Caliornia(http://cardcanhelp.org).

The FRCOG hired a coordinator and created an advisory council o

local service agencies, rst responders, residents, and other interestedparties. The goal o the project was to help local residents prepare oremergencies. The rst step was to identiy local needs. The FRCOG

convened ocus groups o county residents, including members opopulations that might need help in an emergency (e.g., vulnerableolder adults).

Focus group members reported that most people do not know howto prepare or emergencies. The FRCOG responded by developing

a training program or residents, service agencies, and communitygroups (e.g., religious congregations, an Alzheimers support group,

community health workers, municipal housing employees).

The success o the project in Franklin County led oicials in three

nearby counties to apply or unding rom the Western MassachusettsHomeland Security Council or similar projects. All our counties

received unding rom the council and created a regional collaborativeto help residents with special needs prepare or emergencies. Toimprove emergency planning among local groups, the collaborative

created a series o conerences or community-based organizations,service agencies, and rst responders.

Formoreinformationandresources,visitwww.naccho.org/topics/demonstration/disability/MA.cfm.



Older Americans Act (OAA)As noted previously, the OAAcreated the AoA, which isresponsible or advancing theconcerns and interests o olderadults and their caregivers throughSUAs and local AAAs. Te OAAand its amendments create severalrequirements o SUAs and AAAsthat relate to preparedness planningor older adults (see able 1).

Americans with DisabilitiesAct (ADA)Older adults are not necessarilydisabled because o their age.However, emergency preparedness

ofcials should consider therequirements o the ADA whenplanning or older adults becausemany members o this populationhave disabilities such as impairedcognition or mobility. Te ADAprohibits discrimination directedtoward individuals on the basis odisability in employment, state andlocal government programs andservices, public accommodations,

commercial acilities, transportation,and telecommunications. Te ADA

also requires covered entities tomake reasonable modicationsto their policies and practiceswhen necessary to accommodatethe needs o individuals withdisabilities.25 Te ADA does notinclude specic reerences topreparedness and response, butits provisions are applicable.26 Inaddition, Executive Order 13347,signed by President George W.Bush on July 22, 2004, requiresederal agencies to (1) address the

needs o people with disabilities intheir emergency preparedness plansand (2) help state, local, and tribalgovernments do the same. ExecutiveOrder 13347 also created theInteragency Coordinating Councilon Emergency Preparedness andIndividuals with Disabilities andcharged it with ensuring that theFederal government appropriatelysupports saety and security orindividuals with disabilities insituations involving disasters.27

able 1. Selected Provisions o the Older Americans Act Related toEmergency Preparedness

SectionNo. DescriptionofProvisionSection 306(b)3 Permits area agencies on aging (AAAs) to make

recommendations to government oicials in the planningand service area and the state on the needs o olderindividuals with regard to emergency preparedness.

Section 306(a) Requires that each AAA shall, in order to be approved bythe state agency, prepare and develop an area plan or aplanning and service area or a 2-, 3-, or 4-year period,as determined by the state agency.

Section 306(a)17 Requires the plans reerenced in Section 306(a)to include inormation detailing how the AAA willcoordinate activities and develop long-range emergency

preparedness plans with local and state emergencyresponse agencies, relie organizations, local andstate governments, and any other institutions that haveresponsibility or disaster relie service delivery.

Section 307(a) Requires that each state unit on aging (SUA) shall, inorder to be eligible or grants rom its allotment underthis title or any scal year, submit to the AssistantSecretary a state plan, which under Section 307(a)29is required to include inormation detailing how thestate will coordinate activities and develop long-rangeemergency preparedness plans with AAAs, localemergency response agencies, relie organizations, localgovernments, state agencies responsible or emergency

preparedness, and any other institutions that haveresponsibility or disaster relie service delivery.

Section 307(a)30 Require that the SUAs plans include inormationdescribing the involvement o the head o thestate agency in the development, revision, andimplementation o emergency preparedness plans,including the state Public Health EmergencyPreparedness and Response Plan.

Source: Older Americans Act, 42 USC, itle III, 306 et seq. www.aoa.gov/AoARoot/AoA_Programs/OAA/oaa_ull.asp#_oc153957672.



Health Insurance Portabilityand Accountability ActTe Health Insurance Portabilityand Accountability Act o 1996(HIPAA) Privacy Rule providesederal protections or personalhealth inormation held by coveredentities and gives patients anarray o rights with respect to thatinormation. At the same time, the

Privacy Rule is balanced so that itpermits the disclosure o personalhealth inormation needed orpatient care and other importantpurposes.28 Because o uncertaintyabout how this rule should beapplied during an emergency,service providers who work withthe Aging Services Network andother social service organizations

may have concerns about theirliability i they share the names oolder adults who need help.

In 2001, HHS released a guidancememo to the AoA that states thatprograms that operate under the

OAA do not meet the criteriaor a covered entity as a healthplan. However, because they maymeet the criteria or a health careprovider and collect the type oindividually identiable healthinormation covered under theOAA, they may be subject to theHIPAA Privacy Rule.29

State Legal Authorities

State public health, emergencymanagement, and other publicsaety agencies are created andempowered under state laws.State legislatures enact laws, andadministrative agencies promulgateregulations relevant to emergencypreparedness and response andthe protection o vulnerablepopulations.

Tese legal authorities mayperorm essential unctions suchas maintaining registries o peoplewho need help during emergencies,setting up special needs shelters,and rewriting laws to allow greaterexibility or relling prescriptionsduring emergencies.

Many states mandate certainconsiderations or people with

special needs. However, our researchsuggests that most states do not havestatutes or regulations that requirejurisdictions to develop plans orprotecting vulnerable older adultsin all-hazards emergencies. Animportant exception to this ndingis Florida.30

Using the Law to Protect Older Adults

Public health legal preparedness or emergencies and

other public health priorities is dened as the attainmentby a public health system...o specied legal benchmarks or

standards essential to the preparedness o that system.31

Its core elements include the need to

Ensure the presence o eective legal authorities to carry outessential public health services.

Establish and sustain the competencies o public healthproessionals to apply those laws.

Provide or coordination o law-based eorts across jurisdictionsand sectors.

Develop and make accessible inormation about public health lawsand best practices.

Government agencies at all levels can improve their legal preparedness

or protecting vulnerable older adults by (1) identiying and assessingtheir jurisdictions relevant legal authorities and (2) ensuring that key

oicials (e.g., health oicers, emergency management directors) knowhow to apply legal authorities across jurisdictions and sectors.

Working Across JurisdictionsMutual aid agreements are important law-based tools that promote thesharing o emergency response resources across jurisdictions.32 For

example, in June 2008, when heavy rains in Iowa produced foodingthat displaced or threatened large segments o the states population,

about 65,000 Iowans aged 60 years or older needed help.33

The states area agencies on aging were overwhelmed and sought

help rom the national Administration on Aging. Oicials there knewthat subject matter experts in nursing, environmental health, and aging

were available in Florida and could be deployed to Iowa through theEmergency Management Assistance Compact (EMAC).

This event underscored the need or public health, emergencymanagement, and aging services oicials to be aware o law-basedagreements such as EMAC, which give states a simplied way to ask

or and share expertise and resources. These agreements can alsohelp states improve their legal preparedness or protecting vulnerable

older adults during emergencies.



Authority to DevelopEmergency OperationsPlans (EOPs)In general, states develop EOPspursuant to their police power.Although ederal law does notmandate that states develop EOPs,some ederal laws and agencies(e.g., Sections 319C-1 and 319C-2o the PHS Act) require thatstates create EOPs that complywith ederal plans beore theycan receive unds or emergencypreparedness. Tis requirementencourages greater coordination oresponse eorts across jurisdictions.

For more inormation about

the ederal legal ramework,which generally directs andinuences all-hazards emergencypreparedness, and additionalresources, visit the Web site oCDCs Public Health Law Programatwww.cdc.gov/phlp.

Defning Categorieso Emergenciesand HazardsOfcials ace dierent challengesin preparing or and respondingto emergencies depending on thetype o hazard. Dierent types ohazards also can aect older adultsdierently and require specic typeso planning. For example, oodsand other natural disasters thatdisplace people rom their homes

and communities are likely to aectvulnerable older adults dierentlythan contagious disease pandemicsor major winter storms that isolateindividuals and populations. Anall-hazards approach to prepared-ness recognizes the ull spectrumo hazards and potential events

and includes planning or themore common problems thatcan occur during an emergency.34Dierent organizations categorizeemergencies and hazards in severaldierent ways. FEMA, or example,uses more than 15 categories. (See

www.ema.gov/hazard/index.shtmor more inormation.) able 2lists and briey describes the majorcategories o emergencies andhazards. By understanding howdierent types o hazards aectolder adults, emergency planners

Understanding the HIPAA Privacy Rule

The Health Insurance Portability and Accountability Act o

1996 (HIPAA) Privacy Rule seeks to protect individuallyidentiable health inormation rom uses and disclosures

that may unnecessarily compromise a persons privacy.28At the same time, the rule permits disclosure o protected healthinormation without authorization rom the individual or specic

purposes, including or treatment and payment.

The Privacy Rule applies to health plans, health care clearinghouses,

and any health care provider who transmits health inormation inelectronic orm in connection with transactions or which the Secretary

o Health and Human Services has adopted standards under HIPAA(dened as covered entities). The Privacy Rule applies only to

covered entities. Many organizations that use, collect, access, anddisclose individually identiable health inormation will not be covered

entities and thus will not have to comply with the Privacy Rule.

Examples o covered entities include the ollowing:

Health plans, such as company health plans, government programsthat pay or health care (e.g., Medicare, Medicaid, health care

programs or military personnel and veterans), health insurancecompanies, and health maintenance organizations.

Health care clearinghouses, including entities that process non-standard health inormation received rom another entity intoa standard ormat or vice versa.

Health care providers, such as chiropractors, clinics, dentists,nursing homes, pharmacies, physicians, and psychologists.

The ollowing types o agencies are not covered entities under thePrivacy Ruleif they do not meet the criteria as covered entities: social

service agencies, centers or independent living, paratransit authorities,protection and advocacy organizations, and public agencies thatperorm public health activities. The terms discussed in this section

(e.g., health plan, health care provider) are specically dened in theHIPAA Privacy Rule. Local and state organizations should consult their

legal counsel to determine i their operations meet the criteria or acovered entity.

I the President o the United States declares an emergency or disasterand the Secretary o Health and Human Services declares a public

health emergency, the Secretary may waive sanctions and penaltiesagainst a covered hospital that does not comply with certain provisions

o the HIPAA Privacy Rule. However, the Privacy Rule remains in eect,and waivers apply or limited periods only.
http://www.cdc.gov/phlphttp://www.cdc.gov/phlp



at community, regional, tribal, andstate levels can improve their abilityto protect vulnerable older adults.

Using OperationalModels o Emergency

ManagementEmergencies can be classied intoone o three phases o emergencymanagement: (1) Preparedness,(2) Response and Operations, and(3) Recovery and ransition.35 Eacho these phases dictates specicunctional and operational consid-erations, including planning, useo registries, transportation, and

discharge. Although many o theseconsiderations may be part o thepreparedness phase, their relevancemay increase depending on thecircumstances and evolution othe hazard.

able 3 illustrates the overlap othe domains o unctional andoperational considerations acrossthe three phases o emergency

management. Tis table wascreated during the course odeveloping this guidein order to providea temporally phasedramework or theunctional andoperational elements oemergency management.

Tese elements can helppreparedness ofcials

identiy and plan orhow to meet the specicneeds o vulnerableolder adults during eachphase o an emergency.

able 2. Categories o Emergencies and Hazards

Category Description

Pandemic A worldwide epidemic o a disease. For example,an infuenza pandemic may occur when a newinfuenza virus appears or which the humanpopulation has no immunity.

Natural disaster andsevere weather

Includes earthquakes, extreme heat or cold,foods, hurricanes, landslides, tornados, tsunamis,volcanoes, wild res, and winter storms. Someemergencies may be urther compounded by theemergence o associated ancillary hazards, suchas communicable disease outbreaks.

Mass casualty events May result rom intentional actions (e.g., aterrorist attack) or may be unplanned (e.g., thederailment o a train with tanker cars carryingtoxic chemicals). This type o emergency has thepotential to overwhelm medical and emergencyresponse personnel and resources.

Radiation emergency May occur when radioactive material is releasedinto the environment as the result o intentionalactions or unintentional events. May result incontamination o ood and water.

Chemical emergency Occurs when a hazardous chemical that mayrepresent a threat to human health has beenreleased. Chemical releases can be the result ointentional actions or unintentional events.

Bioterrorism The deliberate release o microbial agents (e.g.,viruses, bacteria, toxins) or the purpose o causingillness or death in humans, animals, and plants.

Sources: U.S. Department o Health and Human Services,www.u.gov/pandemic/about and

CDC, http://emergency.cdc.gov/hazards-specic.asp .

able 3. Functional and Operational Considerations Related to ProtectingVulnerable Older Adults Across the Tree Phases o Emergency Management

PreparednessResponseand

OperationsRecoveryand

Transition

Planning

Competencies

Registries

Geographic Inormation Systems Mapping

Communications and Messaging

Evacuation andTransportation

Sheltering and Mass Care

Medication and Medical Needs

Discharge
http://www.flu.gov/pandemic/abouthttp://emergency.cdc.gov/hazards-specific.asphttp://emergency.cdc.gov/hazards-specific.asphttp://www.flu.gov/pandemic/about


23/56 Strategies and Options 15

3STRATEGIES AND OPTIONS FOR IDENTIFYINVULNERABLE OLDER ADULTSOur ability to accurately identiywhich older adults areor willbecomevulnerable is limitedand is a primary obstacle tohelping those in need during anemergency. Planning eorts alsocan be hampered by a lack o

understanding about how olderadults will act in an emergency,which makes it harder to ensurethat the right services and resourcesare available.

Although no best practices ortested approaches currently existto identiy vulnerable older adultsbeore an emergency occurs, avariety o strategies are being

used across the country. Manycommunities are working to assessthe needs o their older adultresidents and create plans to closegaps in preparedness.

Among the many potentialapproaches or identiying vulner-able populations or preparednessplanning, our research identiedour methods that are currentlybeing used: characterizing thepopulation; using geographic inor-mation systems (GIS); building,using, and maintaining registries;and using shelter intake proceduresto identiy vulnerable older adultsin the community.

Characterizing thePopulationOfcials at all jurisdictional levelsneed to understand the basicepidemiologic characteristics otheir older adult population to

plan appropriately or this group.Epidemiologic data can be usedto plan the delivery o services,medications, durable medicalequipment, and other materialsneeded to support this populationduring all phases o an emergency.For example, data that indicatea high prevalence o diabetes

Preparing or Emergencies in Rural AreasFranklin County is a large rural county in Western

Massachusetts. Its population covers about 725 squaremiles in an area that is geographically isolated rom the

states major urban centers. Like many rural communities,Franklin County aces challenges in preparing or emergencies(isolation rom services, less unding, and ewer resources) that are

dierent rom those in urban or suburban areas.

But rural communities also have strengths that support emergency

response and recovery in a disaster. Residents have a strong senseo community, but are also independent and sel-reliant. They see their

isolation and independence as a strength that will help them through

hard times. Residents in isolated areas know that help rom outside thecommunity might not come or more than 72 hours, so they have to beprepared to take care o themselves and their neighbors.

To overcome the challenges o less unding and ewer people torespond to emergencies, oicials in rural areas oten serve in multipleroles. For example, in the town o Deereld, elected members o the

Board o Selectmen also serve as the Board o Health. The emergencycoordinator or the Franklin Regional Council o Governments also

volunteers as a public health nurse in her community.


24/5616 Strategies and Options

among older adults in a particularcommunity can lead to morecomprehensive stockpiling andplanning or distribution o insulinduring an emergency. Categorieso inormation that can helpjurisdictions develop preparednessplans or older adults include

Demographic characteristics,including the number o olderadults and their age, sex, and

race/ethnicity, as well as the sizeand types o cultural subgroups.

Prevalence o chronic medicaland behavioral health conditions,disabilities, and unctionallimitations.

Prevalence o chronic conditions

that require specic medications,durable medical equipment, orspecial medical care.

Primary language and otherlanguages spoken by signicant

portions o the population.Te proportion o older adults

who live in the communityand the proportion who livein independent living, assistedliving, or long-term-careacilities.

Residency patterns, includingproportions that are permanent,seasonal, or periodic.

Te proportion o older adultwho receive services throughorganizations such as theAging Services Network, socialservice agencies, or home healthagencies and the proportion ocommunity-dwelling adults whodo not receive services rom any

organizations.

Potential sources or these datainclude the ollowing:

Aging Services Network clientdatabases (aggregated).

Behavioral Risk FactorSurveillance System (BRFSS).

Community surveys.Disease registries.

Hospital discharge databases.Medicaid and Medicare databases.State data centers.Pharmacy databases.U.S. Census.

Using GeographicInormationSystems (GIS)GIS is a collection o science

and technology tools used tomanage geographic relationshipsand integrate inormation.GIS helps us analyze spatially-reerenced data and make well-inormed decisions based onthe association between the dataand the geography.36 Although

Creating and Sharing Databases

To protect vulnerable older adults in an emergency, AAAs

must be able to manage client data and respond to publicinquiries. To achieve this goal, Florida developed a state

network o Aging Resource Centers (ARCs) within its 11AAAs and a central Inormation and Reerral database. Beore thisresource was created, each AAA had its own database and reerred

people to services through Elder Helplines in each county.

Oicials in the Florida Department o Elder Aairs decided to create a

central database to improve oversight and access to aging services.The Older Americans Act provided ederal unding to support the

project. Sta training was critical, and a work group with sta rom eachAAA/ARC was created to guide the transition to the new system. The

group held weekly conerence calls to set standards or collecting andreporting data and classiying resources. The group continues to meetmonthly to ensure proper maintenance o the system.

Transerring Services in an EmergencyThe new database allows helpline calls and condential client records

to be transerred rom one AAA/ARC to another in an emergency.The agency on the receiving end can take calls rom residents in the

aected area, create new client les, update existing client records, andcoordinate services. Transers are usually requested by the AAA/ARCin the aected area, but i the situation is unexpected, an AAA/ARC in

another area can activate the transer. Sta members also can connectto the database through the Internet rom another site i AAA/ARC

oices are not accessible.

In 2008, the system was tested during a real emergency, Tropical Storm

Fay. As the storm approached, calls and client records rom Miami-

Dade County were transerred to the AAA in St. Petersburg. When thestorm threatened operations in St. Petersburg, calls and records weretranserred to Tallahassee. Once the storm passed Miami-Dade County,the AAA there was able to resume handling its own calls, as well as

those rom Jacksonville, which was then under threat rom the storm.

To protect client inormation, data are backed up and transerred to astorage server daily, then moved to another site each week; the dataare stored at this site or at least 8 weeks. In addition, the databases

servers are backed up to a secure location in South Carolina.



Using GIS Technology in Hawaii

Many communities have recognized the benets o using

GIS technology to create maps o local populations,potential hazards, and community resources. In Hawaii,

the State Department o Health, State Civil Deense, andState Executive Oice on Aging work with the Pacic Disaster Center

(PDC) to make GIS mapping an integral part o their emergencyplanning eorts. The PDC is an applied science, inormation, andtechnology center that seeks to reduce the negative eects o disasters

on peoples lives and property. It is managed by the University oHawaii and primarily serves the Pacic and Indian Oceans, Hawaii,

Alaska, and other jurisdictions o the Pacic and Indian Ocean regions.

Through this partnership, planning oicials in Hawaii created a socialvulnerability indexthat includes actors such as age, race, socioeconomicstatus, health status, gender, and housing type. This inormation is used

to create a map that can be overlaid with inormation about acilities thatserve older adults (e.g., adult day care centers, assisted living acilities,adult residential care homes) and potential hazards (e.g., food zones,

volcanoes). The result is an at-a-glance visual image o the locations ovulnerable populations in relation to hazards. Planning oicials use this

inormation to decide where shelters and education are most needed.

The PDC ocuses on Hawaii and the Pacic Rim, but its Web site (www.

pdc.org) has ree tools that all states and communities can use to improvetheir mapping capabilities and prepare or all-hazards emergencies.

Evacuating and Transporting Vulnerable Older Adults

Evacuating and transporting vulnerable older adults in emergencies can be challenging or

emergency planners. A 2005 AARP survey ound that 15% o adults aged 50 years or olderwould not be able to evacuate their homes without help. O this group, hal would need help romsomeone outside their household. In addition, 25% o adults aged 75 years or older would needhelp.1 Older adults are also more likely to not have access to a car, and many use medical equipment or

assistive devices that are hard to transport.27 Even older adults with cars may need more time to prepare thanyounger adults because o diiculties driving in heavy traic or medical conditions that make it unsae or them

to sit in traic or long periods.37

Another challenge or emergency oicials is that some people may not want to evacuate. Reasons include

a distrust o government, ear o not returning home, previous experiences in shelters, and concerns aboutpets.37,38 To overcome these challenges, emergency planners work with an array o partners and use a variety

o strategies. These partners include city, county, and state departments o transportation and transit agencies,who can help to identiy and transport residents in emergencies. Registries can be used to identiy older adults

who know in advance that they will need help.Depending on the emergency, oicials can use dierent types o evacuation methods. Multi-tiered evacuationsmay be useul when oicials know when a hazard (such as a hurricane) is likely to occur.39 Under this strategy,

older adults are encouraged to evacuate beore other groups to reduce stress and the amount o time spentin traic. Publically assisted evacuation plans identiy ways to provide transportation to people who cannot

evacuate on their own (e.g., because they do not own a car or cannot drive).

No matter what evacuation method is used, an eective communication plan is key.38 Older adults need clear,

concise messages rom trusted sources, and these sources may dier by community (see Communicating withOlder Adults in an Emergency, page 4).

GIS technology can be appliedto many areas o public health,its ability to simultaneouslymap the location o populationsat risk, community resources,and potential hazards makes itextremely valuable to emergencypreparedness planning orvulnerable populations.

In the response and operationsphase o emergency management,GIS technology can be usedin real time to create a map oa disaster or outbreak that canprovide critical inormation torst responders, the media, andthe public and promote betterdecision making.

In the recovery and transitionphase, it can be used to identiypopulation shits that are due tomigration, changes in topography



that are due to an event, and thelocation o remaining communityresources.40 During the pre-eventphase, GIS mapping is useulor identiying geographic areaswith signicant populations oolder adults and the locationo known individuals who mayneed help during an emergency.Tis demographic and locationinormation can then be overlaidwith data on potential hazards(e.g., volcanoes, ood plains,nuclear power plants, chemicalmanuacturing sites).

Te resulting map can helpemergency planners ocus theireducational and communityawareness eorts on older adults inparticular neighborhoods. It alsocan help them choose saer, moreconvenient locations or evacuationroutes, shelters, transportationpickup points, supply distributionsites, and other services thatolder adults may need during anemergency.

Barriers to UsingGIS TechnologyAlthough GIS technology can oera lot o inormation to help ofcialsprotect vulnerable older adults inan emergency, it is not available inall jurisdictions. In addition, theInstitute or Advanced Biometricsand Social Systems Studies hasidentied several barriers tocommunities using GIS technology.Tese barriers include a lack ospecialized training, the high cost osotware, a lack o awareness aboutexisting data sets, and a lack oincentives or sharing data.40

Legal and LiabilityConsiderationsTe use o GIS technology to mappopulations also raises privacy,condentiality, and liabilityconcerns.41 Te data collected oremergency planning may or maynot identiy individuals. However,even when maps present onlypopulation-level data, individualscould be identiable in small

communities. Under the PrivacyAct o 1974, which applies to datacollected by ederal agencies, anindividuals location may or maynot be considered the individualspersonal identier.

With respect to privacy laws ingeneral, the National ResearchCouncil notes that, the lawsurrounding the collection,maintenance, use, and disclosure opersonal inormation by researchersand others is typically vague,incomplete, or entirely absent.41

Another concern is liabilityassociated with the accuracy and

completeness o the data collectedand disseminated as part oemergency management eorts.Agencies such as FEMA thatpresent GIS data on their Web sitespost disclaimers that state explicitlythat they will not assume liabilityor the accuracy, completeness,or useulness o the inormationprovided.42

Building, Maintaining,and Using RegistriesIn the context o emergencypreparedness, the purpose o aregistry is to identiybeore anevent occursthose individuals whomay need special attention orhelp beore, during, or ater anemergency. Registries can be basedon the specic type o help a person

needs (e.g., medical, transportation,or other special needs), or they canbe used or the broader purpose oidentiying any person who mightneed any type o help during anemergency. Many jurisdictions alsouse registries as a way to provideinormation to older adults on howto prepare or emergencies.

Exampleo GIS

Map



Development, Maintenance,and ResourcesLocal registries are oten theproduct o collaborations betweengovernment entities, communitygroups, and social service providers.In some jurisdictions, registriesare developed and maintained bya local or state government entity,such as the ofce o emergencymanagement. In areas where

unding is limited (e.g., rural areas),groups may pool their resources todevelop regional registries.

o account or changes in place oresidence, special needs, and otheractors or people already registered,as well as or incremental additions,

registries must be updated regularly.Keeping registries up-to-date isdifcult because the number opotential registrants is alwayschanging as people visit or moveinto or out o a given area. Methodsor maintaining and updatingregistries include annual remindersto registrants to review theirinormation. Tese reminders canbe sent with utility bills.

Registry development and mainte-nance requires sustained stafngand resources. Some jurisdictionsund registries through emergencyresponse unds, while others relyon volunteers and communitycollaboration.

ypes o registries may include theollowing:

Special needs registries mayhave a broad scope, listing anyperson who might need helpduring an event, or be limited

to specic special needs (e.g.,individuals with specic typeso physical or mental disability,impaired mobility, dependenceon medication or medicalequipment, or limited cognitiveunction). As discussed in theIntroduction, the term specialneeds is not standardized andcan have meanings that varyby context.

Medical needs registries arelimited to individuals who havespecic, identiable medicalneeds. Tese registries mayrequire documentation roma doctor about the personsspecic diagnosis and medicalrequirements (e.g., or oxygenor dialysis).

ransportation registriesidentiy people who cannot

evacuate a location or areabeore an event without help(e.g., older adults, people withspecial or medical needs).

Legal AuthorityRegistries can be mandated bystate law or local ordinances, orthey may be developed by anygovernment ofcial in the normalcourse o his or her duties, subject

to enabling legal authority. Localordinances (e.g., those enacted bycity or county governments) maydirect a local agency or ofce todevelop and maintain a registry opeople with special needs, althoughsuch authority is not required.

Mandating the Use o Registries: Florida

The Florida state legislature requires the use o registries

or emergency planning as part o the State EmergencyManagement Act.43 This act notes that Florida is vulnerable

to a wide range o emergencies and that recent populationgrowthparticularly in the number o older adultscomplicates eorts

to coordinate emergency management activities.The act requires that local emergency management agencies maintain

registries o people with special needs in their jurisdictions to meetthe special needs o persons who would need assistance duringevacuations and sheltering because o physical, mental, cognitive

impairment, or sensory disabilities. Rules or the registries includethe ollowing:

The registration shall identiy those persons in need o assistanceand plan or resource allocation to meet those identied needs.

To assist the local emergency management agency in identiyingsuch persons, home health agencies, hospices, nurse registries,

home medical equipment providers, the Department o Children

and Family Services, Department o Health, Agency or HealthCare Administration, Department o Education, Agency or Persons

with Disabilities, and Department o Elderly Aairs shall provideregistration inormation to all o their special needs clients and to all

persons with special needs who receive services.The registry shall be updated annually.The registration program shall give persons with special needs the

option o preauthorizing emergency response personnel to enterhomes during search and rescue i necessary or saety and welare

ollowing disasters.



Methods or collecting inormationon registrants may include theollowing:

A Web orm that people canuse to submit and update theirinormation.

A central phone number thatpeople can call to register.

Social service workers orvolunteers who collectinormation rom clients whenthey apply or other publichealth services.

Direct-mail registration ormsthat people can ll out andreturn.

Some older adults might bedistrustul o providing personalinormation to an unknown entity.For this reason, registry ofcialsmay nd it easier to collect personalinormation and register olderadults in person at a senior center orthrough a known service provider,such as a home health care aide.

Legal Considerations

LiabilityJurisdictions may be concernedabout liability and about creatingthe expectation that, by enrollingan individual into a registry, helpis guaranteed. o address thisconcern, many jurisdictions require

that registrants be ully inormedabout the ollowing:

With whom the inormationwill be shared.

How inormation will be used.Security measures in place or

protecting inormation.Te type o help that may be

available.Limitations on help (e.g., help

is not guaranteed).

EffectivenessRegistries are used with varyingdegrees o eectiveness andare inuenced by actors suchas geography, demographics,

perceived risks, requirements orupdates and maintenance, andresource allocation. Communitiesshould ully assess whether they cansupport a registry and tailor theirregistration process to the specicdemographics o their community.Although many state and localjurisdictions have developedregistries, ew have been evaluated

to assess their utility, eectiveness,or impact.

Using Shelter IntakeProcedures to IdentiyVulnerable Older AdultsSheltering people aected bydisasters is a key componento emergency managementand response. Shelters providetemporary protection and reugeduring and immediately ateran emergency or hazard. Teshelter intake process also can bean eective way or emergencymanagement ofcials to identiyolder adults in the community whoneed special help.

Identiying Vulnerable Native Populations

One way to identiy areas o need in an emergency is

to estimate the number o vulnerable older adults in acommunity and compare it with the number o potential

caregivers. This caregiver ratio indexcan help planning oicials identiythe resources available to meet the communitys needs and the gaps

that may exist in an emergency.This issue is especially important or American Indian and Alaska

Native (AI/AN) populations, which oten live in separate, distinctcommunities.44 AI/AN populations are shiting in ways that canaect the way oicials plan or emergencies. For example, in some

communities, the number o younger adults who could serve ascaregivers has dropped in comparison to the number o vulnerable

older adults who need help.

Researchers are also using GIS technology to map the migration o

younger AI/AN adults and the concentrations o vulnerable older adults.The resulting data can help oicials plan or emergencies.

Requiring Shelter Accommodations

or Older Adults: FloridaSome states mandate that shelters provide space or

populations with special needs, such as vulnerable olderadults. In Florida, the State Emergency Management Act

requires the Division o Emergency Management (DEM) to submita state plan that identies the location and size o special needs

shelters.45 The state Department o Health is required to help theDEM meet the needs o people with special needs, who are identiedthrough registries and other sources.



Categories o shelters havehistorically included generalpopulation shelters, specialneeds shelters, medical needsshelters, pet-riendly shelters,specialty population shelters,and unconventional shelters.

Unconventional shelters includeany type o acility, such as hotels,motels, tents, preabricatedmodular acilities, trains, or ships,that are used when traditionalshelters become ull.

In November 2010, FEMAreleased its Guidance on Planningor Integration o FunctionalNeeds Support Services in

General Population Shelters. Tispublication provides guidance toemergency managers and sheltermanagers on how to meet accessand unctional needs o all peoplein general population shelters.16AlthoughFEMAs FunctionalNeeds Support Services (FNSS)guidance does not require new legalobligations, it emphasizes existinglegal rights, such as accessibility

and nondiscrimination.Under the new FNSS guidancerom FEMA, the types o shelterswill include the ollowing:

General population shelter:An organized, temporaryaccommodation or peopledisplaced by an event ordisaster, also reerred to as acongregate or emergency shelter.

Individuals with unctional andaccess needs are accommodatedin this type o shelter i they donot require sustained or ongoingmedical supervision.

Medical special needs shelter:A shelter that serves peoplewho need sustained help or

supervision o their medicalneeds, but who do not havean acute condition requiringhospitalization.

Te American Red Cross operatesgeneral population shelters intimes o emergency and has anorganizational commitment

to serve all people aected bydisasters, including people withdisabilities and unctional or accessneeds. o help integrate the newFNSS guidance into its operations,the American Red Cross developedand distributed internal guidanceor its chapters.46

Planning or Discharge oVulnerable Older Adults: Florida

Any emergency can leave people displaced and in need

o shelter, ood, and support services, temporarily or longterm. People evacuated to temporary settings such asshelters, hospitals, or other acilities may not be able to return

home saely ater an event or disaster, or they may need support

ater they return.

Discharge planning is the process o moving people rom temporaryshelters back into the community during the recovery and transition

phase o an emergency. People may go back to their ormer homeor to alternative housing.47 Discharge planning must begin beore an

emergency to ensure that all necessary partners are involved. Byplanning ahead, emergency management oicials can make sure that

the health o vulnerable older adults does not decline (especially i theyhave to stay in shelters or long periods) and that older adults are notreleased into the community without proper support.

The Aging Services Network oten takes the lead in helping olderadults move back into their communities ater an emergency. Partners

may include local and state health departments, community serviceagencies, the U.S. Department o Veterans Aairs, state agencies that

serve people with disabilities and their amilies, emergency managementorganizations, housing coalitions, hospitals, and assisted living acilities.

Creating Discharge Planning TeamsIn 2006, the Florida legislature enacted House Bill 7121 to improvethe states emergency management eorts and amend the statute that

governs special needs shelters (Section 381.0303). The new law calls orthe creation o multiagency discharge planning teams or special needs

shelters and states that these teams should have specic duties andinclude members o specic state agencies. The legislation authorizes

the Secretary o the Florida Department o Elder Aairs to convene a

discharge planning team at any time it is needed to help local areasset up special shelters. Local agencies can contact state oicials i they

need help.

Members o the discharge planning team work with shelter clients or

their caregivers to ll out a Discharge Planning Tool or Rapid NeedsEvaluation orm. This orm helps oicials determine i clients will be

able to return to their ormer home when a shelter closes. I a personneeds alternative housing, the team helps nd housing and ensures that

support services are available.



Legal AuthoritySheltering or individuals withspecial needs, including vulnerableolder adults, can be mandated bystate law or local ordinances orby any government ofcial in thenormal course o his or her duties,subject to enabling legal authority.Local ordinances enacted by cityor county governments may directa local agency or ofce to developsheltering plans or people withspecial needs, although suchauthority is not required.

Te ADA requires that shelteroperators make reasonable accom-modations and modications to

shelter procedures, including theprovision o auxiliary aids andservices, as well as accommodationsor service animals.

Planning ConsiderationsPartnerships are critical in planningand operating shelters because thecomplex issues that arise during anemergency cannot be solved by oneorganization; the required activities

are cross-cutting. Groups that can

be involved in shelter planningmay include the ollowing:

Aging Services Network.Community service agencies

(e.g., American Red Cross,United Way, Meals on Wheels,

senior centers).Emergency management

agencies.Faith-based organizations.Public health agencies.

Te special needs o older adultsmay present certain challenges toshelter ofcials. For example, someolder adults may be able to walk ontheir own, while others may need

devices such as canes, crutches, orwalkers. Some may be dependenton certain electrical equipment orneed help with medical care, suchas someone to give them theirmedication or a nurse to monitortheir health.

Some older adults may be dependenton others to help them with routinecare and activities o daily living,such as eating, walking, toileting,

and personal hygiene.

Challenges to providing appropriateshelter to older adults include theneed to

Respond to the continuallychanging and evolving nature othe specic event or hazard.

Get the appropriate durablemedical equipment.

Provide a sae, secure environ-ment that takes into accountthe potential or abuse andneglect o older adults becauseo their cognitive and physicalimpairments.

Provide sta members who havebeen trained to care or thespecic physical, cognitive, and

emotional needs o older adults.

When planning or older adults,ofcials must ensure that shelteracilities meet the special needso this population. For example,shelters must

Be accessible to people whoneed help or certain accommo-dations to perorm routine care

or activities o daily living (e.g.,to use the bathroom, bathe,dress, groom, or get into andout o bed).

Be accessible to people whohave certain disabilities, such asthose who use a wheelchair.

Include signs and other ormso communication that can beunderstood by older adults.

Include energy sources or

electricity (i.e., generators),heating, and air conditioning.

Individual ConcernsMany older adults may be aectedby some degree o cognitiveimpairment, limited mobility, andvision or hearing impairment.Older adults also are more likely to



able 4. Planning Concerns or Sheltering in Place, Social Distancing, and Other Forms o Isolation

EmergencyAction

DenitionofAction

PlanningConcerns

Sheltering inplace

Occurs when people are warned to remainindoors and to make a shelter out o the placewhere they are located. Sheltering in placemay be necessary during an event such as achemical spill or radiation emergency.

Promoting personal preparedness. Communicating risk to older adults. Educating the public about saety issues.

Socialdistancing

Reers to inection control measures that limitthe spread o pandemic infuenza or otherinectious agents by reducing the opportunityor people to come in contact with inectedpersons.

Planning or disruptions in access to routinemedical care.

Managing obstacles or in-home serviceproviders to make health visits, deliver meals,or perorm other home-based services.

Managing limitations in the continuity ooperations plans o home health care agencies.

Isolation due tocircumstances

Occurs when people are isolated at homebecause o weather or other environmentalevents, such as an ice storm or fooding, thatinterrupt normal daily activities.

Planning or disruptions in access to routinemedical care.

Managing obstacles or in-home serviceproviders to make health visits, deliver meals,or perorm other home-based services.

Managing limitations in the continuity ooperations plans o home health care agencies.

Sources: CDC,www.bt.cdc.gov/planning/shelteringacts.asp and CDC, Social Distancing Law Project materials,www.cdc.gov/phlp.

be aected by medical conditionsthat require medication, oxygen, ormedical devices. Tese impairmentsand special needs can make it moredifcult or older adults to managetheir experience in a shelter. Otherissues to consider include

Can the person sleep on a cotor mat?

Does the person have a stablemedical condition or anunstable condition that require

Guide to Emergency Planning for Vulnerable Adults

Documents