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In emergency, keeping track of clients is Job One
It’s the worst possible way to learn how your agency will cope in a natural disaster — by weathering one.
For a number of agencies across the West, this summer proved to be a trial by fire, literally. Forest fires raged out of control for weeks, scorching hundreds of thousands of acres and causing evacuations and property damage.
The operators of two such agencies, one in western Montana and another in New Mexico, say that all the disaster planning in the world doesn’t fully prepare you for how a true emergency will test your staff and yourself. (See article, p. 18.)
"A disaster plan can sit there for years and years without anyone pulling it out and looking at it," says Jane Hron, BSN, home care director for Marcus Daly Home Care, Hamilton, MT. "Even if it’s part of your mandatory review, you don’t look at it that closely until you’re right in the middle of [an emergency]."
And the effects of a natural disaster can last long after the event itself has passed.
Sarah Rochester, director of the Los Alamos (NM) Visiting Nurse Service (VNS), says she’s still coping with the financial problems caused by the evacuation of her agency in May. In addition, the dislocations caused by the fires have increased turnover and lowered morale among staff.
"Two of my full-time nurses lost their homes," Rochester says. "And we have lost both of them, because they can’t go through this community anymore. I would think it would be difficult to jump in your car and drive by your own home that had burned down or the route you would have taken. That would have to be devastating."
Warnings, but still surprises
In both cases, the directors say, there were warnings that the fires might threaten residential areas and cause evacuations. But the slow movement of the fires was deceptive: A shift in winds or other factors could put a whole new area at risk overnight, causing agencies to scramble to keep up with clients who were being moved.
In fact, both say keeping track of the movements of their clients and staff constituted the greatest challenge in operating during the fires.
In western Montana, forest fires began threatening residential areas in late July, with residual effects continuing through August and up until rains came over the Labor Day weekend, Hron says.
In Hamilton, Marcus Daly Home Care kept a large map of the coverage area studded with pins marking where clients were living. As the media released information about the movement of the fires in the area, Hron says it was fairly easy to figure out who might be affected.
She says the agency’s planning efforts were aided by emergency management personnel, who tried to alert residents days in advance when they were on standby to be evacuated. "That gave us the leeway as a provider to be talking to patients and saying, If they put you on standby, let us know.’"
However, she says, there were a few instances in which clients left without notifying the agency and had to be tracked down. "That only happened a couple of times, because then the staff were getting better at talking with the patients ahead of time and they started to let us know [about relocations]," Hron says.
She says the mapping procedure already was part of the agency’s disaster plan. But missing from the plan was a way to keep track of the staff, who themselves were being evacuated. Staff members often would have to take several days off to move their own households, Hron says.
In New Mexico, fires set in Bandelier National Monument in May spread out of control, threatening the Los Alamos National Laboratory and the city of Los Alamos.
Rochester says the warnings there came with less preparation time — and had a crushing impact on the VNS’ operations.
Not only did the fires strike one of the areas of town with the largest concentration of retirees, but the agency’s offices also were evacuated.
"They suggested part of the community evacuate on a Monday," she says. "On Tuesday, that group stayed evacuated and one other area of the community was put on potential alert. On Wednes-day morning, everything looked much better, and the firefighters were saying they thought they had it under control.
"Wednesday at noon, the winds whipped up, the fire jumped the canyon, and we were all told to evacuate immediately. It was just amazing."
Rochester says she had 10 minutes to figure out what to take with her from the agency offices. She had the forethought to grab a notebook that listed minimal information about each patient.
After moving the operation to her own home, Rochester and her staff began calling the area’s makeshift shelters — schools, churches, casinos, anywhere the Red Cross had put cots for people to stay.
"Whenever anybody was placed in a shelter, they had to register. We called the shelters — all of them — to find people," she says. "And at the same time, we were hearing from relatives who haven’t heard from their family, saying, Do you know where my mother is?’ or Have you seen my sister?’
"There were a few who took us a few days to find," Rochester says. "Some of them stayed in motels and we had trouble finding them."
The pall of smoke that hung over the towns both before and after the evacuation exacerbated some patients’ existing health problems. In Los Alamos, Rochester says nurses tried to convince respiratory patients to leave the area a week ahead of the evacuations.
One man who decided to stay developed smoke inhalation problems. "I stopped at the storage shed and got a nebulizer and I just thought we’d take care of him," Rochester says. "We got out there and realized we had no infrastructure! We couldn’t possibly used a nebulizer because there was nothing to plug it in to."
Instead, she says, they rigged a camp shower-type apparatus to help give him immediate relief.
In Montana, Hron says people who weren’t in evacuation areas were instructed to keep windows closed and even keep family pets inside. "It was disruptive for breathing most of the time, and for anyone who was compromised at all with asthma or anything else, it would cause a problem," she says. "Our hospital was handing out masks, but along with the masks came the caution that they really only took out the larger particles. It really was still unsafe to be out."
The fires created other challenges. Arrange-ments had to be made with oxygen companies to get oxygen to patients who needed it. Agencies had to make do with skeletal staffs. Arrange-ments also were made with outside home health agencies to take on relocated patients, often with sketchy documentation.
The evacuation of Rochester’s office, which lasted about a week, created a logistical nightmare. Her nurses had no access to patient charts. Patients didn’t know where to call — Rochester had local radio stations broadcast alternate phone numbers so patients could get in touch with them.
And she had no supplies to speak of. Rochester laughs when she thinks back to what she took with her during the evacuation.
"I took the ultrasound machine with us — don’t ask me why," she says. "You don’t think when you leave. I was thinking, "I’d better take the things that will be difficult to replace."
On the bright side, she says the reaction of the entire region was tremendous, and helped fill in many gaps. Hospitals in Santa Fe and Albuquerque helped out with supplies. New Mexico Blue Cross collected donations to help out Los Alamos health care providers. (See article, p. 18.)
"The day after the fire, the phone rings at my house and it’s one of the pizza places saying they’re delivering six pizzas for our staff and anyone else who might want it," Rochester recalls. "It was a gift from the Rural Hospice Network."
Rochester says her agency is still coming to terms with the tremendous destruction of the fire. Morale has suffered, and bereavement counselors have been called in to help.
Aftermath: Still picking up the pieces
Even those who didn’t lose their homes are coping with overwhelming emotions, she says.
"We have a lot of secondary grief here — people who have guilt because their houses didn’t burn and because they do have everything," she says.
Then there is the financial damage. Rochester describes the response of fiscal entities to her agency’s crisis as "laughable."
"We contacted Medicare to let them know we were going to be in a very large financial crunch, and had our CPA talk with the person who was our liaison at [the agency’s fiscal intermediary]," she says. "After much arguing, they agreed to give us an advance.
"But as it turned out, we only had the advance for seven days — they turned around and took it out of our payments."
Rochester says she’s still arguing with VNS’ Medicaid reimbursers, who require billing within 30 days of visits. "That was a joke, there was no way to do that. We’re still arguing that this was a special circumstance; that we were out of compliance for reasons that were beyond our control."
She also learned that the agency’s insurance policy was not sufficient to cope with the special needs of a home health operation. The policy only reimbursed for losses incurred while the agency was unable to use its building. Rochester says losses continued after the evacuation had ended.
"That (type of policy) probably would work for hospitals and day care centers, but it didn’t work for us. Our payment was cut greatly because of the way our policy was written."
Still, both Rochester and Hron count themselves as lucky to have weathered the crisis as well as they did.
Hron says that fortunately, her agency had reviewed its disaster plan in depth as part of preparations for Y2K in 1999.
"I’m sure that helped," she says. "Providers really do need to review their disaster plans with the mindset that they may need to use it, and not just as a mandatory exercise."
Rochester says that even if she’s unable to recoup her losses, she can appeal to the Federal Emergency Management Agency for relief.
And she says she’s happy just to have gotten through the fires.
"I hope it never happens to anybody else," she says. "For us, we just felt grateful that we survived, that the agency survived, because we don’t have a corporate deep pocket."