The Guide: Identifying Vulnerable Older Adults And Legal .

This guide begins with descriptionsof the older adult population andkey definitions, followed by sectionson overarching considerations andstrategies for identifying vulnerableolder adults. It concludes bypresenting a set of potential actionoptions that can be taken in advanceto improve identification, planning,preparedness, and response effortsto protect vulnerable older adultsduring emergencies. The appendicesinclude information on how thisguide was developed and a glossaryof terms used throughout the guide.The Older AdultPopulationThe older adult population is notcharacterized by age alone. Differentlaws use different parameters todefine this population, especiallyin terms of when people becomeeligible for services. For example,although adults are generallyeligible for Medicare coverage atage 65, they also become eligiblefor services and protections at age60 under the Older AmericansAct (OAA).4 The services providedunder the OAA include many typesof assistance—such as meals, homehealth services, personal care, andtransportation—that help olderadults continue to live in theircommunities. For this guide, wedefine older adult as those aged 60years or older. Another factor thatinfluences whether older adultsneed help during an emergency iswhether they live in a long-termcare facility or in a communitysetting. Community-dwelling olderadults may pose more complexchallenges for planning officials thanthose in long-term-care settingsUsing Population Profiles: FloridaThe Florida Department of Health developed a low-tech,low-cost data collection tool that has proven useful foremergency planning in counties and communities. For eachcounty, the state provides a description of the population, includinginformation on age, disability status, residency status (e.g., older adultswho live alone), food stamp receipt, and dialysis use.This information can help counties identify the specific needs of olderadults and other vulnerable populations in an emergency. State officialscollect data at the county and zip code level from human serviceagencies and other sources, such as the U.S. Census Bureau andthe End-Stage Renal Disease Network. Data are given to countiesin a spreadsheet that can be easily shared and accessed duringemergencies.2Introductionbecause these facilities may alreadybe governed by specific regulations.To remain in their homes, manycommunity-dwelling adults relyon care from family membersor caregivers or from servicesprovided by area agencies on aging,community organizations, or homehealth agencies.Interruption of these services duringan emergency can compromise theself-reliance and independence ofcommunity-dwelling older adults.For these reasons, this guide focuseson the protection of older adultswho live in their homes in thecommunity.Older adults are a diverse group interms of their physical and mentalhealth, and vulnerability cannot becharacterized by age alone. Complexvariations in the health status,living environments, and socialsituations of older adults also makeit hard to protect this populationduring emergencies. For example,an independent older adult wholives on the 18th floor of a highrise building may suddenly becomevulnerable if the electricity goes out

during a hurricane, shutting downthe building’s elevators. Older adultsare at increased risk of disease anddeath during emergencies because offactors such as the following: A higher prevalence of chronicconditions, physical disability,cognitive impairment, and otherfunctional limitations. Dependence on support systemsfor medical care, medication,food, and other essential needs. Potential limitations in theirmobility, their access totransportation, or other aspectsof functional autonomy.1,3In addition to the direct relation ship between age and the prevalenceof chronic conditions,5 nearly 82%of Medicare beneficiaries have atleast one chronic condition, and64% have multiple conditions.6The treatment of these conditionsmay require daily medications,specialized equipment, or carecoordination.7If older adults are not able to getthe medications, equipment, orspecial care they need, they can beat increased risk of complicationsand death during an emergency.DefinitionsEfforts to protect older adultscan be complicated by debatesabout the sensitivity and accuracyof methods used to define thepopulation in need. A variety ofterms have been used to definepopulations considered to be“vulnerable” or in need of specialattention in an emergency. Thesechallenges reflect the need for termsthat are specific enough to includepeople who need special attention,but inclusive enough to encouragethe members of this population toparticipate in the planning process.Making Communities Stronger: AARP and New OrleansOne way to improve emergency response and recovery efforts is to build strong communities. AfterHurricane Katrina in 2005, staff in the AARP office in Louisiana and residents in the Hollygroveneighborhood of New Orleans came together to finds ways to make sure the needs of older adultsare 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 after Hurricane Katrina. In2007, AARP staff and eight Hollygrove community leaders began working together to improve the neighborhoodand local partnerships.Training Local LeadersTheir first project was to create the Livable Communities Academy (cosponsored by AARP and the LouisianaState University Agricultural Center). Twenty-seven residents met for 8 weeks to learn about community issues,develop priorities for recovery, and learn new leadership and advocacy skills. After 8 weeks, residents set thefollowing priorities: public safety and resident engagement, economic development, health and caregiving, andmobility and transportation. They continued to meet monthly to find ways to get other residents involved and toaddress the issues identified.The partnership between Hollygrove residents and AARP Louisiana has since received funding from the AARPFoundation and the Harrah’s Foundation. This funding pays for technical, research, and evaluation support andhelps the group build organizational capacity.Preparing for EmergenciesTrinity Christian Community and the CHCDC also developed a block captain program and an emergencypreparedness and response guide for residents. Forty-five residents were chosen to be block captains andlearn how to answer questions about disaster recovery and evacuation. Block captains received manuals withinformation about services such as the Supplemental Nutrition Assistance Program and service providers suchas the American Red Cross and FEMA. The manual also has guidance on how to choose a contractor and howmuch repairs should cost.Block captains identify people who need help during evacuations, and they help residents keep track of theirmedications, financial papers, and family contact information during an emergency.Introduction3

Although no consensus has beenreached on the most appropriateand useful terminology, thissection describes several termsthat are common in emergencypreparedness planning.Vulnerable PopulationsVulnerable populations are definedby one expert group as follows:“People who cannot comfortablyor safely access and use thestandard resources offered indisaster preparedness, relief andrecovery. They may include peoplewith sensory impairments (blind,deaf, hard-of-hearing); cognitivedisorders; mobility limitations;limited English comprehensionor non-English speaking; as wellas people who are geographicallyor culturally isolated, medicallyor chemically dependent, orhomeless.”8Although no universally acceptedterm exists to define specificvulnerable populations, this guideuses the term “vulnerable olderadults” to describe older adults whomay need additional help duringan emergency.At-Risk PopulationsAt-risk populations were definedby a pandemic planning advisorypanel to the Association of Stateand Territorial Health Officialsas follows: “Those people most atrisk of severe consequences fromthe pandemic, including societal,economic, and health-relatedeffects.”9They are defined by the Officeof the Assistant Secretary forPreparedness and Response asfollows: “Some individuals mayhave greater difficulty accessingthe public health and medicalservices they require followinga disaster or emergency. At-riskindividuals have needs in one ormore of the following functionalareas: communication, medicalcare, maintaining independence,supervision, and transportation.”10The functional areas cited in thisdefinition are commonly known bythe acronym CMIST.Communicating with Older Adults in an EmergencyTo be able to take action in an emergency, people need information they canunderstand. Officials who work in emergency planning must be aware of the needsand limitations of diverse populations, including older adults.11 Age-related limitationssuch as cognitive, hearing, and vision impairments can make it hard for some older adults to getand understand health messages or emergency information.12 A person’s cultural background,language, and literacy level can also affect his or her ability to get, understand, and act oninformation in an emergency at any age.When you create health or emergency messages or instructions, keep in mind the needs ofspecial populations such as older adults, people with sensory impairments, and people withlimited English proficiency. At CDC’s Health Literacy Web site, you can find practical information,resources, and tools on how to develop materials for older adults (see ces/OlderAdults/index.html).134Introduction

Special Needs PopulationsThe National Response Frameworkdefines special needs populationsas follows: “Populations whosemembers may have additionalneeds before, during, and afteran incident in functional areas,including but not limited to:maintaining independence,communication, transportation,supervision, and medical care.Individuals in need of additionalresponse assistance may includethose who have disabilities; wholive in institutionalized settings;who are elderly; who are children;who are from diverse cultures; whohave limited English proficiency orare non-English speaking; or whoare transportation disadvantaged.”14Functional Needs SupportServices (FNSS)The Federal Emergency Manage ment Agency’s (FEMA’s) Guidanceon Planning for Integration ofFunctional Needs Support Servicesin General Population Shelters usesa functional needs frameworkto determine which individualsmight need help in an emergency.FNSS are defined as services thatenable individuals to maintaintheir independence in a generalpopulation shelter. They includethe following: Reasonable modification to policies, practices, andprocedures.Durable medical equipment.Consumable medical supplies.Personal assistance services.Other goods and services asneeded.16People RequiringAdditional AssistanceThis term is used by theMassachusetts Task Force onEmergency Preparedness andPeople Requiring AdditionalAssistance.15Introduction5

6Introduction

2OVERARCHING CONSIDERATIONSEvery jurisdiction (community,regional, tribal, state, and national)faces different challenges inpreparing for and protectingvulnerable older adults in anemergency. Many different factorsmust be considered, including theexistence (or lack) of relevant legalauthorities, the type of emergencymost likely to happen, and whetherthe jurisdiction is primarily urban orrural. Other relevant factors includethe jurisdiction’s demographics,geography, and specific environ mental considerations.Despite the local nature ofmany emergencies, events suchas Hurricane Katrina and theterrorist attacks of September 2001showed that planning and responserequirements for major emergenciesmust go beyond the local levelbecause additional help is oftenneeded from state and federalagencies. This section outlineskey overarching considerationsidentified during the developmentof this guide. These considerationsmay help officials at all levels planand implement measures to protectvulnerable older adults duringemergencies.plans should identify essentialagencies, organizations, andother stakeholders. Identify and review relevantlegal authorities. Define the different categoriesof emergencies and hazards tobetter understand how specificemergencies may affect olderadults in the community. Use operational models ofemergency management toidentify the specific needs ofolder adults during each phaseof an emergency.Developing PlansComprehensive, all-hazardsemergency preparedness requiresthe development and maintenanceof emergency operations plans(EOPs) that address the needsof vulnerable older adults. Theplanning process helps encouragekey organizations and entities toestablish and maintain relationshipsessential for community, regional,tribal, and state jurisdictions toeffectively respond to emergencies.Cross-Sector CollaborationCross-sector collaboration betweenall key partners across jurisdictionsis a vital part of preparednessplanning. Planning for special needspopulations, including older adults,may also benefit from includingcommunity members who representspecial needs populations. Basiccross-sector activities should includethe following: identifying vulnerableolder adults and other populationswith special needs before an emer gency occurs, developing plans forrisk communication, providingFor example, planning officialsshould Include older adult issuesand needs when developingpreparedness plans. TheseOverarching Considerations7

shelter, ensuring continuity ofmedical care, transporting thesegroups to shelter and safety, andreintegrating displaced older adultsback into their communities. Essential PartnersAgencies and organizations from avariety of levels will be key in theplanning process. These 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 following: Federal agencies. U.S. Department of Healthand Human Services (HHS)agencies, including CDC,the Administration on Aging,the Centers for Medicare &Medicaid Services, the Officeof the Assistant Secretary forPreparedness and Response,the Indian Health Service, theFood and Drug Administration,and the Health Resources andServices Administration.U.S. Department of HomelandSecurity agencies, includingFEMA and the Customs andBorder Patrol.State agencies.State Attorneys General.Medicaid programs.State civil defense.State departments of behavioralhealth.State departments of publichealth.State emergency managementagencies.State units on aging. Regional agencies. Metropolitan Transportation Authorities.Regional governing councils.Regional planning commissions.Local agencies.Aging services providers.Area agencies on aging.Fire departments.Hospital associations.Law enforcement agencies.Local health departments.Local emergency managementoffices.Long-term-care associations.Tribal organizations.Bureau of Indian Affairs.Local councils.Tribal governments.Ensuring Workforce Competence: HawaiiPartners from many different sectors share responsibilityfor identifying and protecting vulnerable older adults inemergencies. Each group has its own training requirements,which may or may not include information about older adults. Allemergency responders should have a basic understanding of theunique needs of this population in order to plan and care for themin an emergency.The State of Hawaii is a leader in this area. In 2005, the U.S.Department of Health and Human Services funded the PacificEmergency Management, Preparedness, and Response InformationNetwork and Training Services (Pacific EMPRINTS) to providecontinuing education programs for emergency medical personnel andcommunity health providers.17 In 2009, funding was continued by theU.S. Department of Homeland Security.Pacific EMPRINTS works to help health professionals Recognize terroristic and other emergencies.Meet the acute care needs of the population, includingvulnerable populations.Participate in coordinated, multidisciplinary responsesto emergencies.Rapidly and effectively alert the public health system ofan event at the community, state, or national level.The Pacific EMPRINTS Web site offers free, online courses andtutorials, several of which address vulnerable populations. Healthprofessionals who work with older adults in Hawaii also have beentrained through the PREPARE program, thanks to a partnership withMather LifeWays, a nonprofit organization based in Illinois (seehttp://matherlifeways.com/re prepare.asp for more information).8Overarching Considerations

Aging Services NetworkThe Ag

Many different strategies are being used to identify vulnerable older adults across the country, but none of these strategies have been evaluated. No consensus exists on the best way to identify and protect older adults. Gaps exist in legal mandates to protect older adults.