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Challenges of service coordination for evacuees of Hurricane Maria through the National Disaster Medical System

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Abstract

Objective: To describe the challenges of service coordination through the National Disaster Medical System (NDMS) for Hurricane Maria evacuees, particularly those on dialysis. Design: Public health report. Setting: Georgia. Report: On November 25, 2017, there were 208 patients evacuated to Georgia in response to Hurricane Maria receiving NDMS support. Most were evacuated from the US Virgin Islands (97 percent) and the remaining from Puerto Rico (3 percent); 73 percent of these patients were on dialysis, all from the US Virgin Islands. From the beginning of the evacuation response through November 25, 2017, there were 282 patients evacuated to Georgia via NDMS, with a median length of coverage through NDMS for those on and not on dialysis of 60 and 16 days, respectively. Conclusion: The limited capacity and capability of dialysis centers currently in the US Virgin Islands are delaying the return to home of many Hurricane Maria evacuees who are on dialysis.
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203
Journal of Emergency Management
Vol. 16, No. 3, May/June 2018
Challenges of service coordination for evacuees of Hurricane
Maria through the National Disaster Medical System
Neil M. Vora, MD
Aaron Grober, MPH
Bradley P. Goodwin, PhD
Michelle S. Davis, PhD
Chris McGee, LCSW-BCD
Sara E. Luckhaupt, MD, MPH
Jennifer A. Cockrill, MS, MPH
Selena Ready, PharmD
Laura Nichole Bluemle, DPT
Lauren Brewer, BSN, MPH
Angela Brown, EdD
Cassidy Brown, RN, MSHS
Julie Clement, DBH, PA-C
Diane L. Downie, MPH
Michael R. Garner, MPA
Ruby Lerner, RN, MS
Margaret Mahool, RN, BSN
Shirley A. Mojica, Med
Leisha D. Nolen, MD, PhD
Melanie R. Pedersen, LCSW-BCD
Mary Jane Chappell-Reed, MS, RD
Edecia Richards, MSN, APRN, FNP-C
Jonathan Smith, RN
Kitichia C. Weekes, MA
Jeanette Dickinson, MPH
Charles Weir, PhD
Thomas I. Bowman, MS
Jeanne Eckes, RN MBA
ABSTRACT
Objective: To describe the challenges of service
coordination through the National Disaster Medical
System (NDMS) for Hurricane Maria evacuees, par-
ticularly those on dialysis.
Design: Public health report.
Setting: Georgia.
Report: On November 25, 2017, there were 208
patients evacuated to Georgia in response to Hurricane
Maria receiving NDMS support. Most were evacuated
from the US Virgin Islands (97 percent) and the
remaining from Puerto Rico (3 percent); 73 percent
of these patients were on dialysis, all from the US
Virgin Islands. From the beginning of the evacua-
tion response through November 25, 2017, there were
282 patients evacuated to Georgia via NDMS, with a
median length of coverage through NDMS for those
on and not on dialysis of 60 and 16 days, respectively.
DOI:10.5055/jem.2018.0369
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204 Journal of Emergency Management
Vol. 16, No. 3, May/June 2018
Conclusion: The limited capacity and capability
of dialysis centers currently in the US Virgin Islands
are delaying the return to home of many Hurricane
Maria evacuees who are on dialysis.
Key words: hurricane, dialysis, disaster, evacuation
INTRODUCTION
Patients are evacuated following disasters for acute
and chronic indications, each presenting different chal-
lenges for emergency response. Patients requiring dial-
ysis are especially vulnerable because management
of their illness relies on a healthcare system capable
of meeting their dialysis needs.1 The disruption of a
single dialysis center in a disaster region can impact
delivery of life-sustaining treatment to a large number
of patients who routinely use that center, and other
dialysis centers in surrounding areas might not have
the capacity to absorb the overflow.2 Thus, patients
requiring chronic dialysis who are evacuated following
a disaster are uniquely dependent on the availability of
a resource-intensive medical therapy, and their return
home might be delayed for this one reason even if other
criteria for their safe return are met.
In September 2017, Hurricane Maria made land-
fall on the US Virgin Islands and Puerto Rico, lead-
ing to evacuations of patients and their nonmedical
attendants to the continental United States via the
National Disaster Medical System (NDMS). NDMS is
a federally coordinated patient movement and defini-
tive care system and partnership of multiple federal
agencies. NDMS supports state, local, tribal, and
territorial authorities in the United States following
disasters and emergencies by supplementing health
and medical systems and response capabilities.3
Through its Definitive Care Reimbursement
Program, NDMS will reimburse institutions and
practitioners that provide care to patients evacu-
ated as a result of a public health emergency in the
United States (subject to the availability of funds).4
The NDMS Definitive Care Reimbursement Program
generally reimburses any medically necessary service
which is authorized under Medicare Part A, Medicare
Part B, or a State's Medicaid program as long as the
patient (1) experienced illnesses or injuries directly
from the specified public health emergency or (2)
experienced illnesses or injuries or has conditions
requiring essential medical services temporarily not
available as a result of the specified public health
emergency. NDMS Definitive Care Reimbursement
Program coverage ends if (1) the patient's medically
indicated treatment ends, (2) the patient voluntarily
refuses the care, (3) 30 calendar days have elapsed
from the date of the patient's evacuation/placement
(this period of 30 days can be extended under certain
circumstances), or (4) the patient is returned to home
(or a fiscally comparable location).4,5
Federal Coordinating Centers (FCCs) at four
sites (Atlanta, Georgia; Columbia, South Carolina;
Jackson, Mississippi; Shreveport, Louisiana) have
been responsible for day-to-day coordination and
operations related to Hurricane Maria evacuations
via NDMS. The FCC sites were chosen because they
were appropriate patient reception areas, defined
as geographic areas that have ≥1 airfield, and had
adequate patient staging facilities and adequate local
transportation assets to move patients to local, pre-
identified, non-Federal, acute care hospitals capable
of providing definitive care.5 Georgia received the
highest number of evacuees of all FCC sites.
The purpose of this report is to describe the chal-
lenges of service coordination through NDMS for
Hurricane Maria evacuees in Georgia, particularly
those on dialysis.
SERVICE COORDINATION
Service Access Teams (SATs) of the US Public
Health Service have been used to deliver NDMS-
supported services in response to Hurricane Maria.6
SATs typically operate out of FCCs and are tasked
with tracking patients who are evacuated through
NDMS and assessing and monitoring ongoing health
and human service needs of patients.6 The primary
objective of SATs is to coordinate the safe return
of patients to their homes. Patients are generally
allowed to return to their homes once they are well
enough to travel, their home is safe for return, and
the patients have means of meeting their basic needs.
Until NDMS coverage ends, SATs are also responsi-
ble for coordinating medical care, transportation, and
services such as housing and food. A limited number
07-JEM_Vora_180023.indd 204 10/07/18 3:05 PM
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Vol. 16, No. 3, May/June 2018
of nonmedical attendants of each patient are eligible
for service coordination through SATs.
Patients and their nonmedical attendants were
evacuated through NDMS from the US Virgin Islands
and Puerto Rico shortly after Hurricane Maria because
of illness and injuries that patients experienced
directly resulting from the hurricane and because of
the unavailability of medical services for managing
pre-existing patient conditions (eg, dialysis for chronic
kidney disease). Of note, some patients were evacu-
ated for Hurricane Irma to locations that were sub-
sequently affected by Hurricane Maria, and so were
evacuated again for Hurricane Maria. Patients were
still being evacuated in November 2017 from the US
Virgin Islands and Puerto Rico for acute conditions
that occurred after Hurricane Maria because essential
medical services had not yet been fully restored.
As of November 25, 2017, the SAT operating out of
Atlanta was the only SAT that remained active in the
continental United States and on that day was track-
ing a total of 295 evacuees (208 [71 percent] patients,
87 [29 percent] nonmedical attendants) in Georgia.
Most patients were evacuated from the US Virgin
Islands (n = 201; 97 percent) and the remaining from
Puerto Rico (n = 7; 3 percent). Most of these patients
were on dialysis (n = 152; 73 percent), all of whom were
evacuated from the US Virgin Islands; the remaining
patients were evacuated for a range of conditions such
as trauma and cardiovascular events. These patients
were housed in hotels (n = 137; 66 percent), skilled
nursing facilities (n = 36; 17 percent), hospitals (n = 30;
14 percent), with family/friends (n = 3; 1 percent), and
at charity houses (n = 2; 1 percent). As of November 25,
2017, among all 282 patients for whom services have
been coordinated by the SAT in Atlanta since it was
stood up in response to Hurricane Maria, the median
length of coverage through the NDMS Definitive Care
Reimbursement Program for those on dialysis and
those not on dialysis was 60 days (interquartile range:
56-62 days) and 16 days (interquartile range: 8-41
days), respectively (two-tailed t-test, p < 0.001).
While patients evacuated for acute conditions are
sometimes able to return to the US Virgin Islands or
Puerto Rico within days of receiving treatment in the
continental United States, most patients evacuated
from the US Virgin Islands for dialysis have been
unable to return because of the limited capacity and
number of dialysis centers operating in the US Virgin
Islands since Hurricane Maria. It might take months
or even longer before dialysis services resume in the
US Virgin Islands at levels sufficient to care for all of
these patients, and the SAT in Atlanta will therefore
likely remain activated through part of 2018. Thus,
while the SAT in Atlanta is focused on health and
human service needs of evacuees (patients and non-
medical attendants), it has become part of a larger
evacuee management team with the goal of address-
ing additional needs of these evacuees during their
stay in Georgia. For example, the SAT in Atlanta col-
laborates extensively with numerous federal, state,
and local partners to address evacuee needs such as
replacing identification documents, delivering per-
sonal items such as clothing and toiletries, and pro-
viding spiritual and behavioral health support.
A large number of patients have lost the social
support systems that they relied upon at home, such
as family members who were able to help them man-
age medications and take them to medical appoint-
ments. In an effort to replace these services, patients
who are staying in hotels in Atlanta are currently also
receiving nursing and social work services through a
number of contracts to support these needs. As the
response to Hurricane Maria moves into a recovery
phase, a major priority for the SAT in Atlanta is to
therefore identify patients who previously functioned
independently and situate them in their new com-
munity such that they are able to maintain their
independence until they are able to return home.
However, a sizeable subset of these patients have
complex health needs and, as these patients are iden-
tified and if they consent, they are being transferred
to accepting skilled nursing facilities and assisted liv-
ing facilities to receive appropriate care.
CONCLUSION
Hurricane Maria has been a humanitarian cri-
sis for which NDMS has been activated to facilitate
evacuations from the US Virgin Islands and Puerto
Rico, and we describe the challenges of service coordi-
nation through NDMS for Hurricane Maria evacuees
07-JEM_Vora_180023.indd 205 10/07/18 3:05 PM
206 Journal of Emergency Management
Vol. 16, No. 3, May/June 2018
in Georgia, particularly for those on dialysis. While
patients not on dialysis are often able to return home
because their acute medical issue has resolved, the
limited capacity and capability of dialysis centers cur-
rently operating in the US Virgin Islands is prevent-
ing many dialysis patients who have been evacuated
for Hurricane Maria from returning home. This is a
novel situation that NDMS has not previously faced.
Dialysis patients represent a unique subset of
the vulnerable population as their medical needs are
so specific. For most disasters, the impact of the loss
of several dialysis centers can generally be absorbed
within the affected area. However, as described here,
the loss of the majority of dialysis capacity and capa-
bility in a geographically isolated area (eg, an island)
will likely require the relocation of dialysis patients to
another area for months. Thus, as part of emergency
planning for dialysis patients, geographically isolated
jurisdictions can consider the size of the dialysis pop-
ulation that they serve. Specialized agreements can
be established with other jurisdictions for receiving
and supporting evacuees on dialysis in case of a disas-
ter or plans can be developed to stand-up temporary
facilities for dialysis to aid in recovery efforts.
ACKNOWLEDGMENTS
The findings and conclusions in this article are those of the
authors and do not necessarily represent the official position of the US
government or the NYC Department of Health and Mental Hygiene.
We thank Assistant Secretary for Preparedness & Response’s Incident
Response Coordination Team-4; Administration for Children and
Families; Agency for Community Living; American Red Cross;
Centers for Medicare and Medicaid Services; Department of Housing
and Urban Development; Federal Emergency Management Agency;
Georgia Department of Health; Georgia Division of Family and
Children Services; Georgia Healthcare Association; Government
of the Virgin Islands; Health & Human Services Region IV Office;
Health Resources and Services Administration; US Public Health
Service.
Neil M. Vora, MD, Centers for Disease Control and Prevention; New
York City Department of Health and Mental Hygiene.
Aaron Grober, MPH, Agency for Toxic Substances and Disease Registry.
Bradley P. Goodwin, PhD, Agency for Toxic Substances and Disease
Registry.
Michelle S. Davis, PhD, US Virgin Islands Department of Health.
Chris McGee, LCSW-BCD, Federal Bureau of Prisons.
Sara E. Luckhaupt, MD, MPH, Centers for Disease Control and
Prevention.
Jennifer A. Cockrill, MS, MPH, Office of the Assistant Secretary for
Preparedness and Response.
Selena Ready, PharmD, Food and Drug Administration.
Laura Nichole Bluemle, DPT, Indian Health Service.
Lauren Brewer, BSN, MPH, Centers for Disease Control and Prevention.
Angela Brown, EdD, Centers for Disease Control and Prevention.
Cassidy Brown, RN, MSHS, Federal Bureau of Prisons.
Julie Clement, DBH, PA-C, Centers for Medicare and Medicaid Services.
Diane L. Downie, MPH, Centers for Disease Control and Prevention.
Michael R. Garner, MPA, Department of Health and Human Services,
Office of the Assistant Secretary for Preparedness and Response.
Ruby Lerner, RN, MS, Food and Drug Administration.
Margaret Mahool, RN, BSN, Immigration and Customs Enforcement.
Shirley A. Mojica, Med, Department of Health and Human Services,
Administration for Children and Families.
Leisha D. Nolen, MD, PhD, Centers for Disease Control and Prevention.
Melanie R. Pedersen, LCSW-BCD, Federal Bureau of Prisons.
Mary Jane Chappell-Reed, MS, RD, Federal Bureau of Prisons.
Edecia Richards, MSN, APRN, FNP-C, Department of Health and Human
Services.
Jonathan Smith, RN, Indian Health Service.
Kitichia C. Weekes, MA, Centers for Medicare and Medicaid Services.
Jeanette Dickinson, MPH, Department of Health and Human Services,
Office of the Assistant Secretary for Preparedness and Response.
Charles Weir, PhD, Department of Health and Human Services, Office
of the Assistant Secretary for Preparedness and Response.
Thomas I. Bowman, MS, Department of Health and Human Services,
Office of the Assistant Secretary for Preparedness and Response.
Jeanne Eckes, RN MBA, Department of Health and Human Services,
Office of the Assistant Secretary for Preparedness and Response.
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07-JEM_Vora_180023.indd 206 10/07/18 3:05 PM
... In response to this hurricane-related disaster, the SRMC emergency department moved all operations to medical tents pitched in the parking lot. 9 During these operations, hospital patients whose care exceeded the resources of SRMC, including as many as 200 dialysis patients, [10][11][12] were evacuated to St Croix, Puerto Rico, and locations in the continental United States. On September 19, 2017, hospital staff received an order to disassemble their tent ED and shelter for a second Category 5 storm, Hurricane Maria, which was headed for the island. ...
... In keeping with the already noted problems with missing data in the ED charts, there is a paucity of data on such transfers, with a fairly wide range in the estimated number of air evacuations that occurred: the hospital had a line listing with 171 transfers, the territorial health department noted 796 transfers for both St Thomas and St Croix, and a paper from the Atlanta area reported that there were 282 patients (97% from the USVI) air evacuated to Georgia hospitals by the National Disaster Medical System. 11 Even less is known about the fate of these patients, with the territorial health department reporting to the territorial legislature in April of 2018 that they had follow-up data on only 536 of the total USVI evacuees, including 49 known deaths. [26][27][28] Only 125 patients were reported to have returned to St Thomas and St John, with more than 500 of the total evacuees said to still be receiving treatment off-island. ...
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Department of Housing and Urban Development
  • Medicaid Centers For Medicare
  • Services
Centers for Medicare and Medicaid Services; Department of Housing and Urban Development; Federal Emergency Management Agency;
PhD, US Virgin Islands Department of Health
  • Michelle S Davis
Michelle S. Davis, PhD, US Virgin Islands Department of Health.
Office of the Assistant Secretary for Preparedness and Response
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  • Ms
  • Mph
Jennifer A. Cockrill, MS, MPH, Office of the Assistant Secretary for Preparedness and Response.
Office of the Assistant Secretary for Preparedness and Response. Ruby Lerner, RN, MS, Food and Drug Administration
  • Michael R Garner
  • Department Of Health
  • Human Services
Michael R. Garner, MPA, Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response. Ruby Lerner, RN, MS, Food and Drug Administration.
Med, Department of Health and Human Services, Administration for Children and Families
  • A Shirley
  • Mojica
Shirley A. Mojica, Med, Department of Health and Human Services, Administration for Children and Families.
Office of the Assistant Secretary for Preparedness and Response
  • Jeanette Dickinson
  • Department Mph
  • Human Of Health
  • Services
Jeanette Dickinson, MPH, Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
PhD, Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response
  • Charles Weir
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