Most behavioral health agency executives who witnessed one or more fierce storms during the past two hurricane seasons would agree with the adage, “If you fail to plan, you plan to fail.” But many of those who experienced some of Mother Nature's fury would quickly warn that even the best planners will see that their plans inevitably change.
In military terms, “No plan survives the first shot,” says James Clifford, CFO at Peace River Center in Bartow, Florida, where operations were affected several times during Florida's hurricane ordeal of 2004. “But if you have thought about it, and then things don't go the way you expected, you're far ahead of the people who haven't thought about it at all.”
Lessons in disaster planning and response that were learned across a wide area from Texas to Florida over the past two years hold great importance for behavioral health agencies nationally. The lessons are applicable whether the event confronting the agency is a weather emergency, a man-made threat, or even the untimely death of a beloved staff member. Large-scale events can affect every aspect of an agency's operations. But many agency leaders who have had recent practice in disaster response say an organization accomplishes a lot when it takes care of its people and thereby puts them in a position to do the same for clients.
Even in their inland surroundings east of Tampa, staff members at Peace River Center know to be prepared for what tropical weather might have in store. CEO Mary Lu Kiley explains that disaster-planning efforts have traditionally focused on making the center's network of 19 facilities in three counties self-reliant when trouble occurs.
As a result, all facilities that remain open 24/7 are equipped with water tanks to supply fresh water in emergencies. Each residential facility maintains a disaster kit, with the contents varying by location. All facilities with computer servers have installed lightning protection for their systems. And all of the organization's maintenance trucks carry wet-dry vacuuming equipment and power generators. “If they can get into a facility, they have power to do work,” Clifford says.
Still, unforeseen circumstances require constant communication among members of the center's executive team. “We make decisions as we go along,” Kiley says. For example, when Hurricane Charley in 2004 ripped through one of the center's outpatient clinics in the community of Wauchula, staff members traveled north to Bartow to obtain necessary medications for clients.
Some facility leaders found last year that decision making on the fly became the norm, and that it often took partnerships with other organizations to allow critical functions to resume. Hurricane Katrina caught operators in the south central Mississippi service area of Pine Belt Mental Healthcare Resources largely flat-footed. “We had a plan that worked for minor storms, but it all assumed that we would be able to communicate,” says Jerry Mayo, executive director of the Hattiesburg-based organization. Leaders had expected to communicate with staff through the media and with clients via telephone, but neither of those was operating in the days following Katrina's arrival.
If clients could get to their facility, they would leave notes at the door, and case managers would follow up as soon as they could, Mayo recalls. By 48 hours after Katrina hit, some staff were working at Pine Belt's main location, which stayed open for 4 hours in the middle of the day even though it still had no electricity.
“The number-one priority was to get back in business, to have some visibility in the office as soon as possible,” Mayo says. That is made all the more complicated when a storm of Katrina's magnitude causes severe disruption in staff members’ own lives, and Mayo acknowledges that the response effort got off to a slow start. “There is a day or two of shock, and then it starts happening,” he says.
One effort that allowed normal operations to resume more quickly involved an arrangement between Pine Belt and a local hospital. For group home clients who had to be relocated to a Pine Belt residential facility, the hospital agreed to help fill prescriptions and keep track of medication needs. “We'll figure out how to pay for it when all is said and done,” Mayo says. “In the future we would try to have everything in place in advance.”
Similarly, Spindletop MHMR Services in Beaumont, Texas, realized the benefits of partnerships last year when Hurricane Rita hit—at a time when it was already busy serving Hurricane Katrina evacuees from Louisiana. While some arrangements for clients had been made in advance, such as the transfer of clients from a 16-bed crisis stabilization unit in an evacuated area to a state facility, others had to be negotiated when the need arose. About a dozen key managers were able to negotiate the use of space at another mental health center to establish a central command.
“We took many of our servers, and we were able to set up a system that was active within 24 hours,” says N. Charles Harris, Spindletop's CEO. “This gave us access to important financial data.” In addition, Harris says, the center was able to establish dedicated phone lines through an arrangement with the Texas Council of Community Mental Health Mental Retardation Centers, Inc.
Weathering the Financial Storms
Lakeview Center, Inc., of Pensacola, Florida, has seen its share of disasters in the past decade. After a one-two punch from Hurricanes Erin and Opal in 1995, Lakeview felt Hurricane Ivan's wrath in 2004, followed by blows from Hurricanes Dennis and Katrina last year. The hurricanes not only lashed at Lakeview with punishing wind and rain, they took a swipe at its pocketbook, too. Ivan was particularly bruising, inflicting $5 million in damages, followed a year later with $350,000 to $500,000 in costs from Dennis and $125,000 to $150,000 from Katrina.
Although Lakeview maintains an emer- gency-preparedness plan, “I don't think you can ever say you're completely financially prepared for a disaster of the scope of an Ivan or Katrina,” says Gary Bembry, CPA, president and CEO of the human services organization, whose service array includes behavioral healthcare.
Part of Lakeview's financial emergency preparedness involves maintaining 90 to 120 days of cash reserves to ensure that it will be able to provide services to the community during a crisis. “We are the safety net for this area, and we have fiscal and stewardship responsibilities to make sure we are here and operating after disasters,” says Bembry. Lakeview's prepaid capitated arrangements for services smoothe the reimbursement process after disasters. But no amount of money can make up for having dedicated staff ready to help out after a tragedy. “I think it's the investment we make in people and culture that ultimately gets you through these kinds of crises,” says Bembry, noting that much of his staff showed up to work—some by boat—only days after Ivan.
One way in which agencies can make sure that this staff goodwill lasts is to ensure that employees get paid regularly during times of crisis. During the Rita cleanup effort, Spindletop was able to pay its staff via Western Union; employees had to visit a Western Union center and show identification to receive their money. At Peace River Center in 2004, fiscal and IT staff took laptop computers and a printer to the location where the center's servers are located to perform the functions necessary to maintain payroll. “We made darn sure that people got paid,” Kiley says.
Pensacola is still recovering from Ivan (and Dennis and Katrina), and Lakeview is looking to make some capital outlays to better prepare for future storms, such as by purchasing more building-dedicated generators, completely rebuilding some facilities, and increasing its supply of portable toilets (Ivan unexpectedly knocked out water service). Lakeview, however, is still awaiting payment for claims related to past storms, and some financial staff spend most of their time working with the Federal Emergency Management Agency and property insurance companies.
EHRs Rise to the Fore
Last year's weather assault on the Gulf Coast could serve as the catalyst to transform healthcare into the electronic age: “We will look back on Katrina as the significant event that helped healthcare move from paper-based to electronic health records,” believes Pat Wise, vice-president for electronic health initiatives at the Healthcare Information and Management Systems Society (HIMSS). “Hurricane Katrina is going to be a landmark event in the evolution of EHRs—this event will show the worthiness of keeping healthcare data electronically.”
Paper records in a hurricane's path don't have much of a chance, and in many emergencies there probably isn't enough time to pack and haul away important medical records. Such was the case with Hurricane Katrina, whose wrath destroyed thousands of paper records in Louisiana, Alabama, and Mississippi. Yet EHRs don't have those vulnerabilities, Wise says. Providers can electronically send all their data to a secure location and leave the premises knowing that all patient information is safe. As efforts to create a nationwide EHR network evolve, Wise says providers—no matter where they're located—will be able to access patient information, which would have been helpful to caregivers of last year's hurricane evacuees.
EHRs might have particular value to mental health and substance abuse organizations during emergencies. Says Wise: “Success in behavioral health is due to a well-thought-out treatment plan with adjunct medications as needed. It seems to me that you would want to make sure everyone who encounters the patient knows the treatment plan.” She notes that patients often do not remember what particular medications they are taking, but EHRs can give providers unfamiliar with their care plans instant access to the information they need. And if a person did request a specific medication, such as a prescription-strength painkiller, the clinician could review the EHR for signs of past abuse, without having to rely only on the patient's word.
Yet some behavioral health leaders are quick to add that being prepared technologically can also mean having access to “lower forms” of technology during emergencies. For example, managers at Peace River Center learned in 2004 that cell phones don't always offer the best option during a crisis—cell phone towers sometimes go down, or lines get jammed from too much usage. At times during 2004's spate of storms, officials could have used access to more working landlines, says Bennie Allred, Peace River's clinical director.
Importance of Risk Analysis
Officials at Centerstone, Tennessee's largest behavioral health agency, were not affected by last year's fierce weather to the south. But being in a tornado- and flood-prone area has made disaster planning an ongoing priority. Becky Stoll, Centerstone's director of crisis and referral services, recommends that behavioral health agencies conduct an analysis to identify all potential risks, then outline policies and procedures for a response to each risk identified. “We usually recommend development of a crisis response team,” says Stoll.
She also recommends that agencies establish ties with key safety personnel in their locations. Many law enforcement departments will conduct a free safety analysis of agencies’ building sites, she says. “You want to get blueprints of your buildings to law enforcement ahead of time. These are the kinds of things that help build a good relationship with law enforcement.”
It is also worth it to get to know first responders in an agency's jurisdiction and to be familiar with emergency-management procedures at the county level and for major utilities. “We thought there was a priority process for restoring power, but we found that the electric companies will work on what gets the majority of customers online,” Peace River's Allred recalls.
Rising to the Challenge
Many agency executives who experienced a major weather emergency over the past two years report being impressed with the commitment of their staff to get things done under trying circumstances, as well as clients’ overall ability to cope with the disruption to their lives. “Seeing what the staff did was an amazing thing to watch,” says Spindletop's Harris. “People sort of fed on one another, because there were so many things to try to do.”
Hurricane Rita displaced consumers to many different locations in Texas, Harris says, but outside of a few isolated problems they handled the situation well. Perhaps a sense that everyone was in this together gave people some comfort: “You had victims dealing with victims.”
Mayo at Pine Belt says it's important for staff to remember that even as they face their own personal trials during major disasters, much will be expected of them in their work role. “It is unacceptable to not make an effort,” he says. “You've got to take care of clients; they look for you to take care of them. We need to be available to the extent we can.”
See the September/October 2005 issue of Behavioral Health Management (p.12) for tips community mental health centers can take to prepare for future emergencies.