1. Rhode Island Long Term Care Mutual Aid Plan (LTC-MAP)
Leadership Education 1

2. What Led to Mutual Aid in New England:
Learning from experiences in:
NY State – 1st Plan (began in 1983)
2001 Tropical Storm Alison (Houston)
2001 9/11
2005 Hurricanes Katrina / Rita
Massachusetts Disasters (1st New England State)
May 2006 Flooding (Mother’s Day Storm)
November 2006 Chemical Explosion (Danvers)
2008 Ice Storm in Central & Western MA
In 1982, a 404 bed nursing home evacuated in Western NY. The first Mutual Aid Plan in the nation (long term care) was built by Russell Phillips & Associates in That plan is still in existing today at the Greater Rochester Mutual Aid Plan. Multiple disasters solidified the reason to have mutual aid. The New England plans then started based on several events in Massachusetts. See next slide for the Mothers Day storm.

3. Mary Immaculate Evacuated (250 beds) (Evacuation: May 2006 / Recovery: Sept. 2006) Source: Boston Globe.com
FOLLOWING A RAIN STORM, NOW KNOWN AS THE MOTHER’S DAY STORM IN 2006, DAMS WERE OVERFLOWING IN THE SOUTHEAST AND NORTHEAST SECTIONS OF THE STATE. VERY SIMILAR TO THE FLOODING DEVASTATION VERMONT EXPERIENCED IN IRENE.
EVENT DESCRIPTION: THIS IS A PICTURE OF ONE OF THE LARGER NURSING HOMES IN MASS, MARY IMMACULATE. DURING THE MOTHER’S DAY STORM THIS HOME, WHICH ABUTS THE SPIGOT RIVER, EVENTUALLY HAD TO BE EVACUATED WHEN A DAMN IN NEW HAMPSHIRE BECAME OVERWHELMED RESULTING IN THE FLOODING YOU SEE HERE. EVENTUALLY, THE BASEMENT AND FIRST FLOOR OF THE FACILITY BECAME FLOODED AND RESIDENTS HAD TO BE RESCUED. RESIDENTS WERE LITERALLY FLOATED OUT OF THE BUILDING IN LINEN HAMPERS WHICH BECAME MAKE SHIFT RAFTS FOR RESCUE WORKERS.
THERE WAS NO MUTUAL AID PLAN IN PLACE AT THIS TIME: DPH AND THE FACILITY WORKED WITH AREA NURSING HOMES, ONE AT A TIME, TO ACCEPT THEIR RESIDENTS FOR SHORT TERM AND THEN PERMANENT PLACEMENT. EXTENDED TIME TO ACCOMPLISH THIS AND THE INITIAL EVACUATION PUT ALL OF THE RESIDENTS IN MULTIPLE AREA HOSPITAL BEFORE THE MOVE TO THE NURSING HOMES.

4. Other Incidents where Mutual Aid Plans were Activated
Aug/Sept Tropical Storm Irene/Lee Flooding
Oct/Nov “Halloween Storm” - Snowstorm/ Power Failure
July 2012 – MA Nursing Home Generator Failure
Oct/Nov Superstorm Sandy
Jan 2013 Influenza Event – Boston & Hartford, CT Activations for Hospital Resident Decompression
Feb 2013 – Blizzard (NEMO)
Jan 2014 – Snowstorm
In recent years, New England’s mutual aid plans have proven to be up to the challenge during actual events.

5. OVERVIEW of the RI LTC-MAP

6. Plan Operation is 1st within your town/city. Additional Support will
come from your Region
then other regions in a widespread
disaster.
~500 LTC / 30 Hospitals / 4 LTACs or Rehab Hospitals
213 LTC / 11 Hospitals
Regions 1, 3, 4 & 5
Sister Mutual Aid Plans are currently operating in Massachusetts and Connecticut. In a widespread disaster, these Sister MAPs have all promised to support one another.
151 LTC

7. Northern & Southern Region

8. The Basics
Identify needs and provide supplies/ equipment/pharmaceuticals as necessary
Assist with transportation of supplies / staff / equipment / evacuated residents
Provide staffing support (whether a facility is evacuating or isolated)
Place and support the care of evacuated residents (continuity of care / surge locations)
LTC-MAP provides a framework within which LTC facilities can efficiently and effectively give and receive assistance during disasters.

9. Member Responsibilities
Memorandum of Understanding (MOU)
Sign it - Transfer Agreements with everyone
If no MOU=No transfer agreement (per HEALTH, DHS & CMS)
Who are we qualified to care for? (# and type)
Surge Capacity – Accept 110% of licensed beds (not mandated; but a process to support others)
Required Plan Forms for Use:
Resident Emergency Evacuation Form
Resident / MR / Staff / Equipment Tracking Sheet
Influx of Residents Log
Controlled Substance Receiving Log
Mandatory Attendance at Annual Meeting
Exercise Annually with the LTC-MAP
LTC-MAP Member facilities have agreed to shoulder certain specific responsibilities.
One of the responsibilities member facilities have accepted is the obligation to use certain tracking forms and tools during disasters that require the evacuation of a facility. Some of these forms track evacuating residents; other forms track the pharmaceuticals, equipment and supplies that may be moved from facility to facility.
These forms are used in concert with web based tools.
Hard copies of these forms may be downloaded from the LTC-MAP website under the DOCUMENTS TAB (LTC-MAP Plan Documents) and each facility should have two or three part NCR for the evacuation forms.

10. Memorandum of Understanding (MOU) (Located in Section 8 of the plan)
The MOU is a “voluntary agreement” among members
By signing the (MOU) all facilities agree to their intent to abide by the terms in the event of a disaster. The terms are to be incorporated into the facility’s Emergency Management Plans and Emergency Operations Plans
PUSH IS FOR A SUMMER OF 2014 MOU SIGNATURE AND RETURNED TO Alysia Mihalakos, Interim Chief of CEPR, Rhode Island Department of Health (HEALTH):
This is being revised and all facilities will have a final copy provided electronically in the summer 2014.

11. Are You Required to Take Residents in an Evacuation?
NO – Why?
If you are impacted by the disaster, it could be more dangerous to move them to your location
Infrastructure issue
Staffing issue (and they can’t send staff)
Example: Superstorm Sandy – NYC was looking to move 2,000 residents into CT. ONLY facilities that were on commercial power were considered.
While the plan may have teeth when activated (meaning, it follows specific protocols), a facility has flexibility whether they are able to participate in a disaster. Always put yourself on the side of being the facility in trouble to determine if you are able to provide assistance.

12. Responsibility for Care
Resident Accepting Facility (RAF) receives the resident:
Do not admit (being reviewed with DHS)
Under the care of the RAF
Return the resident to the facility or origin after completion of the disaster
Ethical standpoint – no marketing efforts to the residents and their families
Process is being vetted through DHS. HEALTH and CMS concur on the process. (RIHCA and LeadingAge RI will work to support the approaches for the best interests of members)

13. Reimbursement Approach
Disaster Struck Facility
Can the facility reopen within 30 days?
IF YES – The resident is never discharged and they are “sheltered” at the RAF
IF NO – The resident is discharged and permanent placement will be addressed
Process of not admitting (“sheltering”) – enables surge to 110% of licensed beds to take place (waiver)
HEALTH & CMS will support this process
30 days is a key indicator. If you know you can re-open within 30 days, you will never discharge the residents. If you can’t re-open, once you know that (typically within 15 days of the disaster), start the process of discharging residents.

14. Reimbursement Approach
Disaster Struck Facility
Paid by CMS (Medicare), DHS (Medicaid) or private pay
RAF is paid by DSF at DSF rate
If 100% of services provided by RAF, 100% of payment
If staff, equipment and meds come from DSF, amicable division (incremental labor costs & consumables)
If exceeding licensed beds, amicable division
Mediation or Arbitration (called out in MOU)

15. Facilities Still Must Be Ready Internally
What we need to have internally:
Have an Incident Command System (Nursing Home Incident Command System – NHICS)
Full Building Evacuation Plan
Get residents to the sidewalk
Influx of Residents (Census Reduction / Surge Capacity Plan)
Resources & Assets for 96 hours
Self-sustainability
No matter what the LTC-MAP does for us, we still need to have our own internal procedures, training and exercises to complement the process.

16. Disaster Struck Facility

17. Shelter-in-Place / Evacuating
Disaster Struck Facility (when speaking with HEALTH and Local Emergency Manager or 911)
Size-up the Situation
Resource & Assets needs to stay operational
Failure of infrastructure to remain in the facility
Who – Your contact name and phone number
Where – Facility Name, Address and Town/City
What – What is the issue?
When – Window of time the resources will be required in / How long until the evacuation must commence
Why – Reason
Things to think about when you are first impacted by the disaster. Prepare to always answer the 5 W’s 17

18. Shelter-in-Place / Evacuating
Sheltering-in-Place is the best option in 99.9% of the situation. Still, decisions need to be made as to what works best. Let’s use this algorithm as part of our decision-making process. 18

19. Actions of Disaster Struck Facility
NOTIFY: Call 911 / begin Internal Activation process
ACTIVATE: HEALTH Duty Officer (CEPR) at to activate the LTC-MAP and Critical Partners through the alert notification system
ACTIVATE: Emergency Reporting System
(Could be done by HEALTH)
PREPARE: Evacuation? Staffing? Equip? Supplies?
PREPARE: Transportation Evacuation Tool - Complete (if evacuating)
PREPARE: Generator Information - Update (if pre-storm/event)
This information is all from the Algorithm. Review your LTC-MAP binder and the first pages include the activation algorithms (1.1 and 1.2). 19

20. Transportation Evacuation Surveys (transportation tab on website)
Provides Department of Health, Fire, EMS and Emergency Management with strong knowledge of the resources needed to evacuate our facility (Ambulances, wheelchair vehicles and buses)
Consider completing with monthly fire drills (each resident care area)
On website for an automated tool
We recommend you complete this with monthly or quarterly fire drills, when there is a pre-storm alert and during disaster exercises. You will log-in (see the next slide) to complete this electronically, but the hard copy piece to gather the information is at on the right hand side of the page under “Statewide Tools”. No log-in is necessary to get the hard copy tools.

23. Transportation Resources
Total Vehicles Owned by Members
160 Vehicles
1,266 Total seats
179 Residents in Wheelchairs
Capacity: 1,445 Transportable Residents
Supplies / Equipment: 11 Dump / Box Trucks & Pick-ups / Golf Cart / Gators
These are resources between all of the LTC-MAP members. These could be deployed to support other members in a disaster for movement of staff, residents, equipment and supplies.

24. Pre-established Evacuation Sites
Primary sites should be pre-selected using the LTC Patient Care Categories (next slide – from website)
Address highest acuity residents first
Who matches up best with our residents
Address their surge numbers next
Always assume they have no open beds
How many of your residents can they accept at 110% surge
Process to communicate with them
Know where they are, their point person and contact information
Pre-select evacuation sites. Up to 10 that best fit with your organization. 24 24

25. Cross reference other facilities in the region against your own facility. Run the Report entitled LTC Patient Care Categories for your region and see who best matches up with your facility.

26. Resident Tracking – What goes with the Resident
Resident Emergency Evacuation Form
1 per resident - info and acuity / mobility / risks
Active Chart (or Current Service Plan for AL)
Include MAR (Med List), Meds/Controlled Substances
Wristband (name / DOB)
Resident, MR, Staff & Equip Tracking Sheet
List of residents; by facility they evacuated to
Transportation vehicle info and time departed
What (and whom) went with them
Photo, if possible
DNR Bracelets / Personal Belongings
Five essential tracking tools are used in the LTC-MAP.
The Resident Emergency Evacuation Form tracks INDIVIDUAL residents. You should have these on hand for 150% of your residents. These are 3 part NCR forms.
The Resident, Medical Record, Staff and Equipment Tracking Sheet tracks GROUPS of evacuating residents, and the items that may be traveling with them. You should have these on hand for about 1/3 of your residents. These are 3 part NCR forms.
The Influx of Residents Log mirrors the Resident, Medical Record, Staff and Equipment Tracking Sheet , and is used by receiving facilities. You should have these on hand as well. Maximum of 5-10 are necessary. These are 3 part NCR forms.
If you don’t have these forms click HELP on the home page of an address box will appear addressed to Russell Phillips & Associates. Please inform them of the forms that your facility needs
Some of the other tools, such as the LTC Facility Tracking Board, is primarily used by the HEALTH LTC Group, but could be used by any member facility.
All of these forms are available for download from the LTC-MAP website under DOCUMENTS / LTC-MAP PLAN DOCUMENTS

27. Resident Accepting Facilities/Lenders

28. Actions of Resident Accepting Facilities/Lenders
Prepare to receive residents
Open beds vs. Surge Area
Complete Emergency Reporting
Complete the Influx of Resident Log - residents arrive
Confirm with DSF or HEALTH LTC Group that the residents are received – “CLOSE THE LOOP”
Start a new chart for resident
Notify HEALTH and your local AHJ about activating a Surge Plan (Influx / Surge Guidelines)
If Lender: Prepare to provide Resources/Assets
During an emergency, most member facilities will perform the role of Resident Accepting Facility (RAF), or Lender.
RAFs and Lenders have specific responsibilities to discharge during activations. 28

29. What happens at 2:00 AM? Anyone who might answer the phone:
Basic knowledge that RI LTC-MAP exists (there is a plan)
Get the name of the person calling, facility, contact number and issue or request
OR – Listen to the automated message and take down directions for what it tells you to do
Inform the Nursing Supervisor ASAP
Nursing Supervisor – Scope will determine actions
Immediate analysis of open beds – M / F / Either
Activate internal emergency notification tree
Complete Emergency Reporting-
Evacuation? Prepare to receiving incoming residents
Resource & Asset Request: Prepare to provide staff, equipment, supplies or transportation
The call to “activate” might come in at any time. Therefore, at least some rudimentary training across the shifts must take place at each member facility.

30. Influx of Residents / Surge Plan Algorithm
This is a tool that you should adopt at your facility if you have not already done so. It is located under Statewide Tools on and is an agreed upon document by HEALTH. Great process to handle an Influx of Residents in a disaster or handling an influx of members of your community as well.

31. (all tabs are specific to our facility based on data we enter)
RI LTC-MAP Website
(all tabs are specific to our facility based on data we enter)
The LTC-MAP website functions as a repository of information that is collected from members well in advance of any disaster.
It also performs as a high tech tool that can be used to collect “real time” information from members during emergencies (Emergency Reporting)

32. Example above shows where you can house your generator information
Example above shows where you can house your generator information. But, look at all tabs.
Contacts – 3-7 people we need notified in a disaster and check off the name of the Executive Director or Administrator as the Licensure contact.
LTC Bed – Your categories of care you provide and surge information.
Evacuation Sites – Pre-selected evacuation sites.
Stop Over Points – Areas you could move to rapidly to shelter residents (very close proximity to your facility).
Equipment and Supplies – Not your inventory, but what you have that could be used in emergencies (extra or emergency stock).
Transportation – This is your transportation evacuation survey tab.
Vehicles – Vehicles that you own.
Vendors – Select list of vendors that populates a master index of vendors by category for all plan members.

33. Know your generator information in advance of an emergency
Critical generator information that your local emergency responders, the LTC-MAP, your generator vendor and your internal team should have.

34. Emergency Reporting
Designated Facility Leadership or Nursing Supervisor (complete for LTC-MAP when requested)

35. Internal Situation-Status Report & Emergency Reporting: What You Should Know (and WHY)
Operational Issues at your facility (other plan members)
Open Beds
Available Transportation for
Resident Transportation
Movement of Supplies and Equipment
Resources & Assets (needed)
Resources & Assets (you could provide)
Equipment
Supplies
Staffing
HANDOUT
HANDOUT
This was made available as a tool at the 2014 LTC-MAP annual meeting. Provide to all parties who are attending your education session.

38. This is where you run reports during a window when the plan is activated to see what else is going on in your region.

39. HEALTH Department Operations Center (DOC) HEALTH LTC Group

40. HEALTH Department Operations Center (HEALTH LTC Group)
HEALTH has equipped multiple sites to function as the HEALTH LTC Group.
Some LTC-MAP Steering Committee Members have volunteered to serve as LTC Group Responders. These Responders are trained and divided into groups that will work in shifts whenever the HEALTH LTC Group is activated.
If you would like more information on being a LTC Responder or a Steering Committee Member contact Jim Garrow, Scott Aronson or Darren Osleger at Russell Phillips & Associates at

41. Function of the HEALTH LTC Group “Air Traffic Control”
Staffed by HEALTH & volunteers from the LTC-MAP
Assist with resident placement
Support resident tracking - “Close the loop”
Assist with obtaining staff, supplies and equipment
Assist with transportation of residents, staff, supplies and equipment
Support interaction with local and state agencies
ENSURE ALL MEMBERS ARE ACCOUNTED FOR
The HEALTH LTC Group performs these basic functions for the LTC-MAP. It is helpful to think of the HEALTH LTC Group as “air traffic control” for the long-term care facilities.

42. Who to go to with Questions?
Department of Health
Center for Emergency Preparedness & Response
Alysia Mihalakos Joseph Reppucci
Russell Phillips & Associates
Jim Garrow Scott Aronson
Lori Cheever Darren Osleger
David Hood
Scott Aronson 42