EXECUTIVE SUMMARY

Case manager leaders found that preparing staff to be mobilized or available via phone was crucial during Hurricane Harvey.

• Staffing could include dividing people into teams, including one that will ride out the storm.

• Employees often need emotional support after a disaster, particularly when their homes or families are affected.

• Case managers should prepare for a disaster by calling community partners and resources to ensure they have adequate space or equipment to assist in the event of a storm or flooding that affects transportation and the electrical grid.


Houston hospitals and case management departments were well prepared for disasters before Hurricane Harvey struck Texas in August 2017. They experienced 40 inches of rain and massive flooding with Tropical Storm Allison in 2001, and they made preparation changes after that event.

Still, Harvey broke all rules and showed that even the best plans might not be enough. The following are disaster preparedness and relief strategies that can help case managers and healthcare organizations cope with natural disasters:

• Establish a staffing plan. “MD Anderson had nearly 1,000 employees onsite during the storm so they could take care of all the needs of more than 540 patients,” says Donna Ukanowicz, RN, MS, ACM-RN, director of case management for MD Anderson Cancer Center in Houston. “We also had 120 clinical volunteers who came from other organizations outside of Houston to help,” she adds. “They were from New York, Ohio, Arizona, and Dallas, TX.”

Prior to the storm, Houston-based Texas Children’s Hospital asked staff to volunteer for one of three mobilization groups, says Gay Matthews, MSN, RN, CCRN-K, assistant director of care management at Texas Children’s Hospital.

The groups included a preparation group that helps the department prepare for the disaster, a ride-out group that stays in the department around the clock during the hurricane or storm, and a relief group that comes in to relieve the ride-out group as soon as travel is possible, she explains.

After Harvey, they found that the mobilization system should be tweaked. When the disaster hit, the ride-out team already was in place, ready to stay put in the department until the worst part of the storm and flooding were over. Then, they could go home when the relief team made it into work, Matthews explains.

It was a good system, but didn’t work perfectly because Hurricane Harvey was a much different event than they anticipated, Matthews says.

“It lasted much longer than a normal hurricane, so the ride-out team was here for an extended period of time — not just for a couple of days,” she says. “From now on, we’re going to put the prep and relief teams together so we have more people on ride-out.”

It was stressful for the ride-out team to spend days in the hospital while they heard of their family and friends’ travails.

• Mobilize case managers and other staff. For health systems, mobilization efforts could include electronic communication methods such as text messages and emails.

“We had a ring-line, where you call that number and hear a recorded message to tell you what’s open and closed,” Ukanowicz says. “We also use social media channels, and public relations did some outreach; we had lots of communication opportunities, but if you didn’t have power, it would have been difficult.”

Ukanowicz also keeps a printed list of staff’s contact information so she could still reach them by another phone or a landline if she lost access to her computer or cellphone. The hospital also uses automatic messaging strategies.

“We have a new system in the hospital that staff can sign up for,” Matthews says. “Via text messaging, they receive alerts — even when their cellphone calls won’t go through.”

• Provide staff with resource support. MD Anderson started a Caring Fund to collect donations used to help health system staff with their emergency needs and to supplement their recovery funds.

“I was able to direct my staff, who were greatly impacted, to apply for some funds to help them get back on their feet,” Ukanowicz says.

Also, MD Anderson covered salaries for employees affected by the disaster, extending their time off to give them time to recover, she adds.

Employees at Texas Children’s Hospital received three “Harvey days.” They could use the extra days off to meet with contractors to repair damage to their homes. Employees with more extensive rebuilding needs could use extra Harvey days that had been donated by other staff, Matthews says.

During the storm and flooding, Matthews witnessed a wonderful act of generosity between case management staff: “One employee’s house was fine, and the other one had to evacuate with her dogs,” she says. “They weren’t good friends, just co-workers, but the one woman told the employee who had to evacuate that she could bring her dogs and go to her house. People were just so supportive of each other.”

• Provide emotional support. “I think of our staff as a family, and we look out for one another,” Ukanowicz says. “When you have these types of emergency disaster situations, you care about one another and want to make sure everyone is safe.”

Case management staff would meet in hallways for huddles to talk and share stories, she says.

“If someone was out for an extended period of time, we would welcome her or him back, and I’d leave it up to the employee to decide how much to share,” Ukanowicz says. “We’re a close group and we do meet frequently, so the opportunity is there to provide support.”

Employee assistance programs and health system chaplains also can provide support and counseling. Texas Children’s Hospital chaplains made the rounds, visiting employees at work to see if people needed to talk or pray. “One chaplain wrote the most unbelievable prayer,” Matthews says.

There were no deaths or injuries among the case management department’s staff, but people still were traumatized by the disaster and had to deal with property damage and loss, the hassles of cleanup and hiring contractors, and worry, Matthews says.

“Sometimes, we just let people cry on shoulders about the precious things they lost,” she adds.

• Go over lessons learned of what worked and what didn’t. Texas Children’s Hospital had called for early activation of its disaster staffing plan, and that proved to be an excellent idea, Matthews says.

“We had our ride-out team in place early on Saturday, and we didn’t let people go home when the hurricane didn’t hit on Saturday,” she says. “Some sister hospitals said, ‘If I had come in a day earlier, it would have been so much better because I was trying to drive in the water and couldn’t see the road.’”

When the hurricane and flooding hit Sunday night and into Monday, the case management department was ready. Employees didn’t have to drive or walk through floodwater to get to work because they were already there and well-prepared.

MD Anderson’s case management department learned after Hurricane Allison in 2001 that case managers would need an inventory of available community services. Once the roads were open to traffic, they would need to facilitate transitioning patients to the community, and they’d need to know which services would be available for them, Ukanowicz says.

“We had to contact providers of durable medical equipment to see what they had in their inventory and how long it would take them to deliver equipment to patients’ homes,” she says. “We had to inventory nursing homes to see if they were open for business because some were impacted by flooding and couldn’t accept new patients.”

Case managers also determined what their patients needed if they were leaving Houston and helped them make safe travel arrangements. “The past experience helped us to know that those were our priorities,” Ukanowicz says.

Even the question of whether staff would have laptops or the ability to work remotely was a lesson learned, she notes.

On typical workdays, the department doesn’t encourage employees to take home their laptops. But for some case managers, having one at home during the disaster would be the only way they could complete their work. The answer was to encourage supervisors to take home their laptops before the storm and to ask other employees to make sure they would have access to a cellphone or another electronic device for communication, Ukanowicz says.

“I live 16 miles from the medical center and had no way to travel to get to work during the flooding,” she explains. “But I had electricity at home and had a computer, so I was able to work from home.”

• Make changes when planning for the next big one. Another lesson learned has to do with the central command center.

“As a care management leader, I’m responsible for being in the health system’s command center,” Matthews says.

But while she was needed in the command center during the disaster, she was equally needed in the care management department where people had to call patients and families and oversee discharges. Plus, case management staff was told to call the department leader, and Matthews was in a place where she could not spend her day on the phone, fielding these calls. Since Hurricane Harvey, they decided that they’ll need two leaders on the campus at all times during a disaster — one at the command center and the other in the department, Matthews says.

Ukanowicz was unable to head to her hospital’s incident command center, but she found during the Harvey disaster that she could fulfill her role remotely.

“My role was to talk about where we were with community resources, how many patients we thought were ready for discharge, and what I could do to assist with discharge,” she says. “I also talked about anticipated discharge delays and barriers and how much of our staff was impacted by the hurricane.”

Command center work included estimating how many employees would be back to work on days seven and nine, how many would need more time, and how this would affect case management operations, Ukanowicz adds.

“We didn’t have any patient discharges for four days,” she notes.

The case management department also learned that more planning was needed for the care continuum and transitions. Houston’s disaster was so widespread and encompassing that transitioning patients to home was a scary prospect for many families.

For instance, a child who was ready to be transitioned home might need home health, durable medical equipment, or other services that were delayed or unavailable during the early days of the flooding. Or, the child might not have a safe, unflooded home or access to a shelter that could provide care for a technology-dependent child. But keeping the same child admitted for continued medical care was not the answer, Matthews says.

“They didn’t need the medical care, and insurance wouldn’t pay for it,” she says.

The lesson case management learned is to have a plan for when these parents show up at the hospital. Besides patients that could not be discharged, there were former patients who returned with their families during the storm and flooding. The families didn’t know where else to go, Matthews says.

“We need a plan of where these children can be placed, and it should be a place where parents can take care of them and bring their own equipment,” she explains.

The hospital tried in the week before the hurricane to let parents know that they’d need a plan, but people still showed up, hoping to receive help.

“Because we have a complex care clinic here, we made phone calls to technology-dependent families to tell them they needed a backup plan of where they would go if they were uncomfortable in their homes,” Matthews says. “The hospital should not be their backup plan.”