Florida case managers deal with the effects of back-to-back hurricanes

Discharge planners went into high gear

After weathering three major hurricanes in just over 30 days, case managers in Florida hospitals have some advice for their counterparts in other parts of the country: Plan ahead and be flexible.

Here is what some of them experienced:

  • The three hospitals in Port Charlotte had to transfer 550 patients to other hospitals because of damage caused by Hurricane Charley.
  • Sarasota Memorial Hospital took in 167 special-needs patients and admitted 35 other patients from South Florida hospitals.
  • At St. Vincent’s Hospital in Jacksonville, as Hurricane Frances approached, the case managers arranged for some patients who live alone to be discharged to a family member’s home or temporarily to an assisted-living center.

When hurricanes Charley, Frances, and Ivan roared into Florida, hospitals in the predicted path of the storms pulled out their disaster plans and prepared to ride out the storms.

Florida hospitals are required by law to have a disaster plan that includes hurricanes and to conduct a disaster plan drill twice a year.

About seven days before a hurricane is expected to hit Florida, the hospitals activate their emergency plan and start making preparations for the possible evacuation and transfer of patients and preparing the physical plant for the storm, says Rich Rasmussen, vice president for strategic communication for the Tallahassee-based Florida Hospital Association.

If the storm appears to be heading toward their area, hospital discharge planners begin the process of identifying patients they can discharge earlier and looking for placements elsewhere in the state for patients who need to stay in the hospital.

The back-to-back storms presented a lot of challenges to discharge planners, says Linda Quick, director of the South Florida Hospital Association.

The hospitals needed to discharge as many patients as possible to free up beds for people who might be injured in the storms, but they often faced challenges in finding safe places for the patients to go.

"It was difficult discharging some of these patients, particularly if they lived alone. The discharge planners had to either find a family member or long-term care unit to take the patients," Quick says.

In fact, a few weeks after Hurricane Charley swept through the southern part of the state, a few elderly or medically fragile patients remained in special-needs shelters because they were on oxygen or a ventilator and still had no power at home.

"It was a very stressful situation for the hospital staff. South Florida hospitals transferred their patients further up north for cardiac catheterization and other interventions, and the patients ended up staying a long time because they had no air conditioning at home," says Mary Ellen Beasley, RN, BSN, division director for case management for HCA’s West Florida division, with headquarters in Palm Harbor, FL.

Hospital staff had to copy patient records to send with patients being transferred to other facilities and to make sure the records that went with the patients were accurate, she points out.

Between Hurricane Charley and Hurricane Frances, the case management staff at Sarasota Memorial Hospital began to take a stronger role in coordinating the intake and care of special needs patients, says Judy Milne, RN, MSN, CHPQ, director of integrated case management and quality improvement.

Because the county does not have a special needs facility, people from the community who qualified for special needs care come to Sarasota Memorial Hospital. During Hurricane Charley, 167 special-needs patients went there.

Under the new plan, the case managers evaluated patients who came to the hospital as Hurricane Frances approached, determining what services, such as oxygen, medication, and home health, they would need when they departed.

"We redesigned the intake process to get more information on the front end to anticipate what we need to do to get these patients back home with the kind of medical support they had prior to the storm," Milne says.

After Hurricane Charley struck, the hospital admitted 35 patients who were evacuated from South Florida hospitals that were closed because of the storm.

"As patients started coming up from South Florida, our hospital filled up quickly. As they recovered, we were in the position of having to transition people to home who didn’t have a home. We learned a lot about the whole shelter system," Milne points out.

Shortly after Hurricane Charley hit the state, the hospital sent four case managers to local shelters to help the Red Cross and the state health department find placements for residents who fled their homes in South Florida and who had medical needs. Four case managers worked for two full days coordinating admissions for displaced residents to extended care facilities and assisted-living facilities.

"We had an increase in people coming to our emergency department. Many were from the hard-hit areas. They couldn’t get to their usual physician because the office was blown down and their local hospital wasn’t available, so they migrated north," Milne says.

Hurricane Frances presented a different set of challenges, because a large portion of the Sarasota area was left without electricity.

"We had patients who were in the hospital for a few extra days because they had oxygen concentrators that needed electricity or respiratory problems that meant they couldn’t handle the humidity with no air conditioning," she says.

Massive evacuation employed

Immediately after the hurricane, 550 patients had to be evacuated to other areas. Hospitals in the Port Charlotte area sustained little damage and had power, but the area’s water and sewage system was damaged, making it necessary to evacuate all three hospitals in Charlotte County. The Florida Hospital Association helped facilities transfer the patients, using helicopters provided by Florida hospitals, the Coast Guard, and the National Guard.

"We had to begin shifting those patients north to Tampa, Sarasota, and the Fort Lauderdale area," Rasmussen says. Patients on ventilators had to be evacuated by air by helicopters equipped to handle ventilator patients. Other critically ill patients also were evacuated by air.

Those who did not need immediate assistance were evacuated by ground transportation. "The important thing is that through all three storms, we had thousands of patients transferred across the state without incident. They were safely transported, and their health care continued in a new facility, and we did it all without a single patient’s health being compromised," Rasmussen says.

South Florida hospices were challenged, especially if they were in areas where they were having problems providing services. In some cases, families had been dislocated and did not notify the hospice of their location, Quick says.

Case managers had to use their ingenuity during the storms and power outages, she adds. For instance, some people brought their oxygen with them to the special needs shelters in their local hospitals, but the oxygen ran out. "They were able to get the company that provides the hospital oxygen to provide some tank oxygen," Quick notes.

When the winds from Hurricane Frances hit Jacksonville, a large number of employees of St. Vincent’s Hospital were left with wind-damaged homes and electricity outages.

"We watched the storm carefully and activated our disaster plan. We did a lot of planning at the department level to determine who could get in and who couldn’t and to make sure that people came in early if they thought they might not be able to get in for their shift," says Wanda Gibbons, RN, vice president of patient care and chief nursing officer. St. Vincent’s is a community hospital licensed for 538 beds, with a 240-bed nursing home on the same campus. The hospital’s normal plans for discharge don’t always work in the event of a natural disaster, she points out.

"The hurricane made it necessary for our discharge planners to be flexible in working with patients to meet their needs and find a situation where they would be safe," Gibbons adds.

For instance, some patients were discharged to a family member’s house instead of their own home or to an assisted-living center for a short time. Just before the storm, staff had some difficulties in placing patients in some area nursing homes that were holding beds in case other facilities had to be evacuated.

As the hurricane approached the area, some staff slept at the hospital to make sure they would be available the next day. Other staff stayed late until the weather lifted. "We didn’t want people to be unsafe by driving to work in the middle of the storm," Gibbons says.

Staff who stayed overnight slept in an older nursing unit that used to be a pediatric unit and in the same-day surgery area.

The bridges that cross the St. Johns River, which runs through the middle of Jacksonville, are closed when winds hit 40 miles per hour. "We had to anticipate that the bridges were going to be closed and bring people from the other side of the river in early," she explains.

The hospital arranged for a local cab company to bring in staff who typically ride the bus system or who had other transportation issues.

In the days before the storm, the discharge planners went into high gear, working to discharge patients who were ready to go home to free up beds in case people were injured in the storm, Gibbons says. "The discharge planners were concerned about not sending someone home who might need to be in a special-needs shelter when the storm hit," she says.

Hospitals throughout the state of Florida staff special-needs shelters for medically fragile, elderly, and disabled people who don’t need to be in the hospital but may need medical care or special assistance. For instance, patients on ventilators or those who use oxygen may come into the special-needs shelters because they don’t have electricity.

When making plans for rural residents from Florida and South Georgia who come to St. Vincent’s for cancer treatment, cardiac, and other specialty care, the discharge planners had to take into account that families who rely on a well for their water could be without a water supply, Gibbons adds.

After paying close attention to three hurricanes with the potential to hit the area, the St. Vincent’s staff are considering additions to the disaster plan that include an area for family members and a place where staff can bring their pets.

"When school is closed and there’s no electricity or telephone service at home, parents are reluctant to leave their children. There is a need for a place for family members to go when we have a disaster," she says.

The hospital is considering setting up an area in a well-ventilated garage where employees can leave their animals in a pet carrier and feed and care for them when they get a break.

"Some people don’t know how long it will be before they get home or how long they’ll be without electricity. Having their children and pets with them will give them a comfort level they wouldn’t have otherwise," Gibbons says.

At Homestead Hospital, as soon as the area was under a hurricane watch, the discharge planners worked aggressively to start early discharge planning, says Jill White, RN, director of case management and performance improvement.

"Once there’s a hurricane watch, the community resources start shutting down. The nursing homes stop accepting patients, and home health won’t guarantee that they can provide services. It’s difficult to place patients during a hurricane watch situation. We have to be very creative," she says. In some cases, patients have come to the hospital emergency department from a nursing home, but the nursing home won’t take them back because of the storm. In that case, the hospital provides a safe shelter.

Case management staff pay close attention to the documentation for patients whose length of stay is extended by the storm.

"As long as the insurance companies are open, we work with them trying to set up a plan. They’re very aware whether we can get a patient out or not," White explains. Hospital staff concentrate on making sure that patients get the care they need during a disaster and worry about reimbursement later, she says.

"Most of our concern about the payment angle is after the fact. When the storm is headed our way, our top priority is taking care of the patients, making sure they have what they need, and that if they are discharged, it’s to a safe place," White says.

Here are some tips from hospital staff who have been through a disaster recently:

  • Develop a disaster plan and practice regularly.

"You never know what you’re going to encounter. Plan for the unthinkable," Rasmussen says, pointing out that Florida was hit with three hurricanes in 30 days with another one looming just afterward.

  • Plan ahead and know your plans will change as the storm moves through.

"The key is to have everything planned out in advance, because during the peak of the storm, you can’t do anything except ride it out," notes Gibbons.

For instance, most Florida hospitals have reciprocal arrangements with hospitals in other areas to take their patients in the case of an emergency.

  • Be flexible and creative.

"Sometimes the staff take a lot of encouragement because they’re worried about getting here. Our nursing supervisor spent a lot of time telling people how to get here using different routes, and we sent cabs out for people who couldn’t come in," Gibbons says.

Constant communication is the key to a successful disaster management plan, Rasmussen says. A few days before the hurricanes hit Florida, the Florida Hospital Association developed a database of key hospital personnel in areas in the path of the storms. The advance planning paid off when Charley hit and disabled Charlotte County emergency operations center, leaving the area with limited communications. The hospital association was able to facilitate communication using its database, he adds.