[Senate Hearing 115-379] [From the U.S. Government Publishing Office] S. Hrg. 115-379 DISASTER PREPAREDNESS AND RESPONSE: THE SPECIAL NEEDS OF OLDER AMERICANS ======================================================================= HEARING BEFORE THE SPECIAL COMMITTEE ON AGING UNITED STATES SENATE ONE HUNDRED FIFTEENTH CONGRESS FIRST SESSION __________ WASHINGTON, DC __________ SEPTEMBER 20, 2017 __________ Serial No. 115-9 Printed for the use of the Special Committee on Aging [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT] Available via the World Wide Web: http://www.govinfo.gov _________ U.S. GOVERNMENT PUBLISHING OFFICE 30-022 PDF WASHINGTON : 2018 SPECIAL COMMITTEE ON AGING SUSAN M. COLLINS, Maine, Chairman ORRIN G. HATCH, Utah ROBERT P. CASEY, JR., Pennsylvania JEFF FLAKE, Arizona BILL NELSON, Florida TIM SCOTT, South Carolina SHELDON WHITEHOUSE, Rhode Island THOM TILLIS, North Carolina KIRSTEN E. GILLIBRAND, New York BOB CORKER, Tennessee RICHARD BLUMENTHAL, Connecticut RICHARD BURR, North Carolina JOE DONNELLY, Indiana MARCO RUBIO, Florida ELIZABETH WARREN, Massachusetts DEB FISCHER, Nebraska CATHERINE CORTEZ MASTO, Nevada ---------- Kevin Kelley, Majority Staff Director Kate Mevis, Minority Staff Director CONTENTS ---------- Page Opening Statement of Senator Susan M. Collins, Chairman.......... 1 Statement of Senator Robert P. Casey, Jr., Ranking Member........ 3 Statement of Senator Thom Tillis................................. 5 PANEL OF WITNESSES Karen B. DeSalvo, M.D., Former Health Commissioner, City of New Orleans, New Orleans, Louisiana................................ 6 Kathryn Hyer, Ph.D., Professor and Director, Florida Policy Exchange Center on Aging, School of Aging Studies, University of South Florida, Tampa, Florida............................... 9 Paul Timmons, President, Portlight Inclusive Disaster Strategies, Inc., Charleston, South Carolina............................... 11 Jay Delaney, Fire Chief and Emergency Management Coordinator, City of Wilkes-Barre, Wilkes-Barre, Pennsylvania............... 12 APPENDIX Prepared Witness Statements and Questions for the Record Karen B. DeSalvo, M.D., Former Health Commissioner, City of New Orleans, New Orleans, Louisiana................................ 30 Questions submitted for Karen B. DeSalvo..................... 33 Kathryn Hyer, Ph.D., Professor and Director, Florida Policy Exchange Center on Aging, School of Aging Studies, University of South Florida, Tampa, Florida............................... 36 Questions submitted for Kathryn Hyer......................... 38 Paul Timmons, President, Portlight Inclusive Disaster Strategies, Inc., Charleston, South Carolina............................... 42 Questions submitted for Paul Timmons......................... 45 Jay Delaney, Fire Chief and Emergency Management Coordinator, City of Wilkes-Barre, Wilkes-Barre, Pennsylvania............... 47 Additional Statements for the Record Senator Marco Rubio, Statement for the Record.................... 50 Katie Smith Sloan, President and CEO, LeadingAge................. 50 James R. Balda, President and CEO, Argentum...................... 52 Teresa Osborne, Pennsylvania Secretary of Aging, and Rick Flinn, Director, Pennsylvania Emergency Management Agency............. 56 DISASTER PREPAREDNESS AND RESPONSE: THE SPECIAL NEEDS OF OLDER AMERICANS ---------- WEDNESDAY, SEPTEMBER 20, 2017 U.S. Senate, Special Committee on Aging, Washington, DC. The Committee met, pursuant to notice, at 9:06 a.m., in Room SD-562, Dirksen Senate Office Building, Hon. Susan Collins (Chairman of the Committee) presiding. Present: Senators Collins, Tillis, Fischer, Casey, Gillibrand, Donnelly, and Cortez Masto. OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, CHAIRMAN The Chairman. The Committee will come to order. Good morning. Recently, Hurricanes Harvey and Irma left a path of destruction along the gulf coast of Texas, across Florida, and throughout the Caribbean. Homes, businesses, and entire communities were destroyed and lives were lost. Days after Irma, we learned the tragic news that eight seniors, ranging in age from 71 to 99, died in a Florida nursing home that lacked air conditioning because the power had been knocked out. One press account described the facility as ``a death trap'' because the elderly are particularly susceptible to heat-related illnesses. Last month, this photo of residents of an assisted living facility in Texas who were trapped in waist-deep water went viral. As these recent disasters make clear, older Americans are particularly vulnerable before, during, and even after a storm. In fact, when Hurricane Katrina slammed into the gulf coast 12 years ago, more than half of those who died were seniors. As the then Chair of the Senate Homeland Security Committee, along with Senator Joe Lieberman of Connecticut, I led a bipartisan investigation into the response to Hurricane Katrina at the federal, state, and local levels. Our investigation, which resulted in this extensive, some would say weighty report, revealed many weaknesses in our Nation's emergency response system, and although I doubt very many people read the whole report, it does have an excellent summary that I was just discussing with the chief. And it was evident to me in rereading it that we have learned many of the lessons of Katrina, but we still have a long ways to go. One of the weaknesses in our Nation's emergency response system included the failure on the part of all levels of government to plan and provide for timely and effective evaluation of our most vulnerable seniors. Since then, we have expanded our efforts to improve emergency preparedness and response across the entire country, and we have emphasized the protection of the most vulnerable. Meanwhile, Mother Nature continues to unleash her fury. Today, even as we meet, yet another hurricane, Maria, is battering a region still struggling to recover, and it is expected to hit Puerto Rico particularly hard. This morning, we will discuss how our federal, state, and local emergency response efforts have been critical in limiting the scope of these recent tragedies, and we will identify where more work is still needed. On the positive side, improvements in emergency response efforts at the Centers for Medicare & Medicaid Services have helped to identify those seniors who require relocation in order to maintain their dialysis. I was talking with the head of CMS just yesterday about this, and she said one of the problems was that the demand was so great that people were not able to have complete dialysis. They were hooked up to the machines for 2 hours when they needed a far longer period of time, but the demand was such that they were just trying to maintain people. In addition, local emergency response teams implemented strategies to identify those most in need and provided designated shelters that offered necessary medical care and support. But that, tragically, was not always the case. The lack of electrical power apparently contributed to the death of those seniors in the nursing home and to the worsening health condition of others, suggesting a very troubling lack of preparedness in some health care centers. While we have made many strides since Hurricane Katrina twelve years ago, we must ask ourselves: Can we better protect the most vulnerable members of our communities? What gaps exist that could jeopardize lives in the next catastrophe, whether it is a storm, an earthquake, or some other unanticipated event? We should not have to wait for the next Irene, Sandy, Harvey, Irma, or unnamed disaster to strike. Today we will discuss concrete solutions to protect and stabilize vulnerable seniors from maintaining necessary resources and connections during emergencies to relocating and returning to safe and secure homes during the recovery period. We will consider the challenges of making the correct choices of whether it is better to shelter people in place or evacuate and relocate. And as I have looked more into this issue, I have learned that that is often a very difficult decision to make, particularly if you are dealing with people with some sort of dementia. Just one day after Hurricane Irma slammed much of Florida, a CNN reporter waded about a mile in waist-deep water, contaminated with oil and garbage, to knock on the door of a mobile home in Bonita Springs. He had been told that an elderly couple lived inside and that they did not heed the warnings of local and state officials to leave prior to the storm. Inside this mobile home, which was now surrounded by water, lived an 88 year-old woman and her 93 year-old husband who suffered from Parkinson's disease and diabetes. When the reporter asked the woman why they did not evacuate, she simply replied: ``We have everything we need here. We have his medications. It is just easier.'' Now, I am very grateful that this couple was found safe, but to me this story illustrates how we must expand our efforts to protect vulnerable seniors, not only those who are living in facilities such as assisted living or long-term care facilities, but instead are living in their own homes. For many of those seniors, evacuation is not as easy as packing a bag and jumping into a car. They may not be able to drive, for example. Some of these homebound older adults are alone and frail. They may suffer from diseases. And many of them have lived in their homes for so long that they just do not want to leave it behind and are fearful of what will happen if they leave. Let me conclude by offering my condolences to all those who experienced losses as a result of these violent hurricanes. My heart goes out to all of those who are suffering and now face the considerable challenges in the weeks and months ahead. I also want to extend my gratitude to the first responders, including the volunteers, such as a medical team from Maine and everyone who has reached out to help a neighbor in need, even as in so many cases they, too, are dealing with the devastation caused by these terrible storms. While we can and must continue to improve our emergency response so that the tragic deaths in Florida's nursing homes do not happen in the future, we should not overlook the heroic actions of so many. I want to thank our witnesses for being with us today, and I am delighted to now recognize the Ranking Member, Senator Casey. OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., RANKING MEMBER Senator Casey. Chairman Collins, thank you very much for having this very important hearing, especially at this time. I join the Chairman in thanking the work of those who have done emergency response tasks over many, many days now. The countless volunteers who have helped them throughout these many days of challenge, we are grateful for that work, and we join in thanking them for doing that great work. Together they have worked endless hours over these last several weeks to save the lives of people in Texas, in Florida, the U.S. Virgin Islands, and now, of course, folks in Puerto Rico are facing a difficult number of days ahead; and we are thinking of them and praying for them at this time. To say that these actions have been heroic is an understatement. There is no way to adequately describe that kind of commitment, that kind of heroism. But, unfortunately, today we are here because we know that, despite great efforts by a lot of good people across the country, older Americans and individuals with disabilities face extraordinary challenges in a disaster. And, again, that is an understatement. So many of us were both outraged and enraged when we saw what happened in Florida, that people died, seniors died in the midst of this crisis. We are also heartbroken for the loss of life and also the loss that those families suffered. In this case it was apparently something as simple as a lack of air conditioning--something that many of us take for granted just even on a day like today in this building. It is hard to comprehend the sadness that will engulf those families and those communities. So that is one of many challenges we will speak to today. Just yesterday, Senator Nelson, who has done great work in his home State of Florida dealing with these issues, said the following, he said: ``One life lost is one too many.'' I am proud--and I know that Chairman Collins as well is proud--that we have joined him in introducing legislation that would do the following: It would require the Secretary of Health and Human Services to establish a national advisory committee on seniors and disasters. A 15-member panel would be appointed by the Secretary of HHS and made up of federal and local agency officials as well as non-federal health care professionals with expertise in disaster response. It is a good bill. It is bipartisan. We should pass it. Both Senator Nelson and Senator Rubio have introduced it. So that is one thing that we can do together to better plan for and respond to these challenges in the future. But like all Americans, and I think every American was stunned by the viral photo that the Chairman just showed of one nursing home and the water that was rising around those seniors, in this case in an assisted living facility in Houston where they were sitting in waist-deep water waiting to be rescued. These are folks who, indeed, to say they are our greatest generation does not adequately capture it. These are folks who fought our wars; they worked in our factories; they built the middle class; they gave us the kind of life that we take for granted sometimes. They have sacrificed so much, and they have lived lives of quiet dignity. We have a sacred obligation to them to make sure those scenes that were depicted in that photograph and that happened in Florida never happen again. Just as the Chairman said, all the good lessons that were learned in the aftermath of Katrina, we have to implement better practices, best practices to make sure that we learn from these recent disasters as well. So we need to ensure that we are doing everything possible to learn from these tragedies, and we also have to make sure that we are focused, on a day like today, on better policy. And that is why we gather today with such a great panel of witnesses. These witnesses bring not just experiences from the recent past, but in many cases from years of experience, from Hurricane Katrina to Hurricane Harvey. They have faced the double whammy, so to speak, of Hurricanes Lee and Irene back in 2011, as well as the four hurricanes in 6 weeks that ravaged Florida in the year 2004. We have learned--and they have learned even more--from each of these experiences. So we hear from our witnesses, incident management infrastructure is more robust in some important areas like hospitals. That is good news, That means we have learned lessons to implement those changes. Coordination efforts in advance of storms have been improved, and there are more comprehensive emergency response requirements being implemented for nursing homes so that seniors will be better protected. But we have a long way to go to make sure that we get this right. Older citizens should not suffer for days and then die in the unbearable heat. No person with a disability should have trouble following evacuation orders because of inaccessible transportation or shelters. And it should go without saying no senior should fear drowning in their own home, no matter where they live. Our witnesses here today will explain how we can do better, because we must do better. We have a sacred obligation to do better. I want to thank the witnesses for bringing their experiences, their expertise, and their passion to these issues. And I want to thank Chairman Collins for gathering us on this day. The Chairman. Thank you very much, Senator Casey. I am delighted that we have Senator Tillis, Senator Fischer, and Senator Cortez Masto here with us today, and I very much appreciate their participation. I know that Senator Tillis has to get off to the Judiciary Committee, and so I would like to offer him the opportunity for any comments he would like to make. OPENING STATEMENT OF SENATOR THOM TILLIS Senator Tillis. Thank you, Madam Chair. I do have to chair the Judiciary Committee, so once I get there, I will not be able to come back. But I wanted to thank you all for being here. The building is a little empty today because we adjourned last night, but you see the focus that these members have to be here, and thank you all for being here. You know, I am glad that we framed this as really a response to disaster. We are going to immediately leap to the disaster that right now is occurring in Puerto Rico with Maria making landfall with 175 mile per-hour sustained winds. We can talk about the recent storms Harvey and Irma, but I could talk about an enormous impact in North Carolina called Matthew a year ago on October 8th. And I have a personal story to tell there because our office, our staff had to help a senior who had gotten lost in the process, who had left her home, as she should have. We had almost 20 inches of rainfall in about a 24- hour period that was devastating to the community, and then the river rises afterward were even worse, so much so that when they would go to one shelter, that shelter got closed down because the water threatened those shelters. And so it really raised a question, Mr. Timmons--I am going to submit some questions for the record for all of you to potentially respond to, but it raises a question about how well we track evacuees through the life cycle. And I think that life cycle needs to go before the disaster ever occurs and then until there is a resolution that makes us feel like that senior is safe and secure. I think one of the reasons that we have a challenge with evacuating seniors is they just have a fear of the unknown. And if we did a better job of communicating what this would look like earlier, where they are likely to go, and how we are going to be stewards of them over the course of the process, then I think that many who feel like the safest thing to do is to shelter in place will be replaced with a sense of comfort that they are going to be taken care of through the process, up to and including getting them back into their home and living independently again or living in a facility where they have been taken care of. So that life cycle, where it needs to start, how do we better educate, how do we better link--what we ended up doing in our office is gluing together--and I think it can be instructive for things that we need to do differently. But, fortunately, our Governor, our emergency management folks in North Carolina helped us find this lady, get her medications, which were desperately needed, and get her connected to her family. So that sort of life cycle of disaster that starts before the disaster ever occurs, until we know that that senior is safe and sound, is something that I think would be very helpful and instructive to us to see how we can actually work at the federal, state, and local level to make that happen. Thank you all for being here, and thank you for being focused on helping us come up with a solution. And, again, Madam Chair, thank you for your work on this subject. The Chairman. Thank you very much, Senator Tillis. I am now going to introduce our excellent panel of witnesses. First is Dr. Karen DeSalvo. Dr. DeSalvo is a physician and public health expert. She served as health commissioner in New Orleans, where she worked hard to restore health care to areas of the city devastated by Hurricane Katrina. She has also served as the former Assistant Secretary for Health at the U.S. Department of Health and Human Services. Next we will hear from Dr. Kathy Hyer. Dr. Hyer is director of the Florida Policy Exchange Center on Aging at the University of South Florida. Dr. Hyer has researched and written extensively about vulnerable older Americans and the structure of the emergency response systems. I want to particularly thank you, Dr. Hyer, for being here today even as the long recovery process in Florida continues. We will also hear from Paul Timmons. Mr. Timmons is president of Portlight Inclusive Disaster Strategies in Charleston, South Carolina. Despite that mouthful of an organization's name, he is a leader in the field of disaster preparedness and response for people who are aging and those with disabilities. Finally, I am going to turn to our Ranking Member to introduce our witness from Pennsylvania. Senator Casey. Thanks very much. I am pleased to introduce Jay Delaney, who is fire chief and emergency management coordinator for the city of Wilkes-Barre, Pennsylvania. Chief Delaney led the response efforts when it became clear that Hurricanes Irene and Lee could cause the Susquehanna River, the 16th largest river in the United States, to overwhelm our levees in the community of Wilkes-Barre, Pennsylvania. With the clock ticking and the waters rising, Chief Delaney safely evacuated 15,000 people in just 10 hours, including our hospitals and nursing homes. I look forward to the chief's testimony. Thanks, Chief. The Chairman. Thank you very much, Senator. We will start with Dr. DeSalvo. STATEMENT OF KAREN B. DeSALVO, M.D., FORMER HEALTH COMMISSIONER, CITY OF NEW ORLEANS, NEW ORLEANS, LOUISIANA Dr. DeSalvo. Thank you, and good morning, Chairman Collins and Ranking Member Casey and distinguished members of the Committee. Thank you all for making time in a very busy agenda of the Senate to talk about this priority issue of seeing that we have an opportunity to better support and protect older Americans in times of disaster and every day. I am Karen DeSalvo. I am a physician, and I was formerly the health commissioner in New Orleans--not during the time of Katrina but subsequently, and I certainly was in New Orleans at Katrina. But I want to share a story that started a little bit later. It was 2012, and I found myself standing in the Emergency Operations Center in New Orleans being asked by our power company how to prioritize power restoration for our community. I was relatively new to the job. It was August. It was hot. We knew that we were just about 7 years after Katrina, and though we had done very much to heed the advice of better preparations and planning, what we had is an event that was not about flooding but was actually about power outage from prolonged high winds. We were prepared in many ways. We had hardened the infrastructure, particularly of our hospitals. We have better relationships, particularly heeding the advice of Senator Collins of not exchanging business cards during disaster but doing it well before. And we had done much better planning. In fact, our hospitals had returned to normal functioning. The question I was being asked to address was how to prioritize power for the rest of the community, and the situation was complicated, of course, because we were getting reports of seniors struggling in the heat throughout our community. And we had offered evacuation assistance to many of those seniors who had been registered in our medical special needs registry, but they wanted to shelter in place and did not take the opportunity to voluntarily evacuate. Though we knew some about them, we did not know where they were clustered and who was at highest risk and who was electricity dependent. And so in the end I resorted going door to door throughout our community to try to help prioritize power restoration based upon who answered the door when we knocked on it. We were able to help a lot of people because we did this with the support of first responders like fire, but it was not a great feeling, nor was it very efficient. And so going forward, we did not want to repeat that experience of having to be somewhat haphazard in trying to determine how to restore power in our community, and we worked with HHS to leverage Medicare data and new technologies like geomapping to be able to create a map in our community of where seniors who are electricity-dependent lived. We did a drill in the community with fire and police and volunteers and went door to door to the dots on this map, a subset of them, knocked on the door, and said, ``We are from the government, and we are here to help.'' We actually did say that. I did. And people willingly opened their doors and learned that we were trying to find out if they were electricity-dependent and how we could be helpful for them not only in disaster but every day. We learned the Medicare data worked. It was accurate. And we also learned something perhaps more concerning: that of the some 600 people who were on the list as electricity dependent for their oxygen, we only knew of 15 of them in our medical special needs registry. That system, called ``emPOWER,'' has been taken to scale and is available to be used across the country in every community, not only in disaster response but also in preparedness. And it is an example of how we can use technology and local experiences married with federal resources to really do better in preparedness and response. And, in fact, HHS recently used this tool in Irma and in Harvey. We do tend to focus on those disasters that make the headlines and also on those who are most frail and in nursing homes, but I just want to take a moment to talk about additional important work that we need to do beyond supporting those most frail in our community that are in institutions. When I went door to door in the community after Isaac, the bulk of the people I saw were individuals that were living independently, in community-based settings, often in subsidized housing and high-rises. And, frankly, what I saw was really heartbreaking. These are people who are living on the edge every day and are not likely to be broken only by a major disaster but by, frankly, all the little disasters that touch their lives on a regular basis. And tools like emPOWER are a great way to get them on a medical special needs registry so we know how to find them, but they require human touch as well, and that is part of the resiliency building that we all need to do. I agree that since Katrina we have made a great deal of progress in hardening our infrastructure, in building the relationships that are necessary to help us better prepare and respond, but there is so much we still need to do to support our seniors. And in that vein I offer actions in three areas that I think can help build a stronger infrastructure. There is more in my testimony, but I will just highlight a few today. One, is tools like emPOWER remind us that we have now technology and data, but it is only as good as the data in it. So, for example, in emPOWER, if we expanded it to include Medicaid and commercially insured populations, we could do more good for more people. And Congress needs to support the action on the ground. It is one thing to have information in a box, but we have to also be able to act upon it on the front lines, and that requires training exercises perhaps with local public health and the Public Health Service Commission Corps. Second, we need to support the local public health and response infrastructure. They are under-resourced to meet their statutory obligations to support the community and the most vulnerable in times of need. This includes public health, but other agencies and the private sector who are trying to help seniors and older Americans every day. Third, we need to do more to protect. I think the CMS Emergency Preparedness Rule is a step towards strengthening the infrastructure, but it requires robust implementation. It is not pieces of paper and checklists. It is actually really drilling and paying attention in an ongoing fashion to things like fuel supplies for generators. And, finally, I think the administration should think about creating best practices tools that can help guide policy and regulation and local ordinances that can support areas that sometimes we forget about for preparedness like building codes. Thank you again for raising the profile of the need to better support seniors, older Americans, and the most vulnerable in our community in times of disaster, but also every day, and I look forward to your questions. The Chairman. Thank you very much, Doctor. Dr. Hyer. STATEMENT OF KATHRYN HYER, PH.D., PROFESSOR AND DIRECTOR, FLORIDA POLICY EXCHANGE CENTER ON AGING, SCHOOL OF AGING STUDIES, UNIVERSITY OF SOUTH FLORIDA, TAMPA, FLORIDA Dr. Hyer. Good morning. On behalf of my colleague Dr. David Dosa, who could not be here today, I want to thank all of you for being here and for giving me the opportunity to testify on a topic I have studied since 2004 when four hurricanes traversed Florida in 44 days. Since that time, my colleagues and I have studied the effect of disasters on frail older adults and disabled individuals living in nursing homes and assisted living, and we have worked to improve disaster preparedness, response, and readiness. My remarks reflect more than a decade's worth of research that has been carried out with generous grants from the John A. Hartford Foundation, the Kaiser Foundation, the Borchard Foundation, and the National Institutes of Health, specifically, the National Institute on Aging. In 2004, as Senator Collins alluded to, nursing homes only became part of the State Emergency Response System after repeated hurricanes crisscrossed the State, and emergency personnel finally recognized that nursing homes were actually health care facilities, taking care of frail elders. ESF recognized nursing homes needed help getting fuel for generators, getting power restored. Only then were nursing homes recognized as part of the health care provider system. They were ignored until then. Following Katrina, our research team interviewed nursing home administrators about their experience during Katrina. Across the board these nursing home administrators revealed that they wrestled with the important decision about whether to evacuate their residents prior to the storm. They cited pressure from emergency managers urging them to evacuate despite the difficulty of evacuation, having elders pushed on buses, having them evacuate to gymnasiums without supplies and adequate materials and mattresses. And they recognized that these patients declined. They saw their own staff hurt trying to help and move residents. And they believed that they would be better served staying where they are. This initial work became the impetus for the National Institute of Aging's study that we did looking at the effects of Hurricanes Katrina, Rita, Gustav, and Ike on nursing home residents. Our research showed that among 36,000 nursing home residents exposed to those gulf hurricanes, the 30- and 90-day mortality and hospitalization rates increased considerably compared to the non-hurricane control years regardless of whether they evacuated or sheltered in place. In total, there were 277 extra deaths and 872 extra hospitalizations within 30 days after exposure to the storms. Natural disasters result in bad outcomes for elderly and disabled individuals. Our research, however, asked a second question. We asked whether or not it was better to evacuate or shelter in place. Using those same data from those four storms and methodological techniques that are in the appendix that we have provided, our research concluded that the very act of evacuation prior to the storm increased the probability of death at 90 days and increased the risk of hospitalization, independent of all other factors. It should be noted that our data took into account the fact of certain nursing homes that did not evacuate, including St. Rita's and Lafon Nursing Homes where there were, tragically, many deaths. Despite these tragic deaths, evacuation proved to be cumulatively more dangerous than sheltering in place. Based on our research and our experience, we have the following recommendations: We need generators to support medical needs and air conditioning to cool reasonable temperatures as well as fuel for both nursing homes and assisted livings. These generators need to be elevated to ensure continued operation. Emergency plans for both nursing homes and assisted livings must be publicly and easily available for all to see and for residents and families to understand before they enter a nursing home. Nursing home surveyors and emergency managers also need to be sure all plans are actually tested, and this means real drills and actual implementation. Assisted living communities require much more oversight. Assisted living communities routinely accept patients who would have received care in a nursing home only a decade ago. Waiver payments for residents with Medicaid have also increased, thereby making the Federal Government at least an interested party in assisted living regulations. Evacuations should not be all or nothing. Senator Collins already talked about the importance of dialysis residents being evacuated. We need a much more nuanced and better researched understanding of who should evacuate before and then how people can be sustained appropriately. Nursing homes and assisted livings must be built in places that minimize flooding, and they have to be built to standards that allow administrators to shelter in place if at all possible. Every state and local emergency management organization in this country must identify and prioritize nursing homes and assisted living communities for restoration of power services and other services. Some degree of litigation protection must be considered for facilities that abide by regulations and provide heroic care during disaster scenarios. There are many people working very hard to try to care for elders and disabled people all over Florida, continuing as we speak. Finally, older adults matter. I am the PI on a HRSA Geriatric Workforce Enhancement Program grant. We need continued commitment to geriatric education programs and training programs. I can only provide the evidence I am providing today because research and training was approved years ago, but it dried up in the years following Katrina. Our country needs ongoing geriatric training. We need consistent research funding to evaluate disasters. We know that disasters will continue to occur, and we must be prepared. Thank you for allowing this testimony, and I look forward to questions. The Chairman. Thank you very much. Mr. Timmons. STATEMENT OF PAUL TIMMONS, PRESIDENT, PORTLIGHT INCLUSIVE DISASTER STRATEGIES, INC., CHARLESTON, SOUTH CAROLINA Mr. Timmons. Thank you, and good morning. Portlight is the Nation's only NGO with a specific mission to serve the disaster relief needs of people with disabilities and older Americans. Portlight is a 20-year-old grassroots organization with a proud history of serving on the ground in virtually every major national disaster since Hurricane Katrina. Our Partnership for Inclusive Disaster Strategies leads and coordinates over 100 disability, aging, emergency, public health, public safety, and other local, State, and national stakeholder groups, including FEMA and the Red Cross, with a shared commitment to the emergency preparedness and disaster-related needs of the Nation's 59 million people with disabilities and 67 million Americans over the age of 60. We have been convening stakeholder calls daily to identify problems and find solutions and operating our hotline to assist disaster survivors from Harvey and Irma, and we are currently preparing our incredibly dedicated volunteers for Hurricane Maria. Given that people with disabilities and older adults are two to four times more likely to die or be seriously injured in a disaster, the urgency of our work cannot be understated. This is due frequently to poor planning, inadequate accessibility, and the widely shared but incorrect assumption that people with disabilities and older adults are ``vulnerable,'' ``special,'' or ``particularly at risk'' simply because of their diagnoses or stigmatizing beliefs about disability and aging. In fact, we are extremely valuable experts on emergency problem solving, with far more practice than younger people and people who do not navigate inaccessible environments and programs on a daily basis. The appropriate approach focuses broadly on the access and functional needs of people with and without legal disability rights protections. In a disaster, providing equal access and meeting functional needs makes the difference time and again for individuals, families, and communities. In fact, the phrase ``people with access and functional needs'' has been codified by DHS and is the work term of art among emergency management professionals, and it perfectly fits our discussion here. Ineffective and inappropriate evacuation, hospitalization, nursing home admission, and separate sheltering and strategies for assisting millions of people with access and functional needs might look right on papers; however, it is a deeply flawed approach in practice, and it must be stopped. It has been clearly proven in story after disturbing story to be even worse than we expected. Here are a few examples of the consequences and shortfalls in accessibility and the disproportionate impact that is the result. A Florida man with quadriplegia using a power wheelchair, separated from his fiancee and was sent to a special needs shelter, then discharged without any assistance or plan other than to return to his destroyed dwelling. He had to sleep outside for several nights until the temperature caused him to have heat stroke. In partnership with the FEMA Disability Integration Advisor, we have assisted him to obtain temporary sheltering in a wheelchair-accessible hotel room. A woman called from a nursing home she had been transferred to after evacuating from Houston to Dallas. She told us the nursing home wanted her to sign over her Social Security and FEMA benefits, which would make leaving the nursing home impossible. We have connected her with legal assistance to protect her rights and address her need to return to Houston as soon as housing can be found. Many older adults and people with disabilities in highrises, trailer parks, and other locations have been disconnected from response and relief resources, and still are, and have had no food, water, or power. Our community-based partnerships have been their saving grace time and again. In my written testimony submitted for the record, I have enumerated a short list of recommendations and impactful actions to improve our national approach to whole community inclusive emergency preparedness and disaster response. In summary, we are calling for the establishment of a national commission on disability and aging emergency preparedness and disaster management to take the many lessons observed and turn them into whole community inclusive actions. For the 59 million Americans with disabilities, including over two million in nursing homes, and the 67 million Americans over age 60, providing equal access to emergency services and programs is not just the right thing to do or simply smart business practice; it is also a legal obligation. People with disabilities have a legal right to equal access and nondiscrimination. Our civil rights are not waiverable. There is no disaster loophole that allows for the suspension of our civil rights. Ensuring the federally mandated civil rights of people with disabilities will well serve everyone with access and functional needs. A national commission on disability and aging emergency preparedness and disaster management will serve to leverage the priceless expertise of those of us most impacted and will manifest the mantra of the disability rights movement which applies to everyone with access and functional needs. Nothing about us without us. Thank you. The Chairman. Thank you very much, Mr. Timmons. Chief Delaney. STATEMENT OF JAY DELANEY, FIRE CHIEF AND EMERGENCY MANAGEMENT COORDINATOR, CITY OF WILKES-BARRE, WILKES-BARRE, PENNSYLVANIA Mr. Delaney. Good morning, Chairman Collins, Ranking Member Casey, and members of the U.S. Senate Special Committee on Aging. Thank you for inviting me here today to discuss how cities and towns across the country can help ensure the health, safety, and resilience of older Americans and individuals with disabilities during and after disasters. I am the fire chief for the city of Wilkes-Barre, Pennsylvania. I have been honored to serve the city in this role for over 12 years and have a total of 36 years in emergency services. I am also the emergency management coordinator for the city of Wilkes-Barre and a certified paramedic. Over 40,000 people reside in Wilkes-Barre, a city located in Luzerne County. Nineteen percent of the county's residents are over 65, which is 3 percent higher than the average in the State. And many of the older residents are concentrated within the city limits. Like any fire chief or emergency management coordinator, I feel a great sense of responsibility for these older Pennsylvanians, many who live by themselves. My concern for their well-being is heightened whenever there is a threat of a severe storm or weather event. That is due to a 10,000-square-mile watershed that drains into Wilkes- Barre from the Susquehanna River, threatening to flood our streets and our neighborhoods. In 2011, the threat became very real as the east coast braced for Hurricane Irene and Lee to make landfall. What transpired over the next week explains why early weather tracking, data, surveillance, and the flow of information across all levels of government is a priority and critical to the health and safety of our residents. About 7 days before the storms were scheduled to hit, we heard from the National Weather Service, Mr. Dave Nicosia. They started to send us regular updates about the storm patterns and the possible rainfall and potential crests of the Susquehanna River. The Pennsylvania Emergency Management Agency disseminated critical data to the county emergency management officials and the emergency management coordinators for our municipality. Wilkes-Barre is protected by a U.S. Army Corps of Engineers levee to a river level of approximately 42 feet. The Susquehanna River crested on September 9, 2011, at a record and historic level of 42.66 feet. For years, the gauges that measured the water height of the Susquehanna River in Wilkes-Barre were broken, and they were the responsibility of the U.S. Geological Survey. Senator Casey led the charge here in Washington to secure the resources to replace our broken gauges. It is because of Senator Casey that we can track, in real time, the possibility of a flood and critical river level data. This type of surveillance information provided the needed data to make risk- based decisions for possible evacuation. Using maps of flooding that took place in 1972 after Hurricane Agnes, we created an evacuation zone. And on September 9, 2011, we successfully evacuated 15,000 residents of Wilkes-Barre in about 10 hours. This evacuation included Wilkes-Barre City Hall, Wilkes-Barre Police Headquarters, Wilkes-Barre Fire Headquarters, as well as the entire downtown, including King's College and Wilkes University. We alerted the local hospital and two nursing homes in the evacuation zone. They executed their Emergency Preparedness Plans and safely evacuated 250 seniors. And if at any time they thought they were going to have trouble evacuating in the time required, they knew to request additional help from the Wilkes- Barre City Emergency Operations Center. We would send ambulances and personnel to help if needed. But it was the older Pennsylvanians, the seniors, and those with disabilities who still lived in their homes and in the community that I worried most about--the Mr. and Mrs. Smiths, the Mr. and Mrs. Joneses, who have lived in their homes for 50 years. In preparation for a possible evacuation, we developed a grid designating areas of responsibility for the Fire Department, for the Police Department, and members of the National Guard. We drove through South Wilkes-Barre and the downtown making announcements from our vehicles, knocking on doors, and posting evacuation orders. We knocked on every door. We left notes on doors of the homes where no one answered and made an additional check to ensure their evacuation. Most people heeded the request to evacuate on the first try, but if anyone resisted, they took their names, wrote down the addresses, and we spent additional time working to get them out of their homes. We successfully executed our plan because of the seamless collaboration and communication among officials at the national, state, and local levels. But even so, after every major event, we look back and discuss how can we improve. For example, should we ever need to evacuate again, we now have a contact in place with a local bus company that agreed to drive routes throughout the city to pick up people and take them to safety. Following Hurricanes Harvey and Irma, I hope that Congress will conduct its own after action review as it did after Hurricane Katrina in August of 2005. While Presidential Directive 5 started the advancement of the National Incident Management System, it was for the most part put into action after Hurricane Katrina and is now the model for how all levels of government manage all types of emergencies and disasters. As part of that review, I hope that Congress will commit to continue to fully fund the National Weather Service and FEMA and invest in surveillance tools so that we have the most comprehensive information available before, during, and after a disaster to guide our decisionmaking. Without early weather surveillance, we have little time to plan and prepare for potential weather events. I am grateful to the Senate Special Committee on Aging for the opportunity to add my voice to this conversation here today, and I thank you. The Chairman. Thank you very much, Chief, and thank you for reminding us that while our neighbors to the south tend to be disproportionately affected by weather disasters, we who live in the Northeast are not immune either. How well I remember the historic ice storm of 1998--I had been in the Senate for a year--which left so many of my constituents without power for so long and required the opening of emergency shelters through much of the State. So the point is it can happen anywhere, and all of us need to be prepared. So thank you for recounting your experience as well. Dr. DeSalvo, I was very interested in learning about the emPOWER program, which you have been so instrumental in setting up and sharing with other states. Obviously, electrical power is key. It is key whether we are talking about air conditioning in Florida or we are talking about keeping warm in Maine. What other gaps do you see that seniors and disabled citizens need? Dr. DeSalvo. Senator, a tool like emPOWER that uses medical claims data gives us a sense of people's health on a population level, so it can identify not only people who are electricity dependent but also people who are on dialysis, individuals who have ambulatory challenges, may be wheelchair bound, as an example. And in New Orleans, when I was health commissioner-- and we still use it regularly--it is a way, for example, if there is a boil water advisory, that we are able to target individuals who might be on special feedings or on dialysis, and we want to forewarn them in advance of water issues. So it is not just for electricity. But, on the other hand, it has to be used, and I cannot emphasize that enough. Just because we want to try to make the evidence-based decisions and we want to use data in respectful ways to identify people at risk, there have to be humans on the other end that can take that information and make use of it by making phone calls, by going to people's doors. But really the opportunity is pretty great not only in big disasters but in the smaller ones that communities face every day to try to target limited resources to reach those who have the highest risk. The Chairman. Thank you. Dr. Hyer, you gave an excellent explanation of the dilemma that many long-term care facility administrators face when deciding whether or not to evacuate, and I remember reading of the controversy over the mayor of Houston's decision to not order an evacuation; and yet in other cases where evacuations have been ordered, more people died in automobile accidents trying to get out of the area. And I can see you are nodding in agreement, so I am saying that for our court reporter here. So the act of evacuation, while totally appropriate, in many cases can actually be more dangerous than sheltering in place. And you talked about what is needed, however, for people to safely shelter in place. We have also talked about seniors who simply may be very fearful or unable to evacuate. So give us a little more guidance on how you would advise public officials or nursing home administrators to make the critical decision between sheltering in place and evacuation? Dr. Hyer. Thank you, Senator Collins. Yes, with Rita, there were 22 people who were killed in that bus as they evacuated. I think it is a very complicated but critical question. The emergency management people that I work with say ''you run from the water''. If you expect that there will be high levels of water and you cannot maintain safe care of residents, then you should leave. But those emergency managers ask if ``you can hide from the wind''. I think we need to think about having buildings built in places that are appropriate and can sustain usual low level disasters. I am not sure that nursing homes should stay, if a Category 5 hurricane is coming in directly at them. It is just devastating. However, I think for the most part, many buildings can, in fact, shelter in place appropriately. In countries--in Taiwan, they build water gates, and that is exactly what they did in Houston. And people will evacuate up onto higher floors. You can stay within the building, but be sheltered on a different floor. Now, that requires a lot of planning and a lot of forethought. It also requires you to make sure that you have in place the necessary equipment and food and water. Those are usually in place for nursing homes. Those regulations have been in existence for a long time. But one of my colleagues in Florida always says you shelter in place until you cannot shelter in place. Things happen after storms. There were 40 evacuations in Florida of nursing homes after Irma. Some of those were because trees fall, things happen, winds rip open roofs, and the place is not safe, it becomes inhabitable. Those evacuations are appropriate. But many of those evacuations occurred because power was not restored, because there were not generators, or the generators were not appropriately built in a way that they can sustain residents. There was not enough fuel. Those regulations have been changed by CMS for nursing homes, not for assisted livings. I do not even know if assisted livings in Florida are required to have generators. Assisted livings really are under the radar. So I think the answer is that you want to be able to have people stay in the building, but the building has to be hardened. They cannot be built in flood areas that routinely, in heavy storms, continue to flood. And there are building codes that allow that to occur. We also need to have them hardened and have generator capacity. Some buildings are very old. Many nursing homes in this country are very old. And I think we need to think about if we are going to allow capital to be used to replenish them or if we have got certificate of needs, replacing some of them, I think we need the new buildings to require generators with sufficient capacity to run air conditioning and other support systems for a period of time. And 96 hours is what hospitals are required to have. The Chairman. Thank you very much. Senator Casey? Senator Casey. Thanks very much. I will start with Chief Delaney. Chief, first of all, thanks for being here and thanks for your testimony and your continued leadership doing a tough job. We are grateful for that. I have a good recollection of what we all saw in 2011 in your home county, Luzerne County. I cannot remember how many counties I went to, but we had northeastern, central, and southeastern Pennsylvania, almost virtually half the State, affected by--and I want to use the right terminology. Irene was a hurricane, Lee was a tropical storm, I think technically, but---- Mr. Delaney. They were both bad. Senator Casey. The combination was terrible. And for me, it was an eye opener because I had never been affected personally by a terrible storm or a flood. And even as a public official, I am not sure I had ever been as close to it as I was in 2011 when we would be walking through those communities in most cases a few days after, I guess in some maybe only hours. But what I learned from that is just how violating that is or how devastating that is in a very personal, even emotional way. I remember a friend of mine who was kind of the ultimate tough guy, never bothered by anything, always confident, even cocky about everything. I walked up to him--his house had been flooded, and I walked up to him and said, ``How is it going?'' He just dissolved in tears. This really tough, tough guy just was absolutely devastated. So that gave me an insight, I guess, into the horror of it, and what we saw in Texas and Florida and we are seeing all these days in all these other places is maybe even worse than I saw in 2011. So one point that you made was the importance of good data and to informed decision making. We worked together, as you mentioned, on the stream gauges and helping to gather information. Talk to us about what data you use to inform your decision making when you have got an emergency, in this case an impending hurricane. What data do you use? Mr. Delaney. This is not really hard. We start with the critical data, hydrological data from the National Weather Service. That is why I say that agency is critical for the information that they send to PEMA, the Pennsylvania Emergency Management Agency, down to the Luzerne County Emergency Management Agency, and that flow of data to us. They have some of the best scientists available that can predict what the rainfall will be, what the river cresting will be, and that data we use for risk-based analysis to decide whether we are going to evacuate or not. And as you know, the river gauge that did not work almost crippled us where we did not know what the river was doing. So I think from an emergency management standpoint, we can prepare for a lot of these disasters because we have some of the best scientists in the world that can predict what is going to happen. So we take that data. We make sure we have our emergency operations plans. We make sure we write a plan with our municipal officials. In particular, for Lee and Irene, Luzerne County opened their Emergency Operations Center early on because of this prediction, which set the National Guard there in place so that if we needed to evacuate, that tool was already there to help us. So I think a lot of the surveillance data is critical for that flow of information to come down, number one. And, number two, the National Incident Management System and unified command is used to make decisions. So I am the emergency management coordinator, but I have a boss, and he is the mayor. And we have a city administrator; we have department heads. In emergency management, one person does not make the calls. You talked about sheltering in place. We had a small fire in a nursing home in Wilkes-Barre two weeks ago, and we decided--it was only a really small fire--to shelter in place. We probably had ten decisionmakers there to help make the decision on what the best well-being would be for the 166 residents that lived in that place. So we have systems in place. We really need to use them and use them adequately. Senator Casey. I know I am almost out of time. I was going to ask you as well about sometimes we think of, as you point out, response tools being things, equipment, whether it is to remove downed trees--but the challenge you have is having enough personnel, enough manpower, human capacity, human infrastructure to be able to go door to door. Talk to us about that. Mr. Delaney. Sure. On a daily level, you know, we have 12 to 14 firefighters and paramedics working and maybe the same amount of police. But by getting this surveillance information data, we can go to our bosses, our elected officials, and say, ``Listen, we need to prepare. We need to have all 80 firefighters at work for the next 3 days.'' We did that during the disaster--I should say the winter weather event, the blizzard we had in northeastern Pennsylvania this past year, we utilized that. So, you know, to make these decisions, that information early on, and I always have to put my request in for AFG and SAFER, the Federal programs that help us to have the proper staffing. My department does about 11,000 calls a year. We are set up for all hazards. But we deliver babies, we put fires out, we rescue people from the river, we take care of hazmat incidents, we take the tree branches--we do all those things. So, yeah, staffing is critical. This early information early on helps us to have the right amount of people to handle the event. Senator Casey. Thanks, Chief. The Chairman. Thank you very much. Senator Cortez Masto? Senator Cortez Masto. Thank you. First of all, let me just say thank you to Chairwoman Collins and Ranking Member Casey and all of you here. It is such an important topic, and I so appreciate the conversation this morning. I had the opportunity to work in state and local government in the State of Nevada, and I think people do not realize how important emergency management at the local, state and federal level is. And people are working every day so hard to get it right. God forbid something should happen, but they want to make sure they get it right. And many times the emergency management services are underfunded or they are challenged, and they need more support. I have a couple of questions, because it came to my attention that the Department of Housing and Urban Development recommends, but does not require, that public housing authorities establish emergency preparedness and response plans. I am curious if you are aware of this, and/or in your own communities, how have you brought in some of those vulnerable populations that live in some of the housing that is established through HUD? Dr. DeSalvo. Senator, I want to take this opportunity to thank you for raising the issue of HUD and housing because it is a great reminder to us that emergency response is more than people in uniforms with lights and sirens and even public health and health care officials, that there are a lot of people who have roles to play in a lot of agencies. And housing in particular, I think what you have heard thematically here is that that is a place where we can do a lot of good if we prepare properly and think about building code and building preparation, whether that is elevating generators or thinking about having exit lighting that is available as part of the generator. In addition, though, what HUD has access to is a lot of information about people who live in the housing, and so better communication and coordination of what they know about the disabilities or the special needs of people in housing could be of great benefit to the people who are on the front lines, and also in between, building resiliency, making sure that people have the kinds of supports so they can individually be prepared. I just want to point to an example more recently where HUD, I think, leaned in quite well, and that is in Flint, Michigan, where when we were trying to understand how to reach kids and families to let them know about opportunities to get screened and treated for lead poisoning, that the HUD agencies locally were able to get their databases and know where there were kids and helped direct resources. So I have seen it in action in a slower-burn emergency, but I think there is a lot of opportunity at the federal, state, and local level to better coordinate the information and the resources. Senator Cortez Masto. And I appreciate that because I think just like your interaction in gathering the data and working with Medicare to identify a population, HUD can do the same thing. Federal agencies have access to this data that can help emergency management at the state and local level as well, and I think there needs to be more of that partnership. And so that is why, Mr. Timmons, when you talked about needing and recommending a national commission--can you talk a little bit more about that? And is that your thought, that there is more of that interaction and that sharing of data and information with the state and local emergency management systems? Mr. Timmons. That is exactly right, Senator. In my mind, this comes down to planning, and I differentiate between plans and planning, much as General Eisenhower did. Plans are worthless. Planning is invaluable. It is not a matter of just creating a plan and hitting the print button. I think we need to be in a perpetual state of planning, and some sort of national infrastructure to facilitate that I think is critical to give us consistency and to help us leverage. The aging and disability stakeholder organizations need to be involved in this process from the beginning. We are the experts on what we need, and we are the experts on how to negotiate getting that in the most efficient fashion. I would like to see each state have an access and functional need coordinator within its emergency management function. We have a couple of models of that in Mississippi and California, notably, and it is making a tremendous difference. At the end of the day, I believe this is a relationship thing. Where we see this work is where there are preexisting relationships between emergency managers and stakeholder organizations. Where we see it not work so well is where there are not, and I do not think it is coincidental. So what I am suggesting is creating some sort of a framework to do this in an efficient and effective and impactful manner. Thank you. Senator Cortez Masto. Thank you. I notice my time is up. Thank you so much for the conversation and the work that you do every day. The Chairman. Thank you so much. I am going to follow up on the questions that my colleague just asked. Chief Delaney, let me start with you, and you had talked about emergency preparedness must start with the communities. What are some ways beyond looking at HUD data, which I thought was an excellent idea, that we can involve organizations--I can think of Meals on Wheels, Area Agencies on Aging--that have regular contact with seniors in our communities and would be aware of who would need help or whose housing might not withstand the blow of a hurricane or an ice storm or a flood? Are they involved at your level with the emergency preparedness planning that you do? Mr. Delaney. Well, there is a lot of individual programs that are out there, but, again, how do we engage Mr. and Mrs. Jones, Mr. and Mrs. Smith, who have lived in their house for 50 years? That is a tough nut to crack because when you have to evacuate 15,000 people in 10 hours, you do not really have the time to sit and say, ``Well, here is why you have to go, ma'am,'' or, ``Here is why you have to go, sir.'' That is a difficult question. If we could get that answered, I would think we were well on our way. But I did want to address the assisted living facilities and nursing home facilities. That is critical that they have their plans and their plans address how to get out, because when we evacuated in 2011, we trusted their judgment. We said, ``You have 10 hours to evacuate your facility.'' In their plans, they have strike forces of ambulances. They have all the critical data needed to get out. So I think mandating these plans is critical. I just received a 40 page document the other day. It seems as though we are getting better at getting these plans, but there needs to be a regulatory agency to say you have to have this plan. The local officials need to get this plan so that we are aware of what is in their plan. But, Senator, to address you, I think that is a great discussion to have. The organized facilities have--they know what to do. It is the average citizen that kind of does not understand it. They have not talked to folks for days or weeks about anything potential that might go on. So it takes a long time. And when we need to get them out, we do not have the luxury of all that time. So that is a great conversation to have, I think. The Chairman. Thank you. Mr. Timmons, I really appreciate your reminding us that this conversation on emergency preparedness needs to go beyond seniors and also focus on individuals with disabilities. What is your assessment of the level of emergency preparedness in terms of meeting the needs of people with special needs? Do they have shelters that are equipped to take care of people with disabilities? Are they staffed with people who will understand what they need? This is an area that I do not think has received as much attention, so I would love to have you elaborate on it? Mr. Timmons. So, particularly with the Red Cross, we have made some progress in the last couple of years in terms of trying to create an infrastructure, with them working with the community and with our stakeholder organizations and aging stakeholder organizations so that all shelters are accessible. I would again reiterate that in my mind this is a civil rights issue. So the Red Cross is the primary shelter operator across the country, and we have seen a tremendous amount of progress from them in terms of being ready and engaging in planning and engaging in exercising. And so in a number of places, we are seeing a tremendous difference. They are sort of the industry leader in this, and it is my hope that in areas where perhaps they do not operate the shelters, those who are will learn some lessons from that. So we are making incremental gains. It is a slow haul. But we are beginning to see some understanding, I think, from the folks in the shelter business that this is a civil rights issue, that it makes economic sense to make all of the sheltering and all of the servicing accessible to everyone. It is a legal obligation. It just makes sense. It is a great business case. So we are making progress, Senator. The Chairman. Great. Thank you. Senator Casey? Senator Casey. Thanks. Dr. DeSalvo, I wanted to ask you about a related topic. We are in the midst of yet another health care debate, and even in the midst of that, we have had some good bipartisan work on health care the last number of weeks, more than two weeks now. In your testimony you made clear that you have seen in real time, both in your clinical practice and as a public health leader, the devastation that a hurricane can cause to seniors with chronic conditions, as well as individuals with disabilities and others. So given that experience, how concerned are you about the latest health care bill that the Senate is considering? Dr. DeSalvo. Well, Senator, Louisiana in 2005 was a state with the unhealthiest population in the country and some of the highest rates of uninsurance, and access to care for low-income and high-need people, largely emergency rooms, which prevented them from having relationships in primary care, so people who knew about their health and could reach out to them in between disasters. When they were evacuated, it meant that they arrived sometimes in other states without any way to get care because they did not have a way to pay for it, and the absence of having public or private insurance and having relied in our state on the charity hospital system. And I will tell you, someone who has been in Louisiana for decades and have been telling my colleagues about what it was like to practice in an environment where your patients were uninsured and you sent them out sometimes on a hope and a prayer that they were going to be able to get that colonoscopy or get the medications that they needed, it was really shocking to my colleagues in other states that were on the receiving end of these individuals who had so much medical need and in many cases social need and not a means to pay for it when they arrived in a new state. And I think it spotlighted for certainly us in Louisiana but our colleagues around the country that having a great institution or place is not the only solution to access to care. You have got to have an affordable way to pay for your care, not only in disaster but every day. So far in Louisiana in the last decade, with the recent expansion of Medicaid, actually the opportunity for us is less focused on what is going to happen to those folks who are uninsured or who maybe do not have the means, than how can we make the system really work better for them. And I would not want us to take a step back, not only in Louisiana but as a country. And, Senator, if I could, I just might mention the sort of additional piece that has been raised because it is also part of the thinking of how to--what may happen in this bill, which has cuts to the prevention fund, which supports public health across the country. And public health, an unsung hero in disaster and every day, literally saves your life every day. It makes sure you can drink water safely and eat food and be rescued in the event of a disaster. But it is struggling already, much less having additional cuts. And it is so pertinent to this threat of conversation about people with disability, people who have special needs, because you do not want to, as in my case, learn about that in the middle of a disaster. As I showed you in Isaac, you want to know about those folks well in advance, and you need to be able to leverage local community organizations who have connections to those individuals, whether it is Meals on Wheels or the faith- based community. That kind of coordination and communication and relationships does not happen just by happenstance. It requires work and it requires resources, human resources, time resources, and that requires financial resources to make sure that local communities have the bandwidth in time to work together. So I hope that we will not step back, but continue to step forward. Senator Casey. I appreciate that. Mr. Timmons, I wanted to ask you as well about among your recommendations is the idea of a federal task force or committee to coordinate efforts across not only Federal Government agencies but state and stakeholder groups as well. What are some of the advantages that communities would see if planning were better coordinated? Mr. Timmons. Thank you. In this way I would hope we could optimize our limited resources, reduce duplication of efforts that we see, again, create and nurture relationships because the time to do that is when the sky is blue, and so do that in a consistent and meaningful way, using people with access and functional needs as force multipliers rather than seeing us as liabilities. Planning perpetual vigorous planning and exercising is something that we would like to see consistently done around the country. Optimizing health, reducing the need for acute medical care in these situations I think would be a tangible result that makes business sense. Universal accessibility, ensuring the civil rights of people with disabilities affects the broader access and functional needs community. So doing this in a consistent, federally mandated, overarching way just makes sense. It has been said all disasters are local. There is truth to that, and in this way I think we could build up the local piece so that folks like the chief are serving their community and that people are working together to achieve the goals we are all after. Thank you. Senator Casey. Thanks very much. The Chairman. Thank you. Senator Cortez Masto? Senator Cortez Masto. Thank you. In Nevada, and I am sure in many of your States, we have rural communities that are challenged--forget just getting resources there--professionals, you name it, it is--and geographically challenged. Some of our rural communities it takes four hours just to drive into, there are no planes, there is no bus service. And so I am curious how we support a state in a statewide effort to pull our rural communities into this emergency management preparedness and if you have any thoughts on that. Dr. DeSalvo. I will start, and maybe I will spark some additional conversation. I am really glad that you raised it, that when you map the challenges in rural communities, it will overlap with challenges in individuals' resources, access to transportation, all the things that make them more vulnerable to disaster. And also our experience in Louisiana is that it also is a challenge because those may be individuals less willing to relocate to shelters, particularly if they are living on the coast. For lots of reasons, cultural and otherwise, they want to shelter in place. And it is just a good reminder that there has to be coordination across jurisdictional lines. Our experience locally was that we had a regular cadence, a battle rhythm, where--a terrible term, but that is the exchange preparedness language of each of our local jurisdictions, in our case parishes, have their own preparedness conversations about their populations but scaling that across the day to make sure that we were thinking about regional and then statewide support and coordination, because this is the thing, and Isaac is a great example of this. We did not flood in New Orleans Parish in Hurricane Isaac. We had a power outage situation. But the parishes just next to us, the counties just next to us flooded. And so because we were hardened and ready from an acute-care standpoint and because we were communicating, we were also hardened and ready to take people from the surrounding parishes and stand up a medical special needs shelter to support people. And some of those are pretty rural environments on the coast. But without, again, those preexisting relationships when the skies are blue, the communication infrastructure and everyone knowing kind of what a sister relationship will look like, we are not really ready to help each other. And so though it is local, there has got to be coordination that scales to help bridge the gaps. Mr. Timmons. In some ways I think maybe the paradigm should be that we let the local communities draw us into the way they do this, Senator. There is a lot to be said about the power of community in some of our more rural areas. I live in South Carolina. We saw this two years ago with the flood, and we saw it last week as we experienced some of Irma. A lot of the things that I am talking about, the broader community engagement, the local nature of this, is done really well in our rural communities. There are some challenges, but there are also some lessons to be drawn from that that we can apply in other areas as well. Senator Cortez Masto. Thank you. Thank you very much. The Chairman. Thank you, Senator. I want to thank all of our witnesses for your testimony today and for the really important work that you are doing at the local, county, and state level, private sector, public sector, nonprofits. You are all making a difference on the front lines. I also want to thank our staff, which worked hard to bring this hearing together. We delayed the date of this hearing because we did not want to interfere with the immediate response that was occurring in Florida, for example, and in Texas, because I know from the medical team that helped out in both places that first responders from all over the country were assisting in the response, which is a real tribute to the first responder community. September is National Preparedness Month, and this year's theme is: ``Disasters do not plan ahead. You can.'' We should take that motto to heart, and from this hearing today I can see the huge amount of progress that has been made since I conducted that investigation so many years ago into the very inconsistent and in some ways failed response to Hurricane Katrina. So we have made great progress, but we still have a long ways to go. I love Dr. Hyer's list of exactly the four--I wrote them down, things that need to be done. I would note that Governor Scott has issued an order that says that assisted living facilities also have to have generators and fuel to supply them. So we are learning from every disaster, and we are learning how being prepared today can make the difference between safety and danger, and in many cases literally the difference between life and death. For older Americans and those with disabilities, there are ways to anticipate the unique challenges associated with aging, mobility impairments, and medical needs. For seniors living at home, for those in assisted living facilities, and for those in nursing homes, there are ways to prepare even though disasters can strike with little warning, and I think we have learned a lot today about the importance of communication, working together, and as Dr. DeSalvo notes, my favorite expression is to say that you should not be exchanging business cards when disaster strikes. That is the worst time. And you have to prepare in advance. I want to close my remarks by also warning the residents who have been affected by these storms of the many scams that have already arisen. This Committee has held hearing after hearing on financial exploitation of our elderly. There are two scams in particular that seem to be very prevalent. One is what I would call the charity scam where people are trying to get donations that purportedly are going to the victims of the hurricanes but, in fact, are lining their own pockets. So I would urge people to deal with recognized charities, to be very careful. And I know the former Presidents have come together to encourage donations. You can be sure that is a safe one. But that is a scam that is relentless and heartless. And the other one is an old scam that occurs every time there is a disaster like that, and that is when people are pretending to be qualified to repair homes to make them habitable again and ask for an up-front payment and then they will do the work. And, of course, they disappear with that up- front payment and are never heard from again. So my heart goes out to people who have been affected by the storms, but I also want to give them a caution to be very wary of people who would exploit the suffering of others and the devastation of these storms in order to line their own pockets. And I just wanted to mention that this Committee will put out a bipartisan alert to try to raise awareness among the victims of the storms. Again, thank you to all of our witnesses, to all of our members who are here today, and Committee members will have until Friday, September 29th, to submit any additional questions for the record. I should say that both of the Senators from Florida, who are on this Committee, really wanted to be here today, but they rushed back to their home state as soon as they possibly could to help out. And that is certainly understandable as well. Senator Casey, do you have any closing comments you would like to make? Senator Casey. I do. Madam Chair, thank you very much, and thanks for calling this hearing. Dr. DeSalvo, Dr. Hyer, Mr. Timmons, and Chief Delaney, we are all grateful that you are here today and giving this testimony, bringing real expertise and experience to these issues. A special thanks to Chief Delaney. We live in the same home area, one county away, and we are grateful you made the trip down from Pennsylvania. I share Senator Collins' commitment to making sure that we are doing everything, everything within our power to ensure that seniors and people with disabilities are prioritized in emergency response in the midst of these horrific challenges. It should not take the deaths of Americans or the kind of photos that we saw to cause us to take action and to move this issue to the top of the agenda, including here in Washington. That is why we are grateful that we now have legislation that will begin to address some of these issues. We need to learn from these tragedies, and we need to commit ourselves to the goal that they will never happen again. So I look forward to continuing to work with members of this Committee on these issues, and we are grateful for this opportunity today. Thank you, Madam Chair. The Chairman. Thank you. Senator Cortez Masto, since you are such a dedicated member of this Committee, if you have any final words, feel free. Senator Cortez Masto. No, I am good. Thank you very much. The Chairman. Thank you. Thank you for your participation. This hearing is now adjourned. [Whereupon, at 10:34 a.m., the Committee was adjourned.] ======================================================================= APPENDIX ======================================================================= ======================================================================= Prepared Witness Statements and Questions for the Record ======================================================================= Prepared Statement of Karen B. DeSalvo, M.D., Former Health Commissioner, City of New Orleans, New Orleans, Louisiana Good morning Chairman Collins, Ranking Member Casey and distinguished members of the Special Committee. Thank you for the opportunity to testify today to share my experiences and perspectives on opportunities to better support older Americans both in times of disaster and every day. I am Dr. Karen DeSalvo, a physician and former Health Commissioner for the city of New Orleans. I am honored to participate in this panel with my distinguished colleagues. Disaster Preparedness and Response for Older Americans is a topic about which I have great passion--both as a doctor and public health professional. Raising awareness of the challenges they face and opportunities to better support them is a critical conversation. Though there has been a great deal of progress in the last decade, more can be done. My goal is to share with you some of my experiences from New Orleans as a physician and as Health Commissioner and to offer solutions aimed at building a stronger infrastructure and support network to improve outcomes for some of the most vulnerable in our community--older Americans. Experiences From the Front Lines Hurricane Katrina It is now a dozen years since Hurricane Katrina wrought devastation to my hometown of New Orleans. In New Orleans, though we escaped the direct impact, our catastrophe was failed flood walls, leading to inundation of our city with water for weeks and devastation of our entire health care and public health infrastructure. From 911 to major hospitals, access and capacity were submerged, along with Charity Hospital, the primary provider for the poor and uninsured in New Orleans. According to a report from the Louisiana Department of Health and Hospitals, 986 Louisiana residents died as a result of Hurricane Katrina. Older adults were disproportionately impacted: the mean age of victims was 69 years with 63% over the age of 65. Amongst the dead were 70 people who died in nursing facilities either during the storm or in the days immediately following landfall. I was actively practicing medicine and most of my patients were older adults. It was a terrible feeling to know that my most vulnerable patients were disconnected from me, from their therapeutic regimens and care. At the time, like most of the country we were a paper-based health care system and those medical records turned to useless bricks. As people quickly evacuated or later landed in shelters or on rescue boats, they most often did not have their medicines or even a good list of them. This meant that essential information to guide clinicians trying to help displaced patients was not available. And those of us still in New Orleans did not have the capability to find our patients easily or to mine data to identify vulnerable patients in need of additional help. There were exceptions; Ochsner Health System and the Veterans Affairs health system were digitized and, as a result, able to provide more seamless care such as refilling medications for chronic disease or preventing gaps in cancer care. The contrast was stark and a great motivator to us in the health care system to make a transformational change that would link everyone to a medical home. By digitizing the health care records, we could have a health system more resilient for disaster and for every day. This shift would be particularly critical for older Americans who tend to have a higher burden of significant medical problems and more complex medication regimens. New Orleans, like the rest of the Nation, has transformed and now has a digital health care infrastructure that is increasingly connected. It also includes patient portals so that people can view their records to find up-to-date medication lists and medical histories. This infrastructure was used during Hurricane Harvey in Houston shelters to access health information in a way we only dreamed about 12 years ago during Katrina. Hurricane Isaac Six years after Hurricane Katrina, I had begun my service as Health Commissioner for the city of New Orleans. It was during my tenure, in August 2012, that Hurricane Isaac roared ashore in Louisiana some 7 years to the day that Hurricane Katrina had landed. Fortunately, New Orleans, like much of the country had heeded the lessons learned in the health care and public health system. We were better prepared. Words from Senator Collins at the time of Katrina were a rallying cry for me: `` . . . the last time officials should be exchanging business cards is in the midst of a crisis.'' My efforts as a physician, advocate and now public official focused on building a more connected system to support those in need in the wake of disaster. In the intervening years, Louisiana and the New Orleans community had developed more targeted emergency and disaster preparedness planning for older residents and those with special needs such as those in nursing home settings. One of these actions by the New Orleans Health Department was the creation of a medical special needs registry to maintain a list of those most in need of assistance for evacuation during preparations or in response operations. We had been working aggressively to shift from paper to an electronic, searchable version. By 2012, we had improved our registry of high-risk individuals with special medical needs and had tripled the number of residents enrolled. In advance of the storm's landfall, we reached out to these high- risk individuals directly and through social and traditional media to offer opportunities for evacuation, providing transportation for those who wanted to leave. We worked with the dialysis network to ensure that people accessed dialysis early and we coordinated with newly developed medical homes to see that people received supports, including adequate supplies of medications to carry them through potential disruptions of pharmacies. In the end, Hurricane Isaac did not flood New Orleans proper. Rather, the challenge New Orleans faced was prolonged power outage. Hurricane Isaac was a particularly problematic storm for power outage because it had a large wind field, which remained strong for days. This prevented repair crews from assessing outages and restoring power. More than 900,000 customers in Louisiana lost power representing half of the population. 400,000 were still without power September 1st, four days after landfall. The health care system fared well because of improvements in emergency preparedness made following Katrina. Though some hospitals lost power early in the storm, their back-up generators functioned as expected and maintained operations at facilities with very few exceptions. We were also watching the nursing homes carefully, and fortunately they reported working generators at their facilities as well. As the days dragged on, I found myself standing in the Emergency Operations Center being asked by our power company to give them guidance on the prioritizing power restoration. Hospitals were already on the priority power restoration list and returned to normal function for their inpatient and outpatient services. The question at hand was how to prioritize the remainder of our facilities and neighborhoods. The situation was further complicated by reports that seniors were struggling with the heat. For a variety of reasons, many high-risk individuals had not evacuated, despite our efforts to assist those in independent living situations. This included those in nursing homes and assisted living, but also people living in subsidized, high-rise housing around the city. Without information on where individuals with the most risk were clustered, we were compelled to go door to door for 3 days to try to assess need and help prioritize power service restoration. For those who would, we evacuated them to a newly established medical special needs shelter in the city. Leveraging Data and Technology Following Hurricane Isaac, we worked with the HHS Assistant Secretary for Preparedness and Response to create more efficient and effective methods of identifying the most vulnerable in our community, not only to target power restoration, but also to support them in other hazards as well. We needed an approach that could scale to support the approximately 2.5 million Medicare beneficiaries who are electricity- dependent for medical and assistive equipment. In June 2013, HHS and the city of New Orleans piloted a first-in- the-nation emergency preparedness drill. Using Medicare claims data we identified individuals with electricity-dependent durable medical equipment and securely disclosed it to a local health department. Along with first responders (particularly the fire department), we visited the homes of people identified on the list from CMS as being electricity-dependent. We wanted to know if Medicare claims data was accurate in identifying individuals using a home oxygen concentrator or ventilator. It was 93% accurate. In addition, of the 611 people that the claims data had identified in the New Orleans community, only 15 were on our medical special needs registry. The drill findings reinforced our hope that medical claims data could be useful in improving preparedness and response for high-risk populations. This effort, now called emPOWER, has been scaled by HHS and is available to help first responders in planning and response. Every community can use the map to find the total of Medicare beneficiaries with electricity-dependent equipment claims at the U.S. state, territory, county, and zip code level. ``Real-time'' natural hazard and NOAA severe weather tracking services identify areas that may be impacted by disaster events and by prolonged power outages. HHS continues to deploy emPOWER to support communities in disaster including in the recent hurricanes Harvey and Irma, as well as for other emergencies ranging from boil water advisories to tornadoes. Beyond the Headline Disasters It is easy to focus on the national disasters that make headlines and on those who seem most frail such as those living in nursing homes. There is indeed work that needs to be done to ensure their safety in major events. The added expectations in the Centers for Medicare and Medicaid Services (CMS) Emergency Preparedness Rule are steps in the right direction. If robustly implemented by the providers, they could provide further protections for seniors. Those older Americans who are not in CMS regulated institutions, but rather are in community-based settings, living independently are also at significant risk. These older Americans need our help not only in disaster but every day. They are exactly the people who wanted to ``shelter in place'' for Hurricane Isaac and likely every other major event. They want to stay in their homes and will resist evacuation to a shelter, including one with medical personnel. These are the people that we should focus on as we work to make the next order improvements to our disaster preparedness and response plans. These are the bulk of the people that I saw as I went door to door after Hurricane Isaac. Many are in federally subsidized housing, living alone or with other debilitated peers. What I saw was heart breaking. For many, they were trapped on higher floors, unable to navigate the stairs to escape when the elevators stopped working because they were wheel chair bound, dependent on a walker or simply not strong enough. What was clear was that they were not only isolated because of a hurricane, but were living on the edge every day. Any small disaster can easily cause them to decompensate. Leveraging tools like emPOWER to build more complete Medical Special Needs Registries is a start. But they also need ``human touch'' on an ongoing basis to help build their resiliency to withstand disasters large and small. The evidence is clear that older Americans are more likely to be lonely and socially isolated and those circumstances are associated with increased risk of medical complications and death. Efforts underway by national groups such as AARP's Connect2Affect to address social isolation are an important start, but these programs should also help link seniors with emergency preparedness personnel and programs. Opportunities to Strengthen Preparedness and Response Though we have made progress, we must do everything we can to protect the most vulnerable in our communities, with special attention to older Americans. It is in that vein, that I offer actions that would build a stronger infrastructure and support network to improve outcomes for some of the most vulnerable in our community--older Americans. Leverage Data and Technology The reach of a tool like emPOWER should be expanded to a broader group of at risk individuals using data from Medicaid and private payers. In addition, technology tools like emPOWER are only helpful if the local officials are aware of the resource and able to use it. Congress could provide resources to support training exercises by the Public Health Service Commission Corps to test the use of emPOWER in communities across the Nation and help prepare the Public Health Service Commission Corps members to use the tool in disaster response. Older Americans will be best served when their health information is available when needed to inform care and evacuation decisions before, during and after disasters. The infrastructure is in place for this vision to be a reality but behavior in the health system is preventing technology from helping people when they need it most. Data blocking is one such behavior. Congress has already taken action to advance interoperability of electronic health records and other health data systems through the MACRA and 21st Century Cures legislation. In particular, expectations for providers to attest that they are not blocking data and the additional authorities for HHS are an important step to improve data flow on behalf of consumers. Congress should press the Administration to accelerate their timeline to develop educational, incentive based and punitive measures to address blocking. Furthermore, Congress should encourage the Office of the National Coordinator for Health Information Technology in partnership with the Assistant Secretary for Preparedness and Response to continue working with states and local communities on efforts aimed at leveraging electronic health record information for disaster preparedness and response. It is essential to quickly ensure private and secure data flow for existing health information given the opportunities on the horizon as new technologies like telehealth and wearable technology will be increasingly ubiquitous and able to support older Americans in preparedness and response. Support Local Public Health Infrastructure Local public health agencies are the only health entities with statutory responsibility to address preparedness and response. But they are under-resourced across the county, impairing their ability to support communities, including older Americans. The specific efforts that are often under-resourced include: Medical Reserve Corps, Medical Special Needs Registry, and preparedness staffing. Congress could ask the National Academy of Medicine to undertake a review of needs for local public health preparedness funding and make recommendations on approaches to addressing the gap. Congress should provide resources to support public and private sector programs that address loneliness and social isolation. The Medical Reserve Corps (MRC) is one such potential. It is a national network of volunteers, organized locally to improve the health and safety of their communities. The MRC volunteers include medical and public health professionals, as well as other community members who may not have a health care background. MRC volunteers are an essential tool to strengthen local public health and improve emergency response capabilities. They could also be an essential resource to build individual and community resilience between disasters. Protect Consumers The Centers for Medicare and Medicaid Services Emergency Preparedness Rule is an opportunity for the public and private sector to strengthen their all hazards disaster planning. CMS should work with ASPR, OASH, the CDC and state Medicaid programs to ensure a robust implementation including mock disaster exercises (table tops) in conjunction with local public health and/or regional HHS staff. Disaster plans should also require review to ensure adequate details such as representation in incident command meetings with emergency preparedness leads, logs tracking generator maintenance, generator fuel plans, and transportation contracts for evacuation. Congress should encourage the Administration to build a best practices tool kit for local regulation to support the development of state and local laws, ordinances, and policies that can provide additional protections for older Americans during disasters. These might include building permit expectations requiring elevators and emergency exit lighting be supported by generators. Conclusion In closing, protecting those most vulnerable in our communities should continue to be our priority. Thanks to the combined efforts of the health care sector and first responders to apply solutions to lessons learned from previous challenges such as Hurricane Katrina, as a nation we are better prepared and more resilient to successfully address disaster response and preparedness for our seniors. We must ensure an ever more effective and rapid response to disasters that threaten older Americans. This applies not only to those older Americans living in institutions, but also to those in community based settings who can be more disenfranchised and at higher risk. What is also essential, is that we pay attention to their needs not only in disaster, but in their every day. Doing so is vital to ensuring that all communities across the Nation are prepared to respond to and recover from future public health disasters, fulfilling our collective promise to never again repeat the chaos, disorder, and despair that followed Hurricane Katrina. Thank you again for the opportunity to testify. I will be happy to work with you on any of these issues as you consider your opportunities to strengthen support for older Americans. I look forward to your questions. __________ Questions for the Record To Dr. Karen B. DeSalvo From Senator Elizabeth Warren Climate change is the greatest disaster preparedness and response issue of our time. A 2016 publication by the Environmental Protection Agency noted that the consequences of climate changes are serious for us all, but particularly for older Americans. Additionally, the nation's population over age 65 is expected to nearly double by 2050, and approximately 1-in-5 older adults live in an area that was directly impacted by a hurricane or tropical storm within the last decade.\1\ --------------------------------------------------------------------------- \1\ Environmental Protection Agency. ``Climate Change and the Health of Older Americans.'' (May 2016) (https:// 19january2017snapshot.epa.gov/sites/production/files/2016-10/documents/ older-adults-health-climate-change-large-fonts_0.pdf) --------------------------------------------------------------------------- You have done considerable work looking at the social determinants of health--meaning all the social and economic factors that influence an individual's health. Question: Is the environment a social determinant of health, and will the changing climate significantly impact the health outcomes of seniors? Answer: Climate change has a significant impact on the social determinants of health. Its effect on clean air, safe drinking water, and access to food and shelter inarguably impacts the health of all Americans, including seniors. The World Health Organization has declared that climate change contributes to widening disparities in health equity and is responsible for 250,000 deaths worldwide each year. The American Public Health Association has compiled the ways in which climate change impacts the social determinants of health:
Severe storms and floods can lead to water contamination, drowning, injury, mold, job insecurity, and vector-borne disease transmission. Extreme heat can cause dehydration, heat stroke, increased pollution and particulate matter, aggravated allergy and asthma symptoms, and worsened mental health, including dementia and schizophrenia. Drought-induced wildfires can harm lung and heart health as well as reduce access to healthy foods. Seniors experience unique vulnerabilities like low immunity, pre- existing conditions, and limited mobility that put them at risk for these and other health threats associated with climate change such as heart disease, psychological stress, and falls. Question: As the climate changes--as temperatures rise, air quality worsens, and flooding increases--what are the particular health risks posed to older Americans? What are the particular factors that increase the risk of climate change for older Americans? Answer: Seniors live with a higher physiological risk for heat exhaustion and cold exposure due to a decreasing capacity to sense changes in body temperature. As a result, they are less able to adjust to changing temperatures around them. This is particularly challenging for seniors living on a fixed income who may not be able to afford adequate air conditioning or heating. Additionally, aging has other impacts such as loss of muscle strength, balance, and cognitive function that renders seniors less ambulatory. In the event of flooding, power outages, fire, or other disaster, they may find themselves unable to evacuate timely or at all. They are also less likely to be able to prepare for sheltering in place such as by stocking up on food and water since many no longer drive. Furthermore, hearing and sight loss may interfere with their ability to respond to disaster preparation or offers of help including recommendations to evacuate. Older Americans are also more likely to have multiple chronic health conditions, which require medications and medical devices for treatment and support. Power loss will interfere with cooling of medications such as insulin or prevent use of life-saving treatments such as use of electronically powered wheelchairs or oxygen equipment. Finally, because climate change can affect the quality of the air we breathe, seniors with respiratory conditions such as asthma or chronic obstructive pulmonary disorder will be at heightened risk for respiratory distress in events like wild fires that worsen air quality. __________ From Senator Marco Rubio Question: Are there new lessons that could be learned from Hurricanes Harvey, Irma, and now Maria? In particular, do you have any recommendations as to how we could better respond to the needs of dialysis patients--whether they receive care at an outpatient clinic or in their own home? Answer: In order to respond to the needs of vulnerable populations during disaster, we need to know where they are so that first responders can prioritize their efforts to address these special needs first. When utilized, tools like emPOWER provide an unprecedented capacity to locate and respond to different patients with specific needs, like those undergoing dialysis. Currently emPOWER is limited in scope, only identifying individuals covered by Medicare. Expanding this program to a broader group of at risk individuals by using data from Medicaid and private payers would help first responders extend their impact in times of disaster. Of course, tools like emPOWER are only helpful if local officials are aware of the resource. Resources are needed to support training exercises by the Public Health Service Commission Corps to prepare members to use the tool in disaster response. Question: What would you recommend to the families with loved ones in assisted living facilities or nursing homes about how to make sure a particular facility is able to respond to an emergency? Answer: 1. Families have an important role to play to see that their loved ones will be protected in times of disaster. There are a number of steps families can take to be better informed and to ensure that the institutions and their loves ones are prepared. They can begin by asking key questions of facilities. These should include questions about building readiness in disaster to support ``shelter in place'' and preparedness for evacuation. 2. Families should ask about readiness to support sheltering in place, particularly regarding power backup system. It is not only important to ask whether the facility has a backup system, typically in the form of a generator, but also whether it has the capacity to power life sustaining parts of the facility such as the elevators and cooling and heating systems. They should inquire about whether the generator is raised above the flood plain, how frequently the generator's functionality is tested, how many days of fuel it can provide, and what the specific plans for fuel replacement entail. They should also inquire about staffing plans including access to higher level clinical care such as through an in-house nurse practitioner or telehealth opportunities. 3. Communications systems are another important area to inquire about. They should understand when and how they will be contacted in the event of disaster. They should also understand whether the facility will have redundancy in systems supporting telecommunications and internet access. 4. Families should also be clear about plans for evacuation in the event of emergency. They should be clear about whether and how their loved ones will be evacuated, including asking if the facility already has a transportation contract in place to support the evacuation. They should also understand any responsibilities the family may have, particularly if the family member resides in an assisted living facility. Additionally, families should inquire about plans for staffing during evacuation and whether there is a preexisting arrangement with a ``sister facility'' to serve as temporary shelter. 5. Other actions a family can take include maintaining a list of doctors, medical problems, and medications. This can be on paper or electronic, but they should also see that they have access to their family member's electronic medical record of their primary care physician through their patient portal. For those family members with end of life wishes expressed in living wills, they should ensure that those documents and wishes are known to the facility, accessible electronically, and known to the family member's physician. 6. Additionally, people should ensure that their family member or loved one is registered with the Medical Special Needs Registry with local health department. This is particularly important for seniors living in assisted living facilities or other community based settings. This will ensure that they are on a priority list for assistance before, during and after an event. __________ Prepared Statement of Kathryn Hyer, Ph.D., Professor and Director, Florida Policy Exchange Center on Aging, School of Aging Studies, University of South Florida, Tampa, Florida and David Dosa, M.D., MPH, Associate Professor of Medicine and Health Services, Policy and Practice, Brown University, Associate Director, Center of Innovation for Long Term Services and Supports, Providence VA Medical Center On behalf of my colleague Dr. David Dosa who could not be here today, I would like to thank the Senators and the Senate Special Committee on Aging for providing the opportunity to testify here today on a topic that I have studied since 2004 when four hurricanes traversed Florida within 44 days. Since that time my colleagues and I have studied the effect of disasters on the frail older adults living in nursing homes and assisted livings and have worked to improve disaster preparedness, response, and recovery. I would like to focus my remarks on more than a decade's worth of research that has been carried out thanks to generous grants from the John A. Hartford Foundation, The Kaiser Family Foundation, The Borchard Foundation, and the National Institutes of Aging. My focus will be on the issue of evacuation of nursing homes; but for background, in 2004, Florida nursing homes only became part of local and state emergency management operations after repeated hurricanes crisscrossed the state and emergency management personnel finally recognized nursing homes needed help replenishing medical supplies, water, restoring power and getting fuel for generators to continue to operate. Following Hurricane Katrina, our research team interviewed nursing home administrators about their experiences during the storm. Across the board, these interviews revealed that administrators wrestled with the important decision of whether to evacuate their residents prior to the storm or ``shelter in place'' during a hurricane. Administrators noted to us that they were, ``damned if we do and damned if we don't'' in terms of the decision to evacuate. They cited pressure from emergency managers to leave their homes despite the difficulties of evacuating frail older adults on school buses to high school gymnasiums--often without adequate staffing and supplies. In general terms, many administrators noted that they saw patients decline, staff endure injuries moving residents, and believed more casualties occurred if they evacuated than if they remained in their own facility. This initial work became the impetus for a National Institutes of Health sponsored study that evaluated the effect of Hurricanes Katrina (2005), Rita (2005), Gustav (2008), and Ike (2008) on nursing home residents. This research eventually showed that among 36,389 NH residents exposed to the Gulf hurricanes, the 30 and 90 day mortality/ hospitalization rates increased considerably compared to non-hurricane control years regardless of whether they evacuated or sheltered in place. In total, there were 277 extra deaths and 872 extra hospitalizations within 30 days after exposure to anyone of the storms. While everyone suffers in disasters, our data indicate that exposure to natural disasters such as Hurricanes Harvey or Irma clearly results in excess death and hospitalizations among frail populations. Our research, however, does more than simply evaluate what hurricanes do to nursing home residents. We asked the simple question. Is it better to evacuate or shelter in place? Using the data from the four storms and some methodological techniques described more fully in our research, we concluded that the very act of evacuation prior to the storm increased the probability of death at 90 days by 2.7%-5.3% and increased the risk of hospitalization by 1.8%-8.3%, independent of all other factors. It should be noted that this data took into account the multiple deaths that occurred at St. Rita's and Lafon Nursing Homes during Hurricane Katrina. Despite these tragic deaths, evacuation proved to be cumulatively more dangerous then sheltering in place. Why it is potentially more dangerous to evacuate from a hurricane than to shelter in place? Definitive studies are not available but we offer several explanations: 1. Hurricanes often deviate from their expected paths after the decision to evacuate must be made. In general, safe evacuations must occur at least 48-72 hours before landfall. Unfortunately, hurricanes make last minute turns and speed up or down. Hurricane Irma was expected to be a Category 4 making landfall near Miami. Many nursing homes evacuated west only to be evacuated a second time as Irma's path moved westward and threatened the very areas that residents had evacuated to. 2. The evacuation of frail older adults is a logistics nightmare and requires exquisite planning prior to the event. Good materials exist to help with plans (http://www.ltcprepare.org/) but even under the best-developed emergency plans, evacuations create anxiety for both residents and staff that appear to have serious adverse outcomes. 3. Older adults are susceptible to adverse outcomes whenever they transition from one environment to the next--even under optimal circumstances. Safe transitions require optimal communication among providers, keen knowledge of the patient, and access to medical records, correct medications, and appropriate supplies. In emergencies, transitions are seldom ideal and we have shown the consequence of such forced transitions in our hurricane research. 4. Older adults with dementia represent a particular hardship for evacuating facilities. Without the cognitive ability to follow directions, or participate in their own self-care, residents with dementia suffer significantly during evacuations. 5. Common comorbidities such as congestive heart failure, chronic obstructive pulmonary disease, and various cardiovascular diseases require clinician's knowledge of the resident, careful observation, adequate temperature control (e.g. air conditioning), and adherence to specific medication regimes, physical and occupational therapies, and specific dietary needs. 6. Medical records and medications are often misplaced or poorly adhered to during disasters. 7. Evacuations occur after the storm because nursing homes and assisted living may not be a priority for restoration of power. Florida had 40 nursing homes and 177 assisted living communities evacuate after the storm; the majority evacuated because their generators weren't operating correctly. Based on our research and experience, we have the following recommendations: 1. Generators to support air conditioning and other medical needs must be required for both nursing homes and assisted livings. Ideally these generators need to be elevated to ensure continued operations during flooding. I am proud that last Saturday, Florida Governor Scott announced emergency rules requiring a generator and the appropriate amount of fuel to sustain operations and maintain temperatures at 80 degrees or less for at least 96 hours following a power outage. http://www.flgov.com/wp-content/uploads/2017/09/AHCA916.pdf http://www.flgov.com/wp-content/uploads/2017/09/EN_DEA.pdf 2. Emergency plans for nursing homes and assisted livings are not always available nor understood by residents or family members. Regulations must require that emergency plans for both nursing homes and assisted living be posted and available for inspection prior to admission. More work needs to be done to help people make choices based on posted disaster plans and to ensure the posted ``plan'' is actually a workable plan. Optimal preparedness means real drills and plans that are tested--even if only partially. 3. Assisted living communities require more disaster preparedness oversight than they currently receive. We know older adults and disabled people want care in the community in less restrictive environments. Nevertheless, assisted living communities routinely accept patients that would only have received care in a nursing home a decade ago. Waiver payments for residents with Medicaid have also increased, thereby making the Federal Government an interested party in assisted living regulations. Currently, we don't even know whether a particular Medicare/Medicaid patient resides in an assisted living facility. This inadequacy in disaster response must be rectified. 4. Evacuation must be nuanced and must take into account the size and severity of the storm, the ability of the facility to withstand wind and potentially storm surge, and the needs of the residents. Evacuation should not be ``all or nothing.'' There are times where certain medically complex patients (e.g., dialysis patients) might be more optimally treated with early evacuation while other more stable patients shelter in place. More research to identify the types of patients that benefit from evacuating or sheltering in place must be conducted. 5. Nursing homes and larger assisted living communities must be built in places that minimize flooding risk and must be built to standards that allow administrators to shelter in place if at all possible. 6. Every state and local emergency management organization in this country must identify and prioritize nursing homes and assisted living communities for restoration of services. 7. Some degree of litigation protection must be considered for those facilities that abide by the regulations and provide care during disaster scenarios. Our research clearly shows that hurricanes affect all nursing home residents, regardless of whether they evacuate or shelter in place. Unfortunately, this did not prevent many administrators from being sued repeatedly for the heroic care that they provided following Hurricane Katrina. 8. Finally, older adults matter. I am also the PI on a HRSA-funded Geriatric Workforce Enhancement Program grant. We believe that a continued commitment to geriatric education programs that help the nation's health workforce better serve the older and disabled population must be a priority. I can provide evidence today because the research and training developed after Hurricane Katrina has led to improved disaster response across the country. However, the funding rapidly dried up in the years that followed Katrina. Our country needs ongoing geriatrics training for population aging. We also need consistent research funding to evaluate the disaster needs of older adults and develop best practices. We know disasters will continue to occur and we must be prepared. Thank you for allowing this testimony. __________ Questions for the Record To Dr. Kathryn Hyer From Senator Marco Rubio Dr. Hyer, in the recent tragedy at the nursing home in Hollywood, Florida, we have heard accounts that this nursing home had an emergency response plan in place and they simply were not following it. Question: What are some of the ways we can create a backstop for instances like this, when emergency plans are not adequate or they are simply not followed? Response: Background: According to the Centers for Medicare & Medicaid Services (CMS) interpretive guidance, the new Emergency Preparedness rule becomes effective November 15, 2017. Guidelines were issued in September 2016 and there were national training on the rule conducted in March 2017. CMS has good training materials for nursing homes on its Web site. Currently, in Florida, there is diffusion of responsibility between approval of nursing home emergency plans and the inspection of the plan in a specific nursing home by nursing home trained inspectors. The diffusion complicates coordination during disaster preparedness and during recovery as the Hollywood Hills nursing home exemplifies. The local county or city emergency operations center (EOC), generally a part of the Department of Health, reviews and approves the nursing home comprehensive emergency plan for that area. Then, the Agency for Health Care Administration (AHCA) inspects the nursing homes and verifies if the emergency preparedness plan is approved by the local EOC. During disasters and recovery there does not appear to be a standard protocol for AHCA participation at the local EOC. As Senator Collins says ``You shouldn't be exchanging business cards during a disaster.'' Yet, during Irma, many counties that did not have local AHCA staff present during the pre-emergency period nor during recovery. Many AHCA staff had no history of routinely working with the EOC during non-emergency events. Importantly, routine disaster preparedness drills and exercises at the local EOC level do not seem to routinely include local nursing homes, AHCA regional inspection staff in that area, or EOC personnel. At the state level, the Department of Health and the AHCA work together well, in my judgment. My experience is that during any emergency, the Emergency Support Function for Public Health (ESF-8), operated by the Department of Health, is staffed with high-ranking representatives from AHCA who inspect the nursing homes and assisted living facilities in Florida. I think the system at the state level is well coordinated and there seems to be excellent communication between and among the Department of Health, AHCA, and state associations for nursing homes and assisted living facilities. These new standards became effective during the 2004 storms and have been improving since then. At the county or city level, the EOC, the Department of Health and the local AHCA survey office do not communicate routinely and do not have a history of working together--that is the hallmark of the State's EOC. Recommendations: 1. Require the State of Florida's Field Operations for the Division of Health Quality Assurance within the AHCA to determine if the nursing home is compliant with the new emergency preparedness rules by using a survey protocol that has been developed with the EOC. 2. Require generators and fuel for 96 hours. The rule hearings for both assisted living and nursing homes were held on November 3. 3. Require that EOCs and nursing homes practice the emergency operations plans and that they report the practices. Require AHCA staff to be included in the simulations or table tops. To make this efficient, some coordination could occur using web-based reviews and participation. But, the plans must include both the Department of Health and the AHCA staff, as well as nursing home providers. a. Any exercise should include an actual evaluation of the exercise using evaluation criteria that are available. (Did the home use an incident command system and actually use the written emergency plan when it was conducting its exercise? Did the nursing home submit a revised plan based on the exercise?) b. Target and prioritize homes with more intensive emergency drills: Facilities that have lower quality ratings, such as special focus facilities, or poor quality stars (one star) might be required to participate in ``table top'' exercises with others and the EOC. Facilities in flood evacuation Zone A might also be required to conduct a partial emergency exercise where they are required to evacuate one part of a home to determine how viable the plan actually is and to test how long it will take. 4. Disaster plans should require a detailed staffing plan--how will nursing homes supplement staff to meet staffing requirements during disaster and during the recovery? Irma preparations began on Thursday, September 7, for most nursing homes in south Florida. Nursing home staff worked 12-hour shifts during preparation and then the recovery period began on Monday, September 11. While technically the staff may have had 12 hour rest periods, many must have been exhausted after 4-5 days of working. Irma was an unprecedented storm because of its size but we must learn from it. Emergency plans should include staffing contingency plans, including who is responsible for high-level administrative staff, such as director of nursing and administrator during recovery if those staff leave. Penalties for not complying with the plan should be reviewed but clearly the agency already has the authority to close the facility and move residents to other facilities. 5. New CMS guidelines require nursing homes to have power sources to keep ambient temperature between 71-81 degrees. However, rules don't specify how many rooms or areas must be covered. This should be specified in an emergency plan that includes details for sheltering in place. If the conditions are not met, the plan should provide how the nursing home would evacuate. Nursing homes must create plans to evacuate during recovery if they are not able to care for residents. Question: Are there ways we could confirm emergency plans are being followed, apart from just relying on the word of the nursing home? Response: Florida has good infrastructure for nursing home communication with EOCs. A review of adherence and enforcement is recommended. FLHealthStat Florida leads the country because it has instituted a web-based tracking system--FLHealthStat--which is used by AHCA, the Florida Department of Health, and state and local emergency management offices to identify issues for all health care providers (hospitals, nursing homes, intensive care facilities, and assisted living communities). The FLHealthStat data base preserves information over disaster rather than the earlier tracking system which updated (overwrote) provider data until disaster ended. All nursing homes and assisted living communities must register in FLHealthStat. All nursing homes and assisted living communities are expected to update and report to AHCA in the FLHealthStat system before, during, and after the storm. During Preparation: AHCA and EOC use FLHealthStat to identify nursing homes and assisted living communities with unoccupied beds that should be able to accept new residents either from the community or from other providers. During Recovery: FLHealthStat includes measures of providers' status and critical needs, including power needs, resident needs, staffing needs, damage, and water outage. Re-entry Into Evacuated Home: Nursing homes that evacuated must obtain clearance from the EOC, fire marshal or AHCA, depending on if damage was sustained in the facility. If the disaster plan that was approved by the local EOC is deviated from at all, the facility must contact the local EOC to communicate the change in the plan and obtain approval. AHCA kept requesting associations to help providers to update information. AHCA is surveying providers to learn about opportunities for improvement in system. While FLHealthStat is an improvement over earlier systems, there were complaints the system was cumbersome. Potentially, sanctions or penalties for not reporting or updating the information might be appropriate, after a review of current rules and opportunities to improve the reporting system. Senator Rubio Dr. Hyer, your testimony mentioned that nursing homes have not always been part of Florida's local and state emergency management operations, and they were ultimately included after Hurricane Katrina. In the days after Hurricane Irma, we heard reports about how a number of other facilities and providers were not designated as such by the state, local government, or electricity provider. This including nursing homes, assisted living facilities, retirement homes, oxygen providers and others. Question: Do you know how often state and local governments update the lists of providers like these so they are able to quickly respond to their needs? Response: I believe FLHealthStat includes licensed health care providers including nursing home, assisted living, hospices and home care. Retirement communities are not included. I do not know if medical equipment suppliers are included. Recommendation: Disaster plans, approved by the local EOC, should be publicly available for all health care providers. Question: Are assisted living facilities and retirement homes fully incorporated in state and local government response plans--in Florida and elsewhere? Response: Assisted living facilities are required to have disaster plans and to register with the Department of Health's web-based tracking system-- FLHealthStat--which is used by AHCA, the Florida Department of Health and local emergency management offices to identify nursing homes' status and critical needs. Recommendations for Assisted Living Communities: I think this is a new and important area for state and potentially federal oversight and coordination. Given the current use of assisted living communities for Medicaid waivers under long-term care supports and services, assisted living is an increasingly important part of community care. Many of the small assisted living communities provide care for low-cost and there are important implications for increased regulations on the viability. However, given that over 400 assisted living communities evacuated for Irma, their role in providing care for disabled and older adults is important. 1. Opportunities for increased coordination between the Department of Health's EOC and AHCA is harder to achieve with assisted living. Florida licenses 3,003 assisted living communities with approximately 94,000 beds. Because so many are small homes (under 16 beds), the ability to thoroughly review plans is more complicated. 2. Assisted living communities are not licensed as health care providers. They are licensed under Chapter 429 and are considered ``community dwellings''. Licensing requirements are different. 3. Assisted living inspections also occur every 2 years unless there is a complaint. More frequent inspections, annually, is recommended. Disaster plans can then be reviewed annually and any drills can also be monitored. 4. It has been reported that the utility companies did not have accurate data for some assisted living facilities because they did not register with the utility company as an assisted living facility. Some assisted living communities registered as a private home. It is not clear what the motivation is, but regulations should be reviewed to determine if assisted living communities must register with a utility as an assisted living community. It may be important to review the tax status on things like home-owners exemptions for small assisted living facilities as well. 5. Assisted living requirements for disaster plans may need more thorough review by both the EOC and by AHCA inspectors. 6. Assisted living communities disaster plans should be reviewed carefully by the EOC and made public on the AHCA Web site. New residents might be required to review and acknowledge they have seen and understood the disaster plan. Changes to the plan would have to be sent to all residents. 7. Assisted living fines or sanctions for not complying with disaster plans need to be reviewed and perhaps changed based on experience with Irma. __________ From Senator Bill Nelson Dr. Hyer, thank you for your research on disaster preparedness in nursing homes and long-term care facilities in Florida. I am still devastated about the 12 seniors who died after being trapped in a nursing home in high temperatures after Hurricane Irma knocked out the facility's power. The failure to transfer these seniors to a functioning hospital some fifty yards away is unacceptable. The Centers for Medicare and Medicaid Services (CMS) finalized a rule requiring facilities participating in Medicare and Medicaid, including nursing homes, to update their plans for disasters and coordinate with government agencies to ensure facilities are equipped to respond to an emergency. The regulation was finalized in September 2016, and facilities are required to comply with this rule by November 2017. Question: Does the CMS emergency preparedness regulation address some of the problems that led to the deaths at the Hollywood nursing home? Does the emergency preparedness regulation go far enough? Answer: The new CMS emergency preparedness regulations require nursing homes to have alternative sources of power and to have temperatures that do not exceed 81 degrees when power is lost. How well nursing homes will be able to comply with the regulations is an ongoing issue and enforcement is a powerful tool to be certain these rules are implemented. I believe the state inspectors have to receive additional training, especially the inspectors who generally do the fire and safety inspections. CMS guidance is also probably needed to teach inspectors how to review the plans and be able to determine if the proposed plan would actually provide the ambient temperatures required for the residents to be safe. Question: How important is it for CMS and state governments to prioritize robust implementation of this rule and ensure facility compliance in states before another disaster hits? Answer: It is critical for CMS to work with every state to make sure the state and local emergency management structures for health (ESF-8 functions) include long-term care providers, specifically nursing homes. I do not believe that all states have nursing homes as part of the ESF-8 team at the state level. Florida only added nursing homes during the 2004 hurricane season. Most local EOCs do not have good representation of nursing homes within the local Emergency Operations Center. This is a critical breakdown in systems for two reasons. 1. The new CMS rules require local EOCs to approve the disaster preparedness plans. If the EOC does not visit or recognize the needs of the nursing home, the plan can easily become a ``paper exercise'' not an actual plan that works. 2. The EOC needs to include local nursing homes in the preparedness exercises. Robust preparedness requires EOCs to work with the nursing homes in a meaningful way that allows the EOC to protect nursing home residents and others in the community. Senator Nelson As it is currently structured, Medicaid can respond to public health emergencies and natural disasters. As the needs go up, whether it's because more people become eligible because they've lost their jobs or homes, or their health needs grow, federal funding goes up automatically in response. The Graham-Cassidy amendment that was unveiled last week would cut $1 trillion dollars from Medicaid, according to the nonpartisan Congressional Budget Office. The bill would create a block grant, which provides a fixed amount of funding, and would cap the underlying Medicaid program. We've had three hurricanes in a matter of weeks, and the Medicaid program is especially important to hurricane recovery efforts. I am not only worried about my home State of Florida under this proposal, but also how Puerto Rico and the U.S. Virgin Islands will fare. As they struggle to recover from Hurricane Maria, their Medicaid programs are subject to a block grant that won't adjust for the greater demands as the islands recover. Question: How would the Graham-Cassidy bill provide states with sufficient funding to respond to natural disaster like hurricanes? What happens when more people need health coverage or costs rise on a per- beneficiary basis? Answer: I do not have expertise in this area. Senator Nelson I introduced the Protecting Seniors During Disasters Act with Senators Rubio, Casey and Collins. The bill would create a national advisory commission on seniors and disasters to provide expert advice to the U.S. Department of Health and Human Services on the unique needs of seniors. Question: Given your experience, why do you think a national advisory commission on seniors and disasters is important? Do you believe a commission like this can strengthen disaster preparedness and response for older adults? Answer: I think a national advisory commission on seniors and disasters is important and would identify ``best practices'' across the country that could be disseminated. It would make a difference because improved practices heighten the understanding that our nation needs to be prepared. Such a commission would reinforce the learning that has occurred since 2004 storms and Katrina. __________ Prepared Statement of Paul Timmons, President, Portlight Inclusive Disaster Strategies, Inc. Chairman Collins and Ranking Member Casey, thank you for the invitation to speak before the Committee on this important topic. My name is Paul Timmons, President of Portlight Inclusive Disaster Strategies. I have been working in the field of disaster preparation and response for people who are aging and those with disabilities for 15 years and have led Portlight since 1997. In my time I will share with you some of my observations related to our most recent disasters and make a number of recommendations for improving disaster preparedness. As the news media began to cover the story of the horrific conditions at the Hollywood Hills Nursing Home in Hollywood, FL and the deaths of eight of their residents on September 13, Portlight Strategies had begun our 18th straight day of round the clock disaster response efforts to address the disproportionate impact of hurricanes Harvey and Irma on older adults and people with disabilities. Given that people with disabilities and older adults are two to four times more likely to die or be seriously injured in a disaster, the urgency of our work cannot be understated. The disproportionate rate of injury and death is due to poor planning, inadequate accessibility, and the widely shared but incorrect assumption that people with disabilities and older adults are ``vulnerable,'' ``special,'' or ``at-risk,'' simply because of their diagnoses or stigmatizing beliefs about disability and aging. In fact, older adults and people with disabilities are extremely valuable experts on emergency problem solving, with far more practice than younger people and people who don't navigate inaccessible environments and programs on a daily basis. Since August 26, our work at Portlight has been spent, around the clock, organizing lifesaving rescues with our partners, organizing delivery of food, water, generators, wheelchairs, medical equipment and supplies, sign language resources, addressing civil rights violations, answering non-stop calls to our hotline, and pointing people to lifesaving and life sustaining emergency resources to meet the critical needs of older adults and people with disabilities. We have organized daily national, state, and issue specific public- private coordination calls between governments, the Red Cross, disability organizations, and stakeholders to optimize limited resources and minimize duplication of effort. For every heartwarming tale of heroism (and there are many), we are navigating the devastating stories from people who have not benefited from the considerable tax payer investments in local, state, and national emergency preparedness initiatives. Local resources, the most knowledgeable daily lifeline for people with disabilities and older adults, are rarely funded before, during, and after disasters, with federal funds and donations going to organizations without a local foot print or experience in meeting the daily needs of older adults and people with disabilities in the impacted areas. What has happened since the Post Katrina Emergency Management Reform Act was passed in 2007? Great progress was made for many years, primarily by heavily investing in whole community inclusive initiatives, with true partnerships between FEMA and disability and older adult led organizations. People with disabilities and those who are aging need to be at the table when planning for disasters. There is no more important time for the adage ``nothing about us, without us'' to be a reality. At the local, state, and federal levels, and in non-profit agencies dedicated to disaster preparation and response, those who are aging and disabled need to be both participants and leaders. Right now, most planning occurs ``FOR'' people with disabilities and older adults, not ``WITH'' us. Moving forward we need to ensure there is substantial leadership and participation during emergency planning. To truly include older Americans and Americans with disabilities in the planning process, the following issues need to be addressed in order to reduce injuries, avoid deaths, and ensure response is as effective as possible: Ensure communication about emergency services are broadcast and distributed in American Sign Language and clear, plain language in all cases when communication about a disaster is made to the general public; Ensure that all emergency response communications, including 911, 311, and 211 emergency and information lines are accessible; Ensure all building evacuation procedures include procedures for those who need mobility support, have sensory disabilities, intellectual disability, and anxiety and other mental health concerns, and that personnel are trained to implement those plans; Ensure that all transportation to evacuate older persons and those with disabilities are fully accessible, have personnel who know how to operate the vehicles and the accessibility features, and are available during the emergencies; Ensure access to food, water, medicine, and power; Ensure all information about what to do, where to go, and how to get help is available in accessible formats, including video with captioning, audio, and plain language formats; Ensure all shelters, including both general population shelters and ``special needs'' or ``special medical needs'' shelters, are ready to support older adults and those with disabilities and that personnel staffing those sites are trained to support people with disabilities and those who are aging; Ensure all shelters are accessible and have trained personal assistants, accessible showers and toilets, flexibility in meals to meet dietary restrictions and requirements, and equal access to communication; Ensure admissions to medical facilities and nursing homes are not substituted for meeting civil rights obligations to provide equal access to emergency services and programs in their community; Ensure that all tracking information systems are up-to- date and personnel know how both to use the systems and maintain confidentiality; Ensure there is equal access to emergency registries operated by state, federal, and non-profit emergency programs; Ensure voluntary registries are not only used in preparation for a disaster but are actually used as part of the response; Significant delays (up to 30 days, if the caller could even complete their call) in receiving ``critical and immediate needs'' assistance from FEMA and Red Cross, despite announcements to apply; Ensure individuals who use service animals are admitted to shelters and are able to stay with their animals while in shelters; and Ensure individuals who use mobility devices, sign language interpreters, personal assistants, communication devices, and health maintenance items are not separated from those devices and services. Despite extensive planning, many of these items were not completed for the response to Harvey and Irma. We learned lessons from Katrina and Sandy but did not implement many of those lessons. Hopefully we will be able to implement more lessons from the most recent storms. The following are my priorities to improve responses to reduce injuries and save lives. Recommendations 1. Create an inclusive disaster relief fund for Independent Living Centers and other consumer controlled community disability and aging organizations to engage in emergency preparedness, response, recovery, and mitigation. Invest $1 billion over 5 years to serve the people of their community before, during and after disasters. Those who are aging and those with disabilities are the experts on housing, access to health maintenance services, accessible transportation, getting people back to work, and keeping people out of nursing homes. Currently, independent living centers and other consumer directed agencies receive no funding to do their emergency preparedness and disaster response, recovery and mitigation work. Funding for these efforts should not compete with first responders, public health, and state and local emergency managers. So it is essential to fund preparation and response work through separate sources. 2. Establish a National Center for Excellence in inclusive Disability and Aging Emergency Management. The initial focus of the center should include community engagement, leadership, training and exercise development, evacuation, sheltering, housing, and universal accessibility. I suggest a budget of $1 billion over 5 years to stand up the center. 3. Direct the U.S. Department of Justice, and provide the Department with resources, to monitor and enforce the use of all disaster funds to ensure compliance with the civil rights requirements of the Rehabilitation Act of 1973, as amended and the Americans with Disabilities Act of 1990, as amended. 4. Provide Department of Homeland Security grant funds to specifically fund qualified and experienced Statewide Access and Functional Needs Coordinators for all states and territories. These coordinators would serve as statewide subject matter experts across preparedness, response, recovery and mitigation to engage and coordinate whole community collaboration among disability leaders, community organizations, first responders, emergency managers, public health and safety, private sector and other stakeholders. 5. Conduct a study of the use of volunteers to determine efficacy in sheltering services to individuals with disabilities and older adults. Objectives of the study should include determining if the use of volunteers is adequate to comply with disability equal access and non-discrimination obligations. 6. Refresh the Post Katrina Emergency Management Reform Act to better define State and Federal Government obligations to plan for, respond to, recover from, and mitigate all hazards in compliance with disability civil rights laws. 7. Exempt the cost of disability related repairs and replacement from the FEMA Individuals and Households maximum grant ceiling (currently $33,300). Disability related repairs and replacement of durable medical equipment and other disability items includes replacing wheelchairs, customized vehicles, medical devices, entrance ramps, elevator installation to meet home elevation requirements, and other items that provide equal access for people with disabilities in recovering from a disaster. 8. Establish an American Independence Corps, similar to FEMA Corps made up of at least 5,000 citizen members with and without disabilities to carry out planning and preparation activities in each state, DC and Territory year round. 9. Direct FEMA and the Administration on Community Living to lead a coordinated effort across Federal Government agencies, the states, CBOs, foundations, and other sectors, with those who are aging and those with disabilities in leadership roles, aimed at achieving on- going planning, preparation, and implementation of these recommendations. Implementing these recommendations will: Prevent, minimize, and rectify the institutionalization and/or loss of critical home and community based services for children, adults and older persons in the lead up to, during or following a disaster; and Increase the ready supply of accessible, adaptable, affordable, and disaster resistant permanent and temporary housing nationwide. Conclusion Let me be very clear, most of the failures and shortfalls we address are a direct result of the failure to plan at the local and state level and the failure to place subject matter experts in leadership roles at every level coupled with failure to include people with disabilities and older adults as key stakeholders in planning efforts. This has been coupled with blatant disregard for the unwaiverable civil rights obligations associated with the expenditure of every federal dollar spent by government, grantees and contractors without any monitoring and enforcement by the Federal Government over its civil rights obligations. To further emphasize this point, there are no civil rights loopholes releasing anyone from their legal obligations in emergencies and disasters. Period. Despite years of planning, people with disabilities and older adults in Texas, Florida, and the U.S. Virgin Islands, and other hurricane impacted states have, once again, paid the price for our collective emergency planning shortfalls. Many thousands are still without the basic necessities to meet their independence, safety, and health maintenance needs. Most have been denied their basic right to equal access to federally funded emergency programs and services. We receive daily requests to assist people without food and water. Some of the people calling are in high rise buildings without power. Callers are unable to obtain prescription medications, return home from evacuation placement in nursing homes hundreds of miles away, having extreme difficulty in reaching FEMA and Red Cross to request assistance and being informed about wait times of up to 30 days for crisis and immediate assistance funds for food, water and medication. Effective practices for whole community inclusion must be led by experts in disability and aging inclusive emergency management. The people most knowledgeable about the needs in their own community are best suited to lead disaster response and recovery. We must find a way for these organizations to have adequate resources to do the complex and long-term work that is needed for people with disabilities and older adults to participate with government and the disaster business giants to get grants, donations, and tax payer dollars to optimize whole community inclusive disaster recovery. Portlight Strategies and our national Partnership for Inclusive Disaster Strategies stand ready to assist the American people to get this right. Thank you for allowing me this opportunity to share my experience and recommendations with the Committee and I stand ready to answer any questions you might have. Portlight Inclusive Disaster Strategies, Inc. is a nonprofit, nonpartisan, disability inclusive disaster relief organization established in Charleston, SC, in 1997. Portlight Strategies does not receive federal funding. Portlight Inclusive Disaster Strategies, Inc. P.O. Box 14109 Charleston, SC 29422 (843) 817-0671 www.portlight.org __________ Questions for the Record To Paul Timmons From Senator Elizabeth Warren Climate change is the greatest disaster preparedness and response issue of our time. A 2016 publication by the Environmental Protection Agency noted that the consequences of climate changes are serious for us all, but particularly for older Americans. Additionally, the nation's population over age 65 is expected to nearly double by 2050, and approximately 1-in-5 older adults live in an area that was directly impacted by a hurricane or tropical storm within the last decade.\1\ --------------------------------------------------------------------------- \1\ Environmental Protection Agency. ``Climate Change and the Health of Older Americans.'' (May 2016) (https:// 19january2017snapshot.epa.gov/sites/production/files/2016-10/documents/ older-adults-health-climate-change-large-fonts_0.pdf) --------------------------------------------------------------------------- Question: As increased flooding, heatwaves, droughts, and other extreme weather events become more common, does America have the right preparedness plans in place, or do we need to be doing more to respond to the needs of seniors and those with disabilities? Answer: Despite the huge investment in preparedness across the country through the development and implementation of the National Preparedness System, plans are only in place on paper in most communities. Where there is actual planning, it generally excludes older adults and people with disabilities, and where older adults and people with disabilities are included, the general perspective is that their needs are special and their contributions are not a key element of a whole community inclusive approach to universal accessibility and inclusion. __________ From Senator Marco Rubio Your testimony emphasizes the importance of including older Americans when developing emergency response plans. Question: In your experience, what are some common misunderstandings that you hear from state and local governments when it comes to meeting the needs of older Americans after a disaster? Answer: Misunderstandings include: Accessibility is ``nice to have'' not required. Civil rights and equal access obligations associated with the use of federal funds can be waived in a disaster. Older adults and people with disabilities need to be ``planned for'' rather than engaged as knowledgeable partners in whole community planning. Exercises can be effective without using real people with disabilities and older adults participating. It isn't necessary to fund accessibility experts and community organizations. Funding goes to generalists and practitioners without accessibility expertise, and this is adequate to meet obligations. Older adults and people with disabilities are ``vulnerable'' and their needs are medical, rather than needing physical accessibility, effective communication accessibility and program accessibility to maintain health, safety and independence. Question: Do the residents of nursing homes, assisted living facilities and others typically have the necessary level of information about how the facility plans to respond to an emergency? Answer: Residents of nursing homes, assisted living and others rarely have access to actionable information to plan for, respond to and recover from emergencies and disasters. This is despite ongoing efforts to build and implement inclusive planning initiatives locally, statewide and nationally, and is an example of the deficiencies resulting from using generalists and medical approaches rather than accessibility and inclusion experts. __________ From Senator Bill Nelson You emphasized the need for a commission or national infrastructure to connect and coordinate stakeholders involved in emergency preparedness. I introduced a bill with Senators Rubio, Casey, and Collins to create a national advisory commission to advise the Department of Health and Human Services on disaster preparedness for seniors. The commission would consist of Federal agency heads, local agency representatives, and non-Federal emergency healthcare professionals. Question: Why are advisory commissions like the one described above important? Answer: Disability leaders believe in the adage, ``nothing about us, without us''. We believe emergency preparedness must be inclusive, this means planning with us, rather than for us. Advisory boards are a tool for bringing subject matter experts with lived experience to the table. We would strongly encourage that the membership of the National Advisory Council include a majority of older adults and individuals with disabilities. Senator Nelson You spoke at length about the need to promote inclusiveness in disaster preparedness and response plans for individuals with disabilities, and I fully agree. In your testimony, you stated that people with disabilities and older adults are two to four more times likely to die or be seriously injured in a disaster. In Florida, we are still in the process of recovering and rebuilding in the wake of Hurricane Irma. And Puerto Rico and the Virgin Islands are in the midst of a humanitarian crisis. Question: What recommendations do you have for Congress, and State and local governments so that we improve disaster preparedness efforts to better account for older Americans and people with disabilities? Answer: We strongly recommend monitoring and enforcement of the Rehabilitation Act requirements in all use of federal funds. Meeting the obligation to provide physical access, program access and effective communication access throughout all preparedness, response, recovery and mitigation activities actually offers a great opportunity to provide equal access and full inclusion through universal design. This is smart practice for optimizing limited resources and minimizing unnecessary use of medical and responder resources simply because of a lack of inclusive planning. It's time to directly fund local independent living centers and disability organizations. These are the experts on housing, health care, transportation and benefits navigation needs of older adults and people with disabilities. During and after disasters, they usually end up providing the services that the funded organizations are unfamiliar with. However, they are not funded and the impact on their resources limits services to both disaster survivors and individuals not impacted by the disaster. Finally, training and technical assistance in achieving and maintaining disability inclusive whole community readiness and resilience must be led by experts. Too many amateurs are using unproven practices, and failing to establish objectives or measure results. We strongly recommend the establishment of a National Center of Excellence in Whole Community Inclusive Emergency Management. __________ Prepared Statement of Jay Delaney, Fire Chief and Emergency Management Coordinator, City of Wilkes-Barre, Pennsylvania Chairman Collins, Ranking Member Casey, and members of the U.S. Senate Special Committee on Aging, thank you for inviting me here today to discuss how cities and towns across the country can help ensure the health, safety, and resilience of older Americans and individuals with disabilities during and after disasters. I am the Fire Chief for the city of Wilkes-Barre, Pennsylvania. I have been honored to serve the city in this role for over 12 years and a total of 36 years in Emergency Services. I am also the Emergency Management Coordinator for the city of Wilkes-Barre and a certified paramedic. Over 40,000 people reside in Wilkes-Barre, a city located in Luzerne County. Nearly 19 percent of the county's residents are over age 65, which is three percent higher than the average for the state. And, many of the older residents are concentrated within the city limits. Like any Fire Chief or Emergency Management Coordinator, I feel a great sense of responsibility for these older Pennsylvanians; many who live by themselves. My concern for their well-being is heightened whenever there is a threat of a severe storm or weather event. That is due to a 10,000 square mile watershed that drains into Wilkes-Barre from Susquehanna River, threatening to flood our streets and neighborhoods. In August 2011 the threat became very real as the east coast braced for Hurricane Irene and Lee to make landfall. What transpired over that next week explains why early weather tracking, data, surveillance and the flow of information across all levels of government is a priority and critical to the health and safety of residents. About seven days before the storms were scheduled to hit, we heard from the National Weather Service. They started to send us regular updates about the storm patterns and possible rainfall and potential crests for the Susquehanna River. The Pennsylvania Emergency Management Agency disseminated critical data to the County Emergency Management Officials and the emergency management coordinator for each municipality. Wilkes-Barre is protected by a U.S. Army Corp of Engineers levee to a river level of approximately 42 feet. The Susquehanna River crested on September 9, 2011 at a record and historic level of 42.66 feet. For years, the gauges that measured the water height of Susquehanna River in Wilkes-Barre were broken and were the responsibility of the U.S. Geological Survey. Senator Casey led the charge here in Washington to secure the resources to replace our broken gauges. It is because of Senator Casey that we can track--in real time--the possibility of a flood and critical river level data. This type of surveillance information provided the needed data to make risked based decisions for possible evacuation. Using maps of flooding that took place in 1972 after Hurricane Agnes, we created an evacuation zone. And, on September 9, 2011, we successfully evacuated 15,000 residents of Wilkes-Barre in about 10 hours. This evacuation included Wilkes-Barre City Hall, Wilkes-Barre Police Headquarters and Wilkes-Barre Fire Headquarters as well as the entire downtown, King's College and Wilkes University. We alerted the local hospital and the two nursing homes in the evacuation zone. They executed their Emergency Preparedness Plans and safely evacuated over 250 seniors. And, if at any time, they thought that they were going to have trouble evacuating in the time required, they knew to request additional help from the Wilkes-Barre City Emergency Operation Center. We would send ambulances and personnel to help. But, it was the older Pennsylvanians, the seniors, and those with disabilities who still lived in their homes and in the community that I worried about most--the Mr. and Mrs. Smiths who have lived in their home for 50 years. In preparation for a possible evacuation, we had developed a grid designating areas of responsibility for Fire Department, the Police Department and members of the National Guard. We drove through South Wilkes-Barre and the downtown making announcements from our vehicles, knocking on doors, and posting evacuation orders. We knocked on every door. We left notes on doors of the homes where no one answered and made an additional check to ensure their evacuation. Most people heeded the request to evacuate on the first try, but if anyone resisted, they took their names and wrote down their addresses and we spent additional time working to get them out of their homes. We successfully executed our plan because of the seamless collaboration and communication among officials at the national, state, and local levels. But, even so, after every major event, we look back and discuss how we can improve. For example, should we ever need to evacuate again, we now have a contact in place with a local bus company that agreed to drive routes throughout the city to pick people up and take them to safety. Following Hurricanes Harvey and Irma, I hope that Congress will conduct its own after action review as it did after Hurricane Katrina in August 2005. While Presidential Directive 5 started the advancement of the National Incident Management System it was for the most part put into action after Hurricane Katrina and is a model for how all levels of government manage all types of emergencies and disasters. As part of that review, I hope that Congress will commit to continue to fully fund the National Weather Service and FEMA, and invest surveillance tools so that we have the most comprehensive information available before, during and after a disaster to guide our decision-making. Without early weather surveillance we have little time to plan and prepare for potential weather events. I am grateful to the Senate Special Committee on Aging for the opportunity to add my voice to this conversation. Thank you. ======================================================================= Additional Statements for the Record ======================================================================= Statement of Senator Marco Rubio I would like to thank our witnesses for their time and willingness to testify before the Senate Aging Committee, and I wanted thank Dr. Kathryn Hyer in particular for making the trip from my home State of Florida. The topic of disaster response for older Americans is especially important for states, like Florida, with a large senior population, and I thank you for your work. In the wake of a natural disaster, we can be painfully forced to grapple with our own shortcomings and failure to prepare for all scenarios. In the aftermath of Hurricane Irma, 11 senior citizens senselessly died in Hollywood, Florida. The victims in this particular case were later found to have body temperatures far above safe levels, some reaching nearly 110 degrees. According to the CDC, temperatures over 103 degrees puts people at risk of a heat stroke and that senior citizens are more vulnerable to high temperatures. My own mother is in an assisted living facility and I cannot imagine the pain that these victims' families must be dealing with. I am committed to working with my colleagues to fill the gaps in our current emergency response system, starting with legislation that Senator Bill Nelson and I introduced that would establish an Advisory Council on Seniors and Disaster. This legislation would require the heads of multiple federal agencies to assess the specific needs of seniors, our nation's current capacity to quickly meet those needs after a disaster, and work with state governments to ensure they have the necessary tools and capabilities to care for older Americans in the wake of a disaster. This advisory committee is only part of the solution, and I look forward to learning from our witnesses about other ways to fix this problem. __________ Statement of Katie Smith Sloan, President and CEO, LeadingAge LeadingAge appreciates this opportunity to comment on the need to improve planning, preparation and protection for vulnerable populations threatened by disasters such as the recent hurricanes in Texas and Florida. We commend the Committee's efforts to ensure the safety of America's older adults in emergency situations. The mission of LeadingAge is to be the trusted voice for aging. Our 6,000+ members and partners include not-for-profit organizations representing the entire field of aging services, 38 state associations, hundreds of businesses, consumer groups, foundations and research centers. LeadingAge is also a part of the Global Ageing Network, whose membership spans 30 countries. LeadingAge is a tax-exempt charitable organization focused on education, advocacy and applied research. Vulnerable older adults must be protected in the event of disaster. This effort must involve collaboration between public and private agencies. Not only must older adults be kept safe during events like a severe storm or other natural disaster, but they often need assistance in the aftermath with services like food, fresh water, and electricity to power essential medical equipment. We support a three-pronged approach to emergency preparedness on behalf of older adults: A Federal regulation that will be effective November 15 will require certain providers of health care and long-term services and supports to have plans for foreseeable natural and man-made disasters. Senators Bill Nelson, Marco Rubio, Bob Casey, and Susan Collins have introduced the Protecting Seniors During Disasters Act, which will establish a National Advisory Committee on preparing seniors for an emergency. Federal, state, tribal, regional and local emergency preparedness authorities must recognize the special needs of older adults and put this population and the organizations that serve them on priority lists for restoration of essential services. Emergency Preparedness Final Rule On September 8, 2016 the Centers for Medicare and Medicaid Services (CMS) posted a final rule, Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers. The rule becomes effective on November 15, 2017. The rule applies to all health care providers that participate in Medicare and Medicaid, including hospitals, nursing homes, hospice and home care agencies. Having an emergency preparedness plan in place will be a requirement or condition of participation in Medicare and Medicaid for all providers. The inspection or ``survey'' that nursing homes undergo annually will include a review of the nursing home's emergency preparedness plan. To implement the new requirement, providers are to take an ``all hazards'' approach, assessing the organization's vulnerability to natural and man-made disasters. The kinds of disasters for which providers must plan include emergencies related to patient care; loss of water or other utilities; loss of part of the facility, equipment failures, communication breakdowns, unavailability of food and medication shipments, and similar emergencies. Emergency preparedness plans must take into account the special needs of the populations the provider serves, such as limited mobility, dependence on medical equipment, etc. Providers must develop policies and procedures to protect residents and patients in the event of potential disasters, train their staff in these procedures, and regularly test the adequacy of the procedures. Staff training must include exercises conducted among senior staff in an organization and full-organization drills involving the entire staff. CMS guidance issued on the final rule includes consideration of evacuation plans and back-up evacuation plans in the event that the planned destination becomes inaccessible or is unable to accept more patients. The guidance notes that mobility can be an issue for many at-risk populations, including older adults and persons with disabilities. Emergency preparedness plans must ensure that transportation is available and that staff responsible for transporting older persons know the procedures to be followed. Alternative facilities that could be destinations for evacuated patients and residents will have to be identified, along with the financial resources that will be necessary to carry out the plan. Issues of potential leadership succession must be addressed in emergency plans, ensuring that personnel are available to fill critical decision-making roles. Plans also must include protection of vital records and health information technology. An important aspect of the emergency preparedness rule requires coordination and collaboration with public authorities in charge of emergency response. To comply with the new rule, providers will be required to document the ways in which they have collaborated with these public authorities in the development of their emergency preparedness plans. Since the final rule was issued last year, LeadingAge and its state partners have published and disseminated information for our member nursing homes, home care and hospice providers on developing and implementing the required emergency preparedness plans. We also have conducted numerous education sessions for our members, both in person and electronically. We will continue doing everything possible to ensure our members' successful compliance with the new requirement. And we urge the Special Committee to take the new rule into account in considering what action is needed to make sure that older adults are protected in the event of disasters. Protecting Seniors During Disasters Act LeadingAge commends Senators Bill Nelson, Marco Rubio, Bob Casey, and Susan Collins for their introduction of this legislation, which will establish a National Advisory Committee on Seniors and Disasters. This kind of committee could encourage better coordination and collaboration among the various public and private entities responsible for proactive steps to ensure older adults' safety. We are pleased to see that a wide range of federal officials and agencies is to be represented on the Advisory Committee. We would recommend, in addition, that a representative from the Department of Housing and Urban Development (HUD) be added to the commission. Residents of public senior housing communities are especially vulnerable to damage to their homes and interruptions in their supply of food, water, and essential medications as a result of natural disasters. All too often following a disaster, we see that older adults with high needs living independently in their communities are not given priority by public authorities for emergency supplies of food, water and essential services. As an example of the kind of services needed by older adults living in the community, in mid-September LeadingAge and our member National Church Residences established the Hurricane Services for Seniors hotline. National Church Residences serves as a clearinghouse, matching needs for housing and services with older adults affected throughout Texas, Florida, and Puerto Rico. The hotline shares resources and connects callers with available housing. Service coordinators help guide the older adults through the steps of filing for federal and state assistance. The hotline is an example of a service that could be expanded through collaboration with the Administration on Community Living at HHS and HUD using a network of specially trained HUD-housing service coordinators. While their needs may be addressed to some extent by home health care agencies or other health care providers under the final rule discussed above, we are concerned that these older adults could fall through the cracks of public and private emergency preparedness plans. It is not just their medical and health care needs that must be addressed; restoring access to food and water is of critical importance. We therefore urge that an official responsible for senior housing programs within HUD be added to the advisory committee. Older Adults Must Be Given Priority Status in Public Preparedness Planning As discussed above, the final rule on emergency preparedness requires health care providers to document their efforts to work with public emergency and disaster preparedness authorities on plans to ensure older adults' safety. As our member organizations have worked on developing their plans, unfortunately they do not always have the cooperation of public authorities in their regions. In some areas, authorities apparently believe it is sufficient to give priority to the local hospital for restoring water and other utilities but not long-term care and senior housing. A broader view of priorities will be essential if the needs of older persons in emergencies are to be met. We urge the committee to use its influence with state and local authorities to make them aware of the importance of including all providers of services to older adults in their plans for responding to emergencies and disasters. LeadingAge commends the Committee for its attention to this critical issue and we look forward to working with you to ensure the safety of older persons during and after disaster strikes. __________ Statement of James R. Balda, President and CEO, Argentum On behalf of Argentum, which advocates for excellence in senior living, we thank you for holding a hearing on the important topic of the special needs of older Americans when it comes to disaster preparedness and response. This population is one of the nation's most valuable resources, but also one of the most vulnerable. Argentum is the leading national association exclusively dedicated to supporting companies operating professionally managed, resident- centered senior living communities and the older adults and families they serve. Argentum member companies operate senior living communities offering assisted living, independent living, continuing care, and memory care services to older adults and their families. Since 1990, Argentum has advocated for choice, independence, dignity, and quality of life for all seniors. Argentum has worked with the senior living industry in all states to advance industry standards and regulations to ensure that all senior living communities continue to provide high quality care and quality of life as well as appropriate supports and services to the diverse array of residents served, including effectively preparing for the inevitability of natural disasters. Caring for a population that includes frail seniors in the face of a natural disaster offers many challenges, such as safe transportation; providing appropriate health services and nutrition; meeting the needs of people with special conditions such as dementia, limited ambulation, and vision or hearing impairments; ensuring there is access to medical records and life-saving medicines; emotional issues such as separation from loved ones and caregivers; vulnerabilities to those who prey on older adults through elder abuse; and other risks related to evacuation. As you know, the senior living industry is regulated in every state and must follow the relevant state laws, regulations, and codes to ensure the safety of community residents. States that are the most successful in integrating the needs of seniors in their emergency preparedness plans are those that offer clear, collaborative efforts between their emergency management and health agencies, and long-term care providers. Advanced planning, prevention, communication, and state and local partnerships are critical in helping to ensure the safety and well-being of older adults, especially those who are vulnerable in a disaster or emergency. Assisted living communities in each state are required to have an emergency management plan in place to rely on during a dynamic environment such as a natural disaster. We were heartened to hear that the nearly 190,000 residents and patients served in long-term care communities in Florida remained safe thanks to the smart planning of long-term care employees in preparing communities to cope with an emergency situation such as a natural disaster. For example, Legend Senior Living based in Wichita, Kansas, owns and operates eight Florida-based senior living and memory care communities, which house more than 640 residents and employ more than 540 people across the state. A 24-hour command center was immediately organized at the home office in Wichita. Generators were tested and prepared for use. Nursing staff ensured that sufficient medication was in stock. Residence directors communicated with neighboring fire departments and hospitals to discuss possible emergency situations. The home office had calls with each community every four hours to ensure they were equipped and safe. When electricity went out, the phone system rolled to Wichita. The Florida communities worked hard to alleviate resident unease and were fortunate to have a chef who could continue to prepare meals and popcorn for residents to enjoy while watching football on television. Other providers that needed to evacuate residents sent them to sister communities nearby or in some cases companies rented out entire hotels to move in residents, staff, and their families. The widespread nature of these two disasters brought out the best in senior living providers. In Texas, memory care specialist Silverado took in 30 patients from a hospital that needed to evacuate. Providers opened their doors to residents from nearby cities and towns who arrived wet and cold and were given warm clothes, food, and a place to stay. Every emergency situation is different. At some point, a decision must be made on whether to shelter in place or evacuate. It's not an exact science and as was demonstrated in Florida, hurricane paths can swiftly change. In Texas, the Dickinson-based community that received negative national attention was told to shelter in place by the city's mayor. At some point, that decision did need to be reversed when the rising waters filled the community. Thankfully, everyone was safely evacuated. Professionally managed senior living communities are structured to cope with the distinct needs that older adults pose in the face of natural disaster. Each stage of an emergency, whether sheltering in place or evacuation, must be treated differently when dealing with frailer adults than other populations. Community staff understand the custom care plans that an older adult may not be able to experience from a shelter or relief organization unfamiliar with a frail individual. Some valuable lessons were learned from Hurricane Katrina resulting in much better care in a natural disaster emergency. During the recent hurricanes in Florida and Texas, wrist bands with names and community were immediately placed on resident wrists along with medication identification. Families were notified where their loved ones would be taken in case of evacuation. We have all learned from past tragedies, and Argentum currently is in discussions with Florida and Texas officials about regulations that have proved effective. For example, Texas in 2011 passed a law prioritizing assisted living communities for restoration of electricity following an extended power outage. Assisted living is not on such a priority list in Florida. We must have thoughtful discussion about the role for generators, adequate fuel supply, and safety considerations such as significant fuel storage on the site of a caregiving community. Several of our member companies were unable to access fuel to power their community generators and buses post-Hurricane Irma and searched for gas as far away as Maryland and Tennessee. We also hope this situation spurs a discussion about a need to consider in the future possible alternative energy sources and technology uses that could help long-term care organizations navigate this issue successfully. Natural disasters are inevitable and can occur anywhere, at any time, in the United States. Argentum and its members have worked hard to elevate the importance of disaster preparedness. We take it very seriously. The lives of each and every resident is precious and let's not forget the caregivers who were the real heroes during these storms. They spent night after night in the senior living communities caring for residents and many were not able to be with their own families during this time. While the safety of the senior living residents took priority, many caregivers finally went home to realize they had lost everything. Many companies in Texas and Florida have been fundraising with company matching programs to help these employees get back on their feet. Argentum has pledged to match up to $50,000 in donations from the senior living industry to communities and employees negatively affected by Hurricane Harvey. Please see the Addendum that follows which highlights just a few of the many stories we received of compassionate care, heroism, and acts of kindness from residents, families members of residents, and staff members from communities across the states affected by the hurricanes. We look forward to continuing our dialog with you to ensure that all of our nation's seniors are housed safely at all times in a caring, nurturing environment. Argentum is available to further address any of these issues. We sincerely appreciate your consideration of these comments. ADDENDUM Preparing and Caring in the Face of a Natural Disaster Senior Living Prioritizes Resident Safety and Comfort Caring for Residents, Staff, and Community Below are a sampling of the many letters of appreciation and support that have poured in from family members following the recent hurricanes in Texas and Florida: Family Member of Belmont Village Resident (Texas): First I want to say I felt that you all handled the lock-down for the residents of Belmont Village Hunters Creek during Hurricane Harvey really well. I appreciate the e-mail updates and the 800 call-in number to stay up to date of daily on goings. I had complete peace of mind that my parents were well-cared for, busy, and kept in their normal routine during that stressful time. Also I don't think they had much understanding of what was going on outside the walls of the building, all over the city of Houston. So they were not frightened, for which I was very thankful. A heartfelt thank you goes out to you all. After Hurricane Harvey, Atria Senior Living held a Texas-Sized Feast at the Support Center--as did many of its communities across the country--to raise funds for Atria Cares and affected employees. So far, more than $200,000 has been raised. Family Member of Atria Evergreen Woods Residents (Florida): The most precious people in my life are those that raised me as a child. With many others in Florida and as Atria Evergreen Woods residents, they were confronted with the path of hurricane Irma in September 2017. While many citizens of Florida were struggling with the idea of evacuations, Atria had everything planned and under control. You moved your Atria residents to a location in Orlando. The fact that Atria had a preplan and a hurricane safe location ready was extremely re-assuring for me and my family. The larger success story comes with the level of service, support and care that the Atria employees gave to its residents in the Orlando location during and after the hurricane. My aunt and uncle raised me from very young and they mean everything to me. Living in New York, you can imagine how difficult it was for me to deal with the situation. The feedback I would like to give you, which I hope is cascaded to the service providers, is that they were given first class attention and service during this natural disaster. Medication Tech, Autumn Leaves of Estero (Florida): It was the most humbling experience I have ever had. This storm made me appreciate a lot of things and look at life differently. Autumn Leaves opened their doors to my family in order to keep them safe and us together. They opened their doors to help others affected by the pending storm. They kept all of us safe and free from harm. I would not change anything and would do it all over again to care for our residents and families! Retirement Management Center was able to give shelter to two senior brothers, who were neighbors from across the street. Retirement Center Management (Texas): On Sunday, August 27 around 3 p.m., the community received a call from the nephew of Chris and Johnny, brothers who live across the street from a Retirement Center Management community. One is diabetic and the other is an amputee with a prosthetic leg. A person kayaking down the street was asked by the community staff to assist Chris across the street. The staff was concerned about him walking in the water since he had some open sores and is diabetic. The community nurses did an assessment when the brothers arrived at the building and were able to provide them shelter from the storm with a warm location, dry clothes, and food and water. The community served as an emergency storm shelter for more than 10 people during the severe flooding. The Fountains at Boca Ciega Bay in St. Petersburg (Florida): Located right on the Bay, this community was ordered to evacuate two days before Irma hit. The task was nothing short of monumental, but every Watermark community has a custom, detailed Emergency Preparedness Plan and the Fountains at Boca Ciega Bay followed each step for a successful evacuation and return. Details range from ``unplug computers and appliances'' to ``arrange for pharmacy and follow all medical charts'' and ``coordinate buses with chair lifts and bathrooms'' plus everything in between. Residents of our independent neighborhood evacuated to the Mission Inn, a resort hotel an hour or two from the community. Temporary housing in a big ballroom provided a safe experience and the hotel staff worked tirelessly alongside our associates to ensure a positive experience. Residents played games and cards thanks to quick thinking community life associates who grabbed them all on the way out. Exercise programs, club meetings and classes were held with enthusiasm to keep the days fun and to offer residents a routine as close to our typical lifestyle as possible. One resident brought her harmonica and entertained folks during and after the storm, with sing-a-longs of everyone's favorites. Resident at Five Star Senior Living, Horizon: The staff was absolutely wonderful during this hurricane. Many stayed here to assist and the attitude was one of what can we do to help--friendly, smiling, eager to please--which combined with older people already upset and sometimes confused, was a real positive attribute in these circumstances. The nurse remained on duty the entire time checking in on every resident who might have needed her aid. Our Director was here full time during the hurricane, as were several of the sales staff and servers. Resident at Brookdale First Colony (Texas): During the weeks and days that Harvey waged his ``war'' on our State, I was moved by the care and love which emanated from Brookdale First Colony staff who remained with us during the deluge. They calmed our nerves, welcomed our displaced relatives with open arms and were deeply concerned for all. They say heroes are made in times of war. These associates were our heroes and deserve Medals of Honor. Uniting and Rebuilding Many senior living companies quickly rallied resources to ensure staff and communities negatively affected by these natural disasters were taken care of. Here is a sampling of their efforts: Watercrest Senior Living Group of Vero Beach, Florida is spearheading a $100,000 fundraising initiative coined `Watercrest CARES' in support of Samaritan's Purse for Hurricane Harvey disaster relief. Samaritan's Purse is a Christian organization led by Franklin Graham, son of Billy Graham, serving victims of disaster worldwide. Watercrest principals, Marc Vorkapich, CEO and Joan Williams, CFO, launched the `Watercrest CARES' fundraising campaign with a starting donation of $10,000, encouraging others to contribute to the campaign's relief efforts. Sunrise Senior Living community The Fairfax held a ``fill the truck'' fundraiser on September 21 to benefit those affected by Harvey and Irma. The Army Retirement Foundation-Potomac, a 501c3 charitable organization that founded The Fairfax Military Retirement Community near Fort Belvoir, VA, is also managed by Sunrise Senior Living. Co- hosted along with TAD Relocation (TAD relocation assists in planning and downsizing of residents moving into The Fairfax and other senior living communities), a Fill a Truck event was held today to collect items by those affected by Hurricane Harvey. They filled the entire truck (a 26 foot moving truck!) with donations of clothing, bedding, hygiene and personal care products, children's toys, furniture, food, kitchen items, and pet items. Legend Senior Living based in Wichita, Kansas, with communities in Florida, set up a $20,000 fund for associates impacted by the storm, and other Legend associates gave another $5,000 to it. It is helping associates who have flooded homes, cars, and the many who lost power who had to re-stock the refrigerator. The company housed all our associates 24-7 who worked during the hurricane's passing as well as their families. They said they felt safer in the Legend building than at home. Belmont Village financial contributions to the company's relief fund, BVCares, now total $106,000 including the company match, creating a source of critical support funds to help Belmont's staff recover from damage to home and property. Atria Senior Living raised over $200,000 for their Atria Cares, an employee-funded nonprofit organization that provides emergency financial assistance to Atria staff in need. Best Practices and Lessons Learned The senior living industry has applied its knowledge gained over the decades of caring for older adults, including best practices gleaned from coping with natural disasters. Here are some of the highlights from lessons learned that made senior living able to successfully navigate many of the challenges presented by hurricanes Harvey and Irma. 1. The decision of whether to evacuate or shelter in place is a complicated process that requires a complete and thorough assessment of the situation. Both options have advantages and challenges. But assisted living providers are prepared for both through the development of emergency disaster management plans. State rules require that communities have food, water, and other necessary supplies for emergency situations that require sheltering in place. Plans also need to specify procedures for evacuations. 2. In addition to well thought out emergency plans, regularly scheduled drills involving team members and residents is critical to the successful implementation of the plans. 3. States that are the most successful in integrating the needs of seniors in their emergency preparedness plans are those that offer clear, collaborative efforts between their emergency management and health agencies, and long-term care providers. 4. Advance planning, prevention, communication, and state and local partnerships are critical in helping to ensure the safety and well- being of older adults, especially those who are vulnerable in a disaster or emergency. 5. Companies with a headquarters outside of the affected zone can take on many of the administrative and coordination responsibilities to free up staff to care for residents. For example, Legend Senior Living based in Wichita, Kansas, owns and operates eight Florida-based senior living and memory care communities, which house more than 640 residents and employ more than 540 people across the state. A 24-hour command center was immediately organized at the home office in Wichita. The home office had calls with each community every 4 hours to ensure they were equipped and safe. When electricity went out, the phone system rolled to Wichita. 6. Other providers that needed to evacuate residents sent them to sister communities nearby or in some cases companies rented out entire hotels to move in residents, staff, and their families 7. Providers opened their doors to residents from nearby cities and towns who arrived wet and cold and were given warm clothes, food, and a place to stay. In Texas, memory care specialist Silverado took in 30 patients from a hospital that needed to evacuate. In at least one example, the assisted living community took in elderly living alone in their own homes who did not have the supplies necessary to survive the hurricane. 8. Many lessons were learned from Katrina. For example, during the recent hurricanes in Florida and Texas, wrist bands with names and community were immediately placed on resident wrists along with medication identification. Families were notified where their loved ones would be taken in case of evacuation. 9. Autumn Leaves offered real-time updates on Web sites during each of the recent hurricanes for friends and family to get up to the minute information on their affected communities. http://autumnleaves.com/hurricane-harvey-update/ (Harvey) http://autumnleaves.com/hurricane-irma-update/ (Irma) 10. Argentum is establishing an Emergency Preparedness Standards Board to develop assessment tools, sample plans and training to senior living providers in the emergency preparedness efforts. __________ Statement of Teresa Osborne, Pennsylvania Secretary of Aging, and Rick Flinn, Director, Pennsylvania Emergency Management Agency Chairman Collins, Ranking Member Casey, and Members of the Committee, thank you for holding a hearing to examine disaster preparedness and response for older Americans. September is National Preparedness Month and this year's theme is, ``Disasters Don't Plan Ahead. You Can.'' Recognizing that we are in the immediate aftermath of Hurricane Harvey and Hurricane Irma, disasters like these serve as a reminder that each of us must be prepared for emergencies that can easily affect us where we live, work, or visit. Being prepared for the next potential emergency is a top priority for the Wolf Administration. As such, the Pennsylvania Emergency Management Agency (PEMA) and the Department of Aging have been engaged in conversations about emergency preparedness and Pennsylvania's older population. A recent survey conducted by PEMA revealed that only 26% of Pennsylvanians age 65 and older have a plan in place for when disaster strikes. This sobering statistic tells us that we all have friends, family, neighbors, and consumers who have no plan for how to act when a disaster is imminent, don't know how to respond after one has struck, and may not know how to communicate if they need assistance. Older Pennsylvanians have some of the same needs as the general population during a human-made or natural disaster. However, for older adults and persons with disabilities, they may also have a wider variety of functional limitations and some additional challenges to consider, including medical equipment, accessibility and transportation issues, and access to prescription medications. Approximately half of those over age 65 have two or more chronic health problems, such as heart disease, diabetes, and Alzheimer's disease. These conditions increase a person's vulnerability during periods of time without food, water, shelter, and adequate rest. According to the 2010 U.S. Census, of the older adults who were living outside nursing homes or hospitals, nearly one third (11.3 million) lived alone. This reality makes the creation and maintenance of a support network particularly important. Because emergencies and disasters strike quickly, you might be forced to evacuate your neighborhood or be prepared to be confined to your home. While first responders and relief workers will quickly be on the scene, they may not be able to reach everyone immediately, meaning that help may arrive in hours or even days depending on the extent of damage. What would you do if your basic services: water, gas, electricity, or communications, were cutoff? Even if you have physical limitations, you can still learn how to protect yourself and cope with disaster by planning in advance and by working with those in your support network: your family, neighbors, friends, and caregivers, as well as your local responders as a team. During September, the month dedicated to emergency preparedness, we are encouraging all older Pennsylvanians and their families to be informed, prepared, involved and ready. We are sharing three easy steps that they can take: 1. Visit www.ready.PA.gov to take the ``Ready PA Preparedness Pledge'' 2. Download the ``Get Ready Now'' pocket guide, a 3-step guide on emergency preparedness for older adults. To access the guide, go to www.aging.pa.gov, hover your mouse over the ``Publications & Reports'' dropdown, then click on ``Emergency Preparedness'' (Direct link: www.aging.pa.gov/publications/documents/Seniors.pdf) 3. Call your local Area Agency on Aging (AAA), which is poised to participate on every level of emergency preparedness planning, and meet the needs of the communities they serve in times of crisis. Find your local AAA at www.aging.pa.gov/AAA We are sharing these steps with the Committee to the extent that they can be used as a model for other States, in taking extra precaution in preparing for a disaster. Pennsylvania will continue to be a leader in the area of preparedness and response, and we look forward to working with the Committee to ensure older adults across the Commonwealth and country are prepared for the possibility of a disaster.