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FQHCs – Proven Community Partners in Emergency Response SW Community Recovery

Conference – Coyote Crisis

Collaborative

Lessons from JoplinSeptember 19, 2013

Debra Davidson, PhD Chief Operations Officer 1

ACCESS Family Care demographics

�ACCESS clinics cover 4 counties in SW MO�ACCESS employed 130 people then, now 160� 3 Medical/Dental clinics & 1 solo medical clinic�Half of our workforce is located at our Joplin clinic

� Joplin is located in the far SW county; Jasper– 49,024 population– 174,300 metropolitan statistical area, swells to 270,000/day– 400,000 persons reside within a 40 mile radius of Joplin, making it the fourth largest metropolitan area in Missouri

– Healthcare is the largest industry in Joplin 2

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ACCESS is located SW corner of MO

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Emergency Preparedness Plan

1. Our recall roster is regularly updated and distributed2. ACCESS has emergency equipment on hand 3. New employees are educated about ACCESS’ plan4. Staff are informed of changes in response assignments

and participate in annual safety and emergency training5. ACCESS participates in two Local Emergency

Preparedness Collaboratives (2 separate sub-region collaboratives for our state: region D)

6. Our assigned response role includes:• Provide mass vaccination due to a terrorist event or epidemic

proclamation, in collaboration with the health department(s)• Care for walking-wounded• Send a representative to the Emergency Operations Center• Support other elements as needed of the medical community• Respond to community disasters in a supportive function

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Sunday, May 22, 2011 – 5:41pm

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Sunday, May 22, 2011 - 5:41pm• Tornado touchdown at west edge of Joplin

• Cut a path 3/4 mile wide, 6 mi across the center of town & continued for 7 1/2 mi

• Thunder, lightening, rain, and hail

• Winds in excess of 200mph, designated as an EF5 tornado

Forward speed of the tornado clocked at 20mph while it remained on the ground 6

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Sunday, May 22, 2011 - 5:41pm

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Remnants of St Mary’s Church –now a surviving icon.

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Emergency personnel walk through a neighborhood severely damaged by a tornado near the Joplin Regional Medical Center in Joplin, Mo., Sunday, May 22, 2011. A large tornado moved through much of the city, damaging a hospital and hundreds of homes

and businesses. (AP Photo/Mark Schiefelbein)

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St. John’s Regional Medical Center –2 blocks north of Freeman Hospital

75% of Joplin’s school buildings were destroyed

(AP Photo/Mark Schiefelbein)

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Tornado - May 22, 2011 – toll

• 8,000 total properties destroyed; 545 businesses

• 19,000 vehicles destroyed

• 5,000 homes severely damaged

• Insured property loss in excess of 2 billion dollars

• 12,000+ people displaced

• 25%+ commercial/residential areas completely destroyed

• 75% of the schools including Joplin High School destroyed

• 2,500 tornado related injuries treated

• 161 Tornado related deaths – deadliest tornado in U.S. history since 1947

• Immeasurable human tragedy & suffering 11

ACCESS’ TRIAGE AREA:Utilized our spacious waiting room - 20 cots, medical supplies, paper charts, medications were quickly gathered in our large waiting room, partitioning an area off, which facilitated greater access rather than transporting the injured through doors and hallways to the exam rooms

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Respond, Recover, Rebuild

That night @ ACCESS:

ACCESS Family Care (an FQHC) responded � Initiated response to assess situation of the Joplin clinic and

surrounding area

� Our CEO, COO and Joplin’s clinic manager all initiated their roles according to our Emergency Response Plan and activated the call roster - report to the Joplin clinic -

• Joplin Clinic Manager opened the Joplin clinic (which was only 13 blocks outside the zone of destruction)

• Limited staff along with family & volunteers arrived at the clinic to serve

• COO reported to Joplin’s Emergency Operations Center (EOC)

• 4 of our staffs’ homes were destroyed, death of a family member and several staffs’ property damaged to different degrees 13

ACCESS’ Response

That night @ ACCESS:

• Casualties began to arrive in large numbers • Our nurses, doctors, dentists and nurse practitioners

assembled• The injured were triaged and treated as they walked in,

carried in or were transported to ACCESS• Several patients were worse than “walking-wounded” • Critically injured or those requiring x-rays or required a higher

level of care were transported (often by our staff) to outside area facilities

• Patient care continued until 2am, when the injured ceased arriving.

• Reopened clinic the next morning, our usual time @ 8am.• Over 125 community members treated that night 14

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The Tornado’s Impact on ACCESS’ Business

Decrease in productivity:� No Show rates as high as 75% on our medical and dental schedules for the Joplin Clinic

Interruption in internet access:� Our IT vendor’s building was severely damaged

� Disabled EHR for all of our clinics including those located counties away

Decrease in cash flow:� Due to internet disruption, our billing staff (located in Neosho) was unable to submit claims for any

of our clinics’ services

Communications interruptions:� Clinic phones operable only within the clinic

� Landline phones (including fax) were available

� Cell Phone reception was undependable – texting worked best

Water pressure extremely low with a boil order� Port-a-potties were delivered and placed near our front door

� Hand sanitizer distributed everywhere

� Utilized bottled water, particularly in dental operatories15

Respond, Recover, RebuildOutside Assistance began arriving @ ACCESS:� Missouri Primary Care Association (MPCA) & fellow FQHCs responded:

– SEMO Health Center’s support staff arrived with initial supplies, a large portable generator & ideas about dealing with disasters, especially the importance of getting out into the neighborhoods as soon as allowed.

– MPCA’s Emergency Preparedness Coordinator arrived a few days later to the EOC to deliver specific items requested from ACCESS’ COO – such as white socks and sun block for the search and rescue teams.

– MPCA’s CEO arrived to collaborate and tour the “zone” with ACCESS’ CEO so to better communicate throughout the PCA the community’s devastation ACCESS’ response and requests for assistance.

– MPCA got our COO in contact with outside partners, such as AmeriCares, Direct Relief, and Operation USA, whereby ACCESS was able to order donated medical supplies, medications, hygiene/personal items for community distribution and potential grant funds. ACCESS initiated our first order of 3,000 tetanus vaccines through these sources.

– Other FQHCs donated supplies and money.16

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Evolution of Recovery and Lessons Learned

You may need to change your attitude, receptivity and resource allocation for EMERGENCY PREPAREDNESS

• Are the FQHC in the City/County response plans and have a defined role, participating in the healthcare response?– As our Emergency Collaboration plan dictated, we responded with “care for the walking

wounded and mass vaccination”

– When disaster struck a representative from your Community Health Center (CHC) reported to the Emergency Operations Center (EOC)

• ACCESS was present at the city/county EOC that

night & throughout the week+:

• ACCESS staff received up-to-date, timely communications

of the recovery and rescue efforts as well as what was

going on throughout the area

• ACCESS participated to a greater extent because we were

there when city/area plans were formulated

• ACCESS’ COO was authorized to offer our services, storage space, make-shift pharmacy and its staff’s commitment

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Evolution of Recovery and Lessons Learned• ACCESS was allowed into the “disaster zone”

• Out-lying ACCESS clinics staff reported to Joplin with family members, friends and volunteers

• ACCESS set up stationary First Aid Stations

• ACCESS staff devised “Roving units” , referred to as our “Red Wagon Brigade”

• The Joplin clinic continued to operate

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Evolution of Recovery and Lessons Learned• Coordinated through the City’s EOC, ACCESS was in the forefront of

immediate response along with the local health departments in getting into the disaster zone– Before the EOC’s tetanus vaccine orders arrived in Joplin, ACCESS had

initiated and secured 3,000 doses of tetanus vaccine to supplement the health departments’ supplies

– 5,000 doses were requisitioned at the resource table through SEMA at the EOC

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Evolution of Recovery and Lessons Learned• The EOC’s Information Officer informed the public of first aid & tetanus vaccination locations

• ACCESS triaged & treated the injured as well as rescue personnel: Volunteers flooded in from all over the country, unprepared for the task at hand: flip flops, tank tops and shorts = resulting in sunburns, dehydration, puncture wounds and abrasions

• ACCESS administered 1,888 tetanus

immunizations in the field and the clinic

• 18,000+ doses administered throughout

Joplin

Despite the many injuries no cases of

tetanus were reported. 20

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Evolution of Recovery and Lessons Learned� Communications = top priority:

• Phones– Most cell phone communications were out or sketchy at best, but texting worked

– Consider alternative phone systems: Ethernet/web-based versus landline

– Have printed emergency facility contacts available

• Keep communication devices charged and ready for use– ACCESS used short wave radios and Walkie-talkies within the clinic– Long range 2-way radios were the main means of communications for days between

EOC & designated sites and services (Multiple frequencies assigned for clearance) Hospitals

– HAM radio communication was set up but no operators readily available. Practice with the hospitals and the health departments on a regular basis

– Weather radios – off the air

� Business Continuity Plan• Include the hospitals and health departments

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Evolution of Recovery and Lessons Learned

• Documentation:– Keep manual forms preprinted and available

– When computers are down• If servers are off site is there a way to move it on-site as temporary measure

• Keep a manual process for developing x-rays (we used chemicals and daylight processing – as we had no darkroom is available) or other options

• Allow additional time during appointments for reassessing current status of patient’s case without access to their medical or dental record

– Health records and x-rays were found as far as 70 miles away

– Develop a process to get information to outlying clinics & hospitals• Print and then fax records to the other clinics - we sent schedules, H&P, allergies,

med lists, vaccination records

• Fax clinical manual records to hospitals anticipating ER and/or admission

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Evolution of Recovery and Lessons Learned

• Opportunities:– ACCESS offered our large unfinished space within the Joplin clinic to accept and store

medical supplies. The EOC directed medical supply donations to ACCESS

– ACCESS coordinated the receipt, storage and distribution of donated medical suppliesthroughout the community

Volunteers assisted in setting up shelving made possible from funds provided by Operation USA and in reorganizing the temporary warehouse

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Evolution of Recovery and Lessons Learned

• Opportunities:� ACCESS had space available for a

pharmaceutical distribution site:• Through the EOC, we met with all the

pharmacy representatives and the hospital pharmacists to develop a plan

• Survivors who lost their medications and/or prescriptions, whose regular doctors or pharmacies could not be found, were directed to ACCESS

� ACCESS procured a used van in order to distribute donated medications and medical supplies:� Supplies transported to and from multiple

sites within the community

� Tetanus vaccines distributed to roving vaccination units & first aid stations

� Transported donated insulin from American Diabetes Association’s temporary site

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Evolution of Recovery and Lessons Learned• Develop Memorandums of Understanding (MOU) and Mutual Aid

Agreements (MAA) in advance with community partnersEmergency Collaboratives * Health department(s) * Supply Vendors * Community Partners * Hospitals * IT support

• Let the community know what would improve your ability to respond to a future disaster– Mercy-St. John’s donated an analog x-ray unit and Direct Relief a film processor to facilitate

radiology services at ACCESS

– ACCESS received HAM radios from a another FQHC (Missouri Highlands Health Care)

• Build your partnerships and networks before disaster strikes– ACCESS is now requested as a partner in other recovery and rebuilding efforts

– We are recognized as a valuable member of the City/County emergency Preparedness/Response team with a credible and respected status

• Have a disaster plan, know it, exercise it: Participate in city/county Emergency Preparedness meetings and drills– ACCESS has been invited to assist in community–wide drills

– We provide oral health screenings at the Human Services Campus at the largest trailer park

– Our role is recognized by the area hospitals

– Healthcare entities notify us of upcoming training and webinar availability

– Region D’s two Emergency Preparedness collaboratives value our input25

Evolution of Recovery and Lessons Learned

• Insure that staff carry their work identification and proof of professional licensure – Don’t leave your home without these, even when off duty

• Update phone rosters with personal cell/text information– Keep printed copies at the clinic and available at home

• Register medical & dental licensed professionals with “Show Me Response” – state registry of volunteer Healthcare Professionals– Complete verification of credentials of clinical volunteers in advance to

facilitate readiness for dispatch during a declared emergency

– Deployment is expedited by advance registration

• Support the expansion and utilization of the EMSystem to include FQHCs

• Let others know of your clinic’s potential capabilities

• Let others know what you need26

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Evolution of Recovery and Lessons Learned

• ACCESS coordinated with both hospitals’ mental health professionals to provide psychological first aid to staff and patients

• Identify those in need of further help early

• Use all available assets – clergy, professional counselors and other behavioral health providers

• Debrief as identifiable phases evolve:– Record immediate impressions

– Review your notes and diaries

– Make a plan for improvements

Psychological Impact of the disaster was significant, widespread and long lasting

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Respond, Recover, Rebuild

• Vital to Emergency Response is to become and remain integrated within the communities your Community Health Center (CHC) serves

• Play an active role in planning so when needed the partners recognize you

• Be part of the Medical Surge Plan

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Joplin Rebuilds• Joplin’s tornado ranks as one of

Missouri’s and America’s deadliest and also the costliest single tornado in US history.

• Recovery required collaboration of federal, state and local resources!

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Joplin RebuildsThe cost to rebuild Joplin by summer’s end of 2011 had already exceeded $3 Billion!

Summer 2011 - Extreme Home Makeover: completed construction of 7 homes in 7 days

2011 Habitat for Humanity initiated 10 homes constructed in 16 days, and has returned to build 73 year-to-date Aug 2013.

• By July 2012 80% of those business destroyed had reopened

• Fastest Wal-Mart built in history, built from recycled bricks from the original store

• About $837mil has been spent on construction since 2011 tornado & Aug 2013

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By summer 2013: 82 homes have been constructed by “Rebuild Joplin”

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Mercy – St. John’s former site

Mercy’s new site along I-44825,000 sqft @ $335mil

Joplin’s new High School finallyunder construction

Volunteers from Everywhere Came to Help Joplin Recover and Rebuild

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Beauty out of tragedy

Reaching to the sky in hopes of a better tomorrow for Joplin

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How ACCESS used their lessons learned:

This experience made us proud of ACCESS Family Care and the important rolewe played in recovery from this disaster

This event publicized our existence to the community, elevating our status asa significant healthcare resource

All staff now understand and appreciate the importance of disaster planning and practicing to respond to various scenarios

All managers receive the weather alerts on their cell phones

We have become acutely aware of the necessity of adequate insurance coverage

We will be even better prepared next time

We stand ready to provide assistance when disaster strikes our neighbors

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Contact information:

Debra Davidson: ddavidson@accessfamilycare.org

(w) 417-451-9450, ext 207(c) 417-389-3117

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