Located along Florida’s central eastern coastline, Brevard County is a geographically and socio-economically diverse community with a population of greater than 500,000 citizens. Located in a subtropical clime, Brevard has its share of natural disasters such as hurricanes and tornadoes. The environmental situation in the county is also unique due to a lengthy 72 mile coastline, creating a county one-third of which is water and of the remaining land mass, 60% is flood prone. Combined with 10% of the housing consisting of manufactured homes, Brevard demonstrably has a large evacuee population during hurricane events.
Brevard also has a large population of people with special needs. Current data states that there are almost 90,000 people in the community with disabilities. Brevard County Health Department (BCHD) therefore, has to shelter record numbers of people with special needs during mass disaster events. And as the events surrounding Hurricane Katrina have demonstrated, ensuring the welfare of the most vulnerable independent citizens during a disaster event is a both a moral and national priority.
Florida has long led the nation in preparedness, both for natural events and acts of terrorism. Brevard County additionally garnered experience as one of the first counties to voluntarily deploy during Hurricane Andrew in 1992. From those lessons learned, and due to Brevard’s vulnerability, the BCHD, sought out cooperative agreements and partnerships and put the best interests and input from these citizens with special needs at the helm. This culminated in the creation of the Coordinated Care Special Needs Shelter (CCSNS) model with the goal of ensuring the health and welfare and safe return home if available, for all of these sheltered citizens. Victorious events of this network of care were successfully demonstrated in the 2004 hurricane season, when Brevard County expertly sheltered and safely shepherded home or to safe havens, 100% of the County's most vulnerable citizens on three separate occasions back to back.
The Coordinated Care Special Needs Shelter (CCSNS) model, through its community collaboration, successfully addressed the entire continuum of care of the medically vulnerable independent population by ensuring their health and welfare and safe return home during and after disaster events. As expertise at ensuring this cohesive network of care grew, the Brevard County Health Department (BCHD) realized that some of the citizens with more exceptional needs, including home ventilator patients, traditionally institutionalized pre-hurricane, did not require tertiary hospital care resources and its associated costs and risks. Moreover, if a special needs client at the shelter required further skilled medical care beyond BCHD's scope, they were then emergently transported to an institutional facility. This additionally burdened (1) shelter workers especially if there was no available transport, without the skills and supplies to provide further enhanced care, (2) emergency medical services, (3) hospitals, and (4) the special needs citizen, who after emergent transport with delayed medical care and institutionalization may be unable to maintain independence.
Nationally, Hurricane Katrina highlighted gaps in services, demonstrating that communities need local plans in place for care of their medically at risk during disaster events. There exists no nationally approved standard. Applauded by the Agency for Health Care Administration and cultivated in Florida’s advanced preparedness environment, the Brevard County Health Department (BCHD) through creation of the Coordinated Care Special Needs Shelter (CCSNS), models easy, common sense, replicable solutions towards ensuring the health, welfare and safe shepherding home of all of the most frail but independent members of society. Through its blanket of care continuum, the CCSNS addresses every need of these vulnerable citizens through establishing a network of partnerships attending to all aspects of care. This model tested by multiple real life incidents, evolved to include explicit communication/back up plans, established medical protocols, including infection control, and typing of skill sets to allow triage into assigned levels of care. The BCHD invented innovative solutions to resolve issues that will arise for other communities, including the need to do background screenings on both workers and the sheltered; and contingency consolidation plans if clients can not return home.
This cohesive structure has been established through written pre-planned shelter roles that the BCHD team trains with drills and “just in time,” instruction. Many shelter workers have no medical background, but successfully perform the required pre-established responsibilities due to shelter team training and through unambiguous assignments. As a partner in the National Response Plan, the BCHD created a model consistent with the National Incident Management System, providing for explicit duties through asset typing and establishing specific spans of control and chains of command allowing for swift and easy duplication of the CCSNS model in any community for any mass incident. And finally, after-incident reports and debriefings ensure continual improvement.
Agency Community RolesThe Coordinated Care Special Needs Shelter (CCSNS) model is a partnership. Unique to Brevard County, the CCSNS successfully works though a network of collaborative efforts championed by the Brevard County Health Department (BCHD) and supported by the county government, school district, law enforcement, transit authority, children’s medical services, emergency management, and public and private medical partners to name but a few. This mantle of care wraps services around independent people with special needs ensuring their health and welfare and eventual safe passage home after a mass incident.
This community network long maintained by the Brevard County Health Department also grows through partnership driven evolution. Examples include full service hospital teams (physicians, nurses, respiratory therapists and equipment), now available within the shelter during the height of the storm. The county provides both fiscal and human resources. The school district ensures available hurricane worthy shelters with back up generators and facility workers. Private businesses appreciate having a pre-designated shelter to supply with linens, oxygen, medical equipment and personnel. Law enforcement transports and disinfects cots, supplies officers at each site, shelters sexual predators with special needs at their medical facility and provides victim advocates for stress counseling.
This entire blanket of security attending to each and every need of all of the medically vulnerable but independent population sheltered during a mass incident is more than any single private or government entity could undertake alone. As it continues to grow in scope and complexity, it attains even greater accomplishment and acceptance each year, functioning as an interdependent community-based response to an essential public health need, thus perpetuating continuous buy-in from all parties. By allying together this network offers the full breadth of protection, shares costs, in the long term saves money, and allows all of the vulnerable population dignity and safe shepherding home.
ImplementationAs part of its core public health mandate to protect the health and welfare of its citizens, the Brevard County Health Department (BCHD) took the lead by gathering community members involved in caring for the most vulnerable community members of all ages. Through partnerships and mutual aid agreements, a virtual network of care was created, wrapping all of the necessary services of special needs independent citizens safely around them. This safety net of care not only includes medical supports, such as life saving oxygen supply including tubing/cannula, canisters, connections and electricity, but more personal needs, like ostomy/wound care, bowel/bladder assistance and supplies, and even “wish list” desires such as stress mental health counseling. This Coordinated Care Special Needs Shelter (CCSNS) model allows the BCHD to successfully and seamlessly meet the goal of ensuring the health and welfare and safe shepherding home of this most vulnerable population during a disaster event, through a cohesive network of care, fostered by the health department and coordinated among BCHD's many partners.
This collaboration includes, but is not limited to:
Support from the emergency management team who contact medical home health agencies and advertise to pre-register clients,
Cooperation from the school board through construction of hurricane worthy facilities with backup generators; supply of facility workers, including principals, to ensure operations during the event; storage within the schools for supplies; and food and cafeteria workers,
Provisions from the county for annual monetary support for supplies and equipment, county workers to manage, help run the shelters, and others who, after the event, investigate the citizens’ homes to ensure their safety upon return,
Commitment from private suppliers (linen, oxygen, durable medical equipment companies, home health agencies, hospice) to provide to specific pre-designated shelters, both supplies and workers,
Prearrangements with Space Coast Area Transit Authority and Coastal Ambulance Service to provide handicapped and regular transport for clients to and from the shelters,
Pact with the Brevard County Sheriff’s Department to store, clean, and transport special needs cots to and from each of the four shelters, place officers in shelters, and to house the sexual predator special needs clients in their medical jail,
Compacts with pharmacies near each of the shelters to stay open during the event and supply necessary medications,
Understandings with Florida Power and Light to place the shelters and dialysis units on their “priority” list for electricity return,
Agreements with the Florida Crisis Consortium to provide crisis counseling to both clients and workers,
Assistance from the Department of Elder Affairs in “discharge planning,”
BCHD and Children’s Medical Services medical and non-medical workers to coordinate, train workers, and tend to the care of the independent vulnerable fellow persons.
This successful CCSNS model of a comprehensive continuum of care was cultivated by the Brevard County Health Department in Florida’s preparedness environment, tempered through actual disaster experience, and nurtured by a county wide network of collaborative efforts.
The ability to develop, test, and implement change is essential for any venture that wants to continuously improve. Creatively combining these change ideas with a process evaluation tool such as the Plan-Do-Study-Act (PDSA) cycle tests for real improvement. The Brevard County Health Department (BCHD) successfully uses this PDSA concept in its continual improvement of the Coordinated Care Special Needs Shelter (CCSNS) model. During the yearly planning cycle, processes are identified and evaluated at full stakeholder meetings. Novel concepts resulting from newer technologies, opportunities and partners are brought to the table and in a PDSA cycle reviewed. Currently, new ways to transport cots, looking into the new portable on demand storage industry, are being studied. After this study process, new agreements and methods are incorporated into the model and tried. During-the-event innovations are identified, reviewed and if successful, integrated. Debriefings and after-incident reports also demonstrate lessons learned that are celebrated and added to the model. The triumph of this process evaluation leads to dynamic model improvement that keeps all stakeholders integrated into the success of the CCSNS.
The positive outcome evaluation of this model was demonstrated by the success of attaining BCHD's goal of ensuring the health and welfare and safe return home of 100% of the sheltered, most medically vulnerable individuals through the program's full continuum of care safety net, during three back to back hurricane events in 2004. The plan also had mini-objective celebrations within this major goal triumph. Plans for back up electricity and re-supply of oxygen were utilized to ensure that oxygen dependent people stayed alive. Pharmacies stayed open for the shelters and dispensed needed medications. Enhanced hospital sponsored care within the shelters “transferred” individuals into their care and successfully treated others who stayed within the standard special needs area. Fall back communication plans within the shelter and to incident command in the Emergency Operations Center allowed for sharing of information and resources. Ensuring dialysis units had quick power return was also life saving. The Florida Crisis Consortium provided much needed crisis counseling to both shelterees and workers. The consolidation plan was successfully enacted for members of the Barefoot Bay Community who no longer had homes.
SustainabilityThe sustainable nature of the Coordinated Care Special Needs Shelter (CCSNS) model actually derives from the strength of its community collaboration. In this new age of preparedness, post-Katrina and 911, the entire community has a vested interest in ensuring the health, welfare and safe return home of the most vulnerable population during disaster events. By presenting neighborhood stakeholders with an accomplished model that has been tested during real life mass incidents, any community partner will quickly realize that through continued performance of their normal operations and with minimal added effort and cost base, they can be a successful part of this complete blanket of care.
Sustainability is realized because this model equitably meets the needs of all stakeholders. Consequently, as it grows in scope and complexity, it attains even greater accomplishment and acceptance each year, functioning as an interdependent community-based response to an essential public health need, thus perpetuating continuous buy-in by all affiliated as it continues to provide the successful complete full service, wrap-around blanket of care originally envisioned by BCHD for the most vulnerable citizens. In sum, the CCSNS model has been triumphantly successful during real disaster events, and with it’s built in sustainability has proven to be a win-win solution for all community stake holders through it’s simple, replicable and economically driven best practices that places a mantle of complete protection around the most vulnerable citizens.
Key Elements ReplicationUnique to Brevard County, the CCSNS works though a network of collaborative efforts championed by the BCHD and supported by the county government, school district, emergency management, and medical partners. However, this is more than just a win-win alliance among cohorts, but a venture that can be easily and inexpensively replicated by other health departments and communities in the best interests of the special needs evacuee. Not only does the CCCSNS help maintain the pre-event independence and health of all of the sheltered at risk populations, it decreases expensive and dangerous emergency transfers, and allows for the sharing of expertise among all the partners involved in the goal of maintaining the health and well being and safe homecoming of the most vulnerable populations.