disaster preparedness update: cms surveys and aspr tracie ... · patient triage behavioral health...

Disaster Preparedness Update: CMS Surveys and ASPRTRACIE's Home Care and Hospice Surge Project

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Disaster Preparedness Update: CMS Survey and ASPR TRACIE’s Home Care

and Hospice Surge Project

Disaster Preparedness Update: CMS Survey

Barbara Citarella RN, MS, CHCE, NHDP- BC

President

RBC Limited Healthcare & Management Consultants

www.rbclimited.com

Copyright 2019 RBC Limited 2

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Final Rule Emergency PreparednessSeptember 16, 2016


Why This Regulation?


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Natural Disasters The Worst Natural Disasters Of 2018

• Fall 2018 California Fires. 3 wildfires in California have displaced hundreds of thousands of people and destroyed thousands of homes

• Hurricane Michael• The Indonesia Earthquake And Tsunami.

Events in 2018


• Transplant Centers

• Long-term Care Facilities

• Intermediate Care Facilities

• Home Health Agencies

• Comprehensive Outpatient Rehab

• Critical Access Hospitals

• Community Health Care Centers

Who Are the Providers


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• Organ Procurement Organizations

• Rural Health Clinics

• Federally Qualified Health Centers

• End-Stage Renal Disease Facilities

• Clinics, Rehabilitation Agencies, and Public Health Agencies as providers of outpatient physical therapy and speech language pathology services



• Hospitals

• Religious Non Medical Health Care Institutions

• Ambulatory Care Centers

• Hospice

• Psychiatric Residential Treatment Facilities

• PACE



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Each Medicare provider can have its own plan or be part of a system plan as long as the

regulations for each provider can be met.

Integrated HealthCare Systems


• Ensuring the safety and well being of patients and staff;• Maintaining continuity of care to patients;• Ensuring agency financial viability and continuity of business

operations;• Providing agency legal protection;• Ensuring appropriate utilization of resources; and• Supporting community and community partners during a disaster.

Supporting the critical infrastructure.

Source: CMS Federal Register Disaster Preparedness Rule 2016

Home Care and Hospice Role In The Regulation


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Emergency Preparedness Program

Plan

Policies

Communication

Train/Test


• Risk assessment

• Establish a plan

• Policies and procedures that address the plan

• Communication plan

• Train and orient staff

• Test the plan

All Providers


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• Conducted by either health surveyors or Life Safety Code (LSC) surveyors

• Surveys are in conjunction with regularly scheduled survey cycles

• Information from November 2017 to September 2018

First Year Survey

Copyright 2019 RBC Limited

Source: CMS Presentation at 2018 National Healthcare Coalition Preparedness Conference

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Provider Types By Citation Ranking

• Nursing Facilities• ICF• ESRD• Home Health• Ambulatory Care• Rural Health• Hospice• Outpatient PT/ST• Hospitals

Source: CMS


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• EP Testing• EP Training and Testing• Develop and Maintain EP Program• Development of EP Policies and Procedures• Subsistence needs for staff and patients.

DEFICIENCY

Top 5 Deficiencies Overall



• EP Testing

• EP Training Program

• EP Collaboration

• Policies and Procedures for Volunteers

• Maintain and Annual EP Updates

Top 5 Deficiencies for Home Care



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Agencies should have a process for the role of integration of state and federally designated health care professionals to address surge needs. Health and Human Services coordinates three programs that maintain registries of health care volunteers.

• Emergency System for Advance Registration of Volunteer Health Professionals (ESAR-VHP)

• Medical Reserve Corps (MRC)

• National Disaster Medical System (NDMS).

Volunteer Use


• EP Testing

• EP Training Program

• Maintain and Annual EP Updates

• Names and contact information

• Arrangements with other facilities

Top 5 Deficiencies for Hospice



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• Lack of plans that meet regulations

• Lack of education and training

• Lack of partnerships

• Role expectation deficits

• Lack of policies as related to HVA

• Surveyors in some states want everything in the “plan”

Deficiencies/Issues


Staffing Shortages

• Impact our ability to respond and having prepared staff

• Supporting the community

• Impact surge capability

Additional Concerns Home Care and Hospice Industry


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Inclusion in Plan: 1135 Waiver


Orders of succession are a formal, sequential listing of organization positions (rather than specific names of individuals) that identify who is authorized to assume a particular

leadership or management role under specific circumstances.

Inclusion in Plan: Succession Planning

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3Copyright 2019 RBC Limited 24

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Ongoing Analysis Of Citations byCMS and ASPR TRACIE

The purpose of this effort is to:

‒ Identify ways to strengthen emergency preparedness efforts of

health care providers and suppliers at all levels (National; State;

Regional; and Local Healthcare Entity)

‒ Enhance technical assistance efforts

‒ Highlight variances

‒ Create a baseline of information that can be updated and

monitored


ASPR Technical Resources, Assistance Center, Information Exchange (TRACIE)Home Care and Hospice Conference and ExpoOctober 15, 2019

Jennifer Nieratko, MPH, ICF TRACIE Special Projects Managerhttps://asprtracie.hhs.gov/

Unclassified/For Public Use

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ASPR’s Priorities: Building Readiness for 21st Century Threats


ASPR TRACIE: Three Domains

• Self‐service collection of audience‐tailored materials

• Subject‐specific, SME‐reviewed “Topic Collections”

• Unpublished and SME peer‐reviewed materials highlighting real‐life tools and experiences

• Personalized support and responses to requests for information and technical assistance

• Accessible by toll‐free number (1844‐5‐TRACIE), email ([email protected]), or web form (ASPRtracie.hhs.gov)

• Area for password‐protected discussion among vetted users in near real‐time

• Ability to support chats and the peer‐to‐peer exchange of user‐developed templates, plans, and other materials


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ASPR TRACIE‐Developed Resources

ASPRtracie.hhs.gov/tracie‐resources


CMS EP Rule Resource Examples• CMS EP Rule Resource Page

• CMS and Disasters: Resources at Your Fingertips

• CMS EP Rule General Briefing Slides

• CMS Emergency Preparedness Rule: Integrated Healthcare Systems Implications

• Provider and Supplier Types Covered by the CMS Emergency Preparedness Rule

• Facility‐Specific Requirement Overviews (16)

• CMS EP Rule Citation Analysis Project


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HCCs: Coordinating a Regional Approach to Health Care and Medical ResponseAn HCC is a group of individual health care and response organizations in a defined geographic location. HCCs play a critical role in developing health care preparedness and response capabilities.


Expanding Health Care and Medical Response Coordination

• Urgent Care Centers

• Health Clinics (Federally Qualified Health Centers, Rural Health Clinics)

• Practice‐Based Primary Care Providers

• Accountable Care Organizations

• Home Health and Hospice Agencies


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Medical Surge and the Role of Home Health and Hospice

• Sought to learn what role Medicare‐certified home health and hospice agencies saw for themselves in emergency preparedness and response.

• Recruited convenience sample of home health and hospice agency leaders through outreach by the National Association of Home Care & Hospice.*

* Online survey and telephone interviews were conducted in accordance with the Paperwork Reduction Act under Office of Management and Budget Control Number 0990‐0379, approved February 1, 2019. ICF’s IRB reviewed and determined the project was exempt from IRB review on January 18, 2019.


Project Participants

• Analyzed data from 245 online survey responses and 25 telephone interviews with home health and hospice agency leaders.

• Participants represented 43 states in all 10 HHS regions.


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Services Provided by Survey Participants

89

42

39

30

15

0 10 20 30 40 50 60 70 80 90 100

Home Health Care

Home Hospice Care ‐ in a private residence

Home Hospice Care ‐ in a residential facility

Inpatient Hospice Care ‐ in a hospital or nursing facility

Inpatient or Home Hospice Care ‐ in a hospice agency‐ownedfacility or hospice agency‐owned space in another entity's

facility

% of Participants

n = 245


Participation in Preparedness Activities

• Home health and hospice leaders reported their agencies participated in coordinated emergency preparedness activities with a variety of partners.

• Ranged from active involvement to being unable to establish partnerships.

n=[VALUE], 72%

n=[VALUE], 69%

n=[VALUE], 66%

n=[VALUE], 62%

n=[VALUE], 54%

n=97, 40%

n=[VALUE], 6%

Emergency Management Agency

Healthcare Coalition

Hospital(s) in the Community

Health Department

Nursing or Long‐term Care Facility(ies)

Non‐profit Organizations

Other


n = 245

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Perceived Role in Emergency Response

• The majority of survey respondents believed their agency would have a role in the response to both an infectious disease outbreak and a natural disaster.

• However, some interviewees were unsure exactly what that response role would be.

YESn=[VALUE]

84%

YESn=[VALUE]

88%

NOn=[VALUE]

16%

NOn=[VALUE]

12%

Infectious Disease Outbreak (n=243) Natural Disaster (n=244)


Potential Services in Hospice Agency‐Owned Facility or Space

79%

92%

71%

42%

29%

92%

71%

88%

54%

38%

0% 20% 40% 60% 80% 100%

Medical Care for Low Acuity Patients

Prophlyaxis/Vaccination

Patient Triage

Behavioral Health Support/Treatment forStaff

Behavioral Health Support/Treatment forPatients

Natural Disaster Infectious Disease Outbreak


n = 24

• 15% of survey respondents provide hospice services in facilities or spaces owned by their agencies.

• Most reported they could provide patient triage, prophylaxis or vaccination, or low acuity patient care in the event of an emergency in their community.

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Tested Ability to Implement Emergency Procedures

• Home health and hospice agencies have tested their ability to communicate and implement a variety of procedures and protocols either through preparedness exercises or a real‐life incident.

• Interviewees described elements of their business continuity plans, including having offsite servers, the ability to switch to paper records, access to GETS cards for communications, and agreements with partners for office space or patient care.

n=[VALUE], 76%

n=[VALUE], 74%

n=[VALUE], 73%

n=[VALUE], 71%

n=[VALUE], 64%

n=[VALUE], 59%

n=[VALUE], 56%

n=[VALUE], 56%

n=[VALUE], 52%

n=[VALUE], 40%

n=[VALUE], 28%

n=[VALUE], 32%

n=[VALUE], 54%

n=[VALUE], 18%

n=[VALUE], 14%

n=[VALUE], 26%

n=[VALUE], 25%

n=[VALUE], 48%

Establish incident command

Maintain patient records (i.e., paper‐based) ifelectronic health record is inaccessible

Receive/send notifications to otherpreparedness/response partners

Contact staff during off hours

Evacuate staff and patients

Financial preparedness

Procedures to shut down operations

Procedures to restart operations

Contact patients during off hours

Yes – through an exercise Yes – through a real‐life emergency


n = 243

Previous Experience in Emergency Response

• Nearly two‐thirds of those surveyed have been involved in the response to an emergency or disaster.

• Interviewees reported responding to: hurricanes, fires, flooding, tornadoes, winter weather, shooting/bomb threats, power outages, water breaks, and cybersecurity incidents.

• Based on those experiences, they updated communications systems and plans, revised procedures for power outages, added scenarios to their emergency plans, and worked to improve tracking systems for evacuated patients.

YESn=[VALUE]

63%

NOn=[VALUE]

37%


n = 245

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Factors to Facilitate Participation in Preparedness and Response

• Interviewees mentioned access to communication equipment or technology, funding for time spent on preparedness, a structured system to integrate into community response, better collaboration with community partners, and SME guidance as helpful.

• Tailoring resources and adapting requirements for small or rural agencies were also mentioned.

n=[VALUE], 72%

n=[VALUE], 63%

n=[VALUE], 56%

n=[VALUE], 55%

n=[VALUE], 39%

n=[VALUE], 37%

n=[VALUE], 36%

n=[VALUE], 7%

n=[VALUE], 55%

n=[VALUE], 56%

n=[VALUE], 46%

n=[VALUE], 44%

n=[VALUE], 42%

n=[VALUE], 37%

n=[VALUE], 32%

Access to Additional Training and Exercises

Inclusion in Notification/Information Sharing

Funding/Reimbursement

Guidance/SME Support/Technical Assistance

Access to Additional Personnel

Legal Protections

Access to Supplies/Equipment

Other

Preparedness Activities Response Activities


n = 229

Challenges in Meeting CMS Final Rule Requirements

• Collaborating and engaging with community response partners was the greatest challenge mentioned by survey respondents and interviewees.

• Those who have successfully addressed this challenge reported very positive interactions with partners.

n=[VALUE], 66%

n=[VALUE], 57%

n=[VALUE], 31%

n=[VALUE], 21%

n=[VALUE], 21%

n=[VALUE], 15%

n=[VALUE], 15%

Collaborating and Engaging with other CommunityEmergency Response Partners

Conducting/Participating in Emergency PreparednessExercises

Developing/Maintaining an Emergency PreparednessTraining Program

Developing Emergency Preparedness Plans forPatients

Developing/Maintaining an Emergency PreparednessCommunication Plan

Developing/Implementing Emergency PreparednessPolicies and Procedures

Developing/Maintaining Emergency Plan n = 234


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Barriers Contributing to Challenges in Meeting CMS Final Rule Requirements• Lack of time was

overwhelmingly identified as the greatest barrier to meeting CMS Final Rule requirements.

• Interviewees also mentioned having a geographically dispersed staff, finding partners, uncertainty about their overall role, and preparedness not being a priority for their patients as challenges.

n=[VALUE], 64%

n=[VALUE], 38%

n=[VALUE], 37%

n=[VALUE], 33%

n=[VALUE], 20%

n=[VALUE], 12%

Not Enough Time to Devote to PreparednessGiven Other Competing Responsibilities/Priorities

Unsure of Role/Not Engaged in CommunityPlanning for Emergency Response

Continually Changing Patient Population/CareSetting

Lack of Staff Expertise in Emergency Management

Other

Unsure how to Access Technical Assistance toImprove Understanding of CMS Final Rule

Requirements


n = 236

Key Findings• Home health and hospice have capabilities that could be valuable in responding to

a medical surge, but the overall emergency management role of home health and hospice has not been clearly defined in most communities.

• Wide variation exists in the capacity and infrastructure of home health and hospice with particularly limited resources among those in rural areas or with less established community partnerships.

• Most home health and hospice agencies reported engagement in coordinated emergency preparedness activities with various partners, but also noted collaboration is challenging.

• Awareness of CMS Final Rule requirements is high, but home health and hospice would benefit from training and technical assistance to support their implementation efforts.


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Opportunities to Improve Preparedness

• Better define the role of Medicare‐certified home health agencies and hospices in overall community emergency management efforts.

• Increase the quality of engagement of home health and hospice with healthcare coalitions and other community partners.

• Enhance mechanisms for communication and collaboration among home health and hospice and the other healthcare providers and facilities who provide services to their patients.

• Promote opportunities for knowledge exchange and learning, particularly highlighting the lessons learned of home health agencies and hospices with emergency response experience.

• Support home health and hospice in implementing CMS Final Rule requirements, particularly through targeted training, technical assistance, funding, and other resources.


Available Resources• Full report:

https://files.asprtracie.hhs.gov/documents/aspr‐tracie‐medical‐surge‐and‐the‐role‐of‐home‐health‐and‐hospice‐full‐report.pdf

• Summary: https://files.asprtracie.hhs.gov/documents/aspr‐tracie‐medical‐surge‐and‐the‐role‐of‐home‐health‐and‐hospice‐summary‐final.pdf

• Q&A document: https://files.asprtracie.hhs.gov/documents/aspr‐tracie‐engagement‐of‐home‐health‐and‐hospice‐agencies‐in‐medical‐surge‐activities‐q‐and‐a.pdf


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ASPR Programs

• Critical Infrastructure Protection Program (CIP): www.phe.gov/Preparedness/planning/cip

• Division for At‐Risk Individuals, Behavioral Health & Community Resilience (ABC): www.phe.gov/Preparedness/planning/abc

• emPOWER: https://empowermap.hhs.gov/

• Hospital Preparedness Program (HPP): www.phe.gov/preparedness/planning/hpp

• Biomedical Advanced Research and Development Authority: https://www.phe.gov/about/barda/Pages/default.aspx


Contact Us

asprtracie.hhs.gov 1‐844‐5‐TRACIE [email protected]


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