DISCUSSION

In this study, we sought to examine the association between patient characteristics and whether disaster preparedness education was provided by practitioners in the VHA HBPC program. As noted by Gamble et al,Reference Gamble, Hurley and Schultz ⁴ the increase in managed care has led to more elderly individuals remaining in their homes and a corresponding increase in the need for appropriate, accurate, and trusted information about disaster preparedness. The new Medicare and Joint Commission policy guidelines recognize the need for home health agencies to increase their involvement in improving mitigation and preparedness amongst their patients, ²⁰ yet research has found that program staff and leadership desire more direction in how to make their preparedness protocols more robust.Reference Wyte-Lake, Claver and Der-Martirosian ^{15 ,} Reference Wyte-Lake, Claver and Dalton ¹⁹ Few articles have evaluated the robustness of tools developed or adopted to support preparedness in home health programs,Reference Al-Rousan, Rubenstein and Wallace ⁵ and none that we are aware of have evaluated the extent to which disaster preparedness is actually covered with patients. Through evaluation of the HBPC Patient Assessment Tool, this survey provides an opportunity to begin to identify strengths and challenges in supporting the preparedness activities of patients served by home health programs such as the VHA HBPC program.

There is strong evidence that older adults, particularly those served by home health agencies, are more vulnerable in times of disaster because of a series of chronic comorbidities as well as poor social support.Reference Gamble, Hurley and Schultz ^{4 -} Reference Dostal ^{6 ,} Reference Khorram-Manesh, Yttermyr and Sörensson ¹⁴ Veterans receiving care at the VHA HBPC program are a subset of the aging American population. Our results highlight the need for understanding how to best support these individuals, as well remembering the role of the home health program as a preparatory entity rather than a responder.Reference Claver, Wyte-Lake and Dobalian ¹² Nonetheless, HBPC programs, like other health programs that engage with patients in their homes, have a potential unique advantage in preparing patients for disasters. Having the opportunity to provide direct education and the ability to tailor the message to the patient’s home environment, home health practitioners can act as trusted advisors, a role that has been shown to provide more valued messaging to vulnerable populations such as homebound patients.Reference Eisenman, Cordasco and Asch ^{22 , 23}

There are marked inconsistencies in the comprehensiveness and type of preparedness education disseminated by home health programs.Reference Wyte-Lake, Claver and Der-Martirosian ^{15 ,} Reference Wyte-Lake, Claver and Dalton ¹⁹ Practitioners in the field can often feel they have an enormous amount of information to cover with patients in a very short amount of time. One of the proposed benefits of the Patient Assessment Tool is to provide a user-friendly but quick and comprehensive checklist of preparedness items to be reviewed by the practitioner with the patient. Our results show that certain items on this list are more frequently discussed. This finding might be due to the fact that certain education topics are easier to discuss or more easily remembered by patients. For example, most adults are aware of 911, and therefore a simple review of how to activate 911 services is not much more than a straightforward reminder. Similarly, reviewing how to evacuate a home or the importance of having an emergency plan requires few additional resources from either the patient or the practitioner. These are not complicated action items on the part of the patient. The study findings indicate that some preparedness topics, such as putting together a home emergency kit, which for this population is often an economic challenge, and information on emergency shelter registration and emergency specialty transport, which may not be readily available to the practitioner in the field, were less likely to be discussed. Previous research has shown that not knowing where to evacuate to and challenges with transportation were primary barriers to evacuation in large scale natural disasters.Reference Eisenman, Cordasco and Asch ²² Improved provision of this information to home health programs, which could then disseminate the information to patients via practitioners, could support mitigation efforts for this vulnerable segment of the population.

Three associations between patient characteristics and dissemination of preparedness items stand out in our study as noteworthy to help create a better understanding of how HBPC practitioners can effectively provide preparedness education to some of their most vulnerable patients. Previous studies have shown risk categorization systems play an important role in how programs triage their patients in the case of an emergency.Reference Zane and Biddinger ²⁴ Our results show that a patient’s risk category was associated with the likelihood of receiving disaster preparedness education and could possibly influence a practitioner’s decision-making process when it comes to providing key pieces of preparedness information. As previously mentioned, during an average medical visit, practitioners often find themselves pressed for time to cover emergent medical concerns. For patients presenting with multiple complex problems, such as is found in the HBPC population, covering items outside of the immediate medical issue becomes even more challenging.Reference Fiscella and Epstein ²⁵ And yet, for 6 of the 9 educational topics, preparedness education was actually more likely to be disseminated to the higher risk patients. Examining vulnerability from another perspective, the results also show that when a patient presents with a physical limitation, such as severe ambulation limitation or oxygen dependence, there is an increased association with receiving preparedness education. Once again, we see the practitioner highlighting the importance of sharing preparedness education with their most high-risk patients. Both sets of associations highlight the unique role of the home health practitioner in supporting the care for individuals identified to be some of the most vulnerable members of our society. It is possible that, compared to less complex patients, the relatively greater vulnerability of these patients brings preparedness to the forefront of practitioners’ concerns and makes them more likely to discuss these actions with these patients. Lack of social support, sometimes seen as social isolation, is an additional vulnerability common among the elderly.Reference Eisenman, Cordasco and Asch ²² Our findings, which suggest that patients with no social support were more likely to receive preparedness education, underscore 1 of the unique values of home health programs: connecting with individuals who have limited community networks and providing them with resources and support not otherwise available.

On the other hand, 3 items were not associated with risk category. Two of these, reminding patients of the HBPC handbook and reviewing the need for an advance directive/POLST, are educational items covered irrespective of the fact that they are also related to preparedness education. The ability to evacuate the home, the third item not associated with risk category, could perhaps be considered one of the most basic and fundamental pieces of preparedness when considering the homebound population, as it was 1 of the topics most frequently covered with all patients and has no association with risk category or patient characteristics. One of the main tenants of this population is having difficulty leaving the home, so addressing this underlying risk factor is critical in providing appropriate preparedness education.

One of the most important preparedness challenges for the homebound elderly population is the number of comorbidities with which they present, including the growing presence of cognitive impairment.Reference Toner ^{8 ,} Reference Oliva, Wexler and Gullickson ²⁶ There is a growing body of literature addressing the unique needs of individuals presenting with cognitive impairments such as dementia, which can carry with it symptoms such as communication limitations and behavioral disturbances. ²⁷ Our findings are mixed for these patients. In some cases, education is more likely to be disseminated to patients with cognitive impairments, while in others it is less likely to be shared. Some of these items, such as reminding patients that the preparedness recommendations are in the VHA HBPC handbook, may seem straightforward for much of the population but are possibly more of a challenge for patients with cognitive impairment. For those items where practitioners are less likely to disseminate preparedness education (eg, education on importance of CO and smoke detectors and copies of important documents in 1 place), our findings underscore the challenges of caring for this population and providing information effectively to either them or their caregivers. There are a limited number of studies that discuss the creation of specific resources for individuals (and the families caring for them) who present with dementia,Reference Toner ^{8 ,} Reference Oliva, Wexler and Gullickson ²⁶ but organizations such as the Alzheimer’s Association, the Red Cross, and the US Administration on Aging have developed tools and resources to specifically support disaster preparedness activities for people with dementia and their caregivers, as well as training modules for first responders to be better aware of how to work with individuals with dementia at the time of an emergency or a disaster. Many items overlap with standard preparedness practices such as putting together emergency kits and having family emergency plans in place. Recommendations unique to this population include ensuring that persons with dementia are enrolled in programs to assist with identification and reunification if they become lost or separated from their family and making sure to pack calming objects in the emergency kit to help a disoriented person with dementia feel calmer in unfamiliar circumstances. ²⁸ Training home health practitioners about these resources, as well as including the specific resources, tips, and tools in the disaster preparedness materials that home health programs distribute, would be a crucial step in supporting the preparedness of a growing segment of our population.