Principal Deputy Assistant Secretary
Administration for Children and Families
U.S. Department of Health and Human Services (HHS)
Disaster Case Management: Developing a Comprehensive National Program Focused on Outcomes
Committee on Homeland Security and Governmental Affairs
Ad Hoc Subcommittee on Disaster Recovery
United States Senate
Wednesday December 2, 2009
Senator Landrieu, Senator Graham, and members of the Subcommittee, thank you for the opportunity to testify about the Administration for Children and Families' (ACF) disaster case management efforts. I share your commitment to improving the well-being of children, the elderly, persons with disabilities, and families affected by disasters, and appreciate your support for a well-coordinated comprehensive disaster case management strategy following a Presidentially-declared disaster.
ACF’s approach to disaster case management seeks to help disaster survivors by assisting States in rapidly connecting individuals and families with critical services that can help them get back on their feet. In the development of our disaster case management model, we worked closely with all of our partners, including the Federal Emergency Management Agency (FEMA), the HHS Office of the Assistant Secretary for Preparedness and Response, the HHS Administration on Aging, Voluntary Organizations Active in Disaster (VOAD), and States, to incorporate a shared vision into our model design. Further, we recognize the importance of ongoing collaboration with all our partners, including FEMA and States, in order to design and manage a process that will meet the needs of individuals and families at their most vulnerable time following a disaster.
Disasters can create particularly serious difficulties for persons with special needs, including the elderly and persons with disabilities, who have their support systems and caregiver assistance disrupted or eliminated. If these supportive service needs are not met in a timely manner it can have significant consequences for both the individuals and the community health care system. A study published in the January 2009 issue of the American Journal of Managed Care revealed that New Orleans-area residents aged 65 and over who were affected by Hurricane Katrina had a post-Katrina illness rate that was four times greater than other U.S. residents in that age range. Emergency Department visits by these vulnerable and at-risk older residents increased 21 percent during the year following the hurricane, compared to the previous year.
My testimony today will focus on ACF’s ongoing disaster case management (DCM) efforts and our progress to date, including the development of a disaster case management model, a program implementation guide, and a pilot project. As requested, I will share a brief overview of lessons learned from our work and assessments of the pilot project and highlight our planned steps to continue this vital work. Before discussing each of these activities in more detail, I would like to share some background on how ACF became involved in disaster case management.
After Hurricanes Katrina and Rita, it became apparent that individuals and families impacted by disasters often require case management services to regain self-sufficiency. However, at the time, there was no Federal authority to fund disaster case management as part of a Robert T. Stafford Disaster Relief and Emergency Assistance Act (Stafford Act) declaration. In response, the Stafford Act was amended by the Post Katrina Emergency Reform Act of 2006 to authorize the President to provide funding for case management services to survivors of major disasters.
ACF created the Office of Human Services Emergency Preparedness and Response in 2007 to focus attention on human services preparedness and response. One of the primary goals of this office is to promote self-sufficiency by providing access to health care, mental health services, emergency aid, and recovery assistance. Through our work with States, individuals, families, and special needs populations are assisted prior to, during, and after disasters. A holistic disaster case management program is a key element in this process.
Efforts to Develop a Disaster Case Management Program
As one of its first efforts, ACF, with support from FEMA and the HHS Office of the Assistant Secretary for Preparedness and Response, determined that it was feasible and beneficial to develop a disaster case management program. Our first action was to reach out to Voluntary Organizations Active in Disaster to discuss the project and learn more about their efforts during previous disasters. To ensure that the work was based on the best available evidence, ACF awarded a contract to review past practices and best practices in disaster case management, and to develop, demonstrate, and evaluate a pilot project.
The ACF disaster case management model is based on five principles: self-determination, self-sufficiency, Federalism, flexibility and speed, and support to States. These principles derive from the premise that individuals and families adversely impacted by a disaster have the same rights and responsibilities as everybody else, and that government aid to individuals adversely impacted by a disaster should, therefore, seek to support their self-determination efforts as they seek access to public benefits and, if necessary, consider relocation opportunities. Disaster case management seeks to restore children, families, the elderly, and persons with disabilities to a pre-disaster level of self-sufficiency that maintains clients’ human dignity.
Based on these principles, the pilot project was designed to augment existing State and local capability to perform disaster case management following a Presidentially-declared disaster. We implemented a two-week pilot project in September 2008 following Hurricane Gustav in Louisiana. FEMA requested that we continue our work throughout the recovery process. Therefore, we extended the pilot project as requested by FEMA with the support of the United States Public Health Service and our contract with Catholic Charities USA, the organization we contract with to provide disaster case management services. In addition, we expanded the pilot to include survivors of Hurricane Ike, to allow enrollment of new clients for up to six months post-disaster and to provide case management services for up to 12 months following enrollment. This expansion from Hurricane Gustav to Hurricane Ike was seamless and resulted in no break in service to disaster survivors. The total program across all sites is designed to run for 18 months after implementation. To date, we have provided case management services to approximately 21,000 individuals, a number far greater than the 12,000 we expected to serve. The majority of the clients served had incomes below $15,000 and were part of female-headed households; 35 percent of all individuals we served were children. Some of these clients’ cases have been closed, but we will continue to support the remaining disaster survivors who need help through March 2010.
In order to improve the program, ACF has worked diligently to assess and evaluate its disaster case management efforts. Through consultations with Federal, State, and local governments, voluntary organizations, academia, and non-governmental organizations, we have gathered lessons learned from previous and ongoing case management programs, both for disaster survivors and for other clients. We also have obtained a great deal of useful feedback over the course of the last two years through our participation in conferences sponsored by the entity known as the “National Voluntary Organizations Active in Disaster” and FEMA for Emergency Support Function 6 partners.
Outside of consultation, our evaluation efforts include the preparation of an After Action Report on the initial two-week pilot period following Hurricane Gustav. This report identified numerous strengths of the program, including its ability to initiate services within 72 hours of activation. Given our ability to respond so quickly, a substantial number of clients received disaster case management services during the two-week pilot, especially clients from vulnerable populations. Other strengths include the use of volunteers as program support and subject matter experts; the creation of effective links to health care, human services, mental health, and disaster related resources; and the establishment of a call center to serve as a key point of intake for clients seeking services. The report also identified areas requiring improvement, including the need to pre-identify case managers for deployment; determine the availability of full time case managers from the voluntary organizations; and establish team member roles and responsibilities upon initial deployment. Because so many communities lacked existing resources prior to the disaster, such as adequate housing for the poor and case management for individuals with mental illness, forging connections to available services has been an overall challenge to disaster case management efforts. In response, we now develop resource lists for every State that identify existing resources to assist case managers.
ACF’s program implementation guide provides an overview and specific implementation instructions, including procedures to initiate the delivery of disaster case management services, transition services to the State, close client cases, as well as team member roles and responsibilities and staff selection and training information. We sought public comments on the working draft of the program implementation guide through a Federal Register notice in September 2009, with input from subject matter experts representing Federal, State and local governments, Voluntary Organizations Active in Disaster, and academia, and recently completed the revised version incorporating public comments. While this working draft of the program implementation guide currently serves as a directive for the pilot program, in order to strengthen this key document continually, the public comment and review process will be repeated again at the end of the program in March 2010 in coordination with FEMA.
In addition, we contracted with PricewaterhouseCoopers to evaluate the organizational structure and processes used throughout the pilot, and to identify any significant implementation barriers that may have impacted clients’ return to self-sufficiency or access to needed services. After the pilot ends in March 2010, we plan to conduct an assessment of the impact and outcomes of case management services on individuals’ abilities to return to self-sufficiency and get back on their feet, along with types of case managers and programs that lead to successes and types of services provided most frequently. The focus on outcomes responds to the concerns cited in GAO’s report, “Greater Coordination and an Evaluation of Programs’ Outcomes Could Improve Disaster Case Management,” that the Federal disaster case management evaluations conducted to date addressed only process and implementation issues, rather than participant outcomes.
We are working closely with FEMA on finalizing this month an Interagency Agreement (IAA) to allow for implementation of the ACF Disaster Case Management Program after a major disaster has been declared by the President, where Individual Assistance has been authorized, and the State's request for disaster case management has been approved by FEMA. The IAA states that, in coordination with FEMA and the State, ACF will initiate disaster case management within 72 hours of notification and for the duration of 30 to 180 days. At the end of the deployment period, ACF will assist with the transition of disaster case management to existing State resources or a FEMA-funded State DCM program. In exceptional situations, FEMA may authorize ACF to continue services until such time as the State is able to assume disaster case management, meanwhile continuing to provide States technical assistance as needed.
Drawing upon lessons learned from the pilot project and existing human services and disaster management networks and expertise, ACF’s FY 2010 budget request would fund a contract with a voluntary organization to provide a Federal disaster case management system and technical assistance for human services. This contract would ensure that trained personnel are credentialed and available when a serious disaster strikes.
As these efforts demonstrate, since funding through FEMA was provided for disaster case management, we have worked with our partners at the Federal, State, and local government level, academia, voluntary organizations, and non-governmental organizations to provide assistance to States in responding to the needs of children and families affected by major disasters.
Together, we have had a positive impact on the lives of disaster survivors and demonstrated the importance of providing disaster case management within 72 hours after a disaster. A few stories reinforce the significance of these efforts on the lives of individuals. Joe was a 49-year-old man with a disability who lived alone. The roof of his home had been damaged badly by Hurricane Gustav. He had repaired this damage with his own money, but his roof was damaged again by Hurricane Ike. Joe, who had been surviving on his own until faced with costs stemming from two hurricane disasters, now needed assistance. A case manager and an Americorps volunteer conducted a home visit, helped him apply for food stamps, and delivered the food stamp card to his home. The case manager also located a crew of Americorps volunteers to assist with roof repairs.
Case management that occurs immediately after a disaster can help mitigate cascading events that can have long-term adverse impacts on an individual's health, safety, and overall well-being. Due to lack of funds for transportation and lodging, a single mom in St. Tammany Parish, along with her five children, did not evacuate her mobile home prior to Hurricane Gustav. The family remained in a home that was flooded and without power for several days, with windows broken and appliances and flooring damaged. After meeting with a case manager, this woman received immediate assistance through established service providers and existing disaster relief programs for food stamps, clothing, crisis counseling and disaster unemployment assistance. The client also was referred to local officials who determined that her home was unsafe and irreparable. The case manager coordinated housing services through FEMA, helping her and her children secure a safe place to live, and maintained an ongoing relationship to ensure the long-term needs of this family were met.
Another example highlights the flexibility and agility of this vital program. A young married couple had been living in a homeless shelter in New Orleans, which was closed following Hurricane Gustav. The couple moved to a Red Cross shelter in Marrero, Louisiana. The woman had multiple medical problems and was without medication. They had no money for food or transportation. A case manager met with them and, through consultation with a Red Cross mental health volunteer and a U.S. Public Health Service nurse, determined that her medical problems required immediate care. The case manager helped the woman receive attention at the local hospital, and also connected the couple to a local non-profit organization that provided housing and funds for the couple to relocate to Atlanta to reconnect with family.
These and many other examples underscore the importance of this program, which is helping thousands of individuals and families – adversely impacted by disasters – to strengthen their recovery process.
I truly appreciate the opportunity to appear before the Committee and look forward to working with you on this vital effort.
I would be pleased to address any questions you may have.
Last revised: April 19, 2011