Interview with Dale Knee and Jan Jones

Dale Knee, CEO of Covenant Hospice, which serves northwest Florida and southern Alabama, and Jan Jones, CEO of Alive Hospice in Nashville, Tennessee, talked with Amy Tucci, vice president of programs for HFA, about hospice disaster preparedness, Hurricane Katrina and efforts to assist Katrina’s victims.

Jan Jones was CEO of Catholic Hospice in Miami when Hurricane Andrew, a Category 5 hurricane, struck the area in August 1992. Dale Knee has led Covenant Hospice through Hurricane Ivan, a Category 3 hurricane in September 2004, and numerous other tropical storms and hurricanes. Both CEOs shared their perspectives on lessons learned.

Q: How many hospice patients have you taken in as a result of Hurricane Katrina?

Knee: We’ve admitted just under 20 to date, and expect more. We don’t know what the total number will be. I believe the number will increase because evacuees were in temporary situations and now they are starting to move closer to family and friends in other parts of the county, and northwest Florida will be reportedly receiving many of the evacuees. How many we actually receive is a total unknown. One indicator actually occurred yesterday – we have a former Builders Square building, where we hold an annual, three-day garage sale. Yesterday we opened the site up to evacuees to shop, at no charge, for clothing, household items, linens, toys, and other essentials. In less than four hours we had over 1,000 people visit and shop.

Jones: To date we have admitted one patient whose family was displaced by Hurricane Katrina. The situation is very stressful for the patient, wife, young children, and family with whom they are staying – the hospice plan of care becomes more complex as a result. Nashville is seeing a tremendous influx of evacuees. We’ve not been greatly impacted with patients but we anticipate an impact on our Grief Center in the coming months and are preparing for that.

Q. Were your operations impacted by Hurricane Katrina, and if so, how did you respond?

Knee: We lost our Mobile (Alabama) office for almost a week because of a loss of power, but that was minor compared to our counterparts to the west. But with the help of portable generators and one of our adjacent branch offices, we were able to continue operations in the Mobile area without any interruption in services. And compared to the impacts of Dennis and Ivan on us, we were extremely fortunate with Katrina.

Jones: Middle Tennessee actually got some rough weather as a result of Hurricane Katrina, but it was barely a thunderstorm compared to what our neighbors on the Gulf Coast experienced. Prior to the storm we enacted our disaster policy and our staff made sure our patients’ needs were met and that their disaster plans were in place. I also sent an all-staff voicemail to remind staff to enact their own personal disaster plan.

Q. How are the hurricane-related hospice patients coming to be cared for by Covenant; how are they being referred to you?

Knee: They are coming from multiple directions. Many are being referred by the families and caregivers because we are in an area where they have other family members and thus relocated. I know that hospices in Texas and Baton Rouge got patients almost immediately, but in our case there was a few days delay. Some patients were transferred to us through emergency medical services transport. We have a couple of referrals that came from hospitals. As of today, we have only received one transfer from a hospice that was directly affected by the storm but that may increase as well.

Q. What are the special needs you are seeing from hospice patients who endured Hurricane Katrina?

Jones: In disasters such as Hurricane Katrina, there is a disruption of the opportunity for hospice patients to live their lives in the way that they expected so the sense of loss of control is heightened. Psychosocial and spiritual needs become more acute. Just going through the experience of a hurricane is a tremendously emotional experience – add to that the stress of the dying process and it becomes an almost unbearable emotional drain. Physically, medications may not be available for symptom management, loss of electricity renders equipment useless, and oxygen supply may run out before it can be accessed so symptom management becomes more of a challenge. Family members are deeply affected, too. For example, some might not be able to get to the hospice patient because of the travel conditions. There can be an exacerbation of guilt feelings on the part of family because they weren’t able to do all they wanted to comfort their loved one or to say their goodbyes.

Knee: Generally speaking they are in need of concentrated psycho-social assistance and spiritual care. Some were without medications and supplies. There are a lot of serious family issues which need to be resolved since the patient’s caregivers were also affected by the storm. And of course, all of the usual stresses created by facing end-of-life issues and the physical issues have been exacerbated. We have not seen any difference in terms of the length of stay of those patients, and all of the patients we have admitted are still living. Many of these patients have been moved multiple times, have been removed from their own homes, and generally had their lives turned upside down. Some have been disengaged from their caregivers, and that is obviously very difficult.

Q: Jan, how would you compare Hurricane Katrina to Hurricane Andrew?

Jones: Meteorologically, I think they were quite different. Andrew was a huge and powerful but dry hurricane. In Andrew we did not have all the flooding that occurred with Katrina causing the large number of deaths. I think the sense of being in a war zone is the same in both – the devastation so complete!

Q. After experiencing Andrew, how did you feel watching Katrina?

Jones: I didn’t watch a lot; I just couldn’t – it was too painful. It brought back memories for me about the lack of coordination of well-meaning volunteer efforts and how that can hamper recovery efforts. These sorts of disasters bring out the best and the worst in people – I was reminded of the looting and the price-gouging we experienced in the aftermath of Andrew. People were charging $50 for a 5 pound bag of ice because they could – construction prices soared – construction jobs were started and never completed so people were left with crushed dreams and no homes. The military presence was needed but, again, contributed to the feeling of being in a war zone. On the positive side many wonderful acts of kindness were given. Neighbors, friends, and total strangers sharing whatever they had to support each other.

Q. From a business perspective, how have you handled the billing issues for patients coming from the hurricane?

Knee: The short answer is that we don’t give that primary consideration. The first consideration is to determine that they are a patient needing hospice care, and, if not, referring them to another segment of the health care sector, although at this point all of the referrals were in need of our care. The last thing we do is to look at payment source. Regarding Medicare, the Centers for Medicare and Medicaid Services has said it will be very liberal as long as receiving hospices do all they can to ensure documentation is maintained. In the case of Medicaid patients, we applied on a temporary basis for Medicaid payment through Louisiana and Mississippi. Since we already serve Alabama, certification was not an issue.

Jones: It’s certainly not our first thought – providing appropriate care is. CMS is being flexible about the usual requirements for billing and will work with providers receiving patients from the affected areas. The Governor of Tennessee has provided for an expedited process to receive TNCare (Tennessee’s version of Medicaid). We don’t feel that billing issues will be a barrier to hospice services.

Q. Communication has been difficult in the Katrina-affected area. How has Covenant been getting the word out about its ability to help hospices there?

Knee: We’ve tried to announce as widely as possible our ability and desire to help. We’ve had the typical exchange among CEOs in the area, and we’ve also communicated with the emergency operation centers. We’ve communicated through NHPCO, the Alabama Hospice Organization and the Florida Hospices and Palliative Care Organization as well.

Q. Do you have adequate staff to deal with an increasing census as a result of Katrina?

Knee: We have an average daily census of over 1,000 patients, and we typically experience growth every month. We always have newly recruited staff in the pipeline, and typically recruit about 30 days ahead of time in anticipation of growth. So being prepared to receive additional evacuated patients has not and will not prove to be an issue. We also have a significant inpatient capabilities, both in our own facilities and contracted facilities, and several of the patients who are evacuees are going to require the inpatient level of care.

Q. Have hospice employees from the Gulf State region sought employment at Covenant Hospice as a result of Hurricane Katrina?

Knee: Yes, but I do not know the exact number at this time. We have had inquiries and applications at our offices both in Alabama and Florida, and I expect that will continue to increase as more people seek employment in our service areas. We will hire as many as we possibly can. In early November, we will open a 16 bed dedicated hospice center in West Florida Hospital in Pensacola, and are recruiting for the staffing of that facility in addition to our normal recruitment. We have had discussions with the state licensure boards of both Alabama and Florida, and we have established the ability for licensed nurses to obtain temporary licenses. We show on our website that we want experienced hospice staff to apply. We also have put a special package prepared to assist them in obtaining a temporary license.

Jones: Yes, I’m not sure how many applicants at this point. We’ve been in touch with Tennessee Board of Nursing about the licensure requirements and they’ve agreed to issue immediate licenses. We are in need of staff as we are always recruiting to match our growth and are currently in the process of opening an inpatient facility. We welcome recruits from the affected areas!

Q: Jan, you were CEO of Catholic Hospice when Hurricane Andrew hit Miami in 1992. Did you feel adequately prepared?

Jones: It was the first warning of a major hurricane since the inception of Catholic Hospice. Being a relatively new entity, we had a disaster plan but it was not as thorough as the one we realized we needed after the fact.

Q. What did you do?

Jones: The warnings persisted and on Saturday before the storm hit, (it hit in the middle of the night/early morning on Monday) prior to enacting a telephone tree, the leadership team just showed up at the office and began triaging our patients.

We talked to patients and their families about their evacuation plans and encouraged them to put them into place – especially in those locations considered mandatory evacuation areas. For those who refused to evacuate we made sure they had adequate equipment, supplies, and medication as we did for all of our patients. We had two inpatient units, both of which were on the beach in mandatory evacuation areas. We moved these patients into a nursing home in Homestead (Fla.) (Ironically, Homestead was hit badly and the nursing home was hit directly but we did not lose a patient).

Throughout it all, we did not lose a single patient or staff member. Most of our staff had some cell phone coverage, I personally never lost electricity or phone service at my home, and we were able to dispatch people to physically check on patients and staff from whom we’d not heard.

Q: After Hurricane Andrew, did you take another look at your disaster plan?

Jones: We developed a much more in-depth response. I was extremely proud of the staff all the way through Hurricane Andrew and after the fact we were able to sit down and debrief. The state of Florida was doing the same thing at the same time, and we worked closely with people who were coordinating future disaster preparedness, particularly regarding medical shelters – prior to Andrew there were no special needs shelters – the current approach to them (Medical Shelters) came out of our experience.

We were able to carry out a disaster plan during Andrew and put it all down on paper afterward. In addition, we were able to get necessary documentation in place, such as formal agreements with facilities that we would use if we needed to evacuate patients.

Q. Alive Hospice is not especially vulnerable to hurricanes. Do you have a disaster plan there?

Jones: Yes, we do. We may not be vulnerable to hurricanes but a year after I came here a tornado hit downtown Nashville. We are in downtown Nashville, lost part of our roof. We have a very well-defined disaster plan for our patients and our business. For example, one of the things in our plan includes a triage system whereby each patient is assigned a category of need – this is reevaluated during the course of the patient’s stay to determine if changes are necessary. In case of disaster we are then able to quickly dispatch our staff appropriately. You cannot prepare for a tornado like you can prepare for a hurricane, but at least we know where we would focus our energies first if one hit.

Q. Dale, will you describe Covenant Hospice’s similar hurricane experience with Hurricane Ivan last year? And, how would you compare the two storms?

Knee: As devastating as Ivan was, and then followed recently by Hurricane Dennis, the devastation from Katrina is far greater because of the extent of the flooding. And, from what I have learned, the impact on the hospices which served those areas has been staggering. With Ivan, however, our corporate headquarters (in Pensacola, Fla.) was completely destroyed. We lost everything. We ran our operation on tables that we set up in our parking lot for a week, and then to a church meeting hall and eventually we got into temporary buildings. We are still not completely stabilized in terms of buildings, but making progress all the time. Nevertheless, between then and now, we have had about a 30 percent growth in census.

Q. How did you prepare for Hurricane Ivan?

Knee: Much as we have in the past. As a storm was approaching we locate a mainframe computer in a remote location to switch over our information systems. Our telephone system was rerouted through a call center company in the Northeast. When our Pensacola offices were destroyed, all the calls being directed in this area were shifted over to that area and then routed back to us on cell phones and other hard wire phones which still worked. We also made use of other branch offices that were not as affected by Ivan. Within just three or four hours after Ivan passed. seventy percent of our staff in Pensacola reported to work and were retrieving what we could out of the affected buildings, and setting up operations in the parking lot. Within two hours of getting set up in the parking lot, we were actually getting referrals and beginning to admit patients.

Q. Were your preparedness efforts for Hurricane Ivan, including rerouting your phone system and getting staff back to work quickly, part of a larger emergency plan that you have?

Knee: Yes. We have had a comprehensive emergency plan since 1994 for both natural disasters, such as hurricanes, and man-made disasters, such as a chlorine tanker derailment or terrorism. Our plan is realistic, flexible, and we test it often. We have been very diligent in continually challenging how the plan can be improved upon.

We also have completed an office-by-office, area-by-area hazard vulnerability assessment. As part of our admissions package, we have an evacuation plan in place for each patient. We have that “what if” conversation with them, or with their family. We discuss options should they need to be evacuated, such as a family members’ home or an inpatient unit or nursing facility. Basically, it is the care teams who are responsible for exercising the plans for individual patients. It’s really a matter of the team decision and quite frankly decentralized decision making, within the larger plan, is critical.

Our plan includes the stockpiling supplies. We have a minimum five-day supply of all medications, and a five-day oxygen supply. All of the lessons we have learned over the years have been incorporated into our plan.

In the case of staff, if we evacuate patients to a facility, staff goes with the patient and stays with them. It is on a voluntary basis, as long as their own family situation is stabilized, but we have not had a shortfall in that regard.

To ensure enough staff, we keep our administrative staff who are clinicians trained and their credentials maintained so that they are able to deliver care, and management is carved down to a small group of people. We stop doing things that we would normally do and concentrate on taking care of patients, and one another.

And there are two more things that are very important. First is the leadership of the senior managers and their ability to instill the staff’s faith in them. Second, is a need to find the correct balance between centralized planning and control, with the frequent need for the decentralized execution of the plans. In other words, you must empower managers, supervisors and other staff to make decisions as they see necessary, support those decisions, and be prepared to assist as necessary. When there are serious interruptions in communication, you must rely on everyone to simply do what is needed and do the right thing as best they can.

Q. In putting your emergency plan in place, did either of you call in a consultant to help?

Jones: We did not, it never occurred to me to consider one. That does not mean that a consultant wouldn’t have been helpful but I think the debriefing process is critical to contingency planning and we did that well – I don’t believe a consultant would have added to that.

Knee: No. I am retired Naval Officer during the last four years of that career I was the Navy medical contingency planner with the Joint Chiefs of Staff and Secretary of the Navy’s staff. With that experience I learned that contingency planning is best done by the people who are going to be affected, and who can ask the question “What if?” as it applies to their operations.

Our original emergency plan was developed during a retreat, where we asked ourselves, “If this occurs what would we do. How are we going to staff and communicate? How are we going to safeguard and care for our patients? What do we do when normal communication capabilities fail? What is the backup plan to the plan? And after an actual disaster, we have always met and looked at the things that went well, and more importantly, the things that didn’t go well, and we have adjusted our plans.

We must always ask ourselves about our obligation to take care of dying patients. But concurrently, we have an obligation to have a plan to take care of the staff and their loved ones for without them the care is not going to be provided.

Q. What is the backup to the backup if cell phones don’t work? Many people have talked about the importance of satellite phones in disasters because the phone networks go down. Do you have satellite phones?

Knee: We do not currently have satellite phones, but the lessons being learned from Katrina indicate we need to investigate that capability as well.

Jones: We may look at getting satellite phones. We already have a system in place as part of disaster preparedness, communication central, if you will, which routes all of our communication through an alternate site. Part of our contingency planning is looking at what we would do if all our systems weren’t in operation.

Editor’s note: In a separate conversation with Jamey Boudreaux, executive director of the Louisiana and Mississippi Hospice and Palliative Care Organization, HFA learned that the satellite phone that HFA provided to Mr. Boudreaux was of limited use in the Hurricane Katrina aftermath for a variety of reasons.

Q. What advice would you give hospices regarding developing emergency plans for natural and man-mad disasters?

Jones: I think No. 1 is to really put a great deal of thought into contingency planning. The group charged with that responsibility in our organization is the Safety Committee. Communication is very important. I would say have your best minds available to be part of the planning process. Be sure everyone knows what the plan is – be sure the plan includes staff needs. I would strongly advise practicing it, have drills.

One of the things that can be neglected in all of these disasters is the staff. With Andrew, you could tell when people got their electricity turned back on…because before that they were miserable – and for some staff it was months before that happened. Some staff lost their homes in Andrew. Fortunately, none of our staff lost their life.

It is important to remember that after a disaster the grief needs are also extreme for the staff, not just the patients and families. If you don’t take care of your staff and help them take care of themselves they can’t properly take care of their work.

Q. How difficult do you think it going to be to rebuild the hospice network in the Katrina-affected area?

Knee: For any hospice that is a freestanding hospice, it is going to be very difficult to restore their business if they have been totally wiped out. The difference with us is that because we have multiple offices over a large geographical area, we have the ability to relocate to another location almost immediately. But, I am sure the hospices are already doing all they can to restore some sense of normalcy and that they will receive tremendous community support and national support. Hospice people are very resilient and flexible, with great spiritual faith, and those qualities will help them overcome the obstacles they are facing.

Hurricane Katrina does raise some really interesting questions that have been going through my mind, particularly for smaller hospices. Would it behoove them to have contingency plans with other hospices as part of their standard emergency plans? I think that is one of the lessons we are going to all learn from this. The CEO of a hospice to our east and I had a conversation last week about how we should be planning more closely.

We need to be thinking about it.

Jones: I don’t know the individual hospices in that area in terms of their ability to survive such a cataclysmic event but what I do know is that the human spirit is a remarkable thing. In my mind that includes the spirit of important missions and businesses. I agree that it is going to be very difficult. Maybe the hospices will join forces in their recovery efforts. My hope and prayer in that area is that they return as soon as possible.

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