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Papers by Joseph June

Disaster Medicine and Public Health Preparedness, 2022

Objective: Thea aim of this study was to explore the relationship between Florida nursing home an... more Objective: Thea aim of this study was to explore the relationship between Florida nursing home and assisted living facility characteristics and their ability to comply with a new emergency power rule in the aftermath of Hurricane Irma. Methods: This study used characteristics data on Florida nursing homes (NHs) (N = 680) and assisted living facilities (ALFs) (N = 2940) in operation between September 2017 and January 2019. Logistic regressions were used to determine whether certain characteristics were associated with compliance with the emergency power rule by January 1, 2019. Results: A total of 219 (32.9%) NHs and 2219 (75.5%) ALFs had an emergency power plan implemented by January 1, 2019. Results suggest having a dementia care unit increased the odds of compliance for NHs, while chain membership, for-profit status, and a higher reliance on Medicaid decreased the odds. Additionally, smaller size, mental health specialty license, and higher reliance on supplemental state funding i...

Innovation in Aging, 2021

Previous research establishes that hurricanes adversely affect nursing home (NH) resident health ... more Previous research establishes that hurricanes adversely affect nursing home (NH) resident health but specific causal pathways are still unclear. We combined power outage data with Medicare claims to determine the effects of power loss from Hurricane Irma(2017) among NH residents in Florida. Out of 580 facilities, 289 reported power loss. These facilities had higher star ratings; higher beds counts, and were preferentially in the Southeast region of Florida compared to facilities without outages. There were 27,767 residents living in a NH without power. They were comparable in characteristics to residents that did not lose power (N=26,383). We ran adjusted generalized linear models with robust standard errors, clustering for NH. We found power loss was associated with a trend towards increased odds of mortality within 7-days (OR:1.12, 95% CI:0.96, 1.30) and 30-days (OR:1.10, 95% CI:1.00, 1.21) post-storm, but not with hospitalization. Future research should investigate the time-speci...

Innovation in Aging, 2021

Disaster preparedness among assisted living communities (ALCs) has not been widely researched, de... more Disaster preparedness among assisted living communities (ALCs) has not been widely researched, despite the growth of ALCs and evidence of disability in this population. An additional issue of concern is the way in which ALCs vary, including variation by size. The purpose of this paper was to explore the experiences of ALCs in Florida that experienced Hurricane Irma in 2017 and how experiences varied by ALC size. Qualitative interviews and focus groups were conducted with representatives of small ALCs (<25 beds; n=32) and large ALCs (25+; n=38). Transcripts were analyzed using Atlas.ti version 8, and research team members collaborated to reach consensus on codes and further analyze differences based on ALC size. Results suggest there are differences among ALCs in their disaster preparedness and response, and these differences are related to size (e.g., access to resources, organizational characteristics). Implications for ALC resident wellbeing and future disaster planning will be...

Innovation in Aging, 2021

The risks to older adults in nursing homes (NHs) and assisted living communities (ALCs) exposed t... more The risks to older adults in nursing homes (NHs) and assisted living communities (ALCs) exposed to disasters are evident in prior research. However, little research has been conducted to understand the factors related to facilities’ vulnerability. This research examined NH and ALC experiences during Hurricane Irma in 2017. Qualitative interviews were conducted with representatives of facilities (N=100), transcripts were analyzed using Atlas.ti version 8. Team members met to reach consensus on codes and major themes and subthemes, which they analyzed using a conceptual model designed to identify factors related to the disaster vulnerability in long-term care (LTC). We found physical factors (e.g. location, physical characteristics) are important, but physical strength is not enough. Multiple social/organizational factors are critical. Results indicate managing a major disaster and protecting LTC residents involve social and organizational connections across a range of groups from sta...

Innovation in Aging, 2021

Collaboration between nursing homes (NHs) and assisted living communities (ALCs) with state and l... more Collaboration between nursing homes (NHs) and assisted living communities (ALCs) with state and local entities (e.g., emergency operation centers (EOCs)) is critical during a disaster. The corporate structure of NHs and ALCs can make a difference in their ability to collaborate with these entities during a disaster. This mixed-method study examines differences in satisfaction with collaboration with state and local entities during Hurricane Irma in Florida in 2017 between corporate-owned NHs (N=24), larger (25+ beds) ALCs (N=38) and smaller ALCs (N=30). We also explore collaboration in Florida NHs (N=35) and ALCs (N=123) specific to COVID19. Scaled 1-5 survey data results indicate that small ALCs are the least satisfied (M=2.90) with EOC collaboration, compared to NHs (M=3.04) and larger ALCs (M=3.33) during Irma. Smaller ALCs were more dissatisfied with COVID19 mandates compared to larger ALCs and NHs. Ways to improve collaboration during a disaster, especially for smaller ALCs, wi...

Innovation in Aging, 2021

Loneliness is a common problem in long-term care. It has been associated with a higher risk of de... more Loneliness is a common problem in long-term care. It has been associated with a higher risk of depression, aggressive behaviors, and anxiety and may be a risk factor for cognitive decline. Loneliness can exacerbate social isolation. The COVID-19 emergency brought on measures in Florida, beginning in March 2020, to separate nursing home (NH) and assisted living community (ALC) residents from each other and family members to limit virus spread. This study examines results of a survey with Florida NH (N=59) and ALC (N=117) administrators concerning effects of these measures. Scaled (1-5, lowest to highest) data indicate that resident anxiety was higher in NHs (M=3.40) than ALCs (M=3.17). Care disruptions related to limited resident-to-resident contact also were worse in NHs (M=3.74) than in ALCs (M=3.21), while care disruptions related to loss of family support were higher among ALCs (M=3.19) than in NHs (M=2.86). Implications of these findings will be discussed.

Innovation in Aging, 2020

Little is known about the effects of disasters on assisted living community (ALC) residents. This... more Little is known about the effects of disasters on assisted living community (ALC) residents. This is a concern given the growth of the AL industry and the increasing numbers of AL residents with functional limitations and chronic health conditions. This research examined the experiences of AL administrative staff to better understand the impact of Hurricane Irma. Qualitative interviews were conducted with representatives of ALCs across Florida (N=70), and transcripts were analyzed using Atlas.ti version 8. Research team members met regularly to reach consensus on codes, identifying five major themes across the interviews, 1) planning and preparation, 2) leadership, including plan execution and managing the unexpected, 3) effects/consequences of the storm, including effect on residents and staff, 4) lessons learned, and 5) electrical power. Results provide a broad view of ALC preparedness, how it varies across different types of ALCs and implications for resident wellbeing and future...

Innovation in Aging, 2020

The U.S. Gulf Coast hurricanes of 2004-08 led to research and policy reports highlighting the nee... more The U.S. Gulf Coast hurricanes of 2004-08 led to research and policy reports highlighting the need for more emergency preparation among nursing homes (NH). In 2016, the federal government issued final rules requiring Medicaid and Medicare providers to develop comprehensive preparedness plans. The state of Florida previously imposed its own long-term care (LTC) preparedness requirements. Hurricane Irma tested the readiness of LTC facilities that care for disabled and vulnerable residents. This research examined the experiences of NHs (N=30) affected by the hurricane through qualitative interviews with administrative staff. Research team members analyzed the transcripts, identified codes, and met to reach consensus on themes. Three major themes emerged, 1) managing the unexpected, including last-minute evacuation orders, 2) caring for vulnerable residents amid the crisis, and 3) the struggle of maintaining staff. Results suggest LTC preparation has increased but long-standing problems...

Innovation in Aging, 2020

Hurricane Dorian devastated parts of the Bahamas in 2019 with 185-mph winds. As it moved toward F... more Hurricane Dorian devastated parts of the Bahamas in 2019 with 185-mph winds. As it moved toward Florida, the state went on alert. This paper examines whether assisted living communities (ALCs) in affected counties evacuated or sheltered in place in the context of emergency management communications concerning evacuation. In 16 coastal counties, 66 ALCs were under mandatory evacuation orders, but 12 sheltered in place. Of 603 ALCs not under orders, 17 evacuated. Seven ALCs evacuated contrary to orders in one county, which issued a mandatory order Sept. 1, delayed it to Sept. 2 as Dorian weakened, and lifted it Sept. 4. Interviews with ALC administrators and emergency managers will be used to understand more about their decisions. Given prior findings that evacuation (versus sheltering in place) increases the mortality and morbidity risk of long-term care (LTC) residents, this research suggests a need for clearer LTC evacuation standards and communication. Part of a symposium sponsore...

JAMA Health Forum, 2021

IMPORTANCE Exposure to hurricanes is associated with increased mortality and morbidity in nursing... more IMPORTANCE Exposure to hurricanes is associated with increased mortality and morbidity in nursing home (NH) residents, but the factors contributing to these outcomes are less understood. One hypothesized pathway could be power outages from hurricanes that expose NH residents to excess ambient heat. OBJECTIVE To determine the association of power loss from Hurricane Irma with hospitalization and mortality in NH residents in Florida. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of NH residents residing in Florida when Hurricane Irma landed on September 10, 2017, assessed mortality at 7 and 30 days after the storm and hospitalization at 30 days after the storm. The analysis was conducted from May 2, 2021, to June 28, 2021. All NH residents residing in Florida at landfall were eligible (N = 67 273). We excluded those younger than 65 years, missing power status information, or who were evacuated (13 178 [19.6%]). EXPOSURE We used state-administered surveys to determine NH power outage status. Exposed residents experienced a power outage poststorm, whereas unexposed residents did not experience a power outage poststorm. MAIN OUTCOMES AND MEASURES We used Medicare claims to assess mortality and hospitalization after Hurricane Irma landfall using generalized linear models with robust standard errors. RESULTS In the aftermath of Hurricane Irma, 27 892 residents (18 510 women [66.4%]; 3906 [14.0%] Black, 1651 [5.9%] Hispanic, and 21 756 [78.0%] White individuals) in 299 NHs were exposed to power loss and 26 203 residents (17 620 women [67.2%]; 4175 [15.9%] Black, 1030 [3.9%] Hispanic, and 20 477 [78.1%] White individuals) in 292 NHs were unexposed. Nursing homes that lost power were similar in size, quality star rating, and type of ownership compared with NHs that did not lose power. Power loss was associated with an increased adjusted odds of mortality among all residents within 7 days (odds ratio [OR],1.25; 95% CI,1.05-1.48) and 30 days (OR, 1.12; 95% CI,1.02-1.23) poststorm and hospitalization within 30 days, although only among residents aged 65 to 74 years (OR, 1.16; 95% CI, 1.03-1.33). CONCLUSIONS AND RELEVANCE In this cohort study, power loss was associated with higher odds of mortality in all affected NH residents and hospitalization in some residents. The benefits and costs of policies that require NHs to have emergency alternate power sources should be assessed.

The Gerontologist, 2021

Background and Objectives Assisted living facilities (ALFs) have experienced rapid growth in the ... more Background and Objectives Assisted living facilities (ALFs) have experienced rapid growth in the past few decades. The expansion in the number of ALFs may cause markets to become oversaturated, and a greater risk of unprofitable ALFs to close. However, no studies have investigated ALF closure. This study adapted a model developed for the nursing home market for the ALF market to examine the organizational, internal, and external factors associated with closure. Research Design and Methods Data on 1,939 ALFs operating in 2013 from Florida were used to estimate a logistic regression to examine the organizational, internal, and external factors that were associated with closure between 2013 and 2015. Results During the 2-year study period, 141 ALFs (7.3%) closed. Significant factors associated with increased odds of closure included fewer beds, not accepting Medicaid, and more deficiencies. Two factors (market concentration and population density) were marginally significant. Discussio...

Innovation in Aging, 2021

Background and Objectives Protecting nursing home and assisted living community residents during ... more Background and Objectives Protecting nursing home and assisted living community residents during disasters continues to be a challenge. The present study explores the experiences of long-term care facilities in Florida that were exposed to Hurricane Irma in 2017. Research Design and Methods We used an abductive approach, combining induction and deduction. Interviews and focus groups beginning in May 2018 were conducted by telephone and in person with 89 administrative staff members representing 100 facilities (30 nursing homes and 70 assisted living communities). Analyses identified themes and subthemes. Findings were further analyzed using the social ecological model to better understand the preparedness and response of nursing homes and assisted living communities to Hurricane Irma. Results 3 main themes were identified including: (1) importance of collaborative relationships in anticipating needs and planning to shelter in place or evacuate; (2) efforts required to maintain safet...

Public Policy & Aging Report, 2021

Journal of the American Medical Directors Association, 2020

Objectives: To investigate the factors associated with whether assisted living communities (ALCs)... more Objectives: To investigate the factors associated with whether assisted living communities (ALCs) in Florida evacuated or sheltered in place for Hurricane Irma in 2017, focusing on license type as a proxy for acuity of care. Design: Cross-sectional study using data collected by the state through its emergency reporting system and a post-hurricane survey. Setting and Participants: Analyses included all 3112 ALCs in the emergency reporting system. A subset of 1880 that completed the survey provided supplementary data. Methods: c 2 tests were used to examine differences between ALC characteristics (license type, size, payment, profit status, rural location, geographical region, and being under an evacuation order) and whether they evacuated. Logistic regression was used to test associations between characteristics and evacuation status. Results: Of 3112 ALCs, 560 evacuated and 2552 sheltered in place. Bivariate analysis found significant associations between evacuation status and evacuation order, license type (mental health care), payment, and region. In the adjusted analysis, medium and larger ALCs were 43% (P < .001) and 53% (P < .001) less likely to evacuate than ALCs with fewer than 25 beds. Compared with ALCs in the Southeast, nearly every region was more likely to evacuate, with the highest likelihood in the Central West (odds ratio 1.76, 95% confidence interval 1.35-2.30). ALCs under an evacuation order were 8 times more likely to evacuate (P < .001). We found no relationship between evacuation status and having a license to provide higher care. Conclusions and Implications: Prior research highlighting harm associated with evacuation has led to recommendations that long-term care facilities carefully consider resident impairment in evacuation decision-making. Evidence that small ALCs are more likely to evacuate and that having a higher-care license is not associated with evacuation likelihood shows research is needed to understand how ALCs weigh resident risks in decisions to evacuate or shelter in place. Ó 2020 AMDA e The Society for Post-Acute and Long-Term Care Medicine. Residents of long-term care (LTC) are especially vulnerable to harm in natural disasters. 1 Research in this area has focused largely on nursing homes (NHs). 2 Dosa et al 3 examined NHs affected by Gulf Coast hurricanes in 2005 and 2008, addressing the complexity of the decision to evacuate or shelter in place. They found all residents were at greater risk during the hurricanes; however, the act of evacuation compounded morbidity and mortality. Laditka et al 4 and others have reported on the difficulties of transporting and providing care to

Innovation in Aging, 2019

The decision to evacuate or shelter in place during a natural disaster such as a hurricane is com... more The decision to evacuate or shelter in place during a natural disaster such as a hurricane is complicated and poses risks to long-term care residents. While research has documented the difficulty of the evacuation decision for nursing home administrators, little is known about how assisted living residence (ALR) administrators make this decision. This is a concern given the physical and cognitive impairment level of many ALR residents, the increasing number of ALRs in the U.S., and the frequency of natural disasters. The purpose of this paper was to explore the factors that influenced whether assisted living administrators evacuated their ALRs for Hurricane Irma, a large hurricane that made landfall on Florida’s Southwest coast in September, 2017. This qualitative study used semi-structured interviews and focus groups with ALR owners or administrative staff (N=60) with questions including how they prepared for Hurricane Irma, their experiences during the hurricane, including whether...

Innovation in Aging, 2019

The importance of communities in disasters has been well established since Hurricane Katrina. Smi... more The importance of communities in disasters has been well established since Hurricane Katrina. Smit and Wandel’s bottom-up approach to assess risks during a disaster involves community stakeholders. Administrators of assisted living (AL) environments increasingly have to assess the risks of hurricane evacuation for vulnerable older adults. The current study examines intersections between social networks, communication and preparedness during a hurricane for AL administrators. We conducted focus groups and interviews with AL administrators (N=60) in Florida about communication patterns with community associations, emergency management officials, AL staff, residents and their families during Hurricane Irma (2017) and about their perceptions of preparedness. A content analysis approach was used. Atlas.ti v7 was used for initial and axial coding. Co-occurrences were found among communication and preparedness themes. Some prevalent themes included “social capital”, “high versus low tech s...

Innovation in Aging, 2019

In 2018, in response to deaths of nursing home residents after Hurricane Irma, Governor Scott and... more In 2018, in response to deaths of nursing home residents after Hurricane Irma, Governor Scott and the Florida legislature enacted an emergency power rule for nursing homes and assisted living communities (ALCs). It mandates these settings to have a generator to regulate ambient air temperatures during loss of primary power by Jan. 1, 2019. However, due to cost and supply challenges the implementation of these plans has been difficult, particularly for small and independently owned ALCs. The purpose of this mixed methods study is to determine the characteristics of ALCs that were able to comply with the rule and concerns raised by ALC administrators. Using data from state regulatory agencies on all Florida ALCs (N=3082), we determine associations between ALC characteristics (size, specialty license, low-income residents) and non-compliance to the rule, using chi-square and t-tests. Additionally, we conducted interviews and focus groups with ALC administrators (N=60) about issues of i...

Journal of Aging & Social Policy, 2019

In 2014, more than 800,000 older adults reside in assisted living communities (ALCs) in the Unite... more In 2014, more than 800,000 older adults reside in assisted living communities (ALCs) in the United States, yet few studies have examined whether state licensure inspection and citation information can be used to help consumers infer quality in choosing facilities. We examined the quality of ALCs using the deficiency citation data from the State of Florida. Data on 2,457 licensed ALCs operating between 2013 and 2015 were used to estimate logistic and negative binomial regression models to determine ALCs' structural characteristics that were associated with any and the number of deficiency citations. There were 2.6 deficiencies per facility (range 0-21); one-third of all ALCs received no deficiencies and one-third received four or more deficiencies. Specialty license and region were associated with receiving any deficiencies; ownership, rural location, and Northeast region were associated with receiving more deficiencies; and Southwest region was associated with receiving fewer deficiencies.

Innovation in Aging, 2018

Innovation in Aging, 2018

Disaster Medicine and Public Health Preparedness, 2022

Objective: Thea aim of this study was to explore the relationship between Florida nursing home an... more Objective: Thea aim of this study was to explore the relationship between Florida nursing home and assisted living facility characteristics and their ability to comply with a new emergency power rule in the aftermath of Hurricane Irma. Methods: This study used characteristics data on Florida nursing homes (NHs) (N = 680) and assisted living facilities (ALFs) (N = 2940) in operation between September 2017 and January 2019. Logistic regressions were used to determine whether certain characteristics were associated with compliance with the emergency power rule by January 1, 2019. Results: A total of 219 (32.9%) NHs and 2219 (75.5%) ALFs had an emergency power plan implemented by January 1, 2019. Results suggest having a dementia care unit increased the odds of compliance for NHs, while chain membership, for-profit status, and a higher reliance on Medicaid decreased the odds. Additionally, smaller size, mental health specialty license, and higher reliance on supplemental state funding i...

Innovation in Aging, 2021

Previous research establishes that hurricanes adversely affect nursing home (NH) resident health ... more Previous research establishes that hurricanes adversely affect nursing home (NH) resident health but specific causal pathways are still unclear. We combined power outage data with Medicare claims to determine the effects of power loss from Hurricane Irma(2017) among NH residents in Florida. Out of 580 facilities, 289 reported power loss. These facilities had higher star ratings; higher beds counts, and were preferentially in the Southeast region of Florida compared to facilities without outages. There were 27,767 residents living in a NH without power. They were comparable in characteristics to residents that did not lose power (N=26,383). We ran adjusted generalized linear models with robust standard errors, clustering for NH. We found power loss was associated with a trend towards increased odds of mortality within 7-days (OR:1.12, 95% CI:0.96, 1.30) and 30-days (OR:1.10, 95% CI:1.00, 1.21) post-storm, but not with hospitalization. Future research should investigate the time-speci...

Innovation in Aging, 2021

Disaster preparedness among assisted living communities (ALCs) has not been widely researched, de... more Disaster preparedness among assisted living communities (ALCs) has not been widely researched, despite the growth of ALCs and evidence of disability in this population. An additional issue of concern is the way in which ALCs vary, including variation by size. The purpose of this paper was to explore the experiences of ALCs in Florida that experienced Hurricane Irma in 2017 and how experiences varied by ALC size. Qualitative interviews and focus groups were conducted with representatives of small ALCs (<25 beds; n=32) and large ALCs (25+; n=38). Transcripts were analyzed using Atlas.ti version 8, and research team members collaborated to reach consensus on codes and further analyze differences based on ALC size. Results suggest there are differences among ALCs in their disaster preparedness and response, and these differences are related to size (e.g., access to resources, organizational characteristics). Implications for ALC resident wellbeing and future disaster planning will be...

Innovation in Aging, 2021

The risks to older adults in nursing homes (NHs) and assisted living communities (ALCs) exposed t... more The risks to older adults in nursing homes (NHs) and assisted living communities (ALCs) exposed to disasters are evident in prior research. However, little research has been conducted to understand the factors related to facilities’ vulnerability. This research examined NH and ALC experiences during Hurricane Irma in 2017. Qualitative interviews were conducted with representatives of facilities (N=100), transcripts were analyzed using Atlas.ti version 8. Team members met to reach consensus on codes and major themes and subthemes, which they analyzed using a conceptual model designed to identify factors related to the disaster vulnerability in long-term care (LTC). We found physical factors (e.g. location, physical characteristics) are important, but physical strength is not enough. Multiple social/organizational factors are critical. Results indicate managing a major disaster and protecting LTC residents involve social and organizational connections across a range of groups from sta...

Innovation in Aging, 2021

Collaboration between nursing homes (NHs) and assisted living communities (ALCs) with state and l... more Collaboration between nursing homes (NHs) and assisted living communities (ALCs) with state and local entities (e.g., emergency operation centers (EOCs)) is critical during a disaster. The corporate structure of NHs and ALCs can make a difference in their ability to collaborate with these entities during a disaster. This mixed-method study examines differences in satisfaction with collaboration with state and local entities during Hurricane Irma in Florida in 2017 between corporate-owned NHs (N=24), larger (25+ beds) ALCs (N=38) and smaller ALCs (N=30). We also explore collaboration in Florida NHs (N=35) and ALCs (N=123) specific to COVID19. Scaled 1-5 survey data results indicate that small ALCs are the least satisfied (M=2.90) with EOC collaboration, compared to NHs (M=3.04) and larger ALCs (M=3.33) during Irma. Smaller ALCs were more dissatisfied with COVID19 mandates compared to larger ALCs and NHs. Ways to improve collaboration during a disaster, especially for smaller ALCs, wi...

Innovation in Aging, 2021

Loneliness is a common problem in long-term care. It has been associated with a higher risk of de... more Loneliness is a common problem in long-term care. It has been associated with a higher risk of depression, aggressive behaviors, and anxiety and may be a risk factor for cognitive decline. Loneliness can exacerbate social isolation. The COVID-19 emergency brought on measures in Florida, beginning in March 2020, to separate nursing home (NH) and assisted living community (ALC) residents from each other and family members to limit virus spread. This study examines results of a survey with Florida NH (N=59) and ALC (N=117) administrators concerning effects of these measures. Scaled (1-5, lowest to highest) data indicate that resident anxiety was higher in NHs (M=3.40) than ALCs (M=3.17). Care disruptions related to limited resident-to-resident contact also were worse in NHs (M=3.74) than in ALCs (M=3.21), while care disruptions related to loss of family support were higher among ALCs (M=3.19) than in NHs (M=2.86). Implications of these findings will be discussed.

Innovation in Aging, 2020

Little is known about the effects of disasters on assisted living community (ALC) residents. This... more Little is known about the effects of disasters on assisted living community (ALC) residents. This is a concern given the growth of the AL industry and the increasing numbers of AL residents with functional limitations and chronic health conditions. This research examined the experiences of AL administrative staff to better understand the impact of Hurricane Irma. Qualitative interviews were conducted with representatives of ALCs across Florida (N=70), and transcripts were analyzed using Atlas.ti version 8. Research team members met regularly to reach consensus on codes, identifying five major themes across the interviews, 1) planning and preparation, 2) leadership, including plan execution and managing the unexpected, 3) effects/consequences of the storm, including effect on residents and staff, 4) lessons learned, and 5) electrical power. Results provide a broad view of ALC preparedness, how it varies across different types of ALCs and implications for resident wellbeing and future...

Innovation in Aging, 2020

The U.S. Gulf Coast hurricanes of 2004-08 led to research and policy reports highlighting the nee... more The U.S. Gulf Coast hurricanes of 2004-08 led to research and policy reports highlighting the need for more emergency preparation among nursing homes (NH). In 2016, the federal government issued final rules requiring Medicaid and Medicare providers to develop comprehensive preparedness plans. The state of Florida previously imposed its own long-term care (LTC) preparedness requirements. Hurricane Irma tested the readiness of LTC facilities that care for disabled and vulnerable residents. This research examined the experiences of NHs (N=30) affected by the hurricane through qualitative interviews with administrative staff. Research team members analyzed the transcripts, identified codes, and met to reach consensus on themes. Three major themes emerged, 1) managing the unexpected, including last-minute evacuation orders, 2) caring for vulnerable residents amid the crisis, and 3) the struggle of maintaining staff. Results suggest LTC preparation has increased but long-standing problems...

Innovation in Aging, 2020

Hurricane Dorian devastated parts of the Bahamas in 2019 with 185-mph winds. As it moved toward F... more Hurricane Dorian devastated parts of the Bahamas in 2019 with 185-mph winds. As it moved toward Florida, the state went on alert. This paper examines whether assisted living communities (ALCs) in affected counties evacuated or sheltered in place in the context of emergency management communications concerning evacuation. In 16 coastal counties, 66 ALCs were under mandatory evacuation orders, but 12 sheltered in place. Of 603 ALCs not under orders, 17 evacuated. Seven ALCs evacuated contrary to orders in one county, which issued a mandatory order Sept. 1, delayed it to Sept. 2 as Dorian weakened, and lifted it Sept. 4. Interviews with ALC administrators and emergency managers will be used to understand more about their decisions. Given prior findings that evacuation (versus sheltering in place) increases the mortality and morbidity risk of long-term care (LTC) residents, this research suggests a need for clearer LTC evacuation standards and communication. Part of a symposium sponsore...

JAMA Health Forum, 2021

IMPORTANCE Exposure to hurricanes is associated with increased mortality and morbidity in nursing... more IMPORTANCE Exposure to hurricanes is associated with increased mortality and morbidity in nursing home (NH) residents, but the factors contributing to these outcomes are less understood. One hypothesized pathway could be power outages from hurricanes that expose NH residents to excess ambient heat. OBJECTIVE To determine the association of power loss from Hurricane Irma with hospitalization and mortality in NH residents in Florida. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study of NH residents residing in Florida when Hurricane Irma landed on September 10, 2017, assessed mortality at 7 and 30 days after the storm and hospitalization at 30 days after the storm. The analysis was conducted from May 2, 2021, to June 28, 2021. All NH residents residing in Florida at landfall were eligible (N = 67 273). We excluded those younger than 65 years, missing power status information, or who were evacuated (13 178 [19.6%]). EXPOSURE We used state-administered surveys to determine NH power outage status. Exposed residents experienced a power outage poststorm, whereas unexposed residents did not experience a power outage poststorm. MAIN OUTCOMES AND MEASURES We used Medicare claims to assess mortality and hospitalization after Hurricane Irma landfall using generalized linear models with robust standard errors. RESULTS In the aftermath of Hurricane Irma, 27 892 residents (18 510 women [66.4%]; 3906 [14.0%] Black, 1651 [5.9%] Hispanic, and 21 756 [78.0%] White individuals) in 299 NHs were exposed to power loss and 26 203 residents (17 620 women [67.2%]; 4175 [15.9%] Black, 1030 [3.9%] Hispanic, and 20 477 [78.1%] White individuals) in 292 NHs were unexposed. Nursing homes that lost power were similar in size, quality star rating, and type of ownership compared with NHs that did not lose power. Power loss was associated with an increased adjusted odds of mortality among all residents within 7 days (odds ratio [OR],1.25; 95% CI,1.05-1.48) and 30 days (OR, 1.12; 95% CI,1.02-1.23) poststorm and hospitalization within 30 days, although only among residents aged 65 to 74 years (OR, 1.16; 95% CI, 1.03-1.33). CONCLUSIONS AND RELEVANCE In this cohort study, power loss was associated with higher odds of mortality in all affected NH residents and hospitalization in some residents. The benefits and costs of policies that require NHs to have emergency alternate power sources should be assessed.

The Gerontologist, 2021

Background and Objectives Assisted living facilities (ALFs) have experienced rapid growth in the ... more Background and Objectives Assisted living facilities (ALFs) have experienced rapid growth in the past few decades. The expansion in the number of ALFs may cause markets to become oversaturated, and a greater risk of unprofitable ALFs to close. However, no studies have investigated ALF closure. This study adapted a model developed for the nursing home market for the ALF market to examine the organizational, internal, and external factors associated with closure. Research Design and Methods Data on 1,939 ALFs operating in 2013 from Florida were used to estimate a logistic regression to examine the organizational, internal, and external factors that were associated with closure between 2013 and 2015. Results During the 2-year study period, 141 ALFs (7.3%) closed. Significant factors associated with increased odds of closure included fewer beds, not accepting Medicaid, and more deficiencies. Two factors (market concentration and population density) were marginally significant. Discussio...

Innovation in Aging, 2021

Background and Objectives Protecting nursing home and assisted living community residents during ... more Background and Objectives Protecting nursing home and assisted living community residents during disasters continues to be a challenge. The present study explores the experiences of long-term care facilities in Florida that were exposed to Hurricane Irma in 2017. Research Design and Methods We used an abductive approach, combining induction and deduction. Interviews and focus groups beginning in May 2018 were conducted by telephone and in person with 89 administrative staff members representing 100 facilities (30 nursing homes and 70 assisted living communities). Analyses identified themes and subthemes. Findings were further analyzed using the social ecological model to better understand the preparedness and response of nursing homes and assisted living communities to Hurricane Irma. Results 3 main themes were identified including: (1) importance of collaborative relationships in anticipating needs and planning to shelter in place or evacuate; (2) efforts required to maintain safet...

Public Policy & Aging Report, 2021

Journal of the American Medical Directors Association, 2020

Objectives: To investigate the factors associated with whether assisted living communities (ALCs)... more Objectives: To investigate the factors associated with whether assisted living communities (ALCs) in Florida evacuated or sheltered in place for Hurricane Irma in 2017, focusing on license type as a proxy for acuity of care. Design: Cross-sectional study using data collected by the state through its emergency reporting system and a post-hurricane survey. Setting and Participants: Analyses included all 3112 ALCs in the emergency reporting system. A subset of 1880 that completed the survey provided supplementary data. Methods: c 2 tests were used to examine differences between ALC characteristics (license type, size, payment, profit status, rural location, geographical region, and being under an evacuation order) and whether they evacuated. Logistic regression was used to test associations between characteristics and evacuation status. Results: Of 3112 ALCs, 560 evacuated and 2552 sheltered in place. Bivariate analysis found significant associations between evacuation status and evacuation order, license type (mental health care), payment, and region. In the adjusted analysis, medium and larger ALCs were 43% (P < .001) and 53% (P < .001) less likely to evacuate than ALCs with fewer than 25 beds. Compared with ALCs in the Southeast, nearly every region was more likely to evacuate, with the highest likelihood in the Central West (odds ratio 1.76, 95% confidence interval 1.35-2.30). ALCs under an evacuation order were 8 times more likely to evacuate (P < .001). We found no relationship between evacuation status and having a license to provide higher care. Conclusions and Implications: Prior research highlighting harm associated with evacuation has led to recommendations that long-term care facilities carefully consider resident impairment in evacuation decision-making. Evidence that small ALCs are more likely to evacuate and that having a higher-care license is not associated with evacuation likelihood shows research is needed to understand how ALCs weigh resident risks in decisions to evacuate or shelter in place. Ó 2020 AMDA e The Society for Post-Acute and Long-Term Care Medicine. Residents of long-term care (LTC) are especially vulnerable to harm in natural disasters. 1 Research in this area has focused largely on nursing homes (NHs). 2 Dosa et al 3 examined NHs affected by Gulf Coast hurricanes in 2005 and 2008, addressing the complexity of the decision to evacuate or shelter in place. They found all residents were at greater risk during the hurricanes; however, the act of evacuation compounded morbidity and mortality. Laditka et al 4 and others have reported on the difficulties of transporting and providing care to

Innovation in Aging, 2019

The decision to evacuate or shelter in place during a natural disaster such as a hurricane is com... more The decision to evacuate or shelter in place during a natural disaster such as a hurricane is complicated and poses risks to long-term care residents. While research has documented the difficulty of the evacuation decision for nursing home administrators, little is known about how assisted living residence (ALR) administrators make this decision. This is a concern given the physical and cognitive impairment level of many ALR residents, the increasing number of ALRs in the U.S., and the frequency of natural disasters. The purpose of this paper was to explore the factors that influenced whether assisted living administrators evacuated their ALRs for Hurricane Irma, a large hurricane that made landfall on Florida’s Southwest coast in September, 2017. This qualitative study used semi-structured interviews and focus groups with ALR owners or administrative staff (N=60) with questions including how they prepared for Hurricane Irma, their experiences during the hurricane, including whether...

Innovation in Aging, 2019

The importance of communities in disasters has been well established since Hurricane Katrina. Smi... more The importance of communities in disasters has been well established since Hurricane Katrina. Smit and Wandel’s bottom-up approach to assess risks during a disaster involves community stakeholders. Administrators of assisted living (AL) environments increasingly have to assess the risks of hurricane evacuation for vulnerable older adults. The current study examines intersections between social networks, communication and preparedness during a hurricane for AL administrators. We conducted focus groups and interviews with AL administrators (N=60) in Florida about communication patterns with community associations, emergency management officials, AL staff, residents and their families during Hurricane Irma (2017) and about their perceptions of preparedness. A content analysis approach was used. Atlas.ti v7 was used for initial and axial coding. Co-occurrences were found among communication and preparedness themes. Some prevalent themes included “social capital”, “high versus low tech s...

Innovation in Aging, 2019

In 2018, in response to deaths of nursing home residents after Hurricane Irma, Governor Scott and... more In 2018, in response to deaths of nursing home residents after Hurricane Irma, Governor Scott and the Florida legislature enacted an emergency power rule for nursing homes and assisted living communities (ALCs). It mandates these settings to have a generator to regulate ambient air temperatures during loss of primary power by Jan. 1, 2019. However, due to cost and supply challenges the implementation of these plans has been difficult, particularly for small and independently owned ALCs. The purpose of this mixed methods study is to determine the characteristics of ALCs that were able to comply with the rule and concerns raised by ALC administrators. Using data from state regulatory agencies on all Florida ALCs (N=3082), we determine associations between ALC characteristics (size, specialty license, low-income residents) and non-compliance to the rule, using chi-square and t-tests. Additionally, we conducted interviews and focus groups with ALC administrators (N=60) about issues of i...

Journal of Aging & Social Policy, 2019

In 2014, more than 800,000 older adults reside in assisted living communities (ALCs) in the Unite... more In 2014, more than 800,000 older adults reside in assisted living communities (ALCs) in the United States, yet few studies have examined whether state licensure inspection and citation information can be used to help consumers infer quality in choosing facilities. We examined the quality of ALCs using the deficiency citation data from the State of Florida. Data on 2,457 licensed ALCs operating between 2013 and 2015 were used to estimate logistic and negative binomial regression models to determine ALCs' structural characteristics that were associated with any and the number of deficiency citations. There were 2.6 deficiencies per facility (range 0-21); one-third of all ALCs received no deficiencies and one-third received four or more deficiencies. Specialty license and region were associated with receiving any deficiencies; ownership, rural location, and Northeast region were associated with receiving more deficiencies; and Southwest region was associated with receiving fewer deficiencies.

Innovation in Aging, 2018

Innovation in Aging, 2018