Functional Needs Support Services: A New Paradigm in Emergency Shelter Operations

“Functional needs” is a collective term used to describe individuals who typically function independently or with a support system. During times of disaster, they face particular challenges when interruptions occur that affect their normal support structures. Populations with functional needs have also been referred to as vulnerable “special needs” persons, or medical special needs (MSN) populations. Today, the term functional needs is also used to describe a shift toward broader accommodation in times of emergency for those with a broad spectrum of diverse needs.

Rather than referencing vulnerability or medical special needs per se, the term functional needs is used to denote the establishment of a framework that better supports the autonomy of those with such needs. Although the definition is still evolving, it now includes but is not limited to such groups as senior citizens, newborns, and pregnant women in addition to those with autism, cognitive disabilities, mental health issues, deafness, visual impairment, or mobility impairments as well as those: (a) who require “service animals” such as seeing-eye dogs; and/or (b) those – dialysis patients, for example – suffering from medical conditions that require ongoing support. Each of these groups typically includes individual citizens representing a wide variation in their own degree or level of need. Moreover, many individuals in each group face multiple challenges that span across two or more of the needs categories mentioned – but usually if not always can still function reasonably well if the proper provisions for their care are made.

Providing functional support for the diverse needs within and across these groups is one of the most challenging aspects of managing an emergency situation of any type. There have been many success stories in recent response activities, in fact – but the overall U.S. track record for adequate provision of care for those with functional needs also includes numerous examples of errors and oversights.

Katrina: Natural Disasters Compounded by Human Errors

This problem was particularly evident in the aftermath of Hurricane Katrina. Shocking stories, particularly concerning the plight of those suffering from one or more medical and/or mental disabilities, were broadcast around the world as responders moved into the most heavily stricken areas attempting to identify and assist those in need.

One such story involved an elderly woman named Ethel. The retired 91-year-old was legally blind, bedridden (because of two broken hips), and had to be fed through a feeding tube. The family chose not to evacuate her because of her fragile condition. Her home survived the initial storm but, as the flood waters continued to rise, her son placed her in a passing boat and asked the crew to take her to the Superdome. As the crew members made their way in that direction, though, a law-enforcement official instructed them to go instead to the New Orleans convention center. While waiting in the heat for the arrival of buses, Ethel died. A well publicized photo of her sitting deceased in her wheelchair became a sad testament to the many missteps made, by obviously well intended people, in caring for at-risk populations during that massive catastrophe.

Following the Hurricane Katrina response, a variety of lawsuits were filed on behalf of those with disabilities. The litigation extended beyond the response activities themselves to include shortfalls in the recovery phases of the disaster. For example, individuals with mobility impairments needed the FEMA (Federal Emergency Management Agency) trailer-park areas to be paved with smooth surfaces that could accommodate wheelchairs and other assistive devices. Instead, the parks were paved with gravel roadways and walkways. The trailers themselves also needed accessible kitchens and bathrooms, widened doorways, and usable entry ramps. Instead, those vitally important facilities not only were set several feet above the ground but also lacked the ramps needed by those with mobility challenges. 

Recognizing the Problem, Then Solving It: The Oakland Example

Such “accessibility” problems have not been limited to FEMA trailers. There also have been issues identified with fixed facilities used as shelter sites that are not in compliance with the national ADA (Americans with Disabilities Act) requirements. A 2007 lawsuit was brought against the City of Oakland, California, for example, over a lack of consideration, in local emergency-shelter plans, for people with disabilities.

Responding to the charges included in that lawsuit, Oakland officials worked closely with disability advocates in developing recommendations that have become the city’s “Functional Needs Annex for Mass Care and Shelter.” In the end, the outcome was mutually beneficial. The City of Oakland worked through major planning challenges and made significant strides, by engaging those in the disabilities community, in providing for those with functional needs during disasters.

In many jurisdictions, most individuals with “special needs” arriving at general population shelters have for many years been quickly referred to shelters designed and staffed specifically to support them. The use of such “designated” shelters – rather than trying to accommodate a broad range of functional-needs citizens at all shelters – seems, or seemed to be, a rare triumph of common sense. The designated facilities are typically referred to as “special needs” or “medical special needs” (MSN) shelters. The concept not only is well intended but also recognizes the reality of the much higher costs inevitable by trying to provide for everyone requiring any type of special support at all general population shelters.

Common Sense & the Law: Bridging the Gap

Shifting those with functional needs from several general population shelters into a single MSN shelter not only provides better care for those with special needs but also reduces overall operational costs. Unfortunately, there is a major political and legal problem with this long-standing approach – namely, that it creates perceived and actual disparities across the groups of individuals with functional needs, an outcome that is in violation of the Americans with Disabilities Act, the Fair Housing Act, and other federal laws prohibiting emergency-program discrimination.

The evolution of Functional Needs Support Services (FNSS) has finally reached a point, however, where generally acceptable policy changes have been developed and are now in the process of being implemented. According to new FEMA FNSS guidelines, advance planning must be initiated that includes collaboration with relevant stakeholders representing a variety of functional needs. In addition, steps to accommodate them must now be hard-wired into local planning and response activities. These guidelines will change staffing patterns in all shelters to include personal-care assistants, provide communications support for those who are hearing- or vision-impaired, and require translators for those with language and cultural differences.

All of which requires more medical staffing support and additional assistance with durable medical equipment as well as the specialized transportation resources that are often needed. In addition, the dietary needs and pharmaceutical support of all with functional needs must be accommodated. In short, the new FNSS guidelines will change the way shelters are established and operated as much as the then-new ADA requirements changed building design in the 1990s.

The new shelter-program changes will be both costly and challenging. Undoubtedly, mistakes will continue to be made, just as they did during the implementation phase of the ADA requirements. But the process will continue to improve. Shelter plans across the nation will be adjusted to provide significantly upgraded functional needs support, and a number of other promising improvements will emerge and become common practice. Finally, it seems, the difficult issues associated with coordinating the details of FNSS and paying for the additional services will be resolved.

In fact, the transition from special needs to functional support has already begun, and was perhaps best summarized by Richard Devylder – formerly of the California Emergency Management Agency, and now serving as the U.S. Department of Transportation’s Senior Advisor for Accessible Transportation – when he said: “It is no longer special – it’s part of what we do.”

Bruce Clements

Bruce Clements is the Public Health Preparedness Director for the Texas Department of State Health Services in Austin, Texas, and in that post is responsible for health and medical preparedness and response programs ranging from pandemic influenza to the health impact of hurricanes. A well-known speaker and writer, he also serves as adjunct faculty at the Saint Louis University Institute for BioSecurity. His most recent book, Disasters and Public Health: Planning and Response, was released in 2009.



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