Access and Functional Needs: ESF-6, ESF-8...
Karl Schmitt, PMP
Project Management | Program Management | Emergency Preparedness
Individuals with access and functional needs (AFN) daily require AFN support services (AFNSS). And meeting their unique needs when disaster strikes are exponentially more challenging. Emergency managers must plan for AFNSS during disasters, which is hard, given that most related services live in the private sector. And for those looking to the?National Response Framework (NRF)?for answers, the solutions seem lost in translation.
In disaster planning, accounting for individuals with AFN requires a fresh lens across numerous Emergency Support Functions (ESFs), including:
Aside from ESF-15, these ESFs generally need only reference the needs of individuals with AFN and point to the specific activities nested in other ESFs. But ESF-15 most likely requires a thorough reassessment of how public messaging is being done today with a keen eye for what is missing. For example, look no further than the demographics of those who perished during Hurricane Ian in the Fall of 2022.
AFNSS: The provision of services, devices, and equipment that enable individuals with access and functional needs to maintain their independence in a shelter, their home, camp, or care facility.
So, I hear you asking, "what about ESF-6 and EFS-8? You've skipped over them?" I'm happy you noticed because ESF-6 and ESF-8 are where AFNSS live and breathe and are the crux of policy and planning falling shortfalls at all levels of government. And, yes, they are in the title for this post.
Federally, delivering AFNSS should be a primary focus in ESFs 6 and 8. It is not. The Federal Emergency Management Agency (FEMA) often uses the term "Access and Functional Needs" in the NRF,?Developing and Maintaining Emergency Operations Plans: Comprehensive Planning Guide (CPG) 101, and other guidance documents. But adding words does not correct the foundational problems with emergency operations plans.
The primary challenge with AFNSS is that, like ESFs 6 and 8, they are human-facing, each with numerous associated activities. But, unlike other ESFs, they require a person – trained and often state-licensed or certified – to interact directly with the client or patient. That's why AFNSS, ESF-8, and ESF-6 are the Achilles' heel for government agencies, which lack the necessary in-house staff, expertise, supplies, and equipment to deliver direct services. Instead, the resources live in the private sector, out of the reach of the NRF and the?National Incident Management System (NIMS).
Indeed, state governments often pay for such resources through healthcare and human services-related contracts and program grants. And much of states' funding comes from U.S. Department of Health and Human Services (HHS) programs authorized and funded by Congress. But the operative takeaway is that the government rarely employs professionals with boots on the ground that do the work during peacetime.
Federal, state, and local planning efforts must focus on integrating this private sector health and human services network. And for FEMA, under the NRF, it all starts with disemboweling and rethinking ESF-6 and ESF-8.
What is AFN?
It'd be awkward to talk about planning for individuals with AFN if we didn't explain what it is, right? You'd think a quick look at any federal preparedness guidance would be enough, but it's not. Unfortunately, the definition of AFN depends on whom you ask or which federal guidance document you have in hand.
So I know what you are thinking; "here he goes again on a rant about a lack of definitions." Yes. But bear with me. You see, unlike "disability," there is no definition for AFN baked into federal law or regulation. And without such a definition, federal agencies are free to go it alone – and they have.
It'd be nice if at the very least the federal agencies responsible for activities under ESF-6 and ESF-8 horizontally integrated plans and guidance with the NRF, but only if the NRF had it right. Unfortunately, it does not. As we discussed in the LinkedIn series,?NRF: Is ESF-8 Full of Holes, FEMA did not include definitions in the NRF. Further, they have different definitions for AFN across their own guidance documents.
And that has left the Centers for Disease Control and Prevention (CDC) and the Administration for Strategic Preparedness (ASPR), the federal agencies that own most of ESF-8 and support services for ESF-6, the opportunity to go solo.
Here's where federal definitions stand today.
So, what is a state or local jurisdiction to do? You guessed it; just like the CDC and ASPR, they must create their definitions. Ideally, all would reach out to the AFN community to get assistance. But it's important to understand that settling on a definition for AFN may be challenging even when they do.
You see, as I learned while advising the?Illinois Emergency Management Agency (IEMA) Director's Access and Functional Needs Advisory Committee,?there's a propensity for individuals with specific conditions to want to be included explicitly in the adopted definition. And once you start listing conditions in a definition, the chance of missing a few is a problem. Just know that it isn't easy to reach common ground on what constitutes an individual with AFN versus one who is merely "at risk."
So, absent a definition in federal law or regulation or standard FEMA, ASPR, and CDC jointly agree to, the IEMA AFN Advisory Committee went – you guessed it – solo. It took three meetings over six months to gain consensus on six definitions.
Regarding AFN, they settled on the definition below – a core definition we'll adopt, giving you a foundation for today's musings.
Is it right? Without standards, that's up to you to decide. But, of course, you can always go solo.
Access and Functional Needs (AFN):?Individuals who need specific resources to manage a disability, as defined by the Americans with Disabilities Act (ADA), chronic health care or behavioral health conditions, age-related deficiencies, and communications deficits before, during, and after a disaster or public health emergency. Access-based and function-based needs are not mutually exclusive and may overlap.
Now that we know what AFN is, how do we plan to deliver these services to individuals in the community? Do we prepare for every condition individuals with AFN might present with? Fortunately, no.
In 2017, disabilities advocate June Isaacson Kailes and others from?The Partnership for Inclusive Disaster Strategies?convinced FEMA, the CDC, and ASPR to adopt Kailes' functions-based approach to planning for AFNSS,?The CMIST Framework. That'd be a functions-based approach that should nest within the NRF's function-based annexes, right?
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What is the CMIST Framework?
Per Ms. Kailes'?2020 post on The Partnership for Inclusive Disaster Strategies website, she laid CMIST's foundation "[a]t a 2006 United States Health and Human Services, "Working Conference on Emergency Management and Individuals with Disabilities and the Elderly." There she "proposed a function-based approach to include people with disabilities in emergency planning, response, and recovery. The intent was to accurately guide and increase clarity regarding including the emergency needs of a large segment of the population in planning and service delivery."
CMIST is an acronym for:
Per Ms. Kailes, Communication access "addresses the needs of individuals who need assistance, with the receipt of information they can understand and use due to hearing, vision, speech, cognitive, or intellectual disability, and/or limited or no ability to read or speak English. During an emergency, people with communication accessibility needs may not be able to hear verbal announcements; see and/or read scrolling text or directional signs; or understand how to protect themselves or get assistance."
Communications support services live predominantly under ESF-6 in the NRF.
Per Ms. Kailes, Maintaining Health "moves away from viewing disability in the context of medical care. People are not sick because they live with a disability. However, when you examine society's terms associated with disability, it is understandable why disability is often mistakenly and inaccurately associated with sickness and medical needs. Society has adopted the medical care reimbursement language for items that some people with disabilities commonly use to maintain their health and Independence."
Health maintenance support services live predominantly under ESF-8 in the NRF.
Per Ms. Kailes, Independence "is the overarching goal, the steady state that an individual wants to maintain in an emergency. This is addressed by planning for meeting needs related to:
Kailes goes on the state that these functional needs can and do overlap.
"Independence is a level of function. If it cannot be maintained at a pre-disaster level, it should be optimized to the greatest extent possible to ensure an individual's health and safety. Independence is represented by a large center gear, surrounded by four linked gears representing functional needs: communication, transportation, safety support, self-determination, and health."
Independence support services live predominantly under ESF-6 in the NRF.
Per Ms. Kailes, Safety, Security, and Self Determination is "[a] core value reflected here is that independent living does not mean doing everything without assistance, rather it is being in control of how, when, and what things are done, regardless of whether one uses the services and assistance of others."
Support, Safety, and Self Detarmination support services live predominantly under ESF-6 in the NRF.
Per Ms. Kailes, Transportation acknowledges that "[i]n emergencies, many people have transportation needs because of lack of access to personal transportation; need for accessible vehicles/transport (due to mobility disabilities, age, and temporary conditions and injuries; and driving restrictions. Wheelchair-accessible transportation (vehicles that are lift or ramp equipped) is a critical element that must be factored into the planning for and allocation of emergency evacuation resources. This support includes public information on how to access accessible transportation during an evacuation."
Transportation support services live predominantly under ESF-6 in the NRF.
Where Do We Go From Here?
Addressing the provision of AFNSS in planning and operations is critical for all jurisdictions. But, like ESF-6 and ESF-8, it's hard because there's generally no department or agency with the resources to turn to. And even if the local health department is assigned ESF-8 primary and ESF-6 support responsibilities, doing so does not magically make the resources appear.
As one begins the policy analysis and planning processes, it's important to remember the following:
So, knowing the state of federal AFN planning and the fact that waiting for direction is a poor option, where does one start?
For state emergency managers, the work begins with assembling an AFN steering committee with representatives from state aging, Medicaid, public health, and human services agencies. Then, it extends to the umbrella associations for the Centers for Independent Living (CILs), Area Agency on Aging (AAAs), disability services organizations, and home care providers.
Ideally, states will take the lead in setting state standards. Then, when the state framework is ready for implementation, they would develop local planning guidance based on it for local emergency management agencies. Doing so enables them to integrate local plans with those of the state vertically.
Whether or not the state emergency management agency provides local planning guidance, local emergency managers must assemble an AFN steering committee that includes their regional CIL, AAA, local disability services organizations, and home care providers. It is this group that will provide the subject matter expertise necessary for planners to build effective, operationally relevant plans.
Stay Tuned!