One of the most destructive storms ever to

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1 DISASTER CARE By Mary Ann Christopher, MSN, RN, FAAN, and Jill Goldstein, MA, MS, RN The Visiting Nurse Service of New York s Response to Hurricane Sandy An analysis of the planning and improvisation that proved crucial in meeting medical and infrastructural challenges. One of the most destructive storms ever to hit the New York City metropolitan area, Hurricane Sandy caused 53 deaths in New York, with a total of at least 117 in the northeastern United States. 1 Sandy was categorized as a posttropical cyclone by the time it made landfall in New Jersey on the evening of October 29, 2012, but damage from the powerful winds, rainfall, and record storm surge was no less extreme. It continues to affect the greater New York City area almost two years later. Close to 2 million New Yorkers lost power. 2 Lowlying parts of New York City were soon flooded 51 square miles in all including large sections of all five boroughs (Manhattan, Brooklyn, Queens, the Bronx, and Staten Island). (See Figure 1.) High winds and rising waters battered buildings and other structures, effectively shutting down the city and halting transportation while destroying many homes. The storm forced companies, schools, hospitals, and stores to close, cutting residents off from vital services. New Yorkers woke to an altered city the next morning. Graver than the material losses was the loss of life that the Visiting Nurse Service of New York (VNSNY) learned about as we took stock of the destruction. Our teams listened to tales of devastation from New Yorkers who lost loved ones as well as belongings and property. Sandy Merlino, vice president of business development for the VNSNY s home care department and a longtime Staten Island resident, relayed one such story. As the waves crashed on Staten Island, a couple (who frequently volunteered with Ms. Merlino at a local nonprofit) who were safely sheltered in their attic decided they wanted something from a lower level of the house. Just as they ran downstairs, a huge wave came crashing in. The woman hurried back upstairs, believing her husband was behind her; but when she turned to look, he was gone. We also heard stories of bravery and hope. We heard about neighbors and volunteers taking in friends, saving each other s lives, and showing what it means to be part of a community. Figure 1. A map of New York City shows the areas of flooding (in red) caused by Hurricane Sandy. Reprinted with permission from Compton s by Britannica, 2010 by Encyclopedia Britannica, Inc. Amid staggering personal and societal loss, the VNSNY a not-for-profit, community-based home health care organization focused its energies on providing immediate medical and practical aid to patients during the storm and throughout its continued impact in the weeks and months that followed. Our patients include people challenged by age, chronic illness, disability, and poverty. The VNSNY s collaborative care model, its partnership with community organizations, and its emergencymanagement plans see The VNSNY s Emergency Response Plans 3 enabled us to respond quickly. This case study demonstrates a scalable way for community organizations, care providers, and ajn@wolterskluwer.com AJN October 2014 Vol. 114, No

2 DISASTER CARE Police cars and others are submerged on 7th Street and Avenue C in Manhattan on the evening of October 29, 2012, after the severe flooding caused by Hurricane Sandy. Photo by Christos Pathiakis / Getty Images. policymakers to plan for catastrophes and support vulnerable populations when disasters occur. It illustrates the VNSNY s tactics, both planned and improvised; identifies challenges surmounted and lessons learned; and provides the VNSNY s organizational perspective on best practices for a coordinated emergency response. DISPLACEMENT AND INFRASTRUCTURAL BREAKDOWN Evacuation. At around noon on October 28, 2012, Mayor Michael Bloomberg issued a mandatory evacuation order for the approximately 375,000 people living in New York s most flood-prone areas, then called Zone A. Many people refused to leave their homes (in some cases because they expected a hurricane of lower intensity, such as 2011 s Hurricane Irene). Evacuation is particularly daunting for those who are old, disabled, frail, or ill they are often concerned that their health demands will not be met if they are relocated to a shelter. After the storm, those who needed help were in houses and apartments, assisted congregate care facilities, hospices, shelters, schools, and elsewhere. A number of residents were trapped in high-rise buildings 56 AJN October 2014 Vol. 114, No. 10 without power, in some cases cut off from the rest of the city because of damage to the public transportation system. Last-minute measures. By October 28, many experts were predicting that the eventual storm surge in New York Harbor could reach a record-breaking 11 feet (it ultimately reached almost 14 feet at its peak), which, along with sustained high winds, would cause power outages, downed power lines and trees, and scattered debris. Hospitals were given the option to shelter patients in place, and it was announced that mass transit would be suspended at 7 pm that evening. With a few hours between the evacuation order and the transit shutdown, our staff needed to act quickly to secure patients safety and connect with their family members to tell them their loved ones would be monitored. But first, VNSNY managers asked their teams to prepare themselves and their own families by checking whether they lived in an evacuation zone, charging their mobile devices, and stocking supplies. Communication and transit disruption. During and after the storm, power outages and downed cellular phone towers limited the VNSNY s capacity ajnonline.com

3 The VNSNY s Emergency Response Plans Having flexible emergency-management plans to handle an array of crises is key for a care organization. The Visiting Nurse Service of New York (VNSNY) has long prioritized emergency planning and preparedness training and has plans in place for a range of disasters, including biohazards, floods, fires, and blackouts. (This follows the model laid out by the Federal Emergency Management Agency s incident- preparedness approach, the National Incident Management System [NIMS].) Our first plans were created in 2004, and there were 39 activations before Hurricane Sandy. Our emergency response mechanisms are also scalable and applicable to organizations of varying sizes and in different locations. Further, we integrate our plans with those of the larger New York community. The VNSNY belongs to the Home Based Care Alliance; participating groups in this alliance take turns representing the needs of patients in the New York City Office of Emergency Management s operations center during disasters. Plans years in the making. Practice is essential to ensuring that plans hold up during actual emergencies, so our emergency response team holds regular drills to prepare for worst-case scenarios. We also use outside consultants to run exercises for our staff; getting people to focus on hypothetical disasters is difficult during day-to-day operations. Our incident command system is a major component of our emergency response; it follows the NIMS model for a chain of command. One hundred fifty senior staff members (out of 700 and 18,000 total VNSNY employees) have designated roles on our incident command team. During drills they assume their roles; during incidents, the VNSNY activates certain roles. (Between October 26 and November 26, 2012, many staff members spent the majority of their working hours dealing with Sandy-related occurrences.) Prioritization of patients. The VNSNY assigns patients priority codes based on their conditions and living situations; this is a key component of our tracking and reporting system. Patients are categorized as 1, 2, 3, or 4, with 1 indicating highest risk. Medical conditions, whether a patient lives alone, and whether she or he would be at risk without service from an aide were some of the factors informing this rating. These codes helped us determine which patients needed an aide to stay with them during Hurricane Sandy. Logistical coordination. Empowering staff to make quick decisions is essential for an effective disaster response. As the VNSNY s emergency response system manager later wrote in an internal report, Leadership in emergencies often requires making rapid decisions with limited information. As such, all decisions made are good. Sandy necessitated massive logistical coordination to accommodate aides and clinicians who could not get to their regular charges. VNSNY leaders granted staff the autonomy to attend to patient needs promptly. Finance officers signed off on budgetary requests, allowing field staff to take in new patients and let the organization resolve all billing later. We authorized our finance and personnel teams to act quickly to get employees the necessary funds to navigate gridlocked streets and pay for basic expenses. We also paid all employee wages for October 29 through October 31 in advance to support those staff members who were unable to report in because of the storm. Servant leadership. After Sandy, we urged all available RNs on our staff including those who no longer make home visits (executives and those in supervisory roles, for example) to assist patients in the field. More than 5,000 of our 18,000 staff, including nurses, aides, social workers, and physical therapists, served patients during and after the storm. Allison Chisholm, a VNSNY nurse who drove from Brooklyn to Manhattan on hazardous streets to visit patients on October 30, told the New York Times, It was treacherous driving during the hurricane. But it s just something you have to do as a nurse. That continuity of care helps the healing. 3 Such measures are only as effective as the team at hand, and an inherent sense of mission among employees in essential care is critical, coupled with strong training and a culture that places the meeting of others needs above all else. The VNSNY model is evidence that community-based home health care organizations are unique assets in caring for vulnerable populations during times of crisis. Familiarity with affected communities and with the larger landscape of care and government resources allows such groups to coordinate responses effectively and act as essential conduits for relief efforts. ajn@wolterskluwer.com AJN October 2014 Vol. 114, No

4 DISASTER CARE to communicate. Staff were unable to get reception or recharge their devices a severe handicap for field aides and traveling clinicians. Care agencies and patients were also stranded: there was little time between the announcement of a subway shutdown and its implementation later that day. The organization s emergency plan anticipates disruptions to public transportation the plan had been effective during Hurricane Irene, major snowstorms, and the 2003 Northeast blackout but Sandy caused unprecedented difficulties, including widespread gas shortages and restrictions implemented by the city to address traffic surges. Private transportation was challenged as well: cars traveling into Manhattan had to carry three or more passengers and fuel shortages led to hours-long lines at gas stations, another major obstacle nurses had to overcome in reaching patients. Hospital closures. Many area hospitals were forced to completely or partially close, their backup generators flooded following various blackouts in different parts of the city. Several of these hospitals remained closed for prolonged periods after the storm. RESPONDING TO A DISASTER During and after the storm, more than 5,000 nurses, rehabilitation therapists, home health aides, social workers, and staff from every administrative department in the VNSNY were working in the field, making sure our 62,000 patients and other locals were safe. (There were about 17,000 patients in Manhattan, 15,000 in Brooklyn, 16,000 in Queens, 12,000 in the Bronx, and 2,000 in Staten Island.) We activated an emergency response plan on October 25, classifying the situation as Level One: Potential Impact based on weather reports that placed New York City in Sandy s crosshairs. Initial response. Our senior incident command team assumed previously appointed roles: incident commander, information technology technical specialist, operations section chief, communications unit leader, administration section chief, human resources section chief, planning section chief, and situationstatus unit leader. Regular conference calls began on October 26 (with ongoing briefings continuing until November 27, a full month later). During this initial phase, clinicians and managers also prepared their regular patients, asking them about their plans for the storm and whether they intended to evacuate. Nurses and other members of VNSNY interprofessional teams moved up their scheduled home visits, readying those patients in evacuation zones either to leave with family or to shelter in place. Staff provided lists of necessary supplies and made sure patients had a week s worth of medications and provisions on hand, including flashlights, batteries, and nonperishable food. Setting up command centers. We already had fully developed programs in areas that were hit hard by the storm; these continued to function after the worst of the storm s immediate effects had passed. About three weeks after the storm hit, we set up a one-day command center in a generator-powered New York City Housing Authority (NYCHA) trailer in a housing complex in Red Hook, Brooklyn, after becoming aware of a number of pressing needs in this hard-hit area; the Federal Emergency Management Agency (FEMA) also had a command center nearby. The established VNSNY office on Staten Island was in an evacuation zone and had to close during the worst of the storm. Fortunately, the Staten Island office was able to use our Manhattan headquarters as a primary command location. As in Red Hook, we set up a one-day command center in Staten Island about three weeks after the storm hit to triage immediate needs. The temporary command centers served as impromptu patient-intake centers, filled with phones and laptops so that the team could process referrals for residents. In Red Hook, our nurses paired up with NYCHA workers to canvass every apartment in the housing complex that held our command center. And from each center, physicians, NPs, and other field staff also went out canvassing, came back with patient referrals, and wrote prescriptions as the teams identified needs. We then helped arrange the delivery of medications to the residents; VNSNY intake staff processed referrals for home care services. There was also administrative staff to field calls and oversee the process, pharmacy staff, a logistics team to transport field staff, and security personnel to accompany staff. (For a more detailed description of one of our command centers, see Helping the Rockaways.) Evacuating VNSNY patients. We evaluated the needs of the hundreds of our patients living in Zone A according to our prioritization system that rates patients based on their condition and living situation: about 20% of patients were in the highest-risk category. Many patients needed access to their usual medications, from which they had been cut off because of the storm. We also saw many patients wounded from debris and needing tetanus shots and many with upper respiratory problems, often requiring antibiotics, caused by the dampness of their flooded homes. Then teams were deployed, some transporting those in wheelchairs down darkened stairways, others charting optimal routes within decimated regions. After the city shut down mass transit, 147 home health aides chose to stay overnight with patients during the storm; others spent many nights with high-risk patients or 58 AJN October 2014 Vol. 114, No. 10 ajnonline.com

5 Helping the Rockaways Relief efforts in the Rockaway Peninsula in Queens. After hearing from team members in the Rockaways, including our senior vice president for managed care (a Rockaways resident), we called on a team of senior leaders to direct the area s community relief efforts. This team organized canvassing squads, which included nurses, NPs, home health aides, physicians, social workers, and security escorts, and designated the areas to be covered each day. The command center. The teams began by establishing a command center at the school of St. Francis de Sales church in Belle Harbor about eight days after the storm hit. (The VNSNY nurse who secured the space is also a parishioner there.) The teams converted classrooms into work centers and divided them into sections, including an operations command, a pharmacy, a food and staff room, and a clinical operations intake room. Information technology staff established communications on site, bringing smartphones and laptops for field coordination and intervention data entry. Each night, our vice president of congregate care assessed what canvassing roles would be needed the next day. Our vice president of acute care for Queens (as well as neighboring Nassau County) staffed follow-up visits with volunteers from area clinics and our own acute care teams. Every night we held briefings with the command team leaders to assess progress. Each morning, assignments were posted in the classroom library, along with medication orders for the pharmacy. Canvassing. We started canvassing the Rockaways on November 9, 2012, and continued through April A large-scale map was used to make a grid of the neighborhood blocks to be canvassed. When visiting homes, canvassing teams referred to a checklist of potential needs and followed a script for interviewing. (To see the VNSNY visiting program checklist and visit script, go to A61.) Residents were asked if they had food, water, blankets, and clothing; whether they had any ongoing or recent health conditions like fever or diabetes or were in need of an oxygen tank; and whether they had any emotional or mental health concerns. As the situation developed, so did the checklist, with critical epidemiologic metrics added as the public health issues and population-based needs became central to the recovery effort. Eight to 10 groups went out to canvass every day at around 9 am and returned at 2:30 or 3 pm. (Without electricity, it was imperative to begin and end canvassing efforts during daylight hours.) Nurses and aides who were accustomed to navigating these neighborhoods, as well as to treating wide-ranging medical needs, contributed to the effectiveness of the outreach. NPs and physicians also lent invaluable support; they were able to conduct assessments, diagnose conditions, develop treatment plans, and prescribe medications as needed. Patient intake. In order to normalize a system for new patient intake, we adapted our standard procedures to this field setting, translating new cases into referrals that followed protocols from the New York State Department of Health (DOH). Normally, we input new patient referrals into the database with the status pre-admit. We then conduct a thorough assessment, contact the patient s physician, and follow up by either formally admitting the patient into one of our programs or closing out the patient s record once her or his needs have been met. During the disaster, the intake staff was able to work with minimal data to generate referrals the only information we could gather in most cases was a patient s name, address, phone number, and chief medical complaint. These records allowed us to enter patients into our system temporarily and then formally follow up with them after the initial effects of the storm had subsided. Partnerships. As word of the community canvassing spread, teams from the Federal Emergency Management Agency, the Red Cross, and Verizon arrived at our command center. Physicians came to offer support to both Rockaways residents and our field staff. We directed behavioral health professionals and volunteers to one area of the church, positioned clinicians in another, and stationed those who could help manage communications technology in yet another. For those suffering from emotional trauma, the behavioral health team set up outside with a sign that read Need to vent? See me in the warming tent. People began sending in coats, food, and supplies, which the VNSNY and partners delivered locally. The organization s strong network of partnerships enabled us to divide and conquer. New York Cares (a volunteer agency that works with more than 1,000 other nonprofits) and the National Guard handled basic demands, providing coats, blankets, food, and water, while the VNSNY fielded prescription and medical supply requests. ajn@wolterskluwer.com AJN October 2014 Vol. 114, No

6 DISASTER CARE Helping the Rockaways (Continued) Walgreens pharmacy also provided help. Our field teams soon discovered that many people were running out of their medications (or had lost them in floods), and there were no open pharmacies within a twomile radius. With the gas shortage, damaged roads, and a number of newly housebound residents in high-rise buildings, transporting medicine was difficult. The VNSNY turned to Walgreens, and the company responded quickly. By the next day, five pharmacists arrived and set up a makeshift pharmacy near the school nurse s office, stocking bookcases with over-the-counter medications and other supplies. Clinicians would bring prescription and insurance information (if available) to the pharmacists, who were equipped with wireless scanners. These devices communicated by satellite with pharmacies elsewhere, allowing prescriptions to be processed overnight and, as roads gradually improved, delivered to the school in the morning. At this point, medications were either picked up by or delivered to patients. When some patients could not pay for medications there were no functional ATMs or banks nearby the VNSNY fronted some costs and determined later how to bill patients. In most cases, Walgreens and insurance companies were sympathetic, declining to bill patients or the VNSNY for costs incurred during field canvassing. Transition and lasting damage. After an intensive two-week period, the VNSNY slowly withdrew field units, disbanding the command center shortly before Thanksgiving. The DOH took over referrals and the VNSNY began to return its primary focus to its regular patients. But the DOH continued to follow the intake procedures that the VNSNY helped develop and through April 2013 continued to refer to us patients suffering from the aftereffects of Sandy. accompanied patients to shelters. (In accordance with the New York State Department of Health [DOH], we do not require aides to stay with patients who refuse to evacuate, but we do require that they document their efforts to convince patients to leave.) When our own hospice unit in Manhattan s Bellevue Hospital Center was evacuated on November 1, our staff helped to escort patients; Bellevue s basement fuel pumps for the 13th-floor backup generators were shorted out by floodwater. Aided by the National Guard, we carried 16 hospice patients downstairs on evacuation sleds. Some were relocated to functioning hospitals, some to nursing homes, and some were brought to their own homes. VNSNY social workers and counselors were also on hand to support hospice patients and their families. Improvised communications and transportation. We needed to immediately improvise because of the major power outages in different parts of the city: our technology specialist quickly enabled texting (then more reliable than call service) on field staff cell phones. We also discovered the importance of bulk recharging: employees came to the VNSNY s headquarters on Broadway and 31st Street, which had narrowly avoided Lower Manhattan s blackout, to recharge their phones (or they presented VNSNY IDs and were allowed to recharge their phones at fire stations). We then established charging stations throughout the city. We sent our 27-foot marketing team RV and four vans into affected neighborhoods, bearing water, dry ice, batteries, candles, flashlights, and power strips enabling up to 13 devices to be recharged simultaneously. These vehicles visited locations in all five boroughs. The VNSNY also devised makeshift solutions like deploying Hertz rental cars to regional offices and coordinating carpools. Aides in Manhattan often walked to their patients, while some coordinators and managers worked remotely. New patient intake. Manhattan hospitals, overwhelmed with patients from evacuated facilities, needed immediate help with discharges. But because of transit problems as well as because staff were occupied with existing patients, our own intake capacity was compromised and we couldn t accept new patients until November 1. So we devised an impromptu solution, instructing our central intake unit to begin releasing cases, and our operations staff then assessed our ability to see potential patients. We handled referrals by first triaging according to how badly the patient s area was affected and how many nurses were available in the area. Then we triaged according to medical status: if patients required injections, wound care, drains, or tubes, or were otherwise considered at high risk, they were given priority. Lastly, we addressed caregiver support and competency, prioritizing patients who had no capable caregivers. 60 AJN October 2014 Vol. 114, No. 10 ajnonline.com

7 Having freed up staff, we were then able to take on 150 new patients, including those who, because of the storm, had found themselves without access to physicians or prescription medications. We followed up on their cases and provided the care they needed after partnering with a broad spectrum of government agencies, health care providers, and community-based organizations. Going door to door. As we attended to patients and witnessed the wide-ranging destruction around the city, we realized that the situation in several neighborhoods was particularly dire. People in low-lying areas like the Rockaways, Staten Island, Lower Manhattan, Coney Island, and Red Hook desperately needed assistance. We harnessed our resources to canvass these hard-hit areas. In Staten Island, Red Hook, and Lower Manhattan, the VNSNY s canvassing took the form of friendly visiting, going door to door to see how a particular population was faring. LESSONS LEARNED The pressures we faced during Sandy challenged our emergency planning and our organization to an unprecedented degree, revealing areas that needed to be addressed both by the VNSNY and by the larger health care and policy communities. Local knowledge. No matter where they are or what the emergency is, all community-based home health organizations have an integral role to play in a natural disaster like Sandy: they must know their neighborhoods and be prepared to partner with the efforts of groups like the Red Cross. These partnerships, both with major health organizations and local community institutions, enable tailored and precise responses following a disaster. We were able to lead local canvassing efforts collaborating with city agencies, nonprofits, corporate partners, and volunteers because of our understanding of both patient needs and the New York City streets we serve. We saw many patients wounded from debris and many with upper respiratory problems caused by the dampness of their flooded homes. Forced to improvise, we canvassed with members of various other organizations, combining our individual strengths. In Lower Manhattan, New York University turned to us to help check on elderly residents living in faculty housing. Our vice president of congregate care organized 70 staff members and outside volunteers into 10 teams to go door to door. These teams consisted of New York University College of Nursing students, Queensborough Community College nursing students, Red Cross assessment unit nurses, VNSNY Behavioral Health Program staff, and social workers from VNSNY community mental health services. We also sent teams into Staten Island to check on the residents of 540 private homes spanning 18 blocks. Half of the deaths caused by Hurricane Sandy would occur in this borough; there was great need for behavioral health support. Once residents with behavioral and physical health problems were identified, they were forwarded to the Behavioral Health Program for follow-up. By the time community relief efforts concluded, our canvassing teams had knocked on more than 10,000 doors and devoted a total of 5,414 hours to this work. Having a plan. Our emergency plans were vital to the VNSNY s work. We encourage all health care organizations to make emergency planning a dedicated part of all senior team members roles and to integrate that planning including an established emergency chain of command like ours throughout their organizations. The effectiveness of our response depended on the staff s all-handson-deck approach, which would not have been possible without the incident command system. (Furthermore, after every emergency, the VNSNY analyzes our response through staff surveys and small-group meetings, documenting our actions and identifying areas for improvement.) Communication. Any emergency plan should include backup communication plans in case traditional means falter. For example, texting was more reliable in Sandy s aftermath than placing calls, although there is no substitute for speaking to a patient to fully understand her or his condition. Future disaster planning should also involve establishing bulk recharging capabilities. The recharging of staff cell phones at our headquarters and elsewhere was essential to relief efforts. By making recharging available to many New Yorkers, we gave those ajn@wolterskluwer.com AJN October 2014 Vol. 114, No

8 DISASTER CARE affected by the storm a chance to connect with their families and to help themselves. The VNSNY will incorporate bulk recharging services into future planning, both as an internal resource and as a key part of relieving the strain on disaster victims. Collaboration with government. The gas shortage that struck the New York City metropolitan area demonstrated the importance of working with government authorities: home care nurses should have the privilege (already afforded to first responders) to bypass gasoline lines in an emergency. In November 2013, the VNSNY testified before the New York State Assembly about the need for changes in the law to facilitate such access in future disasters. Government leaders must also work with health care providers to roll out evacuation procedures; we must ensure that senior citizens and the chronically ill have the infrastructural support including shelter care equipped to address diverse medical needs to enable them to safely leave their homes in an emergency. With adequate home care, hospitalizations may be avoided as well as 911 calls and potentially life-threatening care interruption. Collaboration with hospitals. While disasters necessitate last-minute solutions, enhanced advance coordination with hospitals to designate alternative sites of care is important when disaster strikes. Organizations crafting comprehensive emergency plans should work with area hospitals to identify such sites. Advance planning for the possibility of hospitals being crippled on a mass scale will be a major part of future VNSNY emergency planning. Aid from the government further enables a largescale response. We incurred nearly $500,000 in Sandyrelated expenditures for food, transportation, shelter, supplies, and security, as well as for overtime pay and repair costs for our damaged facilities. We applied to FEMA, the U.S. Small Business Administration, and our insurers for reimbursement to cover some of these expenses. Flexibility. Emergency plans must adapt in order to be effective in an unpredictable event. Sandy showed the importance of transcending institutional divisions in an organization like the VNSNY, with its many departments, affiliates, and partners. We need channels in place to effectively reassign staff when our labor force is reduced. We had addressed redeployment in our emergency planning, conducting exercises to identify how we might cope if faced with a crisis such as a medical pandemic. But Sandy, with an impact lasting far longer than any past crisis, showed us as only an actual event can that we must refine these plans so that our entire organization can truly work as one. Intraorganizational collaboration is key in enabling improvisational relief work to meet unanticipated needs, as is quickly forging interorganizational partnerships. Flexibility was also crucial when it came to signing off on staff expenses and our decision to pay out employee wages in advance. These factors prevented the response from being hampered by staff financial concerns. All realistic emergency planning must build in flexibility in these areas. LOOKING AHEAD The next crisis will surely bring new challenges, ones we cannot anticipate. We hope that by describing how our partners were indispensable in Sandy and by sharing our experiences during these extraordinary circumstances, we have identified how the wider health care community can optimally work together before future disasters strike. In the case of Sandy, we had preparation time as we monitored the storm s movement and received updates from the New York City Office of Emergency Management. But even with advance notice, Sandy s impact was like nothing our organization had experienced before. And disasters can easily strike with no warning. A community recovers. The whole community must address the ongoing mental health issues that still affect Sandy victims. At this writing, people are still displaced. Many are still renting accommodations (mostly subsidized) or living with family members as they continue to wait for relief funding. In addition to displacement, the long-term consequences of Sandy include financial loss, limited transportation, low rates of employment, and an environment that still requires major reconstruction. As people repair their houses, they further confront environmental health risks, such as mold caused by flooding. And we are still seeing cases symptomatic of posttraumatic stress disorder, depression, and anxiety the lingering effects of a supremely trying time. Mary Ann Christopher is president and chief executive officer of the Visiting Nurse Service of New York, where Jill Goldstein is vice president of postacute care (Bronx and Westchester), infusion services, and the emergency response system. Contact author: Mary Ann Christopher, maryann.christopher@vnsny. org. The authors have disclosed no potential conflicts of interest, financial or otherwise. REFERENCES 1. Centers for Disease Control and Prevention. Deaths associated with Hurricane Sandy October-November MMWR Morb Mortal Wkly Rep 2013;62(20): New York Special Initiative for Rebuilding and Resiliency. PlaNYC: a stronger, more resilient New York. New York: The City of New York; html/report/report.shtml. 3. Leland J. Enduring the storm for homebound patients. New York Times 2012 Nov 1. nyregion/enduring-the-storm-for-homebound-patients.html. 62 AJN October 2014 Vol. 114, No. 10 ajnonline.com