Are Human Service Agencies Ready for Disasters? Findings from a Mixed-Methods Needs Assessment and Planning Project

Abstract

A mixed-methods design was used to assess the current capacity of human service agencies to provide services in a major disaster, identify challenges and successful strategies for providing those services, and formulate specific recommendations for government planners and the nonprofit sector to promote the integration of human service agencies into emergency preparedness and response. A web-based survey was completed by 188 unique human service agencies, 31 semistructured interviews were conducted with human service agency and government leaders from southeastern Pennsylvania and the mid-Atlantic region, and a collaborative planning meeting was held to review the findings and develop systems-based recommendations. Survey results indicated that human service agencies serve the most vulnerable communities during disasters and would welcome integration into preparedness and response plans, but they currently face challenges that include a lack of real-time communication and opportunities for collaborative planning with government partners. Interview findings were grouped according to 5 themes that emerged: capacity, coordination, communication, training, and leadership. This study identified recommendations to assist human service agencies, local health departments, and emergency management agencies as they work to ensure that needed human services are available during disasters, despite the resource challenges that most agencies face.

A web-based survey and semistructured interviews were conducted with human service agency and government leaders to assess the current capacity of agencies to provide services in a major disaster, to identify challenges and successful strategies for providing those services, and to formulate specific recommendations for government planners and the nonprofit sector to promote the integration of human service agencies into emergency preparedness and response. Survey results indicated that human service agencies serve the most vulnerable communities during disasters and would welcome integration into preparedness and response plans, but they currently face challenges that include a lack of real-time communication and opportunities for collaborative planning with government partners.

Increasingly, community preparedness for large-scale disasters has focused on improving the outcomes for populations who are most vulnerable to experiencing severe consequences.^1-6 Many emergency preparedness planners expect to rely on nonprofit agencies that provide human services to meet the social service needs of at-risk populations during disasters.^7,8 Engaging human service agencies that provide case management, housing, education, emotional support, and health services for vulnerable individuals in the community has thus become a priority for mitigating the human consequences of disasters and public health emergencies.

The mission of most human service agencies is to provide social or health-oriented services to vulnerable communities who need external support and assistance. These organizations are most familiar with the unique needs of the populations with whom they work, have earned their trust, and are likely to be the first source of information and assistance during a disaster.^4,7,9 Human service agencies have played an important role in assessing postdisaster needs and in mobilizing community and local resources to help facilitate recovery. Globally, nongovernmental organizations (NGOs) are often the mainstay of relief efforts following major humanitarian emergencies and catastrophic events such as the 2004 Indian Ocean tsunami,¹⁰ the 2010 earthquake in Haiti,^11,12 the 2011 earthquake in Fukushima, Japan,¹³ and the tsunami that struck the Philippines in 2013.¹⁴ In the United States, where the nonprofit sector is less practiced in disaster relief, human service agencies have also supported communities in need.^15,16 Following Hurricanes Katrina and Rita, these agencies provided immediate relief services such as food, water, shelter, clothing, medical services, personal hygiene services, and transportation, and they were instrumental contributors to human recovery, particularly for at-risk populations.^17,18

Despite this recent history, little is known about the readiness of most human service agencies in this country to deliver services during a major community-wide emergency, particularly one that requires integrating efforts with public safety and government partners.⁹ In fall 2011, the United Way of Greater Philadelphia and Southern New Jersey (UWGPSNJ) commissioned the Drexel Center for Public Health Readiness and Communication (CPHRC) to develop a white paper to assess the capacity for providing human services during disasters in the Philadelphia metropolitan area and to make recommendations for government planners and for the nonprofit sector to ensure the delivery of services in a coordinated fashion in this region. To accomplish this task, the CPHRC used a mixed-methods, systems-based approach to data collection that included a survey of human service agencies and interviews and meetings with representatives from both government and nonprofit agencies. This article summarizes the findings from that project.

Methods

Survey

A web-based survey was administered to human service agencies in the metropolitan region of Southeastern Pennsylvania (SEPA) to assess their existing capacity, needs, and perceptions of their ability to provide human services during and after major disasters. An email with a link to the survey was distributed electronically to 664 unique agencies in Bucks, Chester, Delaware, Montgomery, and Philadelphia counties (combined population 3.7 million) using databases and listservs maintained by the UWGPSNJ, the United Way of Chester County, and the Philadelphia Department of Public Health. The survey was also piloted with a group of 6 agencies similar to the intended sample population but located outside the SEPA region. The survey was accessible for 4 weeks in February 2012, and results were analyzed using SPSS data analysis software.

Interviews and Joint Planning Meeting

Following the survey administration, 31 semistructured interviews were conducted with SEPA human service agency and public sector leaders. The interview protocol was designed (1) to supplement the findings from the current literature and the survey results, (2) to determine how current emergency response and human service agency leaders view the roles of human service agencies in the emergency management cycle, (3) to identify current barriers to effective collaboration between human service agencies and the public sector, and (4) to formulate recommendations for increasing effective collaboration between human service agencies and government agencies.

Key informants were systematically selected from different regions in SEPA, from both the public and human service sectors. Interviews were held with emergency management and public health agency planners, preparedness program managers, volunteer management coordinators, and human service agency leaders from across the region, including representatives from disaster relief agencies as well as agencies without a traditional disaster mission. Several interview subjects worked for regional or county-based United Way organizations in the study area, including the UWGPSNJ, which sponsored this study. Interviews were also conducted with similar individuals from other areas of the country, including Virginia, Georgia, and New Jersey, that had experienced major disasters. Following each interview, we reviewed the findings independently and then again as a group. This iterative process of analysis allowed for a constant refinement of the interview protocol and ensured agreement on major emergent themes.

The Drexel CPHRC and the UWGPSNJ convened a collaborative planning meeting on October 22, 2012, with 32 key stakeholders from government and nonprofit sectors (many of the attendees had been interview subjects) to review the research findings and discuss how best to address human service needs after disasters. One week after this meeting, Hurricane Sandy struck the mid-Atlantic region of the country, affecting counties in this study area. Additional interviews were held with stakeholders from government agencies and human service agencies in affected counties in Pennsylvania and New Jersey to integrate experiences and lessons learned following the storm.

Results

Survey Results

Description of agencies and emergency preparedness capacity

Of the 664 agencies that received the survey, 596 met predetermined inclusion criteria (ie, they were located in the 5-county region of metropolitan Philadelphia and provided human or social services as a primary mission; hospitals, museums, institutions for religious worship, and institutions of higher learning were excluded), and 188 responded, yielding a response rate of 31.5%. Additional characteristics of responding agencies are summarized in Tables 1 and 2.

Table 1.

Characteristics of Human Service Agencies in Southeastern Pennsylvania Who Responded to Survey (N=188)

Characteristics	N (%)
Services
Human/social services	134 (71.3)
Healthcare related (home health services or community health center)	14 (7.4)
Both human services and health care	40 (21.3)
Staff size
1-25	74 (39.4)
26-100	55 (29.3)
>100	54 (28.7)
Missing response	5 (2.7)
Volunteers
0-25	80 (53.7)
26-100	56 (18.7)
>100	49 (26.1)
Missing response	3 (1.6)
Average number of clients served per year
≤1,000	78 (41.4)
>1,000	106 (56.4)
Missing response	4 (2.1)
Employ licensed healthcare professionals
Yes	92 (48.9)
No	95 (50.5)
Missing response	1 (0.5)

Table 2.

Types of Services Provided by Human Service Agencies Who Responded to Survey (N=188) (agencies could select multiple services)

Type of Human Service	Percentage of Agencies
Social work/case management services	53.2
Home visits/community outreach support services	41.0
Education services	38.8
Meals, nutritional support services	34.0
Mental health/behavioral health services	27.7
Housing services	26.1
Childcare services, after school programs	20.7
Childcare services, preschool programs	19.7
Transportation of clients services	18.6
Financial and benefits counseling	17.6
Medical care (onsite) services	16.5
Language translation and interpretation services	14.9

The majority of agencies reported serving communities generally considered to be at high risk for severe outcomes following disasters. Most (80.8%) provide services to either children or senior citizens (>65 years); 79.1% serve low-income or homeless communities; 73.8% serve traditionally underserved populations such as recent immigrants, people who are homebound, racial or ethnic minorities, or people who have been recently incarcerated; 71.1% of agencies provide services to individuals with chronic medical conditions or functional needs; 65.2% serve populations with either limited English proficiency or low literacy. A total of 135 agencies (71.8%) indicated that they know who their most vulnerable clients are and where they are located.

Agencies in the sample demonstrated a range of preparedness capabilities. With respect to business continuity planning, 86.2% have a plan in place to communicate with staff during a disaster, 76.9% have a plan in place to keep the agency's records secure during a disaster, 70.5% have a plan in place to maintain operations of critical services during a disaster, and 53.7% have a plan in place to coordinate service delivery information with other human service agencies during a disaster. Roughly one-third (34.6%) of agencies have all 4 of the aforementioned planning components in place, and of the entire sample, only 30.9% had used their plan in an actual emergency. Agencies that provide services to recent immigrants, culturally diverse populations, and homebound people (multivariate OR 4.457 [CI 1.711, 11.609]) or individuals with special medical or functional needs (multivariate OR 5.246 [CI 1.983, 13.879]) were more likely to have an emergency response plan.

Resource needs for emergency planning

Agencies identified a number of barriers to their efforts to operate during emergencies. The majority of agencies (73.9%) reported that they wanted to coordinate planning with funders to ensure they would have access to financial resources during disasters. Nearly two-thirds (64.9%) reported that communications equipment (eg, computers, cell phones) would be useful for their preparedness efforts. Eighty-five (45.2%) reported that they lacked sufficient staff or time to develop plans, and 55 (29.3%) reported that they had too many other priorities and preparedness planning was not critical to their mission. More than half of the agencies surveyed (56.4%) indicated a need for training in specific emergency scenarios (eg, pandemic, flood, radiation accident) and their likely effects. A smaller percentage indicated an interest in training to write emergency plans that addressed continuity of operations during a disaster (46.8%); first aid and CPR (45.2%); how to explain health information and concepts (43.6%); and psychological first aid and other mental health support measures (43.6%).

Real-time communication and information exchange with government and nonprofit partners was the most frequent resource identified as being needed for emergency preparedness and response (78.7%). The majority of agencies also indicated that they wanted opportunities for coordinated planning with government and other human service agencies (76.6%), access to a forum to share best preparedness practices with other agencies (73.9%), and the ability to plan with funders to ensure that resources and funding would be available during a disaster (73.9%). These data are summarized in Table 3. More than half of the responding agencies (52.1%) reported that they needed more information from government agencies to know what was needed from their organizations.

Table 3.

Resources Identified by Agencies as Useful for Emergency Planning and Response (N=188)

Question: Would these resources or activities be useful to your agency for emergency planning and response activities?	“Yes” Responses (%)
Real-time communication and information exchange with government and public safety agencies during disasters and emergencies	148 (78.7)
Coordinated planning with government and other human service agencies to clarify mutual expectations prior to disasters	144 (76.6)
Access to a forum to share best practices and other resources for human service agencies who wish to improve their disaster preparedness plans and capacity	139 (73.9)
Planning with funders to ensure that funding and other resources are provided	139 (73.9)
Communications equipment (eg, computers, cell phones)	122 (64.9)

Emergency response roles for human service agencies

Agencies were asked about their willingness to provide services during a major disaster in their community. Nearly one-third of the agencies (58 of 188, 30.9%) believed that government agencies were not sufficiently aware of their organization and the skills they might provide in an emergency. Over 80% responded “yes” (59.6%) or “maybe” (21.3%) when asked if they would be willing to participate in a community-wide response effort. Agencies with comprehensive emergency response plans were no more likely to be willing to participate in a larger response effort than were agencies without comprehensive plans in place. Respondents indicated that they would be willing to perform a variety of proposed roles, including providing information and education, needs assessment and outreach, supply distribution, psychological support, and sending staff to help public safety agencies. Responses are summarized in Table 4.

Table 4.

Potential Health Service Agency Response Roles During Emergencies

Question: In an emergency, would your organization be willing to:	%Yes	%Maybe	%No
Tell community where to obtain disaster assistance	68.6	22.6	8.8
Provide education and information about the disaster	59.6	32.9	7.5
Assess the needs of your clients and report them to public safety agencies	56.9	25.0	4.8
Give out supplies to disaster victims	39.4	33.0	13.3
Provide psychological and emotional support to people who are victims of the disaster	37.3	34.2	28.6
Send staff to volunteer with public safety agencies to assist in response efforts (eg, dispensing medications, staffing a call center)	35.0	41.9	23.1
Translate information and/or health education materials from English into another language	34.2	26.7	39.1
Perform outreach to people with physical or cognitive disabilities	31.3	39.4	29.4
Distribute pills or medications to clients (provided by the health department)	26.1	23.9	36.2
Deliver food and other supplies to people who are confined to their homes	25.0	30.3	29.8
Give out vaccines (shots) to clients	24.5	14.9	48.9
Transport clients to a shelter or other location for emergency aid	12.8	28.2	44.1

Interview Findings

Five major themes for human service agencies in disasters emerged from interviews and meetings with human service agency staff and government officials: capacity, coordination, communication, training, and leadership.

Capacity

Capacity, defined in this study as the ability to maintain human, financial, and supply resources that human service agencies require to provide services, was the major concern for both agency leaders and government agencies. Disaster-oriented agencies in the Southeastern Pennsylvania Volunteer Organizations Active in Disasters (SEPA VOAD) structure expressed concerns about their own capacity to respond to a major event, the capacity of the overall disaster response system, and the need for more agencies to participate. One member of SEPA VOAD said, “We need to overcome the perception that ‘Red Cross and FEMA do that, that's not our role.’ ” Many agencies without a traditional disaster relief focus did not perceive that they had a role in disaster response and believed that they could not meet the additional demands of disaster response and preparedness, particularly in light of recent budget cuts. “Every day is an emergency for us,” was a theme that recurred throughout interviews with agency directors. Moreover, agencies did not believe that government planners should rely on them to assist the large numbers of people in the community who have special needs, citing capacity concerns and the fact that many individuals with functional needs such as physical disabilities, intellectual and developmental disabilities, or communication challenges live independently in the community and have no affiliation with a social service agency.

Capacity challenges were also paramount after Hurricane Sandy. In several counties, the services of non-disaster-oriented agencies were enlisted to provide translation services in shelters, mental health support, food, and clothing to hurricane victims. Yet, additional agency participation was needed. The director of a major information and referral service in the region reported that there were insufficient resources for individuals with physical disabilities. Several area food banks were also quickly depleted of resources and had to suspend operations.

Coordination

Coordination, the ability of agencies to provide social services in an integrated system that matches resources with needs in optimal and efficient ways, was another predominant concern, particularly for government agencies. Emergency management planners expressed frustration at the lack of a comprehensive database of human service agencies in the region. There was uniform praise for SEPA VOAD as a successful planning and response organization that fostered agency coordination through preevent meetings and conference calls during major incidents, yet fewer than 20 agencies routinely participated in these calls. Some counties had begun to form county-based rosters of local human service agencies that they could draw on in an emergency. Emergency management and public health agencies that had hired “volunteer management coordinators” for this purpose felt that this was a worthwhile investment. During emergencies, these rosters or listservs were used successfully by emergency operations center staff to push out information and social service requests.

Communication

Communication is the exchange of information among government partners, peer agencies in the nonprofit sector, and the general public. Outside of the VOAD organization, there were many counties that lacked a formal communication infrastructure to reach human service agencies and engage them in disaster preparedness and response. One agency representative stated in a planning meeting, “If we're not asked, we cannot help, even though we have the capacity.” After Hurricane Sandy, the lack of a communications network in SEPA was a particular challenge for agencies. Several organizations involved in clean-up activities were quickly integrated into SEPA VOAD, which allowed for efficient communication of service requests. However, as noted earlier, food banks in one highly affected county were unable to replenish resources in the absence of any formal connection to the emergency management response structure.

The state of New Jersey benefited from a 211 call center system to receive and coordinate requests for social services. Representatives from New Jersey organizations thought that this system served the state well during Hurricanes Irene and Lee and during Hurricane Sandy by maintaining an up-to-date roster of agencies and available services and sharing information regarding service needs with the state's emergency management agency. After Hurricane Sandy, the representative from NJ 211 Partnership reported that they handled more than 90,000 calls and connected callers to “shelters, food, government resources, and, if needed, a mental health counselor.” Conversely, one SEPA VOAD member reported “The lack of 211 in Southeastern Pennsylvania was glaringly obvious; we really needed it. It was a major communication nightmare.” The United Way of Greater Philadelphia and Southern New Jersey has since launched a 211 system for the SEPA region.

Human service agencies also reported that, despite knowing who their most vulnerable clients are, they have little ability for proactive communication with their entire client base prior to or during a disaster. They felt that their outreach efforts during a disaster, while potentially valuable, would be limited.

Training

Training was defined as meeting the educational needs of the human service sector with respect to preparing for and responding to emergencies. Several concerns predominated in this area. Agency leaders stressed the lack of time to devote to training and education and the difficulties of taking any time away from work directly related to the agency's mission. They preferred on-site training so that most staff could benefit. Agencies also emphasized the need for “just-in-time” training during disasters that would optimize their capacity to provide disaster-appropriate services. Following Hurricane Sandy, SEPA VOAD was able to meet some of those needs, providing safety training to groups involved in tree removal and clean-up efforts.

A representative from a local public health department in this region reported that they provided successful emergency preparedness training to human service agencies in their community settings, encouraging them to promote personal preparedness planning and to participate in county response efforts.¹⁹ Public health department representatives also expected that human service agencies would assist with communication to clients during health emergencies. However, some agencies were hesitant about being asked to serve as “trusted intermediaries” for the transmission of health-oriented information that was outside the scope of their professional expertise. A planner from a state health department outside this region cited the use of “promotoras,” or lay individuals trained to serve as community health workers to provide health education in Hispanic communities, as a resource-intensive but successful program that improved immunization acceptance during the 2009 H1N1 pandemic.²⁰

Leadership

In both the interviews and the collaborative planning meeting, representatives from both government agencies and human service agencies called for leadership, defined in this study as the direction and guidance necessary to assure the coordination and availability of human services during disasters. Many felt that leadership was needed to engage the broad community of human service agencies without a specific disaster mission, ensure that they had plans for maintaining business continuity during emergencies, and integrate them into community-wide planning. Leadership in government and the nonprofit sector was also highlighted as critical for long-term recovery planning in both the SEPA region and in other areas of the country that have experienced major disasters.

Many human service agencies viewed the United Way as a “go-to” agency and welcomed their involvement in emergency preparedness planning and response. Representatives from both the SEPA VOAD organization and emergency management agencies also believed that the United Way should coordinate the efforts of regional social service agencies during disasters. A number of interview subjects pointed out that United Way organizations across the US had assumed leadership roles in recovery planning and in the distribution of financial resources after disasters, specifically in counties in New Jersey and New York after Hurricane Sandy, and in Russell and Washington counties in Virginia following severe tornadoes. The United Way leaders that were interviewed believed that the United Way was well suited for these tasks, given its experience with community development, the financial management of nonprofit agencies, and its relationships with government and the philanthropic community. However, not all United Way organizations had the resources, the internal infrastructure, or the support of their board of directors for this role, which is not central to their primary mission.

Discussion and Recommendations

Government public health and emergency management agencies have high expectations for community-based nonprofit human service agencies to provide services for vulnerable populations at high risk for severe consequences. This study aimed to assess the preparedness capabilities of human service agencies in a major metropolitan area of the United States, the degree to which they have been integrated into community-wide planning, and their ability to serve populations with special planning needs. To date, this study is among the largest of its kind to use mixed methods—survey data, interviews, and collaborative planning meetings—to identify gaps, needs, and solutions through future partnerships.^15,17,18

The survey component of this project confirmed many assumptions about the potential of human service agencies and the challenges they face. The clients they serve are among the highest-risk communities for poor outcomes during disasters. A lack of resources, a mission that is not focused on disaster relief, and a limited understanding of government agency needs and expectations are barriers to their integration into a community-wide response to emergencies. Despite these challenges, agencies reported that they were willing to serve a large number of useful disaster-response roles and participate in a community-wide response effort. Overwhelmingly, their most frequent request was for opportunities to plan and coordinate their emergency plans with government partners and to receive real-time information during disasters.

The interviews and group meetings that followed this survey reinforced these findings. Five significant issues emerged that should be addressed for human service agencies to participate fully in disaster preparedness in this region: capacity, coordination, communication, training, and leadership.

The capacity of individual human service agencies to maintain operations in a disaster remains a major challenge. Educating agencies regarding regional emergency management infrastructure and planning, and requiring even a modicum of participation in organizations like regional VOAD and other coalitions, would provide agencies with access to government resources during disasters, including additional volunteers and critical supplies. Agencies that provide case management, housing services, food, translation, home health, and mental health services have obvious roles to play after disasters, as do “gatekeeper” agencies that work with vulnerable or disenfranchised individuals, despite the fact that their primary mission is not disaster relief. Their integration into disaster preparedness coalitions would considerably increase the region's capacity to meet the social service needs of disaster victims. Ensuring that human service agencies have business continuity plans will also advance their capacity to serve clients during emergencies.

Coordination of the many human service agencies that exist in the region is a challenge even in the absence of disasters that generate significant human service needs while disrupting the system that meets them. Government and nonprofit organizations that fund human service agencies can require that they participate in regional emergency planning coalitions, county or regional VOAD organizations, and in local, regional, and statewide 211 information and referral services. Even a “no-commitment-required” participation, given the understandable reluctance of many agencies to promise service delivery and expansion during disasters, would provide the groundwork for bi-directional communication during disasters that could help to sustain agencies and their services. Volunteer management coordinators, working on behalf of government agencies or other organizations charged with outreach and liaison to the social service system, are also another successful approach to organizing the work of many well-intentioned individuals and agencies during disasters.

Communication is the foundation for the collaborative mechanism that engages and supports the work of human service providers. Regional coalitions like VOAD create opportunities to address these issues in disasters, as does participation in information and referral services like 211 systems. These initiatives also provide a way for government public safety agencies to clarify the expectations for human service agencies before as well as during disasters, to plan, and to promote partnerships. In the days that followed Hurricane Sandy, many communities relied on volunteers for door-to-door outreach to homebound seniors and others who lacked electricity, heat, food, and medication.^21,22 While this outreach served a critical purpose, it was often uncoordinated and not linked to public safety agency efforts. Predisaster planning with human service agencies might have anticipated these as well as other roles that human service agencies played in the wake of that storm, to help them meet their operational needs and coordinate their service delivery.

Training in disaster preparedness is important for social service agencies whose mission does not focus on disaster relief, but it is a luxury that requires staff time most organizations cannot afford. Emergency management and public health departments will need to plan to provide some just-in-time education for organizations during disasters, but focused preevent training can build relationships and expand capacity. Annual conferences and forums for all human service agencies held at the county or regional level can extend social service capacity and promote broad engagement in emergency preparedness. In addition, public health agencies have longstanding partnerships with human service agencies to provide services in important public health programs like maternal and child health, HIV education and testing, and other health promotion and disease prevention projects. The community health workers in these organizations have a skill set and commitment to the health of diverse communities that has benefited preparedness efforts, particularly during emergencies with health impacts. Leveraging these relationships requires advance planning and additional training to take advantage of the knowledge base and trusted intermediary status these organizations have in the community during incidents that require nongovernment voices for risk communication.

Finally, leadership from government agencies, the nonprofit community, and the philanthropic sector is needed to define roles and promote the activities that are needed to provide human services following a disaster. In many places, United Way organizations have emerged as leaders and coordinators of recovery efforts, despite the fact that they are not primarily a disaster relief enterprise. Their contributions and success in assisting communities in the wake of disasters should be acknowledged by their boards and perhaps integrated into their mission and vision. Their support of 211 systems across the country is an example of an investment that provides both day-to-day support for social services and access during disasters when demand for those services is most critical.

Conclusion

Effective planning for human service delivery during disasters requires the collective leadership of government agencies, umbrella organizations like United Way, and both disaster and nondisaster-focused agencies. Human service agencies have very real human resource and financial needs that will undermine their ability to provide services in disasters. These concerns are major barriers to their participation in predisaster planning and in regional coalitions and must be acknowledged early and by all sectors before planning can begin in earnest. This study identified a number of best practices to assist both government public safety agencies and the nonprofit human service sector as they work to ensure that needed human services are available during disasters, despite the resource challenges that most agencies face.

While this study focused on one metropolitan region, the findings and recommendations that were identified are relevant in regions across the country, where social services are an important component of community resilience. Government agency planners and leaders from the nonprofit social service sector should collaborate to take advantage of the expertise that human service agencies have regarding the needs of at-risk communities, so that they are prepared and connected to organizations that can assist them when needed. Ultimately, disasters play out in unpredictable ways and a community's ability to endure and recover may depend on the human service agencies that can assist the people who may have suffered the most.

Footnotes

Acknowledgments

The authors wish to thank Sara Pagni, Tara Gaudin, and Wendy Davis of the United Way of Greater Philadelphia and Southern New Jersey for assisting with survey distribution, qualitative data collection, and compilation of the white paper that led to this manuscript. Chad Thomas of the Philadelphia Department of Public Health and Terry Kenworthy of the United Way of Chester County assisted with survey distribution to human service agencies. Hilary Kricun and Rachel Peters of the Center for Public Health Readiness and Communication, Drexel University School of Public Health, contributed to study design, data collection, and analysis. Yvonne Michaels of the Drexel University School of Public Health provided oversight for the data analysis. Financial support for this project was provided by United Way of Greater Philadelphia and Southern New Jersey (UWGPSNJ). The contents of this article are solely the responsibility of its authors.

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. Old, frail and in harm's way. New York Times November 5, 2012. http://newoldage.blogs.nytimes.com/2012/11/05/old-frail-and-in-harms-way/?module=Search&mabReward=relbias%3Aw%2C%7B%222%22%3A%22RI%3A15%22%7D. Accessed June 1, 2014.