INDIVIDUALIZED EMERGENCY PREPAREDNESS PLAN

The Agency therapist/nurse has assigned you to the following home health triage level:
Level I (Red) Life-threatening (or potential) – Services required as scheduled
  • Requires ongoing medical treatment/care
  • Any equipment dependent upon electricity should be listed with the power company
  • Oxygen dependent patients should be supplied with a back-up tank from provider
  • Does not have a caregiver capable of providing care
  • Requires assistance with transportation to hospital or specialized shelter

Level II (Orange) Not life-threatening, but patient might suffer severe adverse effects from interruption of services. Services could be postponed 24-48 hours
  • Like daily insulin, IV meds, sterile wound care with large amounts of drainage
  • Symptoms controlled with difficulty
  • Death appears imminent
  • Capable caregiver present
  • Will require transportation assistance to hospital or specialized shelter

Level III (Yellow) Visits could be postponed 24-48 hours without adverse effects – Services could be postponed 3 or more days
  • Sterile wound care with a minimal amount to no drainage
  • Symptoms need intervention but are fairly well controlled
  • Able to care for self or willing and able caregiver
  • Transportation available from family, friends, or others

Level IV (Green) Visits could be postponed 72-96 hours without adverse effects – Services could be postponed up to 2 weeks or longer, as needed
  • Sterile wound care with a minimal amount to no drainage
  • Symptoms well-controlled
  • Able to care for self or willing and able caregiver
  • Transportation available from family, friend or others

During a Disaster I Plan to:

Stay with a relative/friend in the area

Stay in Residence

As a Last Resort: Go to a shelter

Other – please describe ______

Assistance Required

Do You Anticipate Needing the Assistance of Another Person?

Yes

No

If so, do you have a caregiver that could go with you?

Yes

No

If Yes, Name: ______Relationship: ______

Telephone: ______Cell Phone: ______

Transportation Plan

Car

Taxi

Bus

Van

Ambulance

Name of Transportation Company or Family Member: ______

Transportation Company Telephone Number: ______

Medical Care Information(Check those that apply)

Memory Impaired

Speech Impaired

Sight Impaired

Hearing Impaired

Mobility Impaired

  • Walker/Cane
  • Wheelchair/Manual
  • Wheelchair/Scooter (powered)A
  • Other: ______

Mental Health Impaired – describe ______

Alcohol/Substance/Tobacco Use or Dependence

Insulin Dependent

  • Insulin Self-Administered

Open Wounds

Incontinence

Obesity – weight

Service animal ______

Bedridden

Oxygen dependent (portable) – oxygen supplier and phone number: ______

Dependent Upon Electrically Energized Equipment

Required electrical equipment

  • CPAP/BiPAP
  • Nebulizer
  • Respirator Dependent Details ______
  • Oxygen Concentrator

Dialysis Dependent

  • Hemodialysis
  • Peritoneal Dialysis
  • Dialysis, Portable
  • Other ______

Electrical Equipment Required: ______

Other: ______

Emergency Contact Information
Primary Emergency Contact Person / /
Call 911 for Emergencies / /
Non-Emergency Local Police / /
Local Red Cross / /
Local Emergency Management Office / /
Primary Care Physician / /
Pharmacy / /
Medical Equipment Supply Company / /
Critical health & human services / /
Poison Control / /

KidsCare Home Health Patient Emergency Preparedness Plan 1 of 1