Defining "At Risk" Populations

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Purpose

A number of definitions currently exist that attempt to define what “at risk” populations means. This document is intended to review several major definitions and compare and contrast them. Minnesota has for some time utilized a definition that included thinking of those considered “at risk” as having concerns with Communication, Medical, Independence, Supervision, and Transportation services, otherwise know as CMIST. Over time this approach has been adopted by most federal agencies and others. There are slight variations between some of them, but in general they are very similar. To hopefully clear up any confusion we will present the main definitions, discuss similarities, differences, and then present the definition here in Minnesota.

In all cases, the definitions presented may appear as people who fall into specific categories, but the key to understanding any of these is based on function. Understanding how a person is functioning during and after a disaster. An individual may for example have a low or no vision, however, this does not automatically mean they have a “special need.” That individual may have done personal planning and or have the necessary equipment needed to maintain functional independence and therefore may function better than others who appear to not fall into any of the categories. On the other hand, if that same individual lost access to the equipment or aids that allowed for daily functional independence, then he/she may need assistance in securing the items needed to regain functional independence.

Overarching Principles

Several overarching principles rise to the surface when determining who may be considered “at risk”:

1. Not all people who are considered “at risk” are
2. One cannot automatically tell who is “at risk” simply by appearance
3. There may be differences in who is more “at risk” than others depending on the type and or kind of crisis.
4. CMIST is a useful tool but is just a starting point

Major Definitions in Use

There are three main definitions out there from federal and other agencies;

The definition used in the National Response Framework (NRF) is as follows;
Populations whose members may have additional needs before, during, and after an incident in functional areas, including but not limited to: maintaining independence, communication, transportation, supervision, and medical care. Individuals in need of additional response assistance may include those who have disabilities; who live in institutionalized settings; who are elderly; who are children; who are from diverse cultures; who have limited English proficiency or are non-English speaking; or who are transportation disadvantaged.

The Comprehensive Preparedness Guide (CPG) 301, Emergency Management Planning Guide for Special Needs Populations Federal Emergency Management Agency and DHS Office for Civil Rights and Civil Liberties:

This definition is the same as the NRF.

A second definition is put forth by the US Department of Health and Human Services, At Risk, Behavioral Health, and Human Services Coordination (ABC) are using the following definition:

Before, during, and after an incident, members of at-risk populations may have additional needs in one or more of the following functional areas: communication, medical care, maintaining independence, supervision, and transportation. In addition to those individuals specifically recognized as at-risk in the Pandemic and All-Hazards Preparedness Act (i.e., children, senior citizens, and pregnant women), individuals who may need additional response assistance include those who have disabilities, live in institutionalized settings, are from diverse cultures, have limited English proficiency or are non-English speaking, are transportation disadvantaged, have chronic medical disorders, and have pharmacological dependency.

The third definition by the Association of State and Territorial Health Officials (ASTHO) is similar to the one adopted by ABC, but adds in additional factors to consider such as economic disadvantage and a lack of a support system.

Comparisons

These three definitions are very similar and compatible with the National Response Framework (NRF), although there are subtle differences as the HHS definition adds in pregnant women, chronic medical disorders, pharmacological dependency, and the ASTHO also adds in factors that could lead to becoming at risk with the economic disadvantaged and lack of support system.

Minnesota and “At Risk” definitions

After reviewing these definitions and looking at them from a functional perspective, a combination of the three seem to make sense when considering how Minnesota looks at the “At Risk” populations. 

Starting with the CMIST categories, examples may include (Kailes and Enders 2006):

Communications - Most people who have limitations that interfere with the receipt of, and effective response to information are self-sufficient, but need information provided in methods that they can understand and use. This is a very large and diverse population of those who will not hear, see or understand, in addition to those who cannot hear, see or understand. They may not be able to: hear verbal announcements, see directional signage to assistance services, or understand how to get food, water and other assistance because of a hearing, understanding, cognitive or intellectual limitations.
They include people who:

• are culturally diverse,
• Have limited or no ability to speak, read or understand English,
• have reduced or no ability to speak, see, and hear, and
• have limitations in learning and understanding.

Medical - includes individuals who are not self-sufficient, or do not have or have lost adequate support from family or friends and need assistance with:

• Activities of daily living such as bathing, feeding, going to the toilet, dressing, and grooming;
• managing unstable, chronic, terminal or contagious health conditions that require observation, and ongoing treatment;
• Managing medications, intravenous (IV) therapy, tube feeding and/or regular vital signs readings;
• Dialysis, oxygen, and suction administration;
• Managing wounds, catheters or ostomies; and
• operating power-dependent equipment to sustain life.
  People with visible disabilities tend to be automatically, but often mistakenly, placed in this category.

Maintaining functional Independence:
Maintaining functional independence can include:

• Medical stabilization – replacing essential medications (blood pressure, seizure, diabetes, psychotropic, etc), and
• Functional mobility restoration – replacing lost or damaged durable medical equipment (wheelchairs, walkers, scooters, canes, crutches, etc) and essential consumable supplies (catheters, ostomy supplies, padding, dressings, sterile gloves, etc.), and assistance with orientation for those with visual limitation.

Supervision needs - Support for individuals who are at risk of losing adequate support from family or friends. People with supervision needs can include:

• people who require assistance from a personal care attendant
• People who decompensate because of transfer trauma, trauma stressors that exceed their ability to cope, or lack of ability to function in a foreign environment;
• People with conditions such as dementia, Alzheimer’s and psychiatric conditions such as depression, schizophrenia, and intense anxiety;
• People who function adequately in a familiar environment, but become disoriented and lack the ability to function in an unfamiliar environment;
• Unaccompanied children

Transportation needs: Emergency response requires mobility. Many people cannot drive due to disabilities, age, addictions, legal restrictions, etc. (Littman 2005). This may include people who are old, poor, and people who need wheelchair accessible transportation. Many non-drivers and people from zero vehicle households can function independently once evacuated to safety.

Adding in the additional factors from the ASTHO definition of economic disadvantaged, socially / culturally isolated often impedes their ability to potentially receive information, have adequate transportation, have adequate support systems or have needed resources.

It’s easy to see that some individuals may fall into more than one category using the CMIST acronym. While this appears at first glance to be an overwhelming number of people, it is important to remember that not all who could fall into the “at risk” definition are unable to manage.

Many folks considered “at risk” are perfectly capable and able to manage during crisis and disaster, especially if prepared ahead of time.

While planning for the “at risk” populations seems an insurmountable task, task to undertake, it is manageable, especially when one understands and knows the communities they serve. Pre-planning is the key. Understanding our communities, understanding who lives in the communities, and what organizations are there makes it possible to prepare. It is not necessary that we know each individual, but knowing who to partner with is. Each community will have people in all of the CMIST categories, but each community also has differences. Each community has community based organizations that provide services as well as faith communities that are often very willing to partner. Another entity that provides services / programs is the local DHS office. They often are aware of programs that serve many of the “at risk” populations in the area and could be good sources of not only information but possibly also introductions. Adding in emergency management as well and the potential exists there to coordinate educational efforts as well as learning who the leaders are within the community that has local connections. 

Often, once members of the CMIST communities become aware of who they need to know, opportunities may develop to provide education, communities begin to understand where and who to seek out for accurate and timely information, and the task becomes a shared partnership rather than an overwhelming responsibility.

One caveat when defining “who” is considered “at-risk,” is also understanding that there will be times when these parameters shift a bit. For example, in the case of extreme heat, others may be also considered at risk such as outdoor workers and athletes or in the case of pan flu, some groups may be considered at higher risk than others and target groups may be added. The CMIST group along with other factors is used as a base and adjustments may be necessary depending on the specifics of an incident.