STRENGTHENING COMMUNITY RESILIENCE: Supporting Older Adults Through Emergency Preparedness and Response in a Post-COVID Era An Update to "Resilience Communities: Empowering Older Adults in Disasters & Daily Life"" AUTHORS Clara Scher, LMSW, MSc | Mario Rubano, MPH Andrea Diep, MPH | Elana Kieffer, MBA NEW YORK ACADEMY OF MEDICINE THE TABLE OF CONTENTS EXECUTIVE SUMMARY........ccceunee. 3 INTRODUCTION. ..o, 4 METHODS........ooeees 9 RESULTS.....cociiieeerrrree 11 RECOMMENDATIONS........cccoveeen. 16 ACKNOWLEDGEMENTS................. 18 REFERENCES.......coooiiiiiiiies 19 Executive Summary Problem New York City (NYC) has faced several new and unprecedented challenges brought on by the ongoing climate crisis and COVID-19 pandemic. When COVID-19 reached the United States, NYC became the epicenter of the outbreak. It is estimated that in the first three months of the pandemic, approximately 77% of COVID-19 related deaths in New York State were of those 85 and older. Older adults are disproportionately affected by COVID-19 due in part to the increased presence of chronic conditions (e.g., hypertension, cardiovascular disease, and diabetes) and immunodeficiency. The purpose of this report is to summarize the ways in which older adults and aging service providers have demonstrated resilience in responding to the COVID-19 pandemic and ongoing climate change events as well as develop recommendations to support older adults and the professionals who work with them-in NYC and beyond-in the face of future emergencies. This report was guided by the RAND Corporation''s Framework for Community Resilience, which suggests that a community's response to and recovery from a disaster is determined by the extent to which it draws on several levers of community resilience. Approach NYAM conducted a review of relevant literature to understand the knowledge base around community resilience among older adults and aging service providers. To inform our findings, we also consulted the U.S. Census Bureau's American Community Survey and NYAM's mapping visualization tool, the IMAGE:NYC Interactive Map of Aging (http://imagenyc.nyam.org/), to understand the sociodemographic landscape among older adults in New York City during and immediately after the peak of the COVID-19 pandemic. In addition, we conducted six hour-long key informant interviews with several stakeholders who had considerable experience working with older adults both before and during the COVID-19 pandemic. We also conducted six 90-minute focus groups with older adults at JASA sites in Brooklyn (Coney Island and Bushwick], the Bronx (Crotana Park East and Van Cortlandt), Manhattan (Harlem), and Queens (Far Rockaway). The data analysis involved developing a preliminary coding shell based on sensitizing concepts from the RAND Community Resilience Framework. An iterative coding process was then conducted by three coders using NVivo 12 qualitative analysis software. Key Themes Our analysis revealed-before and during future disasters and emergencies--the importance of; 1. Developing partnerships between government, non-governmental organizations, volunteers, and interns, as well as older adults partnering with each other to provide peer-to-peer support. 2. Educating older adults about disaster preparedness and response through one-one-one communication (e.g., emails, calls, texts); webinars, presentations and trainings; and cable access television. 3. Ensuring efficiency of programs and services such as COVID-19 related services, case management and wellness check ins, and virtual programming. 4. Promoting access to resources, services, and opportunities for social connection among older adults. Next Steps NYAM plans to disseminate recommendations based on the findings of this report through a webinar targeting a national audience in partnership with relevant stakeholders. In addition, we will also disseminate a resource in English and Spanish that is geared specifically towards older adults that includes concrete action steps based on these recommendations. Finally, we will engage in policy analysis and advocacy towards the implementation of these recommendations to increase community resilience within New York City and improve future outcomes for older people in future disasters. NYAM.org 3 INTRODUCTION OVERVIEW Since the release of The New York Academy of Medicine's [NYAM]) original 2014 report, Resilient Communities: Empowering Older Aduits in Disasters and Daily Life,! New York City (NYC) has faced several new and unprecedented challenges. The ongoing climate crisis poses new dangers as higher temperatures lead to more frequent, rapidly intensifying storms and hurricanes as well as heat-related illnesses.? In addition, since the City's first confirmed case in February of 2020, approximately 45,000 New Yorkers have died of SARS-CoV-2.34 These crises have tested the resilience of New Yorkers and the communities they live in-and, in particular, older adults whose physical and mental health have been disproportionately impacted by the virus.® The COVID-19 pandemic highlighted ingrained ageism in American society. Older adults were often portrayed as vulnerable® and unworthy of resource-intensive COVID-19 response efforts." Aligned with the Reframing Aging Initiative's mission to enact social change by improving the public's understanding of the many ways that older adults contribute to our society,? researchers and advocates alike have called for using a strengths-based perspective to highlight the resilience of older adults and the providers who worked with them during the COVID-19 pandemic.57® NYAM's 2014 report evaluated the assets and needs of community-dwelling older adults during disasters that resulted in power outages and service interruptions, with a special focus on the impacts of Hurricane Sandy.! In addition, the report presented recommendations to improve formal and informal support systems to enhance future outcomes following adverse events. The purpose of the current report is to summarize the ways in which older adults and aging-service providers THE NEW YORK ACADEMY OF MEDICINE 4 have demonstrated resilience in responding to the COVID-19 pandemic and ongoing climate change events as well as build on previous findings to develop recommendations to support older adults and the professionals who work with them-in NYC and beyond-in the face of future emergencies. This data analysis for this report was guided by the RAND Corporation's Framework for Community Resilience,"® which suggests that a community's response to and recovery from a disaster is determined by the extent to which it draws on several levers of community resilience. THE IMPACT OF COVID-19 ON OLDER ADULTS The application of community resilience frameworks to support older adults during an emergency is timely given the rapidly growing population of older adults. Figure 1displays the projected population changes among adults aged 65 and older in NYC from 2010 to 2030. In various neighborhoods within all five boroughs, the population of adults 65 and older is expected to increase anywhere from 25% to 100% by 2030. Currently, NYC is home to more than 1.2 million adults over the age of 65, representing approximately 15% of the City's total population." When COVID-19 reached the United States, NYC became the epicenter of the outbreak. It is estimated that in the first three months of the pandemic, approximately 77% of COVID-19 related deaths in New York State were of those 65 and older.? Older adults are disproportionately affected by COVID-19 due in part to the increased presence of chronic conditions (e.g., hypertension, cardiovascular disease, and diabetes) and immunodeficiency. East Orange Hicksville NEWARK Floral Park Levittown We Elmont Hempstead Union Linde ELIZABETH _ Bayonne Valley Stream . Freeport Projected Population 2 Change Age 65+ 2010-2030 the projected change in population age 65+ from 2010 to 2030 Woodbridge e AT [ Decrease 25% or more (x'/ g Decrease up to 25% ["] Increase up to 25% B Increase 25 to 50% ok B Increase 50 to 100% d Bridge B 'ncrease more than 100% Figure 1. Project Population Changes Among Adults 65+ in New York City As aresult, the COVID-19 pandemic had substantial health and social effects on older New Yorkers living in both community and institutionalized settings," and these effects were particularly evident among older adults who are ethnoracially marginalized. Structural racism contributed to the racial and ethnic inequalities in COVID-19 burden that manifested due to factors such as an increased risk of exposure to the virus and disparities in healthcare access and quality. For example, one study that interviewed residents aged 70 and older in New York City during the pandemic found that 29% of Latino NYAM.org respondents screened for depression compared to 15% among all ather races."® The study also found that 43% of Black and 43% of Latino respondents reported using a food pantry during the pandemic, compared to 35% of respondents of another race and ethnicity and 18% of non-Hispanic white individuals. In addition, results suggested that while 78% of respondents in the study had internet access, only 68% of Latino respondents and 71% of Black respondents reported having access compared to 84% of white individuals. In addition, social isolation brought on by the COVID-19 pandemic resulted in negative effects on older adults' mental health, such that in New York City older adults experienced double the rate of depression in 2020 to 2021 (19%]) compared to the 2017 New York City Community Health estimate of 9%." Furthermore, many older New Yorkers live alone,®and this presented a significant challenge in providing adequate social support due to strict social distancing measures. Those without established support systems had to navigate obtaining necessities like groceries and medications on their own.'® In addition, older adults who lived in long-term care facilities experienced social isolation as visiting and communal hours were restricted or eliminated. In New York City, visitation was not allowed unless there were no new COVID-19 cases in the facility for the past 14 days, adequate staffing was available, and/or adequate testing of patients was available." COMMUNITY RESILIENCE IN RESPONSE TO COVID-19 Use of Community Resilience Frameworks During the COVID-19 Pandemic Chandra et al. (2011] define community resilience as "the ongoing and developing capacity of the community to account for its vulnerabilities and develop capabilities that aid that community in 1) preventing, withstanding, and mitigating the stress of a health incident; 2) recovering in a way that restores the community to a state of self-sufficiency and at least the same level of health and social functioning after a health incident; and 3] using knowledge from a past response to strengthen the community's ability to withstand the next health incident." A proliferating number of studies have adopted community resilience frameworks to guide research on response and resilience to the COVID-19 pandemic.?® Researchers have stressed that resilience among older adults during the COVID-19 pandemic was primarily achieved through enhancing social connectedness through technology.8%° The RAND framework for community resilience used in the original 2014 report to guide the analysis of results] is valuable as a model because it aims to guide federal, state, and local leaders who are developing plans to enhance community resilience for health security threats."® Figure 2 displays the framework which identifies several levers of community resilience including:™ » Wellness-promoting pre- and post-incident population health o Access-ensuring access to high-quality health, behavioral health, and social services o Education-ensuring ongoing information to the public about preparedness, risks, and resources o Engagement-promoting participatory decision-making in planning, response, and recovery activities o Efficiency-leverage resources for multiple use and maximum effectiveness o Self-sufficiency-enabling and supporting individuals and communities to assume responsibility for their preparedness; and o Partnerships-developing strong partnerships within and between government and nongovernmental organizations. THE NEW YORK ACADEMY OF MEDICINE 6 Levers of community resilience Wellness-Promote pre- and post-incident population health, including behavioral health Core components of community resilience Access-Ensure access to high- quality health, behavioral health, and social services e Education-Ensure ongoing information to the public about Social and economic well-being of the community Physical and psychological health of population preparedness, risks, and resources before, during, and after a disaster Engagement-Promote participatory decisionmaking in planning, response and recovery activities Effective risk communication information for all populations A Social connectedness for resource exchange, A4 Self-Sufficiency-Enable and support individuals and communities to assume responsibility for their preparedness A4 Partnership-Develop strong partnerships within and between government and nongovernmental organizations v Integration and involvement of organizations (govt/ NGO) in planning, response, and recovery cohesion, response, and recovery Community context \ /anoinq » ( development of community "\ \\resilien(e Ongoing disaster experience Ongoing activities Efficiency-Leverage resources for multiple use and maximum effectiveness [Quallty-Collen, analyze, and utilize data on building community resilience] Figure 2. The RAND Corporation's Framework for Community Resilience According to the framewaork, these levers of community resilience enable communities to maximize five core components of community resilience-social and economic well-being, physical and psychological health, effective risk communication, social connectedness, and integration of organizations-all of which determine how successfully a community can respond to a disaster. For the purposes of the current report, we focus on four levers of community resilience that were particularly relevant to the COVID-19 pandemic-partnerships, education, efficiency, and access-based on the perspectives of older adults and other key informants (e.g., aging-service professionals] living and working in NYC. Importantly, the framework is limited in that it does not explicitly address challenges to disaster preparedness and response due to inequities in social determinants of health among older adults, such as disparities in income, education, food insecurity, and housing. Community Resilience Among Older Adults There were several ways that older adults demonstrated resilience in response to the COVID-19 pandemic. For example, one common method to cope with social isolation was via technology, using methods such as texting, email, or social media platforms to engage with friends and family.®® Beyond social support, older adults also leveraged technology to assist with everyday tasks such as ordering food online or participating in telehealth appointments."® In addition, some older adults took faith-based or spiritual approaches to mitigate social isolation and connect with others, such as attending religious services on Zoom or by phone.® Older adults demonstrated resilience in terms of their outlook on the disaster. One study that interviewed homebound older adults living in NYC during the early stages of the pandemic found that compared to younger adults in NYC the older adults reported higher rates of depression but less negative mental health consequences.? The researchers speculated that this could be due to increased coping skills and resilience from experiences over a lifetime. Another study examined whether individuals maintained a positive outlook throughout the COVID-19 pandemic, and found that older age was associated with higher levels of hope and focus on "silver linings."2 NYAM.org Community Resilience Among Aging Service Providers in NYC NYC provided a wide array of services targeting the older adult population during the COVID-19 pandemic. In particular, area agencies on aging [AAAs}-community-centered organizations that serve adults aged 60 and over-drew on their expertise in community needs assessments and cross-sectoral partnerships to serve older adults during the crisis.?® For example, NYC Aging-the AAA serving NYC-partnered with NYC Emergency Management to provide masks and hand sanitizer to older adults in older adult centers and cooling centers. In addition, the Get Coal program--facilitated by NYC Emergency Management--distributed and installed approximately 73,000 free home air conditioners to low-income adults aged 60 and older living in both New York City Housing Authority public housing and private housing.?* An evaluation of this program found that it successfully kept older adults at home during hot weather events and minimized feelings of heat-related iliness.% Previous research has shown that Black, Latino, and low-income residents are less likely to have AC units compared to non- Hispanic white individuals, therefore making home-based cooling a necessity to address disparities in access.® Other services were also provided to mitigate the negative mental health effects of the pandemic. NYC Aging, in partnership with the Mayor's Office of Community Mental Health, developed the Friendly VOICES program that matched volunteers with older New Yorkers to reduce social isolation. Much like a friendly visiting program in which volunteers visit older adults in their homes, the Friendly VOICES program had volunteers keep in touch with their matches via phone or video calls.?® An estimated 183,290 older adults in NYC lived in food-insecure households in 2020.2 To maintain food access during the pandemic, older adult centers remained open to offer Grab & Go Lunches.?® Some older adult centers provided meal delivery and additional frozen meals to minimize the number of visits.?® Furthermaore, once the Johnson & Johnson vaccine became available in March 2021, NYC rolled out an in-home vaccination service to homebound older adults. This service had a considerable effect on vaccination rates since the program also vaccinated eligible household members, therefore protecting older adults and any family members or friends they lived with.?7 By the end of May 2021, mare than 9,000 homebound New Yorkers had received the vaccine, and more than 3,000 of their respective household members were also vaccinated.® Focus of the Report Given the health impacts of the COVID-19 pandemic on older New Yorkers, this report sought to build on the results of the 2014 report to address the following questions: 1. How did older adults and aging-service providers respond to the COVID-19 pandemic? 2. What recommendations can older adults and aging-service providers offer to help prepare and guide planning for future disasters? THE NEW YORK ACADEMY OF MEDICINE 8 METHODS Review of Existing Literature NYAM conducted a review of relevant literature to understand the knowledge base around community resilience since the publication of the original 2014 report. Guided by the previous report, NYAM used a combination of keywords such as "older adults;' "COVID-19;" *pandemic," "disaster," "emergency," response, 'evacuation, "preparedness, mental health, and "community resilience" to search several databases such as PubMed, Ageline, and Google Scholar, as well as nonacademic literature such as reports or blog posts. Analysis of Secondary Data To inform our findings, we drew on the U.S. Census Bureau's American Community Survey to understand population health changes among older adults in New York City at the peak of the COVID-19 pandemic. We also consulted NYAM's innovative mapping visualization tool, the IMAGE:NYC Interactive Map of Aging (http:// NYAM.org imagenyc.nyam.org/), an interactive online mapping tool used by practitioners and policymakers to visualize and analyze local New York City data and resources inan effort to address unmet needs among older adults. Interviews with Key Informants We conducted six hour-long key informant interviews with several stakeholders who had significant experience working with older adults both before and during the COVID-19 pandemic (see Appendix for the structured interview guide used for key informant interviews). Some interviews were one-on-one, while other interviews included multiple stakeholders from the same arganization. The key informant interviews were conducted with aging-services professionals, including an older adult center staff member, a naturally occurring retirement community (NORC) director, a municipal employee, a leader of a disaster preparedness and response coalition, a case manager, and a nurse. Focus Groups We conducted a total of six 80-minute focus groups with older adults in Brooklyn (Coney Island and Bushwick], the Bronx (Crotana Park East and Van Cortlandt), Manhattan (Harlem) and QUeens Far Rockaway). These focus groups were facilitated at senior centers and NORCs. Four of the focus groups were conducted in English, and two were conducted in Spanish [see Appendix for the structured interview guide used for focus groups). Participant recruitment was completed in collaboration with JASA (Jewish Association Serving the Aging)-a community- based agency that provides essential support services to older adults-and other neighborhood partners within the NYAM network (age-friendly neighborhood organizations, community-based organizations, etc.). NYAM also reviewed the 2023 "Community District Needs Statement"31-a profile which identifies the top concerns for community members and indicates areas of focus for the ensuing year-for each community district where focus groups were conducted to inform the development of relevant focus group questions. Participants were given $25 Amazon gift cards in appreciation for their time. Analytic Strategy An iterative coding process was conducted by three coders using NVivo 12 qualitative analysis software. The analysis involved developing a preliminary coding shell based on sensitizing concepts from the RAND Community Resilience Framework. NYAM staff conducted several rounds of coding to elicit key themes and recommendations from aging-service providers and older adults. THE NEW YORK ACADEMY OF MEDICINE 10 ! oy e e RESULTS PARTNERSHIPS The theme of partnerships emerged when stakeholders or older adults described developing strong relationships with and between government and nongovernmental organizations." To accomplish their work during the pandemic, key informants shared the ways in which they partnered with local government (e.g., the Borough President's office, local community boards), nongovernmental organizations (e.g., local foundations and nonprofits), as well as volunteers and interns. In addition, older adults discussed the ways in which they supported one another throughout the pandemic. Government Several key informants shared the impartance of forming relationships with local government in the event of an emergency. In particular, funding from local government was instrumental in developing and sustaining programs and services during disasters. For example, one key informant shared how their organization NYAM.org received funding from the Office of the Borough President to "provide micro-grants to community- based organizations to do education and equity work around vaccines" which "allowed our organization to reach more marginalized populations of older adults." Another key informant discussed how local community boards were essential in forging relationships with other organizations, describing how "we work extensively with our local community board...their district manager knows everyone and facilitated many connections for us." Local government was a key partner in facilitating emergency services, such as distributing personal protective equipment (PPE] to community members during the pandemic: "We got the rapid test kits to the Borough President's office and instructed all Council Members' chiefs of staff to go pick up a few boxes and bring them to their local offices so we could use their offices as distribution hubs to disseminate rapid test kits locally." 1 Nongovernmental organizations Key informants explained the ways in which several nongovernmental organizations were crucial partners in their crisis response efforts. For example, organizations such as LiveOn NY and OATS provided important information about COVID-19-services available to older adults and ways older adults could engage with technology- that key informants were able to pass along to their clients. In addition, one key informant described how their partnership with a church enabled them to distribute home-delivered meals to older adults: "Our organization is located in the basement of a church. The pastor of the church is the treasurer of our board and he was able to reach out to his congregants and got a number of them to help us fill in when we were strapped for manpower with the home delivered-meals." Volunteers and interns Partnering with volunteers and interns was essential to aging-service providers during the pandemic given the increased need for services among older adults. One key informant explained how partnering with their social work interns allowed their organization to "make more wellness calls to older adults with serious mental illnesses and supportive housing needs." In addition, another key informant described how volunteers allowed the organization to make and distribute large quantities of home-delivered meals: "Our volunteers helped make our cold packs that go out along with our hot meals [to our older adult clients]. The cold packs were hand- assembled every morning by our volunteers and we served 650 people a day." THE NEW YORK ACADEMY OF MEDICINE Peer-to-peer support Older adult participants discussed the ways in which they supported one another during the pandemic. For example, one older adult shared that */ got food that | couldn't eat so | called people that | knew could use it and gave it away," while another "would pick up some things from the grocery store for those [older adults] not able to go." Participants also talked about the ways they provided emotional support to one another during the crisis: "l knew [an older adult] who was single and didn't have any help, so | was always calling in to check on them."" Furthermore, one older adult described their building "like a family-if [other older adults who live in the building] didn't see us for two or three days, they would knock on our door to make sure we're all right." EDUCATION The theme of education emerged when stakeholders "ensured ongoing information to the public about preparedness, risks, and resources before, during, and after the disaster."™ Key informants shared two primary approaches to educating older adults during the COVID-19 pandemic: 1) one-on-one communication (e.g., emails, calls, robocalls, and texts); and 2] informational webinars, presentations, and trainings. While older adults benefitted from these educational opportunities, many also received pandemic-related information from cable access television, 311, and social media platforms. One-on-one communication with older adults Service providers used several methods to connect with and keep older adults informed during the COVID-19 pandemic. For example, one key informant shared that "the greatest service we provided was just calling older adults to check in...and reminding them we have resources available and that we are ordering new allotments of masks and test kits on a monthly basis" In addition, one organization used robocalls to provide information on virtual activities or emergencies "because 12 most of our clients don't have email and they don't know how to read texts... Our IT department sets it up and we provide them with the phone numbers that need to be called" In addition, one organization used a platform called Everbridge to send important alerts to clients: "We're lucky to have the Everbridge platform free of charge provided to us through NYC Emergency Management. You can upload your contact list and send out messages via the app. The app also allows people to click the link and respond to it so you know they received your message." Webinars, presentations, and trainings To ensure older adults had the most accurate information about the constantly developing crisis, some providers developed webinars and presentations to educate their clients. One provider shared how their "nurse on staff was able to deliver two presentations and answer all of our clients' questions about COVID." In addition, because technology was necessary for older adults to stay connected and receive services during the pandemic, education around using technology was essential. One key informant described how a nonprofit organization was able to run technology support trainings for older adults as well as for staff members who were providing technical assistance to older adults: 'An agency we know of does online tech support. They teach staff how to be patient and meet the client where they are. You have to be able to see how they think. What is more comfortable for them? Is a touch screen better? Is a desktop better? Can they see it? Are the letters too small and does it need to be enlarged? Do they have a hearing issue and would it be difficult for them to use it?" NYAM.org Cable access television and other informational sources Older adult participants expressed concerns over the lack of reliable virus-related information available to them during the pandemic, as well as services they might be eligible for. Many older adults spoke about getting information through announcements on cable access TV. One participant stated, "They announced the food distribution at local schools on television. That's the only way | knew about it." Others were able ta call 311 or use social media platforms to get information. EFFICIENCY The theme of efficiency emerged as stakeholders leveraged resources for multiple use and maximum effectiveness." During the COVID-19 pandemic, service providers leveraged their organizations' resources to focus more on "food, isolation, and basic necessities rather than more complex referrals, home care, and things we weren't able to do anymore." The primary programs and services that service professionals offered included COVID-19-related services (e.g., testing, vaccine distribution, PPE delivery], food distribution and home- delivered meals, case management and wellness check- ins, and virtual programming. COVID-19-related services One key informant explained how they volunteered at city-wide vaccine pods established by the NYC Department of Health and Mental Hygiene that "set aside time in the mornings just for older adults to get vaccinated, since they had borne the brunt of hospitalizations and deaths early on in the pandemic." Organizations also delivered masks and other PPE to their clients and staff members. In addition, some professionals dedicated time to scheduling COVID-19 testing and vaccination appointments for their older adult clients: 13 "The biggest initiative was getting people to test. And then when the vaccine was available, getting them to get the vaccine. | did a few online appointments for COVID tests and the vaccine for our clients and escorted the seniors to their appointments." Food distribution and home-delivered meals Several key informants discussed how they mabilized to provide home-delivered meals to those already receiving them as well as those clients who were receiving their meals at the center before the pandemic. To expand the home-delivered meal service, it was important that those in leadership positions at the organization were involved in the process and that they secured additional funding explicitly for this purpose. Despite the success of organizations in providing meals to their clients, both key informants and older adults alike shared that there were challenges that occurred during food distribution. For example, as noted above in peer-to-peer support, some older adults received an excess of food, and others didn't receive enough: "Many of our clients were signed up for so many different food programs. One of our clients even put a sign outside his door, 'No more food.' They kept delivering so much more food than he actually needed. | also heard some of these larger apartment buildings where they were just dumping off food and it ended up getting thrown away. The City needs to rethink that for the next big emergency." Case management and wellness check-ins Providers were able to work remotely with older adults to ensure that they received their basic entitlements during the COVID-19 pandemic. Several professionals also shared the importance of conducting routine wellness checks via phone calls with their older clients, given that "everyone was scared and there was a lot of THE NEW YORK ACADEMY OF MEDICINE misinformation, so these phone calls really helped them." One key informant shared a strategy they learned from their experiences during Hurricane Sandy, which was to keep a comprehensive list of contact information and other pertinent details about their clients. This enabled them to conduct thorough wellness check-in calls: "We learned from Hurricane Sandy to have a list of our clients that we serve, their home number, their address, and then how frail they are and if they need a walker or a cane, etc. We have that list as a hard copy and on the computer because you never know." Virtual programming One key informant reflected on the ways in which "COVID forced so many older adults on the fence to climb over and embrace technology because they realized the importance of staying connected." Many service providers were able to transition to virtual programming, such as one aging-service professional who shared how "our lead exercise instructor was able to get our clients to embrace Zoom and do exercise from home." While some leaders shared barriers to virtual programming due to a lack of digital literacy among their older clients, others were able to build upon their previous technology training efforts with their clients: "We used to have a computer and technology training. And maybe six months before the pandemic hit, we were giving seniors tablets, computer cameras for desktops, and we were teaching them how to use their smartphones. So the technology was already in place when we started to go to Zoom. It allowed us to extend our programming to virtual programming." 14 ACCESS The theme of access emerged as stakeholders ensured availability to high-quality health, behavioral health, and social services." Three themes emerged with regard to access: access to resources, services, and opportunities for social connection. Access to resources Two key resources that were essential for older adults during the COVID-19 pandemic were food and PPE. To distribute food to older adults in their homes, service providers used several approaches such as home- delivered meal programs as well as setting up an Instacart or Amazon delivery service so older adults could receive food deliveries. In an effort to increase access to masks and COVID-19 test kits among older adults, aging- service providers partnered with organizations that serve older adults, and in particular those older adults who are historically marginalized: "PPE requests have been through organizations that work with older adults who are immunocompromised or are developmentally disabled. So we make sure we are getting PPE to those groups." Access to services While older adults were given priority to sign up for the COVID-19 vaccine, many experienced difficulties with the online scheduling process and concerns around traveling safely to vaccination sites. In response, one aging-service professional described how "we hired staff to help seniors navigate the online process to schedule vaccinations and NYAM.org then provided transportation to and from the vaccination site." In addition, older adults and aging-service professionals alike discussed how important it was for older adults to receive their necessary routine medical care during the pandemic despite social distancing protocols. To address this, aging-service providers described providing technical assistance to older adults so that they could attend telehealth appointments. Furthermore, older adults described the benefits of free bus fare during the pandemic, which increased access to appointments. Finally, one key informant shared their use of a grant from a ride-booking company to facilitate rides for older adults to their appointments: "We had an Uber grant that allowed us to facilitate rides for those first six months of the pandemic when a lot of our members needed to get to the doctor." Access to opportunities for social connection Given that many older adults experienced social isolation due to social distancing protocols during the pandemic, key informants discussed the importance of ensuring access to opportunities for social engagement. One key informant shared how their organization "got Amazon Fire tablets for older adults" so that they could engage in activities such as "writing emails and logging on to chair yoga classes." In addition, several older adults shared the importance of seeking out relationships with others in their building and neighborhood for support in case of an emergency. One said, "You should ask for people's phone number and knaw at least two or three people." 15 RECOMMENDATIONS Older adults and key informants provided information that informs the following recommendations. The recommendations are organized by four levers for community resilience: partnerships, education, efficiency, and access. PARTNERSHIPS o Local, national, and federal governments should provide funds for developing preparedness work before a disaster, such as to support staff time to develop emergency response plans. » Aging-service organizations should develop an interdisciplinary steering committee to share information, facilitate referrals, and coordinate disaster response activities before, during, and after an emergency. » Mobilizing volunteers and interns is essential to meeting client demand during a crisis. o Institutional support from one's agency (e.g., technology, funding for food for clients, high-quality Wi-Fi for staff, etc.] is imperative during a crisis. THE NEW YORK ACADEMY OF MEDICINE o Older adults can partner with one another to initiate regular meetings in their building and/or neighborhood during a disaster to keep everyone informed and socially connected. Older adults living in the community should be consulted about which aspects and assets of the community have proven useful to them in previous emergencies (for additional recommendations related to engaging older adults in disasters planning and response specific to weather emergencies, please see the AARP Disasters Toolkit)* cite reference #2. Partnerships should be developed with faith-based organizations to deliver trusted messaging and provide spiritual and emotional support in disaster recovery. 16 EDUCATION o There should be increased awareness campaigns around resources available to older adults during a disaster (e.g., mental health services). o Emergency plans-specific to aging-service organizations and local neighborhoods-should be widely disseminated to older adults during both emergency and non-emergency times. EFFICIENCY o Building management strategies in older adult residences should be improved, such as naming floor captains for emergencies, developing a building- specific plan, identifying someone older adults can call in an emergency, maintaining the efficiency of elevators, etc. o Disaster preparedness tools should be installed and monitored, such as emergency lighting in stairwells and free smoke and carbon monoxide alarms. o Toimprove the quality of services available to older adults during a crisis, advancements to the following services should be considered: quality of food from Citymeals on Wheels, a system for medication refills, and shorter wait times on the City's public phone lines (e.g.,31). » More trained staff are needed to effectively provide services in clients' homes during a disaster. o Ongoing assessment of home-delivered meal needs should be implemented to eliminate food waste. ACCESS » Toincrease access to virtual services among older adults, technology training and free Wi-Fi in older adult residences should be established. » Toensure access to pertinent information during a disaster, information should be provided in a variety of languages and accessible for those older adults living with disabilities. » Service providers should rely on a variety of NYAM.org communication strategies to increase access to information, such as phone calls, texts, emails, cable access TV, and social media platforms. o Toincrease access to services among older adults, transportation systems should be improved during a disaster (e.g., improvements to Access-A-Ride), and designated older adult food shopping hours should be initiated. ¢ Portable chargers, as well as training on how to use them, should be provided to ensure older adults' ability to communicate using technology with friends, family, and healthcare providers during a disaster that involves power outages. CONCLUSION This report relied on careful collection of qualitative input from stakeholders and robust review of secondary data and literature to summarize the ways in which older adults and aging-service providers have demonstrated resilience in responding to the COVID-19 pandemic and ongoing climate change events. In addition, the report builds on previous findings in order to develop recommendations to support older adults and the professionals who work with them-in NYC and beyond-in the face of future emergencies. The results demonstrate the many ways in which older adults and aging-service professionals used specific levers of community resilience to respond during the crisis. Specifically, older adults and those who care for and work with them leveraged their human, tangible, and social capital to develop partnerships, maximize efficiency of programs and services, educate older adults about COVID-19 and resources available to them, and increase access to those resources, including communication, transportation, and telehealth. Learnings from this work informed a set of recommendations intended to guide policymakers, researchers, and practitioners and inform disaster preparedness and responses to future pandemics and other emergencies. 17 ACKNOWLEDGEMENTS First and foremost, we would like to thank the older adults and aging-service professionals who generously shared their experiences during the pandemic by taking part in the key informant interviews and focus groups. These focus groups were made possible through our partnership with Alan Cohen and Danielle Palmisano at JASA. We thank them for this and for their exceptional work on behalf of older adults before, during, and after the COVID-19 pandemic. We also appreciate the contributions of NYAM staff member Carolyn Stem who conceptualized the idea for this report; NYAM summer intern Holly Riccio who conducted an extensive literature review; Gina Ravosa, NYAM's Director of Communications and Strategic Alliances and Nicole Zheng, NYAM's Graphic Designer for bringing this report to the finish line; NYAM staff members Maya Scherer and Alexandra Kamler for sharing their expertise and input on the focus group and stakeholder interview guides; and Luisa Cérdenas and Berenice Medina for skillfully facilitating the Spanish language focus groups. THE NEW YORK ACADEMY OF MEDICINE 18 REFERENCES 1. Goldman, Finkelstein, Schafer, Pugh. Resilient Communities: Empowering Older Adults In Disasters & Daily Life. Published 2014. 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Morrow-Howell N, Galucia N, Swinford E. Recovering from the COVID-19 Pandemic: A Focus on Older Adults. J Aging Soc Policy. 2020;32(4-5):526-535. doi:10.1080/08959420.2020.1759758 8. The National Center to Reframe Aging. Reframing Aging Initiative: countering ageism by changing how we talk about aging. Published n.d. Accessed July 10, 2023. https.//www.reframingaging.org/ 9. Prusaczyk B, Carpenter BD, Morrow-Howell N. Situating the Pandemic in the Life-Course: Older Adults' Perspectives on the Challenges and Positives of the COVID-19 Pandemic. J Gerontol Soc Work. 2023;66(5):603-612. doi:10.1080/0163437 2.2022.2135659 10. Chandra, Acosta, Howard, et al. Building Community Resilience to Disasters.; 2011. Accessed June 14, 2023. https:./www. rand.org/pubs/periodicals/health-quarterly/issues/vl/n1/06.html 11. U.S. Census. U.S. Census Bureau QuickFacts: New York City, New York. Published n.d. Accessed July 8, 2023. https:/www. census.gov/quickfacts/newyorkcitynewyork 12. KFF. 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Published n.d. Accessed June 14, 2023. https.//www.nyc.gov/site/dfta/services/friend- ly-programs.page 26. Appel D. Keeping New York City Senior Citizens Fed During COVID-19. NYC Food Policy Center (Hunter College). Published March 25, 2020. Accessed June 14, 2023. https://www.nycfoodpolicy.org/keeping-our-seniors-citizen-fed-during- covid-19/ THE NEW YORK ACADEMY OF MEDICINE 20 27. Pereira B, Fehl AG, Finkelstein SR, Jiga-Boy GM, Caserotti M. Scarcity in COVID-19 vaccine supplies reduces perceived vaccination priority and increases vaccine hesitancy. Psychol Mark. 2022;39(5):921-936. doi:10.1002/mar.21629 28. ABC7. COVID NYC Update: New York City expands in-home vaccinations to 75+ and disabled - ABC7 New York. Published 2021. Accessed June 14, 2023. https://abc/ny.com/vaccine-at-home-homebound-senior-vaccines-to-your-nyc-covid- update/10703079/ 29. Suleimany M, Mokhtarzadeh S, Sharifi A. Community resilience to pandemics: An assessment framework developed based on the review of COVID-19 literature. Int J Disaster Risk Reduct. 2022;80:103248. doi:10.1016/].ijdrr.2022.103248 30. Chen LK. Older adults and COVID-19 pandemic: Resilience matters. Arch Gerontol Geriatr. 2020;89:104124. doi:10.1016/j. archger.2020.104124 31. nyc.gov. NYC Community District Profiles. Published n.d. Accessed July 10, 2023. https://communityprofiles.planning.nyc. gov/ NYAM.org 21 Appendix A Focus Group Guide - 2023 Resilience Report Update Thank you for taking the time to meet with us today. Mynameis______and |workasa with the New York Academy of Medicine. We want to briefly talk to you about your experiences during the COVID-19 pandemic, particularly as they relate to your community. We will also ask you questions about emergency preparedness and planning. We are gathering this information in order to develop recommendations for improved emergency planning and response that better ensures the safety and well-being of older adults and their communities in NYC. We want to mention some guidelines for discussion: Today's discussion is scheduled to last 90 minutes. You are not expected to answer every question. Today's discussion will be recorded and transcribed by a third-party agency in preparation for qualitative analysis. The information shared here should be treated as confidential by everyone present today. However, we can't control what people say after the group, so if you are worried that something you say might be repeated later, you need not say it. Also, we want to make sure everyone gets a chance to talk, so we will guide the discussion in such a way that allows all the participants to share their answers. Finally, it's okay to disagree with one another-everyone had their own unigue experience of and response to the pandemic-so people should expect and respect that. Does anyone have any questions before we begin? Introductory Questions 1. What motivated you to join today's focus group? 2. How long have you lived in this neighborhood/building? Questions about your COVID-19 pandemic experience [past) First let's discuss your experiences in your home: 3. Did you receive help from your community in obtaining food, PPE, and sanitizers, prescription medicine, home care, or accessing healthcare services? If so, how were those resources provided and were they adequate/sufficient? 4. |If applicable, can you describe any disruptions in home-based services that you were receiving before the pandemic? (Home maintenance, home healthcare, cleaning services, meal/grocery delivery, etc.) 5. Didyou feel that you had access to relevant, up-to-date information throughout the pandemic? What sources of information did you rely on? (TV, radio, internet, family/friends, other] 6. Didyour landlord and/or superintendent provide any type of assistance, information, or regular check-ins? If so, please describe those supports. 7. How will you prepare for an emergency, especially given what we have gone through in the last three years? Are there programs/benefits that you are still receiving today that you began receiving during the pandemic? (Companions/visitors/phone calls, emergency broadband benefit, grocery delivery, digital skills training, etc.) Now we will talk about your experience in your community: 9. What did your community do well and not do well during the pandemic? (Community can be defined as your housing site, your block, your neighborhood, or other.] THE NEW YORK ACADEMY OF MEDICINE 22 10. In what ways did you assist other members of your community during the pandemic? Questions about planning/readiness regarding public emergencies including weather/natural disaster, pandemic disease, and other climate-related scenarios. First let's talk about how you can best prepare for a future emergency: 1. 12. 13. 14. 15. 16. Do you currently have a personal emergency plan? a. Whois a part of that plan? (Family, friends, neighbors, older adult center staff, aide/caregiver, etc.) There are many forms of communication, including cell phones, landlines, email, and social media. Which form of communication do you think you will feel the most comfortable using, provided it is available, to communicate with family/friends or to receive updates about an emergency? What are ways that your building can support you (landlord, superintendent, tenant association leaders, floor captains, etc.) o What are ways that you can help a neighbor (or a neighbor can help you) during an emergency? How can you take care of or address your mental health needs in a future emergency? Do you know how to access those supports? What do you think you will need from NYC public transportation to safely travel/commute outside of your home? Which items of "basic need" would make you feel more prepared to face a future pandemic or natural disaster? (Batteries, TV, radio, canned food, water, blankets, etc.) Now we will discuss how your community can best support you in a public emergency: 17. 18. 19. 20. How can buildings best prepare for emergencies, particularly for their older tenants? For those of you who receive home care (either a family caregiver or professional caregiver), is your caregiver aware of your emergency plans? a. What supports could help you build a useful emergency plan with your caregivers? What organizations or professionals would you contact if facing some type of public emergency? Is there anything else you would like to add that we have not discussed yet? NYAM.org 23 AppendixB Key Informant Interview Questions Thank you for taking the time to meet with me today. My name is and Iworkasa with the New York Academy of Medicine. This interview is part of an assessment that our team is conducting, funded by New York Community Trust. The goal of the Resilient Communities 2023 Update is to understand the experiences of aging-service providers during the COVID-19 pandemic, and their perceptions around disaster preparedness and emergency response for climate-related emergencies in New York City with the aim of informing recommendations for improved planning and responses to ensure the safety and well-being of older adults in NYC, as well as their families and communities. In addition to these interviews, this assessment includes focus groups with clients of JASA, a nonprofit aging-services organization serving older New Yorkers. You were identified to participate in this interview because of your experience and expertise in one of more of the following sectors: aging services within New York City, emergency management, and/or disaster preparedness. This interview is scheduled to last one hour. *Ask whether interviewee has a hard stop.* Your name will not be associated with the published findings. However, we will include a list of the organizations that we engaged as part of these interviews. To ensure that | have an accurate record of what you said, | would like to ask your permission to please record this conversation. This recording will be for transcription purposes only and will be deleted after the reports are completed. Do you have any questions before we begin? (If interviewee agrees, press record.) Section I: Getting to Know You and Your Organization Tostart, I'd like to ask some background questions about you and your organization. 1. Canyou briefly describe your role in your organization? 2. Howdid clients interact with your organization prior to the pandemic (i.e., what services were they coming to your organization to access)? 3. What general emergency plans did your organization have in place before the onset of the COVID-19 pandemic, if any? Next, I'd like to ask some questions about your organization's experience with providing services to clients during the COVID-19 pandemic. 4. How did the COVID-19 pandemic impact the type of help clients sought out from your organization? Please explain. a. Which services were in greater demand? Please explain. b. Were there specific groups of clients requesting certain services more than others (e.g., based on age, income, gender, ability-status, religion, race)? 5. Which services were you able to provide clients during the COVID-19 pandemic? a. Generally, were your clients able to access the support they needed? Why or why not? 6. What services, if any, were a challenge for your organization to provide to clients during the COVID-19 pandemic? THE NEW YORK ACADEMY OF MEDICINE 24 Please explain. a. What happened if your organization was unable to provide a specific service to a client (e.g., they went without the service, you referred them to another organization)? Now, I'd like to ask about how your organization fared during the COVID-19 pandemic. 7. Inwhat ways do you think your organization's emergency plan enabled it to continue to deliver on its mission and services during the COVID-19 pandemic (i.e., what did your organization do well)? 8. What were the most significant challenges faced by your organization during the COVID-19 pandemic? Now I'd like to discuss the resources -accessed and still needed-to support the maintenance and health and safety of older adults in NYC. What resources did you rely on to get accurate, reliable information on how to respond to the pandemic and continue to meet clients' needs? a. Where were they from (e.g., community-based organizations, news outlets, agencies, professional networks)? b. How useful were they? 9. Howdid you use these resources, if at all, to inform your response to meet the needs of older adults your organization services? 10. What role did other community-based organizations play in helping your organization provide services during the COVID-19 pandemic? a. What communication does your organization maintains with other local institutions (churches, libraries, schools, etc.] for responding to disasters, if any? b. Howcan these local institutions better support your organization during future emergencies? 1. How did City/State/Federal government agencies provide support to your organization, if at all? a. What challenges, if any, did you encounter in accessing that support? 12. Did your organization rely on volunteers to provide support to your organization? a. Canyou describe how you deployed these volunteer resources? b. Did your organization have a sufficient existing pool of volunteers? i. [If no] Did you conduct volunteer recruitment? 13. Inthe future what resources will your organization need to better meet the needs of older adults in your community for emergencies? Please describe. a. Which specific groups of clients, if any, should resources be focused on to address inequities that would be exacerbated by future emergencies? 14. The digital divide, and its impact on older adults, has been highlighted during the pandemic. What support does your organization need to build adequate digital communication infrastructure to provide emergency communications to your clientele? a. How will your organization prepare to meet the communication needs of older adults who do not use digital devices and prefer analog communications? (Newsletters, phone calls, mailing lists) 15. Isthere anything else that we should have asked but did not, or anything else you would like to add that we have not discussed yet? Thank you! NYAM.org 25 The New York Academy of Medicine (NYAM) tackles the the barriers that prevent every individual from living a healthy life. NYAM generates the knowledge needed to change the systems that prevent people from accessing what they need to be healthy such as safe and affording housing, healthy food, healthcare and more. Through its high-profile programming for the general pubic, focused symposia for health professionals, and its base of dedicated Fellows and Members, NYAM engages the minds and hearts of those who also value advancing health equity to maximize health for all. For more information, visit NYAM.org The New York Academy of Medicine 1216 Fifth Ave, New York, NY 10029 T RN A RGNS Twitter | Center for Healthy Aging @ AgefriendlyNYC 2023 The New York Academy of Medicine. All Rights Reserved. NEW YORK ] ) 0] 1S {e]) ]2 al=