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AN EVALUATION OF THE IMPACT OF THE NATIONAL DISABILITY RIGHTS NETWORK PARTICIPATION IN THE KATRINA AID TODAY PROJECT

Submitted by Laura M. Stough, Ph.D. Amy N. Sharp, Ph.D. The Center on Disability and Development Texas A&M University to The National Disability Rights Network Washington, DC March 2008

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TABLE OF CONTENTS

Introduction ................................................................................................................................3 Purpose of Evaluation .............................................................................................................3 Design of Evaluation...............................................................................................................3 Evaluation Questions ..................................................................................................................5 Primary Questions of Interest..................................................................................................6 Secondary Questions of Interest ..............................................................................................7 Evaluation Procedure..................................................................................................................8 Participants .............................................................................................................................8 Analysis of Evaluation Data....................................................................................................9 Timeline of Evaluation.......................................................................................................... 12 Results...................................................................................................................................... 13 Quantitative Results .............................................................................................................. 13 Demographic Focused Questions ...................................................................................... 14 Case Management Focused Questions............................................................................... 17 Summary of Quantitative Results ...................................................................................... 30 Results from Surveys of Case Managers ............................................................................... 31 Results from Interviews of P&A and NDRN Administrators................................................. 39 Results from Focus Groups ................................................................................................... 48 Summary of Focus Groups................................................................................................ 68 Summary of Evaluation ............................................................................................................ 70 Primary Questions................................................................................................................. 70 Secondary Questions of Interest ............................................................................................ 75 Appendix .................................................................................................................................. 78 Open-Ended Telephone Case Manager Questions ................................................................. 78 Survey Questions for Case Managers .................................................................................... 79 Questions for Focus Group.................................................................................................... 81 P&A Administrator Interview Questions............................................................................... 82

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INTRODUCTION
Hurricane Katrina was the largest disaster in U.S. history. The effects from this hurricane resulted in loss or destruction of housing for over 1.5 million individuals. It is estimated that 23 percent of those affected by this disaster were individuals with disabilities (National Organization on Disability, 2006). The United Methodist Committee on Relief (UMCOR) and the Voluntary Organizations Active in Disasters (VOAD) were awarded an unprecedented $66 million dollars in October 2005 through the Department of Homeland Security to provide case management for evacuees affected by Hurricane Katrina. This initiative led to the formation of the National Case Management Consortium (NCMC) and the Katrina Aid Today (KAT) project. Recognizing the critical support needs of individuals with disabilities affected by Hurricane Katrina, National Disability Rights Network (NDRN) proposed that it would provide case management services targeted at those survivors with disabilities. NDRN set as its goal as a consortium member to provide high quality, cost-effective nationwide case management services for approximately 7,000 displaced individuals with disabilities and their families.

Purpose of Evaluation
The purpose of this evaluation design was to provide a mechanism through which NDRN could obtain both formative and summative information on 1) the quality of case management provided to people with disabilities, and 2) the impact of case management on the Protection and Advocacy (P&A) Centers as legal services organizations.

Design of Evaluation
The evaluation of this project used two different methodological approaches and four data collection methods in order to investigate the role of National Disability Rights Network

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(NDRN) in the Katrina Aid Today (KAT) project. A quantitative approach examined the differences in the outcomes of case management provided by NDRN as compared to the other KAT partners, while a qualitative approach was used to describe the nature of the participation of NDRN in the KAT project. The strength of this dual approach to evaluation was that the quantitative information in this report has been summarized and statistically analyzed while the descriptive data obtained through the qualitative approach provides an in-depth analysis of case management provided to individuals with disabilities. Data resulting from the quantitative analysis, as will be seen in that section, is primarily numerical and descriptive in nature. This data includes information on the quantifiable performance of these agencies as part of case management, and compares data from the nonNDRN case managers to the NDRN case managers who were part of the KAT project. This analysis used group data and does not identify any other partner group as an individual. The data needed to analyze these questions was submitted through the CAN database or through documentation collected by the KAT monitoring and evaluation staff. Data resulting from the qualitative analysis was primarily descriptive in nature but provides a rich context for the quantitative data in that it includes quotes and a narrative description of NDRNs participation in the KAT project. This data was directly collected from state P&A case workers and staff, as well as from NDRN administrative staff, by the investigators. In our review of the research literature, we found few evaluations and very little evidence-based research involving individuals with disabilities and disaster. The results from this evaluation give NDRN both demographic and comparative statistics which will be helpful in producing policy-related materials and position papers on case management for people with disabilities. This evaluation thus provides NDRN data that is based on one of the few systematic

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studies on the effects of disaster, and perhaps the only available study on the long-term recovery of individuals with disabilities.

EVALUATION QUESTIONS
The following two pages present the Primary Questions of Interest and Secondary Questions of Interest. The Primary Questions are those that were identified by NDRN administration as of greatest interest and the data associated with these questions are primarily qualitative in nature. The Secondary Questions are those that consist of descriptive or comparative statistics and are primarily quantitative in nature. As both categories of questions serve important functions in the overall evaluation of this project, their designation as primary or secondary questions are given as a the result of NDRNs expressed areas of focus, rather than an assessment by the evaluators of their relative importance.

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Primary Questions of Interest


Qualitative Evaluation Questions 1. What is the impact when a legal services organization provides case management to people with disabilities who are evacuees? 2. What kind of impact does case management provided by disability service experts have on outcomes experienced by people with disabilities? 3. What effect did NDRN participation have on the delivery of services by the Katrina Aid Today partner organizations and on Katrina Aid Today organization? 4. What does case management look like when the evacuee client is a person with disabilities? Hypothesis NDRN case workers and staff have access to legal knowledge that makes a difference on both how cases are managed and how they are resolved. NDRN-affiliated case managers are disability subject-matter experts whose knowledge makes a difference in outcomes for evacuees. NDRN staff and affiliate staff educate their partner organizations and KAT administration through their actions as both a resources and an instrument of systemic change Case management with individuals with disabilities differs, in part, along the dimensions of time, intensity, location of services, level of selfdetermination, and topography The effects of the Need for Disability Supports on the process of case management Impact of the needs of the individuals with disability on the nature of case management provided. NDRN Evaluator Advocacy for and Education about individuals with disabilities Disability Knowledge and Disability Services Knowledge The impact of disability knowledge and disability services knowledge on outcomes for evacuees The impact of advocacy and education on KAT organizations NDRN Evaluator NDRN Evaluator Major Themes Legal Knowledge and Legal Advocacy Measured Impact The impact of legal knowledge on outcomes for evacuees Responsible Party NDRN Evaluator

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Secondary Questions of Interest


Quantitative Evaluation Questions 1. Were clients as satisfied or more satisfied with the case management that they received from the P&A case managers as compared to clients who used other Katrina Aid case managers? 2. Were P&A case managers rated as knowledgeable or more knowledgeable about the recovery process and resources available as compared to other Katrina Aid case managers? 3. Were individuals with disabilities referred to LTRC/Unmet Needs Tables at a higher or equal rate than were individuals without disabilities? 4. How were P&A case managers rated with regards to providing information and services that met the clients needs as compared to other Katrina Aid case managers? 5. How did the primary needs reported by individuals with disabilities differ from those without disabilities? 6. Were the individuals who were referred to disability services listed in the CAN database also referred to NDRN? Type of Data and Analysis Comparison of groups: NDRN clients vs. other clients. Quantitative tests of equality: e.g., t-test, Chi-square. Comparison of groups: NDRN clients vs. other clients. Quantitative tests of equality: e.g., t-test, Chi-square. Comparison of groups: NDRN clients vs. other clients. Quantitative tests of equality: e.g., t-test, Chi-square. Comparison of groups: NDRN clients vs. other clients. Quantitative tests of equality: e.g., t-test, Chi-square. Descriptive statistics, measures of association (correlations) Descriptive statistics, measures of association (correlations) Data Source Katrina Aid Today Client Satisfaction Survey Responsible Party UMCOR Evaluators/ NDRN Evaluators

Katrina Aid Today Client Satisfaction Survey

UMCOR Evaluators/ NDRN Evaluators

CAN data base

UMCOR Evaluators/ NDRN Evaluators UMCOR Evaluators/ NDRN Evaluators

Katrina Aid Today Client Satisfaction Survey

CAN database

UMCOR Evaluators/ NDRN Evaluators UMCOR Evaluators/ NDRN Evaluators

CAN database

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EVALUATION PROCEDURE
To answer the Primary Questions of Interest, we used four methods of data collection: 1) quantitative analysis, 2) surveys, 3) semi-structured interviews of NDRN administrators and P&A staff, and 4) focus groups of clients. Each of these methods is described below. For each of these methods, we detail the participants, procedures, and instruments that were used.

Participants
To clarify the terms that we are using for the participants, we provide a guide to our usage of labels in this document: NDRN Administrators: Administrators working at NDRN headquarters in DC overseeing the KAT project. These are the Tier 1 and Tier 2 contacts for UMCOR. P&A Administrators: KAT Administrators: Administrators who oversee the state P&A offices. KAT administrators at the state P&A offices. These are referred to by UMCOR as Tier 3 contacts. Case Managers: KAT case managers working at the P&A offices.

Evaluators of this project followed the requirements of an Institutional Review Board and the guidelines of the Belmont Report for the Protection of Human Subjects. A copy of the approval of these procedures can be obtained from the Texas A&M Institutional Review Board or from one of the principal investigators. Data collected from the surveys, interviews, and focus group parts of the evaluation was treated confidentially and any identifying information obtained was changed or deleted to protect the confidentiality of the participants. The evaluators have modified statements in this report so that they cannot be linked to any given individual

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participant and responses from case managers and KAT administrators have had their geographical associations removed to protect the identity of these employees.

Analysis of Evaluation Data


The following section details how the evaluation data was collected for the purpose of answering the Primary Questions and the Secondary Questions as well as how this data was analyzed. Quantitative Analysis. Data collected through the CAN database was analyzed to answer several of the primary and secondary evaluation questions. Information from the CAN database was extracted by UMCORs Measurement and Evaluation staff in July of 2007 and sent to the investigators for analysis. In order to address the secondary questions, we extracted those cases that were managed by NDRN and compared them to those cases managed by other KAT partner agencies. A limitation with this comparison was that some individuals with disabilities were not referred to KAT-NDRN for case management and were also represented in the partner agency sample. However, this comparison did allow for analysis of demographic differences and service delivery difference between the two groups of consortium members. Surveys of case managers. Surveys were administered and collected by the investigators. These surveys were structured, in that the questions were predetermined and the method by which the survey was conducted was consistent across all case managers. All case managers received the same survey questions (see Appendix A). These questions were piloted by Drs. Laura Lein and Holly Bell, who were the evaluators for two other Katrina Aid Today consortium partners, and were derived from focus groups that they conducted with case managers for evaluation purposes.

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The Tier 3 KAT administrators in the four Gulf States affected by Katrina were asked to distribute information about the survey to the case managers in their state and to schedule times during which the investigators might contact them. Some KAT case managers were not included in these schedules and in these cases they were directly contacted via email by the project evaluators and asked to schedule a time to complete the survey. When these two methods did not elicit an appointment time, then the project evaluators contacted the case manager by telephone in order to set up an appointment. Each case manager was contacted at least three times in an attempt to set an appointment time. The surveys consisted of a set number of questions that elicited demographic and factual information from each participant (see Appendix). In addition, the evaluators used a Critical Incident Procedure to obtain specific information on case management of individuals with disabilities. This procedure was used to obtain a description from the case managers about one particular case that they had managed that they believed was successful, as well as about one case which seemed to be more difficult to manage, as well as the factors that they attributed to these descriptions. Survey data was analyzed as whole group data. Descriptive statistics were generated and the responses of the case managers were tallied for those questions in which the responses could be tabulated. Qualitative responses were open coded to categorize the responses. These codes were grouped to form overarching categories. These categories were then compared across case managers to determine those that we most representative of these case manager responses. Interviews with Administrators. Thirteen P&A administrators and three NDRN administrators were interviewed. All interviews, with the exception of one, were conducted faceto-face at the office at which the administrators were employed. Five questions were asked of

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each administrator (see Appendix) and follow up probes were used to elicit more specific or elaborative information as needed. The interviews took from 20 to 40 minutes. Consent forms are on file in Dr. Stoughs office at Texas A&M University. Variance occurred across the interviews in that questions designed to elicit clarification and elaboration were asked during the interview. Thus, these interviews were designated as semi-structured rather than structured. Interviews and focus groups were analyzed following the similar procedures. All sessions were audio taped and these audiotapes were transcribed for analysis. Data analysis of interview and focus group information were performed using Grounded Theory analysis (Glaser & Strauss, 1967; Strauss & Corbin, 1990), in which the transcripts of the interviewees were analyzed using a line-by-line approach to collect and analyze the data. Grounded Theory focuses upon the data that is elicited from the participants in a study and produces an inductively derived conceptual model that is grounded in this data. This methodology allows for the comparison of new data to previous cases so that the addition of new information from additional interviewees allows the evaluator to iteratively gain more precise information on the question of interest. Grounded Theory is a particularly appropriate method to use when the area of interest has not been previously investigated, as is the case in this evaluation of the experience of individuals with disabilities following disaster. The outcome of the analyses of these of these two methods produced 1) categorization of the results, 2) statements and quotes that exemplified and elaborated on each category, 3) text descriptions of each category of interest, and 4) a text summary of how the result categories interact and affect each other. Focus Groups. Focus groups were the fourth data collection method used as part of this evaluation. The focus groups provided an opportunity to ask participants to given elaborative

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responses and to obtain detailed information about particular survey items. Each focus group consisted of three to eight participants who were asked a series of five questions (see Appendix) over a period of one and a half hours. Field Notes. Field notes were collected while gathering the data. They served to remind the evaluator of contacts made with the participants in the evaluation, to note supplemental information obtained during the data collection process, and to record initial analysis of the phenomena under study. During this evaluation, field notes were collected during interactions with NDRN staff and P&A staff. Field notes were also recorded following interviews and focus groups. Field notes were collected at the same time as the other four methods of data collection. For the purposes of this evaluation, it was not necessary that field notes be analyzed separately.

Timeline of Evaluation
The timeline of the data collection and analysis was as follows. Evaluation Timeline MAY 2007 PRIMARY QUESTIONS: Contact and set up data collection schedule with NDRN and State P&As Semi-structured interviews at P&As and at NDRN Survey of all case managers Focus groups at P&As and NDRN Analyze data from primary questions SECONDARY QUESTIONS: Obtain permission for access to quantitative data collected by KAT Meet with UMCOR evaluators Obtain first year of group data from UMCOR (Jan.Dec. 2006) Input data and clean up database Analyze data Write up and report results XX XX XX XX XX XX XX XX XX XX XX JUNE 2007 JULY AUG SEPT 2007 2007 2007 OCT 2007

XX

XX

XX XX XX XX XX XX XX XX XX

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RESULTS
Data collected from the procedures described above were analyzed separately and the results of these analyses are reported in the following section.

Quantitative Results
Data sets extracted by program evaluation personnel at United Methodist Committee on Relief/Katrina Aid Today (KAT) from the Coordinated Assistance Network (CAN) database in July 2007 were analyzed to answer demographic-focused and case management-focused questions about NDRN as compared to other KAT partners. These analyses were conducted after consultation and discussion on their composition with Nachama Wilker at NDRN. Most of the questions were answered by tally and cross-tabulation of data elements in CAN records to analyze frequencies for NDRN as compared to all other KAT partners. A few of the questions asked about continuous quantities (e.g., length of time that a case stays open) and were answered by comparing means for NDRN with means across the other partners. Additional questions were answered by comparison of numbers presented in built reports.

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Demographic Focused Questions Is there a difference in age or gender of NDRN clients as compared to the other KAT partners?

The majority of clients served by NDRN and across the other KAT partners were female (66% and 73%, respectively). NDRNs clients were older as compared to those served by the other partners: 1 average age of NDRN clients was 53 compared with 45 for clients of the other partners. Although the clients served by NDRN and across the other KAT partners most often were Black/African American (64% and 79%, respectively), the proportion of White clients was significantly greater for NDRN as compared to the other partners (34% and 14%, respectively).2
1

Proportion of clients ages 46-99 was slightly but significantly greater for NDRN than for the other partners (chi square 8.37, p<.01). Average age of 53.17 + 16.01 for NDRN was slightly higher as compared to 44.82 + 15.43 for clients of the other partners (F=1028.47, p<.001, eta squared = 0.02). These calculations are based on database records for which age was recorded, 3794 or 83% of NDRN cases and 51376 or 98% of cases across the other partners.
2

Chi square=12.09, p<.001. The proportion of clients for whom no information about ethnicity was recorded was significantly greater for NDRN compared to the other partners (chi square=5.99, p<.05): in nearly one-fourth of cases (24%) no information about ethnicity was recorded for NDRN clients compared to 10% for the other partners.

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Is there a difference in the Katrina impact factors for NDRN clients as compared to others?

Nearly all NDRN clients, like those of the other KAT partners, were displaced and had experienced damage to their housing by Hurricane Katrina. NDRN clients were less likely compared to the other partners to have been a mandatory evacuee (61% NDRN compared to 81% other partners) or to have experienced loss of income (17% NDRN, 57% other partners).3 NDRN clients were recorded to have slightly fewer numbers of impacts as compared to clients of the other partners; the average numbers of impacts summed across the seven categories were 2.75 + 1.00 NDRN as compared to 3.46 + 1.02 for other partners.4

Chi square 8.56, p<.01; chi square = 32.62, p<.001 for NDRN as compared to other partners for mandatory evacuee and loss of income, respectively.
4

F=1012.25, p<.001, eta squared = .03

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Calculations and comparisons were based on the 2,260 NDRN clients and 34,271 clients of other partners with at least one impact recorded in the database. The percent of cases with zero impacts recorded were surprisingly large but not significantly different for NDRN and the other partners (50% NDRN and 39% other partners). Is there a difference in numbers of clients that lived in Section 8 or public housing predisaster?

A minority of clients of NDRN and of the other partners were recorded in the database as having resided in subsidized housing pre-Katrina (12% of NDRN clients and 15% of clients of the other partners). For those clients who did reside in subsidized housing, Section 8 vouchers was the most frequent type of subsidy (7% of NDRN clients and 9% of clients of the other partners).

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A surprisingly large percentage of cases had no information recorded in response to the question asking if the clients pre-disaster housing was subsidized (53% NDRN and 41% other partners). There were no significant differences for NDRN clients as compared to the other partners in the presence of information or the type or frequency of pre-disaster housing subsidy. Case Management Focused Questions What is the length of time a case stays open?

Average number of months from the date the case opened to the date it closed for the 1,273 NDRN clients and the 20,039 clients of other partners with closed cases were 4.90 NDRN and 6.03 other partners. The difference was not statistically significant. The range was less than

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one month (0.03) to nearly 3 years (30.44 months) for NDRN clients and 0.03 months to nearly 4 years (47.08 months) for the other partners. What are the property-related needs of NDRN clients as compared to the other partner agencies?

The majority of clients needed housing with NDRN clients more likely to need housing as compared to the other partners (73% NDRN, 60% other partners).5 The next most frequent property-related needs are furniture/appliances (30% NDRN, 39% other partners) and utilities/services (23% NDRN, 32% others). Less than one-fourth of clients had need indicated for transportation, clothing, or financial assistance.

Chi square=4.40, p<.05.

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Average number of needs across the 6 types of property-related needs was trivially smaller for NDRN clients as compared with others: 1.82 + 1.21 for NDRN, 2.00 + 1.21 others.6 These calculations are based on the 2,137 NDRN clients and 31,195 others with at least one need recorded in the database. A surprisingly large number of records had no needs indicated: 53% NDRN, 44% others. The proportion of NDRN cases with zero needs indicated was not significantly different from that for the other partners. What are the person-related needs of NDRN clients as compared to the other partner agencies?

F=43.79, p<.001, eta square=.001

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The most frequent personal need was health & well-being and was not significantly different for NDRN as compared to the other KAT partners: 45% NDRN, 39% others. Less than a third of clients had need indicated for food/nutrition, employment/job training, aged/disabled services, and less than 10% had need for services for children & youth. NDRN clients were notably less likely to need employment/job training as compared to others (12% NDRN, 29% others)7and notably more likely to need aged/disabled services (23% NDRN, 8% others).8 Average number across the 5 types of person-related needs was trivially smaller for NDRN clients as compared to others: 1.09 + 1.06 NDRN, 1.17 + 1.06 others.9

Chi square 7.85, p < .01 Chi square 9.77, p < .01 F=9.68, p < .01, eta square = .00

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What are the procedural needs of NDRN clients as compared to the other partner agencies?

Only a few clients had procedural types of need indicated in their database records with need for application assistance the most frequent type of procedural need: 8% NDRN, 11% others. Less than 10% of clients had need indicated for legal assistance, benefits restoration, and language assistance. There were no differences for NDRN clients as compared to the clients of other partner agencies Average number across the four types of procedural needs was trivially smaller for NDRN as compared to others: 0.19 + 0.44 NDRN, 0.23 + 0.55 others.10

10

F=10.71, p <.01, eta square = .00

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When number of needs was calculated across all 15 types of needs (6 types of propertyrelated needs, 5 types of person-related needs, and 4 types of procedural needs), the average for NDRN clients was trivially smaller as compared to others: 3.10 + 2.01 NDRN, 3.39 + 2.10 others.11 What is the participation profile of NDRN clients as compared to the other partners? Partners NDRN Caseload Total number of KAT cases in CAN database 55301 4825 # of Recovery Plans developed 43694 3502 % of cases with a developed Recovery Plan 79% 73%
Clients Estimated number of people served Average household size Staffing # of Paid Case Managers # of Volunteer Case Managers Total number of Case Managers Case Management # of opened cases 29383 2582 # of closed cases 24873 2093 # of Referrals provided 47511 3299 # of Referrals utilized 188308 10261 Estimated total value of services provided $ 77,077,222.00 $ 3,583,307.00 Average estimated value of services provided per case $1,393.78 $742.65 565 1323 1888 71 7 78

147635 2.67

11098 2.30

Inspection data presented in the 60% Benchmark Report for KAT and NDRN12 showed NDRN serving 8% of cases and nearly 8% of people served through the KAT National Case

11

F = 42.63, p < .001, eta square =.00

12

Report supplied by United Methodist Committee on Relief (UMCOR) September 4, 2007 from CAN Built Report.

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Management Consortium. Similar to those of the other KAT Partners, approximately threefourths of NDRN clients had a developed Recovery Plan. The proportion of closed to open cases was similar for NDRN and the other Partners (43% and 45%, respectively). The ratio of volunteer to paid case managers was notably less for NDRN as compared to the other partners (approximately 1:10 versus 2:1). The ratio of total cases to total case managers was notably greater for NDRN as compared to the other partners (approximately 62:1 versus 29:1). The ratio of referrals provided to total cases appeared similar for NDRN as compared to the other partners (approximately 1:10). Amount of referrals utilized and total value of services provided as a ratio of total cases appeared to be less for NDRN as compared to the other partners: referrals utilized approximately 2:1 NDRN versus 3:1 other partners and dollar value of service provided approximately 743:1 NDRN versus 1394:1 other partners.

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Is there a difference in referral to long term recovery committees?

Less than five percent of clients are recorded as referral to Long Term Recovery Committees (LTRC) with no difference for NDRN as compared to others: 3.8% NDRN, 4.8% others. The average value of services provided when presented to LTRC was approximately 6.5 to 6.9 thousand dollars with no difference for NDRN as compared to others: $6,478.84 + $9,070.45 for NDRN, $6,979.40 + $16,134.34 for others. The calculation of average value of services is based on those few cases for which the information was recorded in the database: n=57 NDRN, n=1,772 others. Combining cases across NDRN and the other partners, the average value of services provided when presented to LTRC was greater when the client was indicated as needing

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aged/disabled service: $10,834.26 + $15,575.66 for clients needing aged/disabled services compared to $7,894.90 + $17,355.86 for clients NOT indicated as needing aged/disabled services.13 Is there a difference in reasons for case closure?

The most frequent reason for case closure for clients of NDRN and of the other KAT partners was primary needs met. Thirty-five percent of NDRN closed cases and 35% of other closed cases were indicated as closed by reason of primary needs met. Other reasons for case closing included recovery plan achieved, client relocating, client withdrew, and case transferred out of the KAT network. Substantial numbers of NDRN cases were closed with the reason Unable to resolve because of lack of resources; 17% of NDRN cases compared to 5% for
13

F = 4.09, p < .05, eta squared = .00

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others.14 Other reasons for case closure included losing contact with the client, client refusal of services offered (e.g., refused to go to the unmet needs committee), and needs are beyond the services and resources of the program. A surprisingly large number of case records with status closed indicated no reason for case closure. NDRN was not significantly different from others in proportion of closed cases without any reason recorded: 40% NDRN, 34% others. Is there a difference in clients perception of extent to which needs are met at time of case closure?

The majority of clients of NDRN and of other partners who answered the question about their perception of extent to which needs were met indicated their needs were completely or
14

Chi square = 6.37, p < .05

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mostly met, although NDRN clients were slightly less likely to report this level of positive outcome: 62% NDRN, 77% others.15 The clients perception of outcome is recorded in the database for only about one-fourth of the closed cases and is not different for NDRN as compared to others: 72% NDRN, 74% others. How did clients rate their case managers on the client satisfaction survey?

Nearly all (i.e., more than 90%) of respondents to the client satisfaction survey indicated satisfaction with their case managers. They agreed or strongly agreed the case worker was courteous and professional; knowledgeable about the recovery process and resources available; and understanding of my challenges and concerns. There were no differences in proportions of satisfied clients for NDRN as compared with the other partners.
15

Chi square = 5.97, p < .05

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The overall survey response rate was low. Stated as a proportion of all cases closed, only 6% of clients completed the satisfaction survey (i.e., the vast majority of clients eligible to the complete the survey did not do so). The low rate of response was the same for NDRN and for the other KAT partners. Did clients indicate satisfaction with services?

Nearly all (i.e., more than 90%) of clients who responded to the satisfaction survey that was made available to them at case closure indicated they agreed or strongly agreed they were satisfied with almost all aspects of services that were queried on the satisfaction survey. Survey respondents were slightly less likely to express satisfaction with the way various agencies assisting my recovery from Hurricane Katrina have responded. Slightly less than 90% of survey

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respondents at the other KAT partners (88%) and only about half (63%) of NDRN survey respondents agreed they were satisfied with the way the various agencies responded.16 Survey responses from clients of NDRN and those from the other Partners regarding services within their respective case management agency indicated almost uniform satisfaction i.e., more than 90% agreed or strongly agreed the Agency responded promptly after my case was initiated; Overall, agency staff were courteous and professional; I am satisfied with service I received from this agency; The Agency did everything it could to help me address my needs; and I received information and services that met my needs.

16

Chi square = 15.57, p < .001

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Summary of Quantitative Results Similar to clients of the other partners, NDRN clients were: Predominantly female and predominantly Black/African American; Nearly all displaced and had experienced damage to housing; Not likely to have lived in subsidized housing pre-disaster; Likely to have their case open an average of 4 to 6 months; Not likely to have their case referred to Long Term Recovery Committee; Likely to have primary needs met or recovery plan achieved as reason for case closure; and If they answered the client satisfaction survey, likely to indicate satisfaction with their case manager and with services received. In contrast to clients of the other partners, NDRN clients were: Older; Less likely to have been a mandatory evacuee or to have experienced loss of income; More likely to need housing and services for aged/disabled but less likely to need employment/job training; More likely to have case closed for the reason unable to resolve because of lack of resources; Less likely to report their needs were met; and If they answered the client satisfaction survey, were less likely to express satisfaction with the various agencies assisting in their recovery had responded.

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Results from Surveys of Case Managers


Sixty-two case managers were submitted by the KAT administrators to be surveyed. Of the list of 62, 68% (n=42) were surveyed. Three people on the list were actually administrative personnel and not included in the case manager sample (5%). One of the people listed was actually a Vista Volunteer and 13 of the case managers had left their positions (21%) and could not be contacted. Three additional case managers were unable to be contacted and no interview was conducted with these three (5%). At least three attempts were made to contact each case manager. All case managers were administered the same survey questions (see Appendix). Of the 42 case managers surveyed via telephone, 100% of them responded that they were employed as a case manager. The case managers interviewed had been employed in their position an average of 12.6 months with the high being 96 months and the low being two months. The case manager who had been employed for 96 months had been previously employed with her P&A as a case manager in another capacity. Of the case managers interviewed, 14 were from Mississippi, 12 from Louisiana, four from Alabama, nine from Texas, and three from Georgia.

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Gender of case managers

male 17% female male female 83%

Educational status of case managers


J.D. 3% Some ph.D. college 3% 6% master's 23% Bachelor's 65%

Some college Bachelor's master's ph.D. J.D.

Of the case managers interviewed, 83% were female and 17% were male. Ethnicity broke down to 47% African American and 53% White. Thirty-six percent were single, 50% married, 14% separated or divorced and there was a range of 0 to 4 children living in the homes. Six percent of the respondents had some college, 65% had a Bachelors degree, 23% had a Masters degree, 3% had a PhD, and 3% had a JD. Of the case managers interviewed, 62% were working in a damaged area (n=26) and 64% considered themselves to be a survivor. Twenty-seven percent of the interviewed case managers volunteered during the immediate aftermath of the storm. There were a total of 2,047 cases that were part of the case load of this population of case managers with a high of 240 for one case manager and a low of seven for another case manager. The average number of cases per case manager was 48. One hundred percent of cases were

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Katrina survivors. Of all the cases managed by these case managers, 1,046 had been closed with a high of 100 closed cases for one case manager and a low of zero for another. Case managers were asked a series of questions about their experiences with NDRNKAT clients and the factors that affected their recovery following Hurricane Katrina. When case managers were asked about what made some cases successful in recovering following the storm, the responses generally centered around the ability of the case manager to find appropriate resources for the clients, the awareness of the disability-related systems in place, the ability to coordinate amongst agencies, and client motivation. Identifying and accessing available resources was the category of concern expressed most often throughout the interviews: Being disabled you are limited to when and where you can go so if you arent there at a particular time you miss out.17 The client then goes to the doctor and to the store occasionally, and so has limited access to resources. The CM believed that providing case management made the client aware of services available that otherwise would go overlooked. Several case managers mentioned that timing sometimes played a large role in how successful they were as accessing resourcesthe timeliness of contacting the client, cooperation from the client, collaboration from other agencies, and accessing resources. Another example of timing and being able to find the appropriate resources: Everything just came together. It had to do with the particular needs of the clients and what I could offer. These clients just needed furniture but had obtained their own mobile home. They are older and disabled. What their needs were and what I could provide matched up.
17

Throughout this evaluation report consistent effort was made to respect the voice and expression of the participants. As a result, in some cases, quotes in this report will appear ungrammatical or to have syntax errors. Each transcript was checked twice in order to render as accurately as possible the words of the participant. Quotes are included as intact as possible and only edited when it increased readability. In these cases, the format was used to indicate deleted words except in the case of repeated words or verbal fillers. When words were included for readability, brackets were used.

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Yet another case manager illustrated that having knowledge of the system by both the client and the case manager is helpful in achieving success. The coordination of services between the social worker, the client and the CM made the case successful and led one case manager to remark, It helps when the client is more interested in their recovery than you are. The client put a lot of effort into their recovery plan. The client followed up on paperwork, was patient, was aware that some services are not given, and gave the CM the necessary paperwork to get the additional funding and the services that they needed. Case managers were also asked about challenges in providing case management. Lack of resources was the primary response on this query. Many case managers communicated that their ability to navigate the disability arena allowed them to access more services and resources for their clients. I had a client who was diabetic, he could not walk. Lived in a FEMA trailer and FEMA is closing the trailers soon. He found a place to live 300 miles away with family, but the local resources initially would not agree to support him if he moved that far away. The case manager was subsequently able to get the support needed to execute the move. Knowledge of the disability system and knowledge of the needs of clients was also identified as important by the case managers in being able to achieve success; not having this knowledge was a perceived barrier. An agency did not understand the needs of the clients and was very judgmental about the clients situation. This agency has judged the client and made it difficult for them to receive services. FEMA was not aware of the clients needs, especially the clients needs that had to do with the clients disability status. The CM had to help FEMA understand the clients situation. This issue was with FEMA in the housing department. It is an ongoing situation as the case is not yet closed.

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Another case manager gave an example of the limitation some people with disabilities have when accessing social support services. A young man was in a nursing home and needed to be moved to another city. Medicaid, Medicare wont pay for it because he isnt going to hospital but to a home to be closer to his family. Not a medical necessity, FEMA says it has been too long after the hurricane for them to assist. The ambulance service cut their costs but we still dont have the means to pay $800 to move him. He is medically fragile. The case managers interviewed perceived the biggest challenge faced by clients in their area as housing. Other significant challenges include working through the system, transportation, locating resources (both tangible and financial) and paperwork (amount of, literacy, and organizational skills needed). One case manager summed it up by sharing that: Everyday needs are more accessible in a small town such as food and clothing. In a small town I can go to any Goodwill, Salvation Army, soup kitchen and in a matter of minutes get my daily needs met. In a place the size of Houston they know nothing about the lay of the land and it is so spread out, that getting your everyday needs getting met is an impossibility, you cant go to your neighbor and get some soap or ramen noodles. The ability to advocate for their own selves is stunted when faced with a large city. Even with help it is kind of hard. The focus on housing as the primary challenge was overwhelming supported by case managers. Housing, housing and housing [laughed]. That is a loaded question, they face so many challenges. Clients who were living in low-income housing find that there is none left now. Even finding an apartment is difficult. Housing. Living in the area a lot of things have changed, clients have difficult time adapting to the new area and the new ways. Housing is big problem, no affordable housing. Used to be able to get a 1br for $400, now if is $800 if you can find it. The prompt regarding the perception of cultural differences amongst clients and case managers elicited a balance of responses. Forty-one percent of case managers did perceive a difference and 59% did not. The primary perceived difference was focused around cultural and

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regional differences. These differences encompass many things including the way the social services systems operate and the language used within each system, perceived client dependency, and the perception of Katrina survivors as being lazy and taking advantage of the system. Statements from case managers illustrating these differences included: There is a cultural difference in the standpoint of services offered in different areas. Some are used to one type of service and when they relocate the services are different. People that didnt experience the storm dont understand the gravity. Another case manager noticed that in New Orleans case managers were like Mamas, they did everything for you. She shared that, in her area, case managers give the client the information and they do it for themselves. Transportation was another issue here. Clients were used to public transportation. They became stranded because they no longer had that public transportation. When asked about what advice they would give the KAT, the case managers surveyed responded that all agencies needed in-house monies to meet client needs. As the system is now, agencies must scramble to obtain resources; as one case manger said, We are going out and doing the bulk of the work to get resources. We dont have a backup, we have to convince other agencies of the value of what we are doing. We should be able to show who we are and get resources from other agencies for our clients. I feel triple worked. Another case manager shared that, Empower the case management organizations with some funds. [Our agency] has a contract to help broker information to people with disabilities. Immediate needs could be dealt with effectively if we had some money to help them get back on their feet. Empower case managers with some money to disperse for immediate needs. Not a Walmart card but some money that the case manager could help immediate needs. We try to raise money for this purpose and it goes out immediately. Other advice to KAT was to provide more resources, streamline paperwork process, and to refine CAN and then leave it alone and to stop making changes mid-stream.

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The paperwork, input, and project evaluation rigors that centered around KAT, which was not perceived to be a fully functional database that was user-friendly, were perceived to need some streamlining. KAT was reported to undergo changes on a fairly regular basis causing some confusion amongst users. It [KAT] is a wonderful project but the expectations have been out of control. They have expected us to keep accurate data on a program that is not accurately working. They take their information from this system but it is not working. We do quarterly report and ours does not compare to their report. CAN has the potential to be an awesome system but there are many kinks and it is not the tool they expect it to be. Another case manager shared that the supervisors need to be people who are down here and more visible with us, there is a huge disconnect that leads to miscommunication, misunderstanding, etc. When asked if the P&A had influenced other KAT agencies, the response was 86% positive. The P&A agencies were perceived as experts on resources for people with disabilities and a group with specialized knowledge. One case manger noted that she believed that they provided a service to the CM in the other agencies, It makes their job easier because we are doing the footwork for people with disabilities. When asked if cases of people with disabilities differed from cases of people without disabilities 83% of the case managers agreed with this statement. The reasons given were that people with disabilities had more specialized needs, their clients required more guidance, and the cases required more specialized knowledge on the part of the case manager. As one case manager explained, Yes. It is like driving a standard versus an automatic. They both go straight, and turn and back up. But to accomplish that you have to have a little more involvement and a little more knowledge.

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Another case manger shared how it is sometimes difficult to obtain resources and support due to the involved nature of the cases. I think that our clients bring a lot less [tangible efforts] to the table to contribute. At the LTRC tables when asked What they have they come with. What have they done for themselves? they come with a lot less. You have to look a lot harder to get the resources that they need, you have to be a lot more creative with donations and volunteer labor. Recovery was also perceived by this group as being more difficult for someone with a disability (86%). Again, the specialized services and the need for a case manager with this knowledge was the primary challenge. One case manager shared that, Somewhere along the way if they dont plug into some agency that can address their needs they will miss out on services that they are entitled to and need. Case mangers need to have some knowledge of what is available for [IDD]. Other challenges to a successful recovery included having the knowledge to know how to function within the social service system, mental health complications and transportation. A person with disabilities has to navigate with in the typical system so a typical case manager cannot imagine if it is already hard for a non-disabled person to navigate a typical environment, it is enhanced when you have a disability. There is so much more to deal with. Upon conclusion of the interview, case managers were asked if they had anything else they would like to share. Many of the case managers wanted to emphasize that while the work was challenging, it is also very rewarding. It is the most stressful job I have ever had and the same time the most rewarding. Being able to help someone who has lost all hope it does something to you that you cant describe in words. Another primary issue was that the case managers felt that to do a good job they needed to be backed up by financial resources that they could pull from to meet the needs of the client. Most of the other Katrina Aid Today partners had financial resources and donations that they

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could use to support the clients using case managers through their agency. The KAT affiliates did not have such a mechanism in place before the storm, although some of the offices did have short-term monies that they were able to distribute to some clients at the beginning of the project.

Results from Interviews of P&A and NDRN Administrators


After coding and categorization of the responses from the P&A administrators and NDRN staff the responses were reviewed across the five questions that were used to solicit responses. The results of this analysis are organized by question in the following section: Question 1: What has been the impact of providing case management to Hurricane Katrina/Rita evacuees on this organization? Respondents overwhelmingly pointed out that participating in case management to disaster survivors was a new role for the organization. Prior to Katrina, NDRN and the P&A had been primarily a legal services organization and, as noted by more than one respondent, P&As dont do case management. Involvement with emergency management organizations was new to the organization, as was involvement with the faith-based organizations that are the most common provider of long-term disaster recovery resources. P&A administrators pointed out a number of management challenges that were part of the program. First, the start-up of the program was fast and the P&As were challenged to keep up with the rapid ramp-up of the program. Second, the employment and supervision of the over 50 case managers who had been hired as part of the Katrina Aid Today program provided a special challenge as the nature of the work of the case managers was markedly different from that of the other employees working at the P&As. Sometimes this meant that the KAT employees worked at offices at different locations than the other employees at the P&As or that the P&A had to find temporary space in which to house them. Pay rate for the KAT case managers was shaped by the

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funds available from the larger KAT grant and sometimes differed from that of the P&A colleagues. For most of the P&As, these factors made the integration of the KAT staff with the other P&A staff challenging and several directors mentioned special efforts they had made at helping the case managers feel as though they were part of the rest of the agency. Third, funding from the larger KAT program was designated primarily for salaries for case managers and little was allocated for administrative costs and support. All of the P&A administrators noted that their agencies then needed to find funds in order to cover unanticipated costs, such as for additional hours for the human resources or secretarial support, or for extra copying and telephone costs, which had not been planned for in their original KAT budgets. These budgetary needs were also impacted by the administrative oversight and reporting functions that were required by the KAT Monitoring and Evaluation teamtime and personnel were needed to comply with these requirements and all the P&As reported on the challenges of providing such oversight given their KAT budgets. Data keeping and paperwork functions required by KAT were different than those used in the past by the P&As for other programs and the KAT employees had to quickly learn these functions. Especially during the first year of the program, reporting demands to KAT changed often and learning new procedures on a short timeline was reported as stressful for all of the P&As. P&A staff explained that implementing new procedures and activities while at the same time developing the program and recruiting clients was a challenging task. There were several positive impacts of participating in the KAT program that were mentioned by the P&A administrators. One consistently mentioned positive impact was that the P&As received higher visibility regarding their work with people with disabilities. Working toward the shared goal of recovery of hurricane survivors also assisted with forming

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collaborations with agencies and organizations with whom the P&As had not previously had relationships. Some of the agencies with whom they are collaborating were not agencies that they had targeted previously for collaboration. For example, one administrator shared that, we now interact with other social service agencies like Catholic Charities that allows us to bring a new perspective to these organizations. As a KAT partner, we have put a focus on disability issues. In other cases, the program strengthened relationships with existing partners. In addition, the P&As had the opportunity to serve clients with characteristics that they had not previously served. For example, elderly people with functional limitations who did not typically consider themselves as having a disability, survivors who were Vietnamese, or those with mental illness. P&A staff believed that individuals with disabilities in the community became more aware of the P&As with the expanded role that the agency was playing in the recovery process. The majority of the respondents mentioned that the experience with KAT would make their organizations more prepared to serve survivors with disabilities in future disasters. Question 2: Some case managers and administrators have expressed that the management of cases of evacuees with disabilities differs from the management of cases of evacuees without disabilities. Do you agree with this statement? Why or why not? The respondents overwhelmingly agreed that the management of cases of evacuees differed from the management of evacuees without disabilities. In some cases, the respondents stressed that the difference was not primarily in the types of services needed by these individuals, but in the nature of the case management itself. The respondents characterized the case management services needed by people with disabilities as requiring more frequent contacts, more time, lasting longer, and being overall more intensive than that provided to individuals

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without disabilities. The multiplicity of issues of individuals with disabilities was seen as being greater as was their knowledge about services that would meet those multiple needs. The end goal, however, was the same in that the objective was to connect these individuals to needed services. Most people with disabilities have additional services that were disrupted to them in terms of what was required to live. The traditional case management model of putting people back into the same place they were does not understand the services of people with disabilities. Yes. That was our premise going and I have not been dissuaded since. There may be similarities, the loss or the lack of svc system is no question that if you are middle class you lose your roof, you put it back you go on. So many who were living in the community that are now in nursing homes, institutions, in more restrictive settings. They dont have the resources to get back to near where they were. A huge reliance on social service systems is apparent. It is important for an organization with disability awareness to be involved because they would have knowledge of these factors. Administrators also believed that individuals with disabilities as a group had characteristics that made management more challenging. For example, as a group, individuals with disabilities are less likely to be homeowners. This meant that some of the FEMA programs were not of use to them or, in the case of FEMA trailers, were not accessible to them. Individuals with disabilities were also seen as less likely to be employed, which affected their ability to pay utility bills or to purchase furniture. It also impacted their ability to relocate after the storm as they may not have the resources or transportation needed to relocate. Individuals with disabilities were more likely to have medical needs and in some cases assistive devices or durable medical equipment needed to be replaced. Most administrators mentioned that case management for people with disabilities necessitated knowledge of how to communicate with the disability community. Some administrators believed that the skill of working with people with disabilities

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was one that could be provided through training by the P&A and not a necessary prerequisite for hiring as a case manager with the P&A. Question 3: Some case managers report that recovery from disaster is more difficult for individuals with disabilities and requires knowledge of disability services in order for a successful recovery plan to be designed. Do you agree with this statement? Why or why not? In general, the administrators agreed that recovery from disaster was more difficult for individuals with a disability. Case management with the survivors with disabilities was seen as taking longer in part because multiple areas of support needed to be addressed. Needed knowledge include information on disability resources and sources for durable medical equipment. It was also noted that people with disabilities might be more at risk for depression or anxiety. Another reported factor was that people with disabilities, on average, have more support needs that those without disabilities. For those evacuees that were displaced, those natural supports were seen as more difficult to reassemble as they had been developed to accommodate the particular needs of these individuals and put place over time. Some administrators noted that those accommodations that were in place before the storm might no longer function in the new environment. The respondents believed that case managers who had knowledge of disability services would be more successful than those that did not. Essential to the success of these case managers was understanding of disability services and eligibility for those services. Part of the reason it was seen that people with disabilities were more reliant on public services such as public transportation and social services, and that public infrastructure was seen as being particularly of importance for individuals with disabilities.

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Clients have reliance on so many federal programs and the long term nature of the systemic presence does affect how they access support. Special education, even housing requires access to federal programs. There is a broader array of services and systems for people with disabilities. It is not a question of getting roof repaired and sending them on their way, there are stiff bureaucracies to deal with. In the beginning money is donated, people are helping; people with disabilities dont recover that quickly. Finally, it was reported that case workers needed to be able to aware of the attitudes and biases that society have against individuals with disabilities and be prepared to deal with those attitudes when seeking resources for their clients. Question 4: In our conversations and interviews with P&A staff we have heard stories about the influence that the KAT-NDRN staff and case managers have had on the case management and administrative practices of their colleagues in the other KAT agencies. Do you think that the participation of your P&A as part of the KAT consortium within the state had an influence on other KAT agencies? If so, how? The response to this question was a guarded yes. The reservation of most of the respondents was that they had yet to see the results of their advocacy and education activitieswhich made the respondents unsure about the extent to which the P&As had concretely and definitively influenced their partners. The respondents did believe that the partner agencies were more aware of their services and that their participation in KAT had heightened their profile among agencies, but that there was still some misunderstanding about what was the role of the P&A. Partner agencies were likely to call the P&As when they needed disability-related information, and appreciated that the P&As had disability-related expertise, but this did not necessarily translate to the transfer of cases to the P&As. The involvement of the P&As was seen as elevating awareness of disability-related issues among the partner agencies. In most cases, the P&As took leadership among the KAT partners in hosting meetings at their offices,

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demonstrating best practices in case management, or providing training and information on working with individuals with disabilities. Statements regarding impact on partner agencies focused on the awareness that the partner agencies now had about the role of the P&As. Despite this awareness, the concrete impact that the P&A participation had had on the partner agencies was hard to see for most of the respondents. While the partners provided much information and referral to disability-related services the partner agencies, the reported impact was one of disability-awareness rather than an increased knowledge of disability resources. As such, the influence that the P&As saw themselves as being most valuable was in providing technical assistance. More definitive change was seen as part of the legal actions that the legal side of the P&As took regarding accessibility of services and information in accessible format. Some respondents pointed out that these actions had influence outside of the KAT partnership, such as legal actions taken on Red Cross and FEMA. In some cases, the administrative staff made a point to communicate with other agencies about the rights of individuals with disabilities. All of the respondents believed that they had influenced the other partners to at least think about disability issues and the rights of individuals with disabilities. On the national level, NDRN administrators pointed out the effect that NDRN and the P&As had gained credibility among the emergency management organizations and this enabled them to have a stronger voice and thus the potential to affect change. Perhaps the most significant impact was on the Stafford Act, which legislates the accommodations that people with disabilities who are receiving case management and sheltering have after a disaster. This advocacy was seen as having long-term effects on recovery practices and as having changed the legal requirements of agencies providing sheltering and services.

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In short, respondents believed that presence of the P&A partners at the disaster recovery table made the partners think about disability issues in a way in which they had not done before. Partners were seen as being more aware of the needs of people with disabilities, but respondents did not know if this would ultimately affect practice and were unsure if this involvement would substantially change how services would be delivered in the future. Question 5: What advice would you give to Katrina Aid Today (KAT) in improving services for the next disaster? Among the P&As, and particularly among the Tier 3 supervisors, advice about changes were fairly consistent. The strongest recommendation for change focused on the measurement of outcomes of the program, specifically, the use of number of cases as being the primary and almost exclusive outcome measure. . One Adminstrator commented that. The administrative structure did not work well, it set up competition. Lot of time was spent on numbers and not on the quality of case management. That was set up by design, not purposefully but that was the impact of the design. Case management of individuals with disabilities was presented as more intensive and time consuming, which meant that fewer cases could be managed by each individual case manager. Case management by the P&As was sometimes referred to as holistic or deep case management as the support needs of individuals were seen as necessitating a more intensive level of case management. A related recommendation was that the expected time that survivors would need to recover from the disaster should be modified. Time for recovery was seen as being particularly important as individuals with disabilities were seen as needing an even more extended time for recovery. Part of this time for recovery was linked to the need for the existing public

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infrastructure to be rebuilt or modified as an essential part of the supports that people with disabilities are reliant upon. For example, for those individuals with disabilities with visual impairments who were unable to drive, the public transportation system was an essential support that needed to be in place before they could effectively mobilize within the city. Paperwork and input into the CAN database were seen as excessive and taking time away from assisting clients. Paperwork and procedures required by the KAT program were seen as being a barrier to connecting clients to services, rather than facilitating the case managers work. Many administrators commented on the changing requirements of paperwork, particularly during the two quarters of the KAT program, and how these changes had been challenging to their case managers because of the time involved in updating their records. In most cases, the P&As chose to keep their own records of client services in addition to those required to be entered into CAN. An administrator commented that one state [received less than $18,000] and had four site visits illustrating the paperwork requirements. Another area of improvement suggested by administrators was to make services available through individual partners available to ALL the partners. This suggestion was particularly of issue for the P&As who did not have access to additional disaster relief funds as did, for example, Catholic Charities or the Salvation Army. The point was made that if the partners were part of a consortium then the partner resources should be made available to all partners within the consortium. The P&A did not have tradition of handling donations for distribution to clients. Some administrators believed that, as a result, clients would seek out services from partner agencies that could provide material resources in addition to case management.

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Results from Focus Groups


The five focus groups took place at five different locations, chosen in collaboration with administrators at NDRN, at which a P&A was directing a Katrina Aid Today case management program. The five focus group locations were in Houston, Baton Rouge, New Orleans, Gulfport, and Atlanta. The Tier 3 administrator at each location collaborated in selecting a location in which to hold these focus groups, as well as in contacting potential participants for this evaluation study. The administrators were asked to invite eight participants that 1) had been in contact with the P&A during the previous 60 days, 2) who had received at least six months of case management services from Katrina Aid Today, 3) who were over 18 years of age as of the date of the storm, and 4) who represented a wide range of disabilities. Case managers of potential participants were given a brief description of the study to read to the potential participant as well as a copy of the consent form that was approved by the Institutional Review Board at Texas A&M University. Participants were told that their transportation to the focus group would be paid for and, in the case that it was needed, accessible transportation could be provided by the research team. Interested participants were informed that lunch would be served immediately before the focus group took place and that they would receive a $25 stipend for their participation in the focus group. Once the case managers had obtained a list of interested participants, contact information for any participants needing transportation was then given to the Principal Investigators. Six to nine interested participants were invited to each group. Participants were called and reminded of the upcoming focus group 24-48 hours before each of the groups were scheduled. When they arrived at the focus group, participants were asked to complete a brief demographic survey sheet. The demographic make up of the groups was as follows:

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Focus Group Ethnicity


Unidentified 3% European American 13%

African American European American Unidentified African American 84%

The focus groups consisted of 71% female (n=22) and 29% male (n=9) participants. The ethnicity of the focus groups was primarily African American (n=26). Four European Americans participated as well as one participant who did not disclose her ethnicity.

Focus Group Marital Status


Widowed 3% single/never married 24% separated/divoc rced 24% Married Married 49% separated/divocrced single/never married Widowed

The average age of the focus group participants was 51 with a high of 74 years and a low of 31 years. The participants reported the number of children in the home ranging from zero to five, with an average of 1.3. The focus group participants reported that 14 of them were married, one was widowed, seven were single, and seven were separated or divorced.

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Focus Group Educational Levels High School, no diploma High School diploma Some college, no degree Associate's degree Bachelor's degree 3rd Grade education J.D.

3rd Grade education J.D. 4% 4% Bachelor's degree 11% Associate's degree 11%

High School, no diploma 21%

Some college, no degree 21%

High School diploma 28%

The focus group participants had a large range of educational levels. One participant had completed a third grade education and another had a J.D. Graduates were almost equally distributed among the educational levels of no diploma, (n=6), high school with diploma (n=8), and some college with no degree (n=6).
Focus Group Disability Category
18 16 14 12 10 8 6 4 2 0 16

7 4 1 VI 1 LD 2

Mobility

Mental Illness

Medical Needs

Multiple

Focus group participants reported a range of disabilities. Most (n=16) participants reported multiple disabilities. Of the 31 participants, 15 reported either mental illness or

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depression as a disability. Nineteen participants participated in the focus group and represented themselves as person with a disability, four participated as a family member of a person with a disability, and eight participated as both a person with a disability and as a having a family member with a disability. Open coding was completed on each focus group transcript. These codes were collapsed into overarching categories. As the intent of this evaluation report is to report the responses to predetermined focus group questions, these categories were then compared across transcripts to determine those held in common across the five focus groups. In the following section, these categories are presented and organized under the questions used by the investigator to elicit responses: Question 1: What have been things that prevented you from recovering? This question, originally intended to be asked as the last of the series of five, was moved to become the first in the list of questions. At our first focus group in Houston participants insisted on starting their discussion by reporting on barriers to their recovery, rather than on the supports that they had received post-disaster. In fact, they seemed unable to talk about their recovery. As one focus group member in Houston stated you cant really say that you have actually recovered. Its not easyyoure not there yet, youre still not there... The investigators moved the question about recovery to become the first in order to facilitate the flow of discussion in the remaining four focus groups. Of all the questions asked the groups, the question of barriers to recovery most easily elicited responses, and without exception, participants were able to identify multiple factors that had negatively affected their recovery. These factors were categorized and then consolidated so that we could examine commonalities across the five groups. Some participants contributed

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narratives of their disaster or recovery experiences as part of their response to this question. These brief narratives were then coded to identify categories of barriers that the participant mentioned. The first overarching category, one that was easily identified by the participants, concerned the lack of the concrete resources they believed would help them recover. Participants returned repeatedly to this theme during the focus groups, even in response to other questions. They cited assistance that they had received soon after the storm had occurred but were aware that resources had become substantially reduced by the time the focus groups were held, almost two full years following the disaster. With regard to the specific supports needed, the largest majority of respondents reported housing or home repair as the primary need preventing their recovery. Most respondents had received FEMA housing assistance at some time during the previous two years. However, responses indicated that ongoing FEMA assistance was fraught with uncertainties, required complicated and excessive recordkeeping, and was maintained only through repeated and sometimes stressful interactions. One participant commented: Thats like thats how they do ya, they find all kinds of loopholes not to give you the money, you know You didnt cross your Ts you didnt dot your IYou know Im in needforget about thatgive me what I need. I need it, thats what I say but they dont see it like that. (New Orleans Focus Group) Most participants expressed uncertainty and anxiety about the future of their housing and over 90% were living in rental properties or with other families. Additionally, many participants stated that rental properties that were affordable for them before Katrina were now much too expensive. Further complicating their housing challenges was that most participants income significantly decreased after Katrina. One participant stated:

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And then all of sudden apartment buildings I would see that were one bedroom that might have been say $400 dollars [before Katrina] now its $700 dollars. (Mississippi Focus Group) Another participant said: In a two bedroom, one bathroom house. Six adults, five children. And that is because we are not making it, we just are not making it. We are paying twice the rent and we not making half the money we was making (Georgia Focus Group) In some cases, the housing provided to them was not appropriately accessible or was located where there was limited or no public transportation. One participant remarked: Praise God for [name of case worker]! And, um, they tore my house down just about three weeks ago and she is going to use my insurance money to help get me a handicap accessible home not the trailer I am inYou know, I have a trailer, andI am uncomfortable in a way because the sofa is old. I am sleeping on top of a pillow because the back bedroom the bed is so high I cannot get into it. And they got one air conditioning unit in there and it does not cover the whole trailer. Certain parts of the day it gets hot.... (Mississippi Focus Group) Anther participant related a similar experience: I got a telephone call, Ohwe have a trailer for you, you have to come on home so you can inspect the trailer and all this. Im handicapped, she gives me a trailer as big as this room here, its not handicapped equipped. Ok, she promised me faithfully, ohthat youre here now, we gonna take care of this. Just give me about two weeks and were gonna put you in a handicapped. So we spent two months, six months, eight monthsnow Im getting ready to be kicked out of my trailer, ok. (New Orleans Focus Group) Employment was another primary category of need for these participants, most of whom had been employed before the disaster. Some of the jobs that the participants had had predisaster did not exist in their new location: You know there is no professional doorman where you can just go and get another doorman job and then it is not going to pay as much as it did in New Orleans. You know what I mean, he was making $200$300 dollars cash sometimes. You just cant replace that. And then I had my hustle. I had my little sewing business where everyone in the school system wore uniforms so everyone needed their uniform altered and I had my little business going. Everything was just going swell and lovely andyoure back down to the bottom again. (Georgia Focus Group)

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Transportation was another service need consistently identified by the participants. Without transportation respondents were unable to seek employment, obtain medical services or to search for more appropriate housing. Most of the thing that I am really looking for right now is to get me some transportation, some better transportation than what I got. Basically from there, I think I can make from there, but I know it is going to be a little rough up the road, but basically I just need transportation. (Mississippi Focus Group) If I could just get a place, get my house fixed and get some transportation so my daughter can carry me to where I need to go then I She can drive, but I cant so if I had some transportation where she could take me (Mississippi Focus Group) Medical supports, including the need for durable medical equipment such as wheelchairs, and prescriptions, were another category of need in this group. my baby needs medicine right now, but CVS will not take his Medicaid card and he catch pneumonia. He has a respiratory disease, and he catch pneumonia like three times a year. And I got a prescription right now and they are like we are not taking that you know and it is just I am scared to transfer and then I am scared not to. (Georgia Focus Group) Despite the desired concrete service needs, most of the participants agreed that most of the needs identified above could be fulfilled by adequate financial support, either in the form of compensation for employment or from some form of public assistance, which might include support from FEMA, Social Security, disability benefits, or insurance payments. Well, like with me I am just staying in an old trailer that was there. I had no help to fix it, I am on low income, I am on disability. But I just dont have money to fix it. But I have not had any help from nobody so I am just doing the best I can, what can I do about it? (Mississippi Focus Group) Another participant said: so we came to, itll be a year next week, to Houston and weve been really living on my social security, which has been very difficult to make it and, um, FEMA just got to the point where I didnt even know how to talk to them because I had a lot of medical issues as a result of Katrinaso we just do what we have to do to survive. (Houston Focus Group)

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The second overarching category that connected the narrative responses to this first question was that of the difficulty in obtaining services. This category was exemplified by participants comments about getting the runaround, gate-keeping in different forms, and competition for resources. it is the most frustrating thing is to call a number and they tell you theyre going to be able to help you but then when you call that number, Right, but let me give you another number you can call and then you call that number Heres another number you can call, and youre sittin there with a list of numbers and you call that whole page [but] you still have nothing. (Georgia Focus Group) Another participant said: Nobody knows whats going on and youre right there in the middle of thisyoure already in all the confusion. You go there and guess what? They are like Oh, well, heres the birth certificate, here that then they still need more so I tell you what Im out of here (New Orleans Focus Group) Paperwork and lack of information about services were other barriers to obtaining needed resources. One woman, whose husband died during the storm, commented: My husband was a 100% disabled veteran and his income is greatly missed. And the VA they denied me his benefits and now it is on appeal. The doctor said, see if you could have his file sent back to New Orleans. So the VA here finally decided to send the file back because at first it seemed like they didnt want to do it for whatever reason. So the file is back in New Orleans and as far as I know they are looking into it. (Georgia Focus Group) Some participants were quite candid about the psychological effects of the disaster and how these had affected their ability to persist in seeking out services. In each group there were at least two participants who self-identified that they were experiencing depression. In response to the question about his biggest barrier, one participant replied; mentally, I guess. [Name of case manager] has helped a lot with getting a down payment of the mobile home and getting furniture, but you have got to deal with the mental stuff. And you see all this stuff in the paper every day that Katrina is gone, get over it, and all this stuff. But it aint gone for everybody. (Mississippi Focus Group)

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Another participant said: I dont sleep. That was the first thing I have had to eat [referring to the lunch provided at the focus group] since yesterday. I dont really have an appetite, I eat once a day. I dont know why, I guess the stress has got me gaining weight, maybe the lupis is acting up, but Im swelling. I dont have no help whatsoever. But yet they say I want a handout. All I want to do is go to work. All I want to do is pay my bills, put food on my table, put gas in my car. I want to be able to come and go like a human being. (Georgia Focus Group) The reason for the experienced depression was not directly linked to a loss of resources rather it was usually connected conversationally in the focus group to an increasingly limited pool of options and the bureaucracy of applying for aid: It is like we have lost our hope. No one answers our phone calls, no one calls us back, you know. We have been left out. By asking certain questions or asking for something that we need, desperately need, and it just Call this number, well, call this number, call this number. I had six in one day, different ones to call and nobody had any answers for me. So that has been a very long drawn out thing. Getting the answers as to who do we talk to. (Mississippi Focus Group) In some cases, depression became in of itself a barrier to the recovery of some individuals: see its not just a better job for meI dont know how to explain it but I have like a sadness in me that comes out every night and I get really, really depressed, I really do. Sometimes I be like that for weeks on. And the other people they wont know that I just get in a rut and I just cant get past it and come home from work just go to sleep. (Houston Focus Group) Another participant said: I was talking to a social worker because I was having a whole lot of issues as far as my thoughts were concerned, and at one point I was even thinking about suicide. I was thinking that if I would take myself out then people wouldnt have to worry. (Georgia Focus Group) When asked about the biggest barrier to recovery another participant replied, The frustration of it all. I had quit smoking years ago, I started smoking again. Im taking pills for depression. Her hairs falling out. I mean its, its I dont know you I dont know how to deal with it. (Mississippi Focus Group)

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Resources were seen as being unequally distributed or more available in other states. The focus group in New Orleans consisted of participants who had lived in New Orleans before the storm and who had returned. Several of the participants had been displaced and had returned after living for several months in temporary housing in other states. The group believed that the services that they had received in other states had been superior to those that they were being provided in Louisiana and that financial delays and corruption in the state affected the aid that they were receiving. The researcher then asked, You know, I dont get this though because you guys are all glad to be back home. The participants, as a group, replied, Theres no place like home and one woman remarked, We [are] like abused children. But stillyou got that block that say, I love my mom, I hate my momma, I love my mom but you do get abused. (New Orleans Focus Group) Question 2: What has helped you recover from Hurricane Katrina? When this question was asked as the leading question to the first focus group in Houston, participants quickly changed the topic from what has helped to what things have prevented your recovery. Participants across all groups consistently reverted to talking about barriers to recovery even when asked directly about factors supportive of their recovery. What became apparent after interviewing all of the groups was that, without exception, every participant in each of the focus groups was still recovering from the disasternone saw themselves as having recovered. Recovery was seen as an ongoing process in the midst of which the participants still found themselves. As all of the participants in the focus groups were still receiving case management, it is perhaps not surprising that these individuals presented themselves as still in the recovery process, however, their responses emphasized that they were not satisfied with the

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conditions within they were now living and that they believed that their lives had been better before. For example, when asked about recovery, one participant said: Its not really a recovery moment you cant really say that you have actually recovered. Its not easy so its like your not there yet your still not there. (Houston Focus Group) When asked what had helped them during their recovery process, the groups overwhelming responded, in order of importance, family, friends, and prayer/spiritual support. In the cases that the participant was living apart from their family or friend before the storm, they emphasized the support that they had received from their church or from their spiritual practice: My familys not hereIm alone here and I went through a great deal. I had a heart attach and triple bypass surgery two weeks after the storm and it was just me and God. (Houston Focus Group) Where you all have destruction [referring to others in the group] I had devastation and I did a lot of praying. My church kind of like stepped in a littlewe still trying to rebuild that but, really and truthfully the prayers helped me. (New Orleans Focus Group) Um, I guess mainly the support from people here, from my church. Just from family and friendsSo basically it has been relationships that have been the strongest piece, I think. Cause even with working with persons with some of the other agencies there have been relationships that have been developed from that communication and that contact with persons from other agencies. That is basically what it has been, relationships. (Georgia Focus Group) But its like you gotta help you know you got to reach out and help one another because if the, if the system kick in and try to help you its gonna take you a real long time to get any help you know and they need help. (New Orleans Focus Group) Prayer and my people. My son and my sister. Out of thirteen of us I only have two left. So like, if I need something I call my sister. She needs something, if I got it I call her. My mother and my father always teached usnothin like your own. (Baton Rouge Focus Group)

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Question 3: What help or services have helped you get the things you need? Responses to this question were closely linked to that of Question 2. In all of the focus groups, however, participants had to be prompted to identify the formal supports or agencies that had provided them with support. Most respondents reported getting assistance from FEMA or Red Cross immediately or soon after the storm: I didnt get housing assistance until I got to Texas. When I was in Omaha Nebraska there was this church, I cant recall the name of the church, but they was a affiliated with the Red Cross as well they put me up in a hotel for a couple of months. (New Orleans Focus Group) Almost half of the participants identified, after prompting, a faith-based recovery group such as Catholic Charities or Lutheran Social Services as helpful in connecting them to needed resources. Some participants listed the P&A as an important support: Disabilitylink has helped me tremendously and [KAT] has helped me tremendously because I didnt have any transportation even when Disablitylink got me into [a] Section 8 program I had no way to find a house because I had no transportation. So when I did get in touch with [KAT] they took me to look at houses, they took me for the inspection of the houses and just helped meWithout them I dont know what I would have done. The Disability Link and [the P&A case worker]she has been putting me in touch with Catholic Charities who assisted me in some other ways. So, it was like a network, I guess they had between each other, and they found out what would best suit me and she [the case worker] referred me to themThey have been tremendous in helping me, especially since I had my stroke, I dont remember so good all the time. (Georgia Focus Group) Although this question was designed to elicit naming of agencies and organizations that had provided supports, participants commented that reliance upon these formal supports had not been part of their life pre-disaster. Most reported relying on family and friends for needs in their communities: you could make a phone call, you could call an aunt or an uncle, a cousin, a niece, a nephew, someone you grew up with, you know, a childhood friend, but just that connection you could that could be a last resort you say well, look, Im

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in need, can you, Im stuck in traffic, can you pick up the kids for me, can you make sure and that (Georgia Focus Group) theres a place here in New Orleans its the Ninth Ward its like a country, a country, and I think it deals up from there because those people were country and country people like they believe in really gellin togetheryou cant depend on the system. (New Orleans Focus Group) my neighbors really my big support system because like I saidhe cut grass and if I need something I could, you know, I try to get with him and cut grass and, you know, get things situated. (Baton Rouge Focus Group) Among the formal support agencies mentioned, Red Cross, Catholic Charities, St. Vincent de Paul, Salvation Army, and Lutheran Social Services were mentioned most often, as were local churches where the focus group members were attending. One participant had financial support to rebuild his home but believed that compassion was also needed in supporting him as a disaster survivor: If I could have one or two maybe three or four workers that are hanging there with [me] and [being] very humanistic with [me]. But then you got this other people that come along and they like, they just doing their job. You have to do your job but you have to have that compassion. You have to relate to whats going on. No, you may not have been in that situation, but [its] kinda like step back and see whats going onput yourself in [my] shoes or something (New Orleans Focus Group) In the Mississippi Focus Group participants talked about groups assisting them with obtaining a new wheelchair, prescriptions, and presenting their case at the long-term recovery table. I did get a wheelchair through Medicaid. But what happened when I got it, it was in my daddy van, in the back of the van, and he open it up and it fellMedicaid come back and picked it up and they tried to get it fixed and they couldnt get it fixed and they told me that I cant get another chair for five more years. And this chair is [broke] and I need another chair but I am dealing with this one here, you know. (Mississippi Focus Group)

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Question 4: How has Katrina Aid Today (this Advocacy Center) helped you? Most participants had not been in contact with the P&A before the disaster and had contacted the agency to seek services during the recovery period: I found out about this program here through a friend of mineand she said The Advocacy. I had never heard of this programIm not going to lieI had never heard of it before but I called... I wasnt gonna call because I know the situation that everybodys going through and I said Lord, I cant go through this but when I called it was a whole different thing, you know. (New Orleans Focus Group) Few participants spontaneously mentioned the case management services that they were being provided through Katrina Aid Today as an important source of services as part of their responses. Those that did were appreciative of the efforts of their case manager but some saw limitations in what their case manager had provided to them. I havent received anything from the agencywe just got all this process. (Houston Focus Group) Another participant said: I think that I have given my case manager more resources than shes given me because I look for them. And I call so much with the resources that I got off the Internet, I called them so much they said, Miss [name] you are already in the system, you need to wait. You have a case manager and if you would just let her do her job and Im still waiting. (Houston Focus Group) Another Houston Focus Group member said that the search for available resources from all the different organizations was like going from having one pimp to having four or five pimps, you just have to work extra hard. Most did not separate the services that Katrina Aid Today provided from the services that their case manager had provided. you know how they have those FEMA meetings and I went there and Id just gotten to Houston and everything they were telling me didnt apply and it seemed like only those people who received services was if it was for welfare were able to get help. So I stared crying cause I just couldnt stand it and I was standing in the

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middle of the floor and this lady walked up to meso they had a table for Katrina Aid. [Name of case manager] was there so he started talking to FEMA on my behalfand Red Cross. (Houston Focus Group) Another participant stated: Im always been on my own since seventeen and I dont believe in dependin on charities and I wouldnt have went there at that time if my checks would have came on time but thats the reason I went there and the reason I got a social worker and I just got her and I been here two years. Thats the first time I ever asked her was last month and I dont ask for nothin I dont believe in askin for nothing because I say it like this, they got a lot of poor people out that really need it, I prefer them to get itI only been here two years and I used her last month for the first time in two years and thats it. (Baton Rouge Focus Group) Other participants related these experiences: So you know uh so now we down to eatin peanut butter and jelly you know from time to time just so so you can make it but I dont know where theres any resources for anything. (Houston Focus Group) Red Cross only gave three hundred and sixty dollars but this is what they did they gave me a voucher for medication for one hundred and eight dollars, they gave me a voucher for clothes for I think for one hundred and thirty something dollars and when they gave the checks for the cash they deducted the medicine and the clothes voucher from that so I got a grand total of one hundred and twenty two dollars that was tangible you understand (Houston Focus Group). There are so many people devastated by this storm and there are not enough case managers to go around. They have got so many people. They are trying to help so many people. (Houston Focus Group) Question 5: How has your case manager helped you? When this question was asked, the overwhelming majority of the respondents agreed that their case manager had been attentive and supportive during their recovery process. Three categories of support were consistent across the focus groups; assistance with paperwork, listening and emotional support, and information and referral services. A participant stated: Housing. You know, just if [name of case worker] had not come along we probably would still be struggling, but she helped us along the way and we appreciate that. It is like I said, its hard to gethelpThey forgot about the elderly and the poor. (Mississippi Focus Group)

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Another participant stated: She assisted me to get furniture for my home and so I have furniture. I appreciate that, that was going to be a big hurdle to jump if I didnt get no furniture. She got that for me so I appreciate that very much. At least I have a bed to sleep in and a couch to sit on and a dining room table. That was nice. (Mississippi Focus Group) Some participants talked about the importance of having a personal relationship with their case management that blurred the boundaries of the service provider-case dynamic. One woman commented: She even went to church with me on Sunday and I really appreciate that andI think that I knew thats what a lot of people need because then when you have somebody thats in this program and know whats going on andyou can get them to understand what you need (New Orleans Focus Group) Another participant said: If it werent for [name of case worker] I would not be where I am at now, but she still gave me the motivation. Because I felt like someone was still trying to help me so I got up and tried to help myself. But before [name of case worker] I didnt know what to do. I just sit and just sit there until she came along. She gave me hope. (Mississippi Focus Group) Another participant responded: its like a glass of cold, cold water when you deal with somebody who is there for you and justsays Well, look, let me go to my supervisor and get back to you, and get back to you even if they got to say No they have gotten back to you. (New Orleans Focus Group) Another participant stated: she helped me a lot, she was pointing out a lot of things to me about, you know, about getting myself situated back in, you know, working stuff, like that, and she also pointed out things that helped me get around and she was kinda showing me about the system how I take the bus so I can, you know, be from point A to point B. (Baton Rouge Focus Group)

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Another stated: Ive had a good experience thus far and, like I said, hes been, he listens. Hes given me a list of other resource to use so I have no complaint. (Houston Focus Group) Even when the resources were not forthcoming, the participants felt that they benefited from their relationship with their case manager: Mr. ____ hes very helpful to me because even though I got to keep more papers more papershe calls me, he even calls me Sunday to let me knowhow I get through thisLike I said, he also intervened between FEMA and I, because I had given up with FEMAI couldnt emotionally I couldnt deal with them (Houston Focus Group) Some clients did not have good responses from case workers, although when questioned further these were usually not the P&A case managers that they were referring to: No because theyre too busy to contact you. You have to contact them and then when you try to contact them you gettin voice mails and you get this and that and the other or you know it just aint happenin. (Houston Focus Group) One participant from Houston who had been in a high-ranking human resources job before the hurricane observed that many of the agencies and positions formed as a result of emergency funding had limited experience in the human services arena: In most cases what Katrina did it created a lot of jobs a lot of these agencies and you got people working in these agencies who got crash courses on how to do human services have never worked in human services. [They] do not know how to communicate or relate to people and some are just there for the dollar and they could care less how they talk to you andjust here to get this dollar and when the program ends Were gone. Context Contextual categories provide the backdrop against which the other categories interact. In other words, a contextual category does not fall within the overarching categories outlined above but influences how these other categories were manifested or influenced each other. In the focus group part of this study the context that influenced the results reported above was that of a sense

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of displacement. All of the participants from Houston, Baton Rouge, and Atlanta had been living in the greater New Orleans area at the time of the disaster while the participants in Mississippi had been living along the affected coast. Following the disaster, all had to shelter in different locations. One participant did stay in his home during the storm, but then relocated to other states for several months following the storm. The four participants in the New Orleans group had returned to the city, however, they returned to a city and to neighborhoods that were unfamiliar and irrevocably changed in its composition. The two participants who returned to their homes in Mississippi were similarly unsettled and still waiting for assistance in repairing their homes. What was striking was that not one of the focus group participants felt as if their current living situation was settled or permanent, even those who had employment or who had returned to their homes. One focus group participant stated: I think its more then moneyits you know where you live, the ground that you walk on and when you wake up you know where you are and, you know, its just your whole live has changed and I dont think youll ever really recover because youll never get back what you had. Everybodys lost friends and family scattered all around the country Another participant shared: it is like a record scratching, you feel like you keep jumping back to the same point. Wherever you was at in New Orleans once that happened it just put everything on the halt, just stuck (Houston Focus Group) This group repeatedly expressed that they were unsure about the future, frustrated by the length of time their recovery was taking, and unfavorably compared their current living situation with that before the disaster. This context of uncertainty permeated their comments about recovery and was reported as its own source of stress for these individuals. As one focus member in Houston said, I dont know what recovery meansI dont know if Ill ever recover. One participant said,

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Having doubts for two years, just having doubts. And then our case worker come along and she finally gave us a little bit of hope, you know. She has been the only hope we have had since the hurricane. (Mississippi Focus Group) Another similar salient expression of displacement was the feeling of being cut off from home and family. This separation was strongly expressed by a member of the Georgia Focus Group; I can relate to slaves (they were my ancestors) but all my family is like scattered. Other participants shared: You had family there [New Orleans], you know and people dont understand that all of that is just gone, it is taken from you, it is jerked from you. We was plucked out of that situation and put just anywhere. The first year that we were apart from each other I cant listen to holiday songs, look at TV and commercials with the family, I could not do none of that, I just couldnt, it was just too emotional. (Georgia Focus Group) I will say another barrier is not just FEMA, it is our resources like family. I have none. They are from New York to Jersey to Texas to West Coast so no more going to big mamas house on Sunday. We were very close. It is like I have no culture anymore it is like, I feel like, what did they call us? A refugee, yeah. (Georgia Focus Group). Even when participants were able to return to their home, they were disturbed by the damages to their homes and frustrated by the lack of resources to help them rebuild. These factors contributed to make them feel unsettled even when living at home. One participant reported, I dont have a home anymore. I mean, thats the way I look at it. I mean, even though we just got a home you dont feel like youre home. I dont know if that makes sense to anybody, but that is the way I feel. Its lost. (Mississippi Focus Group) A participant from the New Orleans Focus Group said: You know when that storm hit, my home is the only two story in that area. I had, what, thirteen, fifteen neighbors over there at my house. Didnt know them, didnt know their names. Didnt know they stayed around the corner, but I know that I was the only shelter that they had and I took them all in...About three days later, Coast Guard came and got everybody and I stayedin that house over three weeks.

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I been around the world at least six to seven times. Red Ocean, Pacific Ocean, Gulf War, AtlanticI been around the world to Egyptand they always trained us for when the ship [might] sink. And since 1987 we never had one experience whereI had to worry about ships sinking in the middle of the oceanbut here I am in my own home, and Im seeing water rise above me, trying to knock a vent out on the roof thinking Im going to drown right there in my own home. (New Orleans Focus Group) These expressed feelings of displacement were heightened by the view that receiving resources was seen negatively by others. Many participants that had been displaced to other cities remarked on what they saw as unwelcoming attitudes in their new location and the perception that they were undeserving of the level of support that they were receiving. Several participants commented on how others in their new environments seemed to view them: as far as the money, when they start dishing out the money then people look at that that he got more than what I have you know that whenthat animosity comes in (New Orleans Focus Group) its like a bunch of crabs in a basketonce you get to the top theres always somebody to pull you back down (New Orleans Focus Group) Everybody thought just because you came from New Orleans you didnt work or you werent educated or whatever. That wasnt the case they had like what seven or eight universities out there that everybody came from all over the place you know so people didnt realize yeah we go to work a lot of people were entrepreneurs. (Houston Focus Group) I go places sometimes and people see that I am from Louisiana and I have getting a lot of nasty things said to me while I am driving. I just feel scared here, I dont feel secure or welcome (Georgia Focus Group) even like in the barber shop seems like they angry at us for gettin certain things butthey dont realize that we lost practically everything... But they are looking at 18 months free rent and they like How did they get that? and they like They get more than I get, and I am like What do you mean we get more than you? We trying to get up to the ground level where everybody at! When you have a group of people who are not used to that, when they see one person get throwed the bone it is hard for them to sit there without salivating. But that is a racial thing, that is a cultural thing. (Houston Focus Group)

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A Houston focus group member commented at first everybody is nice to us, but now that we are here everybody has flipped the switch, you know. You are not even wanted, that is what you feel like, not wanted. Indeed, two years following the storm, resources for hurricane survivors have dissipated and competition for scare resources was evident throughout both the housing and the employment sectors along the Gulf Coast. The sense of increasing community hostility was seen by these participants as complicating their recovery process. Summary of Focus Groups The central phenomenon around which the discussions revolved was the clients lack of recovery following Hurricane Katrina: Not one of the participants in these focus groups felt that they had recovered from the disaster. The primary reason for the lack of recovery was overwhelmingly, and yet simply, identified as a lack of the resources needed to return to normalcy. Clients acknowledged that, for most of them, their recovery would be to a new normalcy rather than a return to their former homes and neighborhoods. However, a lack of basic services and supports, primarily housing, employment, transportation, and health care, were barriers to their recovery. For those participants with mobility impairments or who had chronic medical needs, disability supports and durable medical equipment were identified as critical resource needs. While identified mental health issues, particularly depression, also were mentioned as barriers (and a discernable level of depression was evidenced by several participants in each group), these issues were usually discussed in conjunction with a lack of resources or due to the challenging process of acquiring resources. Not only was the lack of resources and services a barrier to recovery, but the difficulty in obtaining these services was a barrier. Participants identified gatekeeping, getting the run around, and excessive paperwork as being barriers to obtaining services. For some individuals

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the lack of information about services or conflicting information about services added another level of difficulty in obtaining services. As this search for services often took place in an unfamiliar city, this heightened the difficulty for the participants. Agencies, organizations, and case managers were not identified as the most helpful in the recovery process. Rather family, friends, and prayer/spiritual support were identified as most helpful. When the groups were directly asked about formal supports, most reported getting assistance from FEMA or Red Cross soon after the storm but were not receiving support from these agencies at the time of the focus group. Similarly, participants did not mention disaster recovery organizations or faith-based organizations unless directly prompted about receiving support from these groups. Participants did not usually mention the case management services that they had received through Katrina Aid Today as a support, however the majority of those who did spoke positively of them. Many times the emotional and social support that the case manager offered was appreciated most by the participants, even when resources were not forthcoming.

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SUMMARY OF EVALUATION
The previous sections detail the results obtained from each procedural method used to collect data. The following section provides an integrated summary of these results across these methods. The summary is organized using the primary and secondary evaluation questions developed in conjunction with NDRN at the beginning of the project.

Primary Questions
What is the impact when a legal services organization provides case management to people with disabilities who are evacuees? Participating in the Katrina Aid Today consortium was a new role for NDRN and its P&A affiliates and these organizations were challenged to incorporate the new function of disaster case management into their agencys activities. In particular, the management of the program and the reporting requirements were more time consuming and burdensome than the P&As and NDRN had anticipated. As most of the funds used for the program were for direct case management, the P&As and NDRN had to contribute staff and resources toward the project beyond what they had anticipated when joining the program. A noted stressor across administrators was the pressure to meet their numbers of cases handled, while still providing what one administrator referred to as deep casework for individuals who had support needs in addition to just disaster-related support needs. The origin of the pressure to meet numbers was clearly top-down in that the UMCOR-KAT administrators communicated their concern to Tier I administrators, who communicated it to Tier II administrators, and then was most felt by Tier III administrators who were the direct supervisors of the case managers. Results from the surveys obtained from the KAT case managers supported this finding in that the case managers were

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aware of the pressure to meet numbers but these same case managers verbalized their commitment to providing quality case management to their clients rather than simply touching cases in order to increase their number count. The top-down organization of Katrina Aid Today also shifted the relationship between NDRN administrators and the P&A affiliates in that NDRN was functioning as the contractor for a project within whose structures the P&As had to function, rather than functioning as autonomous organizations. What kind of impact does case management provided by disability service experts have on outcomes experienced by people with disabilities? Results from the case managers strongly suggested that disability-related expertise was important in delivering quality case management to individuals with disabilities. This belief was supported by them with examples of cases in which their knowledge of the disability service system enabled them to provide better case management to their clients. These responses were supported even more strongly by the administrators, who also believed that knowledge of disability-related services was essential. Few participants in the focus groups, however, referred to the disability-related knowledge of their case worker although most case workers were regarded highly by their clients. For most clients, their involvement with KAT represented the first experience they had had with a formalized social support agency and they therefore did not have a basis for comparison with other case workers. In addition, participants in the focus groups were overwhelmingly focused on their need for resources in order to aid their recovery rather than on the disability-related knowledge of their case workers. The disability-related references that were made by the participants were almost always made in connection to health-related disabilities or to durable medical supports. Results from the case worker surveys and the quantitative analysis suggest that NDRN-KAT clients represented more complex cases that

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involved multiple needs. Data from the focus groups seems to support this hypothesis as most participants reported having more than one disability. Participants in the focus groups also rarely mentioned a single support need rather they discussed a multiplicity of resource needs. These resource needs were usually were compounded by reports of limited physical or mental wellbeing. No significant quantitative difference was found, however, in the length of time that cases stayed open that were managed by the P&A case managers as compared to those managed by the other KAT consortium members. This result was in direct contradiction to the results obtained from the survey of the case managers and from the interviews conducted with the KAT administrators, who overwhelmingly believed that cases managed required additional time and effort in order to resolve. We believe that the inconsistency in these results is due to the nature of the data obtained from CAN database: Data used for the purpose of this evaluation were extracted in July of 2007 when just under 40,000 cases were part of the CAN database. Katrina Aid Today administrators became aware of incomplete and sometimes inaccurate case information that was in the CAN database and, during the Spring and Summer 2007, began urging KAT administrators and case workers to completely fill out requested information in the CAN database. For example, in the data analyzed for this evaluation, there were a number of clients for whom the database recorded had been receiving case management for over three years, despite the project having only been in place for 18 months. In addition, the number of closed cases at the time of the data extraction for this study was only 21,312 (with just 1,273 from NDRN) and these cases were logically those that were able to be closed most quickly. We recommend that this same analysis be rerun at the end of the project when a larger number and variety of cases have been inputted into the CAN database. The resulting analysis will then give

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a more accurate measure of the differences between the lengths of time needed to manage NDRN-KAT cases as compared to those of the other consortium members. What effect did NDRN participation have on the delivery of services by the Katrina Aid Today partner organizations and on the Katrina Aid Today organization? The P&A administrators were unsure about the concrete affects of the participation of the P&As on the practices of their KAT partners. They did believe that the primary effect of their participation was one of awareness and that their consortium members knew more about both the needs and rights of people with disabilities due to NDRN-KATs participation. However, to a person, all of the administrators agreed that participating in Katrina Aid Today was the right thing to do, regardless of the additional demands that participating in the project had placed on their agencies. In reflecting on their participation in the program, however, the majority of administrators suggested that there might be a more appropriate role, such as technical assistance, that their agency could fill in disaster recovery rather than direct case management. Another contribution that the P&A and NDRN administrators reported was that their agencies assisted indirectly by impacting the recovery and emergency management system overall through legal action. Through their advocacy for changes to the Stafford Act and through their pursuit of equal access to services delivered through FEMA and Red Cross, NDRN and the P&As provided leadership that affected the recovery system in a way, which while not visible to clients, ultimately not only affected current case management, but will affect the design and delivery of services to individuals with disabilities affected by future disasters. What does case management look like when the evacuee client is a person with disabilities? Case managers and administrators believed that case management was more complex and expensive for individuals with disabilities. In fact, the average value of services provided to

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clients with aged or disability service needs was significantly greater then those who did not need these services. The dollar amount of services provides was less for NDRN-KAT, however it should be remembered that 1) NDRN did not have supplemental resources that it could contribute to its clients, and 2) that individuals with disabilities were included in cases that other agencies that were providing services, so using the aged/disabled services categorization may be a more accurate marker to use for analysis. Case managers and administrators strongly believed that case management for individuals with disabilities took longer than did that of individuals without disabilities. Data from the quantitative analysis, however, did not support this view. As the extraction of data took place in July of 2007, and thus the project was still ongoing for most of the consortium partners, a better measure can be obtained by repeating this analysis at the end of the Katrina Aid Today program in 2008. The length of case management delivered by the P&A ranged from four to six months, which did not significantly differ from the length of case management provided by the other agencies. However, case managers also reported that type of case management provided was more intensive and required more contacts from the case manager, which could not be measured given data extracted from the CAN database. The primary barrier that the hurricane survivors who participated in the focus groups identified was a lack of concrete resources. The surveys of the case managers found that the case managers continued to work on the behalf of their clients and were strongly committed to assisting them in their recovery process. However, although they were positive in their comments about the KAT program and appreciated the efforts of their case managers, not one participant in the focus group believed that they had recovered from the disaster. Similarly, results from the quantitative analysis of the CAN database found that they were more like to

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have had their case closed for the reason unable to resolve because of lack of resources, and were less likely to report that their post-disaster needs had been met. The premise of the Katrina Aid Today case management program was that it would assist clients in connecting to needed supports and services. In the absence of these resources, case management no longer fulfills this purpose. NDRN-KAT was particularly affected by the diminishment of services in that it did not have a non-profit arm, as did most of the other consortium members, for collecting donations or contributions that could be given to their clients.

Secondary Questions of Interest


Were clients as satisfied or more satisfied with the case management that they received from the P&A case managers as compared to clients who used other Katrina Aid case managers? Nearly all clients were satisfied with their P&A case managers, however, no significant difference was found in the satisfaction rate with the P&A case managers as compared to the case managers from the other partner agencies. As the satisfaction ratings with case managers for both groups was high (over 93% of the clients replied agree or strongly agree to all of the statements concerning satisfaction with case managers) a ceiling effect decreased the statistical power of this analysis. It should also be noted that the overall client satisfaction survey response rate was low: Less than 6% of the clients returned surveys, which, in turn, decreased the statistical power needed to analyze this question. Clients did seem to clearly distinguish between the support given to them by the case worker and the reality that there were few resources available to them. Even though they were frustrated by the lack of resources available to them they appreciated the psycho-emotional support that they were given by their case managers:

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Well, shes really mainly just being really kind, honestly. Shes just been kind and understanding, shes kind of You know I hate to call and let you know but the funds have been exhausted and this is what we can do I guess shes just kinda just been supportive just with overall. But as far as actually getting anything it hasnt come yet. (Houston Focus Group) In many cases, the case manager themselves was used as a resource by clients and we heard a number of examples of case managers who provided transportation to their clients or who served as a compassionate listener for clients who were distraught or depressed. Were P&A case managers rated as knowledgeable or more knowledgeable about the recovery process and resources available as compared to other Katrina Aid case managers? A premise of the Katrina Aid Today consortium, and an argument for using the Coordinated Assistance Network (CAN) database was that this network would better provide for the coordination of services and decrease the amount of paperwork required of the client. However, direct reports from clients who participated in the focus groups included numerous examples of how paperwork and a seemingly endless circle of referrals functioned as barriers to recovery. The P&A case managers assisted their clients in negotiating these barriers and clients overwhelmingly appreciated the efforts of their P&A case managers. However, in light of the lack of resources previously discussed, it is questionable the extent to which continuing to apply for disaster recovery resources was contributing to the clients recovery. How were P&A case managers rated with regards to providing information and services that met the clients needs as compared to other Katrina Aid case managers? In response to the client satisfaction survey, clients reported on their level of satisfaction with services that they had received. Responses for both NDRN-KAT and the other agencies were almost uniformly positive with the exception of the response to the statement I am

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satisfied with the way the various agencies assisting my recovery from Hurricane Katrina have responded. Only 63% of the individuals with disabilities served by NDRN-KAT were satisfied with the way in which various other agencies had responded, in comparison with 88% of other clients. The difference between the two groups was statistically significant. This difference is particularly of note as it deviates from the pattern of response to all other questions on the client satisfaction survey. The response also distinguishes between the level of satisfaction with assistance received from NDRN-KAT and that received from other agencies: Individuals with disabilities did not feel as well served by other agencies as did other individuals. Again, as the number of Client Satisfaction Surveys returned was low we suggest that this analysis be replicated at the end of the project period when more data has been inputted into the CAN database. Were individuals with disabilities referred to LTRC/Unmet Needs Tables at a higher or equal rate than were individuals without disabilities? Less than five percent of the clients were recorded as having been referred to a Long Term Recovery Committees. Interestingly, a substantial and significant number of NDRN cases were closed for the reason Unable to resolve because of lack of resources and were also statistically less likely to report that their needs had been met at the time of case closure. Together with data gathered from the interviews and surveys we believe that this is additional evidence that individuals with disabilities experienced disproportionate difficulty in obtaining resources and in recovering from the disaster.

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APPENDIX Open-Ended Telephone Case Manager Questions


Interviewer: Hello, this is [name of interviewer], from the Center on Disability and Development at Texas A&M University. It is our understanding that you are a case manager with Katrina Aid Today. The Center on Disability and Development, in collaboration with Katrina Aid Today National Case Management Consortium and the National Disability Rights Network, is conducting research on case management services for survivors of Hurricane Katrina. We are interviewing over 50 case managers employed by the National Disability Rights Network. Consent Interviewer: Hello, this is [name of interviewer], from the Center on Disability and Development at Texas A&M University. It is our understanding that you are a case manager with Katrina Aid Today. The Center on Disability and Development, in collaboration with Katrina Aid Today National Case Management Consortium and the National Disability Rights Network, is conducting research on case management services for survivors of Hurricane Katrina. We are interviewing over 50 case managers employed by the National Disability Rights Network. Consent Interviewer: The interview should take approximately _30-40_ minutes to complete. Your participation is voluntary. If you do not wish to participate, you may stop at any time. Information from this interview will be coded so that no personally identifying information is attached to it. Should the data resulting from your participation be made available to other researchers in the future, the data will contain no identifying information that could associate you with it, or with your participation in any study. There are no personal benefits or compensation for participating in this study; however, the information collected in these interviews and from the online survey will lead to the development of a report designed to support future disaster planning. If you have any questions or problems regarding the research, the names and contact information for the appropriate person to speak with is Amy Sharp at sharp@tamu.edu OR 979-845-4612. Do you have any questions about the purpose of this interview? [if yes, answer them at this time.] Are you willing to participate? Yes No [If no] Thanks for your time. Goodbye. [If yes] Great, then we can begin.

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Survey Questions for Case Managers


These first questions are to get some basic information about your job and your previous experience. 1. What is your job title? Are you an employee, intern or volunteer? 2. 3. 4. 5. How long have you been at your current job? (in months)

What is the name of the agency where you are currently working? What city and state is this agency located in? Can you tell me a little bit about your previous work experience? (Probe for three most recent jobs. Ask about their job titles, basic job tasks, and how long they were employed in that position.) a. b. c.

6. o o

Do you work for NDRN? Yes No

The following questions have to do with your experience with Hurricane Katrina. 7. Are you working in an area damaged by Hurricane Katrina? Yes No . Do you think of yourself as a survivor of Hurricane Katrina? Yes . No . Other (specify) Did you volunteer with any organizations during the Katrina evacuation? Yes (go to 9b) No (go to 10) 9b. 10. 11. If so, can you tell me a little bit about that experience?

8.

9.

How many Katrina survivor clients are you actively serving in your caseload? What proportion of your case load is made up of Hurricane Katrina survivors?

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12.

How many Katrina Aid Today (KAT) cases have you closed?

Examples from your experience can help us understand what your day-to-day work is like . . . 13. 14. 15. Id like for you to think of a relatively recent case that you would consider a success. What do you think made this case successful? Now Id like for you to think of a particularly challenging case. What do you think made this case so challenging? In your opinion, what are the three biggest challenges clients face in your area? a. b. c. 16. Case managers working with Katrina survivors we have interviewed in other research have talked about [cultural] differences they experience between themselves and their clients. Were there situations where you have felt such differences? If so, can you tell me about them? What advice would you give to Katrina Aid Today (KAT) in improving services for the next disaster? In our conversations and interviews with P&A staff we have heard stories about the influence that the KAT-NDRN staff and case managers have had on that case management and administrative practices of their colleagues in the other KAT agencies. Do you think that the participation of your P&A as part of the KAT consortium within the state had an influence on other KAT agencies? If so, how? Some case managers and administrators have expressed that the management of cases of evacuees with disabilities differs from the management of cases of evacuees without disabilities. Do you agree with this statement? Why or why not? Some case managers report that recovery from disaster is more difficult for individuals with disabilities and requires knowledge of disability services in order for a successful recovery plan to be designed. Do you agree with this statement? Why or why not? Is there anything else that you would like to tell us about your experience as a case manager?

17. 18.

19.

20.

21.

Thank you so much for your participation. This has been very useful. The results will be made available once the study is complete.

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Questions for Focus Group


Question 1: What have been things that prevented you from recovering? Question 2:What has helped you recover from Hurricane Katrina? Question 3:What help or services have helped you get the things you need? Question 4:How has Katrina Aid Today helped you? Question 5:How has your case manager helped you?

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P&A Administrator Interview Questions


Question 1: What has been the impact of providing case management to Hurricane Katrina/Rita evacuees on this organization? Question 2: Some case managers and administrators have expressed that the management of cases of evacuees with disabilities differs from the management of cases of evacuees without disabilities. Do you agree with this statement? Why or why not? Question 3: Some case managers report that recovery from disaster is more difficult for individuals with disabilities and requires knowledge of disability services in order for a successful recovery plan to be designed. Do you agree with this statement? Why or why not? Question 4: In our conversations and interviews with P&A staff we have heard stories about the influence that the KAT-NDRN staff and case managers have had on the case management and administrative practices of their colleagues in the other KAT agencies. Do you think that the participation of your P&A as part of the KAT consortium within the state had an influence on other KAT agencies? If so, how? Question 5: What advice would you give to Katrina Aid Today (KAT) in improving services for the next disaster?

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