Protected Health Information Town Hall Meeting

1. Protected Health Information Town Hall Meeting

2. A Suicide Case Study Financial Difficulties Difficult Divorce Depression Unit Did Not Know Six medications Source: 2010 US Army Health Promotion, Risk Reduction, and Suicide Prevention Report UNCLASSIFIED

3. Building the Puzzle Depression • Not the only reason for suicides • One of many areas of focus “No universal solutions found in any community; suicides must be addressed from a holistic and multidisciplinary approach” Debt Divorce Meds Divorce Legal Source: 2010 US Army Health Promotion, Risk Reduction, and Suicide Prevention Report UNCLASSIFIED

4. Entering the Maze Triggers Stressors “Suicide/equivocal deaths are an indicator of the larger problem of stress comprised of preexisting conditions, OPTEMPO, Family separation, combat fatigue, behavioral health, etc.” Source: 2010 US Army Health Promotion, Risk Reduction, and Suicide Prevention Report UNCLASSIFIED

5. Protected Health Information Town Hall Meeting How Do We Communicate About At-Risk Soldiers? Sarah L. Martin, MD Department of Behavioral Health, IRACH UNCLASSIFIED

6. Briefing Agenda • Introduction • Scope of the Problem • Suicide Risk • Balancing Privacy and Disclosure • Silos of Information • Opportunities • Top 10 things Commanders and Medical Providers should know • Panel discussion PURPOSE: Bring Commanders and Medical Staff together to discuss issues related to the communication of psychological and health information of Soldiers at risk. UNCLASSIFIED

7. Introduction • Goal: stimulate discussion about communication • Format: slideshow followed by a panel discussion • Please: save questions for the panel UNCLASSIFIED

8. Scope of the Problem • Multiple deployers are at increased risk for BH concerns. • The stigma of BH continues to pose an obstacle to getting help. • The complex problem of suicide requires constant vigilance. Source: 2010 US Army Health Promotion, Risk Reduction, and Suicide Prevention Report UNCLASSIFIED

9. Entering the Maze Triggers Stressors “Suicide/equivocal deaths are an indicator of the larger problem of stress comprised of preexisting conditions, OPTEMPO, Family separation, combat fatigue, behavioral health, etc.” Source: 2010 US Army Health Promotion, Risk Reduction, and Suicide Prevention Report UNCLASSIFIED

10. Balancing Privacy with Disclosure More willing to seek help if information is kept private Less willing to seek help if information is not kept private Command Awareness Medical Awareness Stigma Help-seeking Behavior is a good thing! More awareness of individual patients does not necessarily decrease risk in the general population UNCLASSIFIED

11. Vignette • A 25 y/o male has been in treatment with Behavioral Health for three months. His squad leader finds out that this Soldier’s wife has left and has stolen all his money. Worried about the Soldier, he calls the Soldier’s BH provider and asks how the Soldier is doing. He is irritated by the fact that the provider will not give him specifics about the Soldier, but goes ahead and tells the provider why he is worried. The provider then calls the patient and asks him to come in as a walk in. At the appointment, the Soldier admits to worsening symptoms and suicidal thoughts, and agrees to be hospitalized.

12. Vignette • LEARNING POINTS: • Even though we will not release specifics to anyone but the company commander or above, anyone of any rank can call us and tell us why they are worried about their Soldier or colleague or friend. You all have lots of information we need in order to keep our Soldiers as safe as possible. • We are always willing to give recommendations on how commanders can improve work performance or how you can be supportive to a Soldier who is having a hard time.

13. Vignette • Medical and command teams have the same goal: keeping Soldiers safe and functioning well. As medical personnel we believe that confidentiality of patient information makes it much easier for our patients to make the decision to come into treatment. • Commanders that limit how much personal information they put out to unit leadership greatly increase their Soldiers comfort level in seeking treatment. • In balancing safety and confidentiality, safety always takes precedence.

14. Silos of Information PTSD Physical Altercations? Depression Infidelity at home? Polypharmacy Difficulty making friends? Non-Medical Indicators Medical Indicators Alcohol abuse UCMJ Behavioral Health Diagnoses Financial Challenges? Soldier feels inadequately Trained for duty position Addiction to prescription meds UNCLASSIFIED

15. Opportunities SRP Touch Points TOUCH POINT #1 Pre-deployment Health Assessment:60 days before estimated date of deployment. 1 TRAIN/READY TOUCH POINT #2 In-theater prior to re-deployment:1-90 days screening for risk assessment. • TOUCH POINT #5 • Periodic Health Assessment Screening: Annual screening and intervention. AVAILABLE 5 2 RESET 3 • TOUCH POINT #3 • Reintegration PDHA: 6-30 days (before block leave) redeployment screening for risk assessment with additional BH assessment and wellness intervention. • . 4 TOUCH POINT #4 Reintegration PDHRA: 90-180 days re-deployment screening and intervention for risk assessment with additional BH assessment and wellness intervention. UNCLASSIFIED

16. Opportunities • Distinct Situations • Command Directed Mental Health Evaluations (CDMHE):provides guidance for BH providers and MTF commanders on procedures for CDMHEs and the required feedback to leaders following a CDMHE. • Missed Behavioral Health Appointments: outlines procedures for notifying unit command officials in specific cases where a Soldier misses a scheduled BH appointment • During PCS • In/Out Processing: outlines procedures for clearing Soldiers who had BH appointments in the 60 days prior to PCS • Medical Stabilization Prior to PCS: provides guidance on directing medical stabilization prior to PCS for BH treatment UNCLASSIFIED

17. ASAP • ASAP is a command program and the commander is considered part of the treatment team. As such his/her input into the Soldier’s treatment is invited and valuable. • ASAP works with company level commander and/or commander’s designee, typically 1SG. ASAP cannot share information with platoon sergeants, squad leaders, other personnel unless they are part of the treatment team with the Soldier’s awareness. • Commander will be notified of anyone seeking ASAP treatment regardless of referral type: Self, Medical, and Command referrals all require commander’s signature on referral form (DA 8003)

18. ASAP • Commander will be contacted following the initial assessment for a Rehab Team Meeting to discuss treatment recommendations; Command must be in agreement with recommendations for treatment to occur. • Commander will be informed of missed appointments including off post treatment as well as any new or continued substance use • Commander will be updated on the Soldier’s progress or lack of progress and investment in treatment as well as recommendations for treatment changes or closure of treatment

19. FAP • Family Advocacy Program also involves commanders and its goal is to maintain safety in our families. • PHI is even more highly protected in this program, in that they have separate paper records, but the commanders have much more information about the situation because cases are only opened if safety is an issue (often not the case in a typical BH patient). • FAP staff also act as advisors to the commanders, so if anyone is ever worried about domestic violence, child abuse or child neglect, please contact them and they will help you keep your Soldiers and their families safe.

20. Top 10 Things to Know MTFs must take reasonable steps to limit the disclosure of PHI to the minimum necessary to accomplish the intended purpose. Healthcare (HC) providers must balance notification of Commanders with operational risk. HC providers must not limit communication to “sick call slips” alone. HC providers will not communicate the reason for medical appointments, routine medical care, the clinical service seen nor specific details about particular appointments (exception #5). HC providers will not notify Commanders when a Soldier’s medical condition does not affect the Soldier’s fitness for duty HC providers will notify Commanders when a Soldier obtains behavioral health care under the following circumstances: Harm to Self, Harm to Others, Harm to Mission, Hospitalization, Substance Abuse Treatment or for personnel enrolled in the Personnel Reliability Program. UNCLASSIFIED

21. Top 10 Things to Know 6.HC providers will notify Commanders about change in duty status due to medical conditions: Inpatient Care, Substance Abuse Treatment (ASAP), missed appointments 7. HC providers will notify Commanders about MEB/PEB related data 8. HC providers will notify Commanders about Acute Medical Conditions Interfering with Duty/Mission and duty limiting conditions. 9.HC providers will notify Commanders the results of Command Directed Mental Health Evaluations. 10.Commanders should also share information with providers relating changes in Soldier behavior or other information that could impact a diagnosis or treatment: UCMJ, physical altercations, infidelity, financial challenges, Soldier feelings of inadequacy, or when the Soldier has a significant change in social contacts. Commanders have a responsibility to protect a Soldier’s health information. Release this information to others (i.e., subordinates, supervisors) ONLY on a need to know basis. UNCLASSIFIED

22. Panel Discussion • Potential Topics for the Panel • Are communication problems really due to HIPAA limitations? • Experiences with HIPAA/PHI • Where do you fall on the wiggle scale? • In what circumstances will you deny information to a Commander? (or stories of a CDR who wanted too much) • How often do you call a Commander about a Soldier? • SJA: What are the legal implications of inappropriate disclosure? Lack of disclosure? • Commanders: experiences in which provider would not disclose needed information? UNCLASSIFIED

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