Objectives • Identify four challenges of the behavioral health impact that will influence public health response. • Recognize the behavioral health components necessary to an effective public health plan • Specify strategies to effectively use resources to address mental health related needs
Behavioral Health Why is it important to Regional and Hospital Planning?
US Public Opinion Poll Results (2003) • 93% of Americans recognize primary goal of terrorist attack is to generate fear & distress • 50% are concerned re: family member distress • Increases to 65% for parents • Only 25% think the nation’s public health system is meeting terrorism-related mental health needs • 70% of Americans agree that it is just as important to develop programs to assist with distress from terrorism as to take security precautions at airports • 70% go on to say the threat of terrorism caused them to realize what is truly important in life
Behavioral Health Behavioral Health Needs: Ratio of 4 to 10 times the rate of physical health needs • Mental Health • Alcohol and Drug Health • All populations • Reducing anxiety by providing information about common reactions • Predicting that behavioral health responses may occur after an event can help the patient understand their reactions through the course of their illness.
Challenges in Managing the Behavioral Health Response • Anxiety and fear • Triggers past traumas • Communication difficulties • Multiple complications • Citizens surge to Emergency Rooms
Shelter in place Evacuation of contaminated site Decontamination Surveillance Mass treatment Prophylaxis Community containment Discontinue public gatherings Travel restrictions Isolation Quarantine Hospital containment Screening & triage Cancel elective procedures Visitor limitations Public Health Converges with Behavioral Health
Why Include Behavioral Health in a Hospital or Regional Plan? • Extended period of uncertainty • Longer duration • Complications • Surge Capacity and management
Fear Anger Guilt Isolation Quarantine Why Include Behavioral Health in a Hospital or Regional Plan? • Outrage and anger that characterize responses to terrorism • Severe economic disruption • Mistrust of government and associated entities • Social effects of contagious disease management:
The Behavioral Health Plan • Goals and Outcomes of the Plan • Rationale for addressing behavioral health needs • Challenges • Specific Stakeholder Groups • Indicators of success or shortcomings
Organizational Structure • Leadership for behavioral health components and relationship to the hospital/region incident command structure • Organizational relationships • Key resources for training • Internal/External resources for delivery of Psychological First Aid (PFA) • Compilation of stress management fact sheets/brochures, referral sources/numbers, crisis line numbers
Organizational Structure • Physical plant configuration • Role in establishing a Family Assistance Center in the region or by the hospital impacted • Methods for integration of PFA into medical treatment • EAP Program activation • Communication: • Local Community Mental Health Center • Local Emergency Management Agency • State Emergency Management Agency (SEMA) • DMH – state mental health authority
Surge Capacity Considerations • Behavioral health impact of early discharges to make room for causalities (go packs with stress management information) • Physical and behavioral health screening conducted outside the emergency department to prevent contamination and/or to manage surge • Pre-planned Behavioral Health Triage System • Mass casualty/mass fatality events will necessitate hospital involvement with victim and family support centers and family assistance centers • Management of the waiting room and family members:
Planning Strategies • Matching Behavioral Health deployment levels to the scale of the event • Identification of behavioral health and spiritual care resources for effective surge capability • Response to spontaneous, unaffiliated volunteers • Effective credentialing, training, supervision, and support of non-employees used for surge capacity
Planning Strategies • Collaboration with local public health authorities, volunteer organizations active in disaster (VOADs), funeral directors, and other hospital and health care organizations (local clinics) • Protocols for identifying the need to request additional assistance and methods for making such requests: DHSS, SEMA, DMH;
Planning for At Risk Populations • Physical and cognitive disabilities • Diverse cultural backgrounds • Literacy and language barriers • Seniors • Children
Planning for At Risk Populations • Written materials in languages common in community • Availability of language translators and sign interpreters • Accessible surroundings and knowledge of specialized resources (i.e. if triage unit is set up outside of hospital) • Relationships and Resources with service systems that serve at risk populations • Pre-identification of residential settings to meet the needs of individuals living there – manage surge.
Psychological Casualties Concerned Citizens at Emergency Room • Planning considerations: • Triage Team Make-up • Triage of patients primarily distressed from those with known exposure or injuries • Labeling: Conveys concern & promises continued monitoring • High Risk • Moderate Risk • Minimal Risk (Hall, Molly; Norwood, Ann; Ursano, Robert, Fullterton, Carol. Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science, Vol. 1, no.2, 2003. Copyright Mary Ann Liebert, Inc.
Psychological Casualties Concerned Citizens at Emergency Room • Planning considerations: • Establish a co-location to emergency room for monitoring • Clinical Registry for follow-up on patients who are distressed • Chemical Warfare: Effects of chemical agents may be confused with emotional and psychological effects; Do not assume that chemical trauma victims are psychological in nature. (Shapiro et al. (1994)
Risk Communication Planning “Medical studies indicate most people suffer a 68% hearing loss when naked.”
Risk Communication Planning • Public Information • Ascertain ways to reach identified populations with guidance • Incorporate information that promotes adaptive responses and cooperation • A comprehensive behavioral health planning component to include regular, appropriate media releases • Increase knowledge = decrease fear • Large scale events • Provide information to media regarding what is being done to keep patients, patients’ families and staff safe. • Information about how agent is transmitted
Behavioral Health Communications Planning Component • Methods to promote collaborative development of key media messages and public education materials (involve mental health experts and hospital PIO’s) • Promotion efforts related to stress management and self-care skills for behavioral health concerns as well as physical health issues
Behavioral Health Communications Planning Component • Effective internal communications that promote employee and family well-being in public health or bioterrorism emergencies • Specialized messages and methods of communication • to patients in exposure scenarios • When containment measures are taken: i.e. no visitor policies, isolation or quarantine
Training and Preparedness • Integration of PFA into medical care • Education of mental health workers regarding the unique aspects and interventions associated with disasters or public health emergencies • Address: • Strategies to acquire or develop curriculum for health care providers in emergency departments, social work, psychology, psychiatry, chaplaincy • Value added application of skills to motor vehicle accidents, fires, attempted suicides or homicides, etc
Training and Preparedness • Address: • Promotion of culturally competent service delivery informed by community demographics • Effective supervision strategies to promote application of learning and reinforce skill development • Identification of resources for disaster and bioterrorism-related training or training materials including pre-event training and “just-in-time-training strategies
Behavioral Health Guidelines for Isolation This section comes from: Behavioral Health Guidelines for Medical Isolation Prepared by: University of Nebraska Public Policy Center and University of Nebraska Medical Center, January, 2007; Denise Bulling, Ph.D., Robin Zagurski, M.S.W., Stacey Hoffman, Ph.D.
Behavioral Health Guidelines for Isolation • Patients admitted to isolation units: • Higher rates of anxiety and depression • “Anxiety increases the demand on the individual. It competes for time and attention and draws on already taxed resources – coping, listening, emotional reserves and courage…Anxiety can cause secondary, unrelated illnesses, e.g. angina, ulcers, hypertension and more pertinently….it can decrease resistance to infection by suppressing the immune system.”(Gammon, 1998) • Rate themselves lower in areas of self esteem and sense of control (Gamon, 1998; Davies & Rees, 2000) • Under stress regress to lower levels of functioning, i.e. more assertive, demanding, more fussiness, temper (Denton, 1986)
Isolation • Medical staff spend less time in room interacting with the isolated patient due to: • Time is spend in putting on gown/gloves • Cuts down on impromptu visits • Patients may not understand the difficulty in maintaining isolation, but perceive it as reluctance to enter the room (Kelly-Rossini, Perlman, & Mason, 1996)
Planning • Plan for how to isolate the “organism, not the patient” (Denton, 1986). • Measures for continuing behavioral health treatment for those with a pre-existing diagnosis – procedures with identified behavioral health provider • Communication to Person in Isolation: Message Sent = Message Received • Statements of empathy within the first 30 seconds of approaching a person under stress- allows person to deescalate enough to hear the rest of the message (B. Reynolds Centers for Disease Control and Prevention, Personal Communication, January 23, 2007) • Repetition, multiple formats • Plan for cultural differences and language barriers (People who speak English as a second language may lose some of their English-speaking skills under stress).
Planning Communication to Family Members – • Plan for regular briefings & information to assist families in healthy practices • Policies and procedures to guide staff interaction • Consider family’s feeling of isolation, guilt, role strain, fears of transmission • Family avoidance; possible stigmatization by community • Hospital restrictions: PPE, restriction on contacts with person in isolation
Planning for Staff Care • No non-essential employees Plan for “Redeployed Staff” Increases feeling of being valued • Planning should include: • Enforced breaks for all staff (senior staff model) • Availability of trained peers to listen and provide support • Healthy snacks/food available for staff • Regular staff meetings with honest communication • Quiet break environment • Private space and phones/communication devices for confidential phone conversations with family
Behavioral Health GuidelinesHospital Isolation Precautions Patients Staff Family Community
Behavioral Health GuidelinesHospital Isolation Precautions Patients: • Inform • Support • Triage • Psychological triage/emotional status assessment – repeated regularly • Alcohol/Drug assessment • Consulting psychiatrist/psychologist • Patient’s preferences about visitation; also revisit this;
Behavioral Health GuidelinesHospital Isolation Precautions • Treat – Behavioral Health • Pre identify behavioral health specialists that can be trained to function in isolation units – mental health and alcohol/drug specialists • Provide common reactions • Referrals • Psychotherapy or psychiatric services – in-person, teleconference, videoconference • Suicide precautions as protocol
References & Resources • Missouri Department of Mental Health Disaster Services: http://www.dmh.mo.gov then click on Coping with Disaster. • SAMHSA Disaster Readiness and Response Site http://www.samhsa.gov/Matrix/matrix_disaster.aspx • SAMHSA Disaster Technical Assistance Center http://www.mentalhealth.samhsa.gov/dtac/default.asp • CDC Mass Trauma webpage http://www.bt.cdc.gov/masstrauma/index.asp
Contact Information: Jenny Wiley, Coordinator Disaster Readiness 573-751-4730 firstname.lastname@example.org Department of Mental Health 1706 E. Elm Jefferson City, MO 65102