1. Behavioral Health Emergency Planning for Hospitals and Regions

2. 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

3. Behavioral Health Why is it important to Regional and Hospital Planning?

4. 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

5. 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.

6. Challenges in Managing the Behavioral Health Response • Anxiety and fear • Triggers past traumas • Communication difficulties • Multiple complications • Citizens surge to Emergency Rooms

7. 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

8. Why Include Behavioral Health in a Hospital or Regional Plan? • Extended period of uncertainty • Longer duration • Complications • Surge Capacity and management

9. 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:

10. 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

11. 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

12. 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

13. 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:

14. 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

15. 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;

16. Planning for At Risk Populations • Physical and cognitive disabilities • Diverse cultural backgrounds • Literacy and language barriers • Seniors • Children

17. 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.

18. 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.

19. 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)

20. Risk Communication Planning “Medical studies indicate most people suffer a 68% hearing loss when naked.”

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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.

27. 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)

28. 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)

29. 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).

30. 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

31. 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

32. Behavioral Health GuidelinesHospital Isolation Precautions Patients Staff Family Community

33. 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;

34. 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

35. 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

36. Contact Information: Jenny Wiley, Coordinator Disaster Readiness 573-751-4730 jenny.wiley@dmh.mo.gov Department of Mental Health 1706 E. Elm Jefferson City, MO 65102