6: Toolkit Part 2: Behavioral Health

INTRODUCTION

This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide decision making about behavioral health during a disaster. Because integrated planning across the emergency response system is critical for a coordinated response, it is important to first read the introduction to the toolkit and materials relevant to the entire emergency response system in Chapter 3. Reviewing the toolkit chapters focused on other stakeholders would also be helpful.

Behavioral health is a term encompassing many topics. While there is growing use of and consensus on the term’s application and meaning, there is also some inconsistency in its use and meaning. For the purposes of this document, behavioral health is intended to include factors related to overall psychological, psychiatric, and psychosocial healthiness and well-being. It also refers to specific psychiatric and substance abuse disorders.

Behavioral health is a pervasive factor affecting the response capabilities of decision makers and response personnel. It also affects the survival capabilities of the general public and those persons who require either acute or longer-term behavioral health treatment. Each of these groups faces common challenges in extreme events as well as unique stressors and intervention needs and opportunities.

It is important to highlight the centrality of understanding and attending to the sometimes unique needs of those whose roles include administration of, and response to, an extreme event. If the health of those involved (including behavioral health) is impacted in ways that adversely impact role function, the entire response can become compromised and, in extreme cases, fail. Preparedness activities must include detailed and strategic planning, which anticipates and addresses behavioral health consequences for both decision makers and responders. Preparedness activities should address issues such as strategies for identification, monitoring, and interventions geared toward stress reduction and management, as well as post-recovery resilience promotion and mitigation of posttraumatic stress disorder.

During an emergency, communities are confronted with a surge in demand and need for behavioral health intervention in health care facilities, in sheltering sites, at numerous public and private outpatient care venues, and through risk and crisis messaging and communications. When local health care capacity is being stretched beyond conventional care standards, the need for behavioral health alternative care strategies



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6: Toolkit Part 2: Behavioral Health INTRODUCTION This chapter presents a discussion and decision-support tool to facilitate the development of indicators and triggers that help guide decision making about behavioral health during a disaster. Because integrated plan- ning across the emergency response system is critical for a coordinated response, it is important to first read the introduction to the toolkit and materials relevant to the entire emergency response system in Chapter 3. Reviewing the toolkit chapters focused on other stakeholders would also be helpful. Behavioral health is a term encompassing many topics. While there is growing use of and consensus on the term’s application and meaning, there is also some inconsistency in its use and meaning. For the purposes of this document, behavioral health is intended to include factors related to overall psychological, psychiatric, and psychosocial healthiness and well-being. It also refers to specific psychiatric and substance abuse disorders. Behavioral health is a pervasive factor affecting the response capabilities of decision makers and response personnel. It also affects the survival capabilities of the general public and those persons who require either acute or longer-term behavioral health treatment. Each of these groups faces common challenges in extreme events as well as unique stressors and intervention needs and opportunities. It is important to highlight the centrality of understanding and attending to the sometimes unique needs of those whose roles include administration of, and response to, an extreme event. If the health of those involved (including behavioral health) is impacted in ways that adversely impact role function, the entire response can become compromised and, in extreme cases, fail. Preparedness activities must include detailed and strategic planning, which anticipates and addresses behavioral health consequences for both decision makers and responders. Preparedness activities should address issues such as strategies for iden- tification, monitoring, and interventions geared toward stress reduction and management, as well as post- recovery resilience promotion and mitigation of posttraumatic stress disorder. During an emergency, communities are confronted with a surge in demand and need for behavioral health intervention in health care facilities, in sheltering sites, at numerous public and private outpatient care venues, and through risk and crisis messaging and communications. When local health care capacity is being stretched beyond conventional care standards, the need for behavioral health alternative care strategies 125

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becomes essential either as an adjunct to general health care treatment or as a primary intervention for major behavioral health conditions (including substance abuse and addictive disorders). Nobody who experiences a crisis (e.g., one described by scenarios provided) is unaffected by its psycho- social impact. The individual and collective impact will introduce considerable variability in people’s ability to function. Behavioral health sequelae will impact the function of leaders, providers, and victims on both individual and collective levels. Understanding, anticipating, and specifically planning for these impacts is central to protection and promotion of the public’s health and successful event and recovery management. Discussions within local communities that include the widest array of stakeholders with the goal of planning alternatives to conventional care and preparing for the eventuality of providing only crisis care can mitigate the premature and/or inappropriate movement to this level of care through a proactive planning and resource allocation process. The recognition and inclusion of behavioral health stakeholders and factors in these complex decisions is an essential component of sound preparedness, response, and recovery. Roles and Responsibilities In the broadest sense, nearly every organization and system and every governmental level has a stake in ensuring efficacious response to behavioral health factors in large-scale emergencies and disasters. Address- ing adverse impacts of stress, suggesting actions, and implementing strategies that promote resilience, and ensuring efforts that provide appropriate care of those with behavioral health disorders, is in everybody’s best interest. Additional discussion about behavioral health in planning for and implementing crisis standards of care (CSC) is available in the Institute of Medicine’s (IOM’s) 2012 report Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Special Circumstances All extreme events require understanding of, and adaptation to, new and complex challenges. All of these challenges have behavioral health (as defined earlier in this chapter) elements. While all extreme events are stressful and demanding, some are especially difficult and complex. In these types of events, it is espe- cially important that planners and incident leaders/managers understand the special psychosocial sequelae involved and ensure that behavioral health content experts are fully integrated into both decision making and response implementation. These include • Situations where a transition must be made in the fair and just allocation of resources and care when circumstances will not allow for the optimal level of care for all: These are among the most difficult challenges that health care professionals can face. These are extraordinarily complex and difficult decisions that not only involve ethical and legal factors but also have major psychological impact on those involved in these actions and choices. Planners are strongly encouraged to involve behav- ioral health professionals in preparing for and implementing these difficult transitions. Integrat- ing behavioral health consultation and services into this process will enhance the probability that adverse psychological consequences for those involved can be reduced. 126 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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• Situations resulting in large-scale incapacitation or death of health care workers: These situations not only degrade the capacity and capability of the health care system, they often bring grief and bereavement to remaining colleagues and coworkers. The result may increase the need for support services (including behavioral health) and result in performance problems in workers. • Events producing extremely large numbers of fatalities: These events (especially with special circum- stances; e.g., contaminated, partial, unidentifiable, or difficult-to-retrieve remains) create special challenges. Although these regrettable circumstances may actually result in low use of prehospital and hospital care, they frequently result in a significant expansion of behavioral health issues and needs. • Events resulting in potential long-term or unknown health consequences: Events resulting in these types of health consequences can have a long-term impact on not only the medical status but also the psychosocial well-being of both workers and the general population. • Death or incapacity of key leaders and/or decision makers: Sound disaster and emergency preparedness and response rely heavily on capable and trusted leadership. In the event these leaders are unable to play their important roles, the entire response will likely be compromised. In preparing for these events it is critical that strategies be developed and implemented that anticipate absent and/or impaired (including psychological) leadership. • Events evoking extreme emotions: While all disasters provoke significant emotional responses in many, if not most, of those who experience them, some events evoke extreme emotions in large numbers of people. These reactions can have a significant impact on the health system (including behavioral health). As an example, some types of events can produce widespread rage. These events may include terrorism, violence disproportionately impacting the most vulnerable (e.g., children), and perceived social injustice. Planners should include these types of events and their impact on the public’s health in their preparedness activities. Because panic is so widely misunderstood, a brief discussion about it may be helpful. Panic is defined as behavior in which individuals and groups engage in actions that are motivated exclusively by self-preservation, even at the expense of the health, safety, and lives of others. Issues about panic in extreme events are often not well understood. Inaccurate assumptions sometimes lead to compromised preparedness and response efforts. While panic does occur, it is extremely rare. Several conditions are typically present in those rare instances where panic does appear. These include imminent threat to life, novelty of the situation, absence of leadership and/or authority, and extremely limited or nonexistent behavioral options. Planners should chal- lenge assumptions that panic is a common, widespread, and easily triggered phenomenon. Planning should include strategies to address conditions where panic may occur, but recognize that it is far less common than is often assumed. DISCUSSION AND DECISION-SUPPORT TOOL Building on the scenarios and overarching key questions presented in Chapter 3, this tool contains addi- tional questions to help participants drill down on the key issues and details for behavioral health. It also contains a chart that provides example behavioral health indicators, triggers, and tactics, and a blank chart TOOLKIT PART 2: BEHAVIORAL HEALTH 127

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for participants to complete. The scenarios, questions, and example chart are intended to provoke discussion that will help participants fill in the blank chart for their own situation.1 Participants may choose to complete a single, general blank chart, or one each for various scenarios from their Hazard Vulnerability Analysis. Discussion Participants and Key Stakeholders Suggested participants and key stakeholders for a discussion focused on behavioral health are listed below. • State and local public health agencies; • State disaster medical advisory committee; • State and local emergency medical services agencies; • State and local emergency management agencies; • Health care coalitions (HCCs), and where appropriate, U.S. Department of Veterans Affairs Medi- cal Centers (VAMCs) and military treatment facilities (MTFs) that are part of those HCCs; • State associations, including hospital, long-term care, home health, palliative care/hospice, and those that would reach private practitioners and other community-based providers; • State and local law enforcement agencies; • State and local elected officials; • Representatives of key systems and stakeholders where changes in medical and public health (including behavioral health) status might present (e.g., large employers, primary and secondary schools, colleges and universities), law enforcement; • Senior agency representatives for at-risk and vulnerable populations, such as persons with develop- mental disabilities, elder affairs, children and families, persons with acute and chronic behavioral health disorders, and developmental disabilities; • Behavioral health practitioner associations and related licensing and regulatory boards; • Members of the faith-based sheltering network and representatives of the behavioral health advo- cacy community, including, for example, Mental Health America and National Alliance on Mental Health, child/family advocacy groups, and the addiction recovery community; • Behavioral health crisis response agencies tasked with operating various aspects of the community crisis response operations: (1) crisis lines, (2) mobile crisis teams that conduct face-to-face assess- ments, and (3) non-hospital-based crisis stabilization programs; and • Additional nongovernmental agencies that could include chemical dependency recovery programs, methadone clinics, domestic abuse/sheltering agencies, and certified psychological first aid provider agencies. 1  The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards. 128 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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Key Questions: Slow-Onset Scenario The questions below focus on the slow-onset influenza pandemic scenario presented in Chapter 3.2 Assumptions for Responding to a Slow-Onset Event The gradual-onset pandemic scenario presents a complex set of behavioral health issues. The pre-event readiness planning process activated preparedness structures addressing ethical, legal, public health emer- gency management, and public stakeholder/advocacy concerns and responsibilities. The medical advisory committee (critical care, emergency department physicians, infectious disease and pediatric specialists) established guidelines (indicators and triggers) necessary to ethically and legally move from conventional standards of care to contingency and ultimately to CSC. Each developing phase of the pandemic, starting with pre-event planning, the onset of the event, the initiation of emergency operations, monitoring of the event features, and ongoing situational awareness, is accompanied by a corresponding degree of behavioral health assessment and intervention. The emerging discrepancy between behavioral health response capabili- ties and increasing demand from providers, patients/families, and the general public correspond directly with the intensity and complexity of the disaster event. The behavioral health discussion will need to address the crosscutting issues and population needs before, during, and after the event. The five key elements of ethical grounding, community and provider involvement, legal authority, clearly specified indicators, triggers and lines of responsibility, and the provision of evidence-based interventions are applicable to the development of CSC for behavioral health. Key Questions3 1. Has the specificity of the Concept of behavioral health Operations integrated into command and response structures been tested? 2. What are the specific capabilities and capacities required for patients and families? 3. What are the specific capabilities and capacities required for providers? 4. What are the specific capabilities and capacities required for the general public? 5. What is necessary for rapid triage assessment and self-assessment behavioral health triage? 6. What is the continuum of acute behavioral health interventions needed? 7. What is the continuum of acute behavioral health interventions available? 8. What is the behavioral health risk/crisis communications strategic plan for each phase of the event? 9. What is the plan for postevent gap analysis to determine short-term strategies to meet additional behavioral health demand for services? 10. What is the strategy for building and sustaining health care provider resilience for all phases of the event? 11. What epidemiological surveillance capabilities and indicators require monitoring of behavioral health factors? 2  These questions are provided to help start discussion; additional important questions may arise during the course of discussion. The questions are aimed at raising issues related to indicators and triggers, and are not comprehensive of all important questions related to disaster preparedness and response. 3  Some of these questions are derived from Box 4-4 of IOM (2012, p. 1-90). TOOLKIT PART 2: BEHAVIORAL HEALTH 129

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Key Questions: No-Notice Scenario The questions below focus on the no-notice earthquake scenario presented in Chapter 3. Assumptions for Responding to a Rapid-Onset Event A rapid-onset event assumes immediate and massive destruction of the physical infrastructure and signifi- cant injury and loss of life to the general population within the incident area. The behavioral health impact is immediate and pervasive throughout the general population and the immediate responder community (also part of the general population). No-notice catastrophic events require strategies for addressing immediate loss of pre-event treatment capacity and accommodating mass fatalities and injury throughout the general population. Postincident trauma involves acute traumatic stress reactions throughout the responder and gen- eral population affecting all response capacity in the community. Activation and reassignment of behavioral health staff from non-impacted areas should be an integral feature of any initial (72-hour) response plan. Key Questions 1. What behavioral health response strategy/resources can be deployed immediately and in 24-hour increments for the initial 72-hour postincident response period? 2. What specific actions should a hospital take to manage a surge involving both injured and uninjured (seeking information/bereaved) citizens? 3. Is/how is assessment of first responder capacity and fitness for duty (both physical and behavioral health) occurring? 4. Are triage strategies for the general population and delivery of low-level calming interventions in place? 5. What are the strategies for inpatient and residential behavioral health population evacuation? Are these strategies integrated with strategies of other required systems? What considerations have been made for the evacuation of the behavioral health population that receives care from community providers? 6. How is the first responder stress management cadre staffed and deployed? 7. How is surveillance of alternate care and sheltering sites for surge in demand for behavioral health intervention accomplished? 8. What are the strategies for treating widespread addiction/withdrawal? 9. What is the continuum of acute behavioral health interventions needed? 10. Is a behavioral health risk/crisis communications strategic plan in place for each phase of the event? Is there a strategy to have behavioral health input into risk/crisis communications of other stakeholders (e.g., public health, political leadership)? 11. What is the plan for postevent gap analysis to determine short-term strategies to meet additional behavioral health demand for services? 12. What is the strategy for building and sustaining health care provider resilience for all phases of the event? 13. What epidemiological surveillance capabilities and indicators require monitoring? 14. Has a disaster crisis line been activated and contact information published through traditional and other social media outlets? 130 CRISIS STANDARDS OF CARE: A TOOLKIT FOR INDICATORS AND TRIGGERS

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Decision-Support Tool: Example Table The indicators, triggers, and tactics shown in Table 6-1 are examples to help promote discussion and provide a sense of the level of detail and concreteness that is needed to develop useful indicators and triggers for a specific organization/agency/jurisdiction; they are not intended to be exhaustive or universally applicable. Prompted by discussion of the key questions above, discussion participants should fill out a blank table, focusing on key system indicators and triggers that will drive actions in their own organizations, agencies, and jurisdictions. As a reminder, indicators are measures or predictors of changes in demand and/or resource availability; triggers are decision points (refer back to the toolkit introduction [Chapter 3] for key definitions and concepts). The example triggers shown in the table mainly are ones in which a “bright line” distinguishes function- ally different levels of care (conventional, contingency, crisis). Because of the nature of this type of trigger, they can be described more concretely and can be included in a bulleted list. It is important to recognize, however, that expert analysis of one or more indicators may also trigger implementation of key response plans, actions, and tactics. This may be particularly true in a slow-onset scenario. In all cases, but particu- larly in the absence of bright lines, decisions may need to be made to anticipate upcoming problems and the implementation of tactics and to lean forward by implementing certain tactics before reaching the bright line or when no such line exists. These decision points vary according to the situation and are based on analysis, multiple inputs, recommendations, and, in certain circumstances, previous experience. Discussions about these tables should cover how such decisions would be made, even if the specifics cannot be included in a bulleted list in advance. Note: (SO) designates indicators, triggers, and tactics that are most relevant to slow-onset scenarios, and (NN) designates indicators, triggers, and tactics that are most relevant to no-notice scenarios. Indi- cators, triggers, and tactics without such a marking are relevant to both no-notice and slow-onset scenarios. TOOLKIT PART 2: BEHAVIORAL HEALTH 131

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TABLE 6-1 132 Example Behavioral Health (BH) Indicators, Triggers, and Tactics for Transitions Along the Continuum of Care Indicator Category Contingency Crisis Return Toward Conventional Surveillance data: Indicators Indicators Indicators Community • Widespread acute anxiety and agitation • All data indicate continuing and increasing • Decline in demands for services indicators increases presentations for treatment to and demand for BH-related services • Reduction of waiting lists to beyond normal limits • Hospital services become increasingly preevent levels • Hospitals experience a surge of not only compromised as a result of demands of • Number and severity of “new” medical patients, but searching family searching family members (NN) cases declines members; increased calls to hospitals as more • BH service providers are at capacity and • Reduced reports from police, people search for missing family members refuse to take on new cases social services, schools, and (NN) • Increased public presentation of BH others regarding BH issues • Police, social services, schools, and others casualties (e.g., overtly psychotic citizens, Triggers: report increasing incidents of disruptive/ people ill from detox, increased drug- • X% decline in demands for anxiety-driven behaviors (e.g., civil unrest related crimes, etc.) services and domestic violence, driving under the • Widespread acute anxiety, agitation, and • Reduction of waiting lists to pre- influence, etc.) demand for care threaten integrity of event levels • Increased psychiatric presentations in treatment systems/sites • X% decline in number and emergency department (ED) • Alternative care/diversion programs (e.g., severity of “new” cases • Increased calls to BH-related crisis lines (e.g., domestic violence shelters) are at capacity • X% reduction in reports from suicide, domestic abuse, etc.) and cannot admit more law enforcement, social services, • Increased waiting list for appointments in BH • Jails are at capacity schools, and others regarding BH providers Crisis Triggers: issues • Hospitals begin to prematurely discharge BH • HCOs report that they can no longer admit • Pre-event BH service capacity patients (e.g., psychiatric, detox) patients exhibiting acute anxiety and reestablished Triggers: agitation Tactics: • X% increase in law enforcement/social • Roads become impassable as a result • Continue and enhance services reports of citizens evacuating and searching for monitoring of BH issues and • Jail and alternative diversion programs are at members (NN) service needs capacity • EDs threaten closure because of inability • Identify areas and/or populations • X% increased psychiatric presentations in ED to manage BH-related cases (e.g., no beds, with different patterns of • X% increased calls to BH crisis lines no referral options) recovery • X% increased waiting list for appointments in Tactics: BH providers • Implement a variety of local mutual aid • X% of BH providers report seeing only agreements and federal disaster medical emergency cases assistance teams and National Disaster Tactics: Medical System resources (NN) • Implement and expand early BH intervention • Diversion of psychiatric patients strategies (e.g., psychological first aid, or PFA) • Seek funding and other resources • Implement/expand strategies to enhance including government and refer to Disaster crisis leadership Medical Response Units (DMRUs) and • Increase overtime shifts for existing staff medical special needs shelters • Appropriately adjust and implement • Route calls searching for missing family comprehensive risk/crisis communication members to disaster hotline strategies

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• Seek and expand temporary employment of workers (including retirees, former employees, etc.) • Implement health care organization (HCO) plan to cope with surge, sort BH and other health issues, and support staff and searching family members (NN) • Route calls searching for missing family members to disaster hotline • Transfer patients to alternative psychiatric and correctional sites designated for disaster response (SO) • Expand sheltering and treatment capacity of state hospitals for civil and forensic patients (SO) Community and Indicators: Indicators: Indicators: communications • Families cannot find their loved ones (NN) • Road congestion becomes increasingly • Restoration of public services infrastructure • Family members are separated (e.g., in acute (NN) Triggers: different locations at time of earthquake or • All data indicate continuing and increasing • Acute anxiety, agitation, and transported to different treatment sites) (NN) demand for BH-related services demand for care no longer • As a result of building damage, transportation • BH service providers are at capacity or threaten integrity of treatment system degradation, and communications have compromised facilities and refuse to systems/sites systems failure, the population is unable to take on new cases Tactics: gather for support and ceremonies (NN) • Increased public presentation of BH • Continue and enhance • Communication mechanisms are degraded or casualties (e.g., overtly psychotic citizens, monitoring of BH issues and nonexistent (NN) people ill from detox, increased drug- service needs • Other utilities (e.g., water, electricity) are related crimes, etc.) • Identify areas of infrastructure degraded or nonexistent (NN) • X% of workplaces and schools are closed improvement and degradation • Roads and systems are becoming overloaded (NN) • Identify populations with as a result of families trying to find their • Workplaces and schools report X% different patterns of recovery and members (NN) increases in lateness/absenteeism and different infrastructure challenges • Road congestion is complicated by arriving decreases in productivity resulting from emergency vehicles from other jurisdictions infrastructure degradation (SO) (NN) Crisis triggers: • General services are compromised and goods • HCOs report that they can no longer admit are in short supply, causing increased anxiety patients exhibiting acute anxiety and and agitation agitation • BH providers report delays and short supplies • Alternative care/diversion programs (e.g., of prescription medication (e.g., antipsychotic, domestic violence shelters) are at capacity methadone, antidepression) because of and cannot admit more supply line disruption • BH providers report they can no longer • Agitation increases as many/most basic provide prescription medication (e.g., community services are compromised antipsychotic, methadone, antidepression) • Workplaces and schools close; status of because of supply line disruption persons in those structures unknown (NN) • Widespread acute anxiety, agitation, and • Work and school logistics become demand for care threaten integrity of increasingly complex as schedules adapt to treatment systems/sites impact of event (causing increased fatigue and agitation) (SO) continued 133

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TABLE 6-1 134 Continued Indicator Category Contingency Crisis Return Toward Conventional Community and • Agitation increases as mail is delayed, Tactics: communications automated teller machines are not • Expand mutual aid arrangements for BH infrastructure replenished, etc. medications and staff (continued) Triggers: • Expand work-from-home programs (SO) • HCOs report that they can no longer admit • Seek funding and other resources, patients exhibiting acute anxiety and agitation including government • Alternative care resources and diversion- • Implement alternative internal and receiving facilities are at capacity and cannot response-related communication protocols admit more (NN) • EDs threaten closure because of inability to manage BH-related cases (e.g., no beds, not referral options) • Jails are damaged and/or at capacity • Crisis phone lines and hotlines are disrupted • Forensic psychiatric unit is severely damaged; there is an immediate need to treat injured patients and evacuate others (NN) • Treatment facilities are damaged; extent of damage and continued use is unclear (NN) Tactics: • Implement risk/crisis communications strategies to inform, comfort, and reassure the public • Implement strategies for alternative sources for, and reallocation of, prescription medications • Monitor and prioritize infrastructure and supply degradation for early identification and anticipatory response • Identify regional facilities or temporary facilities that can provide capacity Staff Indicators: Indicators: Indicators: • Staff are also earthquake victims; their ability • Requests to BH staff for patient • BH staff become more able to [Refer also to the to report to work is unclear (NN) evaluations and services approach provide patient evaluations and worker functional • Requests for evaluations and services from BH capacity services capacity table in staff increase • Requests for BH specialty care (e.g., • Availability of BH specialty care Toolkit Part 1 (Table • Requests from ED for BH specialty care (e.g., children, etc.) approach capacity (e.g., children, etc.) begins to 3-1)] children, etc.) begin to increase • Frequency and severity of psychological return toward baseline • Increased frequency of psychological stress stress responses among health workforce • Staff resources increase and responses among health workforce (e.g., (e.g., distractibility, hostility, hypervigilance, exhausted staff are able to rotate distractibility, hostility, hypervigilance, emotional extremes, interpersonal out of deployment emotional extremes, interpersonal conflicts, conflicts, etc.) compromise patient care etc.) • Frequency and severity of psychological • Increased absenteeism/presenteeism of stress responses among health workforce critical staff persons compromise relationships among staff at any or all levels within the organization

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• Increased demands on employee assistance • Absenteeism/presenteeism compromises • Frequency and severity of programs (EAPs); private BH practitioners are patient care and/or organizational function psychological stress responses not readily available (SO) • EAP resources approach capacity among health workforce allows • Increases in requests for psychological fitness • Requests for psychological fitness for duty for resumption of routine staffing for duty assessments of staff assessments of staff approach capacity to ratios • Increased reports of stress-related sequelae process • Absenteeism/presenteeism in other systems (e.g., law enforcement, social • Increasing reports of stress-related declines services, faith organizations, etc.) sequelae in other systems (e.g., law • Requests for psychological Triggers: enforcement, social services, faith fitness-for-duty assessments of • Requests to BH staff for patient evaluations organizations, etc.), school, employers staff decline and services increase by X% (SO) • Reports of stress-related • Requests for BH specialty care (e.g., children, Crisis triggers: sequelae in other systems (e.g., etc.) increase by X% • Requests to BH staff for patient law enforcement, schools, • X% increase in staff absenteeism (NN)/ evaluations and services reach capacity employers, etc.) decline presenteeism (SO) and no additional service can be provided Triggers: • X% increases in frequency of psychological • Existing services cannot be maintained • BH staff are able to meet needs stress responses among health workforce • Requests for BH specialty care (e.g., for patient evaluations and (e.g., distractibility, hostility, hypervigilance, children, etc.) can no longer be fulfilled services emotional extremes, interpersonal conflicts, • Absenteeism/presenteeism causes • Reduction in absenteeism/ unscheduled time away from duty station, shutdown of services presenteeism to level where increased demand for stress management • EAPs can no longer accept new referrals services begin functioning support, etc.) and/or manage existing caseloads • EAPs begin to accept new • X% increase in demands on EAPs • Requests for psychological fitness for referrals and/or can now manage • X% increases in requests for psychological duty assessments of staff increase to a existing caseloads fitness for duty assessments of staff level where they cannot be processed in a • Requests for psychological • X% increase in informal personnel complaints timely/quality manner fitness for duty assessments of Tactics: • Increase in formal personnel complaints staff decrease to baseline and • Implement and expand early BH intervention cannot be processed in a timely/quality can be processed in a timely/ strategies (e.g., PFA) manner quality manner • Implement/expand strategies to enhance Tactics: • Decrease in formal personnel crisis leadership • Implement and expand early BH complaints/litigation to baseline • Implement expanded and alternative ways to intervention strategies (e.g., PFA) and can be processed in a timely/ establish and maintain contact with staff (NN) • Implement or expand strategies to support quality manner • If possible explore and establish a means for leadership staff families to be housed and supported at • Appropriately adjust and implement HCO (NN) comprehensive risk/crisis communication • Appropriately adjust and implement strategies comprehensive risk/crisis communication • Seek to expand temporary employment strategies of workers (including retired, former • Expand temporary employment of workers employees, etc.) (including retired, former employees, etc.) • Review and appropriately modify • Review and appropriately modify personnel personnel policies and practices where policies and practices where possible possible • Assess the potential to obtain or enhance • Assess the potential to obtain or enhance specialized consultation in areas of workplace specialized consultation in areas of stress and disaster BH workplace stress and disaster BH • Mobilize stress management team for • Implement mutual aid and other resource responders and staff enhancement strategies • Mobilize stress management team for responders and staff (NN) 135 continued

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TABLE 6-1 136 Continued Indicator Category Contingency Crisis Return Toward Conventional Space/infrastructure Indicators: Indicators: Indicators: • Specialty psychiatric units experience • Specialty psychiatric units exceed capacity • Specialty psychiatric units are no increased use • Specialty psychiatric units experience longer at capacity • Specialty psychiatric units experience damage damage and must treat injured and/or the • Admission of and services to BH and must treat injured and/or consider decision is made to evacuate (NN) (e.g., psychiatric, detox) patients evacuation (NN) • Hospital triage results in reduction of BH admitted increases (NOTE: This • Hospital triage results in BH (e.g., psychiatric, (e.g., psychiatric, detox) patients admitted marker of recovery involves detox) patients being discharged before • Increased numbers of BH patients being increasing admits because it is scheduled maintained in ED or general medical relative to the ability to admit vs. • Health care facilities initiate alternative space treatment areas prior lack of beds.) use plans to accommodate additional beds • Very heavy use of service provision/ • Decreasing numbers of BH and space for families consultation in ways other than face to patients being maintained in ED • Increases in service provision/ consultation in face or general medical treatment ways other than face to face • BH problems increase in hospitals as areas • Social distancing reduces support for patients, patient families, searching family members, • Health care facilities require less families, community (SO) and bereaved family members share space alternative space usage, freeing Triggers: and services (NN) up beds for BH patients • Specialty psychiatric units exceed capacity • Increasing BH problems resulting from • Care and consultation again • Hospital triage results in BH patients being social distancing (e.g., depression, suicide, begin to occur face to face discharged before scheduled substance abuse, etc.) (SO) • Decreasing BH problems Tactics: Crisis triggers: resulting from social distancing • Increase alternate care sites/services for BH • Specialty psychiatric units not available (e.g., depression, suicide, patients and unable to safely board in ED or other substance abuse, etc.)/less social • Increase surveillance of BH needs and locations distancing resources across systems • Alternative BH treatment sites/services are Triggers: • Update mutual aid strategies/plans at capacity • Specialty psychiatric units • Update plans and strategies for obtaining • BH patients can no longer be maintained in admissions and census return to outside BH or other help ED or general medical treatment areas baseline • Refer to DMRUs and medical special needs • Most service provision/consultation occurs • Admission of and services to BH shelters (NN) in ways other than face to face (e.g., psychiatric, detox) patients • BH problems compromise function/ returns to baseline services in hospitals as patient families, • BH patients being maintained in searching family members, and bereaved ED or general medical treatment family members share space and services; areas returns to baseline key hospital resources are redirected to Tactics: manage the situation (NN) • Maintain/increase surveillance of • Pervasive BH problems resulting from BH needs and resources across social distancing (e.g., depression, suicide, systems substance abuse, etc.) (SO) • Deactivate incident-specific Tactics: hotlines and alternate care • Increase surveillance of BH needs and spaces resources across systems • Activate plans and strategies for • Update mutual aid strategies/plans release or return of outside BH or • Activate plans and strategies for obtaining other help outside BH or other help

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Supplies Indicators: Indicators: Indicators: • Demand increases for psychiatric medications • Demand or projected demand for • Demand for psychiatric and medications used to treat substance psychiatric medications and medications medications and medications abuse disorders used to treat substance abuse disorders used to treat substance abuse • Supply of psychiatric medications and exceeds supply disorders and is returning toward medications used to treat substance abuse • Supply of psychiatric medications and baseline disorders decreases medications used to treat substance abuse • Supply of psychiatric medications • Patients have lost their prescriptions/ disorders decreases to the point of limited and medications used to treat medications in the earthquake or are unable medication provision substance abuse disorders to access them (NN) • Self-medication becomes a significant increases • Remaining functioning pharmacies have factor in large numbers of law • Self-medication becomes limited computer capacity to confirm enforcement, emergency medical services a declining factor in law prescription status (NN) (EMS), hospital encounters enforcement, HCO encounters • Reports of self-medication increase • Health care organizations are referring • HCOs see a declining number of • Increasing numbers of patients begin to increasing numbers of patients patients experiencing/exhibiting experience/exhibit withdrawal symptoms experiencing/exhibiting withdrawal withdrawal symptoms Triggers: symptoms Triggers: • Demand for psychiatric medications and Crisis triggers: • Demand for psychiatric medications used to treat substance abuse • Key psychiatric and substance abuse medications and medications disorders increases by X% treatment medications are no longer used to treat substance abuse • X% reduction in supply of psychiatric available disorders returns to baseline medications and medications used to treat • Self-medication becomes a significant • Supply of psychiatric medications substance abuse disorders factor in large numbers of law enforcement and medications used to treat • X% increase in numbers of behaviorally and health care organization encounters substance abuse disorders agitated patient requests for detox services and compromises systems function (e.g., adequate to meet community for withdrawal symptoms of any type (from a adverse impact on worker productivity, needs wide variety of licit and illicit drugs) high demand for medical intervention, • HCOs see a return to baseline Tactics: increased costs, etc.) in the number of patients • Increase monitoring of supply and demand for Tactics: experiencing/exhibiting BH-related medications • Increase monitoring of supply and demand withdrawal symptoms • Implement strategies to optimize efficiency of for BH-related medications Tactics: supply lines/processes • Implement strategies to optimize efficiency • Continue/improve monitoring • Explore alternative supply lines and processes of supply lines/processes of supply and demand for BH- to ensure medication availability • Implement alternative supply lines related medications • Circulate guidance on alternative medications, processes to ensure medication availability • Evaluate efficacy of strategies dangers of self-dosing, and resources for • Implement BH patient evacuation to out- to optimize efficiency of supply help/detox of-state hospitals (SO) lines/processes • Recommend triage strategies and dosing • Review and revise strategies to address critical shortages recommendations for medication use/triage continued 137

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TABLE 6-1 138 Continued Indicator Category Contingency Crisis Return Toward Conventional Other categories: Indicators: Indicators: Indicators: Fatality management • Hospital and civic morgues approach capacity • Death rate continues unabated or • Death rate declines • Community distress over visible disinterment increases • The population is increasingly in local cemeteries (NN) • The population is unable to gather for able to gather for support and • Death becomes an increasing topic in support and ceremonies because of ceremonies conversation, media, and public meetings contagion • Death becomes less dominant in • Recovered remains are partial, creating • Hospital and civic morgues are at or over conversation, media, and public increased stress on workers, families (NN) capacity meeting • It becomes increasingly clear that body • Death dominates conversation, media, and • Burials are resuming; issues of recovery will be a protracted process, public meetings storage of remains become less increasing stress on workers and families (NN) • Delayed recovery, including decomposition acute • Citizens are increasingly agitated because of of remains, increases stress for workers • Death certificate processing delays in issuance of death certificates and and families (NN) times are becoming shorter resulting inability to obtain survivor benefits Crisis triggers: • Media sensational and and services • Temporary interment and “unofficial” provocative stories about bodies Triggers: burials occurring or considered decline and are replaced with • Community experiences mass fatalities in a • Death-related supplies cannot be obtained stories of survival, resilience, and very short period of time (e.g., body bags, caskets, etc.) moving forward • Death-related supplies are increasingly • Storage of remains becomes a problem Triggers: difficult to obtain (e.g., body bags, caskets, and temporary solutions are employed • Hospital and civic morgues can etc.) Tactics: accommodate demand • Burials are delayed • Implement and adapt mass fatality plans • Death-related supplies are Tactics: • Open family assistance center (NN) more available (e.g., body bags, • Review mass fatality plans • Seek advice from BH bereavement caskets, etc.) • Seek advice from BH bereavement specialists, specialists, DMORTs, faith community, Tactics: disaster mortuary operational response other experienced sources • Evaluate and modify mass fatality teams (DMORTs), faith community, other • Expand risk/crisis communication training plans experienced sources • Continue to convene stakeholders on a • Update roster of BH bereavement • Review and provide risk/crisis communication regular basis to monitor and assess trends/ specialists, DMORTS, faith training issues community, other experienced • Convene stakeholders on a regular basis to • Implement mutual aid (including sources monitor and assess trends/issues temporary morgues) • Enlist those who can help the • Coordinate with faith-based and cultural community memorialize the advocacy groups to address concerns and event and its aftermath as a manage expectations about burial options, way of individual and collective processes, risks healing • Expand and institutionalize risk/ crisis communication training • Continue to convene stakeholders on a regular basis to monitor and assess trends/issues • Demobilize family assistance centers and other resources as appropriate

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Other categories: Indicators: Indicators: Indicators: Risk/crisis • Key government officials refuse to make • Public is increasingly insistent and angry at • Public is increasingly satisfied communications public statements lack of direction and answers with information they are • “Experts” in media are increasing community • Media continue to provide inconsistent receiving; less public anger and fear/confusion/anger messaging even when provided with frustration • Racial and ethnic groups in the community credible information • Emerging community leaders are are differentially affected or obtaining and • Some community leaders are discredited solidified in their roles as credible understanding different information as sources of information; they are sources of information • Rumors are growing marginalized and/or removed • Discredited leaders are seen and • There is inconsistency in health messages • Key government officials continue to heard from less from various official sources refuse to make public statements • Key government officials increase • Messaging is increasingly inconsistent with • “Experts” in media are increasing public visibility and apply risk/ current standards of care and status of health community fear/confusion/anger; some communications training in their system elements come to the community and create public statements • Issues of social justice, historical animosities, increased disruption • The media are moving on incapable leadership, etc., begin to increase in • Racial and ethnic groups in the community to other stories and outside the media and at public events are differentially affected or obtaining and “experts” are seen less frequently; Triggers: understanding different information; talk of the community is increasingly • Event involves high degree of risk or concern demonstrations and civil protest increases perceived as able to handle (contagion, contamination, delayed effects) • Rumors are growing challenges • Public is demanding answers/reassurance/ • There continues to be inconsistency in • Different racial and ethnic direction health messages from various official groups in the community are • Media are providing inconsistent messaging sources increasingly getting the same Tactics: • Messaging is increasingly inconsistent with credible information; talk of • Community leaders promoted as credible current standards of care and status of demonstrations and civil protest sources of information health system elements decreases • Review, update, and implement crisis • Information is inaccurate and changing • Rumors are identified early and communication plans about locations for vaccinations, causing accurate information is effectively • Implement Joint Information System— anger among the general population communicated develop, vet, and circulate press and Crisis triggers: Triggers: information releases • Issues of social justice, historical • Media are providing more • Proactively schedule briefings and make animosities, incapable leadership, etc., consistent messaging and credible experts available dominate the media and public events increasingly use credible • Provide just-in-time crisis communication • Civil unrest occurs information training for formal and informal leaders Tactics: • Consistency in health messages • Seek specialized consultation and advice • Aggressive implementation of crisis from various official sources regarding risk/crisis communication communication plans—additional resources increases • Increase content monitoring and analysis for rumor control, specific population • Messaging more accurately of media (including social media) for tone, targeted messages, social media responses reflects current standards of care accuracy, usability, consistency • Provide just-in-time crisis communication and status of health system • Obtain information from nontraditional training for formal and informal leaders Tactics: sources to determine how information is being • Seek specialized consultation and advice • Evaluate and revise crisis provided/interpreted in vulnerable or specific regarding risk/crisis communication communication plans cultural groups • Increase content monitoring and analysis • Institutionalize crisis of media for tone, accuracy, usability, communication training for consistency formal and informal leaders • Update roster of specialized consultants/advisers in risk/crisis communication continued 139

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TABLE 6-1 140 Continued Indicator Category Contingency Crisis Return Toward Conventional Other categories: • Deploy crisis counseling teams to health • Continue and enhance content Risk/crisis resource lines to address social unrest monitoring and analysis of media communications • Convene stakeholders regarding issues of, for tone, accuracy, usability, (continued) and strategies for, crisis communication consistency • Focus on positive accomplishment or • Continue to convene developments in communications stakeholders regarding issues • Meet with major media to emphasize of, and strategies for, crisis gravity of situation and attempt to address communication conflicts in messaging • Focus on positive accomplishments/developments • Continue to aggressively address rumors and monitor new developments

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Decision-Support Tool: Blank Table to Be Completed Prompted by discussion of the key questions above, participants should fill out this blank table (or multiple tables for different scenarios) with key system indicators and triggers that will drive actions in their own organizations, agencies, and jurisdictions.4 Reminders: • Indicators are measures or predictors of changes in demand and/or resource availability; triggers are decision points. • The key questions were designed to facilitate discussion—customized for behavioral health— about the following four steps to consider when developing indicators and triggers for a specific organization/agency/jurisdiction: (1) identify key response strategies and actions, (2) identify and examine potential indicators, (3) determine trigger points, and (4) determine tactics. • Discussions about triggers should include (a) triggers for which a “bright line” can be described, and (b) how expert decisions to implement tactics would be made using one or more indicators for which no bright line exists. Discussions should consider the benefits of anticipating the implemen- tation of tactics, and of leaning forward to implement certain tactics in advance of a bright line or when no such line exists. • The example table may be consulted to promote discussion and to provide a sense of the level of detail and concreteness that is needed to develop useful indicators and triggers for a specific organization/agency/jurisdiction. • This table is intended to frame discussions and create awareness of information, policy sources, and issues at the agency level to share with other stakeholders. Areas of uncertainty should be noted and clarified with partners. • Refer back to the toolkit introduction (Chapter 3) for key definitions and concepts.  4  The blank table for participants to complete can be downloaded from the project’s website: www.iom.edu/crisisstandards. TOOLKIT PART 2: BEHAVIORAL HEALTH 141

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142 Scope and Event Type: __________________________________ Indicator Category Contingency Crisis Return Toward Conventional Surveillance data Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Communications and Indicators: Indicators: Indicators: community infrastructure Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Staff Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Space/infrastructure Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Supplies Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics: Other categories Indicators: Indicators: Indicators: Triggers: Crisis triggers: Triggers: Tactics: Tactics: Tactics:

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REFERENCE IOM (Institute of Medicine). 2012. Crisis standards of care: A systems framework for catastrophic disaster response. Washington, DC: The National Academies Press. http://www.nap.edu/openbook.php?record_id=13351 (accessed April 3, 2013). TOOLKIT PART 2: BEHAVIORAL HEALTH 143

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