Federal Disaster Mental Health Response Policy: Building Resilient Communities

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Federal Disaster Mental Health Response Policy
Building Resilient Communities
LCDR Nicole L. Frazer, PhD, USPHS Office of the
Deputy Assistant Secretary of Defense (Force
Health Protection Readiness) LCDR Jeffrey L.
Goodie, PhD, ABPP, USPHS Assistant Professor of
Family Medicine/Health Policy Analyst Uniformed
Services University/Office of ASPR CDR Harvey
Ball, USPHS Office of Assistant Secretary of
Preparedness and Response
UNCLASSIFIED
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Overview

• Models of Community Resilience
• The Roles of the Office of the Assistant
  Secretary for Preparedness (ASPR) and Division of
  At-Risk, Behavioral Health, Community
  Resilience (ABC)
• The National Health Security Strategy (NHSS)
• The Roles of the Office of the Assistant
  Secretary of Defense, Force Health Protection and
  Readiness (FHPR)

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What is Resilience?
New Orleans 2005
Haiti 2010
Japan 2011
Memphis 2011
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Model of Stress Resistance and Resilience
Norris et al. (2007). Am J Community Psychol.
41127-150.
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Resilience Definition

• A process linking a set of adaptive capacities
  to a positive trajectory of functioning and
  adaptation after a disturbance

Norris et al. (2007). Am J Community Psychol.
41127-150.
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Research-Based Conclusions Behavioral Health
Interventions

• Behavioral and cognitive early interventions may
  prevent problems
• Psychological debriefing approaches are
  contraindicated
• It is inappropriate to prescribe formal
  psychological services to all victims of
  disasters
• It is reasonable to expect that most people will
  be resilient and/or demonstrate a normal recovery
• Disaster-response professionals should not wait
  to provide psychological care until problems have
  become chronic

Ruggiero KJ et al. Beh Therapy 200637190-205
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Community ResilienceNetworked adaptive capacities
Norris et al. (2008). Am J Community Psychol.
41127-150.
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Networked Adaptive CapacitiesEconomic Development

• Number/Amount of economic resources
• Diversity of economic resources
• Capacity to distribute resources to those who
  need it most

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Networked Adaptive CapacitiesSocial Capital

• Network structures and linkages
• Loosely coupled organizations that
  coordinate/collaborate
• Tight coupling may increase danger encourage
  group think
• Social support
• Provide actual assistance, embed into social
  relationships
• Received
• Perceived (twice as likely to evacuate)
• Community bonds, root, commitments
• Sense of communityattitude of trust , belonging
  to others
• Place attachment--emotional connection to
  community
• Citizen participationengagement in formal
  organizations

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Networked adaptive capacitiesInformation and
Communication

• Systems and Infrastructure for Informing the
  Public
• Survives only if it is correct and correctly
  transmitted
• Communication and Narrative
• Shared meaning and purpose

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Networked Adaptive CapacitiesCommunity Competence

• Collective Efficacy and Empowerment
• Shared belief that a group can effectively meet
  demands and improve lives through concerted
  effort

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Building Community ResilienceRAND report
(Chandra et al., 2011)
Levers of community resilience
Core components of community resilience
Wellness Promote pre-/post-incident
health Access Ensure health/social services
access
Social/Economic well-being Physical/Psychological
health
Community context
Education Info preparedness, risks, resources
Effective risk communication
Engagement Promote participatory
decision-making Self-Sufficiency Individuals
/communities assume responsibility for
preparedness.
Developing Community Resilience
Social connectedness for resource exchange,
cohesion, recovery
Integrating /involving govt NGO in planning,
response, and recovery
Ongoing disaster experience
Partnership Develop strong partnerships within
and between government and NGOs
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Research Implications

• Although there is consensus that early
  behavioral health interventions should be
  routinely incorporated into disaster response,
  there is mixed evidence on which strategies are
  most effective and how best to deploy them.
  Furthermore, best practices for surveillance for
  mental health problems and substance abuse during
  disasters remain largely undeveloped.

Yun K, Lurie N, Hyde PS. N Engl J Med 2010
3631193-1195.
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Research Directions

• Basic/lab-based research past and future?
• Other research literatures?
• Testing models in disasters
• Real-time data collection
• Can community resilience be changed?
• Measures that predict resilience in specific
  populations
• Interventions that support resilience in at-risk
  populations

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Questions Complicating Research/Communication/
Understanding

• Resilience and Community definitions
• Funding studies
• Measurement
• Defining success/improvement

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• Community Resilience and Policy

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ASPR OPP Division of At-Risk, Behavioral Health,
Community Resilience (ABC)

• Mission Provide subject matter expertise,
  education, and coordination to internal and
  external partners to promote community resilience
  and ensure that behavioral health issues and the
  needs of at-risk individuals are integrated in
  the public health and medical emergency
  preparedness, response, and recovery activities
  of the nation.

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ABC

• Key Responsibilities
• 1. Policy Coordination
• Provide policy guidance on at-risk individuals,
  behavioral health, and community resilience and
  serve as subject matter experts to other ASPR
  programs
• 2. Response
• During response, provide expertise and technical
  assistance to OPEO Emergency Management Group and
  coordination of ESF 8 partners to
• Address the functional needs of at-risk
  individuals, including children and people with
  special medical needs
• Address behavioral health considerations of
  impacted members of the public, survivors, and,
  in particular, federal responders

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ABC

• 3. Interagency Coordination
• Represent HHS to White House Recovery Initiative
  on behalf of ASPR
• Chair Emergency Preparedness Health Subcommittee
  of the DHS Interagency Coordinating Council on
  Emergency Preparedness and Individuals with
  Disabilities (ICC)
• Coordination of Childrens HHS Interagency
  Leadership on Disasters Working Group lead ASPR
  liaison with National Commission for Children and
  Disaster
• ASPR Liaison to Human Services (ACF) ASPR
  Liaison to Intradepartmental Council on Native
  American Affairs (ICNAA)
• Represent ASPR on Healthy People 2020, Federal
  Education and Training Interagency Group (FETIG)

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What is an At-Risk Individual?
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HHS Definition for At Risk Individuals

• In simple terms, at-risk individuals are those
  who, in addition to their event-related medical
  needs, have other needs that may interfere with
  their ability to access or receive medical care.

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At-Risk Example

• The health status of an individual receiving home
  dialysis treatment who relies on a local
  Para-transit system to attend medical
  appointments and food shopping could quickly
  become critical if 40 of the drivers are ill and
  transportation is suspended. In addition to
  treatment for influenza, his functional needs
  would be medical care (for dialysis) and
  transportation.
• Without addressing those functional needs, he
  cannot get healthcare services.

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How Does Behavioral Health Fit in?
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Disaster Behavioral Health

• Disaster behavioral health is the provision of
  mental health, substance abuse, and stress
  management to disaster survivors and responders.
• Behavioral Health Concerns of Survivors and
  Responders
• Distress is common - symptoms and reactions
  include
• Emotional - irritability, excessive sadness
• Cognitive - decision making, following directions
• Physical - headache, stomach pain, difficulty
  breathing.
• Behavioral - alcohol/drug use, interpersonal
  conflict, non-compliance with medication needs.

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Disaster Behavioral Health Strategies

• Assure Basic Needs
• Psychological First Aid
• Needs Assessment
• Monitor the Recovery Environment
• Outreach/Information Dissemination
• Fostering Resiliency/Recovery
• Consultation/Technical Assistance
• Triage
• Treatment

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HHS ASPR ABC/Behavioral Health

• Part of the nations public health response per
  ESF 8.
• Behavioral health needs often emerge immediately
  following a disaster, but may also develop over
  time.
• ABC works to address the behavioral health needs
  of disaster/emergency survivors as well as the
  needs of the response workforce (force
  protection) as these pertain to ESF 8.
• ABC also works to forward behavioral health
  approaches to promote individual and community
  resilience.

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Community Resilience and the NHSS
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At-risk, BH, and Community Resilience in the NHSS

• Public education to inform and prepare
  individuals and communities including information
  for and about at-risk individuals and the
  psychological aspects of preparedness
• Build, connect, and engage local social networks
  for preparedness, response, recovery, and
  resilience
• Integrated support from non-governmental
  organizations...including policies to develop
  neighborhood resources for at-risk individuals
• Risk communication ...including messages in
  appropriate languages and in alternative,
  accessible formats with special attention to
  needs of at-risk individuals

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At-risk, BH, and Community Resilience in the NHSS
(cont.)

• Case management support or individual
  assistance...utilize whole family approaches,
  including crisis counseling... follow up
  regarding the physical and behavioral health
• Reconstitution of the public health, medical, and
  behavioral health infrastructure
• Access to health care and social servicesfor all
  community members, including at-risk
  individuals/special medical needs patients
• Evidence-based prevention and treatment services
  assess behavioral health needs among incident
  victims and response workers, monitor physical
  and behavioral health outcomes

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At-risk, BH, and Community Resilience in the NHSS
(cont.)

• Fatality management ... support families with
  factual information and compassion
• Develop bystander response until emergency
  responders arrive, (including the need for
  psychological support addressing the needs of
  at-risk individuals)
• Recovery planning should address behavioral
  health services for affected communities and
  responders
• Resilient communities have robust social networks
  and health systems that support recovery after
  adversity...including social and psychological
  resources

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Pandemic and All Hazards Preparedness Act (PAHPA)

• Passed in Dec 2006 to improve the Nations
  public heath and medical preparedness and
  response capabilities for emergencies, whether
  deliberate, accidental, or natural
• Established
• Assistant Secretary for Preparedness and Response
  (ASPR)
• Every four years prepare the National Health
  Security Strategy

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National Health Security Strategy (NHSS)

• National health security
• a state in which the Nation and its people are
  prepared for, protected from, and resilient in
  the face of health threats or incidents with
  potentially negative health consequences.
• Establishes a national, NOT federal only, set of
  goal and strategic objectives for national health
  security.

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Community Resilience at the National Level

• The vision for health security described in
  the NHSS is built on a foundation of foundation
  of community resiliencehealthy individuals,
  families, and communities with access to health
  care and with the knowledge and resources to know
  what to do to care for themselves and others in
  both routine and emergency situations.

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Community Resilience at the National Level

• Communities help build resilience by
  implementing policies and practices to ensure the
  conditions under which people can be healthy, but
  assuring access to medical care, building social
  cohesion, supporting healthy behaviors, and
  creating a culture of preparedness in which
  bystander response to emergencies is not the
  exception but the norm.

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Framework for the NHSS
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Key Elements of the NHSS

• Build, connect, and engage local social networks
  for preparedness, response, recovery, and
  resilience
• Integrated support from non-governmental
  organizations
• Risk communication
• Case management support or individual assistance
• Access to health care and social
  servicesincluding behavioral health for all
  community members, including at-risk
  individuals/special medical needs patients
• Resilient communities have robust social networks
  and health systems that support recovery after
  adversity...including social and psychological
  resources

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Resources

• NHSS Web page http//www.phe.gov/Preparedness/pla
  nning/authority/nhss/Pages/default.aspx
• HHS ASPR Web site
• http//www.phe.gov/
• HHS ASPR Division for At-Risk Individuals,
  Behavioral Health, and Community Resilience (ABC)
  Web page
• http//publichealthemergency.hhs.gov/preparedness
  /planning/abc/Pages/default.aspx

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• Department of Defense
• Disaster Mental Health Policy

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What Well Cover

• Force Health Protection and Readiness
• Policy Development
• Military Health System Quadruple Aim
• Disaster Mental Health Background
• DoD Disaster Mental Health Policy
• Summary

UNCLASSIFIED
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Force Health Protection and Readiness (FHPR)

• Psychological Health Strategic Operations
  develops policies and programs
• - To build psychological health and resilience
• - To mitigate operational stress across the
  deployment cycle
• - To ensure a fit and ready fighting force
• Currently four mental health policies in
  coordination

UNCLASSIFIED
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Policy Development

• Mental health policies are shared between Force
  Health Protection and Readiness (FHPR) and
  Clinical and Program Policy (CPP)
• FHPR has deployment related psychological health
  policies
• CPP has garrison-focused clinical care policies
• Mental health subject matter experts (SMEs)
• Defense Centers of Excellence (DCoE) for
  Psychological Health and Traumatic Brain Injury
• CPP/Office of the Chief Medical Officer (OCMO)
• FHPR/PHSO
• Policy development requires close collaboration
  among these offices, along with Service
  proponents/leads

UNCLASSIFIED
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Policy Development
U.S. Air Force photo by Airman 1st Class James
Bell/Released
UNCLASSIFIED
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Policy Initiatives Support the MHS Quadruple Aim
Disaster Mental Health Policy

• Ensure Access to Care

Enhance Psychological Health and Resiliency
Ensure Individual and Family Medical Readiness
UNCLASSIFIED
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Disaster Mental Health Background

• National Health Security Strategy 2009
• Report of the DoD Independent Review
  2010-Protecting the Force Lessons from Fort Hood

U.S. Air Force photo by Senior Airman Nicole
Mickle, 5/27/10, Port San Antonio
UNCLASSIFIED
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DoDs Disaster Mental Health Policy
Remember this?
UNCLASSIFIED
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Wheres the Beef?
DoD Instruction 6055.17 DoD Installation
Emergency Management (IEM) Program
DoD Instruction 6200.03 Public Health Emergency
Management Within the DoD
Disaster Mental Health Policy
UNCLASSIFIED
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Whats in DoDI 6055.17?All-hazards

• All-hazards. Any incident, natural or man-made,
  including those defined in DoDI 6055.07, that
  warrant action to protect the life, property,
  health, and safety of military members,
  dependents, and civilians at risk, and minimize
  any disruptions of installation operations.

UNCLASSIFIED
48
Whats in DoDI 6055.17?Installation Emergency
Management

• Disaster mental health representative now
  included on the Installation Emergency Management
  Working Group (IEMWG)
• Installation Emergency Management (IEM) plan now
  will include disaster mental health, will be
  coordinated with other protection-related program
  plans, and will be updated annually

UNCLASSIFIED
49
Whats in DoDI 6200.03?Definitions

• Disaster mental health (DMH). Provision of
  prevention, outreach, screening, psychological
  first aid, education, and referral services to
  individuals and groups who may have or who have
  had exposure to an all-hazards incident.
• Disaster mental health response team (DMHR).
  Designated team that provides command
  consultation, prevention, outreach, screening,
  psychological first aid, education, and referral
  services following an all-hazards incident.

UNCLASSIFIED
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Whats in DoDI 6200.03?DMHR Teams

• Comprised of a multidisciplinary team, to
  include, at a minimum, individuals in each of the
  following areas
• mental health
• spiritual support
• family support
• Can include non-MH providers trained in acute
  mental health intervention
• Identify and train primary and alternate team
  members
• Commander enters into agreements, as
• needed, to ensure access to a DMHR team

UNCLASSIFIED
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Whats in DoDI 6200.03?DMHR Team Responsibilities

• Establish standard operating procedures (SOP)
  that include, at a minimum
• the composition and role of the team
• a listing of the available, locally trained
  resources with contact information
• a description of local conditions and any
  identified high-risk groups
• a response plan for team activation
• plans for conducting DMH needs assessments and
  surveillance
• maintenance of team member psychological health
• training plan

UNCLASSIFIED
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Whats in DoDI 6200.03?DMHR Team
Responsibilities

• Required training topics

PREVENTION OUTREACH
SCREENING TRIAGE
REFERRAL EDUCATION
PSYCHOLOGICAL FIRST AID CONSULTATION TO COMMAND

• Train at least quarterly as a DMHR team
• Train annually as part of the overall
  installation emergency management exercises

UNCLASSIFIED
53
Bottomline in DoD

• New DMH policy ensures each installation will
  have a trained DMHR team to respond to an
  all-hazards incident
• DMHR Team
• Identify DMHR team members
• Develop SOP
• Develop training plans and training
• Supports the MHS Quadruple Aim

UNCLASSIFIED
54
Summary

• Community Resilience
• Models developed, need testing
• Federal Policy
• NHSS guiding current federal efforts
• DoD Policy
• DMHR Teams being established

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Questions?
UNCLASSIFIED