Communication of Protected Health Information and Command Directed Behavioral Health Evaluations

Terminal Learning Objective Given a Soldier needing mental health assistance, utilize proper procedures for requesting a Command Directed Behavioral Evaluation (CDBHE) IAW Department of Defense (DoD) Instruction 6490.04, Mental Health Evaluations of Members of the Military Services, 4 March 2013 while safeguarding Protected Health Information (PHI).

The stigma of BH poses an obstacle to getting help. Scope of the Problem The stigma of BH poses an obstacle to getting help. Multiple deployers are at increased risk for BH concerns. The complex problem of suicide requires constant vigilance.

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

BH Care Portals and PHI PHI disclosure to Command might depend upon how and why the Soldier accesses BH care Why: Potential and likelihood to harm self or others Soldier displays excessive sadness or recent behavioral changes Recent or unusual withdrawal from others Excessive angry outbursts or irritability Decrease in job performance Persistent or recent “at-risk” family issues Command Referral Why: Healthcare provider refers Soldier for specialty care PHA/PDHRA Medical Referral Why: Soldier deems he/she needs assistance Command/leaders encourage Soldier to seek assistance (non-emergency) Chaplains/ACS and other agencies assist the Soldier in accessing care Self Referral UNCLASSIFIED

BH Self Referrals and Protected Health Information (PHI) Soldiers should always be encouraged to seek BH care as a self-referral before psychological concerns become unbearable or overwhelming. Commanders can always receive the following minimum essential information for any healthcare: General Health/Profile status Scheduled appointments and appointment reminders Kept appointments Information discussed with a BH provider is considered confidential communication and not routinely disclosed to others outside the treatment without the express written consent of the Soldier. BH Provider is not at a confidential status unlike priest, chaplain, JAG. BH Provider is ethically responsible to report such issues as child abuse, etc. BH Provider has limited confidentiality. Health care providers will notify a commander when a member obtains mental health services in the following circumstances: Harm to Self: The provider believes there is a serious risk of self-harm by the member. Harm to Others: The provider believes there is a serious risk of harm to others. This includes any disclosures concerning child abuse or domestic violence. Harm to Mission: The provider believes there is a serious risk of harm to a specific military operational mission to include cognitive deficits that could result in inadequate judgment Special Personnel: The member is under the Personnel Reliability Program or is in a position that has been pre-identified by Service regulation or the command as having mission responsibilities of such potential sensitivity or urgency that normal notification standards would significantly risk mission accomplishment. Inpatient Care. The member is admitted or discharged from any inpatient mental health or substance abuse treatment facility. Acute Medical Conditions Interfering With Duty: The member is experiencing an acute mental health condition or acute medical regimen that impairs his/her ability to perform his/her duties. Substance Abuse Treatment Program: The member has entered into a formal outpatient or inpatient treatment program. Command-Directed Mental Health Evaluation: The mental health services are obtained as a result of a command-directed mental health evaluation consistent with DoD Instruction 6490.4.

BH Self Referrals and Protected Health Information (PHI) Exceptions to confidential BH communication: Harm to Self Harm to Others Harm to Mission Special Personnel – Personnel Reliability Program or other potentially sensitive mission responsibilities Hospitalization Substance Abuse Treatment The BH provider is required to notify the Commander within 24-hours of the appointment if any of these exceptions apply. Health care providers will notify a commander when a member obtains mental health services in the following circumstances: Harm to Self: The provider believes there is a serious risk of self-harm by the member. Harm to Others: The provider believes there is a serious risk of harm to others. This includes any disclosures concerning child abuse or domestic violence. Harm to Mission: The provider believes there is a serious risk of harm to a specific military operational mission to include cognitive deficits that could result in inadequate judgment Special Personnel: The member is under the Personnel Reliability Program or is in a position that has been pre-identified by Service regulation or the command as having mission responsibilities of such potential sensitivity or urgency that normal notification standards would significantly risk mission accomplishment. Inpatient Care. The member is admitted or discharged from any inpatient mental health or substance abuse treatment facility. Acute Medical Conditions Interfering With Duty: The member is experiencing an acute mental health condition or acute medical regimen that impairs his/her ability to perform his/her duties. Substance Abuse Treatment Program: The member has entered into a formal outpatient or inpatient treatment program. Command-Directed Mental Health Evaluation: The mental health services are obtained as a result of a command-directed mental health evaluation consistent with DoD Instruction 6490.4.

Conditions to Consider for CDBHE Potential and likelihood to harm self or others. Soldier displays excessive sadness. Recent or unusual withdrawal from others. Recent behavioral changes. Excessive angry outbursts or irritability. Decrease in job performance. Persistent or recent “at-risk” family issues. The word “strange” should be discussed. Give examples of strange behaviors among Warriors (presenter’s experience) Example: extreme opposite behavior - a quiet Warrior becomes unusual boastful or a very boastful confident Warrior suddenly becomes quiet and/or withdrawn. Recent behavioral changes could be consistent late to formation. Behaviors that do not fit the social context.

CDBHE Procedures Consult with behavioral health (BH) provider, if not available, consult with physician or senior confidential non-physician provider. BH provider will provide advice about whether the evaluation should be conducted ROUTINELY or on an EMERGENCY basis. Commander completes the request for evaluation sheet Role of Supervisor in routine and emergency cases BH provider conducts behavioral health evaluation. BH provider submits written feedback to Commander. Commander will follow through with recommendations from BH provider. * For Routine: Supervisor- Equivalent to the rank of a Commissioned Officer. If a supervisor requests a CDBHE, BH provider may chose to contact the SM’s Commander regarding the request prior to conducting the evaluation. Supervisor has the responsibility of contacting the SM’s Commander to discuss the referral of the CDBHE. Recommendations made from the CDBHE are ultimately the Commander’s responsibility to carry out (i.e. admin sep, safety precautions) *For Emergency: Role of Supervisor- In enlisted cases, Commander or supervisor can designate a senior enlisted SM to order the CDE. Officers- Commander or supervisor can designate an officer senior to the patient to order the CDE.

Command Directed Behavioral Health Evaluation Decision Tree Soldier needs an evaluation (See box A for conditions that warrant CDBHE) Is this an emergency? No CDR discusses with BH provider BOX B CDBHE Findings Diagnosis Prognosis Precautions Administrative Treatment plan Fitness for duty Yes CDBHE recommended by BH provider No No further CDR action Provide an escort for Soldier safety BOX A Conditions for CDBHE Harm to self Harm to others Extreme sadness Withdrawal Behavior change Excessive anger Job performance Strange behavior Yes CDR notifies BH provider CDR completes referral sheet and returns to provider and appointment is scheduled Soldier attends appointment Concur with BH recommendations No CDR notifies Senior CDR and MTF CDR CDR counsels Soldier on no stigma Yes Soldier attends appointment CDR receives BH provider recommendations (See box B for minimum recommendations) CDR and Soldier complete recommendations CDR receives BH provider recommendations (See box B for minimum recommendations)

Conducting an Emergency CDBHE Referral First priority is to protect the Soldier and other potential victims from harm. Have Soldier escorted to the nearest BH provider or emergency room. Discuss with BH provider the statements or behaviors that prompted the CDBHE emergency referral.

Conducting a Routine CDBHE Referral Provide the Soldier with counseling informing Soldier of day/time of appointment and that there is no stigma associated with seeking behavioral health care A Commander may NOT restrict a Soldier from lawfully communicating with the Inspector General, an attorney, Member of Congress or other person about the referral for mental health evaluation. Use of escorts is recommended but not required. May not restrict a SM from lawfully communicating with an IG, attorney, Member of Congress or other person about the Service member’s referral for mental health evaluation. Use of escorts is recommended but not specifically stated in the guidance Commanding officer’s first priority shall be to protect the SM and potential victims from harm Make every effort to consult a mental healthcare provider Shall take actions to safely convey the SM to the nearest mental healthcare provider Implies the use of escorts

CDBHE BH Response (1 of 2) BH provider will provide a written response (DA 3822) to the Commander within one business day after completing the CDBHE. Information provided will include: Safety precautions Soldier’s diagnosis Soldier’s prognosis Recommended treatment plan Fitness for continued service Mental healthcare provider shall provide to the commanding officer within one business day after completing a mental health evaluation of a SM referred by the commanding officer a memorandum that shall, at a minimum, diagnosis, prognosis, treatment plan and recommendations regarding fitness and suitability for continued service and shall make recommendations about precautions, if appropriate, and administrative management of the SM Document in the medical record: Clinical assessment, including the assessment of risk for imminent dangerousness Treatment Plan Progress of treatment Discharge assessment Recommendations to commanding officers Notification of potential victims Shall review the signed memorandum including the Statement of Service Member’s Rights Confer with the referring command to clarify issues about the process or procedures used in referring the SM Shall advise the SM referred for mental health evaluation of the purpose, nature and likely consequences of the evaluation before the evaluation begins and shall advise the SM that the evaluation is not confidential

CDBHE BH Response (2 of 2) Additional Recommendations Recommended precautions: Move into barracks. An order to avoid the use of alcohol. An order not to handle firearms or other weapons. An order not to contact potential victim or victims. Recommended administrative management of the Soldier (i.e., administrative separation). Recommendations regarding restricted access to classified information, if appropriate. Recommendations regarding fitness for duty.

Commander Actions Review mental health findings. Implement recommendations. Continue communication/consultation Provider and commander will discuss patient care, impact diagnosis may have on current missions, collaboration on treatment plan Protect a Soldier’s health information – Information should be shared with others (e.g., subordinates or supervisors) ONLY on a need to know basis.

Actions when a Commander Non-concurs with CDBHE Recommendations If a Commander does not concur with the BH provider’s CDBHE recommendation to separate from service: Provide written notification to the next senior Commander Describe reasons for non-concurrence. Submit notification to MTF Commander. Continue to communicate with the BH provider to promote collaboration and successful management of the Soldier.

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

10 Things to Know about PHI 6. HC providers will notify Commanders about change in duty status due to medical conditions: Inpatient Care, Substance Abuse Treatment (ASAP), missed appointments 7. HC providers will notify Commanders about MEB/PEB related data 8. HC providers will notify Commanders about Acute Medical Conditions Interfering with Duty/Mission and duty limiting conditions. 9. HC providers will notify Commanders the results of Command Directed Behavioral Health Evaluations. 10. Commanders should also share information with providers relating changes in Soldier behavior or other information that could impact a diagnosis or treatment: UCMJ, physical altercations, infidelity, financial challenges, Soldier feelings of inadequacy, or when the Soldier has a significant change in social contacts.

Review of Key Points The CDBHE is a Commander’s tool to refer a Soldier for a Behavioral Health Evaluation. Commander’s are responsible for advising the Soldier that there is no stigma associated with obtaining BH services when referring the Soldier for a CDBHE. BH providers are required to provide Commander’s with written feedback following a CDBHE on a DA 3822. In certain situations BH PHI will be released to Commander’s for self-referrals. Commander’s must take all precautions to protect a Soldier’s PHI. Constant and regular communication with the BH provider is the key to a solid collaborative relationship to help Soldiers in need of BH assistance.

REFERENCES DoD Instruction 6490.04, “Mental Health Evaluations of Members of the Military Services.” March 4, 2013 MEDCOM/OTSG Policy 13-020, “Command Directed Behavioral Health Evaluations,” April 12, 2013 Section 546 Public Law 102-484, “National Defense Authorization Act for Fiscal Year 1993,” October 23, 1992 DoD Directive 7050.6, “Military Whistleblower Protection,” August 12, 1995 DOD Instruction 6490.08, “Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members, August 17, 2011 OTSG/MEDCOM Policy 10-042, Release of Protected Health Information (PHI) to Unit Command Officials, 30 June 2010.