Abstract: Gaps and challenges in the integration of public health and behavioral health disaster response Emergency management and public health services have provided leadership in disaster response programs due to safety and injury as primary concerns. Over the past thirty years, with the federal crisis counseling program responding to devastating events with long lasting emotional repercussions, behavioral health concerns have become recognized as the second leading effect of these events. Public health emergency services have made significant gains in planning and preparedness efforts on a national level as well as on a state by state basis. Requirements that public health departments integrate behavioral health services into their preparedness and response plans has proved difficult despite a growing awareness of the need to progress in this area. Disaster behavioral health’s entrance into the public health domain brings with it new skills to be added to an already overloaded curriculum. The emerging disaster behavioral health field has struggled with the lack of evidence based early interventions and this has significantly slowed the public health discipline from identifying and training their disaster response workforce in best practices. In the wake of the last decade of catastrophic disasters, emergency management and public health responders are increasing their awareness of the stress they themselves experience in their work and learning how to mitigate its effects. This is allowing more responders to understand the concept of a public health application to disaster behavioral health response and is serving to move the integration process forward. More behavioral health disaster research is needed to build a solid evidence base to support staged disaster recovery interventions. Learning Objective: Participants in this session will be able to describe three ways that disaster behavioral health interventions may be integrated into an overall public health response to an emergency. Summary: This session discusses how public health and emergency management staff plan for disaster preparedness and recovery response activities to meet the needs of trauma victims of large-scale and scope events such as catastrophic weather events, public health emergencies and terrorist attacks involving mass casualties as examples. It will include background information, key concepts in public health and behavioral health response stressing integrating health and behavioral health approaches to disaster response.

1. Gaps and Challenges in the Integration of
Public Health & Behavioral Health
Disaster Response
-A Responder’s Perspective
Anthony A. Barone, M.P.H., CHMM, CHS-V, FF/EMT-B
Image: FEMA Stock ID 54866
Wednesday, October 31, 2012

2. Presentation Snap-Shot
Presenter Disclosure
Disaster Behavioral Health
The Perfect Plan
Practice Integration
Wrap-up
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 1

3. Presentation Snap-Shot
Presenter Disclosure
Disaster Behavioral Health
The Perfect Plan
Practice Integration
Wrap-up
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 2

4. Presenter Disclosure
 The following personal financial relationships with commercial
interests relevant to this presentation existed during the past 12
months:
– No Relationships to Disclose
 Whereas today’s presenter is a member of a various
organizations, both private and governmental, content provided
herein is representative solely of the presenter’s perspective,
experience, and lessons learned acquired throughout his career
in the emergency preparedness arena.
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 4

5. Presentation Snap-Shot
Presenter Disclosure
Disaster Behavioral Health
The Perfect Plan
Practice Integration
Wrap-up
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 5

6. Disaster Behavioral Health: Defined
“… comprises the mental health issues related to
disasters and the means of addressing them,
including proactive methods to build resiliency and
short- and long-term approaches to restoring and
maintaining psychological and emotional health in
the face of an emergency.” - PPHR
“… the provision of mental health, substance
abuse, and stress management to disaster
survivors and responders.” - HHS
Project Public Health Ready (PPHR) – 2012
http://www.naccho.org/topics/emergency/PPHR/Criteria.cfm
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7. Disaster Behavioral Health: A Public Health Practice
 A common challenge with the integration of public health and behavioral health
disaster response is the recognition of behavioral health as a public health practice.
 Just like environmental health, epidemiology, and biostatistics, behavioral health is a
public health practice.
 Disaster Behavioral Health (DBH) further applies behavioral health concepts in times
of a disaster to survivors, responders, and other populations.
 What is unique about DBH is that it applies to everyone:
– Survivors of the affected community, individuals and populations of surrounding
communities, and at times others across the Nation (e.g. Hurricane Katrina) and
throughout the world (e.g. September 11, 2011 terrorist attacks)
– Responders (e.g. Police, fire, EMS, utilities, volunteers, crisis counselors, etc.)
– Providers (e.g. First receivers, mental health professionals, etc.)
Image: FEMA Stock ID 33425
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8. Presentation Snap-Shot
Presenter Disclosure
Disaster Behavioral Health
The Perfect Plan
Practice Integration
Wrap-up
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 8

9. The Perfect Plan
One major challenge is knowing what to use; when to use it; how to use it...
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10. The Perfect Plan
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11. The Perfect Plan: National Incident Management System (NIMS)
The National Incident Management System
(NIMS) defines preparedness as "a
continuous cycle of planning, organizing,
training, equipping, exercising, evaluating,
and taking corrective action in an effort to
ensure effective coordination during
incident response."
This 'preparedness cycle' is one element of
a broader National Preparedness System
to prevent, respond to, recover from, and
mitigate against natural disasters, acts of
terrorism, and other man-made disasters.
http://www.fema.gov/preparedness-1
Image: FEMA Stock ID 58278
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12. The Perfect Plan: Presidential Policy Directive (PPD) 8 – National
Preparedness
National Preparedness: The actions taken to plan,
organize, equip, train, and exercise to build and sustain the
capabilities necessary to…
… prevent,
… protect against,
… mitigate the effects of,
… respond to, and
… recover from…
… those threats that pose the greatest risk to the security of
the Nation.
Image: FEMA Stock ID 58278
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13. The Perfect Plan: Presidential Policy Directive (PPD) 8 – National
Preparedness
National Preparedness Goal
National Preparedness System
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14. The Perfect Plan: National Preparedness Mission Areas
Prevention
Protection
Mitigation
Response
Recovery
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15. The Perfect Plan: National Preparedness Mission Areas
“Whole Community”
Prevention
Protection
Mitigation
Response
Recovery
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16. The Perfect Plan: National Preparedness Mission Areas & Key
Capabilities
“Whole Community”
Prevention
Protection
Mitigation
Response
1.Community Recovery
Resilience Mass Care
1.
Planning
Operational
Public Information
2. Risk &Services
Disaster 2. Public Health
Resilience Medical Health and
and 1.
Coordination
& Warning Services Social Services
Assessment
Image: FEMA Stock ID 54866
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17. The Perfect Plan
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18. The Perfect Plan
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 18

19. The Perfect Plan: Federal, State, Territorial, Tribal, and Local Plans
Federal Plans State, Territorial, Tribal, and Local Plans
The Integrated Planning System (IPS) Comprehensive Planning Guide (CPG) 101 V.2
 Describes planning doctrine and the  Describes the fundamentals of planning
Federal plan development process and developing emergency plans
 Provides structure for:  Provides guidance for:
– Federal Strategic Plan – Strategic Plan
– Federal Concept Plan – Operational Plan
– Federal Operations Plan – Tactical Plan
 Plans described:  Plans described:
– Contingency (pre-incident/event) – Emergency Operations Plan (EOP)
– Crisis Action (post-incident/event) – Standard Operating Procedure / Guideline
(SOP / SOG)
– Field Operations Guide (FOG) or handbook
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20. The Perfect Plan: Federal, State, Territorial, Tribal, and Local Plans
Federal Plans State, Territorial, Tribal, and Local Plans
The Integrated Planning System (IPS) Comprehensive Planning Guide (CPG) 101 V.2
 Describes planning doctrine and the  Describes the fundamentals of planning
Federal plan development process and developing emergency plans
 Provides structure for:  Provides guidance for:
– Federal Strategic Plan – Strategic Plan
– Federal Concept Plan – Operational Plan
– Federal Operations Plan – Tactical Plan
 Plans described:  Plans described:
– Contingency (pre-incident/event) – Emergency Operations Plan (EOP)
– Crisis Action (post-incident/event) – Standard Operating Procedure / Guideline
(SOP / SOG)
– Field Operations Guide (FOG) or handbook
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 21

21. The Perfect Plan: CPG 101 V.2
State, Territorial, Tribal, and Local Plans
Comprehensive Planning Guide (CPG) 101 V.2
 Describes the fundamentals of planning
and developing emergency plans
 Provides guidance for:
– Strategic Plan
– Operational Plan
– Tactical Plan
 Plans described:
– Emergency Operations Plan (EOP)
– Standard Operating Procedure / Guideline
(SOP / SOG)
– Field Operations Guide (FOG) or handbook
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 22

22. The Perfect Plan: CPG 101 V.2
State, Territorial, Tribal, and Local Plans
Comprehensive Planning Guide (CPG) 101 V.2
 Describes the fundamentals of planning
and developing emergency plans
 Provides guidance for:
– Strategic Plan
– Operational Plan
– Tactical Plan
 Plans described:
– Emergency Operations Plan (EOP)
– Standard Operating Procedure / Guideline
(SOP / SOG)
– Field Operations Guide (FOG) or handbook
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 23

23. The Perfect Plan: CPG 101 V.2
 Introduction and Overview
 1. The Basics of Planning
 2. Understanding the Planning Environment: Federal, State, and Local Plans
 3. Format and Function: Identifying the Right Plan for the Job
 4. The Planning Process
– Step 1: Form a Collaborative Planning Team
– Step 2: Understand the Situation
– Step 3: Determine Goals and Objectives
– Step 4: Plan Development
– Step 5: Plan Preparation, Review, and Approval
– Step 6: Plan Implementation and Maintenance
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 24

24. Presentation Snap-Shot
Presenter Disclosure
Disaster Behavioral Health
The Perfect Plan
Practice Integration
Wrap-up
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 25

25. Practice Integration
• Public health and behavioral health disaster response lack consistant
collaboration and standardized integration with preparedness partners
• The concept of the “Whole Comminity” calls for the
leveraging, collaboration, and cooperation of all key players and
stakeholders
• Public Healh, as the lead for Emergency Support Function (ESF) 8:
Public Health and Medical Services, is expected by the public to provide
health and medical direction, guidance, support, and services to
individuals, families, and communities during disasters
•Disaster Behavioral Health services are an expectation of the public, and
a critical need for responders
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26. Practice Integration
Steps forward in the National Capital Region (NCR)
• Regional preparedness and coordination efforts
• Regional health and medical planning
• Public health and behavioral health at the table with emergency
management, public safety, hospitals, and others
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27. Practice Integration: Responder Focus
 It’s time to take a second look at responders
 Responders provide a unique challenge for public health and behavioral health
disaster response:
– Provide initial contact with survivors
– Expected to triage and treat patients according to scope and protocol,
maintain incident safety and security, and/or conduct other emergency
operations
– Subjected to continuous exposure to a disaster scene and traumatic
incidents
– Are often survivors themeslves
– Lack standardized training, guidance, procedures, and protocols for
application in the field
• While many resources do exist, police/fire academies and EMS schools
do not incorporate sufficient training, education, or competencies for
responders
Image: FEMA Stock ID 54866
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28. Practice Integration: Responder Focus
“Psychological first aid is one of the most important skills
my team can have in the field.”
Christina Catlett, MD, FACEP
Medical Officer, MD-1 DMAT
Director, Johns Hokpins Go Team MRC
Image: FEMA Stock ID 54866
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29. Practice Integration: Responder Focus
 Disaster Behavioral Health (DBH) integration into
first/disaster responder training, education, and
certification process would help bridge the DBH gaps
during the initial interactions of the survivor and responder.
 Standardized core DBH competencies for responders, in
conjunction with requirements for skill demonstration (e.g.
CPR, ACLS, etc.) would help bring DBH to life in practice,
in training, and subsequently the field.
 Standardized guidance for survivors provides an
opportunity for unaffected survivors to actually care for
responders.
– For example, encouraging survivors to demonstrate
appreciation to responders for their duties is a
powerful tool in refreshing and refueling responders.
Image: FEMA Stock ID 54866
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30. Practice Integration: Responder Focus
Time Operations You
0  Rotate On-call  Prepare, train, and exercise
12hr  Alerted and placed on standby  Check your gear, notify work, secure
24hr  Activated and provided family and property... and you wait...
48hr providers orders  Report to ralley-point
 Deploy  Begin your journey
72hr  Travel by land, air, sea, land  While excited, you are weatherd by
again, prior to arrival exhausting travel modalities
 Mission assignment pending  You wait...
 Relocated to an alternate  Just when you’ve begun to settle,
96hr
location the journey continues
 Mission begins  Faced with limited resources, long
Week 1 hours, tough decisions, you work
 Mission changes time again
Week 2  Exhausted, dazed, and longing for a
 Mission ends
Image: FEMA Stock ID 54866 shower (hot or cold!)
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31. Practice Integration: Responder Focus
... filling gaps, overcoming challenges
 On every deployment I encourage my team to focus on “controling the
controlables”
 This is accomplished by:
• Taking care of one’s self, first
“ cura te ipsum”
• Next, taking care of one another
• Lastly,taking care of our patients through difficult decision making on
when, and when not, to advance care
“ primum non nocere”
• While not always overtly apparent, more often than not it’s not medical care
we’re providing, but rather behavioral
• Consequently, this is also an area where many responders are not familiar
Image: FEMA Stock ID 54866
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32. Practice Integration: Responder Focus
Important considerations to accept, pre-disaster!
 Team unity and support is critical to mission success
 All disasters are different, and something new is learned on every deployment
 You will be required to improvise, adjust, and operate outside of your comfort
zone
 Disasters require personnel to wear many diffferent hats
 ”While I may be a physician in my day-to-day practice, when my boots hit
the ground I will be a shoulder to cry on, a pharmacist, a nurse, a tech, a
transporter, and a grunt moving resources.”– DMAT NJ-1 Medical Officer
 Disaster responders and providers are forced to make difficult decisions
 Knowing, deciding, and accpeting when to provide care (e.g. Haiti)
 Disasters are physically, socially, mentally, psychologically, and spirtually
draining
 Down-time reading a book or listening to some tunes is a must
 What can go wrong, will go wrong
Image: FEMA Stock ID 54866
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33. Practice Integration: Responder Focus
“I personally haven't saved a lot of lives in disasters...
… but I've given a lot of hugs and held a lot of hands.”
Christina Catlett, MD, FACEP
Medical Officer, MD-1 DMAT
Director, Johns Hokpins Go Team MRC
Image: FEMA Stock ID 54866
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34. Practice Integration: “Whole Community”
 Integrating Disaster Behavioral Health (DBH) Dynamically across
the “Whole Community”
– Survivors
– Responders
– Providers
– Animals
Survivors Responders Providers Animals
Survivors S-S R-S P-S A-S
Responders S-R R-R P-R A-R
Providers S-P R-P P-P A-P
Animals S-A R-A P-A A-A
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35. Practice Integration: Information Technology & Mobility
Health Information Technology (HIT)
Health Information Exchange (HIE)
 The use information technology and mobility in the disaster response is here.
 The time for Public Health and Behavioral Health Disaster Response to get
involved is now.
 Southeast Regional HIT-HIE Collaboration (SEARCH): Final Report, ONC State
Health Policy Consortium Project: Health Information Exchange in Disaster
Preparedness and Response, July 2012
http://www.healthit.gov/sites/default/files/pdf/SERCH-White-Paper.pdf
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36. Practice Integration: HIE in Disaster Preparedness & Response:
Five Recommendations for State HIEs
(1) Understand the State’s disaster response policies and align with the State agency
designated for Emergency Support Function #8 (Public Health and Medical
Services) before a disaster occurs.
(2) Develop standard procedures approved by relevant public and private stakeholders
to share electronic health information across State lines before a disaster occurs.
(3) Consider enacting the Mutual Aid Memorandum of Understanding to establish a
waiver of liability for the release of records when an emergency is declared and to
default state privacy and security laws to existing Health Insurance Portability and
Accountability Act (HIPAA) rules in a disaster. States should also consider using the
Data Use and Reciprocal Support Agreement (DURSA) in order to address and/or
expedite patient privacy, security, and health data-sharing concerns.
(4) Assess the State’s availability of public and private health information sources and
the ability to electronically share the data using HIE(s) and other health data-
sharing entities.
(5) Consider a phased approach to establishing interstate electronic health information-
sharing capabilities.
Source: Southeast Regional HIT-HIE Collaboration (SEARCH): Final Report, ONC State Health
Policy Consortium Project: Health Information Exchange in Disaster Preparedness and
Response, July 2012, http://www.healthit.gov/sites/default/files/pdf/SERCH-White-Paper.pdf
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37. Practice Integration: Health Information Exchange
• Patient Admission
• Patient Discharge
Notification
Examples
• New Laboratory Result
• New Radiology Result
• Final Microbiology
• ER Admission
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38. Presentation Snap-Shot
Presenter Disclosure
Disaster Behavioral Health
The Perfect Plan
Practice Integration
Wrap-up
The information contained in this document is proprietary. Copyright © 2012 Capgemini. All rights reserved. 39

39. Wrap-up
Disaster Behavioral Health: a public health practice
The Perfect Plan: knowing what to use; when to use it;
how to use it
Practice Integration: responder focus
Practice Integration: the “whole community”
Practice Integration: Health Information Technology (HIT)
and Health Information Exchange (HIE)
Image: FEMA Stock ID 33425
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40. Anthony A. Barone | M.P.H. | CHMM | CHS-V | FF/EMT-B
Senior Consultant | Public Sector
Capgemini Government Solutions
anthony.barone@capgemini-gs.com
www.capgemini-gs.com
The information contained in this presentation is proprietary.
© 2012 Capgemini. All rights reserved.

41. About Capgemini
With around 120,000 people in 40 countries, Capgemini is
one of the world's foremost providers of consulting,
technology and outsourcing services. The Group reported
2011 global revenues of EUR 9.7 billion (approximately
$13.5 billion USD).
Together with its clients, Capgemini creates and delivers
business and technology solutions that fit their needs and
drive the results they want. A deeply multicultural
organization, Capgemini has developed its own way of
working, the Collaborative Business ExperienceTM, and
draws on Rightshore ®, its worldwide delivery model.
Rightshore® is a trademark belonging to Capgemini
www.capgemini-gs.com
The information contained in this presentation is proprietary.
© 2012 Capgemini. All rights reserved.