Nursing Care Plan Guide

hello, and welcome to the podcast, "disaster substance abuse services: planning and preparedness." my name is ed dewolfe, and i am the moderator for today's podcast. we're aiming for a 30-minute presentation, and then our speaker will answer some questions, for a total of 45 minutes. â  thank you for your interest. in addition to this podcast, you can locate other disaster behavioral health resources on the samhsa disaster technical assistance center, or samhsa dtac, website, located at www.samhsa.gov/dtac. we also invite you to provide feedback on this podcast by clicking on the link www.samhsadtac.com/dsa. i will provide the link again at the end of the podcast. and now, i'll hand this over to our host, ms. julie liu, a public health advisor from samhsa, who

will introduce our speaker and tell us more about the podcast. julie liu is a public health advisor for the crisis counseling program with samhsa's emergency mental health and traumatic stress services branch. she has more than nine years of crisis counseling experience and more than 17 years of clinical experience, and specializes in mental health and substance abuse disorders, child abuse, and trauma. julie responded to the aftermath of 9/11 in washington, dc, and worked with hurricane katrina survivors. her experience also includes providing expertise to a national program of training and technical assistance designed to improve the quality of services for individuals with co-occurring mental health and substance abuse disorders. thank you, and welcome to the podcast. we are fortunate to be joined by today's speaker, dee owens. ms. owens is a social science analyst and the lead at the center for behavioral health statistics and quality, and focuses on the

community early warning and monitoring system. in this capacity, she creates and manages programs to help communities use existing data to discover local trends and target resources efficiently in a near real-time fashion. the purpose of this podcast is to help disaster substance abuse coordinators and others who work with people who have substance abuse issues understand the importance of disaster planning and preparedness. at the end of this podcast, participants will be able to: recognize the importance of including substance abuse planning into the disaster planning process. identify and integrate local treatment centers and other agencies that serve people with substance abuse issues into the planning process, and apply the concepts learned to exercises and plans.

now i would like to introduce dee owens. ms. owens spent nearly 13 years at indiana university, bloomington, where she directed the alcohol-drug information center and served as research faculty in the school of public health. in 1995, while she was serving as deputy commissioner for substance abuse services in oklahoma, the bombing of the alfred p. murrah federal building took place, and she helped stand up services, such as a suicide hotline, trained substance abuse providers, and helped direct project heartland. dee has worked nationally and trained internationally in substance abuse planning, preparedness, and response. she was also part of the response effort to the 9/11 attack in new york city, hurricane katrina, and the 2012 henryville tornado in indiana, where she led the state's mental health and substance abuse response on the ground. thank you, julie. i'd like to start off the podcast with a quote. i know we are all busy, and just when we think we are done with one crisis, another one seems to come about. well, as much as we would all like to schedule them, anyone who works in the disaster behavioral

health field knows we can't. most of us are familiar with section 416 of the stafford act, which authorizes the president to provide disaster mental health services to survivors in the aftermath of a declared disaster, which happens an average of every two weeks. we must also plan and prepare for the local, smaller-scale disasters that are major to those who experience them. there are three keys to successful planning: relationships, more relationships, and even more relationships. we hear it all the time in emergency management: the worst time to introduce yourself to other community stakeholders is in the middle of the response phase. how does this relate to disaster substance abuse? next, i'm going to talk about community agencies you should consider reaching out to, if you have not already. building relationships with other community-serving agencies before an incident occurs can help you get to know your colleagues in a less

stressful environment. it can also ensure that plans for people with substance abuse issues are integrated in as many services your community provides as possible. for example, your local health department is responsible for point of distribution, or pod, exercises in most states; partnering and practicing with that agency will serve you well, when the time comes. on this and the next slide are listed the community stakeholders with whom you might consider planning and preparing. just like our services, each of these has something to offer in disaster response. of course, your entire plan should mirror your state's plan; check out the samhsa dtac podcast on "implementing your dbh plan" to learn about overall integration. on this slide i have listed some organizations you may not have yet considered working with, such as media outlets. media contacts can help you share information with many residents during a response, and can help you keep the public informed throughout the incident. for example, they can distribute messages of hope, of the locations of ad hoc self-help

meetings, and can tell residents where to receive triage services. as you are reaching out to your stakeholders, it is important to keep these planning concepts in mind. planning should: be relevant to all stakeholders be sustainable programmatically be practical and simple to follow establish reliable communication channels provide seamless service delivery, and prevent duplication of effort next, i will cover key planning activities that can put these concepts into motion. when working on your disaster substance abuse plans, it is important to take your response teams, generally organized by fema district, through the following activities. each of these activities calls for all team members to be trained—each member has something to add to the team. a needs assessment can help determine what community organizations and resources are available and interested in helping during

response. who can help you locate treatment slots and spaces for hospital detoxification? samhsa recently released a behavioral health disaster app that can help responders quickly locate local treatment. now let's take that a little further. by working with local hospitals, you will learn where triage will be; more importantly, all involved will know who to contact for referral. while few people need actual substance abuse treatment in the response phase, those newly in recovery may need detoxification. in fact, in new york city after 9/11, we found that many clients wanted to go back to treatment because they felt safe there. during a system assessment, it is important to build upon your relationships, and ask agencies how you can help them with their own disaster substance abuse plans. often you will find the organization has no plan for those they serve who might have substance abuse issues or relapses. this can highlight critical gaps, including a lack of specific services in a community, allowing you access to include

them in planning, future service provision, and in training assessments, where you can determine what substance abuse service training is needed so that all partners can recognize and refer, at minimum. a systemic design review will help determine if there are holes or missing partners and then you can... identify missing community stakeholders, ensuring your plans are integrated and addressing substance-abuse issues before a disaster strikes. having a well-designed communication system includes partners like the media and public information officers in local emergency management and public health agencies, to ensure a smooth flow of information. finally, institutionalizing those relationships with formal mous - or memorandum of understanding - and agreements can help reduce confusion during an actual disaster. of course, we could dedicate an entire podcast to each of these steps; this overview, however,

gives you an idea of what is needed to ensure substance abuse services are comprehensive and included in emergency management plans. as part of the planning process, it is important to ensure your plans are culturally sensitive and incorporate the demographics of the area you serve. here are some questions to think about while working on your disaster substance abuse plans: is your area more rural? suburban? urban? substance abuse problems and needs often vary significantly by this factor alone, especially when it comes to availability of services. has there been a recent influx of immigrants into your community? if so, how can you reach them to determine their substance abuse needs? do you work with tribal nations or are they nearby? have you included their leaders? do you (or do they) have an accurate assessment of their substance abuse needs that might be exacerbated during a disaster? are languages other than english spoken in your community? if so, try to locate resources in

those languages, or ask a stakeholder for help translating documents and messages. additionally, other cultures have different norms surrounding substance abuse; do you have someone on your team who can tend to these differences during a disaster? do businesses in your community have employee assistance programs? it is a good idea to include these employers on your planning team. other populations in your community could have significantly different cultures and norms. special populations, including those with sensory impairments or those who rely upon wheelchairs, must be included in both the planning process and the plan. your relationships are in place, your communications systems are all set, and you have a good understanding of your community's needs when it comes to disaster substance abuse. now what? practice, practice, and practice.

training with your own agency and key stakeholders as part of an overarching state or regional plan will both help to keep your skills sharp and share with others who may not yet understand what kinds of substance abuse service needs may arise during disaster response. drills and practice with other agencies can help you identify any gaps that still need to be addressed as well as aspects of your plan that work well and could be replicated. critiquing your plan—or having other objective people do so—is another good way to identify gaps, incorrect assumptions, or missing elements in the plan. it is also important to revise your disaster substance abuse plan regularly, always working within your state's plan, as well, by developing a feedback loop that includes input from partners, local and state officials, and findings from after-action reports and hot washes.

ensure inclusion of all partners, and yes, that includes clients, who often see what we cannot! other samhsa dtac podcasts provide more detail about items on this slide, but it is important for you to know that all planning for response must include a basic knowledge of incident command structure and certification in national incident management system, or nims. under any state's plan, you must receive training in both areas to receive credentials, a badge, and participate in response. learning about communication flow and scaling up and down is part of this training. additionally, professionals with skills in substance abuse prevention and treatment may be needed in the acute phase of response, such as those of prevention specialists in schools affected by disaster. we often don't think of including school personnel in training, but we must! in new york city, we realized that a large group of first responders included, in fact, school prevention officials and dare officers. these professionals should be included in nims and in other trainings. by bringing all parties to the table in planning and training, each can see

where particular skill sets may be highly relevant to a particular response. training is integral to planning, and relevant training topics are on this slide and the next. in addition to basic planning and nims, it is important to know what state statutes say you can/cannot do. learning about how both mental health and substance abuse services are provided differently in various phases of response, as well as the link between trauma and post-traumatic stress disorder, or ptsd, are required topics. training on terrorism and bioterrorism may be more relevant to areas near a big city or nuclear plant, for example, but location may not be the only indicator. no one ever thought of oklahoma city as a terror target. we asked ourselves over and over again, "why us?" terrorism creates a kind of fear that can cause spikes in use and abuse and relapse, especially as safe places, such as treatment centers, are destroyed or disabled. as skill sets are developed, more advanced trainings such as these will help providers to sharpen their substance abuse skills, as well,

and will allow those providers to share what they know with others. it is important to understand that helping people to feel safe and to help them gain control, some control, over their out-of-control situations is key to disaster recovery. in new york city, for example, we discovered that people wanted to go back to their treatment centers, where they felt "safe." outreach and psychological first aid, or pfa, are basic techniques that every responder should learn to use in the immediate aftermath of any type of disaster. it's also important to know where the self-help meetings are. is someone willing to start one? at ground zero after 9/11, responders formed their own group that met at noon and after work hours so that those in recovery could avoid the free alcohol offered by the still-open bars in the area. mass casualty management and death notification are more advanced skills that are generally not required by most responders but that can broaden your toolkit.

finally, it is important to remember that while clinical interventions for substance abuse are generally not used in the acute phase of response, cbt (cognitive-behavioral therapy) and psychiatric treatment are important training topics. again, recognizing and referring, as well as attending to safety needs, are skills that substance abuse providers bring to the planning table and should be an integral part of any community or state plan. when disaster strikes, you will be ready. lives may depend upon it! it is exactly when you think you don't need a plan or training that you do. while training during or just after a disaster can be done, it is difficult, and trying to figure out who should receive what kind of training will pose a challenge. do it now, before the next event strikes. most states have minimum training requirements for anyone interested in serving on a behavioral health response team. providing participants with professional credits can help motivate local stakeholders to attend training.

and participants are more likely to "buy into" the information shared by credentialed trainers. first responders deal with a great many emotions and alcohol/drug issues every day. they always appreciate what you have to offer! finally, don't exclude certain staff from training because you think they "don't need it." who answers the phone when there is a disaster? are they trained to respond to calls from people in crisis? or who are experiencing withdrawal? looking for a clinic that has been damaged or decimated by a disaster? be sure everyone knows the plan is more than a piece of paper hanging on a wall. practice it in your facility, blend it with your community, and be sure you are a part of your state's overall plan. to reiterate: once your training and plan is finalized, providers and others must then be further trained to implement it. local teams can use the state plan as a guideline for building local plans. participation by substance abuse services personnel in table-top and live disaster exercises helps all to see gaps and needs, and

demonstrates exactly why your services should be integral to any plan. once your plan is ready, be sure to do your follow up. are trainees properly credentialed, or listed by the state so they can be? are your mous in place? are you prepared to train, drill, and practice? can you discuss why your substance abuse services and skills are important to the response? creating a listserv and e-newsletters to be distributed online to training participants are inexpensive but powerful ways to get information to your responders, keeping them at the ready. include as many as you can! so, what have we learned so far? first, disaster planning—especially as it relates to substance abuse—is top priority! it is so important to train staff now, before an incident—especially in issues related to ptsd—since ptsd and substance abuse often go "hand in hand" in a disaster setting. management must ensure self and staff care.

remember that a disaster is a community as well as an individual event. substance abuse services are an important part of the plan, and the response. in 2002, the center for substance abuse treatment released a report that highlighted lessons about substance abuse, treatment, and prevention services learned after the 9/11 attack in new york city. the authors list lessons learned by substance abuse providers; these findings can help you understand potential pitfalls and to prepare for disaster response. all roads lead to planning! i'd like to give you an example of how that planning can help. in new york city, the communication systems were on different buildings, and in order to hear the television, you had to be able to go through an antenna. all the antennae on top of the world trade center were wiped out; however, those that were still on top of the empire state building, the uhf channels, were still usable if you knew how to fold a coat hanger and put it in the back of your television set. and so we learned there that having redundant systems could be helpful.

that's just one of the examples of the report in 2002 that can be helpful to you and your planning. i'd like to close with this reminder: when we work together, we can lessen the impact a disaster has on communities and individuals. it is important for us to learn about ptsd and substance misuse and abuse. all responders should be trained to recognize people in distress and refer them as needed. and all of us should be participating in local and state disaster planning. it is also important to know where to refer survivors; meetings and resources can be found at these websites. the risk of relapse in those who are sober/drug free for six months or less is high after disaster, and usage of other drugs, including alcohol, shoots upward. knowing your resources ahead of time, and having them for placement in post-disaster publications (as we did in henryville after the 2012 tornadoes) goes far to provide the security that recovering persons need. in henryville, we published a daily paper with resources and progress, and it was distributed by hand to the entire county so the residents

would know exactly what was going on, and so the responders would know as well. and it was a highly successful endeavor. this is just one piece that can help you after disaster. so plan, plan, plan, and always be sure substance abuse needs are considered and included. in this way, our clients will be served, even in the aftermath of a disaster. and now, ms. owens, i'd like to ask you some questions that we frequently hear in the field. why should we ensure there are substance abuse services available immediately after a disaster? good question! several categories of people are in danger after a disaster, including those in recovery, and especially those with six months or less under their belts. typical disaster reactions like high stress and anxiety can easily trigger relapse, including for staff in treatment centers, another group at risk. persons who are alcohol or other drug abusers who are teetering on the edge of addiction may go fully into it and

need referral services. for example, research tells us that firefighters as a group are heavier users of alcohol, and their regular jobs are rather stressful. add a disaster response, and many cross the line into addiction. alcohol and other drug use, and resulting issues, including intimate partner violence, have been shown to rise after disaster, causing expert service need. finally, disasters resulting in child injury or death can weigh heavily on those who care for our children, such as prevention specialists and school safety officers, or any other responder. excessive use of alcohol or other drugs can reduce inhibitions, allowing suicidal ideation to creep in. substance abuse services are not only recommended after a disaster, they are critical. what guidance does samhsa have for methadone administration in a disaster? we know methadone will not be included in the strategic national stockpile in case of emergency, so "guest-dosing" must take place. since records are often wiped out when a clinic is (and why tips for redundant recordkeeping and other guidance are contained in the new york

report i mentioned earlier), samhsa administered emergency guidance after hurricane katrina as follows: a. the emergency guest patient should show a valid picture identification which includes an address in close proximity to the area impacted. b. the patient should show some type of proof that indicates he or she was receiving services from a clinic located in one of the affected areas (e.g., medication bottle, program identification card, receipt for payment of fees). in cases where the patient does not have any items of proof including a picture id, the physician should use his or her best medical judgment, combined with a stat drug test for the presence of methadone (e.g., lab test with quick turn-around or a dip stick test). c. an opioid-treatment provider (or an otp) may administer the amount of medication that the patient reports as his or her current dose; however, remind each patient that the dose that is reported will be verified with the home program as soon as possible. in cases where the reported dose appears questionable, it is best to use good medical judgment when determining the dose level.

in new york city, however, despite the wiping out of the methadone clinic and closing of several others in south manhattan, and guest dosing without any of these protocols, there's not a single report of anyone asking for more medication than they were supposed to have. and for this reason, we were kind of given an opportunity, i think, to come up with these protocols, which are now standard. finally, why should substance abuse professionals be trained in systems like nims and pfa? well, in order to function in an incident command structure, it is imperative that all responders be properly trained in nims. when working in the field after a disaster, an infinite number of situations can arise—some related to substance abuse, and some more general—including with your own teams, consumers, and other responders, and it is imperative to be familiar with the language of incident command so that you can quickly and effectively request the specific assistance you need. for example, understanding that a public information officer, or pio, speaks for the unit is

important to properly get information to the public. also, if you need resources for your deployed team, proper paperwork must be filed so the incident commander can secure your items. and psychological first aid is not treatment, but is, rather, a method to help disaster survivors feel safe and secure, and to empower them to deal with the new normal. it is, finally, of the utmost importance that you deal with your own issues, exhibit self-care to your team, and eat and rest as properly as the situation allows. you are of no good to others if you are strung out, so to speak. we need you there! thank you so much. now i'm going to share some information about samhsa dtac. established by samhsa, dtac supports samhsa's efforts to prepare states, territories, and tribes to deliver an effective behavioral health response to disasters. their toll-free number is 1-800-308-3515, and the web address is www.samhsa.gov/dtac. you can also send an e-mail to dtac@samhsa.hhs.gov.

the samhsa disaster behavioral health information series (also known as dbhis) contains themed installments and toolkits about disaster behavioral health preparedness and response. some of the installment topics are specific to disasters, and others focus on children and youth, disaster responders, older adults, and resilience and stress management, to name a few. all resources for which links are provided are in the public domain or have been authorized for noncommercial use. the following is a direct link to the dbhis: www.samhsa.gov/dtac/dbhis. you can always email or call samhsa dtac directly. the email address is: dtac@samhsa.hhs.gov, and the toll-free telephone number is 1-800-308-3515. samhsa also recently released a behavioral health disaster app that can help responders provide quality support to survivors. users can share resources and learn about pre-deployment preparation, on-the-ground

assistance, and post-deployment resources, all from one button on the home screen. you can also contact the samhsa disaster distress helpline.â just dial 1-800- 985-5990 or text "talkwithus" (in one word) to 66746. there are many related resources available on the national center for posttraumatic stress disorder's website including the published international literature on traumatic stress, or pilots, database. the address is www.ptsd.va.gov. thank you, ms. liu. this concludes today's podcast, "disaster substance abuse services: planning and preparedness." i'd like to thank both of our presenters and you, our participants. please feel free to reach out to either speaker using the contact information given in the slide. also, please visit www.samhsa.gov/dtac for additional resources, including additional archived webinars and podcasts.