The Use of Telebehavioral Health in Afghanistan

1. The Use of Telebehavioral Health in Afghanistan

2. Outline Background Summary of TBH in Afghanistan Standard of Care, Consent, and Contraindications TBH Encounter Flow and Best Practices Soldier Feedback Provider Feedback Communications Issues Lessons Learned Way Ahead Demonstration

3. BLUF Telebehavioral Health is increasingly being used to provide behavioral health (BH) care in the deployed environments All BH providers need to be ready to deliver care over this modality

4. Background 7,500-8,000 Soldiers in RC-East have high combat exposure Soldiers with higher combat exposure are more likely to have behavioral health (BH) issues These Soldiers are usually not located on the FOBs where BH resources are based BH providers travel throughout the battle space to go to the Soldiers in need of care Geographic and tactical issues severely limit this circulation Telebehavioral health (TBH) is used to increase BH access and enhance the delivery of BH care

5. What is Telebehavioral Health? Telebehavioral health is a process employing information technologies and telecommunications infrastructure to deliver behavioral healthcare.

6. Telebehavioral Health (TBH) Concepts PRE-CLINICAL: Anonymous contact with a trained BH provider through secure chat Can be done by any Soldier on their personal computer If a need for behavioral health is assessed, then will refer to local BH provider If a safety issue is identified, then will inform command Still in conceptual stage, not being done in theater CLINICAL: Facilitate communication between provider-provider, or Soldier-provider between remote locations within a Task Force Primary intention for patient treatment or clinical recommendations Involve visual and auditory communication with sufficient quality to allow assessment and therapy Clinical TBH started to be implemented in Afghanistan in Fall 2010

7. Potential TBH Benefits Improve access to BH care by extending the reach of BH Providers Augment not replace behavioral health circulation Allow providers located at remote outposts to continue to see other patients Providers have been �stuck� at a location for 13 days Improve access to BH Providers for Soldiers in need of emergency behavioral health evaluations Assist the evaluation of Soldiers by doctoral level providers without travel Allow psychiatrists to make give recommendations without the need of Soldier travel Help balance BH �gaps� from provider shortfalls

8. TBH in Afghanistan TBH started in fall 2010 as a CJTF-101 pilot program in RC-East Required extensive collaboration between medical and line assets Pilot program consisted of 4 TBH nodes Clinical not pre-clinical TBH care Program demonstrated validity of the TBH concept RC-East is now expanding its TBH capabilities RC-South and RC-West are starting to implement TBH

9. Tele-behavioral Node Design

10. The 971st MEDLOG company and colocated 7220th Blood Support Detachment serves as the theater level Medical Logistics Hub in RC East. Each US Brigade Level Task Force has an organic Brigade Medical Supply Office that provides direct Medical Supply and Maintenance support to the Brigade task force and colocated EAB Medical activities. Additionally the 971st MEDLOG has a Field Distribution Team at FOB Salerno providing Direct Support to the Role II CSH- at Salerno and TF Rakkasan units in Khost Province. The 971st RIP/TOA as of 1 Nov 2010. The Medical Logistics Company operates out of Bagram with an Forward Distribution Team, FDT, at Salerno and Jalalabad. The 971st MEDLOG company supports all of the BMSOs within RC(E) except for the Craig Joint Theater Hospital, CJTH. CJTH obtains its Class VIII support directly from USAMMC-SWA in Qatar. For medical maintenance TF 62 assists with the larger repair/preventive maintenance. All Operational Needs Statements for new equipment are managed through TF 62. The 7220th Blood Support Detachment provides collection/storage/distribution of blood/blood products in the ATO. It has split-based ops in Bagram and Kandahar. The BSD supports 35 sites throughout USFOR-A and one site in Kyrgyzstan. The facilities supported include Combined Joint Theater Hospitals, Air Force Theater Hospitals, Combat Support Hospital, Mobile Trauma Bays, All Role Levels, and Forward Resuscitative Surgical Systems. The BSD handles routine and emergent blood resupply for RC(E). As of 22 Nov 10. The 971st MEDLOG company and colocated 7220th Blood Support Detachment serves as the theater level Medical Logistics Hub in RC East. Each US Brigade Level Task Force has an organic Brigade Medical Supply Office that provides direct Medical Supply and Maintenance support to the Brigade task force and colocated EAB Medical activities. Additionally the 971st MEDLOG has a Field Distribution Team at FOB Salerno providing Direct Support to the Role II CSH- at Salerno and TF Rakkasan units in Khost Province. The 971st RIP/TOA as of 1 Nov 2010. The Medical Logistics Company operates out of Bagram with an Forward Distribution Team, FDT, at Salerno and Jalalabad. The 971st MEDLOG company supports all of the BMSOs within RC(E) except for the Craig Joint Theater Hospital, CJTH. CJTH obtains its Class VIII support directly from USAMMC-SWA in Qatar. For medical maintenance TF 62 assists with the larger repair/preventive maintenance. All Operational Needs Statements for new equipment are managed through TF 62. The 7220th Blood Support Detachment provides collection/storage/distribution of blood/blood products in the ATO. It has split-based ops in Bagram and Kandahar. The BSD supports 35 sites throughout USFOR-A and one site in Kyrgyzstan. The facilities supported include Combined Joint Theater Hospitals, Air Force Theater Hospitals, Combat Support Hospital, Mobile Trauma Bays, All Role Levels, and Forward Resuscitative Surgical Systems. The BSD handles routine and emergent blood resupply for RC(E). As of 22 Nov 10.

11. RC-East TBH Standard of Care (1 of 3) TBH is used when it augments, expands, or enhances the delivery of healthcare services Providers follow the normal standard of BH care when using TBH Providers only engage in TBH after ensuring that it will be done in a safe manner Securing the Soldier�s weapon outside of the room Ensuring that there is an alternate means of contact Personnel at the receiving location are trained to deal with a potential safety issue Providing a generic disposition description to medical personnel at the distal site

12. RC-East TBH Standard of Care (2 of 3) Patients provide informed consent regarding the likely differences between receiving telebehavioral health and in person behavioral health care The use of TBH is voluntary unless it involves a command-directed evaluation TBH encounters can be recorded only after written consent is obtained from the patient

13. RC-East TBH Standard of Care (3 of 3) Traumatic Event Management sessions will not be done over telebehavioral health All telebehavioral health encounters shall be accomplished over a secure network or through another modality that is compliant with current HIPAA standards All telebehavioral health encounters are documented and archived within the DoD electronic medical record Brigade Surgeons must first sign a formal written agreement before TBH is used to share BH resources between Task Forces Telebehavioral health can be used to supervise non-independent behavioral health providers

14. Tele-behavioral Health Consent (1 of 2) Participation in telebehavioral health services is completely voluntary Soldiers may withdraw consent to participate in telebehavioral health services at any time without affecting the right to receive traditional treatment and services Telebehavioral health carries the same risks as any behavioral health encounter but has additional benefits and risks to consider Benefits: Will likely lead to an encounter with a behavioral health provider sooner and more frequently if needed Avoids the risk, time, and incurred expenses of travel

15. Tele-behavioral Health Consent (2 of 2) Risks: Delays in medical evaluation and treatment could occur due to equipment transmission delays or failure The possibility exists of �drop off� in the middle of the encounter The quality of the transmission may at times not be sufficient to allow for appropriate medical decision making Health care providers cannot guarantee, but will use reasonable means to maintain the security and confidentiality of information sent and received Some medical information may be shared with the medical provider at your site

16. Absolute and Relative Telebehavioral Contraindications ABSOLUTE CONTRAINDICATIONS: Soldiers who refuse TBH services RELATIVE CONTRAINDICATIONS:* Acutely violent, agitated, unstable, or impulsive Soldiers Soldiers with whom news should be shared in person Soldiers with specific mental symptoms that could be exacerbated by the use of TBH (psychotic, etc.) Soldiers with sensory deficits limiting their ability to communicate coherently with this technology Decompensated Soldiers due to delirium, intoxication, medication toxicity, or medication interaction needing immediate hospitalization Soldiers requiring monitoring not available in their AO

17. Tele-behavioral Health Equipment

18. Tele-behavioral Health Encounter Flowchart

19. Best Practices Proper Environment Proper Lighting Proper Audio Proper Preparation Interactions with Patient Body Language Style of Speech

20. Proper Environment Secure room at both sites to prevent interruptions or overheard conversations The best d�cor is plain, simple, and uncluttered Extraneous objects cause reduced video quality Avoid moving objects in the camera�s field of view Have something in the view that indicates you are deployed Keep the background simple and neutral in color if possible Wear a uniform (preferrably ACU�s or FRACU�s) that is in the same style and has the same patches as the distal site Place the VTC four to six feet from the participant. This allows for a comfortable �personal space� Position the VTC at eye level and speak directly to the image on the VTC

21. Proper Lighting Good lighting is crucial to optimal video TBH encounters Use one primary light source in the room so that the camera does not have to adjust to varying levels and types of light Have enough light falling on the face from the front to minimize shadows and maximize true skin tones

22. Proper Audio Know how to mute and unmute the microphone, and know the status of the microphone (muted or not) at all times Check the volume levels so that everyone can hear clearly and speak in normal tones Microphones are sensitive; therefore, finger tapping, paper shuffling and whispering can cause distraction

23. Proper Preparation Have support staff prepare the telehealth equipment before the encounters start Connections: is the system connected? Was it connected and were you able to make a successful call? Video: Can both ends see each other? What is the quality of the picture? Audio: Can both ends hear each other? Is the sound clear? Re-established the connection by placing the call again If that fails then reboot the computer

24. Recommended Patient Interactions Introduce everyone in the room at the start of the encounter Inform patient that the connection is on a secure network Explain the process and what the patient can expect Review the TBH consent form with the patient and answer any questions that remain At each session assess the patient�s comfort with TBH. Answer any questions or concerns Use of TBH appears to have minimal effect on the therapeutic working alliance.

25. "Small talk" is a powerful tool in TBH A Soldier at a remote site might doubt whether the provider can understand them or understand their world Demonstrating an awareness of events and geography of their base can help develop rapport Talk about your last visit to their FOB Intentionally engage in seemingly inconsequential topics relevant to the Soldier Pause more often and longer than normal Speak more deliberately Slight delays in transmission make interrupting patients easier Wait an additional instant before speaking to avoid interrupting or speaking over the patient Recommended Verbal Communication

26. Constantly utilize the �Picture in Picture� function to see what you are visually portraying to the patient Minimize unintentional movements to reduce possible interference Slow and broaden the intentional movements you are trying to convey Sometimes a more dramatic gesture is necessary Make hand gestures chest level and above Intentionally use nods of head and small verbal cues to indicate you understand what the patient is trying to say When trying to emphasize a connection between yourself and the patient lean forward to the camera to frame your face on the videoscreen

27. Soldier Feedback As part of a PI/QI project, Soldiers were given an voluntary and anonymous opportunity to complete a satisfaction survey 23 surveys are complete A more comprehensive review of Soldier�s perceptions of depoyed TBH care is required

28. TBH vs. �Normal� BH Encounters

29. Overall TBH Satisfaction

30. TBH Effect on Feelings of Comfort

31. Perceptions on TBH Communication Barriers

32. TBH Effect on Patient Attention or Distractibility

33. TBH Effect on Patient Self-Consciousness

34. Provider Feedback As part of a PI/QI project, Providers were also given an voluntary opportunity to complete a satisfaction survey 18 surveys are complete A more comprehensive review of provider�s perceptions of deployed TBH care is required.

35. TBH vs. �Normal� BH Encounters

36. Impact of TBH on Access to Care

37. Perceptions on TBH Impact on Clinical Care

38. Overall Provider Satisfaction with TBH

39. Perceptions on TBH Communication Barriers

40. Perceptions on TBH Communication Barriers

41. TBH effect on Provider Attention or Distractibility

42. TBH and Patient Privacy

43. Providers TBH Confidence

44. Line of Sight Bandwidth Impact

45. Satellite Bandwidth Impact

46. Lessons Learned

47. Way Ahead Continue to expand TBH services in Aghanistan and Iraq Formalize training of deploying BH personnel in TBH care Consider inclusion of telebehavioral health training into military behavioral health training programs The Army Institute of Public Health will be releasing a report on the evaluation results of TBH in theater in both Afghanistan and Iraq

48. The 971st MEDLOG company and colocated 7220th Blood Support Detachment serves as the theater level Medical Logistics Hub in RC East. Each US Brigade Level Task Force has an organic Brigade Medical Supply Office that provides direct Medical Supply and Maintenance support to the Brigade task force and colocated EAB Medical activities. Additionally the 971st MEDLOG has a Field Distribution Team at FOB Salerno providing Direct Support to the Role II CSH- at Salerno and TF Rakkasan units in Khost Province. The 971st RIP/TOA as of 1 Nov 2010. The Medical Logistics Company operates out of Bagram with an Forward Distribution Team, FDT, at Salerno and Jalalabad. The 971st MEDLOG company supports all of the BMSOs within RC(E) except for the Craig Joint Theater Hospital, CJTH. CJTH obtains its Class VIII support directly from USAMMC-SWA in Qatar. For medical maintenance TF 62 assists with the larger repair/preventive maintenance. All Operational Needs Statements for new equipment are managed through TF 62. The 7220th Blood Support Detachment provides collection/storage/distribution of blood/blood products in the ATO. It has split-based ops in Bagram and Kandahar. The BSD supports 35 sites throughout USFOR-A and one site in Kyrgyzstan. The facilities supported include Combined Joint Theater Hospitals, Air Force Theater Hospitals, Combat Support Hospital, Mobile Trauma Bays, All Role Levels, and Forward Resuscitative Surgical Systems. The BSD handles routine and emergent blood resupply for RC(E). As of 22 Nov 10. The 971st MEDLOG company and colocated 7220th Blood Support Detachment serves as the theater level Medical Logistics Hub in RC East. Each US Brigade Level Task Force has an organic Brigade Medical Supply Office that provides direct Medical Supply and Maintenance support to the Brigade task force and colocated EAB Medical activities. Additionally the 971st MEDLOG has a Field Distribution Team at FOB Salerno providing Direct Support to the Role II CSH- at Salerno and TF Rakkasan units in Khost Province. The 971st RIP/TOA as of 1 Nov 2010. The Medical Logistics Company operates out of Bagram with an Forward Distribution Team, FDT, at Salerno and Jalalabad. The 971st MEDLOG company supports all of the BMSOs within RC(E) except for the Craig Joint Theater Hospital, CJTH. CJTH obtains its Class VIII support directly from USAMMC-SWA in Qatar. For medical maintenance TF 62 assists with the larger repair/preventive maintenance. All Operational Needs Statements for new equipment are managed through TF 62. The 7220th Blood Support Detachment provides collection/storage/distribution of blood/blood products in the ATO. It has split-based ops in Bagram and Kandahar. The BSD supports 35 sites throughout USFOR-A and one site in Kyrgyzstan. The facilities supported include Combined Joint Theater Hospitals, Air Force Theater Hospitals, Combat Support Hospital, Mobile Trauma Bays, All Role Levels, and Forward Resuscitative Surgical Systems. The BSD handles routine and emergent blood resupply for RC(E). As of 22 Nov 10.

49. Conclusion Telebehavioral Health is used to provide behavioral health (BH) care in the deployed environments Soldiers and Providers have responded positively to this care All BH providers need to be prepared to deliver care over this modality