U.S. Army Medical Command Behavioral Health Division

1. U.S. Army Medical CommandBehavioral Health Division FOR World-Wide Family Advocacy Program Conference LTC Kathleen P. Foreman, MSW, LCSW MEDCOM, Deputy Social Work Programs Manager 10 Aug 09 UNCLASSIFIED

2. Outline PURPOSE: To provide Behavioral Health Division (BHD) informational brief regarding current missions and initiatives with emphasis on the Family Advocacy Program (FAP). • “One Staff”, Behavioral Health Proponency (BHP) and BHD • FAP • Social Work Care Managers (SW CM) • Marriage and Family Therapy (MFT) • Army Substance Abuse Program (ASAP) • Educational and Developmental Intervention Services (EDIS) • Exceptional Family Member Program (EFMP) • Combat Operational Stress Control (COSC) • Challenges • The Way Ahead

3. Take Away Messages • Current BH activity is enormous and complex and all involved are under intense pressure to meet the ever increasing BH needs of the Force • Provider compassion fatigue is extremely high • AMEDD Command Climate Survey, 2009 • “We can’t get enough counselors. Quite frankly, they’re not there.” • GEN Peter Chiarelli , Army Times, 1 Aug 2009 • FAP (Treatment ) is tenuous due to operations tempo, staffing levels, turnover rates and increased demands

4. “ONE STAFF” Office of the Surgeon General / OTSG / Falls Church, VA U.S. Army Medical Command / MEDCOM / San Antonio, TX

5. OTSG / MEDCOM “ONE STAFF”

6. BHD Organization

7. Mission To provide services, policies and oversight to promote behaviors that enhance Soldier and Family Readiness • MEDCOM responsible for: • Medical “fixed facilities” / Table of Distribution and Allowances (TDAs) • Medical care delivered in physical structures that don’t move • FORSCOM first line responsibility for: • Table of Organization and Equipment (TO&E) units • Medical care that deploys and moves • BH care in Combat Support Hospitals • Combat Stress Detachments • Combat Stress Companies • Brigade Combat Teams • Other (Detainee OPS, Area Support MED CO)

8. BHP and BHD Tasks • Strategic Planning • Provide guidance, interpret, evaluate and develop BH policies • Analyze Data • Business Case Analysis for BH Projects • BH Contract Development and Management • Information Papers/White Papers • Assist Army Medical Department Center & School in Training (Post-Traumatic Stress Disorder, Suicide Prevention I & II, Battlemind, Master’s Program, Provider Resiliency Training) • Congressional and Public Affairs Responses • Training and Briefing

9. Suicide Prevention Army Campaign Plan for Health Promotion, Risk Reduction and Suicide Prevention (ACPHP) From GEN Peter W. Chiarelli, Vice Chief of Staff of the Army: “In calendar year 2008, the Army’s confirmed suicide rate reached an all-time high of 20.2 per 100,000, a measure of tragedy and loss to our Army and Nation that we will simply not allow to continue. The intent of this Campaign Plan is to take a strategic approach to mitigating suicides and high-risk behavior across the Army. The Army will employ every available resource, and every member of the Army team, towards promoting overall Soldier and Family health.” “The Army’s charter is more about holistically improving the physical, mental and spiritual health of our Soldiers and their Families than solely focusing on suicide prevention. If we do the first, we are convinced that the second will happen.” 29 March 09

10. Suicide Prevention ACPHP / Suicide Prevention Task Force Critical Tasks • Program / Service Integration • Comprehensive Health Promotion, Risk Reduction, and Suicide-Prevention Plan • Strategy to Increase Awareness – Aggressive Marketing • Specific Programs / Staffs (ASAP, FAP, AFAP) • Primary and Behavioral Health Care • Family / Friends Participation • Warrior Transition Units • Reducing High Risk Behavior • Education and Training [Suicide Prevention (I & II)] • Medico-legal and Command Systems (Tracking) • Postvention and Investigations

11. BHD Initiatives • Suicide Prevention Task Force Initiatives / Impact on FAP • Evaluate combining FAP (Prevention and Treatment) • Army Central Registry database • Installation In and Out-processing through BHD • Suicide Prevention Training I & II • Tele-BH support for FAP case consultation (assessment and treatment) • Medical Management of Victims of Sexual Assault • Provider Resiliency Training (Regional) / Professional Quality of Life Scale • BH Case Managers for Soldiers referred to Tri-Care Network • BH Providers added to BH staff at FORSCOM installations / MTFs • Post-Traumatic Stress Disorder (PTSD) and Mild Traumatic Brain Injury (mTBI) Chain Teach • AMEDD Battlemind Training (Soldier, spouse, child, sustainment, advance, First Aid)

12. Family Advocacy Program Mission:Effectively evaluate and treat child and intimate partner abuse Organization: U.S. Army Chief of Staff ACSIM OTSG/MEDCOM MTF/SW FMWRC IMRs FAP • Assessment • Case Review Committee • Case Management • Treatment ACS FAP • Prevention • Education

13. Family Advocacy Program Initiatives / Working Issues: • Department of Defense Instructions (DoDI) Updates • Joint Basing (Supporting and Supported) • Fort Lewis – McChord AFB • Fort Myer – Henderson Hall • Fort Bragg – Pope AFB • FortsSam Houston, Dix, Monmouth, West Point, Richardson, Eustis, Story, and Monroe • Walter Reed – Bethesda NB • Family Advocacy System of Records - Enhancements due out Summer 09 • Research (Intimate Partner Risk Assessment - Forts Hood and Riley) • Medical Workload Coding - FAZF • Recent Policies (Credibility Assessment & First Time Exclusion-Pending) • AMEDD Center and School working on Standardized Patient Domestic Violence exportable training package • Pilots (Victim Impact Statement and FAP Intake Document) • Tele-BH support to Reserve and National Guard

14. Social Work Care Managers Mission: • Warrior Transition Unit (WTU): Provide a comprehensive behavioral health psychosocial assessment, manage risk, ensure that behavioral health counseling/treatment is provided • Deployment Cycle Support (DCS): Provide behavioral health services / support to Soldiers and Family with deployment-related needs (outreach and direct care) Initiatives: • WTUs and Community Based WTUs • Automated Risk Assessment and Care Management Tool (Psychological and Behavioral Health Tools for Evaluation, Risk and Management / PBH-TERM) • BH Risk Estimate to focus assets on higher risk cases • MEDCOM Regulation pending • DCS • Located in MTFs, Primary Care Clinics, Soldier Readiness Processing Centers and embedded with Brigades • Pending conversion to permanent

15. Marriage and Family Therapy Mission: Provide Marriage and Family Therapists at installations identified as having inadequate support within a 50 mile radius and / or continuous deployment / operational stress Initiatives: • Apr 09 - MFT contract in place / 60 total providers / 13 OCONUS / 19 installations • Located in Departments of Social Work • MEDCOM Quality Management policy in staffing that will allow Licensed Marriage and Family Therapists to be credentialed to work independently (must be graduates of programs with specific M&FT curriculum) • Providing marital counseling to low-level, low risk FAP clients • Regional training for MFTs in Military / Deployment Issues, PTSD, Substance Abuse and Family Advocacy

16. Army Substance Abuse Program Mission: Provide policy and oversight management for all Army Substance Abuse Program clinical functions Initiatives: • Jul 09 - Public Health / Prevention Model (treatment part of model) • Vice Chief of Staff deciding whether ASAP which organization the program fall under Installation Management Command or Medical Command • Possible change in Manpower Staffing Ratio (1:1250) / SPTF • AHLTA Policy • Pilot Programs • Self-referral without command notification (Hawaii, Lewis and Richardson) • Revitalize inpatient programs (Eisenhower in Sep 09 / Fort Belvoir after Base Realignment) • Partial / intensive outpatient programs (Fort Hood TBD)

17. Educational and Developmental Intervention Services Mission: • Provides services pursuant to the Individuals with Disabilities Education Act (IDEA) and as mandated by Public Law 102-119, amending the Defense Dependent Education Act • Early Intervention Services (EIS): Improves functional independence of eligible infants/toddlers with developmental delays or disabilities and their Families • Related Services (RS): Supports Special Education Programs in DoD Dependents Schools (DoDDS) by providing Related Services (RS) to eligible special education students Initiatives: • Recommended Transfer of EDIS to DoD Education Agency (DoDEA) • Comprehensive System of Personnel Development (CSPD), including staff training modules (tiered certification of Early Childhood Intervention Specialists) • Implementing routine-based Assessments and services in natural environments, per nationally recognized best practices • Converting the Special Needs Program Management Information System (SNPMIS) from service-based to web-based • Added to Regulation: Family Protection Act (mandatory developmental screening by EDIS when a victim of suspected child abuse or neglect is under 3 year old)

18. Exceptional Family Member Program Mission: • Enroll Soldiers in EFMP by identifying, screening and registering Family members with special needs in the Army’s EFMP database • Screen All Family Members for OCONUS Travel • Coordinate with HQDA Human Resources Command (HRC) on the projected assignments of Soldiers with registered Family members Initiatives: • Implementing revised DoD forms for EFMP screening and enrollment • Implementing new screening requirements for children with Autism Spectrum Disorders • Promoting Soldier compliance with mandated 3-Year Review of EFMP enrollment information • Designing a web-based EFMP Data System

19. Combat Operational Stress Control Mission: Implement the Army Combat and Operational Stress Control (COSC) Program in accordance with DoD guidance, the Army Transformation, changing missions and military operations Initiatives: • Restructuring of BH assets to the Brigade Combat Teams (BCT) / Brigades (BDEs) / Aviation BDEs / Sustainment BDEs (2+2) • Mental Health Advisory Teams I -VI (MHAT) Completed and Reports for MHAT I-V Released; MHAT VI pending release • Revision of Field Manuals and Regulations • Renewed Combat and Operational Stress Control (FM6-22-5), 7 Mar 09 • Mandatory COSC training for all deploying BH providers • Tele-BH support planned for consultation, assessment, diagnosis and treatment • Pilot: Dog Therapy in Iraq (2 Labrador Retrievers / Fort Gordon) • Exploring Animal Assisted Therapies (Equine Pilot)

20. Challenges for FAP • Staffing • Multiple programs which require behavioral health providers • Family Advocacy (losing experienced FAP providers to other jobs) • Marriage and Family Therapy, Care Managers (DSC & WTU), Social Workers in the Emergency Department, Behavioral Health Departments, ASAP, Sexual Assault, Veteran’s Administration, Military Family Life Consultants, etc. • Salaries for FAP not competitive with other programs • Funding • Current FAP staff funding not meeting the current DoD staffing model / ratio • Automation / Technological efforts • Research • DoD to POM for FAP funding • Space • Unable to hire FAP personnel due to limited space • New buildings on larger installations; however, limited space to house providers • Quality Assurance (QA) • Need infrastructure within medical regions to regionalize QA initiatives

21. The Way Ahead • BHP and BHD • Improve physical, behavioral and spiritual health of the Soldier and Family • Leadership and strategic communication to de-stigmatize BH • Implement and sustain the ACP for Health Promotion, Risk Reduction and Suicide Prevention recommendations by the Suicide Prevention Task Force • Re-Initiate the Behavioral Health Campaign • Standardize and automate BH processes • Promote and standardize evidence-based practices • Integrate services and cull out ineffective programs • FAP • Staff program and retain FAP staff to support safe and quality care • Continue to develop and pursue evidence-based program initiatives / Research • Technology integration with BH and AHLTA / Automation improvements • Ensure space allocated for FAP providers • Continue to professionally train FAP staff and CRC members

22. Questions?

23. Information Army BH website: http://www.behavioralhealth.army.mil/ BHD website on AKO: https://www.us.army.mil/suite/group/27327 BHP Policy: https://akocac.us.army.mil/pki/akocaclogin/external_silent_autologin. jhtml?client_name=AKO&client_URL=https://www.us.army.mil/suite/kc/943142

24. Information FAP website on AKO: https://www.us.army.mil/suite/group/380