ATT012_XP012_DisruptiveMember.pdf

25-012-XP

Disruptive Member External Standard Operating Procedures

Original Publication April 2025

Introduction The World Trade Center (WTC) Health Program strives to provide high-quality, compassionate care for members’ WTC-related health needs. To accomplish this goal, the WTC Health Program contracts with a network of vendors who provide direct services including member support, medical monitoring, and treatment for certified WTC-related health conditions. Together, with these providers, the WTC Health Program addresses needs and concerns of members and their health effects related to exposures from the September 11, 2001, terrorist attacks.

Disruptive behavior from a member potentially impedes WTC Health Program operations and affect the delivery of healthcare services. The WTC Health Program does not tolerate behavior that shows disrespect for others, or any interpersonal interaction that impedes delivery of care (See Acronyms & Definitions). If such incidents are reported to the Program, immediate steps will be taken to address this behavior and to help ensure a safe and respectful environment for our members, staff, representatives, and affiliated facilities and personnel. Some of these disruptive behaviors include (but are not limited to) chronically missed appointments, verbal altercations, violence, and threats of violence.

Disruptive behavior may result in the WTC Health Program developing a revised care plan for the member. A member’s plan for care following a disruptive event may be impacted by variables, such as the location, nature, and severity of the incident(s), as well as law enforcement involvement, and the member’s socioeconomic needs, active treatment needs through the Program, and other options for receiving services.

This standard operating procedure outlines the WTC Health Program’s approach to address disruptive member behavior in coordination with WTC Health Program vendors. While vendors may have varying mechanisms to address member incidents because of their organizational processes or policies, this policy harmonizes the process for coordination and communication regarding incidences of disruptive behavior.

Stakeholders Affected This standard operating procedure applies to any WTC Health Program vendor or affiliate interacting with members, including:

• Clinical Centers of Excellence (CCE) and Nationwide Provider Network (NPN) staff;

• Health Program Support (HPS)/Third Party Administrator (TPA) and its subcontractors (e.g., the Call Center);

• Pharmacy Benefits Manager (PBM);

• External (affiliated) providers; and

• WTC Health Program staff.

Roles and Responsibilities Vendors are responsible for reporting incidences of disruptive behavior to the Program, as further outlined below. Reports should include details such as date, type of incident, history of incidents, police involvement (including applicable police reports/documentation), summary/description of the incident, actions taken, mitigation plan, and potential courses of action initiated by the vendor.

The WTC Health Program must maintain records of disruptive behavior incidents (including records of incidents directed toward WTC Health Program staff), consult with vendors on mitigation plans, receive escalation requests from vendors regarding access to care, and work with vendors to determine courses of action.

Vendor Process and Procedure Incident Documentation and Notification When disruptive behavior occurs, vendor staff should follow their organizational protocols to handle the immediate situation. Staff should inform the member of the possible consequences of the disruptive behavior. If the behavior threatens imminent harm and/or warrants onsite security or local law enforcement involvement, vendors should follow their organizational policies and procedures and state/local laws, as applicable.1

1. The vendor must send a notification as soon as possible that includes the members information to the Central Accessible Realtime Enterprise (CARE) portal, DL-WTCHP- MS, with a brief description of the incident that occurred. Then send a notification to the Member Services Team (MST) via the wtchpmemberservices@cdc.gov email directing their attention to the CARE thread. Do not include any Personal Health Information in the email.

2. Complete a Disruptive Member Incident Report form “Disruptive Member Incident Report” (available in the CARE portal library) and attach it to the CARE thread within three business days of the occurrence2 with all required fields in the Incident Report completed, including:

• Member’s name and 911#;

• Reporting person’s name and role within the organization;

• The member’s Program certifications (if any);

• Description of active treatment(s) the member receives through the Program (if any);

• Detailed description of incident, including date and time;

• When and how the member was notified of their disruptive behavior(s);

• All interventions already taken by the organization, including law enforcement or security intervention (if applicable); and

1 Vendors should involve law enforcement if a possible crime may have taken place (e.g., credible threats, violence, harassment, vandalism, fraud).

2 This is the best practice. If contract requirements differ, please ensure contract requirements for reporting are followed at a minimum.

mailto:wtchpmemberservices@cdc.gov

• Interventions the vendor would like to take (including justification) and any requests for Program-level intervention.

2.1 Attach all other relevant documentation, including, but not limited to previously executed behavioral agreements, copies of communications sent to or from the member (e-mail, letters, etc.), interventions implemented by the organization (i.e., health system, hospital), associated medical notes, applicable call recordings, and security/police reports.

3. After submitting the Incident Report send an email to the WTC Health Program:

wtchpmemberservices@cdc.gov referencing the associated CARE thread. Do not include any Personal Health Information in the email.

3.1 Email should state “A Disruptive Incident Report has been sent via CARE thread XXXXX”. No additional information is to be provided in the email.

3.2 If an incident is serious in nature and/or requires the vendor to consider limiting or restricting care, the vendor must call their WTC Health Program’s assigned MST point of contact before submitting the Incident Report. Examples of a serious behavior may include but not limited to:

• Acts of violence or threats against staff or other patients, including verbal or physical abuse and physical assault;

• Rude or vulgar language, including cursing or shouting; and discriminatory, racist, sexist language;

• Throwing and striking objects;

• General harassment or stalking;

• Sexual harassment or assault;

• Concealing or using a weapon;

• Engaging in criminal behavior.

Mitigation Plans

4. A vendor should submit the Incident Report form prior to executing a mitigation plan to allow the Program to respond.

4.1 When determining a mitigation plan, vendors should align with their institutional policies and procedures when applicable.

5. The vendor can request meetings with the Program to collaborate on next steps.

6. If a vendor executes a mitigation plan in response to a disruptive incident, they should notify the Program as soon as possible, using the Incident Report form.

6.1 Below are examples of interventions/mitigations that may be taken by the vendor, depending on the situation:

• Written warning letter.

mailto:wtchpmemberservices@cdc.gov

• Request for WTC Health Program involvement (e.g., conversation with member);

• Use of telehealth monitoring/treatment visits, where possible.

• In person visit restrictions.

• Restriction to written-only communications.

• Behavioral Agreement/Contract.

• Transfer to another CCE/NPN, and/or

• Anger management/counseling (not provided by the Program unless related to the member’s certified WTC-related health condition).

7. The above list is not exhaustive because interventions will be determined on a case-by-case basis.

Member Transfers to another (CCE/NPN)

8. When other mitigation strategies are no longer effective or appropriate, the CCE/NPN may consider initiating a member transfer.

9. The CCE/NPN must provide a Disruptive Member Incident Report to the WTC Health Program within three business days3 and follow the Transfer Handbook process4.

Discharge without Alternative Placement

10. If all mitigation efforts have been unsuccessful and attempts to transfer the member to another CCE/NPN are declined, then the member may be discharged from the CCE/NPN and Program services may be suspended. The following process should be implemented.

CCE/NPN

11. Complete Disruptive Member CCE/NPN Incident Report and send to MST within three business days of the occurrence.

12. Contact MST to schedule meeting to discuss discharge prior to communicating to the member to ensure that options to mitigate issue(s) have been addressed.

13. In preparation for discharge, the CCE/NPN must do the following:

• Ensure that the member has at least a 90-day supply of medication(s) available, if applicable.

• Ensure that the member is stable and not in need of critical care.

3 This is the best practice. If contract requirements differ, please ensure contract requirements for reporting are followed at a minimum.

4 See the WTC Health Program Member Transfer Handbook located in the CARE Document Library at https://care.cdc.gov/catalogs/detail/c5dae93d-ec71-4396-9ad3-6c743a95fdc0 https://care.cdc.gov/catalogs/detail/c5dae93d-ec71-4396-9ad3-6c743a95fdc0

• Provide benefits counseling to notify the member of community resources for care (verbally or in writing).

• Notify the member that they are being discharge in writing. Explain to the member that they will have to use their personal insurance.

Program Member Services Team

14. The Program will write a letter to the member, signed by the administrator, notifying them that their services have been suspended due to their discharge and inability to be placed with another CCE or NPN. Explain to the member that they will have to use their personal insurance.

15. Update systems according to established internal processes.

Follow-up After a Disruptive Incident

16. After resolving a disruptive member incident, the WTC Health Program may request to debrief with involved CCE/NPN personnel to assess the response and identify areas for improvement.

Acronyms & Definitions Term Definition

Discharge Formal, written notification to a member that because of disruptive behavior(s), care cannot be provided by a specific provider, in a specific clinic, or with the entire ambulatory (outpatient) care service. Applies to CCEs and/or NPN.

Disruptive Behavior

Acts by a WTC Health Program applicant or member that show disrespect for others, or any interpersonal interaction that impedes the delivery of care by subverting the Program’s culture of respect and safety.5 Disruptive behavior can be in-person (verbally or non-verbal), in writing, or through electronic means, e.g., voicemail, etc. Disruptive behavior may also impact other members, program staff, providers, and healthcare organization employees. Members agree to not engage in disruptive behavior as a condition of participation in the Program.6 Disruptive behavior includes, but is not limited to:7

• Acts of violence or threats against staff or other members, including verbal or physical abuse.

• Rude or vulgar language, including cursing or shouting.

• Throwing and striking objects.

• Harassing or stalking.

• Concealing or using a weapon.

• Engaging in criminal behavior; and

5 See Agency for Healthcare Research and Quality, Disruptive and Unprofessional Behavior at https://psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior.

6 See WTC Health Program website, Member Rights and Responsibilities at https://www.cdc.gov/wtc/rightsresponsibilities.html.

7 See the WTC Health Program Member Handbook, Disruptive and Abusive Behavior, p. 49, at https://www.cdc.gov/wtc/handbook.html/ https://psnet.ahrq.gov/primer/disruptive-and-unprofessional-behavior https://www.cdc.gov/wtc/rightsresponsibilities.html https://www.cdc.gov/wtc/handbook.html

• Refusal of or failure to attend initial health evaluations, annual monitoring visits, obtain other health insurance, or comply with treatment plans.

Law Enforcement Reporting

Implementing regulations for the Health Insurance and Portability Act of 1996 (HIPAA) allow covered entities to disclose Protected Health Information (PHI) to law enforcement officials under specific circumstances. Vendors must follow HIPAA regulations and any other applicable federal and state laws and regulations, as well as their organizational policies and procedures around law enforcement reporting.8

Mitigation Plan A plan of action implemented by a vendor (or the WTC Health Program) to address a member’s disruptive behavior.

Resumed A member is permitted to access monitoring, screening, and treatment-related services through the Program after their disruptive behavior(s) resulted in a suspension.

Suspension of Services

The status of a member that no longer has access to Program services due to discharge from a CCE/NPN without alternative placement. The member is formally notified by the Program through a letter.

Threat When a person puts another in perceived or actual risk of harm – regardless of whether the person intends to (or is capable of) that harm.

8 See U.S. Department of Health and Human Services, Health Information Privacy at https://www.hhs.gov/hipaa/for-professionals/faq/505/what-does-the-privacy-rule-allow-covered-entities-to-disclose-to-law-enforcement-officials/index.html.

https://www.hhs.gov/hipaa/for-professionals/faq/505/what-does-the-privacy-rule-allow-covered-entities-to-disclose-to-law-enforcement-officials/index.html https://www.hhs.gov/hipaa/for-professionals/faq/505/what-does-the-privacy-rule-allow-covered-entities-to-disclose-to-law-enforcement-officials/index.html

Acronyms & Definitions