ATTACHMENT 14 - DHA-PI 6490.01 - inTransition Program Change 1.pdf

Defense Health Agency

PROCEDURAL INSTRUCTION

NUMBER 6490.01

May 23, 2017 Incorporating Change 1, Effective (July 12, 2019)

HCO/CSD

SUBJECT: inTransition Program

References: See Enclosure 1.

1. PURPOSE. This Defense Health Agency-Procedural Instruction (DHA-PI), based on the authority of References (a) and (b), and in accordance with the guidance of References (c) through (g), and (i) through (k j):

a. Establishes the Defense Health Agency’s (DHA) procedures for implementing the DoD inTransition Program for Service members transferring or separating from the military who are receiving mental health and/or moderate to severe traumatic brain injury (TBI) care pursuant to Reference (g).

b. Implements provisions of References (e) and through (f g).

c. Incorporates and cancels Reference (h).

2. APPLICABILITY. This DHA-PI applies to OSD, the Military Departments, the Office of the Chairman of the Joint Chiefs of Staff and the Joint Staff, the Combatant Commands, the Office of the Inspector General of the DoD, the Defense Agencies, the DoD Field Activities, and all other organizational entities within the DoD (referred to collectively in this instruction as the “DoD Components”). The DHA, Transition to Veterans Program Office, Military Departments, Service Surgeon’s General, and military medical treatment facilities (MTFs).

3. POLICY IMPLEMENTATION. It is DHA instruction pursuant to References (d) through (g):

a. To oversee implementation of the enrollment process for the inTransition Program.

DHA-PI 6490.01

Incorporating Change 1, Effective (July 12, 2019)

Change 1, (July 12, 2019) 2

b. That all Service members who are separating from the military and have received mental health and/or moderate to severe TBI care within 1 year prior to their separation be automatically enrolled in the inTransition Program.

4. CANCELLED DOCUMENT. This DHA-PI cancels the following document: Health Affairs Policy Memorandum 10-001, “Department of Defense inTransition Program,” January 12, 2010.

45 RESPONSIBILITIES. See Enclosure 2.

56 PROCEDURES. See Enclosure 3.

67 RELEASABILITY. Cleared for public release. This DHA-PI is available on the Internet from the DHA SharePoint site Health.mil site at: http://www.health.mil/dhapublications.

78 EFFECTIVE DATE. This DHA-PI:

a. Is effective upon signature.

b. Will expire 10 years from the date of signature if it has not been reissued or cancelled before this date in accordance with DHA-PI 5025.01 (Reference (c)).

Enclosures

1. References

2. Responsibilities

3. Procedures Glossary

Incorporating Change 1, Effective (July 12, 2019)

Change 1, (July 12, 2019) 3 ENCLOSURE 1

ENCLOSURE 1

REFERENCES

(a) DoD Directive 5136.01, “Assistant Secretary of Defense for Health Affairs (ASD(HA)),” September 30, 2013, as amended

(b) DoD Directive 5136.13, “Defense Health Agency (DHA),” September 30, 2013

(c) DHA-Procedural Instruction 5025.01, “Publication System,” August 24, 2018

(d) DoD Instruction 6490.09, “DoD Directors of Psychological Health,” February 27, 2012

(e) DoD Instruction 6490.10, “Continuity of Behavioral Health Care for Transferring and Transitioning Service Members,” October 28, 2015 March 26, 2012, as amended.

(f) Executive Order 13625, “Improving Mental Health Services for Veterans, Service Members, and Military Families,” August 31, 2012

(g) White House Joint Fact Sheet, “DoD and VA Take New Steps to Support the Mental Health Needs of Service Members and Veterans,” August 26, 2014 S. 2987, SASC Rpt for FY 2019, 115-262, Pages 203-204, “Warm Handoff for Transitioning Service members Suffering from PTSD and TBI”1

(h) Health Affairs Policy Memorandum 10-001, “Department of Defense inTransition Program,” January 12, 2010 (hereby cancelled) (i)(h) Title 45, Code of Federal Regulations, Parts 160 and 164 (also known as “HIPAA Privacy Rules”), current edition (j)(i) Title 5, United States Code, Section 552a, “The Privacy Act of 1974” (k)(j) Alcohol, Drug Abuse, and Behavioral Mental Health Reorganization Act, July 10, 1992

(k) DoD Instruction 6490.08 "Command Notification Requirements to Dispel Stigma in Providing Mental Health Care to Service Members," August 17, 2001, as amended

(l) DoD Instruction 6490.03, “Deployment Health,” August 11, 2006, as amended

(m) DoD Instruction 6490.12, “Deployment Mental Health,” February 26, 2013, as amended

(n) DoD Instruction 6290.06, “Counseling Services for DoD Military, Guard and Reserve, Certain Affiliated Personnel, and Their Family Members,” April 21, 2009, as amended

1 This reference can be found at: https://www.armed-services.senate.gov/imo/media/doc/THE JOHN S. McCAIN NATIONAL DEFENSE AUTHORIZATION ACT FOR FISCAL YEAR 2019 BILL REPORT.pdf

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Change 1, (July 12, 2019) 4 ENCLOSURE 2

ENCLOSURE 2

RESPONSIBILITIES

1. DIRECTOR, DHA. Under the authority, direction, and control of the Under Secretary of Defense for Personnel and Readiness and the Assistant Secretary of Defense for Health Affairs, and in accordance with DoD policies and issuances, the Director, DHA, will:

a. Assume operational management for policy implementation and monitoring of the inTransition Program.

b. Provide strategic guidance for the development and implementation of the inTransition Program.

c. Ensure Provide the inTransition Contractor obtains necessary data regarding military separations and past mental health and/or moderate to severe TBI treatment to support implementation of this DHA-PI.

d. Ensure Confirm these procedures are implemented at National Capital Region Medical Directorate activities.

2. SECRETARIESSURGEONS GENERAL OF THE MILITARY DEPARTMENTS. Under the authority, direction, and control of the Secretaries of the Military Departments will:

a. Ensure Confirm that Medical Command and enhanced Multi-Service Market-level policies and implementing guidance conform to this DHA-PI.

b. Ensure Confirm that separating Service members who have received mental health and/or moderate to severe TBI care within 1 year prior to their separation are informed of their automatic enrollment in inTransition and ensure validate that Service members who opt out of inTransition services are identified, and information concerning them is communicated to the inTransition Program Manager.

c. Ensure Confirm that Reserve Component Service members with mental health issues or concerns identified on deployment and in periodic mental health assessments are enrolled in the inTransition Program as noted if referral is indicated on the DD Form 2900 these forms consistent with References (l), (m), (n) and this DHA-PI.

d. Ensure Confirm each Medical Treatment Facility (MTF) Commander designates a point of contact (POC) to work with the inTransition Program Manager to conduct outreach and marketing activities.

e. Encourage program utilization by participating in outreach and marketing activities, and

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f. Confirm that all healthcare providers are aware of and follow the guidance and procedures in Enclosure 3.

3. DIRECTOR, TRANSITION TO VETERANS PROGRAM OFFICE (TVPO). The Director, TVPO, will coordinate with the Director, DHA, to ensure inclusion of necessary inTransition Program information into the Transition Assistance Program (TAP) that is required to implement References (e) through (g), and support Section 4 of Enclosure 3.

4. DIRECTOR, DEFENSE CENTERS OF EXCELLENCE FOR PSYCHOLOGICAL

HEALTH AND TRAUMATIC BRAIN INJURY (DCOE). J9, Deputy Assistant Director, Research and Development (DAD-R&D). The Director, DAD-R&D will ensure the Division Chief, DCoE PSYCHOLOGICAL HEALTH CENTER OF EXCELLENCE (referred to as the “inTransition Program Manager” for the purposes of this instruction DHA-PI), will:

a. Maintain a contract to provide telephonic coaching and supportive services to Service members during their transition to a new medical care facility, a new geographic location, or new health care system which ensures:

(1) A nationwide cadre of psychological health professionals is maintained to provide services.

(2) That the inTransition Contractor complies with established contract requirements.

(3) Coaching services are available during normal business hours, Monday through Friday, 8:00am–5:00pm. During non-business hours, a call center network will be available to provide coaching services.

(4) Coaches are licensed mental health providers with a minimum of a Master’s degree in social work or other human services field and at least 3 years’ experience in health care delivery.

(5) The inTransition Program Contractor agreement incorporates DHA Business Associate Agreement verbiage, if appropriate.

b. Implement a robust strategic communications plan targeting health care providers, veteran service organizations, Service members, and their families regarding the inTransition Program.

(1) Create and disseminate education and outreach materials at referring DoD and Department of Veterans Affairs’ (VA) facilities to encourage program utilization.

(2) Coordinate with the MTF designated POC point of contact to provide on-site or

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(3) Coordinate with Reserve and National Guard Directors of Psychological Health to promote the availability of and access to the program.

(4) Provide public awareness on the availability of the program to discharged Service members who have a mental health need and require assistance connecting with the VA or a community provider.

c. Develop data that describes the regular operation and outcomes of the inTransition Program, including the number of Service members enrolled, those contacted, those opting out, and those who made positive contact with the receiving health care system, and provide that data no less than quarterly to the Services and other stakeholders.

d. Coordinate yearly update with the TBI Center of Excellence to ensure all TBI related information is up to date with state of the science clinical standards.

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Change 1, (July 12, 2019) 7 ENCLOSURE 3

ENCLOSURE 3

GUIDANCE AND PROCEDURES

1. PROGRAM DESCRIPTION

a. The inTransition Program offers specialized coaching and assistance to support Service members receiving mental health and/or moderate to severe TBI care who are relocating to another assignment, returning from deployment, transitioning from Active Duty to Reserve Component, Reserve Component to Active Duty, or preparing to leave military service.

b. The primary objective of the program is to support the Service members’ efforts to achieve and maintain wellness and to ensure continuity of needed services. Coaching and assistance is designed to encourage the continuation of mental health and/or moderate to severe TBI care through transitions in geographic location and health care systems.

c. The inTransition Program provides a bridge for Service members’ transitions to a new medical care facility, a new geographic location, or into a new health care system.

d. Transition periods may range from as short as a week to much longer if the Service member is returning to Reserve Component status from Active Duty.

e. The inTransition Program does not replace case management of medical conditions or referral services that are already being provided. The inTransition Program is not a covered TRICARE benefit, which precludes Managed Care Support Contractors from referring directly to the inTransition Program.

2. PROGRAM SCOPE

a. All Service members leaving military service who have received care for mental health and/or moderate to severe TBI within 1 year prior to their separations will be automatically enrolled in the inTransition Program but may decline participation at any time. All categories of discharge are eligible for the inTransition Program.

b. Transferring Service members with mental health and/or moderate to severe TBI conditions or concerns who are currently receiving care are eligible for assistance under this program. The patient population to be served may include, but is not limited to:

(1) Service members scheduled for a permanent change of station (PCS) or an extended temporary duty station who recently received or are receiving mental health and/or moderate to severe TBI care.

(2) Wounded, ill, and injured Service members who recently received or are receiving mental health and/or moderate to severe TBI care and are returning to their home station

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(3) Reserve Component Service members being activated who recently received or are receiving mental health and/or moderate to severe TBI care and must transition VA care to an MTF or TRICARE network.

(4) Service members or Reserve Component members moving from one location to another, including a deployed setting, who are/have been receiving mental health and/or moderate to severe TBI care, which do not fall into one of the categories above.

c. Any Service member may self-refer if they have received any type of discharge from the military with a documented or self-perceived mental health and/or moderate to severe TBI care need requiring assistance connecting with a new health care provider. Service members who have previously opted out of the inTransition Program and reconsidered this decision may self-refer at any time.

d. Additional information about the inTransition Program is available at:

http://intransition.dcoe.mil/ https://www.pdhealth.mil/resource-center/intransition.

3. PROGRAM ENROLLMENT PROCEDURAL GUIDANCE. Neither written consent from the patient nor a signed authorization of disclosure form is required to enroll the Service member to the inTransition Program.

a. Automatic enrollment during the Separation History and Physical Examination (SHPE).

(1) Health care providers will screen separating Service members with any mental health and/or moderate to severe TBI issues to determine if they would like to remain in or opt out of the inTransition Program. Service members who have already enrolled will require no further action from the SHPE.

(2) If the Service member does not opt out of the program, health care providers or designated staff will:

(a) In collaboration with the Service member, start the enrollment to the inTransition Program by calling the inTransition number at (800) 424-7877.

(b) Provide the following information to the inTransition coach at the time of the referral: name; complete telephonic and electronic contact information (home phone number, cell phone number, and e-mail address); destination or discharge status (e.g., PCS destination, discharge from active duty, etc.); and diagnosis.

(c) Complete the inTransition portion of the SHPE form, and document acceptance with date of referral or declination.

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b. inTransition Program automatic enrollment by outbound calls.

(1) DHA will provide a list of all separating Service members and those identified during the SHPE to the inTransition Program.

(2) The inTransition Contractor will ensure all lists are balanced against the current enrollees in the inTransition Program to eliminate multiple contacts for Service members in the program.

(3) Service members who have not opted out or enrolled in the program will be contacted by an inTransition Program Coach via telephone and may accept or opt out.

c. Optional enrollment for transferring Service members.

(1) Any health care provider treating a patient’s mental health and/or moderate to severe TBI condition may refer eligible patients as described in Section 2.b. of this enclosure to the inTransition Program (with the exception of Managed Care Support Contractors) whether or not the patient is present.

(2) Optional enrollment can be managed as follows:

(a) Utilize the procedures as described in Section 3.a.(2) of this enclosure.

(b) Provide information materials on the in inTransition Program.

d. Self-referral. The inTransition Program is available to Service members who are going through some type of transition and also have a mental health and/or moderate to severe TBI care need or self-perceived mental health and/or moderate to severe TBI care need without restriction by calling the inTransition number at 1-800-424-7877.

e. Military Support Community. As described in the glossary, non-medical personnel may support the Service member enrollment process by providing information available at http://intransition.dcoe.mil.

4. TAP (TAP COUNSELING). The following actions will be conducted by the TVPO during the TAP Pre-separation/Transition Counseling briefing:

a. Brief each separating Service member that they will be contacted by an inTransition Coach after separation if they have been seen for mental health and/or moderate to severe TBI reasons within the past year while on Active Duty.

b. Promote the availability and dissemination of inTransition Program materials available at http://intransition.dcoe.mil/ https://www.pdhealth.mil/resource-center/intransition.

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5. inTRANSITION COACHING

a. The inTransition Coaches will:

(1) Connect within 7 days of receiving notification/referral of a Service member’s planned separation from the military then make regular telephonic contact (at least weekly) until the Service member has been transitioned to the new provider and/or opts out of the program.

(2) Provide specialized one-on-one motivational coaching, information, support, and education through regular telephonic contact to encourage continued engagement with mental health and/or moderate to severe TBI services and promote the Service member’s greater participation in their own care.

(3) Educate Service members on the inTransition Program and educate the referring health care providers on program scope and responsibilities when requested.

(4) Ensure providers understand that the inTransition Program is not a replacement for case management and is not designed to meet standards of practice for clinical transfer of care.

The health care provider who initiated the enrollment retains primary responsibility for the Service member until successful transition of care.

(5) Deliver coaching on life skills such as stress management, time management, problem solving, rest, nutrition, exercise, balancing work and family activities, and similar topics.

(6) Provide guidance in obtaining assistance and resources in the Service member’s immediate area. Provide expert information on mental health treatment options, modalities, and techniques, and on existing support networks and benefits.

(7) Provide current and relevant patient education on specific conditions, such as posttraumatic stress disorder, and/or moderate to severe TBI to inform misconceptions, reduce stigma, and mitigate symptoms.

(8) Facilitate scheduling the first appointment for the Service member; the inTransition Coach will contact the accepting DoD, VA, TRICARE, or other health care provider offering referral information.

b. The inTransition Program is not intended to be a suicide hotline or crisis intervention line.

However, in a crisis, the inTransition Coach will ensure the Service member is referred to local resources and will encourage the patient in distress to take steps to ensure their safety.

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6. TERMINATION OF inTRANSITION COACHING SERVICES

a. The inTransition Coach assigned to a Service member will discontinue coaching services after the Service member has engaged in care with an accepting provider, or when the Service member otherwise informs the inTransition Coach. One of the following outcomes constitutes a completed/closed case:

(1) Appointment kept;

(2) Service member withdraws after appointment information provided notifying the coach;

(3) Service member withdraws or disengages from the inTransition Program prior to completion (this is a closed but not completed case); or

(4) Service member opts-out.

b. If the Service member withdraws or disengages from the inTransition Program prior to completion, the inTransition Coach will attempt to reconnect with the Service member via three follow-up calls and additional communication channels.

7. inTRANSITION PROGRAM EVALUATION

a. The inTransition Contractor will perform program evaluation at their contractor or government location identified by DHA Business Associate Agreement verbiage. At a minimum, the inTransition Contractor will collect the following data as part of an Outcomes Evaluation Program:

(1) Disposition of outbound calls:

(a) The number of Service members eligible for the program;

(b) The number of Service members who could not be reached by the inTransition Coaches;

(c) The number of Service members who decline the inTransition Program because they are already engaged in care;

(d) The number of Service members who opted out of the program;

(e) The number of Service members who are enrolled in the program.

(2) Disposition of inbound calls:

(a) The number of Service members who accepted inTransition services;

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(b) The number of Service members who declined inTransition services.

(3) The total number of enrollees who remain in the program (from initial enrollment to hand-off to gaining site/provider) compared to the total number of enrollees in the program;

(4) A quarterly report of the disposition of program participants, including:

(a) The number of Service members receiving mental health care;

(b) The location of service to which the referral was made (i.e., the VA, private health insurance, TRICARE, etc.);

(c) The number of Service members lost to follow-up (unable to contact after initiation of the program).

(d) Specific breakout on the outcome metrics listed above for cases with a diagnosis of post-traumatic stress disorder or moderate to severe TBI to assess progress pursuant to Reference (g).

(5) A quarterly report relating to the termination of inTransition Coaching Services as defined in Section 7 of this Enclosure.

(a) A report of the effectiveness of the program based on the data described above will be prepared and provided to leadership annually.

(b) The program will be modified as needed based on the results of the evaluation.

(6) A quarterly report of individual closed cases.

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GLOSSARY

PART I. ABBREVIATIONS AND ACRONYMS

AOC alteration of consciousness DCoE Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury DAD R&D Deputy Assistant Director, Research and Development DHA Defense Health Agency DHA-PI Defense Health Agency-Procedural Instruction

LOC loss of consciousness

MTF Military Medical Treatment Facility

PTA post traumatic amnesia

SHPE Separation History and Physical Examination

TAP Transition Assistance Program TBI traumatic brain injury TVPO Transition to Veterans Program Office

VA Department of Veterans Affairs

PART II. DEFINITIONS

mental health. A state of subjective well-being and successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity. Mental health is indispensable to personal well-being, family and interpersonal relationships, and contribution(s) to community or society.

Military Support Community. A support community which consists of non-MHS Military Health System staff who provides support to the Service member/veteran community but is not limited to: Chaplains, military line leaders, Veterans Service Organizations, and family support programs.

Moderate to severe TBI. TBI severity is classified by using findings from imaging studies, loss of consciousness (LOC), alteration of consciousness (AOC) and post traumatic amnesia (PTA).

Moderate TBI is normal/abnormal structural imaging findings, LOC 30 minutes to 24 hours, AOC greater than 24 hours in addition to other criteria, PTA 1 to 7 days. Severe TBI is normal/abnormal structural imaging findings, LOC greater than 24 hours, AOC greater than 24 hours in addition to other criteria, PTA greater than 7 days.

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