Attachment 20 - SDVAMS MCM 11-97 Prevention and Management of Disruptive Behavior.pdf

VA SAN DIEGO HEALTHCARE SYSTEM MEMORANDUM 11-97

SAN DIEGO, CA August 1, 2021

PREVENTION AND MANAGEMENT OF DISRUPTIVE PATIENT BEHAVIOR AND

WORKPLACE VIOLENCE

1. PURPOSE: To establish policy and procedures regarding the prevention and management of disruptive behavior by patients.

2. POLICY: The VA San Diego Healthcare System (VASDHS) is committed to ensuring the delivery of Veteran-centric healthcare consistent with VA Core Values (Integrity, Commitment, Advocacy, Respect, and Excellence). Safe and effective health care is based on mutual respect between employees and patients.

However, some patients demonstrate disruptive behaviors when interacting with VASDHS personnel or while on the property. VASDHS fulfills best practices to manage disruptive patient behaviors and prevent workplace violence by promoting healthcare as a partnership between a patient and his/her care team, training staff to de-escalate or disengage from conflict, and designating the Disruptive Behavior Committee (DBC) to conduct disruptive patient behavior risk assessments, recommend safety plans to address and mitigate risk factors, and communicate safety guidance to staff. All patients, family members, and visitors are expected to adhere to the VASDHS Code of Conduct for Patients and refrain from behaviors that are disruptive or pose a threat to the rights or safety of other patients and staff. All reports of patient disruptive or violent behaviors in the health care setting are taken seriously and are dealt with in accordance with procedures consistent with 38 CFR 17.107 and Veterans Health Administration (VHA) Directive 2012-

026. This medical center applies restrictions on “the time, place, and/or manner of the provision of a patient’s medical care by written order of the Chief of Staff of the VA Medical Center of the jurisdiction or his or her designee, “but that " the order {must be} narrowly tailored to address the patient’s disruptive behavior and avoid undue interference with the [disruptive] patient’s care.” (38 CFR, Part 17.106).

3. DEFINITIONS:

a. Disruptive Patient Behavior: is defined by 38 CFR 17.107 and VHA

Directive 2012-026 as:

1) Behavior by patients that is intimidating, threatening, or dangerous and may pose a threat to the health or safety of other patients, VA employees, or visitors to the facility;

2) Behavior that interferes with the delivery of safe medical care to other patients at the medical facility; or

3) Behavior that impedes the operations of the facility.

4) Specific examples of disruptive behavior include, but are not limited to: verbal abuse such as name-calling, racial or ethnic epithets, sexual harassment, loud or profane language; direct, indirect, or implied threats; physical abuse ( i.e., bumping, shoving, slapping, striking, or inappropriate touching); unwanted approaches toward or contact with others; possession or brandishing of weapons; persistent or intense outbursts; or, disruptive behavior to such a degree that it interferes with the ability of other patients to access care (i.e., excessive calls to the 24-hour call center without a clear medical need, leaving repeated voicemail messages on a provider’s voice mail in such quantity that no other patients are able to leave a message, and misuse of Secure Messaging).

b. Treatment Non-Adherent Behavior: Patients have the right to refuse to accept medical advice, treatments, or procedures. Although non-adherent behavior does not necessarily constitute disruptive behavior, some forms of non-adherent behavior may develop over time into disruptive behavior, e.g.

when a patient becomes threatening when refused early refills of narcotics.

c. Category I Behavioral National PRF: A national PRF advisory viewable by any VHA employee at any medical center in the nation accessing the patient’s record in CPRS. PRFs will be implemented and used only as a tool to ensure safe, appropriate, timely, and respectful care for patients and a safe environment for staff and visitors. A Category I PRF identifies a patient exhibiting behaviors including, but not limited to, the following:

1) A history of physical violence against patients or staff at a medical center or clinic.

2) Documented acts of repeated violence against others.

3) Credible verbal threats of harm against specific individuals, patients, staff, or VA property.

4) Possession of weapons, or objects which could be used as weapons, in a health care facility.

5) A history of a suicide attempt and/or self-directed violence within health care facilities.

6) History of threatening or assaultive behavior while in the possession of weapons or objects used as weapons.

7) History of sexual harassment towards patients or staff.

d. Code of Conduct for Patients: Specification of patient behaviors that interfere with VASDHS health care team members’ ability to provide safe, effective health care and Veteran’s services. VASDHS responds to violations of the Code of Conduct for Patients by directly communicating with patients that a patient conduct violation has occurred. Communications to patients involve clinical and administrative actions including, but not limited to, written correspondence, direct counseling, notification of assignment of a PRF and requirements that specify how, when and where a patient may access health care. Refer to Attachment A to review the Code of Conduct for Patients.

e. Prevention and Management Disruptive Behavior (PMDB): A VHA disruptive behavior prevention and training curriculum which teaches how to recognize, de-escalate, and prevent disruptive or threatening patient behavior incidents.

PMDB training is differentiated into four levels based on training needs related to workplace behavioral risk (Refer to Attachment B for additional details). All VASDHS employees will complete the Level 1 “Prevention and Management of Disruptive Behavior training in the Talent Management System (TMS). New employees and volunteers will receive the “Prevention and Management of Disruptive Behavior” Level II training during New Employee Orientation. All employees who work in areas designated “high risk” (e.g. Emergency Department and Inpatient Psychiatry) will complete all four levels of PMDB training and be retrained annually.

f. The Disruptive Patient Behavior Committee (DBC): A multidisciplinary group operating under the authority of the Chief of Staff and Director. The DBC is comprised of representatives from the Mental Health Hybrid Care Line, the Nursing Service, the Patient Advocate Office, Police Service, Primary Care Service, Risk Management, and Social Work Service. The DBC provides recommendations to Executive Leadership regarding PRFs.

Incidents of inappropriate communication, physical violence, sexual assault or harassment, property damage, and threats of harm by patients are expected to be reported to the Disruptive Behavior Committee using the Disruptive Behavior Reporting System.

g. Disruptive Behavior Reporting System (DBRS): The DBRS is a standardized VHA reporting tool for alerting the Disruptive Behavior Committee, VA Police, and other appropriate staff about patient behaviors that undermine the culture of safety. Incidents of disruptive patient behavior must be reported electronically via the DBRS within 24 hours. Refer to Attachment C to review Frequently Asked Questions for DBRS.

h. Reconciliation Resource Council (RRC): A team approach to assist health care providers to work more effectively with disruptive patients by providing tools, coaching, staff education, case conferences, and clinical care solutions utilizing onsite consultation and intervention. Members of RRC are identified at VASDHS sites through approval by designated supervisors and/or clinic managers. Each RRC will have a member who serves on the facility’s Disruptive Behavior Committee. RRCs meet monthly to discuss disruptive patients whose behaviors interfere with effective care but do not meet criteria for referral to the DBC.

i. Violence Risk Assessment: A structured assessment designed to guide clinicians assessing a patient’s risk for violence and recommending clinical and administrative actions for a safety plan.

j. Therapeutic Limit Setting: A patient-centered, integrated, multidisciplinary, and transparent approach to providing health care to all eligible Veterans, including those whose behavior or behaviors undermine a culture of safety.

Refer to Attachments D and E to review types of therapeutic limit-setting including counseling, Letters of Concern, Health Care Agreements, and Orders for Behavioral Restriction.

4. RESPONSIBILITIES:

a. The Director is responsible for:

1) Ensuring employees and volunteers are provided a safe and healthful work environment.

2) Ensuring employees utilize the Disruptive Behavior Reporting System (DBRS) to report disruptive behavior incidents

3) Ensuring all employees or volunteers complete appropriate disruptive behavior prevention training.

b. The Chief of Staff is responsible for:

1) Ensuring occurrences of disruptive patient behavior are properly examined and an appropriate safety plan is recommended, including but not limited to, assignment of a Category I Patient Record Flag

(PRF).

2) Ensuring a process for requesting, assigning, reviewing, evaluating a Patient Record Flag and appealing an Order for Behavioral Restriction

(OBR).

3) Providing written notification to the patient of the restrictions in the OBR and the process to request a review by the Veterans Integrated Services Network (VISN) Director to appeal the OBR.

4) Providing written notification to the patient of the VISN ND final decision regarding the patient’s OBR request for appeal.

c.The VASDHS Disruptive Behavior Committee is responsible for:

1) Providing a multidisciplinary review and risk assessment of incidents of physical violence, property damage, and threats of harm by patients and an assessment of the violence risk factors utilizing a standardized and systematic approach.

2) Recommending safety plans and/or restrictions to the Chief of Staff/Medical Director for the institutional management and care of seriously threatening or violent patients to preclude recurrence of disruptive and/or violent behavior incidents. These actions and restrictions are consistent with 38 CFR 17.107 and VHA Directive 2012-026.

3) Recommending assignment of a Category I Behavioral Patient Record Flag (PRF) to the Chief of Staff/ Medical Center Director based on a structured risk assessment.

4) Submitting all critical information and supporting documentation that must accompany OBR requests for review in Patient Advocate Tracking System -Replacement (PATS-R)

5) Communicating with clinical and administrative staff about the clinical implications and corrective actions related to a PRF.

6) Consulting with staff that identify patients with high- risk behaviors and/or specific clinical care needs and who have already accessed onsite disruptive behavior resources (e.g. Clinical or Administrative Program Manager, Patient Aligned Care Team (PACT) huddle, Reconciliation Resource Committee, Medicine Chief or Site Leader) to resolve problem behavior.

d. Veteran Experience Program Director is responsible for:

1) Creating Order of Behavioral Restriction (OBR) requests for review cases in PATS-R, assigning the case to the Disruptive Behavior Committee, and tracking processing status.

2) Routing cases with supporting documentation in PATS-R to the VISN Director for review.

3) Attaching the final decision letter from the VISN Director into PATS-R and ensuring that the Disruptive Behavior Committee (DBC) is aware of the outcome.

4) Completing the OBR case in PATS-R by coding and closing the case.

5) Ensuring OBR review requests are appropriately tracked, trended, reported, and addressed according to standard operating procedures.

e. Chief, VA Police Service is responsible for:

1) Ensuring incidents involving violence at VASDHS are reported and addressed according to standard operating procedures.

2) Collaborating with the Disruptive Behavior Committee to develop recommendations and implement corrective action(s) intended to preclude recurrence of disruptive behavior and/or violence.

f. Service Chiefs or their designees are responsible for:

1) Ensuring all employees or volunteers complete appropriate PMDB or other disruptive behavior management and prevention training.

2) Ensuring that employees understand when and how to submit a DBRS report in response to disruptive patient behavior.

3) Ensuring that employees or volunteers who are verbally or physically assaulted or who witness disruptive and/or violent behavior in the workplace, are provided with immediate support such as a debriefing and/or referral to the Employee Assistance Program, as appropriate.

g. Employees and volunteers are responsible for:

1) Completing PMDB training and any other training related to the prevention and management of disruptive patient behavior. This includes: recognizing and reporting disruptive patient behavior to supervisory personnel and in the Disruptive Behavior Reporting

System; and avoiding words and actions that escalate conflict and disruptive patient behavior,

2) Adhering to safety procedures in support of workplace safety:

withdrawing from unsafe conditions and following the plan and specific guidance in Category I Patient Record Flags.

h. Patients are responsible for:

1) Adhering to the VASDHS Code of Conduct for Patients

2) Participating in a partnership with their care team to optimize clinical outcomes

3) Sending a written OBR request for review letter to COS c/o Veteran

Experience Program within 30 days of receiving an OBR notification.

5. PROCEDURES:

a. Verbal De-escalation: Is appropriate in any situation in which a patient is becoming agitated, the goal is to respectfully and calmly bring the patient’s level of arousal down to allow a dialogue, and a weapon is not present. Refer to Attachment F for the “How to de-escalate angry or disruptive patients” Handout.

b. Disruptive Behavior Reporting:

1) Staff use the Disruptive Behavior Reporting System/DBRS within 24 hours to report disruptive behavior, including threats, acts of violence, possession of a weapon, or destruction of VA property.

2) Staff are always expected to also immediately contact the VA Police to make a Report of Contact when threats, acts of violence, possession of a weapon, or destruction of VA property occur.

3) Incidents of disruptive patient behavior are also reported to the appropriate supervisor or clinic manager.

c. Requests for Disruptive Patient Consultation:

1) All staff may request a consultation with the Disruptive Behavior

Committee by submitting a DBRS report,

2) All staff may directly contact the DBC Chair, Co-Chair, or members to discuss disruptive patient behavior issues.

d. Flagging Procedure:

1) A DBRS Report must be submitted if staff identify a patient whose behavior poses a threat to their safety.

2) Patient Record Flags (PRF) are assigned based on DBC review of a DBRS report, and if indicated, on a structured violence risk assessment.

3) The DBC will review and approve, as appropriate, patient specific PRFs as recommended by individual services, programs, providers, or clinical teams that identify patients with high-risk behaviors and//or specific clinical care needs.

4) The DBC will communicate to the patient directly, if possible, about activation of a non-restrictive PRF, the specific behavior or circumstances that triggered the PRF, and the purpose of a PRF in a medical record.

5) The Chief of Staff or designees will ensure Orders for Behavioral Restriction (OBR) associated with PRF are communicated in writing to inform patients of the specific plan, their right to request an appeal, and the steps in the appeal process.

e. Patient Record Flags Assigned by Other VA Facilities

1) Staff are advised to always follow the specific safety guidance in a

PRF assigned by another facility (i.e.: if the PRF states no appointments in CBOCS, do not schedule visits in a CBOC).

2) Staff are advised to notify the DBC Chair or Co-Chair via email or phone contact when they identify a patient with a flag assigned by another VA facility.

3) If notified, the DBC will assess the Veteran’s status and may request transfer of the PRF to modify the PRF narrative to meet local needs or discontinue the PRF, if indicated.

f. Request for Non-VA Care due to Disruptive Behavior:

1) When Non-VA Care is recommended therefore for a patient’s repeated failure to follow the VASDHS Code of Conduct for Patients, the request will be reviewed by the DBC.

2) In exceptional cases, the DBC may recommend a referral for non-VA care following review of an independent assessment by a DBC clinician at the site of care with findings that it is not possible to provide care safely and effectively at this facility.

g. Procedures for Responding to Specific Patient Behavior:

1) Treatment non-adherence includes behaviors are addressed directly by the clinical team responsible for the patient’s care. Optimal approaches to non-adherent behavior include seeking and documenting feedback from on-site and consultative resources such as team huddles, RRC, Patient Case Conferences, and use of Letters of Concern, Counseling, and Health Care Agreements to engage a patient in discussion to change non-adherent behaviors.

2) Refer to the Disruptive Behavior SharePoint to review specific procedures necessary to respond to high risk, threatening and other disruptive patient behavior.

6. REFERENCES

a. VA San Diego Healthcare System MCM 11-69, Patient Record Flag (PRF)

Policy, April 1, 2018. Accessed at:

http://vaww.docushare.visn22.med.va.gov/dsweb/Get/Document- 29406/MCM%2011-69%20Patient%20Record%20Flags%20update.docx

b. 38 CFR, Part 17.106. VA Response to Disruptive Behavior of Patients. Dec.

2010.

c. VA OIG Healthcare Inspection Report: Management of Disruptive Patient Behaviors in VHA (Report No. 11-02585-129).

d. Deputy Under Secretary for Health for Operations and Management (DUSHOM) Memorandum; Workplace Violence Prevention Guidance Regarding Management of Disruptive Patient Behavior at Veterans Health Administration Facilities,” August 28, 2013.

e. VASDHS Code of Conduct for Patients.

f. Drummond, D. J. (2011). Patient-centered Therapeutic Limit-setting: A Tool kit (Version II).

g. OIG Evaluation of VHA’s Policies and Procedures for Managing Violent and

Potentially Violent Psychiatric Patients (Report No. 6h1-A28-038).

7. RECERTIFICATION DATE:

8. FOLLOW UP RESPONSIBILITY: ACOS/ Mental Health

9. RECOMMENDED REVIEW DATE:

10. RECISSION: MCM 11-97 dated February 20, 2019.

11. DATE APPROVED BY MEC: September 1, 2021.

X Kathleen Kim Kathleen Kim, MD, MPH Chief of Staff/Medical Director Signed by: Kim, Kathleen M.

http://vaww.docushare.visn22.med.va.gov/dsweb/Get/Document-29406/MCM%2011-69%20Patient%20Record%20Flags%20update.docx http://vaww.docushare.visn22.med.va.gov/dsweb/Get/Document-29406/MCM%2011-69%20Patient%20Record%20Flags%20update.docx

X Robert M. Smith, MD Director

Attachments: A, B, C, D, E, F, G Distribution: SharePoint

Attachment A August 1, 2021

Attachment B August 1, 2021

VHA PREVENTION AND MANAGEMENT OF DISRUPTIVE BEHAVIOR

CURRICULUM

The Prevention and Management of Disruptive Behavior (PMDB) program consists of four curriculum elements:

• Level I: Web-based Violence Prevention Awareness Training

• Level II: Observational and Verbal Skills

• Level III: Personal Safety Skills

• Level IV: Therapeutic Containment Skills

All VHA staff are required to complete Level I. All training levels are required based on the facility’s workplace behavioral risk assessment (WBRA) findings for the workplace area where each employee works. VHA staff who work in elevated risk work areas are required to complete Levels I-IV.

Level I: Violence Prevention Awareness Training This web-based Violence Prevention Awareness Training focuses on identifying negative, potentially disruptive situations involving affective (emotionally driven or impromptu) violence and introduces skills needed to resolve those situations effectively.

Level II: Observational and Verbal Skills Participants learn and practice specific skills for identifying and verbally de-escalating disruptive behavior. This training course emphasizes early interventions to reduce the likelihood that situations will escalate to actions involving physical violence.

Level III: Personal Safety Skills Participants learn escape and purely defensive techniques to minimize immediate danger and afford time to devise an appropriate response to situations involving physical violence. PMDB is designed to maximize the safety of patients and staff.

Level IV: Therapeutic Containment Skills Participants learn to be part of a team able to contain a disruptive or violent individual physically with the least amount of harm to everyone involved.

Attachment C August 1, 2021

Frequently Asked Questions: Disruptive Behavior Reporting System (DBRS) What is disruptive patient behavior?

Behavior by patients or a patient’s family member or visitor that is intimidating, threatening, dangerous and poses a threat to the health and safety of other patients, VA employees, or visitors to the facility; behavior that interferes with the delivery of safe medical care to a disruptive patient and other patients at the facility; behavior that impedes the operations of the facility and disturbs the environment of care.

What is the DBRS?

The DBRS is a secure website within the VA San Diego intranet. Any employee with access to the VHA intranet may submit a DBRS report of disruptive patient behavior. When a report is submitted, the Disruptive Behavior Committee (DBC) will review the incident, evaluate the behavioral history of the disruptive individual, do a violence risk assessment, if indicated, and recommend actions to maintain a safe workplace.

How is the DBRS accessed to make a report?

At VA San Diego, DBRS can be accessed through the facility Intranet Homepage by:

• Selecting “Employee Pages” options to access a link to the DB SharePoint

• Selecting “Business Applications” to locate a link to the DBRS report, or

• Selecting the Computer and Education icon on the Desktop and opening the Safety

Folder where the link to the DBRS Report is found.

What are reportable behaviors? (If unsure the incident is reportable, please make the report.)

• Inappropriate communications, including in electronic or telephonic form

• Verbal or written threats of physical harm

• Physical violence or intimidation

• Sexual harassment

• Sexual assault

• Possession or brandishing of weapons

• Property damage

• Behaviors that may affect the initial moments of future care

What if the patient says later he/she did not intend to be threatening or intimidating?

The definition of disruptive behavior does not depend on the patient's stated intentionality or justification for his/her behavior, the presence of psychological or physical impairment, or whether the patient later expresses remorse or an apology.

What if I don’t want my name associated with an incident report?

An employee who desires to file an anonymous report may choose to discuss this concern with their supervisor or the DBC Chair. To file a report anonymously, the person wishing to file a report SHOULD NOT file the report themselves. They should find another willing employee they trust: a supervisor, coworker, or DBC member.

What are my additional reporting responsibilities related to disruptive patient behavior?

• Always report threats and criminal behaviors to the VA Police

• Report all disruptive behaviors in DBRS, even if reported to the VA Police

• For any kind of physical and/or sexual assault, enter both a DBRS and PER

• Report all disruptive behavior within 24 hours of the incident

Refer to local SharePoint Homepage of the Disruptive Behavior Program for tools/resources Contact Ellen Lavin, Ph.D. x 3159 and Robyn Stein, RN, MSN/Ed x1604 for question

Attachment D August 1, 2021

TYPES OF THERAPEUTIC LIMIT-SETTING

1. Counseling: A conversation held between a patient and a health care provider or another member of the health care team at the site of care. Counseling addresses behaviors that interfere with the effectiveness of patient care. Behaviors that call for counseling include yelling, rude or inappropriate language, or episodes of conflict with the health care team that disrupt the environment of care. It is often helpful to also involve a mental health professional directly or indirectly in the counseling process. Counseling includes direct feedback on more effective ways to communicate with team members and should be documented in the patient's medical record.

2. Letter of Concern: Written correspondence describing why behavior(s) that undermine a culture of safety are of concern, summarizing prior efforts to assist the patient to obtain care, and providing specific recommendations for how the patient can most effectively fulfill health care needs and access future services.

The Letter of Concern may be generated and presented by the primary provider, a team member or the clinic supervisor or manager. When counseling has either not been possible or has been unsuccessful in gaining a patient’s cooperation. A letter may be most effective when presented during counseling or a face- to- face visit for a behavioral intervention. Refer to Attachment D for sample template.

3. Individualized Behavioral Intervention: A consultation provided by appropriate staff including, but not limited to, a member of the direct care team in the clinic, other onsite disruptive behavior support resources, or a member of the DBC. During an individualized behavioral intervention, there is an assessment of a patient’s treatment interfering behavior and current treatment needs. Treatment recommendations and consequences for continuing treatment interfering behavior are communicated to the patient. A behavioral intervention also helps connect a patient to the care team by clarifying how the patient can best access care and specifying needs that require further consultation or referrals.

4. Health Care Agreement (HCA): A written agreement to formally establish expectations for behavior of the patient, expectations for performance by the facility, and obligations of the facility to the patient, when previous efforts to modify behaviors that undermine safety or effective care have been documented and failed, or when the patient’s behavior poses a significant risk of harm to the patient.

Health Care Agreements require DBC input. Please see Attachment E. to review a sample template.

5. Order for Behavioral Restriction (OBR): A restrictive form of therapeutic limit-setting to mitigate risk of further behavioral incidents when previous efforts to modify behavior(s) that undermine the culture of safety have failed, or when the presenting behavior(s) poses such an elevated risk of harm to others that restrictive intervention is warranted. An OBR may restrict the time, place, and/or manner of the provision of a patient’s care. An OBR is issued in the form of a letter by the Chief of Staff, following an evaluation of the problematic behavior and recommendations for a safety plan by the DBC.

Attachment E August 1, 2021

Sample Letter of Concern #1:

DATE: Month XX, 20XX

Dear Mr. Veteran:

As your primary care provider, I am writing in hopes of addressing the concerns I have about difficulties providing you with care. This includes a pattern of using aggressive and abusive language in your communication with clinic staff, threatening to record conversations on the phone, failing to provide requested laboratory specimens and not following up on recommended consultations with Mental Health and Substance Use Treatment Programs.

All Veterans receiving VA San Diego Healthcare System (VASDHS) care are expected to abide by the enclosed VASDHS Code of Conduct for Patients. Interacting with staff in a verbally aggressive manner interferes with the delivery of safe, effective care and, if continued, will result in changes in how you access your future health care.

While I remain committed to providing you care, this situation has made it difficult for me to do so safely and effectively. At this time, I am requesting the assistance of onsite support specialists who will be contacting you to arrange a visit. This is one of our standard procedures for clarifying your needs and helping you successfully fulfill them.

In the interim, I will continue to provide your care to the extent that I can do so safely. I strongly encourage you to speak to the staff at this clinic respectfully and to reconsider providing a 24-hour urine specimen upon receipt of this letter.

As a reminder: for life-threatening emergencies, you should come to the VA San Diego Medical Center Emergency Department or go to the closest non-VA emergency department at your own expense. If you are suicidal, please call the VA’s Suicide Hotline at 1-800-273-TALK (8255) at any hour of any day.

Sincerely, Staff, MD, Any Clinic

Sample Letter of Concern #2

DATE: Month XX, 20XX

Dear Mr. Veteran, When I assisted you with your transportation arrangements for your recent medical procedure, I explained the need for us to have an understanding about the frequency and nature of your future contacts and messages to me. Since that time, I have received fifteen voice messages from you within two days. In addition, I was subjected to profanity and verbal aggression throughout these telephonic communications.

I would like to be of assistance to you; however, I am writing to remind you that patients receiving care at the VA San Diego Healthcare System (VASDHS) main campus and community-based outpatient clinics or accessing our telephonic and secure messaging resources must adhere to certain standards of conduct.

I am requesting you limit your messages and calls to me to once per week or less without the use of profanity. Enclosed is a copy of the VASDHS Code of Conduct for Patients.

In addition, I am seeking the special assistance of onsite support specialists to contact you and arrange a visit to clarify your needs and discuss some better ways to meet them.

Sincerely, Staff, RN

Care Manager, Any Clinic

Sample Health Care Agreement (HCA)

Primary Care

DATE: Month XX, 20XX

Dear Mr. Veteran:

As your primary care provider, I am concerned about problems encountered in trying to provide you the health care you need. Treating your medical and psychiatric conditions (obesity, hypertension, chronic pain, and osteoporosis, depression, and anxiety disorder) has been extremely difficult based on poor attendance at scheduled appointments and lack of adherence to treatment plans.

I recognize that chronic illness, particularly chronic pain and depression, significantly impact the quality of a patient’s life and can cause increased stress, frustration, and a sense of hopelessness. Complete resolution of a patient’s chronic pain is not possible.

However, the effects of pain can be significantly diminished with the patient’s full cooperation in a comprehensive approach to treatment. You have recently expressed a renewed interest in Guided Imagery for Chronic Pain, and I have sent a consult for you to be contacted about this service. Keeping scheduled appointments, using prescription medications as directed, and following treatment plans, including physical therapy or exercise programs, control of blood sugars, and mental health therapy, will be essential to monitoring and treating your pain, depression, and anxiety in a safe and effective manner.

Untreated depression and anxiety may also contribute to an individual's experience of pain. I am pleased to see that since the time of the initial referral to my office, you have engaged in care with the Mental Health Clinic.

I asked your Patient Aligned Care Team (PACT) Care Manager, Clara Barton, RN to present you with this letter and allow you the opportunity to share any concerns you might have.

The VA is very committed to caring for all veteran patients. It is our goal to work with you, but your cooperation with the following terms is important if you are to avoid more serious medical problems:

1. I will continue to serve as your primary care provider for your medical conditions.

2. If you have questions about your medical care, you are to contact your providers using the Primary Care Call Center by calling 1-858-552-7475.

3. You are asked to keep scheduled clinic appointments. If you are unable to keep an appointment due to an unforeseen emergent situation, please be responsible for notifying your providers within 48 hours and reschedule. Transportation difficulties are not considered emergent. (If you require assistance with transportation to your appointments, please let us know of that fact so that we may assist you.)

4. You are asked to participate in treatment plans and medication therapy as agreed to with me and your specialty providers. This includes taking medications as directed. To ensure safe administration of chronic narcotics, they are prescribed under the terms of an Opioid Medication Agreement. Failure to adhere to the terms of the Opioid Agreement may be grounds for discontinuation of these medications.

5. Safe medical care is based on mutual respect between provider and patient. You are asked to adhere to the VASDHS Code of Conduct for Patients and treat the staff of this medical center with respect, and you will receive respectful care from the medical center staff.

The VA San Diego healthcare System can only provide safe and appropriate medical care so long as you cooperate with the requirements described above. I hope that you will work with your health care team so that we can look forward to being able to continue providing you safe and appropriate health care.

Sincerely, Staff, MD

I have read and understand the above information and have been given the opportunity to ask questions.

Patient Name Date

Sample Health Care Agreement (HCA)

Specialty Care

Community Living Center

Antibiotic Therapy Healthcare Agreement

Mr. Veteran his Healthcare Agreement is presented to Mr. Thomas Veteran by the VA San Diego Healthcare System (VASDHS) Community Living Center (CLC). Its purpose is to outline a safe and effective plan for intravenous (IV) antibiotic therapy for a condition which may result in amputation of a limb if not treated effectively. Mr. Veteran remains at risk for more significant complications based on his history of IV drug use. Mr. Veteran has been well informed about and understands the need for a six-week course of IV antibiotic therapy in a supervised setting, as well as the risks and consequences of not complying with this treatment or use of IV drugs.

The following plan and expectations have been developed with Mr. Veteran’s specific care needs in mind for effectively treating his infection. Mr. Veteran is being discharged to the VA San Diego's CLC for the duration of IV antibiotic therapy. In addition, he has been informed of the availability of the VASDHS’s Alcohol and Drug Treatment Program and PTSD treatment programs and is strongly encouraged to seek their services. Successful recovery of this current infection will also depend on his abstinence from IV or another drug use.

The staff of the CLC, Orthopedics and Infectious Disease Services are committed to providing Mr. Veteran with this urgent therapy in a safe and appropriate manner. In keeping with this commitment, Mr. Veteran understands that successful treatment depends on his full cooperation with this treatment plan and agrees to the following:

Supervised Antibiotic Therapy:

1. Mr. Veteran will receive IV antibiotic therapy while residing at the CLC. The purpose of this supervised setting is to provide the level of care necessary for administration of IV medications and to minimize the potential for misuse of IV access.

2. Mr. Veteran understands that failure on his part to complete the course as prescribed above places him at serious risk for worsening infection, life-threatening complications, loss of limb, and death.

3. Mr. Veteran understands that tampering with his IV line for the use of illicit substances while in the CLC places him at serious risk for an adverse drug reaction, potentially life-threatening condition, or death. Such action will also result in the discontinuation of IV antibiotic therapy, discharge from the CLC, and a referral of his case to the Chief of Staff for decisions about future VA care.

Substance Abuse:

1. Mr. Veteran understands that for his mental/physical wellbeing and long-term survival, abstaining from the use of illicit substances is essential.

2. To support a course of sustained abstinence while in the CLC, Mr. Veteran understands that he may be asked to provide urine drug screening. Evidence of any drug use will result in discontinuation of IV access, conversion to oral antibiotics, and may result in discharge from the facility.

This Treatment Plan is being presented to Mr. Veteran prior to his hospital discharge on June 5, 2015. Mr. Veteran has read and understands this Plan and has been given the opportunity to ask questions about its content. The patient acknowledges this by his signature below. A copy of this Plan will be entered into the electronic medical record.

Veteran Date

Attachment F August 1, 2021

HOW TO DE-ESCALATE ANGRY OR DISRUPTIVE PATIENTS

Attachment G August 1, 2021

PROCEDURES FOR RESPONDING TO SPECIFIC DISRUPTIVE

PATIENT BEHAVIORS

1. High Risk Behaviors: credible threats of harm, physical violence, stalking, property damage, sexual harassment, weapons possession, physical intimidation, actions jeopardizing staff safety

a. Disengage and Maintain Safe Personal Distance

b. Call Code/ Request Police/Security Response

c. Make Reports: Supervisor/ Clinic Manager and VA Police

d. Enter Electronic Report in DBRS

e. Document Incident in CPRS

f. Debrief Incident with appropriate staff or VASDHS Psychological First Aid

Team

2. Verbal Aggression: yelling in clinics and at staff, disrespectful language in face to face interactions with staff. (See Attachment H)

a. Follow de-escalation protocol to defuse conflict

b. If de-escalation is unsuccessful, disengage and ask another staff member to help try to de-escalate conflict.

c. If the patient continues to escalate, disengage immediately and call for Police or onsite Security intervention and document in CPRS.

d. If a. or B. are successful (patient de-escalates), arrange for the patient to meet with a disruptive behavior support team member and document action taken in CPRS.

e. An onsite team member can help clarify the patient’s needs and develop an individualized plan to address immediate concerns and document the plan in CPRS (e.g. counseling or limit-setting related to violation of the Code of Conduct for Patients, referral to Behavioral Medicine or Mental Health services, appointment with the PACT Care Manager to discuss how to better access care),

f. If the patient is not de-escalated and leaves the clinic on his/her own without meeting with a member of the team, clinic staff will huddle to determine next steps and document. the plan (i.e.: send the patient a Letter of Concern that addresses the problem behavior and requests a specific change in the patient’s behavior to optimize care, call the patient to come for a team meeting to discuss resolving the patient’s concern, schedule discussion of the patient at a Patient Case Conference).

g. Advise the patient directly or in a Letter of Concern that continuing this verbally aggressive behavior interferes with the delivery of safe, effective care and may jeopardize the time, place and location of his/her future care and document warning.

h. A special case of verbal aggression occurs when the patient’s behavior occurs in the context of intoxication. Advise the patient directly or in a Letter of Concern that this behavior interferes with the delivery of safe, effective care and may jeopardize the time, place and location of his/her future care and document warning.

i. Debrief incidents of verbal aggression with appropriate staff or VASDHS Psychological First Air Team

3. Verbal Aggression in Telephonic Communications

a. Follow de-escalation protocol to defuse conflict.

b. If de-escalation is unsuccessful, inform patient you cannot continue the call.

c. If verbal aggression is communicated via voice messages, communicate directly to the patient that this behavior is inappropriate and violates the Code of Conduct for Patients.

d. Advise the patient directly or in a Letter of Concern that continuing this behavior interferes with the delivery of safe, effective care and may jeopardize the time, place and location of his/her future care and document warning.

e. Recommend a visit with a team member to clarify needs, discuss how to better access care, and identify issues that require additional consultation, treatment, or referrals.

4. Verbal Aggression in Secure Messaging (SM) Communications

a. If verbal aggression is communicated via voice messages, communicate directly to the patient that this behavior is inappropriate and violates the Code of Conduct for Patients and the Secure Messaging Agreement. If desired, send a Letter of Concern and attach a copy of the Secure Messaging Agreement.

b. Advise the patient directly or in a Letter of Concern that continuing this behavior interferes with the delivery of safe, effective care and may jeopardize future access to Secure Messaging system and document warning.

c. Recommend a visit with a member of the Disruptive Behavior Support Team to clarify the Code of Conduct and a specific Health Care Agreement, if indicated.

d. After issuance of a documented warning to the patient to discontinue verbal aggression, a request to revoke SM privilege can be made to the SM Manager if another SM conduct violation occurs.