D.12 Response to Information that a Veteran May Be At Risk 02.pdf

DEPARTMENT OF VETERANS AFFAIRS (VA)

SALT LAKE CITY HEALTH CARE SYSTEM

Salt Lake City, Utah

MEMORANDUM 116.10 October 25, 2016

RESPONSE TO INFORMATION THAT A VETERAN MAY BE AT RISK

1. PURPOSE:

To establish policy and procedures for staff within the VA Salt Lake City Health Care System (VASLCHCS) to respond to information that a Veteran may be at risk in situations in which someone other than the Veteran provides the information.

2. POLICY:

Providing a safe and therapeutic environment for patients is the mandated standard of practice for all VA health care providers and employees. Therefore, staff must act on any information that indicates a Veteran may be at risk.

3. OVERVIEW:

a. Staff may receive information suggesting that a Veteran may be at risk from a variety of sources other than the Veteran. This may include information given by family, friends or community providers of healthcare or support services. This information may be provided by phone, e-mail or in-person.

b. While there are significant limitations on sharing a Veteran’s healthcare information, staff may receive information about a Veteran without violating confidentiality.

c. “At risk” is defined as situations in which there is potential that a Veteran could be harmed or harm her or himself or situations that are likely to deteriorate without immediate intervention. Examples include, but are not limited to, elevated suicide risk, evidence of onset of mania or psychosis, worsening of medical illness, adverse effects of medication or risk of the Veteran harming others.

4. RESOURCES:

a. Suicide Prevention Team (SPT): Available from 0730 – 1630 weekdays.

The Suicide Prevention Team (SPT) tracks and monitors patients for a 90 day period who have been placed on the high risk list and received a Category I Patient Record Flag (CATI PRF) in CPRS. Additionally they provide case management support and suicide prevention training, and consultation. Contact SPT by calling 385-414-1110.

D.12 RESPONSE TO INFORMATION THAT A VETERAN MAY BE AT RISK

36C25923R0008

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b. Access Crisis Team (ACT): Available 24/7/365. Contact ACT by paging 801-241-2579. The Access Crisis Team (ACT) provides evaluation and assistance with the management of suicidal patients in the ED and all outpatient areas of the SLC VAMC except Blue Clinic (which is covered by the Behavioral Health Service described below). ACT is available by phone to assist CBOC clinicians.

c. National Crisis Hotline: Available 24/7/365 at 1-800-273-8255.

d. Emergency Medical Services may be activated by dialing 911.

5. GENERAL POLICIES AND PROCEDURES:

a. Any information indicating that a Veteran may be at risk must be acted on immediately if the risk is imminent or in a timely fashion if the risk is less acute.

(1) It is the responsibility of any clinical staff member to act on any information received that indicates that a Veteran may be at risk.

(2) Non-clinical staff must immediately report the information to their supervisor. If a supervisor is not available, then the ACT team should be paged at 801- 241-2579 for mental health crisis situations or Emergency Medical Services activated by dialing 911 for medical urgencies/emergencies.

(3) Vigilance about disclosures of protected health information remains of utmost importance and thus, information provided to outside agencies must be limited to the minimum needed to elicit an appropriate response (i.e. activate Emergency Medical Services, initiate a welfare check, ask a family member if they know the status of a Veteran). Typically this disclosure is limited to, who, what, where and when. The Privacy Officer must be consulted if additional guidance about disclosure is required for specific situations.

6. SPECIFIC RESPONSES:

a. Response to the at risk situation will almost always require either phone or in-person assessment of the Veteran who may be at risk.

b. In some situations, contact with someone other than the Veteran may be adequate. For example, a family member reports the Veteran is currently being evaluated for the issue at a community ED. However, the staff clinician must still determine what if any follow-up is required and ensure this occurs.

c. If the Veteran cannot be contacted directly, then the clinician, depending on the clinical situation shall:

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(1) Attempt to contact the Veteran’s emergency contact and/or

(2) Contact community law enforcement and request a wellness check.

Staff should contact community law enforcement directly. If the clinician would like consultation, call ACT (pager 801-241-2579). If it is unclear which law enforcement agency to contact, then it is appropriate to call 911 or to contact the VA police (4444) for advise on which law enforcement agency to contact.

(3) Call 911 and request an Emergency Medical Services response.

d. An appropriate treatment plan must be developed based upon the assessment. The plan must include appropriate follow-up.

e. If indicated, a safety plan must be completed during the assessment. If an in-person assessment, then the Veteran must be given a copy.

f. The assessment, clinic decision-making and treatment/follow-up plan must be documented in a CPRS note.

10. RESCISSION: None

11. RECERTIFICATION: This policy is scheduled for recertification on or before the last working day of October 2019.

12. FOLLOW-UP RESPONSIBILITY: Access Crisis Team Leader (116OP).

SHELLA STOVALL

Acting Director