Interim COVID-19 Guidance for Behavioral Health and Homelessness Care Providers

 

Purpose of Guidance

The Hawaiʻi Department of Health’s Behavioral Health Administration (DOH/BHA) in partnership with the Governor’s Coordinator on Homelessness and the Department of Human Services’ Homeless Programs Office (DHS/HPO) has prioritized the control of the spread of coronavirus disease (COVID-19) in Hawaiʻi among behavioral health and homeless populations while ensuring continuity of coverage of essential services including behavioral health and homelessness services.

These three entities along with City and County agencies will be coordinating as the Behavioral Health and Homelessness Statewide Unified Response Group (BHHSURG) in response to COVID-19. Together, these entities oversee the majority of the state’s behavioral health and homelessness services systems. Other partners will be added to help coordinate and lead the response as needed. Behavioral health and homelessness services remain essential during this worldwide pandemic, and will be vital far beyond its resolution because of the pandemic’s economic, social and psychological impacts. The purpose of this document is to provide unified guidance and support to staff and providers across the behavioral health and homelessness services systems of Hawaiʻi during the COVID-19 pandemic.

1. What individual measures can limit spread and prevent exposure to COVID-19?

Practice Everyday Protections

  • Wash your hands often with soap and water for at least 20 seconds.
  • Avoid touching your eyes, nose, and mouth.
  • Avoid close contact with people who are sick.
  • Cover your cough and sneeze with a tissue, then throw the tissue in the trash.
  • Sanitize and sanitize often. Clean and disinfect frequently touched objects and surfaces (telephones, doorknobs, tables, chairs, computers, state cars etc.) Sanitizers can include household chlorine bleach diluted in water (about 5 tablespoons per gallon of water), 60% alcohol solutions, or most common EPA-registered household disinfectants.
  • Wear a face mask especially when visiting a health care facility or when you have any flu-like symptoms of COVID-19. In the event of lack of facemasks, use items such as a handkerchief, scarf, or other clothing and ensure it is fully covering your mouth and nose.

Stay Home or Go Home if You Feel Sick

  • If you are experiencing symptoms such as fever, cough, shortness of breath or have traveled to an area of sustained community exposure (China, Iran, Italy, South Korea, the continental United States, and most European Countries) within the last 14 days, please stay home and ensure rest in an isolated room, avoid sharing bedding or clothing, and ensure adequate nutrition and hydration.

Call Your Physician

  • In general, you should seek medical attention if you have a fever lasts longer than 24 hours or have other symptoms such as vomiting or shortness of breath or if their condition appears to be worsening.
  • If you have severe symptoms such as difficulty breathing, pain or pressure in the chest or abdomen, or are unable to drink or keep liquids down, seek medical attention right away and call 9-1-1.

2. What information should I provide to clients during this stressful period?

The impacts of COVID-19 are significant not only for physical health but also mental health and overall well-being, especially as the COVID-19 situation prolongs over time. To mitigate the psychological impacts of COVID-19, BHH providers have an essential role of providing information to help clients and families cope, develop resilience, and self-care such as informing clients and families the following messages:

  • You Are Not Alone. As many as 1 in 3 people will experience a mental illness – and it is common to care for someone with a mental illness.
  • Continue to Seek Medical Care. During an epidemic, patients should still continue to seek health care services including preventive screenings, primary care visits, and behavioral health visits.
  • Stock on Medication. Fill prescriptions for 90 days rather than 60 to minimize the need to go and get refills.
  • Recognize Signs and Symptoms. Contact a medical provider via telephone if you notice signs of anxiety and depression in children/dependents including changes in appetite, sleep disruptions, aggression, irritability, and fears of being alone or withdrawn.
  • Maintain Food Stocks. Provide at-home food-pantry services and/or ‘meals on wheels’ and/or gift certificates to chain fast-food to-go restaurants to mentally ill.
  • Self-Care During Isolation. Self-care is what will get us all through this “new normal.” There are ways to care for yourself and others even when physical distancing is critical to flattening the curve in this pandemic. Physical isolation does not mean that you cannot communicate with and connect with others.
    • We live in a time with technology that allows us to stay connected even if without a physical presence. Take the time to call and connect with friends and family that you normally see and maintain social connections.
    • Exercise is critical not only for mental health but also physical health.
    • Reconnect with nature. Go for walks, hikes, and run outside while maintaining physical distancing. Breathe. Take a moment to enjoy the calm and fresh air. Go outside and work in the yard, fly kites. Listen to music and dance.
    • Keep consistent house routines including regular bedtime, mealtimes, chore schedule, and exercise.
    • Utilize available online distance learning and educational activities for children.
    • Communities of faith and others should set up phone-trees to maintain contact with housebound mentally ill. Members of the public may know a family with a mentally ill family member. Offer to call and chat with the person.
  • Limit Fear. During this stressful period, television can be particularly traumatizing and so television exposure to individuals with mental illness should be limited. Try refocusing techniques like engaging in fun activities, games, or crafts.
  • Acknowledge Your Emotions. We all need to talk about our feelings, worries, and concerns. We need to acknowledge that these feelings are normal and talk about them. It is important for family members or caregivers to assist with promoting safety, fostering calm and comfort, promoting connectedness, and encouraging self-empowerment.
  • Seek Help When Needed. Call 1-(800) 753-6879 or text ALOHA to 741741.

3. What immediate preventive measures should I take in my clinic or site?

Train and Educate Healthcare Personnel

  • Provide staff and health care providers with job- or task-specific education and training on preventing transmission of infection agents, including refresher training.
  • Trainings and information can be found on the CDC Infection Control Training website.
  • Staff must be medically cleared, trained, and fit tested for respiratory protection device use (e.g., N95 filtering face piece respirators)
  • Ensure that staff are educated, trained, and have practiced the appropriate use of personal protective equipment (PPE) prior to caring for a patient, including attention to correct use of PPE and prevention of contamination of clothing, skin, and environment during the process of removing such equipment.

Screen Your Clients for COVID-19

For behavioral health providers:

  • A few days before appointment: If clients are scheduled to come into a behavioral health or homeless programs office or center, call them to remind them of the appointment in advance and ask them to reschedule if they are sick, have been exposed to someone with COVID-19, or have traveled off island in the past 2 weeks.
  • On the day of appointment: Ideally, every client should be screen upon entry into the office or site. Check the temperature of every individual entering a facility and sanitize the thermometer according to the instructions before each use. If possible, use a no-touch thermometer. Screenings should include the following questions:
    • Do you have any of the following symptoms?
      • Fever or chills
      • Dry cough
      • Shortness of breath
    • Have you traveled outside of the state in the past 14 days?
    • Have you had close contact with a person exhibiting the previously listed symptoms?
    • Have you had close contact with a person confirmed to have COVID-19 infection?
  • A sign should be posted on each site’s entrance with the screening questions above asking patients to call or alert the front desk if they are exhibiting any of those symptoms or fit the other screening criteria. The front desk number should be written on the sign.
    • For example: Aloha and welcome to [office name]! We are currently open by appointment only as we are working out of the office. Pleae call our front desk at [insert front desk number] to check in for or schedule your appointment. Before you come inside…If you or someone you ar with have a fever, have a cough and/or shortness of breath, have recently been with someone who has COVID-19 or the flu, or have traveled outside of the state in the last 14 days, please call our front desk and someone will help you right away.
  • Ideally, medical sites should have a screening log of patients where staff can document if appropriate screenings were done. Minimally it should have the date, patient name, and a column for whether the patient was screened, and whether that patient responded “Yes” to any of the screening criteria.
  • If a patient responds with “Yes” to any of the screening criteria staff should:
    • Ensure the providers and patient both have masks and providers undertake all necessary protections for PPE.
    • Ensure that the patient is isolated from others or in a well-ventilated area spaced at least six feet apart from others.
    • Ensure that the patient is assessed for telehealth services if possible.
    • Minimize the number of staff that are interacting with the patient.

For homeless service and shelter providers:

  • Upon entering a facility, ask every individual – client, staff, volunteer, or visitor – to report any symptoms of COVID-19.
  • A screening document has been developed to assist with identifying clients who may need to be isolated, triaged for testing, and triaged for immediate medical attention.
    • The screening document is available here:
  • Create a safe environment to allow disclosure of symptoms without penalty or stigma. Do not turn away clients merely because they have symptoms, but adhere to appropriate spatial distancing (see below on sleeping accommodations).

Screen Clients for Vulnerability and Behavioral Health Conditions

  • Screen patients if they have elevated risk during COVID-19 or are vulnerable (see below).
  • As part of standard procedures, continue screening for behavioral health conditions as part of your routine clinical workflow. Consider screening for other conditions such as depression, anxiety, or suicidality which may be exacerbated during this stressful period.

Provide Enhanced Support for Vulnerable Populations
All individuals are at risk of COVID-19, but some individuals are more vulnerable to severe COVID-19 with higher risk of death if they are infected. Hence, providers should make focused efforts to provide enhanced support for these vulnerable populations:

  • They have an underlying health condition such as diabetes, liver disease, kidney disease, cardiovascular disease, or other condition such as a mental health condition and substance use disorder;
  • They are seniors or are older individuals;
  • They are experiencing homelessness or at risk of experiencing homelessness;
  • They do not speak English or are limited-English speaking;
  • They are immune-compromised (including pregnancy); or
  • They have physical or other disabilities.

Protect the Waiting Room

  • Advise people to sit 6 feet apart (e.g., place chairs 6 ft apart).
  • Ensure that patients with symptoms consistent with COVID-19 or other respiratory infection are masked and isolated in private rooms.
  • In some settings, medically-stable patients may opt to wait in their cars or outside and contacted by mobile phone when it is their turn to be evaluated.

Communicate with Staff, Clients, and the Public

  • Post signs at entrances and in bathrooms sharing how staff and individuals can protect themselves and others at the facility.
  • Signs are available on the CDC website
  • Voicemail scripts for public-facing voicemails have been developed with information on the COVID-19 and how to ensure access to services:
    • Aloha, this is [Name and office site], if you are in a crisis, call Crisis Line of Hawaii at 1-800-753-6879. If you have a medical emergency, please call 911. Our offices are open by appointment only from 7:45am to 4:30pm, Monday thru Friday and closed on weekends and holidays. You received this message because we are unable to take your call. As a reminder, if you are sick with a cold or flu-like symptoms or have traveled out of the state in the last 14 days, please give us a call before coming in. If your symptoms are severe, please seek appropriate medical care. If you have questions about Coronavirus, a good source of the latest information is the Department of Health website https://hawaiicovid19.com. Please leave a message after the tone. Thank you.
  • Incorporate mental health messages to facilitate recovery and encourage self care (see above).
  • Whenever possible and appropriate, facilitated meetings (e.g., treatment team meetings, community meetings, workgroups) should be conducted by phone or Zoom.
  • Encourage clients to participate in the same everyday protections.
  • Ensure that your office has an up-to-date emergency phone tree and ensure that your staff are familiar with the process.
  • The state has developed responses for various labor-related issues associated with COVID-19.
  • Encourage staff to ask questions and respond to the best of your ability.
  • Talk with your coworkers about official COVID-19 updates as they arise.

4. How will BHH providers ensure continuity of services for our clients?

All Behavioral Health Services are Essential

  • Behavioral health and homelessness (BHH) services are essential. These services are essential for overall well-being during times of calm but especially during times of anxiety such as during a pandemic. As part of our BHH ʻohana, we all bear the crucial kuleana to facilitate access to such services.
  • Mental health and substance use services are essential not only for current clients, but also because of new clients as a result of the pandemic, e.g. bereavement, depression, post-traumatic stress disorder, and substance use when friends or relatives become seriously ill or die. Mental health professionals and social workers are essential to help reduce panic associated with a pandemic.
  • Homelessness services are essential during a pandemic as these populations are often the most vulnerable and at risk.

Providers are Called to Ensure Continuity of Care

  • Especially during an emergency period or an epidemic, staff and providers of behavioral health and homelessness services is called to serve in ensuring access to all these essential services. Behavioral health and homelessness services are asked to continue to operate with continuous coverage as much as possible and to make use of telehealth and other non- Face to Face options where you are able. During this period, staff and providers should make all efforts to maintain minimum levels of coverage where they are able.
  • Staff and provider safety is of utmost importance. We ask all to be mindful of the safety and protection of clients and staff through maximum physical distancing and hygiene practices and implement necessary preventive, containment, and mitigation measures to reduce the spread of COVID-19.
  • This guidance will be reassessed on a regular basis and adjusted accordingly.

Revamp Behavioral Health Group Therapy Models for Face-to-Face Services
In residential treatment centers, people may congregate in small or crowded spaces. For patients lacking telehealth connectivity, consider ways to mitigate exposure and spread of COVID19:

  • Minimize number of people per group: Seek to control the spread of COVID-19 by converting behavioral therapy conducted in groups of more than 10 people to groups of no more than 5 people per group or when feasible into individual therapy.
  • Find a large well-ventilated space: All therapy should be held in a large well-ventilated room or outdoors or otherwise with adequate physical distancing between all individuals participating in the therapy.
  • Appropriately shift to patient-centered use of telehealth services (see below).

Ensure Access to Medications

  • Follow-up with patient’s medication stock: With the risk of lockdown and quarantine and with limited capacity by patients for self-care, providers should seek to follow-up with patients on the adequacy of their medication stock.
  • Seek exceptions to OTPs: Most patients on an Opioid Treatment Program (OTP) are required to come in daily to receive their medications. As a provider, you may seek individual or blanket exceptions from SAMHSA to decrease pickup schedules and reduce the number of in-person visits. Go to these links to make those requests and view official guidance:
  • Telemedicine for controlled substances:
    • After the US Secretary of Health Azar designated a public health emergency on January 31, 2020, DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation under certain conditions.
    • For more information, see DEA Diversion on Coronavirus
  • Withdrawal symptoms: The Hawaii Health and Harm Reduction Center (HHHRC) has developed excellent guidance around substance detox and withdrawal procedures available here: HHHRC Detox & Withdrawal Protocols

Make Telehealth Services an Option for Patients

  • Telehealth services are generally allowable: Some clients may wish to use telehealth services rather than in-person visits in order to maximize physical distancing in an epidemic. Telehealth services are allowable and approved for both direct providers in BHH as well as providers contracted by BHH. Effective immediately, BHH providers and staff should offer telehealth services as an option to all patients while ensuring continuity of coverage of all services.
  • Circumstances under which telehealth services are allowable: BHH will continue to provide patient-centered care, which means that care that is tailored to a patient’s needs and circumstances. BHHwill seek to offer patient-centered care through telehealth services by its state-operated providers and contracted providers under the following circumstances:
    • only when a patient has telehealth connectivity and prefers telehealth consultation, and
    • if the visit can be safely rescheduled or moved into telehealth platforms or into telephones without significant impact to patient health over a two-month period.
  • Identify clients who may not have access to technology: Some of BHA’s most vulnerable clients may not have access to technology, such as smart phones or other devices, that would allow them to receive services virtually. Enhanced efforts should be made to ensure these clients still access services either in person with adequate physical distancing or with other arrangements made for these clients.
  • Refer to BHA and division standard operating procedures for providing telehealth services to clients:
    • For ADAD: Currently, ADAD providers are not providing this service. Due to this pandemic emergency ADAD is encouraging providers to utilize telehealth. ADAD is working with SAMHSA for guidelines to develop policies and procedures so providers would be able to continue to utilize telehealth services even after this pandemic emergency.
    • For AMHD: Refer to CMHC telepsychiatry P and P.
    • For the CAMHD, telehealth guidelines are listed in the Teal Book, page I-11.
    • For DDD: Currently, DDD providers through the 1915(c) Waiver do not provide this service. The DDD is working on an emergency response amendment (1135 Waiver, Appendix K) through CMS and if approved telehealth could be an option for providers and case managers to use during the pandemic emergency.
  • General principles for offering telehealth services:
    • Providers should inform families of the risks and benefits of using telehealth. The risks include that clinical important information could be missed due to not being physically present with the clinician.
    • A conventional consent form for services is required for all treatment. Telehealth can be added as a service modality to your existing form. On a temporary basis verbal consent may be documented in a service note, with the date, guardian name, and documenter name. Sample: “The family agrees to services offered via telehealth, defined as secure video and audio, in addition to in-person sessions.”
    • Ensure that your work-provided laptop has appropriate VPN configurations to access EMRs and other important and confidential client information.
      • AMHD and CAMHD are providing Zoom licenses for all interested providers and can be requested through helpdesk.
      • CAMHD: (808) 733-9309 or [email protected]
      • AMHD: 236-8291 or [email protected]
    • Adhere to federal statutes (HIPAA, 42 CFR Part 2) regarding patient privacy and security. See guidance below regarding HIPAA and 42 CFR Part 2 considerations during the emergency period declared by the federal government. Briefly, during the COVID-19 nationwide public health emergency, providers can use any non-public facing remote communication tool (Zoom, FaceTime, Skype) to communicate with patients to provide telehealth without risk that OCR might seek to impose a penalty for noncompliance with the HIPAA Rules related to the good faith provision of telehealth during the COVID-19 nationwide public health emergency. Providers should notify patients that these third-party applications potentially introduce privacy risks, and providers should enable all available encryption and privacy modes when using such applications. Please reference: Notification of Enforcement Discretion for telehealth remote communications during the COVID-19 nationwide public health emergency

Providers may bill for telehealth services:

  • All telehealth services are allowable and expanded use of telehealth for as many procedures and services as possible are encouraged. Unless specifically established otherwise, telehealth services may be billed as if they were face to face within contract parameters.
  • As a payer of health services, BHA divisions and other BHH-SURG payors may choose to establish and calibrate telehealth billing policies and procedures as needed.
  • As a provider of health services, BHA providers who bill MedQUEST to seek reimbursement for telehealth services should follow MedQUEST policies and procedures regarding telehealth reimbursement, such as:
    • Adhering to State of Hawaiʻi definition of telehealth of sessions having both audio and video. Audio alone is not sufficient for billing services as telehealth.
    • Billing appropriately using CPT and HCPCS codes for telehealth services. See MedQUEST attachment on eligible CPT and HCPCS billing codes here:
    • At this time, we are unaware of when audio calls without video are reimbursable by payors including MedQUEST.
  • All HPO services are essential. HPO will allow the option of providing homeless outreach and case management for applicable services telephonically for regularly scheduled appointments, check ins, and follow up services. For households without access to a phone homeless outreach providers are to set up drop-in centers near identified encampments and/or partner with other government agencies to assist with administering services.
  • Training staff to conduct telehealth services:
    • There are many resources available for telepsychiatry and telehealth that providers can consult, including from American Psychiatric Association Telepsychiatry resources, best practices, and toolkits and the Pacific Basin Telehealth Resource Center based at the University of Hawaii.
    • In coordination with relevant experts and partners, BHA will offer training to direct providers and contracted providers for the use of telehealth services to rapidly train providers to:
      • Basic clinic flow (if needed)
      • Basic equipment i.e. smartphone, tablet, laptop or desktop computer connected with a camera and microphone
      • Rapid training – quick and short training videos

Re-examine Visitation Policies

  • All behavioral health services are essential and continuity of care must be maintained in the best interest of the patient, not the convenience of staff.
  • All behavioral health services are essential and continuity of care must be maintained in the best interest of the patient, not the convenience of staff.
  • During the initial 15-day period issued by Governor Ige and until otherwise notified, providers are encouraged to work with clients to reschedule other client and/or family visits if family members or clients are sick.
  • Specific BHA Site Visitation Policies:
    • For youth at the detention home or Hawaii Youth Correctional Facility: No family or outside visitors are allowed at this time.
    • For clients at the Hawaii State Hospital: No family or outside visitors, other than those state workers deemed “essential” (e.g., case managers, court evaluators) are allowed at this time.
    • Dental Clinics (Diamond Head Health Center, Lanakila Health Center, Leeward Health Center, Windward Health Center, Hawaii State Hospital) – Postponing all elective dental procedures from March 17 to April 8, 2020. All Clinics are still open and will only provide emergency (emergent/urgent) dental care for patients. Emergency care includes but are not limited to dental pain or trauma, swelling, and infections. This was based upon the American Dental Association’s recommendation to all dental offices and clinics (03/16/20). Staffing is maintained in the ordinary course of business. Postponing all elective dental procedures from March 17 to April 8, 2020. All Clinics are still open and will only provide emergency (emergent/urgent) dental care for patients. Emergency care includes but are not limited to dental pain or trauma, swelling, and infections. This was based upon the American Dental Association’s recommendation to all dental offices and clinics (03/16/20). Staffing is maintained in the ordinary course of business.

5. How do we identify whether staff are providing an “essential” function or “nonessential” function?

  • As noted above, all behavioral health and homelessness care services are essential. To that end, all staff needed to ensure continuity of coverage for the provision of behavioral health services are therefore essential.
  • During this period and especially as the situation prolongs, BHH providers should not reduce access to services, but rather maintain levels of access to services, if not expand access as demand grows.
  • Each division head should identify which staff may have “essential” functions to ensure continuity of coverage. DOH has released telework guidance for staff which have “nonessential” functions (see below).We also recommend that decisions regarding which staff are considered “essential” and “nonessential” are made by provider organizations.
  • Please note that although all behavioral health and homelessness care services are essential, some staff have “essential” functions which require them to be in the office whereas some have “nonessential” functions, which require them to continue to telework.

Personnel in Critical Infrastructure Positions

  • Some personnel fill critical infrastructure roles within communities. Based on the needs of individual jurisdictions, and at the discretion of state or local health authorities, these personnel may be permitted to continue work following potential exposure to SARS-CoV-2 (either travel-associated or close contact to a confirmed case), provided they remain asymptomatic.
  • Persons in these essential positions will be notified they are in these critical roles.
  • Persons in these essential positions will be notified they are in these critical roles.
  • Personnel who are permitted to work following an exposure should self-monitor under the supervision of their employer’s occupational health program including taking their temperature before each work shift to ensure they remain afebrile. On days these individuals are scheduled to work, the employer’s occupational health program could consider measuring temperature and assessing symptoms prior to their starting work. Exposed healthcare personnel who are considered part of critical infrastructure should follow existing CDC guidance.

6. How does telework affect HDOH behavioral health services provided?

Emergency remote work/telework in response to social distancing and the COVID-19 pandemic should be done wherever possible. Programs are encouraged to identify essential vs no-essential staff as a way toward mitigating prolonged contact. Generally:

  • “Essential” employees are required to report to their worksite and continue to perform work as usual. They may be able to perform work remotely if deemed appropriate by their supervisor.
  • “Nonessential” employees that can telework should work from their alternate/remote worksite for this specific period, follow their normal working hours, and follow their supervisor’s direction. They may be directed by their supervisor to report to the work if the situation changes and/or be reassigned other duties within their job description and classification that can be completed remotely.
  • As much as possible, programs and centers should welcome visitors by appointment only. Face to Face services should be limited to those activities that are not feasible to conduct remotely or through telehealth options. HIPAA and 42 CFR restrictions have been significantly relaxed for these purposes.
  • As much as possible, work to hold all meetings by phone or video conference (e.g., treatment team meetings, community meetings, workgroups).
  • For those employees deemed eligible for telework, ensure supervisors have a plan to manage those employee’s workload, then have them meet with the employee to inform them of the situation and your expectations.
  • Alcohol & Drug Abuse Division (ADAD)
    • ADAD Administration released guidance on Thursday, March 19, 2020 to all staff: “All ADAD team members unless you have been specifically designated otherwise by your supervisor are, for the purposes of responding to Governor Ige’s 15 Days to Slow the Spread of COVID-19, deemed “nonessential” and are assigned to TELEWORK from home starting no later than 4:30pm Friday, March 20th, 2020.
    • Staff that were deemed “nonessential” are responsible to sign the remote work acknowledgement form and submit to your supervisor.
  • Adult Mental Health Division (AMHD)
    • AMHD Administration released guidance on Thursday, March 19, 2020 to all staff: “All AMHD team members assigned to work at Kinau Hale, Waimano/Hale F, CEB, and TSS clinics/Clubhouses, unless you have been specifically designated otherwise by your supervisor are, for the purposes of responding to Governor Ige’s 15 Days to Slow the Spread of COVID-19, deemed “nonessential” and are assigned to telework from home starting no later than 4:30pm Friday, March 20th, 2020.
  • Child & Adolescent Mental Health Division (CAMHD)
    • As of Friday, March 20, 2020, all Family Guidance Centers will welcome visitors by appointment only. Most staff are teleworking and can continue to be reached by phone, email or the main Family Guidance Center line. We unfortunately do not have HIPAA complaint drop boxes at all sites, so we humbly ask that you mail or fax necessary documents.
    • We will work to hold all meetings by phone or video conference (e.g., treatment team meetings, community meetings, workgroups).
    • If you have questions, please do not hesitate to reach out to Provider Liaison, Carol Evans via email or 808-733-9857.
  • Developmental Disabilities Division (DDD)
    • DDD Administration released guidance on Thursday, March 19, 2020, to all DDD staff: For the duration of the COVID-19 state of emergency, Governor Ige has directed the Departments to identify employees as:
    • “Essential” employees who will work either at their work site, or if approved, from an alternative worksite (like home) using telework, or both. Some “essential” employees can only work at their work site as their function can only be provided there. All “essential” worker will be asked to sign the agreements referenced below in the event their work may move to telework at some point. By signing the agreement, it does not mean you will be working from an alternate site.
    • “Nonessential” employees who will work performing their duties via telework exclusively. These employees perform work on state-issued or their own devices. Our IT staff is working with people to ensure they have the connectivity they need to access O365 and/or INSPIRE.
    • “Nonessential” employees who will be assigned other duties in their position description because they can’t perform the duties they would at work during this time.
    • Your supervisors will discuss your designation and work assignments with you. The Department is maintaining continuity of services to every extent possible. We are implementing social distancing to ensure the health and safety of our community. Please note that the fluidity of the situation may change the working conditions.
    • An eSign of the Public Health/State of Emergency Remote Work Acknowledgement form is forthcoming. Please complete and eSign. The approval for telework will be approved by the Department.
    • If you have any questions, please discuss with your supervisor. If your supervisors need clarification, please communicate through the chain of command.
  • Governor’s Coordinator for Homelessness (GCH)
    • Effective March 18, 2020, staff of the Governor’s Coordinator on Homelessness are working remotely. The office can be reached at (808) 586-0193 or by email.
    • Daily shelter vacancy reports will continue to be sent out and staff will continue to be available for issues related to Ohana Zones contract monitoring and oversight.

7. Which HDOH behavioral health services can be provided remotely?

Behavioral health and homelessness services are essential and all providers in this system of care help ensure continuity of coverage of all services, either in person or through telehealth. BHH-SURG will continue to identify and issue subsequent guidance on which services can potentially be done remotely through telehealth arrangements. Again, some in-person services must still be offered in order to ensure patient-centered continuity of care for vulnerable patients or patients without connectivity.

All ADAD Substance Use Disorder (SUD) Continuity of Care (COC) Contracted Services are Essential
Contracted SUD COC providers are highly encouraged to utilize the broadened methods of ensuring continuity of services as listed above based on the providers capacity to deliver services while ensuring the safety of their staff and clients.

  • Hawaii CARES Line
  • Residential Programs
  • Day Treatment Programs
  • Intensive Outpatient Programs
  • Outpatient Treatment Programs
  • Therapeutic Living Programs
  • Residential Social Detoxification Programs
  • Methadone Maintenance Outpatient Programs
  • Clean and Sober Housing
  • Care Coordination
  • Pretreatment Services
  • Assessments>
  • Outreach Services
  • Early Intervention
  • Recovery Support Services
  • Opioid Treatment Program

All AMHD Mental Health Services are Essential
Essential mental health services include inpatient care as well as outpatient services (early identification and treatment, counselling, access to medications, and mental health promotion and prevention activities).

  • Hawaii State Hospital
  • State-operated Specialized Residential Services Program (SOSRP)
  • License Crisis Residential Services (LCRS)
  • 24/7 Crisis Line
  • Crisis Mobile Outreach
  • Crisis Support Management
  • Court Evaluation Services
  • Clubhouse
  • Day Treatment
  • Peer Specialists
  • Contracted Services
  • Supported Employment
  • Supported Education
  • Case Management Services
  • Community-based
  • Intensive (non-homeless)
  • Intensive (homeless)

All AMHD Housing Services are Essential

  • Specialized Residential Services Program (SRSP)
  • Therapeutic Living Programs (TLP)
  • Semi-independent Housing
  • 24-hour group homes
  • 8-16 hour group homes
  • Transitional housing
  • E-ARCH

All CAMHD Services are Essential
We expect that all levels of care will continue to serve clients to the best of their abilities in the current pandemic.

  • Crisis Mobile Outreach
  • Assessment
  • In-Home Treatment Programs
  • Out-of-Home Treatment Programs
  • Out-of-State Services
  • Family Court Liaison Branch Services

All DDD Services are Essential
All DDD services can be done via Telework

  • Case Management – Individualized Service Plans (ISPs), Quarterly Face-to-Face meetings, process changes to the supports budgets during pandemic per emergency waiver allowance.
  • Family Services and Support Program
  • Neurotrauma HelpLine
  • Communication to Providers
  • Waiver Renewal

8. How is HDOH service-related client and family travel affected by COVID-19?

All client travel is suspended until further notice, except for travel for placement or discharge – which requires approval by the Director of Health. At this time, we cannot authorize home passes or therapeutic treatment visits and it is advised those be done over video.

9. What are relevant practice changes from other partners within the system of care?

Child Welfare Service (CWS): CWS workers have been instructed to arrange all visitations via telecommunications.

Department of Education: Schools within residential programs will continue to be on leave through April 6th. The Department of Education is currently working on plans to offer virtual instruction after that.

10. What is HDOH BHA’s role in providing psychosocial support during an emergency or pandemic?

Self-Care Packets for Clients: BHA in partnership with partners may develop self-care packets which contains signs and symptoms of stress reactions and post-traumatic stress disorder, directory or phone list of key behavioral health contacts, self-help support, and tailored clinical self-care plan in the event of being homebound or clinic closure which also contains a client’s contact info for their social supports.

Training for First Responders: BHH in partnership with EMS and other partners may develop psychological-support training to all first responders and law enforcement providers, health care providers, and other individuals who are not mental health professionals. This training may cover anxiety; coping skills; delivering bad news; and self-care.

11. How do we implement infection control measures?

Protect Frontline Workers

  • Frontline workers are those who engage with clients within a 6-foot distance. These workers need to be prepared to protect themselves and their clients, provide health education information, and help direct their clients to care as necessary (see box).
  • Staff interacting with symptomatic clients (see below) should wear face masks with face shields. If face shields are unavailable, wear a regular face masks plus reusable protective goggles and sanitize the goggles after each use.
  • When feasible, employers should limit which staff interact with patients presenting with symptoms or with those rooms assigned for those with symptoms. Staff interacting with patients should wear PPE.
  • Check for the latest CDC guidelines on PPE including how to don and doff PPE.

Ensure Adequate Stocks of PPE

  • Assess current stock of PPE including masks, face shields, gloves, tissues, alcohol-based hand sanitizer, and soap.
  • Provide supplies for respiratory hygiene and cough etiquette, including at least 60% alcohol-based hand sanitizer, tissues, no touch receptacles for disposal, and facemasks at entrances, waiting rooms, and patient check-ins.
  • If there is a shortage of masks, alternatives such as bandanas, towels, handkerchiefs, scarves, and other clothes that are routinely washed each day can be used if properly covering both the mouth and nose.
  • Soap and water are adequate even in the absence of alcohol-based hand sanitizer.
  • If toilets or handwashing facilities are not available nearby, provide access to portable latrines with handwashing facilities for encampments of more than 10 people.

Ensure Facility Hygiene and Maximum Physical Distancing

  • Maintain facility hygiene through frequent disinfection and implementation of maximum physical distancing between clients.
  • Disinfect any room where an individual with symptoms has occupied. You can use household chlorine bleach diluted in water (about 5 tablespoons per gallon of water), alcohol solutions, or most common EPA-registered household disinfectants.
  • For clients with mild symptoms, ensure maximum physical distancing through:
    • An isolated room; or
    • Creating physical barriers or buffers using curtains; and
    • Pursuing a “head-to-toe” sleeping arrangement.
    • Refer to guidance below on when to refer clients and workers for testing.

Refrain from Clearing Encampments

  • Unless individual housing units are available, refrain from clearing encampments during community spread of COVID-19. Clearing encampments can cause people to disperse throughout the community and break connections with service providers. This increases the spread for infectious disease. All populations should be encouraged to shelter in place in locations with adequate ventilation and maximum physical distancing.
  • Encourage people staying in encampments to set up their tents/sleeping quarters with at least 12 feet x 12 feet of space per individual.
  • Ensure nearby restroom facilities have functional water taps, are stocked with hand hygiene materials (soap, drying materials) and bath tissue, and remain open to people experiencing homelessness 24 hours per day.
  • If toilets or handwashing facilities are not available nearby, provide access to portable latrines with handwashing facilities for encampments of more than 10 people.

12. Where can I access our continuity plan?

Guidance and links to be provided.

13. How do we refer our clients to receive appropriate testing for COVID-19?

If your client meets the following criteria, they should be referred for testing to private labs or DOH for testing. The criteria for testing continue to get updated over time.

Clinical features for referring clients to receive appropriate testing for COVID-19.

Credit: Queen’s Medical Center

14. If my client meets the criteria for testing, should I transport my client?

If your client meets the criteria for testing, case managers should not provide transport to clients to prevent possible exposure and spread of COVID-19. Case managers should arrange for transportation through emergency medical services.

15. If my client does not need to get tested, may I transport my client?

If your client does not meet the criteria for testing, then you may still transport your client. In that situation:

  • The frontline worker should wear a mask and gloves
  • Ensure that your client puts on a face mask snugly
  • Transport your patient for the service that they need
  • Perform hand hygiene and sanitize the vehicle after transportation

16. What are the privacy rules if a client discloses that they have COVID-19?

42 CFR Part 2

  • Waiver: Pursuant to both federal and state declarations of the state of emergency, SAMHSA has deemed that the COVID-19 is a bona fide medical emergency that justifiably inhibits normal procedures required to obtain written patient consent. COVID-19 pandemic is therefore a bona fide emergency that allows providers to release information to medical personnel without consent if necessary.
  • Obtaining consent: Providers should nevertheless make an effort to keep their clients informed, including obtaining verbal consent and informing the patient of how their information was obtained/disclosed.
  • Typical documentation needed: Providers must nevertheless document in the patient’s record the name and affiliation of the medical personnel receiving the information, the name of the individual making the disclosure, the date and time of the disclosure, and the nature of the emergency. See this SAMHSA resource for more information.
  • HIPAA

    • HIPAA Privacy Rule recognizes the legitimate need for public health authorities and others responsible for ensuring public health and safety to have access to protected health information that is necessary to carry out their public health mission. Therefore, the Privacy Rule permits covered entities to disclose needed protected health information without individual authorization:
    • To a public health authority, such as the CDC or the DOH that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury or disability. This would include the reporting of disease or injury; reporting vital events, such as births or deaths; and conducting public health surveillance, investigations, or interventions.
    • To persons at risk of contracting or spreading a disease or condition if other law, such as state law, authorizes the covered entity to notify such persons as necessary to prevent or control the spread of the disease or otherwise to carry out public health interventions or investigations. See 45 CFR 164.512(b)(1)(iv).
    • For health care providers, Secretary of the U.S. Department of Health and Human Services (HHS) Alex M. Azar declared a public health emergency on January 31, 2020, and exercised the authority to waive sanctions and penalties against a covered hospital that does not comply with selected provisions of the HIPAA Privacy Rule for hospitals only. See here for more information on the limited waiver of the Privacy Rule.
    • HIPAA applies only to health care providers or providers performing a health care services or function including billing for health care services.

    17. What if a client who visited my site/my office/my program is found to be infected with COVID-19?

    • If your client is later confirmed to have COVID-19 and if the case manager develops either a fever or other respiratory symptoms, the case manager should seek testing as they fulfill the criteria noted above.
    • Identify which staff was in close contact with the client (within 6 feet for a prolonged period) and:
      • Notify those staff.
      • Inform them of the testing criteria (i.e. if they have at least one symptom).
      • If these staff have at least one, they should get tested.
      • Refer to CDC guidelines for hygiene.
      • Clean all frequently touched surfaces in the workplace, such as workstations, countertops and doorknobs. Use regular cleaners and follow the directions on the label.

    18. What if a staff member is exposed to or diagnosed with COVID-19?

    • Exposed health care workers are considered part of critical infrastructure and should follow existing CDC guidance.
    • If your staff member fulfills the criteria for testing because of contact with a confirmed COVID-19 case and displays at least one symptom (see criteria above), then they should be tested.
    • If your staff member was in close contact (within 6 feet for a prolonged period) but is asymptomatic, then they do not need to be tested though they should continuously self-monitor their symptoms. This staff member may continue to work provided they remain asymptomatic. This staff member should self-monitor including taking their temperature before each work shift.

     

    Appendices of Selected Guidance on Federal Statute

    APPENDIX 1: GUIDANCE ON TELEMEDICINE FROM THE US DRUG ENFORCEMENT AGENCY (DEA)

    Question: Can telemedicine now be used under the conditions outlined in Title 21, United States Code (U.S.C.), Section 802(54)(D)?

    Answer: Yes

    While a prescription for a controlled substance issued by means of the Internet (including telemedicine) must generally be predicated on an in-person medical evaluation (21 U.S.C. 829(e)), the Controlled Substances Act contains certain exceptions to this requirement.

    One such exception occurs when the Secretary of Health and Human Services has declared a public health emergency under 42 U.S.C. 247d (section 319 of the Public Health Service Act), as set forth in 21 U.S.C. 802(54)(D). Secretary Azar declared such a public health emergency with regard to COVID-19 on January 31, 2020. For as long as the Secretary’s designation of a public health emergency remains in effect, DEA-registered practitioners may issue prescriptions for controlled substances to patients for whom they have not conducted an in-person medical evaluation, provided all of the following conditions are met:

    • The prescription is issued for a legitimate medical purpose by a practitioner acting in the usual course of his/her professional practice.
    • The telemedicine communication is conducted using an audio-visual, real-time, two- way interactive communication system.
    • The practitioner is acting in accordance with applicable Federal and State law.

    Provided the practitioner satisfies the above requirements, the practitioner may issue the prescription using any of the methods of prescribing currently available and in the manner set forth in the DEA regulations. Thus, the practitioner may issue a prescription either electronically (for schedules II-V) or by calling in an emergency schedule II prescription to the pharmacy, or by calling in a schedule III-V prescription to the pharmacy.

    Important note: If the prescribing practitioner has previously conducted an in-person medical evaluation of the patient, the practitioner may issue a prescription for a controlled substance after having communicated with the patient via telemedicine, or any other means, regardless of whether a public health emergency has been declared by the Secretary of Health and Human Services, so long as the prescription is issued for a legitimate medical purpose and the practitioner is acting in the usual course of his/her professional practice. In addition, for the prescription to be valid, the practitioner must comply with any applicable State laws.

    APPENDIX 2: GUIDANCE ON OPIOID TREATMENT PROGRAM (OTP) FROM SAMHSA

    Opioid Treatment Programs may:

    • Request from SAMHSA a blanket exception for all stable patients in an OTP to receive 28 days of Take-Home doses of the patient’s medication for opioid use disorder; and
    • Request from SAMHSA 14 days of Take-Home medication for those patients who are less stable but who the OTP believes can safely handle this level of Take-Home medication.

    As of March 19, 2020, agency-wide requests may be submitted through the SAMHSA OTP extranet website.

    For any blanket exception requests, OTP medical directors must also please include details about agencies policies and procedures, including but not limited to, changes in urine drug screen frequency, changes in counseling frequency, rationale for changing phase requirements for each phase of treatment, and plans for handling patients in crisis and/or relapse situations. Any large-scale exception request must not be for more than a two-week period. Renewal of large-scale exception requests must be resubmitted shortly before the expiration of the approved exception request. OTP medical directors must explicitly state detailed rationale for providing a renewal for these requests.

    APPENDIX 3: GUIDANCE ON HIPAA PRIVACY AND COVID-19 FROM HHS

    In response to President Donald J. Trump’s declaration of a nationwide emergency concerning COVID-19, and Secretary of the U.S. Department of Health and Human Services (HHS) Alex M. Azar’s earlier declaration of a public health emergency on January 31, 2020, Secretary Azar has exercised the authority to waive sanctions and penalties against a covered hospital that does not comply with the following provisions of the HIPAA Privacy Rule:

    • The requirements to obtain a patient’s agreement to speak with family members or friends involved in The patient’s care. See 45 CFR 164.510(b).
    • the requirement to honor a request to opt out of the facility directory. See 45 CFR 164.510(a).
    • The requirement to distribute a notice of privacy practices. See 45 CFR 164.520.
    • The patient’s right to request privacy restrictions. See 45 CFR 164.522(a).
    • The patient’s right to request confidential communications. See 45 CFR 164.522(b).
    • The waiver became effective on March 15, 2020. When the Secretary issues such a waiver, it only applies: (1) in the emergency area identified in the public health emergency declaration; (2) to hospitals that have instituted a disaster protocol; and (3) for up to 72 hours from the time the hospital implements its disaster protocol. When the Presidential or Secretarial declaration terminates, a hospital must then comply with all the requirements of the Privacy Rule for any patient still under its care, even if 72 hours have not elapsed since implementation of its disaster protocol.

      Sharing Patient Information

      Treatment Under the Privacy Rule, covered entities may disclose, without a patient’s authorization, protected health information about the patient as necessary to treat the patient or to treat a different patient. Treatment includes the coordination or management of health care and related services by one or more health care providers and others, consultation between providers, and the referral of patients for treatment. See 45 CFR §§ 164.502(a)(1)(ii), 164.506(c), and the definition of “treatment” at 164.501.

      Public Health Activities The HIPAA Privacy Rule recognizes the legitimate need for public health authorities and others responsible for ensuring public health and safety to have access to protected health information that is necessary to carry out their public health mission. Therefore, the Privacy Rule permits covered entities to disclose needed protected health information without individual authorization:

      • To a public health authority, such as the CDC or a state health department such as the Hawaii State Department of Health (HDOH), that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury or disability. This would include, for example, the reporting of disease or injury; reporting vital events, such as births or deaths; and conducting public health surveillance, investigations, or interventions.
      • To persons at risk of contracting or spreading a disease or condition if other law, such as state law, authorizes the covered entity to notify such persons as necessary to prevent or control the spread of the disease or otherwise to carry out public health interventions or investigations. See 45 CFR 164.512(b)(1)(iv).

      Disclosures to Family, Friends, and Others Involved in an Individual’s Care and for Notification A covered entity may share protected health information with a patient’s family members, relatives, friends, or other persons identified by the patient as involved in the patient’s care. A covered entity also may share information about a patient as necessary to identify, locate, and notify family members, guardians, or anyone else responsible for the patient’s care, of the patient’s location, general condition, or death. This may include, where necessary to notify family members and others, the police, the press, or the public at large. See 45 CFR 164.510(b).

      • The covered entity should get verbal permission from individuals or otherwise be able to reasonably infer that the patient does not object, when possible; if the individual is incapacitated or not available, covered entities may share information for these purposes if, in their professional judgment, doing so is in the patient’s best interest.
      • For patients who are unconscious or incapacitated: A health care provider may share relevant information about the patient with family, friends, or others involved in the patient’s care or payment for care, if the health care provider determines, based on professional judgment, that doing so is in the best interests of the patient. For example, a provider may determine that it is in the best interests of an elderly patient to share relevant information with the patient’s adult child, but generally could not share unrelated information about the patient’s medical history without permission.
      • In addition, a covered entity may share protected health information with disaster relief organizations that, like the American Red Cross, are authorized by law or by their charters to assist in disaster relief efforts, for the purpose of coordinating the notification of family members or other persons involved in the patient’s care, of the patient’s location, general condition, or death. It is unnecessary to obtain a patient’s permission to share the information in this situation if doing so would interfere with the organization’s ability to respond to the emergency.

      Disclosures to Prevent a Serious and Imminent Threat Health care providers may share patient information with anyone as necessary to prevent or lessen a serious and imminent threat to the health and safety of a person or the public – consistent with applicable law (such as state statutes, regulations, or case law) and the provider’s standards of ethical conduct. See 45 CFR 164.512(j). Thus, providers may disclose a patient’s health information to anyone who is in a position to prevent or lesson the serious and imminent threat, including family, friends, caregivers, and law enforcement without a patient’s permission. HIPAA expressly defers to the professional judgment of health professionals in making determinations about the nature and severity of the threat to health and safety. See 45 CFR 164.512(j).

      Disclosures to the Media or Others Not Involved in the Care of the Patient/Notification In general, affirmative reporting to the media or the public at large about an identifiable patient may not be done without the patient’s written authorization (or the written authorization of a personal representative who is a person legally authorized to make health care.

      Minimum Necessary For most disclosures, a covered entity must make reasonable efforts to limit the information disclosed to that which is the “minimum necessary” to accomplish the purpose. (Minimum necessary requirements do not apply to disclosures to health care providers for treatment purposes.) Covered entities may rely on representations from a public health authority such as HDOH that the requested information is the minimum necessary for the purpose, when that reliance is reasonable under the circumstances.

      Safeguarding Patient Information

      In an emergency situation, covered entities must continue to implement reasonable safeguards to protect patient information against intentional or unintentional impermissible uses and disclosures. Further, covered entities (and their business associates) must apply the administrative, physical, and technical safeguards of the HIPAA Security Rule to electronic protected health information.

      Other Resources

      For more information on HIPAA and Public Health, please visit: https://www.hhs.gov/hipaa/for-professionals/special-topics/public-health/index.html

      For more information on HIPAA and Emergency Preparedness, Planning, and Response, please visit: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency- preparedness/index.html

      General information on understanding the HIPAA Privacy Rule may be found at: https://www.hhs.gov/hipaa/for-professionals/privacy/index.html

      For information regarding how Federal civil rights laws apply in an emergency, please visit:
      https://www.hhs.gov/civil-rights/for-individuals/special-topics/emergency- preparedness/index.html

    APPENDIX 4: GUIDANCE ON 42 CFR PART 2 GUIDANCE FROM SAMHSA

    GOAL:

    • Many substance use disorder treatment provider offices are temporarily closed, or patients are not able to present for treatment services in person.
    • There is a need for telehealth services, and in some areas without adequate telehealth technology, providers are offering telephonic consultations to patients.
    • As a result of telehealth consultations, health care providers may not be able to obtain written patient consent for disclosure of substance use disorder records.

    SAMHSA GUIDANCE ON 42 CFR PART 2:

    • The prohibitions on use and disclosure of patient identifying information under 42 C.F.R. Part 2 would not apply in these situations to the extent that, as determined by the provider(s), a medical emergency exists.
    • Under 42 U.S.C. §290dd-2(b)(2)(A) and 42 C.F.R. §2.51, patient identifying information may be disclosed by a part 2 program or other lawful holder to medical personnel, without patient consent, to the extent necessary to meet a bona fide medical emergency in which the patient’s prior informed consent cannot be obtained. Information disclosed to the medical personnel who are treating such a medical emergency may be re-disclosed by such personnel for treatment purposes as needed. We note that Part 2 requires programs to document certain information in their records after a disclosure is made pursuant to the medical emergency exception. We emphasize that, under the medical emergency exception, providers make their own determinations whether a bona fide medical emergency exists for purposes of providing needed treatment to patients.

     

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    BHHSURG on COVD-19 question and feedback form.

     

    Last reviewed on March 26, 2020