Mental Health All-Hazards Disaster Planning Guidance

PART THREE - PLAN CONTENT

In creating this document, extensive consideration was given to whether States should be encouraged to follow a common approach or to create their own design and content. No current authority requires States to adopt a single, uniform conceptual model; there is merit to unique approaches. However, there was consensus that States should be encouraged to follow a consistent content format and conceptual model based on the FEMA-supported all-hazards approach, which is being universally utilized by SEMAs. It was agreed this common approach will enhance the integration of SEMA planning and operations as well as cross-State collaboration — both important values in this endeavor. However, within this common model there is significant opportunity for States to devise and implement plans reflecting their particular needs, characteristics, and unique and creative approaches.

It also should be noted that SMHAs vary considerably in the programs that are included in the agency, as well as how they are organized internally. For example, in some SMHAs the tasks of disaster and emergency preparedness and risk management are organizationally separate. This document was developed on the assumption that these two functions are combined. Responsibility for developing various parts of the plan will fall to different parts of the organization in those States where these functions are separate. In all cases, the content should be integrated regardless of which part of the organization has the lead.

There are several basic elements to an all-hazards disaster mental health plan. This section will describe the suggested contents of each element. Appendix A contains a comprehensive matrix to help planners in ensuring that they have included all the relevant information in the plan. In reviewing this matrix, States may find items that do not apply to their particular situation.

It is worth noting again that not all States will have the resources to develop or sustain a plan that contains all of these elements. This information is meant to serve as a guide-a comprehensive menu for choosing initiatives when formulating an all-hazards disaster mental health plan.

BASIC PLAN ELEMENTS

Several boilerplate elements should be in the introduction of the plan including material such as those listed below:

• A signature page to assure readers that the plan is official;
• A dated title page with a record of changes. It will assure readers that they are reviewing the current version;
• A record of the plan's distribution to ensure that those who need to review and access the plan have done so;
• A table of contents; and
• An optional executive summary may be helpful to those who do not have the time or need to review the entire plan.

To set the stage and context for the more detailed portions of the plan early on, the following elements should be included:

• A statement of the general purpose of the plan;
• General situations and assumptions inherent in the plan. This information should include basic assumptions, such as limits of the SMHA's responsibilities and highest probability scenarios as well as special considerations having significant impact on planning, including vulnerable populations, special facilities, and low probability/high impact events. A matrix capturing some of this type of information has been developed by the Texas Department of Mental Health and Mental Retardation and is included in Table 4. Some States may find it helpful to differentiate hazards into two categories: physical events or damage that is easily identifiable (e.g., flood, school shooting), and events not easily identifiable (e.g., bioterrorism, epidemics, reaction to perceived risk);
• A general concept of operations, including the SMHA's overall approach to an emergency situation; jurisdictional responsibilities; the general sequence of action before, during and following an event; requests for aid, etc. While this section should cover many topics, it is intended to be relatively brief, providing only the most general overview, primarily for readers of the plan who will not need the level of detail contained in the remainder of the plan and for those who may be unfamiliar with the SMHA and its function in disasters. As a broader topic, establishing and implementing a concept of operations is complex and will vary considerably among States. Hopefully, States will share this information with each other and additional discussion and guidance can be provided as more plans are developed and implemented; and
• References to specific legal authorities that enable the SMHA to fulfill the elements of the plan or to maintain existing services.

Table 4:

Texas Department of Mental Health and Mental Retardation Disaster Matrix
(TDMHMR, 2002)

Organization and assignment of responsibilities in times of emergencies relate to the following components:

• Identification of tasks (both within the SMHA and outside) to be performed and positions and organizations responsible for carrying out these tasks. Documentation of tasks may use the FEMA-suggested format (defines objectives, characterization of the situation, general plan of action, delegation of responsibilities, information on resources, and administrative support necessary to accomplish tasks including descriptions of treatment responsibilities). Additionally, one of the most important assignments to clarify is responsibility for modifying and updating the disaster mental health plan;
• Tasks related to other departments and agencies, such as FEMA, SAMHSA/CMHS, and the Justice Department (victim rights and assistance);
• Integration of preparedness and coordination of operations with other important components of State and local government, such as health agencies, substance abuse agency, criminal justice agencies, law enforcement, fire and rescue, and agriculture (including the extension service and veterinary services); and
• Connection with State emergency plan and Federal response plan (the SMHA's plan must be consistent with the expectations of these two important plans in the likely event that an incident that activates the SMHA plan also activates other State and Federal plans).

An appropriate response may be ensured by adequate preparation of the following administrative issues (using documentation expected from FEMA and CMHS may help if funding from these sources is anticipated):

• Record keeping for program activities (which services are being provided to whom, and by whom);
• Record keeping of expenditures and obligations. In the course of a response, the SMHA may incur significant, atypical expenses, such as car or generator rentals. It is important before an incident to have a means of documenting these types of expenditures to ensure that future problems are minimized and reimbursable expenses are accurately documented;
• Record keeping for human resource utilization. This is important not only for potential reimbursement, but for planning to ensure adequate staffing as well;
• Expected format, frequency, and content of situation reports. Again, this information is critical, especially in the early parts of a response, to top resources and to project service, fiscal, and human resource needs. Situation reports can also serve as important political resources as SMHA and other State leaders present the status of response to others; and
• Management of volunteer services. Development of a plan to address use of volunteers prior to an incident will help ensure that human resource levels and skills are appropriate to service needs. Many States have learned difficult lessons about the management of well-intentioned but unneeded and/or inappropriate volunteer resources. The SMHA should consider the use of a volunteer coordinator position in large-scale disasters/events. This position/function would centralize decision making and control of voluntary mental health assistance. Pre-disaster, the plan should include a decision tree for use by the voluntary utilization function to ensure consistency in the selection and deployment of unsolicited assistance.

During the preparation stages, it is important to consider the following key logistics issues:

• Arrangement for support (food, shelter, etc.) needed for the mental health operation, including the ability of the mental health operation to be self-supporting for at least 72 hours. Operations can quickly be compromised if staff must rely on others during this critical and often chaotic period;
• Arrangement to repair and/or replace essential equipment (such as radios, computers, phone service); and
• Arrangement for personnel to access the areas where they are needed. The most heavily impacted areas are not accessible without proper credentials and transportation in the early hours after a disaster. The SMHA should work closely with the SEMA to assure that essential mental health staff members are able to get to where they need to be. It is important to ensure that these credentialing arrangements are included in both the SEMA and SMHA plans. Transportation of mental health workers may need to be jointly planned in cases where mental health staff need to be transported by resources outside the SMHA (e.g., the National Guard). As noted earlier, familiarity with the incident command system (ICS) will make planning for access and exit easier.

A necessary but challenging activity for content planning is ongoing needs assessment. Critical questions to consider are listed below:

• How are needs to be assessed? Is there a needs assessment tool? Who is responsible for compiling the assessment? What is the process for implementing recommendations?
• Who will be served? Are original assumptions still accurate? Is information being collected with respect to the extent of exposure, degree of personal impact, and demographic characteristics? CMHS Crisis Counseling guidance may be helpful in making this assessment.
• How will they be served? What services are available; what are needed? Are requests for services being answered in a timely manner?
• How are needs changing? AAre the needs of some satisfied so that resources can be redeployed? Are there emerging groups? Are geographical areas of need emerging?

An assessment with these types of questions is critical for resource management, establishing program priorities, documentation of effort, and long-range planning. A process to provide continuous information flow to planners and managers is also critical because of the rapidly changing environment that characterizes large-scale disasters. The CMHS needs assessment formula is included in Table 5.

Table 5:
CMHS Needs Assessment Formula (CMHS, 2000)

B. Needs Assessment Formula. Using the CMHS Needs Assessment Formula (located below) estimate the number of persons you will serve in each designated area (fourth column of the following table). Attach a CMHS Needs Assessment Formula sheet for each designated area.
CMHS Needs Assessment Formula for Estimating Disaster Mental Health Needs This is an estimate for the following disaster area:_____________________________________ Date of Report:___________________ Completed by:___________________________________
LOSS CATEGORIES Type of Loss	NUMBER OF PERSONS Number	ANH Multiply by ANH 1	RANGE ESTIMATED At-Risk Multiplier(Percent)	TOTAL Number of Persons Targeted Per Loss Category
Dead			100
Hospitalized			35
Non-hospitalized injured			15
Homes destroyed			100
Homes with “major damage”			35
Homes with “minor damage”			15
Disaster unemployed			15
(Other loss—specify)			10
Total estimated persons in need of Crisis Counseling services (add total column)
1 ANH means Average Number of persons per Household. This figure can be obtained on a county/parish/area basis from the Census Bureau. If the State is unable to determine the ANH for an area, then use the average figure of 2.5.

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INTEGRATING ACTIVITIES WITH THE STATE PLAN

• The availability of medications and where they need to be located are special mental health concerns. The plan should address the transportation of medications to where they are needed, as well as the safeguarding of their administration, recording, and storage.
• When — in the assessment of the local agency or the SMHA — the requirements of events exceed the service capacity of the responsible jurisdiction, mutual aid agreements with other jurisdictions (e.g., counties, States) can be very helpful and are strongly encouraged. The plan should document the existence and scope of such agreements.
• Identify risk is communicated in emergency situations has a significant psychosocial impact. While the primary responsibility typically lies outside the SMHA, the SMHA has much to contribute to this process and therefore the description of the SMHA role in risk communication should be clear.

To make the response and recovery activities both more efficient and to reduce vulnerability to litigation, the plan should address the following legal issues prior to the event:

• Knowledge and understanding of State licensing laws. Are there waiver provisions during emergencies for recognition of those licensed in other jurisdictions?
• Informed consent, confidentiality of conversations with victims, and records kept by service providers; and
• Liability (How is personal, professional, and organizational liability addressed? In what ways are service providers vulnerable? Are there legal provisions for waiving certain contracting/procurement rules during emergencies?).

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FUNCTIONAL ANNEX CONTENT

State emergency plans typically contain a series of functional annexes. Annexes are typically parts of a plan that begin to provide more detailed direction and information. Planning in these areas should focus on assignment of responsibilities, key tasks, and specific actions that should be taken. The annexes described in this section follow the FEMA all-hazards annex components and will be reflected in most SEMA plans. They are general in nature and apply to many, if not most, types of events that would activate the plan. Planning related to specific types of events, also as reflected in the FEMA all-hazards approach, is discussed in the next section.

Communications

Functional and reliable communication is frequently a problem following major events. In some types of disasters, the event itself may compromise communications, (i.e. cell phone transmitters were located atop the World Trade Center buildings) or they may become so over utilized that they are of little use. These issues can be a major concern for SMHAs as they typically rely on existing communications systems to assess the status of existing programs and emerging needs, as well as to deploy and track mental health resources. During planning stages, the following key elements of communication should be considered:

• Identify situational assumptions such as the types of situations that might occur and the types of communication necessary (e.g., telephone and data transmission). Close integration with the SEMA will be helpful in this activity;
• Identify methods of communication among key sites such as the SMHA and psychiatric facilities, community treatment facilities, State emergency management, hospitals and clinics, and sites where victims may be sheltered and mental health staff may be stationed. A good communication plan begins with the assurance that the SMHA is on the notification list of the Governor's Office and State emergency management when emergencies occur;
• Identify alternatives when planned communications fail, as well as the availability of personnel with the technical expertise to make and keep communications functional. Plans should include multiple options for communications; and
• Identify risk is communicated in emergency situations has a significant psychosocial impact. While the primary responsibility typically lies outside the SMHA, the SMHA has much to contribute to this process and therefore the description of the SMHA role in risk communication should be clear.

Public Information

Communication with the public is an important part of all emergency responses. It ensures that those affected by an event, or at risk of being affected, take appropriate action to mitigate adverse effects. This function assumes even greater significance in mental health. Everything communicated to the public, how it is communicated, and by whom it is communicated can exert a significant effect on the psychosocial experience of the event. State and local SMHAs should work closely with the SEMA's public information officer, since this position is typically responsible for this function during State and federally declared emergencies. Key elements of an optimal public information plan are listed below. More detailed information is available in Communicating in a Crisis: Risk Communication Guidelines for Public Officials (U.S. Department of Health and Human Services, 2002).

Identification of Responsibility

• It is important to identify key roles and policies, such as the designation of the SMHA liaison(s) to the media and restricting media access to other personnel.
• Public information materials should exist prior to an event (e.g., fact sheets, guidance on how to access services, guides to coping). These materials should be available in a variety of languages.
• Identification of experts in trauma and disaster/emergency mental health by the SMHA, prior to an event, will significantly reduce the likelihood that the SMHA will have to locate and assess expertise in the midst of a response and will increase the likelihood that the SMHA can exercise some control of the messages given.
• Establishing relationships with the local media prior to an event will help ensure that mental health is considered in coverage and may reduce the potential for the media to seek out or accept mental health information from sources unconnected with the response. Existing SMHA media relationships may be helpful. Briefing the media on the planning process and the importance of accurate information about behavioral sequelae may be an opportunity for mental health promotion and problem prevention. Relationships with reporters who cover health issues may be especially productive.

Warning: Mobilization Related to Internal Mental Health Systems

It is important that the SMHA receive as much information as possible, as early as possible, when an event occurs or is likely to occur. The SMHA, therefore, must have mechanisms in place to mobilize the mental health response. Key elements in this process include:

• The SMHA and local mental health agencies should be linked to the SEMA warning and notification system/process;
• The plan should identify methods and procedures for notifying staff, facilities, service providers, and others, as appropriate in a given State;
• The plan should include policies and procedures for SMHA offices and facilities, such as sending staff home, holding staff in place, recall of staff who are off duty, and evacuating facilities. In some States, these functions are controlled by the SMHA risk management unit rather than those involved in disaster preparedness. In those States, it is important that these two parts of the organization integrate their plans; and
• Warning and mobilization of those outside the SMHA also are important roles of the SMHA. Plans should identify groups with special needs (such as those who have mental disorders who are also deaf) and include plans to notify the larger mental health system (e.g., counties, contract providers) as well as private sector mental health resources.

Evacuation

Events may cause evacuation of large or small portions of a State. In all cases, evacuations have had significant effects both on direct SMHA operations as well as on potential service sites. Integration with SEMA planning is essential, as always. In most cases, the SMHA will not have direct responsibility, except in their own facilities, but evacuation can have significant impact on all involved, including staff. Planning considerations follow:

• It is critical that SMHA evacuation plans are integrated with State emergency management plans;
• Clearly established plans are needed for the evacuation of SMHA offices and facilities. Responding to the Needs of People with Serious and Persistent Mental Illness in Times of Disaster Disaster (U.S. Department of Health and Human Services, 1996) may provide useful ideas in planning for the needs of those in State facilities;
• Alternate sites should be established to conduct vital SMHA activities. Emergency managers typically describe these sites in terms unfamiliar to those in mental health. Sites in place, unused for any other purpose, and capable of being fully functional during emergencies, are called "hot sites." Those sites with some functionality, but also used for other functions in non-emergency times are called "warm sites." And those existing sites that do not become active until an event occurs are called "cold sites;" and
• The plan should include provisions for mental health services at shelters and mass care facilities.

Mass Care

Caring for large numbers of displaced victims is a major, complex part of disaster planning. While mental health does not have primary responsibility in this area, it is common to find the SMHA playing a secondary, supportive role. Typically, the Red Cross has the lead in mass care, but the SMHA may be asked to provide support in terms of ongoing needs assessment, staffing for shelters or places where families await information on the status of loved ones, and referral of those identified as suffering from serious psychological reactions. When planning ideas for the SMHA role in mass care, be sure to confirm:

• Documentation of coordination with the SEMA mass care plan; and
• A description of linkages between the SMHA, the Red Cross, and National Voluntary Organizations Active in Disasters (See Part IV for contact information).

Many SMHAs have had experience with mass care. States are encouraged to utilize State-to-State consultation regarding mass care preparations. For example, most of the Gulf States have well-established evacuation plans that have significant mass care components. The SAMHSA Disaster Mental Health Technical Assistance Center (DTAC) can provide technical assistance on this topic (See Part IV for contact information).

Health and Medical

While health and medical response is only part of the SEMA plan, it is the heart of the SMHA plan. For this reason, SMHAs should pay particular attention to the content of this annex in the SEMA plan and ensure that planning is integrated. The SMHA plan will be far more comprehensive and detailed with respect to behavioral health issues. It is important that the SEMA be briefed on its content when the SMHA plan is complete so that the SEMA is aware of the scope, depth, and limitations of SMHA responsibilities and resources.

When reference is made to the SMHA in State emergency management plans, it probably is included in the Health and Medical Annex. Typically, the emergency management plan will task the SMHA with providing crisis counseling services and/or caring for people with serious mental illness who are within the SMHA service system. Some State emergency management plans describe additional functions. For the purposes of the SMHA's disaster plan, the following points are suggestions for integration with the emergency management plan, as well as for other significant roles the SMHA can play.

• The plan should document coordination with the State emergency management plan, especially in the areas of staffing, logistics, costs, and availability of pharmaceuticals.
• The SMHA plan should include mental health services and consultation as part of the State's emergency medical plan. Typically, this part of the State's emergency management plan will reflect utilization of Veterans Administration resources (which offer a considerable number of mental health professionals skilled in dealing with psychological trauma). The State plan also will use Emergency Support Function Number 8 (ESF-8), an item under the Health and Medical Annex of the Federal Response Plan. ESF-8 addresses the availability of services provided by the National Disaster Medical System (NDMS), a joint Federal-medical response capability involving the U.S. Public Health Service, the Veterans Administration, the Department of Defense, and FEMA (See Part IV for contact information). ESF-8 also mandates the provision of mobile medical teams for deployment in major emergencies. There are several types of these ESF-8 specialty teams including mental health professionals in addition to general medical teams.
• The plan should contain clearly identified roles in the areas of services and consultation to primary victims, secondary victims (those not directly impacted by injury, death, and destruction but who are nevertheless experiencing disaster related stress), response and recovery workers (fire, police, rescue, morgue), incident command leadership and staff, and to other State agencies and departments (such as health epidemiology, education, and social services).
• The plan should document coordination with the Red Cross disaster mental health services.

Resource Management

The purpose of the Resource Management Annex is to ensure that the SMHA documents the means, organizational structure, and process through which it will locate, obtain, allocate, and distribute necessary resources during an emergency. Several key considerations are listed below.

• As noted earlier, a number of issues arise related to personnel, including how will personnel be notified, mobilized, transported, and deployed in the context of a changing response environment?
• The plan should describe how communications and other emergency equipment would be obtained, distributed, and maintained (including repairs).
• The plan should describe the mass care supplies needed to sustain SMHA resources should they be isolated or need to remain at their service locations.
• Mutual aid agreements within the State should be described in the event that local resources are not sufficient.
• As noted earlier, response efforts can be made more efficient and effective with a plan for managing unsolicited offers of assistance, as well as solicited volunteers.
• The Resources Management Annex should describe the nature of and process for obtaining resources from other States and the Federal government.
• The plan should document policies and procedures for maintaining financial and legal accountability.

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HAZARD-SPECIFIC PLANNING

There is a need to plan for the specific and sometimes unique aspects of different events in the context of plan content applicable to nearly all types of events. Events may have unique characteristics with special resulting psychosocial consequences that have significant implications for the SMHA (i.e., slow-rising, long-standing flooding may result in delayed reconstruction or repair to homes, which may further result in victims spending longer periods of time in shelters or with friends and families. This can generate additional individual and family stress).

Some types of events are accompanied by significant government regulations that directly affect response and recovery, which may result in or affect psychosocial sequelae. For example, the locations in which suspected terrorist events occur are considered crime scenes. This may result in delayed body recovery and release of surviving victims. It also may result in recovery workers becoming witnesses in criminal proceedings. These special factors can have a significant impact on the course and timing of psychological recovery.

Hazard-specific planning by the SMHA also should occur in the context of similar planning by the SEMA. The SEMA workers will have performed significant and detailed risk assessments that can be utilized by the SMHA. This planning will also include identification of events when an agency other than emergency management (e.g., the FBI or military) is in control of the response. Plans should include identification of types of risks, as well as geographic areas that are believed to be at risk. Not all States are susceptible to the same risks, and different portions of States may be at greater or lesser risk for different types of events. In addition, the SMHA may have facilities in high-risk areas or facilities to be used as backup facilities.

A detailed listing of the types of risks a State may experience is included in Appendix A.

Terrorism

Planning for the consequences of terrorist acts presents numerous challenges. The national experience and the experience of most individual States is limited, and there are many types of potential terrorist acts to consider during planning. The scientific knowledge about the psychological and medical aspects of some types of terrorist acts, especially bioterrorism, is not as precise and complete as needed. Because so much emphasis currently is being placed on preparing for a wide variety of terrorist incidents, the planning environment is changing rapidly — with new laws, guidelines, and key players emerging constantly.

In some cases the SMHA plan could reference the SEMA plan. Consider using excerpts from the SEMA plan to add detailed context to situational assumptions and HazMat considerations. There may also be reluctance to put some material in a plan that is posted on the Web or is otherwise easily accessible to a very wide audience. Again, taking the SEMA's lead may be the best strategy. With these factors in mind, the SMHA plan for terrorism should be developed by being informed of the following issues.

• An understanding of potential hazards such as chemical, biological, nuclear/radiological, explosive, cyber, or combined events. Many types of events might stem from these overall classifications. States with rural areas and agribusiness industries should also include Foreign Animal Diseases (FADs) that may be introduced accidentally or criminally. Planning should reflect the types of events that the SEMA has included in their plans.
• Identification of potential targets that reflect or are consistent with those identified by the SEMA (e.g., chemical manufacturing plants or nuclear power generating facilities). This will not only ensure that there has been SMHA and SEMA communication on these potential targets, but also that planning between the two agencies is consistent.
• Situational assumptions of the SEMA plan including environment (e.g., prevailing winds), populations and population centers, urbanicity, infrastructure (water, sewer), transport patterns (roads, railways), airports (public, private, military), trains/subways, government facilities (non-military), military installations, recreation facilities, and facilities containing hazardous materials, as well as other high-risk targets such as financial institutions, universities, hospitals, research institutes, schools, and daycare centers. By completing a description of situational assumptions, the SMHA will ensure that planning is consistent with the SEMA, while considering where needs may arise, what mental health resources may be at risk, and where to place preparedness priorities.
• Description of the SMHA's terrorist incident management protocol, with special attention to aspects where incident management may be different than in other types of disasters.
• Reflection of the State emergency plan's modeling of potential releases of hazardous materials or biological agents. This again will increase the potential for SEMA/SMHA plan coordination, as the SMHA will be able to identify specific scenarios (e.g., evacuations, decontamination sites, etc.) that may generate special mental health needs, assess vulnerability of mental health service sites, identify alternative sites, evaluate the deployment of mental health resources, etc.
• Documentation of how incident management by the SMHA reflects the roles of other State and various Federal agencies and resources.
• Description of how the plan's consequence management reflects the involvement of various Federal components (such as FEMA, SAMHSA/CMHS resources, Office for Victims of Crime in the Justice Department, and Safe and Drug Free Schools in the Department of Education).
• A description of the State emergency plan in cases in which terrorist events trigger different response, authorities, and policies within the functional annexes described in the previous section.
• Identification of links to health and medical entities to assist in screening potential victims for mental disorders and psychogenic symptoms, functional impairment, substance abuse, etc. One of the great concerns following a bioterrorist incident is the rapid utilization of health and medical resources not only by those who have been exposed but also by those who believe they have been exposed. This is an area in which close collaboration in the planning and response phases among the SMHA, the health agency, local hospitals, and other health care facilities is paramount.
• Links with the health agency for surveillance, screening, consultation, intervention planning, and risk communication. In events with major public health implications, the State health agency will have a lead role. The valuable role that the SMHA can and should play in the activities described is often not understood by the State health agency. Collaboration in the planning process can result in enhanced response by both the SMHA and the health agency.
• A description of the SMHA's authority in risk communication and response. As noted before, this is an area in which collaboration between the SMHA, the health agency, and the State emergency management public information structure is critical.
• Plans should reflect the fact that mental health providers typically are not first responders to HazMat incidents. When they are deployed to the site and are present at the site, their safety should be a prime concern to planners and administrators. Adequate preparation should be undertaken to ensure safety, such as training on proper use of safety equipment and protective gear. Without preparation mental health providers quickly and easily can become part of the population needing health, medical, and mental health services.

Continuity of Operations for the State Mental Health Agency

No organization can mount a response to a disaster if the fundamental operations of that organization are not functioning. SMHAs are no exception. Additionally, preexisting and ongoing responsibilities of the SMHA do not stop, even when disaster strikes. As a result, part of a meaningful plan are provisions that will enable the SMHA to continue its essential functions when disaster strikes through a Continuity of Operations Plan (COOP). In many States, these issues will be addressed in documents separate from the SMHA's disaster plan. In some States, they will be integrated as part of the disaster plan. In any case, there is certainly a role for disaster planners in preparing for worker stress issues inherent in any situation that would activate a COOP. To ensure continuity of essential operations, the following points should be addressed.

• A statement of goals for the COOP is necessary. The goal in most States is to maintain or reestablish vital functions of the SMHA during the first 72 hours following any event that would compromise or halt normal operations.
• As in other components, there should be documentation of coordination with the overall State COOP.
• The plan should identify vital functions, records, and data to be maintained within the first 72 hours.
• The plan should identify plans related to human resources, such as essential staff, staff notification, and family support. Note that these functions may be different from those described earlier, which focus on disaster-related services. In this case, the concern is with maintaining preexisting SMHA functions and responsibilities.
• The plan should identify alternate locations for essential operations as well as provide for transportation and staff support (food, rest/sleeping areas, etc.).
• In case the primary records are destroyed or inaccessible, it is important that duplicate vital records and documents be housed prior to an event in at least one alternate site. These types of records might include the SMHA disaster plan, staff rosters, and vital patient medical records.

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SPECIAL PLANNING CONCERNS FOR MENTAL HEALTH

The following list includes elements of the SMHA disaster plan that represent issues of special concern to SMHAs. As States develop their plans, they may want to personalize the list.

• The description of the SMHA's presence and role in the State emergency management structure. As has been noted, this relationship is central to effective planning and plan implementation. In many States in which this positive relationship exists, it is based upon personal relationships. Committing these relationships to writing can help ensure that the relationship is sustained as key people change.
• Documentation of regional or multi-State planning and coordination. The SMHA should not and cannot plan alone. If a plan is to be effective and support the sharing and flexibility of human and other resources, it must involve other jurisdictions.
• Descriptions of licensing issues in disasters. A variety of licensing-related issues for mental health professionals come into play in emergency and disaster situations. SMHAs are advised to consult with appropriate officials within the State to explore issues including licensing of out-of-State providers, the appropriate scope of practice guidance, and the clarity of the types of disaster mental health activities that require a license.
• Documentation of plans to prepare and support mental health staff during and following deployment under the plan. These plans should include attention to physical and psychological health, special medical needs, and family support. Unfortunately, the needs of the providers frequently are overlooked, or are secondary considerations. Attention to these issues in the planning process can help assure that providers do not become secondary victims in the course of performing their important work.
• Documentation of public sector links with private mental health resources. When disasters occur, the line between public and private mental health concerns is not as clear as in "normal" times. SMHAs will be well-served by pre-event planning and collaboration that explore roles, skills, and availability of mental health resources as well as contract planning.
• Documentation of appropriate links with businesses, corporations, and other private sector interests engaged in planning for behavioral health response and consequences. Business and corporate emergency planning has expanded dramatically in recent years. Some are incorporating behavioral health issues into their plans, though many are not. The SMHA may improve outreach capability and enhance community support by reaching out to these organizations during the planning process.
• Documentation of appropriate planning links with institutions of higher learning. Academic departments may be able to provide specialized expertise helpful in planning and/or actual resources when disasters occur. In addition, their student health services could benefit from information, consultation, or training related to disaster mental health.
• Assurance that SMHA facilities meet the standards of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) or other appropriate standards for disaster and emergency preparedness. Like other organizations, health care facilities have increased their attention significantly to prepare for emergencies. SMHAs should ensure that facilities under their responsibility are prepared. The Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org) has disaster and emergency guidance that may be helpful.
• SMHA involvement in disaster training and exercises. Short of real disasters, disaster exercises are among the best ways to test plans. SEMAs routinely conduct exercises involving differing event scenarios. SMHAs are advised to make certain that not only the SMHA is involved in these exercises, but also that content related to psychosocial consequences are built into exercise scripts. With proper involvement, the exercises will become more realistic and the SMHA will have the opportunity to learn more from the experience. Following drills, after-action reviews should be conducted to identify "lessons learned" for incorporation into planning and exercise development.
• Description of roles in coordination of research. While not often a common role, the SMHA may play a very helpful and valuable role in helping to coordinate research following an event. The balance between services and research is often a delicate one, especially when balancing the need for increased disaster mental health research and the need to ensure that government entities charged with service provision protect the importance of that mission. The SMHA can play a central role in helping to maintain that balance.
• Plans for data collection and evaluation of programs. The same delicate balances described above apply in the area of data collection and the evaluation of services. Potential problems can be avoided to the extent that data collection and evaluations can be described and agreed upon prior to an incident. SAMHSA currently has seven FEMA/CMHS program guidance documents "developed to ensure consistency in addressing key program issues" in crisis counseling training, including Recommended Approaches to Evaluation of Crisis Counseling Grant Projects. The documents are listed on the Web at www.samhsa.gov.

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STANDARD OPERATING PROCEDURES AND CHECKLISTS

The response phase will certainly be more efficient, and likely more effective, if procedures can be standardized and shared prior to an event and used consistently during an event. Developing these procedures during an event is time-consuming and distracting to the primary mission.

In the planning phase, SMHAs should consider the types of procedures and checklists (e.g., emergency contact numbers) that could be helpful, and develop them during the planning process. The Texas Department of Mental Health and Mental Retardation has created a detailed procedural guide for community mental health centers to use in "pre-disaster preparation and initial response." The guide is available online at www.mhmr.state.tx.us.

GLOSSARY OF TERMS

Plans have large and diverse audiences. Also, a major purpose of a plan is to communicate clearly. For these reasons, States have found it helpful to include a glossary of State-specific, emergency management, mental health, and public health terms as a part of their plan. A sample glossary of acronyms and definitions is included in Appendix C.

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