key: cord-1036768-xns0ity0
authors: Bernstein, Carol A.; Bhattacharyya, Sriya; Adler, Shelby; Alpert, Jonathan E.
title: Staff Emotional Support at Montefiore Medical Center During the COVID-19 Pandemic
date: 2020-11-18
journal: Jt Comm J Qual Patient Saf
DOI: 10.1016/j.jcjq.2020.11.009
sha: 84250d7a8cb0aae6515722d83329eddd95aeecac
doc_id: 1036768
cord_uid: xns0ity0

CONTEXT: During the COVID-19 pandemic, frontline workers have experienced high levels of stress and anxiety. Montefiore Medical Center recognized the urgent need for mental health support to mitigate and treat psychological distress among staff. Various mental health support services were implemented. We provide an overview of the interventions implemented at Montefiore and provide preliminary insights on the utilization and value of these ongoing services. OUTCOMES: The interventions instituted at Montefiore included: psychoeducational resources, a phone support line, staff support centers, a clinical treatment program, team support sessions, peer support outreach, mental health and wellness programs, and clergy support. The most heavily used service during the pandemic were the staff support centers and the least used service was the clergy support. INSIGHTS: With institutional encouragement and the collective efforts of over 150 mental health professionals and other staff it was possible to set up durable mental health supports with multiple points of access. Although many services were available to both clinical and non-clinical staff, outreach was primarily to clinical staff. Additional efforts in the future are needed to more fully reach non-clinical frontline workers. NEXT STEPS: Our next steps include evaluation of emotional health and distress among clinical and non-clinical staff using validated self-report measures administered over multiple time intervals. Lessons learned about staff support during COVID-19 will also be integrated into future efforts to support staff well-being more broadly.

Research on prior disease outbreaks has demonstrated major impacts on the mental health of frontline health care workers. During the COVID-19 pandemic, preliminary studies revealed that a significant proportion of health care professionals, particularly at the epicenters, were experiencing unprecedented levels of anxiety, insomnia, depression, and distress. 1, 2 Montefiore Medical Center (MMC), located in the Bronx, the borough hardest hit in New York City (NYC), 3 implemented various mental health services to support the emotional needs of staff. Preliminary insights were gained on the acceptability and utility of each type of support.

Montefiore Health System (MHS) is a multi-site complex health care system located in NYC and surrounding counties, serving a diverse patient population-including communities disproportionately affected by COVID-19. In addition to a robust ambulatory care network, MHS has 2,977 inpatient acute care beds and 150 skilled nursing beds. MMC is the tertiary care academic component of MHS and includes 1,558 licensed beds, of which 136 comprise the Children's Hospital at Montefiore (CHAM).

MMC includes three legacy campuses-Moses, Weiler, and Wakefield-and serves over 600,000 unique patients. MMC is also the largest employer in the Bronx, with many employees living in the diverse communities we serve. On March 11, 2020, the Moses campus admitted two patients diagnosed with . Subsequently, at the time of this writing, more than 6,000 patients with COVID 19 were admitted to MMC (91% from the Bronx), and over 1,300 patients and 22 staff have died. 4 From the outset, there was concern that a surge of patients could overwhelm capacity for care and that MMC's workforce might experience unprecedented levels of stress and trauma. On March 15, 2020, psychiatry leadership collaborated with leadership from various sectors of MMC to establish the Staff Emotional Support (SES) Team. Over ten weeks during the initial phase of the pandemic, the SES Team created a variety of mental health services to meet the needs of as many staff as possible, understanding that individuals respond to traumatic experiences and to support services in diverse ways. These services (in order of implementation) included psychoeducational resources, an emotional support line, staff support centers, individual clinical treatment services, team support sessions, peer support outreach, a wellness series, and clergy support. Support services were primarily communicated to faculty by word of mouth, through the Montefiore website, and through informational meetings such as grand rounds and other departmental/division meetings. Many of these services are ongoing, and the SES Team continues to meet regularly to plan, debrief, and support one another.

Recognizing that other hospital systems across the globe are facing similar circumstances, we provide an overview of the support services implemented at MMC in order of execution. Although no systematic analyses or evaluations were conducted at the time, we provide preliminary insights on the utilization and 4 perceived favorability of these services. We hope to shed light on feasible interventions that other hospital systems can implement to support frontline workers' mental health in the midst of an infectious disease pandemic.

At MMC, psychiatry department faculty delivered multiple grand rounds and other invited presentations on mental health and parenting support during COVID-19 to individual departments and divisions within the larger Montefiore community. Grand rounds and other talks were delivered to colleagues from a variety of specialties (e.g., Anesthesiology, Medicine, Pediatrics), with a focus on imparting skills and information and enhancing resiliency. Topics included general insights on behavior and experiences during disasters, identifying burnout and mental distress in oneself and others, establishing techniques that enhance well-being, and finding ways to manage grief. Resources on these topics were collated from numerous sources, including The Center for The Study of Traumatic Stress. 5 Web-based resources were also developed and placed on the MMC internal website, which served as an institutional repository for timely and evolving COVID-related information (e.g., infection control guidelines). Resources also included infographics with emergency phone numbers, anticipated reactions to a pandemic, breathing exercises, coping skills, and food and child care resources, along with a mental health resource guide with information on internal and external mental health services. Supplemental infographics targeting youth-based concerns were also developed that included guidance on talking to children about COVID-19, managing challenging child behavior and child anxiety, and helping youth cope with grief and loss. All resources were created in English and Spanish. Subsequently this and other information were also posted on the Albert Einstein College of Medicine website (at https://einstein.yu.edu/intranet/coronavirus/virtual-support-center/), where it was available to the general public as well as other health care workers and researchers within and beyond the Montefiore/Einstein community.

As of June 11, 2020, infographics were accessed online via the Montefiore intranet approximately 180 times and over 200 printed copies were distributed to staff in person. Anecdotal feedback suggested these resources to be both validating and practically useful.

At MMC, a phone support line was developed for health care workers, facilitated by psychologists, social workers, and psychiatrists from the Department of Psychiatry and Behavioral Sciences and other 5 departments. Initially, the service was available with limited hours, but it was quickly expanded to include access from 8:00 A.M. to 10:00 P.M., seven days a week.

The support line was used infrequently, consistent with prior findings in the literature. In total, 240 calls were received between March 24 and June 19, 2020. Calls often involved distress about being deployed to unfamiliar services or roles, fears about infecting loved ones, and feelings of inadequacy about not being able to do more to help patients and families. Some calls were related to questions about services and resources.

Although the calls appeared to be meaningful, the absolute number was consistently low even during the height of the pandemic, as well as when the census of COVID-positive patients declined, with fewer calls placed over the weekend. The phone line was discontinued on June 19, with callers referred to MMC psychiatry outpatient services and employee assistance programs, as well as to a NYC mental health hotline (NYC Well).

Caregiver Support Centers (CSC) across the main campuses of MMC were previously established to provide a comforting environment for family members with loved ones in the hospital. On March 18, 2020, as visitors were generally no longer allowed in the hospital, the CSC at the Moses campus was converted into a Staff Support Center (SSC) for frontline workers. The SSC consisted of a main entrance room and four additional smaller spaces, with couches, massage chairs, and computers. A glass wall with a waterfall was located near the entrance and tranquil music softly played in the background. The SSC was advertised as a place to balance work with self-care and a safe place to nurture one's whole self.

The CSCs at Weiler and Wakefield were also used for this purpose and were similarly equipped, although Volunteers were responsible for ensuring a steady supply of food, assisting with cleaning and sanitation, and providing psychological first aid for visitors. Frequently, visitors would form relationships with volunteers and cited these connections as particularly important to them.

Refreshments were provided at all sites, including numerous donations of meals and snacks. Eleventhousand individual therapeutic art kits, positive affirmation stones, and breathing cards, created by a licensed art therapist, were available for staff visitors to take home. All staff were asked to sanitize carefully upon entry. Centers all underwent deep cleaning on a nightly basis.

Since inception, utilization of the SSC grew from 25 visits on the first day to more than 750 daily visits at the height of the pandemic. There were more than 32,000 visits from March to mid-June; with the Moses Center receiving 23,515 visits, and CHAM, Wakefield, and Weiler receiving 3,170 visits, 2,422 visits, and 3,354 visits, respectively. Unsolicited comments from attendees included the following:

-Oh man, this place is the best.

-The energy in this room-we know you care and listen and take good care of us.

-I would not be able to get through the day without you.

-The SSC has provided a space for me to rejuvenate, nourish, and relax.

-The staff has been so supportive and makes it such a warm and welcoming space during this hectic time.

Although we refrained from conducting a formal survey of visitors to minimize burden and obviate concerns about confidentiality during an overwhelming time, the volume of visits and the influx of requests to maintain some form of similar staff support beyond the pandemic generally support the degree to which this form of support was felt to be feasible and supportive.

To address some of the additional unique challenges during the global pandemic, the Swift Montefiore Associate Response Team (SMART) was created on March 30, 2020 to provide rapid short-term telehealth psychotherapy and/or medication treatment (typically 2-12 sessions) targeted at COVID-19related distress, such as anxiety, depression, and grief among Montefiore staff. Many staff were selfreferred. Others were referred from the Emotional Support Line and the Montefiore Emotional Support Allies (MESA) program. All were seen at no out-of-pocket cost regardless of insurance. An assigned provider reached out to staff associates within 24 hours of referral.

As of June 22, 2020, 94 associate referrals for SMART had been received, of whom 73 were still actively involved in treatment, 8 had completed a treatment course, 9 were non-responsive to outreach, 2 initiated 7 treatment but were lost to contact, and 2 were referred to other clinic services for conditions not directly related to COVID-19. Treatment was based on individual need and delivered by trained clinicians.

Several weeks after SMART was developed, we noted that the stress of parenting was a recurring theme as we met with staff. SMART-FAM was developed to provide support using personalized evidence-based treatments, such as cognitive behavioral therapy for anxiety/panic, to parents and caregivers facing the unique challenges and stressors related to childcare and parenting during quarantine, remote learning, intergenerational cohabitation, and care for elderly parents.

In addition to providing individual therapy, SMART-FAM parenting groups were also developed with a heavy emphasis on parent management training, mindfulness training, and acceptance and commitment therapy-based self-compassion training. Parenting skills group sessions were offered via telehealth weekly, with between-session materials exchanged via email. Group session topics were focused on teaching parents how to establish structure and daily routines for their children, how to share developmentally appropriate information about the pandemic, and how to manage their own stress about the challenges of parenting. Continuously updated written materials were also provided to parents.

As of June 15, 2020, a total of 23 referrals were made to SMART-FAM, 20 individuals completed treatment, and 4 SMART-FAM parenting skills group sessions had been conducted. SMART and SMART-FAM clinicians were largely drawn from among psychology, psychiatry, and social work in the Department of Psychiatry and Behavioral Sciences.

At MMC, team support sessions were conducted for frontline health care workers both remotely and in person. Sessions ranged from providing trauma-informed therapies consisting of psychoeducation, skills building, emotional processing, grief support, and self-compassion exercises to more informal opportunities to reflect on unprecedented experiences and inform teams about relevant resources.

Sessions were led by clinicians who also often provided mindfulness and breathing-based exercises. Team support and time frame were arranged for clinical units on request by local managers and clinical directors.

Session duration varied by request from brief (e.g., 15 minutes) to longer (e.g., one hour); some sessions were discrete (one time), while others were ongoing, but time-limited (e.g., weekly for 4 weeks).

Decisions about the length, content, and format of sessions were often made by mental health clinicians in 8 conjunction with discussion with unit leaders who had an appreciation for the needs of their teams as well as the clinical demands of their areas. Briefer sessions that lasted 15 minutes were usually conducted during morning rounds and were focused on providing support and identifying resources. Group leaders were given written guidance outlining a framework of ways to provide emotional support in a group setting.

More than 100 support sessions were provided to a wide variety of departments and units. Common themes included a sense of helplessness and inadequacy, loss of autonomy, guilt, moral injury, concern about adequacy of PPE and other safety measures, problems related to sudden deployment to new areas, fears of infecting loved ones, and coping with one's own anxieties and losses while also caring for patients.

Unsolicited remarks from staff included the following:

 It was nice to have a space where we could express ourselves, not be expected to work, and know someone who was there to take care of us.

 [A member of your team] was outstanding this morning with our group. She connected so beautifully with them, giving to them her compassion, empathy, and direction, opening the door for them to grieve, and begin the healing process.

Requests for these sessions were often based on word-of-mouth referrals from other units that had found them helpful as well as repeat requests from units that had sessions earlier in the pandemic, suggesting their usefulness.

At MMC, discussions between colleagues in Psychiatry and Medicine highlighted a need for proactive peer outreach and support. It was recognized that despite many forms of support already developed, many clinical staff were too stoic or overwhelmed to access them. The Montefiore Emotional Support Allies (MESA) program was created as a format in which nurses, physicians, physician assistants, respiratory therapists, and house officers serving on the frontlines were paired with a Montefiore psychologist, social worker, psychiatrist, or psychiatric nurse practitioner as an ally, who offered peer support, information about resources, and assistance, if needed, with referral for treatment.

Frontline staff received an email with their allies' contact numbers and information on the program. Once initial contact was made, staff were able to text, email, call, or opt out. A total of 134 mental health allies were assigned to approximately 2,556 staff in or deployed to frontline units (e.g., ICUs, EDs, Inpatient Medicine, or Labor and Delivery). Participation rates were variable, ranging from 10% to 20% of those contacted by a given ally.

To our knowledge, this is the first program of this type, although similar interventions have been used by soldiers in war (battle buddies) and have been demonstrated to be successful. 6 Unsolicited comments from faculty included the following:

 What you are doing during this difficult time is very important.

 I appreciate you checking in during this challenging time.

While we believe this proactive program had a positive impact, a formal survey to assess volunteers' experiences is currently underway.

Virtual meditation and art sessions for workers were offered at MMC to reduce stress and improve resilience. Meditation, led by wellness experts, was offered at various times three times a week. Virtual art sessions (30 minutes) were offered twice daily three times a week.

During the month of May, 2020, 20 associates attended the meditation and art therapy sessions. Reported barriers to participation included lack of time, insufficient advertising, and lack of awareness and support from higher level management.

To address individual coping styles and cultural preferences, fifty clergy people were recruited to support Montefiore workers for whom a faith-based approach might be more acceptable and effective. Clergy support was offered through referral by a psychologist coordinator at MMC.

Very few health care staff chose to participate in this service. Anecdotally, we believe staff interested in faith-based supports sought those within communities familiar to them rather than through the workplace.

Our experiences at an academic medical center in one of the urban communities that was among the earliest and most intensely affected by the novel coronavirus in the United States have demonstrated that implementing support interventions for frontline health care workers requires considerable commitment of time and staff, repeated active outreach to overextended staff who are often not used to seeking help for themselves, and substantial training for clinicians with differential levels of skills, expertise, comfort, and availability in the setting of a public health crisis. We drew heavily upon a robust existing mental health infrastructure at Montefiore in which a small number of clinicians were given dedicated time for these efforts and most others volunteered time while, in their day jobs, they provided care on inpatient units, in the emergency department, or through largely telehealth services in ambulatory areas.

Although our goal was to provide support to all staff at a NYC epicenter, many of our services, such as MESA and team support sessions, were concentrated on clinical rather than nonclinical staff such as sanitation, cafeteria, and patient transport workers. As this population includes employees who generally have lower incomes and are more likely to be people of color, these groups are potentially more profoundly affected by the virus along with its economic effects and other downstream impacts.

While our phone lines, support centers, online resources, and SMART and SMART-FAM clinics were available to these staff, the lack of more direct outreach to this vulnerable population was an oversight we regret. We believe this omission was likely related to the fact that outreach was guided by clinical leaders much more familiar with the clinical departmental staff than with the nonclinical departmental staff who are often unionized and served by employee assistance programs but not by comparable outreach during COVID-19. We are aware that future planning must more effectively involve leaders in these nonclinical areas to develop meaningful and inclusive outreach for all staff.

Investigators at our institution have developed a longitudinal Emotional Health Survey for clinical and nonclinical staff at Montefiore Medical Center and Albert Einstein College of Medicine designed to provide further insights into the short-and long-term mental health consequences of COVID-19 among health care workers on and beyond the frontlines. We also are surveying staff to obtain further quantitative and qualitative feedback on the impact of the individual supports described to advance knowledge about effective interventions for supporting the mental health of health care workers and mitigating against the development of post-traumatic stress disorder and other potential consequences of a pandemic such as COVID-19. We hope to incorporate this information as we develop playbooks for effective supports recognizing the inevitability of future pandemics and other public health crises that profoundly affect the mental health of health care workers.

Multiple interventions were instituted at Montefiore, including psychoeducational resources, a phone support line, staff support centers, mental health treatment programs, team support sessions, peer support outreach, wellness programming, and clergy support. Staff support centers were the most frequently used option, while other services, such as phone supports, individual treatments, the wellness series, and clergy supports, were much less frequently accessed.

We believe that staff support centers were the most frequently used because they were easily accessible places for respite, refreshment, and recharging and offered a basic form of human connection not necessarily associated with the potential stigma of seeking formal support. We further hypothesize that the relatively low number of calls to the phone support line and the low number of participants in SMART and SMART-FAM was related to the enormous stress and physical exhaustion experienced during the height of the pandemic as well as the characteristic disinclination of many health care workers to acknowledge vulnerability or seek care for themselves.

The authors report no conflicts of interest.

Factors Associated With Mental Health Outcomes Among Health Care Workers Exposed to Coronavirus Disease

Prevalence of depression, anxiety, and insomnia among healthcare workers during the COVID-19 pandemic: A systematic review and meta-analysis

Variation in COVID-19 Hospitalizations and Deaths Across New York City Boroughs

I fought two plagues. The New York Times

COVID-19 Pandemic Response Resources