key: cord-1055845-n9hia6bk
authors: Trivedi, Harsh K.
title: Sheppard Pratt: Lessons Learned During COVID Across a System of Care
date: 2022-02-24
journal: Psychiatr Clin North Am
DOI: 10.1016/j.psc.2021.11.015
sha: 5aa19d6b39be30e690b19486623a7c9199cda333
doc_id: 1055845
cord_uid: n9hia6bk

Across the nation, each organization and every leadership team has become battle-tested during the coronavirus disease 2019 (COVID-19) pandemic. Health care has been impacted in every community, and the mental health toll of the pandemic continues to worsen each day. Key leadership and operational lessons learned during COVID are presented for a health system with 387 care sites, across 160 programs, serving 70,000 patients. General preparedness, maintaining access to care, staffing plan strategies, supporting our employees, and moving forward beyond the pandemic are presented.

Across the nation, each organization and every leadership team has become battletested during the coronavirus disease 2019 (COVID-19) pandemic. Health care has been impacted in every community, and the mental health toll of the pandemic continues to worsen each day. At Sheppard Pratt, we have offered several webinars, resource tools, and technical assistance to our colleagues across the nation throughout the pandemic. The lessons highlighted in this article form key learnings made possible through discussions from within the organization and reflections of many colleagues nationwide.

In early 2020, coronavirus was not a household name and certainly not a worldwide pandemic. Instead, our nation was grappling with all-time high rates of suicide, including an alarming trend among young people. Drug overdose deaths soared, and people lacked access to psychiatric services.

As COVID-19 cases continue to surge and are well nearly 45 million in the United States at the time of this writing, an even larger crisis is barreling toward us like a tidal wave-the impending behavioral health surge created by COVID-19 (Fig. 1) .

In the aforementioned depiction, within that first wave, those that have psychiatric comorbidity were staying at home trying to manage their condition or illness so they would not end up in an emergency room. As we moved into the second wave, we saw an impact on non-COVID conditions and how people were having negative health outcomes as a result.

Then there is the third wave-interrupted care for chronic conditions, including mental health. The fourth wave is pending. After nearly 2 years of uncertainty, fear, social isolation, stress, and anxiety, we are seeing the beginnings of this wave: psychiatric trauma, mental illness, and burnout.

In a 2020 Centers for Disease Control and Prevention report, 10% of respondents reported having seriously considered suicide in the prior 30 days. 2 Only 4% of respondents in a relatively similar study considered taking their own lives in 2018 3 -and in that year, 48,000 died of suicide. 4 Suicide rates, which were already alarmingly high prepandemic, are expected to increase. In addition, the CDC report indicated that almost 41% of respondents reported at least one mental health concern, and experiences of distress such as depressive and anxiety symptoms were reported as 3 to 4 times greater than prepandemic periods. 2 The Maryland Opioid Operational Command Center reported an overall 9.1% jump in drug-related overdose deaths in the first half of 2020 compared with the same period in 2019, 5 which it attributed to the COVID-19 pandemic.

We envision a greater need for behavioral health services due to the burnout of health care providers and the broader community, as well as the generalized trauma many have seen and experienced due to racial injustices and COVID. 

What helps to make Sheppard Pratt unique is also what has been most challenging in planning a response to COVID-19. Since its founding in 1853, Sheppard Pratt has been innovating the field through research, best practice implementation, and a focus on improving the quality of mental health care on a global level. As the nation's largest private, nonprofit provider of mental health, substance use, developmental disability, special education, and social services in the country, there were challenges in our response. Challenges ranged from managing COVID protocols across 387 sites of care to maintaining access for patients across the nation and the globe. As a safety-net provider, we had to ensure solutions worked for people with serious mental illness and who have significant barriers to accessing care, such as homelessness and lack of broadband access. We serve more than 70,000 individuals in more than 160 programs, including inpatient and outpatient treatment, housing, education, job training, and rehabilitation services, among many others. With such a broad and diverse system of care-including heterogeneity in types of programs and levels of care-the first lessons became quite clear, quite fast (Fig. 2) .

From the beginning, what we believed to be true and the directives coming from local, state, and federal authorities were rapidly evolving. In order for an organization to be nimble enough to keep up with the breakneck pace of change, there had to be an acknowledgment that a strictly top-down approach was not feasible. Rather, the importance of empowering local leaders and frontline staff to problem solve and share what works became energizing to teams across our organization.

During times of significant and rapid change, one of the greatest problems can be information gaps. Increasing anxiety combined with a lack of transparency leaves ample room for conjecture or detrimental misinformation to take hold. Updates should be 

From the onset of the pandemic, we had regular conversations with leaders across the organization. These virtual calls allowed nearly 300 leaders to hear directly from members of the executive team on a regular basis. Beyond data and updates, careful effort was placed to help leaders set the tone for a robust and organized response. We had discussions that framed the response to COVID as being a marathon and not a sprint. We discussed the importance of a leader in helping to smooth the bumps, rather than feeding into the uncertainty. The message was consistent from the beginning-we will get through this together, supporting one another, helping each other through difficult days at work and at home, and providing the care we would expect for our own loved ones throughout. We routinely refocused on our mission and why we each come to work.

As behavioral health needs are increasing across the nation, we are seeing an alarming trend of decreasing behavioral health services across many communities. The number of state-funded psychiatric beds per capita has decreased by 97% between 1955 and 2016, 6 with the per capita psychiatric inpatient bed count approximately 70% lower than the average among developed nations. 6 Many hospitals and health systems were decreasing bed capacity before COVID-19, and as COVID continued, more had to reduce bed capacity due to COVID-19 concerns as well as close units temporarily to accommodate patients with medical/respiratory COVID-19. In June 2020, the University of Washington Medicine shut down its 14-bed psychiatric unit amid financial shortfalls. 7 Providence Behavioral Health also ended its inpatient services in June 2020 reducing the number of psychiatric beds for children and adolescents in the western part of Massachusetts to zero. 8 Heywood Healthcare in Massachusetts also closed its adult mental health unit in April 2020 as a result of the financial effects of COVID-19 and was uncertain if it would be able to reopen. 9 In contrast, Sheppard Pratt recognized the importance of remaining open and providing access for those who need care and services at a time when the need for behavioral health services is greater than ever. Sheppard Pratt has more than 160 programs across more than 380 sites of service in Maryland and West Virginia. It was critical to support the patients, clients, and students we serve so they had timely access to quality care and services (Fig. 3) .

Sheppard Pratt rapidly adapted its care and services across the continuum of care to meet the wide-ranging demands. We have been able to keep all 19 of our hospital inpatient units open and operating during the pandemic. In addition, we reimagined our community-based and school-based programs to ensure our clients and students were able to get the support and help they needed.

Part of the process early on in COVID was forming good partnerships with health departments at the county and state level in an effort to maintain our services. Substantial education and partnership was required so as not to accept the status quo of psychiatric care being automatically deemed congregate care. Rather, officials were engaged to understand that every emergency room across our state would come to a standstill if Sheppard Pratt was unable to maintain the flow of psychiatric patients in acute crisis.

We developed a personalized patient care approach in our hospitals during COVID that differed from patient to patient. We looked closely at managing our therapeutic environments to maintain social distancing-from rearranging and eliminating furniture to changing the size of our therapy groups (Fig. 4) .

For example, on our child unit wherein the children are very active and often cling together, how could we maintain a therapeutic environment and keep them safe from an infection control perspective? We gave visual cues to help our patients see what it means to be socially distanced. This was helpful with many of our specialty units (Fig. 5) .

Patients were also encouraged to wear a mask to practice infection control prevention measures. When patients were noncompliant with wearing personal protective equipment (PPE), we took an individualized approach with successful interventions for all patients. We ensured staff maintained social distancing. There were also alternative activities provided that were therapeutic and interactive, but could be Sheppard Pratt accomplished at a distance. In addition, we had PPE code kits so that staff assisting for medical or psychiatric emergencies had everything they needed at a moment's notice to feel protected and safe. We also reduced the areas from which staff could respond to minimize interactions and potential spread should anyone become COVID positive (Fig. 6) .

Our partial hospitalization programs also had to get creative when it came to programming as our day programs went virtual. We made sure patients had access to zoom rooms. We have provided a mix of individual sessions while also using interactive sessions to get them up and moving, like yoga or helping them walk through guided meditation or mindfulness.

In any given year, Sheppard Pratt cares for patients from 42 states and 19 foreign countries. Many of our hospital programs are renown in their expertise, and people travel from outside of the region to receive this specialized care. In the early months of COVID, when there were hotspots, we wanted to ensure the safety of our patients and employees. We focused our specialty program admissions on areas within driving distance, tested upon arrival, and had a mandatory quarantine period.

For our regular hospital admissions from emergency department (ED) referrals, the ED tested for COVID before approval. Patients were subsequently room restricted for the first 72 hours of their stay with clinical services delivered in the room. We also limited dual occupancy rooms to ensure that we were not placing someone who had quarantined already with a new patient in the quarantine period.

Our Care Connect team, similar to a call center, was critical during this time. Team members act as navigators for Sheppard Pratt's programs; they triaged calls and responded to e-mail inquiries to connect people to the program that fits their needs-from level of care, to therapeutic interventions, to insurance, and location. Our national outreach team was similarly working with referring providers to help them with the referral process to get patients the specialty care they needed and make the admissions process as smooth as possible, including managing travel logistics. 

Much of our outpatient care was converted to telehealth, providing virtual access to thousands of patients, including more than 500,000 virtual visits that were conducted from April through just the first half of 2021. For our most vulnerable, staff members were redeployed to conduct home visits across 200 supportive housing locations to help manage food and shelter, providing more than 250,000 meals to the community. And for those who need long-acting injections, we created mobile nursing teams to provide in-home medication administration and injections. We worked closely to help people learn to manage their own care, especially some of our more vulnerable populations with developmental disabilities. We ensured people had thermometers, and we taught them how to check their own temperature. We are certain that we kept thousands of people with serious mental illness alive and safe during this most uncertain time (Figs. 7 and 8) .

In April 2020, we also launched our Virtual Psychiatric Urgent Care, which was an extension of our in-person services for those seeking emergency psychiatric care; it provides those in crisis with an online mental health assessment and then connects them to the most appropriate level of care and services. The program was meant to decrease the volume of psychiatric patients in emergency rooms, which are integral when hospitals are taking care of patients with COVID-19. From April 2020 through June 2021, our virtual crisis clinic provided more than 3500 crisis evaluations and urgent follow-up appointments for medication management or psychotherapy. Telehealth can be a game changer and equalizer when it comes to access. For many, transportation can be a barrier to accessing quality care. Following the virtual evaluation, if in-person care was needed, our transportation team picked up the patient and brought them to the program for further evaluation and treatment. This innovative virtual program was awarded the Innovation in Health Care award by a local business publication. Our chief of medical staff and medical director of outpatient services received the health care outcomes award from our local business journal for his work with our Virtual Psychiatric Urgent Care.

We developed and launched other programs to support our community. The Retreat, our premier program for mood disorders and substance use, began offering a virtual program in light of the COVID-19 pandemic. The continued uncertainty surrounding COVID-19 has caused many people to evaluate the impact of anxiety, obsessive-compulsive disorder (OCD), and related disorders on their daily lives. Sheppard Pratt launched the Center for OCD and Anxiety during the pandemic in response to increased community need to help more people get the specialized and compassionate care they need. We also added confidential access to crisis care for health care workers that are on the frontlines of this pandemic, including internal counseling appointments and resiliency training.

Our schools and school-based programs continued to support students and families in Maryland and the surrounding area. We operate 12 nonpublic special education schools throughout the state that support more than 700 students with autism spectrum disorders, behavioral disabilities, and intellectual disabilities.

During COVID, our schools pivoted to develop continuation of learning plans for when schools were not in session and established a comprehensive task force to review metrics and develop safe reopening strategies. Our teams had to think creatively about how to deliver not only education but also mental health services in new and innovative ways, whereas both our schools and public schools remained closed during the COVID pandemic. Last fall and winter, clinicians made therapy kits that included some basic materials such as journals, crayons, color pencils, and fidget toys. These resources served as materials to be used during the telehealth sessions and also for the children to have some materials when they felt anxious or upset.

Throughout all the transitions, changes, and uncertainties, bottom-up solutionfinding was encouraged. Employees were empowered to suggest solutions that could help the organization and those we serve thrive.

Within our hospitals, we created almost 19 different subpockets so our units became sites where we did not look to do transfers from unit to unit. These are things that naturally occur when we are in non-COVID times, but are especially important to limit during the current environment.

We also used a modified provider staffing schedule of 7 days on/7 days off, with one provider on a unit at a time and another provider that is supporting off-unit via telehealth. Normally, we could have anywhere from 2 to 3, maybe even four doctors or nurse practitioners providing care on our inpatient setting. We limited it to just one doctor or nurse practitioner on the unit at any given time. During their 7 days on, it was one person physically on the unit that could be seeing up to 20 patients, maybe even up to 22 patients if our largest unit was filled. We did a similar staffing schedule with nurse leaders.

From an infection control standpoint, but also from a burnout standpoint, we saw the impact COVID was having and how it was wearing our employees down. Having an alternate schedule gave some reprieve. With our other frontline staff, we were also trying to compress their schedules so that they are on 3 or 4 days at a time and not on/ off/on to get a much-needed reprieve as well as limit their exposure.

In addition, we worked to limit our float pool. Before our first patient with COVID-19, we tried to find a home base for our float pool so that we had extra people in service lines and areas to limit floating. We have also been very attentive to when staff get sick and how we support them. We set up a screening process early on in the pandemic, which includes screening before entering our hospitals and throughout the day on our units. And we pay really close attention to how people are feeling. We send people home, and we encourage them not to come to work if they have any symptoms.

From the onset, in addition to ensuring we provide the best care and services to those we serve, our focus has also been on our 5000 employees. We know how critical they are to the success of the organization and providing the high-quality, compassionate care that we are known for.

As we adapted to the changing circumstances of COVID-19, it was critical that employees had timely and accurate information. Our executive leadership team began hosting daily calls with more than 200 leaders in our organization to share important information about COVID, share success stories, as well as support our leaders so they could in turn support their team. These calls have moved to a biweekly update, but still continue today. In addition, to better communicate with all employees, we launched an internal communications platform that was accessible via desktop and mobile to not only provide information about COVID-19 and resources but also keep employees energized and motivated about the work they were doing each day (Fig. 9) .

Early on during the pandemic when an executive order to shut down schools in Maryland was issued-including our own special education schools-it became clear that our employees would need support while working and handling duties as caregivers. We quickly created day camps staffed by our school-based employees at 5 locations across the state to provide a free, safe space for children of our employees (Fig. 10) .

We also provided telehealth counseling resources for our staff, offered free therapy groups for employees led by one of our providers, as well as provided our leaders access to coaching resources to help them lead and to support their staff. Employees and their loved ones also had access to a wealth of mental health, wellness, and self-care resources that we developed and housed on our Web site including blogs on reducing anxiety and sharing mindfulness tips, links to free at-home fitness options, and resources for parents about coping with online learning and managing during a lockdown. We regularly encouraged employees to access these free resources and to also use our Employee Assistance Program.

As leaders, we needed to role model vulnerability and healthy behaviors. It is the role of leadership to carry organizational anxiety and work actively to reduce barriers. Our leadership team prioritized making it "okay to not be okay." We encouraged employees to embrace uncertainty and know that this was a marathon not a sprint. Employees were also encouraged to stop and share how hard the journey has been and support one another to the finish line. And where possible, encourage people to take time off to recharge, find ways for people to disconnect from work, and place an importance on family and community.

Following the state of emergency declared by the Governor of Maryland in March 2020, Sheppard Pratt initiated a Code Yellow (Disaster/Emergency code) to ensure we were on standby notice and ready to activate our emergency preparedness plan as needed given the potential surge of patients to hospitals.

Although a surge did not mean our hospitals would receive patients with potential or confirmed cases of COVID-19, it did mean that we needed to think about our discharge plans for patients so that we can continue to receive psychiatric patients (who are not medically at risk) from other area hospitals. This proactive thinking allowed area hospitals to have greater capacity to care for those in our communities with the virus. We maintained ongoing dialogue with area hospitals regarding our admissions so that we could be a resource and quickly move psychiatric patients to our facilities.

All throughout COVID, we were fortunate to stay ahead of PPE needs by empowering our supply chain team to use their expertise and ensure adequate PPE supply. Our operational excellence team developed new programs for supply control and sourcing materials to sites across the state, something practically unheard of within psychiatric hospitals. To ensure we had sufficient supplies of PPE at each location, we developed a new process for requesting and tracking daily consumption of supplies to manage our organizational supply chain most efficiently. We identified designated PPE requestors to submit daily consumption tracking of PPE and new requests for PPE-related supplies. All PPE-related requests went through these designated requestors for processing. By following this process, we maintained an efficient and centralized critical supply distribution process.

It was also seen as an imperative for Sheppard Pratt to lead the way and secure COVID-19 vaccine access for our broader mental health community. Beginning in late December 2020, we hosted vaccine clinics daily at our conference center in Baltimore County as well as through pop-up clinics throughout the state to help vaccinate employees, including our psychiatry residents/fellows, as well as vaccinating some of the most vulnerable in our group homes (Fig. 11) .

We also contacted the Maryland Psychiatric Society as well as local providers to offer access to our vaccine clinic to ensure psychiatrists and other mental health practitioners were vaccinated. Fig. 11 . Hosted vaccine clinics to vaccinate employees as well as some of the most vulnerable in our communities. 

The last 2 years have shown that mental health services are needed now, more than ever. Beyond managing our COVID response, Sheppard Pratt doubled down on innovation and developing the next set of resources our nation would need. From opening a brand new psychiatric hospital in the Baltimore-Washington corridor, to opening additional crisis beds, to beginning a replication of Vermont's statewide hub-andspoke model for opioid treatment, to penning the next Textbook on Hospital Psychiatry for the field, we have mobilized all of our care teams and dedicated care providers to do more. We do not plan to give up the organizational agility that we have gained during COVID because there is so much more that we all need to do (Fig. 12) .

We have also seen the need for solutions to meet the increased demand for behavioral health services locally, regionally, and nationally. Recently, we launched Sheppard Pratt Solutions, a new division that uses the extensive expertise of our mental health professionals to provide consulting, management services, and development-based partnerships to help health care organizations nationwide establish and improve delivery of hospital and community-based behavioral health services in their community (Fig. 13) . Now begins the hard work for all of us to work together and find the path forward. As the need for more behavioral and mental health treatment options increases and as psychiatric bed capacity remains almost full, it is critical to have access to care and services. Sheppard Pratt has been integral to the COVID response, and all of us will be ever more integral during the recovery.

The author has nothing to disclose.

Mental health, substance use, and suicidal ideation during the COVID-19 pandemic -United States

Sheppard Pratt Solutions partnerships to meet the behavioral health demand in communities nationwide as of

Substance Abuse and Mental Health Services Administration. Key substance use and mental health indicators in the United States: results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54)

Data Brief 355. Mortality in the United States

Drug-and alcohol-related deaths across Maryland jump more than 9% due to the coronavirus, officials say

The high cost of compliance: assessing the regulatory burden on inpatient psychiatric facilities

UW Medicine shuts down psychiatric unit amid financial shortfall

This is a scary, ugly system': Families say loss of Providence Behavioral Health Hospital beds endangers kids

Heywood healthcare closes mental health unit in cost-saving move