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Addressing Skilled Nursing Facilities' COVID-19 Psychosocial Needs Via Staff Training and a Process Group Intervention

Published:April 29, 2020DOI:https://doi.org/10.1016/j.jagp.2020.04.023
      Past research has demonstrated a clear link between isolation, contact precautions, and delirium
      • Day HR
      • Perencevich EN
      • Harris AD
      • et al.
      Association between contact precautions and delirium at a tertiary care center.
      and depression.
      • Purssell E
      • Gould D
      • Chudleigh J
      Impact of isolation on hospitalised patients who are infectious: systematic review with meta-analysis.
      In the midst of the current COVID-19 pandemic, it is critical that patients in skilled nursing facilities (SNFs) and psychiatric centers continue to receive appropriate care and that their care teams understand the risks associated with isolation. In China, poor self-rated health status during the COVID-19 outbreak was associated with increased depression and anxiety, especially for those with chronic medical comorbidities.
      • Wang C
      • Pan R
      • Wan X
      • et al.
      Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in china.
      Moreover, clinicians caring for patients with COVID-19 are also at high risk for developing anxiety and depression during this crisis.
      • Lai J
      • Ma S
      • Wang Y
      • et al.
      Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019.
      SNF and psychiatric center staff are clearly stressed: they are caring for vulnerable patients, navigating ever-evolving isolation precaution regulations, and worrying about the risk that their job poses to their own and loved ones’ health. Prior to COVID-19, SNF staff were identified as being at greater risk of burnout than peers in other settings and in need of educational support.
      • McHugh M.D.
      • Kutney-Lee A.
      • Cimiotti J.P.
      • et al.
      Nurses' widespread job dissatisfaction, burnout, and frustration with health benefits signal problems for patient care.
      With these factors in mind, we decided to offer assistance to SNFs and collaborating psychiatric centers engaged in the University of Rochester Geriatric Telepsychiatry Program.
      We invited SNF and psychiatric center staff to a 1-hour videoconferencing session, hosted twice during the early phase of the pandemic in our community. Sixty-seven participants, representing 7 SNFs, 11 psychiatric centers, and 3 other organizations joined the videoconference and 61 participants reprsenting10 SNFs and 3 major organizations joined another. For the first 20 minutes, we delivered a didactic on the increased risk of delirium in isolation and provided recommendations to monitor and evaluate for delirium. In the following 40 minutes, we facilitated a discussion to explore interventions to reduce loneliness and isolation in a safe and physically distanced way and acknowledge the challenges that facilities were encountering and their approaches for addressing them. Within this forum, individuals and teams shared their personal reflections regarding the emotional struggles of their work. Themes of anxiety for their patients, their personal safety, and that of their loved ones emerged. They exchanged ideas on how they were coping and still supporting one another even when working remotely. We validated these ideas and efforts while also noting the importance of self-care in order to successfully maintain the well-being of their patients.
      We received uniformly positive feedback for this session. Participants reported increased awareness of ways to monitor and support patients in isolation and that they benefited from attending to their self-care. Participants shared that they liked, “that the importance of self-care was discussed and specifically how it translates into better patient care,” “the open discussion…it reminded us we are not alone,” and the recognition that “COVID-19 is influencing everyone's life – staff and patients alike.” As a byproduct of this initial session, additional sessions are being offered: isolation and depression management, and staff burnout prevention.
      Our experiences suggest that directed training and process group support delivered via videoconferencing may ameliorate COVID-19’s negative psychosocial effects on SNF and psychiatric center staff as well as support staff in addressing isolation's mental health effects on residents. As this initiative is part of a larger service through our institution, we are continuously engaged in program evaluation and collecting data regarding our participants’ learning experience. Evaluation of this and similar efforts, modified based on the scope and scale of the program, could include: 1) pre-/post-test changes in the SNF participants' well-being as well as competency in the reviewed didactic areas, 2) whether the participants' SNFs had implemented strategies from the didactic sessions for SNF patients referred for psychiatric consultation, and 3) SNF assessment data (e.g., depressive symptoms and aggressive behaviors) from the Minimum Data Set.

      Author Contributions

      All authors met the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. LDR and JG developed the study concept and design and had primary responsibility for the preparation of the manuscript. LPE and LW had primary responsibility for collecting the data. LDR, JG, AS, LPE, LW, and MH all provided input regarding the study concept and design as well as with drafting and revising of the manuscript, critical review of the manuscript for important intellectual content, and approval of the final manuscript.

      Disclosure

      Thank you to the New York State Office of Mental Health (NYS OMH) and HRSA for financial support of the URMC Telepsychiatry Program and to participants from the NYS OMH, the Finger Lakes Geriatric Education Center, and the Finger Lakes Chapter of the Alzheimer's Association.
      There are no conflicts of interest to report.

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