Building Resilience in the Face of Crisis: Lessons Learned from a Community Behavioral Healthcare Organization.

The novel coronavirus (SARS-CoV-2 or COVID19) has defied the healthcare system at every turn. The impact of this pandemic on ensuring the health and safety of individuals with serious and persistent mental illness-particularly those living in community-based residential settings-has been challenging. As one of the largest community behavioral health organizations in Oregon, the authors present a descriptive study of an organizational response to the COVID-19 pandemic. This paper presents barriers, strategies, and lessons learned, through firsthand experience and interviews with key residential staff. This paper is not formal research, but the integration and assessment of staff perspective, and organizational experience and knowledge. By sharing these insights and experience, this paper contributes to a collective roadmap for the future, to guide responses to public health crises or other unprecedented events that threaten organizations caring for some of the most vulnerable members of the community.

Background

Cascadia Behavioral Healthcare is the largest community based behavioral healthcare provider in Oregon, serving approximately 18,000 individuals per year. Cascadia’s twenty-seven residential facilities and supported housing sites provide housing and care for some of the community’s most vulnerable members, including individuals with serious and persistent mental illness (SPMI) and co-existing chronic health conditions. These individuals receive an extensive number of daily in-person services to support their mental health and daily functioning, including case management, individual and group therapy, and skills training. Although residential facilities share commonalities with nursing homes and extended care facilities, they are distinct in the population they serve and thus in their approach to safety and supporting mental health during COVID-19. The combination of group housing, complex integrated health needs, 24 h per day staffing requirements, and the extent of services provided, bring unique and unprecedented challenges in protecting staff and residents during a crisis. When the first cases of coronavirus appeared in Oregon in late February 2020, Cascadia Behavioral Healthcare acted quickly to ensure the safety of staff and patients in residential sites, with the development of an incident command center (ICC) and safety plan in place by March 4, 2020.

Individuals living in residential treatment facilities often live with significant SPMI or other conditions such as traumatic brain injury (TBI), that influence cognition, memory, and emotional response. Some individuals with SPMI may therefore not understand the extent of a pandemic, and may have difficulty complying with physical distancing restrictions, stay at home orders, or the use of personal protective equipment (PPE); this places them, and others, at greater risk of infection.[1] Masks may be triggering for individuals with SPMI, as masks eliminate one of the most critical elements of human connection; communication using facial expressions.[2] In fact, researchers have found that individuals unconsciously mirror facial expressions during social interaction. For example, interacting with a person displaying a fearful expression may then elicit fear in the observer.[3] Additionally, state-level restrictions enacted in the spirit of protecting public health, but which influence personal freedoms such as restricting movement within and from the building, may feel particularly isolating for someone with a serious mental health concern. These challenges, compounded by reductions in in-person services, limited space for social engagement, and alterations to routine, all required consideration in Cascadia’s response, to safely and effectively meet the health needs of this vulnerable population. Cascadia’s research director conducted interviews with residential leadership about their experiences supporting clients and front line staff during the start of the pandemic. In this descriptive study, the authors present the themes that emerged from the interviews, as well as a review of notes from the ICC and staff communications, and then discuss the implications for the changing landscape of behavioral healthcare post pandemic.

Methods

Elements of success during crisis

The authors conducted in-depth, semi-structured interviews of approximately 30–45 min, with seven staff in administrative and clinical leadership roles that support Cascadia’s residential services. Staff were identified based on having an active role in leading the crisis response in residential settings, and all staff asked to participate engaged in an interview with the interviewer, who holds a non-clinical research position at the organization. Staff represented the nursing team (2), quality management (1), residential leadership teams (2), crisis leadership (1), and human resources (1). Interviews were recorded with permissions, and were transcribed by the interviewer and analyzed for emerging themes using an exploratory framework. Four distinct themes emerged: leadership and decision-making, communication and collaboration, innovation, and organizational culture. While some of these themes are specific to Cascadia’s response to COVID19, others are deeply woven into the fabric of Cascadia’s values and mission as an organization. All are essential to successful management of a crisis.[4]

Results

Leadership and decision-making

Each interview revealed elements of leadership as a critical component of success. Cascadia’s leadership was characterized by a proactive versus a reactive approach; staff quickly developed and enacted recommendations and policy around COVID19, sometimes with limited guidance from federal and state governance. For example, although Cascadia reached out to the state for guidance at the start of COVID19, the state was not yet prepared to advise on managing a crisis within a community-based mental health residential setting. Despite this challenge, by March 4th Cascadia’s medical leadership developed and implemented cleaning checklists for each site, shelter-in-place and absenteeism plans, and communications for staff and clients. Telehealth services were in place by March 26th. Staff noted this prompt response and early decision-making as key in protecting clients and staff in residential settings where potential for spread of the virus is high.[5] Early cases of the coronavirus in two residential sites necessitated rapid decision-making to protect clients and staff. To reduce the chance of a possible outbreak, staff immediately reduced the number of beds in these sites, and developed alternate plans for housing clients in hotels and other locations, while still maintaining services. In light of additional exposures to potential COVID-19 cases, they subsequently closed one of the sites entirely, to enable extensive cleaning and testing of staff and clients. These protective measures, coupled with collaboration with Nursing Leadership and Medical teams, enabled Cascadia to reopen the site and serve clients after only seven days.

One staff discussed the importance of and difficulties inherent in, creating “policy as you go.” Cascadia was quick to develop policies related to PPE, symptom screening, testing, and self-isolation, prior to guidance from the Centers for Disease Control (CDC). Leadership staff approached policy making in a decisive, yet flexible way, to ensure the greatest level of prevention and protection for clients and staff. While quickly developed and enacted policies may require revisions and multiple rounds of dissemination, a proactive, “act quickly and adjust later” approach was key to supporting safety and also keeping dialogue open for changes. Cascadia’s first version of the PPE policy, for example, was developed and disseminated to staff very quickly. After working within the policy for a short time, staff provided feedback to managers, which was incorporated into the updated version of the policy, along with any relevant new federal and state guidelines. Staff felt engaged in the process, and open to providing feedback with the assurance that leadership staff would pivot and update policies as needed. Over one year into the pandemic, the staff policy is frequently updated, and changes are shared with all staff. Cascadia’s proactive and flexible approach, combined with open communication, helped to ensure emotional and physical safety.

Communication and collaboration

One of the most tangible and successful outcomes of Cascadia’s leadership was the immediate development of an Incident Command Center (ICC) to lead the organization’s response to the crisis. The ICC continues regular (now weekly) meetings, 15 months after the start of the pandemic. Cascadia’s ICC evolved directly out of a need to quickly gather information from across a large organization; brainstorm and innovate; disseminate information effectively; and create a supportive environment to foster teamwork and support staff well-being. The ICC includes a particularly diverse group of stakeholders representing each department (clinical and non-clinical). Staff was selected for specific knowledge bases and skill sets necessary for rapid development and implementation of plans, and not based on organizational hierarchy. While the “intensive teamwork” identified as a part of the ICC was critical in responding to COVID-19, the aspects of the ICC that staff discussed as integral to success extend beyond traditional characteristics of leaderships and teams.

Staff noted that each member of the ICC had a voice regardless of their position in the organization. Individual strengths were recognized and celebrated in a space where ideas came together to build new structures and processes. “Everyone put their egos aside, which opened up the path to clear communication. This brought people together that wouldn't happen otherwise.” One of the nursing leaders discussed how this approach was critical in implementing processes that were not only based on sound decision-making and clinical guidelines, but also accounted for the capacity of the often-overwhelmed residential staff. Strengths-based solutions were framed around the needs of staff and each residential site, instead of implementing a one-size-fits-all approach. “Working with residential staff (and not above them), and within the bounds of staffs’ current capacity given understaffing, stress, and exhaustion,” the ICC implemented realistic best practice. For example, a digital peer support program was created to fill a critical gap in services and address suicide prevention when capacity of residential staff was limited.

The second key to an effective command center was the spirit and intent behind the meetings. Although the primary purpose of regular ICC meetings was to develop and implement policy to manage the crisis, staff frequently noted finding equal value in the simple aspect of consistency. Leadership teams established a daily ICC call (virtual) at the start of the workday. This 8:30 am call occurred even in instances when there were no agenda items, and during moments of quiet and calm. The ICC call was established—and continues—as a regular practice, led by rotating members of the group, which staff likened to a morning meditation. In fact, the ICC call begins with a daily inspiration provided by a Cascadia staff member, which has included poetry, mindfulness practice, and expressions of gratitude. Members of the ICC rely on the support and group problem solving inherent in this 30-min virtual space. Creating and supporting this space for a predictable, daily meeting felt critical in maintaining a sense of normalcy and cohesiveness during a crisis.

Lastly, staff expressed appreciation for the degree of transparency demonstrated throughout this crisis. Communications regarding the COVID response, testing updates, PPE, and presumptive cases were updated frequently on the internal website for all staff to access. Having access to information and guidance from the organization was critical in ensuring that staff felt safe, valued, and confident. Each team increased the number of virtual meetings, and explicitly created safe spaces for staff to share information and concerns, and ask questions. Residential leaders developed a policy that any staff exposed to a presumptive case in the past two weeks was immediately contacted. While this degree of conscientiousness was not required by the state, Cascadia’s values around communication, transparency, and staff well-being underscored the need for this policy.

Innovation, technology, and creative solutions

Clear and frequent communication, and leadership, was the foundation of Cascadia’s success in managing the crisis, but innovation enabled staff and clients to transcend barriers and maintain a sense of well-being. Several organizational level innovations were crucial in supporting residential staffing. First, Cascadia began offering two abbreviated, mainly virtual, new employee orientations (NEO) per week instead of an extensive in-person NEO every two weeks. This enabled Cascadia to quickly onboard new residential staff, which helped address staffing shortages exacerbated by Cascadia’s need to freeze float staff when potential COVID cases were pending, and to reduce the overall exposure to staff during the crisis. In addition, the recruitment team expanded their reach in hiring, and Cascadia initiated COVID pay, which is additional compensation to an hourly salary, to support all direct care staff who are required to work at on-site locations, through October, 2021. Leadership also created a collective bank for paid time off, to support staff that were forced to take time off due to illness, family, or quarantine protocol.

Telehealth is perhaps one of the most universal innovations that emerged across the healthcare landscape, in response to this pandemic. While Cascadia was not unique in the application of telehealth, staff engaged in tele-services by the end of March, to support residential clients and staff. Cascadia immediately began to transition psychiatric prescribing, individual and group counseling, primary care, and even skills training into virtual formats. The seamless transition into using telehealth to support clients was particularly essential for Cascadia’s residential clients who frequently receive multiple psychiatric, physical health, and basic skills training services on-site. Telehealth protected staff who travel across residential sites from additional exposure, and minimized the potential spread of the virus across sites and staff.

Changes in recruitment, hiring, training, and telehealth reinforced residential staffing, to enable staff to leverage their skills and creativity to support clients. Challenges inherent in serving individuals with SPMI during a pandemic require residential staff to be present, adaptable, and innovative. One of the most tangible challenges residential staff encountered during this crisis was negotiating the balance between client and staff safety, and supporting clients’ rights and freedom. Many residents were unable to engage in simple daily activities that bring them joy, such as riding a bus to the corner store or smoking outside with a friend. In response, residential staff purchased board games, art supplies, and backyard games to fill the time, and continuously remind residents—and themselves—that this is temporary. However, a month into the quarantine, residents are beginning to display an increase in mental health symptoms. Staff has found ways to support clients, including distracting and redirecting. Each day they employ new tools. They consider the individual client and problem solve, as a “one size fits all” approach is not sufficient. One strategy staff has employed to maintain safety for clients who are unable to fully comprehend or remember the restrictions each day, is using visual aids. Signs and images remind clients that we are in the midst of a pandemic and that it is unsafe to be in public spaces, which helps preserve trust between clients and staff. One staff noted that constantly having to remind some clients of the restrictions and limitations can quickly deteriorate important staff-client relationships. Staff discovered that flexibility is critical, as the strategies that work for one client may be harmful to another.

Maintaining safety by requiring that residents and staff wear masks has presented additional challenges. Developing a process to reassure some of the most symptomatic, or cognitively impaired residents through non-verbal cues, is imperative during a crisis. Residential staff navigated this barrier by creating facial expression masks, to allow them to communicate with residents using alterative facial cues. This is just one of many innovations used to support clients during this pandemic; staff has drawn on their creativity, resourcefulness, and passion for helping, to ease some of the pain inherent in the situation for residential clients.

Organizational culture/trauma informed response

The final theme that emerged underscores Cascadia’s deeply engrained culture of caring, support, and trauma informed practices (TIP). While TIP typically refers to care for clients that accounts for their lived experience and exposure to trauma, Cascadia also applies TIP at an organizational level.[6] Residential teams added frequent and regular meetings to support staff’s emotional and professional needs. In these meetings, managers encourage reflection, problem solving, and support. While there is no prescription for the structure or frequency of meetings across the residential teams, the common thread is their focus on team building and nurturing a supportive environment for staff. Residential leadership discussed the importance of reaching out to front line staff often between meetings, and with genuine concern for staffs’ mental and emotional health, and a willingness to talk openly and authentically. A TIP approach is particularly important in navigating discussions equity. For example, while residential staff is considered essential workers, and thus required to work on-site, some staff requested options for working from home for health or other personal reasons. These decisions were challenging to navigate, and resulted in some tension within teams, as each situation was unique and required complex staffing decisions based on principles of TIP.

Although most organizations pledge support for staff well-being (e.g., e-mails encouraging stress reduction and physical activity), tangible actions to support staff well-being are less common. Cascadia applied a trauma informed lens, and actively supported staff by providing resources and opportunities. Residential leadership staff demonstrated their commitment to staff of color by sending e-mails in support of staff attending monthly caucuses for people of color. The nursing team implemented “Ask a Nurse,” which is weekly open call dedicated to any COVID-related questions, concerns around PPE, or other support needed for staff or client concerns. The existence of these opportunities is important, but the engagement and commitment from staff in leadership roles is imperative.

Support for staff on the front lines comes from all levels of the organization. The Communications team regularly updates the internal website to provide information and connection for staff. In addition to COVID-related updates, they expanded the focus to include spaces for sharing staff stories and providing a platform for staff voices on coping, joy, peace, and challenges during this pandemic. Staff noted their appreciation for this human connection with their colleagues. Additionally, staff from across Cascadia made and donated masks for front line staff. Cascadia’s facilities and operations team has been constantly present. They frequently assess staff needs, deliver supplies, and ensure that staff has what they need to feel safe. The simple act of regularly checking in on staff across all sites to ensure that needs are met around PPE and supplies, instilled feelings of confidence and trust that Cascadia leadership staff value staff safety.

Challenges and looking to the future

During the interviews, staff spoke about the challenges inherent in managing their teams and ensuring community safety during the pandemic. Perhaps most significant is the unprecedented nature of this crisis; staff noted that there was no playbook or roadmap from which to work. While Cascadia leaders managed their teams and the crisis with skill, grace, and compassion, COVID-19 has been anxiety provoking, and at times exceedingly hard on staff. One residential leader discussed the difficulty inherent in separating work and non-work time during this crisis. They spoke about carrying home stress compounded over days and weeks. They spoke of constant exposure to vicarious trauma seeping into their personal and family time outside of work. As residents become increasingly frustrated, bored, and confused by the restrictions; and face mental health challenges from COVID-19; identifying ways to support residential staffs’ mental and emotional health must continue to be a priority.

The final phase of a crisis, as defined by James and Wooten (2005) is the learning phase, which requires a fundamental shift within the structures of an organization.[7] In the midst of the pandemic Cascadia is fine-tuning their emergency preparedness plan. Staff has lived the value of having contingency plans for the contingency plans. The emergency response to COVID was—and is—happening in real time. However, the knowledge and experience gained from this event will significantly shape how Cascadia addresses future crises, as the roadmap is under construction and leadership teams are engaged in ongoing conversations around preparedness more broadly, to be prepared for any future crisis.

Staff frequently noted the formation of the ICC as one of the most critical elements of success in managing COVID-19, but also in preparation for the future. Several staff proposed continuing regular meetings of the ICC after the pandemic has ended, to maintain connections, model leadership and transparency, and support information sharing across Cascadia during non-crisis times. Research indicates that having solid relationships within an organization prior to crises, is critical in successful leadership through crisis.[7] Ongoing ICC meetings will support these relationships and strengthen communication and leadership prior to future crises. Lastly, support for continuing the use of telehealth in behavioral health treatment was universal among staff we interviewed. Residential leadership teams discussed telehealth long before COVID-19, but crises often speed up timelines and push boundaries. In Cascadia’s residential settings where it is often difficult to facilitate clients going off-site to see a provider due to fear and anxiety, telehealth may provide a unique opportunity to improve access to care for some of the most vulnerable members of the community. Telehealth was a necessary adaptation in an acute crisis, but will have lasting effects for treatment at Cascadia.

Resilience, or the ability to draw on resources to weather stressors, is tested during a crisis.[8] Residential staff understands the importance of fostering increased resilience among their residents—particularly during periods of trauma—and they are leveraging this crisis as a means to continue this important work. One residential leader spoke about their staff “teaching clients how to draw on their ideas to stay well.” Arming individuals with a SPMI with tools to build their capacity for resilience can help offset the deficit of personal resources caused by their mental illness. Resilience may be the rainbow that emerges from the storm.

Despite the challenges and exhaustion surrounding this pandemic, Cascadia staff remains hopeful, strong, and resourceful. They spoke about the knowledge and growth that has emerged from this crisis, within Cascadia and across the landscape of healthcare. Staff also expressed the comradery that makes it possible to continue this challenging work. Cascadia’s core values of determination, innovation, and respect, are present in every decision, discussion, and policy. Cascadia’s greatest asset is its staff, and they are the reason “Cascadia is special.”

Implications for Behavioral Health

Preparation for a crisis has implications beyond the management of an acute event. Skills developed and strengthened to manage a crisis such as COVID19, including communication, leadership, innovation, and organizational culture, improve regular care of clients with mental health concerns. The innovation and advancements in technology necessitated by this crisis will also help community behavioral health rise to demands of the changing environment of healthcare, including staffing challenges, value based payment models, and financial challenges around reimbursement for services. Lastly, staff-focused supports developed during COVID19 can be an ongoing opportunity to promote staff well-being and self-care, which will ultimately improve the field of behavioral health through increased staff retention and health, ultimately leading to better client care and health outcomes.

Limitations

This was not a formal research study, and the primary researcher and interviewer is also employed by organization highlighted in this paper. Results may be influenced by additional knowledge and experiences of the authors, beyond the interviews and document reviews. However, a formal and unbiased research study was not the intent, and the authors feel that this experience adds richness and insight to the paper. While the specific results may not be generalizable to every community based behavioral health organization, they can guide processes and approaches to manage future crises, which are tailored to the needs of staff and clients, and align with organizational culture and values.