Medical Unit Support Services
Although a robust outpatient behavioral health service was laid out in the JNYMS, the behavioral health team recognized the need to provide mental health interventions within the main patient care areas as well. The intention was to maximize availability and support while minimizing interference to patient care. As previously described, a psychiatric consultation-liaison (CL) team was organized and operated 24 hours a day by early April 2020.9 Indeed, CL psychiatrists have played a valuable role in supporting the unique patient and staff needs in other COVID-19 treatment environments.10 The CL team at JNYMS observed that medical staff were exposed to multiple stressors, including fear of acquiring COVID-19, treating patients with significant medical comorbidities, practicing outside of clinical specialty, working with unfamiliar and limited equipment, and adjusting to frequently shifting changes in personnel and work schedules. Moreover, psychological stress was compounded by long shifts, jetlag, and continuous wear of extensive personal protective equipment, as has been documented in other COVID-19 treatment centers.11
The team of psychiatrists conducted informal rounds to nursing stations to evaluate the morale and develop relationships with the medical team, including nurses, physicians, medics, and other personnel. Areas of high stress and increased interpersonal conflict were identified for more frequent check-ins by mental health clinicians. The psychiatrists and LCSWs were available for informal walk-in therapy when requested by personnel. When the acuity increased, personnel could be accompanied to the individual counseling room for rapid therapeutic interventions. The CL psychiatrists developed professional relationships with the command and medical leadership teams. Through these relationships and sensitive awareness of morale in the medical work environment, psychiatrists were able to advocate for alterations in the nursing work schedule. Leadership was receptive and resultant changes decreased the hours per shift and number of shifts for most nurses. Morale quickly improved, likely resulting in improved quality of patient care and prevention of burnout.
Mental Health Care Beyond JNYMS
Uniformed services and other federal personnel further supplemented health care operations beyond JYNMS. In April 2020, Urban Augmentation Medical Task Forces were organized and distributed throughout regions where COVID-19–related hospitalizations had significantly overwhelmed the local health care force. Urban Augmentation Medical Task Forces often included a psychiatrist, psychologist, and behavioral health technician with the mission to provide mental health support and interventions to patients and medical staff. Combat Operational Stress Control units from US Army medical brigades operated in NYC and the greater northeast region, providing mental health support and resiliency training to military personnel working in civilian hospitals, medical centers, and other health care or support environments. In addition, a LCSW and behavioral health technician worked with New York Army Reserve personnel assigned to mortuary affairs, providing point-of-care interventions at or near the worksite.
A collaborative federal, uniformed services, and state operation led to the development of the HERO-NY: Healing, Education, Resilience, and Opportunity for New York’s Frontline Workforce “Train the Trainer” Series.12 The series was intended to use uniformed services expertise to address mental health challenges related to the COVID-19 epidemic. Psychiatrists and mental health clinicians from JNYMS modeled small group trainings for future medical trainers. In lieu of traditional unidirectional lecturing, which yields limited retention and learning, the panelists demonstrated how to lead interactive small group training with resiliency topics, including goal setting, communication, anger management, and sleep hygiene.
Transition
After the last patient was discharged from JNYMS in May 2020, personnel were quickly redeployed to their duty stations. At the time of mission completion, the JNYMS behavioral health team had been supplemented with psychiatrists, social workers, behavioral health technicians, psychiatric nurse practitioners, psychiatric nurses, and psychologists representing US Public Health Service Commissioned Corps, Army, Air Force, and Navy, and provided comprehensive support to the nearly 1100 patients with COVID-19 and 600 deployed federal and state medical and support personnel.
Lessons Learned and Future Considerations
Behavioral health care provided at JNYMS offers insight into support of frontline workers in pandemic settings, as literature is limited in this area.13 TheJNYMS behavioral health team used strategies similar to military medical interventions in limited and unpredictable environments, such as rapid formalization of team structure and establishment of standard operating procedures to facilitate uniformity across interventions. Physical space was necessary to create an environment conducive to productive mental health interventions, including therapy rooms and quiet and spiritual spaces. Placing behavioral resources in high-traffic areas normalized mental health and maximized accessibility to interventions. Mental health personnel also addressed issues in the work environment, such as providing informal support and crisis interventions to frontline workers. Finally, Urban Augmentation Medical Task Forces mental health personnel and Combat Operational Stress Control units provided therapeutic interventions and resiliency training for military and civilian personnel throughout burdened medical systems beyond JNYMS.
Future operations should consider what equipment and logistic access are necessary to provide psychiatric and psychological care to mobilized federal and uniformed personnel, such as access to frontline worker electronic health records. Given that prior work has found that provision of resources alone is inadequate, frontline medical workers must be aware of where resources are available (eg, signage) and have easy access to material (eg, brochures) focusing on resiliency and psychological health.14 The spaces can be used for formal psychiatric and psychological interventions, such as assessment, therapy, and medication management. Equally important, these spaces serve as a safe place for healthy social interaction and fulfillment of basic needs (eg, nourishment) and a peaceful environment free of stimulation.
Since mental health personnel provide varied services ranging from basic human interaction to complex crisis interventions, mental health personnel should supplement pandemic medical operations. Evidence supports the notion that effective communication and cohesion throughout the entire leadership and health care team structure can improve resilience and implementation of mental health interventions.15 Incorporating mental health personnel into leadership planning meetings would allow for timely recommendations to improve medical logistics and planning of deployment of behavioral health resources. As a general rule, providing behavioral health experts with a seat at the table enhances advocacy and command awareness of the morale and mental health of frontline personnel.
Conclusions
We present the experience of developing mental health support services for deployed personnel during the COVID-19 pandemic and address the real-time mental health treatment and support of deployed uniformed services and federal personnel in the COVID-19 response environment. Timely and effective interventions included securing safe therapeutic space in high-traffic areas, developing relationships with leadership and frontline workers in their own work environments, and disseminating such services throughout the civilian medical system.
Mental health supplementation during the medical response mission strengthened morale in frontline workers in a disaster scenario. We hope that this report and others like it will provide information to improve mental health responses, reinforce mental health support, and encourage research in evidence-based interventions in challenging pandemic and disaster settings.
Acknowledgments
We would like to acknowledge and thank those serving on the frontlines of the COVID-19 pandemic.