CLEVELAND, Ohio — In April, six staff members at FrontLine Service tested positive for COVID-19. As a result, many of FrontLine’s workers made the sudden transition from holding face-to-face behavioral health appointments from the office to telehealth appointments out of their homes.
Hundreds of behavioral health workers in Cuyahoga County and beyond continue to deal with the stress and other challenges of seeing patients remotely during a pandemic that’s limited their access to people in need, and in some cases, creating a unique host of mental-health challenges.
“This work, some positions could be done more seamlessly in a remote setting,” associate director of FrontLine Jane Franzier said. “And while I think we’ve done the best we could, and in our job, and sending everybody remotely, but (it’s a challenge) when you’re taking calls when someone might be holding a gun while they’re talking to you, and add that to a staff member has been here for only six months.”
Cleveland.com launched Coping through COVID, a regular series that aims to help Northeast Ohioans manage the stress of COVID-19 by examining the mental health aspect of the pandemic. In an ongoing series, cleveland.com will explore stories about people’s mental health struggles and talk with experts to explore the challenges and strategies to deal with those struggles.
FrontLine is a private non-profit community mental health center best known as the primary community mental health provider for the homeless and many who live with severe mental disabilities. It also operates a 24-hour suicide prevention line for Cuyahoga County.
Although the pandemic forced a portion of the FrontLine staff to work from home, the clinic never closed, doctors remained available, and it never suspended referral services.
“You feel better as a clinician seeing clients face to face because the initial assessment is important,” Granzier said. “We want to give clients the opportunity to come in for an assessment, so we could recommend the proper treatment.”
Before the pandemic, the staff at FrontLine worked four 10.5-hour shifts a week. The office setting consisted of a large room with individual spaces with three or four supervisors. Staff would take calls, provide face-to-face consultations, and then direct clients to the care or resources they needed.
Today, staff wake up to their laptops with an extra monitor and a headset as they work from home. They review follow-ups and make calls to clients while simultaneously answering the suicide prevention hotline. Granzier says sometimes the program manager might instruct them to go out to see someone.
“We make sure they have masks and face shields for clients and themselves,” Granzier said. “While social distancing, we use skills to try to engage the clients and talk about signs and symptoms, and if the individual is willing to see a psychiatrist, we will bring them in for treatment.”
FrontLine is still providing crisis outreach within the community, but due to the pandemic’s uncertainty, like finding safe, open locations with clients. Before COVID-19 cases began to soar in November, FrontLine staff could pick up clients. Now, they meet them at their homes or in public places, even if it’s on a street corner.
To increase safety, specialists assess people in the community in pairs. One specialist leads the assessment while the other documents the appointment. Specialists drive from opposite ends of the county to meet with clients at their homes instead of dispatching from their office in downtown Cleveland.
The rise in COVID-19 cases also prevented specialists from doing assessments at hospitals — where pre-pandemic evaluations were often provided in emergency departments or inpatient medical units.
Approximately 8-10% of the referral requests received by FrontLine come from hospitals. The agency saw a 30% reduction in hospital requests from the first quarter of the calendar year 2020 to the last three quarters, Granzier added. The decrease stemmed from fewer people checking into hospitals because of shrinking space at hospitals because of the pandemic. The decline also stemmed from concerns over hospital capacity and fears of contracting COVID-19.
Crisis intervention specialist Jean Morran-Hadden works for FrontLine’s child and adult mobile crisis team. She said the children’s team conducted significantly more assessments because at-home learning led to increased isolation and anxiety among children who can’t be with their friends.
Hadden says high school children who received good grades before the pandemic expressed fears of getting into college, repeating their last year of school, and joining the workforce.
One of the most challenging tasks of transitioning to telehealth for FrontLine staff was adjusting to different behaviors, especially children who need special accommodations.
“I have a little one that has ADD, and he puts the phone down, so I have to hang up and call back to make the phone ring,” Hadden says. “And when I have some kids that are autistic, I have to accommodate them as well, but I’m learning to adjust.”
Hadden uses different techniques to keep children engaged in therapy by keeping their peak interests in mind, such as asking them about their favorite colors, foods, and activities.
Granzier adds that children are not the only population struggling with telehealth. She explains that some adults aren’t amenable to doing assessments over the phone.
“Somebody who is not eating or drinking, or someone who is so disorganized that they may walk down the street naked isn’t suitable for a telehealth assessment,” Granzier explained.
FrontLine is not only concerned about keeping clients engaged, but they want to ensure that they’re meeting the needs of everyone, including staff members.
“I’m concerned about my staff and making sure I have what I need so I’m able to support them and make sure they have everything they need to stay resilient themselves,” Granzier said.
Backyard and porch sessions
Jennifer Blumhagen-Yarham, executive director of Applewood Centers Inc., said her organization created a specific goal of ensuring that children and their families continued to get therapy and treatment without interruption during the pandemic. Until Thanksgiving, the staff provided appointments on clients’ front porches or backyards for sessions.
Applewood Centers, another sizeable behavioral health agency, provides services that include foster care and residential treatment. Due to the wide range of services, some clients live at the facility for weeks, sometimes months at a time. Some staff at Applewood are still coming into the office because they are responsible for those who still require face to face mental health services.
Now, the bulk of Applewood’s therapy is done through telehealth since school-based services are limited due to public schools moving to remote learning.
Before the pandemic, therapists would visit schools to see clients, work with teachers, and possibly make some off-site visits before the close of the day.
Now, therapists aren’t sitting in an office or school. And the changes force many therapists to work evenings and weekends because students aren’t available throughout the day because of virtual learning, Yarham said.
“And in cases of emergency when therapists have to travel to see a client, they can’t bring toys, games, or therapeutic tool kits, now all they bring is a laptop and proper protective equipment,” Yarham said.
When necessary, staff will still meet clients in public places, like at a library, and have a socially distanced meeting.
In addition to the new schedule, the Applewood staff must adjust to new precautions to minimize the risk of infections at the facility. New changes included only N-95, and surgical masks could be worn by staff, sanitizing between sessions, and keeping clients in the parking lot. The organization also replaced water fountains with bottle machines and invested a lot of money into PPE.
Yarham credits senior leadership at Applewood for doing a lot of outreach and support for staff to keep them uplifted through the pandemic. However, she’s appreciative of the commitment put forward by staff members to serve clients at such a troubling time.
“Staff has been instructed to stay home, but some have to get into the field,” Yarham says. “To balance the chaos in their own lives and still manage to be here for others is just amazing.”
Yarham said the pandemic means that many mental health workers who work for her organization found it difficult to make plans during the pandemic because they must be much more flexible when it comes to when they see clients.
“A lot of our therapists have their own kids at home,” Yarham mentioned. “They’re spending time helping their own kids manage virtual schooling, as well.”
Senior advisors at Applewood assembled a virtual support group for therapists to communicate and share engagement strategies.
Parents are supportive because they know how much the children need the services, Yarham said, but she predicts increased referrals and demand for mental health services when the pandemic subsides.
“Telehealth will be here,” Yarham explained. “We will always have family or staff that will still need the virtual setting, so flexibility is key. I’m glad the behavioral health community has been able to shift and provide service to the community.”
Share your story: Are you coping with the mental-health effects of COVID and would like to share your story? Email cleveland.com reporters:
Evan MacDonald, [email protected]
Olivia Mitchell, [email protected]
Julie Washington, [email protected]