Challenges of Care with COVID-19

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Home – NEW Forums Module 3 – Assessment of Early Psychosis Fall 2023 Challenges of Care with COVID-19

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    • #10888

      Through the course of COVID-19 providing care has changed greatly by many means, including with more virtual or distance methods, impacts on health care, and the general wellness of the population. In COVID-19 I found my assessments had to consider changes outside of the persons choice including mandatory lockdowns limiting interaction with others, many activities or groups being close, using other methods of care being a barrier for some. As a clinician this implied to me to use this in my judgement when assessing such as considering if the person is withdrawing from friends and family due to pure mental health or due to the rippling effects of the pandemic. I feel like today in practice we still meet similar themes of people recovering from the impacts of COVID-19. I feel it would be appropriate to ask the client outright in a session if changes were due to or impacted largely by COVID or if this was nil related. This is something that has stayed in my back pocket for discussing during interactions as well as a consideration of care.

      After reviewing the 2-Com I reflected on how many of the pieces would be impacted by the pandemic, almost all of the components on the document could be plausible. How do others feel about this? What experiences in practice have you had that impact using your assessment tools?

    • #10890

      Hi Grace,

      I agree that the COVID-19 pandemic has greatly changed our ways of connecting with our clients. In my experience this has often shifted clients away from attending in office appointments, as they will often choose outreach (going out to meet them where they are at) or online (virtual methods). This has advantages for those who attending in-person was a barrier for, as I find some clients more open and engaging in those sessions (and increased attendance rates) and some disadvantages too – some clients will be less engaged than when they had to come into the office – and I too wonder about whether this isolation is an impact of the pandemic and/or mental health or both! I have found some client self-assessment tools helpful, especially during the intake and assessment phase when you are starting with a newer client, however, when it is with a client I have worked with for some time I find that we get into our own pattern of a check-in/self-assessment, and I no longer will use assessment tools (unless perhaps we are updating depression or anxiety scales). I have not used the 2-Com before, and on review I could see how it could be helpful for the client and therapist to begin sessions (I think of assessment tools as ‘conduits’ to discussion). In my office many practitioners still use the FIT (Feedback-Informed Treatment) tool, which has a beginning of session check-in and then an end of session assessment of the therapist’s efficacy in the session (beginning of session, client self assesses and at end of session assesses how the session was for them) – I find some therapists really like it and others do not (too many reasons to unpack for this post).

    • #10891

      Hello Grace,
      Your post acts as a good reminder for me even though the bulk of the pandemic is over (fingers crossed) that it’s effect can still linger and disrupt or change their behaviour today. I worked as a nurse on an inpatient psychiatric unit during the pandemic. Some patients there were admitted with a dominant anxiety-based delusion about how COVID-19 could be transmitted. Early on when the there was less knowledge about how transmission occurred it was understandable for this person to be so distraught and confused to the point of believing that he could catch it from almost anything and anywhere. This may be a more extreme example of how someone reacted to the early and middle days of the pandemic but still a real belief and experience for someone that could’ve happened even if there was no pandemic. The client found it helpful to at least have people there (well masked) to support him and listen to him during this time. With this EPI course I was happy to see the 2-Com checklist (among others) as another tool I can use with client’s to help with difficult conversations and a visual cue/guide during interviews. The 2-COM could’ve been very helpful with this anxious client.

      Personally it helps me to have a visual support for many situations and think this would be helpful to use in many situations. It is something a client could also take home with them and complete on their own time and space if initially, or any time, they weren’t feeling comfortable to engage with myself, their parents, psychiatrist, counsellor, and other support in their life; this guarded and reluctant client example has happened many times so it would be helpful to have another tool to help gather data and learn about the client’s current status. It can be a good conversation starter to some tough topics. Even though these assessment tools are only one tool/avenue to use to understand and engage with a client, it is always helpful to have these as another facet to which connecting to, and supporting, a person.

      • #10893

        Hey Jesse,
        I agree that the 2-COM tool could be well utilized with a client who is less engaged in a session, whether that be from anxiety, negative symptoms, or perhaps active psychotic symptoms. I can see this tool being especially helpful to give to the client prior to our session (or as you said, for them to take home with them to complete prior to their next appointment) and it can be used to set a guideline for what to structure the next session about. I think it could also be helpful in engaging the more introverted client who might feel more comfortable writing about their topics of concern/feelings than they are talking about them. The only potential downside to this tool that I experienced was that it felt very clinical and less conducive to building the therapeutic relationship with the client, although I think this could be mitigated by having the client fill it out prior to the appointment and then using the tool as a jumping off point for the more therapeutic engagement part of the session.

    • #10894

      Hey Everyone,
      I did not start working with clients until after the main waves of COVID-19, but as an outpatient worker, I can see the difficulties that would arise from not being able to meet with clients in person. From reading your posts, I can tell it was, and still is, a difficult element to work around.

      I also haven’t used the 2-COM checklist before, but it does have many similarities to the Strength and Needs Assessment Program (SNAP) used for my clients life skills intake. This may be a good addition to add to the intake process for when the client is disengaged, like Jesse and Breeanne mentioned.

    • #10895

      Hello Grace,
      I’m new to EPI and Psychiatric Nursing so a lot of these assessments tools are new to me. That being said I can appreciate the 2-Com assessment tool because it gives me a starting point for my session with the client. I struggled with everything being virtual during the pandemic and missed the live interaction. The pandemic shifted how we interpret information and has caused us to adapt the assessment tools. I like the concept of the 2-Com as it will provide a snapshot in the clients well-being and provides a clients subjective view(s). The client filling out a 2-Com in a comfortable environment removes most/all the possibility of white coat syndrome being a major influence in an assessment.
      I do like the 2-Com because it’s simple and straightforward and can be used to create topics for in-person sessions. Now that the pandemic is mostly over I find myself using a hybrid model for care with both remote and in-person assessments. I agree with you when it comes to a clinician being more aware of their critical thinking skills when interpreting a clients assessment of themselves.

      • #10898

        Hi Robert, I had similar thoughts (unrelated to the pandemic pieces). As a new mental health clinician, I find it challenging to tease apart what a severe presentation of psychotic symptoms looks like, versus what an ’at-risk’ presentation looks like. At this stage in my understanding, I think relying on assessments provides a helpful foundation to understand my client’s symptoms more fully. For example, I have found that familiarizing myself with the domains on the CAARMS has helped me start to identify and categorize clients’ symptoms more accurately. Further, familiarity with this assessment has helped me shape my questions in sessions to elicit more relevant information surrounding the severity, frequency, and duration of a client’s symptoms.
        I think using a tool like the 2-COM could serve a similar function – to help structure a session and draw out relevant information from the client’s experience, like you mentioned. This could be particularly helpful when a client is unsure of what information is necessary to share, with the added function of helping a clinician shape the goal of their session. It is nice to hear about how other clinicians new to EPI are processing the material.

    • #10896

      Hey all!

      I echo what most of you have already said. I worked on an outreach/ACT team during the majority of the pandemic and saw my practice shift significantly when COVID-19 first came into the picture. We moved to many more virtual interactions, which felt less effective and accessible for most of my clients. I think COVID-19 also impeded the therapeutic relationships I was able to build with my clients during this time because so many of the activities and interactions I used to be able to have with them were limited by barriers like not being able to drive in the same car, not being able to enter their home without PPE (which does not help with stigma btw), etc. It seemed to put more distance between myself and my clients and perhaps they felt like we weren’t as much of a team as we had been before the pandemic. I did find ways to be creative during this time and was able to facilitate assessments when necessary. I’m an Occupational Therapist, so there were often times that functional or cognitive assessments needed to happen in person/the community and I could usually find a way to make it work despite all the COVID restrictions. I think this speaks to the greater capacity we as clinicians have. Sometimes, we can get so bogged down by the “typical way of doing things” that we forget things CAN be done differently and different doesn’t always impact the outcome like we think it will.

      In terms of the 2-Com, I’ve never used it before. I agree with what others have said, that I would likely find it most useful for clients to fill out ahead of an appointment. For me, this would moreso be helpful so that the client has an opportunity to think about what they want to talk about and then can use it as a visual prompt/reminder to use when in the appointment. I’ve often heard from clients that they forget to bring up specific topics when meeting with their psychiatrists and I recommend writing down topics ahead of time. The 2-Com could be a helpful replacement tool for this practice. I also agree with Angela that it may be more helpful to use when you’re first getting to know a client. I tend to find other ways of checking in/self-assessment with clients that don’t involve assessment tools once we know each other well.

    • #10897

      Hello All!

      As many of you have discussed, I found that the pandemic shifted a lot of the care we provide as mental health clinicians from being in-person to virtual. And as many of you have noted this works better for some clients and not so well for others in terms of their engagement or ability to make appointments. Even if some clients prefer it, I do think the quality of assessments is impacted when care is being provided virtually. Mental Status Exams rely on so many visual observations of motor activity, affect, eye contact, etc., and this can be much harder to assess in virtual/video session, and impossible to assess over the phone.

      That said, the increase in acceptance of virtual care has really improved access to some specialist teams and physicians that for those of us that live and work in rural and remote areas of the province. For example, I now have an EPI role in Smithers, a small town in Northern BC, but the town is much to small to require a full EPI team. Instead, I am a satellite of the Prince George EPI team. I provide in-person supports and case management for local clients, and I can help them access psychiatry, cognitive remediation, and family therapy virtually through my colleagues in Prince George team. If COVID hadn’t made virtual services more common, I’m not sure it would have been thought possible to provide EPI services in this way.

      I’m not familiar with the 2-Com either, but I do think that standardized assessments have a place in terms of providing a baseline to measure improvement or decline, and also as others have mentioned, as a starting off point for discussion.

    • #10901

      Hey all!

      I agree with the consensus here– that covid provided some unique challenges for providing care for everyone. While I did not work with the EPI team at that time, I can imagine how it made it much harder to create connections with people. I’d imagine that people experiencing paranoia would have more challenges interacting with a professional on a screen rather than having in person services. I agree with Bart though, there are some neat benefits that came out of the push for virtual delivery, especially for clients in rural and remote areas.

      Also, while I haven’t used the 2-COM before, I appreciate how it hits a lot of the areas and also asked consent regarding talking about them. That second part makes it feel more trauma-informed and client-centered, while still giving the clinician a snapshot of where the client is at.

      • #10909

        Hi Katy, I appreciate that you shared that you have yet to use the 2-COM in practice as of yet, I have not either. I think it is a valuable assessment tool, something I would like to integrate into my practice.
        What is your experience providing virtual care or care to remote areas? How do you feel COVID-19 has changed this?

        I just moved to a rural area this year and have found virtual methods more common in my practice than when I lived in a larger town. Some assessments can be more difficult to complete especially when it is a phone call appointment, you can not see the other person and their body language. That being said it is important to meet clients where they are at, provide the best care possible with the situation at hand.
        Having limited resources or a rural community can definitely change the concept of providing care, impact assessment methods or tools, and cause clinicians to become creative.

    • #10906

      Hi Everyone,

      I considered myself lucky to be on maternity leave during the start of the pandemic and returned to work at the beginning of 2021. Having been out of the office for 18 months and then returning to this strange new world of heath care, it was a shock. It really help me to reflect on the experiences of my clients during the time away. While I didn’t necessarily like the shift to virtual care, I love it now. the fact that our clients and their families have options for care delivery, really helps them to feel they have choices. Switching to a virtual appointment when they would otherwise cancel because of travel or time constraints, or even physical illness, has helped keep them connected to their care team.

      Being new to EPI and knowing personally that I really like paper and scales, the 2 COM is a welcome tool. I feel like it helps to provide structure and direction when sessions aren’t flowing or we are feeling stuck. Also, as I am taking over from another clinician, it has helped me to get to know clients and create a starting point for us working together.

    • #10910

      Hello everyone,

      Working throughout the pandemic and providing care to clients changed in various ways. For myself, working at a walk in center for mental health shifted from in office appointments to being virtually or by phone. However we still did see walk in clients for those who required urgent/immediate attention or were at higher risk in community. I feel that many clients preferred online/phone appointments due to the spread of covid-19 versus those wanting to attend in person appointments due to the fear of contracting Covid. I also found that many clients experienced isolation due to limited interaction in person. As a nurse there were also challenges faced such as feeling more stressed at work due to the fear of contracting Covid, increased work load, extra screening tools/disinfecting and wearing appropriate PPE more than what we would normally do.

    • #10911

      Hi everyone,
      I am relatively new to EPI. I’ve primarily worked with the adult population throughout my career so having to utilize so many of these assessment tools is a new process. However, I can appreciate having these available and being a part of the EPI Program. I think the tools are a great way to keep information on the client’s progress and goals updated. I also agree with many that the COVID-19 pandemic greatly changed the way we made connections with out clients. Many of my clients till prefer phone or virtual appointments; however, I continue to encourage an outreach visit if not in the office. As a Clinician I also worry how the affects of the pandemic have left many of our clients isolated, and some who continue to remain isolated. I’ll be the first to admit that I often forget to utilize the assessment tools because I get into a routine with my clients with our regular check-ins after the initial assessment. I have not used the 2-Com before but upon reviewing it, I can see that I already use this assessment tool informally with my clients during our weekly/biweekly check-ins.

    • #10917

      The one aspect to working in the COVID-19 pandemic and having to meet with clients virtually creates barriers to human connection, but also creates barriers to treatment with clients who do not have access to phone or internet due to socio-economic status and being marginalized. COVID-19, as Christina spoke to, left so many feeling isolated and disconnected from supports and services much needed for their mental and emotional health. For those who did have access to the technology required for virtual visits, it provided a safety net for maintaining connection and follow up for care, as well as an option should they not be feeling well enough to attend in person due to physical or mental illness. Therefore, in some ways in benefited many, and in others, it created further barriers to accessing care.

    • #10921

      Reflecting on the COVID-19 question, one simple barrier I found it provided was losing that direct face-to-face contact and creating a relationship with someone behind a mask. I worked inpatient psychiatry when the pandemic began, and it was often an extra hurdle for clients who may already have difficulties with reading facial cues and interpreting body language to then try and do so when all the nurses and health care staff on the ward had to wear PPE. To break the ice and humanize myself with clients that I have to wear a mask around I will introduce myself as normal and then show them my hospital ID which has a picture of myself and crack a joke about how that’s I how I normally look without the mask. Even though it’s a simple gesture, I think it conveys effort, care and connection.

      When conducting assessments during the pandemic, I have similar reflections to others above around the need to use virtual methods instead of in-person. And found that this made services more accessible for clients who may be more anxious, or have social phobias, but limited a full assessment for others who may verbally present really well but when seen in person exhibit poor hygiene, bizarre clothing choices, or observable behavioural tendencies. Something as simple as seeing someone looking around the room and attending to internal stimuli silently would be lost in a phone assessment. For that reason pivoting to a virtual appointment over Zoom, actively gaining collateral from family or friends who have been around the client, or doing outreach with the appropriate PPE were needed.

      With our population of young adults and youth I do think virtual connection is an asset as a lot of my clients at baseline functioning aren’t comfortable with phone calls – it’s note as commonplace as when we were younger. Texting has been a great tool for engaging with clients who may take time to reply or find it anxiety provoking to anticipate a scheduled call or be surprised with an unannounced call. It also gives them the opportunity to reflect and think on answers prior to providing them. With assessment tools I’ve been trying to go over certain ones in person, explain bits that may be confusing, begin to complete the assessment or questionnaire with the client, and then I will provide a copy of the form to the client to bring home and work on their own. If they have any changes or additions, great! We’ll update what we have on our end, if not, then at the very least they have a copy of what we’ve done.

    • #10926

      I really enjoyed reading your post Mariam, your experience and reflections on working in inpatient psychiatry during the pandemic were helpful as someone who is newer to the field. With recent masking requirements coming back into play in my health authority, I am trying to find ways to communicate and connect after losing that direct face-to-face contact. While the COVID-19 pandemic might be over, we are now living in a world post-COVID, the virus is endemic and it seems will continue to be something we must consider in our healthcare spaces. This means that masking and other PPE precautions will be required more often and in more spaces than prior to the first COVID outbreak. This poses a particular challenge to us working in Mental Health, as you mentioned Mariam, virtual assessments have limitations, and in-person might not be an option. I appreciated all of the insight and experience other clinicians have shared on this forum

    • #10927

      Hi all, I would echo that the acceptance from Island Health for virtual means of connecting with clients (i.e. text communication, zoom, etc) have decreased barriers for some clients. I have heard from many of our youth when offered either in-person or virtual visits, that they predominantly prefer in-person. It can be a challenge when certain services are offered only virtual, such as psychiatry, and the youth feels as though they were unable to fully connect or express their mental health and wellbeing to someone so impactful as a psychiatrist. In addition, I have found that when I am driving a youth around and I am wearing a mask and they are not, that it can be stigmatizing for them and easily identifies them as a person receiving service, which I find is a barrier to building trust, rapport, and relationship. That being said – I appreciate our PPE and infection control very much! Just some thoughts, Adrienne.

    • #10930

      Hi everyone, thank you for sharing your thoughts and experiences about the transition of care during COVID-19. I share the same sentiments where the transition created more barriers in services for populations that already face many challenges in accessibility. Three (almost four) years following the initial outbreak, I feel like many systems have adopted a hybrid model of offering both in-person and virtual support services. It is great having virtual options for meetings and appointments because it increases accessibility for clients and family members who want to engage but are limited in time and resources; at the same time, I encourage in person services whenever possible to better build rapport, create structure and routine, and encourage practicing ADL tasks with our clients. I notice with our clients that access these hybrid models also benefit them in areas outside of EPI, for example, clients who take a step back from school to take care of their mental health can make accommodations to attend lecture online or submit assignments virtually and attend school in person again when they are ready.

      In regards to assessments, I prefer to conduct them in person as much as possible because I am able to assess more aspects of their function- getting to the location, punctuality, grooming, physical presentation, body language, etc. I have been practicing utilizing new EPI tools such as BPRS, HONOS, WHODAS, and notice that the CAARMS tool is similar in that they assess various domains.

    • #11191

      This is a great addition to the conversation in this module. I found an article examining the changes EPI services could make to deliver care given the changes COVID-19’s pandemic introduced. If you’re interested to read this Canadian publication, here’s the link: https://pubmed.ncbi.nlm.nih.gov/34806990/

    • #11430

      As a person who worked in the very early covid days with unhoused individuals who needed to self isolate from close covid contact, and the dynamic mental health challenges that posed this vulnerable, often mentally unwell, typically substance affected group. It became much harder to discern what mental health challenges were related to covid, or to underlying concerns, including psychosis. During this time, something that stood out to me particularly were the reports from this group of individuals about how much more toxic the drug supply was becoming, because of border shut downs, leading to the substances available on the street becoming increasingly cut with a diversity of other substances. I am reflecting now on how this increase in toxic drugs available has contributed to increasing substance induced psychosis, and ultimately potentially triggering long term underlying psychotic disorders.

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