Thread by @HZiauddeen

Tweetpost: COVID planning in community mental health services
Here is a thread about some of the thinking that went into our service’s COVID planning. I’d be grateful for any comments and criticism as they would be a great help in revising plans as we go. (1/24)

So a couple of important points up front. (1) We’re an early intervention in psychosis service (2) This is a service level plan i.e. how we as a service best look after everyone under our care for at least the next 3-4 months and how we look after ourselves to ensure this. (2/24)

(3) Each individual should get (as far as is possible) the care/treatment that was planned/promised before COVID19 in addition to whatever else they need currently. (4) Delivery of both of the above will be affected by staff and/or their families becoming ill. (3/24)

(5) Staff are going to have to deal with additional demands and stresses outside work e.g. childcare, care of elderly relatives, two key worker families. (4/24)

(6) Remote working challenges: so far seems to be working reasonably well but can be/feel less effective/fulfilling and not suitable for everyone. It's necessary but we need to bear in mind that people are missing out on a big part of what keeps them going in the job. (5/24)

Now at any point a community service will have people who are (a) doing well (b) reasonably stable & doing additional/consolidating work e.g. therapy (c) currently unwell & being treated, and (d) seriously unwell and in hospital/crisis resolution & home treatment. (CRHTT) (6/24)

The planning is really about groups (a), (b) and (c). Group (d) comes out of hospital/home treatment and becomes part of group (c).

Btw hospital capacity has reduced to allow for adequate infection control measures and admission thresholds have had to go up (7/24)

We had to consider a situation in which a significant number of the people we looked after would lose important supports (people, work, routines and other structures), experience significant isolation and financial difficulties. (8/24)

How could we help with this? A particular concern is those people whose main support system is us. We also have people would either be in the high risk group for COVID or be living with family members who would be. (9/24)

Add to this the stresses of dealing with the highly unusual situation, the stresses of confinement with family (esp those self-isolating with abusers), the stresses for families confining with unwell family members, and the impact of COVID related illness and deaths. (10/24)

A particular point about support systems. A lot of these are provided by the local council and the third sector and MHPs help people connect with and navigate these systs. Many of these have been severely depleted/suspended because of the COVID situation. (11/24)

Our plan was based on the following anticipated phases. There is no mathematical modeling here just clinical thinking. Remember this is from the service level perspective i.e. what should the service expect and plan for. (12/24)

Each of the following phases therefore is about what might we expect as the dominant element as time goes on. Needless to say, the phases are not neatly separated and service demands will depend on the proportions of people in groups (a), (b) and (c). (13/24)

Quick reminder of the groups: people who are (a) doing well (b) reasonably stable and doing additional/consolidating work e.g. therapy (c) currently unwell and being treated. (14/24)

Final point before we get in, the phases are more about what we should be anticipating next rather than which phase we are in as we may find ourselves working more in one phase depending on the proportions of people in groups (a), (b) and (c). (15/24)

Phase 1: Initial quieting as people get into the lockdown. Loss of social and occupational stresses offsets some of the other losses and limitations caused by the lockdown. (16/24)

Phase 2: People in group (c) start to find it difficult but at this point the lockdown serves to miminise external stresses and the structure of the lockdown helps as a containment intervention. (17/24)

Phase 3: The containment and stress minimisation of the lockdown is no longer effective and people in group (c) become more unwell, making the lockdown harder to sustain for families as well as individuals. (18/24)

Phase 4: People in group (c) become increasingly unwell and requiring acute services. People whose illnesses have spring seasonality (bipolar disorder in particular) become unwell and this will interact/add to this. (19/24)

Phase 5: Impact of lockdown and loss of supports and services starts to affect groups (a) and (b).

Phase 6: Relapses, recurrences and new incidences.

At present we are finding ourselves working in Phase 4. (20/24)

However our plan from the outset was to work in parallel to minimize the impact of Phase 5 and 6 i.e. keep looking after the well and the relatively well and make sure that the demands of the COVID situation do not too heavily impact the ongoing therapeutic work. (21/24)

Some simple measures for this: protect psychologist time, capitalise on STR worker time and support.

Finally a vital part of the whole strategy, look after each other: call in and check, WhatsApp group, virtual drinks and pub quizzes (out of hours). (22/24)

So far we are doing ok, we have a fantastic team but we are feeling the strain. Would appreciate your feedback on the above.

How are other teams managing? (23/24)

With many thanks to @wendyburn @PaulPcf22 @SameiHuda @sameerjauhar @WalkKD @gk_murray for their advice and comments (24/24)