In a recent meeting of Survivors of Torture (SoT) programs, there were a range of approaches shared about returning to in-person work since the COVID-19 pandemic began. Some programs are taking a slow, tiered approach to reopening, with some staff returning to the office, while others remain remote. Others are opening offices for staff but continuing to see clients via telehealth. Some are waiting until September, after children return to school. Here are some of the considerations discussed by SoT programs and Dr. Curi Kim, Director, Division of Refugee Health, Office of Refugee Resettlement, during that meeting. NCB staff also consulted with Ruth Barrett, Director of Global Operations at Center for Victims of Torture, for this article. Also included here is an article written by Eugene F. Augusterfer and Richard F. Mollica for this digest on Post COVID-19 Re-entry with Blended/Hybrid Telehealth. Many thanks to the SoT programs who shared their considerations, guidelines and protocols, resources, knowledge, and contributed to this discussion of reopening!
Masks and Social Distancing
Businesses and organizations can currently set their own guidance on masks and social distancing. What protocols will you set to keep your staff and clients safe? How do you make these decisions? How do you determine when to return to the office? What issues may arise? What should you consider?
The first recommendation is to try to keep perspective and patience. We are all going through this together and doing this for the first time; similar to when we had to quickly shift to remote work and telehealth when the pandemic first began. This is all new, uncharted territory and we can only do our best with what information we have at the time.
The next recommendation is to continue to be flexible. There are constant changes in rates of infection, death rates, changing guidelines, and new variants. It is necessary to be nimble and flexible with the guidelines and protocols you set. Also, allow for flexibility with your staff and especially with clients. Continue to monitor state, local, and CDC guidelines. Ask other programs doing your same type of work in your city about their guidelines and take those findings back to your program. You may need to create a team to work on determining best steps for moving forward and updating or changing your current protocols. Ruth Barrett recommends this team should include a director, a manager, a clinician or provider, administrators, and possibly other staff depending on the type of work you do with clients.
As most programs moved to remote work during the pandemic, consider if continuing fully remote work or a hybrid version is an option for your program. Ask staff and managers their opinions on how well remote work is working. Some programs have surveyed staff asking if they would prefer to work remotely or return to the office. If there is a need to return to the office, ask staff for specific reasons like: Do you need consistent access to equipment, supplies, or paper files that are only located in the office? Do you need better access to computer servers? Are you having internet connection issues at home? Is it easier to work in the office to reduce distractions? If your program is considering remote work as a more permanent option, equitably base decisions on each position and requirements to do the job, not on supervisors’ personal preferences.
Once you decide if you would like to continue with remote work for your staff, then you will need to discuss telehealth versus in-person work with your clients; what are their needs and preferences? See the Your Clients section below for more information.
Your Office and Clinic Space
The size of your clinical space may impact how many staff can safely return to work. Are you in a shared space, part of a larger organization, or co-located within a university or hospital? If so, are there other protocols or guidelines on how your space can be utilized and regarding wearing masks and social distancing? You will also need to determine how many people can be in that space maintaining social distancing should that be required/recommended. Look at the space critically to determine if any of your existing space would need to be reorganized to allow for social distancing.
What type of ventilation do you have? Would a HEPA air filtration unit help you with utilizing all of your space and helping your staff and clients feel safe? One program reported they were able to obtain a grant to help with purchasing a HEPA air filtration unit.
If you are considering seeing clients in-person, here are some things to think about:
- Do you have a waiting room?
- How many clients could be in the waiting room at a given time when social distancing?
- What type of protection would front desk staff need to stay safe: plexiglass barriers, social distancing dots on the floor, hand sanitizer?
- What space could be used safely for in-person meetings? Would that space still be appropriate if you needed to include an interpreter in that meeting?
One program reported they did not have meeting space large enough for in-person meetings with clients. Instead they used two separate meeting rooms – one room for the clinician and the other for the client – and used telehealth technology. This may help with clients who do not have a safe or private space for telehealth meetings. If you are not considering seeing clients in-person, consider using some of your closed meeting spaces for clinicians to use for telehealth visits, some clinicians may have non-private space at home or in the office. Also consider any outdoor space that could be utilized and for what purposes – could you meet clients for one-on-one visits or could you have some of your group meetings outdoors?
One recommendation is to listen to staff and clients about what issues they may have in returning to the office. You could conduct a survey of staff regarding whether they feel ready to return to work, what policies would make them feel safe regarding social distancing and masks, and whether or not they are vaccinated. For more information on this topic see: What You Should Know About COVID-19 and the ADA, the Rehabilitation Act, and Other EEO Laws. Staff may have unvaccinated young children at home and may not be comfortable putting them at risk by returning to the office, their child care options may still not be fully available, or they have children who are home in the summer. Staff may be at a higher risk for complications or provide care for someone who is higher risk which could prevent them from returning to an office environment. Consider staff mode of transportation to the office – i.e. bus, train, or car – this may increase staff risk and stress. It is important to be flexible in allowing remote or hybrid work during this time for staff well-being.
COVID-19 in Your Area
Consider your local and state vaccination rate, COVID infection, and death rates. Use that information to help you determine protocols for your program and when to reopen and what level.
Determine your policy for vaccinations. It may be helpful to first survey your staff to find out vaccination rates within your program. You could do this anonymously or not. Will you require vaccinations for staff to return to work? If some staff are not able to get the vaccine, is there an option to continue to work fully remotely? Will you require proof of vaccinations? Also consider your clients and their safety and comfort level with returning; for more information see the Your Clients section below.
Social Distancing and Mask Guidelines
What are your state and local guidelines for social distancing and wearing masks? Does your program follow those guidelines? What does the CDC suggest? If you are a part of a larger organization or co-located within a hospital or university what are their guidelines? Consider what guidelines and best practices are best for staff and clients. You may determine that you want to be more conservative than local or federal guidelines with social distancing and mask wearing. You can always lower restrictions later.
Talk to your clients about their preference on returning to in-person visits versus telehealth. Some may find telehealth easier because of transportation barriers or lack of child care. Many programs have noted fewer no-shows with telehealth. Some programs have surveyed their clients on preferences for in-person versus telehealth, and some have directly asked clients' vaccination status. For for information on this topic: No, Businesses Aren’t Violating Your Rights When They Ask If You’re Vaccinated. You could include in the survey questions about how to help clients feel safe i.e. do they prefer masks and social distancing. If surveying clients, inform them whether you are collecting this information anonymously or not and provide the survey in their preferred language.
If clients report they are not vaccinated, you could ask if they have questions about vaccinations. One program reported they are co-located in a clinic offering vaccinations; they can walk clients to be vaccinated if they choose. One program reported they partner with a primary care clinic to schedule vaccinations for clients. Another program reported they partner with a transportation service to take clients to vaccination appointments for free. One resource supporting vaccine efforts is the National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM). The NRC-CIM has created hyper localized vaccine campaigns ("Vaccination Is" Campaign, and webinar "Create Covid-19 Health Messages That Speak to Your Community") to match concerns of specific communities and engage community leaders to provide education and combat misinformation.
Also, the New American Neighbors outreach project has produced and posted a set of nine videos concerning COVID-19 vaccination hesitancy. The videos are in Amharic, Arabic, Dari, French, Nepali, Pashtu, Somali, Spanish, and Tigrinya. Videos in Burmese and Karen will be added soon. Each video addresses the facts that the COVID-19 vaccine is safe and effective, and has been scientifically tested. Community members are urged to get their vaccinations when they are available for their priority group, but also to continue the good public health practices of wearing a mask, washing hands, and maintaining social distancing.
Consider protocols you will require for clients coming in the office:
- Will you call before the appointment to ask prescreening questions?
- When clients arrive will you require screening with temperature and health questions?
- How is sanitizing going to be handled?
- Will you clean rooms and general office space after every client or at the end of the day?
Regarding the use of telehealth, Eugene Augusterfer, Deputy Director and Director of Telemedicine of Harvard Global Mental Health: Trauma and Recovery Program, discussed the efficacy, cost savings, and time savings to clients and shared two studies regarding this topic.
- Augusterfer, E. (2020) The Role of Telemental Health, Tele-consultation, and Tele-supervision in Post-disaster and Low-resource Settings (https://pubmed.ncbi.nlm.nih.gov/33247315/). Current Psychiatry Reports Nov. 28,22(12):85
- Shore, J, Brooks, E., An Economic Evaluation of Telehealth Data Collection with Rural Populations (https://pubmed.ncbi.nlm.nih.gov/17535944/). Psychiatry Online June 2007.
Eugene reported studies show that an initial visit face-to-face before doing telehealth with some periodic face-to-face is best. For more information see: Drissi, S (2021) A Systematic Literature Review on e-Mental Health Solutions to Assist Health Care Workers During COVID (https://www.liebertpub.com/doi/10.1089/tmj.2020.0287). Telemedicine and e-Health June 7, Vol. 27, No. 6.
Eugene Augusterfer and Richard Mollica recently wrote this article about telehealth: Post COVID-19 Re-entry with Blended/Hybrid Telehealth.
- Safety Protocols from NESTT: Karen Fondacaro, Director of Connecting Cultures & New England Survivors of Torture and Trauma (NESTT) shared the safety protocol they have developed. Click to view document. Adjust these protocols to fit your specific program and note they were written when NESTT planned to reopen in September of 2020.
- Guidelines and Protocols from CVT: Ruth Barrett shared the Center for Victims of Torture’s guidelines and protocols for staff working at their headquarters building and for the clinics. Note that the clinic protocols changed right before reopening due to the rapid spread of the Delta Variant.
- CDC guidance on masks and social distancing article: “Confused by CDC's Latest Mask Guidance? Here's What We've Learned”
- CDC in-home social guidance references mask wearing and social distancing as of June 1, 2021: “What In-home Social Service Providers and Clients Need to Know about COVID-19”
- State by state requirements for masks from AARP: State-by-State Guide to Face Mask Requirements
- CDC community-based organization guidance not yet updated, but keep an eye on this for helpful guidance for your refugee and survivors of torture clients: “Considerations for Community-Based Organizations”