BACKGROUND/RATIONALE:
Health care services must rapidly and systematically learn and apply lessons from COVID-19 to adequately prepare for future pandemics, as well as other natural and human-made crises. This is especially critical for VA's approximately 250 Mental Health Residential Rehabilitation and Treatment Programs (RRTPs), which offer 24/7 care to Veterans who may be experiencing homelessness and need mental/behavioral health and/or substance use treatment. An aspect of RRTPs is close living quarters (e.g., shared rooms and communal kitchens, bathrooms, and living areas), which may present added challenges for effectively responding to crises in a timely manner. We adapted the World Health Organization (WHO)'s After Action Review (AAR) framework for a methodical, learning-driven assessment of the COVID-19 response of RRTPs in Massachusetts, to be able to assist with their preparation for future crises.

OBJECTIVE(S):
The AAR is a learning-driven constructive review of actions taken in response to an event, which has been used by the WHO and others to systematically learn from major events (e.g., H1N1 outbreak).

Aim 1: Assess how RRTP operations have been impacted by the COVID-19 pandemic. The WHO's framework for Debrief AARs provided an established and methodical approach to assessment. We learned about the steps that the Bedford and Boston RRTPs took to protect the residents, the VA community, and the community-at-large from transmission of the highly contagious COVID-19. We also learned about the impacts of these steps taken by the RRTPs.

Aim 2: Deliver an actionable report of findings from Aim 1, along with other key changes and concerns identified. We adapted the WHO's AAR Report Template to provide a structured report with concrete recommendations for the RRTPs, regarding (i) what was expected, (ii) what actually happened, (iii) what went well and how it can be repeated in the future for similar situations, and (iv) what could have been done differently and thus what changes are needed to ensure better success in future situations.

METHODS:
Aligning to the AAR framework, we conducted semi-structured hour-long small-group discussions (4-7 participants) with RRTP staff from two Massachusetts RRTPs, and also with Veterans who received RRTP care during COVID-19. We prepared for the AAR by developing questions to be used for the discussions, related to (i) emergency response to and communication regarding COVID-19, (ii) impact on care delivery and mental health, and (iii) care coordination, case management, and community engagement procedures during the response. We conducted the AAR by facilitating the discussions to identify the RRTPs' pre-COVID-19 capacities, time points at which components of their response to COVID-19 occurred, and the components' strengths/challenges. We debriefed after the AAR by drafting a summary of the discussions and presenting the summary to key stakeholders, including the RRTP and medical center leadership. We had debriefings culminate in concrete recommendations for the programs to incorporate into their responses to future crises. The small-group discussions were transcribed verbatim for qualitative analysis. We used the four central AAR questions (What was expected? What actually happened? What went well? What could be improved?) as pre-specified codes for directed content analysis, and we also identified emergent themes.

FINDINGS/RESULTS:
The AAR involved staff and Veterans from two Massachusetts RRTPs. Participating staff were from varied clinical/administrative positions. Participating Veterans had received RRTP care during the early months of the pandemic. Three small-group discussions were held, one with six staff from the first of two RRTPs, one with four Veterans from the first RRTP, and one with six staff from the second RRTP. The second RRTP had undergone major changes to program operations that sharply decreased the number of resident Veterans (only a handful resided at the program during the early months of the pandemic), due to which it was not possible to collect data through a small-group discussion with Veterans while keeping their identities confidential when reporting on the data.

Five main themes emerged from the AAR. Regarding COVID safety, participants noted the importance of having access to protective equipment, testing, communal space (e.g., for dining) where social distancing is possible, and an area to isolate and safely treat COVID-positive Veterans not requiring hospitalization (e.g., a negative pressure unit). Regarding communication, participants discussed utilizing a central communication system to share concrete information (including reasons for changes) with staff and residents, having one-on-one conversations to provide COVID education and technology training to residents, and continuing to hold community meetings outside or in large open areas after work hours. Regarding programming, participants deemed it essential to maintain focus on treatment and sense of community while keeping RRTPs open, especially for Veterans who are not able to easily make alternative housing or treatment arrangements at short notice. Regarding mental well-being, participants found it necessary, to make psychoemotional support available 24/7 to help Veterans deal with the uncertainty, stress, and anxiety, especially in the evenings when Veterans frequently expressed feelings and frustrations. Regarding technology, participants emphasized the indispensability of training, internet access, using a single platform for telehealth, and availability of devices for telehealth and communicating with family and friends outside of the RRTP.

Recommendations stemming from the AAR included (i) conveying to Veterans the reasons for COVID precautions and programming changes, (ii) keeping recovery-oriented programming separate from COVID-related information sharing, (iii) developing safe procedures for Veterans to interact with family and activities in the community, (iv) including "how to use technology" into program orientation, and (v) establishing safe procedures for Veterans attending off-site health care appointments. Facilitated discussions of these recommendations with RRTPs enabled collaborative planning of subsequent steps to engage multiple organizational levels in addressing the recommendations.

IMPACT:
Since the start of COVID-19, many health care services have been actively learning from and responding to challenges posed by the pandemic. Our study uniquely contributes to this widespread effort by focusing on RRTPs that provide care for individuals who are affected by multiple complex social determinants of health such as mental illness, substance use disorders, and homelessness. As a 24/7 residential care program, the studied RRTPs needed to coordinate their COVID-19 response around the clock and across shifts, all the while closely monitoring for residents' worsening mental health or additive behaviors. Lessons learned and recommendations voiced by study participants provide valuable findings that other RRTPs and non-RRTP programs (both within and beyond VA) that care for vulnerable populations can apply to their own settings during future crises, including potential resurgences of COVID-19-related threats and other future public health emergencies. Furthermore, our AAR approach can be adapted, beyond the realms of residential treatment and VA, as a consistent framework for reviewing crisis responses across multiple health care services. This will identify commonalities and heterogeneities among services that operate in widely varying contexts, and lead to determining both standardized and tailored preparations that the services can make for future pandemic-related and other crises.

PUBLICATIONS:

Journal Articles

1. Kim B, Petrakis BA, McInnes DK, Gifford AL, Sliwinski SK, Smelson DA. Applying after action review to examine residential treatment programs' responses to COVID-19. The International journal of health planning and management. 2022 Jul 1; 37(4):2461-2467. [view]
2. Kim B, Petrakis BA, Sliwinski SK, McInnes DK, Gifford AL, Smelson DA. Staff and Veteran Perspectives on Residential Treatment Programs' Responses to COVID-19: A Qualitative Study Guided by the WHO's After Action Review Framework. Community mental health journal. 2023 Apr 1; 59(3):600-608. [view]