With the sudden rapid transmission of COVID-19, new federal guidelines on social distancing, and local stay-at-home orders by Massachusetts Governor Charlie Baker in early March, 2020, The Brookline Center, like community mental health centers across the region, was forced to very quickly push out a plan to efficiently, effectively, and safely move the vast majority of their client visits to remote sessions. As a midsize organization, The Brookline Center staffs 80 clinicians and conducts approximately 38,000 client visits per year. Even prior to March, 2020, The Brookline Center (Brookline, Massachusetts) had been planning to offer remote client services. They had launched an electronic health record system and purchased a HIPAA-compliant Zoom account. They developed a draft telehealth policy. Implementation had yet to begin, though.  

As news of a stay-at-home order came in, Ian Lang, Chief Executive Officer, and Hannah Scott, Chief Operating Officer, immediately met with the Program Director and Clinical Directors to generate expectations, workplans, and timelines for clinician training and swift roll-out of telehealth processes. Next, the senior staff developed and piloted a staff training to be delivered remotely using the same technology that the clinicians would be using for client visits.

The single-day training requirements included two prerequisites:

• Review of the organizational policy, procedures, guidelines, and required documentation for remote client visits.
• Review of four short videos about telehealth.

Staff then participated in a two-hour live online staff training session on skill and strategies for conducting client visits using video conferencing technology.

Within one week of Governor Baker’s stay-at-home order, The Brookline Center had finalized their telehealth policies and procedures, trained all their staff, and launched their telehealth services with all 80 staff clinicians. At the end of that first week with a stay-at-home order, The Brookline Center had already conducted 450 remote client visits. Now, six weeks later, they conduct 1,000 remote client visits weekly and have begun to conduct online group sessions as well. The Brookline Center continues to have a small subset of clinicians on site for clinical emergencies.

Tips for Organizations Transitioning to Telehealth

Drawing from their experiences, New England MHTTC staff writer Bethany Marcogliese spoke with Ian Lang, Chief Executive Officer, and Hannah Scott, Chief Operating Officer, about the process and what they would suggest for other organizations making the switch to telehealth.

• Pilot protocols, procedures, and training materials ahead of launching them with staff. The Brookline Center conducted a one-day pilot implementation before training and launching the transition with the entire staff. During the pilot day, a small group of staff clinicians received the training as planned, then used the online meeting platform to role play a client visit with a colleague, and finally conducted a client visit using the technology, protocols, and procedures they had learned. At the end of the day, the pilot group of clinicians provided feedback to the trainers and senior staff on their experiences, specifically addressing areas of the training and documentation that needed to be added, clarified, or revised. By taking a day to pilot the use of these materials, the trainers and senior staff were able to improve the quality, clarity, and completeness of the materials prior to wider distribution.

• Ease staff into the transition with a soft start. Prior to the training, The Brookline Center sent clinicians credentials for the meeting platform they would be using for the training, staff meetings, and client visits. They practiced signing in and navigating the online meeting technology in a low-pressure environment, ahead of the training and full transition. This soft start helped ease the team’s anxiety about the technology itself and allowed for more efficient and effective use of training time.

• Communicate with staff often and in a variety of ways. Senior staff established regular and varied communication channels as soon as their staff began working remotely so that clinicians would continue to feel connected and supported throughout the transition. In the early days of the pandemic when the situation was constantly evolving, Hannah Scott would email the staff daily with updates and any new or changed guidance on protocols or procedures. She has now moved to three emails weekly. In addition, clinicians meet with the full staff and with their clinical teams weekly, where they have the opportunity to share their experiences, ask questions, and provide feedback.

• Build in some fun to break up the intensity. When possible, dedicate time during staff meetings for connection and laughter. The Brookline Center staff has spent time during their meetings sharing pictures of their pets and conducting Kahoot! quizzes to break up the intensity in their day.

Challenges of Moving Staff and Services to Remote

While The Brookline Center was able to rapidly launch remote client visits in response to COVID-19, the transition from an on-site to mostly remote organization has not been without challenges. Ian Lang describes the move to remote client visits as “the tip of the iceberg” of making the organization function remotely. With such a sudden transition, the staff are continually discovering issues that require a whole new way of doing their job. Decisions that were once made by a discussion in the hallway or a transfer of documents that once happened with a fax machine or walk down the hall to a colleague’s office now need to be documented and tracked electronically. The organization has had to completely rethink how they use paper in their day-to-day processes and move these systems online. They are now using Microsoft Teams, Sharepoint, and DocuSign in a much more intentional and nuanced way to help make up for the lack of paper and in-person transactions.

A particular pain point for the organization during this switch was the intake process. Previously, new clients would be evaluated on-site and required to fill out an extensive intake packet on paper. After two weeks conducting remote visits with existing clients, The Brookline Center began seeing new clients remotely. While the switch to remote client evaluations was relatively smooth, the conversion of the intake packet to a HIPAA-compliant user-friendly electronic form and registration process to an electronic transaction required significant effort to test and implement. The transition to an electronic intake process has been fully implemented, which will help support the increasing numbers of new clients The Brookline Center is seeing, as the pandemic becomes a long-duration event.

In a rapidly evolving health care and insurance payment landscape with regulations and requirements for services constantly changing in response to COVID-19, senior staff are continuing to course correct and update the policies, procedures, and guidelines for staff as needed. Hannah Scott has found that frequent email communications and staff and team meetings have helped keep the staff informed and connected.

How are Clinicians and Clients Coping with the Switch?

Overall, the feedback from The Brookline Center clinicians and clients about the switch to remote visits has been positive. Though the sudden transition has been a strain, clinicians report feeling supported, well-trained, and pleasantly surprised at how easy it has been to switch to providing services online. The staff training included guidance for clinicians to orient their clients to the technology and resources for troubleshooting issues with the online platform, which has helped client visits run smoothly. Clinicians have also been able to devise new and innovative ways to engage their clients online. For example, playing online games with their young clients.

The Brookline Center reports a generally positive response to the transition from their clients as well. They have found that most of their clients feel comfortable engaging with clinicians remotely, though they will provide phone-only sessions for clients that do not have the technology or comfort level to use the video conferencing component.

Lessons learned:

• The switch to remote services and internal processes has improved the organization. The Brookline Center has found that the strides made in this condensed amount of time will benefit them post-pandemic. Ian Lang recognizes that, “the pandemic forced us to change for the better.”

• Lack of place does not negate support. The Brookline Center has been heartened by the fact that they continue to provide quality mental health services to the community, even without a physical space for clients to go to.

• Community mental health centers exist for times like this. As a community mental health center committed to providing outstanding, affordable mental health care and community-based social services, The Brookline Center has been able to swiftly respond to the changing needs of their community. Beyond mental health services, they have worked with The Brookline Foundation and the Town of Brookline, to increase their support of rent and basic expenses by nearly 500%, shift from one-time support of basic expenses to ongoing, expand housing services, and support an increasing number of clients who are accessing public benefits for the first time.

Helpful Tools and Resources for Organizations Transitioning to Telehealth

• Select a HIPAA-compliant video conferencing platform, such as Zoom for Healthcare
• Set up a cloud-based secure internal document sharing and communication system for staff, such as Microsoft Teams or G Suite from Google
• Transfer all paper forms (including intake packets) to a secure electronic solution, such as DocuSign.
• Convert your phone lines to a cloud-based platform that can be used remotely, such as RingCentral.
• For more information and best practice strategies for transitioning to telehealth, visit MHTTC’s Responding to COVID-19: Building Telehealth Capacity resource page.