Caring for our caregivers during COVID-19

Amid the COVID-19 global outbreak, it can be a stressful time for those who work on the front lines of health care.

Now more than ever, it's important for health systems and health care organizations to create and ensure an infrastructure and resources to support physicians, nurses and care team members.

The following lists provide practical strategies for health system leadership to consider in support of their physicians and care teams during COVID-19.

Note that any activities involving medical students or other health professions students should be part of a voluntary, student-led program overseen by their school in compliance with guidance from the LCME or other accreditor. No direct solicitation of individual students should occur.

Some items in the list are suggestions, while others have already been implemented by health systems.

• Surveys can be used to track trends in stress levels, identify specific drivers of stress, and develop supportive infrastructures based on these drivers. The American Medical Association is offering two no-cost surveys to help health care organizations monitor the impact COVID-19 has on their workforce during this pandemic.

• The AMA’s caregiver resource, Creating a Resilient Organization, provides 17 steps that health care organizations can take in order to effectively care for health care workers during times of crises. Successful organizations will take a systems approach and focus on becoming a resilient organization prior to times of crises, rather than limiting their efforts to a focus on individual resilience. Resilient organizations will need to rapidly reconfigure their well-being priorities to meet the biggest new drivers of stress in a crisis setting.

• Oregon Health & Science’s primary care division highlights how they adapted to dramatic call volume increases in primary care during COVID-19 by leaning in to support from academic health center and adopting telemedicine practices.
• Physicians/APPs who are at home (on quarantine or for childcare) manage the inboxes and phone calls of those who are at work and provide telemedicine care. Organizations have the ability to redirect or create physician work (wRVU) credit for this work.
  • Atlantic Medical Group has shifted their ambulatory practice care model to telephonic and telemedicine and has reduced office visits significantly. They are considering splitting their offices into teams of staff and physicians and rotating the teams in/out of the office. Rotating shifts would reduce staffing in the office such that everyone isn't in the same very close spaces together. Clinicians not in the office can do phone visits, telemedicine, answer patient questions or be deployed to call centers and testing centers.
• Retraining and/or enhancing the skills of who have not recently worked in the intensive care unit to increase workforce. AMA has curated guidance and resources for those who may wish to return to work or are called upon to do so during the coronavirus (COVID-19) outbreak.
• COVID Staffing provides and online resource to help hospitals understand and manage their staffing needs during the COVID-19 pandemic.
• Administrators and clinicians with extra time due to decreased regular services have offered assist with insurance needs (finding old claims, updating bad addresses, etc.).
• Set up triage hotline. Medical students in multiple states are providing extra staffing for the medical school call center. The purpose of this triage hotline is to provide students/staff/faculty who have traveled or have symptoms of COVID-19 with real-time information on protocol and next steps.
• Allow medical assistants and nurses to make contributions according to their ability, with physician or APP oversight and discretion. This may include nurses or MAs taking verbal orders, performing computerized order entry, doing medication reconciliation or assisting further with visit note documentation. This will alleviate some of the workload on physicians and APPs.

• Ensure that paid time off and sick days remain unaffected for all employees for COVID-19 related illnesses.
• Ensure no out-of-pocket expenses for employees with COVID-19 related illnesses.
• CMS, Surgeon General and CDC have called for cancellation of all elective surgeries and the rescheduling all non-urgent outpatient visits.
• CMS has implemented several blanket waivers (PDF) for COVID-19. This includes additional flexibility for verbal orders.
• Six ways to address physician stress during COVID-19
• The Center for the Study of Traumatic Stress offers information for how health care teams notify families (PDF) after a COVID-19 death.
• Ensure physicians, medical students and all members of the health care teams have access to appropriate behavioral, mental, primary and specialty health care and addiction services

• Medical students at multiple states have volunteered to deliver supplies/meals and run errands on behalf of individuals in quarantine.
• A Denver community has reported the development of “Lunches for Clinicians” in which clinicians can order meals from local restaurants for delivery during shifts. Community members are raising funds to help pay for these meals. Many communities across the country have launched similar efforts.

• Mount Sinai offers childcare and pet care services through their Sinai Kids and Sinai Together initiatives. UW Health has partnered with Epic and Meriter to transform Epic’s old headquarters into a 24/7 childcare center for children of clinicians that are working at local hospitals during COVID-19.
• Several organizations have partnered with their local YMCA to provide additional childcare for their health care workers.
• One system reported a program in which staff members who must stay home to care for their children are still paid their regular rate if they agree to care for children of two other staff members.

• American Dental Association and state dental associations are encouraging dentists to donate their PPE to local hospitals.
• Consider the use of Mask Match in order to request masks (if you are a health care professional) or to donate masks if you have extra. Masks are not for purchase or for sale. Those who are matched with a health care worker are expected to cover the cost shipping and handling.
• Mount Sinai has developed guidelines for health care workers to consider for keeping their family and friends safe when returning home from work.

• The Medical Society of Virginia (MSV) hosted a webinar on its 2020 legislation that protects physicians who seek behavioral health support. MSV also partnered with Vital WorkLife to launch a SafeHaven technology solution to ensure that physicians and PAs can seek support for burnout, career fatigue or mental health reasons.
• Organizations like Mount Sinai and UNC provide online toolkits where all well-being resources are centralized and easy for clinicians to access.
• Consider assigning therapists to strategic locations (e.g., cafeteria, staff lounges, emergency department) to provide easy access for staff. Several health systems offer drop-in hours with a psychologist onsite for their physicians and care teams. Several organizations are offering 24/7 emotional support through their behavioral health teams. In many cases, this includes emotional support for family members of clinicians as well.

• Emergency care CME

  This CME course helps clinicians gain a better understanding of concerns in urgent care and emergency medicine in a peripandemic time.

  Learn Now on AMA Ed Hub™
  Continue to monitor the ability of the Employee Health and Well-Being Unit to meet workload demands, personnel health and safety, resource needs and documentation practices.
• Supervisors can conduct a 5-minute debrief at the end of every shift with their care team. Make debriefing a routine part of the day.
• Several wellness committees and Chief Wellness Officers have shared that intensive in-person rounding to frontline health care workers has proven enormously helpful. Rounding may include:
  • Supplying basic wellbeing needs (food, drinks, hygiene items)
  • Provide in the moment support, direct pathway for more intensive support needs through behavioral health teams, peer support, etc.
  • Elicit concerns/needs that require escalation and advocacy (has led to countless system changes, including prepaying of childcare, scrub service, transparency efforts, creation of a caregiver relief fund, etc)
  • Increase awareness of available support resources
• Consider making mental health resources available to families of clinicians (PDF), as traumatic experiences from COVID-19 will affect them as well.
• The Department of Psychiatry at SUNY Downstate Health Sciences Center has created a COVID-Stress Hotline that can be accessed by everyone at the medical center. The hotline can be accessed by SMS text, email, or call in and was set up using Updox. A second line was established for leadership to communicate about groups that might need help sessions or immediate group interventions.
• AMA offers strategies and resources to manage mental well-being while also caring for patients during the pandemic or any other crisis.
• With the goals of ensuring physicians and advanced practitioners receive the psychological support they need and of paving the way for them to successfully access existing resources through their Physician Assistance Program, the Washington State Medical Association called on Employee Assistance Programs/Physician Assistance Programs with clients in the health care industry to consider the following actions:
  • Change the pre-recorded greeting message on the 1-800 number to clearly communicate that all calls are confidential and HIPAA compliant.
  • Establish a triage system at entry that allows people to identify themselves as clinicians at the frontline of the COVID-19 response. Deploy your most highly trained and skilled staff to support this population, including the provision of cognitive behavioral therapy.
  • Develop custom communication materials targeted to clinicians at the frontline of the COVID-19 response that clearly explain that your mental health care professionals are equipped to help them navigate the COVID-19 crisis and that the services are completely confidential.
  • Work with each of your clients to provide just-in-time group and 1:1 sessions to frontline clinicians while protecting the health of your staff. For example, use telehealth technology to plant multiple virtual mental health professionals inside the most impacted hospitals and/or at health care provider quarantine facilities for easy on-demand access.
  • Ensure your organizations’ emergency response plan includes strategies to adequately handle a surge in requests for services.

• Several organizations, including Methodist Hospital, UCSF and Mount Sinai, are using video conferencing tools to set up peer support “connection groups” in which physicians and care teams can support one another and discuss ongoing challenges. UCSF’s anesthesia department provides virtual support sessions via Zoom for faculty and trainees. These sessions are held once per week—one for faculty and one for trainees. Discussion questions for these sessions includes: What worries you? How are you feeling and what are you experiencing now? How are you processing all of this? Here are some Zoom and moderator tips provided by UCSF.

  Virtual session tips

  • Have everyone turn on their cameras (if possible)
  • Open Zoom chat function so participants can bring up items and moderators can discuss with the group
  • If more than 15 people consider using Zoom breakout rooms
  • Acknowledge each person as they join the Zoom meeting

  Moderator tips

  • Psychological safety is key
  • It may take time for participants to open up, resist the urge to “fill the silence” if there are lulls
  • Let conversations unfold naturally
  • Try to focus more on emotions vs. clinical details or how to fix the problem    
• PeerRxMed is a free, peer-to-peer program for physicians and others working in health care designed to provide support, connection, encouragement, resources and skill-building in order to help participants advance along the Burnout to Thriving Index toward optimal well-being, however you would define that state for yourself. This program provides regular reminders for weekly, monthly and quarterly check-ins with a peer. Reminders include exercises that provide structure for you to connect with a colleague or friend.
• Jo Shapiro, MD (Harvard Medical School) discusses the importance of peer support, the fundamentals for operationalizing a peer-support system in health systems and practices and how it can potentially change organizational culture especially during the COVID-19 pandemic. 
• Nebraska Medicine offers 1:1 peer support through their Peers in Need of Support (PiNS) program. More than 120 volunteers were specifically trained for COVID-19 response using just-in-time training (PDF).
• An ambulatory care clinic in Arizona has set up games for clinicians and patients to play throughout the day to keep morale high.

Through interviews with health system leaders, the AMA highlights programs and initiatives from around the country that are supporting the health care workforce during the COVID-19 outbreak.

• COVID-19 front line: Mount Sinai keeps physician well-being in focus
• 6 ways to address physician stress during COVID-19 pandemic
• Peer support program strives to ease distress during pandemic
• COVID-19 physician well-being initiatives embrace family needs
• 5 wellness task force tactics designed to prioritize physician health 
• 6 ways a health system attacks stress during the COVID-19 crisis
• 6 ways a health system attacks stress during the COVID-19 crisis
• Well-being resources should extend beyond a crisis to include PTSD
• Patient fears rapidly push evolution at a small family practice
• 72 hours that upended how Cleveland Clinic delivers primary care
• Using the power of peer support to positively impact medicine 
• Voicing the need for a national strategy for long-term well-being
• Hit first in the U.S. by COVID-19, Washington doctors eye safe reopening
• Doctors’ big COVID-19 worry is keeping their families safe 

1. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic

   1. This JAMA ViewPoint offers health care leadership with tangible messages and actions to support health care professionals during COVID-19.
   2. Source: JAMA

2. Supporting the health care workforce through the COVID-19 global epidemic

   1. This JAMA ViewPoint offers practical ideas for optimizing safety for our health care workforce amid COVID-19.
   2. Source: JAMA

3. Sustaining the well-being of health care personnel during coronavirus 

   1. This document provides a list of strategies for sustaining health care personnel well-being during the COVID-19 outbreak.
   2. Source: Uniformed Services University Center for the Study of Traumatic Stress

4. UW Medicine COVID-19 support

   1. This resource provides examples for ways in which health systems can set up peer support “drop in” hours via virtual meetings as well as ways in which UW is providing childcare and elder care for employees.
   2. Source: UW Medicine

5. Briefing note on addressing mental health and psychosocial aspects of COVID-19

   1. This briefing note summarizes key mental health and psychosocial support (MHPSS) considerations in relation to the 2019 novel coronavirus (COVID-19) outbreak (key activities that should be implemented, page 10 and specific messages that can be used by health care leaders with care teams working on the COVID-19 response, page 15).
   2. Source: Inter-Agency Standing Committee Reference Group for Mental Health and Psychological Support in Emergency Settings

6. Managing health care workers stress associated with the COVID-19 outbreak (PDF)

   1. This resource provides an overview of specific sources of stress for health care workers treating patients with COVID-19.
   2. Source: Department of Veterans Affairs

7. Emergency responders: Tips for taking care of yourself (CDC)

   1. This resource provides tips for emergency workers to care for themselves in preparation for an emergency response, during an emergency response and immediately following an emergency response.
   2. Source: Centers for Disease Control and Prevention

8. StepsForward®

   1. This website provides several online modules to help care teams and health system leaders build and maintain team cohesion and prevent physician burnout. Relevant modules include: (1) Physician well-being (2) Team cohesion and engagement (3) Hospitalist well-being
   2. Source: American Medical Association

9. Keeping the coronavirus from infecting health-care workers

   1. Drawing on lessons learned from Hong Kong and Singapore, physician and author Atul Gawande describes key tactics for protecting health care workers from contracting COVID-19 while caring for patients.
   2. Source: The New Yorker

10. COVID-19 literature review (Washington University in St. Louis)

    1. Washington University in St. Louis medical and graduate students have begun an initiative to summarize salient research relevant to clinical practice in the hopes that physicians across the country can use these resources as a fast scan of the most recent literature.
    2. Source: Washington University in St. Louis

11. Factors influencing physician practices’ adoption of behavioral health integration in the United States: A qualitative study

    1. The AMA and the RAND Corporation conducted a study on behavioral health integration (BHI) and physician practices to determine specific factors that influence implementation of BHI to inform solutions for this persistent disparity in mental health care. Researchers looked at the motivators, facilitators and barriers to BHI from the perspectives of 30 physician practices with firsthand experience.
    2. Source: Annals of Internal Medicine

• AMA Council on Medical Education guiding principles
• AMA resident & medical student COVID-19 resource guide

How is your organization caring for clinicians during the COVID-19 crisis?

Share your ideas and experiences with the AMA by emailing us. The AMA remains committed to ensuring quick dissemination of ongoing strategies to support physicians and care teams. Your learning and experiences will help other organizations better support their care teams during this time.

Disclaimer: The information and guidance provided in this document is believed to be current and accurate at the time of posting, but it is not intended as, and should not be construed to be, legal, financial, medical or consulting advice.  Physicians and other qualified health care practitioners should exercise their professional judgment in connection with the provision of services and should seek legal advice regarding any legal questions.  References and links to third parties do not constitute an endorsement or warranty by the AMA and AMA hereby disclaims all express and implied warranties of any kind.

With an increased number of people reporting worsening mental health in recent years, it is imperative that people are aware of the 988 Suicide & Crisis Lifeline (formerly known as the National Suicide Prevention Lifeline) telephone program.

People experiencing a suicidal, substance use, and/or mental health crisis, or any other kind of emotional distress can call, chat or text 988, and speak to trained crisis counselors. The national hotline is available 24 hours a day, 7 days a week.

The previous National Suicide Prevention Lifeline phone number (1-800-273-8255) will continue to be operational and route calls to 988 indefinitely.