Treating front-line workers: A step-by-step guide

The COVID-19 pandemic has led to unprecedented stress and trauma for front-line health-care workers. This evidence-based guidance can help psychologists conduct a diagnostic “intake” evaluation with a front-line health-care professional during the coronavirus pandemic.

In addition, here are two clinical templates for psychologists to use or modify as needed. The first template, the Adult Health History form (DOC, 87KB), is to be completed by the patient before a telehealth session. The second template, the Psychological Diagnostic Assessment (DOC, 92KB) is completed by the clinician during the evaluation with a patient.

The overarching rules for the assessment is to “Be Genuine. Express Empathy.” Frame the visit as a consultation.

• Discuss the potential risks/benefits of telehealth sessions with the patient(s).
• Get a signed informed consent from your patient(s) or patient’s legal representative. If the psychologist or patient is quarantined, informed consent must be signed electronically; use encrypted email/messaging.
• Do you have a back-up plan in case of technical difficulties? In case of a crisis? What contact information do you have? Do you know the local resources (e.g., emergency room) located near the patient?
• Provide information on how this session will be billed, including whether the patient will be billed if late or no-show.
• Request that the patient complete the Adult Health History form, GAD-7 and PHQ-9 (PDF, 151KB) and PTSD Checklist for DSM-5 (PCL-5) prior to session.

• Welcome patients to your virtual office just as you would your traditional office. Frame this visit as a professional consultation, and express gratitude for their health-care work.
• Explain that you are doing telehealth services to keep you and them, and your friends/family safe during the COVID-19 crisis.
• Ask them to provide a brief summary of why they are seeing you.

• Understand their past and current roles.

• What is their profession? (e.g., nurse, respiratory technician, physician, etc.)
• What was their role before the pandemic?
• Has their role changed during the pandemic? (e.g., have they been redeployed to do other work, even if the new work is not COVID-19 related?)
• What is their current role?

• Inquire about likelihood of COVID-19 exposure.

• Ask about their perceived risk of exposure first (e.g., on a scale of 0-10 with 0 being no risk, and 10 being highest).
• Ask follow-up questions about frequency of actual exposure(s).

See CDC recommendations of high-risk conditions for COVID-19.

• Conduct standard health/medical history.
  Note: The risk for hospitalization or intensive care is about two-and-a-half times higher if a patient has one or more chronic health conditions.
• Interview for diagnoses of known health disorders related to increased risks from COVID-19. Identify type of disease, course of disease and treatments. Examples include:

• Diabetes
• Heart diseases (including hyperlipidemia)
• Lung disorders
• Immunocompromised
• Chronic renal disease
• Pregnancy
• Neurologic/neurodevelopmental
• Chronic liver disease
• Other chronic disorders (based on CDC with prevalence at or above 5% of the sample = hypertension; thyroid disease; gastrointestinal disorder; cancer or history of cancer; rheumatologic disorder; hematologic disorder; obesity; nonrheumatoid arthritis; musculoskeletal disorder other than arthritis; urologic disorder; cerebrovascular disease; obstructive sleep apnea; fibromyalgia; gynecologic disorder; pulmonary or venous embolism)
• Cigarette smoking history and current status

• Assess if the patient has access to primary and specialty health care, and any recent use.

• Identify primary-care physician (Last visit? Available for telehealth?)
• Identify specialty physicians/providers (Last visit? Available for telehealth?)

• Review COVID-19 stressors on the Adult Health History form (DOC, 87KB). Ask follow-up questions as needed.
• Assess for COVID-19 protective habits and knowledge.

• Has 30-day or more supply of medications?
• Frequent hand washing?
• Physical distancing when not providing patient care?
• Essential travel only?

• Assess biosecurity measures and worries/cognitions about each one (per National Center for PTSD guidance (PDF, 695KB)):

• Do they experience physical strain from wearing personal protective equipment (e.g., dehydration, exhaustion, pain)?
• Do they experience physical isolation (e.g., “no-touch” measures, post-shift isolation)
• What is their level of vigilance for infection control (on a 0-10 scale)?
• Are they strictly adhering to infection protocols (e.g., no flexibility with application of procedures)?

• Assess role transitions and role conflicts during COVID-19.

• Have they made any role transitions during COVID-19, at work, home, other? How well have they and/or their family handled those transitions?
• Do daily activities conflict with COVID-19 safety measures? If so, how?
• How frequent and stressful are the changes in safety protocols and government/public health directives?
• Does their role as a health-care worker conflict with family needs? If so, how?
• Role Strain: How much stress due to conflict between role as health-care worker vs. other roles? (on a 0-10 SUDs Scale)

• Assess stigma of being a health-care worker.

• Do they notice others avoiding them out of fear of infection?
• Are they feeling self-critical or guilty for appropriate behaviors like expressing fear or personal needs to others (e.g. ,“I’m afraid I’m going to die,” “I’m going to infect someone,” “I need a nap, but I don’t want to admit it.”).

• Review patient’s current symptoms of depression, anxiety, and trauma referencing PHQ-9, GAD-7 and PCL-5 screening.
• Follow-up with open-ended questions to identify unhealthy cognitions and behaviors in the following categories (per National Center for PTSD guidance): biosecurity measures (e.g. PPE), risk of disease infection control, multiple medial and personal demands, stigma.

• Identify if behaviors are (a) Avoidant or (b) Over-Compensation.
• Identify whether avoidance strategies produce anxiety and/or depression.
• Identify issues of grief/loss. Assess frequency/severity/impact.

• Review Adult Health History about social, work and financial situation. Confirm and ask follow-up questions as needed.
• Ask for 1-10 SUDS rating regarding current family work status.
• Review Adult Health History about family situation.

• Identify strengths and stressors regarding partner/spouse, children, extended family and others.
• Identify function of stressful relationship(s) — e.g. loss of contact, fear of contaminating others, belief of never seeing/hugging others again.
• Collect 0-10 rating of happiness/satisfaction for current family relationships (0 = worst; 10 = best). 

• Consider social/cultural issues.

• Inquire about patient’s perception of their sociocultural identities and how sociocultural factors (e.g., race/ethnicity, housing, utilities, food access, transportation finances) and the intersection of those factors, affect their coping with COVID-19.

• Consider other assessments, screening and the plethora of personal, family, work, financial and existential stressors.

• Ask permission to discuss treatment planning.
• Ask open-ended questions to help them identify what’s most important in their lives.
• Ask open-ended questions about how treating (anxiety/depression/trauma) could help achieving what’s most important.
• Ask open-ended questions about how treating (anxiety/depression/trauma) could have costs such as initial increase in stress or use of patient’s time.
• Ask open-ended questions about willingness to try treatment for (anxiety/depression/trauma) related to the pandemic.
• If the patient expresses readiness, move to treatment planning.
• If the patient is not ready to change or not ready for psychological treatment, explore their rationale with empathy. Consider delaying treatment until the pandemic passes; recommend alternatives and/or consult with colleagues as needed.

• Offer treatment recommendations — virtual vs. in-person format, frequency, expected duration, areas of focus, etc.
• Consider patient preferences.
• Review patient’s satisfaction with session.
• Ask patient for any questions.
• Schedule next session if the patient says yes to treatment.

This guidance is based on Skillings and Arnold’s 2016 Holistic CBT model of biopsychosocial and integrated care. It was adapted from a protocol (PDF, 363KB) developed by the Center for Cognitive and Behavioral Therapy and Central Ohio Primary Care.