|Year : 2021 | Volume
| Issue : 2 | Page : 65-72
Project CommUnity: Integrating Social Determinants of Health to Meet the Needs of the Underserved During the COVID-19 Pandemic
Eduardo Camps-Romero1, David R Brown2, Daniel Castellanos1
1 Department of Psychiatry and Behavioral Health, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
2 Department of Humanities, Health and Society, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida, USA
|Date of Submission||04-Jan-2021|
|Date of Acceptance||06-May-2021|
|Date of Web Publication||31-Aug-2021|
Dr. Eduardo Camps-Romero
Department of Humanities, Health and Society, Herbert Wertheim College of Medicine, Florida International University, 11200 SW 8th St, AHC2 591, Miami, Florida 33199
Source of Support: None, Conflict of Interest: None
The COVID-19 (coronavirus) pandemic and its consequences have seriously affected Americans' physical and mental health. We developed Project CommUnity, an integrated individual and population health response to the COVID-19 pandemic based on the preexisting foundational principles of the Florida International University Green Family Foundation Neighborhood Health Education Learning Program (NeighborhoodHELP). NeighborhoodHELP identifies and addresses the social determinants of health (SDOH) that can improve the health outcomes for household members by emphasizing social accountability and interprofessional education while providing patient and household-centered care. A lack of pandemic related mental health literature led us to build on a disaster mental health framework that is informed by our community resulting in the elaboration of specific concerns and our program's responses to them. Integrating the systematic assessment of SDOH and addressing these factors as a routine component of clinical care has the potential to improve the health of our underserved patients. We discuss how NeighborhoodHELP has mobilized to address the psychosocial needs of our households by expanding upon our existing programming and providing a range of tailored services in response to the current crisis. It is our aim to present how a social understanding of the current disaster can guide the development of an integrated health care response, focusing on the needs of low-income minority households who are disproportionately affected and least equipped to respond to the burdens suddenly imposed on them.
Keywords: Coronavirus, COVID-19, mental health, pandemic, social determinants, well-being
|How to cite this article:|
Camps-Romero E, Brown DR, Castellanos D. Project CommUnity: Integrating Social Determinants of Health to Meet the Needs of the Underserved During the COVID-19 Pandemic. World Soc Psychiatry 2021;3:65-72
|How to cite this URL:|
Camps-Romero E, Brown DR, Castellanos D. Project CommUnity: Integrating Social Determinants of Health to Meet the Needs of the Underserved During the COVID-19 Pandemic. World Soc Psychiatry [serial online] 2021 [cited 2021 Dec 5];3:65-72. Available from: https://www.worldsocpsychiatry.org/text.asp?2021/3/2/65/324980
| Introduction|| |
The coronavirus (COVID-19) pandemic has become one of the biggest crises in modern history. The pandemic has affected people globally, but in the United States its consequences have disproportionately affected racial and ethnic minority groups who have endured long-standing systemic health and social inequities. The responses required, such as state-wide stay at home orders, closing of schools, social isolation, loss of employment and income, and food shortages have abruptly changed daily life. Social distancing is slowing the spread of COVID-19, but it will undoubtedly have negative consequences for mental health and well-being in both the short term and long term.,,, The COVID-19 pandemic and its consequences are stressful and potentially traumatic. Numerous professionals predict the COVID-19 pandemic will likely result in “substantial” increases in anxiety, depression, substance use, loneliness, and domestic violence., In addition, with school closures, the possibility of an epidemic of child abuse is “very real.”,, A March 2020 national survey by the American Psychiatric Association of over 1,000 individuals in the US showed COVID-19 is seriously affecting Americans' mental health, with half of US adults reporting high levels of anxiety. A larger national survey with almost 15,000 adult respondents was completed in April, after the initiation of social distancing measures, and when compared to the same previously conducted survey in April of 2018, the reporting of symptoms of serious psychological distress increased over 300 fold.
An impact on well-being and mental health consequences can be expected in both the short and long term. These consequences are of enough importance that immediate efforts focused on prevention and direct intervention are needed to address the impact of the outbreak on an individual and population level mental health. A large body of research in disaster mental health has established that emotional distress is pervasive in affected populations; with populations affected by the COVID-19 pandemic likely to display similar distress.,, The limited literature on the mental health consequences of epidemics relates more to the sequelae of the disease itself than to social distancing. However, large-scale disasters, whether traumatic (e.g. the World Trade Center attacks or mass shootings), natural (e.g. hurricanes), or environmental (e.g. Deepwater Horizon oil spill), are almost always accompanied by increases in depression, posttraumatic stress disorder, substance use disorders, a broad range of other psychiatric and behavioral disorders, domestic violence, and child abuse.,
The attack on the World Trade Center in 2001 and its devastating mental health effects taught us some lessons. The work of New York's Office of Mental health and multiple other agencies (”Project Liberty”) revealed that high level of interagency collaboration, engagement of nongovernmental organizations to provide services, media education efforts, and ongoing program evaluation all contributed to successes. One of the lessons learned from this massive disaster-related mental health effort is that success was as much of a social effort as it was a clinical one. It was the determined and passionate work of communities, organizations, affected individuals, and people who delivered services that were an indicator of people's resilience and positive outcomes after such an event.,
This work also taught us that what affected people needed following that disaster was not necessarily psychotherapy, as might be expected, but in fact crisis counseling, or helping impacted individuals and their families regain control of their anxieties and effectively respond to an immediate disaster.,, A person's usual adaptive, problem-solving capabilities are often compromised after a disaster, but they are there, and if accessed, they can help those afflicted with emotional and psychological symptoms following a crisis to mentally endure. Ensuring safety and promoting a return to functioning, as well as being informed about immediately available resources, are the central objectives of crisis counseling, thereby making it a different approach from traditional psychotherapy. Much of the conceptual basis for crisis counseling already aligns with the values and goals of Green Family Foundation NeighborhoodHELP. Key concepts in crisis counseling include:
- It is strength-based; its foundation is embedded in the assumption that resilience and competence are inherent human qualities
- The approach is outreach-oriented, services are provided out in the community rather than in traditional mental health settings. This occurs primarily in homes or in community centers and settings, in person or remotely
- It is culturally attuned, whereby all staff appreciate and respect a community's cultural beliefs, values, and primary language
- It is aimed at supporting, not replacing, existing community support systems activities.,,
Before effective approaches to support individuals and families in our communities could be developed, it was critical to understand their specific sources of anxiety, fear, stress and difficulties. Rather than merely deploying generic approaches to manage stress or enhance resilience, addressing these concerns in a targeted manner has been a key focus of NeighborhoodHELP. The successes of NeighborhoodHELP are steeped in years of collaboration among faith based and other community organizations, city and state governmental agencies, and private foundations. These partnerships helped inform and drive the household and patient centric interventions we developed.
| Florida International University Green Family Foundation Neighborhood Health Education Learning Program (NeighborhoodHELP)|| |
Geographically located in southeast Florida, Miami-Dade County is the most populous county in Florida and 7th most populous county in the US. According to 2019 US Census data, Miami-Dade County's population is estimated at 2,716,940. The county has a large minority population, with 19% Black and 65.6% Hispanic residents. Out of the 67 counties in Florida Miami-Dade County ranks 61st in clinical care, 42nd in socioeconomic factors and 55th in physical environment. In addition, the county has some of the highest rates of uninsured populations in America, with almost 40% of the population uninsured in some neighborhoods.
The Herbert Wertheim College of Medicine is the medical school of Florida International University (FIU), located in unincorporated Miami-Dade County, Florida. In 2006, the Florida Legislature authorized the creation of a medical school at FIU with the first class of students matriculating in 2009. Given the complex needs of uninsured and low-income residents in Miami-Dade County, FIU launched NeighborhoodHELP in 2010. This curricular and service delivery program is the platform for the community-engaged mission of FIU Herbert Wertheim College of Medicine. Emphasizing social accountability and interprofessional education, NeighborhoodHELP trains future physicians and other health professions students to deliver longitudinal care that addresses the social determinants of health (SDOH) to improve health outcomes and well-being. Care is provided to NeighborhoodHELP members in their homes, via telehealth, or through our free FIU mobile health centers (MHC). Three of the four mobile units provide integrated primary, preventive, and behavioral health services. They are 38 feet in length with a fully equipped health care “office” with two examination rooms, as well as phlebotomy, minor procedures, and EKG services. In addition, the Linda Fenner 3D Mobile Mammography Center (the fourth unit) delivers screening mammograms and navigation support services for not only the women who are patients of the FIU MHC and enrolled in NeighborhoodHELP, but for underserved women throughout Miami-Dade County. During the COVID-19 pandemic, the FIU MHC continues to transform service delivery in response to patient needs. In mid-March 2020, we implemented primary and behavioral health telehealth services via telephone and Zoom. NeighborhoodHELP changes the conversation from a purely medical one to a discussion about the deeper issues and determinants of health in a household.
| What are Individuals Concerned About During this Pandemic?|| |
The best way to understand what individuals and families are most concerned about is to learn from historical experiences and to just merely ask them. Outreach team members, interdisciplinary teams, and clinicians have engaged, listened, and heard the individuals and households enrolled in NeighborhoodHELP for over a decade. As the reach of the coronavirus grew, and with the resultant onset of social distancing measures, this engagement with our communities deepened. Within 30 days of the countywide stay at home order on March 26, 2020, we were able to contact 98% of our 851 NeighborhoodHELP enrolled households to provide COVID-19 assessment and health education. Sixteen households were inactivated after declining continuing participation, finding that they had moved, or after multiple unsuccessful attempts to contact them through phone and unscheduled household visits, and contacting referral sources. By the 2nd week of March, an 8 am COVID Response Daily Briefing Call was being held with NeighborhoodHELP leadership and soon a picture of what was most concerning to our enrolled households emerged. The most commonly identified concerns included job loss, reduced work hours, potential future job loss, challenges with applications for unemployment compensation, food insecurity, homeschooling, social isolation, and general pandemic related fears. 32% of households contacted between April 10 and April 13, 2020, reported being currently unemployed or underemployed, with COVID-related layoffs, furloughs or work hour reduction. Food insecurity was reported by 28% of the households, with the majority reporting the cause as not being financially able to purchase food. Understanding and identifying the sources of anxiety allows the NeighborhoodHELP team to develop targeted approaches to address these and other concerns and provides specific support to the families.
Consistent with the work of Shanafelt et al., sources of anxiety identified by NeighborhoodHELP households were mapped to five basic requests: Hear me, protect me, prepare me, support me, and care for me. The principal desire of each request, how these sources of anxiety relate to each dimension, and how NeighborhoodHELP can respond to them were summarized and led to the development of Project CommUnity.
| Project CommUnity|| |
Project CommUnity is an integrated individual and household driven response to the COVID-19 pandemic based on the preexisting foundational principles of NeighborhoodHELP. Utilizing the framework from New York's state and local mental health response to the September 11th terrorist attacks (Project Liberty), and informed by our community, NeighborhoodHELP has elaborated specific concerns and our programs responses to them [Table 1]. The foundation or “Pillars” for successful implementation of Project CommUnity include: Timeliness, Simplicity, Coordination, Uniformity, and Clarity. Ongoing performance evaluation linked to immediate adjustment in plans resulting in additions or changes in programming will also occur.
|Table 1: Requests and responses from neighborhood health education learning program households during the coronavirus disease 2019 pandemic|
Click here to view
Consistent with the NeighborhoodHELP household centered, integrated approach, a minimum of 15 newly developed COVID-19 related initiatives also address behavioral health [Table 1]. The advent of telehealth services has enabled our innovative integrated primary-care behavioral health program, the NeighborhoodHELP Collaborative Care Program (CoCP), absorb a 92% increase in our census from March through July. Providing a socially safe venue to provide clinical care during the acute phase of the pandemic telehealth not only addressed transportation as a SDOH but has also allowed us to increase the number visits by 277% when comparing data from April to July 2019 to the same period in 2020. Utilizing our population health registry we created a novel COVID clinical track so that we could follow patients in the CoCP who were suffering from clinically significant distress or impairment in social, occupational, or other important areas of functioning secondary to the novel coronavirus and found that over a third of our patient population was represented on this track. Incorporation into our registry of NeighborhoodHELP's social screening tool, the Health Risk and Resilience Profile, revealed that patients identified by this tool as struggling with an identified social need were 35% more likely to also be on the CoCP COVID track; highlighting that preexisting social stressors complicate the ability to manage the added burdens of the pandemic. This allows us to strengthen the application of a central tenant of the collaborative care model, a stepped care approach, by increasing targeted services intended to promote resilience in those households with the most needs.
We also sought to increase support to every member of NeighborhoodHELP by developing and deploying a suite of new services guided by what we had learned by reviewing the disaster related mental health literature. Based on core concepts of mass trauma intervention, problem-solving therapy, and crisis counseling, we developed a novel brief supportive model called Disaster Supportive Coaching Skills and provided training to all faculty, staff and student disciplines participating in direct care with our household members in NeighborhoodHELP. The expectation is that each point of contact with our members during the early to mid-term stages of the pandemic is informed by these disaster supportive coaching skills which promote: (1) a sense of safety, (2) calming, (3) a sense of self– and community efficacy, (4) connectedness, and (5) hope.
For those members of our community who needed additional immediate support we developed two new programs. Our aim was to build upon the Disaster Supportive Coaching Skills training and application and deepen the continuum of pandemic related behavioral health services. The next level of these services carries on with the theme of providing convenient access to our members and is a telehealth drop-in group. Offering bi-weekly sessions held on different days of the week, Unity Hour is an interdisciplinary student led group that builds on our skills training while harnessing the dynamic of the group process and providing a safe space for social interaction in a time of social distancing. We have taken advantage of teleconferencing technologies and are leveraging the interdisciplinary nature of our student teams. For example, if an immediate social determinant of health need is shared by a group member, the individual could be offered an immediate warm hand off with a social work student and be placed together in a virtual “breakout room.” Support and resources could be provided privately, in real time, while leaving the option open for the member to later rejoin the larger group in progress.
Progressing up this ladder of tailored support and novel services we developed Unity Coaching. This forum is currently also provided through telehealth and offers a more in-depth series of one-on-one experiences for our members who may require a higher level of support. Led by our Master of Social Work student interns there is an added focus on problem solving and enhancing resiliency. Members who are displaying higher levels of psychopathology and are insured can be linked to mental health providers. For the uninsured they can be seen at the FIU MHC and received by the NeighborhoodHELP CoCP.
Our Integrated Primary Care Services began offering telehealth services by students, staff, and clinicians of all kinds to any uninsured NeighborhoodHELP household members to enable continuing health care while maintaining social distancing. Limited in person care is offered either at the FIU MHC or in the home when telehealth is not sufficient. Our Technology Literacy Initiative offered personal assistance to hour households in establishing E-mail addresses, obtaining free access to the internet, and assistance with registration to our patient portal.
As part of our longitudinal Community Engaged Physician course, medical students reached out to their assigned households to provide a COVID-19 Needs Assessment and address a range of wellbeing related issues. Through NeighborhoodHELP, we have distributed over 4000 masks. Most dramatically have been our Outreach team efforts in response to acute food insecurity seen in our community. We have delivered food boxes directly to 30% of our households, every 2 weeks in some cases.
| Lessons Learned|| |
We have presented how a social understanding of the current pandemic can guide the development of an integrated health care response by focusing on the needs of those in lower socioeconomic groups who are disproportionately affected and least equipped to respond to the burdens suddenly imposed upon them.
We found that the initial step of early communication and understanding of our households was facilitated by our established long-term relationships in the community. This directly informed the development of Project Community, NeighborhoodHELP's integrated behavioral response to the pandemic. The initiation of a broad assessment of SDOH and COVID-19 mitigation strategies was essential to understanding and responding to the needs of the population for which we serve. Central concerns of our enrolled members included access to a variety of resources and measures to reduce the risk of COVID-19, access to COVID-19 testing, and access to care among those with symptoms. Education, navigation, remote symptom and risk assessments, and home monitoring were a central plank in our early efforts. Applying for benefits due to lost work, and assistance with seeking work, also featured prominently at the onset of the pandemic. Food insecurity, which was prevalent before the pandemic, was dramatically exacerbated and persisted throughout the pandemic.
Because of closures and reductions of in-person services, access to technology and technology literacy has become more important. Efforts in support of our households included the provision of food and masks, disaster supportive coaching, tutoring, and technical support for participation in telehealth or remote learning, as well as navigation to a variety of community resources. The most commonly used resources were also added to our publicly available electronic resource guide: Libguides.medlib.fiu.edu/nhelp. Without the support of a broad interdisciplinary team, longstanding relationships and the trust with our households and community partners, reducing these barriers in a holistic manner would not have been possible.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Galea S, Merchant RM, Lurie N. The mental health consequences
of COVID-19 and physical distancing
: The need for prevention and early intervention
. JAMA Intern Med 2020;180:817-8.
Golberstein E, Wen H, Miller BF. Coronavirus disease 2019 (COVID-19) and mental health for children and adolescents. JAMA Pediatr 2020;174:819-20.
Pfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med 2020;383:510-2.
McGinty EE, Presskreischer R, Han H, Barry CL. Psychological distress and loneliness reported by US adults in 2018 and April 2020. JAMA 2020;324:93-4.
Czeisler MÉ, Lane RI, Petrosky E, Wiley JF, Christensen A, Njai R, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic – United states, June 24–30, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1049-57.
Zhang J, Lu H, Zeng H, Zhang S, Du Q, Jiang T, et al.
The differential psychological distress of populations affected by the COVID-19 pandemic. Brain Behav Immun 2020;87:49-50.
Neria Y, Nandi A, Galea S. Post-traumatic stress disorder following disasters: A systematic review. Psychol Med 2008;38:467-80.
Norris FH, Stevens SP, Pfefferbaum B, Wyche KF, Pfefferbaum RL. Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. Am J Community Psychol 2008;41:127-50.
Sederer LI, Lanzara CB, Essock SM, Donahue SA, Stone JL, Galea S. Lessons learned from the New York state mental health response to the September 11, 2001, attacks. Psychiatr Serv 2011;62:1085-9.
Substance Abuse and Mental Health Services Administration. Crisis Counseling Assistance and Training Program (CCP). 2019 February 08. Available from: https://www.samhsa.gov/dtac/ccp
. [Last accessed on 2020 Jun 03].
Greer PJ Jr.
, Brown DR, Brewster LG, Lage OG, Esposito KF, Whisenant EB, et al.
Socially accountable medical education: An innovative approach at Florida International Univ ersity Herbert Wertheim College of Medicine. Acad Med 2018;93:60-5.
Shanafelt T, Ripp J, Trockel M. Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic. JAMA 2020;323:2133-4.
Camps-Romero E, Anderson F, Bruce T, Foster A. Utilizing information technology to Bridge the gap between social determinants of health and clinical care for the underserved. J Technol Behav Sci 2020;5:289-93.
Hobfoll SE, Watson P, Bell CC, Bryant RA, Brymer MJ, Friedman MJ, et al.
Five essential elements of immediate and mid–term mass trauma intervention: Empirical evidence. Psychiatry 2007;70:283-315.