Navigating Uncertainty: Adapting Guidance for Mental Health During the COVID-19 Public Health Emergency & the Crucial Role of Bi-directional Feedback.

In response to the COVID-19 public health emergency, state and local mental health authorities rapidly developed and disseminated guidance to community mental health agencies. While tailored communication is effective to reach target audiences under usual circumstances, strategies to facilitate the implementation of guidance amidst a rapidly evolving public health emergency are not well understood. This project sought to understand factors informing decision-making about adaptations to guidance, and strategies used to disseminate and facilitate guidance implementation among system-level community partners in OnTrackNY Coordinated Specialty Care (CSC) programs for early psychosis. Semi-structured interviews were conducted with New York State Office of Mental Health (NYS OMH) state and local mental health authorities including state leaders (n = 3) and NYS OMH field office directors (n = 4), OnTrackNY program directors (n = 4), and leadership and trainers of an intermediary organization, OnTrack Central (n = 12). Interviews were analyzed using content analysis. Code reports relevant to guidance decision-making and dissemination were reviewed to identify emerging themes. For state and local mental health authorities, decision-making was influenced by changing COVID-19 risk levels, need for alignment between federal and local guidance, and balancing support for workforce capacity and mental health service continuity. For OnTrackNY program directors, decision-making was influenced by internal infrastructure and processes (e.g., program autonomy), availability of resources (e.g., technology), and perspective on managing risk and uncertainty (e.g., COVID-19, regulatory waiver expiration). For OnTrack Central, decision-making focused on balancing CSC model fidelity with OnTrackNY team capacity and resources. Dissemination of guidance consisted of mass and targeted strategies. Information flow was bidirectional such that top-down dissemination of guidance (e.g., from state mental health authorities to providers) was informed and refined with bottom-up feedback (e.g., from providers to state leadership) through surveys and professional forums (e.g., COVID-19 town halls, provider learning collaboratives). Unlike a planned approach to disseminate new policies, public health emergencies create variable landscapes that may warrant a deeper understanding of how guidance may be adapted to fit rapidly evolving community partner needs. Findings may inform efforts to identify processes that contribute to adaptation and dissemination of guidance for mental health during future public health emergencies.