key: cord-350646-7soxjnnk
authors: Becker, Sara; Chaple, Michael; Freese, Tom; Hagle, Holly; Henry, Maxine; Koutsenok, Igor; Krom, Laurie; Martin, Rosemarie; Molfenter, Todd; Powell, Kristen; Roget, Nancy; Saunders, Laura; Velez, Isa; Yanez, Ruth
title: Virtual reality for behavioral health workforce development in the era of COVID-19
date: 2020-10-09
journal: J Subst Abuse Treat
DOI: 10.1016/j.jsat.2020.108157
sha: 
doc_id: 350646
cord_uid: 7soxjnnk

The coronavirus 2019 disease (COVID-19) pandemic emerged at a time of substantial investment in the United States substance use service infrastructure. A key component of this fiscal investment was funding for training and technical assistance (TA) from the Substance Abuse and Mental Health Services Administration (SAMHSA) to newly configured Technology Transfer Centers (TTCs), including the Addiction TTCs (ATTC Network), Prevention TTCs (PTTC Network), and the Mental Health TTCs (MHTTC Network). SAMHSA charges TTCs with building the capacity of the behavioral health workforce to provide evidence-based interventions via locally and culturally responsive training and TA. This commentary describes how, in the wake of the COVID-19 pandemic, TTCs rapidly adapted to ensure that the behavioral health workforce had continuous access to remote training and technical assistance. TTCs use a conceptual framework that differentiates among three types of technical assistance: basic, targeted, and intensive. We define each of these types of TA and provide case examples to describe novel strategies that the TTCs used to shift an entire continuum of capacity building activities to remote platforms. Examples of innovations include online listening sessions, virtual process walkthroughs, and remote “live” supervision. Ongoing evaluation is needed to determine whether virtual TA delivery is as effective as face-to-face delivery or whether a mix of virtual and face-to-face delivery is optimal. The TTCs will need to carefully balance the benefits and challenges associated with rapid virtualization of TA services to design the ideal hybrid delivery model following the pandemic.

The coronavirus 2019 disease pandemic emerged at a time of substantial investment in the United States substance use service infrastructure. Between 2017 and 2019, Congress released $3.3 billion dollars in grants to scale up substance use prevention, treatment, and recovery efforts in an attempt to curtail the overdose epidemic (Goodnough, 2019) . A key component of this fiscal investment was funding for training and technical assistance (TA) from the Substance Abuse and Mental Health Services Administration (SAMHSA) to newly configured Technology Transfer Centers (TTCs), including the Addiction TTCs (ATTC Network), Prevention TTCs (PTTC Network), and Mental Health TTCs (MHTTC Network). To ensure the modernization of the behavioral health service system, SAMHSA charges TTCs with building the capacity of the behavioral health workforce to provide evidence-based interventions via locally and culturally responsive training and TA (Katz, 2018) .

In March 2020, the COVID-19 pandemic upended the United States healthcare system, and challenged the behavioral health workforce in unprecedented ways. To meet the needs of the workforce, TTCs had to rapidly innovate to provide training and TA without service disruption. 

TTCs apply different TA strategies based on circumstances, need, and appropriateness (Powell, 2015) and consider training (i.e., conducting educational meetings) as a discrete activity that can be provided as part of any TA effort. TTCs are guided by extensive evidence that strategies beyond training are required for practice implementation and organizational change (Edmunds et al., 2013) , underscoring the critical need for virtual TA in the wake of the COVID-19 pandemic. In May 2020, we surveyed all 39 U.S.-based TTCs to identify example innovations in each layer of the TA pyramid that the COVID-19 necessitated. Thirty-five TTCs (90%) across three networks (PTTC N=13; ATTC N=13; MHTTC N=9) responded, representing both regional and national TTCs.

consultations. TCCs typically deliver basic TA to large audiences and focus on building awareness and knowledge. Common basic TA activities for untargeted audiences include conferences, brief consultation, and web-based lectures (i.e., webinars). TTCs reported a surge in requests for basic TA during the COVID-19 pandemic and responded with a significant increase in dissemination of information (i.e., best practice guidelines), as well as brief consultations to support interpretation of such information. TTCs emphasized virtual content curation, organizing content to enhance usability. Additionally, TTCs employed novel delivery channels, such as live streaming, pre-recorded videos, podcasts, and webinars with live transcription, to reach wide audiences. Another practice innovation was online listening sessions in which health professionals convened around a priority topic. For instance, two national TTCs co-hosted a J o u r n a l P r e -p r o o f Journal Pre-proof Virtual Workforce Development 6 series of listening sessions titled "Emerging Issues around COVID-19 and Social Determinants of Health" that experimented with "flipping the typical script" by first having participants engage in conversation and then having expert presenters address emergent topics via brief didactics.

This series, which was not sequential or interconnected, built knowledge and awareness around evolving workforce needs.

Targeted TA is the provision of directed training or support to specific groups (e.g., clinical supervisors) or organizations (e.g., prevention coalitions) focused on building skill and promoting behavior change. Targeted TA encompasses activities customized for specific recipients such as didactic workshop trainings, learning communities, and communities-of-practice. Due to the focus on provider skill-building, targeted TA often relies on experiential learning activities such as role plays and behavioral rehearsal (Edmunds et al., 2013) . To transition targeted TA online, TTCs reduced didactic material to the minimum necessary; spread content over several sessions; and leveraged technology to foster interaction among small groups. For example, one regional TTC transformed a face-to-face, multi-day motivational interviewing skills-building series by moving the delivery to a multi-week virtual learning series. This TTC kept participants engaged by limiting the time for each session to 1-2 hours, utilizing the full capabilities of videoconferencing platforms (e.g., small breakout rooms and interactive polling), and extending learning through SMS text messages containing reminders of core skills.

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