Telehealth: Quick Tips to Get Started

Telehealth is rapidly growing as we all adjust our lives due to COVID-19. Here are some quick tips and resources to help you get started.

The Coronavirus COVID-19 and resulting pandemic has changed so many aspects of our lives, that for many of us, life today almost seems surreal. Non-emergency in-office visits are now a thing of the past and telehealth is being pushed on us. We must keep at least a six-foot distance between ourselves and everyone else. For some of us, curfews have been imposed and only essential travel is allowed. And, in Florida, police are present at state lines, screening entrance into the state.

So, for therapists, counselors, psychologists, and all mental health professionals, the only answer is to turn to telehealth, also known as teletherapy, e-therapy, telemental health, telepractice, and telepsychology (among other names), which means a new learning curve. So here are some quick tips to help you get started:

Understand What Is Allowed And What Is Not

At the time of this writing, the HIPAA rules have been relaxed regarding
telehealth. Specifically, the Office of Civil Rights (OCR) of Health and Human Services (HHS), which has authority over HIPAA, states, “A covered health care provider that wants to use audio or video communication technology to provide telehealth to patients during COVID-19 nationwide public health emergency can use any non-public facing remote communication product that is available to communicate with patients.

What that means is that public facing platforms like Facebook Live, Twitch, and Tik-Tok should not be used for providing telehealth. However, platforms like Apple Facetime, Facebook Messenger video chat, Google Hangout video, or Skype can be used.

Important to note that the OCR does not endorse any of these. While greater privacy protection can be obtained by using HIPAA-compliant video communication solutions, the relaxation of the HIPAA policy means that non-public facing platforms – which would normally not be allowed – are now allowed, provided that they are used in connection with the good faith provision of telehealth. This means that to the provider’s knowledge, the platform used is private, and not accessible to the public.

Make Every Effort To Provide A Therapeutic Space

It is a given that when a patient enters an office for therapy, the room will be quiet, inviting, and most important, private and free from distractions. When offering therapy over the internet or phone, however, making the space where therapy will be offered similar to what would be expected in traditional therapy will take some effort.

To begin, be sure that the room you work in is quiet. While some things like your neighbor mowing his lawn may not be avoidable, things like the dog barking, kids screaming or playing in the background should be minimized.

Next ensure that the area you choose is one where you will be free from distractions. This may mean using a door sign for family members that reads, “In Session” so they will know not to interrupt you.

Lastly, choose an area where you feel like you can focus. While this may seem obvious, we do put effort into arranging a traditional office not just to be inviting for our clients, but also to help us feel comfortable, safe, inspired, and focused. So take some time to think about where you will feel most comfortable and if needed, create a space for yourself.

Encourage Your Client To Make His/Her Space Therapeutic

Just like it will take some effort on your end to make your space therapeutic, your clients will also need to think about where in their environment will be most quiet, secure, private, and free from distractions. Perhaps they has a home office that be used, a bedroom that is quiet, or even an outside area like a patio, deck, or backyard.

Again, what is most important is that your clients find a place where they truly feel comfortable and can focus without interruption. This may be somewhat challenging, especially with kids at home, however this is all the more reason to encourage your client to take the time to find the appropriate space, before teletherapy or e-therapy sessions begin.

Know Your Resources

Because telehealth is a new format for many of us, it is always helpful to know where to find more information when it is needed. In response to the emergency, HIPAA Journal has worked with Compliancy Group to set up a free hotline for any questions you may have related to HIPAA compliance during the COVID-19 crisis. That number is (800) 231-4096.

The first place to start is by checking with your professional licensing board website to find guidance specific to your state/profession.
https://www.pdresources.org/page/index/17/State-CE-Requirements

Federal Government Guidance on Telehealth

H.R. 6074, the Coronavirus Preparedness and Response Supplemental Appropriations Act, 2020, signed into law on March 6, gives states the ability to request waivers that would allow them to use Medicare and Medicaid funds for telehealth services without the “originating site requirement.” Under normal circumstances, patients are required to have one or more face-to-face appointments at a qualifying health care site before Medicare or Medicaid will pay for telehealth services. Counselors are not covered under Medicare, but Medicaid coverage varies by state. Most states cover Medicaid services provided by counselors, but some restrict the types of providers that can furnish telehealth services. States that have waivers approved by the Centers for Medicare & Medicaid Services may lift some restrictions temporarily and begin covering counseling services via telehealth. Several other federal government agencies have released guidance important to behavioral health providers.

The National Association of Medicaid Directors lists contact information for each state Medicaid agency. If you are unsure of the status of Medicaid coverage for counselors providing telehealth in your state, contact your state Medicaid director’s office or govtaffairs@nbcc.org.

The Centers for Medicare & Medicaid Services has also released additional guidance on telehealth for state Medicaid programs and provides general information on telehealth benefits in Medicaid.

The Substance Abuse and Mental Health Services Administration (SAMHSA) and the Drug Enforcement Administration (DEA) have issued guidance on the use of telemedicine for medication-assisted treatment. SAMHSA has also released guidance relating to the prohibitions on use and disclosure of patient identifying information under 442 CFR Part 2.

The Department of Health and Human Services (HHS) Office of Civil Rights has stated it will waive potential penalties for HIPAA violations against health care providers who serve patients through everyday communications technologies during the emergency.

The American Psychological Association (APA) has created Practice Resources in Response to COVID-19 (which includes information on telepsychology and telehealth) available at:
https://www.apaservices.org/practice/clinic?_ga=2.125054154.1107876864.1585682285-731192192.1585682285

The American Speech-Language-Hearing Association (ASHA) has posted Telepractice Resources During COVID-19 for Speech-Language Pathologists (SLPs) and audiologists:
https://www.asha.org/About/Telepractice-Resources-During-COVID-19/

The National Board for Certified Counselors (NBCC) has developed a COVID-19 Information Page: https://www.nbcc.org/covid-19

The Trust Practice and Risk Management Association (TrustPARMA) also offers a free sample of an informed consent for e-therapy at: https://parma.trustinsurance.com/Workshops-Webinars/Telepsychology.

The Florida House of Representatives has updated their legislation to include standards of practice for telehealth providers in the state of Florida:
https://www.flsenate.gov/Session/Bill/2019/23/BillText/er/PDF

The Florida Department of Health states: “Individual licensed health care professionals are required to use independent judgement or seek personal legal counsel as it relates to interpreting the Florida telehealth law and the various executive orders regarding telehealth by any method to ensure that the care provided meets the standards of the established scope of practice for the profession.”

The California Association of Marriage and Family Therapy (CAMFT) has also posted an overview of HIPAA considerations for implementing telehealth, as well as options for HIPAA compliant telehealth platforms at: www.camft.org/Resources/Legal-Articles/Telehealth-HIPAA-and-Compliant-TeleHealth-Platforms.

Lastly, the HIPAA announcement regarding the relaxation of policies during the COVID-19 national emergency can be found at www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html.

Offering telehealth is a wonderful resource, and thanks to the relaxation of HIPAA policies, now much more accessible to health professionals, and clients alike. Thankfully, the COVID-19 national emergency need not interrupt mental health services.

Related Online Continuing Education (CE) Course:

E-Therapy: Ethics & Best Practices is a 3-hour online continuing education (CE) course that examines the advantages, risks, technical issues, legalities, and ethics of providing therapy online.

E-therapy can be used to address age-old problems, such as how to reach out to those who might not otherwise avail themselves of psychotherapy services even though they are in acute need. At the same time, it is clear that many providers have embraced the new technologies without a firm grasp on the new and serious vulnerabilities that are introduced when their patients’ personal health information goes online. Included in this course are sections on video therapy, email, text messaging, smart phone use, social media, cloud storage, Skype, and other telecommunications services.

This course is focused upon the ethical principles that are called into play with the use of e-therapy. Among them the most obvious concern is for privacy and confidentiality. Yet these are not the only ethical principles that will be challenged by the increasing use of e-therapy. The others include interjurisdictional issues (crossing state lines), informed consent, competence and scope of practice, boundaries and multiple relationships, and record keeping.

In addition to outlining potential ethical problems and HIPAA challenges, this course includes recommended resources and sets of specific guidelines and best practices that have been established and published by various professional organizations. Course #31-19 | 2019 | 60 pages | 20 posttest questions

Click here to learn more.

Professional Development Resources is a nonprofit educational corporation 501(c)(3) organized in 1992. We are approved to sponsor continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC); the Association of Social Work Boards (ASWB); the American Occupational Therapy Association (AOTA); the American Speech-Language-Hearing Association (ASHA); the Commission on Dietetic Registration (CDR); the Alabama State Board of Occupational Therapy; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology & School Psychology, Dietetics & Nutrition, Speech-Language Pathology and Audiology, and Occupational Therapy Practice; the Georgia State Board of Occupational Therapy; the New York State Education Department’s State Board for Mental Health Practitioners as an approved provider of continuing education for licensed mental health counselors (#MHC-0135); the Ohio Counselor, Social Worker & MFT Board and Board of Speech-Language Pathology and Audiology; the South Carolina Board of Professional Counselors & MFTs; the Texas Board of Examiners of Marriage & Family Therapists and State Board of Social Worker Examiners; and are CE Broker compliant (all courses are reported within a few days of completion).

PDR offers over 150 accredited online CE courses for healthcare professionals. 

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Enjoy 20% off all online continuing education (CE/CEU) courses @pdresources.orgClick here for details.

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Advantages of E-Therapy

Course excerpt from E-Therapy: Ethics & Best Practices

E-therapy benefitsE-therapy (a.k.a. distance therapy, telepsychology, telemental health, remote therapy, etc.) refers to the delivery of mental health services in which electronic equipment and therapeutic communication converge online. Typically the online services include emails, discussion lists, chats, or audiovisual conferencing. This kind of therapy is proliferating rapidly, and its applications have the potential to advance the field of mental health in a multitude of ways.

Research suggests that e-therapy may have similar or, in some cases, even better therapeutic benefits than face-to-face (F2F) therapy. Studies have also suggested that e-therapy for certain purposes can be very cost-effective because it can require minimal or no therapist involvement. However, (good news for all of us?) therapist involvement is still generally preferred.

In their article on home-based telemental health (HBTMH), Pruitt and Luxton (2014) state that “one of the principle benefits of HBTMH is its potential to improve treatment attendance and satisfaction, which can lead to more positive treatment outcomes. The benefits of reduced travel, less time off work, shorter appointment wait-times, and greater personal control are frequently cited as advantages of telehealth-based care over in-person care.”

Patients with Limited Mobility

The main advantage of e-therapy is that it can reach people who might not otherwise seek therapy, such as disabled people or those who live in remote areas; it also reduces the contact time between therapist and patient.

A Sense of Anonymity

It has been observed that online interactions can differ from in-person encounters in that the former imparts a sense of disconnect or anonymity. This phenomenon has been referred to as the “online disinhibition effect.” This is essentially the observation that while online, some people self-disclose or act out more frequently or intensely than they would in person. A positive aspect of this effect – in the context of remote online therapy – is that some individuals may be inclined to disclose information they might not be disposed to share in a traditional therapy session.

Bypassing the Stigma

According to Luxton et al. (2012), “Home-based TMH is a viable solution to provide improved access to quality mental healthcare for those unable or unwilling to seek traditional care because of mobility, geography, or concerns about stigma.”

Even in current times, when it is fairly commonplace for individuals to seek psychotherapy for life’s issues, there is still some residual stigma associated with psychotherapy – at least in the minds of some individuals. Particularly in small communities or certain occupational spheres like the armed services and police departments, it is not unusual for everyone to know everyone else’s business. This concern may play a role in the decision of some not to avail themselves of therapeutic resources, even when they are in need and even when such resources are otherwise available and affordable.

Where therapy offices and waiting rooms are visible to others, concerns about privacy can be a significant issue. In rural areas or small towns, or even in some areas of larger cities, it is not uncommon for patients to encounter people they know in clinical waiting rooms. Patients who forgo seeking treatment due to such privacy concerns may be willing to participate in care if it is provided in a private place such as their own home.

Click here to learn more.

E-Therapy: Ethics & Best PracticesE-Therapy: Ethics & Best Practices is a 3-hour online continuing education (CE) course that examines the advantages, risks, technical issues, legalities and ethics of providing therapy online. E-therapy can be used to address age-old problems, such as how to reach out to those who might not otherwise avail themselves of psychotherapy services even though they are in acute need. At the same time, it is clear that many providers have embraced the new technologies without a firm grasp on the new and serious vulnerabilities that are introduced when their patients’ personal health information goes online. Included in this course are sections on video therapy, email, text messaging, smart phone use, social media, cloud storage, Skype, and other telecommunications services. This course is focused upon the ethical principles that are called into play with the use of e-therapy. Among them the most obvious concern is for privacy and confidentiality. Yet these are not the only ethical principles that will be challenged by the increasing use of e-therapy. The others include interjurisdictional issues (crossing state lines), informed consent, competence and scope of practice, boundaries and multiple relationships, and record keeping. In addition to outlining potential ethical problems and HIPAA challenges, this course includes recommended resources and sets of specific guidelines and best practices that have been established and published by various professional organizations. Course #30-87 | 2016 | 52 pages | 20 posttest questions

This online course provides instant access to the course materials (PDF download) and CE test. After enrolling, click on My Account and scroll down to My Active Courses. From here you’ll see links to download/print the course materials and take the CE test (you can print the test to mark your answers on it while reading the course document). Successful completion of the online CE test (80% required to pass, 3 chances to take) and course evaluation are required to earn a certificate of completion. Click here to learn more.

About the Author:

Leo Christie, PhD, LMFT, is a Florida-licensed Marriage and Family Therapist with a doctorate in Marriage and Family Therapy from Florida State University. Past President of the Florida Council on Family Relations, Dr. Christie is currently CEO of Professional Development Resources, a nonprofit corporation whose mission is to deliver continuing education credit courses to healthcare professionals throughout the United States. He has more than 20 years’ experience in private practice with a specialty in child behavior disorders and as an instructor for over 500 live continuing education seminars for healthcare professionals.

CE Information:

Professional Development Resources is approved to sponsor continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC ACEP #5590); the Association of Social Work Boards (ASWB #1046, ACE Program); the Florida Boards of Clinical Social Work, Marriage & Family Therapy, and Mental Health Counseling (#BAP346) and Psychology & School Psychology (#50-1635); the Ohio Counselor, Social Worker & MFT Board (#RCST100501); the South Carolina Board of Professional Counselors & MFTs (#193); and the Texas Board of Examiners of Marriage & Family Therapists (#114) and State Board of Social Worker Examiners (#5678).

 

Growing your Practice with Technology

By Marlene M. Maheu, PhD, from Ethics & Risk Management: Expert Tips VII

Vague Standards, Guidelines, Laws Create Telepsychology Risks

As a psychologist who’s been researching/writing/practicing/consulting/training online for years, I’m often asked, “Where can psychologists get guidance and training for practicing online?”

Vague Standards, Guidelines, Laws Create Telepsychology RisksJust as frequently, I encounter well-intentioned, ethical colleagues who blithely undertake an online practice without considering their legal and ethical obligations or competencies. In hopes of helping readers avoid many potential landmines, I’ll outline how current guidelines, ethical standards and state regulations can be used to help you avoid trouble and reap long-term benefits of growing your practice with technology.

Professional Guidelines

A joint task force of representatives of the American Psychological Association, the American Psychological Association Insurance Trust and the Association of State and Provincial Psychology Boards has developed telepsychology guidelines.

Guidelines developed by other professional associations can be of benefit to psychologists, but state regulations and guidelines of licensure also must be taken into consideration.

Despite the proliferation of health care technology in the last two decades, including the Internet, many professional associations have struggled to allocate the needed resources to develop clear and timely practice standards or guidelines. Even when they have been clear, many fail to address the current range of technology used in behavioral practice.

Vague Standards, Guidelines, Laws Create Telepsychology RisksFor instance, they might refer to telecommunication technologies for direct care, but neglect the rapid expansion of services delivered as psycho-educational products online, text messaging, virtual reality, robotics, mobile health (mhealth) such as “apps” used with smart devices and other areas.

Some associations are making significant progress; others have barely begun. A number of psychologists are attempting to form a new APA division to address the growing areas that need to be expanded in the definition of psychology and grow the association with vibrant new ideas and enthusiasm.

See the many areas of focus addressed by the proposed Society for Technology and Psychology (http://stp-apa.net) and consider how they are changing traditional in-person care. (Support this movement by signing the petition for inclusion in the APA.)

Even though technology may be outstripping the abilities of professional associations to “keep up,” associations have a responsibility to “catch up.” While many countries are far ahead of the U.S.-based professional associations in both the timeliness and scope of their standards, guidelines or statements of best practice, the following are available online for the psychologist looking for immediate guidance:


For a regularly updated list of currently published standards, guidelines and best practices in behavioral telehealth and telemental health, see Telemental Health Standards, Guidelines and Statements: http://telehealth.org/ethical-statements.

Keep Up On State Laws, Regulations

Despite the best research on recommended standards for the use of technology in psychology, practitioners must also carefully consider the strictures of state licensing regulations.

Licenses are awarded by states and therefore their scopes of practice are defined by the specific states(s) of licensure. Federal laws exempt military and federal government practitioners but otherwise state licensing laws define professional work. From one state to another, laws and regulations can differ substantially, be contradictory or outdated in terms of application to online practice. A number of states are working on updating regulations but they are moving forward in a hodgepodge and piecemeal manner rather than a unified plan. Potential penalties for violating licensing laws include fines, community service, public humiliation or suspension of licensure. In some states, certain laws can be considered “criminal offenses” and lead to the forfeiture of malpractice benefits. Examples include insurance fraud or treating a client in a state where the psychologist is not licensed.

Many psychologists fail to understand that being licensed in one state does not grant them the right to practice in another state or the repercussions of making such uninformed decisions. For example, Vermont and Utah carry $5,000 fines for practicing in their states without a license. Disengaging from treatment with remote clients after learning of such regulatory laws can also create thorny clinical dilemmas.

Role of Professional Associations

In addition to other benefits, professional associations can try to intervene to influence state law. They also typically develop and publish ethical standards and guidelines that not only require that a practitioner adhere to state and federal law but the association’s own rules. Ethical standards are the most stringent and are mandatory. They outline appropriate behavior and set the bar for membership.

For professional associations and practitioners alike, keeping abreast of technological demands is important because an existing set of standards, whether outdated or current, creates a standard of due care.

This Standard in Turn Helps Define Malpractice

Similarly, if professionals do not adhere to standards accepted by their national association, they may be responsible for malpractice in tort. Therefore, it is incumbent upon the elected and staff leaders of professional associations to allocate the needed resources to develop adequate standards and guidelines to protect practitioners in a timely manner. The penalty for failing to adhere to a set of standards is most often censorship or removal from the association.

Guidelines, on the other hand, are aspirational and therefore not required. They usually involve a distillation of the relevant literature and provide guidance in the form of suggestions. But, in many states aspirational guidelines by psychological association are incorporated by reference into licensing regulations and have a long history of being used by prosecutors to establish negligence on the part of practitioners.

Professionals, then, may want to be mindful of and carefully document any departure from both standards and guidelines issued by professional associations. If they don’t agree with standards or guidelines as promulgated by any professional association, they can work within the association to change them or leave the association.

The Challenge

Practitioners attempting to operate innovative technology-based programs within the bounds of vague or outdated ethical standards and guidelines are at risk of being at a distinct disadvantage before an equally vague or outdated licensing board or jury. Unclear standards, guidelines and regulatory law leave the innovative practitioner with many opportunities but not enough direction. Formal professional training is warranted to help forward-thinking psychologists access the strong evidence base that reflects reliable approaches to risk management.

Ethics and Risk Management: Expert Tips VII is a 3-hour online continuing education (CE/CEU) course that addresses a variety of ethics and risk management topics in psychotherapy practice in the form of 22 archived articles from The National Psychologist and is intended for psychotherapists of all specialties.

Professional Development Resources is approved to offer continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC); the Association of Social Work Boards (ASWB); the American Occupational Therapy Association (AOTA); the American Speech-Language-Hearing Association (ASHA); the Commission on Dietetic Registration (CDR); the California Board of Behavioral Sciences; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy, Psychology & School Psychology, Dietetics & Nutrition, Speech-Language Pathology and Audiology, and Occupational Therapy Practice; the Ohio Counselor, Social Worker & MFT Board; the South Carolina Board of Professional Counselors & MFTs; and by the Texas Board of Examiners of Marriage & Family Therapists and State Board of Social Worker Examiners.