COVID-19 Telehealth Best Practices

Telehealth Best Practices for COVID-19 Marlene M. Maheu, PhD Executive Director Telebehavioral Health Institute contact@ telehealth.org 619-255-2788 Copyright 1994-2020 Tel ebehavioral Health Institute, LLC All rights reserved.

Learning Objectives Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Identify at least three basic definitions used in telehealth. Outline a validated model for conducting assessment through video-conferencing. Identify at least three telehealth issues regulated by state boards. Identify at least three telehealth issues regulated by the ethical codes of professional associations.

Learning Objectives Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Describe how you would know which of the many technologies available today meets HIPAA, HITECH and/ pr PIPEDA requirements Describe how to manage your therapeutic relationship in the face of a failing video conferencing platform. Discuss how you would handle an unwanted intruder if they entered your room Discuss how you would handle an unwanted intruder if they entered your client/patient’s room

Disclaimer/Disclosure GOAL: My goal is educational only. No warranty, guarantee, or representation is made as to the accuracy or sufficiency of the information contained in our presentation for your specific circumstance. YOUR PART: You are encouraged to seek practice-specific advice from your legal, regulatory, ethical and malpractice bodies before offering any online services or programs to consumers. Get all such opinions in writing, and have your informed, local, legal counsel review them for their full significance. I have no conflicts of interest with any groups identified in this training. Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Issues involved with COVID-19 are complex, fact-specific and state-specific. They will require legal expertise that I cannot provided in this presentation. I do not, and cannot, provide legal advice. The information that I present does not constitute and should not be relied upon as legal or ethical advice and should not be used as a substitute for obtaining personal legal advice and consultation prior to making decisions about your work. Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Today’s Schedule Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Times: 2 – 6:30 PM Eastern A 15 min. break will be from 3:15-3:30 PM Eastern A 15 min. break will be from 5:00-5:15 PM Eastern

CME or CE Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. You must complete a course evaluation and post-test to unlock and print a Course Completion Certificate for your licensing board Your will see one for all the types of CME and CE offered Just like in-person training, if you arrive more than 15 minutes late, we cannot give you “live” credit We will need you to type a message at the end of all breaks so that we know that you are here Software keeps track of your ISP and times that you comment

Please Interact Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. This was event is designed to be a workshop –we can interact Please contribute to the group discussion The chat room is open for everyone to see I will read your questions and as much of the answers as possible If you get out of hand, I will remove you from the room and refund your fees…

Make a To-Do List C 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Optimize Your Learning Mute your phone, turn off texts and emails, lock your door Organize yourself by making a to-do list as we go Rank order your to-dos by priority Consider meeting with like-minded colleagues to discuss your implementation plan

Attitude Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Reflect on what’s happening worldwide Share views with trusted colleagues Self-discipline Stay sober Get and share the facts to reduce unneeded anxiety Read “The Story of a Coronavirus,” New York Magazine

C 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. CLINICAL EVALUATION AND CARE (TBH Domain I) Evaluation & Treatment (Subdomain I.A) C 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Fundamentals of Telehealth Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. The fundamentals of responsible clinical practice do not change with telehealth. Good clinical practice remains the same regardless of delivery vehicle. Adoption is changing

Fundamentals of Telehealth Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Right now, we are experiencing forced adoption . However, whether you use video, telephone, text, email, apps, artificial intelligence, remote patient monitoring or any other tech, you are responsible through your legal and ethical codes to maintain the same quality of care as in-person.

Fundamentals of Telehealth Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Telehealth is much like driving a car. It can take a few months of regular practice to learn and remember safe response sets, develop reflexes, etc.

Fundamentals of Telehealth Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Telehealth is similar. However, right now, in this extraordinary, worldwide state of emergency, so many clinicians are untrained that the rules must be temporarily relaxed. Keeping clients/patients safe is more important than attending to other safety rules such as privacy right now.

Role of Good Clinical Practice & Work Ethics Practitioners have traditionally been free to practice from their homes, but cautioned to exercise good clinical judgment Same is true today with COVID-19 as well Not time to throw out the rule book Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Home-Based Ethical Issues BOUNDARIES: You may inadvertently violate your own boundaries Noises / sounds (spouse yelling at children) Children / adults in background, seen through windows, doors Personal items visible in background Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Home-Based Clinical Issues Maintaining Consistency/Predictability Help clients/patients focus off your home to thinking of your office Post an image of your office waiting room Post images of your furniture (chair, sofa, desk) Include office décor in your background (picture, vase, etc.) Keep reins on your starting/ending times Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Home-Based Clinical Issues Maintaining Consistency/Predictability Keeps things quiet at home Play ambient music very softly Ask them if it bothers them Be extra cautious about comments regarding your home or family If your doorbell rings, only respond if you suspect an emergency Let the sign on your door direct them Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Home-Based Clinical Issues Maintaining Consistency/Predictability Keep the focus on them Develop a 1-line response to deal with normal curiosity about your home life Use the same line repeatedly and did no diverge They will get the message Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Home-Based Clinical Issues Maintaining Your Therapeutic Frame Don’t deny someone’s reality by lying about: what you just did what they just saw Own it and deal with whatever comes next Be yourself Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Boundaries Are Key You may forget to notify family and friends of your professional appointment schedule – they may unknowingly interrupt your professional time You may be flustered when dealing with an emergency because you have not practiced coping with crisis when using technology. Best to “practice” with colleagues and not clients and patients Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Procedures Are Also Key Start a session with an opening protocol That protocol includes formal procedures to secure both ends of the meeting Ask your client/patient to identify themselves if you don’t know thm well As where they are Ask them to scan room with camera if needed

Procedures Are Also Key Develop a non-verbal, fail-proof system to notify family or friends when you are in session Lock your home office door “Do not disturb” note on door Note on kitchen counter Text message others Turn your camera away from the door

Video “ Ooopsies ” Cameras may show your more than you see on your end Clean your background all the way to the corners of your room Test with family/friends Prepare a response if someone comments on what they see Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Background Distractions Get Amplified Busy Streets, Telephones, Faxes, Televisions, Radios, Stairs, Kitchen, Vacuums, Trains/Airplanes, Doorbells, Children and Teens C 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Home-Based Clinical Issues Stretching Your Comfort Zone Stretching is needed, but don’t over-do Master one thing at a time Avoid multiple platforms, devices, apps, etc. Find a 1-stop shop to deal with several of your tech needs Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Telehealth Guidelines? Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. The American Telemedicine Association and the America Psychological Association published Telepsychology Guidelines in 2013 NASW and other groups published a guideline in 2017 American Psychiatric Association in conjunction with American telemedicine Association published guidelines in 2019 Reading a guideline does not establish competence

Do we really need special telehealth training? Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Competence in behavioral health is NOT equivalent to competence as a telebehavioral health professional All ethical codes require competence in our professional practices Competencies have since been published in telebehavioral health. It would be in your best interest to download a FREE copy, and consider whether you can do what is expected of you as a professional

Do we really need special telehealth training? Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Competencies have since been published in telebehavioral health. Download a FREE copy, and consider whether you can do what is expected of you as a professional

C 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Results: From a total of 4,712 potential references, 453 were eligible for full text review and 77 papers directly related to the concepts. From papers’ references and a review of books and popular literature, 12 other sources of information about TPr and VR were found. Though few studies literally discuss the therapeutic relationship, the impact of technology on clinical engagement and communication is growing, from clinical (e.g., psychotherapy) and non-clinical (e.g., communication, TPr ) literature. Impact of technology on therapeutic relationship

Avoid Distractions The historical evolution of TPr and VR shows that definitions, foci of studies … and assessments vary widely. TP and TBH care can be improved by concepts of TPr , avoiding distractions, understanding the technology-human interface, measures of TPR for clinical use and the use of simulation for training. Reference: Hilty DM, Randhawa K, Maheu MM, McKean AJS, Pantera R. Therapeutic relationship of telepsychiatry and telebehavioral health: Ideas from research on telepresence, virtual reality and augmented reality Psychol Cogn Sci Open J. 1994-2020 ; 5(1): 14-29. doi : 10.17140/PCSOJ-5-145

Clinical & Technical Issues Audio Clarity & Continuity Equipment Quality Type of Microphone Headsets Free Standing Microphone Placement Type of Speaker Speaker Location Minimize Distractions C 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Variations in Connectivity When at Home Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Commercial vs. residential connectivity Differences in bandwidth Bandwidth speed can also differ by time of day. After school is often a high traffic time and Internet speed can be significantly slower.

Difficult to stay focused with the telephone for long meetings. Easy to get bored or distracted. Video is better to keep parties engaged. C 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Can’t blame the technology company, the Internet, or the fact that you didn’t know better. Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. The responsibility is on your shoulders

How do you establish competence? Education/Training Supervision Experience / Self-instruction Documentation Informed Consent Intake forms Progress notes Termination notes Risk assessments Referrals Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Basic Telehealth Legal Errors Billing inaccurately (insurance fraud) Wrong licensure (practicing without a license) Practicing anonymously (precludes mandated reporting) No continuity of care Wrong technology (privacy, security, data integrity) HIPAA and HITECH) Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

HIPAA COVID-19 Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. https:// www.hhs.gov / hipaa /for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/ index.html

HIPAA Rules HIPAA rules are being relaxed by the Department of Health & Human Services Ok to speak with other professionals without explicit release form Traditional HIPAA discussions with clients/patients have included this basic permission for decades anyway. HIPAA basics should be in place

What does COVID-19 mean for your work? Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. The clinical ramifications of giving increased access to you through technology must be weighed with a risk assessment of the person in question. What is their diagnosis? What does that diagnosis tell you about their ability to push any boundaries that you wish to put into place with technology after the current situation subsides? Can you expect compliance?

What does COVID-19 mean for your work? Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Consider video conferencing You may also want to consider any communication channel that you determine to be necessary to keep people safe If you choose to proceed, advise your clients and patients that rules have been lifted temporarily , much as they would be in a flood zone or other natural disaster experiencing an emergency

What does COVID-19 mean for your work? Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Options Beyond Video Conferencing Send emails to keep everyone informed? If yes, email the message to yourself, and BCC your intended recipients so they won’t see each other on the TO: line of your email Communicate with your clients and patients in unsecured text messaging already built into your devices? If yes, think about what you write, how it might be mis-interpreted, and document your communications.

What does COVID-19 mean for your work? Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Options Beyond Video Conferencing Unencrypted text messages either reside on your SIM card or in the circuitry of the mobile phone. Messages then, can be discovered later and given from one party to another through the hardware of the phone. Point: be judicious about what you say Avoid LOL, emoticon, memes, etc. Maintain your professional boundary at all times

What does COVID-19 mean for your work? Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. I’m not a lawyer, but given the circumstance, a reasonable way to proceed could be: Consider diagnosis, risk analysis, history, living situation, physical health and make your determination for each person individually Give your patients or client dynamic informed consent about risks and benefits Document rationale and time/day of IC Carry on

Join Your National, State, Provincial or County Psychological Associations It is time to connect with both our national and local professional communities Get on their mailing lists Give them a hand if you have time Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Licensing Boards Licensing laws are in flux Usually, you have to be licensed where you client or patient is at the time of the contact NOW - Check with your state board’s website Get on any mailing lists Check the Center for Connected Health Policy Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. CALIFORNIA Department of Managed Health Care (DMHC) is requiring all [insurance health] plans to reimburse for telehealth at the same level they reimburse for face-to-face visits.

What are traditional telehealth jurisdictional limitations? Licensing laws are in flux. To comply with licensing law, you must traditionally be licensed in the state (or province) where your client/patient is at the time of the contact, regardless of where you live or work. Much telehealth is conducted by practitioners in their home offices. Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

How to handle? Realize that employer, insurance company and other forms are legal declarations Always tell the truth Always inform your malpractice carrier Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Telebehavioral Health Standards & Guidelines American Medical Association American Counseling Association American Mental Health Counselors Association American Psychological Association American Telemedicine Association Australian Psychological Society British Psychological Society Canadian Psychological Association Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Telebehavioral Health Standards & Guidelines Federation of State Medical Boards National Association of Social Workers New Zealand Psychological Psychologists Board Ohio Psychological Association For specific documents, see: http://telehealth.org/ethical-statements Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Informed Consent Issues IC is Not Directly Relevant in Home-Based Telehealth Delivery IC is a legal as well as ethical issue Most state laws and ethical codes do not ask you to describe where you are at any given time when using telehealth If you mention it however, you will need to deal with consequences as a therapeutic boundary issue Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

COVID-19 Funding Changes affect Medicare, Medicaid and in some states, the 3 rd party payors. See handout by the Center for Medicare and Medicaid Services (CMS) So far, communication equipment must provide 2-way, live interactive video. Telephone is not yet covered, although APA is advocating for telephone to be approved Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Coronavirus Preparedness and Response Supplemental Appropriations Act 1994-2020 Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. The new law limits telehealth services to patients for whom the provider had filed a Medicare claim for within the previous three years. However, CMS guidance states that the Department of Health and Human Services (HHS) will not conduct audits to check whether a clinician’session was a new or a returning patient.

Coronavirus Preparedness and Response Supplemental Appropriations Act 1994-2020 Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Medicare patients are no longer required to be in an originating site and can now receive telehealth services in their own homes as well as in any health-care facility. Telehealth is now available to Medicare beneficiaries in all parts of the country, not just in rural areas.

Coronavirus Preparedness and Response Supplemental Appropriations Act 1994-2020 Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved. Telehealth services are reimbursed for the same dollar amount as in-person visits. Providers may reduce or waive cost-sharing for telehealth visits during this emergency period. This does not apply to brief communication e-Visits (described below).

CPT Codes Interactive complexity (90785) Psychiatric diagnostic interview (90791) Psychotherapy including individual (90832, -34, -37), family (90846, -47), and Psychotherapy for crisis (90839, -40) Psychoanalysis (90845) Health behavior assessment and intervention services, individual and group (96158, -59, -64, -65, -67, -68, -70, –71) Neurobehavioral status examination (96116, 96121) Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

COVID-19 Telehealth Best Practices

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