TBHI 90 min 7 Pillars of TBH 11.18.2020

TBHI 90 min 7 Pillars of TBH

1. | 7 Pillars of

Telehealth Success:
Evidence-Based
Competencies in
Telebehavioral
Health

MARLENE M. MAHEU, PHD
EXECUTIVE DIRECTOR
TELEBEHAVIORAL HEALTH INSTITUTE

[email protected]
619-255-2788

2. Telebehavioral
Health
Institute

Telehealth.org

3. Telebehavioral Health

é Synchronous |
(real time
response)

Asynchronous

(delayed
response)

4. Telebehavioral Health

Text |

Telephone Messaging
Remote |
Video Patient
Monitoring

Email Apps

5. Boundaries of Competence

Required Ethical
Standard

Emotional
reasoning vs
competence

* Education

e Training

* Experience
+ Consultation

+ Example: Using telephone -- many
professionals use and 'feel good”
about using telephone without
understanding complexities

7. 5 Subdomains A

49 Telebehavioral / :
. , ias ie A

146 Telebehavioral
Competencies
Across 3 Levels
Novice Froncient bo

8. CTiBS TBH Competency
Domains

6 a.
nie Legal &

Ethical &
Evidence-
Based

9. De

CLINICAL EVALUATION
AND CARE
(TBH Domain 1)

Evaluation & Treatment
(Subdomain 1.A)

10. Supporting
Research

Godleski, Darkins & Peters
reported in April of 2012 that
hospital utilization in
psychiatric populations at
the Veterans Administration
were decreased by an
average of 25% since the use
of telehealth.

Godleski, L. Darkins, A. & Peters,
J. Outcomes of 98,609 U.S.
Department of Veterans Affairs
patients enrolled in telemental
health services, 2006-2010.
Psychiatric Services, 63(4). 383-
RAR

11. À

12. Remote Patient
Monitoring (RPM)

Use of a non-invasive,
wearable device that
automatically transmits data to
a web portal or mobile app for
patient self-monitoring and/or
health provider assessment and
clinical decision-making.

Can involve subcutaneous
sensor or dermal tattoo, but
these applications are not yet
commonplace

13. Remote Patient
Monitoring

Literature reflects much
enthusiasm for RPM

Despite anecdotal reports,
meta-analytical outcomes
show that patients do much
better when RPM is paired with
ongoing treatment that is
focused on the data collected
by the technology.

This same finding is true with the
evidence base related to apps.

14. Studies are quite
heterogeneous in design,
devices used and outcomes.
Substantial gaps exist in the
evidence base. Caution and
investigation are warranted.

Noah, B., Keller, M. S., Mosadeghi,
S., Stein, L., Johl, $., Delshad, S., ...
& Spiegel, B. M. (2018). Impact of
remote patient monitoring on
clinical outcomes: an updated
meta-analysis of randomized
controlled trials. NPJ digital
medicine, 1(1), 1-12.

15. RPM Study Conclusions o

+ Successful interventions combined RPM
with several evidence-based
components, including:

+ personalized coaching or
+ group-based programs, or

“+ were grounded in validated behavior
change models.

16. Applying CTiBS TBH
Competencies

CONSIDER LOOK AT RATE YOUR
EACH OF THE 7 EACH DEPARTMENT ON
DOMAINS / OBJECTIVE EACH

PILLARS

17. How to Use the CTiBS TBH
mHealth Competency
Domain Article to Conduct
Your Telebehavioral
Competency Self-Assessment

18. TELEBEHAVIORAL HEALTH
Home

INSTITUTE

An Interprofessional Framework for Telebehavioral Health Competencies

4 By: Malone M. Mabou. PhD.

Correction to: An Interprofessional Framework for Telebehavioral Health Competencies

ors: Marlene M. Mahou. Kennet P Dede, Katherine M. Horn, Run Upschutz. Karen Wal & Donald M. Hit

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19. Download your free copy
here:

https://telehealth.org/blog/
an-interprofessional-
framework-for-
telebehavioral-health-
competencies/

20. amor

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Correction to: An Interprofessional Framework for Telebehavioral
Health Competencies

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23. ‘apps with a specific clinical goal in mind.
Understands the privacy limitations of apps
recommended and discusses with patient/client

VIA3 Educates clients/patients that TBH apps
should be evidence-based. Engages in discussion
about diary, data logging, symptom reporting and
other uses of apps.

VI.A.4 Identifies and is compliant with basic legal,
regulatory and ethical requirements for using text,
email and apps e.g., informed consent,
privacy/HIPAA compliance in the U.S., practice
over state/provincial lines.

'VI-A.2 Prioritizes selection of options for clinical
care, understands the privacy monitors
implementation, process and outcomes of it
Links the option with a specific purpose to
complement clinical care eg., integrating
information in an electronic health record versus
client/patient interaction. Helps dients/patients
avoid extraneous or duplicative apps, which may
create confusion or diffuse therapeutic goals.
Helps users reflect on important clinical issues
such as privacy related to who else has access to
the information e.g., family, other professionals,
pharmacists, insurance companies, and
technology repair shop.

VLA3 Utilizes evidence-based apps. Outlines an
evidence-based approach to app use that reflects
technical e.g., installation, trouble-shooting,
selecting features and safety concerns e.g.,
toggling off the option to send “bugs” to app
developer. Documents rationale related to
therapeutic goals.

VI.A4 Maintains legal, regulatory and ethical
standards i.e., maintains confidentiality by
ensuring privacy. Anticipates, prevents and
responds to potential problems related to using
apps.

VLA 2 Researches/evaluates the use of mobile
health technologies including apps by
clients/patients and professionals to build,
maintain and enhance therapeutic care. Teaches
professionals how to select and use peer-
reviewed and when possible, evidence-based
technologies both initially and longitudinally.

VI.A3 Researches and develops peer-reviewed
and when possible, evidence-based apps as well as
their evidence-based review criteria and app uses.
Identifies whether one or more apps used
concurrently is therapeutic for the individual
client/patient. Identifies client/patient factors that
indicate mobile technologies may not be advisable
or should be de-emphasized.

VI.A4 Develops peer-reviewed and when possible,
evidence-based quality improvement strategies to
adhere to and consider adaptation of legal,
regulatory and ethical standards related to use of
apps eg., privacy settings, who has access to
device.

24. VI.A.2 Prioritizes selection of options for clinical
care, understands the privacy monitors
implementation, process and outcomes of it.
Links the option with a specific purpose to
complement clinical care e.g., integrating
information in an electronic health record versus
client/patient interaction. Helps clients/patients

avoid extraneous or duplicative apps, which may
create confusion or diffuse therapeutic goals.
Helps users reflect on important clinical issues
such as privacy related to who else has access to
the information e.g., family, other professionals,
pharmacists, insurance companies, and
technology repair shop.

25. TBH COMPETENCIES -- CLINICAL
EVALUATION & CARE - Subdomain

1.A: Evaluation & Treatment

Assesses for client/patient
appropriateness for TBH services

Assesses and monitors client/patient
comfort with TBH

Applies/adapts in-person clinical
care requirements to TBH

26. 1. Assesses for client/patient

appropriateness for TBH services

How does your choice of technology fit into
the treatment plan?

Device? Bandwidth? Device? Software?
How did you choose the technology for this
person? Approved by your department? Is

your protocol empirically validated?
Internally approved?

What is your proposed workflow?
Documentation?

27. Assesses for client/patient

appropriateness for TBH services

Does patient need to download and
install the software? Know how?
Technical ability? Need family or friend?
Physical ability? Finger dexterity?
Cognitive ability? How will they
remember?

Do they understand how to use the

technology? Can you demonstrate in
session?

28. 2. Assesses and monitors

client/patient comfort with
TBH

What are the client's/patient's
questions / concerns?
Are they concerned about
their privacy being violated?
Do they think you are
recording the sessions?

Are they worried that
someone else will see their
data?

29. 3. Applies/adapts in-person clinical
care requirements to TBH

Once treatment has begun,
adapt/adjust in-person policies and
protocols to formulate and
spontaneously implement a TBH service
plan to meet evolving client/patient
needs

30. TBH COMPETENCIES -- CLINICAL
EVALUATION & CARE - Subdomain

1.A: Evaluation & Treatment

Implements and adapts a TBH service
plan with policies/procedures adjusted
accordingly

Monitors therapeutic engagement
related to each TBH modality
Establishes and maintains professional
boundaries

Provides training, supervision and/or
consultation to others (for Proficient
and Authority)

31. 4.

Implements and adapts a TBH service
plan with policies/procedures adjusted

accordingly

Was it helpful? If not, why not?

Evaluate clinical goals systematically
with respect to the use of technology,
and likelihood of positive/negative
outcomes (e.g. continue current
technology or emphasize another
instead)

32. 5,

Monitors therapeutic
engagement related to each TBH

modality

Monitor engagement by
tracking/commenting on
behaviors that are ambiguous
(e.g. innuendo, nuance,
colloquial expressions); use of
technology slang; and others
that may reflect discomfort

(Follow-up on sarcasm, snide
comments, jokes, etc.)

33. 6. Establishes and maintains

professional boundaries

Self-disclosures, frustrations with
technology as modeling, personal
space via video

Avoid emoticons, memes, LOLs

34. Conduct a formal intake — no
shortcuts

Intake Meet in-person or video when
possible, identify geographic
Process location, organizational culture,
S umma ry take full history, medications

and medical conditions, mental
status and stability, use of
substances stressors, treatment
history, support system, use of
other technology,
suicide/homicide intent

Identify & document diagnosis

35. Intake Process Summary

Decide if, then which technology is
appropriate / Assess technical
competence / ability to arrange
appropriate setting

Obtain names of all other key providers,
get appropriate releases

Verify contact information (address,
phone, email)

Develop emergency plan in writing

Explain & sign informed consent

36. De

CLINICAL EVALUATION
AND CARE
(TBH Domain 1)

Cultural Sensitivity & Diversity
(Subdomain 1.B)

37. CLINICAL EVALUATION AND CARE
DOMAIN, Cultural Competence &

Diversity (Subdomain !.B)

Telebehavioral Objectives

Assesses for cultural factors
influencing care

Ensures communication with a
reasonable language option
Creates a climate that encourages
reflection and discussion of cultural
issues in an ongoing manner

joral Health institute

38. Cultural Competence &
Telebehavioral Health

39. Cultural Competence &

Preferences for Technology

Client/Patient preferences take precedence

Screen for, differentiate between and synthesize
cultural factors that can impact relationship and
treatment that are technology-specific:

Look for preferences:

Some groupe refer traditional telephones
more than video conferencing for treatment,
such Faith-based African Americans, (Robert
Glueckauf, PhD)

Some groups prefer cell phones to computers
Suro Hispanic and African American
adults

elebehavioral Health insti

40. Bridging Language

Differences

Use English proficiency tests if needed to
determine verbal vs. reading comprehension (free
online)

Assesses client/patient preferences for a language
(e.g. English, Spanish, French) are adequate to
sustain treatment (e.g., strong will to use one
language when another may be more effective)

Explore how language differences can influence
the story/narrative and level of intimacy (respect
need for distance while attending to just the most
relevant issues at hand)

41. Bridging Language
Differences

Use translator when needed.
Explore how interpreter's
ethnicity, class, interpersonal
communication style and
interpreting may influence the
interaction with client /
patient with analyzing,
shaping of story/narrative;
short vs long interpretations,
differences in tone, idioms,
slang)

42. De

CLINICAL EVALUATION
AND CARE
(TBH Domain 1)

Documentation and
Administrative Procedures
(Subdomain 1.C)

43. Informed
Consent

+ Legal
Issue

° Ethical
Issue

44. Informed Consent

Discussion VS Document

Represents a "meeting of the
minds”

Information is influenced by many
factors, including:

Client/Patient's capacity for
absorbing information

Time Limits
Clinician's schedule

45. Forms - Progress Note

Document, document,
document

Opening protocol verification
of identity, location, and
privacy (at a minimum)
Clinical protocols followed
(evidence-based research
articles in your specialty niche
or population served)

Time in, time out

46. Telehealth Addendum

Client Name Date of Beth Sesion Date

Creephone Drmai

Um © Dapp Gomer

Typala) of tacnnainay tor
Diserhore Ol

ich Clan! Possestas Adequate Sits
o Trop Damen

Dieermare Dira Den ven
en Chon Ques Dann Bomar

Type of Technology Chosen for Season:
Dinepnars Dimar Oren O

p Dome

Dapp Domer

pee its a ts ofthe a us lic Pic ol e Ei?
ves Duo

Ovas Dita

as are the Banetes and Rallonale far tha Use al Telahsaith In the Treatment of this Client?

Has Continuity of Core Been Discussed withthe Client? Ces Ohio
pi M nat oon
Oreakis}intrlewef auste cannerton éreskis) nur loss arian corn
Drivacyteves Dsscuntyissuns Quser istes te > Need ler Inurıng xn
Dane of the Anne + Not Appicable
A of Probiew
Prato Duran at Prat
Time of Protea Duration of Problem

Date Signature

TBHI Sample
of Telehealth
Informed

Consent
Addendum

47. Progress Note

Crem Name, Date of Bian

Session Date SanóSiop time crt
Dingaask Osama Die

Méedicaions OMure ONecrange Divecicator neeased OMedesten Reduced
Diet emirates Wedcaton Liven or Medication es sd Duo
In

Communication, Other Providers Sines Last Sassion DNA ORO! cn Fle

Lal EC

lent Rafat

Riscfactors Dione Osuicoal ideation Osuicka pan Deonickialiceaton

Qhomesds! tan Csusstances Cloomestis valence Assess

esr
un Taken ot Rsk Fac

Mood / Anacı as Described Batwessn Seran:

Dexa Drítacio Dhiaving Toute
Drotiquec Dlzote ing loss,

Dia y Wanhessrem
Orne

Drareasecı À or limas ta Assess
Distressed
Sommer

Mod / Altect n Session

Dray Desparsve Demacie una
Damon Orstiauso Disote

Drops Dra Ditsne

aight Orisraies Diag

Dcersmeres Day Dis

Dbarnset Dhapatıı cn Daran nr tinnhie in Ass
Oberes Thapaiess Does

Cammert

interpersonal Dirteractve Dcunrdso Dhosie Canawr Otter.

Quantitative Measures: ONore ken Ceri Du Dean

Gument symptams Drames Oberen Dew Déucuminy Oho ch:

TBHI Sample
of Progress

Note

48. Administrative
Guidelines

2

+ Oversight

Agencies

+ Joint Commission

(JCAHO)

+ Council on

Accreditation
(COA)

+ Commission on

Accreditation of
Rehabilitation
Facilities (CARF)

results

49. Administrative
Guidelines

+ Oversight Agencies

+ Utilization Review
Accreditation
Commission (URAC)

+ American National
Standards Institute
(ANSI)

+ Healthcare
Information and
Management Systems
Society (HIMSS)

+ HIPAA (Business
Associate Agreement)

results

50. Virtual Environment
& Telepresence

(TBH Domain 2)

51. Telepresence

Telepresence refers to using a set
of technologies which allow a
person to feel as if they were
present, to give the appearance
of being present, or to have an
effect, via telerobotics, at a
place other than their true
location.

52. Clinical & Technical Issues

Minimize Distractions
Audio Clarity & Continuity
Equipment Quality
Type of Microphone
Headsets
Free Standing
Microphone Placement
Type of Speaker
Speaker Location

53. + Lighting: Shadows, Natural and/or Artificial Lighting,
Illuminate Your Face

‘Copyright 2020 Telebehavioral Health institute, Inc. Al rights
reserved.

54. Consider the
Client's/Patient's
Setting/Environment

55. Practical/Technical:

Audio

Audio Problems

Reverberation
Patient or won't ——————
necessarily tell you

Sound Absorbers:
Carpeting
Plush couches
Drapes
Pillows

Enlist aid of Your Office Mates ss

56. Technology Choices
(TBH Domain 3)

57. Technology
Options

Consider options
and your own
preferences:

Telephone
Video
Email

Text

Apps

58. Internet-based
Companies
Claiming HIPAA
Compliance

WWW.TELEHEALTH.ORG
/DIRECTORY

59. Legal & Regulatory
Issues
(TBH Domain 4)

60. All
Existing
Legal
and
Ethical
Rules
Apply

61. HIPAA, HITECH
& Your
State Law.

62. HIPAA imposes
requirements on us as
“covered entities” --
not on technology

63. Duty to Report /
Duty to Warn

»
\
\
(v) Failing to comply with the |
child abuse reporting |
requirements of Section 11166 |
of the Penal Code.
(w) Failing to comply with the
elder and adult dependent
abuse reporting requirements
of Section 15630 of the
Welfare and Institutions Code.
CA Business and Professions
Code Sections 4989.54 (cont.)

64. Inter-jurisdictional
Practice

+ Licensing Boards that may
assert jurisdiction:

* The one in the
professional's state(s) of
licensure

+ The one in the
client/patient's state of
location at the time of
contact

+ Safest Practice:

*» Provide services only
where licensed

«+ Require patient to attest

to his or her location at
every contact

Cop

oral Health institute, Inc. Alrighis reserved.

65. Center for
Health Policy

= a About CCHP CHP Projects WatisTelehealth? — Teleheatih Poly Resources
. di i i acy ans
at! Pay State Laws and Reimbursement Policies
Mare The Center for Connected Health Policy helps you stay informed about telehealth-
Medien related laws, regulations, and Medicaid programs. We cover current and pending laws,
Legal Barriers legislation regulations for the U.S,, all fifty states and the District of Columbia.

Heath inma Technology

D) Al Current Laws and Policies D Al Pond
he Federal Trade Commission and a Va
Probe Licensure Boards ire

Castornis Poly
pda!

Telehealth Advancement Act

Q, Law and Policies by State:

www.cchpca.org

66. Whatis Telehealth? That Poly Resources

B reteheotth Policy
_— Laws and Reimbursement Policies: Advanced Search

ne DA fu ro

media Program kr Vides Rene

Copyright 2020 Telet Al rights reserved.

67. Ethics
(TBH Domain 5)

68. What does

your
national
professional

association
have to say
about your
digital
work?

Most groups have issued
statements for the last 15-
20 years with regular
updates

Take an hour to read
carefully and make a to-
do list

Ask questions / get
training / not intuitive

69. mHealth
i (TBH Domain 6)
E

70. Choosing
mHealth
Technology

How do you choose the RPM
device or app?

How does the mHealth
technology help you meet
treatment goals?

Is your patient able to use it?

Patient education, install it
with them, teach safety
and privacy settings,
explain how to keep data
private at home and
around others

Monitor use / satisfaction /
outcomes

71. Document
adherence to:

Working Legal requirements
with Informed consent? Static
vs dynamic?
mHealth Transmitting over state
Technology lines? Are you

appropriately licensed?
Ethical requirements
Hospital requirements
Other requirements

(Joint Commission, CARF,
etc.)

72. Practice
Development
(TBH Domain 7)

73. Have you
checked?

What is the public being
told:

About you?

Your organization?
Is it accurate?

Is it up-to-date?
What can prospective
and current patients see

about you on social
media?
Have you checked
your colleague's social
media?
Does any of it need to
be reconsidered?

74. We're here to help!

Marlene M.
Maheu, PhD [email protected]

Executive Director 619-255-2788