Transcript Skype Update 2012: The Good, The Bad & the Ugly TeleMental

Best Practices: Distance
Counseling, Training and
Supervision
Marlene M. Maheu, Ph.D.
[email protected]
Executive Director
TeleMental Health Institute
619-255-2788
Disclaimer
• I am an MFT and clinical psychologist, not an attorney,
physician or Information Technology specialist. My goal is
educational only.
• The information I present is my best attempt to bring you
timely and relevant information in a rapidly evolving area. I
therefore make no warranty, guarantee, or representation as
to the accuracy or sufficiency of the information contained in
my training.
• My goal is to outline the issues and alert you to what's
happening, including legal, ethical and other risk management
issues. Seek specific advice related to your circumstance
from your qualified authorities.
AASCB Slides & References
http://telehealth.org/aascb
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What's Happening
with Health Care
Reform &
Behavioral or
Mental Health?
We are retooling
Health Care Reform Goals
Changes for Healthcare
1. Lower costs
2. Improved outcomes
3. Increase access for more
citizens who need health
care
Changes for Practitioners
1. Documentation requirements
2. Organize documentation
through Electronic Health
Records (EHRs)
1.
2.
Standardize information for
outcomes analysis and
treatment refinement
BIG DATA (informatics)
3. Work in groups
4. Paid for outcomes
Affordable Care Act Repercussions for
Counselor Preparation & Practice
• Much current fund for private agencies will be shifted to the
expanding Medicaid programs to support Health Care Reform
• Referrals to for ACA patients will come from primary care physician’s
offices to large groups of practitioners
– Integrated care
– Patient-centered homes – 85% of care delivered to the home
• Small group and private practices likely to be squeezed out
– Large groups can contain costs across practitioners and clients
• Success of private pay model will decrease in long term
– Everyone will have insurance / most people will want to use that
insurance
• Practitioners will be held accountable for outcomes and paid
accordingly
Affordable Care Act Repercussions for
Counselor Preparation & Practice
• Shorter sessions / more clients
• Reimbursement tied to outcomes, not session length
• More and more specific documentation
– Documentation will require proof of interventions being tied to the
evidence-base (“treat-to-target”)
• Increased reliance on master’s level practitioners
• Increased reliance on technology
– Apps and other self help tools will proliferate
– Required use of electronic health records (to measure outcomes)
• Decreased reimbursement for free-flowing sessions and note-taking
• Increased need for vision / graduate education and professional
education
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Basic Best Practices:
Informed Consent,
Privacy, Confidentiality,
Boundaries of
Competence
Cited Association Standards &
Guidelines
 American Counseling Association (ACA). ACA Code of Ethics
 American Psychological Association (APA). (2013).
Guidelines for the Practice of Telepsychology
 American Telemedicine Association (ATA). (2013). Practice
Guidelines For Video-Based Online Mental Health Services.
• National Board For Certified Counselors. (NBCC).
Policy Regarding The Provision Of Distance Professional Services
For many more relevant association standards and other statements with direct links, go to:
http://telehealth.org/ethical-statements/
ACA Code of Ethics
A.12.3. Laws and Statutes
• Counselors ensure that the use of technology
does not violate the laws of any local, state,
national or international entity and observe all
relevant statutes.
Privacy & Confidentiality
• Privacy: client’s right to
protect their own
information
• Confidentiality: our legal
and ethical duty to protect
the client’s right to privacy
• HIPAA – Privacy is one of 3
“rules”. Privacy has to do
with any digital information
that can be used to identify
an individual, regardless of
source.
Boundaries of Competence
• ACA Code of Ethics (2005)
• A.1.c. Counselors and
their clients work jointly
in devising integrated
counseling plans that
offer reasonable
promise of success and
are consistent with
abilities and
circumstances of clients.
Boundaries of Clinical Competence
Racial, Linguistic, Gender, Religious & Cultural Diversity
Copyright 2014 TeleMental Health Institute, Inc. All rights reserved.
ACES Technical Competencies
• Technical Competencies
For Counselor
Education:
Recommended
Guidelines For Program
Development (2007)
• http://files.acesonline.n
et/doc/2007_aces_tech
nology_competencies.p
df
The Evidence Base
Benefits of Telehealth
•
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Increased client/patient satisfaction
Decreased travel time
Decreased travel, child & elder-care costs
Increased access to underserved populations
Improved accessibility to specialists
Reduced emergency care costs
Faster decision-making time
Increased productivity / decreased lost wages
Improved operational efficiency
Efficacy is on par with in-person care for many groups
Decreased hospital utilization
Recent Supporting Research
Backhaus and colleagues (May, 2012) reported in their abstract of a
meta-analysis that:
• 821 potential articles were identified, and 65 were selected for
inclusion.
• The results indicate that VCP is feasible, has been used in a variety of
therapeutic formats and with diverse populations, is generally
associated with good user satisfaction, and is found to have similar
clinical outcomes to traditional face-to-face psychotherapy.
–
Videoconferencing psychotherapy: A systematic review. Backhaus, Autumn; Agha, Zia; Maglione,
Melissa L.; Repp, Andrea; Ross, Bridgett; Zuest, Danielle; Rice-Thorp, Natalie M.; Lohr, James; Thorp,
Steven R. Psychological Services, Vol 9(2), May 2012, 111-131. doi: 10.1037/a0027924
Size of Evidence Base
• List of 1000+
searchable distance
counseling references:
www.telehealth.org/bibliography
• More than 2500
references exist, not
including those related to
email
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Models of Success
to Illustrate the
“Evidence Base”
Schools
Children’s
Hospitals
Specialty Schools
& Services
• Special Needs
• Autism
• Residential Treatment
Centers
– Drug & Alcohol
– Other
Employers
Rural Hospitals
Rural Hospitals
Military
Veteran’s
Migration &
Model
Administration
Correctiona
Facilities
Nursing Homes
Home Health
The Migration Model
• Start with known clients
• Assess their
need/willingness to use
technology
• Discuss compensation
• Slowly migrate online
• Assess effectiveness at
regular intervals
• Document carefully
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Professional
Training and
Supervision
Professional Training
• Technical Competencies
– Association for Counselor
Education and Supervision
(ACES)
• Clinical Competencies
– Department of Defense
(DoD)
– Ohio Psychology Board
– Professional Associations
• Society for Technology &
Behavioral Health
– TeleMental Health Institute
Supervision
• Videotaped sessions offered
by trainee for comment
– Both counselor/client recorded
• Supervisor and supervisee
may review sessions together
• “Mock” sessions
• Peer supervision groups
• Hybrid Models that include
online, text-based discussion
• Educational Telesupervision
Supervision Informed Consent
• Adhere to all legal/ethical
requirements
• Use HIPAA-compliant
transmission and storage
services
• Refrain from using identifying
information on any transmitted
information
• Review software vendor terms
and conditions every 3 months
(or so) for changes
• Update software versions to
prevent vulnerabilities
Supervision Informed Consent
• Engage in full informed
consent process and sign
document to assure that they
understand:
– They are being recorded
– Supervisee will obtain
supervision
– Supervisor and other colleagues
see/hear/review
recordings/notes
– Have client sign a plain English
release form for supervisor and
all other involved parties
Training & Supervision References
http://telehealth.org/supervision
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Documentation
(Aided by Professional
Association Ethics
Codes & Guidelines)
See this AASCB session’s supplemental handout for the full document
imaged below -- or contact the TMH Institute at
www.support.telehealth.org
APA & ATA Guidelines, 2013
• Consider other
individual
characteristics (e.g. ,
medical status,
psychiatric stability,
physical/cognitive
disability, personal
preferences)
APA & ATA Guidelines, 2013
• Start sessions with an
opening protocol
• Provide and discuss
clear emergency plan
with written
instructions (e.g.,
suicide, homocide,
abuse, other)
American Telemedicine Association
Videoconferencing Guidelines – Emergencies (2009)
• Determine outside
emergency coverage
• Establish guidelines for
determining at what
point other staff and
resources should be
recruited to help
manage emergencies
• Be familiar with local
civil commitment
regulations and have
arrangements where
possible to work with
local staff to
initiate/assist with civil
commitments
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Legal Issues
Inter-jurisdictional
Practice
Licensing Boards that may
assert jurisdiction:
• The one in your state(s)
of licensure
• The one in the
client/patient’s state of
location at time of call
• Both
Safest Practice:
• Provide services only
where licensed
• Require client/patient
to attest to his or her
location on every call
See AASCB 2014 Innovative
Interjurisdictional Practice
Models for More Information …
Informed
Consent
• Definitions differ
by state
• Represents a
“meeting of the
minds”
• Document only
serves as
important
evidence
See: AASCB 2014 Presentation
entitled, Distance Counseling
Informed Consent Essentials for
More Information …
Mandated Reporting
Behavioral professionals
are mandated reporters
• Duty to Report
– Child abuse
– Elder Abuse
– Spousal Abuse
• Duty to Warn
– Tarasoff
HIPAA, Business Associates and HITECH
•
•
•
•
HIPAA: Transactions, Privacy,
Security
All Business Associates in health
care must sign an agreement stating
their adherence to HIPAA standards
• Business Associate’s
Agreement (BAA)
Penalties imposed by
• HITECH ACT
Enforced by the Office for Civil
Rights (OCR)
Copyright 2012 TeleMental Health Institute, Inc. All rights reserved.
HIPAA and Email (Gmail, Hotmail,
YAHOO Mail, etc.)
• HIPAA’s Omnibus Rule was
announced in January, 2013
• The Omnibus Rule became
effective September, 2013
• Allows public email
exchanges with consumers
as long as they are fully
informed of security issues
in the informed consent
process.
• Safest to use secured email
systems and good
explanations of
risks/benefits
• Cloud storage and text
messaging still needs to be
HIPAA compliant
HIPAA requires an “audit trail.” Skype doesn‘t
provide audit trails – and isn’t obligated to ….
Where to find HIPAA Compliant Video
• www.telehealth.org/video
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mHealth (mobile
health)
50% of US citizens own a smart device
It is predicted that 85% of healthcare will be delivered to the home in
the next 5-7 years. Most of these services will be managed through
mobile devices
Copyright 2014 TeleMental Health Institute, Inc. All rights reserved.
CACREP: Professional Identity
1. Professional
Orientation And
Ethical Practice
2. Social and Cultural
Diversity
3. Human Growth and
Development
4. Career Development
5. Helping Relationships
6. Group Work
7. Assessment
8. Research and Program
Evaluation
9. Recommended:
Distance Counselor
Preparation
Elements of Counselor Preparation
1. Training & Certification
2. Credentialing –
appropriate training,
licensing, insurance…
3. Informed Consent
4. Clinical protocols
evidence base
5. Documentation
6. Reimbursement
Practices
7. Emergency planning and
implementation
TeleMental Health
Institute, Inc.
Send email to:
[email protected]
Visit website:
www.telehealth.org