A Guide to Providing Telehealth During the COVID-19 Crisis

ACEs in Pediatrics community manager's note: Although this post by Daren Casagrande is geared toward mental health providers, I thought it had material that could be useful to a wider swath of health care providers. Please comment below if you have any questions or suggestions. --- Laurie Udesky

Many of us in the mental health field are being thrust into unfamiliar territory as clinicians in the midst of the COVID-19 response. We either risk personal health (and the health of our clients) by seeing people in person, or needing to utilize technologies that we may be unfamiliar with. Further, those technologies have fluid legal/ethical standards (and is even more fluid at present to accommodate the pandemic), and which require different skill sets that in-person therapy. I am fortunate (in some ways) to have do more than my fair share of video therapy (though I would call myself an expert by no means), and would love to offer a guide of my experience for those who have yet to wade into the telehealth waters. Keep in mind, the present legal/ethical standards are currently in flux and this is as accurate as I understand things to be at the time of this posting.

Let's get to business!

What software and hardware are appropriate for our use case?

There are a ton of options here (this is not comprehensive and I'm not being paid by any of them, in full disclosure I use SimplePractice and have used Google Meet). 

PLEASE NOTE: Standard Skype, FaceTime, Google Hangouts, Google Voice, etc are NOT HIPAA-compliant. However, the Office of Civil Rights division of Human and Health Services (the Feds) have said they are temporarily suspending imposing fines and penalties for non-compliance of their telehealth standards when it is done in good faith. Nevertheless, where able, I would recommend TRYING to comply, so here are some options:

Some free ones are:

• Doxy.me
• VSee (Though I've read/heard they've had to suspend their free offering due to COVID-19 creating excessive demand). They are $199/month for the paid version.

Some low cost options:

• Google Meet NOTE: This is only HIPAA-compliant if you pay Google's G-Suite services (about $6/month/user, it is the business version of their email/document storage products, etc) AND you sign a Business Associate Agreement (BAA) with them (which you can do HERE, or read instructions HERE). Google has offered Meet to all customers (free or business) for free until July 1, however, to sign the BAA to make it HIPAA-compliant you still need the paid version. Use is simple, go to google calendar, make an appointment, click the dropdown to add conferencing, add client email to guest list, save)
• Spruce Health is $24/month for one provider and $49/month/provider for a group (it also includes HIPAA-compliant VoIP calls, text messaging, etc)
• TheraLink is about $30/month and will provide you the telehealth services without paying for a whole EHR.
• Many EHR/EMR softwares are relatively inexpensive and will add on telehealth functions for a nominal fee. Some of the popular ones are TheraNest and SimplePractice.

More Expensive:

• HIPAA-compiant versions of Zoom ($200/month for medical version) and Skype (Skype=Microsoft) will sign a BAA if you subscribe to their Office 365 for Business products.

What does research have to say (if anything) about teletherapy?

Overall, for how few years teletherapy has been mainstream, it is moderately well researched (which isn't to say there's a lot yet, just that there is more than might be expected). The research so far, seems to support that live video therapy with BOTH audio and video components appears to be similarly effective to in-person therapy. Here is the summary of the research articles I've compiled so far on the topic if you want source documents for that statement. There can be unique benefits to teletherapy, such as the client getting to do counseling "in-vivo" and in the spaces where they feel most comfortable and therefore they may be more comfortable sharing. On the other hand, there is plenty of opportunity for confidentiality issues as well as therapeutic issues depending on one's theoretical positioning.

What are the legal standards?

Here is an efficient site for keeping up with the law temporary exceptions or changes being made due to COVID-19. Many temporary exceptions are being made, with more being laid out by the day it seems. So check it often!

In general, with teletherapy it is complex because it varies by state and license type, so here are resources legal standards:

• CA BBS page discussing telehealth laws (read the drop down), or the laws are here and here. 
• CA Board of Psychology has embedded their standards in the 2019 updated laws and reg guide. See pages 74, 101, and 330 (or use the index, or the search feature of your PDF viewer using the term "telehealth")
• Interstate practice is legal if the client your seeing is physically located in the state for which you are licensed (e.g. if you're licensed in CA you can be living in GA and see clients in CA, but you cannot see clients in GA). The state oversees the protection of consumers, and so you must be licensed in the state where the consumer is receiving service. NOTE: According to an American Teletherapy Association publication the following states have eliminated licensure requirements for out-of-state providers due to localized shortage (meaning you could practice across state lines there temporarily): Texas, Arizona, Tennessee, North Carolina, Mississippi, and Iowa.  
• However, there are also "vacation" exemptions in most states which vary by which state the client is in and by your license type.
• The most comprehensive guide for inter-state practice I've seen is now in an app  from the law firm Epstein, Becker, and Green who specialize on the topic. Here is their legal overview and their free interstate practice app for Android and Apple. NOTE: if the state they are in does not have favorable laws, you can also call their governing body and request an exception. Get it in writing. Many states are temporarily waiving the licensing requirements for inter-state practice at the moment to accommodate the crisis.
• Practicing internationally is poorly regulated and many people do it, but all of the legal guidance I have read states that the protocol would be to contact the relevant governing body for the country where the client is located and attempt to contact them for written approval

What are the legal standards?

Again, varies by license type, here are some best practice/ethical guidelines:

• Current APA Guidelines are HERE
• CAMFT Guidelines HERE. Unique COVID-19 telehealth guidelines HERE
• NASW Guidelines HERE
• A quick and dirty summary of consensus items:
  • Informed consent siting risks (hacking, poorer emergency response options, ability of others to overhear on their end, potential for sessions to be interrupted or prevented by power or internet outages, etc)
  • Verify identity each session via DL, or clear ability to see their face (no backlighting, or camera off, etc)
  • Develop a safety and emergency response plan using resources local to them from the very first session)
  • Develop standards for where they can be when engaging in session (e.g. not at the library, starbucks, etc)
  • Lower allowable threshold of instability before making a referral to in-person (e.g. if they start deteriorating, you refer sooner than you might if they were in person)
  • Come up with a backup plan if internet or computers fail (will you call them? will they assume that you'll have to resume next week? transition to a less secure platform? etc)
  • You still need to function in your professional capacity even if you're in a less formal setting

Do insurance companies allow it and do I need to do anything differently regarding billing?

As a general rule, yes! Often the rules are:

• You need to sign an additional agreement
• You need to enter a different modifier code (95, or GT for MedicAid) on your billing form (sometimes you need a different location code)
• Sessions must have live video AND audio (no phone sessions allowed)
  • Phone sessions are temporarily being allowed by the federal government, but your insurance company may still require this (ask them!)

The best policy is to check with each insurance company you panel with, but the general rules above apply. Typically MediCare has not allowed this, but in unusual times the following has been changed:

• Medicare is temporarily allowing providers to bill for telehealth sessions

What are the best practices for conducting sessions online?

• Make sure you know your software and test out your software and equipment beforehand. Test it on a family, friend, or colleague.
• Soft lighting towards your face (no backlighting, or windows facing the camera), put some lamps with shades on both sides of your desk and use lower Kelvin light bulbs if you can
• Dress professionally, but avoid high-contrast patterns or busy patterns which are jarring to look at on screen
• Avoid busy/complex backdrops which can be stressful or unprofessional (consider doing it from your office so the client feels like things are as "normal" as possible)
• Avoid having fans or other ambient noise that can make it hard to hear you
• Unless you're home alone, or have a white noise outside the room you're in, plan to use headphones to ensure your client's privacy
• Put your cam or laptop at eye level +/- 10 degrees, don't make clients look at your forehead or up your nose
• Try to look at the camera when you're talking so the ct experiences you look at them instead of at your computer screen
• Recognize that you are getting less body language and other visual data from your clients, consider asking more explicit questions about their state of mind/being rather than assuming you're visually capturing the information as normal (or use psychometrics)
• Cameras dampen people's emotional state, so focus on adding extra energy to your communications to have the same effect as normal, also realize it is dampening your client's presentation
• If your client looks up as if someone came in, be quiet and wait. If they have headphones ask yes or no questions like: Do you need to hang up? Is everything safe? Do I need to send 911?

Some reflections and resources for these times.

Clearly, many clients may have to be home with unsafe people or in insecure households during COVID-19. Their distress levels may be high as it is due to COVID-19 and it's response, but further they may have limited time or space to do session if any. Be flexible in this time, suggest or offer them to do some therapy on the phone or on headphones at the park or on a walk, or in the backyard. Or, give them some ideas on how to frame their conversation with you to loved ones (I'm making a business call, or I'm calling a friend, etc).

Obviously, there is also a lot of cortisol and other stress hormones floating around many people's brains right now. Let's help them tap into their parasympathetic nervous system by bringing them back to the present moment either via body-focused mindfulness or environment-focused mindfulness. I've been doing a lot of DBT with people by using Observe-Describe-Participate, suggesting guided meditation readings, and having them spend some time doing Morning Pages. Another useful resource if they like structured activities is UC Berkeley's Great Good in Action (GGIA) lab which makes PDF handouts of different evidence-based practices that support different mental health and wellness needs. You can also refer client's to my office's Facebook Page. I made one to facilitate pushing out self-help resources for clients while they are at home. 

 In fact, you might just want to use the GGIA for yourself as well! Also, Headspace (a guided meditation and mindfulness app) is giving a free subscription to healthcare providers through the end of 2020 (you just need an NPI number) in response to COVID-19.

Stay safe, in good spirits, and spreading some good will!

Feel free to comment if there are great resources you've found that could/should be added above or if there are more current updates you've seen, or if you just have questions! It's a team sport to stay on top of this stuff! Cheers.