We have seen significant changes in how behavioral health services are provided to patients. One of the most significant changes in recent years is delivering these services via telebehavioral health methods. Some of the reasons for utilizing telebehavioral health interventions include serving patients who live in areas where there are limited services, inability of patients to access services in person due to medical and/or behavioral health issues, among others. There are a variety of settings and roles where telebehavioral health may be seen.
You may be working with another behavioral health provider, a psychiatrist, or in a primary care setting where these services are being provided. Additionally, you may work in an integrated care or collaborative care model where there are services being provided across state lines via telebehavioral health. In fact, for those of you who are working with psychiatrists, they are ranked 2nd among medical providers who use these types of services (27.8%). Telebehavioral health is only expected to increase as demand exceeds providers, as technological advances continue to grow, as insurance companies expand their coverage, and as regulatory changes occur. There are some very important risk management issues for you to consider carefully before providing telebehavioral health services.
What is Telebehavioral Health?
Telebehavioral health includes providing behavioral health services via telecommunications technology, including but not limited to video or mobile device. In addition to services being provided via computer, we are also seeing the growth of applications that are being used to provide these services. Additionally, these services are being used to provide in- and out-of-state consultation between providers. While providing telebehavioral health is similar in some ways to providing in-person therapeutic services, there are also some very unique situations which require careful thought and processes. If engaging in this type of practice, here are a few important tips to keep in mind.
Standard of Care
Even though you may be using telebehavioral health methods, the same standard of care applies as if the patient is in your office. It is your responsibility to be aware of the rules and resources (e.g., emergency services) in the area where the patient is and to ensure that you are in compliance. While the standard of care is usually considered to be where the patient is located, the best risk management strategy is for you as the provider to ensure that the standard of care is also met in your location. This is especially important if the patient is located in a different state than where the provider is located.
Rules and Regulations
Know what the rules are in your state and in the state in which the patient is located when you are delivering services regarding:
- Civil commitment
- Duty to Warn/Protect
- Reporting obligations for suspected abuse of children, adults, disabled persons, etc. Each state has its own set of laws/regulations and standards for reporting
- In-state and interjurisdictional practice regulations
- It is important that your office policies comply with state and federal rules. Also, consider reviewing your profession’s website to determine if there are any guidelines. You can also call your board of registration to ask questions.
Privacy and Security
- State and federal regulations (HIPAA) need to be adhered to. Not all systems (e.g., computer, VOIP, telephones) meet the privacy and security standards required by HIPAA, and it is essential you use one that does. Also, be aware of others who may be in the room and hear the session. You need to protect patients’ privacy in the same way as if they were in your office. Network and software security must be in place to maintain patient confidentiality. Your practice should have protocols to guard against inadvertent disclosure.
Whether you are a social worker, psychologist, mental health counselor or other professional in another area of practice, it is important that you are aware of your profession’s guidance on the topic. It is important to review ethical, practice and other guidelines and resource documents. In addition, it is important to remember that your professions’ overall ethics codes still govern your work when you are providing telebehavioral health services, so you must still practice in compliance with those codes.
You must have the ability to practice within the state the patient is located. Know what the rules are in your patient’s state (if it is the same as you or in a different state). If you do not have a license to practice in that particular state, you may experience a board issue, and if there is a claim or a board complaint, you could potentially be denied insurance coverage if you are practicing in a state in which you are not licensed. In some states, it is possible to practice under a temporary practice provision, so be sure you are aware of the relevant laws in the state where your patient is located.
Not all patients are appropriate for telebehavioral health, and it is your responsibility to assess each patient individually. Keep in mind that a patient may be appropriate at one point in time but may have a worsening of symptoms which would make the use of telebehavorial health services inappropriate at another time. Again, know ahead of time how to access emergency services for the patient should an issue arise during a session and immediate help is needed. The creation of a written emergency plan with each patient seen through telebehavioral health services is a good way to address patient safety issues.
Prior to using this method, it is important to obtain informed consent in written form. Remember informed consent is an ongoing process, and the patient may revoke it at any point. Telebehavioral health services are distinct from in-person services, and you should have an informed consent form that addresses the unique aspects of these services in addition to your standard informed consent.
Documentation is vital. Ensure you document thoroughly and that your documentation meets the standard of care for your profession as well as any additional statutory or regulatory requirements. Some of the following items are important to document:
- Risks and benefits of telebehavioral health and document that it has been discussed with the patient
- Evaluation and assessment, including documentation of each session
- Security measures implemented
- Billing documentation. This may identify:
- the type of technology used
- the type of telebehavioral health services provided
- the fee structure for each telebehavioral health service including costs for services
- technological failures or interruptions
- Method, procedure for how data is disposed
- Significant changes
Your Patient is Located in Another Country or Another State
Your patient may be traveling for business or pleasure and want to have a session with you while he/she is away. There are many issues to consider including:
- Licensure- are you authorized to practice there and what are the rules? Inquire about temporary practice laws and determine eligibility in advance.
- Safety issues- know how to access emergency services
- Is this a permanent relocation or how long will the patient be in the other location?
Opportunity and Responsibility
Providing telebehavioral health services offers many opportunities for providers and patients, but it also brings a new set of responsibilities and requirements for technical and other competencies. Good risk management means being aware of those responsibilities and requirements to ensure protection of patients and providers.
The following resources are recommended for further information on telebehavioral health practice.
- American Psychological Association, Guidelines for the Practice of Telepsychology, (https://www.apa.org/pubs/journals/features/amp-a0035001.pdf) developed by the APA, ASPPB, and The Trust
- American Academy of Child and Adolescent Psychiatry. Practice Parameter for Telepsychiatry with Children and Adolescents: http://www.in-sight.net/articles/ Practice-Parameter-for-Telepsychiatry-with-Children-and-Adolescents-2008.pdf
- American Medical Association, Ethical Practice in Telemedicine, https://www.ama-assn.org/delivering-care/ethics/ethical-practice-telemedicine
- American Psychiatric Association, Telepsychiatry resource document, http://www.psych.org/Departments/HSF/UnderservedClearinghouse/ Linkeddocuments/telepsychiatry.aspx
- American Telemedicine Association, Practical Guidelines for Videoconferencing Based Telemental Health,http://www.ATA.org
- Campbell, L. F., Millán, F., & Martin, J. N. (Eds.). (2017). A Telepsychology Casebook: Using Technology Ethically and Effectively in Your Professional Practice. Washington, DC: American Psychological Association.
- Center for Telehealth and eHealth Law, http://www.ctel.org
- National Association of Social Workers Code of Ethics, https://www.socialworkers.org/About/Ethics/Code-of-Ethics/Code-of-Ethics-English, 1.07 (m) Privacy and Confidentiality among other subsections, 2017
- NASW, ASWB, CSWE, & CSWA Standards for Technology in Social Work Practice, https://www.socialworkers.org/includes/newIncludes/homepage/PRA-BRO-33617.TechStandards_FINAL_POSTING.pdf, 2017
- United States Department of Health and Human Services,http://www.hhs.gov/ocr/privacy
Author: Kristen Lambert, JD, MSW, LICSW, CPHRM, FASHRM, Healthcare Practice and Risk Management Innovation Officer