best practices for telehealth* telehealth ralston.pdfapp-based mental health application-based –...
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Best Practices for Telehealth*ALLURA L. RALSTON, M.A.DEPARTMENT OF PSYCHOLOGY, UNIVERSITY OF NEBRASKA-LINCOLN*Note: This webinar will not address recent OMH guidance on Telehealth. For OMH guidance on Telehealth during this time, please visit https://ctacny.org/covid-19-resources
March 23, 2020
Overview• Types of telehealth
• Dos and Don’ts of each type
• Common barriers and overcoming them
Poll Question
What are some concerns you have in using technology for telehealth?
1. I have no concerns2. Logistical use (I'm not tech savvy)3. Participant engagement 4. Confidentiality5. Other
Telemental Health• Phone conferencing (e.g.
by telephone or cell phone)
• Videoconferencing
• Text messaging
Phone Conferencing• Phone conferencing is the most simplistic form of telehealth – it just
requires both parties to have a landline or mobile phone
• Generally, phone conferencing is not the most ideal option as it makes it difficult for both the client and therapist to read social cues
• It can also be difficult to complete certain elements of treatment – such as exposure therapy
• However, while trying to establish a new norm phone conferencing can be a better alternative than not providing services at all
• Additionally, many insurance carriers now cover providing services by telephone which has not been true in the past
Phone Conferencing – Dos and Don’tsDo’s✓ Decide what phone number you’d like to provide clients✓ When working from home – find a quiet place you won’t be disturbed✓ Limit distractions (e.g. set phone to silent or do not disturb, turn off
computer, etc.)
Don’ts✓ Forget to set boundaries with clients if you provide them with your
personal cell phone number✓ Forget to be kind to yourself if it feels like conducting therapy by phone
does not feel the same as in-person
Video Conferencing• This is the best studied and most widely used technology for
disseminating mental health treatments
• Studies examining the use of video conferencing to provide treatment have shown similar reductions in anxiety, depression, and PTSD compared to in-person treatment
• There are few therapy techniques that cannot be completed via video conferencing
• In fact, our clinic ran a study examining whether treatment for social anxiety could be conducted according to a standardized protocol with limited modifications and found that treatment was executed the same way and with the same beneficial results
Programs for Telehealth via Video• There are numerous programs that can be used for telehealth – our
training clinic at UNL uses VSee
• Zoom is another popular option
• Both provide encrypted video services and messaging features which can be incorporated into therapy
• This link provides a nice overview about selecting a vendor and common vendors used to provide telehealth services:https://nosorh.org/wp-content/uploads/2016/11/NOSORH-Telehealth-Vendor-Fact-Sheet-FINAL.pdf
Video Conferencing – Dos and Don’tsDo’s✓ Make sure your audio and video work prior to session start time and make ✓ Be aware of your background (e.g. when working from home what's behind you?)✓ Have a back up plan if video is not working for you/your client✓ When working from home – find a quiet place you won’t be disturbed and
purchase headphones to maintain privacy (unless you have a soundproof room)✓ Limit distractions – close other programs, silence your phone, etc.
Don’ts✓ Forget to practice video conferencing if you are unfamiliar with this practice – look
at the camera if it is in your line of sight, otherwise look at the client on the screen ✓ Speak too quickly or for too long, if possible – sometime video/audio lags
App-Based Mental HealthApplication-based – “Apps”• Occur through mobile technologies
(e.g., phones or tablets)• Internet-based - app continuously uses
the internet to deliver its content• Native - the app is downloaded once
and needing further connection to the internet
Shown to be effective in reducing mental health symptoms
App-Based Mental Health• Using apps right now may be beneficial to meet clients needs if they
are unable to engage in weekly therapy due to various barriers (e.g. time, cost, lack of internet/data access, etc.)
• Apps are also a nice way to engage clients in aspects of treatment between sessions or after termination to keep skills sharp
• Apps generally have some of the lowest risk associated with them –though it is important for providers to research the apps they are suggesting but often the question is – what should I be looking for?
Do’s and Don’ts of App-Based Mental Health
Do’s◦ Look at security features, reviews, and research evidence✓ What are the security features of the app? Do the app creators have
access to the user's information? What information are they collecting✓ What do reviews from users say? Does the app have a lot of
bugs/issues? Does it seem useful?✓ Has any research been conducted using this app evaluating efficacy?
Don’ts◦ Don’t assume apps will work for everyone ✓ Providers should carefully consider which clients would benefit from using
apps and which clients require more “hands on” approaches
Examples of Apps for Mental Health• MoodTools is a CBT-based app primarily used for treating depression
• Anxiety Coach is a CBT-based app used for treating depression
• PTSD Coach created by the National PTSD Center
• There are a few websites that will provide an overview of various apps
including user ratings, research evidence, etc.
◦ https://adaa.org/finding-help/mobile-apps
◦ https://psyberguide.org/
◦ https://www.psycom.net/25-best-mental-health-apps
◦ https://www.mentalhealth.va.gov/communityproviders/clinic_tech.asp
Communicating with Clients• This may be one of the most challenging situations to navigate for
many providers• Some providers are comfortable texting or emailing with clients but
are not using appropriate protocols to ensure HIPAA compliance (e.g. using personal phones or email addresses with no protections in place)
• If you are using text or email to communicate with clients make sure the service, you are using is encrypted
• A good example of an email service is ProtonMail – this can be used to communicate with clients if you find yourself in a situation where phone calls are not easy to make (e.g. closure of clinics, no front desk staff, etc.)
Overall Do’s and Don’tsDo’s✓ Check your state guidelines about conducting teletherapy✓ Conduct informed consent ✓ Determine how terminations, interruption of service, and payment arrangements
will be handled✓ Find a way to securely store client information if you are working remotely✓ Ensure you have the proper set-up to conduct therapy in private
Don’ts✓ Use a non-HIPAA compliant platform✓ Use a public space to conduct therapy✓ Use an email service that is not encrypted to communicate about or to clients✓ Leave your video service running at all times by logging out rather than just
closing the window so clients can’t just “drop in”
Types of Technology and the Barriers they Address
● Telemental Health
● Technology Mediated Self-Help
● Technology Adjuncts to Care
Things to ConsiderEnsure clients have the means to engage in telehealth:
◦ Do they have a working cell phone or landline?◦ If they only have a cell phone: do they have unlimited minutes?◦ Do they have internet access either in their home (e.g. WIFI) or on a
smartphone?◦ If they are using a smartphone: do they have unlimited data? Can they
connect their phone to WIFI?◦ Are they comfortable with technology? If not, do you have a plan in place to
walk them through setting things up?◦ Does your client have a safe, quiet, and private place to engage in
therapy? Is it away from partners, roommates, children, etc.?◦ Are there topics that might be difficult to discuss with the client if someone
were to overhear? Can the client get access to headphones? ✓ This can be one of the trickiest things to navigate - and we’ll discuss ways to
manage this.
Engaging Clients in Telehealth• When discussing telehealth with clients it’s important to assess their
readiness and willingness to engage in distance therapy
• It’s also important to allay any fears they may have about security so knowing the basics about the technology you are using, and having a basic understanding of the security features is important
• Providing a detailed informed consent document can also give clients a resource to refer to if they are feeling uncertain
Engaging Clients in Telehealth• For those using apps, weekly check-ins (or more frequent if needed) can
be helpful in promoting engagement
• It is also helpful to explain to clients that using tele- or video conferencing can be a bit strange at first but that you will work with them to become comfortable
• Remember to look at the camera when speaking with clients (unless you are using a camera that’s way above you!) and make sure you test your video angle before you start! This promotes “eye contact” with the client.
• Check-in with your clients to assess whether they feel their needs are being met and if not, work with them to address barriers
Conclusions• Telehealth is a useful tool in increasing access to care
during a crisis and when care is not easily accessible for other reasons
• Providers should carefully consider which types of technologies they are using, how these technologies might be appropriate for some clients and not others, and ways to protect both the client and themselves
Helpful ResourcesInternational OCD Foundation. (n.d.). Teletherapy in the Time of COVID-19.https://iocdf.org/covid19/teletherapy-in-the-time-of-covid-19/
American Psychological Association. (n.d.). Pandemics. https://www.apa.org/practice/programs/dmhi/research-information/pandemics
McGrath, P., Wozney, L., Rathore, S.S., Notarianni, M., Schellenberg, M. (2018). Toolkit for e-Mental Health Implementation. Mental Health Commission of Canada. Ottawa, ONhttps://www.mentalhealthcommission.ca/sites/default/files/2018-09/E_Mental_Health_Implementation_Toolkit_2018_eng.pdf
NYS Office of Mental Health (OMH)*Note: This webinar will not address recent OMH guidance
on Telehealth.
For OMH guidance on Telehealth during this time, please visit https://ctacny.org/covid-19-resources
Upcoming CTAC OfferingsScreening for Trauma in a Trauma-Informed and Bias Reducing Way in Children’s Mental Health Services‣ Monday, March 30, 2020 | 12PM - 1PM
Visit www.ctacny.org to view past trainings, sign-up for updates and event announcements, and to access resources.
Please send questions to [email protected]