- •The COVID-19 pandemic continues to highlight the immense need for more behavioral health care services, particularly services embedded in the primary care setting whereby many patients present first and solely for their mental health needs.
- •Virtual care provides opportunities for prompt and improved access to behavioral health services.
- •Virtual behavioral health is helping to support reducing health care disparities, particularly among rural and at-risk populations.
- Panchal N.
- Kamal R.
- Cox C.
- et al.
State of Virtual Behavioral Health Before COVID-19
VA expands telehealth by allowing health care providers to treat patients across state lines.
- Centers for Medicare & Medicaid Services
CMS expands medicare telehealth coverage for mental health and addiction treatment services.
Best practice guide: telehealth for behavioral health care.
Efficacy of Virtual Mental Health Services
- Fernandez E.
- Woldgabreal Y.
- Day A.
- et al.
Behavioral Health Conditions Addressed in Primary Care
- •13.3% reported starting or increasing the use of substances33
- •40.9% reported at least one adverse mental or behavioral health condition33
- •30.9% reported symptoms of anxiety or depression33
- •26.3% reported trauma- and stressor-related symptoms related to the pandemic33
- •10.7% reported seriously considering suicide 30 days before completing the survey33
- •Aged 18 to 24 years: 25.5%
- •Hispanic respondents: 18.6%
- •Non-Hispanic black respondents: 15.1%
- •Self-reported unpaid caregivers for adults: 30.7%
- •Essential workers: 21.7%33,34
Key substance use and mental health indicators in the United States: results from the 2019 national survey on drug use and health.
- Substance Abuse and Mental Health Services Administration
Behavioral Health Home Monitoring Tools
- •Evidence-based measures sent and completed via the electronic health record For example, practitioners may send PHQ-9 forms to patients through an EHR to be completed before the session, which may allow the practitioner to understand the patient’s current symptoms, thus informing the focus of the telehealth meeting.
- •Patient-driven device applications (Goldberg and colleagues, 2022)
- ○There are a variety of free and paid apps that can help patients monitor:
- ▪Drug and alcohol use
- ▪Meditation sessions
- ▪Food intake/nutrition
- •Wearable fitness trackers
- ○Fitness tracker information can support the facilitation of treatment goals
Benefits of Virtual Behavioral Health
Benefits of telehealth for behavioral health at the system level
Benefits of telehealth for behavioral health at the provider level
Benefits of telehealth for behavioral health at the patient level
Barriers to Virtual Behavioral Health Care
Barriers to telehealth for behavioral health at the system level
- Warren J.C.
- Smalley B.K.
- Center for Connected Health Policy
- Lucia K.
- Blumberg L.J.
- Curran E.
Barriers to telehealth for behavioral health at the provider level
Ethical principles of psychologists and code of conduct.
Barriers to telehealth for behavioral health at the patient level
- Perrin A.
Best Practices for Virtual Behavioral Health Care
- •The reason for the visit may be a new or uncontrolled mental health issue
- •Screening and intake forms including social history documentation, the PHQ screening, or Edinburgh Postnatal Depression Scale, may identify a need for behavioral health care such as new depression or anxiety, a substance use disorder, or acute stressor
- •The discussion between the PCP and patient may reveal an acute mental health crisis or need for better control of chronic mental health conditions
- •Is having an acute psychotic episode
- •Is actively suicidal or homicidal
- •Does not feel comfortable with virtual communication
- •Does not have access to broadband services
- •Has a disability limiting virtual health capability
- •Has a language barrier, and no translator is available
- •Does not have access to a confidential space
- •Is a victim of abuse with the potential for the abuser to be present
- •Are responsible for caretaking for young children or elderly65
- •May be immunocompromised
- •Struggle with lack of transportation
- •Have busy schedules and cannot afford to take time to travel to the clinic, park, and meet with a psychologist for a full session
- •Struggle with agoraphobia or other behavioral health concerns that make travel difficult
- •Struggle with a disability or other physical health concerns that make travel difficult
- •HIPAA-compliant technology
- •Process for virtual warm hand-offs (secure chat, phone, and so forth)
- •Handling unsafe situations such as suicidal patients
- •Building a team of therapists to provide access to the care needed
Guidelines for the practice of telepsychology.
|Guideline||Rationale||Specific Example(s) of Application|
|(1) Competence of the Psychologist||As telepsychology is an emerging area, psychologists must continuously assess their own competency and risk management practices.||Psychologists should assess and develop their technical competence in addition to their regular professional practice competence.|
Be familiar with local emergency services and prepare a written plan and instructions for patients in case of risk.
|(2) Standards of Care in the Delivery of Telepsychology Services||The same ethical and professional standards of care for in-person services must be upheld for telepsychology services. Assessment of the appropriateness of telepsychology technologies is encouraged.||Conduct a risk-benefit analysis of telepsychology services with the consideration of patient’s unique characteristics and communicate those with the patient.|
Consider the efficacy, privacy, and safety of the chosen telepsychology intervention and technology/platform.
|(3) Informed Consent||Obtain informed consent by including a thorough description of telepsychology services, policies, and procedures. Also consider implementing additional security measures and inform patients about them.||Obtain and document written informed consent that is specific to the type of services provided.|
Include boundaries and procedures in the use of technologies.
Include billing documentation and fees as part of informed consent as it pertains to specific telepsychology services (eg, video chat, texting fees, and so forth).
|(4) Confidentiality||Psychologists must familiarize themselves with risks to confidentiality unique to telepsychology and consult technology experts when needed. Further, psychologists must be thoughtful about boundary issues that may arise from participation in social networking sites.||Consider the risks and benefits of searching patients on the Internet before and during services.|
Set and maintain appropriate boundaries.
Understand the risks to privacy and confidentiality when using electronic communication.
|(5) Security and Transmission of Data and Information||Psychologists must be mindful of security threats (eg, hackers, theft, viruses, and so forth) and take steps to protect themselves and patients against them.||Conduct an analysis of security risk - and consult experts when necessary—to ensure data are accessible only by authorized entities and/or individuals.|
When documenting, specify the types of telecommunications used.
|(6) Disposal of Data and Information and Technologies||Psychologists must ensure the secure destruction of patient information, particularly electronic data and information and the technologies involved in maintaining that data.||Understand means of storage and disposal of patient data specific to telepsychology technologies (eg, videoconferencing file storage).|
Document the procedures followed for both storage, transmission, and disposal of data.
|(7) Testing and Assessment||Psychologists must consider the suitability of assessments created for in-person use when applying them in telepsychology services. Further, they should maintain the integrity of the original assessment as much as possible.||Maintain the integrity of the original assessment as much as possible. Make and document modifications to testing when needed.|
Consider all types of possible distractions during assessment (eg, smell, sound, and so forth), and interpret assessment results accordingly.
Be aware of special considerations when working with diverse populations (eg, age, physical/sensory impairment, and so forth), and enlist an on-site proctor to facilitate the assessment if needed.
|(8) Interjurisdictional Practice||Psychologists must inform themselves of laws and regulations that govern the provision of telepsychology as described by their organizational system, state, province, territory, and country.||When practicing in jurisdictions without laws and regulations in place, search for statements and regulations in relevant governing bodies and nearby jurisdictions to guide telepsychology service delivery.|
Stay informed of the changes in laws, regulations, and the credentialing of telepsychology as this mode of delivery evolves.
Clinics care points
- •When considering if a behavioral health visit should occur via telehealth versus in-person, with a few notable exceptions, this can be driven largely by patient preference, as telehealth is as effective as in-person care in delivering high-quality behavioral health services.
- •When providing behavioral health care via telehealth, providers should consult the American Psychological Association and American Psychiatric Association standards of care to ensure they are providing ethical, quality care via this rapidly evolving mode of delivery.
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