COVID-19 Telehealth Best Practices

Copyright1994-2020TelebehavioralHealthInstitute,LLCAllrightsreserved.
COVID-19 Telehealth
Best Practices
Marlene M. Maheu, PhD
Executive Director
Telebehavioral Health Institute &
Telehealth Institute
contact@telehealth.org
619-255-2788

This is your workshop
Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.
MAKE
COMMENT
S AND ASK
QUESTION
S, PLEASE
STAY ON
TOPIC
WE WILL
TURN THE
CHAT
ROOM OFF
IN
BETWEEN
DISCUSSIO
N PERIODS
THE
SYSTEM
MONITORS
YOUR
PARTICIPAT
ION
DURING
THOSE
PERIODS

Copyright 1994-2020 Telebehavioral Health Institute, LLC All rights
reserved.
How to
Access Your
TBHI
Training
Materials
Level ILevel I

Today’s Program
 Today’s program includes a quick COVID-19 overview
 Followed by a 3-hour clinical best practices interactive
session
 Sound will be muted to limit uncontrollable distractions
 Please interact at designated times
 LIVE CME or CE – not mandatory to keep camera on,
but please show yourself if you can

Today’s Schedule
Times: 2 – 6:30 PM Eastern
 A 15 min. break will be from 3:00-3:15
PM Eastern
 A 15 min. break will be from 5:00-5:15
PM Eastern
 Q&A – chat will be opened 15 before
end of program for you to ask
questions

Prevent Interruptions
Prevent Interruptions to
Optimize Your Learning
1. Mute your phone, turn off
texts and emails, lock your
door
2. Ask your family/friends to
stay away

C1994-2020TelebehavioralHealthInstitute,LLCAllrightsreserved.

Make a To-Do List – Not Same As
Post-Test Questions
Make a To-Do List to
Optimize Your Learning
1. Make a To-Do List
2. Rank order your to-dos by
priority
3. Consider meeting with like-
minded colleagues to discuss
your implementation plan

What’s the Evidence
Base for Telehealth &
Telebehavioral Health?

Evidence-Base
 Evidence base has been building for
telebehavioral health since 1959
 Many people have made many mistakes,
which you do not have to repeat
 The Telebehavioral Health Institute has
documented more than 4,500 published
journal articles and books related to
telebehavioral health alone
 See telehealth.org/bibliography

Evidence Based Care?
Key Studies,
Clinical
Reviews,
Consensus
Documents
01
Clinical
Judgment
02
Client/Patient
Preferences
and Values
03

Fundamentals of Telehealth
 The fundamentals of
responsible clinical practice do
not change with telehealth
delivery
 Good clinical practice remains
the same regardless of delivery
vehicle
 Adoption is changing

Fundamentals of Telehealth
 We are experiencing forced adoption
 Regardless of HOW you deliver
services, you are responsible through
your legal and ethical codes to
maintain the same quality of care as
in-person.
 Not the wild west at all…
 At TBHI we teach you HOW with over
90 hours of telehealth training

Group Therapy
Learning legal & ethical telehealth
is like learning how to conduct
group therapy
 Learn/master similar but
different skills
 Safe response sets/clinical
reflexes
 Be aware of impact of
interventions on entire group
 Identify /anticipate negative
repercussions

Group Therapy
 May need additional skill sets/
training depending on several
factors
 Purpose of group
 Size of group
 Age of members
 Your setting / support

Fundamentals of
Telehealth
Telehealth is similar.
 Many clinicians are untrained
 Trust the evidence-base, not
colleagues
 Keeping clients/patients safe
is primary

Telehealth
Ethical codes are always in full
effect, online or offline
Since 2009, TBHI has been
acutely aware of these
similarities/differences and
teaches:
 Legal and ethical compliance
 Safe, practical & evidence-
based protocols

With integrity, you have
nothing to fear, since you
have nothing to hide.
― Zig Ziglar

Focus on Competencies
 All ethical codes require competence in
our professional practices
 Competence in behavioral health is NOT
equivalent to competence as a
telebehavioral health professional
 Competencies have been published and
continue to be researched in
telebehavioral health

Coalition for
Technology in
Behavioral
Science (CTiBS)
Publication title:
An
Interprofessional
Framework for
Telebehavioral
Health
Competencies

Download your free copy of: An
Interprofessional Framework for
Telebehavioral Health Competencies
 Competencies are in the table at the back
of the article
 Click link in the middle of the page:
https://telehealth.org/blog/an-
interprofessional-framework-for-
telebehavioral-health-competencies/

How Do You
Demonstrate
Your
Telehealth
Competence?
 Education & Training
Documentation
 Graduate Courses
 Course Completion
Certificates
 Supervision
 Practice Documentation
 Informed Consent
 Intake Forms
 Progress Notes
 Termination notes
 Risk Assessments
 Referrals

How Do You
Demonstrate
Your
Competence in
Healthcare
Practice?
 Documentation (cont.)
 Informed consent
Regular, in-person
informed consent
Statement that service
was provided via
telehealth, including the
type of telehealth being
utilized and that
client/patient
agreed/understands risks
and benefits
Safety plan w/ emergency
contacts

How Do You
Demonstrate
Competence in
Healthcare
Practice?
 Documentation (cont.)
 Progress Notes
The potential use of a
non-HIPPA compliant
technology should be
mentioned (PIPEDA in
Canada)
Practicing over state
lines without an
appropriate license 
“beneficence over
malfeasance”

How Do You
Demonstrate
Competence in
Healthcare
Practice?
 Documentation
 Progress Notes (cont.)
The location of the patient
and provider
The roles of people
participating if not
otherwise clearly stated
Documentation to support
appropriate
reimbursement coding

Federally
Qualified Health
Clinics
(FQHCs), Rural
Health Clinic
(RHCs)
Certified
Community
Behavioral
Health Clinics
(CCBHCs)

Clinical Assessment
and Care
(TBH Domain I)
C 1994-2020 Telebehavioral Health Institute, LLC All rights reserved.

Practicing
telehealth is
not intuitive
Naively
jumping into
telehealth can
lead to “Zoom
Fatigue”
Lack of knowledge,
attitude and skills
(competence)
Sense of overwhelm
Burnout – attribute
fatigue to technology

Telepresence
(TBH Domain II)

Avoid
Distractions
Understand the
Risks/Benefits of
the Technology
that You Choose
…TP and TBH care can be improved by
concepts of TPr, avoiding distractions,
understanding the technology-
human interface, measures of TPR for
clinical use and the use of simulation
for training.
Reference: Hilty DM, Randhawa K,
Maheu MM, McKean AJS, Pantera R.
Therapeutic relationship of
telepsychiatry and telebehavioral health:
Ideas from research on telepresence,
virtual reality and augmented reality
Psychol Cogn Sci Open J. 1994-2020;
5(1): 14-29. doi: 10.17140/PCSOJ-5-
145

Technology Choices
(TBH Domain III)

Clinical &
Technical Issues
 Audio Clarity & Continuity
 Equipment Quality
Type of Microphone
Headsets
Free Standing
Microphone Placement
Type of Speaker
Speaker Location
 Minimize Distractions

HIPAA, HITECH,
GDPR and/or
PIPEDA
Requirements?
 Look for A company’s public
declaration of HIPAA, GDPR
or PIPEDA compliance
 Get A business associate’s
agreement in the US, or other
compliance statement from the
company in other countries

Some people are uncomfortable
with technology
Different technologies are better
for specific tasks

Difficult to stay
focused with the
telephone for long
meetings. Easy to
get bored or
distracted.
 Limit distractions
 Close your eyes?
Video is better for
healthcare to stay
engaged

Variations in Connectivity
When at Home
 Commercial vs. residential connectivity
 Differences in bandwidth
 Bandwidth speed can also differ by time of
day. After school is often a high traffic time
and Internet speed can be significantly
slower.

reserved.

Legal Issues of
Relevance to
COVID-19
(TBH Domain VI)

Temporary
Relaxing of
HIPAA vs
Privacy
Enforcement
reserved.
We are in a state of
international emergency
Laws are getting
relaxed, just as they
would be in a hurricane
HIPAA is being relaxed
in some very specific
ways

Temporary
Relaxing of
HIPAA versus
Legal and
Ethical Privacy
Requirements
It is our job to know the laws, and
only relax the ones that we MUST
relax
State laws and ethical principles
related to privacy (and other
areas) are not going out the
window
They will hopefully change, but we
must assume that they were put
into place to protect citizens and
most of them will go back into
effect post-COVID-19

Temporary
Relaxing of
Enforcement w/
HIPAA and
Many Waivers
(See updated
“Documents”
link in your
TBHI Digital
Training
Account)
Only release what you
MUST release
Laws have been changing
but COVID-19 has changed
rate
Basic safety protections
will return

HIPAA COVID-19 Update
Not impose penalties
for noncompliance
under good faith
provision of telehealth
Can use any non-
public facing remote
communication
product during during
COVID-19 emergency

Notify patients that
these third-party
applications
potentially introduce
privacy risks
Use all available
encryption and
privacy modes when
using such
applications

•For added protections,
these are some options
of HIPAA-Compliant
services
Skype for Business,
Updox, Vsee, Zoom
for Healthcare,
Doxy.me, Google G
Suite Hangouts Meet

•Some public-facing
video technologies
should not be used
Facebook Live, Twitch,
TikTok, and similar
video communication
applications are public
facing, and
should not be used

Licensing
Boards
 Traditionally with telehealth, you
must be licensed where you
client or patient is at the time of
the contact
 NOW with COVID-19, Check
with your state board’s website
 Get on any mailing lists
 Check the Center for Connected
Health Policy

Copyright 2020 Telebehavioral Health Institute, LLC All rights reserved.
https://www.cchpca.org/
US Federal & State Issues

Copyright 2020 Telebehavioral Health Institute, LLC All rights
reserved.

Copyright2020TelebehavioralHealthInstitute,LLCAllrights
reserved.

Kentucky State Board Affidavit to practice in Kentucky during COVID-
19  search for state board websites in your profession

Ethical Issues of
Relevance to
COVID-19

Informed Consent
reserved.

Informed Consent Issues
 Informed consent involves a discussion
between you and your patient/client that
leaves you reasonably assured that they
know the risks and benefits associated
with your services, and that they’ve
agreed to try
 Document proves that the discussion
occurred
 Note which questions that were
discussed with them

Informed Consent Issues
 Static informed consent
 Might be too much for the first session
 Stagger discussion over first 2-3
sessions
 Note each session
 Dynamic informed consent
 Every subsequent discussion of
technology risks/benefits

COVID-19
Implications for
Your Work

Update Your Website
 Show image depicting COVID-19
 State definitions of legal services that you can deliver at this
time
 Will spend same amount of time in session
 Will not be recorded
 May need tech check the first time to make sure everything
is adequate on client/patient side
 Directions for how to schedule a virtual appt. with you
 1-page written instructions for meeting you

What does COVID-19
mean for your work?
Weigh decisions using a risk/benefit analysis for the
person in front of you
1. What is their diagnosis?
2. What does that diagnosis tell you about their
ability to tolerate change? Push boundaries now
or later, after the current situation subsides?
3. Can you expect compliance?
4. Can they find a private space to connect with you
and control their environment?

What does COVID-19
mean for your work?
 You may also want to consider any communication
channel that you determine to be necessary to keep
people safe
 Videoconferencing
 Telephone
 Other?

What does COVID-19
mean for your work?
 If you choose to proceed, advise your clients
and patients that rules have been lifted
temporarily, much as they would be in a flood
zone or other natural disaster experiencing an
emergency

What does COVID-19
mean for your work?
 Email?
 Send email to keep everyone informed? If
yes, email the message to yourself, and
BCC your intended recipients so they won’t
see each other on the TO: line of your
email

What does COVID-19
mean for your work?
 Text Messaging?
 Communicate with your clients and patients in
unsecured text messaging already built into
your devices? If yes, think about what you
write, how it might be mis-interpreted, and
document your communications.

Other Tips
TELEHEALTH
IS NOT FOR
EVERYONE
SOCIAL MEDIA IS NOT AN ACCEPTABLE
FORUM TO BE ACKNOWLEDGING
CLIENTS OR PATIENTS IN ANY WAY.
SOCIAL IS THE OPPOSITE OF
PRIVATE…

Other Tips
THE MOST FREQUENTLY REPORTED PROBLEM
RELATED TO TELEHEALTH BY LICENSING BOARDS IS
POOR BOUNDARIES

Copyright1994-2020TelebehavioralHealthInstitute,LLCAllrightsreserved.
Emoticons, LOL’s, memes
and other fun digital images
can be used against you as
evidence of poor
boundaries

Current Technology is
Probably Fine
 Camera on your current device is probably fine
 Stabilize device to put camera at eye level
 Use biggest monitor that you can find
 Get all permissions needed – website download, send
empty form via email (during COVID-19); Send via
surface mail
 Have 1 person in charge of tech issues if possible
 Noise canceling microphone
 Lighting illuminating your face

What does COVID-19
mean for your work?
Video Conferencing
 Backbone of telehealth
 Deep evidence base
 Many proven models
 Mistakes made and corrected
 Protocols for many areas, including
neuropsychological assessment
 Often reimbursable

Ryan Haight Act
 Limited the ability of prescribers
to prescribe over state lines
 Drug Enforcement
Administration (DEA) officially
missed its deadline to submit its
plans to Congress in late 2020
 New waiver as of March 2020
allows for the prescribing of
controlled substances via
telemedicine.

Summary
I’m not your advisor, but given the circumstance, a
reasonable way to proceed could be:
1. Consider diagnosis, risk analysis, history, living
situation, physical health and make your
determination for each person individually
2. Give your patients or client dynamic informed
consent about risks and benefits
3. Document rationale and time/day of IC
4. Help as many people as you can

Reimbursement

COVID-19 Funding
 Changes put into effect by the Centers for Medicare and
Medicaid Services (CMS) have been changed for
COVID-19
 Telehealth services are reimbursable by Medicare,
Medicaid and in some states, the 3rd party payors.
 See handouts by the Center for Medicare and Medicaid
Services (CMS)
 Telephone service is now covered – but only for
Medicare

Reimbursement
Medicare
Bill Medicare for
telehealth services the
same way you bill for an
office visit by using the
appropriate CPT® code
for the service provided.

Covered
Telehealth
Services for
PHE for the
COVID-19
pandemic
Verify your
status by
checking the
handout
under the
“Documents”
tab for this
course

COVID-19 CMS Funding
https://telehealth.org/blog/reimburs
ement-covid-19-telephone/

Can you bill
Medicare for
telehealth via
telephone?
Please read handouts in
the “Documents” link of
this training to
determine your specific
status. TBHI is not
responsible for how you
interpret or apply the
information provided
with this training.
 Effective April 30, 2020,
behavioral professionals
can provide many typical
services by audio-only
telephone.
 Audio-only phone
services may be covered
retroactive to March 1,
2020.

Can you bill
Medicare for
telehealth via
telephone?
this training to
status. TBHI is not
with this training.
 Covered services include
diagnostic interviews,
psychotherapy,
psychological and
neuropsychological
evaluations, along with
other commonly billed
mental health services.

Can you bill
Medicare for
telehealth via
telephone?
this training to
status. TBHI is not
with this training.
 Claims for traditional
audio-visual telehealth
services should include
modifier “95.”
 CMS has not yet provided
guidance on whether a
different modifier is
needed for audio-only
phone services.
 Check the TBHI Blog for
updates:
telehealth.org/blog

Telehealth Modifier Codes
“95” IS NEW
STANDARD CPT
CODE
“11” IS USED FOR
PLACE OF SERVICE
(POS)

Virtual
Visits &
E-visits
Variety of CPT
codes amounting to
about $14 per visit
Brief communication,
typically by
telephone or other
technology

https://www.apaservices.org/practice/reimbursement/h
ealth-codes/online-assessment-management-services

C1994-2020TelebehavioralHealthInstitute,LLCAllrightsreserved.
Group Therapy?

Group Therapy COVID-19 Billing
Two Medicare code sets for telehealth group therapies
under the emergency guidelines for COVID-19:
 Group Psychotherapy by Telehealth (CPT Code
90853), which, as of March 30, 2020, was added to the
temporary emergency provision of services rules
changes for Medicare.
 Health Behavior Assessment and Intervention Group
codes (96164 and 96165).

reserved.
ACCESS HERE: https://telehealth.org/blog/telehealth-group-therapy/

TBHI Resources

TBHI
Free
Resources
offered as
community
service from
Telehealth
Institute
TBHI Newsletter
https://telehealth.org/sig
COVID Resource List in the
TBHI Digital Learning Center
TBHI Blog
https://telehealth.org/blog

FREE
COVID
Telehealth
Training
Telehealth
Institute
501(3)c
Community
service
COVID-19 Legal &
Regulatory Updates
Telehealth from/to the
Home
Telehealth and Opioid
Treatment

Telebehavioral
Health Institute, LLC
Telehealth Institute
Marlene M. Maheu,
PhD
Executive Director
We’re here to help!
contact@telehealth.org
619-255-2788

COVID-19 Telehealth Best Practices

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