Note to TrainerShare the following information with the training participants in the order that works best for your presentation style.Welcome participants to the trainingIntroduce yourselfTell participants that this training is being sponsored by the National Frontier and Rural Addiction Technology Transfer Center (NFAR ATTC). Information about NFAR ATTC is contained on the next slide.
The National Frontier and Rural Addiction Technology Transfer Center (NFAR ATTC) focuses on frontier and rural issues related to addiction treatment and recovery services, and serves as the national subject expert and key resource to PROMOTE the awareness and implementation of telehealth technologies to expand the delivery of addiction treatment and recover services in frontier/rural areas;PREPARE pre-service addiction treatment and allied health students on using telehealth technologies by developing and disseminating academic curricula for infusion into existing courses;Create addiction treatment telehealth competencies and develop policy recommendations for national license portability, to encourage the addiction treatment and recovery workforce to ADOPT the use of telehealth services; andUse state-of-the-art culturally-relevant training and technical assistance activities to help the frontier/rural addiction treatment and recovery workforce IMPLEMENT telehealth services.
These are the topics that will be discussed during this training. Review this slide with participants.
In order to understand the need for and benefit of providing treatment and recovery services using telehealth technology, it is important gain a sense of the challenges specific to frontier/rural areas.The first part of this section presents data specific to frontier/rural issues related to accessing treatment services. The discussion then turns to the definition of telehealth, historical perspective, and current state of telehealth services.
Frontier/rural areas are characterized by small population centers that cannot support the type of healthcare services available in more densely populated centers, including SUDs treatment. Furthermore, in designating HPSAs the frontier definition specifies that ‘the time and/or distance to primary care is excessive for residents’, which includes lack of consistently accessible roads to a healthcare access point. This means that patients may have to drive over 60 minutes one way to receive treatment services, and with little or no public transportation in these areas, attending treatment is difficult if not impossible, especially if clients have to take time off from work. A significant frontier/rural workforce issue is how to expand availability and access to addiction treatment/recovery providers. SourcesNational Rural Health Association. (2008). National Rural Health Association Policy Brief: Designation of Frontier Health Professional Shortage Areas, G.A. Office, Editor: Washington, DC.USDA. Frontier and Remote Area Codes. 2000; Available from: http://www.ers.usda.gov/data/frontierandremoteareas/documentation.htm.
Roughly one quarter of the U.S. population (62 million people) lives in frontier/rural areas that make up 75% of the country’s land mass. Estimates suggest that 16-20% (15 million) of those individuals experience substance dependence, mental illness, or co-morbid conditions. However, SUDs treatment/recovery services, while available in urban areas, are more difficult to find in remote areas.SourceNational Rural Health Association. (2008).Workforce Series: Rural Behavioral Health, G.A. Office, Editor: Washington, DC.
Although individuals residing in frontier/rural areas may have similar prevalence rates of drug/alcohol dependence as their urban colleagues, their mortality rates and risks for suicide are higher and in general their alcohol/drug problems more severe. Some experts believe this is due to individuals residing in frontier/rural areas delaying treatment due to access issues so the problems worsen over time.SourcesBaca, C.T., Alverson, D.C., Manuel, J.K., & Blackwell, G.L. (2007). Telecounselingin rural areas for alcohol problems. Alcoholism Treatment Quarterly, 25(4), 31–45.Goldsmith, S.K., Pellmar, T.C., Kleinman, A.M., & Bunney, W.E. (2002). Reducing suicide: A national imperative. Center for Rural Affairs. Washington, DC: National Academy Press.
There are unique barriers regarding substance abuse treatment in rural locations that are not present in metropolitan areas, including economic, workforce shortages, environmental considerations, cultural norms, and personal perceptions. Even when substance abuse treatment services are available in rural and remote areas, residents attend less due to the stigma associated with receiving treatment services.SourcesFinfgeld-Connett, D. & Madsen, R. (2008). Web based treatment of alcohol problems among rural women: Results of a randomized pilot investigation. Journal of Psychosocial Nursing and Mental Health Services, 46(9), 46-53.Oser, C.B., Harp, K.L.H., O’Connell, D.J., Martin, S.S., & Leukefeld, C.G. (2012). Correlates of participation in peer recovery support groups as well as voluntary and mandated substance abuse treatment among rural and urban probationers. Journal of Substance Abuse Treatment, 42(1), 95-101.(Also see: Conger, 1997; Clark et al., 1999; Fisher, et al., 1997; Leukefeld et al., 2002; Leukefeld, McDonald, Staton, & Mateyoke-Scrivner, 2004; Warner & Leukefeld, 2001).
There is a perception of less privacy in frontier/rural areas than in urban areas.Women who misuse alcohol in rural areas are more highly stigmatized than men.The stigma associated with addiction and getting help for addiction may deter women from seeking treatment services even when treatment is available.In addition, this reluctant to access those services may be due to community norms that support more ‘male-oriented’ mindsets regarding addiction or alcoholism being a condition primarily effecting men.SourcesFinfgeld, D. (2002). Alcohol Treatment for Women in Rural Areas. Journal of the American Psychiatric Nurses Association, 8(2), 37-43.Finfgeld-Connett, D. & Madsen, R. (2008). Web based treatment of alcohol problems among rural women: Results of a randomized pilot investigation. Journal of Psychosocial Nursing and Mental Health Services, 46(9), 46-53.
A 2009 workforce study reported that there were over 350,000 mental health professionals practicing in the U.S. (HRSA’s definition of mental health professionals includes: Psychiatric Advanced Practitioner of Nursing; Psychiatrist, Psychologists, Licensed Clinical Social Workers; Licensed Professional Counselors; and Marriage and Family Therapists). Addiction counselors are not considered mental health professionals according to HRSA.The lowest concentration of mental health professions was found in frontier/rural areas, especially those counties with less than 10,000 people.Trainer NoteAt the end of this slide you may want to make a summary statement about frontier/rural areas regarding workforce shortages, prevalence and severity of substance use disorders, and lack of access. In addition, stigma regarding having an addiction or mental health disorder is exacerbated in frontier/rural areas which serves as a barrier to entering treatment services.SourcesEllis, A.R. et al. (2009). County-level estimates of mental health professional supply in the United States.Psychiatric Services, 6(10), p. 1315-1322.Human Resources and Services Administration (HRSA). (2011). Health professional shortage area (HPSA) NHSC fulfillment of mental health care HPSA needs summary.
To expand access to addiction treatment/recovery treatment, the substance abuse treatment field needs to follow the current trend in medical care by using telehealth technology to deliver services. Telehealth provides an excellent vehicle for expanding access to and availability of treatment services in frontier/rural areas. Telehealthrefers to ‘the use of telecommunications and information technologies to provide access to health information and services across a geographical distance’Telemedicinerefers to ‘the use of medical information exchanged from one site to another via electronic communications to improve patients' health status’ Note to Trainer.Emphasize the importance of knowing the distinction between the two definitions. Most definitions are in agreement that telehealth is the more expansive of the two. Telemedicine refers to the use of medical information and actual medical treatmentTelehealth is more broad and includes educational activities and health information, not just treatment - that is why NFAR uses the term telehealth.SourceInstitute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx
Telemedicine, telehealth, and telemental health each have strong literature support and treatment outcomes, with most studies showing that using these methods produces outcomes as good as in-person treatment strategies.Telehealth includes two types of communication methods Synchronous (videoconferencing; telephone counseling; chat) Asynchronous (email; web-based programs) Synchronous refers to communication that is happening ‘live’ or in the moment, while Asynchronous refers to communication that is delayed (e.g., a counselor sends an email message to client through a HIPAA compliant portal and the client may log-in to the portal and retrieve the counselor’s message at a later time).Some telehealth technologies do include synchronous and asynchronous features to communicate with clients. For example, a web-based recovery support telehealth technology utilizing a web-based portal may allow a client to send an email to their counselor, as well as participate in videoconferencing sessions.SourceInstitute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx.
Telehealth is not a new idea and in fact shortly after the telephone’s creation, professionals were suggesting how it could be used to help deliver medical services. For example, the telephone was created in 1876. Three years later (1879), an article in the Lancet (one of the world’s leading independent general medical journals) talked about physicians using the telephone to reduce unnecessary office visits (IOM, 2012, p11).The first study published regarding telehealth using videoconferencing shows up in the literature in 1961 with the second study in 1972 (Wittson et al., 1961; Wittson& Benschoter, 1972) as discussed by Backhaus et al. (2012).SourcesAronson, H. (1977). The Lancet on the Telephone 1876-1975. Medical History, 21, 69-87.Backhaus, A., Agha, Z., Maglione, M.L., Repp, A., Ross, B., Zuest, D., & Rice-Thorp, N.M., Lohr, J., & Thorp, S.R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, Special Issue: Telehealth, Telepsychology, and Technology, 9(2), 111-131.Institute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx.Wittson, C. L., Affleck, D. C., & Johnson, V. (1961). Two-way television in group therapy. Mental Hospital, 12, 22–23.Wittson, C. L. & Benschoter, R. (1972). Two-way television: Helping the medical center reach out. American Journal of Psychiatry, 129, 624–627.
Annually, 10 million patients receive telemedicine services. Telemedicine is so absorbed into healthcare networks that in many cases, patients do not even know that telemedicine is being used. For example, the internet, telephone, and computer ‘clouds’ have long been used to transmit patient x-rays, CTs, and MRIs from one location to another in order to share studies with other radiologists and physicians. Teleradiology improves patient care and reduces costs by providing medical services without the patient and physician needing to be in the same location. SourceInstitute of Medicine. (2012). The role of telehealth in an evolving health care environment: Workshop summary (pp. 17-29). Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx
Mental health care is a major reason for implementing telehealth. The Veteran’s Administration (VA) is one of the largest providers of telemental health services. In FY2011, 146 hospitals provided 55,000 patients in 531 community-based outpatient clinics with 140,000 telemental health visits. Home telemental health programs provided care to more than 6,700 patients for conditions such as depression and posttraumatic stress disorder. A review of more than 98,600 patients who received clinic-based telemental health care between 2006 and 2010 showed a 25% reduction in hospitalization. A review of 1,041 mental health patients before and after enrollment in home telemental health services by the VA in 2011 showed a 30% reduction in admissions in their first 6 months of care as compared to a similar period of time before enrollment.SourceDarkins, A., Ryan, P., Kobb, R., Foster, L., Edmonson, E., Wakefield, B., & Lancaster, A.E. (2008). Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemedicine and e-Health, 14(10), 1118-1126.Institute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx.
The Indian Health System provides a comprehensive health service delivery system for 2 million American Indians and Alaska Natives, serving members of 566 federally recognized tribes. This is accomplished through a network of hospitals, clinics, and health stations managed by the Indian Health Service (IHS), tribes, or urban Indian health programs.In the early 1970s, a mobile telemedicine service through the "Space Technology Applied to Rural Papago Advanced Health Care" (STARPAHC) project was initiated.The Alaska Federal Health Care Access Network (AFHCAN) utilizes telehealth technologies.The IHS Telenutrition Program began providing nationwide individual and group medical nutrition therapy (MNT) and other nutrition services through videoconferencing to IHS and tribal facilities in November of 2006.SourceInstitute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspxFederal Telemedicine News - http://telemedicinenews.blogspot.com/2012/10/update-on-indian-health-activities.html
The literature consistently demonstrates that diffusion of an innovation is a slow process and success varies. Take, for example, it took farmers 13 years to adopt hybrid corn seed and then another 7 years to use it exclusively (Ryan and Gross, 1943). Or, how it takes on average of 17 years to translate medical research findings in to clinical practice (Balas & Boren, 2000). The lag time in adopting an innovation is consistent from public health and medicine to marketing and communications.Unfortunately, as we look at the literature the addiction treatment field is lagging behind in the use of telehealth services, with few published works on the use of telehealth to provide or enhance substance abuse services in rural areas (Benavides et al., 2013).SourcesBalas, E.A. & Boren, S.A. (2000). Managing clinical knowledge for health care improvement. In Yearbook of medical informatics, 65-70. Bethesda, MD: National Library of Medicine.Benavides-Vaello, S., Strode, A., & Sheeran, B.C. (2013). Using technology in the delivery of mental health and substance use treatment in rural communities: A review. Journal of Behavioural Health Services Research, 40(1), 111-120. Ryan, B. & Gross, N. C. (1943). The diffusion of hybrid seed corn in two Iowa communities. Rural Sociology, 8, 15-24.
A 2009 study conducted by the National Association of State Alcohol and Drug Abuse Directors, Inc. (NASADAD) was the idea of an employee of the Colorado Division of Behavioral Health, Mary McCann, who at the time was the National Treatment Network Vice President. The purpose of the study was to survey her colleagues to determine the level of penetration of telehealth technology in State mental health and substance abuse treatment programs.Substance use disorder or mental health treatment providers in 37 states responded to the email survey.Reported offering web-enabled admin/management tools; videoconferencing; telephone and preventative web-based interventions.SourceNational Association of State Alcohol/Drug Abuse Directors, Inc. (NASADAD). (2009). Telehealth in State Substance Use Disorder (SUD) Services. Washington, D.C.
The next section provides data and information on the current use of technology among the general public.Note to TrainerTraining participants may make comments about this picture, so here are the answers: yes, it’s an old Selectrictypewriter, an old fan, and a tin can. It’s a picture from a video that NFAR staff produced and it can be viewed at the NFAR website: www.nfarattc.org.
According to a report published by the Pew Research Center, 85% of American adults have cell phones & 53% of the population in the US have smart phones Note to TrainerPew Research Center is a nonpartisan think tank that informs the public about the issues, attitudes and trends shaping America and the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. However, Pew Research does not take policy positions. SourceFox, S. & Duggan, M. (2012). Mobile Health 2012. Pew Research Center’s Internet & American Life Project.
80% of people send and receive text messages. These usage rates have increased over the past several years. The population that sends and receives the most text messages are adolescents and young adults. Although recently, there has been an increase in texting rates among people over the age of 50.SourceFox, S. & Duggan, M. (2012). Mobile Health 2012. Pew Research Center’s Internet & American Life Project.
Over half of the people in the U.S. reported looking up health information on their phones and almost 20% have a health app. This is a promising data point as it demonstrates the general public’s comfort level using technology to get answers about health issues.SourceFox, S. & Duggan, M. (2012). Mobile Health 2012. Pew Research Center’s Internet & American Life Project.
About 80% of Americans currently use the internet. However, there are people who live in rural and remote areas that at times have difficulty accessing the Internet. Terms like the “broadband divide” mean that some people still do not have access to the Internet, which is an issue.SourceFox, S. & Duggan, M. (2012). Mobile Health 2012. Pew Research Center’s Internet & American Life Project.
When we talk about access to the internet, we need to look at what clients have access to. The data presented here are from a recent study that examined technology use among clients in urban drug treatment clinics in Baltimore. 266 patients were surveyed regarding their access to technology 91% had access to a mobile phone (in this particular study the mobile phones were most often the prepaid/disposable type) 79% of these particular patients did text messaginga much smaller rate had access to the Internet, email, or a computerThis is important to keep in mind when we are thinking about telehealth and how to expand access for clients.SourceMcClure, E., Acquavita, Harding, E., Stitzer, M. (2012). Utilization of communication technology by patients enrolled in substance abuse treatment. Drug and Alcohol Dependence, 129(1-2), 145-50.
ALTHOUGH, there are some private insurers that are paying for it and some state agencies are contracting for these types of services,there is increased public demand. Customer demand is starting to drive telehealth technologies which in turn is changing how insurance companies reimbursement policies. According to an article posted by the Wall Street Journal, “Virtual doctor visit services—which connect the patient form their homes with physicians whom they meet via online video or phone—are moving into the mainstream, as insurers and employers are increasingly willing to pay for them.”Source Mathews, A.W., Wall Street Journal (Online), New York, N.Y. December 21, 2012
For example:WellPoint Inc., the nation's second-biggest health insurer, plans to offer a new service in all of its employer and individual plans that will allow people to consult with physicians on-demand, using laptop webcams or video-enabled tablets and smartphones.Appealing to clients looking for convenience and accessibility of care. Saving money by avoiding costly ER visits with virtual visits estimated at $40-$45 a visit.Aetna Inc. and UnitedHealth Group Inc., offer virtual-visit services as an option for certain employers.Other examples of companies are Home Depot and Westinghouse Electric Co. Source Mathews, A.W., Wall Street Journal (Online), New York, N.Y. December 21, 2012
Let participants review slide. Additional comments listed below:Mercer is a consulting unit of Marsh & McLennan Companies who provide advice and solutions in risk, strategy and human capital.The ability to communicate with a doctor via the internet at any time without an appointment is attractive to most people.Employers and insurers agree this could be the answer to the shortage of primary care doctors and mental health counselors. By 2014, WellPoint Insurance will have LiveHealth Online Program offered for employer plans in Ohio and California and its success will depend on regulatory status in those states.2014 they will launch with a webcam video, then add a smartphone and tablet capabilities.Virtual visits will be available everyday – 7a.m. to 11p.m.Same co-pay will be required as in “in-office” face-to-face visit.Source Mathews, A.W., Wall Street Journal (Online), New York, N.Y. December 21, 2012 Marsh & McLennan Companies: http://www.mmc.com/index.php
There are number of factors that serve as barriers to people accessing treatment for substance use disorders. In this next section, we will look at the prevalence of individuals meeting criteria for substance use disorders and yet do not enter treatment, and identify barriers to entering treatment and provide examples of how to address these issues.
According to the National Survey on Drug Use and Health (NSDUH, 2011), more than 20.6 million people aged 12 or over met the criteria for substance use disorders. 95%, or 19.2 million, did not feel they needed treatment, and3% felt they needed treatment but did not make an effort to get it.This is an important issue to discuss and reflect upon as a significant amount of people met the criteria for substance use disorders (almost 20 million) but didn’t feel like they needed treatment. Is this due to the stigma that still exists regarding addiction treatment; lack of access to treatment; the costs and hassles related to attending treatment, or other barriers? Nonetheless, there are a number of factors that serve as barriers to individuals accessing treatment services.SourceSubstance Abuse and Mental Health Services Agency (SAMHSA). (2011). The NSDUH Report: Alcohol treatment: Need, utilization, and barriers. Rockville, MD.
All of the issues listed here were identified as common barriers to individuals entering treatment for mental health or SUDs according to several different studies and articles. Using telehealth technologies to deliver treatment and recovery services may help address these barriers, especially for those living in frontier/rural areas.SourceBerwick, D., Nolan, T., & Whittington, J. (2008). The Triple Aim: Care, Health, and Cost. Health Affairs, 27(3), 759-769.Perle, J.G., Langsam, L.C. & Nierenberg, B. (2011). Controversy clarified: An updated review of clinical psychology and telehealth. Clinical Psychology Review, 31(8), 1247-1258.Rheuban, K.S. (2012). The Role of Telehealth in an Evolving Health Care Environment: Workshop Summary. Washington, DC: National Academy Press. Rheuban, K.S. (2012). Planning committee remarks. In The role of telehealth in an evolving health care environment: Workshop summary (pp. 55-57). Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspxSwinton, J.J., Robinson, W.D., and & Bischoff, R.J. (2009). Telehealth and rural depression: Physician and patient perspectives. Families, Systems, & Health, 27(2), 172-182.
This picture was taken in Wyoming and shows a car parked outside a doctor’s office. It illustrates one of the barriers to treatment in small frontier/rural communities where there may be only one counseling center. The assumption is that everyone in town knows your car and if you park it outside an addiction treatment center, everyone will assume that you are receiving treatment. This feeling of a lack of privacy, confidentiality, and that ‘everyone knows everyone’s business’ may cause individuals to be hesitant to seek treatment given the stigma still attached to having a SUD. Using telehealth technologies may help address this barrier by allowing people to access treatment from the privacy of their homes or physician’s offices or community centers where individuals go for more than substance abuse treatment.SourceMoyer, A. & Finney, J. (2004/2005). Brief Interventions for Alcohol Problems: Factors that Facilitate Implementation. Alcohol Research and Health, 28(1), 44-50.
Note to TrainerThis question is a lead in to the next slide and will be answered by the content in the remainder of the training.SourcePerle, J.G. & Nierenberg, B. (2013). How psychological telehealth can alleviate society’s mental health burden: A literature review. Journal of Technology in Human Services, 31(1), 22-41.Kazdin, A.E. & Blase, S.L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37.
Note to TrainerThe point of this slide is to propose that the adoption of telehealth technologies may help providers reach more individuals with SUDs by giving them tools to expand access and enhance treatment services. In addition, most telehealth technologies are delivered in ways that encourage privacy and confidentiality.
For example, the adoption of telehealth technologies by the University of Virginia helped decrease barriers to medical treatment services. This university studied their telehealth program and were able to document that patients avoided 7.2 million miles of travel due to their services being delivered via telehealth technologies. SourceRheuban, K.S. (2012). Planning committee remarks. In The role of telehealth in an evolving health care environment: Workshop summary (pp. 55-57). Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx.
The next section of this training reviews the literature regarding the types of telehealth technologies that are being used to provide treatment and recovery services. This is a lengthy section and is based on a large literature review. All telehealth technologies presented were identified in peer-reviewed journals. Note to TrainerWhile other telehealth technologies certainly exist, it is essential to the viability of this workshop that only telehealth technologies with an evidence-base be included in the presentation. It’s important to note to participants that this workshop does not promote one telehealth technology over another and that then please disclose if you have a conflict of interest regarding any of the telehealth technologies presented/discussed.Ask participants of they know what type of telehealth services are being offered in their state. If internet connection is available in the training room, go to the NFAR ATTC website (www.nfarattc.org) and select an example from the “Telehealth Policies” information section. Select the region/state most representative of the audience or highlight early adopters such as Florida (Region 4)or Iowa (Region 7).If internet connection is not available, prepare a slide or use the next slide as an example of state-specific information regarding Telehealth Policies available on the NFAR ATTC website. Thisdiscussion can be usedas a lead-in for the types of telehealth technologies being used to provide addiction treatment services.
Even though it is becoming the ‘best new thing’ for delivering substance abuse treatment services, telehealth has been around a long time. Specifically, one research study was conducted in 1961 that described the use of videoconferencing to provide mental health treatment services in the Mid-West and one in 1972 in New England.SourceRichardson, L., Frueh, B., Grubaugh, A., Egede, L., & Elhai, J. (2009). Current Directions in Videoconferencing Tele-Mental Health. Clinical Psychology, 16(3), 323-338.Wittson, C. L., Affleck, D. C., & Johnson, V. (1961). Two-way television in group therapy. Mental Hospital, 12, 22–23. Wittson, C. L., & Benschoter, R. (1972). Two-way television: Helping the medical center reach out. American Journal of Psychiatry, 129, 624–627.(See also: Frueh et al., 2000; Hilty, Liu, Marks, & Callahan, 2003; Hilty, Marks, Urness, Yellowlees, & Nesbitt, 2004; Hyler & Gangure, 2003; Monnier et al., 2003; Norman, 2006)
A review of the literature shows that telehealth in mental health and substance abuse treatment services is starting to expand. In this review, it is noted that the number of publications from 2000 to 2008 on telemental health tripled from the previous 30 years. The popularity of using telehealth technologies is certainly growing.According to Richardson and colleagues (2009) there is a need for more “empirical, rather than descriptive, articles” meaning that the majority of the articles on telehealth are case studies and descriptive in nature with the actual amount of empirical studies is limited.SourceBackhaus, A., Agha, Z., Maglione, M.L., Repp, A., Ross, B., Zuest, D., & Rice-Thorp, N.M., Lohr, J., & Thorp, S.R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, Special Issue: Telehealth, Telepsychology, and Technology, 9(2), 111-131.Richardson, L., Frueh, B., Grubaugh, A., Egede, L., & Elhai, J. (2009). Current Directions in Videoconferencing Tele-Mental Health. Clinical Psychology, 16(3), 323-338.
Telehealth technologies are categorized/organized in a variety of ways (e.g. telemental health; etherapy, telepsychotherapy, etc.). This is how it will be catergorized for the purpose of this presentation. While literature exists regarding the use of telehealth technologies for tobacco cessation and gambling treatment, those topic areas are not included in this literature review. We will only be highlighting and discussing addiction treatment and recovery services with a brief mention of telehealth technologies that provide screening and brief intervention. A compendium of these resources and literature regarding telehealth technologies is being developed and will be available at www.nfarattc.org. We will be talking about videocounseling; computer-based interventions; web-screeners; web-based support groups; telephone, looking at using the telephone in continuing care and interactive voice response; smartphones; and web-portals that incorporate videocounseling and messaging using text and email.In addition, this presentation will touch on reimbursement issues related to these types of telehealth technologies. It is important to remember that providers may or may not get reimbursed for utilizing these telehealth technologies based on state regulations and private insurance plans, so it is important to check what is allowable in your state (e.g., it is allowable in some states if it is included as part of the treatment plan).
You may recognize this cartoon… this is Jane Jetson using videoconferencing.Videoconferencing is currently in use by some treatment professionals and is being accessed through HIPAA compliant portals, while others use real-time internet-basedvideoconferencing technologies through personal computers and mobile devices. We will discuss this more later in the presentation.Note to TrainerThis is just a humorous slide and, depending on the age of the participants, they may have comments or break into song.
The Department of Veterans Affairs is the leader and largest provider of telemental health services using videoconferencing and have published research articles about its efficacy. Studies have shown that videoconferencing is as good, if not better in some cases, than face-to-face counseling methods. For mental health related problems the VA delivers services using videoconferencing either at community-based clinics or through home telemental health devices. In addition, the VA has three telehealth training centers for clinicians and 98% of their trainings are web-based. SourcesGodleski, L. Nieves, J.E., Darkins, Al, & Lehman, L. (2008). VA telemental health: Suicide assessment. Behavioral Sciences and the Law, 26, 271-286.Darkins, A., Ryan, P., Kobb, R., Foster, L., Edmonson, E., Wakefield, B., & Lancaster, A.E. (2008). Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemedicine and e-Health, 14(10), 1118-1126.Institute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx.Deen, T.L., Godleski, L., and Fortney, J.C. (2012). A description of telemental health services provided by the Veterans Health Administration in 2006-2010. Psychiatric Services,63, 1131-1133.Godleski, L., Darkins, A., & Peters, J. (2012). Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006-2010. Psychiatric Services, 63, 383-385.
Backhaus et al. (2012) did a systematic review of 891 articles on videoconferencing of psychotherapy – 65 were selected for inclusion and out of that, only 47 were rated as empirical studies. Because of the low number of empirical studies, it is hard to determine if the treatment outcome of videoconferencing is the same as face-to-face. Small sample sizes and lack of randomization also impact the ability to assess treatment outcomes. In 45% of the studies people used CBT in videoconferencing, and 60% of the patients were male. In studies with each of the following populations - African-Americans, Hispanic Latino and American Indians - using videoconferencing psychotherapy demonstrated effectiveness.Studies showed strong patient and provider therapeutic alliance over videoconferencing with high levels of satisfaction. SourceBackhaus, A., Agha, Z., Maglione, M.L., Repp, A., Ross, B., Zuest, D., & Rice-Thorp, N.M., Lohr, J., & Thorp, S.R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, Special Issue: Telehealth, Telepsychology, and Technology, 9(2), 111-131.(See also: Bouchard et al.,2000; Ghosh, McLaren, & Watson, 1997; Morgan, Patrick, Magaletta, 2008; Simpson, 2001; Cluver et al., 2005; King et al., 2009; Morgan et al., 2008; Nelson, Barnard, & Cain, 2003; Ruskin et al., 2004)
Of the 891 articles that have been published on videoconferencing, there are only 3 that address the treatment of substance use disorders. This is an interesting finding and demonstrates researchers interest in studying other telehealth technologies other than videoconferencing.The last article shown in the slide (Training Substance Abuse Clinicians in Motivational Interviewing Using Live Supervision via Teleconferencing) examined using teleconferencing to provide clinical supervision to counselors regarding adherence to MI. SourceBackhaus, A., Agha, Z., Maglione, M.L., Repp, A., Ross, B., Zuest, D., & Rice-Thorp, N.M., Lohr, J., & Thorp, S.R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, Special Issue: Telehealth, Telepsychology, and Technology, 9(2), 111-131.
This is the introduction slide for the discussion on computer-based interventions.
There is extensive literature showing the use and effectiveness of computer-based interventions in other disciplines. Computer-delivered therapy is a computer-based media that provides users with information designed to supply therapeutic treatmentCurrently, there are computer-based interventions that are downloaded as software on individual computers at treatment sites. However, more recently, most computer-based interventions are accessed through a web portal that includes a log-in. Treatment providers buy a licensing fee and then clients are given access to these interventions while receiving services at a treatment program. Soon this term will subsumed and everything will be called web-based interventions using different platforms or devices (computers, mobile phone, and tablets). Think of this way - right now your bank probably offers online banking. How you conduct online banking using whatever tools you have available doesn’t matter. The issue is that you can do your banking online.SourceCarroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426-432.
Computer based intervention programs have been around for some time and have been used to treat a variety of physical and mental health disorders (e.g., cancer, diabetes, heart disease depression, anxiety, poor nutrition, and sexual risk behaviors) with positive outcomes (Klein, et al., 2012; Moore, et al., 2011). However, the literature for using computer-based interventions to treat substance use disorders is more recent. (See the reference section for full citations). Cancer - Gustafson, D. H., McTavish, F. M. et al. (2005). Diabetes - Glasgow, R. E., Nutting, P. A. et al. (2005);Williams, G. C., Lynch, M. et al. (2007); Montani, S., Bellazzi, R. et al. (2001). Heart Disease - Verheijden, M., Bakx, J. C. et al. (2004)Mood Disorders - Farvolden, P., Denisoff, E. et al. (2005)Depression/Anxiety - Cavanagh, K., & Shapiro, D. A. (2004); Kaltenthaler, E., Parry, G. et al. (2008);Reger, M. A. & Gahm, G. A. (2009); Spek, V., Cuijpers, P. et al. (2007)Poor Nutrition - Portnoy, D. B., Scott-Sheldon, L. A. J. et al. (2008)Sexual Risk Behaviors - Ybarra, M. L., & Bull, S. S. (2007);Marsch L. A. & Bickel W. K. (2004) SourcesKlein, A.A. et al. (2012). Computerized continuing care support for alcohol and drug dependence: A preliminary analysis of usage and outcomes. Journal of Substance Abuse Treatment, 42, 25-34.Marks, I.M., Cavanagh, K., & Gega, L. (2007). Computer-aided psychotherapy: Revolution or bubble? The British Journal of Psychiatry, 191(6), 471-473.Moore, B.A., Fazzino, T., Garnet, B., Cutter, C.J., & Barry, D.T. (2011). Computer-based interventions for drug use disorders: A systematic review. Journal of Substance Abuse Treatment, 40, 215-223.
Many computer-based interventions are designed to serve as an adjunct to treatment services, thereby extending the work of the clinician. For example, a computer-based intervention may be used instead of a group counseling session. The client works on a module, learns about drug refusal skills and practices them through a series of learning experiences rather than attending the group session. This allows the counselor to spend their time with clients who may be dealing with other more pressing problems or issues that require their immediate attention. The term clinician extenders appears in journal articles authored by Lisa Marsch, Warren Bickel, and Kathy Carroll. This is about helpingcounselors, not replacingthem, as well as enhancing treatment services.The anonymity of this approach might be appealing to some individuals when dealing with substance abuse and other risk behaviors. These tools can have a significant public health impact by reaching frontier and rural areas, and may be used in a wide variety of settings such as: Web-based interventions offered in the homeCommunity organizations SchoolsEmergency rooms, Health care providers’ officesMobile devicesSourceBickel, W.K., Marsch, L.A., Buchhalter, A.R., & Badger, G.J. (2008). Computerized behavior therapy for opioid-dependent patients: A randomized controlled trial. Experimental and Clinical Psychopharmacology, 16(2), 132-143.Carroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426-432.Des Jarlais, D.C., Paone, D., Miliken, J. et al. (1999). Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: A quasi-randomised trial. Lancet, 353(9165), 1657-1661.Marsch, L. (2011). Technology-based interventions targeting substance use disorders and related issues: An editorial. Substance Use & Misuse, 46(1), 1-3.
Given the difficulty of being trained in every single EBP, Computer-based Interventions can help save clinician time and extend their expertise. For example, most addiction treatment provides need to concurrently address clients use of nicotine while in substance abuse treatment. The following data supports that point:There are 443,000 yearly deaths due to cigarette smoking; this number surpasses the combined death toll from alcohol, illicit drugs, guns, car accidents, and AIDS (CDC, 2008).Alcohol and illicit drugs contribute to approximately 100,000 deaths per year (Mokdad et al, 2004).Over 1 in 3 adults (36%) with mental illness smoke cigarettes, compared with around 1 in 5 adults (21%) with no mental illness. (CDC, 2013).19% of total population smokes (CDC, 2012).Individuals with SUDs account for 4.6% of the US pop, but 8.7% of smokers (SAMSHA, 2013) Instead of training staff on how to treat nicotine dependence a computer-based intervention targeting nicotine based on scientific studies could be used with clients rather than training clinicians to treat this issue as well.SourcesCarroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426-432.CDC. (2008). Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. MMWR, 57 (45); 1226–1228.Mokdad, A.H., Marks, J.S., Stroup, D.F., & Gerberding, J.L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 29(10), 1238-1245.CDC. (2013). Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years with Mental Illness—United States, 2009–2011. MMWR, 62(05);81–87.CDC. (2012). Current Cigarette Smoking Among Adults—United States, 2011. MMWR, 61(44); 889–894.Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (March 20, 2013). The NSDUH Report: Data Spotlight: Adults with Mental Illness or Substance Use Disorder Account for 40 Percent of All Cigarettes Smoked. Rockville, MD.
Carroll & Rounsaville (2010) in their journal article suggested that Cognitive Behavioral Therapy (CBT) could be delivered by computer (subcontracted to the computer), which would allow providers to save clinician time while still providing clients with exposure to an evidence-based practice or approach. While this comment might have been made in a ‘tongue and cheek’ manner it is important for treatment providers to consider this idea.This would allow the client to spend more time practicing a particular counseling skill when the clinician may not be available. Note to TrainerWe chose this picture because back in the day when computers were new and very large no one considered that one day more powerful computers could fit in the palm of your hand. The same may be true regarding the use of computer-based interventions in SUD treatment.SourceCarroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426-432.
Here are some examples of computer-based interventions. The first is CBT4CBT. This is based on Cognitive Behavioral Therapy research done by Cathy Carroll and her colleagues. Two studies were conducted around 2008 and focused on working with outpatient clients using a regular CBT intervention plus six computer modules on CBT. In this particular randomized controlled trial, the group that received the CBT + 6 computer modules (intervention group) did better than those that received the typical out-patient treatment using CBT (control group).Research on the second intervention, Therapeutic Education System (TES), was led by Lisa Marsch and Warren Bickel. TES is based on Community Reinforcement Approach plus Contingency Management and in some cases a little bit of motivational interviewing has been added. The approach has been used as an adjunct treatment for an HIV/AIDs intervention for opioid treatment clients and has shown positive results. Marsch and Bickel also did outpatient opioid treatment + treatment as usual + TES with positive results and then outpatient treatment plus two hours per week of TES. The computer-based intervention actually replaced about two hours a week of group counseling and again showed very positive results. Finally, Marsch and Bickel’s intervention, TES, is part of NIDA’s Clinical Trials Network (CTN) and researchers representing clinical trial nodes conducted a national study on TES. So far the initial results are very positive for this computer-based TES intervention.The next research listed found that a single session of computer-delivered motivational interviewing reduced drug use among post-partum women. These are just three examples. There is a great deal of research being conducted on computer-based interventions with SUD clients. A new NIDA fund-funded P30 center on using technologies to assess and treat SUDs has been developed at Darmouth College in New Hampshire. The url address for the Center for Technology and Behavioral Health is http://www.c4tbh.org/ . Overall, more rigorous clinical trials regarding testing oututer-based interventions is needed but most studies are showing positive outcomes.
This slide leads into the discussion of web-based screeners. This term refers to web-based programs that the general public or a specific group of individuals (log-in required for use) can use to determine if they are participating in risky drinking or have a SUD. Many web-based screeners also include tailored feedback for the individual participating in the screen or a brief intervention. Web-based screeners have been studied extensively especially related to alcohol screening. The following slides discuss web-based screeners for adults and for college students.
Numerous web-based screeners exist. The five listed here have the most literature support. Most of these are open for public use and help to answer questions about alcohol use, and provide feedback on responses and suggestions for next steps.
There are also web-based screeners for specifically for college students. Once again the web-based screeners for college students listed above have good literature support.
This is the slide that introduces the section on web-based support groups.
Web-Based Support is divided into three different categories - Psychoeducational – websites/blogs/informational sites that include papers or brochures that individuals can use to collect information about their condition. Self-help – provides individuals with materials or structured learning experiences to use at their own pace to assist with managing their own health/conditionMutual Support - a forum for people seeking support from others who have the same condition. This support can be provided through online meetings, chat rooms, or blogs.
Some substance abuse treatment providers are using web-based virtual reality programs like Second Life as an adjunct to treatment and recovery services and as web-based support for their clients. To date, there has been few published studies on the use of web-based support programs that use virtual reality for individuals with SUDs. However, as the next slide shows virtual reality programs have been used as a support with other health conditions.
These are just some examples of how virtual reality programs have been used to treat other mental health conditions.Note to Trainer Participants may say, “Have you heard about this program or that program?” Please ask the audience member(s) for information on those programs so we can gather information to use as examples for future trainings (e.g., name of program, authors of study).SourcesMangan, K. (2008). Virtual worlds turn therapeutic for autistic disorders. Chronicle of Higher Education, 54(18), 26.Reger, M. A., & Gahm, G. A. (2009). A meta-analysis of the effects of Internet- and computer-based cognitive–behavioral treatments for anxiety. Journal of Clinical Psychology, 65, 53−75.Wood, D.P., Webb-Murphy, J., Center, K., McLay, R., Koffman, R., Johnston, S., Spira, J., Pyne, J.M., & Wiederhold, B.K. (2009). Combat-related post-traumatic stress disorder: A case report using virtual reality graded exposure therapy with physiological monitoring with a female Seabee. Military Medicine, 174(11), 1216-1222.Chen, C., Jeng, M., Fung, C., Doong, J., & Chuang, T. (2009). Psychological benefits of virtual reality for patients in rehabilitation therapy. Journal of Sports Rehabilitation, 18, 258-268.
Below is the abstract describing this research:“This study examined the impact of a computer simulation designed to provide the opportunity for individuals with alcohol use disorders (AUDs) to practice relapse prevention skills. Participants were 41 male veterans enrolled in an intensive outpatient substance abuse treatment program. Participants were randomly assigned to either view educational slides about treatment for AUD or play a simulation videogame for eight sessions within 12 weeks. Participants were assessed at a 4-week follow-up visit. Outcome measures included relapse rates as well as ratings on the Obsessive Compulsive Drinking Scale (OCDS) and a custom-designed relapse prevention self efficacy scale. While rates of relapse did not differ between groups, those who played the game showed overall reductions in ratings on the OCDS, as well as higher ratings of self-efficacy at week 8, suggesting that the videogame simulation may be a useful adjunct to AUD treatment.” (Verduin et al., 2012).While there might be other virtual reality programs or computer simulation games, this is one that has research attached to it showing that although relapse rates did not differ for those that played the simulation game and those that viewed educational slides about substance use disorders, those that played the simulation game had higher rates of self-efficacy and decreases in craving.SourceVerduin, M.L., LaRowe, S.D., Myrick, H., Cannon-Bowers, J., & Bowers, C. (2013). Computer simulation games as an adjunct for treatment in male veterans with alcohol use disorder. Journal of Substance Abuse Treatment, 44(3), 316-322.
These are some examples of web-based disease management programs that have characteristics of all three of the web-based support activities (psychoeducational, self help, and mutual support) and are supported in the researchliterature showing program effectiveness, customer satisfaction, and usefulness. Cancer - Gustafson, D. H., McTavish, F. M., Stengle, W. et al. (2005). Diabetes - Glasgow, R. E., Nutting, P. A., King, D. K. et al. (2005);Williams, G. C., Lynch, M., & Glasgow, R. E. (2007); Montani, S., Bellazzi, R., Quaglini, S., & d'Annunzio, G. (2001). Heart Disease - Verheijden, M., Bakx, J. C., Akkermans, R. et al. (2004)Mood Disorders - Farvolden, P., Denisoff, E., Selby, P., Bagby, R. M., & Rudy, L. (2005)Depression/Anxiety - Cavanagh, K., & Shapiro, D. A. (2004); Kaltenthaler, E., Parry, G., Beverley, C., & Ferriter, M. (2008);Reger, M. A. & Gahm, G. A. (2009); Spek, V., Cuijpers, P., Nyklicek, I. et al. (2007) SourcesKlein, A.A. et al. (2012). Computerized continuing care support for alcohol and drug dependence: A preliminary analysis of usage and outcomes. Journal of Substance Abuse Treatment, 42, 25-34.
An example of a web-based addiction program that is a recovery based disease management program is MORE (My Ongoing Recovery Experience) out of Hazelden.As part of a continuing care plan, Hazelden offers clients 18 months free use of a Web-based program (MORE) that connects them with the tools, support, and fellowship to build a new life in recovery. Clients have access to a Recovery Coach by phone or by using the MORE messaging system in the passcode protected web-based program. While clients work through the web-based program, Recovery Coaches monitor client evaluations and assessments and contact them if they are struggling or need support. For additional information on this program, visit their website at http://www.hazelden.org/web/public/more_works.pageSourcesKlein, A.A. et al. (2012). Computerized continuing care support for alcohol and drug dependence: A preliminary analysis of usage and outcomes. Journal of Substance Abuse Treatment, 42, 25-34.
Another example of a web-based addiction management program is e-ROSC, (Electronic Recovery Oriented System of Care), a system that connects clients to recovery coaches and is fully integrated with the organization’s electronic health record (EHR). Centerstone, the leader in e-ROSC, offers a public-facing site that includes a public calendar, links to community resources, a blog, a discussion board, and easy access for people who want to make an appointment or talk to a recovery coach or volunteer right now. Additional information on this program can be found at www.v-recover.com
The My Recovery Plan uses the My HealtheVet Personal Health Record as a vehicle to support mental health recovery. It provides Veterans a one stop online secure place to participate in exercises and treatment options specific to their own goals, treatment and recovery. My Recovery Plan has been designed to support the ongoing recovery of Veterans. My Recovery Plan will help facilitate Veterans in achieving self identified goals. It allows Veterans to:· Create, monitor and track progress towards recovery goalsIdentify, monitor, and track mental health symptomsTrack and understand changes in level of functioning and life satisfactionIdentify how medication may affect them For more information use the 30 minute narrated online course developed for health care teams that work with Veterans with mental or behavioral health symptoms, and substance use disorders. My HealtheVet - My Recovery Plan Orientation for Health Care Team Members: http://example.courseavenue.com/PSI/MRP/Player/launchPlayer.html?courseID=1356&courseCode=MRP-MO-HCT
To this point the presentation has focused primarily on ‘high-tech’ ways to deliver addiction treatment and recovery services. However, the role of the more common telephone cannot be minimized. The telephone is a telehealth technology and remains an important tool in many frontier/rural/remote areas as it is not impacted by the ‘broadband divide’ that can keep people from accessing the web. In this section, the telephone and a computerized intervention (Interactive Voice Response) built into a phone will be discussed.
For the addiction treatment field, the telephone has been used primarily in continuing care.
Examples of the research literature that has been done and shown positive results for providing addiction treatment services using Telephone Continuing Care include: The Telephone Monitoring and Adaptive Counseling developed by McKay and colleagues, which has shown good results. Focused Continuing Care,started by the Betty Ford Clinic. Telephone Enhancement of Long Term Engagement - a protocol used by the Clinical Trials Network (CTN). This particular project did not show a great difference between using the telephone or doing typical kinds of aftercare continuing care. However, the other studies actually show better results from using the telephone rather than doing typical aftercare or continuing care type services. Those include:Individual Therapeutic Brief Phone Contact, which was used with adolescents with good results. Telephone Case Monitoring -a brand new study so not much information available yet. Telephone Continuing Care – a study done by Chestnut in Illinois
Another use of the telephone in treatment and recovery services include those with the capacity to access computer-based interventions called Interactive Voice Response. The following slide provides a brief review of the literature regarding use of interactive voice response (IVR) in addiction treatment and recovery services.
Interactive Voice Response or IVR is an automated computer-based intervention that is associated with the telephone. How it works: A person dials a number, logs in and a computerized voice will run through a series of questions with the client that can be answered using the telephone keypad.Advantages of IVR’s: Provide educational models and questions to help people track their drinking and support treatmentLiteracy is not required for useLow CostConsistent deliveryGreater accessibility and availability of supportFlexible scheduling/convenienceIVR has been used in conducting SBIRT Interactive voice response regarding addiction treatment: Used for screening and brief intervention, IVR has been used in alcohol screenings, alcohol brief intervention, and as an adjunct to substance abuse treatment. One of the newer studies is by Moore and colleagues, out of Vermont, and looks at a program called the Recovery Line - an IVR program developed for patients to use in their own environment. Users can receive immediate assistance along with training and support for improved coping. The modules were designed to be brief, less than 15 minutes, and according to researchers are pretty easy to comprehend.SourcesCranford, J.A., Tennen, H., & Zucker, R.A. (2010). Feasibility of using interactive voice response to monitor daily drinking, moods, and relationship processes on a daily basis in alcoholic couples. Alcoholism: Clinical and Experimental Research, 34(3), 499-508.Mundt, J.C., Moore, H.K., & Bean, P. (2006). An interactive voice response program to reduce drinking relapse: A feasibility study. Journal of Substance Abuse Treatment, 30(1), 21-29.
Finally, a brief review of mobile apps is also included in this section.
Maybe you feel this way about mobile phone apps?
One of the more prominent mobile phone apps is one currently being researched at the University of Wisconsin – Madison, called the Alcohol-Comprehensive Health Enhancement Support System (ACHESS). The purpose of ACHESS is to address coping competence, social supports and autonomous motivation, thereby reducing the number of risky drinking days.Note to trainerIt is important for people to understand that there is a theory driven reason for the content of this study and that it was tested in a clinical trial. There are a lot of apps available that are either not based on a clinical theory of treatment or recovery, or have not been tested in a clinical trial. When selecting an application for the delivery of treatment services it is important that it has clinical trial data behind it and is based on an evidence based theory of change.SourcesGustafson, D.H., Shaw, B.R., Isham, A., Baker, T., Boyle, M.G., & Levy, M. (2011). Explicating an evidence-based, theoretically informed, mobile technology-based system to improve outcomes for people in recovery for alcohol dependence. Substance Use & Misuse, 46(1), 96-111.
ACHESS maps self determination theory (Desi et al., 2002) over Marlatt’s relapse prevention theory. Tools in the application are designed to provide social support, increase competency for sobriety and improve autonomous motivation. The tools are designed to either support people in continued recovery or to intervene during times of risk.SourcesDeci, E.L. & Ryan, R.M. (2002). Handbook of Self Determination Research. Rochester, NY: University of Rochester Press. Gustafson, D.H., Shaw, B.R., Isham, A., Baker, T., Boyle, M.G., & Levy, M. (2011). Explicating an evidence-based, theoretically informed, mobile technology-based system to improve outcomes for people in recovery for alcohol dependence. Substance Use & Misuse, 46(1), 96-111.Lowman, C., Allen, J., Stout, R.L. (1996). Replication and extension of Marlatt’s taxonomy of relapse precipitants: Overview of procedures and results. The Relapse Research Group. Addiction, 91(Suppl), 51–71.
This is a list app functions for ACHESS. A clinical trial with 300 subjects indicated that patients randomly assigned to the ACHESS condition had 50% fewer risky drinking days and a higher percent of maintained abstinence than people assigned to post treatment recovery support as usual.Note to Trainer Sometimes during this presentation participants will share the mobile apps that they or their treatment program use. It is important to re-emphasize two points: NFAR is not promoting ACHESS but is simply showcasing it as one mobile app that is used for individuals in recovery; and It meets the criteria that the application is built upon well understood/tested theories and it has undergone clinical trials.
Numerous studies exist on the utility of texting patients as a reminder to: attend appointments; take medications; and engage in positive health related activities. However, there are few studies about using texting in substance abuse treatment or recovery services. Although in some mobile apps, texting is part of the services provided. The Texting- Portable Contingency Management Study combines texting and Contingency Management to help clients remain abstinent from alcohol. Clients are given breathalyzers and a cell phone. Training is provided to clients regarding how to take a video of themselves with the cell phone while conducting a self-administered breathalyzer, including the Blood Alcohol Content (BAC) reading/results, and sending the video back to their treatment provider.In the study, all clients got text messages one hour before, reminding them to take their BAC and send the video in to staff. Clients in the control group received a minimal reward for completing the task regardless of result of the BAC (negative or positive). Clients in the experimental design group who reported negative BACs got vouchers and a thank you text, and had better outcomes than the control group.SourceAlessi, S.M. & Nancy M. Petry (2012). A randomized study of cellphone technology to reinforce alcohol abstinence in the natural environment Addiction, 108, 900–909.
Operation PAR, Inc., is a leading Substance Abuse Mental health Treatment Provider in the State of Florida. It was established in 1970 from a grassroots movement and now operates as a treatment provider offering a full continuum of services from prevention to long term residential as well as medication assisted treatment services. Operation PAR serves all ages and embraces technology to reach more individuals and their family members with mental health and SUDs. Online services are provided through a HIPAA complaint web-base portal and services include: education for client, families and loved ones, family sessions, discharge session with new providers, training for clinical staff, clinical supervision, EBP training and certification, contingency management (client incentives), involvement of family, and support system for clients.OperationPAR uses a HIPAA compliant portal that allows clients to log-in and enter into a safe and secure portal in order to: attend group therapy using videoconferencingemailchat with their counselorsreceive other counseling services This is just one example of a treatment program that uses telehealth technologies.
Another e-services provider is Gateway Connect, which is a sister company to Operation Par. Gateway Connect launched in October 2006 with a SAMHSA grant awarded September 2007 and has served a total of 400 clients over a 3-year period.Platforms like Gateway Launch's are used to meet the client where they are. For example: desktop, laptop, tablet, smart phone, text messaging, IM’ing platforms allow interaction just as if the client were in your office. For additional information on Gateway Connect, go to http://www.gatewaycommunity.com/
Motivation to change a behavior can be difficult, especially when trying to establish abstinence from drugs/alcohol and a healthy lifestyle. Using telehealth technologies may assist in building motivation as help and support can be available “on demand” when motivation is the highest. SourceCopeland, J. (2011). Application of Technology in the Prevention and Treatment of Substance Use Disorders and Related Problems: Opportunities and Challenges. Substance Use & Misuse, 46, 112-113.
The next section will offer a brief overview of Privacy, Security, and Confidentiality as it pertains to telehealth technologies. Note to TrainerAs the next section is being introduced, it is important to remind training participants that you are not an attorney and that any information presented during this training should not be used alone to justify any action on their part to ensure patient privacy, security or confidentiality. It is recommended that providers and counselors consult with the provider’s legal staff and refer to HIPAA’s Final Rule and 42 CFR Part II in order to make informed decisions.
This is not a training on HIPAA Privacy and Security Rules but serves to remind participants that treatment or recovery services delivered through telehealth technologies must also adhere to these rules and regulations.Note to TrainerThis slide provides brief definitions of HIPAA’s Privacy and Security Rules. It is important to point out that the Security Rule is different from the Privacy Rule. For example, a disclosure may be permitted according to the Privacy Rule. However, any disclosure that is in an electronic format must follow the HIPAA Security Rule 29 which requires electronic disclosures to be: stored in a secure Data Center, encrypted, able to authenticate the recipient of the message; and able to create and record an audit trail of all activities. SourcesKarasz, H.N., Eiden, A., & Bogan, S. (2013). Reframing Arguments to Advance Public Health. Text messaging to communicate with public health audiences: How the HIPAA security rule affects practice. American Journal of Public Health, e1-e7.US Dept. of Health and Human Services. Summary of the HIPAA Privacy Rule. Available at: http://www.hhs.gov/ocr/privacy/hipaa/understanding/summary/index.html. Accessed December2, 2012.US Dept. of Health and Human Services. Summary of the HIPAA Security Rule. Available at: http://www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html. Accessed December 2,2012.
In the past this is how we thought about protecting Patient Health Information (The federal confidentiality rules and regulations require that patient treatment records be kept in a locked room inside a locked file cabinet ensuring that the general public does not have access). When considering the use of telehealth technologies, it is important to understand that both HIPAA Rules on Privacy and Security, and the Federal Confidentiality Rules and Regulations 42 CFR Part 2 apply.Addiction treatment providers must be adhere to both the Federal Confidentiality Rules and Regulations and HIPAA Privacy and Security Act, complying with the more stringent of the two codes whenever the codes differ, or in other words, whatever regulations provides the patient with the most privacy. Note to TrainerThe following identifies resources that participants can access that compares 42 CFR Part 2 to the HIPAA Privacy and Security Rules, and the use of 42 CFR Part 2 with Health Information Exchanges. These resources may be shared with the participants at a break if need be, but are not part of the topics covered in this presentation.SAMHSA has a well written document that compares the two. That document, The Confidentiality of Alcohol and Drug Abuse Patient Records Regulation and the HIPAA Privacy Rule: Implications for Alcohol and Substance Abuse Programs (2004) can be found at http://www.samhsa.gov/HealthPrivacy/docs/SAMHSAPart2-HIPAAComparison2004.pdf. More recent documents include two FAQ sheets: Applying the Substance Abuse Confidentiality Regulations http://www.integration.samhsa.gov/financing/SAMHSA_42CFRPART2FAQII_-1-,_pdf.pdfApplying the Substance Abuse Confidentiality Regulations to Health Information Exchange (HIE) http://www.samhsa.gov/healthPrivacy/docs/EHR-FAQs.pdf.
The final rule on HIPAA states that paper to paper faxes, person-to-person telephone calls, video teleconferencing or messages left on voicemail were not in electronic form before the transmission so they are exempt from the HIPAA Privacy Act. What does this mean? The goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being.Who does it apply to? Health plans, health care clearinghouses, and to any health care provider who transmits health information in electronic form.What information is protected? All "individually identifiable health information“. The Privacy Rule calls this information "protected health information (PHI).“ It includes information related to an individual’s past, present or future physical or mental health condition and health care provided to the an individual including payment for services.General Principle for uses and disclosures: The major purpose is to define and limit the circumstances in which an individual’s PHI may be used or disclosed by a provider. A provider may not use or disclose PHI, except either: (1) as the Privacy Rule permits or requires; or (2) as the individual who is the subject of the information (or the individual’s personal representative) authorizes in writing.“Traditional short message service (SMS) text messaging is nonsecure and noncompliant with safety and privacy regulations under the Health Information Portability and Accountability Act (HIPAA). Messages containing electronic protected health information (ePHI) can be read by anyone, forwarded to anyone, remain unencrypted on telecommunication providers’ servers, and stay forever on sender’s and receiver’s phones”. (American Academy of Orthopaedic Surgeons, August 2012)
You must consider using a private network or a portal in order to ensure the client’s privacy during treatment sessions, whether you are using:VideoconferencingEmailChator some of the other telehealth technologies, Remember from our discussion of OperationPAR and Centerstone, portals restrict people with password protection so not everybody can gain access into the network or program.
Telehealth/videoconferencing provides an opportunity for addiction treatment providers to expand services to their clients. There are two major issues regarding use of telehealth technologies:Licensure regulations or limitations of providing services across state lines HIPAA complianceThe medical profession is starting to address the licensing issue. However, the substance abuse treatment field is still far behind.In terms of HIPAA compliance, there are two leading authorities that have conflicting views on programs such as Skype. One says Skype is HIPAA compliant because it doesn’t store any of the videoconferencing sessions. The other says no. As far as we know, Skype has not provided specifics regarding whether it stores the session or not, and therefore we cannot say with any degree of certainty that confidentiality is protected. It will be important as you start considering using telehealth technologies to check your state regulations on licensing and stay up to date on the technology. NFAR ATTC will also provide updated information on our website.
The other issue to consider is the counselor’s use of technology. Ten years ago, many counselors did not have access to computers at work and in many cases computers were only given to administrative staff (e.g., grant writers or individuals working in the billing department). A 2003 article by McLellanand colleagues discussed the poor infrastructures of many addiction treatment providers including the lack of access to technology. In addition, up to five years ago frontier/rural treatment providers shared one or two email addresses among their clinical staff so that ATTCs serving frontier/rural areas had to send training registration confirmations to one general email with the hope that the counselor who registered for the course would eventually receive the information. However, in 2013 most counselors have their own email addresses and computer at work.SourceMcLellan, A. T., Carise, D., & Kleber, H. D. (2003). Can the addiction treatment infrastructure support the public's demand for quality care? Journal of Substance Abuse Treatment, 25, 117−121.
Note to TrainerAsk training participants to answer these questions privately. It’s important not to embarrass training participants or put them on the spot so that is why they are asked to privately reflect on these questions. After a few moments to reflect, move on to the next slide.Take a moment and reflect on these questions: Do you or your staff email or text your clients? If so, do you use HIPAA compliant portals?
So what’s the big deal about emailing or texting clients? Many counseling professionals state that they are only using email or text messaging to confirm appointments and so the risk is minimal, especially since no PHI is being disclosed. However, there are risks associated with emailing or texting clients.First, the clinician has no knowledge or assurances that the client password protects their mobile phone, tablet, or computer. This means their message could be read by others, thereby disclosing that the client is receiving some type of treatment or recovery services. Next, email messages are stored on computers, tablets, phones, and servers. Text messages are also stored on phones and servers, which puts them at risk of being seen by others as well. Finally, although a clinician may only be emailing or texting to confirm or cancel an appointment, the client may respond with a message that includes more data and possibly PHI.SourceKarasz, H.N., Eiden, A., & Bogan, S. (2013). Reframing Arguments to Advance Public Health. Text messaging to communicate with publichealth audiences: How the HIPAA security rule affects practice. American Journal of Public Health, e1-e7.
Two additional points regarding the dangers of sending text messages to clients: 1. errors are made and text messages are sent to the wrong recipient; and 2. text messages lack context and some time are misunderstood. A study by Saurage Research (2009) confirmed these problems with sending text messages. Statistics from this one survey, along with the HIPAA Rules/Regulations, may help dissuade clinicians from text messaging clients.Trainer NoteIf you have time you may want to ask the audience for a show of hands regarding how many people have sent a text message to the wrong person.Sourcehttp://www.saurageresearch.com/key-findings-novemberdecember-2009/
Note to TrainerHave training participants read this quote from the Brooks (2013) article. It’s important to emphasis that text messaging using traditional SMS is not HIPAA compliant. Not all text messaging is banned but it has to meet the following criteria regarding: audit controls; encryption; secure data centers; and recipient authentication. This criteria can be met using web-based portals built for mobile phones. So texting really becomes more similar to messaging.SourceBrooks, A. (2013). Healthcare texting in a HIPAA – compliant environment. American Academy of Orthopaedic Surgeons. Retrieved from http://www.aaos.org/news/aaosnow/aug12/managing5.asp.
This infographic is based on information released by cell phone carriers, with pressure from the ACLU, regarding how long these four carriers store text messages and cell phone call information on their servers. Just the text message detail – that is the date, time, and phone number of a message was sent or received – and not the content of the text message is stored. Actual text message content is only kept by Verizon and stored for 3-5 days. Information regarding how long the text message content is stored on phones is unknown because in some cases the message content can be recovered even after the message has been are deleted. The last area relates to the call record. Again, this is detail regarding number called, date of call, and number of minutes of the call; not content information. AT&T leads the other carriers by keeping data from 5 to 7 years. SourceRetrieved from Wired.com.
There is a new ruling out by the Joint Commission that says:“It is not acceptable for physicians or licensed independent practitioners to text orders for patients to the hospital or other healthcare settings.”Once again, text messaging is not an approved method of communicating with clients or staff especially since the identity of the person sending the text message can’t be verified and there is no way to keep the original message. SourceThe Joint Commission. (2013). Standards FAQ Details. Retrieved from http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=401&ProgramId=1.
These safe practices tips were recommended by HealthIT.gov a website sponsored by the federal government Department of Health and Human Services to provide education and training on protecting patient’s privacy, security, and confidentiality.SourceHealth IT. Mobile Device Privacy and Security. How Can You Protect and Secure Health Information When Using a Mobile Device? Retrieved from http://www.healthit.gov/providers-professionals/how-can-youprotect-and-secure-health-information-when-using-mobile-device.
This is considered as one of the most important strategies a staff member can do to prevent privacy, security or confidentiality breaches - maintain physical control of their mobile device or laptop computer. Of course all workplaces should have policies and procedures in place regarding use of laptop computers, mobile phones, and thumb drives, of which none should have PHI unless these devices meet HIPAA Security Standards.Source:Health IT.gov. Tips to Protect and Secure Health Information. 9. Maintain physical control. Retrieved from http://www.healthit.gov/providers-professionals/9-maintain-physical-control.
Do not send or receive PHI over public WiFi or unsecured networks.Health IT.gov. Tips to Protect and Secure Health Information. 10. Use adequate security to send or receive health information over public WiFi networks. Retrieved from http://www.healthit.gov/providersprofessionals/10-use-adequate-security-send-or-receive-health-information-over-public-wi-f.
If working in a public place, be aware of unintentional disclosures when using a laptop or cell phone.
Make sure that all devices are password protected and change passwords often. Health IT.gov. Tips to Protect and Secure Health Information. 1. Use a password or other user authentication. Retrieved from http://www.healthit.gov/providers-professionals/1-use-password-orother-user-authentication.
Check what is downloaded on mobile devices or computers and keep security software updated.Health IT.gov. Tips to Protect and Secure Health Information. 7. Keep security software up to date. Retrieved from http://www.healthit.gov/providers-professionals/7-keep-your-security-software-date.
Many smartphones have apps or a programs that will wipe/disable its use if stolen or lost so that data is unable to be accessed. This is important as every 3.5 seconds someone loses a cell phone http://blogs.marketwatch.com/paydirt/2012/03/23/lost-phones-cost-americans-30-billion-a-year/ in the United States.Health IT.gov. Tips to Protect and Secure Health Information. 3. Install and activate remote swiping and/or remote disabling. Retrieved from http://www.healthit.gov/providers-professionals/3-install-andactivate-remote-wiping-andor-remote-disabling.
Many providers may already have privacy, security, and confidentiality policies in place, but these need to be reviewed and revised when implementing the use of telehealth technologies. For example, let’s say the XYZ Treatment Center provides email/chat counseling through a HIPAA compliant web-based portal. Can a staff member provide treatment services using the web-based portal from a coffee shop, from their home, or while they are on vacation? These are types of questions that adopting the use of telehealth technologies will bring forward for the treatment provider.SourceUSDHHS. (2013). Health Information Privacy. Retrieved fromhttp://www.hhs.gov/ocr/privacy/index.html.
Finding a way to fund telehealth services is a vital component to offering and maintaining treatment services.Reimbursement through Medicaid, Medicare and/or Commercial Private PayersThey are transforming and beginning to reimburse for some telehealth services; not all telehealth costs are reimbursed.There have been and will be a number of changes that will need to occur in the addiction treatment field as the Affordable Health Care Act increases the need and demand for telehealth behavioral health services.Medicare, to some extent, has set the standard and decides telehealth reimbursement based on where the patient is located.If you or your agency currently accepts Medicare, Medicaid, or private insurance benefits, you are aware that the rules change almost daily.
The passage of the Telecommunication Act of 1996 helped pave the way for the use of technology as a treatment modality by removing certain economic and legal barriers to its use. The federal government currently commits millions of taxpayer dollars each year to promote the use of telecommunications in healthcare. SourceBenavides-Vaello, S., Strode, A., & Sheeran, B.C. (2013). Using technology in the delivery of mental health and substance use treatment in rural communities: A review. Journal of Behavioural Health Services Research, 40(1), 111-120.
Telehealth Policy Resource Center:Provides continuous updates on telehealth legislationIt is user-friendly interactive map to state laws and reimbursement policies.Simply click on a state to view telehealth-related laws, regulations, and Medicaid programs.Another important characteristic of this particular website is you can also view a list of pending laws and complete advance searches. Note to TrainerIt is suggested, prior to presenting this slide, to complete a search and get most recent information for the state(s) in which you will be presenting in. This slide has a hyperlink included, so you can click on the map and be taken directly to the website to provide a demonstration to participants. Source NationalTelehealth Policy Resources Center: http://telehealthpolicy.us/state-laws-and-reimbursement-policies
The Center for Connected Health Policy (CCHP) Report highlights telehealth laws related to Medicaid and the private sector in all states as of December 2012.The survey focused on 11 policy areas, including reimbursement, consent, service location, online prescribing and licensure. Key findings:44 states have some form of telehealth reimbursement for Medicaid programs;Live video was the most prominent form of reimbursed telehealth services, with 44 states paying for live video sessions;Seven states provide Medicaid reimbursement for remote patient monitoring;10 states require informed consent;9 state medical boards issue special licenses or certificates for telehealth; and13 states have legislation pending on telehealth.The report, launched in March 2013, will be continually updated on the Telehealth Policy Resource Center website. In addition, the NFAR-ATTC will have a link to this report on our site as well. (www.nfarattc.org) Source http://telehealthpolicy.us/state-laws-and-reimbursement-policiesRead more at http://www.ihealthbeat.org/features/2013/states-not-keeping-up-with-telehealth-advances.aspx#ixzz2QphzLgc3
“No two states are alike in how telehealth is defined and regulated.” Mario Gutierrez, the Executive Director of the Center for Connected Health Policy states http://cchpca.org/Nuanced SystemState health care laws, statutes and policies payer requirements are nuanced or have subtle differences or distinctions in meanings. These nuances can represent important differences in health care design, delivery and reimbursement depending on your location. All the new telehealth technology that are up and coming, e.g., mobile applications, computer-based interventions, interactive voice response may not be reimbursable through traditional means as of yet. DisclaimerInformation contained in this workshop is current up to date at the time it was presented.Please note, information is subject to change following action taken by your state’s legislature, state agencies and other applicable government or regulatory body. Each counselor/provider is encouraged to understand the telehealth allowances and restrictions covered in their state’s Medicaid program:How those allowances and restrictions are passed down through contracts with their counseling center or community mental health centerWhat their counseling centers or community mental health center’s ability is to provide telehealth services.
Since Medicare has the most prescriptive policies for telehealth, it tends to be less flexible than Medicaid. It is a good rule of thumb to always check your Medicare Manual as well the Medicare.gov website for the most up to date information.
Specific requirements for addiction treatment service coverage:Benefits and Covered ServicesA service must be covered by an individual’s health insurance plan in order to bill and reimburse for the service. For example, under the Affordable Care Act there is a list of federally-required benefits called essential health benefits (EHBs) that certain types of health plans will be required to cover and include as a benefit in 2014. Mental health and addiction treatment services are included in the list of EHBs. Practitioner andProvider Requirements An addiction treatment service is provided by an allowable provider and practitioner type and/or in a place of service that is authorized by the payer.Depending on the payer of the service (Medicare, Medicaid, private insurance), this latter requirement could be stated in contract, state policy, administrative rule, federal law, or a state’s scope of practice act.Eligibility, Enrollment or Patient/Beneficiary ParticipationA person receiving a covered service must be “enrolled” or eligible to participate in a health plan or government sponsored program.“Enrollment” is a term often used when healthcare is covered by a managed care organization.Safety net/public programs that are block purchased or are reimbursed on a fee-for-service basis have their own eligibility requirements.Allowable CodesCPT and HCPCS codes with appropriate modifiers are “open” (billable) in pursuant to a contract or covered in the health plan.Often the modifier “GT” is used to provide further clarification that a service was provided via telehealthSourceshttp://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdfhttp://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.htmlhttp://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.htmlProviders need to pay attention to the conditions for reimbursement. The use of telehealth services in Medicare is restricted by: type of services (procedure type) & must be in real time facility type practitioner geographyallowable codes
Telehealth services and Medicare coverage:Although limited in the number of services that can be provided via telehealth technologies, there is opportunity for addiction treatment providers and their clients.The use of telehealth in Medicare began January 1, 1999 to provide coverage of professional consultation services delivered via telecommunications systems, previously requiring “hands on” or “face to face” interaction with the patient.Medicare does not reimburse for “store and forward” technology, so the interaction must be real-time between a beneficiary (patient) and the practitioner.There have been exceptions made for Alaska and Hawaii. Sourcehttp://www.cms.gov/Medicare/Medicare-General-Information/MedicareGenInfo/index.html
As mentioned earlier, the Originating Site authorized must belocated in a rural-HealthProviderShortageArea (rural-HPSA) ora county outside an Metropolitan Statistical Area or in a federal telemedicine demonstration project (Alaska and Hawaii).* HPSAs may be designated as having a shortage of primary medical care, dental or mental health providers. They may be urban or rural areas, population groups or medical or other public facilities.
Rate of ReimbursementMedicare claim via telehealth is the same as the rate for a non-telehealth service.The originating sites are paid an originating site facility fee and can bill for site fee reimbursement separate to part B payment.Interactive telecommunications systems (audio and video) allowing real-time communication is required as a condition of payment.In addition, the patient must be present at the originating site and participating. An example…. A Federally Qualified Health Center located in a rural area contracts with a specialty addiction treatment provider to provide SBIRT services by a Licensed Clinical Social Worker. Using HIPAA Compliant video-conferencing equipment a patient is screened forRisky Drinking… and receives a brief interventionCPT codes are the same for SBIRT services delivered in person or through telecommunicationsSource CMS Telehealth Services Rural Health Fact Sheet - http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf
Distant Site PractitionersThe following practitioners who perform the telehealth encounter may receive payment for covered telehealth services:Physicians, Nurse Practitioners and Physician Assistants; Nurse midwives; Clinical Nurse Specialists; Registered Dietitians or nutrition professionals; Clinical psychologists (CP); and Clinical Social Workers (CSW)Note: there are restrictions – CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicaid). Note. There are no Licensed Addiction Counselors listed above.Source http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/telehealthsrvcsfctsht.pdf
For purposes of Medicaid, telemedicine seeks to improve a patient’s health by permitting two-way, real time interactive communication between the patient, and the physician or practitioner at the distant site. This electronic communication means the use of interactive telecommunications equipment that includes, at a minimum, audio and video equipment. States have the option/flexibility to define:which telehealth services (i.e. counseling) are eligible for reimbursement;which populations are eligible to receive telehealth services;which practitioners are qualified to provide a reimbursable telehealth service as long as such practitioners are “recognized” and qualified according to Medicaid statute/regulation; where telehealth services can be provided (location); andhow much to reimburse for telehealth services, offering different services delivered via telehealth in managed care arrangements when compared to fee for service arrangements.Reimbursement for Medicaid covered Telehealth services and applications:Must satisfy federal requirements of efficiency, economy and quality of care.States are encouraged to use the flexibility inherent in federal law to create innovative payment methodologies for services that incorporate telehealth technology; for example:States may reimburse the physician or other licensed practitioner at the distant site and reimburse a facility fee to the originating site.States can also reimburse any additional costs such as technical support, transmission charges, and equipment.These add-on costs can be incorporated into the fee-for-service rates or separately reimbursed as an administrative cost by the state.If they are separately billed and reimbursed, the costs must be linked to a covered Medicaid service.Source http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html
Medicaid’s reimbursement can be thought of as a three legged stool
Note to TrainerAllow time for participants to review the slide, then review the three components of Medicaid: Person must be covered and currently enrolled in Medicaid eligible programType of Service covered – both audio and video interactions The provider (professional offering services) is practicing within the states scopeSource http://medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Telemedicine.html
Kentucky issued final rules expanding coverage of telehealth-provided services for Medicaid beneficiaries. Although providers are still limited to using only interactive video-conferencing to qualify for reimbursement, Medicaid beneficiaries will have access to a broader list of providers and telehealth-provided services including a variety of physical and mental health evaluations, counseling and remote disease monitoring. Mental health evaluation or management service, individual or group psychotherapy, and medication management provided by a psychiatrist, a physician, APRN, psychologist, licensed professional clinical counselor, licensed clinical social worker, licensed marriage and family therapist
Coverage of telehealth services under private insurance is either mandated in state law; or up to the insurance company to decide whether or not to reimburse for telehealth services.There are no consistent standards that govern private commercial payers.More and more private payers are starting to recognize the benefits of telehealth and electing to cover for selected telehealth services.16 states now require private insurers to pay for telehealth delivered services at the same rate as in-person services (subject to the limitations of their policies)29 states have pending legislation to create this mandateManaged care plans, both public and private, are also beginning to incorporate telehealth into the services that are covered.Note to TrainerAccording to the Telemental Health Institute, sixteen (16) states mandate some form of Private Payer Telehealth CoverageCalifornia, Colorado, Georgia, Hawaii, Kansas, Kentucky, Louisiana, Maine, Maryland, Michigan, New Hampshire, Oklahoma, Oregon, Texas, and Virginia.The covered services could be telehealth, telemedicine, or both services depending on the state.Four states recently passed new legislation that impact private payers and go into effect July 2013-January 2015: Arizona, Mississippi, New Mexico and Montana.Legislation is consistently evolving and changing everyday. It is important to maintain up to date information in your state or where you plan on offering a form of telehealth services. SourcesTMH Institute – 11/2012 http://telehealth.org/mandated-statesThe National Telehealth Policy Resource Center project is made possible by Grant #G22RH20214 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, DHHS: Telehealth Reimbursement Policy:http://telehealthpolicy.us/telehealth-policy
Take home pointThe biggest drivers of drivers behind an organization’s or practitioner’s ability to provide addiction treatment services via telehealth and be reimbursed:The type of insurance (payor)Insurance (patients health care provider, i.e. Medicare) carrier,Federal lawsState laws and policies
Take home point Live (videoconferencing), interactive (audio/telephone) is the most commonly reimbursed form of services where the patient and doctor are in “real time”.
Currently, only counseling using videoconferencing technology is reimbursed by Medicare, by Medicaid in some states, and by private insurance companies (in some states). In the administrators’ track a more in-depth review of reimbursement for telehealth technologies will be provided.
ALTHOUGH, there are some private insurers that are paying for it and some state agencies are contracting for these types of services,there is increased public demand. Customer demand is starting to drive telehealth technologies which in turn is changing how insurance companies reimbursement policies. According to an article posted by the Wall Street Journal, “Virtual doctor visit services—which connect the patient form their homes with physicians whom they meet via online video or phone—are moving into the mainstream, as insurers and employers are increasingly willing to pay for them.”Source Mathews, A.W., Wall Street Journal (Online), New York, N.Y. December 21, 2012
The next issue associated with ethics is license portability. Portability is the new term that replaces reciprocity, with the idea being that licensed professionals take their license with them, not that a state counseling board grants special permission to practice. One of the barriers to providing services using telehealth technologies is that counselors have to be licensed in the state where their clients reside. This especially impacts individuals living in rural and remote areas who are seeking treatment services and may actually live closer to another state than the state of their official residence. Federal legislation has been proposed that would allow physicians to be licensed in one state but treat patients that reside in other states without being licensed in these other states. This legislation in 2012 never got out of committee.A good resource for questions regarding license portability and telehealth is the Robert Waters Center for Telehealth and eHealth Law www.http://ctel.org
There are all sorts of ethical issues associated with telehealth.
More counselors are using technology (email, smart phones, tablets, etc.) to conduct their business and as such this brings new and unique ethical dilemmas. In fact in some cases, technology use has become so ubiquitous that counselors may forget about Privacy, Security, and Confidentiality issues which puts them at risk for ethical violations.SourceNational Board of Certified Counselors (NBCC). (2013). NBCC Adopts Revisions to Ethical Standards. The National Certified Counselor, 29(1), 1-23.
Professional Associations and states need to revise/rewrite a portion of their ethical codes to address the use of various telehealth technologies.SourceTelemental Health Institute. (2013). Retrieved from telehealth.org.
Listed here are the addiction counseling accrediting bodies that currently all have some specific ethical codes related to the use of telehealth technologies when providing treatment services:SourceNAADAC. (2013). NAADAC Code of Ethics Principles. Retrieved from http://www.naadac.org/membership/code-of-ethics. National Board for Certified Counselors (NBCC). (2012). National Board for Certified Counselors Code of Ethics. Retrieved from http://www.nbcc.org/assets/ethics/nbcc-codeofethics.pdf.American Counseling Association (ACA). (2005). ACA Code of Ethics. Retrieved from http://www.counseling.org/Resources/aca-code-of-ethics.pdf.American Mental Health Counselor Association (AMHCA). (2010). Principles for AMHCA Code of Ethics. Retrieved from http://www.amhca.org/assets/news/AMHCA_Code_of_Ethics_2010_w_pagination_cxd_51110.pdf.American Association of Marriage and Family Therapy (AAMFT). (2012). Code of Ethics. Retrieved from http://www.aamft.org/imis15/content/legal_ethics/code_of_ethics.aspx.National Association of Social Workers (NASW). (2008). Code of Ethics. Retrieved from http://www.socialworkers.org/pubs/code/default.asp.National Council of State Boards of Nursing (NCSBN). (2011). NCSBN Model Nursing Practice Act and Model Nursing Administrative Rules. Retrieved fromhttps://www.ncsbn.org/Model_Nursing_Practice_Act_March2011.pdf.
The American Psychological Association put together a joint task force to develop telehealth guidelines for psychologists and their recommendations should be released soon. SourceAmerican Psychological Association (APA). (2010). Ethical Principles of Psychologists and Code of Conduct. Retrieved from http://www.apa.org/ethics/code/index.aspx.
The International Certification and Reciprocity Consortium, or IC&RC , puts this responsibility on individual states. They do not have a national Code of Ethics.So if you are looking for telehealth technology-related ethical codes and you are an IC&RC state, you will need to go to your local board.SourceIC&RC. Find a Board. Retrieved from www.internationalcredentialing.org/findboard.
consent is especially important when using telehealth technology. For example, HIPAA considers a landline telephone as HIPAA compliant because it does not record or electronically store information. However, a cell phone or smart phone does store data regarding the number that was called, the date, and the number of minutes of the call. In fact, this information is stored on the server associated with both the client’s phone and the counselor’s phone, and on the phones themselves which means the information is unsecure. Even though Protected Health Information is not disclosed, someone could access the client’s phone, look at the list of recent calls, and call the counselor’s number, causing a possible breech. This type of information would need to be shared with the client as part of the informed consent process. In addition, 42 CFR Part II would require that a counselor not call a client’s house and leave a message with a family member unless a signed/valid release exists for each household member. If the client only has access to a cell phone, its important that the counselors discusses the risks with the client regarding using a cell phone to communicate even about appointments. Using telehealth technologies to deliver addiction treatment services includes developing new methods for record-keeping and data storage. Treatment providers have developed different mechanisms for securing client signatures on consent to treatment forms and for storing treatment records in electronic formats. Treatment providers should consult with experts in EHR regarding collecting and keeping protected health information private and secure. Many treatment providers using telehealth technologies still conduct the first treatment session in-person ( a requirement by some payors) in order to complete the required admission paperwork.Counselors are ethically bound to be competent in their clinical work (e.g., possess demonstrated skills in Evidence-Based Practices, offer treatment engagement strategies, understand how to score screening tools, conduct assessment, create treatment plans, and write case notes) and in using telehealth technologies. Competency in telehealth technologies is the same principle as being competent within a counselors’ scope of practice. Counselors who are unable to effectively implement the telehealth technologies they are using are violating most ethical codes regarding competency. This is an important concept for counselors to understand.The following is an excerpt from NAADAC’s Ethical Code regarding the use of electronic devices and electronic records and confidential information. This ethical code pertaining to Confidentiality/Privileged Communication & Privacy, even though revised in 2011, may need further revisions. Other examples from NAADAC Code of Ethics, Rev. March 28, 2011- Confidentiality/Privileged Communication & Privacy:“The addiction professional will explain the impact of electronic records and use of electronic devices to transmit confidential information via fax, email or other electronic means. When client information is transmitted electronically, the addiction professional will, as much as possible, utilize secure, dedicated telephone lines or encryption programs to ensure confidentiality. ” SourceNAADAC. (2013). NAADAC Code of Ethics Principles. Retrieved from http://www.naadac.org/membership/code-of-ethics. When we look at ethical codes related to telehealth technology, it is important to focus on these four areas - informed consent; confidentiality/privileged communication and privacy; records and data; and competency. An example of Informed Consent Confidentiality/Privacy Issues: Before receiving treatment services, all clients must understand the risks and benefits associated with entering treatment. In order to do this, clients must be given all the information regarding treatment and recovery services so that an informed and thoughtful decision can be made. Informed
Begin with a review of definitions:Telephone-based refers to the synchronous distance interaction in which information is received only through audio means.Chat-based refers to the synchronous distance interaction in which information is received through written messages. E-mail-based refers to the asynchronous distance interaction in which information is received through written text messages or e-mail. Synchronous communication such as telephone and chat are coordinated in what is often referred to as “real time” or “live” communication. Remember from the stump speech, the telephone was created in 1876 and in 1879, an article from the Lancet Journal talked about using the telephone to reduce unnecessarydoctoroffice visits. Chat refers to instant messaging (IM) or Internet Relay Chat (IRC) - a completed text message can be viewed almost as soon as it is sent on a computer(Lancet Journal is an independent general medical journal.)Asynchronous communications such as e-mail allows two users to communicate with one another without being simultaneously connected.
This is not an exhaustive list of issues to consider when connecting with clients through TH technologies but will provide a starting point for a discussion on several areas of importance in developing client engagement. Keep in mind it is the professional’s responsibility to seek appropriate education, training, or supervised experience using the relevant technology to deliver services.
Building rapport is how the counselor/client develop a therapeutic relationship. Ask the audience to think about the various ways in which they build rapport with their clients in face-to-face settings. Use the list above as a guide. Active listening: paying close attention to the words, pauses or no pauses, emotionsVerbal engagement: open ended questionsEmotional engagement: getting the client out of their head and in touch with emotionsShowing empathy about the client’s situation and feelings rather than providing a professional interpretationSelf-disclosure: in an office setting, the client will see décor, certificates/degrees and other items that reflect professional credentials and personal tastes, hobbies, etc. In online counseling the use of an avatar such as a photograph or a webpage with a background or biographical sketch would provide the client with more information about who the counselor is and what they are about.In telephone counseling, the counselor could share professional and personal information as relevant to the counseling relationship. In Alemi, et al., 2007, it is suggested that when using email to deliver services, the client and counselor establish contact with an introductory email. It is suggested the counselor email contain:Description of the clinician’s backgroundStatement regarding confidentiality, privacy & security of email exchangesAsk the client to introduce themselves and include age, who they are, what they do, etc.
Published May 2013This practice guidelines document focuses on telemental health services delivered in real-time using internet basedvideoconferencing technologies through personal computers and mobile devices. These guidelines serve as a companion document to ATA’s Practice Guidelines for Videoconferencing-based Telemental Health, a document adopted in 2009 that focuses on real-time videoconferencing-based telemental health services delivered using technologies other than the Internet.
Contact info for both provider and patient should be verified.Reasonable expectations about contact between sessions should be discussed and verified with the patient. The provider should provide a specific time frame for expected response between session contacts. This should also include a discussion of emergency management between sessions.
Professionals should consider the patients’ expectations and level of comfort with home-basedcare to determine the appropriateness of using videoconferencing in this setting. An unsupervised setting requires that the patient take a more active and cooperative role in the treatment process than an in-person setting. Determining whether a patient can handle such demands may be more dependent on the patient’s organizational andcognitive capacities, than on diagnosis.Luxton DD, O'Brien K, McCann RA, Mishkind MC. Home-based telemental healthcare safety planning: what you need to know. Telemed J E Health. 2012;18(8):629-33. Luxton DD, Sirotin AP, Mishkind MC. Safety of telemental healthcare delivered to clinically unsupervised settings: a systematic review. Telemed J E Health. 2010;16(6):705-11.)
“The consent should include all information contained in the consent process for in-person care includingdiscussion of the structure and timing of services, record keeping, scheduling, privacy, potential risks,confidentiality, mandatory reporting, and billing. In addition, the informed consent process should includeinformation specific to the nature of videoconferencing as described below. The information shall beprovided in language that can be easily understood by the patient. This is particularly important whendiscussing technical issues like encryption or the potential for technical failure.Key topics that shall be reviewed include: confidentiality and the limits to confidentiality in electroniccommunication; an agreed upon emergency plan, particularly for patients in settings without clinical staffimmediately available; process by which patient information will be documented and stored; the potentialfor technical failure, procedures for coordination of care with other professionals; a protocol for contactbetween sessions; and conditions under which telemental health services may be terminated and areferral made to in-person care.”
Both the professional and the patient’s room/environment should aim to provide comparable professionalspecifications of a standard services room. The physical environment guidelines pertain to both the patient’s and the professional’s room or environment where the videoconferencing is taking place.Ensure privacy so clinical discussion cannot be overheard by others outside of the room where the service is provided. If other people are in either the patient or the professional’s room, both the professional and patient should be made aware of the other person and agree to their presence. Seating and lighting should be tailored to allow maximum comfort to the participants. Both professional and patient should maximize clarity and visibility of the person at the other end of the video services. Reduce backlighting from windows or light fixtures.Both provider and patient cameras should be on a secure, stable platform to avoid wobbling and shaking during the videoconferencing session. To the extent possible, the patient and provider cameras should be placed at the same elevation as the eyes with the face clearly visible to the other person.
Using videoconferencing involves particular considerations regarding patient safety. There are also additional considerations when providing care to patients in settings without staff immediately available. (17) Below are issues that should be considered in both types of practice followed by separate sections for emergency management for supervised and unsupervised settings.1. Education and TrainingProfessionals should maintain both technical and clinical competence for the delivery of care in this manner. Professionals shall have completed basic education and training in suicide prevention. 2. Jurisdictional Mental Health Involuntary Hospitalization LawsEach jurisdiction has its own involuntary hospitalization and duty-to-notify laws outlining criteria and detainment conditions. Professionals shall know and abide by the laws in the jurisdiction where the patient is receiving services.3. Patient Safety when Providing Services in a Setting with Immediately Available ProfessionalsWhen a professional sees a patient via personal computer and/or mobile device outside of the patient’s home (e.g., local clinic, community-based outpatient clinic, school site, library) or other facility where dedicated staff may be present, it may be important that the professional become familiar with the facility’s emergency procedures and coordinate with the distant site clinic to establish basic procedures. 4. Patient Safety when providing Services in a Setting without Immediately Available Professional StaffFor treatment occurring where the patient is in a setting without clinical staff, the professional may request the contact information of a family or community member who could be called upon for support in the case of an emergency. This person will be called “the Patient Support Person” an individual selected by the patient. 5. Patient Support Person and Uncooperative PatientsIt is possible that a patient will not cooperate in his or her own emergency management, which underlies the practice of involuntary hospitalization in mental healthcare. Professionals should be prepared for this as well as the possibility that Patient Support Persons also may not cooperate if the patients themselves are adamant that they do not want to seek emergency care. Therefore, any emergency plan shall include local emergency personnel and knowledge of available resources in case of involuntary hospitalization.6. TransportationThe professional should know any limitations the patient has in terms of self-transporting and/or access to transportation. Strategies to overcome these limitations in light of an emergency shall be developed prior to starting treatment for patients in settings without staff immediately available. In the event of a behavioral and/or medical emergency, the patient’s Patient Support Person should discuss with emergency personnel whether they should transport the patient.7. Local Emergency PersonnelIn providing care to patients in settings without professional staff immediately available, determining distance between local emergency personnel in the patient’s community and the patient’s location can shape the professional’s decision process in determining appropriate actions.Acquire telephone numbers for local resources in the patient’s community and have that contact information readily available at the beginning of each session. Prior to each session, the provider should also determine the patient’s location and whether there have been any changes to the patient’s personal support system or the emergency management protocol.
Video Conferencing ApplicationA. Video conferencing applications should have been vetted and have the appropriate verification, confidentiality, and security parameters necessary to be properly utilized for video-based clinical services.B. Video software platforms should not be used when they include social media functions that notify users when anyone on a contact list logs on. Many free video chat platforms have this function as a "default setting," that should be changed before providing video-based clinical services. Device CharacteristicsUse professional grade or high quality cameras and audio Personal computers should have up-to-date antivirus software and a personal firewall installed. Providers should ensure their personal computer or mobile device has the latest security patches and updates applied to the operating system and third party applications Provider organizations should utilize mobile device management software to provide consistent oversight of applications, device and data configuration and security of the mobile devices used within the organization.In the event of a technology breakdown, have a backup plan in place: Communicate to the patient prior to starting a session and review the technology backup plan on a routine basis.The plan may include calling the patient via telephone and attempting to troubleshoot the issue together.The plan may also include providing the patient with access to other mental healthcare. If the technical issue cannot be resolved, the professional may elect to complete the session via a voice-based telecommunication system.ConnectivityThe ATA Practice Guidelines for Video-based Online Mental Health Services also provide detailed information regarding bandwidth, video conferencing software and internet connections.PrivacyThe ATA Practice Guidelines also provide very detailed information on the issue of privacy in relation to the following:Videoconference software having the capability of blocking the provider’s caller ID at the request of theproviderAudio and video transmission securityUsing mobile devicesUsing videoconference software that does not allow concurrent session to be opened by a single userStorage of session logs in a 3rd party location must be secure and access only to authorized usersPHI and other confidential data should only be backed up or stored on secure data storage locations – cloud services that can’t achieve compliance should not be used to store this dataProfessionals may monitor whether any of the videoconference transmission data is intentionally orinadvertently stored on the patient or professional’s computer hard drive and educate patients about the potential forinadvertently stored data and patient information and provide guidance on how best to protect privacy.Recordings should be encrypted for maximum security and access granted only to authorized users
Qualification and Training of ProfessionalsProfessionals must receive education and training on how to conduct videoconferencing in supervised settings and those without readily available clinical staff. Also need to determine whether there are site-specific credentialing requirements where the patient is located.Documentation and Record KeepingThis section pertains to:1. Maintaining an electronic record for each patient that has been provided remote services 2. Treatment plans must meet professional discipline standards and guidelines 3. Remote services must be accurately documented with dates, type of service(s) and duration 4. Documentation must meet jurisdictional and federal laws and regulations 5. All communication with patients must be documented 6. Requests for access to records requires written authorization from the patient (including audiovisual data from sessions).7. Billing and administrative data must be secured to protect confidentialityPayment and BillingBefore providing services, the patient must be aware of financial charges and arrangement for payment completed.
Lionrock is a Joint Commission-accredited Intensive Outpatient Program that provides online addiction treatment based out of Mountain View, CA. Clients meet by secure video conference from the privacy of home for group and individual therapy. Lionrock uses state-of-the-art online videoconference technology, encrypted for security and streamed in high-definition video.All communications are handled by a HIPAA-compliant information system. The screen shot above is demonstration of a counselor leading clients (actors) through a group therapy session.http://www.lionrockrecovery.com/online-intensive-outpatient/addiction-treatment-group-video/
This section will discuss how professionals using telehealth (TH) technologies connect differently with clients than in a face-to-face setting. The TH technologies to be covered in this section include telephone, e-mail and chat.The stump speech has provided a great deal of information around using TH technologies to deliver counseling services in regard to the type of computer and software requirements, confidentiality, privacy, portability, reimbursement and ethics yet there is another important aspect and that has to do with client engagement. What skills are needed to build rapport and conduct counseling with clients when utilizing TH technologies such as telephone, chat and email? How do we adapt our basic counseling skills for use in an electronic environment?
Fast or touch-typing: e-mail and especially chat TH technologies may be frustrating for the “hunt and peck” typistInternet modalities and software include instant messaging (IM), chat, email, downloading the latest software program when necessary. Tolerance for technical problemsPrevious online relationships: Ask the audience to consider their own online relationships, e.g., texting, chatting or e-mailing with friends, family, co-workers and how those experiences have impacted the relationships and increased skill sets in electronic communications. Lessons learned about tone, ALL CAPS, reply all, emoticons are part of the personal skill set that both professionals and clients bring to a therapeutic relationship developed through telehealth technology delivery.
In regard to telephone counseling, Rosenfield (2003) says it takes practice for a counselor to learn to trust their “inner ear” and rely only on what they are hearing. Changes in inflection and silences for prolonged periods can represent a communication. The counselor needs to be more interactive and the response style recommended is quick, brief and frequent. Very intensive form of counseling Telephone silences may seem longer than in person and Rosenfield (1997) suggests the counselor break silences that last longer than a minute on the telephone. Just as in face-to-face sessions, it would be important to take into account what was said prior to the silence and counselors may need to provide more reflections, paraphrasing and summary on the telephone.Be ready for unintended distractions or intrusions such as emergency vehicle noise, lawn mowers or other phones/fax machines. Important to reassure the client that no one else is listening-in or can over hear the conversation.
An example of warmth & caring might be conveyed to client by using visual imagery such as “I have a visual image of you trying to juggle your recovery, commitments to family and search for a new job.” This is also seen in descriptive immediacy but is an immediate visual reflection and often used in the beginning or end of the e-mail message, e.g., “I can see you sitting at your meeting, John, trying to be present but distracted and worrying about completing your job application and going to your son’s baseball game.”Writing style should be conversational and less formal and contain frequent use of the client’s name. Attention should be paid to the writing style of the client as well as an indicator or cue to the client’s issues.Suler, J.R. (2004). The psychology of text relationships. In Online Counseling: a manual for mental health professionals (R. Kraus, J. Zack & G. Striker, Eds). London: Elsevier Academic Press. (Lesson 11 DCC Final)
Successful Treatment Outcomes: In Gainsbuby & Blaszczynski (2011) A systematic review of Internet-based therapy for the treatment of addictions,one finding indicated that in several trials where clients used emails, telephone calls and websites as part of their treatment options, they were more likely to have successful treatment outcomes. A review of addiction treatment attrition rates found that clients would remain in treatment longer if the treatment were conveniently located, and they received rapid responses and individualized attention from their counselors (Stark 1992). Using Telehealth technologies to deliver treatment services can provide this convenience, rapid response and individualized attention.Counselor and Client Suitability:Rosenfield (2003, in Goss & Anthony, pp. 100-101) indicate that some clients and counselors may not be good candidates for telephone counseling. Less verbal individuals or those with accents or hearing difficulties may not feel comfortable working over the telephone. Chechele & Stofle, 2003, in Goss & Anthony, p. 48, point out that clients considering online counseling must have a basic grasp of written language and be able to express themselves in writing. These clients may also want time to edit and reflect on their communications with the counselor. Clients who prefer chat usually want a more intimate real-time connection without “lag time” between their communications.In Online Counseling: A Handboook for Mental Health Professionals (2003), Skinner and Latchford address multicultural issues and the impact of distance counseling. For example, if the counselor and client don’t speak the same language misunderstandings can occur and successful deliver may be further impacted by lack of visual or auditory cues when using telehealth technologies.
Note to TrainerIn presenting this slide and the five others that follow, please allow participants to read them on their own. SourceKazdin, A.E. & Blase, S.L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37.Perle, J.G. & Nierenberg, B. (2013). How psychological telehealth can alleviate society’s mental health burden: A literature review. Journal of Technology in Human Services, 31(1), 22-41.
However as we discussed early in this course, there are many people needing treatment but not receiving it for a variety of reasons. One of those reasons is lack of access to services. The is especially true in frontier/rural areas of the country.SourceKazdin, A.E. & Blase, S.L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37.Perle, J.G. & Nierenberg, B. (2013). How psychological telehealth can alleviate society’s mental health burden: A literature review. Journal of Technology in Human Services, 31(1), 22-41.
The technology and resources are available to begin to overcome the substance use disorders treatment burden and make services more available. SourceKazdin, A.E. & Blase, S.L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37.Perle, J.G. & Nierenberg, B. (2013). How psychological telehealth can alleviate society’s mental health burden: A literature review. Journal of Technology in Human Services, 31(1), 22-41.
The question of “How do we facilitate the shift?” hopefully has been demonstrated in this presentation and is summed up in the next two slides…SourceKazdin, A.E. & Blase, S.L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37.Perle, J.G. & Nierenberg, B. (2013). How psychological telehealth can alleviate society’s mental health burden: A literature review. Journal of Technology in Human Services, 31(1), 22-41.
To sum up –Whether it is group counseling in the traditional way or group counseling through videoconferencing ...
. . . or client homework using the old relapse prevention workbooks or using interactive voice response . . .
Again, we believe telehealth is in the best interest of clients AS WELL AS the providers as we are looking to telehealth to help expand access and enhance treatment services to the rural and frontier areas. It is imperative that addiction treatment agencies look at offering services via telehealth technologies to address barriers to treatment and reach those who need help and are not receiving it. For example: NIDA and the Addiction Technology Transfer Centers (ATTCs) are working together to create web-based applications to add to already existing client services, e.g., NIDA-CTN-0044; Web-Delivery of Evidence-Based, Psychosocial Treatment for Substance Use Disorders – (TES).Source Clinical Trials Network, Dissemination Library: http://ctndisseminationlibrary.org/protocols/ctn0044.htm
Catch the Wave:It’s your choice! There is a wave of technology and it is beginning to crest.You can stay on the beach or grab your surf board and ride the wave.We are moving forward with the new way of offering treatment services you don’t want to miss the ride.Next, we will begin to discuss organizational change management, levels of individual resistance to change, types of telehealth readiness, influence implementation effectiveness of telehealth, and the Telehealth Capacity Assessment tool to engage organizations into adopting telehealth services.
Some presenters like to take questions along the way, while others like training participants to save their questions to the end. It is up to the presenter to determine what will work best given their presentation style and the training participants needs.
Telehealth: It's Not about the Technology, It's about Expanding Access and Enhancing Treatment Services
National Frontier & Rural ATTC
Terra Hamblin, MA
James Von Busch, PhD
• Data and Definitions
• Use of Technology
• Barriers to Treatment
• Telehealth Technologies
• Privacy, Confidentiality, Security
• License Portability
• Development of Therapeutic
Alliance Using Technology
Over half of the country’s land mass
is designated as frontier or rural
(NRHA, 2008; USDA, 2000)
Approximately one quarter of the U.S.
population (62 million people) lives in
16-20% of those individuals experience
substance dependence, mental illness, or
co-morbid conditions (NRHA, 2008)
Individuals residing in remote areas have
- higher mortality rates,
- higher suicide rates, and
- more severe alcohol/drug problems
(Baca et al., 2007; Goldsmith et al., 2002)
Studies show that those residing in rural
areas use substance abuse treatment less
often than those in urban areas because
of individual, structural, and geographic
barriers, as well as the stigma associated
with receiving treatment
(Finfgeld-Connett & Madsen, 2008; Oser et al., 2012)
(Finfgeld, 2002; Finfgeld-Connett & Madsen, 2008)
In rural vs. urban areas
• Perceived lack of privacy
• Women more stigmatized than men
lowest concentration of mental health
professionals was found in frontier/rural areas
(counties with less than 10,000 people)
2009 workforce study
(Ellis et al., 2009; HRSA, 2011)
‘the use of telecommunications and
information technologies to provide
access to health information and services
across a geographical distance’
‘use of medical information exchanged
from one site to another via electronic
communications to improve patient
(Institute of Medicine (IOM), 2012)
• Synchronous communications
• Asynchronous Communications
- Web-based programs
• Some telehealth technologies include
both type of communications
is not new
(Aronson, 1977; Backhaus et al., 2012; IOM, 2012; Wittson et al., 1961; Wittson & Benschoter, 1972)
Annually, 10 million
146 hospitals provided 55,000 community-based
outpatient clinic patients with 140,000 telemental
6,700 patients received home-based telemental health
25% decrease in hospitalization for receiving telemental
health services between 2006-2010
30% reduction in admissions during the first 6 months
of care in 2011
(Darkins et al., 2008; IOM, 2012)
Indian Health Services (IHS)
• serves 2 million American Indians
and Alaska Natives representing
566 federally recognized tribes
• includes 600 hospitals, clinics, and
health stations under tribal
• implemented mobile telemedicine
services in the 1970s
• Alaska Federal Health Care Access
Network utilizes telehealth
• Telenutrition Program - 2006
Addiction Treatment Lags Behind
There are few published works on the use of
telehealth technologies to provide or enhance
substance abuse services in rural areas.
(Balas & Boren, 2000; Benavides-Vaello et al., 2013; Ryan & Gross, 1943)
• In 2009, Addiction Treatment Providers
in 16 of the 37 states responding to
the survey reported offering treatment
services using telehealth
• Of those 37 states, 25 reported
providing mental health treatment
services using telehealth
85%of American adults have
53%have smart phones
(Pew Report, 2012)
80%send and receive
(Pew Report, 2012)
Over HALF have gathered health
information on their phone
Almost 20% have a health app
(Pew Report, 2012)
use the Internet
(Pew Report, 2012)
(McClure et al., 2012)
• Survey of 8 urban drug treatment
clinics in Baltimore (266 patients)
• Client’s access to
- Mobile Phone (91%)
- Text Messaging (79%)
- Internet/Email/Computer (39 - 45%)
What do we know about clients?
• WellPoint Inc., the nation's second-biggest health
insurer, plans to offer a new service in all of its
employer and individual plans that will allow
people to consult with physicians on-
demand, using laptop webcams or video-enabled
tablets and smartphones
• Aetna Inc. and UnitedHealth Group Inc., offer
virtual-visit services as an option for certain
(Wall Street Journal December 31, 2012)
Survey by Mercer found
15% of very large employers use
some form of telemedicine, and
another 39% are considering it
Home Depot Inc., Booz &Co., and
Westinghouse Electric Co.
(Wall Street Journal December 31, 2012)
19.3 million people needed but did not receive treatment
for illicit drug or alcohol use
Did not feel
In 2011, 20.6 million people aged 12 or older met
the criteria for substance use disorders
Felt they needed
treatment – Did not
make an effort
Felt they needed
treatment – Did
make an effort
Travel Costs and Burden
Time Away From Work
Lack of Service Providers
(Perle et al., 2011; Swinton et al., 2009)
(Moyer & Finney, 2004/2005)
How do we facilitate a shift that will give
addiction treatment providers greater reach
and tools to serve the population that
experienced barriers to treatment and those
that needed but didn’t receive treatment?
(Kazdin & Blase, 2011; Perle & Neirenburg, 2013)
Largest provider of telemental health services
(Godleski et al., 2008; Darkins et al., 2008; IOM, 2012; Deen et al., 2012; Godleski et al., 2012)
Systematic Review of
• Patients and providers perceived a strong therapeutic
alliance over videoconferencing
• Studies that compared videoconferencing to in-person
psychotherapy reported similar satisfaction levels
between the conditions
• high levels of satisfaction and acceptance with
telemental health have been consistently demonstrated
among patients across a variety of clinical populations
and for a broad range of services
(Backhaus et al., 2012)
Videoconferencing Studies in
• Opioid Treatment-group counseling
(King et al., 2009)
• Alcohol Treatment
(Postel et al., 2005)
• Alcohol Treatment
(Frueh et al., 2005)
• Teleconferencing Supervision (TCS)- MI
(Smith et al., 2012)
(Backhaus et al., 2012)
Use of computers to deliver some
aspects of psychotherapy or behavioral
treatment directly to patients via
interaction with a computer program
(Carroll & Rounsaville, 2010)
To date, more than 100
different computer-assisted therapy
programs have been developed for a
range of mental disorders and
behavioral health problems
(Klein, et al., 2012; Marks et al., 2007; Moore, et al., 2011)
(Bickel et al., 2008; Carroll & Rounsaville, 2010;
Des Jarlais et al., 1999; Marsch, 2011)
• Serve as Adjuncts to standard treatment
• Save clinician time
• Extend clinician expertise
• Integrate other EBTs to provide additional services
to clients with co-morbid conditions
• Provide access to computerized smoking cessations
programs or other health-related conditions
(Carroll & Rounsaville, 2010)
“Delivery of CBT could be subcontracted
to the computer…..”
(Carroll & Rounsaville, 2010)
Examples of Computer-Based Interventions
• CBT4CBT (Carroll et al., 2008)
– Outpatient clients
– CBT + 6 computer modules on CBT
• TES [Therapeutic Education System] (Marsch & Bickel, 2004)
– Community Reinforcement Approach + Incentives
– HIV/AIDS Intervention-Opioid treatment clients (2004)
– Outpatient Opioid Treatment- TAU + TES (2008)
– Outpatient Treatment-2hrs per week of TES + TAU (2012)
• Ondersma (2005/2007)
– single-session computer-delivered MI intervention reduced drug
use among postpartum women
Mental health professionals are now
employing virtual worlds in treating
• Asperger Syndrome
• Combat-related PTSD
(Reger & Gahm, 2008; Wood et al, 2009)
• Emotional Aspects of Physical Disabilities
(Chen et al., 2009)
Computer Simulation Games
• Male Veterans
– adjunct to treatment
– focused on relapse prevention
– Played computer simulation game for 8 weeks
– no different in relapse rates
– results show decreases in craving and
increases in self efficacy
(Verduin et al., 2012)
Web-Based Disease Management
(Gustafson et al., 2005)
(Glasgow et al., 2005; Williams et al., 2007)
• Heart Disease
(Verjejjden et al., 2004)
• Mood Disorders
(Farvolden et al., 2005)
Web-based Disease Management
Programs - Addiction
• MORE (My Ongoing Recovery Experience)
– 7 recovery modules-content tailored
– 18 month period
– Access to counselors and other individuals
(Klein et al., 2012)
Telephone Continuing Care for SUDs
• Telephone Monitoring and Adaptive Counseling (TMAC)
• Focused Continuing Care (FFC) (Betty Ford Clinic)
• Telephone Enhancement of Long Term Engagement (TELE)
(Hubbard et al., 2007)
• Individual Therapeutic Brief Phone Contact (ITBPC)
(Kaminer & Napolitano, 2004) ADOLESCENTS
• Telephone Case Monitoring (TCM)
(McKellar et al., 2012)
• Telephone Continuing Care (TCC)
(Godley et al., 2010)
Interactive Voice Response
• Automated, computer-based interventions have
shown promise in treating substance use disorders
• Fully automated systems offer a number of
potential advantages including:
– low cost
– consistent delivery
– greater accessibility and availability of treatment
– increased flexibility of scheduling and convenience
(Cranford, Tennen, & Zucker, 2010; Mundt, et.al., 2006)
Enhancement Support System (ACHESS)
• Explicitly designed to address three constructs
– coping competence
– social support
– autonomous motivation
• Primary hypothesis is that ACHESS will reduce
risky drinking days
“Given the elusive nature of motivation to
change substance use-related behaviors…
it is important to capitalize on the
Immediacy of many
Privacy, Security, & Confidentiality
Issues with Telehealth
Privacy, Security, & Confidentiality
• HIPAA Privacy Rules - What situations can
individual health information be disclosed, no
matter its format (oral, paper, or electronic)?
• HIPAA Security Rules - How are disclosures in
electronic format made?
(Karasz et al., 2012; www.hhs.gov/ocr/privacy/hipaa/understanding/srsummary.html)
Privacy & Security
Rules are Different
Final Rule specifically states because "paper-to-
paper" faxes, person-to-person telephone calls, video
teleconferencing, or messages left on voice-mail
were not in electronic form before the transmission,
those activities are not covered by this rule (p. 8342).
To ensure the patient’s privacy during
treatment sessions, clinicians should consider
the use of HIPAA compliant portals or
encrypted videoconferencing software.
More than one-third of cell phone users
• have sent a text message to
the wrong person (38%)
• report that a text they sent
was misunderstood by the
“Traditional Short Message Service (SMS)
text messaging is non-secure and non-
compliant with safety and privacy
regulations under HIPAA. Messages
containing ePHI can be read by
anyone, forwarded to anyone, remain
unencrypted on telecommunication
providers’ servers, and stay forever on
sender’s and receiver’s phones.”
“It is not acceptable for physicians or
licensed independent practitioners to text
orders for patients to the hospital or other
healthcare setting. This method provides no
ability to verify the identity of the person
sending the text and there is no way to keep
the original message as validation of what is
entered into the medical record.”
The Joint Commission November 10, 2011
CCHP Report Highlights
• 44 states have a form of TH reimbursement
• Live video most prominent reimbursed
• 7 states provide Medicaid reimbursement
remote patient monitoring
• 10 states require informed consent
• 9 medical boards issue special
licenses/certificates for TH
• 13 states have pending legislation on TH
“No two states are alike in how
telehealth is defined and regulated.”
Who Pays for
Medicare has the Most
prescriptive policies for telehealth
• Type of service (real-time)
• Facility Type
• Practitioner Requirements
• Allowable Codes
Medicare does not reimburse for
“store and forward technology”
so the interaction between a
beneficiary (patient) and the
practitioner must be real-time.
must be located in a
Rural-Health Provider Shortage Area
Non-Metropolitan Statistical Area county
Federal telemedicine demonstration
project (Alaska and Hawaii)
Medicare Telehealth Reimbursement
• Services delivered through telehealth
technologies are billed at the same rate
• Originating site of service may bill separately
• Real time communication through audio or
video technology is required
• Patient must be present at originating site
CMS is proposing to modify how rural
sites are defined to be consistent with
HRSA Office of Rural Health Policy
• Nurse practitioners
• Physician assistants
• Nurse midwives
• Clinical nurse specialists
• Registered dietitians or nutrition professionals
• Clinical psychologists (CP) and clinical social
States Define …
• Telehealth eligible services
• Populations to receive services
• Qualified practitioners
• Telehealth service location
• Define the services delivered in managed care
vs. fee for service arrangements
Medicaid’s Three-Legged Stool
Person covered by Medicaid
Service (the use of interactive audio and video
AND the actual service provided) is covered by
Provider is Medicaid registered and practicing
within the State’s scope of practice
• 32.5K adults ages 18-64 with substance use
disorders will have coverage for substance use
treatment under Medicaid expansion
• 52K adults ages 18-64 with substance use
disorders will have coverage for substance use
treatment within the Health Insurance Exchange
• This represents a two times increase in the
estimated prevalence within the existing eligible
Medicaid population (currently 37K)
• Mental health evaluation or management
service, individual or group psychotherapy, and
• licensed professional clinical counselor
• licensed clinical social worker
• licensed marriage and family therapist
• Either mandated in state law or
left up to carrier to decide
• No consistent standards
• 19 states require coverage
• 26 pending legislation
Use of technology
• is increasing
• presents unique
(NBCC Policy, 2013)
Need to be
• NAADAC (Association for Addiction Professionals)
• National Board of Certified Counselors (NBCC)
• American Counseling Association (ACA)
• American Mental Health Counselor Association
• American Association of Marriage and Family
• National Association of Social Workers (NASW)
Ethical Codes Related to the use of Technology
American Psychological Association (APA)
• recognizes the need for development of
• in 2011 approved a joint task force to
develop telehealth guidelines for
• telehealth technologies are not currently
included in the APA Code of Ethics
International Certification & Reciprocity Consortium
• does not create or maintain a Code of Ethics
• IC&RC member boards deal with matter
individually and recommends contacting
member boards directly
• contact information for all member boards
can be found at
Ethical Codes related to 4areas of
• Informed Consent
• Records & Data
(NAADAC Code of Ethics, Rev. March 28, 2011)
Can a meaningful clinical relationship be
developed if a client and counselor do not
share the same physical space?
(Chester & Glass, 2006)
Therapeutic Alliance Using
• Synchronous communications
• Asynchronous Communications
- Web-based programs
• Some telehealth technologies include
both type of communications
Therapeutic Alliance Building Using
• Active listening
• Verbal engagement
• Emotional engagement
Verification of Location
• Compliance with relevant licensing laws
• Emergency management protocol is dependent
upon where the patient receives services
• Mandatory reporting and related ethical
• Provider payment amounts are tied to location
Who do you report to?
• Contact Information
Verification for Professional
• Verification of Expectations
Regarding Contact Between
To date, no studies have identified any
patient subgroup that does not benefit
from, or is harmed by, mental healthcare
provided through remote videoconferencing.
What about panic
(Day, 2002; O’Reilly et al., 2007; Ruskin et al., 2004)
Considerations where professional staff are not
• Patient expectations & level of comfort
• Patient takes an active & cooperative role
• Patient’s organizational & cognitive capacities
• Patient’s Abilities with Technology….
responsible for equipment set-up, maintenance
of computer settings, and privacy at his or her
site along with technology competency
• Geographic distance to nearest emergency
medical facility, patient’s support system and
What is their
• Follow local, regional and national laws
• Document consent in medical record
• Information included is same as in-person
• Emergency Plan
• How patient information is documented
• Technical failure
• Contact between sessions
• Referrals to more intensive care
• Aim to provide comparable professional
specifications of a standard services room
1. Education and Training
2. Jurisdictional Mental Health
Involuntary Hospitalization Laws
3. Patient Safety in a Setting with
Immediately Available Professionals
1. Patient Safety in a Setting without Immediately
2. Patient Support & Uncooperative Patients
4. Local Emergency Personnel
Absence of face-to-face cues
Skills/Attitudes when working via telephone
• Welcoming manner
• Voice tone/style
• Interactive nature
• Structure-checking in
(Center for Credentialing & Education, 2011)
“It takes practice for a
counselor to learn to
trust their “inner ear”
and rely only on what
they are hearing.”
For the Client
For the Counselor
Development of Therapeutic Alliance
using Telehealth Technologies
Skills/Attitudes when working via e-mail
• Warmth & Caring
• Descriptive Immediacy
• Similes, metaphors and stories
• Writing style (font, captions, colors)
• Empathic mirroring
“I HAVE A VISUAL IMAGE OF YOU
TRYING TO JUGGLE YOUR
RECOVERY, COMMITMENTS TO FAMILY
AND SEARCH FOR A NEW JOB.”
WARMTH and CARING
“I CAN SEE YOU SITTING AT YOUR
MEETING, JOHN, TRYING TO BE PRESENT
BUT DISTRACTED AND WORRYING
ABOUT COMPLETING YOUR JOB
APPLICATION AND GOING TO YOUR
SON’S BASEBALL GAME.”
WRITING STYLE SHOULD BE
CONVERSATIONAL AND LESS FORMAL
AND CONTAIN FREQUENT USE OF THE
CLIENT’S NAME. ATTENTION SHOULD BE
PAID TO THE WRITING STYLE OF THE
CLIENT AS WELL AS AN INDICATOR OR CUE
TO THE CLIENT’S ISSUES.
Successful Treatment Outcomes
• Extensive literature on use of the telephone
• Less literature on use of email and chat
(Gainsbuby & Blaszczynski, 2011)
• Less verbal individuals or those with accents or
hearing difficulties may not feel comfortable working
over the telephone
• Clients who prefer chat usually want a more intimate
real-time connection without “lag time” between
• Clients considering online counseling must have a
basic grasp of written language and be able to express
themselves in writing. These clients may also want
time to edit and reflect on their communications with
There will always be a place for
face to face treatment….
(Kazdin & Blasé, 2011; Perle & Nierenberg, 2013)
However, something must change…
to overcome the limitations facing the
field and the notion that mental
health care services are often not able
to reach all those in need, particularly
those in rural or remote areas.
(Kazdin & Blasé, 2011; Perle & Nierenberg, 2013)
Reach all of
those in need
(Kazdin & Blasé, 2011; Perle & Nierenberg, 2013)
A major shift and expansion of
clinical practice must occur to
overcome the mental health burden
and facilitate positive change.
(Kazdin & Blasé, 2011; Perle & Nierenberg, 2013)
From this, the question becomes,
how do we facilitate this shift that
will give mental health professionals
greater reach and tools to serve the
Greater reach & tools =
Whether its Group Counseling
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