774W - How Can I Legally Practice Telehealth Over State Lines and International Borders?

Practicing Across State lines and
International Border?
Optimizing Telehealth Podcast
Episode 4
Marlene Maheu, PhD
Shawna Wright, PhD

Telebehavioral Health
Institute (TBHI)
CME and CE Training, Consultation & Staffing

Shawna
Wright
PhD
Dr. Shawna Wright is the Associate Director of
KU's Center for Telemedicine & Telehealth.
She is a licensed psychologist who established
an independent telepsychology practice in
2011. Dr. Wright has expertise with treating
rural and underserved populations, and
regularly advocates for telehealth expansion to
increase behavioral health access and equity
in her home state of Kansas. She serves on
several statewide committees as a telehealth
expert.
Dr. Wright enjoys telehealth training and
consultation with a wide variety of professional
groups.

Marlene
Maheu
PhD
For almost thirty years, Dr. Maheu’s focus has
been on telehealth legal and ethical risk
management & compliance. She has served on
a dozen professional association committees,
task forces and work groups related to
advancing telebehavioral health as well as
establishing standards and guidelines for
telebehavioral health. She has written 40+ of
peer-reviewed telehealth book chapters and
journal articles and is the lead author of five
telehealth textbooks.
She enjoys giving telehealth keynotes, training,
consulting and helping organizations meet their
staffing needs.

And there’s you! Please introduce yourself with state, profession and specialty …

Today’s
Program
• Slide and recording access 24/7 for 6
months. Login is required. Please respect
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training to limit uncontrollable
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but if possible, please show yourself to
support the group process and learn from
each other.
Copyright 2021 Telebehavioral Health Institute, LLC All rights reserved.

Today’s
Program
• LIVE CME or CE if you arrived within 15
min. of start, stay the entire time, interact
AND complete the post-test today.
• Otherwise, you will receive a course
completion that awards you
asynchronous course credit hours.
• Ask short questions as we speak.
• Interactive, discussion format.

Today’s
Program
• To get 1 CME or CE, complete the
course evaluation and post-test that are
in left side-bar, underneath the yellow
button that you clicked to enter this
room.
• You are automatically enrolled into our
in-house community news mailings.
• Lock your door, turn off your
phone/email, and strap yourself in 🡪 we
are about to get focused on Optimizing
Telehealth!

1 CME or CE Credit Hour
Learning Objectives
1. Identify at least five telehealth issues regulated
differently by different state boards.
2. Name the various groups who define if and how you can
legally practice over state lines.
3. Identify a free, federally funded resource to help you
identify current and future state laws related to
interjurisdictional practice.

Dr.
Jones
• Works at a college counseling center and sees
approximately 10-15 students per week.
• Transitioned all of his clients/patients to
telehealth services during COVID
• All students were also transitioned to the
university’s online learning platform.
• While many of the students in Mr. Jones’s care
returned to living with their families in state,
about 10% of his clients/patients moved out of
state to be with their families.
• Due to the highly stressful nature of the COVID-
19 Pandemic, most students wanted to maintain
counseling services through telehealth
regardless of their physical location.
• Dr. Jones only maintains a license to practice in
his state of residency.

Coalition for Technology in
Behavioral Science (CTiBS)
An Interprofessional
Framework
for Telebehavioral
Health Competencies
(2018)
Website: CTiBS.org

CTiBS TBH Competency Domains
(We will look at 3 today)
Clinical
Telepresence
Technical mHealth
Ethical &
Evidence-Based
Legal &
Regulatory
Practice Development
7 Domains
An
Interprofessional
Framework for
Telebehavioral
Health
Competencies

What is interjurisdictional
practice?
• Licensing Boards/Colleges that may assert
jurisdiction:
• The one in the professional’s state(s) /
province(s)of licensure
• The one in the client/patient’s state/province of
location at the time of contact
• Safest Practice:
• Provide services only where licensed
• Require patient to attest to his or her
location at every contact

What licensing and regulation
issues should mental health
providers keep in mind before
practicing over state lines?
• Adhere to federal, state, county & city
laws
• Regulations impact all your actions as
a professional
• Read the licensing rules for your
discipline in your state(s) of practice
• Check with your board – get response
in writing
• Examples

Licensing Rules Do Not Change with
Different Technologies
Telephone
Video
Email Apps
Remote
Patient
Monitoring
Text
Messaging

What are licensing boards
doing to support telehealth?
• Actively researching telehealth now
• Issues are complex
• Many haven’t yet decided how to proceed
• Legislative limitations
• Budgetary limitations

How can behavioral health
professionals advocate for
telehealth with their
licensing boards?
• Write your licensing board directly
• Collaborate with your state-level
professional organizations
• Boards don’t know what you need if you
don’t tell them
• COVID-19 implications

Available as a PDF at:
https://www.socialworkers.org
/includes/newIncludes/homep
age/PRA-BRO-
33617.TechStandards_FINAL
_POSTING.pdf
NASW, ASWB, CSWA
& CSWE Technology
Standards

Social Work
Technology
Standards,
Standard 2.06
Competence

Does practicing over state lines
affect my malpractice
insurance?
• Write to your malpractice carrier and
describe your proposed service
• Notify your carrier of every state you
“enter” to deliver care
• Can be nullified if practitioner is
practicing criminally
• For benefits to apply, must have a formal
client agreement for clinician to be
considered as providing professional
service

Can you recommend some risk
management strategies? • Check with an informed, local attorney
who specializes in telehealth.
• Verify that your telepractice is in
compliance with law in all relevant state(s)
• Conduct practice set-up sessions

How do I establish my client’s
location?
• Opening protocol: Ask client/patient to
“attest” to location
• Document their response
• Informed consent
• If not in your state(s) / province(s) of
licensure, ask about whether it is an
emergency
• Use an emergency protocol

Interjurisdictional Practice Models
• Psychologists: The Association of State and Provincial
Psychology Boards (ASPPB) 🡪 Psychology
Interjurisdictional Compact (PSYPACT). For information:
https://psypact.site-ym.com/?
• Counselors: Leadership shown by the American Mental
Health Counselor’s Association (AMHCA)
• Psychiatrists: Federation of State Medical Boards (FSMB)

www.cchpca.org

What should I know about
mandated reporting when I
practice interjurisdictionally?
• Duty to report/warn
• Inform clients/patients of your remote
safety policies in your informed consent
process
• National Conference of State Legislators –
Duty to Warn Differences Across States
• http://www.ncsl.org/research/health
/mental-health-professionals-duty-to-
warn.aspx

https://www.ncsl.org/research/health/menta
l-health-professionals-duty-to-warn.aspx

https://www.cchpca.org/
US Federal & State Issues

Copyright 1994-2021 Telebehavioral Health Institute, LLC All rights reserved.
https://www.cchpca.org/res
ources/covid-19-related-
state-actions

https://www.cchpca.org/reso
urces/covid-19-related-state-
actions

Kentucky State
Board Affidavit to
practice in Kentucky
during COVID-19 🡪
Search for state board
websites in your
profession
Copyright 1994-2021 Telebehavioral Health Institute, LLC All rights reserved.

How Do You Document
Practicing Over State/Provincial
or International Borders w/o a
License?
• Do you document within the
progress note?
• Beneficence vs. maleficence

International
Practice
❖ Where you will be and who you will serve?
❖ In U.S. and serving another country?
❖ In another country and serving U.S.?

International
Practice
❖ Does your profession have a licensing
board in the foreign country?
❖ Speak to your regulatory association
❖ Contact the U.S. embassy for the
intended country

International
Practice
❖ Will you try to collect reimbursement while
your feet are on foreign soil?
❖ Allowed by some insurance companies
❖ Not allowed by Medicare

Tech Talk Time
Tech-Talk Time
Which technologies or products are
related to today’s episode?

https://www.ebglaw.com/telemental-health-laws-app/

FindingLicensing
Information
Look at the regulatory board website
for your profession
Also write to the regulatory
association for your profession:
ASPPB.org – Psychology
AASCB.org – Counseling
FSMB.org – Medical (Psychiatry)
ASWB.org – Social Workers
AMFTRB – MFTs
NCSBN - Nursing

Finding Licensing
Information
Visit websites; read licensure
information with an eye to
telehealth, even if the word is
not mentioned; write to all
involved state, provincial and
national licensing boards to
get requirements
(www.statename.gov)

How to Get
Telehealth Licensing
Information
Contact your
professional
association (ethical or
legal office)

How to Find
Licensure
Information
Write to your
malpractice carrier to
ask about your
telehealth coverage.

Dr.
Jones
• Dr. Jones reviewed the Center for Connected
Health Policy website for background and
direction for addressing his clients’ needs and to
avoid abandonment during the pandemic.
• Dr. Jones identified the states where his
students were residing during the pandemic and
reached out to their licensing boards.
• Dr. Jones updated his telehealth informed
consent form to include details about the
importance of identifying/verifying the client’s
location at every session and the limits of
telehealth availability based on state law.
• Dr. Jones contacted his university’s legal office
for input and guidance about his informed
consent procedure.
• Dr. Jones developed and implemented an
standard opening protocol that he now uses
with every telehealth session.

Keep in touch! ☺
Telehealth.org
contact@telehealth.org
619-255-2788

774W - How Can I Legally Practice Telehealth Over State Lines and International Borders?

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