Managing Real-Time Telepsychology Practice
Telepsychology or real-time videoconferencing for clinical purposes addresses gaps in accessible psychological services, particularly in rural communities. Videoconferencing allows the client and the psychologist to talk with each other and observe nonverbal behavior in real time, approximating the relationship developed in onsite therapy. The visual component in videoconferencing creates a social presence that promotes familiarity, connectedness, and comfort discussing complex topics.
In the absence of national telepsychology-specific guidelines, psychologists rely on the American Psychological Association’s ethics code (2002) that “In those emerging areas in which generally recognized standards for preparatory training do not yet exist, psychologists nevertheless take reasonable steps to ensure the competence of their work and to protect clients, students, research participants, and others from harm.” The core ethical principle to protect the client remains paramount with services over videoconferencing. Attention must be given to clinical, administrative, and technical components of the telepsychology service.
Psychologists considering telepsychology services should first complete a needs assessment within the community to determine perceived interest and availability of such psychological services. This assessment should include candid discussions and meetings across key constituents, including consumers and their families, local mental health professionals, primary care providers, consumer advocates, and other community leaders likely to be affected by telemedicine initiation. Telepsychology works best when seen as complementing or adding to the community’s local care. (p. 691)
The needs assessment should also clarify who the telepsychology service will serve. The choice of who will be seen depends on client/parents’ preferences, developmental and diagnostic considerations, personnel and other resources at the distant site, and the psychologist’s comfort. Telepsychology may be especially suited for younger populations who are often already comfortable and accepting of the technology medium, but there are no data suggesting exclusion based on age. Anecdotally, adolescent clients, in particular, may respond well to the personal space and feeling of control allowed by the televideo system. With telepsychology’s extended reach comes the responsibility of the psychologist to follow all professional standards of cultural competence across ethnicities, languages, genders, religions, sexual preferences, geographies, and other competence areas, including an understanding of the impact of rural culture on the clinical presentation.
Psychologists follow legislative and regulatory requirements at the local, state, and national level when providing services by videoconferencing. Most states require that psychologists are licensed in the state where the client receives service, but psychologists should review state-specific guidelines with their licensure boards. Additionally, institutional requirements concerning credentialing at the client site should be reviewed. Psychologists new to telepsychology should shadow existing providers and be encouraged to seek mentoring from practicing telemental health professionals.
Technological advances in personal com puter-based videoconferencing systems have made inexpensive, user-friendly, reliable videoconferencing more available. With videoconferencing services, the psychologist and distant site must assess the availability of (1) modern, well-functioning televideo equipment; (2) encrypted videoconferencing software; (3) secure clinical space for the equipment setup; and (4) consistent high-speed connectivity. For telepsychology consultations, serious consideration should be given to privacy and security. Most guidelines recommend use of point-to-point encrypted software, with transparent company information about transmission and encryption protocols. Sites sometimes must run an additional network line to support the additional bandwidth requirements associated with televideo services. It is important to discuss payment for equipment, software, and connectivity when establishing the televideo clinic and with ongoing services.
Technicians should support psychologists with strategies to maximize the quality of the videoconferencing encounter. Current videoconferencing speeds have decreased the pixilation/tiling associated with earlier videoconferencing, rendering fewer technical difficulties over time. Important consideration should be given to camera angle, monitor selection, and positioning in order to better facilitate communication. Proper lighting is also important in order for psychologists to clearly see facial expressions and affective responses. Psychologists are encouraged to check in with clients to make sure clients can see and hear psychologists as anticipated. While the technology has the ability to record sessions, the psychologist should discuss with clients that sessions are not videotaped or archived in any way without client knowledge and consent.
Ultimately, the purpose of the psychology clinic should drive the selection of the technology. It is easy to be drawn into the marketing buzz and enthusiasm for the newest technologies; however, the best fit for the outreach purpose may render those technologies less useful, depending on the needs assessment. Similar to other equipment purchases, psychologists should dialogue not only with technology vendors but also with peers who have used the technology as well as telehealth resource centers.
As with establishing any new clinic, it is essential to consider the target population and client characteristics that will affect clinic volume and financial viability (e.g., insurance status, transportation availability, etc.). The psychologist as well as the distant site administrative and clinical staff must discuss the site’s commitment to allow personnel time and space to complete televideo encounters over time. In addition, a written protocol should be established by the psychologist and the client (p. 692) site. This protocol should be revised over time in order to most effectively guide the telepsychology service before, during, and after the telepsychology consult. Key protocol components are described in the next sections.
Referral and Scheduling
Identify psychologist office personnel responsible for scheduling across the client sites (e.g., clinics, hospitals, schools, home, etc.). This person is responsible for coordinating the psychologist’s schedule, the client site schedule, and room availability. As in the face-to-face setting, obtain the referral for the new client and determine whether the client meets the insurance requirements consistent with the practice. Send the client the same paperwork as in the face-to-face setting, often including (a) psychology intake form; (b) registration form, including insurer information; (c) consent form, including telemedicine-specific language; (d) HIPAA-related Notice of Privacy Protection (NPP); (e) previous medical history and documentation; (f) requested lab or other tests prior to the telemedicine encounter; and (g) any other information requested by the telemental health team specific to the consult (e.g., school records/testing, etc.). Best practices related to the transmission of health-related information are followed and the client’s designated medical record is maintained by the psychologist.
Both the psychologist room and the client room are treated as confidential clinical space. Good lighting and quiet, safe, client-friendly space is crucial. The room needs to be large enough to accommodate the client, family, and other relevant community participants (e.g., case managers, teachers, etc.). Test connections are made with new sites. The Picture in Picture feature is often utilized at both the psychologist and client sites. A technician supports the psychologist’s and the client’s equipment to ensure best videoconferencing practices (e.g., that the microphone is not muted, that the camera is focused on the psychologist, that microphones are placed away from the monitor’s speakers, and that the client is aware of any other individuals in the room). The psychologist utilizes the zoom and scan capabilities of the camera if necessary to complete the examination components. Backup plans are in place in the event of technology failure, most often contacting the client site by telephone and discussing appropriate follow-up.
Telepsychology procedures should establish who is expected to attend the appointment (client, family members, case managers, other community members) and who is expected to coordinate the appointment at the distant site (school nurse, clinic nurse, other clinic personnel, etc.). Telepsychology consults, other than in the home setting, most often include a telepsychology coordinator to assist during the consult. The coordinator at the client site facilitates the telepsychology session and often serves as the service “champion.” Psychologists must carefully consider the risks and benefits related to inclusion of a coordinator for their specific clinical purpose. Psychologists often work with coordinators in order to have assistance with the technology, support for the client, and immediate help in the event of safety or other emergent concerns.
Most often, telepsychology sessions approximate all key components of face-to-face sessions both at intake and follow-up visits. The psychologist introduces the client to the telepsychology setting, including a developmentally appropriate explanation of how the technology works. Often, families have utilized videoconferencing for informal communication with family and friends, and it is important to describe the additional security utilized for clinical consultations. Videoconferencing etiquette includes rapport-building strategies and (p. 693) simple adaptations, such as the client showing a photo over televideo or faxing a picture drawn during the session to the therapist. Some programs have utilized innovative solutions such as an online whiteboard, but lower cost measures include mailing common materials/books. Creativity and flexibility before, during, and after the televideo visit facilitate relationship building just as in the onsite setting. The psychologist has full discretion to advise the client/family to be seen in person related to any questions/needs. As in the onsite setting, the psychologist asks a series of questions to gain more information about the client, the current presenting concern, and the relevant history. The psychologist observes the client throughout the session and notes behavior as well as physical presentation (e.g., gait, tics, affect). The zoom feature of the telemedicine camera can assist with this and allow unobtrusive close-up observation of such features. The psychologist completes the same documentation as onsite clinics, including the use of electronic health records when appropriate.
The psychologist and coordinator collaborate to assist the client in understanding and following treatment recommendations and referral suggestions.
The psychologist schedules follow-up appointments based on standard of care practices for the particular diagnosis or concern. The psychologist completes the same releases of information with the client and follows up with the referring provider. If the psychologist is billing for the encounter, the same CPT codes are utilized with the telemedicine (GT) modifier included. The same protocol as onsite visits is utilized for between-session needs of the client/family.
Across telemental health clinics, clients tend to present with the same concerns as seen in traditional clinic settings. No presentation or diagnostic category has been excluded from mental health services over televideo. Due to the fact that clients presenting to telepsychology clinics may have had no previous access to mental health specialists, there may have been significant delays to treatment that may contribute to increased comorbidity and severity of presentations seen through the telepsychology service.
Psychologists should also consider the sustainability of the telepsychology service over time. The initial costs associated with starting telepsychology include equipment and software costs, connectivity/line charges, installation costs, costs of remodeling or adding space, personnel costs associated with telemedicine training, and costs with adding staff to assist with telemedicine or with changing workflow to meet telemedicine responsibilities. Notably, costs decrease over time as client volume increases. Psychologists have used varied initial funding for televideo implementation, including institutional seed money, community and foundational support, state grants, federal funding, billing reimbursement, and contractual agreements. Approximately a half dozen states have legislative requiring that telemedicine services be reimbursed as onsite benefits. A growing number of third-party insurers reimburse telemedicine services, including Medicare, the majority of state Medicaid policies, and many private insurers. Many, but not all, billing codes are covered over televideo, with the addition of a telemedicine GT modifier to the billing code. Some client sites are eligible for Medicare/Medicaid’s originating site fees related to the coordinator assistance. Another option is contractual agreements to cover both psychologist time as well as related costs (e.g., line charges, office management, etc.).
Telepsychology services to primary care settings are anticipated to increase with national and state initiatives around the patient-centered medical home. The medical home model promotes increased coordination and communication between primary care and psychologists. Telepsychology is one strategy to increase access to psychologists in primary care settings. As in other telepsychology settings spanning systems of care, team building and good communication skills remain crucial for a successful delivery of service. New telepsychology models are emerging, including videoconferencing directly to the client’s home. A range of (p. 694) technologies are used for home-based services and psychologists should consider the risks/benefits of the videoconferencing technology, including security and reliability. While access is increased, there is less control over the client’s environment. Psychologists providing service to the home should continue to consider key telepsychology components, including (1) informed consent for telepsychology service; (2) protocols concerning the expected process, including key components discussed in other videoconferencing settings earlier (e.g., scheduling, follow-up, secure environment, backup plans in the event that the technology fails to the home, etc.); and (3) safety plans in the event the client reports suicidal, homicidal, or other safety concerns. Telepsychology services to the home are generally out of pocket. Mobile technologies (e.g., smartphones, tablets, etc.) with video capabilities expand accessibility further, but consideration must be given to the new benefits and risks for the client.
In sum, telepsychology’s utility lies in its ability to connect with individuals in need of psychological services who live in rural or underserved communities. Psychologists considering utilizing this technology should complete a needs assessment at both a community and clinic level in order to address the feasibility of acquiring and using the technology as well as the demand for it. Psychologists who acquire this technology should use it in accordance with APA ethical standards for best practice and develop a working protocol in order to minimize the potential for misuse or error. Additionally, psychologists should be aware that successful telepsychology services are, by and large, a product of a team of professional working together to deliver the service (i.e., technical support, clinical coordinators at both sites, etc.). Furthermore, though telepsychology is often reimbursed to the same degree as in-person psychotherapy, psychologists should weigh the financial burden of implementing this service. Overall, telepsychology offers psychologists new ways of connecting with underserved populations; however, psychologists must be aware of the unique planning and implementations steps this technology demands in order for successful delivery of services.
References and Readings
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