While many clinicians have been serving their clients and patients through telehealth for over a year, many have been reluctant to grow their telehealth practices. They report being unsure of how to proceed, which of course, belies the fact that many do not know that an entire telehealth evidence-base
exists and literally is at their fingertips to help with these issues. The underlying issue, of course, is that most clinicians are practicing telehealth intake without an adequate understanding of the fundamentals involved, a problem that this article is intended to remediate. For those readers who are telehealth aficionados, you will take comfort in my mentioning the fact that the scientific literature has shifted the focus from whether telehealth is appropriate, to how to optimize telehealth services when deciding whether an in-person session is required for good telehealth service delivery to any individual or group.
To be more specific about telehealth intakes and screening, a few scenarios are described below consider when telehealth is appropriate or not
. Let’s start with two key variables related to appropriate telehealth screening: 1) setting and 2) diagnosis.
Telehealth Intake and Screening Scenarios
The three examples below are intended to demonstrate how an understanding of intake and screening can lead to successful outcomes by equipping the clinician with different approaches to the same client or patient, rather than whether or not they have conducted an in-person assessment:
A) Image that your client or patient is in the throes of psychosis and/or suicidal depression (diagnoses) and in a jail cell or in a hospital (a controlled setting). Telehealth has been tremendously helpful in these cases to alleviate local staff from engaging in guesswork related to treatment planning. The setting provides the structure and safety needed for the clinician to conduct their function without worrying about safety or manageability issues that are supplied by staff and the environment. Clinicians in these settings rely on a care team, which frees the clinician to be able to assess, consult, document, and access the care team as needed when other interventions are warranted. The use of telehealth in these settings is considered a consultative model, wherein the distant professionals consult with locally licensed professionals (psychiatrists, primary care physicians, medical psychologists, nurse practitioners, nurses, etc.) to develop a treatment plan, safety plan, and follow-up care.
B) If the same person with the same diagnoses were at home with pre-identified and pre-approved “collaborators” (family or friends establishing the safety of the setting), the collaborators may be guided by the professional and relied upon to support the patient through the crisis. They could most likely be relied upon to get them to a higher level of care as soon as one is available. Religious leaders, AA sponsors, or other trusted professionals are typically identified by the patient in the proper telehealth informed consent process, and the details of contact with these pre-identified parties are thereby included in the consent form. In the case of emergency then, the collaborators are typically contacted to offer assistance through video conferencing, a group plan is made and follow-up is arranged until the patient is safe. If the patient’s pre-identified friends/family cannot be mobilized, emergency response services can be called in and care coordinated in traditional ways via telephone by the telehealth-competent professional.
C) Imagine the same patient as described above at home alone (setting), and in the throes of psychosis, depression, or any other serious mental health disorder, and/or addictions (diagnoses). This is the type of situation that can most easily get out of hand in telehealth. The clinician may find themselves in over their heads, without an easily-accessed and supportive professional community, without the support of their licensing board, and be quite alone to make the best of a truly bad situation. If such a clinician had conducted proper telehealth intake and screening, either in-person or through video conferencing, and obtained a full telehealth informed consent
whereby needed information is obtained ahead of time to prevent emergencies, and emergency response protocols are well-rehearsed
to minimize stress on the professional and protect the vulnerable party.
Telehealth Intake and Screening vs In-Person Interviews
As hopefully is adequately illustrated above, the danger in telehealth is not the lack of an initial in-person interview. There actually isn’t a single study that I’ve seen that supports the belief that an in-person interview differentiates successful from unsuccessful telehealth interventions. On the other hand, there literally are hundreds of studies that call for clinicians to be trained in telehealth fundamentals prior to delivering telehealth. Several state boards, including Georgia, Texas, and Washington, now require telehealth training for their licensed practitioners.
Problems occur in telehealth when the clinician doesn’t understand how telehealth screening, telehealth intake, and informed consent processes need to be properly managed to prevent emergencies, and/or how to ~be prepared ahead of time~ to mobilize needed resources. Rather than being caught off guard, clinicians need to be well trained in telehealth as well as how to navigate the emergency response system in another geographic location where community resources are typically unknown to the professional.
The calls for training also is for clinicians to learn how to use the camera for basic functions such as hygiene checks, gait analyses, and other routine functions that are a part of in-person care, and which are not intuitively derived when practicing online. Much like driving a car is easy enough that any twelve-year-old with long legs can maneuver, but it is when an accident needs to be prevented that driver’s ed is necessary. Telehealth then is best utilized by the professional who understands how it works and has taken the time to think through the needs of the population being served ahead of time. Such forethought can assure that those needs can be met, appropriate evidence-based protocols and related documentation are developed and emergency scenarios are well-rehearsed.
The pivotal differentiating factor then is the telehealth competency
of the professional in question, not an in-person interview
Telebehavioral Health Competency Framework
For a complimentary copy of the telebehavioral health competency framework that my team and I published in 2018, feel free to download it here. After downloading, you may want to flip to the table at the end, and scan the middle column (“Proficient”) to see if, in your opinion, someone equipped with these basic competencies would be able to handle the variety of situations that can arise in telehealth.