While COVID has thrown most behavioral professionals into the deep end of the telehealth pool, many professionals are grateful to learn that the telehealth evidence-base has many “safety floats” to offer for just about any behavioral-practice issue, including telehealth intakes and screening. With most states requiring “evidence-based care” to not only be practiced but also fully documented, along with references, it is especially important for all clinicians to fully understand that telehealth evidence-based practice is also necessary.
More specifically, the definition of evidence-based telehealth practice involves the same three steps as in-person evidence-based practice: 1) a review of the literature to identify relevant peer-reviewed consensus documents or research articles; 2) consideration of the unique needs of the party receiving care; and 3) the full knowledge and consent of the client or patient. Such consent, of course, helps to make the process reflective of patient-centered care. With respect to telehealth screening, the three core factors to consider are: 1) location of the party (setting); 2) local laws; and 3) diagnosis. This article will review each in turn.
Telehealth Intakes & Screening: Setting
In telehealth, the fundamental issue that interestingly enough is overlooked by newbies is the intended care recipient’s location or setting. Proclamations are made for or against working with people of one diagnosis or other via telehealth, as if all settings are the same. In fact, setting the very essence of telehealth practice, because the setting is the one factor that is different from in-person care 100% of the time.
By its very nature then, the setting is what changes, and can continue to change for some people, in telehealth. Without a throughout assessment of the intended party’s setting, proper telehealth screening cannot occur. For example, an actively suicidal or floridly psychotic person may be considered unmanageable by many psychotherapists who are starting a telehealth practice, but the fact is, that in the early days of telehealth and telemedicine, the vast majority of people routinely being treated suffered from one or both of these diagnoses.
The one factor that made telehealth possible when helping them is that they were in hospitals and when needed, on locked wards. Many other people who needed to be assessed and treated were in jails or prisons. Some were on oil rigs, fracking fiends, on the frontier – where a responsible party had arranged for them to be seen and could arrange for them to be safe and with someone reliable until they could be seen again. Setting then, is a crucial consideration.
In teletherapy and telehealth screening, a variety of other issues may complicate the matter. The person may or may not be alone, and they may or may not tell you the truth about whether or not they are alone. They may be eating, drinking, smoking, vaping, watching tv, gaming, gambling, masturbating. They may be cooking dinner, riding in a car, sitting on the toilet, or lying in bed – clothed or partially unclothed. And the list goes on. The questiois that we either have the telehealth competencies to manage our sessions with them or we do not. Whether they allow us to maintain our professional agenda is also part of telehealth screening.
If we are put in a position of acting like a sibling or parent to maintain the therapeutic stance itself, that is part of telehealth screening. If we ask people to put their beer and cigarettes aside, get a shirt on, turn on the light, put their feet on the floor and face us, or pull the car over in a safe place to address us with their full attention, and they do, then we know they will allow us to be professionals. If they do not cooperate with reasonable directives, but rather, arrange themselves and their setting so as to render us mere puppets, that too is part of telehealth screening.
The fact is, with or without telehealth, we have responsibilities to meet. Those responsibilities include being in charge of our “room,” our time, our boundaries, our activities and our discourse during all behavioral sessions.
Questions Related to Setting
When thinking about telehealth, a much greater number of questions about the setting and who else is available to help need to be answered before committing to delivering care. Such questions might include:
- Where is the person who is approaching us for care?
- Can we reliably predict that they will be in the same setting again the next time we schedule an appointment?
- What if they agree to be in the same place, but they are not when we meet them through telehealth at some point in the future?
- Are other people in the same place? Who are they? Can they help with the person’s care or will they only exacerbate the problem?
- Does our treatment model include the use of such “collaborators” If not, might that be a consideration if everyone can be kept safe? If yes, how can we reliably and safely recruit collaborators to help?
- Who else is available in the immediate vicinity? What are the emergency services? Have we investigated them before agreeing to a formal therapeutic contract?
- Is the person willing and able to make a behavioral contract about when a hybrid model of care is to be used, if ever?
- Are they willing to act on referrals to available resources in their area, including 12-step, religious, tribal or other community leaders? Will they sign a release of information so you can contact these local people to follow-up if needed?
- Will they give you a signed release to speak to their local physician? Do they have a physician? If not, does their reasoning make sense?
- Are they transient?
Local Laws – Jurisdictional Issues in Telehealth Intakes & Screening
While TBHI offers several hours of telehealth legal and ethical training, let it suffice for this article to say that without a thorough understanding of all applicable legal ramifications, it is difficult to overestimate how many mistakes even the most well-intentioned practitioner can make. Most of us went to school more than a decade ago (perhaps even several decades ago). Even at that, most graduate schools have not adequately prepared many clinicians for the realities of employment. With regard to telehealth screening then, the devil is in the local jurisdictional details.
Some legal and regulatory telehealth screening issues to consider include:
- What does the individual’s local state law have to say about the exact definition of when a therapeutic relationship has begun? Is it when we say “hello?” Does it begin after an agreed-upon assessment period? Something in between? (Different states differ significantly on the issue of when a formal therapeutic relationship exists – and our “opinion” may not matter…)
- Does the individual’s local state or province require us to report suicidal intent to the police? If not, what will we do with such information if we hear it?
- How are we supposed to document suicidal intent? What about homicide intent? Abuse? If yes, what exactly are the requirements? What are the timelines?
- If we are working over state or international borders, are these rules different in the foreign area? What will we do if someone actually has an emergency on camera? Have we been trained to handle these issues? Has that training been adequately documented?
- What if we begin to deliver care and then decide that to terminate because the individual proves to be unreliable or unpredictable or threatening in telehealth? Is abandonment an issue?
While this list of questions can go on for another few paragraphs, you probably get the point. Full telehealth screening is essential for safety issues in telepractice. Understanding local laws and how they can differ from one jurisdiction to another is also essential. And as mentioned in the introduction, diagnosis is the third essential issue.
The pivotal role of diagnosis may be obvious to most of us, but please allow me to detail it a bit because the devil does lie in the detail. As clinicians, we are obligated to collect enough information to know if we can be of help to any requesting care. If determine that we are not, we are obligated to give appropriate referrals, even if they are not good options during emergency times such as COVID. Bottom line, if we are not equipped to deliver care, we either do what we can while we are getting equipped with more training and/or consultation (and thoroughly document those attempts) or don’t offer care. To pretend that we are acting professionally when we are not is misrepresentation, and can lead to serious negative repercussions – even in national emergencies.
Now that the required precaution is stated, let’s get down to the essential question of how we can possibly render a diagnosis if we are still trying to conduct telehealth screening, and particularly if we are still a bit fuzzy about local laws. Herein lies the point of this article.
Most of us have dealt with the uncertainties of how to sensitively and respectfully conduct intakes and telehealth screening for in-person care. Our business cards and other promotional services limit the types of people we prefer to see, their ages, their locations, who accompanies them, what they are doing when they see us. Most people know to be fully clothed when they came to see us, groomed, and probably even recently showered. In telehealth, many of those assumptions will no longer hold true. Exactly where to draw the line and consider it a sign of serious dysfunction, too serious to tackle through telehealth, is a matter of discussion in this article.
The Function of a Good Telehealth Diagnosis
A good diagnosis, however obtained, is the best predictor of an individual’s future behavior. Without a clear diagnosis, it will be hard for us to know what to expect, whether in-person or through telehealth. It is that simple.
However, if our telehealth screening skills are limited by knowledge of how to screen in-person rather than how to screen through a camera, telephone, text message, app or any other technology, and our decisions are not supported by published research, serious problems can ensue. Those problems can not only exist for us, but also for the individual or groups coming to us for care.
To render a full telehealth screening, we need to think through the diagnostic process once again. Start over with a clear mind and open heart. These questions may help:
- How do we conduct a gait analysis (observe someone’s ability to walk without unusual adjustments) in person vs through a camera?
- If the person is blind, deaf, or in a wheelchair, how do we assess their physical and/or mental abilities?
- Hygiene checks are also quite different in person vs online. How can they be conducted?
- If we use parts or all of a mental status exam, or a mini-mental, what part do we give online?
- Which assessments should we give through iPads or other technology? Have we studied their manuals and other documentation to find information about online administration? Have we contacted or read other materials published by the researchers involved to get all our questions answered?
Can we accurately render a diagnosis that will predict future behavior? Or do we lie in bed at night, second-guessing ourselves? The telehealth literature is quite specific about all these issues. Free and affordable as well as extensive training is available to help guide anyone interested.
Telehealth Intakes, Screening Precautions & Safety Nets
This may go without saying, but I’ll say it anyway: Just as an independent practitioner deciding to start an in-person practice would be ill-advised to work with a client or patient experiencing serious behavioral or physical problems without the involvement of local support, it is unwise to attempt to work with someone experiencing serious behavioral problems via any technology if they are at home, and not in a professionally managed setting, such as a primary care office; a clinic, agency or hospital working with you for your specialty services, or local clinician who has contracted with you and will provide local support. More specifically, if a patient is not stable and lapses into suicidal depressions, bipolar episodes, or alcoholic periods, recreational drug use, intervening could be ill-advised as a private practitioner from 300 miles away via technology when they are in a private, unsupervised home. If friends or family members are recruited, additional community supports are also strongly recommended. If treatment is nonetheless agreed upon without safety nets, the clinician must be forewarned that it is often difficult to terminate care if a client or patient becomes unmanageable, particularly without fully understanding the vagaries of local emergency services. It is important to note that historically, most telehealth programs have included the use of a “telepractice champion” or “site coordinator” to handle issues at the patient site, which traditionally is in a clinical setting such as a physician’s office, a psychologist’s office, clinic or hospital. When an independent clinician is delivering professional care to an unstable patient whose setting is their home, or who does not have a stable setting and a professionally trained and often licensed coordinator is not available, you must understand that liabilities increase proportionally.
As can be surmised from this article, working with severely characterologically disordered individuals, sex offenders, or drug- and alcohol-addicted individuals are not good choices for telehealth services if they are reaching us from unsupervised settings such as their private homes. This caution includes individuals with active paranoid or schizophrenic processes, suicidal, homicidal, or other patients who are in the early phases of treatment and might need community-wide support.
In those cases, telehealth services most certainly can be provided, but perhaps restricted to individuals who are in a controlled environment associated with larger community resources such as a hospital, correctional facility, specialty hospital, and medical office. As with most behavioral practices, common sense is in order.
As you can hopefully see, as professionals we need to be informed about to how to conduct a proper and full telehealth intale and screening to determine if someone is appropriate for telehealth. In our next articles, we’ll discuss more specific considerations for telehealth intakes, creating a therapeutic bond, reimbursement and practicing over state lines. If you’d like to hear live, interactive webinar discussion between three telehealth thought leaders about telehealth screening and how to decide who is most appropriate for telehealth, join TBHI for the webinar training below.