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Using Telepsychiatry for Serious Mental Illness: A ...
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Hello and welcome. I'm Amy Cohen, Associate Director for SMI Advisor and a clinical psychologist. I am pleased that you are joining us for today's SMI Advisor webinar, Using Telepsychiatry for Serious Mental Illness, an Introduction. SMI Advisor, also known as the Clinical Support System for Serious Mental Illness, is an APA and SAMHSA initiative devoted to helping clinicians implement evidence-based care for those living with serious mental illness. Working with experts from across the SMI clinician community, our interdisciplinary effort has been designed to help you get the answers you need to care for your patients. Now I'd like to introduce you to the faculty for today's webinar, Dr. John Torres. Dr. Torres is Director of the Digital Psychiatry Division in the Department of Psychiatry at Beth Israel Deaconess Medical Center, a Harvard Medical School-affiliated teaching hospital, where he also serves as a staff psychiatrist and academic faculty. He is active in investigating the potential of mobile mental health technologies for psychiatry and has published over 75 peer-reviewed articles and five book chapters on the topic. Dr. Torres serves as the technical expert for SMI Advisor's Clinical Expert Team. John, thank you for leading today's webinar. Thank you, Amy, for the introduction, and thank you for all of you online for joining to learn more about this introduction to telepsychiatry. As a disclosure, I have investigator-initiated research funding from Otsuka, but that's not directly related to this talk today. The learning objectives for today are to list three techniques used in telepsychiatry to establish rapport and therapeutic alliance with patients who have serious mental illness, to evaluate patients for telepsychiatry services by considering at least three advantages as well as limitations of the service, and list four considerations for ensuring patient safety as defined in the APA Telepsychiatry Toolkit. So before we get started about talking about this introduction to telepsychiatry, I think there's a couple words we're going to use interchangeably, but tele-mental health is the one I'm going to try to use more so because this is very broad. This is a tool that's going to be used to help our patients with serious mental illness, and as a tool, it doesn't matter if you're a psychiatrist, a nurse practitioner, a social worker, a psychologist, a peer using it. But sometimes the word telepsychiatry is used in different resources, sometimes tele-mental health, sometimes telepsychology, so a fair word of warning. I think two useful resources, I said if you want to learn more about it, if you want some really great references, is the American Psychiatric Association put out that book that you see the cover in that offers, I think it came out only a year ago, so it's very up to date, and offers a very good primer and introduction to it. I wrote a chapter on apps in that, which I don't get any royalties for, and the American Psychiatric Association has a very nice website that anyone can access, you can actually follow it there from the screenshot. But the telepsychiatry toolkit that was built by some leaders in the field like Stephen Chan, Jay Shore, Peter Galilese, Donald Hilty, has a lot of really good information that you can access at your fingertips on demand. What I don't have shown here is we're going to have a learning collaborative about how to get started and use telepsychiatry through SMI Advisor that you should be on the lookout for and you'll hear more about. So again, those are some broad useful resources that you can access and kind of learn more about. Another useful resource is the American Telemedicine Association, the ATA. It's a website, it's an organization, you can join it, and it has a lot of information, but what's most useful here is it has a lot of detailed information about what are the current regulations, what are the rules around tele-mental health in your state, what is pending legislation, what are reimbursement issues, what are liability issues. So there's one group that's keeping a broad lens on all of telehealth, not just mental health, but all of telehealth, it's the ATA, and actually a psychiatrist, Peter Galilese, was the past president of it. So there's a lot of intersection between mental health and the ATA. So again, another useful resource to consider when you're learning more about this and wanting into details. But let's start with the first thing of what is tele-mental health? What are we here talking about? And so telemedicine itself is the process of providing healthcare from a distance through technology, often using video conferencing. Telehealth is a subset of telemedicine and can involve providing a range of services, including psychiatric evaluations, therapy, it can be individual, group, or family, patient education, and medication management. So you're seeing that tele-mental health is a tool that's going to help us provide the type of services and care that we're providing already. And when thinking about tele-mental health, there's a couple types that are worth considering. The first is live video conferencing, synchronous. This is kind of what all of us think when we think of tele-mental health. You turn on your computer, there's a webcam, you're talking to someone, it's real time, it's interactive. But really, that's only one of four types of tele-mental health. There's also store-and-forward, which is asynchronous, so store-and-forward transmission of diagnostic images, vital signs, or video clips, along with patient data for later review that enables primary care or allied health professional to write consultation or render diagnosis. So this would be more like a consultation, where perhaps there's a video clip of the patient, there's information, you're not always responding in real time. There's of course remote patient monitoring, including telehealth, using devices to remotely collect and send data from home health agencies or remote testing facilities. And there's mobile health, mHealth. So we've talked a little bit about remote patient monitoring, mHealth, in prior SMI advisor webinars that you can find, and we're going to talk more about the live video conferencing, synchronous tele-mental health today, but we'll give some examples of the other ones as well. But again, the point being, it's not only just live video, but that is the primary mechanism around this. So the question is, why tele-mental health? And I think when we go through these reasons why, you'll see why it really aligns with SMI and why it's such an important tool that we can utilize. Certainly improving access to mental health specialty care that may not be otherwise available is very important in SMI, bringing care to patient's location, helping integrate behavioral health care, primary care, leading to better outcomes, reducing the need for trips to emergency room, reducing delays in care, improving continuity of care and follow-up, reducing the need for time off work, childcare services, really increasing access to care for our patients, reducing potential transportation barriers, and reducing stigma. And again, when you look at this list, you can see these are really things that we're always trying to improve in SMI care, and tele-mental health can lead us towards all of those. An interesting question is, what type of cases are seen with tele-mental health today? And sometimes it can be hard to kind of get to the raw data or say what's actually happening. This is a really fascinating paper that was in Psychiatric Services published in 2016. It was basically looking at Medicaid enrollees from 22 states and saying, what are people reimbursing for? What are the diagnoses that are being seen with tele-mental health? If you look at that table three figure, you can see that bipolar disorder was kind of number one thing that was being billed, there was ADHD, there was schizophrenia, we have depression there. So you're already getting kind of the three classical SMI diagnosis from bipolar disorder around schizophrenia disorders and around depressive disorders. People are using this already. And the point is, as we'll see, there's no contraindications for any diagnosis in using tele-mental health, but this is being used for a while. And this data actually was collected between 2008 and 2009. So even a decade ago, people were using this, treating patients with bipolar disorder. It's not something new and novel, which is a good thing. This is something that's been tried and tested and has a very strong, robust evidence base. This is data of where psychiatrists are using tele-mental health. Again, I highlight psychiatrists only because that was the data published in this paper. Generally there's a trend where psychologists would probably have similar rates in the state nurse practitioners. And you can see that by states, it varies of who's actually using it. I believe North Dakota there has 24.2%. So there are certainly tele-mental health sources may be more common there. Where I'm calling from in Massachusetts, we can see we have 0.1%, which is a very small number. Texas has 14.2%, California has 2.6%. And this data actually is pretty recent. This was published in June, 2019. So it gives you an idea, there's a lot of variation in different states around who can use it and, or anyone can use it, but who's accessing it as psychiatrists. And I guess the next question is, do tele-mental health services work for patients with SMI? And I think the resounding answer here is there is robust evidence and I underline robust to kind of just make it clear that these tele-psychiatry, tele-mental health services have a very strong evidence base and there's been many reviews that actually say the evidence is so strong that it works and that's effective, that can be safe, that really we need to begin focusing on implementation, getting these services up and running, the other issues. But the evidence base for it is really not in question. This was a review, the slide's a little blurry, I apologize, but they looked at over 134 studies of what is the evidence base for this? And again, they concluded that this really does work well. And I said, does it work again for patients with SMI? There have been a lot of randomized studies. One of the earlier ones was actually in 2004, so about 15 years ago, and they were a large scale randomized control study to investigate tele-psychiatry and treatment of depression. And this is a case where no is good. They really found there were not differences between in-person treatment and tele-psychiatry treatment. So people who got kind of tele-psychiatry, tele-mental health services had outcomes that were equivalent to folks who got the traditional standard in-person care. So again, that's what we'd want to see, that people aren't getting worse care, the quality doesn't degrade, satisfaction doesn't go down. Like all studies, again, we have to consider kind of what are the makeup of the patients in it? What is the diversity of patients? Are they representative? In that study, it was 61% Caucasian, 36% African American, 3% Hispanic Asian, 52% reported a gross income of less than $1,000 a month. In that study, 88% were male. But I think since 2004, that evidence, there's been a lot of evidence saying that really, tele-mental health services are acceptable and feasible to a broad range of people. If you're depending, it's not going to make as much of a difference on race, on income, and gender. It's a tool, again, that we can reach people with. But again, in any paper we look at, it's always important to consider what could be potential biases. So, and again, looking again at more examples of how this could work for patients of SMI really can drive home the point that there's a strong evidence base. This was a more text messaging-based approach for increasing medication adherence that also offered video visits through a smartphone as a randomized controlled trial. And by month four and six, the odds ratios for medication adherence in the tele-psychiatry group was 4.11. There's also a pretty recent study that came out in January 2019. We'll talk about a different study of medication adherence in patients with schizophrenia and bipolar at the end of the lecture that had a slightly different outcome, and we'll talk about why that one didn't see an increase in medication adherence rates. But again, we're trying to say that this evidence is pretty robust, and there's more than offering certainly face-to-face visits and tracking medications. You can also do neuropsychological testing. I like this computer, this picture, because if you look at the computer, you can see that's a little bit old. I said, some of us may still have computer screens like that. But again, point being that these kind of psychological testing done on computers has been around for a while, and I said, certainly the technology has improved, but I think there's a strong evidence that you can administer these scales via technology. Certainly sometimes it can be hard to get neuropsychological testing for our patients. We've had other webinars. It's certainly very important to monitor cognitive function in some patients of SMI, and tele-mental health services can be a way to bridge that gap and offer those services. So now to get into some of the details, looking especially on Medicare and telehealth. And the reason to talk about Medicare is certainly a lot of patients of SMI may have Medicare, they have that coverage, and sometimes offering telehealth services is feasible, but you kind of have to understand what is an originating site, what is a distant site practitioner, what are telehealth services according to Medicare? And so an originating site is not overly intuitive in the words that it is, but basically an originating site is a location where a Medicare beneficiary gets physician or practitioner medical services through a telecommunication services. And so basically it's saying if your patient is going to, has Medicare is going to begin telehealth, they have to be in one of these health professional shortage areas, and that's a map that's kind of on the left to give an idea of where those are. White is again where there's not. And then it basically, the service has to be rendered also at one of the following types of health facilities, a physician or practitioner office, a hospital, a rural health clinic, a federal qualified health center, a skilled nursing facility, community mental health center, very relevant to this talk, but you can see that, and we'll talk on exception coming up, but basically the patient has to be in an area that may be rural where there's less kind of clinical care available. And usually the patient may have to be at one of these places such as a community mental health center physically. And what's really interesting though is the originating site. Again you can see this is July 1st, 2019, so there's a lot of changes in telehealth. There's a support act removed originating site geographic condition and adds an individual's home as a permissible origin telehealth service site for treatment of substance use disorders or co-occurring mental health disorders. So it's actually now feasible to offer tele mental health services to a Medicare person in their home, which is kind of what sometimes we think about when we think of telehealth because of the support act. And again, the point being July 1st, 2019 was not too long ago. That was less than 90 days ago. So there's a lot of change happening in telehealth legislation, telehealth reimbursement, telehealth policy. So sometimes if you had some assumptions that you couldn't do something of telehealth, you were worried about something, it really may be time to actually take a second look. You can submit a consult to us at SMI advisor, but the point being these things are rapidly, rapidly changing. So we talk about what an originating site is again, as of July 1st, there's this exception or this new rule for patients with substance use disorder and co-occurring mental health disorder. And then what is a distant site practitioner? So that would be clinicians in our case for a webinar examples, treating SMI, but physicians, nurse practitioners, physician assistant, clinical nurse specialists, clinical psychologists, clinical social workers, registered dietitians and nutrition professionals. And there's some rules that are particular for each one. What's interesting at clinical psychologists and clinical social workers cannot bill Medicare for psychiatric diagnostic interview examinations with medical services or medical evaluation management services, but there's different codes that different people can bill, but basically you have to be in one of these buckets. And then Medicare actually has CPT codes for different types of telehealth services. What's interesting you see it says you must use an interactive audio and video telecommunication system that permits real-time communication between you at the distant site and the beneficiary at the originating site. So even from the introduction of this talk, you now know about what is the distant site, what is the originating site. And we know that this is kind of Medicare is saying we want to synchronous the first type of telepsychiatry, the live synchronous, not asynchronous, the store and forward or the consult model. So you can see already, we can kind of begin to understand who would be eligible of our to my patients for getting telehealth services and what we would have to do. Certainly I said many patients have private insurance. Not everyone has Medicare and the American Telemedicine Association has a very good resource on this website that can tell you for your state, what type of parity is there for telehealth services? What is being reimbursed and what our private insurance is doing? What are different state insurance is doing? You can get a sense from this map pretty quickly that it does vary state to state on how reimbursements are working for these services. And again, just as we saw the support act, there's always a lot of change in these reimbursements happening sometimes on a monthly basis. So the American Telemedicine Association has a very good job of keeping up to date and kind of keeping a bird's eye view of what's happening in what region in terms of billing and what could be covered. Malpractice is something of course that you have to consider before you start offering these services to patients. Some malpractice providers do cover telepsychiatry as part of their standard coverage. So there's some chance that you may be covered for it, the benefit that you have that you may have not noticed. Other malpractice carriers will have additional policies that may require additional coverage when you're providing telepsychiatry services. So it's something to certainly consider because certainly you don't want to be providing care for patients with SMI and realize that your kind of malpractice coverage is not covering telepsychiatry services. I think licensure is another interesting issue that certainly presents some challenges that aren't initially intuitive and it really comes down to the first bullet point that care is considered rendered where the patient is located. So what this really means is you need to hold a license in the state regardless of where you're conducting telepsychiatry. So if I am here in Massachusetts and I'm talking to a patient in Arkansas, I would need to have a license in Arkansas. And certainly I said I know colleagues who have worked for say a telepsychiatry company and that company will get that person licensed in all 50 states. But certainly if you're treating patients in different states, you really want to make sure that you have a licensure in the state where that patient is located. And there certainly have been cases of clinicians getting into trouble or practicing kind of healthcare or medicine without a license if you're seeing those patients. States really do vary in terms of the requirements around in-person assessment of patients. We'll talk about some specific examples soon, but often individual states will say you have to see someone for a face-to-face in-person visit. Some states have different rules that you have to see someone perhaps every 24 months for in-person. But you have to think about kind of what is the state you're practicing in? Where's the patient? What medical licensure do you need? What are the rules for each state again? And do you have to see the person first usually before you begin offering telepsychiatry services? And there are some exceptions for the federal system and the VA. The VA has been doing a very good job of removing those barriers, especially around state licensure because VA clinicians are usual federal employees. So the Ryan Haith Act is something certainly worth considering, especially for those prescribing. So the Ryan Haith Online Pharmacy Consumer Protection Act of 2008 was created to regulate online internet prescriptions. So it's enforced by the DEA and it imposes rules around prescription of controlled substances through telepsychiatry. And it says that psychiatrists must conduct an initial in-person evaluation and then one at least every 24 months. So if you're going to be prescribing controlled substances, this is kind of on the federal level saying that you have to at least see the person, do an in-person evaluation, and at least every 24 months, you'll have to see them again. Of course, we talked about different states may have different rules that may be more frequent and you'll have to follow those as well. And again, the ATA offers a useful resource and kind of place to learn about those. There are other exceptions again, rules apply, but certainly worth keeping in mind if you're going to be considering prescribing controlled substances using tele-mental health tools. So now we kind of want to talk about, we've talked about some of the nuts and bolts issues to cover, but what are the best practices in video conferencing-based tele-mental health again with a focus on serious mental illness? Another really great resource is the American Psychiatric Association partnered with the American Telemedicine Association, and they put together these best practicing PDF that you can access online for free via that link. And we're going to kind of go through each of them in order. And I think you'll see that makes sense. And then we're going to look at what the American Psychological Association has, and you'll see that it's also very well aligned with the practices. And what I want you to consider as we go through these is in essence, you're likely doing a lot of these best practices in face-to-face care when you're working with patients already, you may be using a different medium and we'll talk about some things to consider, but a lot of what you're doing in offering great care for your patients today is going to be very well aligned with the best practices for offering tele-mental health services. So the first aspect before kind of jumping into tele-mental health or starting a program is really a needs assessment of thinking about what is a program overview, what system services will you be delivering, what is the population you want to serve, what are the technology needs, the staffing needs, how are you going to monitor quality, what are the business and regulatory processes, the space requirements, the training needs, evaluation plans, sustainability, and we're actually going to be doing a needs assessment as part of our learning collaborative. That will be one of our kind of main things that we'll be working with folks on, how to do a tele-psychiatry needs assessment coming later this fall through SMI advisor. But a needs assessment is kind of the first step in kind of beginning to make sure that tele-mental health services make make sense for you, for your patients, it's something that you can deliver. And then the second part is we've talked about a variety of legal and regulatory issues, the licensure and malpractice we covered, the scope of practice we'll get into, what you're going to do and not do, prescribing, we talked about the Ryan Haith Act, informed consent, making sure patients understand it, and billing and reimbursement we talked about. Again, there can be some interesting issues about certainly different parity for tele-mental health services, what it means to get reimbursed via Medicare, and what's the originating site, what are the distance providers. And then certainly you want to have standard operating procedures and protocols. So again, some things are a little bit different when you're delivering care through a screen. At the beginning of the video session with a patient, you really do want to verify and document the name of the clinician and patient, where the patient is, what is immediate contact information for the patient and clinician in case there's a disconnection, in case that you have to kind of call emergency services, you need to kind of locate the patient. What are the expectations of contact between sessions? Just because you're talking of someone again on a phone, on an iPad, on a computer, that doesn't mean that you're always available 24-7, even though potentially you could have a video chat at any time. What is an emergency management plan between sessions? And again, you likely are not going to be on call 24-7, perhaps that's something you do want to do, but what is the way that you're going to kind of have safety plans for patients and what may be different, what may be the same. And again, this will vary if the patient is kind of accessing tele-mental health services through a clinic where there's a staff member who can respond or whether they're at home and there's not a staff member that can respond or kind of they're in the community. Technical considerations, I said anything of technology, we have to talk a little bit about technical considerations. We'll get to later in a talk, actually. You really want a video conferencing platform that works well and is very smooth and easy to use. And integration of video conferencing into other technologies, we have to think, of course, about privacy, security, and HIPAA, and that goes beyond just the technology platform. You have to think about the physical location, the room that you're in. You don't want to be doing this with, say, an open door and people walking behind you in a hallway. That would be, and again, sometimes we don't have to think about that when the patient's in the room, we close the door, we're talking to our patients. One of the questions that always comes up is, is Skype HIPAA compliant? And it's a good question and the answer is no. I guess it's a two-letter answer, but Skype for business can be HIPAA compliant if there's a business associate agreement or a BAA in place with Microsoft who kind of owns it and other requirements are met. So again, Skype is a popular video conferencing tool, but if you're using a tool as part of clinical care, you want to have a business associate agreement, a BAA in place that kind of is connecting you with the person that owns or kind of makes this tool, in case Microsoft. And then Skype does have the kind of privacy protections encryption in place, but if you're kind of using out-of-the-box Skype here now and today, where you're telling a patient, here's my Skype ID, here's your Skype ID, let's talk to each other, technically that would not be HIPAA compliant as it is, but you could make it HIPAA compliant by looking into a business associate agreement. And there actually are many vendors offering teleconferencing kind of video visit platforms that do meet these requirements, but I said the classic question, is Skype HIPAA compliant? The answer is no. And then I said, this is a picture from that book that I had on the first slide, the Telepsychiatry and Health Technology is a Guide for Mental Health Professionals by Peter Yelolese and Jay Shore. This was the illustration that was made by Dr. Stephen Chan, and it gives you a very good sense of just things to consider that, again, you may not always consider, especially if you're offering telepsychiatry services, say from a home office, again, don't put politically divisive or religious items in the background. Again, these tips have been provided because someone has done these before, or adverse events have been reported, or patients have, bad things have happened. Keeping the room well lit, again, may not be something you're noticing, but if you have a small camera, making sure the patient can actually see you. Something kind of is not intuitive, but wearing solid colors rather than stripes or patterns will show up better on the camera. Again, keeping doors and windows closed, not open in terms of privacy. So again, these may seem like nitpicky issues, but you can imagine when a patient is kind of talking to you, you're building your therapeutic alliance, especially through video, just as we know that it really becomes important that your physical setting is representing the type and quality of care that you are providing. So some clinical considerations too we'll talk about is patient and setting selection. And again, sometimes people perhaps out of not knowing as much about working with SMI patients concern, but we'll say, can SMI patients, can patients with schizophrenia, can they use tele-mental health services? And the answer is there really are no absolute contraindications to patients being assessed or treated using tele-psychiatry services. Certainly we all know as clinicians and carers and peers that not every treatment or treatment modality is a perfect fit for every person. Some people may not want to use tele-mental health services for a variety of reasons, but there was no absolute contraindications that says that a person cannot use it. And I said, that's a pretty well-established fact now. I said, we saw some early studies at the beginning of the talk, even from 2004 that have been looking at this. But I think some factors certainly to consider are patient cognitive capacity, level of risk, geographic distance to emergency medical facility, need for in-person physical exam requirements. And I think that there's a very nice paper that was put out and it's a screenshot idea that was looking at what is kind of suicide risk management during tele-mental health visits during kind of tele-practice. And if we look at kind of table two, where we're looking at not elevated risk, low risk, intermediate risk, and high risk. In essence, what we're doing with patients that may be at higher risk of suicide, we can even focus on intermediate risk. The criteria term and risk are endorsement of current homicidal or suicidal ideations without intent to act, or difficulty controlling impulses, frequent induration of ideations, no recent violent behavior. So someone's intermediate risk, what would the clinical response be kind of when offering tele-mental health services? So take precautions that are mentioned above of low risk and consider increased frequency or increased intensity of contact more once per week, something we would probably do clinically if we're seeing people face-to-face. Engage in peer consultation to share and track decision-making processes and determine need for internal, external reporting, disclosure, and mean restriction. So again, you're seeing that we're doing what we would do in person. If someone was at elevated risk, we'd seek peer consultation, we'd think about getting extra resources involved. And I think when someone's certainly at high risk, we really do want to consider if you're evaluating them and they're alone, there's no one to kind of help if we need to do a rescue. That's, I think, where we do want to consider what is a way that we may want to then have that person seen in person, or we can arrange for transportation to a facility or perhaps emergency evaluation. But the point being that the clinical considerations, the risk assessments that you are doing and working with patients with SMI and tele-psychiatry, and sorry, in face-to-face care, those are the same skill sets you're going to kind of be using if you're delivering care via tele-psychiatry. And I think one thing that's a little bit different is considering how are you going to manage the kind of relationship when you're using technology, there's now a screen between you and the patient. And that is a little bit different than when you're offering services face-to-face. But again, I think the same skills that you use to build a therapeutic alliance are in part going to be the same skills that help you build a very strong hybrid patient-provider relationship. So, I mean, providership, very clear policies pertain to communications with patients, as we talked about before. You do want to be setting what are your boundaries, what are boundary crossings, and basically want to make sure the patients understand how they can communicate you, in what ways, what is appropriate to share, what is anticipated response time, especially between sessions. Again, just because you're talking with someone via video, they have to understand that you may not be available at 2 a.m. on Sunday. What is the right way to contact you as a provider, and when? And again, so these are things that you can establish by really having clear policies around communications with patients. And then we talked about the environmental factors, really kind of building rapport by having a professional environment. As I've said, certainly an advantage of telepsychiatry can be that patients can be at different locations, you as the person delivering these tele-mental health services can be at different locations. But you really do have to think about what are the surroundings that you're delivering it from. Like we do in all clinical care, it's delivering empathy and respect, adapting a collaborative problem-solving style, and considering nine kind of forms of nonverbal communication that are important in developing and maintaining this relationship. So thinking again about what are the nonverbal communications that are really going to come across on a screen, and I said this is a terrific paper that kind of went through them. I imagine that each of us are probably again using these skills when we're working with people face-to-face, but we'll review them and you can check off your head if it's something that kind of you're conscious of that you're doing, but maintaining strong eye contact, certainly even if it's through a camera with the patient, but awareness of your voice intonation, respectful touch for both social and diagnostic purposes, assuring body posture and gestures, emotional expressiveness and perceptiveness, professional appearance, so certainly not showing up to a visit in your pajamas. That's sometimes the stereotype, but appropriate use of physical space. We talked about facilitating conversational behavior and effective time management. So again, things that you would be doing in high-quality clinical care, you would also be bringing those to kind of maintain this relationship or build and strengthen the relationship when you're offering these telehealth services. So as we talked about, really it's the same rapport considerations apply as face-to-face care, and I said certainly we know that sometimes when working with patients with positive symptoms, with hallucinations, delusions, in schizophrenia, it can be sometimes more challenging to build a therapeutic alliance, but that said, people have done many studies in patients with psychotic disorders, schizophrenia, even patients that may have more paranoid symptoms, and technology was still feasible for many of those patients. Again, building rapport can be challenging with some patients, it can be easier of some patients, and again, telepsychiatry is not going to make that overly easier or harder. It's not going to be a panacea where if you have trouble making strong relationships, you're now going to make them. It's going to be a mechanism, a portal for those, and again, the studies are saying here just to say, look, even patients who have what some people would consider harder patients to build rapport with, you can build rapport with patients using telepsychiatry, and certainly, I said, I've worked with many patients with schizophrenia, and video visits are completely acceptable. I'm actually not sure why... why that kind of perception has come across that these patients don't want to use video services. Again, and perhaps it's just more in popular culture, perhaps it's more in stigma, but I think it's important to remember that patients with SMI really can use telepsychiatry, it's very feasible. In terms of ethical considerations, I said, certainly, all of the same ethical considerations, be it the American Medical Association, here's the Code of Ethics for Nurses, still apply when you're delivering telemental health services, and so state medical boards are still going to be kind of holding all of us who are providing telemental health services to these same high standards. We're not delivering low quality of care, the same ethical considerations still apply. Cultural issues have to be considered, cultural issues have to be considered, and telemental health providers should be culturally competent to deliver services to populations that they serve. Certainly, an advantage of these telemental health services is that we can reach new audiences, we can increase access to care, and if we're reaching new populations, we have to understand who we're reaching and what could be some cultural factors that could impact care. Again, the same would be if you got in your car and drove to a new region, or treating a new population, you'd have to take those into account. Providers should conduct ongoing assessments of their patient's level of comfort of technology over the course of treatment. It's worth keeping in mind that certainly if you're offering tele-psychiatry, telemental health services, you've probably learned some things about technology and getting it setting up where you're comfortable. Again, assessing to make sure that patients understand how these services work is important too. So, those were kind of the joint American Telemedicine Association and American Psychiatric Association recommendations. I want to quickly run through recommendations for telemental health services through the American Psychological Association. You're going to see that there's a lot of overlap, and there's a lot of overlap of what you're doing already in care. And again, this is getting to the point that this is kind of delivering care through a new mode. Some things are different, but many things are the same. So, follow all requirements for ethical conduct with your profession's code of ethics, regardless of the telemental health medium used, again, via computer, smartphone, tablet. Be familiar with and guided by relevant telemental health service practice guidelines. Learn and follow relevant telemental health laws in all jurisdictions in which you're providing clinical services. We talked about how those can vary state to state and region to region. Assess each potential client's treatment needs to ensure the appropriateness of participating in telemental health, and that the most appropriate medium is used. Make referrals to other competent professionals when it's in the client's best interest. Use a comprehensive informed consent process to address all issues relevant to the practice of telemental health. Take all responsible actions and use all readily available technology to protect each client's confidentiality, such as encryption of email communications. So, again, things that we've kind of covered already, we've talked about. Page two, or the second party's recommendation is only use HIPAA compliant software programs to provide video conferencing with clients. So, a pop quiz would, out of the box, Skype be appropriate? The answer is no, but you all knew that already. Only provide clinical services that you are competent to provide based on your education, training, and relevant clinical experience. Before providing telemental health services, develop competence regarding all hardware and software you'd be utilizing to communicate with clients. Ensure multicultural competence and attend to linguistic and other diversity issues in your online interaction with clients. We just talked about cultural issues in the ATA, APA guidelines. Learn about and follow all duty to warrant and mandatory reporting requirements in a jurisdiction where you're providing telemental health services. So, again, we're saying just because you're offering services via video, you still have to follow all the same ethical reporting issues. Before providing telemental health services, learn about resources in each client's local area and make arrangements there for emergency and crisis situations. Again, thinking about if patients are at higher risk, you're seeing them, what is the plan that you're going to do if you need to activate that kind of emergency or safety plan? Then, of course, document all telemental health services provided just as you would document in-person mental health services, ensuring you record all records are stored securely. Again, you're going to document in the same way. We're not going to take a shortcut. We're not going to do things differently in providing high-quality care. When unsure if a client should be treated via telemental health, utilize an ethical decision making model, consult with experienced colleagues, and maintain appropriate liability insurance, and confirm the amount of practice insurance policy covers provisions for telemental health services. So, again, you're seeing in a good way that there's a lot of overlap between what you're doing already, the American Telemedicine Association guidelines, the APA guidelines, and common clinical sense for it. To wrap up, I said we'll get to questions in a couple minutes, but again, just focusing on schizophrenia, sometimes people have asked me, they said, well, are patients with schizophrenia, do they have access to computers and technology to kind of partake in telemental health? The answer is certainly yes. This was a study that we did with NAMI that is in 2016, and this was looking at patients with schizophrenia who had access to computers, smartphones, landlines, tablets, public computers. The point being that patients have access to these technologies that can do it. And one thing is looking at then how is it working, again, for patients with schizophrenia, and really what modality are you going to use? The use of modalities involved telephone, internet, videoconferencing appear to be feasible. In addition, primary evidence suggests these modalities appear to improve patient outcomes. So, I said there aren't as many research reports looking at schizophrenia, but we're seeing from all the data available that, again, it works well. It can improve outcomes for schizophrenia. One interesting study I bring up where this was a study that was looking at medication adherence in patients with schizophrenia using a smartphone with telemental health involved. And they were trying to say, can they increase rates of engagement with medications? And the actual rate of engagement of medication adherence actually went down at the end of the study. So, perhaps a negative outcome, but there are two interesting points I want to bring up around the study and why I'm kind of focusing on it. The first is that certainly we know that medication adherence, taking of medicines is hard for anyone, whether you have SMI or not, and that alone, telemental health services will not be a panacea for certainly everything. It's a new way to reach patients. But when you're looking at a 12-month study, which is a long period, again, we realize that we have challenges that we all work towards in improving care, but certainly 12-month outcomes are hard. That's a year. And this paper says, look, if you look at a week outcome, if you look at four weeks, you may see a positive outcome, but you really want to look at long-term outcomes too. And long-term outcomes is hard. But the reason this paper was saying actually that adherence for medications didn't go up was that they were saying the platform, the telemental health platform really only works if two parts of the treatment team are using it, the patients, in this case investigators, but the clinicians. You really need telemental health to be a partnership. It can't be that you just hand people with SMI access to video services and say, here are these services, here's increased access to care. There really has to be engagement on both ends. There have to be clinicians who are caring, who are following up. There's a strong bond, there's rapport, there's alliance between both the patients, again, in this case, investigators, but the clinicians. And I think that's an important point to keep in mind. Again, it's not that technology alone is not going to be the solution. The solution is using technology to bring us closer, help us reach more patients, help us form strong therapeutic alliances. But if we just give access to services alone and don't make them as engaging, don't focus on therapeutic alliances, don't focus on all the things that we've learned as clinicians, as caregivers, as family members, as peers, then these services, telemental health, again, is not going to improve outcomes as much as we want. So another just kind of research thing to talk about from the data is sometimes people say, well, is tele mental health going to make certain patients more paranoid? And the results are really that, no, it's not going to make patients more paranoid and patients have had overwhelmingly positive responses to it. And I think the one thing that makes people perhaps upset when using telepsychiatry is when the video conference quality is low, when the picture and audio quality doesn't work. And I think all of us can say from experience that certainly when we're on the phone at staticky or trying to watch something on the internet and it's not loading, that's certainly a negative experience. So that doesn't really relate to SMI, but it gets the point that really, if you are delivering these telemental health services, you really want to make sure you have a strong connection, that you have good internet quality, you have a good platform, it works robustly, it's not going to be laggy, it's not going to be slow, it's not going to disconnect patients. That's actually going to upset, again, anyone, whether you have SMI or not, technology not connecting is something people are concerned about. But intrinsically, telemental health services are not going to make people paranoid. And again, looking at a review of telehealth or psychotic disorders, this is a pretty recent review, one of the most recent I could find, was looking at a lot of different studies and the conclusion being video conferencing intervention seemed feasible for participants with schizophrenia, spectrum disorder, and they showed high acceptance of this intervention modality. So again, the point being that this is something that can work, people accept it, and they're willing to do. So I think we have a little bit of time for questions. Thank you guys for listening, joining in, or tuning in if you're listening asynchronously.
Video Summary
In this video, Amy Cohen, the Associate Director for SMI Advisor and clinical psychologist, introduces a webinar on using telepsychiatry for serious mental illness. SMI Advisor is an initiative that aims to help clinicians implement evidence-based care for those living with serious mental illness. Dr. John Torres, the Director of the Digital Psychiatry Division, is the presenter for the webinar and discusses the techniques used in telepsychiatry to establish rapport and therapeutic alliance with patients, advantages and limitations of telepsychiatry, and considerations for patient safety. He also mentions various resources available such as the American Psychiatric Association's book on telepsychiatry and the American Telemedicine Association's website for information on regulations and liability issues. The webinar highlights that there are no absolute contraindications for using telepsychiatry with patients with serious mental illness and that it has a robust evidence base. It also addresses legal and ethical considerations, technical aspects, and cultural issues when providing telepsychiatry services. The webinar concludes with Dr. Torres discussing research studies that support the feasibility and acceptance of telepsychiatry in patients with schizophrenia.
Keywords
telepsychiatry
serious mental illness
rapport
advantages
limitations
patient safety
resources
schizophrenia
Funding for SMI Adviser was made possible by Grant No. SM080818 from SAMHSA of the U.S. Department of Health and Human Services (HHS). The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, SAMHSA/HHS or the U.S. Government.
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