The NCTRC Webinar Series Presented by The National Consortium of Telehealth Resource Centers

1. May 16, 2019 The NCTRCWebinar SeriesPresented byThe National Consortium of Telehealth Resource Centers

2. www.telehealthresourcecenters.org

3. Webinar Tips& Notes • Your phone &/or computer microphone has been muted • Time is reserved at the end for Q&A • Please fill out the post-webinar survey • Webinar is being recorded • Recordings will be posted to our YouTube Channel: https://www.youtube.com/c/nctrc ? !

4. Distance Counseling in Higher EducationHeartland Telehealth Resource Center Kathryn P. (Tina) Alessandria, PhD., West Chester University American College Counseling Association HEMHA Representative Larry Long, PhD., Counseling Director, Asst Vice Chancellor Benjamin Bizar-Stanton, PhD, JD, Postdoctoral Psychology Fellow Counseling & Educational Support ServicesUniversity of Kansas Medical Center

5. Learning Objectives: • Gain awareness of what the Higher Education Mental Health Alliance is and how to access its free resources; • Be able to define distance counseling, its many variations, and the circumstances under which it might be implemented with college students; • Be able to identify logistical, legal, and ethical dilemmas in providing distance counseling in higher education settings; • Gain awareness of specific procedural workflow issues and challenges through use case examples of distance counseling with college students.

6. Higher Education Mental Health Alliance Through focus on advocacy actions, policy development and review, practice dissemination, and the promotion of research across the mental health continuum – HEMHA is committed to advancing mental health throughout the realm of higher education and improving student recruitment, retention and learning outcomes.

7. Free HEMHA Resources • College Counseling from a Distance: Deciding Whether and When to Engage in Telemental Health Services • Postvention: A Guide for Response to Suicide on College Campuses • Balancing Safety and Support on Campus: A Guide for Campus Teams • Emotional Support and Service Animals on Campus (in process) HEMHA website: hemha.org

8. TMH Guide Purpose: • Outline the potential benefits, limitations, and concerns regarding TMH • Aid college mental health professionals and administrators in engaging in dialogue about these benefits, limitations, and concerns to make informed decisions about whether/when to engage in providing TMH services. • Outline areas to consider in order to ethically practice at a distance when the decision to provide TMH services is made. • Provide links to resources.

9. Benefits and Limitations of TMH Engaging in TMH services requires acknowledgment of its potential benefits and limitations. Mental health professionals and their institutions must: • Carefully weigh the benefits and limitations, • Discern whether the benefits outweigh the limitations, • Put policies and procedures in place to maximize benefits and minimize limitations.

10. What is Distance Counseling?

11. Benefits of TMH • Increased access • Convenience • Cost savings (e.g. cuts out travel time for client) • Barrier removal • Reduced stigma • Authenticity of emotional expression • Effectiveness • Client empowerment • Social justice • Increased clinical capacity

12. Limitations of TMH • Confidentiality • Interception of sensitive data • Keeping pace with ethical codes and best practices • Limited literature on TMH effectiveness • Inability to see communication in context • Service disruption due to technical issues • Credentialing • Administering assessments • Malpractice insurance • Lack of technical infrastructure • Crisis intervention • HIPAA compliance

13. Best Practices • Informed Consent • Staging the Office Environment • Keeping Pace with Technological Advances

14. Defining Eligibility for Distance Counseling Services What are the: • IHE accreditation requirements, • Students’ need for access, and • Is it feasible to offer distance counseling services to students who telecommute to campus (e.g. technology infrastructure and security).

15. Which Students Would be Eligible for TMH Services? • Students on campus taking online courses • Students temporarily away from campus, e.g. Study abroad, internships, alternative spring breaks, etc. • Degree seeking students taking courses from a distance • Non-degree seeking students taking a single online class to transfer back to a home institution – are they considered our students? • Online International students • Students at an institution with smaller branches/programs implemented distant from a main campus that has mental health resources.

16. Logistical Dilemmas • HIPAA compliant technology • Communication technology • Data Collection technology • Technical support for clients and staff • Data security

17. Ethical & Legal Issues • Privacy & confidentiality • Training/competence considerations • Professional competence • Technology competence

18. Ethical & Legal Issues • Practice across state and international boundaries • Check licensure laws in both your location and the student’s location before providing services. • Verify malpractice insurance covers provision of TMH services

19. Healthcare COMPACTS • Many States are requiring insurance companies to cover telehealth • Most healthcare professions are developing interjurisdictional COMPACTs for multi-State practice • States are changing their licensure laws related to guest practice to be more inclusive of telehealth

20. Medical Licensure COMPACT

21. Nursing COMPACT - eNLC

22. Psychologists’ PSYPACT

23. MA Psychologist Treating Student on Spring Break in NH • Licensed, out-of-state psychologists may temporarily practice in NH ≤ 30 days per year. • Licensure requirements in the psychologist’s home state must be equal to or exceed NH’s requirements for licensure. • The out-of-state psychologist must hold one of the following credential: ASPPB’s CPQ or IPC; ABPP; NR’s HSP certification; or other equivalent qualifications determined by the board.

24. Telecounseling at KUMC • 3,000 health science students & medical residents • 700+ counseling clients annually • 3 campus (Kansas City, Salina, Wichita) • Individual Counseling Sessions via Video • Implemented August 2012 • More than 1000 video counseling sessions provided

25. Staff Training & Setup Training • Telehealth.org • Zur Institute • Telehealth Certification Institute • HEMHA Guidebook Setup • Simulated provider practice • Lighting / Background • Eye gaze and engagement

26. Telecounseling Technology Zoom Healthcare (BAA/HIPAA) HD Web Cameras EHR Online Client Portal (BAA/HIPAA) • Scheduling • Secure messaging (not email) • Consents • Visit questionnaires • Surveys (e.g., CCAPS, PHQ9)

27. Client Portal Example

28. Telecounseling Consent Example

29. “Isabella” • Demographics: 19 year-old, Latinx, Cisgender, Heterosexual, Senior Nursing Student • History: Generalized Anxiety and Panic Disorders • Presenting Issue: Panic attack after receiving feedback from supervisor • Reason for Telecounseling: • Preceptorships in both Kansas and Missouri • Prevented her from regular in-person attendance

30. Isabella’s Initial Encounter • Initial telehealth visit • Intake with telehealth screening • Onsite, face-to-face

31. Isabella’s Initial Encounter (Cont.) • Consent/orientation to telehealth • Screening criteria • Benefits/limits • Privacy/confidentiality issues • Crisis / emergency planning • Technology fails / interruptions

32. Screening Criteria (adapted from DoD) Telehealth contraindicated with: • Recent suicide attempt(s), psychiatric hospitalization, or psychotic processing (last 3 years) • Moderate to severe major depression or bipolar disorder symptoms • Moderate to severe alcohol or drug abuse • Severe eating disorders • Repeated “acute” crises (e.g., occurring once a month or more frequently) Isabella did not meet any exclusion criteria

33. Isabella’s Initial Encounter (Cont.) • Consent/orientation to telehealth • Screening criteria • Benefits/limits • Privacy/confidentiality/legal issues • Crisis / emergency planning • Technology fails / interruptions

34. Benefits & Limitations for Isabella • Benefits • Decreased stigma/increased comfort • Regularity of attendance • Limitations • Avoidance of exposure involved with in person treatment • Non-verbal considerations

35. Isabella’s Initial Encounter (Cont.) • Consent/orientation to telehealth • Screening criteria • Benefits/limits • Privacy/confidentiality/legal issues • Crisis / emergency planning • Technology fails / interruptions

36. “Isabella” • Unique challenge: KUMC sits on state line • Supervisor licensed in both Kansas and Missouri • If not, then review different state jurisdictional laws and requirements: • Guest practice laws in Missouri • Differential limits of Confidentiality • Tarasoff (Kansas v. Missouri, need for informed consent) • Privacy Laws and Location: • Change from parents’ house to house with fiance • Informed consent requirements change as location changes

37. Guest Practice & Confidentiality Limits Telepsychology 50-State Review https://www.apaservices.org/practice/advocacy/state/telehealth-slides.pdf Duty to Warn Differences http://www.ncsl.org/research/health/mental-health-professionals-duty-to-warn.aspx

38. Isabella’s Initial Encounter (Cont.) • Consent/orientation to telehealth • Screening criteria • Benefits/limits • Privacy/confidentiality/legal issues • Crisis / emergency planning • Technology fails / interruptions

39. Crisis / Emergency Planning for Isabella • Consult specific jurisdictional differences in requirements/laws • Safety plan • Standard components • Location differences • Collaborator • Local emergency help • Secondary mode of communication

40. Isabella’s Initial Encounter (Cont.) • Consent/orientation to telehealth • Screening criteria • Benefits/limits • Privacy/confidentiality/legal issues • Crisis / emergency planning • Technology fails / interruptions

41. Telecounseling with Isabella • Clinical Practice Consideration • Interoceptive exposure for panic • In person versus telemental health considerations • Clinician comfort • Importance of planning ahead • Important to consider immediacy concerns on front end of treatment

42. If We Were To End Our Telecounseling Program Tomorrow: • Many students and residents would not receive services because... • Remote campus locations (e.g., 3 hrs away) • Students/residents are time poor (and sometimes $ poor) • Academic/clerkship responsibilities prohibit travel time • Stigma of being seen seeking mental health services • Continuity of services would be significantly diminished

43. Resources APA Guidelines for the Practice of Telepsychology (APA, 2013). http://www.apa.org/practice/guidelines/telepsychology.aspx NBCC Policy Regarding the Provision of Distance Professional Services. http://www.nbcc.org/Assets/Ethics/NBCCPolicyRegardingPracticeofDistanceCounselingBoard.pdf Zur Institute. Reviewing the Debate on Skype & HIPAA Compliance and Introducing the Alternative Option http://www.zurinstitute.com/skype_telehealth.html

44. Resources ATA State Telemedicine Legislation Trackerhttps://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/3c09839a-fffd-46f7-916c-692c11d78933/UploadedImages/Policy/State%20Policy%20Resource%20Center/state-legislation-matrix_2016.pdf SAMHSA trainings and resources for individuals interested in providing telebehavioral health services. http://www.integration.samhsa.gov/operations-administration/telebehavioral-healthhttp://www.integration.samhsa.gov/operations-administration/assessment-tools

45. References & Selected Readings Aboujaoude, E., Salame, W., Naim, L. (2015). Telemental health: A status update. World Psychiatry, 14(2), 223-230. doi: 10.1002/wps.20218 Dart, E.H., Whipple, H.M., Pasqua, J.L., Furlow, C.M. (2016). Legal, regulatory, and ethical issues in telehealth technology. In Computer-Assisted and Web-Based Innovations in Psychology, Special Education, and Health, J.K. Luiselli & A.J. Fischer Eds., pp. 339-363. Academic Press: Boston. Kramer, G.M., Kinn, J.T., & Mishkind, M.C. (2015). Legal, regulatory, and risk management issues in the use of technology to deliver mental health care. Cognitive and Behavioral Practice, 22(3), 258-268. DOI: 10.1016/j.cbpra.2014.04.008 Shealy, K.M., Davidson, T. M., Jones, A. M., Lopez, C. M., & de Arellano, M. A. (2015). Delivering an evidence-based mental health treatment to underserved populations using telemedicine: The case of a trauma-affected adolescent in a rural setting. Cognitive and Behavioral Practice, 22(3), 331-344. http://dx.doi.org/10.1016/j.cbpra.2014.04.007 Shore, J. H. (2013). Telepsychiatry: Videoconferenceing in the delivery of psychiatric care. American Journal of Psychiatry, 170(3), 256-262. Simpson, S., Guerrini, L., & Rochford, S. (2015). Telepsychology in a university psychology clinic setting: A pilot project. Australian Psychologist, 50, 285-291. doi: 10.1111/ap.12131 Turvey, C., Coleman, M., Dennison, O., Drude, K., Goldenson, M., Hirsch, P., … Bernard, J. (2013). ATA practice guidelines for video-based online mental health services. Telemedicine and E-Health, 19(9), 722-730. DOI: http://dx.doi.org/10.1089/tmj.2013.9989

46. The NCTRC Webinar Series Occurs 3rd Thursday of every month. Our Next Webinar Telehealth Topic: TBD Presenter: TBD Date: Thursday, June 20th 2019 Times: : 9:00AM HST, 10:00AM AKST, 11:00AM PST, 12:00PM MST, 1:00PM CST, 2:00PM EST

47. Your opinion of this webinar is valuable to us. Please participate in this brief perception survey (will also open after webinar): https://www.surveymonkey.com/r/XK7R72F