Although many behavioral health providers had already dipped their toes into using technology for client visits, many more dove in for the first time when faced with coronavirus disease shelter-in-place restrictions.
At a time when people are feeling more anxious and isolated because of COVID-19, continuation of care is vital to treating people with mental health and substance use disorders.
Because telehealth has been the safest option, many behavioral health professionals and their clients have been forced to adapt to the technology—called “telehealth” or “telebehavioral health”—or skip appointments.
To deal with the distancing restrictions imposed by the pandemic, some clinicians and counselors have scrambled to adopt technology that will allow them to work with patients remotely while protecting themselves, their clients, and their families from exposure to people who might carry the coronavirus.
Easing Regulatory Restrictions
For those providers who did not already have telehealth systems in place, finding affordable and easy-to-implement HIPAA-compliant technology was a big question mark at the start of shelter-in-place restrictions.
Recognizing those difficulties, the U.S. Health and Human Services (HHS) Department’s Office for Civil Rights (OCR) announced that it will not impose noncompliance penalties on healthcare providers for “good faith provision of telehealth during the COVID-19 nationwide public health emergency,” even if the remote communication technologies used don’t fully comply with HIPAA rules.
In an article in Behavioral Health Business, Chuck Ingoglia, President and CEO of the National Council for Behavioral Health, applauded the more flexible stance on reimbursement from the Centers for Medicare and Medicaid Services, which is important to maintaining vital healthcare services. Ingoglia said he would like to see private insurers follow that lead, and some are doing exactly that.
Telehealth is being used in a range of behavioral health settings, and some states are relaxing their regulations to facilitate the use of those options during the pandemic. For example, as an article in the Psychiatric Times notes, Ohio issued emergency rules to ease restrictions on telehealth, and Massachusetts and New York issued regulatory measures to improve private insurance coverage of telehealth.
The Ohio Department of Mental Health and Addiction Services has expanded its telehealth regulatory guidance to eliminate the face-to-face requirement for an initial encounter with a new patient, permit telephone encounters, and allow more flexible monitoring with medication-assisted treatment of opioid use disorders.
One owner of a North Carolina family counseling practice, Julie Sams, LCMHC, applauds the more flexible stance allowing telephone calls as well as video encounters to deal with challenges that have arisen with COVID-19. “The insurance companies have been extremely supportive with softening their rules, which has been extremely helpful,” she said.
As the rules temporarily shift, payment systems may not keep up. Many counselors are finding that insurance reimbursement glitches are common, said Lorelei Lindow, LCMHC, and “that has been a headache for a lot of clinicians.”
First Time Using Telehealth
In addition to existing behavioral health issues, many people are experiencing heightened anxiety about the COVID-19 situation. Therapists are a valuable resource for helping them work through that anxiety.
Many practices providing counseling for mental and behavioral health issues are providing services primarily or exclusively via telehealth systems. With the OCR announcement that it will temporarily relax enforcement of HIPAA rules when providers show good-faith efforts to comply, behavioral health therapists are using a variety of digital platforms to connect with clients for distance counseling.
An HHS notification on telehealth says OCR will not impose penalties if providers use video chat applications such as Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Zoom, or Skype. However, public facing applications such as Facebook Live, Twitch, and TikTok are not acceptable, HHS states.
When the need for social distancing became clear in North Carolina, Lindow realized she needed to convert her counseling and consulting practice to telehealth temporarily and quickly.
Lindow acknowledged that before trying the technology, she had not been in favor of telehealth and was apprehensive about using it. “I didn’t think it would be as effective,” she explained. “I preferred in person to see nonverbal body language.” Under usual circumstances, she also values the level of commitment a client shows by coming to her office.
But Lindow also felt strongly about protecting her clients, her colleagues, and herself from exposure to the coronavirus. When exploring options for telehealth systems, she discovered that her electronic health record system, SimplePractice, had a HIPAA-compliant telehealth add-on app for only $10 more a month.
She created an informed consent document and helpful tips for clients, building on similar versions colleagues had shared with her. Lindow paid it forward by sharing her versions with other colleagues. “Our community has been wonderful about being supportive,” she noted.
Although a few of the people Lindow had been seeing regularly declined to attend telehealth sessions, she said, “most of my clients were extremely supportive and resilient and jumped right on board.”
Converting the Whole Practice to Virtual Visits
Even those therapists who were already using telehealth had some adjustments to make when the pandemic hit. Sams, who owns a practice with three locations and 10 counselors in North Carolina, had been using telehealth with some of her own clients for several years. But only a few of her team members had experience with telehealth sessions before the COVID-19 crisis.
Sams had previously used telehealth when existing clients were sick or had sick children, or their work schedule changed and they needed to meet on lunch breaks.
But finding a system for the entire practice was still a challenge. The system she had been using, doxy.me, was shut down during her practice’s transition to work from home. And some of the options she explored as temporary alternatives were just too expensive.
“As a business owner, you have to think about how you can cut costs. Less people are coming in. Less people are starting therapy,” Sams noted. Like Lindow, she finally settled on an add-on to her practice management software, TheraNest, for $10 a month.
Clients Quick to Adjust After Awkward Starts
When making the transition to online sessions, counselors are finding that some clients are resistant to telehealth. “Initially, they can be hesitant,” Sams observed. But once they get over the initial awkwardness of meeting online, they realize the importance of continuing to stay in treatment. “Once they’ve tried it out,” she said, “they see that it’s better than nothing.”
In some cases, the technology can increase clients’ existing concerns. “People are not always comfortable seeing their own image,” Lindow noted. If someone has body image issues or is struggling with gender identity, for example, the selfie view might be disconcerting. Changing or blocking the screen view is one adjustment Lindow suggests.
For people relying on counseling, the continued support is vital. “I can’t imagine if we couldn’t see these clients,” Sams said, noting that it would be a risk if their counseling were disrupted. For example, people living alone and dealing with depression and anxiety need professional contact even more now.
With telehealth, Sams noted, “I can still guide and help them through the difficult things that they are going through.”
Once clients adjust to virtual visits, some of the biggest hurdles stem from technical difficulties. “There are still challenges with screens freezing or something happening to picture or sound. That can be very disruptive in a session,” Lindow said.
Other challenges include not having the usual variety of tools for supporting clients during counseling sessions. Some counselors use play therapy, sand trays, white boards, and games to encourage their clients to express themselves. Therapists working with children may have to get more creative with online worksheets and more parent-child work.
To complicate matters, services that wrap around counseling, such as occupational or speech therapy, might be temporarily discontinued as well.
New Aspects for Counselors to Consider
Amid social distancing restrictions, many college students who were participating in counseling had to move back home. For some states, if a client wants to continue meeting after moving, the counselor must have a valid license in the state where the client is receiving counseling. Some of these states have made modifications to these regulations or completely waived them amid this national time of crisis.
In terms of the work environment, counselors must think strategically about what is visible in the background during video sessions. “I’m personable and genuine, but it’s important to create healthy boundaries around what you are disclosing to your clients,” Lindow asserts.
Another complication is finding a way to separate the work and personal environments when both are situated in your home. Lindow initially was working from her living room sofa, but she decided to create a different work nook. “My couch is my place of refuge where I relax,” she said, “and it was hard to escape work mentally for me.” So she created a work space at her kitchen bar and posted a sign that says “telehealth office” to reinforce the separation.
Despite being resistant to telehealth before the COVID-19 shelter-in-place situation, Lindow plans to consider using telehealth in certain situations after the crisis is over.
Addiction Treatment Centers Find Ways to Adapt
In recent years, telehealth has been seen as a good option for people in rural areas who may have to travel long distances to find support for mental health and substance use issues. In smaller towns, the private location of telehealth encounters also can help with the perceived stigma associated with seeking mental health assistance.
The Substance Abuse and Mental Health Services Administration (SAMHSA) offers an online program that explains telehealth options and provides training on using the technology. SAMHSA has issued guidance on relaxing telehealth rules in this public health emergency.
During the COVID-19 crisis, licensed clinicians can provide medication-assisted treatment (MAT) services over the phone in certain cases and with specific types of medications. Patients in opioid treatment programs can go home with more days of their prescriptions, limiting their visits with providers and trips to the pharmacy.
The Hazelden Betty Ford organization has a virtual outpatient substance use disorder program called RecoveryGo, which allows video conferencing for counseling and treating patients remotely. As noted in a PBS News Hour article, the program relies on video conferencing for one-on-one patient-counselor sessions and also for group therapy.
Peer Support Services Get Creative
For people with substance use disorders, peer support is key right now, as isolation, anxiety, and depression can lead to relapse. With those dangers in mind, peer support groups are seeking alternative ways of continuing their mission.
For instance, some Alcoholics Anonymous groups are using online video conference tools such as Zoom or Google Hangouts for meetings, and others are having conference calls or keeping in touch via email or social media.
A Narcotics Anonymous statement on the organization’s website notes that each local group will decide what is best in dealing with COVID-19 and health concerns, and that some groups may choose to meet over the phone or online.
Implications for the Future
Now that many behavioral health providers and clients have adjusted to telehealth encounters, some questions remain about how these experiences will influence future regulations, public and private insurance reimbursement, and counselor and client attitudes toward technology-facilitated visits.
For now, the use of telehealth is a life saver for many people. “I feel blessed that we have this mode of communication and that we are able to stay connected with our clients,” Sams said.