Good afternoon to those of you in
the eastern portion of the U.S. And good morning to those of you in
western time zones. Welcome to the first of two very interesting and timely webinars on the topic of TeleBehavioral Health. These webinars are brought to you by the SAMHSA Behavioral Health Information Technology and Standards Initiative. My name is Alan Mogel an associate scientist with Abt Associates, part of the BHITS team. As we now move to our customary housekeeping rules a reminder that a PDF version of this
PowerPoint presentation will be emailed to all registered participants for this webinar. Please note that the webinar is
being recorded and will be posted to SAMHSA’s YouTube page located at Please note that all lines are
muted. You may submit your comments or questions via the chat box feature typically found in the lower right portion of your screen. We’ll save all questions for the
final 15 minutes of our hour together This is the first of a two part series of webinars to be held this month. The next Webinar in this short series will occur at the beginning of next week
Telebehavioral Health What Every Provider Needs to Know. The registration link has been sent out if you would like to be included on the listserv, you may send an e-mail to [email protected] With that I’d like to now introduce today’s featured speaker Dr. Marlene Maheu serves as the
today’s featured speaker Dr. Marlene Maheu serves as the executive director of the
Telebehavioral Health Institute found online at where she oversees the development and delivery of professional training in behavioral health via an e-learning platform that has served consumers and clinicians from over 70 countries. The focus for Dr. Maheu has been legal and ethical risk management related to the use of technologies to better serve behavioral health
patients. She has served as a consultant researcher author trainer and keynoter. And with that Marlene, the floor is yours. Thank you very much, Alan. I appreciate your including me in
your series. First question that typically comes
up is whether there’s enough research in the evidence base to support the use of telebehavioral health. And the truth is that yes indeed there is a lot of research actually
this has been going on since the 1950s in the United States and worldwide as well. So at this point we have about 4,200 articles that we’ve databased at our
institute alone talking about the effectiveness of
telebehavioral health. The reason for this big focus on research is that behavioral health in general is the largest unmet health care need in the United States. So the next question we often get is
why aren’t more behavioral professionals
available online. And the best answer I can give is that indeed the behavioral world has been one of the last ones to come online and all of healthcare in terms of the general practitioner base
understanding what the rules and the regs are. And part of that is because it’s
been a very conservative world. We have to be conservative because a
lot of the people that we deal with certainly not all of people but a lot of people can be struggling with issues like suicide or homicide or abuse. And so we have a procedure carefully that’s what the licensing boards
have done as well as the professional
associations. So as a result of that most behavior clinicians have not been trained and the graduate schools haven’t
gotten to the training either as a matter of fact we’re writing
another book specifically specifically for
graduate schools right now but I believe it will be the first
book that is targeted just for graduate schools and that level of training. So if you want to ask well what can
you do as a consumer to help make behavioral health more available if
you really are interested you can do things like contact SAMHSA and which is a federal government arm that oversees substance use and mental health services which are
now being called Telebehavioral Health. You can thank them for this
educational program and ask for more services, too. You can also contact your state
professional associations and talk about the disciplines
involved and say OK I’ve been interested in social work
then there’s a social work association at
the federal level or the national level which is
National Association of Social Work or there may be one for your state. So Ohio Social Workers Association, Florida Social Business
organization, so states have professional associations and you tell them hey I’m interested in this. So if you work with the channels that already
exist, your voice will be heard a lot more strongly than if you just go on the internet and try to find people out there. You can also contacted state
licensing boards for those disciplines
involved. Once again if you’re interested in
just finding a social worker or psychologist, or psychiatrist depending on what your needs are you
do that. The other thing to keep in mind is
that there are nine behavioral professions in our entire behavioral world. That’s that’s a lot of different groups to keep track
of. So those professional associations include the addiction specialist and behavior analysts behavioral nurse practitioners, counselors, marriage or family therapists, psychologists, psychiatric nurses, psychiatrists and social workers.
psychiatric nurses, psychiatrists and social workers. So giving you these names and if you’re interested in this I want to encourage you to go take a
look at what these disciplines are and who might serve your needs
because you may not may not know the difference between say psychiatrist or psychologist or social worker and counselor psychologist. So every group has its own specialty although there’s a lot of overlap. So if you’re going to look for a professional what should you seek in
a professional? First off look for someone that has
expertise in whatever you’re struggling with. So let’s say it’s raising a family or it’s you’re having marital difficulties. You want a family specialist or martial specialist. Number one because if they’re not trained in a basic thing you
need then no matter what they do it’s not
going to hit the mark. Right? And then you may want someone who has training in
telebehavioral health which is delivering services across distance through a camera or some other type of technology and those really are two separate
types of training. Many people believe including this is rather disconcerting, but a number of professionals believe that it’s all the same. The truth is that everything that
you do as a client or as a consumer or patient gets mediated by a camera when you’re doing video conferencing. And there are a lot of things to be
aware of and to protect yourself with when you’re doing it as well. And the clincian needs to be not only aware of your needs but their needs. Their legal obligations without
complications. So there’s a fair amount of training
involved and the best way to make sure that you’re getting
what you really want is to go with someone who’s licensed. So someone who is licensed has legal responsibilities to you and to the state that they’re
licensed in. So we’re going to go through
some of the ways that you can be sure that yout
clinician will protect your private
information attending to your specific needs. One is to recognize that licensed
professionals are required by law to protect your information. And that there are federal laws that impose very severe penalties for violating your privacy. Some of the examples of those laws
includes HIPAA you might have heard about HIPAA. So that whatever technology you use has to meet standards that are set by the
federal government the high tech act also imposes certain penalties for not paying attention to the HIPAA laws as we go down into the states. There are state privacy and security law so some states have even more privacy security
requirements than the federal government. Texas California there are a number of states that
have additional privacy laws. And these are generally the states
that are known as consumer protection states where they go above and beyond what the
federal government says and requires clinicians to do extra things. So there are certain things in place that
that you can count on when you’re working with a licensed professional. Professionals also are required by an ethics code. They may or may not belong to
professional association. Whether or not they belong to the
professional association they are held to standards of an ethical code. And so you can look once again
social worker, behavioral analyst, the analyst
family therapy whatever discipline you choose out of the nine just know there are professional groups that do set standards. And then of course the licensing law
not only protects your privacy but does that in a number of ways and we’ll get into some more of
these on here. What I’m trying to let you know is
that the entire professional practice of telehealth and telebehavioral health in the United States is also defined by state laws rather than federal law. So if you want the final word on what a practitioner in your state is supposed to do. It’s to be found at the state level at the licensing board where they’re registered as a licensee. OK? Now the thing to note is that
states could be different and this is why we don’t have laws yet with people professionals who
practice overstatement because the different
states haven’t all come to an agreement about what’s OK for their licensing group. So we’ve got a fair amount of
discord between the states and that will take some more time to get resolved. Professionals from one state cannot practice in your state and do so legally. And my advice to you is to make sure that you’re following this carefully when you’re working
on line because there are many ways that
this is getting compromised and that means that your own safety and protections are getting
compromised. The thing is that state laws are in
place to protect you if you choose to work with a professional who’s unlicensed, what are you doing there is choosing to work with someone who could not even demonstrate a level of minimal competency to meet one states standards. That may not be someone that you
want to trust with your emotional health or that of your spouse or your children or your family members. So the licensure helps differentiate that just like a driver’s license helps distinguish who’s at one point
in time passed a minimum competency
exam. Can you back up safely. Can you parallel park safely. If you can’t do that even at one
point in your life then you shouldn’t be driving. Is is that the point of view from the department of motor vehicles. Well that’s the same with licensing. You want to be able to count on somebody having demonstrated with an exam that they do know what the rules are. So if you choose to work with an unlicensed professional the
laws can’t protect you. So if something goes wrong things
can go wrong. Then you really have no recourse. Now where did you try to find
license people that are appropriate to work with you so you can go to the state licensing board and look up who are their licensees. Who might be who might be licensed in your area or if you can get a license number
from a professional. Use all of us that are license are mandated to make that public. They have to make that licensing
number public. So that you can, you know, look them
up at the board if they claim to be licensed and if they’re not there and are lying to you so be careful
about that. Now the job of the licensing board is to keep out the bad apples. Right? So they will only publish the license numbers and names addresses of people that
are licensed. Much like a contractor with a state. Get with the contracting board. You can go look up their license and you could do that, too. The real point here is that
behavioral issues can create serious
vulnerabilities and you may not even be aware of
them. And that could be part of your
vulnerabilities you know you’re vulnerable. So our job is to know your
vulnerabilities and help you identify them and deal with them. So another part of our job is to make sure that we don’t use those
against you that we don’t take advantage of what you don’t understand rather we try to help you understand
it. And so when you’re working as an
unlicensed professional they’re not held to that standard
because there is no standard that are being measured up against. My caution to those be careful
you’re working with licensed people. Hopefully you that point because I
kind of hit that one hard. Now what about your safety on line. It’s a whole other thing licensure
in general. And then what about online. One of the most of what they
think about is that you’re setting is one of the most crucial things to consider. Once again telebehavioral health has
been documented for the last 60 years. Safe and effective protocols have
been identified for decades. But the factor is where you are. If you are in a professional setting
lets say a physician’s office, or a psychologists office those are
recognized by Medicare for people. Then you walk in there with a certain level of expectation. And the professionals are expected
to treat you in a certain way too. There again if you’re on a locked ward in a hospital then you can be worked with there because there’s a lot of people around that environment is controlled you’re safe. So any type of diagnosis that you could possibly
imagine has been treated with Telebehavioral Health. But the setting is what differs and the levels of control that are there to protect you are
different. Now when you start moving to getting services in your home rather than a
professional office there are more variables that can come into play. Your connection could be spottier there are people that do
come in and out of your session. Neighbors might be overhearing you
so fewer things are controlled. So generally it’s not a good idea if you are psychotic to be working from your home because
there’s typically not anybody there to help
you out. So less severe diagnoses are are addressed in home settings. Now there are public settings that can be dealt with as well such as somebody trying to deal with social phobia or the fear of going and speaking and you have to actually speak. So there are certain types of discorders that can be treated
publicly. But there again the therapist
involved with that has had a lot of special training to make sure
they you control what needs controlled in part. So I’m trying to drill down here to
help you find a more qualified telebehavioral professional. So first off start with your private therapist. If you if you’ve got along well with a therapist that’s the first place to go look. Contact that person. If you have insurance ask them who they may have approved already to work with you. It’s not your you’re already the prior therapist and ask if your prior therapist was willing
to get trained if have never done this
before because most professionals have not done telebehavioral health. So there are a number of places that
professionals can training. In addition to the types of training available through this medium here through
SAMHSA there are private instances such as
the one that we run at Call the telebehavioral health
institute. There also are national professional
conferences. I for one give daily workshops two-day workshops around the country. And a lot of them are the national
professional associations. There are many other
people doing that now. You can also look to state
associations as I mentioned earlier they may have
a workshop or a credentialing experience that professionals can engage in. So there again go back to your government entities go back to your state associations your
national associations and ask them and SAMHSA I actually gave you the
URL here where there are some up and coming trainings for telebehavioral health professions. Now, a lot of people ask me Well how else can I find somebody online? Now you may find companies online that sort of have directories of professionals. What you want to ask them to do. That is what we want to do when you evaluate them is to see if they asked you to identify your state of location
at the time. If they don’t ask you to say you’re from Oklahoma or you’re from Florida then they are pulling you into panel of practitioners who probably not licensed appropriately which means you have
no recourse if something goes wrong and they’re asking those clinicians
to practice illegally which is not a good thing at all. So you just want to make sure that
when you go into a system that they’re asking
you to identify your state — we’re not only you live not were you reside but where you
are physically at the time of the contact. They also engage in an informed consent process we’ll
get into some details of that, but there’s a thing
called informed consent process that is key to
protecting you. That is the one thing that you need to be most focused on is did you get full informed consent? Did you agree all substance
of that? OK. And as part of that esspecially for telebehavioral
health the safety plan he has to be identified
as who else can be contacted if there’s
an emergency. Because when you start working in
mental health behavioral health
substance abuse things can come up that you don’t
anticipate. So a good clinician, a licensed clinician is legally responsible to have back up plans and not just be winging it with you and have continuity of care that
he’s available to you over time. In many states that actually show you want to make sure that’s
all part of this informed consent and to have detailed discussion
about what happens if something breaks down. So let’s say we were right now
working in telebehavioral health video and the connection just stops. What are you supposed to do just that you should have sort of a to do list that you can follow there that the professionals worked out with you. So of course what else can you do to find the right type of
practitioner for yourself checked their
professional license at their word level and then contact the state and national association
for the type of professional you might need and ask them if they have
qualified professionals on there. What are some of these companies that this topic about some of these
companies. There are many that have started. And I see about one a week come up some of them are good and some are not. I’m going to try to help you
distinguish between the not so good ones and a good ones so that you can be sure that your that what you’re doing were met meets your needs first. What are the Terms and Conditions file in their Web site who do they make responsible for complaints or something goes wrong. Do they have tech support just or are they trying to pin all the responsibility on the
practitioner and they are just going to act like
a phone company. So look out for that because it would be in your best interest to have to opt into a system where you know exactly where the lines of responsibility lie especially when you’re going for some type of behavioral support. Don’t wanna get caught in between some of these legalese. And the documents that might just
basically let everybody off the hook in you’re
holding the bag. So definitely want to opt into a system that is very clear about who’s
responsible for what and is there a phone number that
you’re supposed to dial if something goes
wrong technically? Call it. Call the number and see what happens. Do you get sent a voicemail message? Do you have a live person answering you if you have to send an e-mail and how long is it take. So I know this takes some up front investigation and some people just don’t want to
bother with that they just want to go
online and that that is your choice. But as a professional who has been
in this field for a long time I would encourage you to take a few extra
steps because even if you want to see somebody in your community and you did an in person type arrangement with somebody you would have to get referrals you would have to get dressed drive over there. You would have to sit in
their waiting room. You’d spend at least an hour or two before you were seated in front of someone. So spend that amount of time doing some investigation upfront
before you pick somebody on line. And I think it would do very well. Also you will be very clear about
who pays for the service and how is that money processed. Is that going to show up on your
credit card bill and if so what is it going to be called on your credit card
statement that you may leave laying around your
house and somebody else picks up and says, “Hey, I didn’t know you
were getting any anger management services from this company. What’s going on?” You know so just companies should not be naming your psychological psychiatric or mental health service services in your credit card statement. So you should be much more discreet and protect your privacy when you’re
dealing. So how else can you look for a qualified practitioner. You can look at some of the online
directories..their start up services and then see if they will let you talk to the professional
ahead of time so you can ask a bunch of questions I’m just
about to give you. That’s the one thing. Second thing is download a copy of their
informed consent document so you can read all of this and see this makes sense to you or if you have questions about it
that you then want to talk to their professional
about. I want to caution you about being leery of some of these online
companies and some of the clinicians you’ll
see online because many clinicians that started out 10 20 years ago thought this was the Wild West make
you do anything they please. So even though they were licensed
they have the misconception that they didn’t have to follow any
of the rules or licensure online. Actually we just published a study
my my research team and I published a study two months
ago that showed that this is still a very very common belief. That misconception that they don’t
have to do anything related to their
licensure if they work online. The Internet is not the Wild West. The internet is controlled. Same exact way is in a person’s
practices. All the things we have to do as
professionals in person. We have to do online. Many the companies that have started
up don’t require it and they may lead to your believing that that’s not required just by the
way they’re set up. So first off you have to know that there are no external authorities that police
claims on company records professional
directories or private websites and you have groups like the Federal
Trade Commission that says you can’t be
fraudulent in your claims that they don’t
actually go out and regularly police these sites. So a lot of them are slipping
through the cracks. Same thing is true of licensing boards. They do set standards for
clinicians. They don’t have an investigative
team that comes out and looks up what clinician A or B or C will be
writing about what their expertise is. And a lot of the clinicians that have gotten online go ahead and list a wide list of specialty areas they’ve work in. They might have had two months of
working with somebody in the prison system but now all of a sudden they are specialists in criminology. Not necessarily true. So they’re a little loosely looser and we’d like to see in their
descriptive profile descriptions of what their
exterpise is. So you can ask questions about that. That’s why look for a
specialist in the issue you think you’re deal with something you need to address and then of course I’m going keep
saying this over and over again check the
clinician’s licensure. Also be leery of the licensed clinician
— let me say that again — EVEN be
leery of a licensed clinician who offer services you platforms that minimize how much information
they can collect from you. Now no matter how well-trained or how good a clinician is they’re
not mind readers. And if a platform only allows them to get a minimal amount of information from you they are not going to know how to work with you. I don’t care if they’re
geniuses or not. It’s physically impossible to know exactly where you come from because if you think
about the Internet people from all around the world in hundreds of languages with thousands of cultural groups and different types of
backgrounds can be typing the same thing into an interface. How is that clinician going to know what your context is? It’s
impossible. So think about how we’re trained as clinicians. We’re trained in person to start
with. And we are trained with somebody watching us and we know the context full context. We actually sit with you we can smell you we can
look all and all of your body listen to your voice from all of
these keys are very important for us in how we we guide somebody. If you strip all that away from a clinician how can they possibly do well? The only way they can do even close to well is if they get some training in how to adjust for that had them make make that difference to person on line so small that it’s really not going to
interfere. But even if you get the number of
hours that we offer our institute which is
15 to 40. None of that is in mind-reading. So you’ve got to be realistic about
the amounts of information that you are giving somebody while it may be
convenient to not show up on video and only do contact in e-mail or text messaging or even telephone you’re not giving your clinician a whole lot to
work with and they cannot they cannot work with what you don’t give them. So I think the best analogy I can up with on this is if you go apply for rent or you go get a mortgage for a home, if you’re looking at homes try to find a new place to
live. We’ll be getting and giving a lot of information. And if you aren’t willing to give
that same amount of information not type — but amount of information then you could be at a disadvantage when you’re trying to work with a clinician who says yes they
can work with you, generally they’re not
equipped to do so. Now what about all of the promises that you’ll find some of these
online companies making. First off pay attention to whether they take responsibility for the claims that they are
marketing to you or are they just plugging you in through to clinician’s? If they’re only a phone company
they’re plugging you through, then they may very well have gotten four million or sixty nine or ten million dollar marketing
budget and they can promise all kinds of
things but that clinician is really
divorced from those promises. They’re just signed up to do license
work that they may not be cognizant of promises. So where does that responsibility lie and does that company that you’re plugging into ask you to
provide emergency information does it ask you to some informed
consent documents, which is required by
state law, for all licensed professionals to identify where you are. If not you just jump on there willy
nilly and think about that. How can somebody possibly do their
job if they’re licensed and they’re supposed to be adhering to certain regulations. And look at the company disclaimer because a disclaimer may give you a clue as to what they’re
accepting responsibility for or not accepting responsibly for. So what not to consider when responding to some of these these things are millions of dollars in funding that come from investors and sometimes investors don’t really understand the industry that
they’re investing in. I hate to say that but it’s really true and the company may use big names they may use movie stars so you know there may be Olympic athletes maybe people that get paid a fair amount of money
to endorse them. But what does that mean in
terms of you and the care you’re going to
get. Probably not a whole lot. They may also flash numbers around. They serve a million people
here. They are serving six million people
there. So what does that have to do with you? Well the devil’s in the details
here. So look at what some of the motivations might be. There are a lot of talk about disrupting and disruptive innovations
disrupting practices and to be honest I’ve been working in Telehealth now to Telebehavioral
Health for 24 years. I’m the biggest supporter for innovation and disruption as long as you adhere to all the rules. If you’re
going to throw the rules out along with the in-person care then you’re not doing in my opinion and I’m doing the
consumer a lot of good. So be careful about things that groups that just get big money and they flash big numbers and they have wonderful campaigns and they explode your inbox or web pages with ads that follow you around the
internet. Be careful about that better stick with people who are licensed, that have demonstrated
they know what to do, and that do follow the things that I’ve been telling
you about…informed consent…you
knowing exactly the terms and conditions filed what’s going on and you won’t find very seasoned clinicians working with some of these very very big outfits on a regular basis. So be cautious about it and also look at the safeguards that they put in
place. What is the intake like? Did they ask much history do they ask you about medications you’re taking? Because medications can really
impact your mood. It can really can make you
focus. It can make you more sluggish. Can make you thick headed and did they ask you about that or they just don’t give you any
answers to some question you ask them Do you have a prior diagnosis? Have you’ve gotten prior treatment? What’s worked? What’s not Worked? These are very important things for
a clinician to deal with when they’re starting to work with you. If there is no informed consent what exactly are you being told about the
information that you’re giving. Where’s it going. So there’s a lot of things they may
want to know about. Now look at the numbers of people that have been used. Are the number is real? When they flash numbers when some of these companies flash big
numbers. Is there some group that that checks on that? Actually no. There’s no official
group that will go out to check on it. Most government groups rely on complaints. Once a complaint is filed then they go investigate. So it’s not what a lot of us would like to have happen but it’s true. So I’m going to shift over to helping you understand informed
consent. Some of the things you need to be made aware of the and these are general rules that are
set not only by licensing boards but by professional associations. You get to choose the technology you
prefer. You don’t have to work in video or on telephone or apps. You don’t have to do any of this if
you don’t want to. And you whatever you do choose to use. You should be given an explanation of what the risks and benefits are. Because it may not occur to you. You also should be pretty much
skilled in how to do it. And if you’re not
familiar with how to use the technology training should be made available to
you so that you are skilled. You definitly don’t want to be using
technology that you don’t know how to use. You also need to know the
clinician’s availability is this a one time thing where
you’re going to talk to them with one question or do you get to see them another time or three or four times. And when is that? Will it be once a week? Once a month? Do you have to wait two months to
see this person again and then meanwhile you’re supposed
to be seeing other people. So get all this information upfront. All of this is part of the informed
consent. If you choose to opt out of the technology. What are the
repercussions. Are there any you should be told
that there are no repercussions. You should have the freedom to come and go as you please. You’re the consumer. What about payment arrangements will
you be billed automatically will you not. What’s going on with your credit card or whatever your payment system is. When will this clinician violate your privacy
because there are certain conditions in a professional practice where if you tell somebody you are abusing
elderly people or children or if they have a reasonable
suspicion to believe that then they will need to report you because clinicians all clinicians and health care
including teachers and police everybody is a mandated reporter to help protect society. So there is no total privacy anywhere even in a private practice if you’re telling somebody that
you’re going to be abusing somebody then there are
repercussions for that or if you’re suicidal or you’re homicidal. So there are repercussions for
uttering those words. And you need to be told that
upfront. That’s only fair to you to be told
that. What about ways you protect your own privacy maybe securing a babysitter for your children. How do you prepare your computer. You take it down sharply the day of
night. All these things should be dealt
with. What about intrusions or interruptions people walking in — into session. How can you handle that? Can you develop code words? It is a
very common practice in telebehavioral work. Telebehavioral Health to develop a word a phrase that lets the clinician know that somebody just walked in there
in your room and you don’t want to necessarily say that but you want you to transmit the message that it would be great if they shut down the session. And then you were not exposed any
more questions about what you were
talking about. So there are things like that agreements that clinicians
should be making with you so that you know you’re okay. If someone walks in and something unexpected happens on your end. And then there should be an
emergency plan including emergency contact names numbers for the clinician to call if
something comes up. So now I’m going to give you a list
of questions to consider that you can ask your clinician when you get started. OK. Number one are they licensed and in which state. Because if you’re a Californian like
I am, and you want to work with me then I’m a clinician and I may be
available to you. But then if you go out of state then I can’t
work with you there. These are not
licensed in that state. So you definitely want the license numbers of everybody you work with and what states are licensed in and then ask them how much experience they have
in the in-person practice. Let’s say
I’m going for family therapy because I’m having
some difficulty managing a 15 year old. OK then how much experience does the clinician have in dealing with that issue? How many people have they treated? It’s always a good question. Oh you’ve treated 12 people very different and you treated 150 families. Right. So where are they in their life. How many years of practice have they
had? You know, that kind of thing. Now you switch to the online role. How many people are being treated
online. Because some people may have very
well practiced 30 years, but they’ve only have one
client online or two or ten well, they’re still learning. OK. Do you really want to be in that
mix? You may but you deserve to know the information and then you make the decision. Well how many people then have you
treated with my issue online? So you see, I’m the drilling down to what’s the best clinician here for
the kind of issue that you want to come in with. More questions. How many hours of formal training
have you had working in Telebehavioral health. Oh, well I heard this thing on the
radio, with NPR. You know I love NPR but that’s not formal training in
telebehavioral health. OK. Someone is trained in Telebehavioral
Heath when they get a course completion
certificate. Any course that offers a continuing education hour in our country is documented which is how many certificates did they get
how many hours of training do they get. Is it three. Well that’s a lot different than 40! Be an informed consumer. Yes. Do they use HIPAA compliant
technology. HIPAA compliant technology by the
way is a federal standard set for privacy and security and any transmission of your
information. They’re not using HIPAA compliant
technology. They don’t know what to [indecipherable] or discontinue treatment. Ask them if they’re recording you
OK. What’s going on. Where’s that recording going. OK. Who is going to have access to any
of the recordings or notes or other records in the system is the project going to be looking
at this is a case manager looking at this? You have the right to know who’s going to be seeing your personal
information. How will you know if anybody else is in their room. Will they scan the room with their camera. Will they
verbally tell you nobody else is in the room. How often will they do that will be
every session or every 10th session. Just how how can you manage that? Is it okay for you to record the
meetings most clinicians will say no. Because some of that can be taken
out of context. But what should you do if someone walks in. Can you give me the high sign. I’m going to pick that up just how is this going to happen. What if someone walks into their
room and you see it and they don’t. How can you you know how can you talk about that with that. Can you bring somebody else into the
session should you tell them ahead of time do you not? Do they just pop in. So
most clinicians will have requirements of you about that. To let them know what’s going on. Who should call who if you get
disconnected or who should what’s the next step
going to be. We just let that go and not come back til the next
session. You know it was all kinds of things
you may just want to think about. And then how can you be sure that they’re following all the rules. See what they say to that because if
they don’t they don’t follow the rules then I need to know that. They can assure you that their
licensed for example. Do they recommend any particular
apps for you if they are or are they validated. Where do they get these apps. They just someone and they heard
what was good? How do they get their apps? Can you text them? If you do text each other which technology? Because if you use technology on
cell phone a traditional cell phone that
is not secure and those messages can stay in your SIM card and your phone as well as the hard
of the circuitry of the phones so do they
know about that and they know protecting
your privacy there. Should you be sending them e-mail
that it includes diaries with long explanations of what’s going on with you. And then can you get get your insurance
to cover if you do have insurance. What can you expect to pay for telebehavioral health It really depends on the service
you’re purchasing. Some companies will sell you the ability to text message somebody and it is a one time thing. There again I want to encourage you
to think about all the requirements. Even thing about informed f
consent How do you inform consent with somebody? Which, by the way, is a meeting of the
minds When you have a clinician you come to agreement about what’s going
to happen with you and the clinicians raising the
issue should understand that if you really need to talk to somebody. You don’t get to hear the voice of
hesitancy just get a text. Yes I agree. So think about that. Is it a one time service with no continuity of care. Does your state require continuity of care for crisis because most
states do. Most states say that if you start a relationship with a consumer that a licensed clinician that’s such a pleasure to have to be available for ongoing services you can’t just you
know meet with somebody one time and that’s it. So there’s a responsibility there. But what is it they are being promised and then look at the fee involved. It’s the same as in person. There’s ranges from free because you can get
free services and in-person services from some specialty clinics, specialty organizations. You can also get a sliding scale for different groups different in
person. You can find the same thing or you can find many chose companies now that do cover with little insurance. Many employers are offering telebehavior health services where telebehavioral health and they’re covering the services in some cases there’s a copay. In other cases it’s not just like in
person and of course there’s private pay where you can
get whatever you want. I would urge you to go for the more conservative route. Right now there are people trying to
figure things out and see how we do with that. before you go into any choppy waters was very very innovative cutting edge cutting edge and then I had the
cutting at the bleeding edge for over two
decades. Now I’ll tell you bleeding is not necessarily a good
idea. So what do you do if you want to wrap up some of the things you can have to do to protect yourself? First off only were the licensed
professional because you’ve got all laws to
protect you. Learn the clinicians full name
their license number and credentials and go look them up. Like I said before and then keep all this information
safe Don’t put on a sticky note and then you lose the sticky note. And if you have a problem with that there is talk to the
therapist as a part of therapy or as part of whatever behavioral healthcare you are getting you’re talking about the relationship and say hey this is really isn’t working out for me. The next thing is keep your cool and don’t post negative reviews that are untrue. We’re seeing an increased number of
professionals that actually suing individuals for overstating their case making all comments in review websites. So now some of the sites are a
double edged sword. Be careful about that. Many people use those sites to vent their grievances and the people who are happy don’t
necessarily go there you know. So they are oftentimes skewed so be careful about paying attention to
that and also so they are because let’s face your name and your home your your I.D.
information can actually be accessed by someone who’s trying to prosecute
you clinician’s upset about them because it’s false. Also if you have a complaint about a
clinician and you are license collision go to their licensing board. And walk away from that clinician you don’t need to be hammering away at a clinician that doesn’t work for you is your
time valuable enough for you that you can
walk away and just go on to somebody else who can help you if you really do
need to speak with someone. I’m open to questions as you sending your questions. Let me also caution you that I speaaking on behalf of Telebehavioral Institute on behalf SAMHSA or any other groups that are
associated with this webinar cannot
endorse any specific service for obvious liability reasons we can’t
say that yes this company is right that company is not. I’m giving you a very long list of things to think about as you
make your own selections. But if you’re going to ask questions
about hey what do you think of this interface that
we really can’t answer your question. (Alan) Marlen thank you so much for a
wonderful session this afternoon. We’ve had several questions come in
so why don’t we go through these in the
order they were received and get through them as best we can. First question. Do you think it’s good to have at least one face to face session? Is that necessary to continue? Tele-sessions? I love this question because it’s
been one of the licensing boards and profiessional associations have
wrestled with since the beginning of
telehealth. The answer is that for most people no because most people are not dealing with a life threatening situation. If you look at the full range of services that are available in behavioral healthcare it can go from someone who’s having an adjustment type reaction and just that it is just getting into something
new. To someone who is totally psychotic we can’t make statements like that in general. But for the most part telehealth at the beginning of its evolution was thought to be was based on technology that was not
as secure as it is today. The systems were as developed in
terms of protocols but now a trained clinician should be able to help render a reasonable diagnosis along with a reasonable treatment plan. If you’re getting you’re getting
care without some type of plan this we call a treatment plan in our world then give a ?? and just stay away from that but somebody comes up with a reasonable treatment plan that you
agree to a party to give informed consent. Is in most cases it is not necessary to have an in-person session although if you prefer in in person session if that helps you feel at ease absolutely then you can require. It’s not as if the the authorities require it really is an individual by individual time. (Alan) Good. Thank you. The next question that came in how
are these services being paid for our insurance companies or especially Medicaid Medicare? Are they paying for these services? Yes. The more and more systems are paying
for it. We are seeing that the vast majority of states have now required insurance companies to pay for Telehealth across the board for
cardiology and dermatology in reality and oncology everything including behavioral
health care. So they have to pay for it. Not all states but most states we have seen a lot of third party carriers come and work with those laws some have
not. Some still are reluctant even if they’re in a state like that. But the laws are catching up with them and they are coming on
board and they are paying for it on par with in-person care so it should
not be a different fee that you get charged to your copays should not be
any different. We’re also seeing the
stats on 75 percent of employers are using some form of telebehavioral health care now. So is a lot of employers through insurance
companies but also some larger companies are self-employed. So you’ll see that they are paying
for it. Medicare has paid for TeleHealth for a very very long time. But it isn’t serving certain
geographic areas. Once again these laws are
changing. This is a rapidly evolving year. So reimbursements in teleHealth is making I don’t know how many bills are in Congress right now that
at any point these days there are about 10 or 12 bill in congress to change the
paying system so a lot of activity is getting bipartisan support even in today’s environment is
getting bipartisan support so we’re seeing a lot of
change. Medicare has paid for a long time but limit to patients that are in rural areas that have to go to a practitioner’s
office or clinic or a hospital. They don’t get the service at home and then Medicaid once again is a state by state thing. So some states do pay Medicaid services and a lot of that to the home by the way and then some states don’t. So that’s still in flux. (Alan) Thank you. Well speaking of the
states Marlene you talked a little bit about the
state by state regulatory environment. What if the state does not have specific guidelines. What would you suggest then. And should that therapist be
practicing telebehavioral health. (Marlene) Well I love this question because some people are really confused
about it. You can practice a clinician a
practice self-help anywhere. There’s no law on the books that says you cannot practice telehealth or you cannot use apps or you cannot use email. States don’t do that. OK states may be mute about technology in which case the clinicians are free to do whatever
they please. All right. Because once you’re licensed you see that license is key to
getting licensed professional is once your licensed. You are required to do a bunch of
things like protecting persons. Your clients friends. Well if I decide to do correspondence therapy right where I’m writing
letters to somebody then I need to go to extra lengths to
make sure this is going to be confidential and that the other day people We could write in code. You’d have to decode the letters to really really understand right. Do you think back 200 years ago. So my job as clinician is to choose the right technology and make sure my client wants that
technology and then figure out how to keep my person safe. Using technology so as in a state that does not mention telehealth at all I still need to make sure my person’s private my person’s information is private but then I’m sort of not giving any guidance which makes
it tougher for somebody in that state. Other states are more innovative and they have now addressed telehealth. And it’s a state by state wide thing. New Jersey just did this by the way
so Jersey just passed what they call
telemedicine law. So that means all of the health care providers
opticians to surgeons to psychiatrists and social workers like everybody
needs to follow this law and the boards get to choose what
that means in each instance. So it’s it’s all over the map
literally. And your best bet is to go to your state and find out. But don’t be misled by clinicians as well I can’t
practice telehealth in in your state. What that means
is they haven’t gotten the training, right? They haven’t learned that yes indeed
they can do that. They just need to know the rules of
general rules that can be readily taught online or in schools online. We traveled we teach people in person as well. There’s a lot of information on how
to do all of this even in some state websites if you go to the California Board of behavioral sciences which is master’s level folks and counselors social workers. You’ll see there’s an entire page devoted to what the consumer needs to
know about telehealth in California. So there’s a lot of information
available about how to protect yourself A lot of questions you are stimulating a lot of
questions from the audience. Marlene I fear we may not get to all of them. We’ll do our best but perhaps I can
suggest that if a caller if your question
does not get asked that maybe that person can contact you through your e-mail
address would that be all right? Yes. As long as I keep you company to
use No I know you’re not allowed to say
that. But let’s go to a very technical question. Are there specific CPT or HCPCS codes that are billed for telebehavioral health services. Absolutely. There are very specific ones but in general the regular codes regular CPT codes are more than adequate. They simply need to have a modifier code which is 95 and the place of service code is 02. That’s more of a kind of
clinician. question, but I’m happy to answer it. yeah. And there are we of course just on that reimbursement so there there are. It’s been simplified especially just recently since simplified a
lot. There are also specific CPT codes for the use of technology to do certain things like mental health screening in a primary
care center. So there are lots of these Psychoanalysis has its own CPT family therapy has its own CPT Code for telebehavioral health interventions. There are codes for a family to talk with a clinician without the patient being present and then there are codes for
families to talk to clinicians with the patient present. Oh yes. (Alan) Thank you. Can you comment on U.S. therapists providing services to patients in other countries. Yes indeed. So there are many therapists who believe. Once again I mentioned that we just
did a research study on this and there are far too many clinicians. think there are no rules. There are rules and I’ll just an example. I was speaking to a group in Ohio a few weeks ago six weeks ago and I was talking about
Japan and talking about the licensing rules in the United States and how that might apply. A Japanese psychologist seated in the audience and she said now in Japan theres a licensing board and I had to fly to Japan to go take the licensing exam as a psychologist in Japan. So many clinicians are many clinicians think there is nobody that they need to connect with or report to or be registered with in a foreign
country. That’s false. What I encourage politicians to do
is do their due diligence then it is the responsibility the
clinician is to talk to the authorities in a foreign country in their
language. And if you can’t do that find their embassy. Every country that’s recognized by the United States has an embassy that
can be contacted and ask for them for the health
authorities their director of the Ministry of Health or whatever it may be
called in that foreign country and try to contact them and see if there’s a board. Because increasingly there are a number of boards that we do
need to be mindful of. Now let me add another thing to that
in some states are quiet about this issue of their licensed
professionals going over state lines with the license they gave. OK. Other states are not. Other states that license clinicians require those clinicians to be literally registered or acknowledged by foreign entities that a foreign state or foreign country. The truth is that it’s easier to get approval from a foreign
country than it is a foreign state in the
United States given the fact that 50 states. We’ve got in most 3 4 5 6 licensing boards that don’t even communicate with each other
within a state never mind across states. It’s kind of a difficult thing right now. But that’s over say over international lines does need some caution. (Alan) OK I think we have time just for one more hopefully brief answer question are peer services available by telehealth? Yes there are peer services
available. Once again they peer services
they’re not licensed professionals. So I have interacted with a number of them
that are very professionally operated and their peers are there. Let’s say that in a chemical dependency world the
addictions world there are people who are peer counselors and they’re very well vetted and trained and they are available online
through internet services. (Alan) Great thank you so much. Marlene it appears that we’ve gone through our 60 Minutes together. I would encourage additional participants on this webinars if you haven’t had your question answered by Marlene or if you have additional questions. I would propose that you contact her directly at the email address shown which is [email protected] And on Tuesday of next week which is August 21st at 2 to 3p.m. Eastern time zone will have Marleen back with us speaking more about telebehavioral health. But this time from the provider’s perspective what does a clinician or the provider need to know if you’d like to be added to our
listserv and be informed about future webinars. Please send an e-mail to [email protected] and you’ll be added to our list. And as a reminder all sessions are recorded and will be posted to
the SAMHSA YouTube page. With that ladies and gentlemen I’d like to thank Marlene for speaking to us today. Thank you for an extraordinary and very informative webinars. So with that we’ll wish you all a
good afternoon.

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