Telemental Health - Online Counseling

Requirements for Telemental Health

• Client suitability for service and telemental health
• Initial documentation and forms outlining the clinical mental health process, regulations, and policies for service
• Meeting the needs for privacy and security
• Understanding the Technology Environment
• Payment Considerations and Policy

Telemental Health refers to any type of mental or behavioral health service that is conducted using HIPAA secure online video services that are live two-way audio and video encounters.

Is a telemental health session suitable for you? 

Most clients become comfortable with the video sessions after a few meetings. This webpage describes the clinical services available and lets the client and referral source know what to expect regarding professional services. The following is to provide an extensive discussion on the factors relating to best practice procedures of telemental health online counseling. 

1. Client suitability for service and telemental health

Mental health professional literature supports the efficacy of telemental health services for nearly all types of patients, even for suicide screening and intervention. Currently there is no data supporting contraindications for telemental health services. 

1. However, some clients still might not be suitable for telemental health services based on the skill level of the practitioner as well as the severity of the client issue. An assessment of acute risk is highly advisable if the client presents such issues as significant and/or recent history of suicide or homicide attempts, or other such symptoms causing the practitioner immediate concern. For the purposes of addressing client suitability, the Dissociative Experiences Scale-II (DES-II) has been determined to be appropriate in assessing suitability, a copy of which is provided herein.
2. If a proper crisis protocol is in place, a client with previous suicidal or homicidal ideations can benefit from online telemental health. It is best to assess each situation on a case by case basis, recognizing that in cases where the client is not fit for telemental health services, and in-person services are not available, there may not be an appropriate treatment option available. The provider will use his best judgment to determine whether telemental health is appropriate for the client, and upon mutual agreement, may consult with the referring health provider in making this decision.
3. Consistent technical difficulties with the client may indicate that the client is not suitable for telemental health.
4. Recognize early if expectations are not being met with telemental health. It may be beneficial to do an in-person meeting or advisable to refer the client to another provider.

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2. Initial documentation and forms outlining the clinical mental health process, regulations, and policies for service 

The materials on this website are easily available and straight forward. The client will be assisted through this process, as needed, by contact via phone, email, or text, where client questions and concerns can be addressed.

1. The Introduction to George W. Laws information sheet provides information of George’s professional history. So too does the “About Me” tab section on this website. Prospective clients are provided these facts to assist making an informed decision for appropriate service.
2. The Telemental Health Informed Consent Form must be read, understood, approved, and signed by the client. It is appropriate for the provider to review this and other informed consent documents with the client prior to, or at the initial session, ensuring that all parties have a mutual understanding and agreement regarding the services offered and how the telemental health process works. This can assist to ease potential anxieties for the client. Telemental health informed consent includes the routine requirements utilized for in-person services, and requirements specific for online counselling to meet the specialized needs for privacy and security. The mental health specific informed consent document is required by most state regulations and association guidelines. Informed consent is intended to provide a potential client with the relevant information needed to make an informed decision about this professional service and is an ongoing exercise throughout the therapy process.
3. The Risk and Crisis Management Plans Form is part of the consent process. A review of this form will occur prior to or at the first session with the client. Contained in this form is a description of the steps for getting started and what is required to prepare for a video session.

        i. The client will nominate an Emergency Contact Person, a Client Support Person, and will create a list of emergency services              in their area, which is reviewed together with the provider and recorded in the Risk and Crisis Management Plans Form. The           client should be made aware that if they experience an emergency, it is vital they contact their local emergency services first,           before attempting to contact their mental health provider. Clients may also utilize 1 800 SUICIDE or 1 800 273 TALK, and for             the deaf 800-799-4TTY. In addition, chat-based, and text-based crisis hotlines are available. International hotlines such as the           Befrienders and Samaritan may also be useful.
       ii. When a client is living in a remote setting, it is particularly important to help a client identify and choose a Client Support Person (CSP) to be a part of their support team and for the client to provide an approved and signed Authorization for Use or Disclosure of Protected Health Information Form authorizing the provider to contact that person in an emergency                       situation. The CSP may, from time to time, be required to be near or in the physical presence of the client and must be                     capable of ensuring the client’s privacy and honoring their vulnerability. This support person must be over 18 and may be a             spouse, friend, or parent. Given the remote nature of telemental health, the expectations of a Client Support Person are                   higher than the typical Emergency Contact Person nominated in the consent process. The CSP must have the ability to                       communicate what is happening to the provider from the client’s physical location. This CSP may also be called upon to                     contact 911 and assist accordingly. It is important to discuss the purpose of the Emergency Contact Person and the Client                 Support Person with the client at the onset of services. In some cases, it may be the same person.
      iii. There are risks in Technology. Some examples of risks include the possibility that the provider may not be able to assist in                 an emergency and that, despite security measures, the client's privacy may be breached.
      iv. Each client is to arrange with the provider how to communicate between sessions regarding hours of availability and policy             for contacting the provider between sessions. Frequently, communications such as text, voice mail and email experience                   delayed responses. The provider will make every effort to respond within a 48-hour period.
       v. The Notice of Privacy Practices and Client Rights Form and the Confidentiality and Cancellation Form address the                     policies and practices contained in the therapeutic relationship, which are discussed in the following paragraph. 

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3. Meeting the needs for privacy and security 

1. George Laws Social Work Services LLC online clinic uses HIPAA secure software with doxy.me.com. This HIPAA secure software and encryption works to protect client identity and information. The client can discuss any such concerns regarding confidentiality and security with the provider early in the first session to develop plans to limit risk.
2. The provider uses industry standard software and compliance standards to meet HITECH and HIPAA privacy and security regulations to protect health information records and communications, including identifying those who might have access to client records through Business Associate Agreement (BAA’s). These programs are:
       i. Doxy.me.com
      ii. Microsoft Business Premium
     iii. Simplepractice.com
     iv. Therapysites.com
   
   (Please note that despite the best encryption and security, there is always a possibility that someone with sufficient technical skills could hack into a system and access information.)
   
   
3. Recording a video session: The technology used in the doxy.me HIPAA secure online clinic does not permit clients to record sessions. That said, some clients could use additional software to record sessions, similar to a client’s ability to bring recording devices to an in-person session. Nonetheless, the Telemental Health Informed Consent Form prohibits the use of any recording devices.
4. To further protect the confidential relationship, the provider and client may elect to establish specific collaborative agreements to address unforeseen incidents, such as if someone enters the client’s room during a session. The agreement might be, “We will only allow people in the room during our session that we both agree upon. When someone enters the room, that person shall immediately be announced and introduced.” All such collaborative agreements represent an effort by provider and client to establish, in advance, a clear policy for maintaining client privacy and security.
5. The client’s role in keeping their information secure and private. The client needs to understand that they are responsible for creating and using additional safeguards when the computer used to access services is shared with others, such as creating secure passwords for computer and email, and maintaining security of the wireless access points. Routers with the original factory set password are easy for hackers to break and should be reset before use. Clients are also responsible for allocating an area of their home, office etc. that is private and free of distractions. The client may need to schedule a time when no one else is in their home or office so that they feel more comfortable speaking freely. Any children and pets must be adequately cared for so the session will not be interrupted. If the client cannot find a secluded environment for telemental health, their privacy for the session will likely be compromised. While it is up to the client to maintain the privacy of their session on their side of the call, the provider may choose to end the session if, based on their professional judgment, it would not be beneficial to continue. In summary, it is the client’s responsibility to protect the privacy of their telemental health sessions by using a private computer, maintaining strict confidentiality of passwords, not recording the sessions, and not allowing interruptions or others to enter the session room.
6. The provider will review protocols for each session with the client to ensure legal and ethical compliance aimed at minimizing potential risks to the client's privacy due to technology. Protocol for each session includes:
     i. Verify the client's identity at the first session and throughout the therapeutic relationship. Professional guidance                           recommends that the client show a state issued identification with their photograph on it. A picture of this ID will be                     recorded with telemental health software. Visual recognition by the provider of the client thereafter is considered sufficient         identity confirmation.
    ii. Verify the location of the client at the beginning of each appointment and document this location. This assists the provider           to avoid meeting with a client who may be out of the area in which the provider is licensed to practice. This can be as simple       as asking the client their current physical address.
        The address is necessary to direct emergency services to the client’s location, should the occasion arise. The provider can             then obtain the phone number of the hospital, mobile crisis unit, or law enforcement agency, that is nearest the client’s               location. The provider may also ask the client directly for the name of the nearest hospital. While not necessary for all                   clients, these precautions can be critical for clients who are at greater risk, and is required by law.
    iii. Since some communication may be through secure email or text, a code word should also be established for use by the              client, to verify the client's identity. If the provider is concerned that someone is sending messages on behalf of the client            and without the client's consent, the provider should document this activity for each session and discuss this with the client.

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4. Understanding the Technology Environment 

No technology is 100% reliable. Thorough preparation and assessment of the client’s IT system can assist to minimize difficulties. Individual assistance is available from the provider for clients who need additional guidance for online teletherapy for such things as: technology setup; room selection and location of video session; computer preparation: video or voice lag; preventing interruptions; lighting; camera adjustments etc.

1. Good computer hygiene in preparing for an online session includes:
      i. Turn off other programs prior to and during the session that might be distracting or slow down the internet connection                speed.
      ii. If possible, it is also highly recommended that all parties wear headphones or earbuds throughout the session to help                 minimize background noise and avoid any feedback or echo that could come from using telehealth equipment. Also,                     conversations with the provider cannot be heard by others when using earphones.
    iii.  Effective lighting is important in the room for all parties. Lighting behind or above a person can make it difficult to see the           person on camera.  The best lighting is usually indirect lighting in front of the person. If the lighting is not addressed                     properly and early in a session, it can become a distraction which inhibits the helping process.
   iv.  Adjust the camera to a natural eye level as this improves the level of appropriate eye contact throughout the session. It is            helpful to have the camera 2 to 3 feet away from the body to provide a view of the head and shoulders. However, at times          there may be a preference to view the entire person and a client may be asked to shift position to meet this request. Most          video systems permit the user to move the image of the other video caller to different locations on the screen. At some                point in the session the provider may ask the client to relocate the image of the provider to a space beneath their video                camera, which gives the impression of eye contact. Also, the client may request the provider to make adjustments for the            client to view the provider better. Visual comfort and ease promote continued rapport and satisfaction in a video session.
2. Steps to prepare for a video session. Technical competence and computer skills are needed to start a pleasurable video call. These include:
     i. Knowledge of the internet service and software programs that you use.
    ii. Ensure an adequate bandwidth internet speed. Test and check that the technical requirements are met prior to the session         (in Google Search enter “Bandwidth test” and choose a preferred format to test your system).
   iii. If necessary, a brief practice session can be organized with the client. If the trial is not successful, the provider may refer the       client to a local, in-person mental health provider when possible.
   iv. Occasionally technical issues may intrude on a session, such as pixilation, short video delays, audio difficulties and other             unforeseen problems.  The provider should be notified if the client cannot hear or see him, or if the client needs to have               something repeated.
    v. In the event of a dropped video call, The Risk and Crisis Management Form outlines alternative methods of re-establishing communication.
3. Technology troubleshooting
     i. While it is tempting to try to fix the problem at that moment, troubleshooting for more than a few minutes during a session         is interruptive and inconsiderate, potentially frustrating the client and shifting the tone of the session.
     ii. If the technical problems cannot be resolved, it may beneficial to continue the session with a phone call and schedule time         with some Technical Support to resolve the issues.
   iii. Technological difficulties can create misunderstandings in communication affecting rapport. Misunderstandings are                     possible with all telemental health modalities, such as telephone, email, and video software, particularly since nonverbal             cues may be relatively lacking. Even with video, misunderstandings may occur when bandwidth is limited and images lack           detail (due to lower variable internet bandwidth or speed, causing pixilation and/or video lag or audio lag and delay),                   causing missing words and phrases. Pixilation or lag on occasion is normal for video systems using the internet. However, in       areas with lower bandwidth or slower internet speed, these issues and problems may occur more often and for longer                 spans with some video systems. The internet service provider may be able to provide solutions for a more reliable and                 enjoyable video conferencing service, e.g. an updated router or an extender. In the event of pixilation or lag, be patient, sit still for camera input, and briefly stop speaking to allow time for the video and audio to load again. Also, ask the provider to repeat what was stated if one of these conditions occurs. Clarity in communication is healthy communication.
   iv. It is possible that a video call can be dropped during a session. If there is an internet interruption, either use the previous           video link to re-enter the online waiting room or wait for the provider to send a new video invitation. Should the video not           reconnect within 5-10 minutes, the provider will make a phone call as soon as possible. It would also be beneficial for the           client to have an alternate contact number for the provider. A VOIC phone service (voice over internet protocol) is also                 dependent on the internet connection and will be unavailable. Therefore, an analogue phone service may be advisable as an       alternative means of communication.

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5. Payment Considerations and Policy

1. How much does counseling cost?
     i. The fee for individual, couples, or family counseling sessions is $125. Sessions are usually 60 to 90 minutes. For                             convenience, cash, personal checks, Visa, MasterCard, Discover cards are accepted.  
    ii. Costs for groups are calculated according to the group dynamic, content, location, activities, duration, and sundries.
   iii. Couple Retreat Costs and Family Retreat Costs are based on design and collaboration with the client(s).
2. What is the benefit of the client being responsible for full payment of services and not having the insurance company pay the provider?
   i.   Privacy: Insurance companies require a diagnosis to authorize treatment, which can become a negative label, potentially             impacting the client’s future insurability. Files are not shared with anyone outside of the professional relationship without           the client’s permission.  
   ii.  Choice: Only the client and the provider oversee the goals, length of treatment, length of session and therapeutic choices.           These are not determined by a third party.
   iii. Savings: Valuable therapeutic time is not lost to conversations regarding insurance processing and paperwork.
   iv. Co-payment: Most insurance companies only pay a portion of the cost of services, leaving the balance to be paid by the               client. The client needs to be aware of what their financial co-pay is. Also, there may be other non-financial costs such as             time, loss of privacy and security for the client.
3. Will the client’s insurance company pay for counseling?
    i. Many insurance plans reimburse for a portion of therapy. The client is to direct all questions to their insurance company              regarding reimbursement policies and limits, demand for diagnosis, what therapeutic choices are covered by insurance,              requirements regarding copies of notes, and claims procedures.
   ii. Out-of-network benefits vary from plan to plan. For details, the client is to contact their insurance carrier and ask about “out-      of-network” benefits for “outpatient mental health services.” Upon request, the provider can provide the client with a                    statement for therapy that can be submitted to their insurance company for reimbursement. It is most important that the          client specifically ask their insurance company what that statement needs to contain to be accepted by the insurance                    company prior to making a request of the provider so the statement will be accepted the first time.
4. What if the client needs to cancel their counseling session?
       There is no charge for any session cancelled at least 48 hours prior to the scheduled appointment time.
5. George Laws Social Work Services LLC offers a money back satisfaction guarantee for any consultation that the client is not satisfied with, at the time of service. And requests that the client come back again, so that a satisfying healing session can be created together.

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