CAC Application

4. Telemental Health Policy Acknowledgment

POLICY

The Center for Apostolic Counseling recognizes the importance and necessity of providing telemental
health services. Therefore, the scope of these guidelines covers the provision of mental health services provided by a licensed healthcare professional when using HIPAA secure, real-time videoconferencing services transmitted via the Internet. These guidelines include telemental health services when the initiating, receiving, or both sites are using a personal computer with a webcam or a mobile communications device (e.g., “smart phone”, laptop, or tablet) with two-way camera capability.
Practitioners must note that telemental health must be acceptable by the licensing board where the
practitioner is licensed and the licensing board where the client is located. The practitioner is responsible
for confirming this information prior to scheduling a session. Also, the approval of the licensing board
does not equate to the approval insurance companies. If the practitioner is accepting insurance for services, then that approval must also be received.

SCOPE

The Center for Apostolic Counseling discourages the use of texting, e-mail, chatting, social network sites,
online “coaching” or other non-mental health approaches to service provision. This document contains requirements, recommendations, or actions that are identified by text containing the keywords “shall,” “should,” or “may.” “Shall” indicates a required action whenever feasible and practical under local
conditions. These indications are found in bold throughout the document. “Should” indicates an optimal recommended action that is particularly suitable, without mentioning or excluding others. “May” indicates additional points that may be considered to further optimize the telemental healthcare process.

PROCEDURES

1. Professional and Patient Identity and Location

At the beginning of a video-based mental health treatment with a patient, the following essential
information shall be verified:

- Provider and Patient Identity Verification: The name and credentials of the professional and the name of the patient shall be verified. Patients shall provide their full name. At the first session, professionals should ask patients to verify their identity more formally by showing a government issued photo ID on the video screen.

- Provider and Patient Location Documentation: The location(s) where the patient will be receiving services by videoconferencing shall be confirmed and documented by the provider. In addition, the location of the provider may need to be documented, especially in cases where such documentation is needed for the appropriate payment of services.
- Contact Information Verification for Professional and Patient: The contact information for both provider and patient shall be verified. This shall include gathering telephone and mail contact information for both the provider and patient and may also include contact information through
electronic sources such as email.

- Verification of Expectations Regarding Contact Between Sessions: Reasonable expectations about contact between sessions shall be discussed and verified with the patient. At the start of the treatment, the patient and provider should discuss whether or not the provider will be available for phone or electronic contact between sessions and the conditions under which such contact is appropriate. The provider should provide a specific time frame for expected response
between session contacts. This should also include a discussion of emergency management between sessions.

2. Patient Appropriateness for Videoconferencing-based Telemental Health

Mental health professionals should consider the patients’ expectations and level of comfort with home-based care to determine the appropriateness of using videoconferencing in this setting. Determining whether a patient can handle such demands may be more dependent on the patient’s organizational and cognitive capacities, than on diagnosis. Determining patient appropriateness for
videoconferencing-based telemental health services should, in addition to considering the patient’s ability to potentially benefit from them, rely on the professional’s assessment of the patient’s ability to arrange an appropriate setting for receiving videoconferencing services and the patient’s continued cooperativeness regarding managing safety issues. Professionals should also consider such things as patient’s cognitive capacity, history regarding cooperativeness with treatment professionals, current and past difficulties with substance abuse, and history of violence or self-injurious behavior. Professionals shall consider geographic distance to the nearest emergency medical facility, efficacy of patient’s support system, current medical status, and patient’s general level of competence around technology when determining patient appropriateness for videoconferencing. Professionals should evaluate the potential for risk factors or problems at the start of providing video-conferencing services in settings where a professional is not immediately available. In addition, evaluation of appropriateness of videoconferencing care should continue throughout the treatment including monitoring of symptoms and patient cooperativeness in assuming the responsibilities inherent in remote care.

3. Informed Consent

A thorough informed consent at the start of services shall be performed. The consent should be conducted with the patient in real–time. Local, regional and national laws regarding verbal or written consent shall be followed. If written consent is required, then electronic signatures, assuming these
are allowed in the relevant jurisdiction, may be used. The provider shall document the provision of consent in the medical record. The consent should include all information contained in the consent process for in-person care including discussion of the structure and timing of services, record keeping, scheduling, privacy, potential risks, confidentiality, mandatory reporting, and billing. In addition, the informed consent process should include information specific to the nature of
videoconferencing as described below. The information shall be provided in language that can be easily understood by the patient. This is particularly important when discussing technical issues like encryption or the potential for technical failure. Key topics that shall be reviewed include: confidentiality and the limits to confidentiality in electronic communication; an agreed upon emergency plan, particularly for patients in settings without clinical staff immediately available; process by which patient information will be documented and stored; the potential for technical failure, procedures for coordination of care with other professionals; a protocol for contact between sessions; and conditions under which telemental health services may be terminated and a referral made to in-person care.

4. Physical Environment

Both the professional and the patient’s room/environment should aim to provide comparable professional specifications of a standard services room. Efforts shall be made to ensure privacy so clinical discussion cannot be overheard by others outside of the room where the service is provided. If other people are in either the patient or the professional’s room, both the professional and patient shall be made aware of the other person and agree to their presence. Seating and lighting should be tailored to allow maximum comfort to the participants. Both professional and patient should maximize clarity and visibility of the person at the other end of the video services. For example, patients receiving care in non-traditional settings should be informed of the importance of reducing light from
windows or light emanating from behind them. Both provider and patient cameras should be on a secure, stable platform to avoid wobbling and shaking during the videoconferencing session. To the extent possible, the patient and provider cameras should be placed at the same elevation as the eyes with the face clearly visible to the other person.

5. Communication and Collaboration with the Patient’s Treatment Team

Professionals shall acknowledge that optimal clinical management of patients depends on
coordination of care between a multidisciplinary treatment team. This shall be discussed with all patients. However, patients may have specific privacy concerns about the release of information about mental health treatment even to other health professionals providing services to them and these concerns shall be respected. For patients who agree to coordination of care, telemental health
professionals should arrange for appropriate and regular private communication with other
professionals involved in care for the patient. Moreover, professionals conducting telemental health to patients in settings without clinical staff immediately available are encouraged to develop collaborative relationships with local community professionals, such as a patient’s local primary care provider, as these professionals may be invaluable in case of emergencies.

6. Emergency Management

Providing mental healthcare to patients using videoconferencing involves particular considerations regarding patient safety. There are also additional considerations when providing care to patients in settings without staff immediately available. Below are issues that should be considered in both types
of practice followed by separate sections for emergency management for supervised and
unsupervised settings.

- Education and Training: Professionals should review their discipline's definitions of
"competence" prior to initiating telemental health patient care to assure that they maintain both technical and clinical competence for the delivery of care in this manner. Professionals should have completed basic education and training in suicide prevention. The depth of training and the definition of “basic” are solely at the professional’s discretion.

- Jurisdictional Mental Health Involuntary Hospitalization Laws: Each jurisdiction has its
own involuntary hospitalization and duty-to-notify laws outlining criteria and detainment
conditions. It is advised that professionals know and abide by the laws concerning involuntary hospitalization in the jurisdiction where the patient is physically located.

- Patient Safety when Providing Services in a Setting with Immediately Available
Professionals: When a professional sees a patient via personal computer and/or mobile
device outside of the patient’s home (e.g., local clinic, community-based outpatient clinic,
school site, library) or other facility where dedicated staff may be present, it may be important that the professional become familiar with the facility’s emergency procedures. In some cases, the facility will not have procedures in place. In such cases, the professional should coordinate with the distant site clinic to establish basic procedures. The basic procedures
may include:

a) identifying local emergency resources and phone numbers

b) becoming familiar with the location of the nearest hospital emergency room capable of
managing psychiatric emergencies

c) having patient’s family/support contact information. The professional may also learn
the chosen emergency response system's average response time (30 minutes vs. 5
hours) and the contact information for other local professional associations, such as the
city, county or state, provincial or other regional professional association(s) in case a
local referral is needed to follow-up with a local professional.

- Patient Safety when providing Services in a Setting without Immediately Available
Professional Staff: For treatment occurring where the patient is in a setting without clinical
staff, the professional may request the contact information of a family or community member
who could be called upon for support in the case of an emergency. This person will be called “the Patient Support Person,” an individual selected by the patient. In the case of an emergency, the professional may contact the Patient Support Person to request assistance in evaluating the nature of the emergency and/or initiating 9-1-1 from the patient’s home
telephone.

- Patient Support Person and Uncooperative Patients: It is possible that a patient will not
cooperate in his or her own emergency management, which underlies the practice of
involuntary hospitalization in mental healthcare. Professionals should be prepared for this as well as the possibility that Patient Support Persons also may not cooperate if the patients themselves are adamant that they do not want to seek emergency care. Therefore, any emergency plan shall include local emergency personnel and knowledge of available resources in case of involuntary hospitalization.

- Transportation: As videoconferencing-based telemental health has developed, in part, to
increase access to patients in geographically remote areas, it is expected that there may be
barriers to transportation to local mental health services. In light of this, the professional shall know any limitations the patient has in terms of self-transporting and/or access to
transportation. Strategies to overcome these limitations in light of an emergency shall be
developed prior to starting treatment for patients in settings without staff immediately
available. In the event of a behavioral and/or medical emergency, the patient’s Patient
Support Person should discuss with emergency personnel whether they should transport the
patient.

- Local Emergency Personnel: In providing care to patients in settings without professional
staff immediately available, determining distance between local emergency personnel in the patient’s community and the patient’s location can shape the professional’s decision process in determining appropriate actions. Professionals shall acquire telephone numbers for local resources in the patient’s community. At the beginning of each session, the professional shall have the patient’s local emergency personnel telephone contact information readily available. Prior to each session, the provider shall also determine the patient’s location and whether there have been any changes to the patient’s personal support system or the emergency management protocol.

- Medical Issues: In case of medication side effects, elevation in symptoms, and/or issues
related to medication noncompliance, the professional should be familiar with the patient’s prescription and medication dispensation options. Likewise, when prescribing, the clinician should be aware of the availability of specific medications in the geographic location of the patient and that should inform prescribing choices. Patients receiving treatment through telemental health services should have an active relationship with a prescribing professional in their physical vicinity. If services are provided in a setting where a professional is not immediately available, the patient may be at risk if there is an acute change in his or her medical condition. The professional should be familiar with whom the patient is receiving
medical services.

- Referral Resources: When the professional is providing telemental health, the professional
should be familiar with local in-person mental health resources, in cases which the
professional needs to make a referral for additional mental health or other appropriate
services.

- Community and Cultural Competency: Professionals shall be culturally competent to deliver services to the populations that they serve. Examples of factors to consider include
awareness of the client’s language, ethnicity, race, age, gender, sexual orientation,
geographical location, and socioeconomic and cultural backgrounds. Mental health professionals may use online resources to learn of the community where the patient resides including any recent significant events and cultural mores of that community.

TECHNICAL GUIDELINES

Videoconferencing can be characterized by key features: the videoconferencing application, device characteristics including their mobility, network or connectivity features, and how privacy and security are maintained. The more recent use of desktop and mobile devices requires consideration of each of these.

A. Videoconferencing Applications:
Only HIPPA-secure video conferencing applications may be utilized for this purpose.

B. Device Characteristics:
When using a personal computer, both the professional device for video-transmission and the patient’s site should, when feasible, use high quality cameras and audio equipment now widely available on personal computers and mobile devices. In the event of a technology breakdown, causing a disruption of the session, the professional shall have a backup plan in place. The plan shall be communicated to the patient prior to commencement of treatment and may also be included in the general emergency management protocol. The professional
may review the technology backup plan on a routine basis. The plan may include calling the patient via telephone and attempting to troubleshoot the issue together. The plan may also include providing the patient with access to other mental healthcare. If the technical issue cannot be resolved, the professional may elect to complete the session via a voice-based telecommunication system.

C. Connectivity:
Telemental healthcare services provided through personal computers or mobile devices that useinternet based videoconferencing software programs shall use bandwidth sufficient to achieve at maximum quality audio/video.

D. Privacy: Providers must use HIPPA-secure applications for telemental health services to ensure compliance
with the Privacy Rules.

ADMINISTRATIVE GUIDELINES

A. Qualification and Training of Professionals:
In addition to clinical, legal, and ethical training required for licensure for in-person services, professionals should pursue and maintain certification and/or formal training in telemental health
provision.

B. Documentation and Record Keeping:
Professionals shall maintain a record for each patient for whom they provide remote services. Such a record should include an assessment, client identification information, contact information, history, treatment plan, informed consent, and information about fees and billing. A treatment plan based upon
an assessment of the patient’s needs should be developed and documented. The plan should meet the professional’s discipline standards and guidelines and include a description of what services are to
be provided and the goals for services. Services should be accurately documented as remote services and include dates, duration and type of service(s) provided. Documentation shall comply with
applicable jurisdictional and federal laws and regulations. Policies for record retention and disposal should be in place. All communications with the patient (e.g., written, audiovisual, or verbal) shall be documented in the patient’s unique record and all such records shall be stored in compliance with
relevant government regulations, such as HIPAA and HI-TECH within the US. Requests for access to such records shall require written authorization from the patient with a clear indication of what types of data and which information is to be released. If professionals are storing the audiovisual data from the
sessions, these cannot be released unless the patient authorization indicates specifically that this is to be released. Upon direction and written approval by the patient, the patient’s record shall be made available to another provider that is caring for the patient. All billing and administrative data related to
the patient shall be secured to protect confidentiality. Specifically, all records are confidential; HIPAA regulations regarding psychotherapy notes are adhered to; and only relevant information is released
for reimbursement purposes as outlined by HIPAA in the US.