Greetings TLPCA members.
This information is designed to provide you with some helpful resources in relation to the COVID-19 pandemic. As we adjust to our ‘new normal,’ I hope this information provides you with information to adjust your work environment and maintain your relationship with your clients.
Some of the unique challenges counselors face include how to deal with risks associated with transmission of information in the counseling setting, how to address anxiety, questions, and concerns of clients, how to address possible reductions in appointment attendance as clients engage in “social distancing,” and how to conduct telehealth sessions legally and ethically. One important recommendation is to balance reasonable precautions with a tone of optimism, focusing on what is within our control rather than what is outside our control.
Below are several resources that might be helpful:
Telehealth sessions are an opportunity for many clients with adequate internet access to continue with their therapy but also minimize possible exposure to the virus. As professionals, our clinical judgement will help us determine the clients that will need to continue therapy because of the pandemic from those that may be able to discontinue therapy until face-to-face options are available again.
Telehealth and the Law
With these current events, the legal aspect of telehealth is a very fluid situation. As I understand it, the federal government is offering extreme flexibility to health providers to meet the needs of their clients, which includes therapy. There are multiple agencies that have not yet responded to the evolving situation. I anticipate there will be responses in the next few days from TennCare, the Tennessee Department of Mental Health and Substance Abuse. I encourage you to continue to monitor these groups for official responses. Until then, here are some resources:
- Response from Centers for Medicare & Medicaid Services https://www.cms.gov/newsroom/press-releases/cms-takes-action-nationwide-aggressively-respond-coronavirus-national-emergency
- Telemental Health Laws App enables you to learn what the laws are state-by-state for counselors conducting telehealth – https://www.ebglaw.com/telemental-health-laws-app/
- Be sure to contact insurance carriers to determine current policies related to telehealth
When using telehealth, it is illegal to use resources such as Skype, FaceTime, etc. that are not HIPAA/HITECH compliant. Below are several options for online counseling:
- Doxy.me – Doxy.me is a cloud-based electronic medical records (EMR) and telemedicine solution designed for practices of all sizes. Doxy.me is a HIPAA-compliant, and Android and iOS apps are available for mobile devices. The product also features a live chat within the telemedicine interface. A Professional account for individual providers is available for $35 per month, which includes the ability to screenshare with clients and to conduct group sessions.
- Simple Practice –SimplePractice gives Behavioral Health Therapists the tools to run great businesses. With an interconnected platform for billing, scheduling, documentation, and client communication, you’ll be able to get organized and grow your practice. Pricing include $35 for basic or $59 for Professional Plan.
- TherapySites – TherapySites integrates professional website design, hosting and content that is HIPAA compliant. The all-inclusive solutions come bundled with tools that make it simple for practitioners to manage their websites. The package includes an intuitive content management system that ensures users can make changes and keep their site current with helpful information for clients. All-inclusive package is $59 per month.
- Zoom – Many counselors get a free Zoom account, having heard that Zoom is HIPAA-compliant, but unfortunately a free Zoom account is not HIPAA-compliant. However, Zoom Healthcare is HIPAA compliant but costs $200 a month (for up to 10 users), which may be a more appropriate tool for agencies vs. individual practitioners. It might be possible to talk with the Zoom sales team to lower the monthly fee.
Telehealth and Ethics
Once you have an appropriate platform, your next task is to ensure that you are abiding by ethical standards developed regarding telehealth.
- American Counseling Association (ACA) – The ACA Code of Ethics (2014) Distance Counseling, Technology, and Social Media (Section H) was developed to provide ethical guidelines that focus on how to ethically use technology and social media within the field of counseling. Specifically, the Code recommends the following: (a) Be knowledgeable about the laws governing distance counseling and social media; (b) utilize distance counseling after gaining competence through training and supervised experience in this specialty area; (c) Inform clients about the limits of confidentiality and potential Internet interruptions due to the nature of technology; (d) Understand the benefits and drawbacks related to distance counseling; (e) Utilize a professional presence if they choose to use social media platforms; (f) Avoid disclosing confidential information through social media; and (g) Utilize informed consent to explain the boundaries of social media.
- American Mental Health Counselors Association (AMHCA) – The AMHCA Code of Ethics (2020) focuses on the specific requirements for the ethical practice of clinical mental health counselors (CMHCs). Section B.6. The Use of Technology Supported Counseling and Communications (TSCC) states:CMHCs recognize that technology has become culturally normative worldwide and may employ modern technology communications judiciously, attentive to both the benefits and risks to clients and to the therapeutic process of using technologies to arrange, deliver, or support counseling.
a. CMHCs understand that the uses of TSCC in counseling may be considered to fall under the following categories:
i. The use of TSCC as the medium for counseling, also called “telehealth” or distance counseling,” which includes but is not limited to the delivery of counseling by video call (e.g., internet, video chat), by voice (e.g., telephone), by synchronous text (e.g., chat or SMS), or by asynchronous text (e.g., email).
ii. The use of TSCC as an adjunct to counseling (i.e., for arranging, coordinating, or paying for counseling services), including the use of payment processing services that are integrated with TSCC (e.g. PayPal, Stripe, Zelle) for receipt of payment for counseling services.
iii. The use of online “cloud-based” services for the storage of counseling records iv. Marketing, educational forums, and other TSCC to include blogs, webpages, chatroom, etc.
b. CMHCs recognize that federal, state, and local laws prevail and that the standard of care for TSCC is expected in the same manner as face-to-face and in-office counseling. Continuity of care is crucial and, at times, may conflict with local laws and regulations. CMHCs should employ a solid ethical decision-making model to secure continuity of care.
c. CMHCs are not required to provide services via TSCC or may decide not to offer services based on appropriateness.
d. CMHCs only provide telehealth or distance counseling when they have had sufficient training which can be gained through education, supervision, or other appropriate activities (see the TSCC section of AMHCA Standards for the Practice of Clinical Mental Health Counseling in Appendix B of the “Essentials of the Clinical Mental Health Counseling Profession” text or online at www.amhca.org/publications/standards).
e. CMHCs need to be familiar with state laws and regulations in both the state in which the CMHC is licensed and the state in which the client is presently located.
f. At the beginning of a course of distance counseling, CMHCs acquire the contact information for emergency services in the location of the client and develop a procedure to follow in the event of a psychiatric or health emergency.
g. In states where there is a legal requirement that CMHCs must include in the client record client communications through TSCC, CMHCs inform the client of that fact.
h. Unless email and text messages are encrypted or otherwise secured or confidential, the client should be informed of the risks and discouraged from using as a means to disclose personal information.
i. Chat Rooms: Typically, unsecured, open chat rooms are discouraged as a platform for communicating with clients.
j. CMHCs may maintain professional profiles that are kept separate from personal profiles. CMHCs need to be aware of their impact on clients should personal information or opinions be disclosed in a public platform. When applicable, CMHCs educate clients on confidentiality, implications for client activity on these pages, and appropriate channels for contacting CMHCs.
k. CMHCs only seek information about their clients through internet searches for the purpose of determining their own or their client’s safety, as necessary to conduct a forensic evaluation, or at the client’s request.
I will reiterate the importance of the standards of practice for using technology- the TSCC section of AMHCA Standards for the Practice of Clinical Mental Health Counseling in Appendix B of the “Essentials of the Clinical Mental Health Counseling Profession” www.amhca.org/publications/standards.
Training and Telehealth
Training is one of the keep aspects of being prepared to provide telehealth services. There are several online trainings available.
- Ethics Rock is providing their $597 training on ethics of telehealth FREE until 3/23/20 (https://ethicsrock.com/services).
- The Telehealth Certification Institute offers free webinars on telehealth, as well as a certification option. https://telementalhealthtraining.com/free-webinars
Professional Environments and COVID-19
If you are continuing face-to-face services, it is important develop a plan in your professional environment to reducing exposure. The CDC offers ways to help protect you and those around you: https://www.cdc.gov/coronavirus/2019-ncov/prepare/prevention.html.
Below are some practical steps to take:
- Refrain from shaking hands with clients for now.
- Disinfect commonly used surfaces such as doorknobs twice a day using Clorox wipes, Lysol wipes, and/or a rubbing alcohol solution.
- Post a reminder and a friendly graphic how to wash hands in bathrooms: https://www.cdc.gov/handwashing/posters.html.
- Post a notice informing clients that if they have flu-like symptoms they should not enter the and should instead call their physician. https://www.cdc.gov/coronavirus/2019-ncov/downloads/COVID19-symptoms.pdf
- Consider a flexible late cancellation policy.
- Apply social distancing rules during face-to-face sessions. http://www.cidrap.umn.edu/sites/default/files/public/php/185/185_factsheet_social_distancing.pdf
Clients and COVID-19
The COVID-19 pandemic raises particular challenging questions for those of us who are treating clients with OCD and anxiety disorders. Below are resources that might be helpful for those clients struggling with such presenting problems:
- COVID 19: Plan for Therapists: Questions, Answers, and Guidelines https://www.zynnyme.com/blog/2020/3/12/covid-19-plan-for-therapists-questions-answers-and-guidelines
- International OCD Foundation: https://iocdf.org/covid19/
- Taking Care of Your Behavioral Health During an Infectious Disease Outbreak https://store.samhsa.gov/system/files/sma14-4894.pdf
- Covid-19 (Coronavirus) Information and Resources https://www.nami.org/getattachment/About-NAMI/NAMI-News/2020/NAMI-Updates-on-the-Coronavirus/COVID-19-Updated-Guide-1.pdf?lang=en-US
- AMHCA The Coronavirus and Covid19: Resources on What You Need to Know and for Your Families, Your Clients and Your Practice https://www.amhca.org/blogs/joel-miller/2020/03/12/the-coronavirus-and-covid19-resources-on-what-you
- Recommendations for Health Care Providers in Managing COVID-19 https://www.healthlawadvisor.com/2020/03/13/recommendations-for-health-care-providers-in-managing-covid-19/
TLPCA will be developing a COVID-19 update page on our website, which will include a blog designed to help mental health providers in Tennessee stay connected. We hope you will find this a helpful resource to avoid isolation and remain connected to your peers and coworkers. If you have any information you think will be helpful, please share! We will send out another notification when the page is ready.
If you have any needs, please do not hesitate to reach out. If I do not have the answer, I will try to find it.
Be well and stay safe!
Robin Lee, Executive Director