Telebehavioral Health: Now a Social Health Imperative
The pandemic has spotlighted the attractiveness and effectiveness of this care model.
At its essence, the social work field is interdependently linked to the social pulse of our communities. As the world faces an unprecedented health crisis, all forms of social work practice have turned to virtual approaches. Typically, the field strives to balance access and community need with the field’s commitment to careful consideration of new methods and adherence to ethical standards.
In response to the pandemic, one formerly emerging model has almost overnight become a practice norm: telebehavioral health (TBH).
Singer explained that barriers to implementation of telehealth technologies created by insurers and government entities disappeared in the wake of the pandemic. For example, practicing clinical social work across state lines, termed social work practice mobility by the Association of Social Work Boards (ASWB), has required being licensed in multiple states. However, through executive order, many states have relaxed jurisdictional barriers and allowed temporary licenses to practice during the pandemic.
With policy and regulatory restrictions lifted, social workers were left to gather the tools and skills for effective and ethical TBH service delivery. In addition, as internships vanished midsemester last spring, social work educators earnestly sought to balance student safety, preserve placements, and provide technical assistance for students and field advisors.
The 2015 ASWB model regulatory standards state that social workers who provide electronic social work services should provide only such services “after engaging in appropriate education, study, training, consultation, and supervision from people who are competent in the use of this technology to provide social work services.”
As COVID-19 pressed communities worldwide, social workers have endeavored to build competence swiftly in these uncertain times, striking a mindful balance between the core values of service and competence.
Crash Course: Developing Competence Quickly
Now, within the context of a global pandemic, we revisit those schools to see how COVID-19 has impacted their efforts.
Mary Dallas Allen, PhD, MSW, an associate professor, MSW program coordinator, and AK LEND social work faculty for the University of Alaska, Anchorage, points out that her program had been already distance-delivered, which she believed positioned the school to serve in guiding others in the use of teletechnologies. Students and faculty were able to help their colleagues and field instructors with how to conduct online meetings.
“In addition, distance-education students are also realizing that the skills that they use for engaging in their online courses are the skills that they use in TBH practice,” Allen says.
The University of Southern California’s Telehealth Online Clinic within the Suzanne Dworak-Peck School of Social Work had been in operation for more than eight years before COVID-19 turned everyone’s attention toward TBH. As to be expected, the pandemic has resulted in an increase in demand for services. As a result, the University of Southern California (USC) Telehealth SAFE-T Program was created in April, offering free, private, and confidential online counseling via a secure internet portal or by phone.
“SAFE-T was in direct response to the impact COVID-19 had on the community and our students,” says Sarah Caliboso Soto, MSW, interim director and a clinical assistant professor for field in USC’s Virtual Academic Center. “COVID’s impact has revealed the value and importance of online programs … and resulted in more openness, reception, and acceptance about TBH.”
Marleen Wong, PhD, MSW, LCSW, senior vice dean, director of field education, executive director of USC’s Telehealth Clinic, and clinical advisor to the Family Nurse Practitioner program, is working with colleagues to provide intervention and training to Guam following a series of devastating typhoons, which brings an international aspect to the potential for treatment and training via teleplatforms.
Across the country at Rhode Island College, Jayashree Nimmagadda, PhD, LICSW, interim dean, a professor, and principal investigator for a Health Resources and Services Administration (HRSA) grant to develop TBH curricula, concurs with her West Coast colleagues. “COVID-19 has completely shifted the paradigm,” she says. “We had intended to train our students in TBH but were more cautious in our rollout of this training.”
When the pandemic hit in the middle of the spring semester, many placements shifted students to interact with clients via video or phone calls. “Our students had to learn the skills needed for this mode of delivery instantaneously,” Nimmagadda says, adding that training students in TBH is now “an essential skill set that students need to have before entering field placements.”
David Wilkerson, PhD, MSW, an assistant professor at the Indiana University School of Social Work at Indiana University-Purdue University Indianapolis (IUPUI) and director of the Office of e-Social Work Education and Practice, previously had led the development of three courses in social work and TBH and coauthored an article about educating students in telebehavioral social work practice, or e-social work.
With the advent of COVID-19, IUPUI implemented a program to assist with skill development including a free TBH practice basics course worth two CEUs. The program, which began in April, had more than 3,000 participants enrolled by late August.
“COVID-19 has presented challenges to traditional social work services delivery that can in some measure be addressed through technology-mediated service delivery,” Wilkerson notes.
Prior to the pandemic, Simmons University in Boston had partnered with community sites providing TBH, an effort that provided internship and professional development opportunities. The Center for Innovation in Behavioral Health Education & Research at Simmons University is “a hub of innovation in training and research in health care, technology, and substance use that aims to serve urban and rural communities by increasing access to high-quality, evidence-informed care.”
In addition, a community-based collaboration started through a grant to Athol Hospital from the Health Policy Commission and HRSA provides TBH to more than 165 children, youth, and their families in rural communities.
Maureen Donovan, MEd, program manager for what has become the Tele-Behavioral Health Counseling Program for the hospital, says the project involves a collaborative “teleteam” of partners, including nurses, educators, social workers, and community health workers. As a result of their involvement with TBH, they were prepared to “pivot and be ready to continue services to students and families in two weeks” when the pandemic forced schools to close.
Donovan and her team have been able to guide others in transitioning to TBH. For example, they recently provided training to colleagues in Maine and Oregon. The network is evaluated by the Northeast Telehealth Resource Center (NE-TRC), which recently completed custom online training for Simmons University to launch a course focused on telehealth implementation.
The NE-TRC is one of 14 regional resource centers funded by HRSA that comprise the National Consortium of Telehealth Resource Centers. Telehealth resource centers provide “technical assistance, training/education, and resources for regional health systems, organizations, and providers interested in increasing access to services via telehealth.”
NE-TRC Director Danielle Louder says the organization has received additional funding during the pandemic to prepare health care providers to implement telehealth both effectively and ethically. “Our goal is to ensure that standards of care are met and the quality of care is equal to or better than in-person,” she says.
At NE-TRC, COVID-19 resulted in a nearly 10-fold increase in the volume of requests for services. Louder and her colleagues around the country have been asked to build relationships for creative solutions, including working with regional colleges and universities to develop curricula for health profession students.
One source of training for practicing clinicians is the Telebehavioral Health Institute (TBHI), led by Founder and Executive Director Marlene Maheu, PhD. Since the start of the pandemic, Maheu says training requests have expanded exponentially—to the tune of 7,000 trainees in 10 weeks. Training efforts include webinars for national organizations.
Maheu believes the pandemic has heralded a shift in thinking—“a planetary focus that galvanized everyone around telehealth.” She notes that the evidence-based technologies were ready, pointing out that telesurgery was happening 15 years ago.
With decades of research and experience in teletechnologies, TBHI offers ASWB-certified training programs. Maheu points out that TBHI training was developed to be cross-disciplinary, with input and approval from “all bodies, incorporating all ethical codes.” She says some large mental health providers are sending representatives for train-the-trainer development designed to build competency within their systems.
Despite the context, Louder says, “it is vital for providers to ensure that they can safely and effectively use technology to serve their clients and meet the core standards and values of their particular discipline.”
“I have been inundated with requests from social workers to identify and discuss relevant ethics standards when practitioners use online and digital technology to deliver services remotely, including changes in HIPAA enforcement rules and licensing laws; communicate with clients; document services and communications; and search online for information about clients,” says Frederic Reamer, PhD, a professor at Rhode Island College who chaired the Taskforces for Technology Standards for Social Work Practice and Model Regulatory Standards for Technology and Social Work Practice.
In response to changes in social work practice as a result of COVID-19, Reamer, who also serves on Social Work Today’s Editorial Advisory Board, has narrowed his focus. “I am focusing especially on updated NASW Code of Ethics standards; NASW, ASWB, and [Council on Social Work Education] technology standards; licensing rules; and federal and state laws,” he says. “In principle, TBH can align nicely with the six core values. However, true alignment requires fidelity—that is, social workers' earnest efforts to ensure that their implementation of TBH is consistent with these values.”
“Every client has different needs, and while it is necessary to initially assess and determine whether telehealth is the right method of service delivery for each individual, each of the core values of social work can successfully be integrated into TBH with effective training and practice,” Louder explains.
The following are key ethical considerations that TRCs are encouraging regional stakeholders to address as they look to implement TBH:
• Proactively establish boundaries with clients as part of the first TBH visit. Use effective telehealth etiquette and set expectations with clients to do the same.
• Use a HIPAA-compliant telehealth solution, regardless of the current flexibilities. Privacy and security remain vital to the safety of clients and families.
• Carefully assess the needs and challenges of each client. For example, do they have an adequate internet connection at home? Are they able to use the technology solution? If an issue arises, do they understand how to troubleshoot? Are there any clinical concerns with respect to the use of technology? Allen, Nimmagadda, and Wong recommend assessing each client’s access to privacy. For example, determine how family members share space and equipment for both work and school.
• As with in-person services, it is critical to ensure that clinicians have a crisis plan in place that has been adapted to telehealth. This includes key steps such as confirming the client location at the beginning of each session and having a protocol for contacting local emergency responders.
“In my experience, social workers would do well to pay close attention to the relative informality of TBH counseling,” Reamer says. “The informality can, for some, place a foot on a slippery slope where boundaries become more elastic. With some clients, this can have advantages in terms of building a therapeutic alliance. However, some clients may struggle with very informal boundaries, particularly if boundary challenges are linked to their clinical issues.”
Next Steps in the New Reality
• How will we prepare for a tsunami of patients who have delayed care and for those who may continue to delay care?
• How will we fix “sloppy” telehealth as a result of issues related to relaxed enforcement of HIPAA standards, limited provider training, and flexibilities on key factors such as patient consent and e-prescribing?
• Now that providers and patients have gotten a taste of telehealth, will we be able to go back to our preexisting policies? Should we?
“COVID-19 may continue to be a threat that waxes and wanes over time, representing new challenges in terms of client access to brick-and-mortar clinics and health care centers,” Wong says.
Allen says, “I hope that our experience with COVID-19 will help social work education to move toward the conversation of ‘how can distance education technologies help us to prepare innovative, effective, and evidence-informed social workers who integrate technology into their micro, mezzo, and macro practice?’”
Wong, who likes the idea of a national clinical license or certification for TBH practice, notes the benefits of teletechnologies connecting practitioners and reducing divisions between practice environments and locations.
Parity is also an important consideration. “ASWB is taking the lead in enhancing licensing mobility. It will be important for individual states' licensing boards to respond to this need,” Reamer says.
Maheu suggests writing letters to licensing boards and policy makers.
“While it remains to be seen which of these extensive policy expansions will be preserved beyond the public health emergency, there appears to be significant support and it will be important for stakeholders to share data and success stories, which promote a strong policy environment for TBH into the future,” says Louder, who adds that cross-jurisdictional compacts already exist in various disciplines such as nursing and psychology. “Educators, including Schools of Social Work, are now becoming poised to undergird this advocacy with a track record of successful TBH instruction and practice.”
Singer predicts that the emergence of TBH during the COVID-19 crisis will have a lasting impact. Patients and clients are now accustomed to more immediate and convenient access to care. Citing various reasons, some clients have reported a preference for TBH. The technology has been shown to help reduce key challenges such as stigma, scheduling, child care and elder care responsibilities, and lack of transportation.
During the pandemic, TBH is providing a critical lifeline amid mass social isolation that exacerbates other preexisting mental health challenges. As Maheu says, “There is no going back.”
— Christiane Petrin Lambert, MA, MSW, LICSW, RYT-500, currently works in community and private clinical practice, now via telebehavioral health, serves as a consultant for program planning, development, and evaluation, and teaches as adjunct faculty at the Rhode Island College School of Social Work.
TELEBEHAVIORAL HEALTH RESOURCES DURING THE COVID-19 HEALTH CRISIS
• American Telemedicine Association: www.americantelemed.org/covid-19
• Center for Innovation in Behavioral Health Education & Research at Simmons University: www.simmons.edu/academics/research/ciber
• Council on Social Work Education: www.cswe.org/About-CSWE/Responding-to-Coronavirus
• Ethics and Risk Management by Dr. Frederic Reamer: https://titles.cognella.com/ethics-and-risk-management-in-online-and-distance-social-work-9781793517746, and www.socialworktoday.com/news/eoe_0420.shtml
• Healthcare Information Management Systems Society, Inc: www.himss.org
• National Alliance for Mental Illness: www.nami.org/Support-Education/NAMI-HelpLine/COVID-19-Information-and-Resources
• National Telehealth Resource Center: www.telehealthresourcecenter.org/covid-19-resources and the Telebehavioral Health Center of Excellence developed by the Mid-Atlantic TRC: www.tbhcoe.matrc.org
• NETRC Telehealth Resource Library: www.netrc.org/resources.php
• Substance Abuse and Mental Health Services Administration offers a series of six trainings to guide practitioners in implementing a TBH program: www.integration.samhsa.gov/operations-administration/telebehavioral-health
• Telebehavioral Health Institute: www.telehealth.org/blog/telehealth-resources, ASWB approved TeleMental Health Training Certificate program