Podcast Series

Bonnie Rausch:

Hello, everyone. The Preferra Insurance Company RRG, formerly NASW Risk Retention Group, NASW Assurance Services, and Western Litigation have teamed up to produce a series of three podcasts to guide behavioral health professionals on the subject of teletherapy during the COVID-19 pandemic. The name of our series is, What You Need To Know About Teletherapy During The COVID-19 Pandemic. I am Bonnie Rausch from NASW Assurance Services and I have joining me today three subject matter experts. From the Preferra Insurance Company RRG, formerly NASW Risk Retention Group, we have with us both Phil Lawson, the vice president of product development and risk, as well as Lonnie Ropp, the director of product management and underwriting. In addition, from Western Litigation, we have Deana Larson, the senior risk analyst and administrative supervisor.

Bonnie Rausch:

The format we will use for this series of podcasts will be Q&A, and we are also going to answer questions we have received from our policyholders regarding teletherapy and the current pandemic. But before starting, we want to tell everyone that our thoughts are with all affected by COVID-19. We are extremely thankful for all of the amazing work of the healthcare and behavioral care professionals as well as all other essential workers. Thank you ever so much.

Bonnie Rausch:

So, without further ado, let’s get started. I would like to address my first question to Lonnie Rob. Lonnie, what are the many ways nontraditional communication can be described?

Lonnie Ropp:

Yeah, there’s a lot of different ways to reference work with individual clients outside of an in-person meeting. These can include but are not limited to telepractice, teletherapy, telemental health, telehealth, online counseling, telephone counseling, video conferencing, self-guided web-based interventions, electronic networks, mobile apps, automated tutorials, emails, text messages, and a host of other options. There’s definitely a lot of different ways to reference this.

Bonnie Rausch:

Absolutely. That is one heck of a long list. Thank you so much, Lonnie. The next question is for Phil Lawson. I have always seen my clients in-person prior to the pandemic. I am aware that many of my colleagues are using technology to provide telehealth services for their clients, and they have been doing so for several years. How do I begin online sessions? And what are the guidelines that I need to be aware of to assure ethical practice, please?

Phil Lawson

Well, that’s a great question. Let me say, regardless of technological progress or change, your state laws take precedence over the delivery of professional services to clients within that state’s venue. So, your state license is only valid in the state that issued the license to you. There’s no system of reciprocity for social worker licenses across states, so we’re focusing in this case on intrastate therapy in this question, which brings us back to your specific state’s laws governing online and teletherapy modalities. Before utilizing online or telehealth therapy with a client, read and understand the laws in your state before contacting your clients. They’re the ones that granted you the license. All state regulating boards have these regulations on their websites. So, check those out. Some states mandate completion of certain education requirements as well, so understanding your state’s laws pertaining to teletherapy and online therapy within that state that issued you the license is critical. It’s also critically important to understand that if a state completely outlaws that practice, do not proceed because the outcomes can be very destructive to licensure.

Bonnie Rausch:

Absolutely. Those are very valid and wonderful points there. State by state by state. Deana, the next question is for you. Can I just choose any form of electronic communication that’s available out there, especially free options?

Deana Larsen

No, not just any form. First, you need to review the guidelines. As Phil noted, know what your state regulations are concerning electronic communications. You want to focus on platforms that offers secure communications, and most importantly, are HIPAA-compliant. Some platforms do offer this, and they guarantee that secure HIPAA-compliant communication, but they’re probably going to have a fee for that option.

Deana Larsen:

In addition to all of this, NASW, ASWB, and CSWA has a document on technology standards that should be available on each of their webpages. That document points out some steps that you need to consider when you’re thinking about protecting confidentiality. Precautions that you need to use or you need to consider would be using passwords, email firewalls, encryption, very important when you’re using email and text messaging, as well as making sure your antivirus software is up-to-date. You want to have a service provider that offers secure communication for data that you are receiving or sending out to your clients. And you also want to ensure a private setting when electronic devices are used on both ends. Neither one of you wants to have a conversation or a session with a client when you’re sitting in a car full of people.

Bonnie Rausch:

Absolutely not. That would not be a good thing. Thank you very much, Deana. Lonnie, this question’s directed to you, please. Can I provide telemental health services to all of my clients?

Lonnie Ropp:

Well, especially given the current and emerging pandemic restrictions, you need to be aware that teletherapy is probably not a one-size-fits-all option. Actually, over time, we understand that you know your clients well and the best way to communicate with them. And definitely, assess each client individually to determine the best available communication resource for them because you may need to pivot. You may need to make some changes. And clients at risk for self-harm, injurious behavior, and those who might be cognitively impaired may not be good candidates for teletherapy. You want to definitely take careful time and effort to document your decision-making process in the client records and definitely assure adherence to confidentiality, HIPAA regulations, and professional ethics, and other relevant regulations in considering these choices. And an especially very helpful resource, as Deana just pointed out in the past question, is to review those technology standards, to explore this further because it does go into great detail.

Bonnie Rausch:

Thank you so much, Lonnie. Very good points. My next question is directed to Phil, please. Once I have cleared other efforts to connect remotely with my clients, should I consider steps to make things clear to them about this change in communication?

Phil Lawson:

Yeah, that’s the next step in implementation. A very good question. It’s critically important to establish expectations with your clients in the state that you’re licensed in, using your intake forms and contracts. This is already an established normal practice prior to providing professional services, and I’m sure you’ve already gone through. But moreover, if your state permits the use of teletherapy and or online therapy, make sure that you comply with your state’s requirements, and address these in what we call an informed consent document that relates to telehealth services. We have a sample document available on the NASW Assurance Services website for your convenience, although your attorney can verify that you complied with your state’s laws in this scope of service, and we recommend that.

Bonnie Rausch:

Thank you ever so much, Phil. Next question is for Deana. Deana, my client will only see me in person and refuses any other communication option. What should I do?

Deana Larsen:

That’s a great question, Bonnie. Given the situation that we’re dealing with now, with the pandemic and social distancing, the social worker should politely explain the importance of social distancing, and keeping the client as well as the social workers safe by not having a face-to-face session. They need to emphasize that it’s important to comply with whatever local mandates are in place concerning social distancing. The social workers should then go through and explain just how telehealth works, whether it’s going to be just on the telephone, or whether it’s some sort of a visual medium is going to be used. Maybe they could offer a trial appointment, just to see how it’s going to work, see what they think.

Deana Larsen:

If all else fails, make an appointment for a later date when the social distancing restrictions have been relaxed. Most importantly, you want to document your conversation with your clients and record whatever decisions you came to together with your client concerning telehealth. Social workers may want to be reaching out to their local mental health facilities, the hospitals, the emergency rooms, wherever they would refer someone who is in crisis, and ask how they want to handle critical patients. Right now, it’s a challenge with hospitals, so you want to have these answers available before you need them and before you have a client that’s in crisis and needs a little extra TLC.

Bonnie Rausch:

Very, very good things to think about and take into consideration. Lonnie, can you please answer this question? What are the best resources to consider further?

Lonnie Ropp:

Yeah, that’s a great question, and you want to yield the best resources and outline the answers to these resources. First and foremost, your state regulatory measure is a good start in understanding what the state provision of social work services looks like, especially as regulation is fast changing to meet our pandemic situation. Secondly, you want to refer to the standards for technology and social work practice, and also the NASW code of ethics. All of them are chocked full with information to help you proceed appropriately. And lastly, there’s a great webinar on NASW, the technology and service, or excuse me, the technology and social work practice webinar. And this webinar is found on the NASWInstitute.InReachCE.com site where they have the continuing ed, and it’s a three-credit course. It’s a great resource.

Bonnie Rausch:

Thank you for that additional information about that resource there, Lonnie. Thank you so much. I would like to ask the following question of all of you, and I’d like to start with Phil, then Deana, and then Lonnie. Phil, if you could provide one recommendation to behavioral health professionals that are currently using teletherapy during this pandemic, what would you recommend?

Phil Lawson:

Well, okay, first, I want to say the teletherapy changes the physical venue in which professional services are delivered. Instead of a private office where only the client and the social worker conduct therapy, each party will be on a telephone and possibly in an uncontrolled public environment. Strangers can overhear conversations and they can hear important information, and that’s unauthorized disclosure of client records, basically. So, it’s critical that the dialogue between the therapist and the client be kept private.

Phil Lawson:

And also, by using computers and telephones and other devices to provide therapy, that opens the therapist up to potential information breach. Not only the dialogue, but also somebody steals a cell phone and it’s got the patient records on it and the phone number and contact information. You then fall squarely, the social worker falls squarely in the federal crosshairs of HIPAA HITECH law 45 CFR part 160, and they’ll be open to civil fines and penalties that involve criminal prosecution and even jail time, depending on the frequency and severity of that crime. So, I’d be very cautious when you use teletherapy and online therapy.

Bonnie Rausch:

Thank you so much. Deana, the same question to you. If you could provide one recommendation during this crisis pandemic, what would you recommend?

Deana Larsen:

My recommendation would be concerning documentation. This is not the time for your documentation to be vague. At the beginning of every telehealth session, the social workers should ask their client where they are physically located, and then record the answer that they give. This becomes important if something happens during the session, and the social worker needs to get medical assistance to that person. And it’s not necessarily that the person goes into crisis. What happens if the person on the other end of the phone or the Skype session or FaceTime or whatever you’re using, what happens if that person has a heart attack, and the social worker is the only person who is aware? They need to know where to tell emergency personnel to get to so that they can assist the client. So, ask the client, and then record that information. Don’t be vague about it. Be specific. Documentation is important.

Bonnie Rausch:

Thank you very much, Deana. And Lonnie, what would your one recommendation be to behavioral health professionals that are using teletherapy, please?

Lonnie Ropp:

Well, our social work professionals are the best risk managers, and I just wanted to encourage them all to arm themselves with the resources that are available online and in different formats relating to state regulation. It’s really a good guide to make sure that they’re in line with everything as regulation changes. Secondly, the technology standards, the NASW code of ethics, all reference the different environments and different realities of this new way of communication that is somewhat our new norm.

Bonnie Rausch:

Absolutely. Thank you very, very much. Phil, Deana, Lonnie, thank you so very much for sharing your knowledge and expertise with us today. Thank you also to our listeners. Please stay tuned for podcast two of this series. In the interim, please all be safe, keep your distance, and don’t forget to wash your hands. Have a great day.