requirements and understand that the legal context of telemental health is continually changing. Licensure and complicated regulations across state lines can be burdensome to clinicians (Lambert et al., 2016; Swenson et al., 2016). In a 50-state survey conducted by Lerman and Quashie (2016), researchers highlighted numerous inconsistencies in telemental health regulations. Psychiatrists, as practicing physicians, must comply with all the obligations that apply to physicians practicing telehealth generally. Very few states exempt mental health services from these requirements, despite the fact that many psychiatrists never have physical contact with patients. Texas is one of the few states that explicitly separate mental health services from the requirements applicable to the provision of other telehealth services. Other findings of Lerman and Quashie (2016) include the following. ● In Delaware, an individual practicing “telepsychology” must conduct a risk–benefit analysis and document findings specific to issues, such as whether a patient’s presenting problems and apparent condition are consistent with the use of telepsychology to the patient’s benefit and whether the patient has sufficient knowledge and skills in the use of technology involved in rendering the service or can use a personal aid or assistive device to benefit from the service. ● Kansas requires psychologists and social workers providing telemental health services to obtain the telemental health–specific informed consent of the patient before services are provided. ● In Maryland, physicians (psychiatrists) are required to develop a procedure to prevent access to data by unauthorized persons through password protection, encryption, or other means and to develop a policy on how soon an individual can expect a response from the physician to questions or other requests included in the transmission. ● Montana psychologists may initially establish a “defined professional relationship” electronically so long as the means of communication involves a two-way, real-time, interactive platform providing for both audio and visual interaction. ● To regulate marriage and family therapists, South Dakota relies on the American Association for Marriage and Family Therapy’s Code of Ethics, which requires that therapists evaluate whether electronic therapy is appropriate for individuals and inform them of the potential risks and benefits associated with electronic therapy. ● Nevada allows advanced practice registered nurses (APRN) to practice by using equipment that transfers information concerning the medical condition of a patient electronically, over the telephone, or by fiber optics from inside or outside Nevada or the United States. Many practitioners have concerns about malpractice issues when providing services through videoconferencing. However, telemental health services are not clinical interventions; rather, they are a modality for the delivery of clinical services (Kramer & Luxton, 2016). Regardless of the modality, whether it is face to face or video technology, standards and guidelines of competent practice apply. Early cases of medical malpractice with telemental health involved prescriptions and failure to provide adequate assessments for the use of controlled substances (Kramer & Luxton, 2016). Many malpractice insurance companies have yet to offer guidelines about liability insurance (Kramer & Luxton, 2016). Practitioners may want to contact their insurance companies to ask about coverage for services provided
through videoconferencing. With the increasing demand for telemental health services, it is likely that professional insurance companies may soon offer guidelines. Establishing a telemental health practice can be daunting, considering the details that must be addressed. The following case example illustrates how one agency established a telemental health service in a rural area in Maryland, addressed challenges, and expanded services over a five-year period (Crowe et al., 2016). Case Study: Arundel Lodge Arundel Lodge, Inc. is a nonprofit organization located in Edgewater, Maryland. The agency provides a variety of services for individuals who have behavioral health and substance abuse disorders. These services include residential services, case management, vocational training, day programs, and outpatient mental health services. The telemental health program was established in response to a severe lack of behavioral health services for deaf and hard-of-hearing individuals living on the rural eastern shore of Maryland. Although the target population was deaf and hard-of-hearing individuals, the steps taken to establish the telemental health program may be similar to those for other populations of interest: 1. Review jurisdictional requirements for telemental health (e.g., telepsychiatry). The therapist first reviewed local and federal guidelines for telemental health services to conceptualize what would be needed to establish the program. The Substance Abuse and Mental Health Administration (SAMHSA), U.S. Department of Health and Human Services, and Center for Integrated Health Solutions (2017) provide online resources for establishing a telebehavioral health practice. There are six modules that address the following areas: Laying the groundwork, reimbursement and engagement, partnerships and financing, technology and logistics, implementation, and launch and refinement. The Centers for Medicare and Medicaid Services (CMS, 2017) offers federal guidelines and billing codes for providing telemental health services. In Maryland, the Maryland Department of Health and Mental Hygiene (2017) offers the legal code regulations for telemental health services. By reviewing the local and federal regulations, a clinician can better understand what will be needed for establishing the framework for a telebehavioral health practice. 2. Secure funding. A therapist in the outpatient mental health clinic at Arundel Lodge located a private foundation that sought proposals for addressing mental health disparities. The therapist wrote the proposal and included an evaluation component that would compare mental health outcomes between a group of individuals receiving face-to-face, traditional psychotherapy and those receiving telemental health services. The grant officer at the foundation requested an individual meeting with the executive director of Arundel Lodge and the therapist who wrote the grant to learn more about the need for services in Maryland and the proposed project. After meeting with the officer, Arundel Lodge received a three-year startup grant to establish telemental health services. 3. Identify collaborating partners. The coordinator of the project (i.e., the therapist who wrote the grant) identified local behavioral health agencies in the target area that could serve as appropriate partners and that had existing videoconferencing equipment. Few private clinics had the expensive Polycom systems; however, the departments of health in each county were already equipped with videoconferencing equipment. There were several unanticipated challenges.
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