The informed consent form (similar to that presented in text box 2) used by Arundel Lodge was adapted for use with telemental health services. The addendum to the orientation packet was a separate form called “Consent for Treatment Using Teletherapy.” This document outlined the specific aspects of treatment using videoconferencing. 9. Collect data (to establish baseline). Once intake and consent forms were completed, the coordinator collected baseline data on specific mental health outcomes. Maryland Medical Assistance currently uses a standardized Outcome Measurement System (OMS) interview. This instrument collects information about the individuals served in Maryland’s public behavioral health system. Questions ask individuals about their living situation, psychiatric symptoms, substance use, general functioning, employment, school performance, recovery/ resilience, legal system involvement, and somatic health. The coordinator also included another standardized state questionnaire called the Consumer Perception of Care Survey. This instrument collects information about clients’ perceptions of their care, including satisfaction with and outcomes of behavioral health services. Data collection is important for two primary reasons. First, it allows both the clinician and client to track progress on specific mental health outcomes and satisfaction. Second, it allows for comparison with other groups, such as individuals who receive traditional face-to- face psychotherapy. This is particularly important as an evaluation tool to determine whether telemental health is an effective way of providing behavioral health care. Comparison of data not only gives practitioners and administrators the ability to evaluate the treatment provided, but it also provides data that can be published in the literature and that adds to the existing knowledge base. 10. Set therapy appointments. After the initial session, the coordinator assists with setting up an appointment with the therapist to begin treatment. With the telemental health at Arundel Lodge, the staff member at the originating site escorts the client into the room with the videoconferencing equipment and actually places the
call by entering the IP address of the Polycom system. When the therapist at Arundel Lodge answers the video call, the staff member leaves the room so that the session can begin with the client. 11. Evaluate service. The telemental health coordinator at Arundel Lodge collected data using the same instruments described previously at six-month intervals. The outcomes were compared between those receiving face-to-face therapy and those receiving telemental health services (Crowe et al., 2016). The findings supported telemental health as a viable alternative to traditional psychotherapy. 12. Apply for a new grant to expand services. As mentioned previously, funding is a major factor for sustainable telemental health programming. Reimbursement for telemental health services is inconsistent and sometimes inadequate. Therefore, exploring new grant opportunities is an important part of helping the program to stay afloat. In October 2017, Arundel Lodge was awarded a grant from the Maryland Agricultural Education and Rural Development Assistance Fund (MAERDAF) to expand the telemental health program across all Maryland counties to individuals who receive medical assistance. Self-Assessment Question 3 Which of the following statements regarding licensure in telemental health is true? a. All states have adopted interstate licensure agreements to streamline the licensing process for practitioners. b. Psychiatrists practicing telehealth are exempt from compliance with the obligations applicable to physicians. c. Many malpractice insurance companies offer clear guidelines about liability insurance for telemental health services. d. Practitioners may be held legally liable for practicing without licenses if they disregard licensure issues.
INTERNATIONAL CONTEXTS
Telemental health services can have a worldwide application, especially in areas that are underserved, under-resourced, and geographically remote. Accessible behavioral health care may be limited in low-, middle-, and even some high-income countries (Bischoff et al., 2017; World Health Organization [WHO], 2009, 2016). Barriers to mental healthcare include resource scarcity, inequity, and inefficiency. Additional barriers, such as stigma, discrimination, and marginalization, can also affect whether one seeks mental health services. Traditional therapy offered by trained professionals is often not available in many international communities. Thus, unconventional models of healthcare are needed to address the diversity and cultural needs of local communities. Telemental health services can improve the quality of care to individuals, increase care coordination among providers, improve care management, and overcome physical distances between providers and their clients (WHO, 2016). In low-income countries and regions that have limited infrastructure, telemental health services are primarily used to link physical and mental health providers with specialists, hospitals, and medical clinics (WHO, 2009). International telemental health programs have the potential to reduce the variability of diagnoses as well as provide vital healthcare services by increasing access, efficiency, and cost-effectiveness. However, barriers such as distrust
by local residents, linguistic and cultural differences, differences in mental health and treatment frameworks, and lack of technological experience can affect whether telemental health services are used. In addition, there is no international legal framework to guide telemental health service delivery. The lack of policies and laws to oversee patient and client privacy and confidentiality can increase the risks and liabilities for professionals offering telemental health services. Implementing unconventional treatment in under-resourced international communities requires creative thinking and flexible interventions. Simply offering telemental health services without proper community support is a recipe for failure. A successful design for telemental health services in an international setting involves several components, including (1) involving community stakeholders, such as local providers, clients, and/or family members; (2) expanding community capacity to develop local resources; (3) designing plans of intervention that include both conventional and unconventional strategies; (4) delivering interventions in unconventional settings; and (5) ensuring the use of family-centered practices (Bischoff et al., 2017). Integrating specific strategies to incorporate comprehensive approaches to mental health services can help to sustain the intervention in the long term. Clinicians who provide telemental health services internationally should partner
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