By Audrey Schoen, LMFT
Therapist in the Sacramento area
March 16, 2020
Online Therapy: Setting Up Your Telehealth Practice Quickly
With the recent concerns about the COVID-19 pandemic, many therapists are seeking solutions to provide their clients with continuity of care and keep their businesses, well, in business. Many therapists are looking to provide online therapy, otherwise known as telehealth.
The CDC predicts that the COVID-19 virus may spread at an exponential rate, and that taking preventative measures can help slow the spread and ease the burden it may cause on the healthcare system. More critically, these measures help protect the most vulnerable among us.
Because transmission occurs prior to symptoms, the standard “if you’re sick, don’t come” policies will likely not be effective at preventing infection. Offering telehealth gives both clinicians and clients options for doing their part to mitigate the impact of COVID-19 on the community and to protect themselves and their families.
I began offering online therapy in 2016 when I became a licensed therapist. I had long been fascinated by the use of technology in therapy and was excited about the potential benefits telehealth offered both clients and clinicians. My colleagues’ responses ranged from supportive and curious to skeptical and even critical. Over the years I have had incredible experiences, made deep and meaningful connections, and helped a wide variety of clients. I am hopeful that the rapid rise in the use of telehealth will help reduce stigmas and increase access and coverage for telehealth services moving forward.
I know that it can be overwhelming to transition your caseload to telehealth so suddenly. The learning curve feels steep. It seems like there is SO much to know, but with just a few steps you can have your online operations set up in no time. We are all committed to providing our clients with the best possible care, and having the knowledge and resources to do that in a secure and effective way allows us to do just that.
Legal and Ethical Considerations
California Board of Behavioral Science: Standards of Practice for Telehealth:
For Marriage and Family Therapists, Educational Psychologists, Clinical Social Workers, and Professional Counselors, the BBS has adopted these Standards of Practice for Telehealth.
BBS Statement on COVID-19 and Telehealth:
The BBS has expanded permissions to perform telehealth for all levels of clinicians. Please see the statement for guidelines specific to your profession and situation: Coronavirus Statement
Code of Ethics
I encourage you to do a google search for your profession and “code of ethics telehealth”.
I have included links for the following:
- CAMFT code of Ethics
- AAMFT best practices for online therapy
- NASW Technology Standards
- APA Guidelines for Telepsychology.
Call your insurance provider and verify if Telehealth is covered, if not take the steps to add it. CPH includes telehealth coverage in every policy and recently released this statement: Coronavirus and Telehealth.
What if my client leaves the state? Practicing across State Lines
You may be wondering if you can continue to work with a current client while they are outside the state of California. In CA therapy is defined as happening where the client is sitting at the time of the session.
The BBS states:
“ A licensee or registrant of this state may provide telehealth services to clients located in another jurisdiction only if the California licensee or registrant meets the requirements to lawfully provide services in that jurisdiction, and delivery of services via telehealth is allowed by that jurisdiction.”
In practice, this means that, in most cases, you need to be licenced in the state where your client is at the time of the session. There are a few states that allow limited cross state practice, in which case you would need to comply with any provisions set forth by that state.
There are a few states that define therapy as happening both where the client AND therapist are located. California is NOT one of those states. This means that you can be located anywhere in the world and provide therapy to clients in CA.
CAMFT: The Practice of Marriage and Family Therapy across State Lines (2016)
ASWB: Regulations Impacting Social Work Electronic Practice (2017)
There’s an app for that! It is called Telemental health laws. And I have generally found it to be up to date and would consider it a great starting point.
CAMFT has published a checklist of provisions for telehealth in CA
- The therapist must document in their notes the address of the clients location at the start of each session.
- Provide informed consent specific to telehealth services. This can be a separate form or added to an updated informed consent for your practice. Some EHR’s provide a template for this or you can purchase one from a variety of providers.
- It is also advisable to have some kind of emergency services worksheet and agreement completed. This should include emergency contacts, local emergency services and a plan to address an emergency should one arise in or out of session.
A note on electronic signatures: As per the E Signature Act 2000, it states that The ESIGN Act is a federal law passed in 2000 that grants legal recognition to electronic signatures and records if all parties to a contract choose to use electronic documents and to sign them electronically. No contract, signature, or record shall be denied legal effect solely because it is in electronic form.
Getting Set Up
There are several free secure video platforms available. Be sure to complete/sign the Business Associate Agreement (BAA) before using any of these platforms. Most if not all allow clients to use both computer and mobile devices. Keep in mind that the rapid adoption of telehealth may cause interruption or glitches in these services as they become overloaded with new users.
- me: free version. The client does not have to create an account. Video quality varies depending on therapist and client location and connection more than others, but it typically works well enough. I keep this as a quick backup or for use with free video consults for new clients.
- Vsee: Free for 25 video sessions per month. This one does require a download. I believe this supports multiple participants from different locations (couples or groups). I personally didn’t care for the user interface and experience.
- Google MEET with a gsuite (paid) email. Does not require a client to have a gmail account.
- Signal is an app that does text, voice and video calls. Both people must have the app, but it is free. Person Centered Tech states that it is so secure that it does not require a BAA. It can be used on your computer and mobile devices. This is a great option for secure phone and text messaging, as other commonly used services (personal cell phones or google voice) are not HIPAA compliant or secure.
Do not use facetime, skype, zoom (free version), WhatsApp or google hangouts. These are not HIPAA compliant and not secure even for a non HIPAA entity.
If you will be communicating with clients via email or sending and receiving private health information via email, it is wise to use a secure email solution. Prontomail has a free version. Hushmail and Gsuite are also popular options. Hushmail and Prontomail (paid version) provide the ability to send encrypted messages, which offers the most protection and security. Gsuite is also HIPAA compliant and with a Gsuite account many of the other services are as well, including Drive, Meet, and more.
Visit G Suite and use the code TAYVF9YFJKGP4WE to get 20% off G Suite Basic Plan or the code 9C49PDJRFGM6V7E to get 20% off G Suite Business plan.
Many EHRs have telehealth options: Simple practice and Theranest are two EHR’s that I know offer a telehealth video platform, and many others do as well. If you have been considering an EHR, this might be the time to take the leap. The great thing about using an EHR is being able to do all your paperless paperwork, payment processing and video sessions all in one place.
Use this link to get your first month free and $50 credit: https://www.simplepractice.com/?p=9bfee6081c
If you don’t have an EHR, you will need to collect payment through a payment processing program. Squareup, IvyPay and Stripe are all commonly used companies for this purpose. All offer a BAA, which you need to ask for it not offered automatically in order to be HIPAA.
Venmo and PayPal are not HIPAA compliant.
“I’m not a HIPAA entity, do I need all that?”
The safest answer is yes. While you might not be a HIPAA covered entity, if there is a security breach you will be held to the standard that MOST therapists follow, and most are covered by HIPAA. So why not do it when it doesn’t cost you anything.
- Check with your clients plan to determine if they are eligible for Telehealth and what coding to use. Most plans reimburse at the same rate. Some unfortunately don’t at all.
- Many insurance companies are or will be expanding telehealth coverage for a period of time.
- Location = 02
- Modifier = 95 or GT
- FB group dedicated to insurance and telehealth for therapists: Telehealth Insurance Billing.
- If your client cannot use their insurance and you need to bill them directly you will need to complete an Opt-out form. You can find an option for template HERE.
Office set up and Tips
There are some things you can do to improve the online therapy experience for both you and your client.
- The more simple your background the better your video quality will be. that’s the same for your clothing. bright colors and busy patterns are harder for computer processors to handle.
- Sit away from the computer so that your chest, shoulders and head are clearly visible. And look at your client. Positioning the window directly under your camera will give the best angle.
- Multiple diffuse light sources (lamps) and/or a cheap ring light help with good lighting. I love my umbrella light. A small ring light puts out a lot of light. An inexpensive one is sufficient if you need the extra lighting and they are readily available on Amazon. Careful that there are no light sources behind you like windows or lamps.
- A hard wire connection to your router is the fastest. While wifi works great, I do notice a difference when connected directly.
- Restarting your computer at the beginning of the day reduces glitches and interruptions. Encourage clients to restart theirs prior to session as well. If you do encounter problems restart your browser and that usually will resolve it.
- Close all other browser tabs and programs. And Turn off notifications.
- Using headphones reduces feedback and makes for a better audio experience for both participants.
- I encourage clients to use a computer whenever possible. But if they are using a phone/tablet, I ask that they use a stand or mount to reduce motion.
Helping your client get the most out of online sessions
Being at home during sessions offers both benefits and drawbacks. Clients are often more comfortable and find opening up comes more easily. Alternatively, some may struggle to find a space conducive to therapeutic work, especially if children are home due to school closures.
Clients will want to find a private space and limit distractions within reason to get the most out of their sessions. They may also need to restart their computer or close browser tabs to reduce glitches.
Resources and Training
Several companies now offer training in Telehealth. Included are links to a couple that have come highly recommended. There are other options as well so please choose the one that fits your needs.
- Zur: This is a 26 CEU Certification and includes 12 CA Law and Ethics Units and very reasonably priced.
- Person Centered Tech: Certificate program with 17 CEU’s and is very well regarded and regularly updated. Currently discounted! They offer a free 1 CE HIPAA training and free form downloads.
- Simple Practice is offering a 1 CE training for free right now. It’s fantastic and accessible to everyone.
- Telehealth Training has several free offerings and a paid certificate program.
- Amber Lyda and Online Therapists Group: LOTS of great information available for free, with new videos posted recently to help you get going fast. She also offers a getting started checklist on her website and paid resources as well.
- Connect TMH
- Person Centered Tech has a lot of great resources for both individual and groups practices.
- You can read another great and comprehensive article on transitioning to Telehealth HERE.
Here is a breakdown of the steps to take.
- Do a quick overview of your legal and ethical requirements.
- Forms: Update your informed consent to include telehealth, and create an emergency services agreement. Many EHR’s provide templates.
- Check your liability coverage for Telehealth, if you have CPH you are good to go!
- Select a video platform: if your EHR has one, try that. Having it all in one place makes it easy for clinician and client. Do a quick test run with a friend or colleague.
- Payment processing: if you don’t have an EHR through which to accept payment, set up a payment portal.
- Check your clients insurance coverage.
- Discuss the change with clients, including recommendations for how to get the most out of online therapy and the updates to informed consent and emergency services agreement.
- Draft an email for clients that includes clear instructions for how to access sessions and what to do when technology fails. Ask clients to “start” their first session a few minutes early in case they encounter technical difficulties, there will be time to resolve them.
I am not an attorney. Though I have included as much information as I can, this should not be considered a comprehensive review of all things tech and therapy. Ultimately you are the keeper of your license and you need to make the best decisions for you, your clients and your and your practice.
About the Author
Audrey Schoen is a CA Licensed Marriage and Family Therapist. Her fully online private practice allows her to serve clients all over California. As the wife and daughter of Law Enforcement, she has a special interest in working with First Responder partners and couples.