Frequently Asked Questions about Teletherapy
Teletherapy: The New Norm in Client Care
A few different references exist for services to individual clients outside of an in-person meeting. These can include, but are not limited to, tele-practice, teletherapy, tele-mental health, telehealth, online counseling, telephone counseling, videoconferencing, self-guided web-based interventions, electronic networks, mobile apps, automated tutorials, e-mail, text messages, and a host of other options.
Please Pause and Review as things are changing daily with client communication regulation as social work and mental health regulation still resides with state boards of social work/mental health providers. It is extremely important to read and understand the laws in your state before contacting your clients. All state regulating boards have these regulations on their websites, so please read them and be ready to take notes, as some states have continuing education completion as an advance requirement.
Most, but not all, states have provisions to allow certain alternative communication efforts; however, the law requires the licensee to confirm adherence to the law in advance of providing services. It is critically important to understand that if a state completely outlaws the practice, DO NOT PROCEED, as the outcomes can be very destructive to licensure.
Important review source is the NASW/ASWB/CSWA Technology Standards, Section 2.02 Services Requiring Licensure or Other Forms of Accreditation (page 12) and Section 2.03 Laws that Govern Provision of Social Work Services (page 14).
NO. First, review the guidelines outlined in state regulation, with an important focus on platforms that are bound to secure communication and are HIPAA compliant. Some platforms will offer and guarantee a secure venue but will likely have a fee for this option.
In addition, as the NASW/ASWB/CSWA Technology Standards point out steps to protect confidentiality on page 24, “precautions to protect confidentiality depend on the type of technology being used, and may include:
- using passwords, firewalls, encryption, and antivirus software
- using electronic service providers that rely on standards of security for data that are transmitted and stored
- ensuring a private setting when using their electronic devices”
Especially given the current pandemic restrictions, be aware that teletherapy is not always one size fits all. Over time, you know your clients well and the best way to connect with them. Assess each client individually to determine the best available communication resource for them. Clients at risk for self-harm or injurious behavior and those who may be cognitively impaired may not be good candidates for teletherapy. Take careful time and effort to document your decision-making process in client records, assuring adherence to confidentiality, HIPAA regulations, professional ethics, and other relevant regulations. Review the Technology Standards to explore this further.
It is critically important to establish expectations for your clients through an informed consent document that is reviewed and signed by your client. Your state may have some requirements or items to include in the informed consent document relating to the telehealth service. It is best to either review and use the Telehealth Informed Consent document from NASWASI or create a document and review it with a local attorney. An attorney can ensure the inclusion of your state laws.
The SW professional should politely explain that it is important to comply with stated local mandates for social distancing. The social worker should explain how the Telehealth process will work, offer a trial appointment or make an appointment for a later date when social distance restrictions are relaxed. Always document your conversation with your clients.
Policyholders might reach out to their local mental health facilities and ask how they want critical patients handled. It’s better to have answers before you need them.
Review the professional standards for the provision of tele-practice services found in The NASW, ASWB, CSWE &CSWA Standards for Technology in Social Work Practice and the NASW Code of Ethics.
Also, check out the Technology in Social Work Practice Webinar – This risk management webinar is an excellent resource if you are exploring new communication options. Technology in Social Work Practice, offered by the National Association of Social Workers, is CEU eligible and a great tool for anyone using technology to deliver services. Visit the Social Work Online CE Institute online. *This course is CEU eligible and would have a corresponding fee.
Access to Records
We are not certain what is meant by “electronic service,” but it is certainly appropriate to print an electronic medical record and provide the paper copy to the client.
Electronic medical record requirements are generally limited to large hospitals or physician clinics. However, check HIPAA and your state regulations to be certain.
Only if you have a secure internet connection.
It appears to be secure and therefore HIPAA compliant, but if you are considering using this platform, do your homework and have a detailed call with the company representative before signing up.
It is too easy to click the wrong contact for a text or phone call and get a friend instead of a client. Additionally, if your phone is hacked or stolen, you have now exposed yourself to multiple HIPAA breaches.
There are phone systems that are secure, but we don’t make recommendations on specific products. It is important to check with companies offering that service.
It is never a bad idea to have a separate consent form for telehealth services. However, you need to check HIPAA and your state regulations regarding telehealth services.
Insurance numbers are considered protected health information. Confirming an appointment is alright if you have an agreement with the client to confirm (or cancel) appointments in this manner.
If someone else got the e-mail, it could be considered a HIPAA breach since information about other providers could be interpreted as protected health information.
Only if the internet connection is secure.
No, unfortunately not.
You should contact your state licensing board for clarification and direction.
No. The consent document does not have any patient identifiers on it. Make sure you have the correct e-mail address to send the consent to.
This is a good practice.
You can have a session by phone if the client has consented in writing to that type of service.
Licensing, Practicing Across States, Outside the Country
The provider would need to have the transfer sessions prior to the client leaving the state. It is inappropriate to continue to treat a client after the client has left the state unless you are licensed in that state. Hopefully, you have enough time with the client prior to their departure to have at least one transition session
If the Licensing Board representative didn’t have a problem with this, it may be alright in your state, especially if the client wants to drive to Maryland.
Each state’s requirements are different, and some states might offer reciprocity with your current state. Contact the state licensing board for more information.
You need to reach out to the state licensing board for information specific to the states in which you are interested in being licensed. However, be aware that license reciprocity means that a state will honor your credentials from another state when you apply and pay for a practice license. This is often confused with the term license portability, which means another state will honor your license from another state.
This is incorrect. You use the client’s current location, or where the phone is located. You cannot practice across state lines.
For example, if you have a social worker who is licensed in Georgia and Florida and is in Florida on vacation, that social worker could treat a client who is physically in Florida
You should consult a business law attorney or a tax professional to get the answer to this one.
With clients who either live or are traveling internationally, do your best to find resources for your clients where they are traveling, but do not treat them yourself while they are out of the country.
No. Refer them to someone who is in your state and let them handle the emergency. It would be a good idea to have someone for the client to reach out to if you are going to be out of state for an extended period of time.
Each state is different, and probably not something that can be granted through a phone call. Don’t assume this is something that can happen – better to ask in advance.
The NASW Code of Ethics does not address licensing. That is the responsibility of the state licensing boards.
If you have a client in crisis, you can talk with her but you should also be referring her to someone in the state where she is vacationing.
You must apply for a license in each state. However, if you have your LCSW, some states will only require proof of your credentials and an application (with the licensing fee). Each state is different.
States differ in the types and levels of licensure their legislature has passed into law. The Association of Social Work Boards (ASWB) has information on state licensing on their website.
You have to trust that your client is telling you the truth when you ask where he or she is located. Make sure to document the conversation. If later they claim you practiced outside your state, you can state that the client stated he or she was in the state when you spoke. It is not a solid defense, and this will wind up causing you a lot of time and heartache. It is best to have a conversation with the client at the beginning of your care and explain the situation.
Check your state’s laws to be sure, but most states require providers to keep records for 7 years from the last contact. The underlined portion is the most important part.
If you are fluent in ASL, then you have half the battle won. Use a secure internet provider so that your conversations will be private, and then you could use FaceTime or Skype or any of the video chatting programs.
There have been problems with that type of storage because the providers sometimes go out of business and leave the provider with no access to their records. An external hard drive would be easier and safer.
Take the machine to a company that specializes in wiping those drives.
If a clinician is part of an agency that uses an EMR or EHR, then they must use the electronic record. Consult a local attorney if you have any specific questions.
Unless you are using a secure phone line, any call is susceptible to hacking. You can try to require a landline, but in this age of cell phones, more people have cell phones than landlines. It could be an impossible requirement.
If there is a question, consult an attorney.
Keep your paper records secure as you always do, continue to document as you always have. Understand that at some point you may have to switch to electronic records.
Very good point! Anything involving electronics is technology.
Very good point!
At a minimum, a Business Associate Agreement is a must. Discussions with the psychotherapist about how to transmit information for billing purposes in a secure manner are also a must. Security of the information should be the most important thing. If you can, you should also get an Errors & Omissions liability insurance policy.
Inform the health care provider about the error and then forget the information, exactly as you would expect if you gave another provider information they should not have.
Circumstances might require that a therapist offer technology for sessions – for example, if the therapist has an office on the second floor of an older building and the client is disabled and unable to use the stairs, technology might be the only way they can work together. If you have concerns about providing services to this client through technology, you could have a conversation with the client to set parameters around the therapy and the expectations for both sides.
Have the client sign a consent acknowledging that they are aware that a Facetime connection is not secure and the information shared in sessions could be accessible.
You would need to consult with each carrier to find out if they cover telehealth services.
The school’s attorney should be willing to work with you to access the records to allow your review prior to your deposition.
If there are policies or standards in the agency that you believe are compromising either your ethics or license, you should discuss the concerns with the management of the agency. If not, you need to find a new agency.
- Health Insurance Portability and Accountability Act of 1996 (P.L. 104-19)
- Protection of Alcohol and Drug Abuse Patient Records (42 CFR Part 2)
- Family Educational Rights and Privacy Act of 1974 (P.L. 93-380, S513)
- Section 215 of the USA Patriot Act of 2001 (P.L. 107-156)
Yes, we offer six of the best and most affordable plans in the industry for individual practitioners.
The best separation would be separate phones.
First, clicking one icon to get to all e-mail accounts without a password is very risky. Anyone who picks up the phone could get to confidential e-mails. That is a higher concern. An out of office message at the end of the day is not necessary.
If a therapist is going to e-mail anything to a client, there should be consent in the file authorizing that type of communication. After that, there is no problem e-mailing links to resources.
Make sure you know who the person is on the other end. If you only communicate by text message, how do you know who you are talking to?
The line must be secure.
The breach is investigated by HHS. We don’t know the specifics of their investigation.
Speak to internet providers and software providers. You’ll need to do homework and ask a lot of questions.
It is better to have them in advance, but in a matter of life and death, you can move without one. If you have a good faith reason for your actions, you should be okay.
The wireless connection is more important than the platform. Both should be secure, but the connection being secure is more important.
The only sure HIPAA compliant way to communicate with clients is by face to face communication. You need to have encryption software. Check with your e-mail provider.
Check with your phone provider.
If it is a secure line, yes.
State laws vary. You should check with an attorney in your state.
It is individual to each insurance panel. Check with the panel to be sure.
Never, unless you have an encrypted texting service.
Only if the phone line is confidential.
Check with an IT expert on that.
Each provider is different. You need to check with the provider to be sure what they will or will not cover.
You could send the form by mail and have it returned prior to your meeting.
Set expectations prior to the session – that the client is not driving and is in a safe location. Try to re-schedule if you realize the client is driving.
Consent forms and all initial documentation should be at around a 5th-grade reading level, in the language the client can understand. You can re-write the forms to make sure they are understandable.
Do your homework in advance. Before you sign up with a web hosting service, find out what to do if there is a confidentiality breach. If a breach occurs, follow your process by disclosing to the client(s) affected and report the breach through the HHS website.
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