Building an emotionally resilient world

1 Clinical and Ethical Principles

Principles relevant to telehealth build on existing national standards for mental health services3 and include

a ConsentConsumers need to consent to receivingtelehealth services If possible consentshould be captured in writing orelectronically and should be clearlydocumented

b SafetyConsistent with the national law4 the safetyof consumers and their health information isparamount Services need to identify manageand mitigate risks including mandatoryreporting requirements (see below)

c ResponsibilityTechnology is not a replacementfor high‑quality care or professionalresponsibility The standards that applyto traditional F2F delivery3‑4 also apply totelehealth consultations

d QualityPractitioners must deliver evidence‑basedcare and regularly review the quality ofservice provision

2 Safety and Risk Management

These are divided into clinical and technical risks

a ClinicalIt is strongly recommended that practitioners

bull Establish processes for identifying andmanaging consumer safety (and safety ofothers) This can involve asking questionsabout suicidal ideation plans meansintent and risks to others including minors

bull Ensure all consumers know what servicesto contact in the event of mental healthcrises

bull Refer people at high risk to emergency orcrisis mental health services and followmandatory reporting requirements

bull Receive regular peer group or individualsupervision

b Technicalbull The technology used to deliver telehealth

services must be secure and proceduresfor securing health information mustfollow relevant national standards

bull Telehealth can be simply and securelydelivered using telephones and securevideo platforms More advancedtechnical platforms that include omni(multi) channel communications andintegrated systems for documentingprogress notes must comply with morestringent technical requirements

bull Practitioners should seek advice frominsurers and professional organisationsabout the security of their technologysolutions

portsorgau 1800 176 787PORTS is funded by the WA Health Alliance Prepared by the PORTS Clinic Team

Key Pointsbull Telehealth involves using technology to

reduce barriers to access but telehealthand technology are not a replacementfor high‑quality care or professionalresponsibility The clinical and ethicalstandards that apply to traditionalface‑to‑face (F2F) delivery also apply totelehealth consultations

bull Telehealth delivered mental health carecan achieve similar outcomes as F2Fdelivery but each offers advantagesand disadvantages Disadvantages oftelehealth can be overcome by carefulpreparation and by modifying onersquostherapeutic approach

bull With appropriate preparation reflectionand evaluation most practitionersfind telehealth presents an efficientand clinically effective way to reachconsumers who might not otherwise beable to access care

bull This guide assumes practitioners areexperienced nationally registeredand receive regular supervision It alsoassumes that consultations aim tosupport consumers better understandsymptoms and symptom cycles to learnand practice psychological skills andadjust to change in their life

bull This guide is agnostic with respect totherapeutic model and assumes thatmost evidence‑based models can bedelivered successfully using telehealthalbeit with appropriate modificationsby the practitioner

bull This guide provides general informationdoes not include information aboutreimbursements or recommendationsabout telehealth technology platformsWe recommend practitioners consulttheir professional organisation andinsurers for specific advice

bull We strongly encourage practitioners toread other high‑quality resources aboutusing telehealth1‑2

GuidelinesThe following four sections summarise key points that will help

A Brief Guide to Using TelehealthThis guide is designed to support mental health professionals (practitioners) to learn to safely and effectively use telephone and video technology (telehealth) to deliver mental health services

Our Partners

3 Preparing for Consultations

Practitioners new to telehealth should spend time preparing for using telehealth including the following

a Technicalbull Devices and internet connections

should be tested prior to use andback‑up methods for communicatingwith consumers should be plannedPractitioners should note that problemswith internet speed can cause disruptionsin audio and video quality and thatthese problems may fluctuate based ondemand for internet services

bull Practitioners should ensure they canoperate devices at the same time astaking notes during the consultation andimportantly should ensure that they havea private and comfortable location fromwhich to conduct consultations

b Consumer EducationConsumers unfamiliar with telehealthwill benefit from a description of whatis involved how they can best preparethe structure and time of each sessionadvantages and disadvantages oftelehealth and recommendations about thephysical location for their consultations suchas a private room with secure and reliableinternet or telephone access

c Consultation BookingsIdeally consumers should receiveconfirmations of scheduled consultationbookings which they can import ortranscribe into their calendar and remindersof bookings

d Mitigating DisruptionsBecause telehealth consultations are moreprone to disruptions that F2F sessions werecommend

bull The first minute of each consultation isused to check that audio andor videoare working properly and if not back‑updevices or connections can be activated

bull It is helpful to have an agreed plan withthe consumer about how the practitionerwill contact the consumer in the eventthe consultation is disrupted

e Documentationbull Telehealth consultations should be

documented in the same way as F2Fconsultations with notes securely stored

bull Unless there is a strong reason for doingso consultations should not be recordedIf they are consent is required andconsideration give to how when andby whom the recordings will be securelystored backed up and then eventuallydeleted

4 Therapy and Process

The process and experience of therapy via telehealth is very similar to F2F therapy albeit with some adjustments as follows

a AssessmentWe recommend using a structuredassessment and questionnaires which areeither posted to the consumer sent viaPDF or available via a website which theconsumers consults during the consultationSuch tools help to engage consumers andbuild their confidence with using telehealth

b Therapeutic EngagementPractitioners are often surprised by thestrength of the therapeutic relationship thatcan fostered using telehealth Consumerengagement is strongly related to outcomeand engagement is enhanced whenpractitioners

bull Describe the advantages and limitationsof telehealth

bull Explain that it produces outcomes asgood as F2F care

bull Instruct consumers how to prepare forconsultations

bull Use a consistent structure for eachconsultation

bull Provide empathic supportive care

c Therapeutic Modelbull Many therapeutic models (CBT cognitive

narrative solution‑focused interpersonaland psychodynamic) can be successfullyadministered using telehealth albeit withmodifications

bull Telehealth can be used to deliver grouptreatments and couples counsellinghowever simultaneously working withmore than one consumer requires carefulpreparation to ensure a successfulconsultation

d Therapeutic Skills and Processesbull Focusing on using core counselling

skills including active listeningreflecting statements and emotionsand paraphrasing can help practitionersadjust to the absence of somebehavioural and emotional cues

bull Building rapport over telehealth can beslower than in F2F Regular feedbackfrom consumers on their experienceof telehealth can assist practitioners inidentifying things the practitioner has donewell or might do to improve their care

bull Practitioners should also focus on useof verbal and non‑verbal communicationprompts to support active engagementincluding questions to avoidmisinterpretations and to ensure a sharedunderstanding of the issues

bull Consumers may be more honest intelephone compared to video or F2Fconsultations which can facilitate thespeed of the therapy process but mayalso surprise some practitioners

bull Telehealth consultations may involveprocesses and mechanisms similarto those that occur in F2F includingprojection and transference Consumersmay experience strong emotions duringconsultations including tearfulness andanger which can be managed withthe same empathic and professionalapproach used in F2F delivery

bull The predictors of therapeutic changeduring telehealth are the same as forF2F delivery that is consumers whohave time and energy for treatment areengaged have goals and motivationengage well with the practitioner and thetreatment model and who make changein their lives are likely to benefit from anintervention

e OutcomesConsistent with national standards4practitioners should routinely use outcomemeasures to monitor quality and effectiveness(eg the K‑10 PHQ‑9 GAD‑7 etc)

f Contra-indicationsA broad range of consumers can benefitfrom telehealth The main contra‑indicationto using telehealth is concern about theaccuracy of an assessment or safety Atthose times we strongly recommendreferral to regular F2F care if available orif safety is a concern to a crisis team oremergency services

Summary

Successful use of telehealth requires some adjustments by both consumers and practitioners But with appropriate preparation reflection and evaluation most practitioners find telehealth presents an efficient and clinically effective way to reach consumers who might not otherwise be able to access care

1 wwwemhpracorgau

2 httpswwwmentalhealthonlineorgauAssetsA20Practical20Guide20to20Video20 Mental20Health20Consultationpdf

3 Australian Government (2010) National Standards for Mental Health Services Canberra

4 Health Practitioner Regulation National Law (2010) wwwahpragov auAbout‑AHPRAWhatWe‑DoLegislation

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Building an emotionally resilient world