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Across the country and indeed the globe, the coronavirus pandemic has upended people’s lives. Over 150 million Americans have been ordered to stay home, and the vast majority of them are not physically ill right now. This news still feels like a shock to the system, but as these radical changes shift from days to weeks and even months, the combination of widespread anxiety and social isolation will be a major strain on our mental health. Here’s what I’m doing (and what you can do) to maintain sanity during this insane time.

Coronavirus news is everywhere, and it is true that the facts are changing by the day. Naturally, I want to know about the latest number of cases, emerging science about the virus itself, and government plans to address the illness as well as the effects on the economy. However, being trapped at home makes the world feel small, and constantly reading about the coronavirus adds worry with little solace. A supervisor once told me that reading fiction is the best training for a psychiatrist. As we move from our own mind to another person’s point of view, we literally practice empathy. I have also come to realize that reading fiction transports me to another time and space (without exposing me to any viruses). This week, I finally read Tara Westover’s Educated. Reading about the Idaho mountains added a breath of fresh air to my small New York City apartment. 

Remember the mind and body are connected. Just because you can’t go to the gym doesn’t mean you can’t work out. I strongly prefer gyms or playing a sport, but these are not options right now. I’m focusing on what I can do from home: 5-minute yoga sequences in the morning to stay limber, and bodyweight workouts that do not require much space. The American Heart Association guidelines suggest we aim for at least 30 minutes of moderate activity 5 times per week or 75 minutes of intense physical activity per week. If you need people to help motivate you, many fitness studios and yoga classes are offering online streaming so that you can continue your group fitness class from the comfort and safety of your home. 

Do that project you’ve been putting off

Let’s face it: with the lack of commute to work and social events, most of us have more time on our hands than we’re used to. Especially for people who are feeling well and suffering from “cabin fever,” try to think of this time as an opportunity. We all have things we’ve been meaning to do when we get more time: clean out our closet, make a scrapbook, learn a language. Now is the time to work on these items. 2020 will be forever remembered as the year of coronavirus in history, but in your personal story it can also be the year you began something new. In my case, I’m working on improving my Gujarati skills to pass on the language of my parents to my newborn child.

Language and communication are the essence of what makes us different from every other animal species. While social distancing is the best public health strategy right now, social isolation runs counter to human nature. Perhaps that is why isolation is a risk factor for depression, anxiety, poor cognition, physical illness, and even premature death. I have family in 4 different states, and we’ve implemented a FamilyFaceTime on Saturdays at 12pm. It really is different (and better) to get dressed and look at one another in real-time. For many younger people reading this, a video-chat may feel intrusive in today’s text message-oriented culture, but remember, if they are a human on this planet, your friends and family are likely at home with more time on their hands too. While you’re at it, consider reaching out to people you care for but have lost touch with. Reconsider strained and estranged relationships in favor of burying the hatchet. Calamities like this one risk isolation and despair, but they are also an opportunity for mutual understanding and coming together.  

Extra time can make anyone stir crazy, but it is also an opportunity to consider what you want out of life. Introspection requires us to pause and think about who we are, what we believe in, and what we want out of life. Mindfulness and meditation using apps like Headspace and Calm can help with focusing our minds in the present moment. For people who find such exercises challenging, this reflection could take the form of journaling about where you are in your life and where you want to go. Finally, for people who have been considering it, now is an excellent time to start therapy - just be sure to find a provider using telehealth. 

College is a time of exploration, growth, and development. It has its own ups and downs. In that context, freshmen who were just getting their feet wet and seniors wrapping up their final semester (and everyone in between) have all been asked to halt everything, return home, and try to take their courses online. Naturally, much of the magic of college occurs in conversations, group meetings, clubs and extracurriculars, and class discussion. Feeling sad, disappointed, and even angry are all normal emotions to have during this time. If you are feeling particularly out of sorts, reach out to your college counseling center. They are likely still functioning (albeit online), and they can help you figure out the best way to get through this situation. 

Wherever you are, I hope these tips help you as we prepare for weeks and maybe even months of social distancing, lockdowns, and more time at home. Take care of yourself. Look after others. And above all, stay safe. 

Ravi N. Shah (@RaviShahMD) is assistant professor of psychiatry at Columbia University Irving Medical Center and Co-Founder of Mantra Health. 

Tips from a Psychiatrist on Coping at Home During Coronavirus

The stay-at-home restrictions and social distancing necessitated by COVID-19 have had sudden ripple effects on mental health services for everyone who counts on these supports and treatments. 

College students have faced their own unique effects, as campuses have emptied requiring students to relocate to their respective homes. Although psychological treatment is included amongst essential services, social-distancing has created a widespread prohibition on in-person therapy. An added wrinkle for out-of-state students who’ve been mandated to leave college housing is that their therapist is most likely not licensed in the students’ home states (not to mention the situation faced by international students returning to their home countries).

Dealing with uncertainty is the core underlying theme of stress and anxiety. Hence, the quick switch to all online classes, its effects on graded assignments, and trying to figure out where and when to study without distraction in the home that now serves as a makeshift, all-in-one school and workplace all produce a state of flux. Not the least of these issues is questions about how to reconnect with or find a therapist for remote treatment – or if this is even possible.

A first proactive coping step is to identify the specific questions you are facing and take stock of your automatic thoughts about them – “What am I going to do about therapy?” Such rhetorical questions are usually veiled negative thoughts – “I’m not going to be able to have therapy sessions.” For a different approach, the next step is to consider actual information – what you know and what you do not know (yet) – and decide on a course of action. In the case of this sort of rhetorical question – “What am I going to do about [fill-in-the-blank]” – the task is constructing a literal answer to it and a realistic, attainable action plan. 

So, let’s focus on what we know about how to access therapy services during the COVID restrictions.

1) First and foremost, remember that psychological emergencies, such as suicidal thoughts, plans, and intentions warrant a trip to or at least contact with a hospital emergency department, urgent care center, or crisis response center, which are still open and accessible. Calling 911 for emergency response is also still the correct response to an imminent risk to one’s life due to suicidal thoughts and actions. Other resources include: 1-800-273-TALK (8255) / https://suicidepreventionlifeline.org (online chat available) / via Twitter @800273TALK

2) Don’t assume that your college counseling services are not available, as many institutions have transferred all of their services to telehealth. Reach out to your therapist and the college counseling center for information about how they are handling established (or new) clients, including out-of-state students.

3) Even before COVID-19, increasing numbers of therapists were using remote video platforms that allow for secure video-therapy sessions. With remote sessions now mandated, even therapists who might have been skeptical are utilizing such options. There has also been a loosening of privacy regulations to allow the use of some popular video platforms for remote sessions, such as Skype and Facetime, to meet the current need for accessibility to services during the emergency.

4) With the stay-at-home mandate, though, you will not have the same privacy of your therapist’s office, as household members are ever-present. The video-therapy platforms mentioned above are accessible by computer, tablet, and smartphone, which allow for portability. If you are open about your sessions with family, you can coordinate sufficient privacy for sessions; otherwise, it will require creativity, such as going outside for a walk, or driving your car and parking somewhere for a session on your phone, or other ideas for safeguarding your privacy that adhere to social distancing standards.

5) Many students live in different home states from where they attend college. Thus, a remote session would be with a now-out-of-state college therapist, which typically violates state licensing laws for the practice of psychology. However, many states have modified these licensing restrictions to address the need for continued, remote psychological services with established clients during the COVID-19 emergency. Although your therapist will be kept abreast of any new changes, you can check The Association of State and Provincial Psychology Boards for daily updates of states’ interjurisdictional remote practice status for COVID-19. See updates at:  https://www.asppb.net/page/covid19

6) Difficulties refilling psychiatric medication prescriptions is another issue that runs up against cross-state practice issues. As with therapy, reach out to your prescriber to collaboratively work out a solution. A complicating factor is that some classes of medications have specific restrictions in being prescribed through telehealth, most notably stimulants for ADHD. In some cases, out-of-state physicians have remotely consulted with students’ home-state primary care physicians to take over specific prescriptions until a return to treatment-as-usual.

7) Money is a common stressor that will span pre- and post-COVID life. Most insurance companies will reimburse for remote sessions during COVID-19 restrictions, even if they had not previously done so. Some are even waiving co-pays during this time and permitting coverage for a 90-day supply of medications. However, you cannot talk about insurance coverage without the time-worn but necessary caveat – contact your carrier as to how it is handling services and reimbursement during COVID.

One of the goals of psychological treatment itself is to better manage the ups-and-downs of life. Current circumstances will put these skills to the test as you reconnect with your therapist, not to mention all the sudden changes thrown at you and other students. Facing the discomfort is what advances not just resilience but anti-fragility, the newfound strength and skills gained by muddling through and getting to the other side of difficult times. 

My therapy in college was interrupted by COVID-19 and I still need it – now what?

Dr Rockland-Miller is a Clinical Advisor at Mantra Health and Director Emeritus of the Counseling Center at UMass Amherst. 

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All of us are experiencing uncertainty and worry in the face of the Coronavirus pandemic.   Social distancing, while necessary at this juncture, comes at a cost. Connection is always critical to our emotional health. Now, more than ever, it is critically important to find ways to maintain deep interpersonal connection.  As therapists, many of us are accustomed to using phone visits when patients are away or sick.   During this current public health crisis, I have learned that several of my colleagues have decided to use phone calls and messaging over conducting face-to-face, video sessions.  In this article, I outline the reasons I overcame my own internal hurdle to try telehealth, and the reason I feel video sessions are preferable to phone visits.

As clinicians, we have a responsibility to our clients to be clear in our communications, to use the clinical relationship as a vehicle for change and growth, and to never abandon our clients. In the past, when faced with a disruption in care, I always turned to phone calls. Although I am generally proficient with technology, telehealth is something that I previously resisted.   Somehow being with a client on a screen just didn’t seem right, and I feared it would not facilitate a genuine connection. In addition, until recently there were many obstacles to the use of video platforms for mental health treatment.   

Now, everything has changed. Most of these roadblocks have been, or are in the process of being, removed. High speed internet and sophisticated video platforms allow for smooth communications. Barriers to third party reimbursement are rapidly fading, and state licensure issues are being addressed. Most patients are expecting to be able to connect via video, and it’s unclear just how long in-person care will be impossible. 

So, in the context of the public health crisis we are all confronting, and wanting to safeguard the health of myself and others, I moved my clinical practice to a video platform.  To start my journey, I rapidly educated myself on the mechanics and ethics of telehealth practice. I quickly took one of the many on-line courses available around telehealth, read several guides, studied the many posts about telehealth on my primary listserv, and subscribed to a HIPAA-compliant video platform (Simple Practice).

For my clients, the transition to video seemed seamless, and I was amazed at the positive feedback I received.  Having a practice that focuses on college/university students, they are all already comfortable with video technology—using Facetime, Skype or Zoom with regularity.  Indeed, they are “digital natives.” That is, they grew up using technology as an essential component of their social and educational worlds. All report that they are finding the video sessions to be helpful, allowing an opportunity to maintain treatment and an important connection, without a loss to the clinical relationship.  They are relieved that their insurance plans have included payment for this service, so that they can continue in therapy even from afar.  Many are happy to not be going into the community where they might risk spreading or contracting the virus.

All of us have had occasion to speak with our clients by phone.  While an important resource, the video connection is so much deeper than that allowed by phone. It seems to offer real capacity to experience the presence of the other. In addition, seeing my patients in their home environment gives me a new glimpse into their lives. I can see their room, whether disheveled or neat, the way they interact with pets, and much, much more.  In this way, I now feel that telehealth offers a unique opportunity to observe and understand my patients deeply. I will be delighted to return to in-person visits, but this experience with telehealth has changed my practice forever. 

For those of you who are finally ready to make the switch (whether by choice or by necessity), here are a few key tips that helped me in my conversion to telehealth: 

Technology—get comfortable with the video platform prior to your first clinical session, perhaps doing a trial run with a friend.

Insurance - Confirm insurance eligibility, and be aware of correct coding modifiers.

Geography – If operating with a client outside of your state of licensure, confirm that your license is valid in another state.  Things are rapidly changing in this domain.

Privacy: While the government has suspended HIPAA requirements during the national emergency, I recommend you use a HIPAA compliant platform so that you can continue to use the same platform in the future. .

Be professional—even with a video call, be sure to dress professionally,  be aware of background and lighting in the room, turn off phones, etc. Some platforms like Zoom have a feature called “virtual background” that allows you to change the background to a blank screen so that clients cannot see your home. 

Confirm that your client is in a private space. If that is not possible, encourage them to use headphones so that your comments are not heard by others. 

Plan Ahead - Have a backup plan in the event that there are technical glitches.

Informed Consent - Obtain and document informed consent for telehealth.

Communicate - You must proactively tell clients about the availability of this modality.

Have fun! Just as we ask our clients to play with new concepts, try to have fun as you learn a new skill. 

Remember - This is about meeting the needs of our clients during this challenging time. For some, you may be the only helpful person that your client sees at all

A technophobe shares why you should use video visits during Coronavirus

This post is written by Kelly Carleton, MA, Clinical Operations Director at Mantra Health. She has a background in managing over $6 million in grant funded programs (e.g., federal, private, etc) to support behavioral health integration and telemental health initiatives at a large medical center. If you have questions related to the grant application process or want guidance on where to start, please contact Kelly directly to set up a free consultation call, or you can book an appointment here. 

Kelly Carleton, MA. kelly@mantrahealth.com

Grant funding can be an excellent way for higher education institutions to lift pilot projects off the ground or enhance existing programs or services. College and university health and mental health care departments may especially benefit from obtaining additional grant funding to support innovations in health care delivery, particularly in light of the recent Coronavirus-19 (COVID-19) public health emergency which has made telehealth services much more ubiquitous. 

In response to its rising popularity, grants supporting telehealth programs have increasingly become a priority topic due to the ability for telehealth to address major gaps in our healthcare system including care access, quality, and patient/provider satisfaction. The COVID-19 crisis has filtered even more funds to support telehealth and has led to deadline extensions from existing funding announcements. For example, to address health care needs during COVID-19, the Health Resources and Service Administration (HRSA) Telehealth Network and Telehealth Resource Centers Grant Programs authorized $29 million per year through 2025 and has relaxed the criteria for who qualifies as an eligible applicant. (1)

With adequate resources and support from someone experienced in the grant application process, colleges and universities can use grant funds to embark on projects that create opportunities for cutting edge and high quality care for their students.

Grant-Seeking Process: High Level Considerations

Though starting the grant application process takes substantial effort to research and plan, there is a methodological way to approach the process that helps save time and increase one’s chances of being successfully awarded funding. Below are some example questions and suggestions to consider while reviewing various funding opportunities. For more information, please contact Kelly Carleton (contact information above) or book a consultation call here, which will include a thorough review of how to prepare for grant applications.

Understand the various types of grants (e.g., federal agencies, regional and national foundations, etc) and determine what funding type best fits the aims of your project.

Does your organization fit within the eligibility criteria listed in the RFP/FOA?

When are awards announced and funds dispersed, and does this align with your budget needs for the project and fiscal year?

Are there any restrictions on how the funds can be used that are going to prevent me from carrying out project activities as desired?

The Rural Health Information Hub is a reputable go-to resource for researching telehealth-related grants with filtering options by topic, geography/state, and active/inactive funding. An exhaustive list of grants, including opportunities from NIH/NIMH, SAMHSA, HHS, and NSF, can also be found at grants.gov, with ability to add parameters such as open/close date, applicant eligibility, funding agency, and keyword search.

To facilitate the grant seeking process, we compiled a list of programs and funding sources whose priority areas align with supporting telehealth related programs at your college or university. Of note, the list below ranges from low to high intensity in respect to how much time and effort is required in the submission process. Interested applicants can book a call with our Clinical Operations Director to help analyze the available funding opportunities and what is the right fit for your project idea.

The priority areas, status, and due dates for the programs listed below are subject to change. We strongly recommend periodically checking program websites for active status grants and/or signing up for email notifications for each respective source.

If you don’t see your state below, email me (kelly@mantrahealth.com). I will research relevant grants available in your state and send it to you directly by email.

Health Resources and Service Administration (HRSA)

Telehealth Network Grant Program ($300,000 per year)

Evidence-Based Tele-Behavioral Health Network Program ($350,000 per year)

Rural Health Care Coordination Program ($250,000 per year)

Telehealth Focused Rural Health Research Center Program ($950,000 per year)

United States Department of Agriculture (USDA)

Distance Learning & Telemedicine Grants ($1,000,000 total)

Patient-Centered Outcomes Research Institute (PCORI) (award varies per FOA)

Agency for Healthcare Research and Quality (AHRQ) (award varies per FOA)

William T Grant Foundation ($600,000 total)

Aetna Foundation (~$50,000 - $100,000 total)

United Health Foundation (award amount negotiable)

Alabama Power Foundation (award varies per proposal)

Vitalyst Health Foundation ($175,000 total)

Northern Arizona Healthcare Foundation ($100,000)

California Health Care Foundation ($250,000 total)

Telligen Community Initiative Grants ($50,000 total)

Caring for Colorado Foundation ($575,000 total)

The Colorado Health Foundation (award varies per proposal)

Florida Blue Foundation ($100,000 per year)

Healthcare Georgia Foundation (~$75,000 total)

The Blowitz-Ridgeway Foundation ($30,000 total)

Baton Rouge Area Foundation (award varies per proposal)

Blue Cross Blue Shield Foundation of Louisiana ($25,000)

Maryand Department of Health (award varies per FOA, up to ~$6,000,000)

The Leonard and Helen R. Stulman Charitable Foundation ($150,000)

The Blue Cross Blue Shield of Massachusetts Foundation ($200,000 total)

Peter and Elizabeth Tower Foundation (~$50-100,000)

Michigan Health Endowment Fund ($500,000 total)

The Superior Health Foundation ($25,000 per year)

Minnesota Department of Human Services (~$2,000,000)

Saint Louis MHB (award varies per proposal)

Health Forward Foundation (award varies per cycle)

Missouri Foundation for Health (award varies per proposal)

The Nicholson Foundation ($500,000 total)

Marion E Kenworthy-Sarah Swift Foundation (~$45,000 total)

New York Community Trust (NYCT) ($200,000 total)

NYS Health Foundation (award varies per FOA, can be over $1,000,000)

The Helmsley Charitable Trust (award varies per FOA, ~$100,000)

Central New York Community Foundation ($150,000 total)

The Duke Endowment (~$150,000; 45% allocated to higher education)

Blue Cross Blue Shield Foundation of South Carolina (~$350,000)

Foundation for the Carolinas (award varies per proposal)

Rural Health Centers Program - Medical Access Plan and Project Grants (award varies per proposal)

Highmark Foundation (award varies per proposal, ~$250,000 total)

Claude Worthington Benedum Foundation (award varies per FOA)

Telehealth Grant Opportunities for Higher Education Institutions

This piece is cross posted from Columbia Business School's publication, here is a link to the original post.

As people around the globe adjust to the new world of connecting with colleagues, friends, and loved ones via video, they are also embracing the notion of receiving their healthcare online. Mental healthcare is well suited to telehealth, and an increasing number of people are availing themselves of remote mental healthcare to alleviate anxiety, depression, and other issues stemming from the coronavirus pandemic. Among the services offering remote mental healthcare is Mantra Health, co-founded by Matt Kennedy ’17. The subscription service allows people to connect via video chat with a nurse practitioner who can prescribe medication and recommend relevant lifestyle changes to help alleviate issues such as depression and anxiety. The company is also expanding its services by partnering with universities who are having trouble keeping up with the demand for mental health services, especially during the coronavirus crisis. Kennedy discusses why he believes telehealth is the wave of the future, the advantages of remote healthcare, and how to maximize your mental healthcare check-in, even if you have to do it from afar.

What pain points does telehealth alleviate in healthcare, aside from allowing patients to stay home?

Telehealth reduces wait times. It increases access. It obliterates the geographic boundaries that a provider historically had to function within (though they still must be licensed in the state in which the patient is located), which was how far a patient was willing to travel. The new geographic boundaries are state licensure laws. There’s also a major labor shortage across our country for healthcare providers, particularly behavioral health providers. Telehealth allows us to expand supply to healthcare deserts. This national crisis might put enough pressure on regulators or state licensing boards to accelerate working together so that providers don’t need to be individually licensed in every state for telehealth patients, which creates unnecessary costs in our healthcare system and limits access.

If you’re new to accessing mental healthcare remotely, what should you do to make it as good an experience as possible?

You should treat the clinical aspect of it like any other in-person appointment. Think about what you want to cover ahead of time. Have your questions prepared. To improve the experience, you also want to make sure you have a good internet connection and a private, quiet space to talk. One thing we found in our data is that most people prefer to use their laptop instead of a mobile phone for video visits because of the screen size. If you’re taking the call on your laptop or desktop, close all the other tabs on your browser and other application that may be running on your computer to improve your video quality. Chrome tends to perform best for our platform. Take advantage of being in the comfort of your own home. Make sure you choose a comfortable space with good lighting. Remember, the provider is going to make a clinical decision based on the interaction. The more authentic you are, the better care you’ll receive. The less disrupted the call is by your dog barking or by a lagging internet connection because your browser has 20 tabs running in the background, the better care you’ll receive.

Are you seeing an increase in demand since the onset of the COVID-19 pandemic? 

Yes. I can’t give specific numbers, but our patient count has doubled in the last two months. In addition, one of the universities we partner with wants to increase the clinical hours we provide for them by almost ten-fold for the next year. We are also getting increased requests from universities that are trying to plan for next year and thinking about how to build a resilient campus.

What inspired you to enter the telehealth space?

I was noticing that in the US healthcare market, a shift to digital was going to be at the forefront. People were getting more informed about where their healthcare spend was going and what they were actually buying. There was a move toward subscription healthcare products, so our initial hypothesis was a subscription digital psychiatry model. Psychiatric care is a specialty discipline where there is tremendous need for more access and improved quality. Currently, 80 percent of behavioral health prescriptions get written by primary care doctors, who don’t necessarily have specialty knowledge or interest to manage these patients well. Our idea was to connect someone with a psychiatric nurse practitioner who specialize in treating mental health conditions to deliver better care than what people would get from their primary care provider and at a lower cost than a psychiatrist.

Why expand from an individual subscription model to a higher education platform, and how does it work?

We found that young adults loved our platform and were interested in our services but were not willing to spend the monthly subscription fee. At many universities, the demand for services is so high that the waiting list could be all semester. Mental health is universally a top concern of school administrators, too. Because of this, we reoriented the business and now partner with higher education institutions. We also built a cloud-based care collaboration portal we license to universities. When universities contract with us, we are able to cut the wait time down to about a week.

Do you think the current health crisis will push the healthcare industry to permanently adopt telehealth as a main method of care?

Telehealth has a lot of excellent uses, including reducing expensive hospital visits for minor issues. I think we’re going to see tremendous adoption of telehealth over the next three to four months. We would have reached that conclusion regardless, but this is forcing the industry and new populations to rapidly adopt telehealth. This is also true of providers, who are turning to telehealth to not only continue delivering care but also maintain their revenue during the national emergency. We’re seeing several years’ worth of adoption happen in a matter of months.

Any tips for getting through this challenging time?

My co-founder, Dr. Ravi Shah, also an assistant professor of psychiatry at Columbia University Medical Center, shares some excellent advice here.

Providing Mental Wellbeing From a Distance

Looking for a telemental health partner for Fall 2020 that is specialized in Higher Ed? Book a call with our Partnerships team here or email us at partner@mantrealth.com

This blog is co-authored by Mantra Health, a telemental health and software platform company focused on serving the needs of higher education, and Epstein Becker Green, a national law firm with an expertise in the provision of health care services in higher education environments.

In early March 2020, the federal government officially declared the novel coronavirus (“COVID-19”) outbreak a national emergency (1), and the U.S. Department of Health and Human Services (“HHS”) declared the COVID-19 crisis a public health emergency under Section 319 of the Public Health Service Act. (2) These events resulted in a myriad of changes to federal laws related to telehealth, as well as many related changes at the state level. These changes have prompted an influx of questions from health care providers who are pivoting to telehealth as their sole modality for providing care. This is particularly true in the higher education setting where university and college students and staff have been evacuated to their homes or other safe environments and education continues on a remote access basis.

This blog series, published by Mantra Health and Epstein Becker Green, was initiated in response to questions from the field of higher education mental health providers who are incorporating telehealth into their settings while concurrently adjusting to support a remote campus. Mantra Health and Epstein Becker Green will be publishing a series of three posts that will cover a range of changes in federal and state laws related to the use of telehealth, including:

Blog 1: Professional licensure, state-specific definitions of telehealth, and acceptable telehealth modalities and platforms

Blog 2: Privacy and security regulations pursuant to the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”)

Blog 3: Remote prescribing and managing high risk patients

As a reminder, our first two blog posts discussed the significant changes to telehealth coverage and reimbursement rules in response to COVID-19 by the Centers for Medicare & Medicaid Services (“CMS”) (1-2) and the Office for Civil Rights (“OCR”) within the U.S. Department of Health and Human Services. (3-4) These changes have included, but are not limited to: 

Waiver of the requirement that providers have a valid license for the state(s) in which they provide care;

Expansion of the list of acceptable platforms upon which telehealth services may be provided;

Statements that penalties for HIPAA non-compliance will not be enforced, and that audits will not be conducted;  and

Suggestions regarding the locations from which providers can conduct telehealth visits, and related guidance regarding ways to maintain the privacy during such sessions.

It is important for providers to recognize that the guidance that has come from CMS is only applicable to federal healthcare programs. Such guidance may not apply to a large segment of the higher education student population, given the relatively small numbers of students receiving coverage under a federal health care program. Nevertheless, it is important to understand the federal-level guidance to the extent it can provide a roadmap for similar changes that may be occurring not only at the state level but also by private insurers. 

Moreover, the relaxation of federal and state laws stems from the COVID-19 national public health emergency and, as specifically stated by many authorities, is temporary in its nature. We cannot predict when the national public health emergency period will end or the extent to which these emergency actions will change the prior regulatory and legal framework more permanently. However, in the absence of evidence to the contrary, higher education providers should anticipate that most, if not all, regulatory and legal changes will revert back to the status quo as it existed prior to the COVID-19 emergency.

FAQs from Higher Education Providers: Telemental Health Regulatory Considerations

What are the current laws regarding prescribing across state lines? What about the prescribing of controlled substances?

Certain provisions of the federal Controlled Substances Act (as amended by the Ryan Haight Act), (5) which state that providers cannot prescribe controlled substances via telehealth unless one of several limited exceptions apply, have temporarily been relaxed by the DEA invoking the public health emergency exception to the Act (6) with the following contingencies: 

Prescriptions must be issued for a legitimate medical purpose by practitioners acting in their usual course of professional practice;

Telemedicine communications must be conducted using an audio-visual, real-time, two-way interactive communication system; and

Practitioners must be acting in accordance with applicable federal and state laws.

The above waivers are only applicable to DEA-registered practitioners acting within the United States6. Prescribing providers also must continue to be mindful of any applicable state laws that regulate the practice of remote prescribing, or prescribing more generally.

Regarding the continuity of care and the issuing of remote prescriptions, psychiatrists should identify a local pharmacy of the student’s choosing for ongoing prescriptions, and/or offer the student a 90-day supply of any medications (for students who are stable). Indeed, many insurance companies are encouraging 90-day supplies when feasible. (7) Obtaining the new pharmacy address, if applicable, should be done prior to ending the telehealth visit to avoid any delays or lapse in treatment if the student runs out of the prescribed medications. As mentioned in our first post, if the treating provider is not licensed in the state where the student is located, and if that state has not (by law, regulation, or executive action) created a professional licensure exception during the COVID-19 national public health emergency period, no therapeutic services should be provided. Instead, the student should be referred to a provider who is licensed in the state the student is located to receive prescriptions until either: 1) the student has returned to campus, 2) the provider has become licensed in that state, or 3) the professional licensure requirements in the state have been modified as necessary to allow for out-of-state providers to practice in that state during COVID-19.

Am I allowed to see new students for telehealth visits who I haven’t yet met in person?

Generally, a “practitioner-patient relationship” must have been established prior to commencing the telehealth services. Depending on the state, establishing such a relationship with a patient requires the satisfying of different criteria. (8-10) This can lead to complications for new students who are seeking mental health services through their college or university during a time when all campus services are being provided on a remote basis.

In light of COVID-19, CMS has implemented a waiver for this requirement, (11-12) but this waiver only applies to services that are otherwise reimbursable under a federal health care program. Providers must therefore be knowledgeable as to the relevant state requirements for establishing practitioner-patient relationships prior to starting therapy or medication management via telehealth for a new patient seeking mental health services. Colleges and universities can download the easy-to-use app created by Epstein Becker Green that allows users to search telehealth laws unique to each state, including the state- and profession-specific requirements for establishing practitioner-patient relationships. 

How do I establish a practitioner-patient relationship via telehealth if it is allowed in my state?

The main way to establish a practitioner-patient relationship via telehealth, while also enforcing privacy and confidentiality measures, is to deploy an identity verification protocol at the start of the telehealth session. Below are some suggestions about how to efficiently capture this information at the beginning of a telehealth session. Identity verification can be done in conjunction with identification of the student’s location for licensure regulation purposes as mentioned in our first post:

Asking the student to share two elements of PHI (e.g., their full name and DOB)

Asking the student to show a government issued ID or their student ID through the video call

 Some state laws, including Idaho, New Jersey, and West Virginia, specify that mental health professionals (e.g., psychologists, psychiatrists) must verify the identity of the patient at the start of the video-conferencing call, (13-15) and that such an identity verification process may even need to be done prior to each telehealth visit throughout the course of treatment. (16) At a time where it is especially unclear where a student is physically located, all providers should consider this a best practice consistent with the most stringent of requirements found under state law. 

What are others doing for emergency appointments and/or higher risk students?

Despite many students crossing state lines to return to their respective home states as COVID-19 has forced all college and university campuses to close, students are still under the care of the school-based provider (and that provider’s license to practice in the state where the school is located) if the student is presently in active treatment. To manage high risk patients and/or emergency appointments as they arise, the provider and the student should have a safety plan in place, an up to date emergency contact, as well as a go-to local emergency resource (e.g., local 911). The provider also should ensure that he/she has the student’s updated current address, in order to locate the nearest crisis resource for the student if needed. It may make sense to do this along with the identity verification protocol explained above.

Do I need separate malpractice insurance for telehealth?

When providing care via telehealth, all providers should ensure that their professional liability insurance covers telehealth services (17) and that such coverage applies to all states in which he/she is providing these services, to minimize potential malpractice risks. (18)  

The above information has been reported to the best of our knowledge, and with the understanding that both federal and state guidance continues to evolve rapidly. We recommend referring to relevant federal and state government websites frequently (e.g., HHS, CMS, DEA, OCR, SAMHSA) for the most current guidance. To stay up to date with the latest regulatory changes, reference Epstein Becker Green’s Coronavirus Resource Center. 

U.S. Department of Health and Human Services. Published March 13, 2020. Accessed at: https://www.phe.gov/emergency/news/healthactions/section1135/Pages/covid19-13March20.aspx

The Centers for Medicare and Medicaid Services. Published on: XXX. Accessed at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

The Office for Civil Rights, Department of Health and Human Services. Accessed at: https://www.hhs.gov/hipaa/for-professionals/special-topics/emergency-preparedness/notification-enforcement-discretion-telehealth/index.html

The Office for Civil Rights, Department of Health and Human Services. Published on March 20, 2020. Accessed at: https://www.hhs.gov/about/news/2020/03/20/ocr-issues-guidance-on-telehealth-remote-communications-following-its-notification-of-enforcement-discretion.html

Department of Justice, Drug Enforcement Administration. 21 CFR Part 1300, 1301, 1304, et al. Implementation of the Ryan Haight Online Pharmacy Consumer Protection Act of 2008. Final Rule. Published April 2009. Accessed at: https://www.deadiversion.usdoj.gov/fed_regs/rules/2009/fr0406.pdf

Department of Justice, Drug Enforcement Administration. Accessed at: https://www.deadiversion.usdoj.gov/coronavirus.html

America's Health Insurance Plans. Published March 27, 2020. Accessed at: https://www.ahip.org/health-insurance-providers-respond-to-coronavirus-covid-19/

The Florida Legislature. 2019 Code § 456.47(2)(b). Accessed at: http://www.leg.state.fl.us/statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400-0499/0456/Sections/0456.47.html

Maryland Department of Health. Code § 10.32.05.05 (last approved January 2020). Accessed at: http://mdrules.elaws.us/comar/10.32.05.05

NJ Rev Stat § 45:1-63 (last approved 2017). Accessed at: https://law.justia.com/codes/new-jersey/2017/title-45/section-45-1-63/

The Centers for Medicare & Medicaid Services. Medicare Telemedicine Health Care Provider Fact Sheet. Published on: March 17, 2020. Accessed at: https://www.cms.gov/newsroom/fact-sheets/medicare-telemedicine-health-care-provider-fact-sheet

The Centers for Medicare & Medicaid Services. Medicare Telehealth Frequently Asked Questions (FAQs). Published on: March 17, 2020. Accessed at: https://edit.cms.gov/files/document/medicare-telehealth-frequently-asked-questions-faqs-31720.pdf

Joint Idaho Psychological Association – Idaho Board of Psychologist Examiners Task Force, Guidelines for Electronic Transmission and Telepsychology in the State of Idaho (approved July 12, 2012).

Senate and General Assembly of the State of New Jersey. N.J. Stat. Ann. § 45:1-63(3)(a) (approved July 21, 2017). Accessed at: https://www.njleg.state.nj.us/2016/Bills/PL17/117_.HTM

West Virginia Legislature. W. Va. Code § 30-3-13a (approved February 2019). Accessed at: http://www.wvlegislature.gov/Bill_Status/bills_text.cfm?billdoc=hb2947%20intr.htm&yr=2019&sesstype=RS&i=2947

Commonwealth of Pennsylvania. 49 Pa. Code § 47.1 (approved September 2010). Accessed at: http://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/049/chapter47/chap47toc.html&d=reduce

American Psychiatric Association. Telepsychiatry Malpractice Issues. Accessed at: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/toolkit/telepsychiatry-malpractice-issues

The Center for Connected Health Policy. Accessed at: https://www.cchpca.org/telehealth-policy/malpractice

Telehealth Regulation (Covid Updates): Remote prescribing and managing high risk patients

This blog is co-authored by Mantra Health, a telemental health and software platform company focused on serving the needs of higher education, and Epstein Becker Green, a national law firm with an expertise in the provision of health care services in higher education environments.   

In early March 2020, the federal government officially declared the novel coronavirus (“COVID-19”) outbreak a national emergency (1), and the U.S. Department of Health and Human Services (“HHS”) declared the COVID-19 crisis a public health emergency under Section 319 of the Public Health Service Act. (2) These events resulted in a myriad of changes to federal laws related to telehealth, as well as many related changes at the state level. These changes have prompted an influx of questions from mental health care providers who are pivoting to telehealth as their sole modality for providing care. This is particularly true in the higher education setting where university and college students and staff have been evacuated to their homes or other safe environments and education continues on a remote access basis.

As mentioned in our first blog post, the Centers for Medicare & Medicaid Services (“CMS”) has made significant changes to its telehealth coverage and reimbursement rules in response to COVID-19, including but not limited to:

Waiver of the requirement that providers have a valid license for the state in which they provide care (3); and

Expansion of the list of acceptable platforms upon which telehealth services may be provided. (4)

Similarly, the Office for Civil Rights (“OCR”) within the U.S. Department of Health and Human Services (“HHS”) has issued guidance related to the application of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) rules during the COVID-19 national public health emergency time period. (5-6) Per OCR’s guidance, these changes include, but are not limited to:

Suggestions regarding the locations from which providers can conduct telehealth visits, and related guidance regarding ways to maintain the privacy during such sessions.


Some elements of HIPAA are relaxed, but do I still need to maintain some level of privacy and protection of PHI?

As college and university mental health care providers transition to virtual communications with students who utilize their services, the basic practices of privacy and security of the records (whether under HIPAA or the Family Educational Rights and Privacy Act (“FERPA”), including unauthorized access, sharing and de-identification of patient information, and data security should continue to be followed. The mitigating circumstances of the COVID-19 national public health emergency should not impact or modify those practices. Providers should continue to incorporate the basic rules of confidentiality into practice in order to avoid a potential breach of privacy. (6-7) Such rules include:

Using unique passwords for each employee accessing the telehealth platform;

Maintaining privacy during interactive audio-video and interactive audio sessions, not only in the space where the provider is located but in the space where the student is located (by reminding and encouraging students to take such precautions prior to starting sessions); 

Using lowered voices and avoiding the use of speakerphones, or recommending that students move to a reasonable distance from others when discussing PHI;

Documenting and maintaining records concerning all telehealth encounters in the electronic health record (“EHR") system;

Restricting access to student medical records to authorized members of the treatment team. 

Communication with Out-of-network Providers

In light of COVID-19, the widespread movement of students from college and university campuses to their respective remote locations may require transfers of care to local providers for certain students, especially if risk levels increase as discussed in our first post. At a minimum, continuity of care should be preserved to the extent possible under all applicable regulations, which may include sharing medical records, existing prescriptions, or other important treatment information with a local referral. As a standard practice, providers always should obtain a student’s consent to disclose information to an external, referral provider. (8) Written consent, which is standard practice, often is not feasible in a remote environment. During the COVID-19 national public health emergency, documentation of verbal consent may be sufficient, particularly as it relates to an emergent situation,9 but providers are encouraged to check applicable state consent laws to confirm how different states have shifted these requirements in light of the current situation.

Although HIPAA non-compliance penalties for using telehealth technology in good faith are not expected to be enforced during the COVID-19 national public health emergency period, (5) we can assume that HIPAA rules and requirements will resume in full force once this period is over. For example, a business associate agreement (“BAA”) is not required in light of the COVID-19 emergency for a provider’s telehealth technology of choice; yet, in anticipation of a “return to normal” with respect to HIPAA requirements, we recommend that colleges and universities consider entering into a BAA with the chosen telehealth vendor, if not already signed, to avoid operational disruption following the conclusion of the current national emergency period by ensuring a HIPAA compliant telemedicine platform for students is in place when the waiver is lifted. 

A majority of states require providers to obtain informed consent prior to starting a telemental health visit. While a number of states permit providers to maintain documentation of verbal consent, some states (for example, Idaho (10) and Delaware (11)) do require that providers obtain written consent.

On a practical level, providers should have students electronically sign consent forms prior to receiving treatment, or should establish documentation in their EHR that a conversation about informed consent took place verbally. Consider including the following elements when documenting informed consent (12) to ensure the student understands the risks and benefits of telehealth:

What are the expected benefits and risks associated with receiving care through telehealth?

What security and privacy measures will be taken during the telehealth visit?

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