Attention-grabbing articles, backed by research.

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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?

Our next and final blog post in this series will focus on changes made in the wake of the COVID-19 national public health emergency to regulations and other requirements related to remote prescribing and managing high risk patients.

The White House. Published on March 13, 2020. Accessed at: https://www.whitehouse.gov/presidential-actions/proclamation-declaring-national-emergency-concerning-novel-coronavirus-disease-covid-19-outbreak/

U.S. Department of Helath and Human Services. Published January 31, 2020. Accessed at: https://www.hhs.gov/about/news/2020/01/31/secretary-azar-declares-public-health-emergency-us-2019-novel-coronavirus.html

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

The Office for Civil Rights, Department of Health and Human Services. Accessed at: https://www.hhs.gov/sites/default/files/telehealth-faqs-508.pdf

The Office of the National Coordinator for Health Information Technology. Last updated September 19, 2018. Accessed at: https://www.healthit.gov/topic/health-information-privacy-law-and-policy

The Office for Civil Rights, Department of Health and Human Services. Published February 2020. Accessed at: https://www.hhs.gov/sites/default/files/february-2020-hipaa-and-novel-coronavirus.pdf

State of Idaho, Division of Occupational and Professional Licenses. Published on May 6, 2016. Accessed at: https://ibol.idaho.gov/ibol/cou/documents/Telehealth%20Guidelines.pdf

State of Delaware: The Official Website of the First State, Division of Professional Regulation. 9.0 Code of Ethics. Accessed at: https://regulations.delaware.gov/AdminCode/title24/3900.shtml

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

Telehealth Regulation (Covid Updates): Privacy, Security & HIPAA

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 

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:

 However, the guidance that has come from CMS is only applicable to federal health care 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. It nevertheless 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. 

Of note, 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. 

How have professional licensure requirements changed? As a provider serving a higher education institution’s student community, and/or providing telemental health services to college and university students, does this mean I can practice across state lines?

With college and university campuses shut down and curriculum moved online, most higher education students have been forced to relocate elsewhere, often to a different state than where the college or university is physically located. Yet, the students are still considered to be under the care of the institution’s student health program and the specific health care providers who are providing treatment to students. These providers remain responsible for maintaining proper clinical care, including a continuity of care, within the scope of their professional licenses. Therefore, understanding states’ professional licensure rules and requirements, and the limits that may apply to providers needing to shift to cross-state practice of their student populations, is critical. 

In the face of COVID-19, a number of states, such as Maryland (5), Mississippi (6), and Massachusetts (7), are temporarily modifying professional licensure requirements (3), allowing out-of-state licensed mental health practitioners to provide services within their states, either by temporarily waiving professional licensure requirements or by modifying such requirements so providers may expeditiously obtain temporary licenses to practice. 

On March 24, 2020, the Secretary of HHS issued a letter to all state Governors, urging all states to offer licensure modifications or waivers in response to the national public health fight against COVID-19. (8) Many states already have taken action and more are expected to follow and take similar actions.

Depending on the breadth and nature of each state’s changes, we recommend tracking not only the licensure requirements in your primary state of practice but also the state(s) in which your student patient populations are located, either permanently or temporarily, during the period of the current national public health emergency. We also recommend that certain cautionary measures be taken by providers, including:

As a best practice, all mental health providers should confirm a student’s location and a unique identifier, such as a phone number or a school-assigned email address, for the student at the beginning of each telehealth visit. If possible, the confirmation of a student’s location should be completed prior to each visit, either via email or another standard method of communication with the student.
 

For students who have remained in the state where the college or university is located, a provider may continue offering mental health services (e.g., therapy, medication management) as planned, provided the student agrees to continue receiving such services via telehealth. Providers should, as a best practice, document a student’s consent to receiving services in this manner. If a student already has been receiving mental health services by remote means, care can continue as it did previously, without any changes.


For students who are not physically present in the state where the college or university is located, a provider may continue providing mental health services as long as they hold a license in the state where the student is located or, if that state has (by law, regulation, or executive action) created a professional licensure exception during the national emergency, follow the guidelines set by such an exception to continue providing treatment. If a provider is not licensed in the state where the student is located and that state has not created a temporary exception to the state’s professional licensure requirements, the provider should not continue providing therapeutic services and, instead, should arrange to refer the student to a provider who is duly licensed in the state where the student is located during this temporary period of time.

For up to date information regarding state professional licensure changes, providers can refer to the Center for Connected Health Policy group, which is providing near-real time updates on COVID-19 policy change, as well as Epstein Becker Green’s Coronavirus Resource Center website.

What activities fall under the definition of telehealth, and does this definition differ across state lines? 

Yes, while there can be significant overlap, the term “telehealth” is not uniformly defined across individual states. Understanding unique state definitions of what constitutes “telehealth” is especially important in determining your chosen virtual care delivery method. All college and university counseling centers should check relevant state laws prior to implementing any telehealth-based technology solution. For example, while some states, including Arkansas, have rigid definitions that prohibit interactive audio (i.e., telephone calls without video),9 other states, including North Carolina, offer a more flexible approach such as using a modality that supports “telepractice, electronic therapy, distance therapy, video-conferencing”, (10) which could include asynchronous messaging or store and forward prescribing. To be safe, real-time audio and video technology is recommended whenever it is feasible. Epstein Becker Green has created an easy-to-use app that allows users to search and review telehealth laws unique to each state. (11) 

There are so many telehealth options out there. How do we choose a HIPAA-compliant platform that is accessible, while also helping providers maintain a clinical relationship similar to in-person care?

During the COVD-19 national public health emergency, HHS has issued a Notification of Enforcement Discretion for Telehealth Remote Communications During the COVID-19 Nationwide Public Health Emergency. In so doing, the Office of Civil Rights within HHS (“OCR”), the division within the agency that is tasked with the enforcement of HIPAA violations, has stated that it will exercise its enforcement discretion regarding regulatory non-compliance of HIPAA with respect to those covered providers who are, in good faith, providing telehealth services during the COVID-19 national emergency. This would apply to the provision of telehealth services used with non-public facing audio or visual communication platforms that might not otherwise be deemed to be HIPAA-compliant12. However, it is important to note the specificity of OCR’s waiver, in that the guidance recommends that providers wanting to utilize telehealth technology in good faith should choose a remote, non-public facing platform that promotes communication with patients and that is adequate to maintain the quality of diagnosing and evaluating patients, as well as ongoing treatment visits.

Selecting an interactive real-time audio-visual option is recommended by HHS, because the real-time video feature offers clinical insight into non-verbal cues that may not be accessible through messaging or real-time audio-only technology. (12) Furthermore, messaging platforms, although secure, are also more prone to privacy issues, given how easy it is to copy and paste information, as well as the fact that there is no supporting, written form of the visit content through video. 

Guidelines for the use of technology, issued by the IT departments at colleges and universities, may create further challenges for higher education providers. Some college and university partners have informed us of issues with implementing certain platforms due to complications with the primary vendor contract in place with the university. 

Our next blog post will focus on changes made to the HIPAA Rules and their implications on practice via telehealth.

U.S. Department of Health and Human Services. Published January 31, 2020. Accessed at: https://www.hhs.gov/about/news/2020/01/31/secretary-azar-declares-public-health-emergency-us-2019-novel-coronavirus.html

The Office of Governor Larry Hogan. Published on: March 16, 2020. Accessed at: https://governor.maryland.gov/2020/03/16/governor-hogan-orders-closure-of-bars-and-restaurants-announces-unprecedented-public-health-surge-to-combat-covid-19-crisis/

The Mississippi State Board of Medical Licensure. Published on: March 15, 2020. Accessed at: https://www.msbml.ms.gov/sites/default/files/news/20200324161355.pdf

Commonwealth of Massachusetts. Published on: March 17, 2020. Accessed at: https://www.mass.gov/doc/march-17-2020-registration-of-health-care-professionals-order/download

American Association of Nurse Practitioners. Published on March 25, 2020. Accessed at: https://www.aanp.org/news-feed/aanp-applauds-administration-call-to-combat-covid-19-pandemic-by-expanding-access-to-np-provided-care

AR Code 23-79-1601(7). Accessed at: https://law.justia.com/codes/arkansas/2017/title-23/subtitle-3/chapter-79/subchapter-16/section-23-79-1601-d-1/

N.C. Social Work Certification and Licensure Board. Published February 2017. Accessed at: https://www.ncswboard.org/files/Position_Stmt_on_Tech_Facil_Services_Amended_2017.2.1.pdf

Epstein Becker Green. Telemental Health Laws App. Accessed at: https://www.ebglaw.com/telemental-health-laws-app/

Telehealth Regulation (Covid Updates): Licensure, definition of telehealth and tech platforms

An old adage of psychotherapy is that as therapists, we must “meet the patient where they are at.” Right now, because of the coronavirus pandemic, students are no longer on campus, but they are online. As college counseling professionals, our delivery of behavioral health services has changed drastically as a result of social distancing requirements. In order to continue to provide care to students, providers now meet with student clients through telehealth platforms, such as videoconferencing or phone.

While our times are challenging, this is also a unique opportunity for those who have had little exposure to using telehealth in higher education counseling to begin their journey. In this article, I am excited to share what I have learned in my time providing telehealth services through HIPAA-compliant platforms for Penn State College of Medicine (PSU-COM). I hope this post will be useful in helping those who are ready to take the next steps in providing care to students using telehealth. 

Here are some suggestions as you contemplate a move to telemental health at your university counseling center.

Select your platform & keep it simple. All universities are in the same boat. Consult with your director or other higher education counseling professionals who are using various software platforms to understand your options related to costs and different features. From my own experience, Doxy.me was a great place to get my feet wet. It is free, HIPAA-compliant, and it has a virtual waiting room. Clients can sign up for an account easily and it allows you to send out a message through your email to alert the client to join the session. The Department of Health and Human Services have suspended requirements for HIPAA-compliant platforms. As long as the service is private, it is acceptable during the national emergency. Fortunately, most platforms for telemental health have been built to be very user friendly and applicable to a wide range of populations. From a practical standpoint, you only need a laptop or desktop computer with a video camera, internet, and limited computer skills. The companies who make these platforms also have customer service links and contact numbers for technical support.  

Have a back-up plan. One of the most important things I’ve learned during my telehealth practice at PSU COM is to have multiple back-up plans in the case of a technology failure, which I review explicitly with the client via email or text. Common technology failures are due to the strength of the internet connection or a problem with the computer itself, both of which are not related to the telehealth platform itself. I notice the connection issue is often related to capacity (I have too many tabs open and programs running at once, or the student is not connected to a strong wifi network). If the issue cannot be resolved, I often move to a phone session or reschedule if that is the student’s preference. 

Know your state laws & protect privacy. It is essential to know your state’s laws regarding telehealth. Given the national emergency, federal and state laws have been dramatically changed to support the use of telehealth. As a general best practice, you should have at least two security barriers to protect student PHI and visit information. I use multiple passwords and encrypt all notes in the case my laptop is misplaced or stolen. I have also found it helpful to reach out to my state board with additional questions related to telehealth practice laws or ethics. They often have helpful answers, point me to a board related document, or tell me that they have “not thought of that specific issue related to telehealth” and that guidance will be coming. 

Know the research that supports your telehealth practice. Sharing that there is sound research to support treatment via telehealth may help both new and existing student clients feel comfortable starting or making the transition to a virtual environment. For example, a recent study showed that online group counseling which employed CBT is just as effective as F2F (Weinberg & Rolnick, 2020). Additionally, a current study by a colleague of mine at Oregon State University found that online counseling through a video application was just as effective as F2F counseling in treating mild to moderate anxiety as assessed by the Beck Anxiety Inventory. Finally, the same online clients were able to achieve an equal level of connection with their counselor as their F2F counterparts, as assessed by the Therapeutic Bond Scale (Novella, 2019). 


There are recommended best practices when utilizing technology with your student clients. One seminal textbook that I would recommend is the Theory and Practice of Online Therapy by Weinber & Rolnick. It has been very helpful in my learning and growth as a telehealth practitioner. I will summarize a few best practices here:

Pay attention to the practical concerns and details of online counseling, as they make a difference. Find a video camera that you are comfortable operating, keeping video placement with the student client in mind. I do this overtly in session, so the student feels I am maintaining good eye contact. Furthermore, I let the student know that I take notes in session and elicit any concern they may have with my breaking eye contact with them. As mentioned above, it is also very important to discuss a back-up plan for what happens if the technology fails, the call is dropped, and is then resumed. Lastly and most importantly, because of a potential lack in proximity to the student client, discuss your crisis response protocols during the intake session with the student and have your emergency policy and procedure explicitly written in your counseling center’s disclosure statement. Providers should also be sure to confirm the student’s current physical location in the case of an emergency.

Have fun with the technology and play with the features. Most of my student clients at PSU COM have also seamlessly made the transition to virtual sessions. Telehealth vendors build their product to easily fit into a provider's workflow without compromising quality of care, and taking advantage of the features related to the video applications has potentiated the effectiveness of my sessions. For example, I often share links to evidence-based educational websites through my platform’s chat feature to increase my student’s resources and health knowledge. I also share my screen with my client during a session and present a video clip that highlights a concept of our work.

Be intentional in increasing your understanding and awareness of empirically validated differences between online and face to face counseling (F2F), and how it may impact your clinical practice. Interestingly, research has shown that online counseling environments increase the sense of anonymity and decrease self-control in client populations, leading individuals to be more honest, spontaneous, and open in virtual environments (Weinber & Rolnick, 2020). It may take some time to understand how the delivery of your clinical interventions translates in a virtual medium with college students.  

You may need to adjust some of your theoretical orientation to allow for the psychology of the internet. For example, if you are a dynamically oriented therapist, the concepts of transference or resistance may present differently with student clients when you are providing telehealth in a virtual environment (Weinber & Rolnick, 2020). In addition, the use of long silences as an intervention may come off as a glitch in the technology rather than the pregnant pause of an in-person session. 

I hope this short introduction to telehealth has been helpful. My aim was to provide an accurate representation of my own experience using telehealth, and further reduce perceived barriers for those who are new to using technology in their university counseling center practice. I also believe there will be continued demand for face to face counseling, but because of the current health crisis and the pace of technological innovation, the present moment is a great time to add to your clinical offerings at your institution, and give telehealth a try.  

Novella, J. K. (2019). A Comparison of Online and In-Person Counseling Using Solution-Focused Brief Therapy for College Students with Mild to Moderate Anxiety. 

Weinberg, H., & Rolnick, A. (2020). Theory and practice of online therapy.

Telehealth 101: Getting up to speed on telehealth for college counseling centers

by Kristel Carrington, Medical Director at Mantra Health

Treating depression involves a holistic approach that addresses its biological, environmental and psychological causes. Medications, when needed, are just one tool I recommend in the treatment of my depressed patients. However I also prescribe non-medication interventions that focus on building positive experiences and reducing symptoms of depression. These natural antidepressants can help to reduce risks of depression, improve current symptoms of depression, and help to prevent recurring episodes of depression. They are readily available and I enjoy helping clients think of ways to incorporate them into their lives. The supplements and lifestyle goals mentioned below have strong evidence for improving symptoms of depression.  

There are dietary supplements that have been shown to improve mood due to their ability to boost the building blocks of hormones that can be depleted in those suffering with depression. [1] Three of these supplements with the most evidence are:

5-HTP (5-hydroxytryptophan) is an important ingredient for making serotonin, a major hormone associated with depression symptoms. 

SAMe (S-adenosyl-L-methionine) is a naturally occurring compound in the body which is involved in the creation of other brain hormones hypothesized to play a role in depression.

Omega-3 Fatty acids have evidence for improving both depression and cognition in adults. Low levels of omega-3 are seen in people with clinical depression. Other than supplements, omega-3 is found in healthy fish, like salmon, and also some nuts and seeds.  

Though research on how diet directly affects depression symptoms is lacking, the food that are shown to promote better health have some things in common: less sugar, lean meats, LOTS of fruits and vegetables. [2] There is an emerging field of research regarding the gut microbiome (the bacteria that populate your gastrointestinal tract) that may offer some clarity as to how diet affects our mental health. [3] 

See our blog piece on food for more information: https://mantrahealth.com/post/developing-your-food-mantra

2. Improve your sleep hygiene: Sleep disruption is a common symptom of depression and can take the form of sleeping more or getting little to no sleep. Sleep hygiene refers to a set of behaviors that promote better sleep. Better sleep means better mood, more energy, more motivation. [4]

See blog piece on sleep habits: https://mantrahealth.com/post/by-kristel-carrington-medical-director-at-mantra-health

3. Establish a routine: There is a specific form of cognitive therapy called behavioral activation. Behavioral activation is a coping strategy designed to increase your contact with positively rewarding activities. In behavioral activation, you small and specific goals and work toward them. The key word is small. Focusing on one or two things that you want to work on. Behavioral activation helps to build a sense of mastery and accomplishment. 

4. Connect with nature: Nature can have a powerful influence on depression. Research suggest that interacting with nature can improve cognition and mood. [5] Many of us live in concrete jungles, which can make it difficult to even think about nature, so try to think about where you can reconnect with it. Remember what it’s like to see the vibrant colors, shapes, and contrasts that natural world offers. 

5. Connect with people: Depression makes the sufferer want to isolate, due to diminished energy to engage in social activities and due to feelings of guilt at the prospect of negatively affecting the moods of friends or family. We are social creatures and connecting with others in positive ways can improve mood and coping.

6. Mindfulness: Mindfulness is a practice that cultivates one’s awareness of the present moment, while calmly acknowledging and accepting one's feelings, thoughts, and bodily sensations. It is used as a therapeutic technique that helps my clients connect their inner and outer worlds, thereby enhancing awareness of their daily lives in a different, more deliberate way. Research shows that activities like yoga, deep breathing, meditation, and journaling, help to promote a mindful mental state. [6]

7. Exercise: No surprise here. Exercise is associated with a greater reduction in depression symptoms, improved cognitive function, and better sleep. Research shows that exercise can be as effective as medication for treating depression. [7] Although there are no clear guidelines regarding advice on exercise for patients with depression, evidence shows that both aerobic and anaerobic exercise has positive effects. Shoot for 120-150 minutes a week of moderate exercise.

8. Challenge negative thinking: Depression can hijack your thinking into becoming more pessimistic and negative. You may find yourself focusing only on things that went wrong instead of the things that are going right. When working with my patients, I teach them about positive affirmations and have them make a list for themselves. They are often skeptical but once doing the exercise, they are reminded of things they are proud of and feel an improved sense of self-worth. They also recognize how much they’ve lost appreciation for those good things.  

9. LAUGH: Laughter really IS medicine. Laughter is a positive sensation, and seems to be a useful and healthy way to overcome stress. [8] I encourage my clients to seek laughter from their favorite sources. I still end up laughing until my stomach hurts when I watch old episodes of Martin. 

10. Seek Inspiration: What are you passionate about? Depression makes it hard to get excited about life. Whether you find it in art, nature, people, animals, volunteering, or activism, it is important to seek and cultivate things you are passionate about. When inspired we feel a deeper appreciation for life. 

Feeling relief from depression is not the only goal. You have to discover (or reconnect with) things that give you a sense of peace. Maintaining this balance helps foster your resilience when faced with challenges. 

Varteresian et al. Natural Products and Supplements for Geriatric Depression and Cognitive Disorders: An Evaluation of the Research. Current Psychiatry Reports. 2015

Firth, Wolfgang et al.The Effects of Dietary Improvement on Symptoms of Depression and Anxiety: A Meta-Analysis of Randomized Controlled Trials. Psychosomatic Medicine. 2019

Dash et al. The gut microbiome and diet in psychiatry. Current Opinion in Psychiatry. Jan 2015

Carney et al. Cognitive Behavioral Insomnia Therapy for Those With Insomnia and Depression: A Randomized Controlled Clinical Trial. Sleep. 2017

Can Nature Walks With Psychological Tasks Improve Mood, Self-Reported Restoration, and Sustained Attention? Results From Two Experimental Field Studies

McCarney et al. Effectiveness of mindfulness-based therapies in reducing symptoms of depression: A meta-analysis. European Journal of Psychotherapy and Counseling. 

Exercise for Depression. JAMA Clinical Evidence Synopsis.2014

Therapeutic Benefits of Laughter in Mental Health: A Theoretical Review

You already know that a healthy diet has been shown to improve physical health, reducing the risk of heart disease, diabetes, and other common chronic conditions. Now, scientific research is increasingly showing the importance of a balanced diet for a balanced mind. It turns out you really are what you eat: diet can affect your emotions, focus, and mood. 

The Mediterranean diet has been shown to promote a healthy heart as well as a healthy mind. While there is no single definition of the Mediterranean diet, it tends to have the following characteristics, per the Mayo Clinic:

Daily consumption of vegetables, fruits, whole grains and healthy fats

Weekly intake of fish, poultry, beans and eggs

High-quality scientific research is emerging demonstrating the Mediterranean diet's benefits on mental health. This makes sense. Your brain uses a lot of energy and needs the right fuel, including nutrients, vitamins and the right fats. BDNF, an important molecule that influences the growth of brain cells, has been shown to increase in response to better nutrition.

The HELFIMED trial was a randomized control trial that compared patients eating a Mediterranean diet and taking fish oil compared to people who were not. The study demonstrated that people eating the Mediterranean diet had significant improvement in their depression scores. Another study, the SMILES study, also showed that patients on a Mediterranean diet were more likely to achieve remission in their depressive symptoms. Not only that, these patients also saved money on phone by eating the healthier Mediterranean diet. Psychiatrist Drew Ramsey, author of Eat Complete: The 21 Nutrients That Fuel Brainpower, Boost Weight Loss, and Transform Your Health and The Happiness Diet is an expert on nutrition and mental health. He identifies several important nutrients for brain health, including: Omega-3 Fatty acids, zinc, vitamin B12, magnesium, folate, fiber and probiotics, vitamin E, vitamin K, vitamin A, carotenoids, phytonutrients, monounsaturated fats, vitamin D, selenium, iron, thiamine, choline, calcium, potassium, iodine, and vitamin C.

“If it came from a plant, eat it; If it was made in a plant, don’t.” - Michael Pollan

The amount of nutritional information out there can be overwhelming. Here are some practical tips to help get you started on your very own happiness diet. Start with implementing one habit at a time and once you’ve mastered it, try the next one.

1. End your weekend with a “Smart Prep”

Schedule time at the end of your weekend to prepare meals for the week. You don’t have to prep for every meal, or even every day. Having a couple of healthy meals ready for the upcoming week will make it easier to eat well during a busy week. Keep things simple by chopping vegetables that you can easily store, or pre-cooking your favorite protein and grains (brown rice or quinoa) to store in the fridge.

Trips to the vending machine have costs on your wallet, but the costs to your health are even greater. Pack easy-to-eat vegetables (carrots, celery), fruits (apples, oranges) and nuts that you can eat during the day. Other healthy alternatives include trail mix and hummus. Having some healthy snacks throughout the course of the day will also help you avoid overeating when it’s time for lunch and dinner. 

It’s easy to feel overwhelmed by the number of recipes out there and numerous ingredients. Try to keep it simple with just 3 ingredient  meals. For example, you can combine one protein, one vegetable and one grain. Or you can combine 2 vegetables and grain. You get the idea. 

When you are extremely busy at work, school, or home, it’s easy to forget to drink water. But not drinking enough water is a huge mistake. Your brain needs ample water to carry out its functions effectively (like the rest of our body, our brain is mainly water). Dehydration can impair your ability to focus and zap your energy levels. Finally, drinking water can help stave off hunger and unnecessary snacking. Try carrying a water bottle with you when you are at work. If you find that you don’t have time to refill your water bottle during the day, get a BIG (32oz+) water bottle to ensure you stay well-hydrated all day. During the winter, switch the water for hot tea to keep you warm. 

Nutrient-rich vegetables are an easy way to add nutrition to a dish. For example, if you’re eating mac and cheese, try adding some Kale to it in order to add some nutrients to what would otherwise be a fairly nutrient-deficient meal. In fact, psychiatrist Drew Ramsey wrote an entire book on Kale and ways to incorporate it into your diet. But it doesn’t have to be kale, try adding spinach to smoothies, cauliflower to your tacos, etc. 

Bonus Tip -  Embrace the crock pot (or Instant Pot®)

Once you find food and recipes that you love, try cooking in larger quantities. Use a slow cooker (or a fancy all-in-one pressure cooker, like an Instant Pot), to cook large quantities of delicious, healthy food without having to be in the kitchen for hours at a time. There are numerous cookbooks that can help you find simple recipes - it’s easy (and fun) to experiment. 

Parked Thoughts

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Telehealth 101: Getting up to speed on telehealth for college counseling centers

Our top 10 natural antidepressants

Developing your food Mantra