NFAR Foundation Manual

www.nfarattc.org

Foundation

Te l e h e a l t h Te c h n o l o g i e s Training of Trainers

Telehealth

Telehealth Technologies Training of Trainers Foundation www.nfarattc.org July 2013

This publication was made possible by Grant Number TI024TT9 from SAMHSA. The views and opinions contained in the publication do not necessarily reflect those of SAMHSA or the U.S. Department of Health and Human Services, and should not be constructed as such.

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Introduction The overall goal of the National Frontier and Rural Addiction Technology Transfer Center (NFAR ATTC), located at the University of Nevada, Reno’s (UNR) Center for the Application of Substance Abuse Technologies (CASAT), is to develop and strengthen the national addiction treatment and recovery workforce, especially those providing services in frontier/rural areas, by increasing use and competency with telehealth technologies. NFAR ATTC will accomplish this goal by serving as the national subject expert on delivering addiction treatment services in frontier/remote areas using telehealth technologies, and developing a website and other products to increase access to resources for counselors, clinical supervisors, administrators, and recovery community.

The use of telehealth technologies is important, especially for individuals residing in frontier/rural areas.

Although residents in these areas may have similar prevalence rates of drug/alcohol dependence as their urban colleagues, their mortality rates and risks for suicide are higher and in general their alcohol/drug problems are more severe. The most significant issue facing individuals with substance use disorders (SUDs) in frontier/rural areas is access to treatment/recovery services.

By utilizing innovative technology transfer strategies to promote awareness, use, and implementation of telehealth technologies, NFAR ATTC is developing a sequence of training/TA events for counselors, clinical supervisors, administrators, and recovery specialists to improve and expand access to frontier/rural treatment and recovery services. This series of trainings is the first of many designed for the purpose of expanding access and enhancing substance abuse treatment services for individuals living in frontier and rural areas of the United States.

Additional information on training opportunities and updated resources can be found on the NFAR ATTC website (www.nfarattc.org). Thank you for your interest and participation in this training event.

National Frontier and Rural Addiction Technology Transfer Center - www.nfarattc.org

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Slide 1.1 Note to Trainer Share the following information with the training participants in the order that works best for your presentation style.

• Welcome participants to the training • Introduce yourself • Tell participants that this training is being sponsored by the National Frontier and Rural Addiction Technology Transfer Center (NFAR ATTC). Information about NFAR ATTC is contained on the next slide.

Slide 1.2 The National Frontier and Rural Addiction Technology Transfer Center (NFAR ATTC) focuses on frontier and rural issues related to addiction treatment and recovery services, and serves as the national subject expert and key resource to • PROMOTE the awareness and implementation of telehealth technologies to expand the delivery of addiction treatment and recover services in frontier/rural areas; • PREPARE pre-service addiction treatment and allied health students on using telehealth technologies by developing and disseminating academic curricula for infusion into existing courses; • Create addiction treatment telehealth competencies and develop policy recommendations for national license portability, to encourage the addiction treatment and recovery workforce to ADOPT the use of telehealth services; and • Use state-of-the-art culturally-relevant training and technical assistance activities to help the frontier/rural addiction treatment and recovery workforce IMPLEMENT telehealth services.

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Slide 1.3 Note to Trainer • Insert the agenda for the current training on this slide • Review with training participants • Share any housekeeping/logistics information

Slide 1.4 This is the tagline for NFAR and reflects the message for all of our curricula (e.g., telehealth technologies will be essential to the delivery of addiction treatment and recovery services in the 21st century). The following quote reflects this emphasis…

“Information technology must play a central role in the redesign of the health care system if a substantial improvement in quality is to be achieved” (Institute of Medicine, 2001, p. 16).

Dr. Jay Shore, a psychiatrist that uses videoconferencing to provide treatment services and conducts research with American Indian Veterans, made the following statement: “Telehealth is not about technology – but serves as a bridge, reaching out to clients so services that support behavior change are available.”

Although this curriculum discusses many technologies and devices, the message remains that telehealth technologies function as mechanisms that promote more individuals receiving services and improve care.

Sources Institute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www. iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

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Slide 1.5 These are the topics that will be discussed during this training. Review this slide with participants.

Slide 1.6 • In order to understand the need for and benefit of providing treatment and recovery services using telehealth technology, it is important to gain a sense of the challenges specific to frontier/rural areas. • The first part of this section presents data specific to frontier/rural issues related to accessing treatment services. The discussion then turns to the definition of telehealth, historical perspective, and current state of telehealth services.

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Slide 1.7 • Frontier/rural areas are characterized by small population centers that cannot support the type of healthcare services available in more densely populated centers, including SUDs treatment.

• Furthermore, in designating HPSAs the frontier definition specifies that ‘the time and/or distance to primary care is excessive for residents’, which includes lack of consistently accessible roads to a healthcare access point.

• This means that patients may have to drive over 60 minutes one way to receive treatment services, and with little or no public transportation in these areas, attending treatment is difficult if not impossible, especially if clients have to take time off from work.

• A significant frontier/rural workforce issue is how to expand availability and access to addiction treatment/ recovery providers.

Sources National Rural Health Association. (2008). National Rural Health Association Policy Brief: Designation of Frontier Health Professional Shortage Areas, G.A. Office, Editor: Washington, DC. USDA. Frontier and Remote Area Codes. 2000; Available from: http://www.ers.usda.gov/data/frontierandremoteareas/documentation.htm.

Slide 1.8 • Roughly one quarter of the U.S. population (62 million people) lives in frontier/rural areas that make up 75% of the country’s land mass.

• Estimates suggest that 16-20% (15 million) of those individuals experience substance dependence, mental illness, or co-morbid conditions.

• However, SUDs treatment/recovery services, while available in urban areas, are more difficult to find in remote areas.

Source National Rural Health Association. (2008). Workforce Series: Rural Behavioral Health, G.A. Office, Editor: Washington, DC.

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Slide 1.9 Although individuals residing in frontier/rural areas may have similar prevalence rates of drug/alcohol dependence as their urban colleagues, their mortality rates and risks for suicide are higher and in general their alcohol/drug problems more severe.

Some experts believe this is due to individuals residing in frontier/rural areas delaying treatment due to access issues so the problems worsen over time.

Sources Baca, C.T., Alverson, D.C., Manuel, J.K., & Blackwell, G.L. (2007). Telecounseling in rural areas for alcohol problems. Alcoholism Treatment Quarterly, 25(4), 31–45.

Goldsmith, S.K., Pellmar, T.C., Kleinman, A.M., & Bunney, W.E. (2002). Reducing suicide: A national imperative. Center for Rural Affairs.

Washington, DC: National Academy Press.

Slide 1.10 There are unique barriers regarding substance abuse treatment in rural locations that are not present in metropolitan areas, including economic, workforce shortages, environmental considerations, cultural norms, and personal perceptions. Even when substance abuse treatment services are available in rural and remote areas, residents attend less due to the stigma associated with receiving treatment services.

Sources Finfgeld-Connett, D. & Madsen, R. (2008). Web based treatment of alcohol problems among rural women: Results of a randomized pilot investigation. Journal of Psychosocial Nursing and Mental Health Services, 46(9), 46-53.

Oser, C.B., Harp, K.L.H., O’Connell, D.J., Martin, S.S., & Leukefeld, C.G. (2012). Correlates of participation in peer recovery support groups as well as voluntary and mandated substance abuse treatment among rural and urban probationers. Journal of Substance Abuse Treatment, 42(1), 95-101.

(Also see: Conger, 1997; Clark et al., 1999; Fisher, et al., 1997; Leukefeld et al., 2002; Leukefeld, McDonald, Staton, & Mateyoke-Scrivner, 2004; Warner & Leukefeld, 2001).

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Slide 1.11 • There is a perception of less privacy in frontier/rural areas than in urban areas.

• Women who misuse alcohol in rural areas are more highly stigmatized than men.

• The stigma associated with addiction and getting help for addiction may deter women from seeking treatment services even when treatment is available.

• In addition, this reluctance to access those services may be due to community norms that support more ‘male-oriented’ mindsets regarding addiction or alcoholism being a condition primarily affecting men.

Sources Finfgeld, D. (2002). Alcohol Treatment for Women in Rural Areas. Journal of the American Psychiatric Nurses Association, 8(2), 37-43.

Finfgeld-Connett, D. & Madsen, R. (2008). Web based treatment of alcohol problems among rural women: Results of a randomized pilot investigation. Journal of Psychosocial Nursing and Mental Health Services, 46(9), 46-53.

Slide 1.12 • A 2009 workforce study reported that there were over 350,000 mental health professionals practicing in the U.S. (HRSA’s definition of mental health professionals includes: Psychiatric Advanced Practitioner of Nursing; Psychiatrist, Psychologists, Licensed Clinical Social Workers; Licensed Professional Counselors; and Marriage and Family Therapists). Addiction counselors are not considered mental health professionals according to HRSA. • The lowest concentration of mental health professionals was found in frontier/rural areas, especially those counties with less than 10,000 people.

Trainer Note At the end of this slide you may want to make a summary statement about frontier/rural areas regarding workforce shortages, prevalence and severity of substance use disorders, and lack of access. In addition, stigma regarding having an addiction or mental health disorder is exacerbated in frontier/rural areas which serves as a barrier to entering treatment services.

Sources Ellis, A.R. et al. (2009). County-level estimates of mental health professional supply in the United States. Psychiatric Services, 6(10), p. 13151322.

Human Resources and Services Administration (HRSA). (2011). Health professional shortage area (HPSA) NHSC fulfillment of mental health care HPSA needs summary.

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Slide 1.13 • To expand access to addiction treatment/recovery treatment, the substance abuse treatment field needs to follow the current trend in medical care by using telehealth technology to deliver services.

• Telehealth provides an excellent vehicle for expanding access to and availability of treatment services in frontier/rural areas.

• Telehealth refers to ‘the use of telecommunications and information technologies to provide access to health information and services across a geographical distance’ • Telemedicine refers to ‘the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status’ Note to Trainer Emphasize the importance of knowing the distinction between the two definitions. Most definitions are in agreement that telehealth is the more expansive of the two.

• Telemedicine refers to the use of medical information and actual medical treatment • Telehealth is more broad and includes educational activities and health information, not just treatment - that is why NFAR uses the term telehealth.

Source Institute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www. iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx

Slide 1.14 • Telemedicine, telehealth, and telemental health each have strong literature support and treatment outcomes, with most studies showing that using these methods produces outcomes as good as in-person treatment strategies.

• Telehealth includes two types of communication methods • Synchronous (videoconferencing; telephone counseling; chat) • Asynchronous (email; web-based programs) • Synchronous refers to communication that is happening ‘live’ or in the moment, while Asynchronous refers to communication that is delayed (e.g., a counselor sends an email message to client through a HIPAA compliant portal and the client may log-in to the portal and retrieve the counselor’s message at a later time).

• Some telehealth technologies do include synchronous and asynchronous features to communicate with clients.

For example, a web-based recovery support telehealth technology utilizing a web-based portal may allow a client to send an email to their counselor, as well as participate in videoconferencing sessions.

Source Institute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www. iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx.

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Slide 1.15 Telehealth is not a new idea and in fact shortly after the telephone’s creation, professionals were suggesting how it could be used to help deliver medical services. For example, the telephone was created in 1876. Three years later (1879), an article in the Lancet (one of the world’s leading independent general medical journals) talked about physicians using the telephone to reduce unnecessary office visits (IOM, 2012, p11).

The first study published regarding telehealth using videoconferencing shows up in the literature in 1961 with the second study in 1972 (Wittson et al., 1961; Wittson & Benschoter, 1972) as discussed by Backhaus et al. (2012).

Sources Aronson, H. (1977). The Lancet on the Telephone 1876-1975. Medical History, 21, 69-87.

Backhaus, A., Agha, Z., Maglione, M.L., Repp, A., Ross, B., Zuest, D., & Rice-Thorp, N.M., Lohr, J., & Thorp, S.R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, Special Issue: Telehealth, Telepsychology, and Technology, 9(2), 111-131.

Institute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www. iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx.

Wittson, C. L., Affleck, D. C., & Johnson, V. (1961). Two-way television in group therapy. Mental Hospital, 12, 22–23.

Wittson, C. L. & Benschoter, R. (1972). Two-way television: Helping the medical center reach out. American Journal of Psychiatry, 129, 624–627.

Slide 1.16 • Annually, 10 million patients receive telemedicine services. Telemedicine is so absorbed into healthcare networks that in many cases, patients do not even know that telemedicine is being used.

• For example, the Internet, telephone, and computer ‘clouds’ have long been used to transmit patient x-rays, CTs, and MRIs from one location to another in order to share studies with other radiologists and physicians. Teleradiology improves patient care and reduces costs by providing medical services without the patient and physician needing to be in the same location.

Source Institute of Medicine. (2012). The role of telehealth in an evolving health care environment: Workshop summary (pp. 17-29). Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx

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Slide 1.17 Mental health care is a major reason for implementing telehealth. The Veteran’s Administration (VA) is one of the largest providers of telemental health services.

• In FY2011, 146 hospitals provided 55,000 patients in 531 community-based outpatient clinics with 140,000 telemental health visits.

• Home telemental health programs provided care to more than 6,700 patients for conditions such as depression and posttraumatic stress disorder.

• A review of roughly 98,600 patients who received clinic-based telemental health care between 2006 and 2010 showed a 25% reduction in hospitalization.

• A review of 1,041 mental health patients before and after enrollment in home telemental health services by the VA in 2011 showed a 30% reduction in admissions in their first 6 months of care as compared to a similar period of time before enrollment.

Source Darkins, A., Ryan, P., Kobb, R., Foster, L., Edmonson, E., Wakefield, B., & Lancaster, A.E. (2008). Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemedicine and e-Health, 14(10), 1118-1126.

Institute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www. iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx.

Slide 1.18 • The Indian Health System provides a comprehensive health service delivery system for 2 million American Indians and Alaska Natives, serving members of 566 federally recognized tribes.

• This is accomplished through a network of hospitals, clinics, and health stations managed by the Indian Health Service (IHS), tribes, or urban Indian health programs.

• In the early 1970s, a mobile telemedicine service through the “Space Technology Applied to Rural Papago Advanced Health Care” (STARPAHC) project was initiated.

• The Alaska Federal Health Care Access Network (AFHCAN) utilizes telehealth technologies.

• The IHS Telenutrition Program began providing nationwide individual and group medical nutrition therapy (MNT) and other nutrition services through videoconferencing to IHS and tribal facilities in November of 2006.

Source Institute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www. iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx Bloch, C. (2012). Update on Indian Health News. Retrieved from http://telemedicinenews.blogspot.com/2012/10/update-on-indian-health-activities.html.

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Slide 1.19 The literature consistently demonstrates that diffusion of an innovation is a slow process and success varies.

• For example, it took farmers 13 years to adopt hybrid corn seed and then another 7 years to use it exclusively (Ryan & Gross, 1943).

• Or, how it takes on average of 17 years to translate medical research findings in to clinical practice (Balas & Boren, 2000).

• The lag time in adopting an innovation is consistent from public health and medicine to marketing and communications.

• Unfortunately, as we look at the literature the addiction treatment field is lagging behind in the use of telehealth services, with few published works on the use of telehealth to provide or enhance substance abuse services in rural areas (Benavides et al., 2013).

Sources Balas, E.A. & Boren, S.A. (2000). Managing clinical knowledge for health care improvement. In Yearbook of medical informatics, 65-70.

Bethesda, MD: National Library of Medicine.

Benavides-Vaello, S., Strode, A., & Sheeran, B.C. (2013). Using technology in the delivery of mental health and substance use treatment in rural communities: A review. Journal of Behavioural Health Services Research, 40(1), 111-120.

Ryan, B. & Gross, N. C. (1943). The diffusion of hybrid seed corn in two Iowa communities. Rural Sociology, 8, 15-24.

Slide 1.20 • A 2009 study conducted by the National Association of State Alcohol and Drug Abuse Directors, Inc. (NASADAD) was the idea of an employee of the Colorado Division of Behavioral Health, Mary McCann, who at the time was the National Treatment Network Vice President. The purpose of the study was to survey her colleagues to determine the level of penetration of telehealth technology in State mental health and substance abuse treatment programs.

• Substance use disorder or mental health treatment providers in 37 states responded to the email survey.

• Reported offering web-enabled admin/management tools; videoconferencing; telephone and preventative webbased interventions.

Source National Association of State Alcohol/Drug Abuse Directors, Inc. (NASADAD). (2009). Telehealth in State Substance Use Disorder (SUD) Services. Washington, D.C.

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Slide 1.21 The next section provides data and information on the current use of technology among the general public.

Note to Trainer Training participants may make comments about this picture, so here are the answers: yes, it’s an old Selectric typewriter, an old fan, and a tin can. It’s a picture from a video that NFAR staff produced and it can be viewed at the NFAR website: www.nfarattc.org.

Slide 1.22 According to a report published by the Pew Research Center, 85% of American adults have cell phones & 53% of the population in the US have smart phones.

Note to Trainer Pew Research Center is a nonpartisan think tank that informs the public about the issues, attitudes and trends shaping America and the world. It conducts public opinion polling, demographic research, media content analysis and other empirical social science research. However, Pew Research does not take policy positions.

Source Fox, S. & Duggan, M. (2012). Mobile Health 2012. Pew Research Center’s Internet & American Life Project.

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Slide 1.23 80% of people send and receive text messages. These usage rates have increased over the past several years. The population that sends and receives the most text messages are adolescents and young adults. Although recently, there has been an increase in texting rates among people over the age of 50.

Source Fox, S. & Duggan, M. (2012). Mobile Health 2012. Pew Research Center’s Internet & American Life Project.

Slide 1.24 Over half of the people in the U.S. reported looking up health information on their phones and almost 20% have a health app. This is a promising data point as it demonstrates the general public’s comfort level using technology to get answers about health issues.

Source Fox, S. & Duggan, M. (2012). Mobile Health 2012. Pew Research Center’s Internet & American Life Project.

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Slide 1.25 • About 80% of Americans currently use the Internet. However, there are people who live in rural and remote areas that at times have difficulty accessing the Internet.

• Terms like the “broadband divide” mean that some people still do not have access to the Internet, which is an issue.

Source Fox, S. & Duggan, M. (2012). Mobile Health 2012. Pew Research Center’s Internet & American Life Project.

Slide 1.26 When we talk about access to the Internet, we need to look at what clients have access to. The data presented here are from a recent study that examined technology use among clients in urban drug treatment clinics in Baltimore.

• 266 patients were surveyed regarding their access to technology • 91% had access to a mobile phone (in this particular study the mobile phones were most often the prepaid/disposable type) • 79% of these particular patients did text messaging • a much smaller rate had access to the Internet, email, or a computer This is important to keep in mind when we are thinking about telehealth and how to expand access for clients.

Source McClure, E., Acquavita, Harding, E., Stitzer, M. (2012). Utilization of communication technology by patients enrolled in substance abuse treatment. Drug and Alcohol Dependence, 129(1-2), 145-50.

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Slide 1.27 There are a number of factors that serve as barriers to people accessing treatment for substance use disorders. In this next section, we will look at the prevalence of individuals meeting criteria for substance use disorders and yet do not enter treatment, and identify barriers to entering treatment and provide examples of how to address these issues.

Slide 1.28 According to the National Survey on Drug Use and Health (NSDUH, 2011), more than 20.6 million people aged 12 or over met the criteria for substance use disorders.

• 95%, or 19.2 million, did not feel they needed treatment, and • 3% felt they needed treatment but did not make an effort to get it.

This is an important issue to discuss and reflect upon as a significant number of people met the criteria for substance use disorders (almost 20 million) but didn’t feel like they needed treatment. Is this due to the stigma that still exists regarding addiction treatment; lack of access to treatment; the costs and hassles related to attending treatment, or other barriers?

Nonetheless, there are a number of factors that serve as barriers to individuals accessing treatment services.

Source Substance Abuse and Mental Health Services Agency (SAMHSA). (2011). The NSDUH Report: Alcohol treatment: Need, utilization, and barriers. Rockville, MD.

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Slide 1.29 All of the issues listed here were identified as common barriers to individuals entering treatment for mental health or SUDs according to several different studies and articles.

Using telehealth technologies to deliver treatment and recovery services may help address these barriers, especially for those living in frontier/rural areas.

Source Berwick, D., Nolan, T., & Whittington, J. (2008). The Triple Aim: Care, Health, and Cost. Health Affairs, 27(3), 759-769.

Perle, J.G., Langsam, L.C. & Nierenberg, B. (2011). Controversy clarified: An updated review of clinical psychology and telehealth. Clinical Psychology Review, 31(8), 1247-1258.

Rheuban, K.S. (2012). Planning committee remarks. In The role of telehealth in an evolving health care environment: Workshop summary (pp.

55-57). Available at http://www.iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx Swinton, J.J., Robinson, W.D., and & Bischoff, R.J. (2009). Telehealth and rural depression: Physician and patient perspectives. Families, Systems, & Health, 27(2), 172-182.

Slide 1.30 • This picture was taken in Wyoming and shows a car parked outside a doctor’s office. It illustrates one of the barriers to treatment in small frontier/rural communities where there may be only one counseling center. The assumption is that everyone in town knows your car and if you park it outside an addiction treatment center, everyone will assume that you are receiving treatment.

• This feeling of a lack of privacy, confidentiality, and that ‘everyone knows everyone’s business’ may cause individuals to be hesitant to seek treatment given the stigma still attached to having a SUD. • Using telehealth technologies may help address this barrier by allowing people to access treatment from the privacy of their homes or physician’s offices or community centers where individuals go for more than substance abuse treatment.

Source Moyer, A. & Finney, J. (2004/2005). Brief Interventions for Alcohol Problems: Factors that Facilitate Implementation. Alcohol Research and Health, 28(1), 44-50.

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Slide 1.31 Note to Trainer This question is a lead in to the next slide and will be answered by the content in the remainder of the training.

Source Perle, J.G. & Nierenberg, B. (2013). How psychological telehealth can alleviate society’s mental health burden: A literature review. Journal of Technology in Human Services, 31(1), 22-41.

Kazdin, A.E. & Blase, S.L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37.

Slide 1.32 Note to Trainer The point of this slide is to propose that the adoption of telehealth technologies may help providers reach more individuals with SUDs by giving them tools to expand access and enhance treatment services. In addition, most telehealth technologies are delivered in ways that encourage privacy and confidentiality.

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Slide 1.33 For example, the adoption of telehealth technologies by the University of Virginia helped decrease barriers to medical treatment services. This university studied their telehealth program and were able to document that patients avoided 7.2 million miles of travel due to their services being delivered via telehealth technologies.

Source Rheuban, K.S. (2012). Planning committee remarks. In The role of telehealth in an evolving health care environment: Workshop summary (pp. 55-57). Available at http://www.iom.edu/Reports/2012/TheRole-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx.

Slide 1.34 The next section of this training reviews the literature regarding the types of telehealth technologies that are being used to provide treatment and recovery services. This is a lengthy section and is based on a large literature review. All telehealth technologies presented were identified in peer-reviewed journals.

Note to Trainer While other telehealth technologies certainly exist, it is essential to the viability of this workshop that only telehealth technologies with an evidence-base be included in the presentation. It’s important to note to participants that this workshop does not promote one telehealth technology over another and that then please disclose if you have a conflict of interest regarding any of the telehealth technologies presented/discussed.

1. Ask participants of they know what type of telehealth services are being offered in their state.

2. If Internet connection is available in the training room, go to the NFAR ATTC website (www.nfarattc.org) and select an example from the “Telehealth Policies� information section.

3. Select the region/state most representative of the audience or highlight early adopters such as Florida (Region 4) or Iowa (Region 7).

4. If Internet connection is not available, prepare a slide or use the next slide as an example of state-specific information regarding Telehealth Policies available on the NFAR ATTC website.

This discussion can be used as a lead-in for the types of telehealth technologies being used to provide addiction treatment services.

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Slide 1.35 Note to Trainer As part of the participant discussion about what type of telehealth services are being offered in their state (previous slide), this slide is an example of state-specific Information regarding Telehealth Policies in Iowa. This is a screen shot from the NFAR ATTC website and it may be difficult for participant members to read the detail.

Emphasize that the information available through this resource highlights the following areas: • Recent news, pending action: example: August 26, 2010 - the Iowa Board of Medicine creates ad hoc committee to study broad range of telemedicine. The committee will study the board’s 1996 policy statement and determine what is needed to make it more relevant to the continually expanding use of telemedicine by physicians.

Source ATA. (2013). State telemedicine policy center. Retrieved fromhttp://www.americantelemed.org/get-involved/public-policy-advocacy/statetelemedicine-policy.

Slide 1.36 Even though it is becoming the ‘best new thing’ for delivering substance abuse treatment services, telehealth has been around a long time. Specifically, one research study was conducted in 1961 that described the use of videoconferencing to provide mental health treatment services in the Mid-West and one in 1972 in New England.

Source Richardson, L., Frueh, B., Grubaugh, A., Egede, L., & Elhai, J. (2009). Current Directions in Videoconferencing Tele-Mental Health. Clinical Psychology, 16(3), 323-338.

Wittson, C. L., Affleck, D. C., & Johnson, V. (1961). Two-way television in group therapy. Mental Hospital, 12, 22–23.

Wittson, C. L., & Benschoter, R. (1972). Two-way television: Helping the medical center reach out. American Journal of Psychiatry, 129, 624–627.

(See also: Frueh et al., 2000; Hilty, Liu, Marks, & Callahan, 2003; Hilty, Marks, Urness, Yellowlees, & Nesbitt, 2004; Hyler & Gangure, 2003; Monnier et al., 2003; Norman, 2006)

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Slide 1.37 • A review of the literature shows that telehealth in mental health and substance abuse treatment services is starting to expand. In this review, it is noted that the number of publications from 2000 to 2008 on telemental health tripled from the previous 30 years. The popularity of using telehealth technologies is certainly growing.

• According to Richardson and colleagues (2009) there is a need for more “empirical, rather than descriptive, articles” meaning that the majority of the articles on telehealth are case studies and descriptive in nature, with the actual number of empirical studies being limited.

Source Backhaus, A., Agha, Z., Maglione, M.L., Repp, A., Ross, B., Zuest, D., & Rice-Thorp, N.M., Lohr, J., & Thorp, S.R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, Special Issue: Telehealth, Telepsychology, and Technology, 9(2), 111-131.

Richardson, L., Frueh, B., Grubaugh, A., Egede, L., & Elhai, J. (2009). Current Directions in Videoconferencing Tele-Mental Health. Clinical Psychology, 16(3), 323-338.

Slide 1.38 • Telehealth technologies are categorized/organized in a variety of ways (e.g., telemental health; etherapy, telepsychotherapy, etc.). This is how it will be catergorized for the purpose of this presentation.

• While literature exists regarding the use of telehealth technologies for tobacco cessation and gambling treatment, those topic areas are not included in this literature review. We will only be highlighting and discussing addiction treatment and recovery services with a brief mention of telehealth technologies that provide screening and brief intervention.

• A compendium of these resources and literature regarding telehealth technologies is being developed and will be available at www.nfarattc.org.

• We will be talking about videocounseling; computer based interventions; web-screeners; web-based support groups; telephone, looking at using the telephone in continuing care and interactive voice response; smartphones; and web-portals that incorporate videocounseling and messaging using text and email.

• In addition, this presentation will touch on reimbursement issues related to these types of telehealth technologies. It is important to remember that providers may or may not get reimbursed for utilizing these telehealth technologies based on state regulations and private insurance plans, so it is important to check what is allowable in your state (e.g., it is allowable in some states if it is included as part of the treatment plan).

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Slide 1.39 Note to Trainer This is just a humorous slide and, depending on the age of the participants, they may have comments or break into song.

Say to participants….

• You may recognize this cartoon… this is Jane Jetson using videoconferencing.

• Videoconferencing is currently in use by some treatment professionals and is being accessed through HIPAA compliant portals, while others use real-time Internet-based videoconferencing technologies through personal computers and mobile devices. We will discuss this more later in the presentation.

Slide 1.40 The Department of Veterans Affairs is the leader and largest provider of telemental health services using videoconferencing and have published research articles about its efficacy. Studies have shown that videoconferencing is as good, if not better in some cases, than face-to-face counseling methods. For mental health related problems the VA delivers services using videoconferencing either at community-based clinics or through home telemental health devices. In addition, the VA has three telehealth training centers for clinicians and 98% of their trainings are web-based.

Sources Godleski, L. Nieves, J.E., Darkins, Al, & Lehman, L. (2008). VA telemental health: Suicide assessment. Behavioral Sciences and the Law, 26, 271286.

Darkins, A., Ryan, P., Kobb, R., Foster, L., Edmonson, E., Wakefield, B., & Lancaster, A.E. (2008). Care coordination/home telehealth: The systematic implementation of health informatics, home telehealth, and disease management to support the care of veteran patients with chronic conditions. Telemedicine and e-Health, 14(10), 1118-1126.

Institute of Medicine. (2012). The role of telehealth in an evolving health care environment – workshop summary. Available at http://www. iom.edu/Reports/2012/The-Role-of-Telehealth-in-an-Evolving-Health-Care-Environment.aspx.

Deen, T.L., Godleski, L., and Fortney, J.C. (2012). A description of telemental health services provided by the Veterans Health Administration in 2006-2010. Psychiatric Services,63, 1131-1133.

Godleski, L., Darkins, A., & Peters, J. (2012). Outcomes of 98,609 U.S. Department of Veterans Affairs patients enrolled in telemental health services, 2006-2010. Psychiatric Services, 63, 383-385.

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Slide 1.41 Backhaus et al. (2012) did a systematic review of 891 articles on videoconferencing of psychotherapy – • 65 were selected for inclusion and out of that, only 47 were rated as empirical studies.

• Because of the low number of empirical studies, it is hard to determine if the treatment outcome of videoconferencing is the same as face-to-face.

• Small sample sizes and lack of randomization also impact the ability to assess treatment outcomes.

• In 45% of the studies people used CBT in videoconferencing, and 60% of the patients were male.

• In studies with each of the following populations - African-Americans, Hispanic Latino and American Indians using videoconferencing psychotherapy demonstrated effectiveness.

• Studies showed strong patient and provider therapeutic alliance over videoconferencing with high levels of satisfaction.

Source Backhaus, A., Agha, Z., Maglione, M.L., Repp, A., Ross, B., Zuest, D., & Rice-Thorp, N.M., Lohr, J., & Thorp, S.R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, Special Issue: Telehealth, Telepsychology, and Technology, 9(2), 111-131.

(See also: Bouchard et al.,2000; Ghosh, McLaren, & Watson, 1997; Morgan, Patrick, Magaletta, 2008; Simpson, 2001; Cluver et al., 2005; King et al., 2009; Morgan et al., 2008; Nelson, Barnard, & Cain, 2003; Ruskin et al., 2004)

Slide 1.42 • Of the 891 articles that have been published on videoconferencing, there are only 3 that address the treatment of substance use disorders. This is an interesting finding and demonstrates researchers interest in studying telehealth technologies other than videoconferencing.

• The last article shown in the slide (Training Substance Abuse Clinicians in Motivational Interviewing Using Live Supervision via Teleconferencing) examined using teleconferencing to provide clinical supervision to counselors regarding adherence to MI. Source Backhaus, A., Agha, Z., Maglione, M.L., Repp, A., Ross, B., Zuest, D., & Rice-Thorp, N.M., Lohr, J., & Thorp, S.R. (2012). Videoconferencing psychotherapy: A systematic review. Psychological Services, Special Issue: Telehealth, Telepsychology, and Technology, 9(2), 111-131.

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Slide 1.43 This is the introduction slide for the discussion on computer based interventions.

Slide 1.44 • There is extensive literature showing the use and effectiveness of computer based interventions in other disciplines.

• Computer-delivered therapy is a computer based media that provides users with information designed to supply therapeutic treatment • Currently, there are computer based interventions that are downloaded as software on individual computers at treatment sites. However, more recently, most computer based interventions are accessed through a web portal that includes a log-in.

Treatment providers buy a licensing fee and then clients are given access to these interventions while receiving services at a treatment program. Soon this term will be subsumed and everything will be called web-based interventions using different platforms or devices (computers, mobile phone, and tablets).

• Think of it this way - right now your bank probably offers online banking. How you conduct online banking using whatever tools you have available doesn’t matter. The issue is that you can do your banking online.

Source Carroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426432.

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Slide 1.45 • There is encouraging evidence that suggests positive treatment outcomes with computer based interventions.

• The National Institute on Drug Abuse (NIDA) and the Addiction Technology Transfer Centers (ATTCs) are beginning to work on a new NIDA Blending Product focused on computer based interventions that utilize the research on Therapeutic Education System (TES). This new NIDA Blending Product is expected to be out by March 2014.

Sources Bickel, W.K., Marsch, L.A., Buchhalter, A.R., & Badger, G.J. (2008). Computerized behavior therapy for opioid-dependent patients: A randomized controlled trial. Experimental and Clinical Psychopharmacology, 16(2), 132-143.

Carroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world.

Current Psychiatry Reports, 12, 426-432.

Slide 1.46 Computer based intervention programs have been around for some time and have been used to treat a variety of physical and mental health disorders (e.g., cancer, diabetes, heart disease depression, anxiety, poor nutrition, and sexual risk behaviors) with positive outcomes (Klein, et al., 2012; Moore, et al., 2011). However, the literature for using computer based interventions to treat substance use disorders is more recent.

(See the reference section for full citations).

• Cancer - Gustafson, D. H., McTavish, F. M. et al. (2005).

• Diabetes - Glasgow, R. E., Nutting, P. A. et al. (2005); Williams, G. C., Lynch, M. et al. (2007); Montani, S., Bellazzi, R. et al. (2001).

• Heart Disease - Verheijden, M., Bakx, J. C. et al. (2004) • Mood Disorders - Farvolden, P., Denisoff, E. et al. (2005) • Depression/Anxiety - Cavanagh, K., & Shapiro, D. A. (2004); Kaltenthaler, E., Parry, G. et al. (2008); Reger, M. A. & Gahm, G. A. (2009); Spek, V., Cuijpers, P. et al. (2007) • Poor Nutrition - Portnoy, D. B., Scott-Sheldon, L. A. J. et al. (2008) • Sexual Risk Behaviors - Ybarra, M. L., & Bull, S. S. (2007); Marsch L. A. & Bickel W. K. (2004) Sources Klein, A.A. et al. (2012). Computerized continuing care support for alcohol and drug dependence: A preliminary analysis of usage and outcomes. Journal of Substance Abuse Treatment, 42, 25-34.

Marks, I.M., Cavanagh, K., & Gega, L. (2007). Computer-aided psychotherapy: Revolution or bubble? The British Journal of Psychiatry, 191(6), 471-473.

Moore, B.A., Fazzino, T., Garnet, B., Cutter, C.J., & Barry, D.T. (2011). Computer based interventions for drug use disorders: A systematic review. Journal of Substance Abuse Treatment, 40, 215-223.

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Slide 1.47 Most computer based interventions have the capability to tailor their programs to meet each clients’ specific treatment or recovery needs. This is based upon clients’ responses to educational materials included as part of the community-based intervention. For example, a client is working on a module on drug refusal skills and based upon their responses to various questions and exercises the computer program will change accordingly to provide another review or educational activity on drug refusal skills or will move the client on to the next module.

Source Moyer, A. & Finney, J. (2004/2005). Brief interventions for alcohol problems: Factors that facilitate implementation. Alcohol Research and Health, 28(1), 44-50.

Fotheringham, M., Owies, D., Leslie, E., & Owen, N. (2000). Interactive health communication in preventive medicine: Internet-based strategies in teaching and research. American Journal of Preventive Medicine, 19(2), 113-120.

Slide 1.48 • Many computer based interventions are designed to serve as an adjunct to treatment services, thereby extending the work of the clinician. For example, a computer based intervention may be used instead of a group counseling session. The client works on a module, learns about drug refusal skills and practices them through a series of learning experiences rather than attending the group session. This allows the counselor to spend their time with clients who may be dealing with other more pressing problems or issues that require their immediate attention.

• The term clinician extenders appears in journal articles authored by Lisa Marsch, Warren Bickel, and Kathy Carroll.

This is about helping counselors, not replacing them, as well as enhancing treatment services.

• The anonymity of this approach might be appealing to some individuals when dealing with substance abuse and other risk behaviors.

• These tools can have a significant public health impact by reaching frontier and rural areas, and may be used in a wide variety of settings such as: • Web-based interventions offered in the home • Community organizations • Schools • Emergency rooms, • Health care providers’ offices • Mobile devices Source Bickel, W.K., Marsch, L.A., Buchhalter, A.R., & Badger, G.J. (2008). Computerized behavior therapy for opioid-dependent patients: A randomized controlled trial. Experimental and Clinical Psychopharmacology, 16(2), 132-143.

Carroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426432.

Des Jarlais, D.C., Paone, D., Miliken, J. et al. (1999). Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: A quasi-randomised trial. Lancet, 353(9165), 1657-1661.

Marsch, L. (2011). Technology-based interventions targeting substance use disorders and related issues: An editorial. Substance Use & Misuse, 46(1), 1-3.

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Slide 1.49 Given the difficulty of being trained in every single EBP, Computer based Interventions can help save clinician time and extend their expertise. For example, most addiction treatment provides need to concurrently address clients use of nicotine while in substance abuse treatment. The following data supports that point: • There are 443,000 yearly deaths due to cigarette smoking; this number surpasses the combined death toll from alcohol, illicit drugs, guns, car accidents, and AIDS (CDC, 2008).

• Alcohol and illicit drugs contribute to approximately 100,000 deaths per year (Mokdad et al, 2004).

• Over 1 in 3 adults (36%) with mental illness smoke cigarettes, compared with around 1 in 5 adults (21%) with no mental illness. (CDC, 2013).

• 19% of total population smokes (CDC, 2012).

• Individuals with SUDs account for 4.6% of the US pop, but 8.7% of smokers (SAMSHA, 2013) Instead of training staff on how to treat nicotine dependence a computer based intervention targeting nicotine based on scientific studies could be used with clients rather than training clinicians to treat this issue as well.

Sources Carroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426432.

CDC. (2008). Smoking-Attributable Mortality, Years of Potential Life Lost, and Productivity Losses—United States, 2000–2004. MMWR, 57 (45); 1226–1228.

Mokdad, A.H., Marks, J.S., Stroup, D.F., & Gerberding, J.L. (2004). Actual causes of death in the United States, 2000. Journal of the American Medical Association, 29(10), 1238-1245.

CDC. (2013). Vital Signs: Current Cigarette Smoking Among Adults Aged ≥18 Years with Mental Illness—United States, 2009–2011. MMWR, 62(05);81–87.

CDC. (2012). Current Cigarette Smoking Among Adults—United States, 2011. MMWR, 61(44); 889–894.

Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. (March 20, 2013). The NSDUH Report: Data Spotlight: Adults with Mental Illness or Substance Use Disorder Account for 40 Percent of All Cigarettes Smoked.

Rockville, MD.

Slide 1.50 • Carroll & Rounsaville (2010) in their journal article suggested that Cognitive Behavioral Therapy (CBT) could be delivered by computer (subcontracted to the computer), which would allow providers to save clinician time while still providing clients with exposure to an evidence-based practice or approach. While this comment might have been made in a ‘tongue and cheek’ manner it is important for treatment providers to consider this idea.

• This would allow the client to spend more time practicing a particular counseling skill when the clinician may not be available.

Trainer Note We chose this picture because back in the day when computers were new and very large no one considered that one day more powerful computers could fit in the palm of your hand. The same may be true regarding the use of computer based interventions in SUD treatment.

Source Carroll, K.M. & Rounsaville, B.J. (2010). Computer-assisted therapy in psychiatry: Be brave-It’s a new world. Current Psychiatry Reports, 12, 426432.

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Slide 1.51 Here are some examples of computer based interventions.

• The first is CBT4CBT. This is based on Cognitive Behavioral Therapy research done

by Cathy Carroll and her colleagues. Two studies were conducted around 2008 and focused on working with outpatient clients using a regular CBT intervention plus six computer modules on CBT. In this particular randomized controlled trial, the group that received the CBT + 6 computer modules (intervention group) did better than those that received the typical out-patient treatment using CBT (control group).

• Research on the second intervention, Therapeutic Education System (TES), was led by Lisa Marsch and Warren Bickel. TES is based on Community Reinforcement Approach plus Contingency Management and in some cases a little bit of motivational interviewing has been added. The approach has been used as an adjunct treatment for an HIV/AIDs intervention for opioid treatment clients and has shown positive results.

• Marsch and Bickel also did outpatient opioid treatment + treatment as usual + TES with positive results and then outpatient treatment plus two hours per week of TES. The computer based intervention actually replaced about two hours a week of group counseling and again showed very positive results.

• Finally, Marsch and Bickel’s intervention, TES, is part of NIDA’s Clinical Trials Network (CTN) and researchers representing clinical trial nodes conducted a national study on TES. So far the initial results are very positive for this computer based TES intervention.

• The next research listed found that a single session of computer-delivered motivational interviewing reduced drug use among post-partum women.

These are just three examples. There is a great deal of research being conducted on computer based interventions with SUD clients. A new NIDA fund-funded P30 center on using technologies to assess and treat SUDs has been developed at Darmouth College in New Hampshire. The url address for the Center for Technology and Behavioral Health is http://www.c4tbh.org/. Overall, more rigorous clinical trials regarding testing computer-based interventions is needed but most studies are showing positive outcomes.

Slide 1.52 The question for the field is not “Do computer-assisted therapies work?”, but …

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Slide 1.53 Note to Trainer Finish the thought on the previous slide by asking participants to read the question on the slide.

We have a developing body of research demonstrating that computer based interventions work. The challenge now is to determine what kind of computer-assisted therapy and at what dose will work best for the specific population being served.

Source Kiluk, B., Sugarman, D., Nich, C., Gibbons, C., Martino, S., Rounsaville, B., & Carroll, K. (2011). A Methodological Analysis of Randomized Clinical Trials of Computer-Assisted Therapies for Psychiatric Disorders: Toward Improved Standards for an Emerging Field. American Journal of Psychiatry, 168(1), 790-799.

Slide 1.54 This slide leads into the discussion of web-based screeners. This term refers to webbased programs that the general public or a specific group of individuals (log-in required for use) can use to determine if they are participating in risky drinking or have a SUD. Many web-based screeners also include tailored feedback for the individual participating in the screen or a brief intervention. Web-based screeners have been studied extensively especially related to alcohol screening. The following slides discuss web-based screeners for adults and for college students.

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Slide 1.55 Numerous web-based screeners exist. The five listed here have the most literature support. Most of these are open for public use and help to answer questions about alcohol use, and provide feedback on responses and suggestions for next steps.

Slide 1.56 There are also web-based screeners specifically for college students. Once again the web-based screeners for college students listed here have good literature support.

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Slide 1.57 Bewick and colleagues (2008) conducted a systematic review of studies that examined the utility of web-based screeners regarding alcohol consumption. 191 articles were identified and ten met the selection criteria regarding the effectiveness of web-based screening and intervention activities (lower alcohol consumption and prevent alcohol abuse). Only one study was a randomized control trial, four used pre/post effectiveness measures, and five used process evaluation methods with these studies being more evaluative in nature. The Kypri and McAnally study is the only study that had a control and experimental design group.

Source Bewick, B.M., Trusler, K., Mulhern, B., Barkham, M., & Hill, A.J. (2008). The feasibility and effectiveness of web-based personalized feedback and social norms alcohol intervention in UK university students: A randomized control trial. Addictive Behaviors, 33(9), 1192-1198.

Slide 1.58 The important take-home message is that the most efficacious web-screeners have the capability to provide automated personalized feedback to participants. It is the personalized feedback that seems to have a positive impact on decreasing risky drinking.

Source Bewick, B.M., Trusler, K., Mulhern, B., Barkham, M., & Hill, A.J. (2008). The feasibility and effectiveness of web-based personalized feedback and social norms alcohol intervention in UK university students: A randomized control trial. Addictive Behaviors, 33(9), 1192-1198.

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Slide 1.59 This slide that introduces the section on web-based support groups.

Slide 1.60 Web-Based Support is divided into three different categories • Psychoeducational – websites/blogs/informational sites that include papers or brochures that individuals can use to collect information about their condition.

• Self-help – provides individuals with materials or structured learning experiences to use at their own pace to assist with managing their own health/condition • Mutual Support - a forum for people seeking support from others who have the same condition. This support can be provided through online meetings, chat rooms, or blogs.

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Slide 1.61 These are examples of Psychoeducational web-based support. There are many podcasts and radio programs available on the Internet or that can be downloaded from iTunes (e.g., 12 step radio; StepUp). Also, there are several free podcasts and radio programs that are recovery focused, such as AA on Air, SMART Recovery, and Recovery Support.

Slide 1.62 This is an example of a web-based self-help workbook for Obsessive Compulsive Disorder that is supported in literature as having a positive effect for participants. Webbased self-help workbooks like this one exist for a variety of conditions.

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Slide 1.63 If individuals with SUDs have access to the Internet, there are a number of opportunities available for getting support and becoming a member of a support group. Web-based support groups are a good option for individuals living in rural and remote areas to consider. Treatment programs are becoming more comfortable with this method of providing support and services. A few studies exist demonstrating the effectiveness of web-based support groups. Some examples of these groups are: Alcoholic Anonymous meetings online; Smart Recovery meetings online; Narcotics Anonymous online chat room; addictiontribe.com online recovery support community; and cyperrecovery.net forums. Often times when using web-based support groups, clients will be less inhibitive (especially in early recovery rather than later) due to the anonymity of using online technologies. It is important to remind clients about maintaining good boundaries around sharing details of their substance use experiences and issues especially in online forums and groups.

Slide 1.64 Some substance abuse treatment providers are using web-based virtual reality programs like Second Life as an adjunct to treatment and recovery services and as webbased support for their clients. To date, there has been few published studies on the use of web-based support programs that use virtual reality for individuals with SUDs. However, as the next slide shows virtual reality programs have been used as a support with other health conditions.

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Slide 1.65 These are just some examples of how virtual reality programs have been used to treat other mental health conditions.

Note to Trainer Participants may say, “Have you heard about this program or that program?” Please ask the audience member(s) for information on those programs so we can gather information to use as examples for future trainings (e.g., name of program, authors of study).

Sources Mangan, K. (2008). Virtual worlds turn therapeutic for autistic disorders. Chronicle of Higher Education, 54(18), 26.

Reger, M. A., & Gahm, G. A. (2009). A meta-analysis of the effects of Internet- and computer based cognitive–behavioral treatments for anxiety. Journal of Clinical Psychology, 65, 53−75.

Wood, D.P., Webb-Murphy, J., Center, K., McLay, R., Koffman, R., Johnston, S., Spira, J., Pyne, J.M., & Wiederhold, B.K. (2009). Combat-related post-traumatic stress disorder: A case report using virtual reality graded exposure therapy with physiological monitoring with a female Seabee. Military Medicine, 174(11), 1216-1222.

Chen, C., Jeng, M., Fung, C., Doong, J., & Chuang, T. (2009). Psychological benefits of virtual reality for patients in rehabilitation therapy. Journal of Sports Rehabilitation, 18, 258-268.

Slide 1.66 Below is the abstract describing this research: “This study examined the impact of a computer simulation designed to provide the opportunity for individuals with alcohol use disorders (AUDs) to practice relapse prevention skills. Participants were 41 male veterans enrolled in an intensive outpatient substance abuse treatment program. Participants were randomly assigned to either view educational slides about treatment for AUD or play a simulation videogame for eight sessions within 12 weeks. Participants were assessed at a 4-week follow-up visit. Outcome measures included relapse rates as well as ratings on the Obsessive Compulsive Drinking Scale (OCDS) and a custom-designed relapse prevention self efficacy scale. While rates of relapse did not differ between groups, those who played the game showed overall reductions in ratings on the OCDS, as well as higher ratings of self-efficacy at week 8, suggesting that the videogame simulation may be a useful adjunct to AUD treatment.” (Verduin et al., 2012).

While there might be other virtual reality programs or computer simulation games, this is one that has research attached to it showing that although relapse rates did not differ for those that played the simulation game and those that viewed educational slides about substance use disorders, those that played the simulation game had higher rates of self-efficacy and decreases in craving.

Source Verduin, M.L., LaRowe, S.D., Myrick, H., Cannon-Bowers, J., & Bowers, C. (2013). Computer simulation games as an adjunct for treatment in male veterans with alcohol use disorder. Journal of Substance Abuse Treatment, 44(3), 316-322.

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Slide 1.67 These are some examples of web-based disease management programs that have characteristics of all three of the web-based support activities (psychoeducational, self help, and mutual support) and are supported in the research literature showing program effectiveness, customer satisfaction, and usefulness.

• Cancer - Gustafson, D. H., McTavish, F. M., Stengle, W. et al. (2005).

• Diabetes - Glasgow, R. E., Nutting, P. A., King, D. K. et al. (2005); Williams, G. C., Lynch, M., & Glasgow, R. E. (2007); Montani, S., Bellazzi, R., Quaglini, S., & d’Annunzio, G. (2001).

• Heart Disease - Verheijden, M., Bakx, J. C., Akkermans, R. et al. (2004) • Mood Disorders - Farvolden, P., Denisoff, E., Selby, P., Bagby, R. M., & Rudy, L. (2005) • Depression/Anxiety - Cavanagh, K., & Shapiro, D. A. (2004); Kaltenthaler, E., Parry, G., Beverley, C., & Ferriter, M. (2008); Reger, M. A. & Gahm, G. A. (2009); Spek, V., Cuijpers, P., Nyklicek, I. et al. (2007) Sources Klein, A.A. et al. (2012). Computerized continuing care support for alcohol and drug dependence: A preliminary analysis of usage and outcomes. Journal of Substance Abuse Treatment, 42, 25-34.

Slide 1.68 An example of a web-based addiction program that is a recovery based disease management program is MORE (My Ongoing Recovery Experience) out of Hazelden.

As part of a continuing care plan, Hazelden offers clients 18 months free use of a Webbased program (MORE) that connects them with the tools, support, and fellowship to build a new life in recovery.

Clients have access to a Recovery Coach by phone or by using the MORE messaging system in the passcode protected web-based program. While clients work through the web-based program, Recovery Coaches monitor client evaluations and assessments and contact them if they are struggling or need support.

For additional information on this program, visit their website at http://www.hazelden.org/web/public/more_works. page Sources Klein, A.A. et al. (2012). Computerized continuing care support for alcohol and drug dependence: A preliminary analysis of usage and outcomes. Journal of Substance Abuse Treatment, 42, 25-34.

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Slide 1.69 Another example of a web-based addiction management program is e-ROSC, (Electronic Recovery Oriented System of Care), a system that connects clients to recovery coaches and is fully integrated with the organization’s electronic health record (EHR). Centerstone, the leader in e-ROSC, offers a public-facing site that includes a public calendar, links to community resources, a blog, a discussion board, and easy access for people who want to make an appointment or talk to a recovery coach or volunteer right now. Additional information on this program can be found at www.v-recover.com

Slide 1.70 The My Recovery Plan uses the My HealtheVet Personal Health Record as a vehicle to support mental health recovery. It provides Veterans a one stop online secure place to participate in exercises and treatment options specific to their own goals, treatment and recovery. My Recovery Plan has been designed to support the ongoing recovery of Veterans. My Recovery Plan will help facilitate Veterans in achieving self identified goals. It allows Veterans to:· • Create, monitor and track progress towards recovery goals • Identify, monitor, and track mental health symptoms • Track and understand changes in level of functioning and life satisfaction • Identify how medication may affect them

For more information use the 30 minute narrated online course developed for health care teams that work with Veterans with mental or behavioral health symptoms, and substance use disorders.

My HealtheVet - My Recovery Plan Orientation for Health Care Team Members: http://example.courseavenue.com/PSI/MRP/Player/launchPlayer.html?courseID=1356&courseCode=MRP-MO-HCT

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Slide 1.71 There are also other web-based telehealth technologies.

Slide 1.72 Email is another example of ways to deliver treatment services via telehealth technologies. In an article on the effectiveness of providing services online, Alemi et al. (2007) indicated that it is not the communications by Internet that matters but the content of the communications.

The results of this study focused on the management of nearly 300 clients online for recovery from substance abuse and demonstrated success with interventions, including individual counseling and participation in an electronic support group as well as developing a recovery team.

Source Alemi, F., Haack, M., Nemes, S., Aughburns, R., Sinkule, J., & Neuhauser, D. (2007). Therapeutic e-mails. Substance Abuse Treatment, Prevention and Policy, 2, 7-18.

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Slide 1.73 Yet another example of delivering treatment services via telehealth technologies is messaging and chat programs.

Slide 1.74 Operation PAR, Inc., is a leading Substance Abuse Mental health Treatment Provider in the State of Florida. It was established in 1970 from a grassroots movement and now operates as a treatment provider offering a full continuum of services from prevention to long term residential as well as medication assisted treatment services. Operation PAR serves all ages and embraces technology to reach more individuals and their family members with mental health and SUDs. Online services are provided through a HIPAA complaint web-base portal and services include: • education for client, families and loved ones, • family sessions, • discharge session with new providers, • training for clinical staff, clinical supervision, • EBP training and certification, • contingency management (client incentives), • involvement of family, and • support system for clients.

OperationPAR uses a HIPAA compliant portal that allows clients to log-in and enter into a safe and secure portal in order to: • attend group therapy using videoconferencing • email • chat with their counselors • receive other counseling services This is just one example of a treatment program that uses telehealth technologies.

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Slide 1.75 Another e-services provider is Gateway Connect, which is a sister company to Operation Par. Gateway Connect launched in October 2006 with a SAMHSA grant awarded September 2007 and has served a total of 400 clients over a 3-year period.

Platforms like Gateway Launch’s are used to meet the client where they are. For example: desktop, laptop, tablet, smart phone, text messaging, IM’ing platforms allow interaction just as if the client were in your office.

For additional information on Gateway Connect, go to http://www.gatewaycommunity.com/

Slide 1.76 To this point the presentation has focused primarily on ‘high-tech’ ways to deliver addiction treatment and recovery services. However, the role of the more common telephone cannot be minimized. The telephone is a telehealth technology and remains an important tool in many frontier/rural/remote areas as it is not impacted by the ‘broadband divide’ that can keep people from accessing the web. In this section, the telephone and a computerized intervention (Interactive Voice Response) built into a phone will be discussed.

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Slide 1.77 The telephone has been used for years to monitor and treat chronic physical and mental illnesses. There are a number of studies available showing the effectiveness of treating individuals with smoking, depression, OCD, hypertension, diabetes, and even arthritisrelated problems by using the telephone. The citations listed on the slide are only a sample of the literature available. Overall, the use of the telephone has been viewed as an equitable substitute to face-to-face counseling. Although many professionals may disagree about its suitability for treating individuals with severe mental health disorders, most crisis call centers that provide intervention services for individuals with mild to severe mental health and substance abuse conditions use the telephone. According to Reese and colleagues (2002), the use of telephone in providing treatment and continuing care services has four strong assets promoting its utility. Specifically, it is inexpensive; HIPPA compliant and provides privacy; affords the client a sense of autonomy; and convenient for the client, eliminating travel time and child care costs.

Sources Godley, M.D., Coleman-Cowger, V.H., Titus, J.C., Funk, R.R., & Orndorff, M.G. (2010). A randomized controlled trial of telephone continuing care.

Journal of Substance Abuse Treatment, 38, 74–82.

Reese, R.J., Conoley, C.W., & Brossart, D.F. (2002). Effectiveness of telephone counseling: A field-based investigation. Journal of Counseling Psychology, 49(2), 233–242.

Slide 1.78 For the addiction treatment field, the telephone has been used primarily in continuing care.

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Slide 1.79 Examples of the research literature that has been done and shown positive results for providing addiction treatment services using Telephone Continuing Care include: • The Telephone Monitoring and Adaptive Counseling developed by McKay and colleagues, which has shown good results.

• Focused Continuing Care, started by the Betty Ford Clinic.

• Telephone Enhancement of Long Term Engagement - a protocol used by the Clinical Trials Network (CTN). This particular project did not show a great difference between using the telephone or doing typical kinds of aftercare continuing care.

• However, the other studies actually show better results from using the telephone rather than doing typical aftercare or continuing care type services. Those include: • Individual Therapeutic Brief Phone Contact, which was used with adolescents with good results.

• Telephone Case Monitoring - a brand new study so not much information available yet.

• Telephone Continuing Care – a study done by Chestnut in Illinois

Slide 1.80 Another use of the telephone in treatment and recovery services include those with the capacity to access computer based interventions called Interactive Voice Response. The following slide provides a brief review of the literature regarding use of interactive voice response (IVR) in addiction treatment and recovery services.

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Slide 1.81 Interactive Voice Response or IVR is an automated computer based intervention that is associated with the telephone.

How it works: A person dials a number, logs in and a computerized voice will run through a series of questions with the client that can be answered using the telephone keypad.

Advantages of IVR’s: • Provide educational models and questions to help people track their drinking and support treatment • Literacy is not required for use • Low Cost • Consistent delivery • Greater accessibility and availability of support • Flexible scheduling/convenience • IVR has been used in conducting SBIRT Interactive voice response regarding addiction treatment: Used for screening and brief intervention, IVR has been used in alcohol screenings, alcohol brief intervention, and as an adjunct to substance abuse treatment. One of the newer studies is by Moore and colleagues, out of Vermont, and looks at a program called the Recovery Line - an IVR program developed for patients to use in their own environment. Users can receive immediate assistance along with training and support for improved coping. The modules were designed to be brief, less than 15 minutes, and according to researchers are pretty easy to comprehend.

Sources Cranford, J.A., Tennen, H., & Zucker, R.A. (2010). Feasibility of using interactive voice response to monitor daily drinking, moods, and relationship processes on a daily basis in alcoholic couples. Alcoholism: Clinical and Experimental Research, 34(3), 499-508.

Mundt, J.C., Moore, H.K., & Bean, P. (2006). An interactive voice response program to reduce drinking relapse: A feasibility study. Journal of Substance Abuse Treatment, 30(1), 21-29.

Slide 1.82 Finally, a brief review of mobile apps is also included in this section.

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Slide 1.83 Note to trainer It is important for people to understand that there is a theory driven reason for the content of this study and that it was tested in a clinical trial. There are a lot of apps available that are either not based on a clinical theory of treatment or recovery, or have not been tested in a clinical trial. When selecting an application for the delivery of treatment services it is important that it has clinical trial data behind it and is based on an evidence based theory of change.

One of the more prominent mobile phone apps is one currently being researched at the University of Wisconsin – Madison, called the Alcohol-Comprehensive Health Enhancement Support System (ACHESS). The purpose of ACHESS is to address coping competence, social supports and autonomous motivation, thereby reducing the number of risky drinking days.

Sources Gustafson, D.H., Shaw, B.R., Isham, A., Baker, T., Boyle, M.G., & Levy, M. (2011). Explicating an evidence-based, theoretically informed, mobile technology-based system to improve outcomes for people in recovery for alcohol dependence. Substance Use & Misuse, 46(1), 96-111.

Slide 1.84 ACHESS maps self determination theory (Desi et al., 2002) over Marlatt’s relapse prevention theory. Tools in the application are designed to provide social support, increase competency for sobriety and improve autonomous motivation. The tools are designed to either support people in continued recovery or to intervene during times of risk.

Sources Deci, E.L. & Ryan, R.M. (2002). Handbook of Self Determination Research. Rochester, NY: University of Rochester Press.

Gustafson, D.H., Shaw, B.R., Isham, A., Baker, T., Boyle, M.G., & Levy, M. (2011). Explicating an evidence-based, theoretically informed, mobile technology-based system to improve outcomes for people in recovery for alcohol dependence. Substance Use & Misuse, 46(1), 96-111.

Lowman, C., Allen, J., Stout, R.L. (1996). Replication and extension of Marlatt’s taxonomy of relapse precipitants: Overview of procedures and results. The Relapse Research Group. Addiction, 91(Suppl), 51–71.

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Slide 1.85 This is a list app functions for ACHESS. A clinical trial with 300 subjects indicated that patients randomly assigned to the ACHESS condition had 50% fewer risky drinking days and a higher percent of maintained abstinence than people assigned to post treatment recovery support as usual.

Trainers Note Sometimes during this presentation participants will share the mobile apps that they or their treatment program use. It is important to re-emphasize two points: 1. NFAR is not promoting ACHESS but is simply showcasing it as one mobile app that is used for individuals in recovery; and 2. It meets the criteria that the application is built upon well understood/tested theories and it has undergone clinical trials.

Slide 1.86 Numerous studies exist on the utility of texting patients as a reminder to: attend appointments; take medications; and engage in positive health related activities.

However, there are few studies about using texting in substance abuse treatment or recovery services. Although in some mobile apps, texting is part of the services provided.

The Texting- Portable Contingency Management Study combines texting and Contingency Management to help clients remain abstinent from alcohol. Clients are given breathalyzers and a cell phone. Training is provided to clients regarding how to take a video of themselves with the cell phone while conducting a self-administered breathalyzer, including the Blood Alcohol Content (BAC) reading/results, and sending the video back to their treatment provider.

In the study, all clients got text messages one hour before, reminding them to take their BAC and send the video in to staff. Clients in the control group received a minimal reward for completing the task regardless of result of the BAC (negative or positive). Clients in the experimental design group who reported negative BACs got vouchers and a thank you text, and had better outcomes than the control group.

Source Alessi, S.M. & Nancy M. Petry (2012). A randomized study of cellphone technology to reinforce alcohol abstinence in the natural environment Addiction, 108, 900–909

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Slide 1.87 Take Home Messages

Slide 1.88 Motivation to change a behavior can be difficult, especially when trying to establish abstinence from drugs/alcohol and a healthy lifestyle. Using telehealth technologies may assist in building motivation as help and support can be available “on demand� when motivation is the highest.

Source Copeland, J. (2011). Application of Technology in the Prevention and Treatment of Substance Use Disorders and Related Problems: Opportunities and Challenges. Substance Use & Misuse, 46, 112-113.

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Slide 1.89 The next section will offer a brief overview of Privacy, Security, and Confidentiality as it pertains to telehealth technologies.

Trainer Note As the next section is being introduced, it is important to remind training participants that you are not an attorney and that any information presented during this training should not be used alone to justify any action on their part to ensure patient privacy, security or confidentiality. It is recommended that providers and counselors consult with the provider’s legal staff and refer to HIPAA’s Final Rule and 42 CFR Part II in order to make informed decisions.

Slide 1.90 These terms are briefly defined in order to assist in training participants understanding the information discussed in this section: • HIPAA - the Health Insurance Portability, & Accountability Act of 1996 In general, the Act is to improve efficiency and effectiveness of the nation’s health care system by encouraging the use of electronic data exchange • HITECH - the Health Information Technology for Economic and Clinical Health Act Subtitle D of the Act addresses privacy and security concerns related to electronic transmission of health information.

• Privacy Rule - Standards for Privacy of Individually Identified Health Information • 42 CFR Part 2 - the federal confidentiality rules and regulations for substance abuse treatment.

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Slide 1.91 The HIPPA Privacy Rule protects all individually identifiable health information, and calls this information PHI or protected Health Information.

Slide 1.92 Trainers Note This slide provides brief definitions of HIPAA’s Privacy and Security Rules. It is important to point out that the Security Rule is different from the Privacy Rule. For example, a disclosure may be permitted according to the Privacy Rule. However, any disclosure that is in an electronic format must follow the HIPPA Security Rule 29 which requires electronic disclosures to be: stored in a secure Data Center, encrypted, able to authenticate the recipient of the message; and able to create and record an audit trail of all activities.

This is not a training on HIPPA Privacy and Security Rules but serves to remind participants that treatment or recovery services delivered through telehealth technologies must also adhere to these rules and regulations.

Sources Karasz, H.N., Eiden, A., & Bogan, S. (2013). Reframing Arguments to Advance Public Health. Text messaging to communicate with public health audiences: How the HIPAA security rule affects practice. American Journal of Public Health, e1-e7.

US Dept. of Health and Human Services. Summary of the HIPAA Privacy Rule. Available at: http://www.hhs.gov/ocr/privacy/hipaa/ understanding/summary/index.html. Accessed December2, 2012.

US Dept. of Health and Human Services. Summary of the HIPAA Security Rule. Available at: http://www.hhs.gov/ocr/privacy/hipaa/ understanding/srsummary.html. Accessed December 2,2012.

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Slide 1.93 In the past this is how we thought about protecting Patient Health Information (The federal confidentiality rules and regulations require that patient treatment records be kept in a locked room inside a locked file cabinet ensuring that the general public does not have access). When considering the use of telehealth technologies, it is important to understand that both HIPAA Rules on Privacy and Security, and the Federal Confidentiality Rules and Regulations 42 CFR Part 2 apply.

Addiction treatment providers must be adhere to both the Federal Confidentiality Rules and Regulations and HIPAA Privacy and Security Act, complying with the more stringent of the two codes whenever the codes differ, or in other words, whatever regulations provides the patient with the most privacy.

Note to Trainer The following identifies resources that participants can access that compares 42 CFR Part 2 to the HIPAA Privacy and Security Rules, and the use of 42 CFR Part 2 with Health Information Exchanges. These resources may be shared with the participants at a break if need be, but are not part of the topics covered in this presentation.

SAMHSA has a well written document that compares the two. That document, The Confidentiality of Alcohol and Drug Abuse Patient Records Regulation and the HIPAA Privacy Rule: Implications for Alcohol and Substance Abuse Programs (2004) can be found at http://www.samhsa.gov/HealthPrivacy/docs/SAMHSAPart2-HIPAAComparison2004.pdf.

More recent documents include two FAQ sheets: Applying the Substance Abuse Confidentiality Regulations http://www.integration.samhsa.gov/financing/ SAMHSA_42CFRPART2FAQII_-1-,_pdf.pdf Applying the Substance Abuse Confidentiality Regulations to Health Information Exchange (HIE) http://www. samhsa.gov/healthPrivacy/docs/EHR-FAQs.pdf.

Slide 1.94 The final rule on HIPAA states that paper to paper faxes, person-to-person telephone calls, video teleconferencing or messages left on voicemail were not in electronic form before the transmission so they are exempt from the HIPAA Privacy Act. What does this mean? The goal of the Privacy Rule is to assure that individuals’ health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public’s health and well being.

Who does it apply to? Health plans, health care clearinghouses, and to any health care provider who transmits health information in electronic form.

What information is protected? All “individually identifiable health information“. The Privacy Rule calls this information “protected health information (PHI).“ It includes information related to an individual’s past, present or future physical or mental health condition and health care provided to the an individual including payment for services.

General Principle for uses and disclosures: The major purpose is to define and limit the circumstances in which an individual’s PHI may be used or disclosed by a provider. A provider may not use or disclose PHI, except either: (1) as the Privacy Rule permits or requires; or (2) as the individual who is the subject of the information (or the individual’s personal representative) authorizes in writing.

“Traditional short message service (SMS) text messaging is nonsecure and noncompliant with safety and privacy regulations under the Health Information Portability and Accountability Act (HIPAA). Messages containing electronic protected health information (ePHI) can be read by anyone, forwarded to anyone, remain unencrypted on telecommunication providers’ servers, and stay forever on sender’s and receiver’s phones”.

(American Academy of Orthopaedic Surgeons, August 2012)

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Slide 1.95 You must consider using a private network or a portal in order to ensure the client’s privacy during treatment sessions, whether you are using: • Videoconferencing • Email • Chat • or some of the other telehealth technologies, Remember from our discussion of OperationPAR and Centerstone, portals restrict people with password protection so not everybody can gain access into the network or program.

Slide 1.96 Telehealth/videoconferencing provides an opportunity for addiction treatment providers to expand services to their clients.

There are two major issues regarding use of telehealth technologies: • Licensure regulations or limitations of providing services across state lines • HIPAA compliance The medical profession is starting to address the licensing issue. However, the substance abuse treatment field is still far behind.

In terms of HIPAA compliance, there are two leading authorities that have conflicting views on programs such as Skype. One says Skype is HIPAA compliant because it doesn’t store any of the videoconferencing sessions. The other says no.

As far as we know, Skype has not provided specifics regarding whether it stores the session or not, and therefore we cannot say with any degree of certainty that confidentiality is protected.

It will be important as you start considering using telehealth technologies to check your state regulations on licensing and stay up to date on the technology. NFAR ATTC will also provide updated information on our website.

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Slide 1.97 The other issue to consider is the counselor’s use of technology. Ten years ago, many counselors did not have access to computers at work and in many cases computers were only given to administrative staff (e.g., grant writers or individuals working in the billing department). A 2003 article by McLellan and colleagues discussed the poor infrastructures of many addiction treatment providers including the lack of access to technology. In addition, up to five years ago frontier/rural treatment providers shared one or two email addresses among their clinical staff so that ATTCs serving frontier/rural areas had to send training registration confirmations to one general email with the hope that the counselor who registered for the course would eventually receive the information. However, in 2013 most counselors have their own email addresses and computer at work.

Source McLellan, A. T., Carise, D., & Kleber, H. D. (2003). Can the addiction treatment infrastructure support the public’s demand for quality care?

Journal of Substance Abuse Treatment, 25, 117−121.

Slide 1.98 Trainers Note Ask training participants to answer these questions privately. It’s important not to embarrass training participants or put them on the spot so that is why they are asked to privately reflect on these questions. After a few moments to reflect, move on to the next slide.

Take a moment and reflect on these questions: • Do you or your staff email or text your clients?

• If so, do you use HIPAA compliant portals?

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Slide 1.99 So what’s the big deal about emailing or texting clients? Many counseling professionals state that they are only using email or text messaging to confirm appointments and so the risk is minimal, especially since no PHI is being disclosed. However, there are risks associated with emailing or texting clients.

• First, the clinician has no knowledge or assurances that the client password protects their mobile phone, tablet, or computer. This means their message could be read by others, thereby disclosing that the client is receiving some type of treatment or recovery services.

• Next, email messages are stored on computers, tablets, phones, and servers. Text messages are also stored on phones and servers, which puts them at risk of being seen by others as well.

• Finally, although a clinician may only be emailing or texting to confirm or cancel an appointment, the client may respond with a message that includes more data and possibly PHI. Sources Karasz, H.N., Eiden, A., & Bogan, S. (2013). Reframing Arguments to Advance Public Health. Text messaging to communicate with public health audiences: How the HIPAA security rule affects practice. American Journal of Public Health, e1-e7.

Slide 1.100 Two additional points regarding the dangers of sending text messages to clients: 1. errors are made and text messages are sent to the wrong recipient; and 2. text messages lack context and some time are misunderstood.

A study by Saurage Research (2009) confirmed these problems with sending text messages. Statistics from this one survey, along with the HIPAA Rules/Regulations, may help dissuade clinicians from text messaging clients.

Trainer Note If you have time you may want to ask the audience for a show of hands regarding how many people have sent a text message to the wrong person.

Source Saurage Marketing Research. (2009). Key Findings November/December 2009. Retrieved from http://www.saurageresearch.com/key-findings-novemberdecember-2009/.

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Slide 1.101 Note to Trainer Have training participants read this quote from the Brooks (2013) article. It’s important to emphasis that text messaging using traditional SMS is not HIPPA compliant. Not all text messaging is banned but it has to meet the following criteria regarding: • audit controls; • encryption; • secure data centers; and • recepient authentication.

This criteria can be met using web-based portals built for mobile phones. So texting really becomes more similar to messaging.

Source Brooks, A. (2013). Healthcare texting in a HIPAA – compliant environment. American Academy of Orthopaedic Surgeons. Retrieved from http://www.aaos.org/news/aaosnow/aug12/managing5.asp.

Slide 1.102 This infographic is based on information released by cell phone carriers, with pressure from the ACLU, regarding how long these four carriers store text messages and cell phone call information on their servers.

Just the text message detail – that is the date, time, and phone number of a message was sent or received – and not the content of the text message is stored. Actual text message content is only kept by Verizon and stored for 3-5 days. Information regarding how long the text message content is stored on phones is unknown because in some cases the message content can be recovered even after the message has been are deleted. The last area relates to the call record. Again, this is detail regarding number called, date of call, and number of minutes of the call; not content information. AT&T leads the other carriers by keeping data from 5 to 7 years.

Source Retrieved from Wired.com.

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Slide 1.103 There is a new ruling out by the Joint Commission that says:

“It is not acceptable for physicians or licensed independent practitioners to text orders for patients to the hospital or other healthcare settings.”

Once again, text messaging is not an approved method of communicating with clients or staff especially since the identity of the person sending the text message can’t be verified and there is no way to keep the original message.

Source The Joint Commission. (2013). Standards FAQ Details. Retrieved from http://www.jointcommission.org/standards_information/jcfaqdetails.aspx?StandardsFaqId=401&ProgramId=1.

Slide 1.104 These safe practices tips were recommended by HealthIT.gov a website sponsored by the federal government Department of Health and Human Services to provide education and training on protecting patient’s privacy, security, and confidentiality.

Source Health IT. Mobile Device Privacy and Security. How Can You Protect and Secure Health Information When Using a Mobile Device? Retrieved from http://www.healthit.gov/providers-professionals/how-can-youprotect-and-secure-health-information-when-using-mobile-device.

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Slide 1.105 This is considered as one of the most important strategies a staff member can do to prevent privacy, security or confidentiality breaches - maintain physical control of their mobile device or laptop computer. Of course all workplaces should have policies and procedures in place regarding use of laptop computers, mobile phones, and thumb drives, of which none should have PHI unless these devices meet HIPAA Security Standards.

Health IT.gov. Tips to Protect and Secure Health Information. 9. Maintain physical control. Retrieved from http://www.healthit.gov/providers-professionals/9-maintain-physical-control.

Slide 1.106 Do not send or receive PHI over public WiFi or unsecured networks.

Health IT.gov. Tips to Protect and Secure Health Information. 10. Use adequate security to send or receive health information over public WiFi networks. Retrieved from http://www.healthit.gov/providersprofessionals/10-use-adequate-security-send-or-receive-health-information-over-public-wi-f.

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Slide 1.107 If working in a public place, be aware of unintentional disclosures when using a laptop or cell phone.

Slide 1.108 Make sure that all devices are password protected and change passwords often.

Health IT.gov. Tips to Protect and Secure Health Information. 1. Use a password or other user authentication. Retrieved from http://www.healthit.gov/providers-professionals/1-use-password-orother-user-authentication.

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Slide 1.109 Check what is downloaded on mobile devices or computers and keep security software updated.

Health IT.gov. Tips to Protect and Secure Health Information. 7. Keep security software up to date.

Retrieved from http://www.healthit.gov/providers-professionals/7-keep-your-security-software-date.

Slide 1.110 Many smartphones have apps or a programs that will wipe/disable its use if stolen or lost so that data is unable to be accessed. This is important as every 3.5 seconds someone loses a cell phone in the United States.

Health IT.gov. Tips to Protect and Secure Health Information. 3. Install and activate remote swiping and/ or remote disabling. Retrieved from http://www.healthit.gov/providers-professionals/3-install-andactivate-remote-wiping-andor-remote-disabling.

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Slide 1.111 Many providers may already have privacy, security, and confidentiality policies in place, but these need to be reviewed and revised when implementing the use of telehealth technologies. For example, let’s say the XYZ Treatment Center provides email/chat counseling through a HIPPA compliant web-based portal. Can a staff member provide treatment services using the web-based portal from a coffee shop, from their home, or while they are on vacation? These are types of questions that adopting the use of telehealth technologies will bring forward for the treatment provider.

Source USDHHS. (2013). Health Information Privacy. Retrieved from http://www.hhs.gov/ocr/privacy/index.html.

Slide 1.112 There are all sorts of ethical issues associated with telehealth.

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Slide 1.113 More counselors are using technology (email, smart phones, tablets, etc.) to conduct their business and as such this brings new and unique ethical dilemmas. In fact in some cases, technology use has become so ubiquitous that counselors may forget about Privacy, Security, and Confidentiality issues which puts them at risk for ethical violations.

Source National Board of Certified Counselors (NBCC). (2013). NBCC Adopts Revisions to Ethical Standards. The National Certified Counselor, 29(1), 1-23.

Slide 1.114 Professional Associations and states need to revise/rewrite a portion of their ethical codes to address the use of various telehealth technologies.

Source Telemental Health Institute. (2013). Retrieved from telehealth.org.

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Slide 1.115 Listed here are the addiction counseling accrediting bodies that currently all have some specific ethical codes related to the use of telehealth technologies when providing treatment services: Source NAADAC. (2013). NAADAC Code of Ethics Principles. Retrieved from http://www.naadac.org/membership/ code-of-ethics.

National Board for Certified Counselors (NBCC). (2012). National Board for Certified Counselors Code of Ethics. Retrieved from http://www.nbcc.org/assets/ethics/nbcc-codeofethics.pdf.

American Counseling Association (ACA). (2005). ACA Code of Ethics. Retrieved from http://www.counseling.org/Resources/aca-code-ofethics.pdf.

American Mental Health Counselor Association (AMHCA). (2010). Principles for AMHCA Code of Ethics. Retrieved from http://www.amhca. org/assets/news/AMHCA_Code_of_Ethics_2010_w_pagination_cxd_51110.pdf.

American Association of Marriage and Family Therapy (AAMFT). (2012). Code of Ethics. Retrieved from http://www.aamft.org/imis15/content/ legal_ethics/code_of_ethics.aspx.

National Association of Social Workers (NASW). (2008). Code of Ethics. Retrieved from http://www.socialworkers.org/pubs/code/default.asp.

National Council of State Boards of Nursing (NCSBN). (2011). NCSBN Model Nursing Practice Act and Model Nursing Administrative Rules.

Retrieved from https://www.ncsbn.org/Model_Nursing_Practice_Act_March2011.pdf.

Slide 1.116 The American Psychological Association put together a joint task force to develop telehealth guidelines for psychologists and their recommendations should be released soon.

Source American Psychological Association (APA). (2010). Ethical Principles of Psychologists and Code of Conduct.

Retrieved from http://www.apa.org/ethics/code/index.aspx.

Slide 1.117 The International Certification and Reciprocity Consortium, or IC&RC , puts this responsibility on individual states. They do not have a national Code of Ethics.

So if you are looking for telehealth technology-related ethical codes and you are an IC&RC state, you will need to go to your local board.

Source IC&RC. Find a Board. Retrieved from www.internationalcredentialing.org/findboard.

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Slide 1.118 When we look at ethical codes related to telehealth technology, it is important to focus on these four areas - informed consent; confidentiality/privileged communication and privacy; records and data; and competency.

An example of Informed Consent Confidentiality/Privacy Issues: Before receiving treatment services, all clients must understand the risks and benefits associated with entering treatment. In order to do this, clients must be given all the information regarding treatment and recovery services so that an informed and thoughtful decision can be made. Informed consent is especially important when using telehealth technology. For example, HIPAA considers a landline telephone as HIPAA compliant because it does not record or electronically store information.

However, a cell phone or smart phone does store data regarding the number that was called, the date, and the number of minutes of the call. In fact, this information is stored on the server associated with both the client’s phone and the counselor’s phone, and on the phones themselves which means the information is unsecure. Even though Protected Health Information is not disclosed, someone could access the client’s phone, look at the list of recent calls, and call the counselor’s number, causing a possible breech. This type of information would need to be shared with the client as part of the informed consent process. In addition, 42 CFR Part II would require that a counselor not call a client’s house and leave a message with a family member unless a signed/valid release exists for each household member. If the client only has access to a cell phone, its important that the counselors discusses the risks with the client regarding using a cell phone to communicate even about appointments.

Using telehealth technologies to deliver addiction treatment services includes developing new methods for recordkeeping and data storage. Treatment providers have developed different mechanisms for securing client signatures on consent to treatment forms and for storing treatment records in electronic formats. Treatment providers should consult with experts in EHR regarding collecting and keeping protected health information private and secure. Many treatment providers using telehealth technologies still conduct the first treatment session in-person ( a requirement by some payors) in order to complete the required admission paperwork.

Counselors are ethically bound to be competent in their clinical work (e.g., possess demonstrated skills in EvidenceBased Practices, offer treatment engagement strategies, understand how to score screening tools, conduct assessment, create treatment plans, and write case notes) and in using telehealth technologies. Competency in telehealth technologies is the same principle as being competent within a counselors’ scope of practice. Counselors who are unable to effectively implement the telehealth technologies they are using are violating most ethical codes regarding competency. This is an important concept for counselors to understand.

The following is an excerpt from NAADAC’s Ethical Code regarding the use of electronic devices and electronic records and confidential information. This ethical code pertaining to Confidentiality/Privileged Communication & Privacy, even though revised in 2011, may need further revisions.

Other examples from NAADAC Code of Ethics, Rev. March 28, 2011- Confidentiality/Privileged Communication & Privacy: “The addiction professional will explain the impact of electronic records and use of electronic devices to transmit confidential information via fax, email or other electronic means. When client information is transmitted electronically, the addiction professional will, as much as possible, utilize secure, dedicated telephone lines or encryption programs to ensure confidentiality. ” Source NAADAC. (2013). NAADAC Code of Ethics Principles. Retrieved from http://www.naadac.org/membership/code-of-ethics.

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Slide 1.119 The next issue associated with ethics is license portability. Portability is the new term that replaces reciprocity, with the idea being that licensed professionals take their license with them, not that a state counseling board grants special permission to practice.

One of the barriers to providing services using telehealth technologies is that counselors have to be licensed in the state where their clients reside. This especially impacts individuals living in rural and remote areas who are seeking treatment services and may actually live closer to another state than the state of their official residence. Federal legislation has been proposed that would allow physicians to be licensed in one state but treat patients that reside in other states without being licensed in these other states. This legislation in 2012 never got out of committee.

A good resource for questions regarding license portability and telehealth is the Robert Waters Center for Telehealth and eHealth Law www.http://ctel.org

Slide 1.120 Part of the problem in looking at cross-state licensing is which state licensing board regulations are to be followed - the state where the provider is located or where the client is located? The general rule with most boards is that counselors must reside in the state their client resides in.

This picture shows the bridge that includes the state line between Nebraska and Iowa.

Can a counselor who is licensed in Nebraska provide services to a client who is residing in Iowa? The answer is no, unless the Iowa licensing board allows the counselor a temporary license.

Source APA. (2009). How Technology Changes Everything (and Nothing) in Psychology: 2008 Annual Report of the APA Policy and Planning Board.

American Psychologist, 64(5), 454-463.

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Slide 1.121 Now, we want to touch a little bit on reimbursement for telehealth addiction treatment services.

Currently, billing for Medicare, Medicaid, and/or private insurance benefits, requires provider patience and flexibility as the rules change almost daily regarding reimbursement.

A brief overview of reimbursement will be provided in the next few slides with a more extensive review coming up in the Administrators’ workshop.

Slide 1.122 • Effective January 1, 2014, 32 million people currently uninsured may have access to insurance through either 1. Medicaid expansion (up to 138% of FPL) or 2. Health Insurance Exchanges ** (**note: Medicaid expansion is a state by state decision. Not all states will expand Medicaid by January 1, 2014. Exchanges in each state will begin operating January 1, 2014 as a state operated exchange, a federally-operated exchange, or a joint statefederal operated exchange.)

• Of the 32 million people, 11 million will have a mental health or substance use condition Source SAMSHA. (2012a). Health Insurance Enrollment. Retrieved from http://www.samhsa.gov/enrollment/.

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Slide 1.123 Note to Trainer When you do the training for this course, please use the prevalence data specific for the state in which you are training. The data on this slide is provided as an example. NFARATTC will provide you with updated data on request.

This is data provided by SAMHSA for Nebraska: • an additional 17.4K adults ages 18-64 with substance use disorders will have coverage under Medicaid • 20K adults ages 18-64 with substance use disorders will have coverage within the Health Insurance Exchange • This represents a five-fold increase. Thousand of others with mental health conditions will also have coverage.

Source SAMSHA. (2012b). Enrollment under the Medicaid Expansion and Health Insurance Exchanges: A focus on those with behavioral health conditions in each state. Retrieved from http://www.samhsa.gov/healthReform/enrollment.aspx.

Slide 1.124 The passage of the Telecommunication Act of 1996 helped pave the way for the use of technology as a treatment modality by removing certain economic and legal barriers to its use. The federal government currently commits millions of taxpayer dollars each year to promote the use of telecommunications in healthcare.

Source Benavides-Vaello, S., Strode, A., & Sheeran, B.C. (2013). Using

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Slide 1.125 Who Pays for Services Delivered Using Telehealth Technologies

Slide 1.126 Currently, only counseling using videoconferencing technology is reimbursed by Medicare, by Medicaid in some states, and by private insurance companies (in some states). In the administrators’ track a more in-depth review of reimbursement for telehealth technologies will be provided.

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Slide 1.127 As the slide says, the presentation is almost done. Therefore, it time to start concluding remarks.

Slide 1.128 Note to Trainer In presenting this slide and the five others that follow, please allow participants to read them on their own.

Source Kazdin, A.E. & Blase, S.L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37.

Perle, J.G. & Nierenberg, B. (2013). How psychological telehealth can alleviate society’s mental health burden: A literature review. Journal of Technology in Human Services, 31(1), 22-41.

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Slide 1.129 However as we discussed early in this course, there are many people needing treatment but not receiving it for a variety of reasons. One of those reasons is lack of access to services. The is especially true in frontier/rural areas of the country.

Source Kazdin, A.E. & Blase, S.L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37.

Perle, J.G. & Nierenberg, B. (2013). How psychological telehealth can alleviate society’s mental health burden: A literature review. Journal of Technology in Human Services, 31(1), 22-41.

Slide 1.130 The technology and resources are available to begin to overcome the substance use disorders treatment burden and make services more available.

Source Kazdin, A.E. & Blase, S.L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37.

Perle, J.G. & Nierenberg, B. (2013). How psychological telehealth can alleviate society’s mental health burden: A literature review. Journal of Technology in Human Services, 31(1), 22-41.

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Slide 1.131 The question of “How do we facilitate the shift?” hopefully has been demonstrated in this presentation and is summed up in the next two slides…

Source Kazdin, A.E. & Blase, S.L. (2011). Rebooting psychotherapy research and practice to reduce the burden of mental illness. Perspectives on Psychological Science, 6(1), 21-37.

Perle, J.G. & Nierenberg, B. (2013). How psychological telehealth can alleviate society’s mental health burden: A literature review. Journal of Technology in Human Services, 31(1), 22-41.

Slide 1.132 To sum up – • Whether it is group counseling in the traditional way or group counseling through videoconferencing

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Slide 1.133 . . . or client homework using the old relapse prevention workbooks or using interactive voice response . . .

Slide 1.134 ‌ Using telehealth technologies is in the best interest of clients as it is a way to expand access and enhance treatment services, especially for people living in frontier and rural areas.

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Slide 1.135 Some presenters like to take questions along the way, while others like training participants to save their questions to the end. It is up to the presenter to determine what will work best given their presentation style and the training participants needs.

Slide 1.136 Thank You!

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Notes

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