Telepresence and Engagement 1 hr

Welcome to Discovery Behavioral Health’s Telepresence and Engagement training. This is the second part of the nine-hour Discovery Behavioral Health Virtual Provider Training. Let’s start by defining telepresence. According to the American Board of Telehealth, “telepresence is the ability for the telebehavioral health professional to create an environment to help facilitate positive patient-provider alliance and create a meaningful encounter through valuable patient-provider interaction.” Telepresence is a related but separate skillset to our traditional clinical skills. In virtual programming a patients’ perception of treatment is based on what a patient can hear and see via their technology. Verbal and especially non-verbal communication are a critical part of telemental health, although the communication does have its own unique considerations. 

In this training we will review how to recognize effective communication techniques that lead to positive health outcomes and collaboration in virtual programming. We will review verbal and non-verbal communication practices that foster therapeutic rapport and how to design the patient and practitioner environment to optimize workflow and rapport building. We will identify best practices for integrated care that ensure an excellent patient experience and to review various social and cultural determinants of health care that can impact telemental health patient’s interactions. 

Communicating virtually is different than the bedside manner we are trained to provide. A clinician who has fantastic bedside manner can lack telepresence because it is a different communication style. A telemental health professional needs to be sharply aware of their body language, eye contact and verbal cues because they all play a part in helping the patient to feel connected and engaged with the virtual program. The clinician also needs to be aware of the technology they’re using along with their appearance and surrounding environment in every virtual session. 

We will be using the Telepresence Framework from the American Board of Telehealth to breakdown the aspects of best telehealth practice. The first part of the framework is Preparation, aimed at getting set up for success. Next is Introductions which is where we will review the importance of introductions in the realm of virtual program. Expectations is the aspect that follows and will review the use of verbal and non-verbal communication techniques in rapport building. Lastly, we will review Recognition which relates to summarizing sessions and gathering feedback for improved collaboration after virtual sessions. 

It’s important to prepare for virtual sessions before they begin. Think about those Monday mornings when you reboot your computer after a long weekend and a busy morning and immediately start to feel stressed, realizing you’re not quite ready for the day. We want to minimize these instances by being intentional and ensuring our spaces are set up for success, just like we would our office if a client was in the same space. Be sure to consider set up, scheduling, admissions or discharges and the sort of environment that you function best in. We want to keep our interactions with patients consistently structured because it makes the encounter feel mor neutral and reliable for the patient. 

Its critical that you can clearly define your role as a telebehavioral health professional within your specific position in Discovery Behavioral Health and feel confident and competent in executing your job duties. Through understanding the care model, environment, and role in the patient-practitioner relationship, the telemental health provider maintains professionalism, creditability and maintains organization. Discovery Behavioral Health uses a direct-to-consumer model where the patient is seen by a telemental health provider as opposed to consultation care where a telehealth practice supports a health organization like an emergency room. 

Screening and scheduling are important components of telemental health. Not all patients requesting virtual programming will be appropriate for telehealth services. It’s important that we engage, educate, and review our discovery behavioral health protocols for all stakeholders included in the treatment journey. A stakeholder in the virtual programming process may include the outreach representatives, admissions team member assigned to your program, the intake specialist, UR manager, the Discovery treatment team, and others committed to the success of the program. I will do my best to train and support our various stakeholders and the communication between the treatment teams and stakeholders is also a vital part of the success of virtual. Consistent communication will promote effective screening and scheduling for telemental health care. Screening protocols will be unique to the various divisions, programs and levels of care so be sure to carefully review the ones that pertain to your team. Overall, we want to identify appropriate clinical use cases and review patient eligibility criteria. We want to determine when and how telehealth visits will fit into their schedule. We will triage patients based on their appropriateness and need for virtual programming. We will ensure our clinicians only provide care in states where they are legally permitted to provide care. Lastly, we will educate patients on telehealth and appointment standards. Our goal will be to schedule all visits to allow for advanced preparation for the providers and patients. 

A major part of being prepared in to know that the technology is working before starting the camera or microphone. Most telehealth services allow you to test your mic and camera through one method or another. Zoom lets you log on to the telehealth session before your patients to check that the camera is working and to evaluate your space so that it’s set up effectively for sessions. You can also test your audio by using their audio test function on their zoom profile. It’s also important to check passwords, bandwidth, and electronic health records before logging on. Issues with logging in can affect the patient and providers timeliness for sessions and its best to make sure you can log in with minimal issues. You can check your bandwidth in a variety of ways. One of the easiest is to use a site like https://www.speedtest.net that will quickly let you know how your internet is functioning. If you’re not a provider who is usually virtual but switching to virtual due to a crisis at the center, then be especially to practice using your technology, update it and review the previously mentioned aspects. If you experience technical issues related to DBH specific technology, be sure to reach out to the IT Helpdesk via the DBH intranet or the appropriate support network if it’s a different issue.

Let’s talk a bit about camera placement for virtual sessions next. Camera placement is helpful to review with patient’s as well. It’s best to angle your camera slightly above eye level in front of you so you can look into the camera easily. It’s best not to have the camera below eye level or to the side of your face if you can avoid it. When cameras are below eye level it can also convey that we are looking down on patients as opposed to being at eye level with them. The camera should also be placed at a reasonable distance from the practitioner so they can easily type, if necessary, without having their face too close to the camera. It’s important to make sure the camera appropriately frames the practices face without cutting off portions of their face while minimizing any distractions in the background. Zoom and other telehealth tools often have features that allow clinicians to blur out their background or use a green screen effect to minimize the distance site environment. The telehealth professional should be centered in the camera and have their shoulders and face in frame. At the beginning of telehealth work with patients we also want to review how to position their camera. Generally, we want the patient’s camera to be positioned appropriate to the setting and to be focused on the patient. This can be especially important for some of the populations we treat like eating disorders. Meal support is a part of eating disorder support and when positioning cameras, we want to make sure that the camera is about 2 feet from the patient and is able to have both the plate and patient in the frame of the camera. A computer or phone stand can be extremely helpful with this to maintain appropriate camera positioning. (show my laptop stand) Another element of camera use that can be helpful for patients and practitioners is the ability to “hide self-view” while on the telehealth platform. For patients with body dysmorphia, this can be especially helpful, but we may need to provide more support to patient if they get out of frame for any reason. Hiding self-view can also allow the provider to see more patients on screen at a time so it’s an important tool to be aware of. We want to be very on top of prompting patients to ensure the camera is focused appropriately on their face, food, etc. Allowing patients to focus the camera on their ceiling or other inappropriate places must be minimized because we want the expectations for virtual programming to be as clear and consistent as possible. If a patient refuses to appropriately direct their camera or is consistently off camera, it is best to address this with the patient one-on-one and develop a success plan to promote effective camera placement and use. It is also appropriate to remove patients from the telehealth sessions if they behave inappropriately or use the camera inappropriately. Just be sure to connect with the patient offline and document the encounter and behavior of the patient, along with the interventions that will be used in future sessions. 

If you have not had a chance before, I recommend taking a break from this training to practice using the telehealth technology you will be using in practice. Write down any questions you have for later in this training or for your treatment team. If right now is not a good time, be sure to practice using the technology before your first day using the technology.

Continuing forward in how to best prepare for sessions, we are going to review electronic health record access. Although we primarily use Kipu across Discovery Behavioral Health, there are some other ones depending on the site. For our scheduled telehealth encounters we want to be sure to always review the outcome measures and other ordered tests prior to sessions. It’s important to ensure we can easily access the results for reference during the virtual encounter and empower the patient to understand how they impact the treatment plan. For example, we want to review the Recovery Assessment Scale or RAS data with our patients to acknowledge changes in the assessment over time and how that connects to their treatment journey. We also want to be able to review lab results if they have any impact on the treatment plan and make sure that the files, we need to access are easy to locate and review in the EHR for patient sessions. 

Consent in telehealth is another important element of preparation. It’s something that needs to be a part of the ongoing treatment journey, starting at the initial point of contact. Even when patients have completed all of the necessary documentation, it’s important to consistently review point of informed consent and especially how it relates to telemental health care. As patient’s get more comfortable with telehealth, they may become more relaxed in their protocols of ensuring they have privacy from members of their household for example. We would then want to review the various elements of consent for treatment including confidentiality, mandated reporting, the importance of the patient location, or the basic pros/cons of telehealth. These ongoing conversations also allow us to assess the patient’s capability to consent to services and to effectively patriciate in treatment via telehealth. We will review consent more in depth in later points of this training. 

Attire and appearance via telehealth should portray professionalism. The joke about working from home is often that we spend all day in our pajama pants, but this may not be the most appropriate choice. On the other hand, it is also not necessary to wear a full suit and tie while on screen most times. We want to identify a wardrobe that fits our telemental health work just like we would for our in-person work. What items of clothing can you wear throughout the day that are comfortable, allow you to sit comfortably in your telehealth environment and allow you to feel a sense of confidence in your professional appearance? Do you need to acquire additional items to build out this wardrobe or just reorganize your closet? Things like name tag requirements may also be different virtually. If you are required to wear a name tag for your role, make sure it is in camera view. Typically, your screen name will act as virtual name tag which is why it’s important that it reflects whatever is appropriate for your role whether it be you credentials or job title. Also be sure to include pronouns as to contribute to a gender inclusive virtual environment. Other attire considerations to make are that some professional organizations argue that loud prints and colors can be distracting, as well as baseball caps, dark sunglasses, or noisy jewelry. Darker colors like blue or black tend to perform well on camera although we want you to feel comfortable and confident in your attire so stick with what works for you and is professional.

Your surroundings and background are nearly as important as your attire. Be sure to eliminate any unnecessary noise. There are digital noise cancelling tools like Krisp which uses artificial intelligence to block extraneous sounds like animals barking or cars passing by. You’re not required to use these tools, but they can be beneficial for your practice, especially if you live in an apartment complex or busy home. Your surroundings also play a powerful role in communicating professionalism. Creating an environment that is consistent and neutral is best, less is more in a sense. Our roles also rely on the relationships we can build with our patients and the contexts we place ourselves in. It can be a helpful relationship builder to surround yourself with appropriate art or decorations that create additional opportunities to connect with patients. Do your best to look over and prepare your space for each session. Try not to have a personal picture that you wouldn’t have in your practice office in camera view. Try to avoid any contentious background décor, such as political art, etc. Maintain a non-cluttered, clean space that promotes a calm setting. Stay away from virtual backgrounds that are distracting or confusing. Ensure you’re using the right technology to provide confidentiality. Minimize any use of personal devices and do your best to utilize your DBH provided technology.  If you are fortunate enough to always have a private space in your remote work environment, then fantastic. If not be sure to consistently coordinate with those who share your space to ensure privacy during sessions. Privacy door hangars can be a helpful tool for this. The use of headphones or sound machines can provide additional privacy. Do your best to schedule breaks in sessions for things like letting the dog out and preparing meals or picking up kids from the bus stop etc. Avoid placing your telehealth in places where the encounter can be viewed through an open window. Also be sure that your lighting is optimal for sessions throughout the day. An affordable desk lamp or ring light can be a helpful addition, especially if you primarily rely on natural light throughout the day. Make sure you have light on your face and not just above or behind you because this can distort the video. It is also recommended that practitioners avoid having food and drinks visible during the encounter unless appropriate with your population or type of session. The mic can also pick up chewing and slurping sounds which can create additional distractions for patients. 

Let’s talk about some special considerations next. When working with children or individuals of a younger developmental age it can be helpful to use creative techniques or props to engage the patient during sessions. It may also be helpful to have a primary care giver in the room or on call for support as needed. Therapeutic games, bubbles, books, and stuffed animals can all help to make the session feel a bit more friendly. 

This concludes the overview of the preparation part of the framework. Next let’s talk about effective introductions for virtual programming. As soon as a virtual visit begins, introductions are your best tool for creative a trusting and safe environment for the patient. Introductions might look different depending on your role and the setting but there are some general considerations and scripting that can make them more effective. In the introductory encounter and in the introductory portions of ongoing sessions you will be continuing the screening process to ensure that the patient and their environment is still conducive to a successful telemental health session. Ensure the patient has set up appropriate strategies to minimize distractions and to ensure they maintain confidentiality. Review any pertinent expectations to maintain professionalism and the integrity of the therapeutic space. For example, telemental health sessions should not take place while the patient is running errands or driving although it’s also important to be understanding and flexible patients when appropriate. It’s a collaborative effort between the providers in patients to work out an optimized system that allows them to participate in virtual sessions. This is one of the trade-offs for virtual. With same-space sessions we may be more worried about them getting to the session on time whereas virtually that’s less of a concern. For example, we want to strategize with new mom’s or busy parents how to best fit virtual services into their life if they’re appropriate patient’s for telemental health and support them in coordinating childcare during sessions whether it be scheduled play dates, nap time, etc. As a part of the introductions, the provider should assess who is currently in earshot of the session and how that may impact the session. For example, a teenager may be less willing to share when their parents are home. However, there are some interventions unique to telemental health that can be utilized like headphones and the chat function when appropriate. The therapist can also support the patient via family sessions on facilitating the optimal therapeutic environment for them. In emergent crisis situations, it may be more difficult to ensure a private space. This is something the therapist should review with the patient as a part of the consent process. An example may be, a patient experiencing intense suicidality while at a grocery store. Although a therapist can coach a patient on finding a safe space for a suicidality assessment and safety planning, it may not be an option and the assessment process takes priority. 

As far as providing virtual care, the patient-practitioner relationship does not change when compared with in-person care. However, we need to be more mindful of technology, telepresence, and clinical technique when virtual. The first step of an introduction in a virtual session should be verifying that participants can hear and see one another. Next the telemental health provider should introduce themselves and their role if they have not done so then prompt the patient to identify themselves with their name, pronouns and date of birth depending on the session type. If anyone besides the patient and provider are in the session, they also need to identify themselves. Before continuing the provider should then ensure they have emergency contact and support contact information in case of emergency. Then review consent with the specific considerations unique to the virtual realm and develop a clearly documented plan for responding to emergencies during sessions and between sessions. For example, if the patient is in a city within your state of licensure than where you live and you’re unfamiliar with the are then you want to ensure you the hospitals and other support centers near them. 

Eye contact is incredibly valuable in any patient-provider session but especially virtually. There are some additional considerations for eye contact when virtual to think about as well. We talked earlier in this training about ideal camera placement which primarily has to do with optimal eye contact. The behavioral health provider should look into the camera whenever possible during sessions. This is an important consideration for technology set-ups where the web camera is not close to the screen in which they are viewing the patient. Whenever possible its best to align your webcam with the screen where you will be viewing the patient. This can be difficult with set-ups like dual monitor systems. In cases where this cannot be accomplished, it’s important to let the participants know you may look off camera and why so the patient does not feel disconnected from you. It’s something to be mindful of throughout your work with patients and to make eye contact with the camera whenever manageable. 

Rapport building is just as important, if not more important, in the virtual setting. Take a few minutes at the beginning of telemental health sessions to focus on rapport building to ensure a supportive patient-provider relationship. This is one the strongest predictors of positive patient experiences and outcomes and its not to be underestimated. Let’s review some tips for effective rapport building. It’s important to empower patients by discussing telehealth and how it works. Review your telehealth experience with the patients so they know some of your expertise. This can create space for patients to share things sooner than they typically might if they know you’ve worked with that specific challenge before. Discuss how virtual treatment can add to their treatment experience. Make appropriate small talk or use engaging icebreakers while using a calm, therapeutic voice while employing therapeutic skills like eye contact and listening without interruption. Reassure the patient throughout the virtual session similarly to how you would in traditional sessions. If the telemental health professional ever has another person in the room then need be sure to alter the patient and let them know what their role is. If it’s appropriate you can give a “virtual tour” of your professional space and invite them to appropriately share their own so you and the patient can confirm there is no one else in the space. 

It can be more difficult for the mental health professional to assess things like personal hygiene, gait, dress, and movement while virtual and this needs to be compensated for by intentional questioning. Explain what you’re doing prior to doing it when appropriate like when taking concurrent documentation. Be sure to use developmentally appropriate language with your patients. Patients should us two patient identifies like name and date of birth whenever possible to minimize security risks. Patients should be prompted to use their camera and mic to set a clear expectation about being prepared for telemental health sessions. Establish a consistent plan for introductions, conducting the session and the conclusion of the session so the patient is used to the flow. 

Now let’s review expectations. Its best to set clear expectations for virtual sessions and to meet them. This will build trust between you and the patients. Expectations include things like time management, verbal and non-verbal cures, communication, and documentation. Follow your profession’s best practice guidelines for time management. This while help the patient and provider to be respectful of each other’s time. Lateness has a compounding effect and can quickly domino out to impact the rest of the day’s schedule. If time management for sessions is something you struggle with for sessions, I recommend creating a script for yourself the cues you to introduce the 50-minute session time. This can also give the patient an opportunity to prioritize their needs in session. Sometimes the convenience and flexibility of technology and telemental health can make it all too simple to slip into less-professional behavior than being in an office would. Its important to continue to check in with yourself regularly in terms of your professional boundaries and seek supervision when appropriate.

Let’s talk about verbal communication next. Just like honing our in-person bedside or office manner, we need to hone our virtual manner. Often when using technology, we speak louder than we would normally, and this can place additional strain on our voices. This should not be necessary. Ensure your mic is set up and working properly. If you continue to have issues with your sound, you take some additional steps to set up an external microphone. There are a lot of good microphones on the market because of the popularity of content creation for podcasts and YouTube videos. A lot of the mics also have the ability for you to change the direction of where the sound is picked up. For example, you could use a mic that is omnidirectional that will pick up all the sound, one that is bidirectional and will pick up the sound of two people across from one another or unidirectional where it only picks up sound from one direction. If you live and work in a noisy building a mic that is unidirectional can be incredibly helpful. A headset with a mic can also be helpful or a mic that you attach to the collar of your shirt. I would always recommend starting with affordable options and then investing in what you find helpful if that is appropriate for you. The work from home stipend that is built into the compensation of remote employees can also be helpful here. Lastly, items you buy for your home office are tax deductible so be sure to keep track of your receipts. Regardless of the technology that’s right for you, try to speak consciously, at an appropriate pace and at a normal volume. Enunciation is critical for clarity. It’s also important to avoid jargon and be mindful of the language that you use. A fifth-grade reading level is a good language level to aim for. Some famous books that use 5^thgrade language are the Harry Potter series, the Series of Unfortunate Events, Stuart Little, the Chronicles of Narnia and Wonder. It’s much more difficult for patients to learn when they are processing complex language. Another verbal communication consideration when virtual is the use of the mute button. Do your best to be aware of your own mute button so that the patient does not miss things you’re trying to say. Also don’t be afraid to use the mute button during groups so that ambient noise can be minimized by whoever is not sharing. Address the expectation that the mute button can and will be used if patients are being inappropriate in group by the facilitator. Explain its not to be rude but to promote optimal group functioning. 

Let’s touch on collaboration. Collaboration will look different depending on your division, population focus and role. Do your best to clarify your role with the team. Work collaboratively with the various departments involved with screening to ensure patients are screened based on their telemental health needs, their access and comfort with technology, their ability to keep themselves safe will in virtual program, etc. Ensure all the appropriate parties are aware of the emergency plan and that is documented. 

Let’s shift to a discussion on listening. The telehealth provider needs to be able to pause and listen, to allow time for the patient and to communicate fully. One thing that happens via telehealth that is a unique conversation is that there can be delays in the video or audio where the practitioner may need to be more patient than normal to ensure they’re not interrupting the patient due to the delay. One way to improve this is to use your phone’s audio while muting your video. To do this be sure to use you Discovery Behavioral Health provided number or phone, often Ring Central. Phone audio can be more reliable than internet-based audio. This is just one method that can be helpful for managing this issue. Looking into the camera and making eye contact will convey active listening along with body language such as nodding, smiling, etc. Minimal encouragers like saying “right,” “tell me more,” “I see,” etc. can be someone more difficult to use virtually because the audio may struggle to pick up shorter sounds. Although they’re still important to use to ensure the patient that you’re listening, you may need to rely more on non-verbal minimal encouragers like appropriate facial expressions and gestures. 

A bit more on non-verbal communication. It’s just as important if not more important than verbal communication while virtual. Telemental health practitioners need to have an exceptionally high level of awareness of their non-verbal communication to contribute to a positive patient experience. We already touched briefly on facial expressions and eye contact. Let’s talk a bit more about hand gestures, posture, and arm positioning. Good posture means sitting up straight without slouching and it conveys engagement, professionalism and that you want the conversation to continue. As a telemental health professional you may be sitting in front of the computer for hours each day and that can take a toll on your body and make good posture more difficult to manage. I recommend taking movement breaks between most sessions and doing simple stretches to encourage mobility. If you’re able, I would recommend investing in a great chair that supports your back. If that’s not an option for you, try using a pill to sit on or to place strategically behind your lower back so that your body is optimally positioned for your work. Hand gestures are also an important consideration. Although we do not want to overuse hand gestures because it can be distracting, they can help convey interest and emphasis. As far as arm positioning, try not to cross them but to rest them calmly in front of your and to convey openness. 

Let’s shift gears to cultural and social determinants. As mental health care professionals we tend to specialize in working in a particular location in the world but with telehealth we can work far outside that range. This means we need to be especially multiculturally competent and prepared to work with a wider range of cultures, knowledge, beliefs, environmental stressors, healing practices, and technology views. This can be especially challenging when the practitioner is providing care in an area they have never been to. It’s important that we assess the whole person, and this includes their environment. Be sure to learn about their environmental health and to assess how it may be impacting their mental health. For example, there are areas of the US that have a higher population of religious groups or cultural groups, and this can contribute to how an individual understand their mental illness and it’s important for us to be aware of that. 

Now onto the last piece of the framework which is Recognition. It’s imperative we end virtual visits and implement adequate follow-up care. Let’s talk about how to review, recap, and gain feedback around this. Recap is another word for summarize and that’s what we want to do at the end of group and individual sessions. Review what you went over in the sessions and any pertinent diagnoses, treatment plan, instructions, etc. and prompt the client to repeat it back to you in some way. Make sure to provide the patient with clear instructions on the follow-up and care plan. Confirm that the patient has the intention to follow with the treatment plan and to document the encounter appropriately. End the session with appreciation for the patient, the originating site staff, or anyone else that may be appropriate. 

Let’s touch on some ways to recover the visit if something goes wrong. Let’s say that there are severe technology issues that lead to ending or cancelling the visit. If this happens, we need to have a back-up plan to switch to another device or if appropriate based on your site to another mode of telehealth like phone over zoom. If the technology issues are not able to be corrected quickly then it’s important to have a strategy for rescheduling and some plans on how to minimize further technology issues. Be sure to collect feedback from the patients or colleagues after a virtual session to be consistently working towards improvements. It’s important to collect feedback for both successful and unsuccessful sessions. One thing we will be doing with the new curriculum is asking that patients share feedback after each group session so we can work to actively improve our group modules. 

Let’s review the framework one more time. Our optimal telepresence framework is 4 steps and includes preparation, introductions, expectations, and follow-up care. Preparation is completed before the visit and starts at the screening process. Considerations include set up, scheduling, and having lab work and other documentation available in a timely manner. Introductions are one of our most powerful tools for creating trusting therapeutic environments. Setting expectations and then meeting them is also critical and allows us keep trust without patients and promote consistency and treatment commitment. Finally we need to ensure we have good follow-up care practices in place to wrap up sessions effectively and continue to support our patients on their next steps.

Telepresence once again is the capability to create a therapeutic environment and create rapport via telehealth. Tips to remember are dress appropriately, always assume you’re on camera, knows what’s in view of the camera, be mindful of body language, have adequate light and know your technology, help your patients to hear by minimizing background noise, be mindful of HIPAA rules, focus on connecting with your patients and keep language simple. Your onscreen demeanor is a skillset you will continue to develop. Keep practicing and observing yourself in order to improve.