Greetings, and welcome to the BHI TeleBehavioral Health 101 series. So glad you're here today. If you've heard talks I've given before, they're very literature-based and stuff. We're not going there today. 

We're going to do some real basics, some things to think about, set up so that you have a successful clinical encounter that is highly professional. So we're going to roll up our sleeves today. We're going to just get down to the nitty gritty and look at some real basics. So here we go. 

So our learning objectives. We're going to describe one key element related to setting up one's professional office to use when caring for patients virtually. You're going to keep hearing me come back over and over again about a professional office or professional encounter. 

When you're doing virtual healthcare, it's up to you. It's up to you as the provider to create that professional environment. Lots of things that we take for granted when we're seeing clients or patients in person, in a medical center, or a clinic, or something like that. 

So much that's already there, that structure, that infrastructure is in place, it sort of sets the professional tone. When we move to the virtual space, not so much. So it's going to be up to you. You're in charge to set up that professional setting and set up that professional encounter. 

So let's see how we can work through that today. Another one of your learning objectives is going to be explain whatever CAPS-LOCK is, because that's going to really help you get through the virtual encounter, and then safety planning. 

You got to know something about safety planning. Like I said before, a lot of things related to safety are baked into the facility or the institution when you're doing in-person care. Not so much for virtual care. It's up to you to provide that high quality, professional, safe encounter. 

So overview. Here's what we're going to do. It's going to get so basic. But it's got to be done. You got to have a talk on this. We can't go launching into talk about AI until we get the basics met. 

So we're going to talk about how do you set up your office for a high quality, virtual session. We'll go over some do's and don'ts. We're going to think about the workflow. Because there's no clinic that handles all that for you anymore. You've got to take care of it. 

How do you get the client or the patient set up so that they can have the virtual session, and what to think about, what to anticipate for? And finally, we're going to talk about safety planning, which is a highly evolving field. I'll give you the latest as I understand it. 

OK. Everyone ready. Everyone's got their sleeves rolled up. Ready to get basic here. So let's talk about setting up your professional virtual office. Look at where you're going to be providing care. Look around. 

Make sure it's quiet. Make sure you don't have people wandering in and out during the session. Look at what's behind you. What can the client or patient see? This might be a good time to take down those pictures of spring break or your latest beach trip may not be-- is that really what you want to be presenting as your professional office? 

Make sure the lighting is good. Make sure you're not backlit and you're just some sort of silhouette. One useful thing is, if you don't have the camera with the self view monitor on it, which we'll talk about more. Turn the camera on and look at yourself. 

Is this how you want to present yourself? Is this going to be setting that professional environment, how you want to take charge of that environment and provide quality care? Another thing is make sure the camera is at eye level. That is one of the biggest complaints that people have. 

Wear plain-colored clothes. Don't wear plaids and things like that because they'll shimmer. And then, as anyone's ever worked with me knows, when I talk about digital health technology, technology fails. It always fails. 

You can count on it failing. So now that you've been warned, you don't be surprised when it fails. You're the professional. You're in charge. It's incumbent upon you to have a backup plan for when that technology fails. 

Don'ts related to professional office. Well, it's the opposite of what we just talked about. But as I said before, think about the background. We don't want it busy or potentially offensive material in sight. 

Don't wear clothes that blends into the background. Don't-- If you got a white wall behind you, don't wear a white shirt. You're going to appear as a floating head, and that can be really distracting. As I said, avoid plaids or clothes that have a lot of design on them. They'll shimmer, tend to shimmer. 

The bitstreams have gotten better, but that's still an issue. We talked about making sure the camera is at eye level. This is the number one complaint from patients when you're doing video. So if you have a self screen somewhere, drag it up and put it underneath your camera. 

Because I don't care how humble you are. It's almost impossible not to look at yourself when you're doing this. And what will happen is if your camera is down below, down on the bottom of your screen, you're going to end up looking at it like this. And you're not making eye contact with your patient. 

They find that very offensive. Or if your cell screen's way up high, right, you're going to end up looking up at yourself. Is this really the professional environment you want, or is this really the professional environment you want to project? I don't think so. 

So put that camera with the self screen right below the camera. That way, you're going to be looking at yourself, but you're going to be looking right into the camera right. Once again, that's the number one complaint of patients when they're doing telehealth. 

And once again, make sure your office is in a quiet place, where plenty of privacy. All make sense. Sounds basic. You probably know all this stuff, but you might not know all of it. So these are just some basics to get started. Take control of that professional environment. 

HIPAA. Let's take a moment and talk about HIPAA. Hence the big red banner up there. During COVID, we had waivers. You could just take care of patients, take care of your clients. Use whatever software you got. It's all good. Just go. 

Those days are long gone. Long gone. So you have to use HIPAA compliant software technology now. Look, your day is hard enough as it is, right. Busy enough. The last thing you need are the feds knocking on your door. 

So make sure that your software and all your technology is HIPAA compliant. If you don't know what I'm talking about, talk to your admin staff. Talk to your leadership. Tell them you're not comfortable providing care till you can be assured that you're using HIPAA compliant material. 

Because when the feds come a knocking, they're going to be talking to you because you're not compliant. So the HIPAA compliance stuff has to be at the same level as what they've done in person. We've talked about make sure that it has encryption, correct passwords, all the safeguards are in place. 

One way to assure this is get a business associate agreement with the vendors that you use. Because they should assure you, they are the ones that are selling you the equipment. They need to confirm that it's all HIPAA compliant. So check for HIPAA requirements. 

Also, need to make sure you notify things in terms of a breach. There's significant penalties in place. So I didn't want to scare you. But hence the big red stand is to take a moment. Just don't assume everything's HIPAA compliant because it might not be. And you will be the one the feds come talking to. 

A few more things to talk about HIPAA. So the last slide was about making sure your patient and everything is all HIPAA compliant. Now, let's talk about the security measures for you in your clinic and making sure that you have the proper security. 

Make sure that no one's walking around behind you. Make sure nobody's recording you. Make sure if anybody does come into the room, you identify them. Sometimes, if people are really paranoid, show them the room. Turn the camera around. 

Make sure they see that there's no one else in your room. We've talked about using HIPAA compliant software and platforms, and make sure everything's encrypted. If you're going to share data. You want to make sure there are no pop ups. 

How annoying would that be? Imagine if you were in person, and there were add pop ups coming up in person in your clinic. That doesn't happen. Of course not. So make sure that that's not an issue. 

You don't want to be sharing your screen. All these things. You want to make sure that's all locked down. Recording. Right. You got to have a recording policy. 

And most organizations don't allow recording because of medical record storage and because in accidental breaches of privacy. So you want to set that all up, get that all done ahead of time. You want to communicate with the patient or client. 

But guess what, they're going to record if they want to. So be prepared. And you can tell them all this great stuff. But with these things these days, if they want to record it, they're probably going to record it. 

The next thing to consider are workflow considerations. This is so important. So important. You got to think about how is your day going to proceed. How is that client or that patient know that they go from wherever they are to being contacted, know about their appointment, being able to connect, complete the appointment, sign out, document, make a return to clinic order. How is that all going to happen? 

So think about get concrete now. How are referrals going to be made to you in your clinic? Who's making appointments? You're virtual now, right. And the in-person office, you had the fabulous clerks or staff assistants, who are the backbone of your clinic. They're taking care of all of that hard work for you. 

When you're virtual, who's doing it? I don't know. That's up to you to figure out. Who's going to notify you and the client or the patient about an appointment when it's coming up? If there's any surveys or forms to submit, what format are you going to use to convey that to the patient, get it to them, have it returned? 

Where are you providing virtual care to? Is it to another clinic? Is it to someone else's home? Where are you sitting? Are you sitting in the clinic? Are you sitting in your home? All these details have to be worked out. 

We've talked about the importance of HIPAA compliance. And then digital literacy. Does the individual you're working with know how to use this equipment you sent them? If they don't, it's just going to become-- they're going to use it as a coaster for their coffee mug if you send them a nice tablet, if they don't know how to use it or open it. 

That's real world. So these are just some real basics. I'm sure you've thought about them, but maybe you have-- maybe there's some gaps we're filling in for you. Some more workflow. Documentation. How are you going to document? 

Do you have an EHR that you use? Is it compatible with being virtual? Can you access it? When the encounter is complete, who's going to schedule your follow ups? Do you place an order or how's that going to happen for you? 

What about the billing? Billing, super complicated. And it really depends upon what system you are in, what state you're in, whether you're in a federal system or-- so work with your admin. Make sure your legal teams, your policy people, make sure that's all worked out for you. 

OK, I'm sure you're a fabulous clinician. I'm sure you know everything. Well, let's say you need to make a consultation, and you need to bring in a colleague. How are you going to do that? How are you going to consult other people virtually? What system do you have in place? 

If you want to do a same day handoff, how is that going to work? How are you going to bring somebody, invite them into your virtual space, or how are you going to refer them to say, if you need a specialist to see them, who may also be doing virtual care, what is the actual steps you need to take to have that done? 

Because it's going to happen. I can tell you that right now. So don't be surprised when it needs to happen. You gotta think this stuff all through ahead of time if you want to create that professional, high quality virtual encounter. OK. Don'ts. Once again, the don'ts are pretty obvious. They're the opposites of what we just went over. 

But just don't assume the patient's going to be automatically checked in your virtual room. If you're working with another clinic, it's all-- and we're going to talk about this over and over. It's always good before your day starts is to contact that clinic. Who's going to be working with you that day? 

Who's going to help be sitting the clients or the patients? If you have tech support, who's going to be that individual work with? Write down their numbers and their contact information. Because they change. Every day, it's somebody different. 

So know that ahead of time. And you would do something similar to that in person? You would know what to do in a crisis. You would know who's working with you that day to alert you. So those are the things you take for granted when you're in a brick and mortar facility. 

The virtual, can't really take that for granted. So think about who are you going to be working with and how that's going to happen. And don't take it for granted, OK. Don't assume your staff knows what to do with a virtual appointment. 

Even though this virtual care has been around for a while, you get a lot of staff turnover, you get a lot of clerical help turnover, the rules related to virtual care and policies are forever changing. So make sure that whoever-- ideally, you have some one or a team that you're working with who are up to date on all this material. 

You're providing home based. That is a whole other level of complexity you have to take on. Because if you're working with another clinic, you have some of that baked in stuff already there. But when you're going home to home or clinic to home, don't. You're starting from scratch. 

And so-- and you may or may not know what the digital literacy or the equipment your client or patient is using. So sometimes, it's not a bad idea to have someone contact the patient or client ahead of time. Make sure they're knowledgeable of all that stuff. That's what we would refer to as a digital navigator. That's a whole other talk. 

If you don't have someone like that in your system, you may want to just schedule extra time in your initial intake to make sure that they're comfortable, they're feeling safe, they're understanding the equipment before you start getting into the nitty gritty of your clinical intake appointment. 

OK. Let's dig down a little deeper. As people have heard me talk before, I usually like to do evidence based, but we're not doing that today. But I usually like to start broad, and we just keep getting more and more specific. And that's what today is all about. 

So I mentioned CAPS-LOCK earlier. So let's say everything I just talked about is, oh, that's too much. I can't remember all that stuff. Well, here's a nice an acronym to remember to all the steps to go through to make sure you're set up to succeed. 

CAPS-LOCK stands for obtaining your consent, confirming the address, confirming a backup phone number, taking a look at where the care is being provided, and being able, for security reasons to lock the video room so you don't have people drifting in and out. OK, so let's now unpack all of these things in a little more detail. 

OK. Regarding consent. I think this is really important. I like using informed consent. Because that immediately tells the client or the patient that you are taking this seriously. This is a recommended form of treatment, just like recommending surgery or recommending medications, or recommending a procedure that you need to go through the informed consent process. 

So doing virtual care. And it just sets the tone from the get go that you're a professional, you're considering this as a professional encounter, and it's going to be treated that way. So what are the basics to informed consent? 

You want to be able to talk about the recommended intervention. You want to make sure that the individual has capacity or the intellectual ability to understand what you're talking about, to be able to render a decision. Remember, we're not talking about competence. 

Competence is a legal is a legal rendering, a legal opinion. As a clinician, you can render capacity, whether they have capacity to make informed, understand what you're talking about. You want to comment on that. You want to be able to talk about the benefits. You want to talk about the risks, and always that they have the option to refuse. 

If they don't want to do telehealth, they don't have to. Don't assume this is obvious. Once again, you're in charge now. You don't have all that baked in brick and mortar stuff in place. 

If you want to be the professional, I know you do, or you want to be attending these sessions, you want to-- you want to take this and make sure you set that structure, set that tone from the get go. All right. So let's unpack these a little further. 

So do. So in terms of specifics, in terms of benefits, talk about the benefits of virtual care. All right. Improved access. Literature is very clear on that. Decreased travel. 

Decreased stress of having to be in a busy wait room. I work at the VA. Imagine if you're a military sexual trauma victim, and you're being asked to sit-in a waiting room full of potential people who could be assaulting you. That's a very stressful situation. 

That's one of the benefits of this. Talk about the risks, right. Transmission of internet, hacking. Even though you're using all the right software encryption, things can happen. Things can break down. 

What did I say about tech? Tech fails. It will fail. Always does. Limits to confidentiality. You talk about disclosing medical information, court orders, how that information would be over. 

And once again, review with them the option to if they don't want to do telehealth, that's fine. But if they don't, what are their options? So you want to be able to document all of this ideally in the first session. OK, moving to the CAPS-LOCK. So we've gotten through an informed consent. 

Knowing where they are is vitally-- and how to contact them is vitally important, both for when tech fails, but also for safety planning. So at the beginning of each session, and I think a template is a header that you can fill this out and drop into the front of your note each time. Works really well to have that template to use. 

Kind of like if you're a pilot, I'm not a pilot. I'd be terrible. But having that checklist to go over at the start of each session that you can fill out their location, their phone number, and backup stuff. So having that is really important. So at the beginning of each session, you want to know where they are. 

Because they can be anywhere these days. Take care of veterans from Canada. I can't care for veterans in Canada. So they drive across the border. They meet me in the parking lot, and they'll say, doc, I'm in the white car. 

So you're in the parking lot on the US. Yes, I'm right there. So be able to identify these things. Get the backup phone number when your video appointment fails. Don't assume they're in the same place every session. They will move around. 

Like I said, have a non-emergent backup plan. Because when new video fails, and it will, what are you going to do? I'm going to call them up. How are you going to call them up? How you going to close the encounter? How do you make sure everything's OK? 

So like I said, this can be really helpful to remember everything. You can create your own little checklist. You can fill it in, copy and paste it in the front of your note each time. And you're good to go. You got all the documentation squared away. 

OK, dude, time to survey. The S in CAPS-LOCK. Take a look at where they're sitting. Is it professional? Do they have proper lighting? Is it private? Are they sitting in some restaurant somewhere, coffee place with people wandering in and out. 

No, you're in charge. You are in charge of saying, no, that's not professional. We're not going to do it that way. Are they driving down the highway, on the phone? No, that's not safe or professional either. So you're in charge. 

Survey the situation. Make sure that it's safe and appropriate. Make sure there's no one else in the room. Make sure they adhere to professional behaviors and set boundaries for communications outside of the session. You can't just have them call the clinic anymore. 

How are they going to communicate with you if they need to get a hold of them, or you need to get a hold of them outside of this appointment? The onus is on you to have this all thought through and in place before you start seeing folks. 

Don't lose control of your boundaries. It's like I said, in the brick and mortar, it's easy. You're in an office. It's not going anywhere. But here, it can get really messy. People can be wandering in and out. Don't allow them to be on their phone while they're doing things. 

No. Set that professional tone. We talked about recording. But assume that they could be recording. So be careful about what you say and your professional behaviors. Make sure they're in a proper, secure space with good lighting. 

It's just amazing to me that I have to bring this up, but don't allow smoking, drinking, or marijuana use. I know it's legal, right. You wouldn't think people would do it in a professional manner, but it happens all the time all the time. You show up to a session, and they got a beer on there, or they're lighting up a joint. 

No. You're in charge. No, not allowed. Set that professional session. Make sure they're wearing appropriate clothing, for goodness sakes. All those things. And we talked about when tech fails, it's up to you to have that backup plan in place. 

Further do's and don'ts for setting up your client, particularly around documentation. And make sure you're dating the time of this. Make sure the information is relayed to those who need to know it. Make sure you're documenting what's appropriate, what's not appropriate. 

Make sure you're documenting the HIPAA compliant material and so forth. Make sure you've got a system to be able to record, whether they you've completed the informed consent process or not. We've talked about many of these type of things, but these are just some more details to think about. 

If you need to do some examination, do you have the right equipment to do a blood pressure check or something like that? Are they trained to do it? Are you trained to do it? How's that all going to work? 

And once again, we're not going to get into billing and so forth because that's pretty complicated stuff that's unique to your client. And make sure you've gone over that in all of these type of things. Talk to your professionals on the clinic side in terms of what you want. 

You don't want to be flailing around with all of these details after the session. But a lot of work at this. You're a professional. You want to do this right. So have all these things in place ahead of time before you go. 

OK, now, let's shift gears a little bit and talk about safety planning. Because it's vitally important. Once again, you're in charge. It's up to you to assure you've got a safety plan. So the first thing let's do is let's talk about safety plan when you're working with clients or patients in a clinic and you're providing virtual care to the clinic. 

Like I said, I really like a header that gets you that information of what the date, where they're located, informed consent has been approved, all these type of things. Their location, your location. 

But when you're working with the clinic, it's also good, like I was alluding to earlier, take a few minutes before the clinic day starts and say, hey, checking in, looking for the clinic today. Who's going to be-- who am I working with? Who's going to be sitting with patients or clients for me today? 

In case there's an issue or a problem, I want to know who to contact, and what's a good phone number I can use? In case you have an emergency, in case you need to hold that individual in the room, and you need to contact the nurse or whoever to go into the room to help with an emergent situation. 

So get that all documented ahead of time. And then what happens when, I don't know, tech fails? Who's your IT person at the clinic? Who is your tech go-to person? They change every day too. 

Make sure you get their name and their phone number all documented too. Think about where you're providing that care. Know what the facilities are in the community. Let's say you need to get them to an ER. 

Where are you? If it's the brick and mortar, you know. You go to that clinic all the time. It's that ER over there that we're using. If you're working in 100 miles, 200, 300 miles away, and you don't know that community, you've never been there before, what ER does this clinic typically use? 

What ambulance service? How are they going to move people in case of an emergency? E911 is really important to know. And this I wish I could give you more details on E911, but it's sort of evolving really fast right now. 

It's really important to use E911 and understand the status of it at your clinic. What am I talking about? Right now, if you've got an emergency, you pick up your phone and you call 911, 911 is going to come to where you're located, right. 

It's tied into your phone, your location, and so forth. You may be having a really bad day, and you're dealing with somebody who's suicidal. You don't want 911 coming to you even though you're having a bad day. You want them going to the clinic to wherever that client or patient is. 

So you've got to be able to relay the address. You already got it. You got that ahead of time. In case of that emergency, you want to be able to get it to the 911 services so they can have whoever needs to go to that clinic in that local area. 

Like I said, I wish I could be more specific, The E911 stuff is changing really fast right now, but find out what system you're using at the clinics you're going to in terms of how to relay that information of the location, the actual location, in case you need 911 to go there. 

Because remember, if you call, they're coming to you. If you're having a bad day, but I would suggest that the person who's suicidal is having a worse day, and you want them to go to that clinic. What about care to home? 

Essentially, everything I just said but take it up another level because you don't have that clinical infrastructure in place now. It's incumbent upon you to build all of this into place. Once again, I love a header. You know that start up each clinic. 

Where are you located today? Got it. Roger that. Who's your-- who's somebody we can contact in case of emergency, their phone number? Got it. Roger that. Get that all documented ahead of time. 

And then when you're documenting, you're pacing the front end note. External peer review. We all have it. They can come in and say, boy, this provider really knows what they're doing. Look at all the things they've done. They've got it all clearly documented. 

So confirm where the patient is there. If you're doing it at home, they could be anywhere, right. And they move, and they change, and they're doing different things. And they're at work. They're not at work, they're at home. They're traveling. They're going to childcare, whatever. 

You got to just if you're going to be professional, you gotta know. We just talked about 911 services in detail. Once again, I would love to give you more detail. It's just evolving really fast right now. Find out the system in place where you're working. 

And like I said, I love a good header. Documents, all that information. Get it all done right at the start of the session. And when you're done, you cut and paste that header, same header you use for every appointment. You just drop it into the note. 

The same thing is with the clinic. Know what the backup facilities are in the general area for that person you're providing. What's the local ER? What are other services? Is there a friend or family member you can contact to help in case of an emergency? Get that all ahead of time. Get that well documented. 

And that's it. That's what I got for you today. I know it's been really concrete. I know it's been really basic. You probably know a lot of this stuff, but my hope is we've been able to fill in some gaps. 

My hope is that at some point in this lecture series, these details need to be attended to. It just must. Like I said, we can't build from here and talk about a lot of other fun, cool digital modalities until we have the basics met. And that's what we're doing here today in terms of the professional encounter, informed consent, safety planning, setting up yourself to succeed, setting up your client or patient assisted, proper documentation using the CAPS-LOCK system to help guide you with all that. 

So my hope is that we were able to successfully relay this information today. However, I want to be very available to you. If you need to get a hold of me, this is how you do it. And thank you for attending today, and good luck with your virtual care clinic. Thank you.