Are you adjusting your practice?

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I seriously cannot believe I am going to be this person, but I'm wondering if anyone (or anyone's employer) is making preparations to shift their practice to primarily telehealth given all this Coronavirus stuff. I am particularly interested in those of you who work in a hospital setting.

I see most of my patients over video as it is, and I'm going to suggest to my in person clients that they get set up for video just in case. I'm debating whether I should start with some of the new group offerings I've been planning or wait a few weeks to see what pans out.

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I work for a large AMC. We haven't rolled out telehealth very widely yet, and it's not something that administrators have emphasized in the response to COVID-19 so far. Mostly the focus is on standardizing risk assessment and infection control. However, it wouldn't surprise me if more clinics started to offer telehealth over the next few months. I'm still in "wait and see" mode, but I already have teleheath training and would offer telehealth if my clinics start to thin out.
 
somewhat. I live & work in the SF bay area and for several weeks now local groups have been suggesting we consider how we'd adjust to a variety of scenarios. At the academic institution we've been reminded about easy prevention measures (hand washing) and asked to think about how we'd carry on remote instruction. For the private practice, local listservs were encouraging folks to talk with clients about telehealth options and to get signed consents should we need to move to remote sessions; I started those conversations last seek.

Anecdotally, two of my clients have links to infected areas of the world -- one visited a parent in China for a few weeks in December, just before the outbreak seems to have been picked up by media, and came back to the US without issue. They showed no symptoms. The second client has a child studying abroad in a different country who came home to the US in Jan, then returned to the academic-host country just as it was emerging as a hot spot. That child was sick while they were here in the US and thought nothing of it as it was also just before news broke. They subsequently spent time quarantined and have eventually returned to the US as the program made the decision to end for the remainder of the semester. Obviously, both clients are concerned about their family's health and it's come up in session. For other clients with no direct links it's less of a worry, however most have expressed some anxiety about the potential disruptions to daily life. I imagine if it's coming up in my small private practice, other clinicians in the area with much larger caseloads must also be discussing contingency plans and working through virus-related anxiety with clients.
 
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Our (VA) administration briefly mentioned that yesterday. We have full telehealth access provided that the patient is set up for it, so that's always an option. We also were just notified of our facility's screening process, although obviously therapists won't be in charge of that.
 
Lol. Has everyone lost their marbles? No one wants to get sick, but paaalease...
 
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Not quite as applicable to neuropsych assessment; if folks are sick, we'd just have to re-schedule. We have video connect capability for feedback appointments as needed, but there hasn't been an effort of which I'm aware to mandate (or even strongly push for) this yet.
 
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Not quite as applicable to neuropsych assessment; if folks are sick, we'd just have to re-schedule. We have video connect capability for feedback appointments as needed, but there hasn't been an effort of which I'm aware to mandate (or even strongly push for) this yet.
Yeah- can't really do remote developmental testing either. Rescheduling is tough too. I'd say that between October and April, pretty much every kid I see has a runny nose and cough, and they (toddlers) are very generous with sharing their boogies and saliva with the rest of us. I can wash the toys and stimulus stuff between sessions, but it just is not possible to wipe down everything within session. Getting sick in my line of work is an inevitability, despite the precautions I take. I do not see any necessary changes at this point because of coronavirus. Wash my hands as much as possible and try to be as generally healthy as possible so I not a high risk for mortality if I do contract something.

I really do wonder if there a more than currently known/reported less sever cases of COVID19 that just seem like a case of regular-old flu. If we are only identifying the most intensely impacted cases, then mortality rates are going to seem much higher.
 
My favorite news story I've read so far:

When an employee of the Dartmouth-Hitchcock Medical Center in New Hampshire showed signs of possible coronavirus last week, a medical worker who had examined him told him to avoid contact with others, pending further tests. Instead, he went to a mixer at a crowded music venue.
Three days later, he was confirmed as the state’s first coronavirus case.

People are idiots

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Lol. Has everyone lost their marbles? No one wants to get sick, but paaalease...
I had the flu about 6 weeks ago. After that, a chunk of my patients asked to switch to video appointments, which I can't really blame them for considering that I practice in a health psychology setting and the vast majority of my patients have conditions that make them particularly vulnerable.

If my kiddo's daycare were to be shut down due to quarantine (which is happening in some areas), I would almost definitely have to work from home and take turns providing childcare with my husband. Thankfully I have a home office set up with sound machine and everything. I don't think it's unreasonable to think about these things.
 
I lucked out that a few weeks back I blocked out larger chunks of time for the next six weeks to do a bunch of legal work, so I've had probably 70% less clinical patients....it's been wonderful.

As for telehealth, I'll like start doing it w my in-house counselor, though only for bad weather days and special circumstances for established cases.

Any info ppl want to share about setting up telehealth work would be welcome.
 
somewhat. I live & work in the SF bay area and for several weeks now local groups have been suggesting we consider how we'd adjust to a variety of scenarios. At the academic institution we've been reminded about easy prevention measures (hand washing) and asked to think about how we'd carry on remote instruction. For the private practice, local listservs were encouraging folks to talk with clients about telehealth options and to get signed consents should we need to move to remote sessions; I started those conversations last seek.

In some ways it feels like this post was a long time ago as so much has changed so quickly.

Some updates: nearly all clients have transitioned to telehealth, although a few still want to be seen in person. The building I'm in (large downtown multiuse office building) is following the Bay Area's "Shelter" guidelines and as such all support services have been suspended (janitorial, main building reception/security). BART, appropriately, was practically empty this morning as are the streets downtown. The academic institution suspended in-person instruction for a month as of Monday; first day of online teaching went well from my campus office.

I'm planning on teaching from home after this week but will continue to come into the office for therapy. I have two toddlers at home and can't imagine trying to see clients with the kiddos running around in the background, but I imagine my students won't mind.

How are others in PP/teaching adjusting?
 
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I’m doing the following-

-Intakes/parent interviews done over the phone
-Families instructed not to come in if anyone is sick or exposed and let them know that any signs of illness will result in them being sent away or not allowed into building. Families are very reluctant to cancel appointments that they have waited 6-9 months for, and would frequently bring in sick kiddos, so this will be a bit of a culture change.
-no toys or magazines in waiting area
-limit assessment participant to child and one parent, as well as only one early intervention staff if necessary (this will be tough as many families have multiple children who are home from school without access to childcare)
-family will text from parking lot and I’ll escort them to testing office (e.g., no waiting room)
-all porous/permeable materials removed from testing kit. Will use disposable material when possible (e.g., cloths/blankets; doll clothes). Play doh thrown out after each child
- schedule enough time between assessments (and ideally only one per day) to submerge wash all testing material ( or appropriately wipe/sanitize non-immersable items) as well as pens and clipboards
- sanitize all surfaces after each client
-do all non direct activities (e.g. report writing) from home
-frequent hand washing and use of
-I take my temperature every day
-I’ll probably shave my beard- it’s kind of a “quarter Gandalf” and is a frequent target for being grabbed by curious toddlers.
-review and update these guidelines daily based on new information
 
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Telehealth pointers:

1) Make sure the connection is HIPPA/HiTEC compliant. Skype is not.
2) For CMS patients, they HAVE to come into an established clinic or hospital. You can be elsewhere, so long as it is inside the USA.
3) There are guidelines stating you should show the patient the room you are in, to establish confidentiality. This can necessitate a swivel for your camera or computer. Think a high dollar lazy susan.
4) Use dual screens. Explain to patients that you are looking at dual screens; lest they think you are being shifty.
5) Have a policy/procedure in place for suicidal patients. This includes having pts addresses.
6) There's some guidelines that indicate telemedicine is only for established pts.
 
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After a PP client showed up to session in person with a cold and asked “can we still meet, though?” and then during session, casually mentioned they’d traveled to a huge tourist event out-of-state a week or two earlier, I made a judgment call that all future sessions are mandatorily phone for the time being in my PP, with the plan to switch to video/telehealth in a few weeks.

Classes are recorded lectures and participating in discussion threads. Group presentations are “online” using Zoom to remotely record their meeting/presentation and then they have to lead a “discussion” in the discussion thread. I had to spend several extra hours figuring out the online transition and Zoom this past week (and ADA compliance), and so far, I’m finding that this format is actually more time-consuming than just having in-person classes/exams, but it’s a small price to pay.

Local colleagues who work in multiple skilled care facilities (no telehealth option) are forced to choose between not working with no pay and annoying their employer (who has been guilting them into continuing to see older adult clients for therapy because they’ll get “lonely”) or continuing to work and exposing the most vulnerable population to illness/contagion in an area hit hard by Covid-19, AND exposing themselves and their families. Really highlights the extent of corporate greed.
 
Telehealth pointers:

1) Make sure the connection is HIPPA/HiTEC compliant. Skype is not.
2) For CMS patients, they HAVE to come into an established clinic or hospital. You can be elsewhere, so long as it is inside the USA.
Looks like (from press conference that is happening now) they are relaxing those standards
 
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After a PP client showed up to session in person with a cold and asked “can we still meet, though?” and then during session, casually mentioned they’d traveled to a huge tourist event out-of-state a week or two earlier, I made a judgment call that all future sessions are mandatorily phone for the time being in my PP, with the plan to switch to video/telehealth in a few weeks.

Classes are recorded lectures and participating in discussion threads. Group presentations are “online” using Zoom to remotely record their meeting/presentation and then they have to lead a “discussion” in the discussion thread. I had to spend several extra hours figuring out the online transition and Zoom this past week (and ADA compliance), and so far, I’m finding that this format is actually more time-consuming than just having in-person classes/exams, but it’s a small price to pay.

Local colleagues who work in multiple skilled care facilities (no telehealth option) are forced to choose between not working with no pay and annoying their employer (who has been guilting them into continuing to see older adult clients for therapy because they’ll get “lonely”) or continuing to work and exposing the most vulnerable population to illness/contagion in an area hit hard by Covid-19, AND exposing themselves and their families. Really highlights the extent of corporate greed.

I'm sorry, that really pisses me off. Clinical directors and regional managers really need to be setting the tone on what is appropriate. Many SNFs are not allowing contractors in anyway.
 
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Telehealth pointers:

1) Make sure the connection is HIPPA/HiTEC compliant. Skype is not.
2) For CMS patients, they HAVE to come into an established clinic or hospital. You can be elsewhere, so long as it is inside the USA.
3) There are guidelines stating you should show the patient the room you are in, to establish confidentiality. This can necessitate a swivel for your camera or computer. Think a high dollar lazy susan.
4) Use dual screens. Explain to patients that you are looking at dual screens; lest they think you are being shifty.
5) Have a policy/procedure in place for suicidal patients. This includes having pts addresses.
6) There's some guidelines that indicate telemedicine is only for established pts.

Dumb question: Is the phone HIPPA compliant? I've been hearing mixed messages.
 
Dumb question: Is the phone HIPPA compliant? I've been hearing mixed messages.

Phone calls to patients: yes, but there are rules in how you have to introduce yourself. Also better to have it in your informed consent.
Leaving messages: depends, but generally no
Text messages: not unless you have a hippa compliant service. Your cell phone is NOT compliant with these standards.
Emails: only if you have hippa/hitec compliant services that include encryption.
Phone calls to other providers: you never need a release, despite what people say.
 
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Another ethical question: for potential clients requesting new services in PP, is it currently acceptable due to the nature of the seclusion that we're all experiencing to conduct intakes over phone or video (even though normally that is frowned upon for able-bodied, local clients with no prior in-person therapy established)?
 
I'm feeling very conflicted about testing next week. My employer has essentially left it up for me to decide but I'm now thinking it may be going against my "patriotic duty."

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I'm feeling very conflicted about testing next week. My employer has essentially left it up for me to decide but I'm now thinking it may be going against my "patriotic duty."

Sent from my SM-G973U using Tapatalk

I would postpone testing if I had a choice.
 
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I cancelled all assessment for 2wks, though neuropsych will likely be a month or more. My counselor is doing telehealth appts. I'm hoping to get another document review or two on the legal side....as I have a few that are in the works. I'm basically taking the next two weeks off from new patients and then I'll re-evaluate. My hope is to have enough legal work to take on new patients more slowly.
 
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Another ethical question: for potential clients requesting new services in PP, is it currently acceptable due to the nature of the seclusion that we're all experiencing to conduct intakes over phone or video (even though normally that is frowned upon for able-bodied, local clients with no prior in-person therapy established)?

I don't see why not. You may want to give them the option of rescheduling for later in person or using phone/video now. You may want to check with their insurance if they are paying and ensure you are HIPAA compliant as well.
 
I have continued my non contact stuff, decreased my air travel, maintained my road travel, increased my Rye and wine holdings, and strengthened my self protection holdings.
 
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I would postpone testing if I had a choice.
We will be suspending all in-person services and moving to telehealth only practice starting immediately. This will include all of our heretofore home based ABA therapy services as well. It’s going to be interesting, and we will all learn a lot about what we do and how we do it.
 
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I have continued my non contact stuff, decreased my air travel, maintained my road travel, increased my Rye and wine holdings, and strengthened my self protection holdings.

Proper hazard planning, I see.
 
I have continued my non contact stuff, decreased my air travel, maintained my road travel, increased my Rye and wine holdings, and strengthened my self protection holdings.

Also taken these precautions. Also planning on increasing the former tomorrow after work.
 
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Proper hazard planning, I see.

I have also identified which one of my neighbors is the most elderly and has the best hoard. You don’t have to prepare, only outlive those that have.

Also taken these precautions. Also planning on increasing the former tomorrow after work tomorrow.


 
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I seriously cannot believe I am going to be this person, but I'm wondering if anyone (or anyone's employer) is making preparations to shift their practice to primarily telehealth given all this Coronavirus stuff. I am particularly interested in those of you who work in a hospital setting.

I see most of my patients over video as it is, and I'm going to suggest to my in person clients that they get set up for video just in case. I'm debating whether I should start with some of the new group offerings I've been planning or wait a few weeks to see what pans out.
Depressing but really glad I got things moving a couple weeks ago.
 
My adjunct teaching gigs have been moved fully online. It will be nice to be able to lecture in comfort from home.

Not sure if any teaching folks are using Zoom or other popular video platforms to record lectures for students to watch later, but processing of video has hit a major backlog now that so many are switching or have switched to online classes. It used to take 2 hours to process a 90-minute video, but it’s now up to 2 days and counting for Zoom. I’m not sure if my lecture recording from Monday will even be ready by Friday. I was 248th in the queue for Zoom tech support, by the way. I’m now in the limbo of having to decide if I should re-record audio only via a phone app and lose another 90 minutes of time. I regret not thinking to record audio as a backup on Monday as I recorded my video lecture!
 
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Anyone have any thoughts on how to effectively use phone sessions? I'm kind of just offering the patient that time to use as they need it. I feel like it'd be really difficult to do, say, worksheets over the phone. Especially since some of these patients are ones I haven't met in person yet.
 
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I think you absolutely can do worksheets over the phone, if you can email them a copy so that you are both looking at the same paper and filling it out simultaneously.
 
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I think you absolutely can do worksheets over the phone, if you can email them a copy so that you are both looking at the same paper and filling it out simultaneously.

I work in the VA so we aren't allowed to email patients. It's made this logistically very difficult.
 
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I think you absolutely can do worksheets over the phone, if you can email them a copy so that you are both looking at the same paper and filling it out simultaneously.

You can only do that if your email is HIPPA compliant. Or at least that was the case 2 weeks ago.
 
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Yes, I'm assuming a HIPAA compliant email system, of course. I know some practices/settings have admin staff that can distribute documents by email even when they have a no-clinicians-emailing policy. Also some have ways of securely sharely documents with patients through online portals. Don't know if any of that is available at the VA though.

Additionally, this wouldn't apply to phone sessions but for anyone using a HIPAA-compliant video conferencing software, many of them have chat features that fall within the HIPAA-compliant functions, so if you have a link to an online PDF or something you can send it through there.
 
Get all your patients signed up for myhealthevet and use secure messaging! They can now sign up for premium accounts without a trip to the medical center.

Secure messaging doesn't work for me. It's a huge mystery that they haven't been able to solve.
 
Secure messaging doesn't work for me. It's a huge mystery that they haven't been able to solve.

In what way does it not work for you? If you don't get the alerts, there is a 'focused' and 'other' inbox in Outlook, the secure message communications go to the 'other' inbox for a lot of people.

We are having problems with VVC/telehealth at my facility. We seem to be testing the capacity of the system and I couldn't schedule a session this morning.
 
In what way does it not work for you? If you don't get the alerts, there is a 'focused' and 'other' inbox in Outlook, the secure message communications go to the 'other' inbox for a lot of people.

We are having problems with VVC/telehealth at my facility. We seem to be testing the capacity of the system and I couldn't schedule a session this morning.

I literally can't access my account.

Yup, VVC is down for us as well. Even our phones are having trouble and calls are getting dropped or not going out. I saw this article earlier and laughed really hard: Nation Close To Getting Videoconferencing Software To Work
 
I really, really, really hope that one thing that comes out of all this is a dramatic overhaul of HIPAA. Of all the poorly thought out crap-tastic laws that create unnecessary problems for patients and healthcare providers alike, this is it. Massive overkill made worse by the fact that it is outdated and was super-vague even at the time it was written.

I look forward to the day it is actually possible to reach a healthcare provider or I can tell them to leave the damn test results on my voicemail and have them actually do it so we don't have to spend 3 weeks playing phone tag. Admittedly some things need should be said in-person or warrant a bit more sensitivity, but you can post my CBC results publicly on your website for all I care. Virtually all of my patients would prefer text, security be damned (and I don't see many younger folks where I imagine it is even more prevalent). Even when I tell them not to text me...they do. Sometimes they even try to text my office phone because what kind of phone can't text these days? If we just rewrote the darn thing to make it so people could "opt-in" to the no-text, no email, call me 50 times until you get me and I provide 18 forms of identification, etc., we could resolve a helluva lot of annoyances most people have with the healthcare system (and *gasp* maybe start to cut costs!).

Sorry. OT rant.

I really hate HIPAA, everyone involved in writing it and everyone involved in enforcing it.
 
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Anyone have any thoughts on how to effectively use phone sessions? I'm kind of just offering the patient that time to use as they need it. I feel like it'd be really difficult to do, say, worksheets over the phone. Especially since some of these patients are ones I haven't met in person yet.

Ranges widely on the patient and case, but has tended to be most effective as less structured and range from check-ins to continuing treatment like we never missed a beat. I just go where the patient wants the session to go. All my patients are in different places emotionally, cognitively, sense of personal safety, f***ks they give about psychotherapy right now, that I leave it up to them until they demonstrate they need me to be more direct with the session content/objectives and take the lead in a more obvious way.
 
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just finishing my first "full week" (1.5 days) of pp since the more extreme distancing/shelter-in-place guidelines have been in place. From a clinical / researcher perspective I am fascinated by the varied ways people are coping. One thing clear to me, at least here in the Bay Area, is an increase in intensity of underlying/preexisting symptoms along with emergence of new interpersonal difficulties -- either couples feeling extra strained or single people feeling extra lonely.

I've also experienced a slight uptick in demand; both in new client inquiries and from former clients who had since terminated but are now seeking to come back in for a few sessions.

One of my coping strategies is intellectualization. I'm leaning into it and so also worked on a new IRB protocol this week through my academic institution to collect qualitative data about how students and professors are coping with the changes and adjusting their teaching & learning.

What other clinical observations are y'all noticing?
 
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Oddly enough, I have had the opposite experience. It is likely partly a function of my current caseload, which just so happens to be a crop of fairly high functioning folks who showed up all at once (I have a small caseload), but it freaking cured everyone. I think some true tragedy can help give the "worried well" some perspective, or at least that is my take this far. We

I love the research idea and wanted to do something similar, but just don't have the bandwidth to put something together right now. If you want a collaborator, feel free to PM.
 
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Anyone have any thoughts on how to effectively use phone sessions? I'm kind of just offering the patient that time to use as they need it. I feel like it'd be really difficult to do, say, worksheets over the phone. Especially since some of these patients are ones I haven't met in person yet.

I think introducing mindfulness skills would be helpful, worksheets not necessary. Admittedly I flat out despise CBT solely because of its worksheets. I have yet to have a client that is organized enough to keep track of a single worksheet. So it was either set them on fire or find another technique. I'm seeing my clients via video, still doing mindfulness, and its going well. If the phone were necessary I'd just keep doing what I'm doing.
 
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Yeah, I've experienced less volume than usual. I guess cancellations and no shows are up a bunch at our facility so it isn't just me. Even for phone sessions, people don't seem to want to talk very long.
 
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I think introducing mindfulness skills would be helpful, worksheets not necessary. Admittedly I flat out despise CBT solely because of its worksheets. I have yet to have a client that is organized enough to keep track of a single worksheet. So it was either set them on fire or find another technique. I'm seeing my clients via video, still doing mindfulness, and its going well. If the phone were necessary I'd just keep doing what I'm doing.

Are you in the VA? That's the only setting I've ever had a problem getting patients to use worksheets in therapy. And, I have worked with some fairly low functioning people. Worksheets should never be the driving force of therapy, but they can be a pretty good demonstration of some skills, and also allow me to show them trends over time.
 
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