Telehealth Best Practices Guide

Determine if telehealth is suitable for your work with youth and families, plan effective telehealth sessions, and troubleshoot common complications that may arise.

This resource is designed to assist providers who are serving youth and families via telehealth. Whether you are considering telehealth as a feasible service modality or looking to enhance your existing telehealth practice, this guide is here to support you.

Its primary objectives are to help you determine if telehealth is suitable for your work with youth and families, plan effective telehealth sessions, and troubleshoot common complications that may arise. You can use this telehealth guide and best practices to gain insights into strategies for successful telehealth delivery. Make the most of this resource by utilizing the accompanying checklist, which offers a comprehensive overview of key considerations for telehealth sessions.

Preparation Phase

Research Relevant Laws and Rules

Different states may have different rules about the practice of telehealth. Professions and states have varied laws about providing services across state lines; for instance, it is often not permissible for a provider licensed in one state to serve a family in a different state without also being licensed there.

Familiarize yourself with local regulations based on where you are practicing from and the youth/family’s location.
You may also need to learn local laws relevant to practice (e.g., age of majority, age of consent, mandated reporting) and to verify that your professional liability insurance covers telehealth activities in all of the locations of your telehealth practice.
Finally, you also may need to consider unique billing practices for telehealth in your area and for insurance panels.

Engage in Training And/or Consultation Prior to Offering Services via Telehealth

Formal training in telehealth and providing services to the communities commonly served via telehealth should be undertaken prior to offering care. Telehealth is an emerging modality with research, professional guidelines, and new technologies evolving rapidly, so seeking continuing education will be key. Important telehealth competencies to acquire and maintain include:

Technical skills (e.g., computer and videoconferencing knowledge)
Triage and assessment skills
Risk mitigation skills
Rapport-building skills
Knowledge of how to adapt services for remote delivery
Consultation skills
Online administrative skills (e.g., online progress monitoring, documentation, billing)
Ethical/legal knowledge
Ethno-cultural considerations.

Establish Policies and Consent for Telehealth

You or your agency should develop thorough policies and procedures specific to telehealth services. You should also provide informed consent to families on these policies, allowing them to understand what they can expect from engaging in telehealth. Such informed consent should include:

Explicit agreement to the virtual modality (and right to refuse the modality)
Risks/benefits of online services
Electronic confidentiality, maintaining privacy of physical space, recording of sessions by the provider only (if a necessary procedure for the setting, e.g., a training clinic), emergency procedures, and your affiliation/location.

It may also be important to have a discussion about circumstances under which telehealth may have to be discontinued.

Service Suitability or Family Match Phase

Consider Family’s Match With Telehealth

Telehealth is an appropriate and convenient service delivery model for many concerns, but not for all. Consider the following factors when determining whether telehealth is the right modality for the family:

Is the family open to a telehealth option?

What are the main concerns for the youth?

Telehealth may not be a good fit for some youth (e.g., children under age 10, youth with behavioral challenges, youth with intellectual/developmental disabilities, or youth with psychosis) who may not be able to stay engaged without more direct interaction.
Telehealth may also be inappropriate for youth with active suicidal risk and/or families with maltreatment/violence history in the home due to the more limited options for maintaining safety and enlisting the help of emergency services during remote sessions.

Will the child or family need assessment or evaluation?

Some forms of testing are easily adapted to the virtual environment; others are not.
Providers working with youth may be more likely to need to administer standardized testing involving manipulatives, demonstration, and extensive instructions.
Consider whether these approaches can be adapted for telehealth without sacrificing standardized assessment validity and reliability.

Assess Access to and Familiarity With Technology

Assess the following technology issues before committing to telehealth:

Do you and the family have access to appropriate hardware and software (e.g., a computer with a webcam and good screen resolution, videoconferencing capabilities, microphones that pick up the pitches of youth voices)?
Is the video software you are using HIPAA-compatible?
Do you and the family have a stable, high-speed internet connection?
Do you and the family have enough familiarity with operating and problem-solving the technology required? If not, would basic training, practice, or an FAQ sheet help resolve the issue?
Can someone be available to offer technical support, such as help filling out forms electronically or trouble-shooting sign-on issues?
Is the telehealth platform available in the family’s preferred language?
If the youth or caregiver has a disability, are you able to provide appropriate accommodations (e.g., closed captioning) on the virtual platform?

Consider Diversity and Adapt as Needed

Telehealth platforms often connect you with families who may be far removed from you both geographically and culturally.

Pay special attention to exercising cultural humility and building rapport. Keep in mind different social groups’ historical relationship with and attitudes toward technology. If a family is meeting with you from their home, you may (with consent) have more access to members of the family, extended family, or even community members to provide information and support the family in services.
Even when providing telehealth services, making a physical visit to the family’s home or community, when possible, can provide a wealth of data about the context and culture the youth exists in.

Engagement/Practice Phase

Ensure Privacy and Confidentiality

Both the family and the provider will need to have audio and visual privacy to conduct a session ethically.
You should use secure, HIPAA-compliant hardware and software for all service interactions and documentation.
Internet connections also need to be private (not public WiFi networks).
You should plan ahead for how to handle any disruptions.
- What if you hear voices in the background?
- What will you do if someone else not involved in the session enters the room?
You should also safeguard your own privacy and boundaries if you will be working from home (e.g., using a neutral wall or obscured/virtual background for meetings, use a white noise machine if needed).

Identify a Safe and Suitable Space

Both the family and you will need to have a safe, well-lit, and distraction-free space from which to meet each time. Other considerations about space may include the following:

IDENTIFIABLE LOCATION:

You will need to be able to confirm a stable location for the youth. The address should be confirmed at each session in case of emergency.
For this reason, it is typically not appropriate for a youth to meet with you from a location without an address (e.g., a car, outdoors removed from buildings).

ROOM SIZE:

Recommend meeting from a room that is:
Large enough to include caregivers and to offer the opportunity to observe youth behavior/activity but small enough to prevent a younger youth from wandering away.

MEETING SETUP:

Cameras and microphones should be placed close enough to pick up the youth’s voice and behavior, but not so close that the field of vision is limited or the technology picks up extraneous or high-volume sound.
If multiple individuals will be present, determine whether they will all meet on one device/location or join from different devices/locations.

For certain types of dangerous home environments or high-stakes evaluations (e.g., forensic, abuse, custody), determine whether the home is a neutral enough environment from which to conduct the meeting.

Establish Expectations for Telehealth Sessions

You should discuss expectations for the session in advance or at the beginning:

MEETING ATTENDANCE

It should be discussed in advance whether adult supervision (in the room or in the home) is required, or who else needs to be present to participate directly in the session.
All people who are in the room for the meetings should be identified, regardless of who is on camera.

FOCUSED PARTICIPATION

Sessions proceed effectively if the youth/family is focused:
- Not moving around
- Not working on other tasks
- Not watching a video or playing a game on the same computer
- Has their camera on
- Refrains from using substances prior to or during
- Maintains appropriate dress code, etc.
For instance, you might ask the youth, “What do you think you can do to make sure you are focused on what we are talking about?”

POTENTIAL DISRUPTIONS

It is important to ask about possible interruptions (someone ringing the doorbell, a pet interrupting, phone notifications) and plan for how to handle these.
For example, you might prepare the family by asking ahead of time, “Can your mom hold on to your phone while we talk so the notifications are not distracting?”
If an unexpected disruption occurs, you could ask something like, “Will asking your mom to entertain your puppy while we talk be helpful?”

Adapt Services to Promote Engagement and Effectiveness

You can make several preparations ahead of time and modify service provision as you go to maximize participation:

You may have to ask for the help of a caregiver for setting up the technology, making other writing/play materials available, managing behavior/redirection, or even implementing certain parts of interventions.
Consider starting services by giving the youth a virtual tour of your office or ask for a tour of their space, both to build rapport and to ensure confidentiality.
Virtual meetings can make reading nonverbal social cues and eye contact more difficult, so you may have to be more animated (e.g., use more hand gestures, intonation) or ask more direct questions of the youth (e.g., explanations of off-screen events or behavior) to gather accurate behavioral observations. Likewise, you may need to pay added attention to the youth’s nonverbal cues, such as changes in eye contact, breathing, or speed in responding. It may be appropriate to call attention to such nonverbals more often (e.g., “I notice that you tend to look away from the screen when I mention your old school. What went through your mind just now when I mentioned it?”).
Minimize verbal discussion and maximize interactive, visual elements (e.g., whiteboards, games) and playfulness (e.g., use virtual backgrounds). Use screen sharing often, but make sure to have other windows and private information on your computer closed prior to doing so.
The greater concentration demands of telehealth sessions may result in your needing to shorten session lengths.
Given limitations of virtual assessment of very young children or those with behavioral challenges, the interview with the parent, behavioral observations, record review, ratings scales, etc. may need to be relied on more heavily.

Important Considerations & Precautions

Evaluate the Potential Effect of Telehealth on Behavior

Remember that the virtual environment may be somewhat unfamiliar, artificial, or constraining for some youth. Asking them to sit in front of a computer for a session for an extended period may result in atypical behaviors with regard to their attention, social interactions, behavioral acting out, or frustration tolerance relative to what you would see in typical in-person settings. Also, you may need to consider that having a familiar adult present (e.g., caregiver) to facilitate the session may affect youth behavior (e.g., acting out, concerns about confidentiality). You may need to take additional time for rapport building and refocusing. Alternatively, the use of technology may make services seem more familiar and less intimidating to other youth and result in increased engagement and self-disclosure.

Anticipate Risk Assessment & Safety Planning

Many aspects of risk assessment and crisis management are the same for telehealth and in-person services; however, some special telehealth considerations may include the following:

Making sure you have a phone number to reach the youth, as well as their current location, and ensuring a caregiver is at home at the time of the session in case of emergencies.
Researching the emergency resources or back-up providers in the family’s local area ahead of time.
Having both audio and video connection for risk assessment scenarios in order to observe the youth’s affect and their current status.
Following thorough risk management steps if a crisis arises:
1. Risk assessment with a formal tool,
2. Caregiver contact/interview,
3. Assessment of risk level,
4. Interventions/safety planning (including planning caregiver actions and evaluating their capacity to complete them),
5. Consultation with other team-members (e.g., teachers, psychiatrist), and
6. Referral to local emergency care, if needed.
Continuing the session until emergency services arrive.
Being prepared with a plan for both psychological and medical/physical emergencies in the event the youth has other health conditions. If there is a known risk, you may consider proactively creating a safety plan or requesting releases of information at the time of informed consent.
Planning strategies for de-escalating strong emotions (e.g., session breaks, breathing exercises) or preventing the youth leaving the session room early when distressed (e.g., parent supervision).

Participate in Ongoing Self-Care

Telehealth can take increased attention/preparation and can even cause physical risks for you (e.g., eye strain, back pain). Some providers feel they are not able to be as effective or that they have more difficulty with boundaries in telehealth or work-from-home situations. As such, it is ethically imperative that you engage in ongoing self-assessment and self-care. Activities may include seeking additional professional support, securing reliable technology, creating a comfortable workspace set up (e.g., well-lit, adequate furniture, access to fresh air), maintaining a manageable workload with time for breaks, increasing access to self-regulating strategies, and potentially engaging in co-therapy to provide a sense of collegial support and connectedness.

Telehealth Best Practices Checklist

View or download the telehealth guide and best practices checklist.