SUPPORTING ACCESS TO TELEHEALTH FOR ADDICTION SERVICES
Regulatory Overview and General Practice Considerations
Purpose of the document
The purpose of this document is to provide guidance to addiction treatment clinicians and programs on the regu- latory and general practice issues related to the use of telehealth during the COVID-19 national emergency, which is also a public health emergency.
This document contains links to other websites and content belonging to or originating from third parties. Such external links are provided for informational and educational purposes only and are not investigated, monitored or checked for accuracy, adequacy, validity, reliability, availability or completeness by ASAM.
In general, telehealth policy at the state level is variable and has rapidly changed during the COVID-19 pandemic. ASAM strives to post state-level guidance as they become available (see “ State Policy Changes” section); however, we recommend that clinicians seek guidance from their state authorities to ensure compliance with changes and appropriate billing. ASAM can also be a resource during this time. ASAM is working with its state chapters and regions to help address concerns related to state regulations and policies. If you have questions or concerns related to the guidance in this document, please email COVID@asam.org.
Benefits of Using Telehealth
The National Consortium of Telehealth Resource Centers defines telehealth as the use of electronic information and telecommunications technologies to support and promote long-distance clinical health care, patient and professional health-related education, public health, and health administration. Federal and state regulators have re- laxed regulations, governing the use of telehealth for general medical services as well as for addiction services including the use of phone only or audio/visual technologies, due to a declaration of a national emergency.
Using telehealth during the COVID-19 pandemic offers numerous benefits that apply across the continuum of addiction services including outpatient, office based opioid treatment (OBOT), residential settings, and opioid treatment programs (OTP).
These benefits include but are not limited to the following:
- Promotes the practice of physical distancing to reduce viral spread – shifting visits and initial patient evaluation to a modality that does not require in-person and face-to-face interaction and thereby limiting the physical contact between staff and patients.
- Addresses COVID-19 and other epidemic situations by limiting exposure to infection for vulnerable popula- tions and health care workers.
- Expands the reach of resources to communities that have limited access to needed services.
- Allows monitoring of patients to identify potential and confirmed cases without person-to-person contact.
- Enables quarantined clinicians to continue to safely treat patients remotely.
- Reduces the risk of spread in high-volume/traffic areas such as waiting rooms by reducing the number of pa- tients requiring face-to-face visits.
- Enables clinicians to continue patient engagement while reducing potential for exposure for those who are considered most vulnerable to COVID-19.
- Reduces the likelihood of patients participating in activities/behaviors outside of the clinic that could increase risk of exposure, such as use of public transportation to attend appointments.
Federal Policy Changes
Like state Medicaid programs, the policies of individual health plans are unique to each payor. Clinicians are encouraged to contact the payors they work with to permit addiction services to be provided via telehealth and or via telephone using the established CPT codes commonly used during in-person care.
General Considerations for Implementing Telehealth
The following considerations were drawn from Best Practices for Telehealth During COVID-19 Public Health Emergency (National Council for Behavioral Health) and the AMA’s Quick Guide to Telehealth.
Vendor evaluation and selection: Check with your existing EHR vendor to see if there is telehealth functionality that can be turned on. Reach out to your state medical association/society for guidance on vendor evaluation, selection and contracting. (AMA)
Communicate visit changes to your patients: Let your patients know about your practice’s telehealth policies. If you will only be providing telehealth visits, post information to your website, consider changing your organizations phone script to include this information at the beginning of your recording, call patients with upcoming appointments and offer telehealth visits. Consider targeted outreach to “high risk” patients. Also ensure that you are able to continue providing care to those patients who may not have access to telehealth services. (National Council)
Practice using technology first: Whatever application you decide to use, practice with other staff before you use it with a patient. You may be able to recommend preferred video conferencing applications to patients and send them test links to make sure a connection is available before starting your session. (National Council)
Create a backup plan: Establish protocols in case escalation of care is required or technology fails. Do you need to consult with another provider? What backup technology could you use? (National Council)
Consider appropriate screening tools: If you are still offering in-person appointments, incorporate approaches for screening for COVID-19 symptoms prior to arrival and upon arrival and protocols for shifting appointments to virtual should someone be presenting with symptoms. If someone is displaying symptoms but is in crisis or re- quires immediate support, consider protocols and partnerships that can alert EMS/crisis response teams. (National Council)
Workflow: Determine when telehealth visits will be available on the schedule (i.e. throughout the day intermixed with in-person visits or for a set block of time specifically devoted to virtual visits). Set up space in your practice and/or home to accommodate telehealth visits. Also, have plans for how to continue providing care to patients who are not able to access telehealth services for whatever reason.
Documentation and record keeping: Ensure you are still properly documenting these visits – preferably in your existing EHR as you normally would with an in-person visit. This will keep the patient’s medical record together, al- low for consistent procedures for ordering testing, medications, etc. and support billing for telehealth visits. Ensure your staff are kept abreast of policy or billing changes as states and private payers adopt and expand access so that documentation is in compliance. (AMA, see resources below)
Check in with patients: Find out where the trouble areas are for them and make changes where necessary. Check in during the visit and afterwards. Did they struggle with this type of communication? (National Council, see re- sources below)
Switching to a different application: Consider testing the patient’s internet and/ or phone connection before the telehealth visit. (National Council, see resources below)
Malpractice insurance: Check with your malpractice insurance carrier to ensure your policy covers providing care via telehealth. (AMA, see resources below)
- AMA Quick Guide to Telemedicine in Practice: https://www.ama-assn.org/practice-management/digital/ama-quick-guide-telemedicine-practice
- American Psychiatric Association: Telepsychiatry and COVID-19: https://www.psychiatry.org/psychiatrists/practice/telepsychiatry/blog/apa-resources-on-telepsychiatry-and-covid-19
- CMS General Provider Toolkit: https://www.cms.gov/files/document/general-telemedicine-toolkit.pdf
- National Consortium of Telehealth Resource Centers: https://www.telehealthresourcecenter.org/
- National Council Resources for COVID-19: https://www.thenationalcouncil.org/covid19/
1 This resource was developed by a Task Force appointed by ASAM’s Executive Council. To enable more rapid development and dissemination it was not developed through ASAM’s normal process for clinical guidance development that is overseen by the ASAM Quality Improvement Council.
This Clinical Guidance (“Guidance”) is provided for informational and educational purposes only. It is intended to provide practical clinical guidance to ad- diction medicine physicians and others caring for individuals with substance use disorders during the COVID-19 pandemic as it unfolds. Adherence to any recommendations included in this Guidance will not ensure successful treatment in every situation. Furthermore, the recommendations contained in this Guidance should not be interpreted as setting a standard of care or be deemed inclusive of all proper methods of care nor exclusive of other methods of care reasonably directed to obtaining the same results.
The ultimate judgment regarding the propriety of any specific therapy must be made by the physician and the patient in light of all the circumstances pre- sented by the individual patient, and the known variability and biological behavior of the medical condition.
This Guidance and its conclusions and recommendations reflect the best available information at the time the Guidance was prepared. The results of future studies may require revisions to the recommendations in this Guidance to reflect new data. ASAM does not warrant the accuracy or completeness of the Guidance and assumes no responsibility for any injury or damage to persons or property arising out of or related to any use of this Guidance or for any errors or omissions.
If you are a patient or family member or friend in need of immediate assistance:
- Disaster Distress Helpline
Call 1-800-985-5990 or text TalkWithUs to 66746
- National Suicide Prevention Lifeline
Call 800-273-8255 or Chat with Lifeline
About COVID-19 Taskforce Members
If you have questions related to the guidance in this document or suggestions for additional topics, please email COVID@asam.org