Staring down a wave of emotional disruption, collateral damage from the spread of COVID-19, counselor Marie Collins knew she was going to have to make a change, fast. By Sunday, a shelter-in-place order was issued for all of Louisiana. It was time for her and her staff to take the plunge into teletherapy.
“I knew there was going to be a need to fill, and we were going to make it happen,” Collins says. Collins is the executive director of The Family Tree, a counseling center in Lafayette. Her office stopped face-to-face interactions with clients. Everything would have to go online.
Before the pandemic, Collins and her nine counselors dragged their feet on getting into telehealth. Insurance restrictions and the extra training required by the state board put it on the back burner. Beyond the regulatory roadblocks, the counselors worried something would be lost in therapy at a distance.
“There’s something about being able to sit in front of another person in the same room,” Collins says. “I guess it’s the assumption of more control.”
When it was clear the state was set to go on near lockdown in the face of mounting tallies of confirmed coronavirus infections, Collins moved. Over the weekend, they selected a HIPAA-compliant therapy portal — doxy.me — that’s friction free for patients. The platform is encrypted, collects no identifying information and doesn’t require any downloads. Family Tree’s staff crammed in some practice sessions over the weekend and did what they could to prepare a new normal. On Monday, they went live. The Family Tree rolled out convenience packages for clients who pay out of pocket. They cut session prices roughly in half and rolled out a 30-minute session option to add more flexibility.
On any given week, The Family Tree books 100 to 150 sessions. Of those, only a handful opted in. Most of the rest preferred to wait until after the storm blew over, Collins says. A wave of anxiety is setting in, but the crash of new bookings may take some time to materialize.
Generally, mental health providers have lagged behind the rest of the healthcare profession to get into telehealth. Counselors worry that the stressors stoked and explored during counseling sessions could push their clientele to drop out of calls without much recourse for the counselor in the session. A nightmare concern is what to do with clients who flare into suicidal thoughts and begin to spiral on a call. How can a counselor prevent a tragedy from miles away.
“I trust that, with training, we’re learning to deal with that,” Collins says, adding that there are protocols in place to deal with emergencies. The required intake forms assess client risk, asking patients to declare whether they have firearms, among other info.
At the moment, The Family Tree’s staff is learning the trade on the go. During the pandemic, the Louisiana Board of Licensed Professional Counselors waived the required nine hours of training for LPCs to practice teletherapy; the social worker board allows its membership to practice teletherapy without the extra training. Those steps were among a slate of emergency public policy changes designed to loosen the regulatory grip on remote counseling. Rules rolled out this week by the state insurance commission require that insurers pay for mental health services, regardless of whether they’re provided in person or at a distance. In cases where counselors take private insurance, remote treatment would have to be covered if the same treatment is covered for in-person visits.
The Family Tree primarily serves a clientele on Medicaid or Medicare and doesn’t take private insurance. But Medicaid’s telehealth rules previously limited the availability of the service to people who could make a case that they needed it; for instance, clients who were too far from clinicians to get care. Changes have cleared those restrictions out of the way, for the time being, opening up the clinic’s range of services.
It’s still taking some getting used to. In a quick demonstration with me, The Family Tree’s Director of Clinical Services Lisa LaRochelle ran into a brief snafu with the platform’s audio — the sort of video-conferencing breakdown we’re all getting more and more accustomed to these days as meetings go virtual. Down the hall, one of LaRochelle’s counselors was in the middle of The Family Tree’s first session. They’re hopeful that after this week, they’ll get the hang of the technology, which runs essentially like Facetime or Skype or Zoom, except with the added security to keep the sessions HIPAA compliant and safe from data harvesting.
It’s still early into the telehealth era for The Family Tree, but so far the challenge has been getting clients on board. Collins and LaRochelle attribute that mostly to the pandemic itself. People are dealing with more immediate needs than their emotional wellbeing, making sure they have food in the pantry and toilet paper to weather the weeks ahead.
The pandemic could strain the nonprofit counseling center’s bottom line. Losing most of their bookings means fewer billable visits. The counselors need to get paid, and if the remote strategy works, they’ll be able to keep some revenue going.
Broadly speaking, telemedicine has struggled to get off the ground in Louisiana, mostly because of the tangle of regulations that restrained its widespread use. Blue Cross Blue Shield healthcare economist Michael Bertaut believes the cutbacks on red tape may yet unlock wider participation in telehealth programs in the medical community. But it’s not a light switch that will turn on immediately.
“We still have to develop the technology, still got to find the docs, and make sure they can get paid,” Bertaut says. “The regulatory hurdles coming down is a great step. If we’re gonna go in that direction, it’s still going to take some technical competence to make that work.”
Blue Cross waived co-pays in its network last week, reducing costs of care during the pandemic. The company already covered telehealth, before the pandemic-related changes, including most teletherapy. Even with enhanced access like that, it’s not uniform that providers can take the fast approach kicked off by The Family Tree. Not every type of care is equally suited to a remote visit. And that’s true even in mental health.
LaRochelle mostly works with kids, a population that’s tough to reach for teletherapy providers. Play therapy — where kids engage with toys while working with a counselor — is more or less impossible. LaRochelle is turning to scheduling counseling sessions with parents instead, in hopes that they can get a little help in how to support their kids. There’s concern that they’ll struggle to intervene in cases of child abuse. More and more kids in abusive homes are now stuck in those environments, and there’s nothing teletherapy can do about that.
For her part, LaRochelle expects that the pattern of need will mimic the waves of emotional fallout after Hurricane Katrina and the 2016 floods. Patients will show up once the physical necessities are in place, and they’ll show up big. To that end, they expect many of those people will take the teletherapy option. COVID-19 forced the issue for Family Tree, and will likely make similar ripples across the healthcare industry, spurring providers to try it and those already doing it to rely on the option more.
“It’s going to depend on the person,” LaRochelle says of her own work, pointing out that many will come back to visit with her in person, when the time comes. “But I’m pretty confident [some] people who begin doing teletherapy won’t go back to face-to-face, because it’s convenient.”