University of Wisconsin–Madison
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Implementing Virtual Human Services: Lessons from Telehealth

  • June 2020
  • Fast Focus Research/Policy Brief No. 49-2020

Telehealth interventions can include messaging, online educational content, and remote visits with providers.

In response to the Covid-19 pandemic, many human services agencies have had to quickly shift to remote case management, using whatever tools are available. In normal times, developing a comprehensive remote system might involve planning, piloting, and iterating repeatedly before beginning wide-scale implementation. Although agencies may not have sufficient time to conduct such a robust planning cycle, the experiences from telehealth and remote home visiting programs can inform their services during the crisis.

This brief summarizes findings from roughly 40 sources, including case studies, resource documents, and implementation guides from various telehealth and home visiting organizations, to outline the lessons learned from telehealth and remote home visiting programs for parents. The health care field has made significant progress in implementing telehealth services such as messaging, online educational content, and remote visits with providers. In addition, home visiting programs for parents have also had some early successes with remote case management.

Keeping key lessons in mind can help providers shifting to virtual services.

Several lessons learned from telehealth and virtual home visiting programs are especially relevant to virtual case management during the pandemic, such as the following:

  • Put the client experience at the forefront. Consider clients with limited internet access or device access and prioritize and communicate processes to ensure client privacy and confidentiality.
  • Pair technology-oriented and mission-oriented individuals within your organization to build an intuitive workflow.
  • Recognize that your initial processes or systems will likely miss some components and be prepared to adapt.
  • Create training that is simple and direct to best engage and prepare staff.
  • Identify several champions—motivated individuals within your organization—to help lead the change and provide support to others throughout the transition.
  • Closely monitor the implementation of virtual technology practice and adjust as needed, focusing on immediate issues.
  • Prioritize and communicate processes to ensure client privacy and confidentiality. This may be especially important for certain populations such as victims of intimate partner violence living with their abusers.

Telehealth offers potential solutions for barriers to virtual case management.

Table 1 identifies specific barriers to remote case management that human services agencies may face. When available, potential solutions are also provided. Note that not all barriers have potential solutions that fully resolve the issues at hand and some recommendations may be hard to implement.

Further, not all populations have the same experiences or challenges with telehealth. Particular barriers experienced by rural and low-income clients may include limited access to the internet (see Figure 1) or unstable connectivity, and some clients may not be familiar with (or own) devices suitable for remote services. Clients may need support in understanding and growing comfortable using the technology and adapting practices for remote context.


Further Reading

Federal Telehealth Compendium (Office of the National Coordinator for Health Information Technology)
Telemedicine Toolkit (American Health Information Management Association)
The CTEC Telehealth Program Developer Kit (California Telemedicine and eHealth Center)

Figure 1: The Dakotas and certain southern states have the highest proportion of poor residents without internet access.
Table 1. Potential solutions to implementation barriers for human services agencies adopting remote service provision
Barrier Potential solutions
Setting up a remote system may require high upfront costs to cover technology, training, and equipment
  • Agencies may balance the costs of transitioning to remote services by scaling back other services while in-person contact is not possible
Shifting to a remote system may require changes in program rules and processes Staff may find technical or policy decisions hard to understand or inflexible
  • Establish new program rules and processes as needed to change an existing program to a virtual setting
  • Consider the range of programs and how they interact when designing processes
Some behaviors are more difficult to observe (e.g., intoxication, client reactions to questions) using remote technologies than during in-person sessions
  • Agencies may need to develop practice standards for a remote context
  • Alternative assessment options, like self-report instruments or questionnaires, may provide information useful to providers
Some environments are more difficult to observe (e.g., home safety for children, elderly) using remote technologies than during in-person sessions
  • Policies may need to be adjusted to allow remote assessment of home safety
  • If the provider cannot adequately observe the environment through video, asking questions may help them assess safety; for example, the provider may ask about exposed wires or if utilities are functioning
Some clients may require shorter session lengths to account for increased distractions, such as caring for a child, in remote sessions compared to in-person sessions; in addition, clients with disabilities may have difficulty focusing for longer remote sessions
  • Agencies may need to adjust scheduling practices
  • Practitioners may need to consult with insurance or other funders to restructure billing for services
Shifting to a remote system requires agency buy-in and training Staff may be unfamiliar and uncomfortable with the technology
  • Implement clear and simple training
  • Provide guidance to staff on documentation and storage processes
  • Appoint a dedicated remote case management program manager
Generating internal staff interest and use may be challenging
  • Find champions, those who understand and are committed to developing the remote system, to help lead change and support other staff
Remote case management may present challenges to client engagement Clients may miss the social contact of in-person meetings
  • Supplement regular remote visits with more frequent text messages or phone calls, which may increase engagement and decrease attrition
  • Consider practical advice on “web-side” manner:
    • Solicit more verbal feedback than usual
    • Limit visual and audio distractions by creating a quiet environment with a simple backdrop, such as a blank wall
    • Reduce backlighting (e.g., close window shades behind the camera)
    • Use headphones
    • Use video equipment that allows for eye contact
It may be more difficult to build trust between client and provider remotely
  • Technology platforms should have an interface that is user-friendly for the client, especially for users who are less comfortable with technology
  • Virtual communication that allows client and provider to see each other may help build trust
  • Providers should solicit informed consent by explaining how to use the technology, what information will be collected, and how it will be stored
  • Providers should establish a “time-out” signal and develop “cool-down” plans for participants at the beginning of the session, as well as a plan to conclude each session
  • Reassess communication methods after two to three sessions
Facilitating group meetings may be more challenging
  • Address individuals by name more frequently in group meetings
Establishing definitive boundaries between staff and clients may be more difficult as clients may be more likely to reach out to staff during nonbusiness hours using remote communication than standard business practices
  • Set expectations with clients around contact between sessions (e.g., boundaries around days or times of day available)
Shifting to a remote system requires that clients have access to broadband and internet-enabled devices and understand how to use the technology There is limited broadband access (particularly in rural areas) and access to devices (particularly for people with low incomes)
  • Providers may be able to loan equipment to clients and negotiate with internet service providers to provide clients with broadband. Collaborating with telehealth providers may help human services providers maximize their impact in this area, as there are federal funds available to telehealth providers to support broadband access in poor and rural communities
  • Identify state and federal programs, such as those through the Federal Communications Commission and U.S. Department of Agriculture, to help connect individuals to technological devices and high-speed broadband
  • Providers should establish backup plans for technology failure. Wired connections are generally more reliable than wireless.
  • Allow flexibility to meet by phone rather than video when video conferencing software is unavailable
Bandwidth may be limited (especially during peak demand and for clients relying on cell service)
  • Determine a back-up communication method, such as phone calls or text messages
Technology may be unfamiliar to clients, especially among older adults
  • Focus initial remote sessions on learning how to use the technology
  • Start sessions by acknowledging the challenges of meeting in this format
  • Determine a back-up communication method, such as phone calls, as wired connections are generally more reliable than wireless
  • Reassess communication methods after two to three sessions
  • Select technological tools based on accessibility and ease of use rather than innovative design features
  • Work with clients (and their caregivers, if applicable) to develop each remote case management plan
Remote systems may raise new concerns around privacy and require agencies to develop new processes to protect the privacy of clients Certain populations such as victims of intimate partner violence may not be able to speak freely in their homes
  • Client use of headphones may increase confidentiality of what the provider says; may need to consider more cautious practices depending on risk level of case
The most readily available software may not provide the best privacy or meet HIPAA requirements
  • Choose video software without social media functions (e.g., make sure to disable default settings that notify users when anyone logs on and that allow the creation of a video chat room that anyone can enter at will)
  • Consider HIPAA requirements and client-informed consent, taking into consideration new guidance and flexibilities from the HHS Office of Civil Rights on data sharing during emergencies
General privacy concerns
  • Solicit informed consent by providing details about data storage
  • Provide clear guidance to staff on documentation and storage processes

Conclusion

Lessons learned from the telehealth field show that thoughtful, planned deployments of remote technology, paired with helpful documentation and ongoing training for staff, have the best likelihood of benefitting clients. While human services providers should consider all these factors when transitioning to and further developing their remote service platform, growth in telehealth usage during the Covid-19 pandemic has been explosive and it will take time for the research literature to catch up. Further, some findings from previous work could well be modified as more is learned about virtual assistance in the human services field.


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