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.
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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.
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Further Reading

Clinical and Ethical Considerations for Delivering Couple and Family Therapy via Telehealth (Journal of Marital and Family Therapy)

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)

Virtual Case Management Considerations and Resources for Human Services Programs (ASPE)

Webinar recording: COVID-19: The Use of Telehealth in Long Term Care Settings During This National Emergency (National Consortium of Telehealth Resource Centers)

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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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Implementing Virtual Human Services: Lessons from Telehealth

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

Telehealth offers potential solutions for barriers to virtual case management.

Conclusion

Bibliography

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