Should Graduate Schools Teach Telehealth Competency?

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HERE IS HOW

A 2001 Institute of Medicine report highlighted the shortcomings of healthcare professional training and ongoing proficiency assessment to enhance patient care and safety (IOM, 2001). Two years later, the IOM identified objectives for educational reform for physicians, pharmacists, physician assistants, nurses, and other allied health professionals, including psychologists, social workers, counselors, marriage and family therapists, and addiction specialists (IOM HPES 2003). As telehealth adoption continues to grow, telehealth competency education and training are the keys to providing safe, effective, evidence-based telebehavioral health (TBH) services.

In 2017 and 2018, Maheu and colleagues published two seminal articles outlining the need for telebehavioral health (TBH) care (Hilty, Maheu, Drude, Hertlein, Wall, Long, Luoma, 2017; Hilty, Maheu, Drude, & Hertlein, 2018) as part of an effort introduced by the Coalition for Technology in Behavioral Science (CTiBS). The group then published a framework for TBH, which included an interprofessional telehealth competency table outlining seven TBH competency domains, 51 behavioral objectives, and 149 cumulative and measurable TBH practices (Maheu, Drude, Hertlein, Lipschutz, Wall, & Hilty, 2018). A core subset of these writers has since then been working with leaders in four behavioral health professions to discuss the implementation of these telehealth competencies.

Many health care providers have since the COVID-19 pandemic offered virtual care for nearly three years, but how many of these practitioners were trained in telehealth? How many graduate students and interns are now getting the training that they need to succeed in telehealth in a world where interprofessional telehealth competencies will dominate? This blog article reviews telehealth competencies in these behavioral health professions: couples, marriage and family therapy, psychiatry, psychology, and social work.

Couples, Marriage & Family Therapy

Members of the original CTiBS competency articles joined to focus on TBH implementation issues in couples, marriage, and family therapy. Authors Hertlein, Hilty, Drude & Maheu (2021) review and conclude that telehealth competencies are not adequately offered in the education and training of couple and marriage and family therapists (CMFTs). They review the CTiBS telebehavioral health competency framework that has not yet been seen in scholarly research in couples, marriage, and family therapy. Professional development to enhance telehealth competency helps providers learn the knowledge, attitudes, and skills necessary for working with mental health populations such as couples and families. The telehealth competency framework includes the following:

The authors take the position that therapists and leaders in the field who currently utilize TBH services should collaborate in developing education and training models to contribute to greater consistency and clarity about the similarities and differences between face-to-face and TBH services.

They recommend that the mental health field adopt telehealth competency-based education for TBH services. Such telehealth competencies should require teaching unique skills that will not only better assure higher quality client care but also greater confidence for providers when delivering TBH services.

These authors discuss the recommendations by Pickens and colleagues (2020) regarding education and training to enhance telehealth competency among providers, which include:

• Education on ethical and legal issues in TBH practice
• How to build a TBH practice
• How to use different types of technology, virtual platforms, and apps
• How to combine TBH with existing theoretical models in counseling and therapy

They advocate for the continued research and implementation of telehealth competencies to produce a structured set of expectations across counseling and therapy educational programs. They further suggest that input and collaboration are needed across licensing boards, policy developers, therapists, and other stakeholders. They conclude that the field should transition to telehealth competency-based education associated with TBH services.

Taking a bold step that has not yet been taken by other national regulatory associations, the American Association for Marriage and Family Therapy Regulatory Boards (2016) has recommended that couples, marriage and family therapists earn 15 hours of initial training toward telehealth competencies and no less than five credit hours of continuing education every five years to establish and keep up with core telehealth competency in technology. From the regulatory board’s perspective, all providers must gain telehealth competency as the field continues to move toward greater numbers of clients engaged in virtual care.

A copy of the paper is available here.

Psychology

Core members of the CTiBS writing team published a paper reviewing applications of the CTiBS interprofessional, telebehavioral health competencies for psychology. They collaborated with Joanne Callan, PhD, Jonathan Neufeld, PhD, Shawna Wright, PhD and Deborah Baker, JD to co-author an overview of the CTiBS interprofessional TBH competencies and their implementation for telepsychology (Maheu, Wright, Neufeld, Drude, Hilty, Baker & Callan, 2021). They chose two competency domain areas to apply the CTiBS framework to everyday telepsychology preparation and practice. The areas selected by the team included the Clinical Evaluation and Care Domain and the Legal and Regulatory Issues Domain. The reader is directed to the published version of the article for specifics.

Regarding the issue of graduate training, the authors stated:

For telepsychologists, the CTiBS competencies provide a way to conduct a top-down, broad-to-specific assessment of competence (i.e., knowledge, attitude, or skill for TP). They allow the clinician to identify needed areas for telehealth or teletherapy training and other key aspects of risk management, as suggested by Kennedy et al. (2014). For educators, supervisors, and trainers, they provide a framework for evaluating the telepractice competencies of students, supervisees, and trainees. Relevant issues in education and training may include (a) the value of competencies in teaching and evaluating TBH practice, (b) strategies for teaching TBH competencies across disciplines in graduate curricula, and (c) learner-specific approaches to guide teaching, assessment, and evaluation of skills and attitudes beyond knowledge acquisition.

An abstract and purchase information for this article is also available.

Psychiatry

Maheu and colleagues published a psychiatric implementation article for the CTiBS TBH competency framework (Maheu, Drude, Hertlein, & Hilty, 2018). This paper explained that the published CTiBS competency framework was structured into seven “competency domains,” further organized into 51 behavioral objectives and 149 discrete, measurable behavioral practices (competencies). It then looked at implementing two behavioral objectives, “Clinical Evaluation and Care” and “Cultural Competence and Diversity.”

In outlining why competency frameworks fail, this paper concludes with these remarks about the importance of building TBH competency training into every level of clinical education, training, and care:

A common pitfall for competency frameworks is confusing competencies/outcomes with knowledge acquisition and the shift in medicine from “knowing it all” to team leaders who facilitate and ask key questions has taken a great amount of time. For any competency framework to be effective intelepsychiatry, TBH, and social media, interprofessional prioritization is key rather than implementing “too many” discipline-specific competencies. Focus on independent “silos” of competencies for TBH may unnecessarily stymie program directors, department chairs, healthcare system leaders, national organizations, and other bureaucratic agencies. In fact, many regulatory boards in the behavioral sciences have not yet published core requirements for the use of technology for their licensees. Furthermore, TBH competencies need to be more than an outlined curriculum for seminar; clinical experience, supervision, feedback, and other pedagogy methods.

Graduate schools are key players in this effort to move TBH education into mainstream medical school curricula.

A full copy of the article is available here for interested readers.

Social Work

Another research team led by Maheu worked with TBH-leading social workers Laura Groshong, LICSW, from the Clinical Social Work Association, Mirean Coleman, LICSW, from the National Association of Social Workers, and Crystal Merrill, PhD in 2021 to apply the CTiBS competencies to social workers engaging with elemental health and telebehavioral health (Merrill, Maheu, Drude, Groshong, Coleman & Hilty, 2022). Given the COVID focus, this social work paper deviated from the previous formula of applying the CTiBS competencies to a broader, more general appeal for education, training, and interpersonal collaboration using the TBH competencies.

Competencies are the integrative link between excellence in clinical practice, education, and technology; they are much needed in this era of service delivery and health care. Traditional training, evaluation, and faculty development can translate TBH research on clinical outcomes and models of care for generations to come. In turn, these well-trained and competent clinicians will leverage resources more efficiently and have the capacity to reach a wider range of populations, e.g., refugees across the world, rural areas, etc. Utilizing best practices from the fields of marriage and family therapy, psychiatry, psychology, addictions/substance use, social work, and other disciplines, if shared and integrated for competencies, will potentially strengthen this movement. With regard to clinical social work, the importance of ethical issues regarding confidentiality, informed consent, emergency services attention to cultural diversity, legal considerations, and all other elements of the social work Code of Ethics must be integrated into TBH practice.

A full copy of the paper is available here.

As with other groups, the social work focus on the CTiBS TBH telehealth competency papers includes a call to action toward working collaboratively with other professions. Not only then is there a call for telehealth competencies, but also for interprofessional telehealth competencies.

Conclusions

The focus of this blog article has been to make a case for interprofessional, telebehavioral health competencies across educational arenas to better prepare the next generations of clinicians for what will inevitably be a technology-bound future.

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References

Drude, K. P., Hertlien, K. M., Maheu, M. M., Hilty, D. M., & Wall, K. (2020). Telebehavioral health competencies in interprofessional education and training: A pathway to interprofessional practice. Journal of Technology in Behavioral Science, 5(1), 30-39.

Hilty, D. M., Maheu, M. M., Drude, K. P., Hertlein, K. M., Wall, K., Long, R. P., & Luoma, T. L. (2017). Telebehavioral health, telemental health, e-Therapy and e-Health competencies: the need for an interprofessional framework. Journal of Technology in Behavioral Science, 2(3), 171-189.

Hilty, D. M., Maheu, M. M., Drude, K. P., & Hertlein, K. M. (2018). The need to implement and evaluate telehealth competency frameworks to ensure quality care across behavioral health professions. Academic Psychiatry, 42(6), 818-824.

Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press. https://doi.org/10.17226/10027.

Institute of Medicine. (2003a). The Core Competencies Needed for Health Care Professionals. Health Professions Education: A Bridge to Quality. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/10681

Institute of Medicine. (2003b). Health Professions Education Summit. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK221516/ Interprofessional Education Collaborative Expert Panel. (2011). Core competencies for interprofessional collaborative practice: Report of an expert panel.Washington, DC: Interprofessional Education Collaborative.

Maheu, M. M., Drude, K. P., Hertlein, K. M., & Hilty, D. M. (2018). A framework of interprofessional telebehavioral health competencies: Implementation and challenges moving forward. Academic Psychiatry, 42(6), 825-833.

Maheu, M. M., Drude, K. P., Hertlein, K. M., Lipschutz, R., Wall, K., & Hilty, D. M. (2018). Correction to: An interprofessional framework for telebehavioral health competencies. Journal of Technology in Behavioral Science, 3(2), 108-140.

Maheu, M. M., Wright, S. D., Neufeld, J., Drude, K. P., Hilty, D. M., Baker, D. C., & Callan, J. E. (2021). Interprofessional telebehavioral health competencies framework: Implications for telepsychology. Professional Psychology: Research and Practice.

Merrill, C. A., Maheu, M. M., Drude, K. P., Groshong, L. W., Coleman, M., & Hilty, D. M. (2022). CTiBS and Clinical Social Work: Telebehavioral Health Competencies for LCSWs in the Age of COVID-19. Clinical Social Work Journal, 50(2), 115-123.

Pickens, J. C., Morris, N., & Johnson, D. J. (2020). The digital divide: Couple and family therapy programs’ integration of teletherapy training and education. Journal of Marital and Family Therapy, 46(2), 186-200.

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