GLORIA UMALI, RN, BSN, MS, MPH, CPHRM
Assistant Vice President, Risk Management Group
AWAC Services Company, a member company of Allied World
The collaborative care approach is often referenced when describing exceptional care, and yet, when it comes to defining collaboration, there is often a lack of understanding of how to collaborate and what collaborative care looks like.1 As the University of Washington’s Collaborative Care Center for Advancing Integrated Mental Health Solutions states, Collaborative Care can be practice-based or telemedicine-based, depending on available resources and needs.2
This article will touch upon the basic principles of in-office and in-person collaborative care, and then focus on best practices for achieving this model in telemedicine.
What Are the Five Elements of Collaborative Care?
Research regarding collaborative care explains that methods for delivering care using this approach vary depending on several key elements. Social and economic factors, patient type, geographic location, and staff training are some of the major determinants identified as influencing the success of collaborative care. According to Molaro,3 the following five integral components must be present for true collaborative care to exist:
- Patient-Centered Care Team: a care team comprised of a non-behavioral health physician (such as a primary care physician) and a behavioral health team working together along the care continuum, including the establishment of goals for all patients.
- Population-Based Care: patients are tracked and monitored regularly to adjust the care and treatment plan accordingly.
- Measurement-Based Treatment Goal: patient outcomes are measured using evidence-based tools.
- The Right Level of Evidence-Based Care: the right level of care is provided for the patient at the right time.
- Accountable Care-based Compensation: focuses on the quality of care and patient outcomes rather than the quantity of patients treated.
While several initiatives may have been underway to build the foundations for true collaborative care, the unanticipated impact of the COVID-19 pandemic demanded the reexamination of the construct of the collaborative care model. Consequently, the pandemic challenged the usefulness of the fixed nature of healthcare delivery while affirming the concept of telemedicine-based collaborative care.
Telemedicine-Based Collaborative Care and Its Challenges
The COVID-19 pandemic created barriers to delivering healthcare, forcing providers to rapidly institute telemedicine. Additionally, the pandemic magnified supply and demand issues, especially in remote and underserved areas where primary care physicians absorbed patient volumes beyond their capacity.
Furthermore, the shortage of specialists, the challenges associated with transitioning to team-based care delivery, and the lack of reimbursement pressed providers, insurance companies, and lawmakers to examine telehealth practices closely to ensure that care was provided safely. For instance, Varrell4 cited that rather than psychiatrists who are trained to diagnose and treat complex mental health issues, it is primary care physicians who are prescribing 70% of antidepressants. This persistent need to fill the gaps in care has pushed primary care, public health organizations, private and government health sectors to collaborate and examine creative ways to deliver care that meets the needs of the patients, the providers, and care team members.
While telemedicine-based collaborative care allows for rapid collaboration, faster access to care, and proper care coordination that extends beyond geographic bounds, its universal adoption remains a significant challenge.
There are regulatory, legal, and reimbursement barriers5 to a full-scale adoption of telehealth among providers including:
- significant variations in rules, regulations, and guidelines for telehealth practice by state
- lack of multi-state telehealth license requirements
- compliance with the state and federal legal requirements that govern the telehealth practice
- privacy and cybersecurity risks
- accuracy of data transmission and misdiagnosis
- variations in the criteria used for establishing provider-patient relationship by state
- prescribing of controlled substances via telehealth
- lack of reimbursement
- liability associated with informed consent, practice standards, supervision requirements for Licensed Independent Practitioners (LIPs)
- Professional Liability coverage when providing telehealth services in other states
Similarly, the survey conducted by JD Power6 provided insight on patients’ experience with utilization of telehealth services. Based on the responses of 4,671 telehealth services consumers, JD Power reported in their 2021 Satisfaction Survey across generations that while 36% of patients have accessed telehealth services in 2021 (up from 9% in 2020), patient satisfaction with telehealth services has declined from 2020. Identified roots of dissatisfaction included:
- Limited services (24%)
- Lack of awareness of cost (15%)
- Confusing technology requirements (15%)
- Lack of information about providers (15%)
In addition, the survey revealed that patients who are healthier demonstrated a better understanding of the information provided during the visit and indicated they had received a clear explanation, reliable diagnosis, and personalized visit.
To sustain engagement and increase confidence on telemedicine-based collaborative care, it is imperative to understand and address the barriers and incentives to utilizing telemedicine, both on the provider and patient side.
Risk Management Considerations
While telemedicine-based collaborative care offers a wide range of benefits, it is not without its own risks. Here are some risk management considerations with telemedicine-based collaborative care that providers should consider:
- Protect yourself from vicarious liability claims. Telehealth blurs the line when it comes to chain of command and supervision requirements due to the collaborative nature of team-based care. Know what your relationship with the patient is and define the role you play on the care team. Depending on the state where you practice, there may be specific guidelines when acting in a supervisory or collaborative role.
- Educate patients about the team-based approach to care by actively engaging them as full participants in their care. Patients should know who to contact if they have a question or concern.
- Consult an attorney experienced in peer review before engaging in peer review activities for professional guidance. Accurate interpretation of the variations in telehealth practice standards and protocols is essential for ensuring a credible peer review process.
- Know the differences in technological systems and internet bandwidth capability and their impact on the accuracy of your clinical assessment and diagnosis. While technical infrastructure will vary by the telehealth services offered, sufficient bandwidth is needed to transmit audio and video data reliably.
- Keep abreast of the changes to state and federal telehealth rules and regulations related to licensure requirements (https://www.fsmb.org/siteassets/advocacy/pdf/states-waiving-licensure-requirements-for-telehealth-in-response-to-covid-19.pdf), patient confidentiality, prescribing controlled substances (https://www.deadiversion.usdoj.gov/), and system security requirements (https://www.healthit.gov/topic/privacy-security-and-hipaa/security-risk-assessment-tool). This helps you maintain compliance with all the rules and laws in each state where you are licensed to practice.
- At a minimum, your informed consent form should describe the nature of telemedicine compared to in-person care, potential benefits, constraints, and risks unique to telehealth (including equipment failures, privacy, and cybersecurity risks). Provide information about the encounter, your prescribing policies, communication and follow-up, records management, scheduling, mandatory reporting, billing arrangements, criteria for when to see a healthcare professional for an in-person visit, and your credentials. Sample telehealth informed consent forms are available from the following websites (https://www.ahrq.gov/health-literacy/improve/informed-consent/index.html and Toolkits Archives | National Consortium of Telehealth Resource Centers).
- Be aware of variations in the anti-kickback and Stark Law statutes by state to avoid unintended violation of these laws. While the practice of telemedicine-based collaborative care allows for expansion of telehealth services, providers need to ensure that the care coordination arrangements do not violate safe harbor provisions.
- Ensure you have coverage for your telehealth practice. Make sure your coverage is in line with your scope of practice and follows the parameters of the relevant state and federal laws.
- Be aware of state and federal telehealth reimbursement requirements. The expansion of coverage for virtual health care services has created complexities. Ensure that you are providing services according with your state laws and regulations. For latest information, contact your state department of health or state medical association.
- Conduct a telehealth risk assessment to assess level of practice readiness for offering telehealth services, identify gaps or areas for improvement, and prioritize them by importance. A sample telehealth readiness assessment tool is available from the following website (Telehealth-Readiness-Assessment.pdf (mhcctelehealthtool.herokuapp.com).
- Perform periodic cyber-security testing to identify vulnerabilities in security solutions. The Office of National Coordinator for Health Information Technology (ONC) in collaboration with the HHS Office for Civil Rights (OCR) developed a downloadable Security Risk Assessment Tool to help you conduct a security risk assessment as required by HIPAA Security Rule and Centers for CMS Electronic Health Record (EHR) Incentive Program (https://www.healthit.gov/topic/privacy-security-and-hipaa/security-risk-assessment-tool).
- Assess the patient’s digital health literacy and proficiency with use of technology and its effect on engagement, understanding, and participation in care and treatment. Follow the best practice of assuming that all patients are at risk for miscommunication regardless of literacy skills. Use a checklist to facilitate clear communication during and after telemedicine encounters. A sample patient checklist is available from the following website (Toolkits Archives | National Consortium of Telehealth Resource Centers).
Telemedicine-based collaborative care facilitates the establishment of virtual relationships with team members from different specialties. It alleviates issues related with shortages in specialists while promoting the integration of specialty care, such as mental health care into the services provided by physicians in the primary care setting. It enables timely access to care, preventing unnecessary hospitalization and overutilization of the limited resources for health care.
While telemedicine-based collaborative care offers an outstanding opportunity to improve healthcare outcomes, its universal adoption is limited by regulatory, legal, and reimbursement constraints. And while efforts may be underway to address the barriers to the transformation and full adoption of telemedicine and telemedicine-based collaborative care, ensuring there is full support and collaboration of stakeholders from various levels of government, providers, insurers, and healthcare organizations to strengthen and advance those efforts will be key.
1 Morley L, Cashell A. Collaboration in Health Care. J Med Imaging Radiat Sci. 2017 Jun;48(2):207-216. doi: 10.1016/j.jmir.2017.02.071. Epub 2017 May 31. PMID: 31047370.
2 The AIMS Center at the University of Washington. Practice-Based and Telemedicine-Based Collaborative Care | University of Washington AIMS Center (uw.edu).
3 Molaro, Chris. The Foundations Of Collaborative Care. The Forbes Council. May 21, 2021 https://www.forbes.com/sites/forbestechcouncil/2021/05/21/the-foundations-of-collaborative-care/?sh=a50f5084abec
4 Varrell, Jim. Collaborative care with a virtual lens: enabling patients and providers to overcome the mental health crisis. MedCityNews. September 2, 2021. https://medcitynews.com/2021/09/collaborative-care-with-a-virtual-lens-enabling-patients-and-providers-to-overcome-the-mental-health-crisis/
5 Gajarawala, SN, Pelkowski, JN. Telehealth Benefits and Barriers. The Journal for Nurse Practitioners. October 21, 2020 Volume 17, Issue 2, 218 – 221. https://www.npjournal.org/article/S1555-4155(20)30515-8/pdf
6 2021 U.S. Telehealth Satisfaction Study | J.D. Power (jdpower.com)