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Home-Based Telemental Health:
A Proposed Privacy and Safety Protocol and Tool
Aditi Sharma, MD,
1,2,i
Vera Feuer, MD,
3
Barbara Krishna Stuart, PhD,
4
Johanna B. Folk, PhD,
4
Bridget T. Doan, PNP,
5,6
Chetana A. Kulkarni, MD, FRCPC,
5,6
Ujjwal Ramtekkar, MD, CPE, MBA,
7,8
Lisa Fortuna, MD, MPH, M.Div,
4,
*and Kathleen Myers, MD, MPH, MS
1,
*
Abstract
Objectives: To describe the development of a protocol and practical tool for the safe delivery of telemental health (TMH)
services to the home. The COVID-19 pandemic forced providers to rapidly transition their outpatient practices to home-based
TMH (HB-TMH) without existing protocols or tools to guide them. This experience underscored the need for a standardized
privacy and safety tool as HB-TMH is expected to continue as a resource during future crises as well as to become a
component of the routine mental health care landscape.
Methods: The authors represent a subset of the Child and Adolescent Psychiatry Telemental Health Consortium. They met
weekly through videoconferencing to review published safety standards of care, existing TMH guidelines for clinic-based and
home-based services, and their own institutional protocols. They agreed on three domains foundational to the delivery of HB-
TMH: environmental safety, clinical safety, and disposition planning. Through multiple iterations, they agreed upon a final
Privacy and Safety Protocol for HB-TMH. The protocol was then operationalized into the Privacy and Safety Assessment
Tool (PSA Tool) based on two keystone medical safety constructs: the World Health Organization (WHO) Surgical Safety
Checklist/Time-Out and the Checklist Manifesto.
Results: The PSA Tool comprised four modules: (1) Screening for Safety for HB-TMH; (2) Assessment for Safety During the
HB-TMH Initial Visit; (3) End of the Initial Visit and Disposition Planning; and (4) the TMH Time-Out and Reassessment
during subsequent visits. A sample workflow guides implementation.
Conclusions: The Privacy and Safety Protocol and PSA Tool aim to prepare providers for the private and safe delivery of HB-
TMH. Its modular format can be adapted to each site’s resources. Going forward, the PSA Tool should help to facilitate the
integration of HB-TMH into the routine mental health care landscape.
Keywords: patient safety, child and adolescent, telemental health, service delivery
Introduction
The COVID-19 pandemic led to a transformation in health care
service delivery and clinical practice across the world. Shelter-
in-place restrictions required both providers and patients to stay at
home, whenever possible. Many child and adolescent mental health
programs rapidly transitioned to the use of telemedicine to deliver
services directly to patients’ homes. In this article, we adhere to the
Center for Medicare and Medicaid Services (CMS) description of
telemedicine as remote service delivery that includes both audio
and video components in a two-way interactive communica-
tion (Center for Medicare and Medicaid Services 2020). When
1
Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA.
2
Seattle Children’s Hospital, Seattle, Washington, USA.
3
Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA.
4
Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California, USA.
5
Department of Psychiatry, University of Toronto, Toronto, Canada.
6
Hospital for Sick Children (SickKids), Toronto, Canada.
7
Department of Psychiatry and Behavioral Health, The Ohio State University School of Medicine, Columbus, Ohio, USA.
8
Nationwide Children’s Hospital, Columbus, Ohio, USA.
*Cosenior.
i
ORCID ID (https://orcid.org/0000-0003-1796-2700).
Funding: Dr. Feuer receives grant support from the Patient Centered Research Institute-grant number PCS-2018 C1-11111.
JOURNAL OF CHILD AND ADOLESCENT PSYCHOPHARMACOLOGY
Volume 31, Number 7, 2021
ªMary Ann Liebert, Inc.
Pp. 464–474
DOI: 10.1089/cap.2021.0020
464
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telemedicine is used to deliver mental health care services, the term
telemental health (TMH) is generally used (Yellowlees et al. 2010),
a convention we follow here.
The increased use of home-based TMH (HB-TMH), in which
patients are treated virtually in their homes, necessitated the devel-
opment of safe approaches to the delivery of mental health services
to this nonclinic-based site of service. Most providers were naive to
TMH in general and to HB-TMH in particular with no available
standardized protocols to guide them in safely providing services to
patients in their homes. Luxton et al. (2010, 2012) work with adults
has suggested safety precautions to address potential crises that may
occur during sessions. Schoenfelder Gonzalez et al. (2019) and Doan
et al. (2020) have specifically addressed safety concerns for children
and adolescents such as needing to modify usual consent procedures
and ensuring the availability of an adult in case safety is compro-
mised. Sharma et al. (2020) have furthernoted their use of a two-part
protocol to assess and minimize risks during HB-TMH. Safety also
relates to providers’ experience. TMH-naive providers experience
stress in transitioning themselves and their patients to HB-TMH
(Morgantini et al. 2020; Rosic et al. 2020). Despite these important
concerns and suggestions, a specific protocol and tool for delivering
TMH services to youth privately and safely in their homes have not
yet been available for general distribution.
The objectives of this article are twofold: to describe the devel-
opment of a protocol for the private and safe delivery of HB-TMH
and to present a tool for implementation of the protocol. Although
many factors contribute to a successful TMH program, such as de-
veloping a virtual therapeutic alliance, ethical practice, profession-
alism, and cultural humility (Nelson et al. 2013; Gloff et al. 2015;
Shore et al. 2018), these topics have been systematically summarized
in formal guidelines for telepsychiatric care (American Academy of
Child and Adolescent Psychiatry Committee on Telepsychiatry and
Committee on Quality Issues 2017). Here, the authors focus on the
development of a practical tool for assessing privacy and safety as
these issues have not been adequately addressed and should con-
tribute to quality improvement for HB-TMH.
Methods
Authors
The authors comprise a subset of the Child and Adolescent Psy-
chiatry Telemental Health Consortium that consists of select faculty
from a nonrandom sample of child and adolescent psychiatry pro-
grams at major North American (United States and Canada) aca-
demic centers that convened to describe their efforts in successfully
transitioning to HB-TMH during the COVID-19 pandemic (Folk
et al. 2021). Pre-COVID-19, the sites had highly variable experience
in TMH. None had major experience with HB-TMH (Folk et al.
2021). Each program transitioned to HB-TMH without existing
protocols or tools to guide them. To address safety, some of the
programs included existing rating scales, such as screenings for
suicide and self-harm, into HB-TMH encounters. Others adapted
their crisis clinic protocols to the home environment. One program
developed a targeted safety tool (Sharma et al. 2020), and two pro-
grams developed comprehensive protocols (Stuart and Colleagues;
Doan and Colleagues, unpublished protocols).
Procedures for the development of Privacy
and Safety Protocol
The authors met weekly for 1 hour over 10 weeks through vid-
eoconferencing to develop a privacy and safety protocol. They
shared their individual sites’ protocols, discussed their experiences in
using these protocols, noted deficiencies in each site’s approach, and
reviewed the literatureon TMH generally and HB-TMH specifically.
They agreed upon the relevant material to include from each site,
modified by their experiences, and extracted relevant material from
published articles. The authors then merged these materials into a
preliminary document describing salient aspects needed to establish
privacy and safety in HB-TMH. Between weekly meetings, indi-
vidual authors provided feedback on each other’s contributions.
Through several rounds of shared iterative group processes, they
honed this document into the Privacy and Safety Protocol. Then, they
operationalized the Privacy and Safety Protocol into a practical
Privacy and Safety Assessment Tool (PSA Tool) by translating core
protocol concepts into concrete action items that were organized in a
flexible modular format and presented in checklists for im-
plementation by different programs according to their needs, ex-
pertise, and resources, as well as for efficient use by providers in
clinical practice. Finally, the Privacy and Safety Protocol and PSA
Tool were reviewed by representatives from five of the eight con-
sortium sites who made constructive suggestions.
Construction of the PSA Tool
The authors conceptualized safety across three domains dis-
cerned from their clinical experience and published TMH standards
of care (American Academy of Child and Adolescent Psychiatry
Committee on Telepsychiatry and Committee on Quality Issues
2017; Rosic et al. 2020): (1) environmental safety; (2) clinical
safety; and (3) safety-driven disposition planning. These three
domains and their components, parsed by timing of consideration,
are summarized in Table 1.
To translate these domains into a practical tool, the authors
adopted concepts from two sources. First is the World Health Or-
ganization (WHO) Surgical Safety Checklist/Time-Out (WHO 2009;
American College of Surgeons 2017) that engages the clinical team
to review a planned clinical procedure with the goal of minimizing
errors and identifying individuals’ responsibilities. In the variation
used here, the ‘‘TMH Time-Out,’’ the provider teams up with the
family to authenticate the patient’s identity, confirm location of
service, identify the responsible adult caregiver or other trusted adult,
ensure privacy and safety, and clarify the intended intervention.
Second, and related, is the Checklist Manifesto that advocates the use
of checklists in routine and unexpected circumstances to ensure
adherence to safety steps as outlined by various professional disci-
plines, including medical practice (Gawande 2011). The checklist
approach also offers efficiency for providers and facilitates integra-
tion of the PSA Tool into the electronic medical record (EMR).
To ensure that the PSA Tool is relevant across sites, regulatory
agencies, providers’ needs, and patient populations, the authors
also considered the following issues:
Compliance with regulations:
BConsistent with state/provincial and federal regulations re-
lated to age-of-consent and confidentiality.
BConsistent with professional organizational guidelines.
BAdaptable to institutional standards.
Ease of implementation:
BAccessible and compatible with digital health, for example,
online completion and/or uploadable to the EMR.
BSufficiently brief to be administered efficiently and consis-
tently without excessive burden to providers or patients.
BSufficiently clear to be easily interpreted and documented.
HOME-BASED TELEMENTAL HEALTH PRIVACY AND SAFETY TOOL 465
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Table 1. Domains and Relevant Components of the Home-Based-Telemental Health Privacy and Safety Protocol and Documentation Tool
Previsit (admin) During visit (clinician) End of visit
Environmental safety
Location, contact
information
Confirm location where the HB-TMH session will be
occurring.
Identify a telephone number for a phone not used for
the TMH connection; this second phone is to re-
establish contact should the video connection fail.
Document numbers.
Confirm location of patient and caregiver and their
contact information. Review contingency plan for
losing connection.
Document updated information.
Participants Identify which adult will be available during the
session (caregiver or other trusted adults) and their
contact information
Confirm identity of participating caregiver or trusted
adult.
Confirm ongoing participation of caregiver or trusted
adult in care.
Additional contacts Identify local emergency services and support
persons. Document numbers.
Confirm awareness of phone number, location of local
emergency services.
Review local emergency services and natural support
contacts.
Privacy Review expectations of privacy and troubleshoot
barriers.
Confirm patient and caregiver privacy.
Determine privacy strategies for sessions for patients
and caregivers.
Agree on ‘‘code words or hand signals’’ if privacy
compromised.
Document privacy strategies discussed for patients and
caregivers.
Lethal means Determine access to lethal means (guns,
medications, other potential lethal substances) in
the home and formulate a plan for securing these.
Review emergency protocol (involve caregiver,
other responsible adults, call 911, etc.) and obtain
relevant releases/contact information for a backup
adult.
Develop a contingency plan for safety concerns that
may arise during the session (revelation of a recent
overdose, self-injury etc.)
Develop and document safety plan and educate on lethal
means restriction.
Review safety considerations for continuation of HB-
TMH.
Consider notifying CPS if concerned about lack of lethal
means restriction.
Clinical safety
Complete HB-TMH screening questions. Obtain
clinical safety screens as per clinic policy, as
indicated.
Screen for clinical risk (e.g., risk of harm to self ),
utilizing empirically validated scales as indicated.
Determine ‘‘triggers’’ to risks.
Assess prior successful approaches to managing risks
and help elicit additional strategies with patients.
Create safety plan with patient (include triggers, coping
strategies, and resources) and review with caretakers.
Provide resources to help with symptom management
between sessions. Utilize safety plan and other self-
help tools to augment HB-TMH interventions, such
as: My3, Calm, Mood Tools, or Virtual HopeBox.
Involve additional supportive individuals (school
principal, community supports, relatives, mentors
etc.) as needed.
Confirm relevant releases and contact information
for a backup adult.
Review contingency plan for current safety concerns. Review contacts for clinical team between sessions.
Disposition plan
Alert clinician to concerns that would impact patient
and caretaker ability to be safely served through
HB-TMH.
Determine whether patient and caretaker are well served
through HB-TMH or whether they should be referred
to in-person care: Initiate HB-TMH
Continue assessment indicates need for in-person care:
switch to in-person care or higher level care as
indicated/available
Consider empirically validated scales for reassessment
of suicide and violence risk
Utilize results to reassess eligibility for HB-TMH
intermittently or as circumstances indicate: Ongoing
HB-TMH
Comments
Note if any state-specific regulations related to age of
consent, confidentiality, and so on.
If safety protocol not implemented and/or tool not
completed, document reason.
HB-TMH, home-based telemental health.
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Broad applicability across populations:
BRelevant across geographic boundaries served by the pro-
gram.
BCulturally responsive and relevant to and easily under-
standable by all patients.
BApplicable to patients’ and caregivers’ varied levels of dig-
ital literacy.
Adaptability to variations in:
BDemographics (e.g., patient age, socioeconomic status).
BClinical conditions (e.g., intellectual disability; caregiver
ability to assist in the patient’s care).
BSetting (e.g., treatment centers, schools, and correctional
facilities).
BModality (e.g., group services).
BLanguage and interpreter services.
BSupervision needs.
BTechnical issues (e.g., screen size, connectivity).
A challenge in developing the PSA Tool was identifying the
unique considerations for ensuring safety and response during HB-
TMH using established clinical standards for assessment and
planning. Certain clinical standards of care are readily applied, such
as screening for firearms in the home and educating on their safe
storage. This issue must be addressed before any clinical session as
part of determining patient appropriateness for HB-TMH, and re-
checked as indicated at subsequent clinical sessions as circum-
stances may change. The PSA Tool adheres to established
guidelines for clinical assessments (American Academy of Child
and Adolescent Psychiatry 2021a) and safety plans (Stanley and
Brown 2012) to ensure consistency with the standards established
for in-person care. The PSA Tool does not prescribe specific in-
struments, but recognizes the need for measurement-based care to
determine and document the patient’s safety and response to
treatment (Fortney et al. 2017; The Joint Commission 2021).
The final PSA Tool, based on the three foundational domains and
their components in Table 1, includes three formats:
BOpen text entry (e.g., address, contact persons, individual-
specific clinical factors, and contingency plans).
BClickable checklists for prior risks and current risks/status
during data gathering.
BChecklist prompts for an action (e.g., completed a contin-
gency plan, reviewed risk assessment at the end of the ses-
sion).
Results
The final PSA Tool is shown in Figure 1 and briefly described
here.
Module 1: Screening for Safety for HB-TMH is conducted
before any clinical sessions and is ideally completed by an ad-
ministrative support staff with the youth and/or caregiver. This
previsit screening emphasizes the special accommodations needed
to address privacy and safety in implementing TMH in the home
environment. Module 1 engages the support staff, youth, and family
upfront in determining whether the patient is appropriate to receive
TMH services in the home and establishing a safe environment.
Module 1A, Environmental Safety, consists of concrete ques-
tions related to the home and lethal means restriction. The first
section uses an open text format to document information specific
to the youth and family, such as the address at time of service and
relevant contacts. The second portion uses a clickable checklist
format with dichotomized responses for ease of administration
regarding the environment. Module 1B, Clinical Safety, continues
the checklist format. It asks sensitive questions regarding suicid-
ality, violence, psychiatric hospitalizations, or use of emergency
rooms, and involvement with juvenile justice or Child Protective
Services. Module 1C, Disposition Planning, requires a final dis-
position by administration support staff, or consultation with clin-
ical staff, regarding appropriateness for HB-TMH and any potential
alternative modalities and level of care. The patient may be
screened as inappropriate for HB-TMH at this point dependent
upon the specific program’s guidelines for services. For example, a
program that routinely serves homeless youth or families living in
abusive situations may have more structured resources to address a
potential compromise of safety in session, compared with a training
program that serves outpatient populations in medical clinics.
The crucial point is that Module 1 authenticates the patient,
determines the patient’s appropriateness for HB-TMH, assesses
safety of the patient’s setting, and lists resources to contact in case
of any crises during the subsequent clinical session. The provider
will need all of this information before establishing a therapeutic
alliance and safely initiating treatment. This approach is consistent
with the eligibility screening and registration steps that in-person
clinics utilize to match appropriate patents with available services
and then to schedule in-person treatment services.
Potential challenges to Module 1 include the need for training of
support staff in asking and responding to sensitive questions
(Module 1B). As an alternative, some sites utilize a nontreating
clinical staff (e.g., nurse, social worker, therapist, psychologist) to
collect all of the information in Module 1. This approach may be
more clinically sound, but more expensive and limiting when
clinical staff resources are scarce. Another potential challenge may
be the additional burden on administrative staff to complete this
screening and disposition process, which could also incur addi-
tional cost to the clinic. Another challenge may be integrating these
items into an existing EMR typically used in private practice rather
than into hospital-based or large organization-based EMRs.
Module 2: Assessment for Safety During HB-TMH Initial
Visit is conducted by the provider during the start of the initial
clinical session. It covers the Environmental and Clinical Domains
with all items presented in checklist format. Module 2A, En-
vironmental Safety, may seem redundant with Module 1A and 1B,
but it includes the ‘‘TMH Time-Out’’ and occurs at a different time
than Modules 1A and B. Thus, Module 2A reauthenticates the
patient, that is, ensures the patient is the same person assessed in
Module 1 when screened by an administrative staff; and that the
environment is the same and consistent for the duration of the
appointment, or has changed from initial screening in Module 1A.
Module 2A may provide new information on the environment, and
is then intended to readdress safety and confirm resources in case of
a crisis. Patient authentication during the ‘‘TMH Time-Out’’ re-
capitulates the authentication that a clinic registration staff con-
ducts when the patient presents for in-person services. The ‘‘TMH
Time-Out’’ can be completed in less than 2 minutes. Module 2B,
Clinical Safety, is consistent with a traditional initial clinical in-
tervention, including history gathering. Module 2B may also in-
clude the provider’s review of any rating scales used for
measurement-based care sent to the family previsit or that the
provider administers as part of this initial visit. A contingency plan
for safety during the session is developed.
Potential challenges to Module 2 may include the provider
needing to react to new information. Examples include the
HOME-BASED TELEMENTAL HEALTH PRIVACY AND SAFETY TOOL 467
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following: no adult available for the visit; patient located in a
nonprivate or unsafe environment; and patient located out of state
(Kramer and Luxton 2016). Providers may discount the need for
Module 2A, thinking that it has already been done. Finally, pro-
viders may perceive the time required to complete Module 2 as
detracting from their time available for clinical intervention.
Module 3: End of Initial Visit Safety and Disposition
Planning is conducted by the provider at the end of the initial
clinical visit. It maintains the efficient checklist format. Module 3
covers the Environmental and Clinical Domains in a condensed
version that focuses on safely completing the first session, in-
corporating new information into disposition planning for level
of risk, anticipating the patient’s return, and planning for a safe
interim period until the next clinical visit or other contact or
transition in care. As is the clinical standard of care for in-person
visits, we recommend utilization of established safety planning
tools as appropriate to the patient’s assessed level of risk, such as
the Stanley Brown Safety Plan (Stanley and Brown 2012; Suicide
Prevention Resource Center 2021) or the My3 application from
the National Suicide Prevention Lifeline (National Suicide Pre-
vention Lifeline 2021). Module 3A is an opportunity for the
provider to give the patient links to readings or websites that
build on treatment and/or provide self-help resources. The chat
function may be helpful for this. Contact information for the
provider’s office and local crisis resources should also be re-
viewed. Module 3B, Disposition Planning, is also a final review
FIG. 1. Home-based telemental health privacy and safety assessment tool. TMH, telemental health.
468 SHARMA ET AL.
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and decision-making step regarding the patient’s appropriateness
for ongoing HB-TMH considering new information obtained
during the session, and/or revision of the safety plan, as indicated.
If the patient is deemed not appropriate for HB-TMH based on
issues such as safety concerns, need for a higher level of care,
need for other services, or poor faith commitment to HB-TMH,
referral resources should be provided. Ultimately, the provider
determines the appropriateness for HB-TMH based on the overall
assessment of the patient’s status and ability to safely engage in
treatment. The provider should clearly document the rationale for
final determination.
Challenges to Module 3 include the stress to the provider of
determining appropriateness. Providers could be burdened by
identifying in-person services if the patient is determined not ap-
propriate for HB-TMH. Psychiatrists who are new to TMH may
also find burdensome coordinating extra steps such as obtaining
rating scales and locating community crisis resources for support in
between HB-TMH sessions. Use of patient portals to exchange
information can be helpful, but takes additional time to set up and
educate families on their use.
Module 4: ‘‘TMH Time-Out’’ and Reassessment is completed
by the provider and intended for all subsequent clinical sessions.
This is the major application of the ‘‘TMH Time-Out,’’ that is, to
establish privacy and safety at each session with collaboration of all
involved individuals, particularly the family. In less than 2 minutes,
the ‘‘TMH Time-Out’’ again quickly reviews safety issues in the
Environmental and Clinical Domains that may have changed since
the prior session. Contingency and disposition planning are ongo-
ing. Module 4’s importance lies in recapitulating the interactions
that typically occur at the start and end of each in-person visit. The
‘‘Time-Out’’ is now regularly integrated into the workflow of
procedural medicine to ensure the identity of the patient, the
FIG. 1. (Continued).
HOME-BASED TELEMENTAL HEALTH PRIVACY AND SAFETY TOOL 469
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procedure to be performed, and the roles of each participant (The
Joint Commission 2021b). It holds great promise for TMH proce-
dures delivered safely to the home.
The main challenge to Module 4 is checklist fatigue. Providers
may omit this step, not appreciating the fluidity of HB-TMH, as
patients may change their location or their available caregiver
and that caregiver may change location. Also, providers may
experience ‘‘change blindness’’ (Rensink 2005). HB-TMH im-
poses additional expectations on the provider. In addition to the
interaction with the patient, providers must attend to alterations
in the patient’s environment, a site that is not familiar to them.
They must also coordinate the technology used during the ses-
sion, such as checking the medical record, typing the note, or
dealing with visual or auditory delays. They may not readily
appreciate changes in the patient’s affect or ideation that occur
in the moment. These additional expectations are fatiguing,
leading to ‘‘change blindness’’ regarding the patient’s response
to interventions.
Workflow
Successful implementation of the PSA Tool depends on work-
flow. A suggestion is shown in Figure 2. The PSA Tool is designed
to be flexible to each program’s expertise and resources. The
workflow is, therefore, modifiable. Suggested potential variations
in implementation of the workflow may include the following:
FIG. 1. (Continued).
470 SHARMA ET AL.
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BVarious staff participate in use of the PSA Tool, allowing
different sites to utilize the PSA Tool as best fits their ex-
pertise, needs, and resources.
BIdentification of staff who would administer sections of the
tool:
o Provider may complete the entire form. The upside is
consolidating the process to one person and the provid-
er’s expertise in discerning the potential need for branch
steps. A downside would mean the provider contacts the
youth and family before officially assuming care. Provi-
ders may incur some liability risk, if they determine that
the patient is not appropriate for HB-TMH, but the pa-
tient assumes that the provider had established care. Also,
screening may not be the optimal approach for the use of
valuable, scarce, and expensive clinical staff.
o A division of labor in which administrative support or
nontreating clinical staff may collect demographics and
contact information, confirm availability of private space
or mitigation strategies to maintain privacy, outline ex-
pectations of visit, obtain consents, and screen for clinical
risk factors. The provider would then review these as-
pects when conducting the initial clinical interventions
session in Module 2. The benefits would include pro-
tecting the time of clinical staff for treatment-related
FIG. 1. (Continued.)
HOME-BASED TELEMENTAL HEALTH PRIVACY AND SAFETY TOOL 471
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activities, flexibility by having various staff share
screening activities, and less expense for the clinic.
A downside may be having to train support staff to ask
sensitive questions related to lethal means restriction or
involvement with social services agencies.
o Patient and/or family completes selected sections of the
PSA Tool online (e.g., Module 1, location of the youth at
time of service, telephone numbers, the caregiver or other
trusted adults available at the site of service, and lethal
means in the home). A support staff or nontreating
clinical staff would then review the information and send
it to the provider. Alternatively, the provider could di-
rectly review the family’s responses. This approach
would likely be appropriate to a limited patient popula-
tion, such as those with sufficient language and digital
literacy. If conducted previsit, a concern may be that
awaiting a youth’s or family’s response could delay
treatment. If an online method is used, a support staff or
nontreating clinician could follow-up via telephone with
families who have not completed the PSA Tool online 24
hours before the appointment.
BIdentification of timing in administering the PSA Tool.
o Support or nontreating clinical staff complete all the
environmental safety components before any intervention
session.
o Provider reviews the environmental safety components
before and at the end of the initial intervention session.
o Provider completes clinical safety components at the start
of the initial intervention session.
BDeciding a process for entering results of the completed tool
into the EMR.
Discussion
The gradually increasing implementation of HB-TMH in the
private and public sectors over the past decade attests to its ad-
vantages to and growing acceptance by patients, providers, and
health care organizations. Its widespread implementation in the
home during the COVID-19 pandemic suggests that HB-TMH will
remain a resource during future crises as well as become part of the
evolving routine mental health care landscape. A major challenge
to this integration is safety. To our knowledge, the development of
our Privacy and Safety Protocol and PSA Tool is the first attempt to
address safety with a practical instrument.
The PSA Tool adheres to the standards for traditional in-person
care (AACAP 2021a) and for clinic-based TMH (American
Academy of Child and Adolescent Psychiatry Committee on Tel-
epsychiatry and Committee on Quality Issues 2017) with modifi-
cations for delivery to patients’ homes. Module 1 most specifically
addresses this modification by identifying private space for sessions
FIG. 1. (Continued.)
FIG. 2. Workflow for privacy and safety planning tool.
472 SHARMA ET AL.
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and documenting community resources in case of a breach of
safety. For example, usual clinic staff are not available to assist
with safety concerns, such as a patient walking out of the visit, or
starting to engage in self-harm. If a parent is not going to be on-site
during the session, the provider needs ready access to the care-
giver’s contact information at the time of service and that of another
trusted adult in case the caregiver is not reachable. Potentially, such
issues may necessitate a modified consent form. Other items in
Module 1 are consistent with an in-person evaluation but are as-
sessed before contact with the provider to determine patient ap-
propriateness for HB-TMH. Modules 2, 3, and 4 entail continuous
safety assessment at different points of contact, as safety assess-
ment transitions to the provider. The checklist format is intended to
make this process routine, efficient, and not burdensome to the
provider. The PSA workflow allows the integration of rating scales
to document safety as well as to document progress of treatment.
While the PSA Tool does not reference a patient portal, sites may
utilize such portals for ease of collecting results of rating scales or
other clinical information.
The COVID-19 pandemic necessitated a rapid transition to
HB-TMH by providers who had no previous training in TMH,
and in the absence of standards for safe delivery to patients’
homes (Pinals et al. 2020). There is now a workforce of experi-
enced HB-TMH providers that can help organizations to take the
next steps in modifying and implementing the PSA Tool across
patient populations, disorders, and acuity (Rienits et al. 2015).
These efforts will concomitantly require resource allocation by
these organizations for continuous quality assurance in HB-TMH
(Halpren-Ruder et al. 2019). For example, ‘‘smart’’ templates
may be adapted for HB-TMH services to prompt providers on
session standards and documentation that optimize consistency
across HB-TMH providers as well as consistency with in-person
services. Online care groups may provide remediation conver-
sations to bolster the digital communication infrastructure to
improve the technology for HB-TMH. Audits for quality im-
provement will likely be part of the growing integration into the
mental health care landscape if reimbursement is to continue, and
increase. Finally, academic programs will need resources to
prepare their trainees for their future practices that will likely
include HB-TMH and use of the PSA Tool.
Future directions include obtaining empirical evidence on use of
the PSA Tool. Ideally, investigators would test the effectiveness of
the PSA Tool in identifying, managing, and reducing risk. How-
ever, violence and suicidal activity are relatively rare outcomes.
Thus, such testing may not be realistic. Rather, descriptive data
regarding providers’ and patients’ input on the feasibility and sat-
isfaction in using the PSA Tool and whether it interferes with the
provision of clinical care would yield useful information. Similarly,
caregiver, patient, and provider adherence to the initial agreements
of providing HB-TMH may comprise a testable hypothesis. Inter-
rater reliability on use of the PSA Tool would certainly be testable.
On a more practical level, future work may also test whether an
online version of Module 1, which patients complete before contact
with staff, produces completion of Module 1’s items comparable
with item completion in the current form. An abbreviated version
may also reduce providers’ burden and could be tested. Finally, a
toolkit specific to HB-TMH, similar to the general telepsychiatry
toolkit (AACAP 2020b), will assist providers in integrating HB-
TMH into their practices.
Crises create opportunities and often bring lasting societal
change. The pandemic highlighted the need to advance TMH
practice to home delivery. Continued innovation in HB-TMH will
allow psychiatry to mobilize more rapidly during the next crisis
(Gates 2018) and to advance mental health service delivery, gen-
erally, to a more patient-centered approach. Our Privacy and Safety
Protocol and PSA Tool aim to help move these goals forward.
Conclusion
The new Privacy and Safety Protocol and PSA Tool aim to
optimize the safe implementation of HB-TMH during future crises
as well as during the integration of HB-TMH into the routine
mental health care landscape. They are based on three domains
foundational to the safety of TMH service delivery. The PSA Tool
is structured on the WHO Surgical Safety Checklist/Time-Out and
the Checklist Manifesto that have been successfully integrated into
other areas of medicine and industry. The modular format allows
the PSA Tool to be utilized across age, mental health specialties,
disciplines, and resources.
Limitations
The Privacy and Safety Protocol and PSA Tool were developed
by a limited group of experienced TMH providers who were not
representative of TMH providers generally. In particular, the au-
thors did not include representatives from the private sector who
did not have organizational guidance and support as they transi-
tioned to HB-TMH. The process of developing the Protocol and
PSA Tool did not follow a formal Delphi or Nominal Group
Technique ( Jones 1995; ASQE 2021) to ensure that all authors had
comparable input to the decision-making in conceptualizing the
Privacy and Safety Protocol or constructing the PSA Tool. Review
of the final Privacy and Safety Protocol and the PSA Tool was
undertaken by only five of the eight Consortium sites.
Clinical Significance
The transition to HB-TMH during the COVID-19 pandemic
demonstrated the need for a structured tool to guide the assessment
of privacy and safety for the delivery of mental health services
through videoconferencing to patients in their homes. The current
article describes the Privacy and Safety Assessment Tool (PSA
Tool) for children and adolescents. It is based on the World Health
Organization Surgical Safety Checklist/Time-Out and the Checklist
Manifesto. The modular format can be modified to fit a site’s needs
and resources. The PSA Tool aims to standardize the assessment of
privacy and safety to facilitate quality improvement, while mini-
mizing burden to providers, in delivering TMH services to patients
in their homes.
Disclosures
No competing financial interests exist.
Supplementary Material
Supplementary Appendix SA1
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Address correspondence to:
Aditi Sharma, MD
Department of Psychiatry and Behavioral Sciences
University of Washington School of Medicine
1959 NE Pacific Street, Box 356560
Seattle, WA 98195-6560
USA
E-mail: saditi@uw.edu
474 SHARMA ET AL.
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