Form F 62589 – Fill Out and Use This PDF

DEPARTMENT OF HEALTH SERVICES	STATE OF WISCONSIN
Division of Quality Assurance
F-62589 (Rev. 07/08)

REQUEST FOR APPROVAL TO USE TELEHEALTH

Completion of this form is optional.

Name - Agency	Certification Number	Date Application Completed
Address - Agency (Street or P.O. Box)	City	State	Zip Code
Name - Person Completing This Form	Telephone Number	FAX Number
Name - Agency Director	Email Address - Person Completing This Form

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(1) APPLICABILITY
This request for approval applies only to mental health
and substance abuse programs, currently certified or
seeking certification under DHS subchapters, who are
anticipating the use of TeleHealth as a means of service
provision to increase access to services.
a. The agency is currently certified under DHS
subchapters for the provision of mental health and / or
substance abuse services.
Yes	No
b. If not certified, has the agency submitted an
application for certification to DHS.
Yes	No
(2) GENERAL

Programs requesting to use interactive TeleHealth for clinical mental health and substance abuse services must be certified under DHS subchapter pertinent to their clinical specialty or facility.

The plan submitted in compliance with certification requirements for any service or facility must include provisions pertinent to the use of TeleHealth if the program is seeking certification including the use of TeleHealth.

The program / agency shall have in place a written document indicating how TeleHealth services are integrated into the overall plan for providing inpatient, outpatient, community support services, comprehensive community services, day treatment, and crisis mental health and substance abuse services.

The plan shall identify appropriate sites where consumers may access services (originating sites). These sites may include: hospitals, emergency care centers, outpatient clinics and mental health and substance abuse facilities, skilled nursing homes, schools, county Health and / or Human / Social Service offices, and other county offices

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appropriate for private clinical evaluations and services.

The plan includes:

A description of how interactive TeleHealth services will be used in the overall strategy for mental health and substance abuse services.

Yes

No

How using interactive TeleHealth services will address the specific needs and strengths of consumers.

Yes

No

A description of services that can be provided via

TeleHealth services.

Yes

No

Criteria for selecting and identifying providers at the agencies to use TeleHealth services.

Yes

No

Criteria for selecting and identifying consumers appropriate for TeleHealth services.

Yes

No

A listing of appropriate originating sites.

Yes

No

The agency has a plan on file with DHS.

Yes

No

The plan includes specific references to the use of

TeleHealth.

Yes

No

(3) PERSONNEL

Only health personnel who are qualified under DHS subchapters may conduct appropriate mental health and substance abuse services via TeleHealth technologies (hereafter referred to as interactive TeleHealth services) for the purposes of diagnosis, treatment, and evaluation.

A regular staff member of the program must be available to present the consumer during clinical visits via TeleHealth unless another county public safety, public health, or Human / Social Service presenter trained in the use of TeleHealth is available.

Consultants, presenters, and any staff involved in interactions via TeleHealth with consumers present shall have training in the psychodynamics, legalities and patient rights pertaining to the use of TeleHealth technologies.

Persons providing consultations via TeleHealth are members of the agency and qualified under DHS

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subchapters.
		Yes	No
All persons presenting during TeleHealth services are
adequately identified in the agency’s plan. These
persons are identified by position, not by name.
		Yes	No
(4) PROGRAM OPERATION AND CONTENT
TeleHealth technologies are used to provide access to
services as outlined in DHS subchapters in:
a.	Outpatient	Yes	No
	Crisis	Yes	No
	CCS	Yes	No
	CSP	Yes	No
	Day Treatment	Yes	No
b.	Services are available 24 hours / day.
		Yes	No
c. If services at the agency are required 24 hours / day
	and not available via TeleHealth, are written
	guidelines available in the agencies plan for obtaining
	in-person services?
		Yes	No
d.	If access by interactive TeleHealth services is the
	primary method for providing outpatient, CSP, CCS,
	day treatment, or crisis mental health and substance
	abuse services, are trained staff available at all times
	for services?
		Yes	No
(5)	ORIENTATION AND ONGOING
	TRAINING

Each agency shall develop and maintain training in TeleHealth applications to include technology, clinical presentation, security and privacy, and documentation requirements specific to the clinical applications. Staff involved in service provision or presenting consumers shall receive training covering all the required components.

An orientation for staff using TeleHealth must include the following components in addition to any required clinically oriented mental health and substance abuse orientation:

Historical uses of TeleHealth

History of TeleHealth

Clinical Applications in TeleHealth

Telecommunications Technology

Technology

Codecs

Cameras

Consumer Peripherals

Transmission equipment

Audio equipment

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Presenting Techniques
Clinical services
Safety and Security During Service Provision
Privacy and Confidentiality
Documentation
Consumer Rights
Back-up Procedures
Patient Preparation for TeleHealth
The required training elements are in place.
Yes	No
At a minimum, annual inservicing is conducted regarding
any changes or updates in TeleHealth applications
including state legislative or regulatory changes.
Yes	No
(6) CLINICAL POLICIES AND PROCEDURES
Each program must have in place clinical policies and
procedures that address the following operational
components of conducting mental health and substance
abuse services via TeleHealth:
Preparation of Videoconference System and Cameras
Purpose: To serve as a guide for setting up
videoconferencing system and cameras for a TeleHealth
visit. The intent of this guideline is to provide direction to
the visit to improve efficiencies for the consumer, provider
and the TeleHealth presenter.
The Policy:
Describes what is needed to prepare the room so
everything is ready when the consult begins to avoid any
technical problems.
Yes	No

Describes the equipment needed and how it works.

Yes

No

TeleHealth Operations – Preparing for a TeleHealth

Consult

Purpose: To serve as a guide for obtaining and setting up equipment for any TeleHealth visit. The intent of this guideline is to provide direction to the visit in order to improve efficiencies for the consumer, provider and the TeleHealth presenter.

The Policy:

Describes the process for preparing charts and forms, room and equipment.

Yes

No

Describes what is needed to ensure the consumer chart and any other forms that may be needed for the consult, i.e. appoint forms, technology reports, prescription forms, etc. are available and accessible.

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Yes	No
Details what is needed to prepare the room, positioning
the chair, lighting that may be needed, privacy signage.
Yes	No

Consumer Information, Security Policy

Purpose: To indicate the clinic respects and will protect every consumer’s right to have all information they share with health professionals kept confidential.

The Policy:

Explains the confidentiality policy.

Yes

No

Explains how technological problems are addressed before and during the TeleHealth consult.

Yes

No

Documentation During a TeleHealth Visit

Purpose: To serve as a guide for documentation during a TeleHealth visit. The intent of this guideline is to ensure compliance with documentation requirements for clinical consultations.

The Policy:

Documents TeleHealth consumer care in a medical record including prescriptions ordered.

Yes

No

Maintaining Technical Integrity During the Interactive

TeleHealth Consult

Purpose: The purpose of this guideline is to ensure that video and audio quality is maintained at a level sufficient for clinical care during interactive TeleHealth consultations.

The Policy:

Defined the staff and their roles and responsibilities including the role of the TeleHealth presenter.

Yes

No

Defined how to address technical failures.

Yes	No
Defined how to report failures.
Yes	No

Conducting a TeleHealth Service

Purpose: To serve as a guide for conducting a TeleHealth service. The intent is to provide direction to the visit to improve efficiencies for the consumer, provider and the presenter (this could be a nurse clinician or other agency staff trained to assist the consumer with the TeleHealth consult).

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The policy addresses:

Procedures for starting the consult Documentation of any meds ordered and the treatment provided

Reasons for the use of TeleHealth

An explanation of what occurs with new consumers, established consumers, charts, treatment plans, grievance policy, medication consents, etc. Medication consent procedures

Conducting the visit

Minimum Transmission Standards

Purpose: To establish the minimum standards acceptable for a real-time, interactive videoconference TeleHealth services. Suggested minimum standards are transmission speeds of 256kbps or higher over ISDN or proprietary network connections including VPNs, fractional T1, or T1 or comparable cable bandwidths such as 10 or 40 mb. Programs using transmission speeds of less than 256kbps should have a documented justification that explains the financial feasibility barriers to high cost transmission lines.

a.The program transmits services via proprietary lines.

Yes

No

b.The program transmits services at speeds equal to or higher than 256kbps.

Yes

No

c.If the program does not transmit services equal to or higher than 256kbps, what is the reason?

Economically not feasible and services would otherwise not be available

Transmission lines for higher speeds not available

Other – Specify:

(7) CONFIDENTIALITY

Maintenance, release, retention, and disposition of consumer service records are kept confidential as required under Chapter 51.30, Wis. Stats., HFS 92, where applicable 42 CFR Part 2, and federal HIPAA requirements.

Yes

No

(8) CONSUMER RIGHTS

All programs using interactive TeleHealth services shall comply with Chapter 51.61, Wis. Stats., and HFS 94, WAC, on the rights of consumers, and federal HIPAA requirements.

Consumers are given the choice of in-person versus interactive TeleHealth consultations.

Yes

No

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(9) CONSUMER SATISFACTION

A satisfaction survey will be conducted for consumers and appropriate family members who use interactive TeleHealth services for access to mental health and substance abuse services. Recommendations include an internal report no less than quarterly and an annual report to the certification agency.

The agency / program has a satisfaction survey tool specific to interactive TeleHealth services.

Yes

No

The results are disseminated to provider, presenter and administrative staff.

Yes

No

There is evidence of program changes and improvements in response to satisfaction feedback.

Yes

No