While the COVID-19 pandemic accelerated the expansion of telehealth treatment services, experts predict continual advances and growth in virtual care for substance use disorders. Listen in as host William C. Moyers talks with clinician Jennifer Nelson, who has been instrumental in Hazelden Betty Ford’s rapid escalation of telehealth care. Nelson outlines technical, clinical and logistical measures involved in ensuring patient engagement, safety and confidentiality in the virtual care setting.
0:00:13 William Moyers
Hello and welcome to another interview in our series of Let's Talk podcasts. From substance use prevention, to cutting-edge research, treatment of addiction and recovery from it, these award-winning podcasts focus on the issues of importance to Hazelden Betty Ford. Issues that we know matter to you, too. I'm your host, William C. Moyers, and yes, it looks different here on the set because as we all know, a lot has changed in the world since our last round of podcast interviews back in the winter of 2020. Hazelden Betty Ford takes seriously the need to do everything possible to prevent the spread of coronavirus among our patients and our employees. Even here in this studio, we are following public health guidelines. As a result I can take off my mask today because the production crew, the Executive Producer, and yes, even my guest, are elsewhere. Today we are joined by Jennifer Nelson, the Interim Manager of Virtual Services for Hazelden Betty Ford. Jenn has been with our organization for about three years. She comes to it with vast professional and personal experience and the academic credentials that she gained when she got her Master's from the Hazelden Betty Ford Graduate School of Addiction Studies. On a personal note and in the interest of full disclosure, I must add that it has been a real honor that Jenn asked me to do some mentoring with her over the past year or so. In truth, I should have been the one to ask her to mentor me. Welcome, Jenn.
0:01:43 Jennifer Nelson
Thank you, William, for having me today.
0:01:46 William Moyers
And tell us just a little bit about what the title Virtual Services—I mean you've got it in your title, what does that mean?
0:01:54 Jennifer Nelson
Yep so Virtual Services is an exciting opportunity that we now offer here at Hazelden Betty Ford for patients that may not have been able to access treatment at one of our physical locations. But now can access treatment in a secure environment. In the comfort of their own home.
0:02:15 William Moyers
And today we wanna talk about virtual care in the context of ensuring safety in a clinical setting and confidentiality in a virtual group. Tell us about that.
0:02:25 Jennifer Nelson
Well with our organization, despite whatever modality it is, we take it quite seriously that we ensure the safety and privacy of all of our patients throughout their treatment experience with us. And it's not any different than in the virtual world either.
0:02:45 William Moyers
We know why safety is important and it's easy to maintain safety when you're all in the same room, on the same site. But how challenging is it to maintain safety in a virtual setting?
0:02:57 Jennifer Nelson
Well we spent a lot of time researching this. And what we found is it's still possible, we still can create a secure environment with the right steps that we take. With our patients and then also the safety of our own staff.
0:03:13 William Moyers
So we know that confidentiality is a cornerstone of what we do at Hazelden Betty Ford. It's required by a federal law, HIPPA. But there's also another reason why confidentiality is important to patients. Can you talk about that, in a general sense?
0:03:28 Jennifer Nelson
Yeah confidentiality is important because we wanna make sure that we're creating a safe and secure environment for patients to share whatever they feel they need to share in order to stay sober between the clinician and then also with their peers.
0:03:44 William Moyers
So how do you do that in a virtual setting? I mean we hear the horror stories of Twelve Step Zoom meetings being "zoom bombed" I think it is or something like that. We know the world of the Internet is rife with hackers and all kinds of people who are up to no good. How does the patient find reassurance at Hazelden Betty Ford that their confidentiality is being protected in a virtual setting?
0:04:12 Jennifer Nelson
So we spent a tremendous amount of time ensuring that all of our virtual platforms with Hazelden Betty Ford are both HIPPA and 42-CFR Part 2 compliant. So the patients knowing that when they go into our services, our virtual services here at Hazelden Betty Ford, despite the modality that they may be in, their treatment is still confidential and secure. As well as we continue to work with our Tech Services team that we have in house with Hazelden Betty Ford that is continuing to monitor that as well. We also sign specific agreements: a BAA and a QSOA with our vendors. So many of you may be wondering what does a BAA, QSOA mean? It means BAA stands for Business Associate Agreement. And QSOA stands for Quality Service Organization Agreement. So in fact, Hazelden Betty Ford goes above and beyond what is required based on the HIPPA rule.
0:05:25 William Moyers
And I believe we even incorporated the MEND platform—it's with a vendor who works exclusively with us, right?
0:05:33 Jennifer Nelson
Absolutely. So we have those agreements with MEND that provides the virtual platform. But then we also have a BAA QSOA Agreement with our other vendor, Recovery Track, that provides our monitoring service.
0:05:52 William Moyers
A lot of technical stuff there but it seems to be working, you know, so far. Do you find that the patients express concerns about the confidential—their ability to converse openly in a virtual group? Or do they all feel reassured?
0:06:08 Jennifer Nelson
Well when we sit down with our patients, we definitely have Informed Consent. And during that time when we sit with the patient, we explain to them that at any point in their treatment they are not allowed to have another individual in the room. During orientation we also go over our confidentiality policy and procedures that we hold here at Hazelden Betty Ford. And we've spent a lot of time developing a specific virtual service patient handbook where we also refer the patients to the confidentiality section of that handbook. And that handbook stays with them at all times.
0:06:50 William Moyers
So that's interesting then I was thinking about confidentiality in the context of the confidentiality that Hazelden needs to—Hazelden Betty Ford needs to maintain with the patient. But there's also the confidentiality that the—we need to maintain with all the other patients, right? I mean you can't have your child or your spouse or a friend in recovery sitting in the group. [Jennifer shakes her head no.]
0:07:12 Jennifer Nelson
No we sure can't. And what—that's where I would title that a "red flag." [uses air quotes]
0:07:16 William Moyers
0:07:17 Jennifer Nelson
In that at any time, what we can do as a clinician it's just part of their Informed Consent, is we can ask the patient then to scan the room with their device. To ensure that there's no one else in the room. And—and that being if we hear a voice in the background but we may not see the other person. Or we see the setting change. Maybe the patient moved outside and that—that could put others at risk including themselves of being overheard. Maybe they moved into a common area, they're home, and you see individuals walking around. We also have to be mindful in the setting that we don't want them driving. And have their windows down and they're sitting at a stoplight engaged with other patients. As well as we can't have 'em walking into public settings. So all of our clinicians are trained to have that eye of knowing when they need to step in and either dismiss the patient from the actual treatment until they're in a secure setting, and remind them before and after breaks of what our policy and procedures are as it relates to privacy.
0:08:24 William Moyers
Completely different set of dynamics and you'd get if somebody was walking into an intensive outpatient group at Fellowship Club in St. Paul, for example.
0:08:32 Jennifer Nelson
Yeah, it is completely different. Yep.
0:08:34 William Moyers
And a steep learning curve. I mean not only for the clinicians, but also for the patients, right? Everybody's gotta be on the same page.
0:08:42 Jennifer Nelson
We do. And so that's why we spend time with them up front so they understand those differences going into it.
0:08:49 William Moyers
And by the way, respecting confidentiality and signing that Informed Consent, are they allowed to access virtual services with their phones?
0:09:00 Jennifer Nelson
They sure can. So we secure through an app but also through any of our vendors at any time that they're entering a secure platform. Despite the device that they're using.
0:09:13 William Moyers
So Jenn we've got confidentiality and we've talked about that. Impressive steps that the organization's taking to ensure that—the criticalness of successful confidentiality. But I wanna also turn and talk to you a little bit about adverse events. [Jennifer nods.] In a virtual setting. First, just tell our listeners and our viewers what is an adverse event in general?
0:09:37 Jennifer Nelson
It can be any crisis situation that a patient may be going through. And—and it needs intervention from one of our clinical staff.
0:09:47 William Moyers
Okay, so that would be somebody who might be under the influence, somebody who's feeling suicidal, somebody who's expressing vulnerability?
0:09:54 Jennifer Nelson
0:09:54 William Moyers
And if you're doing that, and on the unit or in an outpatient setting, you're right there, you've got those resources there. So tell us, how does it work in a virtual setting?
0:10:06 Jennifer Nelson
So what we've done here at Hazelden Betty Ford to ensure the safety at all times for our patients in these settings is we developed a crisis response plan. And we sit down with the patients before they even start treatment and what we're doing with that plan—and I'll just highlight a few areas—is we wanna know the patient's non-emergency number. Because it's not like when we're in in-person we could call 9-1-1 because they're in the same location as us. Many a times our patients are in other locations so 9-1-1 will not work. We have to know those numbers. We also sit down with that plan and find out what does a crisis mean to that patient. How would they describe a crisis in their own words? And then, also, do they have any support people in their home? And if not, who are the support people that are close by that could step in if they were in the midst of a crisis, as well as maybe any support animals they may have in their home as well.
0:11:05 William Moyers
And what about on a serious note, what about intoxication? I mean, you know, certainly in Twelve Step meetings if people come to the group, to the meeting, even if they're under the influence they have a desire to stop drinking or taking drugs, they're welcome, they may need to, you know, just sit and listen and not share. And if they appear at a group on or the unit and are under the influence, it's pretty easy for their peers and for the staff counselors to note that—but how does that work in a virtual setting?
0:11:36 Jennifer Nelson
That's a great question, William. And we've partnered with Recovery Trek. And so at any time, and they provide, they're our vendor for monitoring services. And at any time, if someone we feel is under the influence during group or individual session, we can ask that patient to take a test in their own home. And submit the screen. We can make sure that they have a designated driver and ask the patient to call the designator or find one within their home. If they're unwilling to do that, we can call non-emergency number for an emergency response team to show up if needed. And then we will call emergency response team if we see that the individual is trying to get into their vehicle to protect them and other people that may be on the road. Once that happens, once we're able to get an individual to a secure location, say such as a hospital, or a detox center if needed, we will still make sure like we do in our in-person settings that we inform everyone that we have a release for of what just transpired. So that there's additional accountability there for the patient. And at that time, we will also review all the labs and make the determination of the appropriate level of care. So we are still ensuring the safety no matter if they're virtual or in-person, at all times.
0:13:04 William Moyers
Wow a lot to consider and a lot to address. [Jennifer nods.] In providing addiction treatment within our system of care at Hazelden Betty Ford particularly in these virtual times. We only have about a minute left and you—I wanna ask you what—looking out, here we are in the summer of 2020, looking out into the future, do you see virtual care as continuing to be a viable option and important component of our continuum of care? Even when the pandemic subsides?
0:13:37 Jennifer Nelson
Absolutely. So within six days we were able to flip our facility-based treatment to virtual. And they are in the midst of talking right now keeping virtual still an option in those states that we already exist. As well as we are currently looking at expanding into multiple states. So I absolutely William know that virtual services is here to stay.
0:14:03 William Moyers
Well thanks Jenn Nelson for your great insights and your enthusiasm, the way you articulate it, and your hopes for the future. We're gonna have you back on in another—another time period to follow up on some of the things we talked about today.
0:14:17 Jennifer Nelson
It would be my pleasure. Thank you, William.
0:14:19 William Moyers
Thank you, Jenn. And thanks to all of you for joining us [to camera]. Be sure to tune in again for another edition of our regular podcast, Let's Talk. On behalf of our Executive Producer and our podcast team in the Twin Cities, we wanna remind you to stay safe and to stay healthy in these times and all the time. We'll see ya again.