Telehealth,friend and foe for health care social work

Prior to my academic career, I was a health care social worker for over twenty years, beginning in 1997. I practiced in urban outpatient clinics and emergency departments, and on hospital inpatient floors, and continue to practice a couple times a month in an urgent care clinic. Throughout my years as a clinical social worker, I participated in city-wide disaster drills, worked during global disease threats, and navigated calamities generated by nature and humans. Nothing approaching the magnitude of the catastrophe of COVID-19 was part of my practice experience.

As a health care social worker, I saw patients exclusively in person until COVID-19. The remedy given to many health care workers, including social workers, when the risk of physical exposure to others due to the pandemic outweighed the benefits, has been telehealth. When I started practicing social work, telehealth was not being used in any health setting where I practiced. There was not even an electronic health record (EHR) in the urban, level 1 trauma center where I started my career.

Fifteen years later, I was introduced to telehealth. Managers in the medical system where I worked equipped our five emergency departments on different campuses, all understaffed with social workers, with telehealth stations. With telehealth at our disposal, it was argued, a social worker at one emergency room could assess patients at another campus that was lacking a social worker for any given shift. Most of our interventions were for individuals in crisis, including those presenting with emergent mental health issues, substance abuse, and interpersonal violence, patients for whom telehealth could actually add more stress, and who are also difficult to assess on a screen. None of these were acknowledged as valid barriers by hospital leadership to delivering ethical, effective social work interventions. For example, when I evaluated a homeless patient with psychosis there was a risk that telehealth could exacerbate symptoms of paranoia as well as a risk that I would get an inadequate psychiatric assessment because I could not fully use all my senses in the two-dimensional, virtual environment.

There were plenty of social workers in our urban area to fully staff all the emergency departments at rates of modest compensation, but at the time a new, highly profitable, health care chain had purchased our medical system. The use of telehealth in this case replaced social workers and their attendant salaries and benefits with technology, thereby saving money. At that time there was also relatively little research about the effects of telehealth interventions on health care providers and patients. There were also some professional contraindications to utilization of telehealth with patients with common presentations in the emergency department setting, such as suicidality. My first experience with telehealth was concerning at best. We were short changing, if not doing harm to patients, to increase profits.

Given that I considered that experience, my only experience utilizing telehealth, a serious ethical issue, I was pleasantly surprised to see some benefits to health care social workers and their patients in the current pandemic. Beyond the obvious protection of infection prevention for all involved, it has expanded the capacity of the stressed and inadequate mental health system in my geographic area, in which clinical social workers are responsible for a significant amount of the service provision. When various insurance entities, including Medicare, expanded reimbursement for telehealth, particularly teletherapy, at the start of the pandemic, more individuals were able to access services (Center for Medicare and Medicaid Services, 2020). This was enhanced by additional adaptations, such as the relaxation of HIPAA standards in telehealth delivery (US Department of Health and Human Services, 2020) and in my state, insurance parity for health services offered via telehealth (State of Washington Office of the Governor, 2020). Those who are disabled, homebound, have no access to or cannot afford transportation or childcare, live in rural areas, or cannot travel outside their homes due to medical or mental health conditions currently have more access to health and psychosocial services in many cases.

The urgent care clinic in which I work, a small space with no openable windows, and a constant influx of patients with COVID symptoms, has not been immune to personal protective equipment shortages, leaving staff members sometimes feeling inadequately safeguarded. I have the option of seeing patients with COVID symptoms using telehealth from the social work office rather than in person. That is, if the telehealth technology is functioning properly on any given day. My work setting did not have and did not need the infrastructure for internal telehealth prior to COVID, so it is a work in progress.

Despite telehealth’s advantages during this pandemic, as a health care social worker I still have serious concerns about its potential to steamroll social work values. As social workers, I believe we need to look at telehealth through the lens of patients and their well-being in general, but more specifically and importantly through the lens of our populations of focus, the vulnerable, oppressed, and those living in poverty (National Association of Social Workers, 2018: Preamble). The introduction of telehealth as a standard way of interacting for health care social workers during the pandemic is potentially dangerous in the climate of increasingly corporatized health care in the United States. For example, a recent article in the New York Times (Drucker, 2020) references a medical center in my city as part of a group of wealthy hospital chains across the United States that received billions of dollars in bailout money intended for struggling health care organizations. This multibillion dollar “not-for-profit” institution behaves like a corporation, investing in hedge funds, running venture capital funds, working with private equity firms, and generating over ten billion dollars in cash yearly.

Despite not having shareholders to whom they are accountable for generating profits and stated missions that usually mention the health and well-being of patients, these medical Goliaths are focused heavily on monetary gain, and stray far from any practical emphasis on social justice. As a health care social worker, I have lived the progression of this trend of corporatization over my twenty plus years of practice. The result, in my sphere of health care social work, has been understaffing and decreased resources for vulnerable patients, resulting in an intensification of an already inequitable two-tier health care system, substandard care, and social worker burnout. Given the recent, rapid proliferation of telehealth due to COVID, the increased corporatization and privileging of profits by some health care organizations, and the financial hardship experienced by many health care organizations, there are monetary incentives to retain telehealth as the standard medium of care as the pandemic progresses and recedes.

Telehealth in the hands of corporatized health care has the potential to seriously compromise our professional Code of Ethics (National Association of Social Workers, 2018: Ethical Principles) values of social justice, dignity and worth of the person, importance of human relationships, and competence.

Telehealth can create significant inequities in access to and quality of care. First, there are people who do not have access to computers, high quality WIFI, or both. Where does the proliferation of telehealth leave the homeless with regard to health care access, for example? There are many others who have access to the technology but cannot reliably benefit from it due to physical or mental disabilities, such as hearing impairments, effects of traumatic brain injury, or language barriers. Health care facilities generally use in person language interpreters, or increasingly, interpreters accessed through a separate, portable, video screen, creating a novel, cumbersome, double telehealth arrangement for social work practitioners and patients. There is another group of individuals who have access to computers, WIFI, and the physical and mental capacities to fully engage with telehealth, but lack the privacy needed to speak with health care workers. For example, there are those living in cramped quarters, including homeless shelters, and in households with challenging acoustics or interpersonal violence. Many of these patients are more likely to be uninsured or insured with Medicaid or Medicare, which generally reimburse at lower rates than private insurance, giving financial incentives for health care organizations to leave these patients out by privileging telehealth.

There are concerns surrounding the social work value of dignity and worth of the person, such as patients’ self-determination and best interests. If telehealth continues to dominate the health care experience, patients might not be able to choose what they deem best for them based on preferences, culture, language, abilities, and other personal circumstances. Telehealth research is relatively new and there are contradictions about contraindications for certain types of patients and problems, such as individuals experiencing mental health crises. It is a service modality that ideally needs to be thoughtfully assessed on a patient by patient basis to maximize benefits and avoid harm.

Alignment with the social work value of competence in telehealth interventions has, in my clinical experience, lagged behind delivery due to the speed with which the pandemic unfolded. However, in my prior experience with telehealth there was also no training in effective delivery or successful navigation of legal and ethical complexities. As anyone who was precipitously thrown into interpersonal interaction by video for teaching or social work practice due to the pandemic knows, there is a steep learning curve in technology, legal and ethical considerations, and high-quality service delivery. In many cases I did not know what I did not know until specific issues surfaced during sessions. General training for intervention with telehealth participants is essential, but specialized training is also necessary for all the accommodations and techniques needed to adapt to a variety of individual characteristics, settings, and circumstances.

Finally, there is the consideration of the value of the importance of human relationships. In many health care settings, interventions by social workers are interdisciplinary and highly interactive. There is much lost in clinician understanding, and patient care and well-being in the absence of collaboration with other health professionals in real time, often challenging to accomplish when utilizing telehealth. For patients and social workers alike, there are intangible benefits from in-person, human contact that inexplicably, positively affect the quality of the rapport and relationship, and ultimately healing.

Telehealth has always been a potential friend as well as a foe for health care clinicians, including social workers, but there is a clear risk that the disadvantages of this technology will potentially be exacerbated as we move through, and hopefully out, of the COVID-19 pandemic. I see my tasks in my role as a health care social worker as remaining constantly vigilant about the many complex ways, on mezzo and macro levels, that telehealth can be exploited for profit and convenience to the detriment of the vulnerable, oppressed, and those living in poverty, and advocating to prevent it.