 Good evening, everybody. Welcome along to the almost 500, actually, of you participants who've joined us for tonight's webinar and for viewers who might be watching this podcast at a later stage. It's going to have an awesome mental health professional network. We always wish to acknowledge the tradition custodians of the many lands across Australia upon which our webinar presented and participants are located in that and with that. We certainly do wish to pay respect to the elders, past, present, and emerging from the memories, the tradition, the culture, and the hopes of Indigenous Australia. We really hope that we can do the very best we can to one of our past respects. I'm Conrad Cunger and I'm a little general practitioner in Crossapine in North Queensland. And it's great to welcome you all back to the next of the series on telehealth in deliberate mental health services for those who might not be in the metropolitan area. So once again, I'm going to facilitate the tonight's session. These sessions really are a key. They're some of the most popular ones that NHBN has been doing because there's no doubt that we have so many patients who need our help who can't always get to access face-to-face support at the times that they need it. So the more people who are familiar with it and comfortable with utilisation of telehealth, the better off we're going to be. But I've done plenty of these thoughts with NHBN before. We've got a fantastic panel with us again tonight as well. So when you register in, hopefully you already saw that the bio is for everybody who we've got. But we won't go through all of those again. We'll just go straight to our actual panelist. Just going to introduce Jacinta Bell, occupational therapist. Jacinta, would you encourage your occupational therapist colleague to use telehealth to reply? Hi, Conrad. Thanks for the nice introduction. And yes, definitely, a simple answer is yes, I would. Really, people in rural areas already have very minimal access to our professors. And telehealth is a fantastic opportunity to be able to increase access for people in those areas. It's very, very normal for occupational therapists to see people in their home environment anyway. That's a very common thing that we would do. And so telehealth is really a great opportunity to be invited into somebody's home, potentially. And get to incorporate the environmental context within any of our therapies that we're doing. It really works well for interventions that aren't hands-on. And a lot of the mental health interventions that we do fit very well within that category. And it means that we can always ensure that the environmental context is considered in our therapies. Depending on the device that people are using, sometimes I've even had people show me around their home via telehealth, using their phone or handheld device. That's really, really quite fantastic. And very, very effective. Oh, that's fantastic. Thanks for that, Jacinta. Next, I'm going to move on to Dr Louise Ruckel. Louise is the manager of professional services in the Australian Pathologist Society. Louise, welcome along. Back to the question you just asked. Louise, what do you see the benefits of telehealth for those Australians living in remote areas? Thanks, Conrad. It's lovely to be here tonight for everyone. And my background is in rural and remote Australia. So it's an absolute joy that we finally have access or improved access to psychological services through telehealth. It's obviously not going to be for everyone, but having seen that the lack of access to psychological services in rural and remote Australia, it's going to give at least some people a much greater chance of not having to travel. If there's a choice there that doesn't mean they have to travel so far to access services, it's an enormous bonus. So it's improved the chances that GPs have got to provide services to their clients. We're also now welcoming back Julianne White. Julianne is a social worker who's been practicing in the area for a long time and it's a great experience in here. Julianne, what would you say would be one of the key benefits of using telehealth for a social worker? Oh, thanks Conrad. And it's wonderful, like everyone else has said, to be here again tonight. I think it is a really great issue. The benefit for social workers, like all the other professions, is that one, we're giving people choice, access. GPs can then find clinicians that have got particular expertise that they might be looking for for a client and I think it's just improving the range of services that we can do. And also with the clients that really do struggle, those that can come in occasionally, but there's other difficulties with you know, whether transport commitments on farms, which is one of the problems we've got around harvest and cropping. Often people can't travel the 30 or 40 kilometres in for sessions. Then we can do a beautiful mix of sessions with people. And we've used it a lot and I really love the opportunities and the flexibility it gives the people. So I highly recommend it. Not just for social workers, but for all mental health commissions. But social workers, they're a bit like what Tim just said, he was saying about seeing the person in the context, which from our profession is also a very important consideration. But highly recommend every social worker here to get on board. It's a great initiative. Oh, wonderful. Thank you, Anne. And finally, we welcome Dr Jonathan Ho. Jonathan's a general practitioner in Wagga Wagga and welcome along to the panel for night, Jonathan. I'm wondering, mate, in your work with Indigenous people, have you found Kelly Health a useful tool? Hi Conrad. Yes, I work with the Wiradjuri community and I'm based in Wagga Wagga. In that community, they're fluent in English, they're familiar with technology, similar to Skype or FaceTime. I really think that telepsychology could benefit into aspects. One is confidentiality and with the Aboriginal community, everyone's business is everyone's business. So you say you don't want Uncle Phil to know that you're going to have a chat with a psychologist today. Telepsychology could be flexible enough to say, do the initial sessions over the mobile phone. The second thing is accessibility. With the community I work with, there's lots of complexities that inhibit a patient to attend appointments. Like, it could be as easy as practical matters such as not being able to find transport or having young children to look after or not being able to get up early enough to go to an appointment. So telepsychology could cater for these patients and hence capture a client base that may otherwise fall through the gap. Great, great thoughts. Thanks, thanks Jonathan, and welcome along. So to those of you who may not have been previous participants in the MHP and webinars, just go through a few of the ground rules and what we're doing with the bees. Remember that this is a large event. We've got almost 700 people actually online now already. So it is very difficult to make sure that everybody gets equal access and opportunities. So please make sure that everybody has the best experience tonight. Be respectful of other participants and the panel. Although they're all quite anonymous in this area, make sure that you're acting as though you were in the same room. If you are choosing to interact with each other, please use the chat box facility that we've got there. But just try to make sure that you keep those comments relevant and on topic. If you've actually got technical issues that you're having a problem, you might be able to better off put those into the areas as well. But we've also got the technical support frequently asked questions at the top there. So you might find that you can find a quicker revolution to your problem by clicking on that area. Of course, if you're still struggling, the 1-800-291-863 number will be active throughout the webinar. So give them a call if you're still requiring additional support. Remember though that we've got a lot of people online. If there is actually something which affects the quality of the transmission, we'll make sure that we let you know about it at the time of our announcement. And also remember that it's very difficult to get through everybody's questions and comments in the course of this evening. But we'll try to make sure that we get through as much as we can. At the end of the webinar please also make sure that you take the time to complete the feedback survey which will be located under the tab at the top of the screen there for you. So we'll be making sure that we try to get through as much of the content that you've previously supplied with the registration. There's an overwhelming number of questions that came in which was a great sign of the interest that everybody's got. It's a very very broad area of topics that we're going to try to cover tonight. So please we will do our very very best to cover off on what you've been asking but our greatest apologies if you feel though we don't get particularly to yours. So let's just have a revisit through the learning outcomes for this evening's session. Remembering that we're willing to use these opportunities really to find out how patients who are in rural and remote areas what might telehealth be able to do for those. How can we then recognise those clients who might be suitable for delivery of services via mental health? Identifying some of the risks associated with telehealth services but also getting some of those real practical logistical points about developing contingency plans looking after privacy, making sure we've got informed consent training to start appropriately and record keeping for the telehealth setting. So let's move on to our introductory session. So as I mentioned at the start this is number two in the series for telehealth Department of Health have been kind enough to fund another webinar that means that this is a build-on for the initial webinar which was hosted last year. We're not going to be able to revisit all of that content so please don't encourage anybody who hasn't yet reviewed webinar one. Make sure you do keep an eye on that link and do go back and have a look over that podcast if you feel though tonight you might not have got all of the content because we're just not going to have the opportunity to revisit all of that content. Although we are talking about telehealth we just remember that we're not just talking about the telephone it's not just an audio connection that's indicated with this service but just as we read tonight using audio and visual in the same way if you're using telehealth for delivery of mental health services it needs to be with both of those modalities audio and visual. This initiative is as appropriate for those mental health care professionals who are registered with Medicare so if you're an occupational therapist, social worker or psychologist you certainly are eligible make sure you've got that registration up to date. If you're having any difficulties with understanding the eligibility or the conditions that go around it make sure you have a look through the Department of Health or the Australian Psychological Society website they've got some fantastic information and resources there that you'll be able to use and a reminder that the clients who we're talking about in this modality are those who are living in rural and remote Australia so modified Monash model, MMM 4-7 if you're unsure about if the area you're living in or where you're trying to come in from, the platypized criteria, the link is there also to be able to access what's going on. But remember that what we're wanting to build with these webinar sessions is really being able to work out how can different mental health professionals collaborate with each other. It's not about what all of us bring individually but really how working for the best as a team or as a group of health professionals we really can be looking after the team the best that we can. Now just remember that in that MMM criteria to clients who need to be in that remote area, you yourself don't necessarily have to be in the remote area at all. So let's move on then to how might we be able to determine the suitability of the patient who we're going to be looking at. Julianne I wonder what sort of experience, what type of therapy might be most suited to the telehealth setting? Thanks Conorance here. I think there's a variety of therapies that are really suitable for telehealth. Some of the very intensive ones may not be if you're doing some intense mindfulness or trying to engage with reduction of distress might be tricky. But I think an awful lot of the narrative therapies, cognitive therapies, some of the behavioural therapies, neuroscience type of responses works extremely well with people and I find people engage extremely well with the technologies, especially even talking about deep and meaningful situations or things that are happening for them. So there's a range of therapies and I think that's part of that assessment of the client at the beginning as to how they are presenting on the day and what might be happening for them. I think that's really important to start with. But I think there's a range of therapies that we should continue. I don't think we should exclude any because if a client has a need I think if we've got telehealth as a vehicle then we should probably try and find as clinicians the best way to provide an appropriate therapy for that person. Oh, absolutely. Absolutely. Louise, if you've got any additional thoughts about what might be appropriate therapies for telehealth. Thanks Conrad. I agree with Julie Ann that there's probably not that many specific therapies that are excluded. I guess the only thing I might add is some behavioural interventions, particularly that need to be fairly frequent and perhaps need to be done in conjuncts face to face if it's a particular exposure or that requires you to be face to face. That might not be suitable for as a therapeutic approach done by telehealth but it still lets you combine the two. So remember it's only seven of the ten sessions that can be by telehealth. It can often be a mix of face to face and telehealth that can let you do even the more complex therapies that require you to be face to face. Yeah, well and truly. I suppose some of the concerns we might have in identifying the suitability of our patients for telehealth interventions is what happens if we think that they're not really dealing with their diagnosis or that they're needing a little bit of their extra support. Just since I'm just thinking for those patients who might think are particularly anxious, how would you deal with your anxious clients in the telehealth scene? Thanks Conrad. Certainly people who are anxious, my experience has been and other people might have different experiences that actually telehealth is a great avenue to overcome that initial anxiety because people can be working within their own environment where they're often comfortable and feeling quite safe so to engage initially in therapy via telehealth that can be quite, I guess it can remove one of the barriers to accessing therapy for people who are very anxious. I would say one of the other things that we would look to do is make sure that we've had quite a bit of communication prior to the first telehealth appointment where we are setting up the things so that people know exactly what to expect and there's not going to be any surprises for them. That's going to alleviate as much of that as we possibly can. Yeah, well and truly, bring all those issues out into the open early and making sure that we deal with them explicitly rather than just assuming that everything's going as long as it's really, really important. Of course, Julianne, sometimes our patients are a little bit more at risk than anxiety and we might have serious concerns about their welfare. Would it affect your consideration about their suitability for telehealth if you knew or if you suspected that the client was self-harming? When we're seeing people that are in a really severe day of anxiety or self-harming, if you say, we need to really stay focused on what the clients need are and if they can't get in to see someone that day or can't access the service, then I think we as clinicians have to make sure we provide an appropriate service. And I think we can really engage with people well with telehealth. When you practice the technology, I really encourage clinicians to practice with their screens or their phones, whatever vehicle they use, so that you can really get the eye contact, practice our micro skills, learn to use your voice to engage with an anxious client really well and not be frightened by this technology. Like even on the screen, we can use our heads or how close or far we are can make a huge difference to someone who's anxious. It's about meeting the need now rather than saying sorry, you know, sorry, bad luck, you can't get to anywhere. I think it's about us being before we offer telehealth to anybody, be really comfortable with the technology first and know how we can offer our best service to people because it's clients that matter. And this really is a great example of making sure that we're actually putting the needs of our clients at the front of what they're doing because you're absolutely right, but the fewer barriers that we put into place to them getting the help that they need really is so very important. Louise, are there any other important principles about client suitability that you think? Are there any other factors that we should be considering here? Perhaps, particularly also if we're collaborating with other health professionals about a common client, you live in telehealth. I think what I agree again with what Julianne said Conrad, that if you've got a client who perhaps is at risk of self-harm or even at risk of harming someone else, telehealth doesn't necessarily mean you can't see them. It might mean that you need to give serious thought before you start therapy and setting it up about how you can wrap around the client some of the risk management strategies that you might do in a normal face-to-face session. So it may mean that before you start that you work with the client to understand who the support people could be. Normally if you've got a client at risk of harming themselves, then the clients they're in front of you and you can get much better clues perhaps than what they might from telehealth even using the strategies that Julianne suggested. You can get a good idea face-to-face of what's going on. It can be trickier when you can see them online but that you can certainly put in place some strategies around them. You can work with the, as you said, the referring GP, other services where the client might be living to put in place some safety procedures around that client. Thanks, thanks. Jonathan, of course, as GPs, we're more accustomed to, I suppose, always keeping a holistic view of what's happening for our patients. Even apart from just the diagnostic issues there, what might be some of the practical issues that you think might mean that our patient might be more, telehealth might be a really good option for them to be able to care. Yeah, so I see a lot of patients who are rural and a lot of them have jobs which, you know, they have to work nine to five in flexible bosses. They might have to look after young children transportation issues. So having that flexibility of accessing a service that could actually work for them rather than that they have to fit into the service could be one thing that I will identify for suitability for telepsychology. The other thing is sometimes as a GP you might actually identify that people need, sorry, need psychology but maybe a specific type or actually the patient wants specific type of intervention, whether it's, say, CBT or trauma counseling or something like that. Having telepsychology we have access to different clinicians and where you can just use the technology to link the patient with the clinician is a benefit. Yeah, perfect. So just thinking about, you've been doing these treatments for a while. Just looking about what have you found actually work as far as suitability. So are there particular professionals who you think, Mopin, as you think about this? In terms of what works, most of the work I do tends to be with people who have chronic pain. And I can say that telehealth is an absolutely fantastic avenue for working with people in that category because travel for them is very, very difficult. And I see a lot of people who have got chronic pain via telehealth even though we live in the same area. So obviously it's not under this particular program but as well as people in rural areas. The only thing I think that is a bit challenging for our profession is that quite often we do therapy which involves us doing things with a person. And that's a little bit more difficult. So like Louise said earlier, that is three of those 10 sessions that need to be face-to-face might be the times in which you're doing those strategies. So for example if we're doing great exposure in a shopping centre often we would go with people to do that. So there's some limitations but I think overall there are always ways that we can find to work around and make it work for people so that they can access the service. And I see telehealth as being a really can actually reduce some of the barriers to access for some populations not just rural and remote but also people with anxiety and chronic pain. And Louise of course there are some other practical issues there as well and we remember that this first session does have to be face-to-face. We can't do all of the services for telehealth. But Louise what might be some of the other issues that you want to address in that first session just on deciding whether the subsequent sessions can be via telehealth? I think for some clinicians Conrad that we focus a lot on whether the symptomatology of the client is suitable for telehealth. Are they the sorts of treatment they may need suitable? Are they other issues about risk or anxiety that might not suit or is the symptomatology too severe to be managed by distance? But I think we also need to remember that the technology can be a barrier to access for some clients while access to a phone or to some sort of device might be is not always possible for all clients. And I think the other big issue is the cost of the data usage that the client might incur in a 50 minute regular, 50 minute session. But it's not impossible to even get around that so it's certainly possible to work with referring GPs to find alternative places that the client can go to them. Well that's probably not going to be the local public library because there's a lot of confidentiality there. There may be access through a multi-purpose clinic or some sort of rural clinic service that's got access to a telehealth facility that the client can go to in a private room. So even when there seems to be barriers around technology, there can be solutions if you work with the local referring doctor and the client. Yes, that's right. And those types of areas really do have to be considered. You sometimes have to keep a bit of a lateral mindset on how you're approaching how might you be able to facilitate this care for our patients. Of course, Louisa just mentioned that sometimes we might need to use one of the local health services in the area who might be able to facilitate that visit. And we certainly know that keeping the GPs who are the primary preparers engaged can sometimes be a little bit difficult. One of the other issues that we have of course is following up with the patients, making sure that we're keeping up with what's actually going on for them. Julianne I think that you've probably had a few tried and trusted processes that you've found have been really useful for assisting with checking in with how your clients are going along. Would you be happy to share some of those? Yeah, thanks Conrad. Yes, I would be. And I've also got a few resources that were happy to provide for people around checklists and processes that we've got of Amaranth. So I'm happy to do that for people. But we've actually got a whole of an organisation approach whereby our administrative, once it's been organised with the client through the clinician and through the GP. So usually if I get a referral I'll ring the GP and have a chat to the GP or we ring the client to get an appointment and we discuss the opportunity for tele-health as the client says, oh gosh, it's a bit hard to go. I don't know what I can have an appointment. So we'll actually discuss with them what we're doing. But then I'll hand it over to my admin team who will then do the checks with the person and we've got a checklist which is called our tele-health you know, we've got a consent form. We've got checklists to see you know whether they've got the right environment. So we're going through a quite a comprehensive list of things with the person. Do a bit of a trial first whether they're choosing a computer as a platform or their phone as a platform. We've done an awful lot of work, especially after hours using phones and FaceTime as a very really lovely, easy, convenient thing to do. But we always do a check with people first and make sure that they're happy with the technology. They're happy with us that we can hear each other properly. That's where we negotiate those things about privacy and the what if the call drops out to see a second number we can ring them on. The thing is that we always ring the client first so we don't rely on them to ring us so we make sure we sell it. We'll ring you five minutes before our allocated time just to make sure you're okay. Or we text message them a reminder don't forget you've got a tele-health with Julianne or another clinician tonight. And our engagement with people is really good. The other thing we do is we contact them after the session, either the next day or sometime very within 24 hours just to see whether they're happy with the session, more from a practical perspective with their problems with it. Did they feel that they were listening to? Did they want to do it again? Was it really useful for them? And we actually collect that data as one of our quality processes. And then we review them at a monthly meeting and how do we go with these clients? Is it something we want to continue? So, yeah, I think that's... I hope that answers. Oh, well, truly Julianne. In fact, Julianne's been kind enough to share some of those resources and there's the other templates that she's been referring to. You'll be able to find under the resources tab that'll certainly help out for a lot of other participants tonight. Thanks a lot for Julianne. Jonathan, what might be some of the other ways that you find GPs can better engage those patients who really think are suitable for telehealth? Yeah, just like what Julianne said, I think the GP would really appreciate learning a little bit more about the process of telepsychology. For a GP, I think it's still quite a new thing and you can only imagine that a GP actually has to learn so many things because we're supposed to be experts in life. So mental health is just one very small part of all of the information that we get overloaded with. I think GPs like to be part of the professional community. We like to work with other health professionals, whether they're psychologists or social workers or councillors and allied health. We actually appreciate having a phone call from you or an email from you. We might be so busy that you'll have to leave a phone message, but we want to be engaged and it's an opportunity that you can actually educate us on what's the best way to help a patient seek treatment. The other thing that I think is the GP has sort of this continuity of care. For example, a clinician might only see a patient for 10 sessions, but a GP might actually see that patient for 10 years. Ideally, the GP can say in a non-threatening way, in an interrogating way, ask them how the first or second session went. For me, I always find that the patient gives me an interesting snippet. It could be something say the sound quality wasn't very good or how they found how the report went. I really don't think that this information is a duplicate. I'm sure as a clinician or the administrator might ask these questions, but it's more collaborative to see things from a different angle. Sometimes patients are so polite that they probably won't tell you guys what's really going on, but they feel comfortable in order to share it with the GP. Yeah, that's a really, really valuable insight there, Jonathan. We do tend to sometimes take our role for granted that for a lot of the times, we might actually be your eyes and ears, but if you're only seeing the client maybe once or twice as a face-to-face visitor, it may be four or six weeks since you actually last saw them in person, that there might be times that you might feel as though if you just give the GP a call or get in contact, you can just check up with us about what else might have been happening in the meantime. Might there be something that we can follow up with you when they're next coming in for a script or something. Yeah, that's absolutely right, Jonathan. It's not just the relationship between the mental health professional and the client, but you really can build a useful care team with this telehealth initiative there as well. Of course, we know that it's not just the initial engagement, is it? We really need to make sure we've got that longevity, we know that the GP's necessary for that part of it. How else do you think, Jonathan, that the GP might be able to get that initial engagement going well for the client? Sometimes I find that the clients can be overwhelmed with information, and if they are talking to someone who initially is not familiar to them, they might not be so able to get all the information, just simply practical things. They might forget that some of the sessions have to be face to face after, say, the first one. And having GPs who know about the process and engaged with the process can actually help facilitate the patient to be reminded of how the process goes. As an analogy, I see GPs as sort of like the coach, but also the cheerleader. We're the ones that have the rapport with the patients and can help them kind of like continue on with the process. Some patients might see 10 sessions as quite a long journey, or say like even a marathon. So having that GP to encourage them and cheer them on, I think is really important. So I think that's why GPs should actually be engaged themselves with your help so that we can actually all facilitate the same thing for the patient to have longevity through the process. And Louise, we've been talking about what types of therapies we might be going into, and some of them are quite specific and might be quite foreign to our clients. What would you think that the GP adds for those clients? Certainly from my experience in remote Australia where there are very few psychologists or social workers or OTs, there isn't a community understanding really of what psychological therapy is about. As Jonathan said, that sort of 10 hour long sessions talking to someone for a device seems very unusual and pretty scary when no one you know has done that before this is a very new service. So to have a GP who can encourage a client that it's a chat, it's not scary that the therapist will be guided by you, that it's normal to feel anxious and it will get easier and it's okay to tell them how you're feeling. Can be really encouraging for a client who's really got no concept of what psychological therapy is let alone psychological therapy over a device. The GP in my experience with any sort of psychological therapy even when it was myself or my colleagues face to face made an enormous difference if it was the three of us all working together as a client, the GP and myself and I think it's even more important when we're talking to the GP. Yeah, agree wholeheartedly there would be one from that Louise. Of course it's not always straightforward, there's a lot of, I suppose a lot of risks that we have to face as well with what happens with telehealth. We know that we've got a brief of patience to, it's not the ideal setting for us, we don't have them there in our consulting room with us as well. I suppose with delivery of mental health services via telehealth. Jacinta, would you be happy to address maybe what your strategy might be with some of these? Definitely, I have talked a lot about risk in the initial webinar if people get to have a look at that but look some of the main risks that people face for us as providers is we have a less, maybe a more limited ability to undertake a comprehensive mental state exam via telehealth and sometimes there can be increased frustrations for the client. If there are lags or if there's interruptions in the technology that can really interfere with the therapeutic relationship and our ability to do the assessment. So it is really good to have contingencies for if that happens and so for example you might say do the video link over the over your platform, however you might actually speak over the phone so that you're not limited in your conversation if the screen freezes and you need to sort of work on that and that can really help to build rapport and reduce frustration. Other risks of course I guess people are more likely to disclose deep distress possibly they might feel more comfortable to do that in this type of environment or suicidal ideation and that can be quite confronting for the a little bit more difficult to manage as the provider of the clinician. So when we're dealing with that risk we really want to make sure that we have mitigated the risk as much as possible prior to the appointment. So the sorts of things that you would do in your initial assessment which I like to do that one face to face if possible because then we can do a really thorough risk assessment and make a plan around any potential self harm or suicidal behaviour or potential crisis and get the client's agreement on that plan so that you've got something to enact should anything happen and it's really important to also make sure that the client's very well informed about limitations within the session to confidentiality that arise through electronic communication and that they have a contribution to make in terms of privacy, they're keeping protecting their own privacy and that might include things like making sure that they're in a room with a door that closes so that if there are other people in the house they're not listening in on their conversation. So it's very, very important to not scare people, get them to understand the process of a simple face to face like a simple face to face consult except over the internet and make sure that they're prepared and you've planned for any risk so that you can mitigate that as much as possible. That's enough for me. Absolutely. You're right. I remember going through all of that in the first webinar and thinking, wow, there's so much to think about all of this as well and certainly some of those practical points. Julianne, you've been doing this for a while as well. How do you manage some of the risks involved with the delivery of mental health services by telehealth? Oh, thanks Conrad. Yeah, and look and thank you Jacinta. That was really, really fantastic what you said and I think I totally agree with her but it's really critical whether you have the first session face to face or you don't get that luxury so actually, and I really worry sometimes that we clients may think we're wasting their valuable time if we take up too much time doing checklists and checking, making sure everything's safe and perfect. Honestly, we've done some therapy where a guy's been athlete's tractor sort of as an apathic and it was unexpected. We just had to go with the flow and we did all the risk assessments beforehand and I just said we ought to be in a room safe and quiet because sometimes it's just about being where the client is which is sometimes we have to be ready to respond ethically and appropriately I think as we can. But we do have in one of the documents I've provided is a pathway, a checklist for telehealth sessions and I use this with every session. We put it in the file and I tick through it. Consider the appropriateness, make sure all the information is being given. We've got a little booklet that we give it to people to start with that might have key questions to ask. We ask them to try and speak naturally and just feel what they would expect. We do exactly what we do in a face-to-face session but it's a little bit more condensed perhaps. I'm really mindful too about how much of a person or how much of myself I try to show on the screen. So we're just not doing headshots we're trying to get a body so that they can see that I'm more than just their shoulders and their head that I've got arms and legs and I encourage them to show a bit more of their body so that we feel this more of a I think it's a bit about it's a risk if they don't feel they know you and can feel comfortable with you and I'm conscious of all those other things around animation and like I would in a session. But I do really use this pathway checklist with people and I feel that it gives me from forgetting things and that we cover things off with the person so that we go over things like making sure there's no other people in the room that you want privacy or if they do want a support person, who's that support person, how do I contact them between sessions. A big thing too is to make sure they know what to do to check in with you after the session because I think a lot of people feel that because it's telehealth that they can contact us by messenger or through Snapchat or Facebook. So I think it's really important to also ensure that they're very mindful about what you do expect and what not to expect as well because I've had quite a few people then text me because I use my own mobile phone if I'm doing FaceTime or I'm texting them to remind them and I use my mobile phone as a backup. People then will contact me after hours so I'm very mindful now ensuring that that's covered and people understand my expectations or what I will expect from them and vice-versa. Yeah definitely and certainly having those contacts in place really is so very important but it is ideal to try to make this as natural as you can to remember that all of those same concepts, the importance of non-verbal language and communication are just as important as ever. On Friday I had a situation where the psychologist one of my patients had to keep our patient on the phone talking, talking, talking while she was then trying to get in contact with the mother who was 150 kilometres away and bring my surgery, kind of get an urgent appointment for that afternoon because of concerns she'd had about his condition. So yeah obviously there really is make sure you've got all of those contacts and all of those parts of the puzzle in place early so that if you do find there's actually some concerns going on you're not scrambling at the last minute trying to explain it all to 000 on just what might be going on. Of course in the way you said there's some other concerns that we might have as well and Gillian quite rightly put out that we have to make sure that we're delivering the best service that we can in a way that's appropriate to our patients. What might be some of the other issues if we're not providing the service, if we decide that this is too hard and that we're not proceeding with it? Thanks Conrad. Just before I answer that I was just going to pick up too on what Gillian said about and Jacinta about managing the risk too that it can really be helpful each time you do a telehealth session to ask the client where they are because we can't assume they're always in the same location when it's telehealth so and I think your example Conrad was the good one that the client you're having to chase people up from a distance. Well if the client's not where you think they are it can be very hard to get emergency services to the client so sometimes it helps at the beginning of each session to say you know where are you today because it might not be the same place as it was the last session. But I just wanted to pick up on something Gillian had said earlier on too about sometimes there can be more risk in not providing a rural client with the service and it's often a real conundrum for psychologists working with clients in rural and remote Australia because you need to give a lot of thoughts that you're not going to put a client's risk and sometimes the ethical dilemmas in taking clients on that are high risk when you're a long way away from that client seem insurmountable but often of course when there's no other option but the psychologist or the OT or the social worker by a telehealth that puts the client at more risk than if they've not had a service at all. So I agree with Gillian's point earlier on that sometimes it's a matter of working very closely with the GP with the support people that the client may have finding out who their supports are, what the crisis services, the phone numbers of them in their local region and other services in that region because sometimes the risk is related by you providing it even though it might seem high risk at the beginning. And Melisa of course we're talking about client settings and client locations that that might change and that in fact these clients might not necessarily be in the same state as you. What would be some of the cross border legislation issues relevant to mental health professionals working using mental health services in telehealth? It's certainly possible of course with telehealth that the provider and the client are in a different state and might even be that the client moves during the course of treatment and moves into state so you do have a client not in the same state or territory as where you are as the clinician. And there's a whole lot of different legislation of course that all of us therapists need to comply with and we're all very familiar with the legislation pertinent to us in our particular state and the national legislation and for private practitioners that's the Privacy Act, the National Privacy Act, but there's also state and territory legislation and of course if you're in one state and the client's in another then you've got a tricky legal situation. And I think clearly around some of those issues around health records acts because some of the states have different health records acts and there's variation in what you may be required to do in terms of the clinical records. But of course mandatory reporting is the other area where there's going to be good or bad as the Royal Commission's identified there are state based differences in mandatory reporting. And I just thought the example I would give you is if you're not in Victoria, if you're not practicing in Victoria, you're probably not aware of a relatively new legislation in Victoria that requires all adults to report any incident of a or any reasonable belief that they may have, so acquired in the course of Telly Hill, that a person in Victoria who was under the age of 16 at the time had a sexual offense committed against them by a person over the age of 18 and that has to be reported to the police by any adult including providers of psychological services. So if your client's in Victoria and you're seeing that client from New South Wales or any other state, you need to be aware of that requirement. So if you're going to do interstate work, you need to be very careful and to understand the legal implications of wherever you're providing services to. Well and truly. And of course the security of the platform that we're utilising is a major concern as well that many of our participants tonight have been asking about. Just into have you found these particular platforms which are they're concerned about security of platforms that you've come across at all? Yeah sure so this is just from my own perspective, not speaking on anyone's behalf here, but we offer our client an option of Zoom or Skype as their platforms and we inform them about some of the risks that are associated. I believe that Zoom meets all of the requirements of the APS but for telehealth and Skype does not quite meet them. What we find practically is that people prefer Skype and will choose to use Skype even though they're aware that there might be more privacy concerns around Skype simply because they're familiar with it and people are more likely to use things, want to use things that they're familiar with. So we tried to mitigate our own risk there by making sure that people have informed consent and will sign a consent form saying that they're aware of the risks and they want to proceed with using that platform but in a practical sense that's what people are choosing within our practice anyway. So yeah I fully understand and certainly have been asked about that area. Now of course Jonathan, we've mentioned that as the GP we are sometimes there to fill in the gaps and to maybe follow up with our patients about how they're progressing with their care. What happens if we find that it's actually not working all that well? What do we do then? I find that having a chat with a patient to explore what their concerns are or what their issues are it could just be one example, Doc I just had my session and I go how was it and he said it was amazing but awful at the same time and I go oh what do you mean? Well you know it was trauma therapy and is exactly what he wanted but it was just so overwhelming and just for him he just wanted to stretch out the appointments a little bit more but he didn't know actually how to do that and as a GP you can actually facilitate that and maybe just make the call with the patient's consent to whoever is doing the sessions and say oh could we maybe stretch the appointments out a little bit which actually improves, well decreases dropout rate and improves their ability to continue on with their sessions. The other things that you can think of is I guess a lot of patients actually tell me oh look we just didn't get on and when you sort of explore that their sort of idea of a psychologist is like a para gene you know when I pick the para genes out it has to fit but why does Levi make so many different types of genes you know nobody, not everyone will just fit a Levi's 501 you know and sort of exploring that as a GP because you've already got that rapport can sort of help them be a bit more realistic on how they see the consultation and see the fit. Julianne you certainly have plenty of opportunities to look at how the progression and how the course of sessions goes. When do you feel, what might be some of your strategies if you think that it's not progressing as it should or it's not working well. Look we usually pick that up after the session evaluation when we say look I hate it but it's myself or somebody in the admin team does know what worked, what didn't work, did you like the person, was it what you expected and most people are very honest in giving their answer. We're actually looking at an online version of that through survey monkey where we might say that somebody will flip you an email by the internet with the survey we'd love you to respond with and whether the session worked. We try to do it as quickly as we can after each session rather than wait until the fourth session so that we can actually mitigate any problems before they arise and get people to engage between sessions as well that way. But if it's not working well we do a bit like what Jonathan said, find out what they expected, what they expected were then not the right clinician. I agree. I've never used the Levi-Gene's analogy. I use a fluffy pair of ag groups. So you know, a clinician has to fit. It's not about a person ticking the therapy or the clinician. It should be the other way around. We've really got to make sure we get the right person to be for the right clinician for that person. If it's not me it could be someone else that I need to know the clinicians in the room to serve them on. And use the GP, I think Jonathan's point is brilliant. So we use the GP as that liaison to say, look, I just don't think it's working. I'm not quite sure what's going on. Could you follow it up and maintain that communication. But also I think we've got to be, a lot of people don't know what they don't know so they don't know what, if they've never tried counseling before or therapy that we really, we can surprise them and they just don't know that it's going to be like this. We ask questions that are really difficult sometimes and I think perhaps encouraging people to keep trying to sort of have another go, see how it goes. We'll get them in for a face-to-face if that's possible. Our services try to make for our outreach people a bit of flexibility in seeing people after hours and after six at night. And also on weekends if that helps with accessibility if they're coming into town for other reasons. Often it's the weekend event like football or netball we might be available before the hour or after it depending on what brings people to town. So the ConRoot it's not a simple easy answer there. I think we really try to respond well to each person's concern. But I do find the after-session evaluation is giving you really good clues to what we perhaps could change or do differently next time. And I think certainly that points out also why sometimes you do need to make sure that you've still got those face-to-face sessions happening there as well. So you really do give the opportunity to re-establish that actual connection, that actual therapeutic relationship doesn't have at all just being an instance. And that certainly can be why it's good to space out those face-to-face sessions. Don't just leave them all up to the 8th or 9th sessions. Really getting something in at the 4th session is important. We've mentioned about the drop-out in terms of if our client ceases the therapeutic relationship earlier than what we might have anticipated for their course of therapy. But of course sometimes drop-outs can be a bit more immediate than that as well. What would you suggest for a therapist if the consult actually ends unexpectedly? Sure. So if people are not, if it drops out because of a technological issue, then that's certainly something you would address by having backup using maybe having a second number that you can find, a phone, or another avenue in which to contact somebody if the compote ends unexpectedly in that way. And that the client will be aware of what that process is going to be as well. Sometimes we're having drop-out because people have left the session. That's unusual but it's possible that that could happen. And once again you would have a backup plan for what you're going to do within that session, within that process. So if somebody walks out of the room, maybe they get really distressed and they leave the consult, then you're going to want to have again another number to call and a series of options that you would do to follow up to make sure that that person is getting the support that they need and try and encourage them to come back to the session if that's possible. I would just like to add to in the conversations that you were having before with Julianne that often people don't tell you that they're not finding it very good, although Julianne's process has is a really good one of following up with that. Often they tell you by not coming back or that certainly part of the experience I've seen is that people, you know, I guess give you that feedback by not re-engaging and that's a really an important time if you can't get through to people on the phone to actually make sure we are following up with the GP and giving them the feedback that somebody hasn't returned for the next session and, you know, when they're coming into the next review can they please be followed up. Another little point that is really important is that we need to get a good information to people often over the email or in some avenue in which you're able to actually pass information to people because often in a clinical room we would hand people a handout or give them a book to read or something that, you know, is there doing for homework or following up. It's really, really important that we have a way to give these resources to people and so getting consent from people is really important to use email or fax for invoicing and information exchange that's just something maybe to keep in mind in terms of stuff that's useful to have consent for. I've gone a bit all over the place there but all those things are hopefully quite relevant and important. Oh no, it's so important to make sure that we do cover all of those simple practical bases because, you know, it's too easy for a third to get just wrapped up in the content of the session and not think about all those practicalities you just take for granted when you've got your client there in front of you and, you know, watching for if they're starting to get distressed if they look at that they're not really engaging in therapy but, yeah, you don't want to wait until you've got a silence line on the other end before you realise that they're no longer participating in the session. So, that's a great summary of some of those points there. Louise, you know, we just heard from Julianne and Jacinta on some of those practicalities there as well. Any summary points there for you that you'd like to share with the other participants? Thanks Conrad, I agree with both Julianne and Jacinta that end of session assessments are one way of checking what's going on and certainly the not showing up as to my experience too is the sign that all cancelling appointments are leaving a long time before making the next appointment are some of the signs that it might not be working. I think also though that when we're doing that some of the signs you might pick up in a face to face session that things aren't working too well you don't have the non-verbal cues that you've got face to face and you might have to work a bit harder by telehealth in checking out all the time and clarifying that you are hearing what the patient's saying and clarifying with them that they've understood what you've said as well because without those non-verbal cues you've got to work that little bit harder verbally to make sure that the communication is working and also just want to emphasise again what Julianne pointed out earlier on that the need to appear like a human being to the client and to encourage them too is really important and often it's from your lead that therapists lead that they'll be able to see you using your hands or whatever you need to do to make them realise that you're more than just a person on the screen in front of them. So I think working along those non-verbal cues as well as end of session assessments and of course keeping an eye on cancelled appointments and letting GPs know if things are going astray very early on. Yeah for sure and Jonathan as the GPs we're often the ones who are seeing our patients earlier than making the decision to refer them on and then obviously we're the ones when the course of treatment has finished we're the ones who might be there continuing the therapeutic relationship with our patients as well. What might be some of your closing summary points of what we're talking about tonight with telehealth for our mental health service delivery? Sure I really think that GPs are generally interested in our patients and we really want the best for them so if you can help engage us as well as the patient we're just all going to work together really well. So yeah use us talk to us. Yeah well and truly and look I think that hopefully what we've all been out of tonight's conversation is that it really is trying to make the whole experience as natural as we can remembering that it's not the same as the consultation style that many of you have been accustomed to throughout your careers but it's much much better than not being able to have a service available at all. If you can put in that great preparation, we've got some fantastic templates and checklists available there if you can really identify those clients for whom you think that service delivery by telehealth might work well and even if thinking that it might be a specialized area of therapy that might be a little bit beyond through your immediate circle of recurring professionals are, that's what the professional network is all about and looking a little bit broader as to who else might be out there who can work with you. But of course what we're seeing tonight as we've done so many times it's working as a team with our clients and our patients at the forefront of our thoughts that really we get the best benefits for them. So thank you very much to everybody in our wonderful panel tonight for your participation. That's been fantastic and I think we really have managed to get through those learning objectives quite well. Please to all of our participants in the audience this evening, remember in the resource tab there you will find the link to the Allied Health Professional Department of Health Guidelines and frequently asked questions. And please as I said these series of webinars cover a massive variety of topics. Make sure you keep up to date with them. The next webinar that MHPN will be hosting is going to be next week, next Wednesday night, body dysmorphic disorder and psychological assessment to cosmetic surgery. Also in July we've got another one coming up on bipolar disorder in youth and early intervention on Monday the 23rd of July which is I think that's all I'm talking about. And then a very, very important one that hopefully we'll see a strong turn up for on the Thursday the 23rd of August. So about self-care for health professionals and really that's something that's very important to all of us. So we really do, we make sure that we remember that mental health professional network is a service which is there for your benefit. Please make sure you do complete the feedback tab so we can really continue to build these webinars to meet your needs as hopefully we have tonight. Also remember that it's important that you have these networks in place in your local area as well and worth checking on the list to see if there's actually a network which is already available in your local area. These aren't just about one particular discipline of course. These are just one of the areas of permission where you can share tips and resources build your local referral pathways and engage in CP activities. So please contact MHPN if you're looking, if you're interested in setting up one of the surveys and looking at some further online resources before we go. So finally in closing I'd like to acknowledge the consumers and errors of those who have lived with mental illness in the past and those who continue to live with mental illness in the present. Thank you to everybody who's logged on tonight and to our panelists who are participating. Good evening and we'll see you next time.