Abstract
The use of technology in health service delivery (e.g., telehealth) and subsequently in training and education in preparation for health service careers (e.g., telesupervision) provides both challenges and opportunities. Embracing the opportunities afforded by telehealth and telesupervision will help equip the next generation of health professionals for the realities of the healthcare system of the future as well as promote greater equity for trainees and patients. To ensure maximum gain and minimal negative impact, training programs, researchers, and policymakers must work together. The field can move forward through application of innovative use cases, thoughtful design and implementation of evaluation, and the development of constructive policies. This column aims to inform these different stakeholders by providing applied examples of telesupervision in a telehealth training clinic, discussing the evaluation of telesupervision programs and competencies, and discussing policy implications for telesupervision.
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Introduction
A large body of research and the experience gained during the COVID-19 pandemic have increased confidence in telehealth service delivery as a non-inferior method of care delivery, especially for mental health services (Lin et al., 2022; Thomas et al., 2021). Research on telesupervision also demonstrates non-inferiority to traditional supervision methods (Inman et al., 2019a; Jordan & Shearer, 2019; Reese et al., 2009; Tarlow et al., 2020). However, an evolution in the applications, research, and policies around the use of technology in supervision is needed. Telehealth and telesupervision will play key roles in meeting the needs of an ever-evolving healthcare system, addressing patient preferences for virtual care, leveraging advancements in technology, and reducing disparities and inequities in care (Bailey et al., 2021; Perle & Zheng, 2023). This column will provide applied examples of telesupervision in a telehealth training clinic, discuss the evaluation of telesupervision programs and competencies, and discuss policy implications for telesupervision.
Telesupervision and Program Description
The use of technology in supervision can be synchronous or asynchronous and has specific competencies gained through use and education (Perle & Zheng, 2023). Telesupervision can refer to providing in-person supervision of services conducted via telehealth or supervision provided remotely (either of care provided in-person care or via telehealth). The Telebehavioral Care Program (TBC) at the Texas A&M Telehealth Institute utilizes all the above-mentioned applications of telesupervision. The TBC provides counseling services almost exclusively via telehealth (i.e., videoconference and audio only) to many types of organizations (i.e., schools, jails, medical settings, etc.) and directly to patients from their own devices. Since all services are delivered via telehealth, all supervision occurring in the program meets the definition of telesupervision. Specific applications of synchronous and asynchronous telesupervision include weekly supervision, consultations (emergency and non-emergency) during and after sessions, and live supervision of sessions.
The program, which launched in 2009, has historically provided clinical training primarily to health service psychology doctoral students from multiple universities in clinical, counseling, and school psychology programs accredited by the American Psychological Association (APA). To date, the program has trained over 150 psychology doctoral students. In the last few years, the training model has expanded to include post-doctoral psychologists and master’s level trainees (pre- and post-graduation) in counseling. The program typically supervises between 25 and 30 trainees annually. Trainees provide counseling services across the lifespan for a wide variety of presenting concerns with the most common being depression, anxiety, trauma, and adjustment issues. Counseling is also provided for individuals with serious mental illness when paired with medication management from other providers. Trainees receive didactic training in topics such as the use and troubleshooting of program technology and platforms, telehealth etiquette (e.g., lighting, rapport building, and eye contact), laws and ethics related to telehealth, handling crises remotely (e.g., safety planning and hospitalization), multicultural considerations of telehealth and rural communities, and other treatment considerations of telehealth (e.g., adapting treatments to telehealth and assessing client suitability for telehealthcare). Weekly supervision is typically provided by an appropriately licensed provider for the discipline (e.g., licensed psychologist and licensed professional counselor-supervisor) or occasionally by an advanced or post-doctoral trainee whose supervision is supervised by an appropriately licensed provider. The content of the weekly supervision varies based on the developmental needs of the trainee, the theoretical orientation/supervision model of the supervisor, and the needs of the patients.
Applications of Telesupervision
Multiple sources provide overviews of technology applications in supervision (Inman et al., 2019a, b; Perle & Zheng, 2023). This section details several practical applications of telesupervision, including quotes from supervisors and trainees obtained during a quality improvement initiative. A few selected challenges faced by the program and recommendations for new or expanded implementation are also provided.
Applied Examples
The program uses a mix of in-person and remote options (videoconference with phone as backup) for weekly supervision. The same telehealth platform used for clinical service delivery (Let’s Talk Interactive) is often used for telesupervision, and in some cases, Zoom and Microsoft Teams are used. In this system, these tools meet technology compliance requirements for the Standards of Privacy of Individually Identifiable Health Information set forth by the Health Insurance Portability and Accountability Act (HIPAA; US Department of Health and Human Services, 2003). The weekly telesupervision model was established for two primary reasons: (1) to maintain quality supervision for the growing number of supervisees seeking telehealth training opportunities and (2) to pair trainees with supervisors who provide additional benefits for professional development (Pennington et al., 2019). This model helps trainees gain networking opportunities outside their home institution and get exposure to supervisors with varying theoretical orientations working in different settings.
With telesupervision options, bilingual trainees receive supervision from bilingual supervisors. One student from the program stated, “From previous clinical experiences, I have been the only bilingual trainee and more often than not, have had English speaking supervisors. Telesupervision has connected me with other bilingual psychologists who can support my clinical experiences to consider the unique cultural considerations of working with Spanish-speaking clients.”
Supervisors are comprised of internal staff, faculty, and contracted external supervisors. This has aided in managing the number of trainees assigned to each supervisor. Students have acknowledged this component as especially helpful because they feel their individual supervision experiences are more personable. They report feeling more support than when one supervisor is assigned to many students, as can often be required for university course size requirements.
Other benefits of telehealth for weekly supervision have included the ease of watching session recordings together in supervision or between meetings and the added benefit of transcription availability for in-depth reflection on session content. Facilitating secure and easily accessible videos required upfront coordination with the organization’s information technology, compliance/privacy personnel, and ongoing financial investments for secure storage. Secure storage has become more cost-effective as transitions have been made from physical servers to cloud storage.
One commonly referenced benefit of virtual supervision is the ease of scheduling, which results in more consistent supervision with less rescheduling. One supervisor shared, “As a military spouse I am grateful for telesupervision because it allows me to participate in a large organization doing impactful work regardless of where my family is stationed. Telesupervision is very flexible with scheduling and makes me more available to my supervisees because they can choose a supervision time when they are at the clinic or at home.”
In addition to weekly supervision, the program uses technology to facilitate supervisors joining sessions with trainees. The program has had two telehealth platforms, one allowing for “incognito” mode, equivalent to the one-way mirror in which sessions are observed without interruption. Telehealth platforms most often require the supervisor to join as a participant leading to multiple options described elsewhere in the literature (Pennington et al., 2019; Rousmaniere, 2014). The supervisor can be a known participant as an observer only or the supervisor can join and actively assist a trainee. Trainees and supervisors have reported using this feature in cases such as (1) trying a new intervention or conducting the first intake, (2) needing assistance with risk assessment/safety planning or feeling unsafe with a client, and (3) adding other providers for collaborative care and input on cases.
Another layer of having supervisors join sessions is using secure chat to communicate with trainees and provide live feedback or assistance. This combination of technology solutions (virtual joining + chat) matches the principles of traditional bug-in-the-ear supervision for telehealth sessions. One student stated, “Consultation in crisis is improved using telesupervision as I do not need to leave the client to obtain real-time feedback, guidance, and encouragement in high-stress situations.” Nadan and colleagues (2020) describe this model and noted experiencing limitations of time delay for responses and problems with navigating separate systems to communicate with individuals not in the session.
The program has addressed these barriers through front-end training of supervisees and supervisors on HIPAA-compliant platforms integrated across processes. Specifically, the Microsoft Office suite of apps and services is used university wide and has provided significant advancements in integration. Since faculty, staff, and trainees in the program become familiar and proficient with these tools, many of the previously mentioned barriers are overcome. Microsoft Teams provides immediate feedback to trainees with or without the supervisor joining the telehealth appointment. Supervisors can respond more quickly to trainee questions via Teams than when a trainee must step out to find a supervisor or initiate communication outside the therapy room. These quick exchanges can keep the session moving forward, alleviate trainee anxiety, and enhance adherence to best practices in safety planning and evidence-based interventions. With the proper settings enabled, messages received from the supervisor are unobtrusive (e.g., appear on screen then fade away without action), do not interfere with engagement with the client, and are available to refer to after the session as needed. Over time, as trainees become more familiar with Microsoft Teams and utilize chat as needed, the process becomes less disruptive and a familiar part of navigating clinical/logistical challenges occurring during sessions. Students have identified greater ease and comfort in accessing consultation through chat services to avoid abrupt session interruptions. Using chat and having supervisors join sessions has become a standard and highly utilized training tool as trainees recognized the benefits and were met with non-judgmental, growth-focused supervisor support.
Challenges and Recommendations
Programs wishing to implement or update their telesupervision programs should consider potential key challenges, such as selecting appropriate telecommunication tools, defining communication structures, and ensuring compliance with privacy and accreditation. Research and legislation in the telehealth field are rapidly evolving and require programs to stay up to date on current policies and best practices.
Telehealth tools and platforms are not one size fits all, and finding the right fit for the telesupervision and telehealth service delivery tools and platforms was a primary challenge for this program. Implementers are encouraged to (1) reflect and document aspirations for their telesupervision model, (2) create a list of any problems/ “pain points” with their current tools and platforms which are limiting the supervision model, and (3) create a list of desired features of the tools/platforms. These steps will help inform consultations, product searches, and decision-making. In addition to consulting within their organizations, programs may consider consulting with other entities using telesupervision models or contacting regional telehealth resource centers (National Consortium of Telehealth Resource Centers | Home).
Managing communication between trainees, on-site staff, and remote supervisors has also posed challenges. For example, telesupervisors who are always remote may be less aware of internal policy changes within a program. As such, open lines of communication between telesupervisors and site leads and developing communication strategies are key. Utilizing training and newsletters has been essential to keep telesupervisors informed of changes and other updates. As another example, enacting clear procedures for crisis consultation and mandatory reporting was challenging. Since the individual supervisor is ultimately accountable for care, they should be informed and consulted as quickly as possible. For instances when a telesupervisor is off-site and has other responsibilities, trainees need access to someone (and at least one backup) accountable for immediately responding to support the trainee. Having on-site access to this support may be preferable; however, in practice, technology is still often used as a fast, reliable route to assistance. Successful implementation of these processes hinges on clear documentation, regular training, and ongoing quality improvements.
The program had to pay particular attention to nuances of telesupervision impacted by training accreditation bodies, larger organizational policies, state laws, and licensure requirements. For example, the larger organization required all selected platforms to meet HIPAA standards. Furthermore, with the addition of each new training discipline, the program consulted the training standards to fulfill requirements, such as required percentages of in-person supervision. For example, the APA Commission on Accreditation requires 50% of supervision occur in-person. In-person group supervision and in-person, on-site access to consultation/supervision have been deemed an appropriate accommodation to meet this requirement during APA site visits. Those wishing to implement their own program are encouraged to review accreditation standards, consult with other programs using telesupervision, and document their rationale for training and compliance.
Telesupervision Evaluation
Evaluation of telesupervision is needed to drive innovation in practice and to inform policy decisions. Applications of telesupervision should be evaluated by training programs and organizations to facilitate data-driven decisions about ways telesupervision is enhancing or compromising the quality of training. These evaluations might include collecting information from trainees and supervisors about challenges and facilitators stemming from using technology in supervision. Additionally, tracking proximal (e.g., knowledge, skills, and attitude progression) and distal (i.e., licensure and employment in settings using telehealth) outcomes for trainees would benefit evaluation for program improvement. Establishing data collection procedures for quality improvement also lays the groundwork for disseminating findings and conducting retrospective and prospective studies to drive the field forward.
Another key component of evaluation in telesupervision relates to assessing telesupervision competencies. While agreed-upon telehealth competencies have yet to be adopted by accrediting or licensing bodies, guidance is available from the literature and professional organizations (APA, 2013; AAMC, 2021; Maheu et al., 2021; McCord et al., 2020; Perle & Zheng, 2023). These telesupervision recommendations include targets such as familiarity with literature, proficiency in technology used, understanding of appropriate use and application, security of transmitted data, collection and use of feedback, and adherence to legal, ethical, and other guidelines. Along with these, Perle and Zheng (2023) have taken other practice-focused telehealth competencies and explicitly enumerated their application to telesupervision. Examples include adapting evidence-based interventions and validated assessments, risk assessment, cultural considerations, and practice logistics like billing and handling power and Internet outages.
Existing competency models may benefit from creating evaluation tools or rating scales and validating published scales (Dopp et al., 2021). However, programs/organizations can begin to incorporate these training and evaluation components into their curricula and evaluations to prepare trainees for evolutions in healthcare and prepare their programs for future changes in requirements to match these demands. A succinct summary of other recommendations can be found in a recent column by Drude and Maheu (2023).
Telesupervision Policy
Policies created by organizations, accrediting bodies for training programs, licensing boards, and state legislative bodies all have important roles in protecting the public, trainees/professionals, and their practices. Especially regarding training and unlicensed professionals, adequate oversight is paramount to ensure quality and ethical care. Concerns such as data security, managing crises, losing information typically available during in-person encounters, issues in Internet connectivity, and transfer of evidence-based interventions to virtual applications should not be taken lightly (Blumer et al., 2014; McCord et al., 2015). As a result, many policy making bodies, such as the Association of State and Provincial Psychology Boards, have standards such as requiring at least 50% of supervision be provided in-person (ASPPB, 2020). Technologies are advancing faster than the research desired to create well-informed policies. However, it is not clear what research questions should be answered to assuage policymakers, and there are limitations in supervision research restricting the formation of conclusions (Watkins, 2020). It may be beneficial for policymakers to remove specific requirements for amounts of in-person supervision and instead focus on quality and adequacy of developmentally appropriate supervision based on the specific needs of the organization and trainees.
Conclusion
Just as telehealth service delivery has promoted patient-centered care, decreased disparities, and increased equity (Bailey et al., 2021), telesupervision holds much of the same promise for our next generation of health professionals. Telesupervision can promote trainee-centered options to save time, reduce travel burden, improve flexibility in high-demand schedules, and give access to culturally, linguistically, and professionally diverse supervisors. In a parallel process with mental health access, these qualities of telesupervision may be particularly beneficial for trainees with minoritized identities in higher education who are underrepresented in our health professions (e.g., first-generation students, persons with disabilities, LGBTQ + persons, and racial/ethnic minorities).
Training programs, researchers, and policymakers will need to collaborate to ensure positive adjustments to telesupervision policies. The many potential benefits of telesupervision can move our field forward in a positive direction through continued innovation in applications of technology, advancements in evaluation and research, and constructive reflection of existing policies. Embracing this change will help ensure that our future healthcare professionals are better equipped for changes in technology and promote greater equity for trainees and patients.
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Acknowledgements
The authors would like to acknowledge Texas Health and Human Services, the Texas State Legislature, and the Health Resources and Services Administration for support of the training and service programs that informed this work. The authors would like to acknowledge Katherine Budge for her assistance in outlining potential areas of focus for the column.
Funding
While the authors have received grants from multiple funding agencies to support training and service projects that informed the content, no sources directly funded the preparation of this manuscript. See the “Acknowledgements” section.
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All authors contributed to the conception and writing. The first draft of the manuscript was written by Carly McCord, and all authors contributed additional content and commented on previous versions of the manuscript. All authors read and approved the final manuscript.
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McCord, C., Jackson, K., Dias, K. et al. Innovation in Telesupervision: Application, Evaluation, and Policy Implications. J. technol. behav. sci. 9, 100–105 (2024). https://doi.org/10.1007/s41347-024-00402-0
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DOI: https://doi.org/10.1007/s41347-024-00402-0