Guidelines for Remote MHPSS Programming in Humanitarian Settings: Step 3

3.1 Undertake Awareness Raising and Outreach

• Consider using innovative means for the provision of awareness raising and outreach. Include these in the contingency planning stage and adapt as necessary based on the situation which requires remote programming.
• Outreach workers should share contact details for services and referrals within the community and in all MHPSS service entry and referral points. If necessary, provide orientation to identified referral focal points, such as healthcare providers, teachers, police.
• Consider using the available means of communication for awareness raising, such as social media, hotline/helpline, messaging services, radio, newspaper and television.
• Develop additional information, education and communication (IEC) materials for dissemination in service entry points, such as posters with updated information on how to contact remote MHPSS services or tips and techniques for managing stress.
• If possible, appropriate and with the consent of the recipient, use a postage service to send materials directly.

Note: Broadly disseminating information about remote services may generate more demand than the program can currently meet. Manage expectations when raising awareness about remote services. Use the following case-load decision tree to determine if your team might be able to accept new clients, working with a supervisor to determine whether you are at full or manageable capacity.

3.2 Identify Appropriate Modalities for Remote Support

The Spectrum of MHPSS service modalities

Modalities of communication that provide the richest amount of detail (i.e. verbal and nonverbal communication) and live opportunities for exchange of information are the most effective. For remote support multiple communication methods are often useful and can strengthen the quality of the interaction, for example video calling a client after arranging a time over a messaging service such as WhatsApp (ideally a business account to enforce professional boundaries) or Viber, or following up on a call with materials sent to a client via email. The method used may vary from client to client taking into consideration issues around privacy, familiarity, availability of the modality, access to a functioning network/internet connection and literacy, including IT literacy. Video and phone calls should not be recorded as a way of documenting consultations.

If possible, consider using a hybrid modality, utilizing in-person and remote modalities as appropriate. If a hybrid modality is to be used, consider meeting in-person for initial sessions in order to establish the relationship and build rapport, moving to remote modalities in consultation with a supervisor and taking into account client needs. See Section 3.3 for guidance on client considerations for remote support.

Staff should adhere to the principles of ‘Ensuring Privacy’ when conducting calls or communicating with the clients via other remote means outlined below. Refer to Cross-Cutting Component: Ethical Considerations for more details.

3.2.1 Video Calls/Conferences

• Select the most secure and viable platform and create a separate work account, ideally on a work device and not on a personal phone or computer. Remember the importance of online security and safety.
• Where possible it is recommended to conduct the first session in person. If not, it is recommended to conduct the first remote support session over video if the client feels comfortable doing so (invite the client to share while emphasizing that is optional and there is no pressure to turn on video).

• Staff should follow clients lead when choosing to share their video, i.e. if a client selects to show their video then the staff member should do the same. Where this is not considered appropriate or is uncomfortable for the staff member this must be discussed with their supervisor.
• Video calls can compromise call quality if the internet connection is poor. In these circumstances verbal communication should be prioritized and services providers should revert to voice or phone calls.
• If the internet connection allows for video calls, then service providers should feel confident using verbal communication, looking out for nonverbal communication cues and, if helpful, use visuals such as holding up charts or visuals about different treatment interventions (such as diagrams from Self Help Plus or PM+ manuals) to enable the clients to engage fully with the support being offered.

3.2.2 Phone Call

• Where possible, staff should use work phones and, if at all possible, should not share their personal numbers, so that professional boundaries and confidentiality can be respected.
• Client’s identity should be established at the beginning of every call. If there are additional privacy concerns, consider agreeing on a safe word or pass code with the client.

3.2.3 Text Messaging

• Providing support to clients over directed text (i.e. text messaging, email) is most appropriate for agreeing on times to talk and sharing information from an approved source to reinforce the content of support provided over phone or video conferencing.
• Where a client cannot use phone or video conferencing options, directed text can act as a back-up for checking-in with your client.
• Directed text is not recommended as the only method of remote support, particularly for high priority clients.
• If the clients are not literate then do not rely on text messages and use voice calls instead.
• In exceptional circumstances where the client requests support but cannot use voice or video calls, for example due to privacy or protection concerns, text messaging can be used. Ensure and confirm with the client that all messages are deleted immediately after the conversation/session has ended. Service providers should do the same.
• No confidential or sensitive information should be shared in a text message. For example, no identifying information about the person, their family or their presentations.

3.2.4 Voice Notes

• Voice notes can be used in the same way as text messages and can be used to send reminders to clients about adherence to medication, or to remind clients of psychosocial interventions such as breathing or body scans, goal setting and more.
• Where literacy levels are a problem, then voice notes can be used to send clients reminders of the dates and times of sessions
• However, it is important to note that they are used as an add on to the remote care and not a replacement. For example, sending a voice note cannot be recorded as providing an MHPSS consultation.
• No confidential or sensitive information should be shared in a voice note.

Stored information over text or email or voice note could present a risk to client confidentiality. Staff should not send any sensitive information to clients over directed text. The risks present in using directed text should be discussed with the client and agreement made about whether the staff member should use this method, what type of information if any can be sent and storage or deletion of information.

A reminder on promoting cyber safety:

• Remember to use platforms that ensure authentication.
• Ensure the platforms have end-to-end encryption.
• Keep the machines clean and ensure all laptops, tablets and phone are regularly updated and use the most up to date operating systems.
• If there is any communication from unknown sources or emails/messages seem confused, from strange numbers or email addresses then delete it.

3.2.5 Limited Communication Options

Where a client has no access to any remote communication methods, the case should be discussed with a supervisor, identifying how the level of prioritization of the client and your service capabilities for seeing that client face-to-face on a reduced schedule in a way that maintains the client’s and service provider’s safety. See the next section for further guidance.

3.3 Review Client Considerations for Receiving Remote Support

In consultation with a clinical supervisor, all MHPSS service providers should prepare a list of their active cases, organizing them by stable (mild to moderate conditions) and severe/urgent cases, to better assess cases that can be shifted to remote modality, and those that should continue to receive in-person sessions.

All clients should be contacted, prioritizing severe/urgent cases, then moderate cases, and finally mild cases. Where appropriate, contact caregivers of clients (e.g., for children or actively high-risk adults). To review key considerations working with children and adolescents, see Appendix C.

The following decision tree for active cases can support efforts to reflect upon key client considerations for potentially receiving partial or full remote MHPSS service delivery:

Review client considerations for receiving remote support

3.3.1 Considerations for Screening Clients for Remote Support

• Is the client open to receiving remote support?
• Does client have the means to receive support remotely? (e.g., phone, phone credit, network)
• What is the client’s individual skills, knowledge and typical interaction with remote modalities (e.g., phone, videoconferencing, email, online surveys, etc.)?
• How much experience does the client have with relational communication (communication involved in personal relationships) using remote modalities?
• What previous mental health services, if at all, has the individual received? What worked well? What did not work well?
• How will culture and language affect remote service delivery?
• How easily does the individual become frustrated with or confused by technology?
• What resources could supplement remote services?

3.3.2 Additional Considerations during Public Health Emergencies for Client Prioritization

• People in medical isolation units;
• People who are isolated and without an adequate support system or those with supportive networks that have the potential to be harmful;
• People with severe pre-existing mental health conditions who develop significant health symptoms.

Clients who may face challenges effectively accessing remote support should be discussed with a supervisor, and appropriate arrangements should be made. Where feasible, the arrangements should include support to accessing available services identified during the mapping and referral pathway exercise, and according to emergency management and referral protocols. In addition, if a person is not suitable for remote support, consider providing additional remote support and guidance to the caregiver or family member (See Section 3.8 for further details).

3.4 Conduct Remote Intake

Traditional procedures for conducting an intake session should be modified when transitioning to a remote modality. A sample checklist that outlines each of the key steps and considerations in providing remote support is presented in Appendix D, and should be adapted and made available to all staff delivering remote support.

3.4.1 Collaborative Agreements

All agreements about when and how to hold remote support sessions should be established in collaboration with the client. The agreement must include consideration of:

• Establish and document consent to receive remote services and conditions of confidentiality (via consent form).
• Modality of contact.
• Time, date and duration of contact.
• Confirmation that both helper and client will take the call in a private, confidential space (unless a caretaker/family member’s presence is requested).
• If reminders are necessary and how they should be given, for example by text message, email or phone call.
• Who should initiate the contact.
• What to do if a client does not call/respond to a call at an agreed time.
• What to do if there is a network failure and a call is cut off/not able to be made.
• What to do if there is uncertainty of the identity of the individual who responds using the client’s device/platform account.
• Procedures for coordination of care among multiple service providers as part of MHPSS team.

3.4.2 Registering New Clients

• A system should be in place to confidentially issue a unique identification number for the case and avoid using names or other identifying information.
• Staff should have access to and complete the relevant documentation package when registering new clients.
• If staff have access to an organizational laptop they should complete an electronic copy of the relevant documentation package and store the copy securely (see principles of data protection and recordkeeping sections).
• If staff do not have access to an organizational laptop, they should have access to printed copies of the relevant documentation package and store completed forms securely (see principles of data protection and recordkeeping sections).

3.5 Make Referrals and Follow-up

3.5.1 Referrals

• Service mapping, referral pathways and contact details should be kept up-to-date.
• Liaise with MHPSS and other sectors coordination bodies for updated service mappings and referral pathways developed externally.
• If interagency referral forms are being used, updated templates for remote referrals should be used.

3.5.2 Follow-up

Checking In

• Check-in can occur through messaging, phone or video calls to briefly touch base with clients in between scheduled and routine follow up sessions.

Scheduled and Routine Follow-up Sessions

• Verify that you are talking to the correct person and in a remote modality that suits them. Make sure you verify with the person that you are the correct service provider as well by introducing yourself and your role, verifying the person’s name and any identifying information. Discuss what can be expected from this session.
• During follow-up, it is important to establish whether or not there has been any major change in their mood or situation.
  • Has their well-being deteriorated and should they be considered for face to face support and/or a referral to specialized care?
  • Have they improved? If so, should their treatment be modified?
  • Do they need any referrals to support their recovery needs?
• At the end of the follow-up sessions agree on a time and date for the next follow-up session but explain that in between that time they can contact you on your professional numbers during working hours.
• Agree with them if you will use any check-in methods to support their needs such as text messages, voice notes or calls.
• In the case of people whose wellness has deteriorated, work with family members and caregivers, based on the previously established understanding and agreement with the client, to ensure that they receive the support they need.

3.5.3 Referrals

• Discuss which referrals are recommended or available to the person during a follow-up session.
• If the client consents to be referred then explain what to expect from the referral process, including how long it will take, how they will be introduced to the new service, what is required from them and how to support them to engage with new services.
• Describe to the client how you will follow up on those referrals during follow-up.

If the transition to remote MHPSS services has occurred due to a temporary but necessary scale-down of face-to-face services, referrals to local face-to-face social and health organizations can be very helpful to keep clients engaged until a time that face-to-face support can be reinstated.

Referrals to local social and health services can also be useful as part of creating a person-centered and holistic package of care.

3.5.4 Closing Cases/Discharge

• If after regular follow-up the client has demonstrated improved well-being and functioning, and treatment goals have sufficiently been achieved, consider closing the case and discharging the client from the service.

3.6 Manage Medication

• Adapt the SOPs for psychotropic medication and any supportive documentations (e.g., Medication Record Book, Donation Record book, Delivery Record Book, Prescription Forms) in collaboration with Medical Coordinator/ Director, Pharmacist, Supply Chain Department. In case of lack of any SOPs for managing psychotropic medications (including controlled drugs), develop them in collaboration with all relevant departments.
• Procedures should include:
  • Prescribing psychotropic drugs (electronic generation/paper);
  • Procurement (e.g., mail-order pharmacies); and
  • Distribution and handling (e.g., clinic, pharmacy and/or home visits).
• Circulate the new/adapted SOPs to all service providers and conduct brief orientation, if needed.
• The prescriber should be aware of the availability of specific medications in the geographic location of the client and should inform about existing prescribing choices. Clients receiving treatment through remote MHPSS services should have an active relationship with a prescribing professional in their physical vicinity.
• Consider extended prescription duration (>1 month, but no more than 6 months) for MNS clients with stable conditions and based on their needs and context. (For more information, please see the IASC Guidance on Operational Considerations for Multisectoral Mental Health and Psychosocial Support Programmes during the COVID-19 Pandemic, 2020.)
• At the start of the treatment, the client (and caregivers upon client’s consent) and provider should discuss the type of contact between sessions and the conditions under which such contact is appropriate (see the box below for further guidance). The provider should provide a specific time frame for expected response between session contacts. This should also include a discussion of emergency management between sessions.
• Optimal clinical management of clients can be achieved through a multidisciplinary treatment team. This should be discussed with all clients and consent should be sought. The service provider should arrange for regular communication with other professionals involved in care for the client. In settings where clinical staff are not immediately available, collaborative relationships with local community workers should be developed as these professionals may be invaluable in case of emergencies.

Reference the chart below for the recommended steps on prescribing psychotropic medication to clients during remote service delivery.

How to Prescribe Psychotropic Medication to Clients During Remote Service Delivery

3.7 Understand Risk and Manage an Emergency

• Decisions on managing risk must be made in accordance with updated service mapping and any relevant national or organizational emergency protocols. If clarification is needed on these procedures, and for technical consultation, a supervisor should be consulted.
• When working with clients who are likely to be vulnerable because of their psychological state, protection-related environment, physical isolation, or being a member of a marginalized group, risk should be assessed early to promote their safety and consider their ability for effectively, confidentially receiving remote support.
• In accordance with standard organizational procedures and the confidentiality agreement signed upon intake, clients should be aware of the limits of confidentiality and that their information may be shared with other relevant parties if they are determined to be a risk to themselves or others. Client should be informed prior to breaking confidentiality by service provider.
• If the service provider identifies and/or a client expresses that they are in a situation that presents a risk to themselves or someone else, efforts must be undertaken to identify their whereabouts and conduct crisis intervention.
• Risk should be assessed using appropriate risk assessment and safety planning tools, develop a safety plan and encourage the client to seek support from the nearest available emergency mental health service provider identified in your service mapping.
• Upon determining the need for urgent care, to provide care in person and follow the mhGAP guidelines.
• If it has been identified that the client may be unable to access emergency services (i.e., due to movement restrictions put in place) this should be discussed for preparedness, including the establishment of a safety plan identifying how support can be sought from other services friends or family, in line with national and organizational protocols.
  • If possible, provide additional remote support for caregivers (see dedicated section with additional information).
  • Educate the client and caregiver on when to seek urgent care (mhGAP-HIG curriculum) and bring the client to a health facility.
• Once a client has stabilized following an emergency situation, they should still be considered high priority and provided with regular follow-up.
• If an emergency has occurred and the safety plan has been used, once the client’s condition is stabilized, review the effectiveness of the safety plan and make adjustments as needed based on the experience.
• • Consult a specialist/supervisor and refer for further specialized care (e.g. refer to hospital).

3.8 Support Family Members and Caregivers

In certain situations, it may not be possible to provide remote services directly for clients, for example in emergency situations, if the client is a child, or presently does not have the cognitive ability to receive remote services, or if the client is a person with intellectual disability. In such situations, make a referral to the most appropriate external service provider and keep in close contact with the caregiver, provide practical tips and advice for managing the situation, managing their own stress, normalizing their feelings and provide counseling if necessary.

If possible, prior to beginning remote service delivery, consider developing a comprehensive treatment and follow-up plan, such as Wellness Recovery Action Plan (WRAP) (See the Resources list at the end of this section for guidance on WRAP) in collaboration with the client and caregiver, including specific considerations and action points for the caregiver to take in case of emergency or other situation where support is required but not suitable for the client directly.