La telesalud tiene el potencial de ofrecer a muchos niños y familias una tabla de salvación para acceder a servicios esenciales de salud física y conductual que de otro modo podrían no estar disponibles.¹ Aunque el uso de la telesalud en la práctica del bienestar infantil ha sido de interés durante muchos años, particularmente en las zonas rurales, las jurisdicciones ampliaron su uso para apoyar el acceso de los niños y las familias a servicios esenciales durante la pandemia de COVID-19. La telesalud puede:

• Aumentar acceso a apoyos, atención médica especializada y experiencia en salud mental.
• Mejorar las barreras de transporte y tiempo de los clientes.²
• Mejorar la capacidad del personal mediante reduciendo el tiempo de viaje en áreas remotas.
• Aumentar la aceptación de los servicios por parte de clientes que se sientan más cómodos participando de forma remota.³

Se necesita más investigación específica sobre el bienestar infantil, pero los estudios que comparan los resultados de la atención presencial y por telesalud para los servicios de salud física y conductual generalmente han encontrado que los dos enfoques pueden lograr resultados similares. Este informe estratégico analiza una variedad de usos de la telesalud en el contexto del bienestar infantil, ofrece algunas consideraciones clave para su implementación y presenta ejemplos de uso en jurisdicciones específicas.⁴

Los servicios de telesalud a menudo se proporcionan en tiempo real mediante videoconferencias, chat y mensajes de texto, según el gobierno federal Administración de Servicios de Salud Mental y Abuso de Sustancias. La telesalud también incluye servicios proporcionados a través de correo electrónico, capacitación en línea, programas informáticos automatizados, aplicaciones móviles o mediante una grabación de video de un cliente que un profesional revisa de forma remota en otro momento.

Algunos ejemplos de cómo se puede utilizar la telesalud para apoyar a los niños y las familias involucradas en el sistema de bienestar infantil incluyen:

• Usar la tecnología de telemedicina para realizar exámenes médicos remotos por sospecha de abuso y negligencia infantil. Este enfoque puede realizar investigaciones más preciso y oportuno, y menos gravoso para las familias cuando no hay un pediatra especialista en abuso infantil ejerciendo en el área.
• Dirección evaluaciones estandarizadas de salud conductual y asesoramiento a distancia, monitoreo y manejo de medicamentos.
• Proporcionando visitas domiciliarias virtuales. La mayoría de los modelos nacionales de visitas domiciliarias para la primera infancia respaldaron el uso de videoconferencias y otras tecnologías durante la pandemia de COVID-19 y proporcionaron información relacionada orientación. Un evaluación de las visitas domiciliarias virtuales en Virginia encontró que, durante la pandemia, las familias estaban satisfechas con las visitas domiciliarias virtuales, aunque a los trabajadores les resultó difícil observar las interacciones entre padres e hijos de forma virtual. Los evaluadores recomiendan ofrecer un modelo híbrido de visitas domiciliarias, con algunas visitas en persona y otras virtuales.
• Facilitando cumplimiento de planes de servicio al ofrecer acceso remoto a algunos servicios necesarios, como educación para padres, grupos de apoyo, y tratamiento para el trastorno por consumo de sustancias.
• Ofreciendo una mejor experiencia apoyo de salud mental para jóvenes en cuidado temporal mediante mensaje de texto o videochat. Como muchos jóvenes se sienten cómodos en entornos virtuales, ofrecer servicios en línea puede reducir el estigma y mejorar la participación.

Algunas preguntas a considerar para las agencias de protección infantil que implementan servicios de telesalud son:

• ¿Aborda eficazmente la tecnología seleccionada los objetivos terapéuticos? Como en todos los aspectos de los servicios de bienestar infantil, el juicio clínico y la práctica centrada en la familia deben guiar las decisiones sobre la evaluación y el tratamiento. Denise Macerelli, exdirectora adjunta de la Oficina de Salud Conductual del Departamento de Servicios Humanos del condado de Allegheny (Pensilvania), afirma que esto es algo sobre lo que su agencia fue cautelosa cuando permitió por primera vez que los proveedores ofrecieran telepsiquiatría: ’Queríamos asegurarnos de que la justificación tuviera sentido en términos de atender mejor a los clientes, no solo de crear una ventaja para los proveedores. Durante todo el proceso de solicitud, les hicimos muchas preguntas a los proveedores al respecto“.”
• ¿Cómo se protegerán la seguridad y la confidencialidad del cliente? Durante la pandemia, el Departamento de Salud y Servicios Humanos de EE. UU.’ Oficina de Derechos Civiles announced that healthcare providers would not be subject to penalties for violations of HIPAA (Health Insurance Portability and Accountability Act) privacy rules that occurred during the good faith provision of telehealth. This opened up opportunities for services to be delivered on non-HIPAA-compliant platforms, including FaceTime, Zoom, and Skype. Privacy and confidentiality are still important considerations that bring forth a range of critical questions: How will consent forms be updated to reflect telehealth, and how will client signatures or acknowledgments be obtained? What protocols will be necessary to ensure client privacy at both the provider’s location (such as soundproof work spaces and the use of headphones) and the client’s (such as asking who is present and taking care not to bring up sensitive topics if it is unclear whether the client is alone)?
• How prepared are providers to offer telehealth? Agencies need to consider the preparedness of providers⁵ to deliver services remotely and address the following questions: Can they navigate the platform, troubleshoot, and resolve simple technology problems quickly and effectively? What training or support will be needed to ensure that providers are confident in their ability to build rapport and maintain a natural conversational flow with children, youth, and families in a virtual environment? Relationships⁶ are essential to all child protection-related services. Open communication with providers and among provider agencies is also critical to identify concerns and find solutions.
• How will clients be prepared for telehealth? Clients need access to devices and broadband internet to facilitate smooth audio/video connectivity. In many rural and tribal locations, this is not simply a matter of resources because the telecommunications infrastructure may not support adequate internet speeds. Some agencies have addressed technology challenges by subsidizing enhancements to clients’ internet service plans or providing smartphones if needed. Families may need information on how the telehealth service will be delivered and how to set up the technology. Providers should always establish backup communication plans (a telephone call, for example) in case a virtual video connection is lost midstream.
• How will the agency adhere to evidence-based practices? Research suggests that some evidence-based practices (for example, Cognitive-Behavioral Therapy y Trauma-Focused Cognitive-Behavioral Therapy) can be delivered effectively using virtual communication. The implementation and effectiveness of telehealth likely varies by model, however. It is important to review research and consult with model developers whenever possible. Tracking outcomes of telehealth approaches is important and will continue to build the body of evidence in this emerging area of child welfare practice.
• How will services be billed? During the pandemic, many Medicaid and private insurance billing guidelines were relaxed to allow increased billing for telemedicine. However, not all states, insurers, and healthcare benefit plans allow telehealth services to be billed at parity with in-person visits.

En Colorado, Invest in Kids is a state-based intermediary for a home visiting model, Nurse-Family Partnership (NFP), and a social and emotional program, Incredible Years (IY). Prior to the COVID-19 pandemic, NFP used virtual communication to connect staff across the state, support reflective supervision, and conduct home visits with established clients under specific circumstances (such as inclement weather or a client’s move out of state). In part due to this established foundation, NFP was able to pivot to almost exclusively virtual home visitation quickly after the onset of the pandemic by working closely with model developers and national service offices, expanding on protocols already in place (for HIPAA compliance and client consent), and offering staff training in effective virtual communication techniques. IY staff have also been able to continue established parent groups and support classroom-based social skills lessons via Zoom. Invest in Kids partnered with the University of Colorado to study the rapid move to telehealth as a result of the pandemic. The study brought insight into the priorities for continued telehealth utilization and opportunities for providers to build a more effective, equitable, and patient-centered approach to perinatal care.⁷ In response to lessons learned, the NFP staff in Colorado worked closely with its national service office to develop standardized protocols for telehealth utilization that are now part of model fidelity.

As an urban county with ready access to behavioral health expertise, a breadth of services, and an investment in face-to-face care, Allegheny County (Pa.) has been thoughtful about its approach to implementing telehealth. Before the COVID-19 pandemic occurred, the Office of Behavioral Health and Community Care already had increased access to telepsychiatry to address an emerging shortage of psychiatrists. With the onset of the pandemic, previously strict state regulations were relaxed, and providers were able to maintain and expand clients’ access to mental health and substance use disorder treatment services via telehealth. When comparing the three-year pre-pandemic period of 2017-2019 to the pandemic period of 2020-2022, the use of telehealth for Allegheny County behavioral health services for Medicaid recipients increased dramatically from less than 0.1% to 18.1%. Of the clients and family members that used Medicaid behavioral telehealth services during the pandemic period, most reported that it was easier (78.7%) or about the same (12.8%) as in-person behavioral health services, and they were generally satisfied with the services. Many, though not all, of the regulatory flexibilities that were permissible during the pandemic have remained in place, with additional guidance and requirements to ensure quality and fiscal integrity.

The following resources provide child protection agencies more information about implementing telehealth services for the behavioral health needs of children and families. Some of these resources were created in response to the COVID-19 pandemic but still have relevance today.

AAPC Knowledge Center. (2024). Telehealth 2025: The Final Rule

• This blog summarizes policy changes rolled out by the Centers for Medicare and Medicaid Services in their Physician Fee Schedule Final Rule (PFS) and their potential impact on the telehealth and tele-behavioral health landscape for 2025.

American Psychiatric Association. (n.d.). Telepsychiatry Toolkit

• Developed by the American Psychiatric Association Work Group on Telepsychiatry, this online toolkit covers the history and background of telepsychiatry, training, legal and reimbursement issues, technical considerations, and practice and clinical concerns. Includes videos featuring leading psychiatrists.

Connected Nation, Michigan (n.d.). Telehealth Facts.

• Connected Nation conducted a statewide study of households in rural Michigan about the use, concerns, and perceptions of using telehealth. Resources on this website reflect the findings and include key definitions, tips, webinars, podcasts, videos, and news.

Health Resources & Services Administration, U.S. Department of Health and Human Services (2020). Telehealth.HHS.gov

• This website offers information for providers on starting a telehealth program, federal and state policy changes, and planning telehealth workflow. The site also includes information for patients — what to expect, what equipment is needed, and tips for finding telehealth options.

Seager van Dyk, I., Droll, J., Martinez, R., Emerson, N., & Burrsch, B. (2020). Building Rapport with Youth via Telehealth

• This article, developed during the COVID-19 pandemic, reviews tips for setting the scene, introducing telehealth to patients, building rapport, and keeping children engaged.

Singer, J., & Brodzinsky, D. (2020). Virtual parent-child visitation in support of family reunification in the time of COVID-19. Developmental Child Welfare, 2(3).

• This article focuses on issues and training needs when implementing virtual parent-child visits in juvenile dependency cases, but the points discussed (logistics, child-related factors, and relationship dynamics) are relevant to other types of virtual services.

Substance Abuse and Mental Health Services Administration. (2015).  Using Technology-Based Therapeutic Tools in Behavioral Health Services.

• This manual assists clinicians with implementing technology-assisted care. It highlights the importance of using technology-based assessments and interventions in behavioral health treatment services. The manual also discusses how technology reduces barriers to accessing care.

Substance Abuse and Mental Health Services Administration. (2016).  In Brief: Rural Behavioral Health: Telehealth Challenges and Opportunities

• This guide discusses how telehealth can help overcome common barriers in rural communities to accessing treatment services for substance use and mental health disorders.

Telemedicine and e-Health. (2018). Best Practices in Videoconferencing-Based Telemental Health

• This guide highlights best practices in clinical videoconferencing in mental health, using resources from the American Psychiatric Association and the American Telemedicine Association.

Tiwari, A., Recinos, M., Garner, J., Self-Brown, S., Momin, R., Durbha, S., Emery, V., O’Hara, K., Perry, E., Stewart, R., & Wekerle, C. (2023). Use of technology in evidence-based programs for child maltreatment and its impact on parent and child outcomes. Frontiers in Digital Health, 5.

• This literature review summarizes studies of the use of technology to provide evidence-based parenting and child programs to families involved with the child welfare system. Most studies found improvements in parenting, child mental health, and child behavioral outcomes.

Trauma-Focused Cognitive Behavioral Therapy National Therapist Certification Program. (2020). TF-CBT Telehealth Resources

• This resource site offers telehealth webinars, guides, tools, and research related to Trauma-Focused Cognitive Behavioral Therapy.