How can child protection agencies use telehealth to increase service access for children and families?

Telehealth has the potential to offer many children and families a lifeline to essential physical and behavioral health services that otherwise may not be accessible.1 Although the use of telehealth in child welfare practice has been of interest for many years, particularly in rural areas, jurisdictions expanded their use of telehealth to support child and family access to critical services during the COVID-19 pandemic. Telehealth can:

  • Increase access to supports, specialized medical care, and mental health expertise.
  • Ameliorate client transportation and time barriers.2
  • Enhance staff capacity by reducing travel time in remote areas.
  • Increase acceptance of services by clients who may be more comfortable participating remotely.3

The importance of digital equity

Technology-related inequities in access to basic equipment and broadband are significant. They must be addressed to ensure all families have an equal opportunity to connect with virtual supports and access essential services.

To learn more, see: How can the child welfare system help youth and families access needed technology?

More child welfare-specific research is needed, but studies comparing the outcomes of in-person and telehealth for physical and behavioral health care services have generally found that the two approaches can achieve similar results. This strategy brief discusses a variety of uses for telehealth in the child welfare context, provides some key implementation considerations, and offers examples of use in specific jurisdictions.4

Telehealth under COVID-19 fundamentally changed how we think about treatment. We’re thinking more about the therapeutic benefit of services. Nothing has been sacrificed. If we continue to see better engagement in services, outcomes that are just as good if not better, increased workforce stability, and decreased administrative costs … what an amazing opportunity to take this forward beyond the COVID crisis.

– Denise Macerelli, former Deputy Director, Office of Behavioral Health, Allegheny County (Pa.) Department of Human Services

Telehealth in child welfare

Telehealth services often are provided in real time through videoconferencing, chat, and text messaging, according to the federal Substance Abuse and Mental Health Services Administration. Telehealth also includes services provided through email, online training, automated computer programs, mobile apps, or through a client video recording that a professional reviews remotely at another time.

Some examples of how telehealth can be used to support children and families involved with the child welfare system include:

  • Using telemedicine technology to conduct remote medical examinations for suspected child abuse and neglect. This approach can make investigations more accurate and timely, and less burdensome for families when there is no child abuse pediatrician practicing in the area.
  • Conducting standardized behavioral health assessments and remote counseling, monitoring, and medication management.
  • Providing virtual home visits. Most of the national early childhood home visiting models endorsed the use of videoconferencing and other technologies during the COVID-19 pandemic and provided related guidance. An evaluation of virtual home visiting in Virginia found that during the pandemic, families were satisfied with virtual home visits, although workers found it difficult to observe interactions between parents and children virtually. The evaluators recommend offering a hybrid home visiting model, with some in-person and some virtual visits.
  • Facilitating completion of service plans by offering remote access to some required services, such as parent education, support groups, and substance use disorder treatment.
  • Offering enhanced mental health support to youth in foster care via text or video chat. Since many youth are comfortable in virtual environments, providing services online may reduce stigma and enhance engagement.

Key considerations

Some questions to consider for child protection agencies implementing telehealth services are:

  • Does the selected technology effectively address therapeutic goals? As with all aspects of child welfare services, clinical judgment and family-centered practice should drive decisions about assessment and treatment. Denise Macerelli, former deputy director of the Allegheny County (Pa.) Department of Human Services’ Office of Behavioral Health, says this is something her agency was cautious about when first allowing providers to offer telepsychiatry: “We wanted to be sure that the rationale made sense in terms of better serving the clients, not just creating an advantage for providers. Throughout the application process, we asked providers a lot of questions about that.”
  • How will client safety and confidentiality be protected? During the pandemic, the U.S. Department of Health and Human Services’ Office for Civil Rights 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 and 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.

What has helped us make the switch to telehealth? Doing the hard, messy work all along — thoroughly and thoughtfully honoring where we are, adhering to best practices, and prioritizing difficult conversations. We have a level of trust and engagement with our providers that is unparalleled. We work with them intensely and intentionally, year-round. The pivot was possible because those relationships were already strong.

– Lisa Hill, Executive Director, Invest in Kids

Jurisdictional examples

In 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.

Resource list

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.

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).

  • 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.

1 Substance Abuse and Mental Health Services Administration (2021). Telehealth for the Treatment of Serious Mental Illness and Substance Use Disorders.

2 Riley, E. N., Cordell, K. D., Shimshock, S. M., Perez Figueroa, R. E., Lyons, J. S., & Vsevolozhskaya, O. (2022). Evaluation of telehealth in child behavioral health services delivery during the COVID-19 pandemicPsychiatric Services.

3 Substance Abuse and Mental Health Services Administration (2021).

4 Information in this brief was informed by interviews with Denise Macerelli, Jewel Denne, and Dr. Latika Davis-Jones, Allegheny County (Pa.) Department of Human Services’ Office of Behavioral Health; Dennis Watson, Florida Department of Health; and Lisa Hill, Julie Steffen, and Michelle Neal, Invest in Kids.

5 Hickey, G., Dunne, C., Maguire, L., & McCarthy, N. (2023). An Exploration of Practitioners’ Experiences of Delivering Digital Social Care Interventions to Children and Families During the COVID-19 Pandemic: Mixed Methods StudyJMIR formative research7, e43498.

6 Copson, R., Murphy, A. M., Cook, L., Neil, E., & Sorensen, P. (2022). Relationship-based practice and digital technology in child and family social work: Learning from practice during the COVID-19 pandemic. Developmental Child Welfare, 4(1), 3-19.

7 Kissler, K., Thumm, E.B., Smith, D.C., Anderson, J.L., Wood, R.E., Johnson, R., Roberts, M., Carmitchel-Fifer, A., Patterson, N., Amura, C.R., Barton, A.J. and Jones, J. (2024), Perinatal Telehealth: Meeting Patients Where They Are. J Midwifery Womens Health., 69: 9-16.