TelEPRACTICE IN SPEECH-LANGUAGE PATHOLOGY

1. TelEPRACTICE IN SPEECH-LANGUAGE PATHOLOGY A Forum on Best Practices and Future Directions • Robin L. Alvares, Ph.D., CCC-SLP, Kent State University • Susan Grogan-Johnson, Ph.D., CCC-SLP, Kent State University • Katya Hill, Ph.D., CCC-SLP, University of Pittsburgh and the AAC Institute • Jacquelyn Taylor, M.S., CCC-SLP, Therapy Source Inc.

2. Activity 1 When it comes to telepractice are you…? 1. a flirt (checking it out) 2. courting (considering going further) 3. in a committed relationship

3. WHAT IT IS • Any delivery of services via telecommunications at a distance in time or space is considered teletherapy. • videoconferencing vs. phone conferencing • real time (synchronous) vs. store-and-forward

4. SERVICE DELIVERY MODEL VS. TECHNIQUE • TELEPRACTICE IN SPEECH-LANGUAGE PATHOLOGY IS NOT A TECHNIQUE – IT IS A SERVICE DELIVERY MODEL • Primary use of telepractice has been to allow services to traditionally-underserved populations. • Individuals with physical disabilities or mobility limitations • Individuals with in geographically-distant locations • Specialty consultation

5. QUALITY OF SERVICES • Professional competency – • Principle II, Rule B states that clinicians “…shall engage in only those aspects of the professions that are in their scope of competence, considering their level of education, training and experience.” • Refer to ASHA Knowledge and Skills Document

6. QUALITY OF SERVICES • Adherence to ethnical and legal guidelines (including FERPA and HIPPA) • Evidence-based practice • Quality control

7. Legal Issues • From Denton (2004) • Interstate licensure • Risk management • Technical competencies • Use of support personnel • Informed consent • Privacy/confidentiality Denton, David (2004). Issues related to telepractice. Seminars in Speech and Language 24(4), 313-322.

8. Legal Issues-Ohio Provision of services by telepractice • 4753-9-01 Code of Ethics • B(7) Licensees may practice via telecommunications within the state where not prohibited by law. R.C. 119.032 Provision of supervision by telepractice • 4753-3-01 Application for License • F(2) When onsite supervision occurs via telepractice applications, supervision shall occur using real time, synchronous, encrypted, videoconferencing and shall meet the supervision requirements as specified in this rule. R.C. 119.032

9. The components of EBP to consider in providing telepractice

10. EBP- Pediatrics • No specific techniques or practices directly related to telepractice • Available research documents use of various interventions during telepractice sessions Limited Empirical Research(Hill, A. & Theodoros, D., 2002) Assessment (Palsbo, 2007, Waite, Theodoros, Russell & Cahill, 2010, Waite, Cahill, Theodoros, Busuttin & Russell , 2006) Stuttering (Lewis, Packman, Onslow, Simpson, & Jones, 2008, Wilson, Onslow, & Lincoln,2004, Sicotte, Lehoux, Fortier-Blanc & Leblanc, 2003, Kully, 2002) Supervision (Dudding & Justice, 2004) Audiology (Krumm, Huffman, Dick & Klich, 2008, Lancaster, Krumm, Ribera & Klich, 2008, Krumm, 2007, Krumm, Ribera, & Klich2007)

11. EBP- KSU • Year 1 • NSD in two conditions as measured by standardized tests, progress reports, • NOMS comparison • Satisfaction Survey Results (Grogan-Johnson, Alvares, Rowan & Creaghead, 2010) • Year 2 • Students in both conditions made progress as measured by change in GFTA-2 • scores. However, students in telepractice made significantly more improvement. • Chi-Square test suggests that students in telepractice were more likely to • Master IEP goals then children in side-by-side condition. (Grogan-Johnson, Gabel, Taylor, Rowan, Alvares & Schenker, 2011) • Year 3 • Comparison with School Age NOMS • Caution in interpretation • Similarities in caseloads/Amount of time in tx/Amount of change • Summer Project • NSD with listener ratings and test results for speech intervention provided via telepractice and traditional intervention

12. Equipment Checklist DEPENDS ON LEVEL OF VIDEO CONFERENCING

13. DeskTop/Personal EQUIPMENT • Computer &Webcam • Headphones • Cell phone • Videoconferencing application • Room with door PROS & CONS • Minimal equipment costs/readily available • Lower bandwidth requirements • No ability to control far camera view

14. Small Meeting Room/ Mid-level EQUIPMENT • Dedicated digital videoconferencing equipment • Headphones • Cell phone • Room with door PROS and CONS • Moderate equipment costs • Typically can not data share beyond documents/ELMO • Higher bandwidth requirements • Control of video and audio quality • Control of far camera view

15. TELEPRESENCE/ INTEGRATED ROOM Equipment • Videoconferencing system • Multiple cameras/computers • Dedicated room PROS & CONS • Best video and audio • Advanced collaboration tools • High cost $300,000 + • Network management

16. A word about bandwidth, speed and firewalls • IT Support & Protocols available to you • Available bandwidth • Firewalls

17. Private Therapists’ Equipment • Desk top or Laptop computer (at least 3 GB RAM for therapist) • Webcam (can be separate or built-in) • Headset with Mic • Printer • Scanner • Phones • Direct line to Internet (no wi-fi) • Teleconferencing Platform • Email

18. Telepractice platforms • SKYPE • Infinite Conferencing • AdobeConnect • Megameeting • GoToMeeting • Microsoft Office 365 • Cisco WebEx • iLinc • Blackboard Collaborate

19. Platform Comparison http://web-conferencing-services.toptenreviews.com/

20. Blackboard Collaborate Document sharing Application Sharing

21. WEBEX Document Sharing Application Sharing

22. AdobeConnect Document Sharing Application Sharing

23. iLinc Document Sharing Application Sharing

24. KSU’s Equipment • Desk top computer • Logitech webcam • Microsoft Office Live Meeting • Headset • Scanner • Xerox Copier • Fax Machine • Cell Phones • Priority status/KSU network

25. University of Pittsburgh & ICAN™ Talk clinic’s Equipment • Desk top & Laptop computers • Logitech webcam and Bose speakers • Headset and/or microphone • Internet services: Illuminate Education website and/or Skype • Security features: encryption • Color laserjet copier and Scanner • Fax Machine • Cell Phones & Email

26. Brick and Mortar Challenges • Buy in from teachers, administrators, & parents • Technology – Equipment/infrastructure and support • Start up and operating costs • Ensuring functional outcomes & carryover • Usual challenges • Working effectively/ethically with a paraprofessional • Collaborating with school personnel • Documentation – e.g., Who writes the IEP?

27. SWOT Analysis: telepractice • Strengths • Weaknesses • Opportunities • Threats

28. Evaluation of client & service

29. Performance and outcome measurement Quantitative Data Qualitative Data Personal Evidence User impressions of effectiveness User satisfaction Quality service surveys • Clinical evidence • Assessment and monitoring • Performance measurement

30. Language Activity Monitoring (LAM) • LAM tools were developed to support the collection and analysis of language samples. • The LAM function is the automatic recording of AAC device language events. • Content (One or more letters or words) • Time (One second resolution time stamp) • The LAM Intervention

31. When We Know The content of language events and the time of language events, we can deduce how communication is generated and measure many parameters.

32. AAC Performance Report LAM implementations

33. LAM Recording Protocol • EXAMPLE: From actual logged sample interview • “It’s faster than spelling everything out which is what I used to do “ 16:26:05 SEM "It's " 16:26:08 SEM "faster " 16:26:14 SEM "than " 16:26:41 SPE "sp" 16:26:42 SPE "e" 16:26:45 SPE "l" 16:26:45 SPE "l" 16:26:46 SPE "i" 16:26:47 SPE "n" 16:26:48 SPE "g" 16:26:49 SPE " " 16:26:58 SEM "everything " 16:27:02 SEM "out " 16:27:05 SEM "which " 16:27:08 SEM "is " 16:27:11 SEM "what " 16:27:14 SEM "I " 16:27:19 SEM "used " 16:27:22 SEM "to do "

35. LAM routine at home

36. Flexible cameras allow unique client positions

37. Another unique position

38. Private Practice Considerations • Business Licenses (state to state specific) • State specific speech and language Licensure • Other clearances as needed by individual states • Insurance (liability, workman’s compensation) • Criminal Clearances • Legal Consultation • Accounting/Billing • Taxes • Contractors • Facilitators • Teleconferencing Platform, Security, and Technical Support

39. Hiring the right SLP • SLPs with experience • SLPs comfortable with technology • Organized • Intelligible • Flexible • Willingness to learn

40. Training the slp • SLPs meet with trainer and room features are explained and practiced • Written procedures and examples are provided to SLPs • SLPs MUST practice with others to be comfortable with platform • Trainer is available to answer questions during the practice period • Once comfortable, SLP holds mock therapy session with trainer • If the SLP demonstrates proficiency during mock session, students are assigned • Trainer observes initial session, if there are concerns with technology • Trainer follows up with SLP following initial sessions for troubleshooting, questions, etc.

41. Managing the Contractual SLP • Maximizing Schedules • Assigning Schools • Assigning Students • Troubleshooting sessions • IEP Questions • IEP Meetings • Sharing Materials • Evaluations • Observations • Satisfaction surveys

42. References Dudding, C., & Justice, L. (2004). An E-supervision model: Videoconferencing as a clinical training tool. Communication Disorders Quarterly, 25(3), 145-151. Grogan-Johnson, S., Alvares, R., Rowan, L., & Creaghead, N. (2010). A pilot study comparing the effectiveness of speech language therapy provided by telemedicine with conventional on-site therapy. Journal of Telemedicine and Telecare, 16, 134-139. Grogan-Johnson, S., Gabel, R., Taylor, J., Rowan, L., Alvares, R., & Schenker, J. (2011). A pilot exploration of speech sound disorder intervention delivered by telehealth to school-age children. International Journal of Telerehabilitation, 3 (1), 31-41. Hill, A., & Theordoros, D. (2002). Research into telehealth applications in speech-language pathology. Journal of Telemedicine and Telecare, 8, 187-196. Hill, A., Theodoros, D., Russell, T., Cahill, L., Ward, E., & Clark, K. (2006). An internet-based telerehabilitation system for the assessment of motor speech disorders: A pilot study. American Journal of Speech-Language Pathology, 15, 45-56. Krumm, M. (2007). Audiology telemedicine. Journal of Telemedicine and Telecare, 13, 224-229. Krumm, M., Huffman, T., Dick, K., & Klich, R. (2008). Telemedicine for audiology screening of infants. Journal of Telemedicine and Telecare, 14, 102-104. Krumm, M., Ribera, J., & Klich, R. (2007). Providing basic hearing tests using remote computing technology. Journal of Telemedicine and Telecare, 13, 406-410. Kully, D. (2002, June 11). Venturing into telehealth: Applying interactive technologies to stuttering treatment. The ASHA Leader, 11. Lancaster, P., Krumm, M., Ribera, J., Klich, R. (2008). Remote hearing screenings via telehealth in a rural elementary school. American Journal of Audiology, 17, 114-122. Lewis, C., Packman, A., Onslow, M., Simpson, J., & Jones, M. (2008). A phase II trial of telehealth delivery of the Lidcombe program of early stuttering intervention. American Journal of Speech-Language Pathology, 17, 139-149.

43. References Palsbo, S. (2007). Equivalence of functional communication assessment in speech pathology using videoconferencing. Journal of Telemedicine and Telecare, 13, 40-43. Sciotte, C., Lehoux, P., Fortier-Blanc, J., & Leblanc, Y. (2003). Feasibility and outcome evaluation of a telemedicine application in speech-language pathology. Journal of Telemedicine and Telecare, 9, 253-258. Waite, M., Cahill, L., Theodoros, D., Busuttin, S., & Russell, T. (2006). A pilot study of online assessment of childhood speech disorders. Journal of Telemedicine and Telecare, 12, 92-94. Waite, M., Theodoros, D., Russell, T., & Cahill, L. (2010). Internet-based telehealth assessment of language suing the CELF-4. Language-Speech-Hearing Services in Schools, 41, 445-458. Wilson, J., Onslow, M., & Lincoln, M. (2004). Telehealth adaptation of the Lidcombe program of early stuttering intervention: Five case studies. American Journal of Speech-Language Pathology, 13, 81-93.