Telepractice for School Based Speech & Language Services

Telepractice for School Based Speech & Language Services Michelle Boisvert, Ph.D., CCC SLP Michelle Boisvert, Ph.D., CCC SLP ASHA Certified SLP Ph.D., in the use of telepractice for students with ASD Published author of numerous articles on topics related to telepractice including clinical models and supporting evidence for direct and indirect telepractice services Presented at national and international conferences on the use and application of telehealth service delivery for school aged children Editor of the Perspectives of Telepractice; an American Speech Hearing Association Journal Reviewer for publications such as the Journal of Autism and Developmental Disorders, Journal of Telehealth and Telemedicine and International Journal of Telerehabilitation Owner of NetSLP, a division of WorldTide, Inc., a company that delivers telepractice services to students and adults nationally and internationally Agenda Introduction of Telepractice Equipment, Infrastructure and Materials Environment to Support Telepractice Identifying the Needs and Barriers Telepractice Implementation Team Client Candidacy Legal Considerations/HIPAA and IDEA Clinical Procedures and Quality Assurance Questions 1

When it comes to telepractice are you Just Curious? Considering Telepractice? Already using Telepractice? telepractice is not a different service, but rather a different method of service delivery. General Definition & Overview of J. Brown, 2010 Telepractice What is Telepractice? Telepractice is a way to provide direct and indirect speech/language therapy services. It is relatively new to the field of speech pathology (within the last 5 years), however, has been used for some time to provide medical services, mental health counseling as well as physical and occupational therapy. Services are provided through the use of high speed Internet, web cameras and video conferencing systems in real time. 2

ASHA s definition of Telepractice Telepractice is the application of telecommunication technology for the delivery of services at a distance (ASHA, 2013). This method has become more widely used and is an emerging area of service delivery in speech and language pathology (D. Theodoras, 2011). Approved by the American Speech Language Hearing Association (ASHA) as an appropriate service delivery in 2005. ASHA's position is that Telepractice is an appropriate model of service delivery for the profession of speech language pathology and audiology (ASHA 2012, 2005a, 2005b). Telepractice in the Field of Speech Language Pathology Speech pathologists use telepractice to provide direct and indirect services Articulation Receptive or expressive language Voice & fluency Executive functioning Social pragmatics Non verbal/aac Assessments Supervision, consultation and meetings. There are no inherent limits to where telepractice can be implemented,as long as theservicescomply withnational, state, Benefits & Limitations of Telepractice The strategic use of technology enables telepractice to be a viable method of service delivery for students of all abilities. 3

Benefits of Telepractice Nationwide, thousands of students are in need of speech language services. When sensibly implemented, a telepractice speech language delivery model promotes: Free and appropriate public education (Juenger, 2009) Creates additional or more consistent direct and indirect service opportunities Enables real time collaboration with team members Complements traditional, on site service delivery models and energizes student learning (Juenger, 2009). Can be cost effective (Blaiser et al., 2013) & maximizes efficiency of existing personnel Reduces geographical barriers (ASHA, 2013) Extends clinical expertise (Boisvert, 2014, Hall & Boisvert, 2014, Gorgan Johnson, 2013) Clinical Benefits of Telepractice Select research suggests that students receiving telepractice outperform control groups (same diagnostic and demographic profile) and national benchmarks on (Towey, 2013, Gorgan Johnson, 2011): Expressive Language Receptive Language Social Pragmatics Speech Sound Production/Articulation Access to experienced school based SLPs Flexible scheduling for student/teacher needs Organizational commitment is necessary for a successful program! Clinical Benefits to Telepractice Speech therapy telepractice is emerging as a standard of care that promises to be equal to or better than traditional table top therapy (Towey, 2013). Telepractice can be a force multiplier for speech pathologists who work in multiple schools. Therapist and client work in online programs in a highly motivating digital learning environment (Christensen, Johnson, & Horn, 2008). Therapy sessions can be recorded, edited, saved and later viewed online by the client, caregivers, family members and/or teachers who are granted access to the materials. The client can go online multiple times to access the therapy program for additional practice and learning. 4

Telepractice Enables Professionals to We have found online speech services to be an interesting, exciting and effective way to provide our students with a high quality service in an innovative way. We are very pleased with all aspects of it! -School Administrator Educate Collaborate Communicate [etherapist] worked so well with my son and brought him so far. She worked with his teachers and tutors and it is all reflected in the outstanding work that my son is increasingly able to produce. I can t thank you enough! -Parent Limitations of Telepractice Space: Dedicated or shared room is required. Budget: Telepractice equipment can be expensive, but doesn t have to be. On site Support: Paraprofessional staff and support may be required. Broadband: Need high speed Internet. Security Concerns: Federal standards for HIPAA and FERPA must be considered. Network Firewall: On site firewalls may block videoconferencing site. Licensure Requirements: SLPs/AuDs are required to be licensed in each state they are practicing in. Community Awareness Limitations of Telepractice Physical manipulation Managing behavioral issues strategies must be in place! Technical knowledge and ability to troubleshoot Collaboration with on site staff procedures must be in place! Difficulties in team teaching Difficulty promoting carryover of skills in the classroom Scheduling (research does NOT support this: attendance rate 94 75%) Overall acceptance of a new method to deliver services 5

Models of Service Delivery Face to Face Store and forward Hybrid Approach Models of Telepractice Various platforms have been developed to support service delivery in telepractice, which fall under three broad headings: Synchronous (direct and in real time) Asynchronous (indirect and can be offline) Hybrid (both direct and indirect) Synchronous or Direct Delivery Model Synchronous services are conducted with interactive audio and video connection in real time. A live, interactive videoconference session is one in which the specialist and the client are present at the same time, but not in the same location. Communication is facilitated by using secure digital videoconferencing. The specialist conducts sessions as if they were in the same room in a live and interactive format. 6

Asynchronous Delivery Model An asynchronous service model, or store and forward, is one in which information is captured from the patient at one time and location and evaluated by a specialist at another time and location. Information is captured and stored in a digital file at one location and then transmitted or forwarded to another location for evaluation (Telehealth Resource Center, 2013). Examples include transmission of voice clips, audiologic testing results, or outcomes of independent client/patient practice. Hybrid Delivery Model Hybrid sessions use components of both live, interactive and store and forward consultations. A hybrid consultation has the advantage of making better use of all technologies that are available to diagnose, treat and consult with the client and their team and is not limited to a single communications channel. Examples of hybrid approaches include: Remote Monitoring Distance Supervision econsultation Record and Monitor Stable and reliable technology and infrastructure are key to a successful telepractice General Overview the Technology program & Equipment 7

Introduction Properly designed and equipped facilities at all locations as well as sufficiently high quality telecommunications to support the clinicianclient interactions. Protocols must be in place to assure high quality and consistent service delivery. Many concerns that apply to the facility for face to face services also apply to telepractice services including: Privacy Comfort Utility Additional telepractice considerations: Determining Technology & Equipment Needs When determining the equipment needs of the telepractice program there are several key questions: What is to be accomplished (direct service, supervision, mentoring, etc.)? What is the clinical population? (e.g., voice, speech sound production, AAC) What is the setting of the services (i.e., 1:1, small group, classroom based, training) What delivery model is being used (i.e., f2f, SaF, Hybrid) What are the security requirements? What are the resources available (i.e., existing equipment, budget, support, bandwidth) The Needs Assessment will help determine resources. Goals & Clinical Population Security Requirements Successful Program Setting and Delivery Model Resources Available Online Video Conferencing Live, interactive F2f interactions occur through videoconferencing 8

Levels of Digital Videoconferencing Platforms There are a wide variety of technology that can be used to conduct videoconferencing The options of devices and equipment used to conduct digital videoconferencing typically range from: Mobile Desktop Small Meeting/Telepresence Mobile Videoconferencing Mobile Devices include: ipad, Tablet, Smart Phones, etc. The pros of using mobile videoconferencing: High level of accessibility Applications Mobile end user can be anywhere The cons of using mobile videoconferencing: Limited control of video and audio Limited end user control of material Security/encryption Wireless needed Desktop Videoconferencing Desktop Equipment: Computer/Laptop, Webcam/Headset, Software The pros of using desktop videoconferencing: Low bandwidth requirements Available software Minimal equipment costs Available material Better encryption and security The cons of using desktop videoconferencing: Limited control of video and audio Limited ability to control end user camera Limited ability to move location 9

Small Meeting/Telepresence Small Meeting: Dedicated Equipment, Integrated System The pros of using small meeting videoconferencing: Corporate staff with technical knowledge of firewall and Internet technologies Better video and audio quality Control of end user camera Encryption and Security The cons of using small meeting videoconferencing: Moderate equipment costs Higher bandwidth requirements Videoconferencing Software The software that can be used to conduct videoconferencing ranges from low end to high end. Free Web Conferencing: Skype, Oovoo, Yahoo Messenger, Windows Live Messenger, Facetime, Jabber, TeamViewer (there are others) Considerations: Security does NOT meet HIPAA/FERPA standards, quality of audio and video, ability to screenshare (do you need another program), do have white board, etc. These free systems are NOT recommended for telepractice (emergency only) Commercial Web Conferencing: GoToMeeting, Adobe Connect, Microsoft Office Live, Eluminate, Vidyo, Infinate Conferencing, Cisco WebEx (there are others) Hardware There is mandatory hardware at both sites 10

Mandatory Hardware To deliver and receive telepractice, each site must at least have the following: Computer Windows XP: 2 GB of RAM; P4 with 2GHZ processor or equivalent Windows Vista / Windows 7 / Windows 8: 3 GB of RAM; P4 with 3GHZ processor or equivalent Mac OS X 10.4 (Tiger) or 10.5 (Leopard): 2 GB of RAM; 2 GHZ Large monitor or integrated conferencing system Web camera with 15 FPS (frames per second) capture rate (built in or separate) Headset with attached microphone (analog or USB) In room phone or cell phone Supplementary Equipment Supplementary material and equipment may enhance the type of services provided Supplementary and Peripheral Equipment Supplementary equipment can enhance the overall quality of direct/indirect services provided via telepractice. Additional tools, devices and equipment vary according to the application of services and the desired outcomes. For example, additional monitors, web and document cameras, headphones, cell phones, Bluetooth earpieces, and back up storage devices may be needed for telepractice services. For direct services, a large monitor (over 20 inches) or dual monitors support the dynamic exchanges that occur when providing telepractice for clinical services. 11

Types & Uses of Supplementary Equipment Bluetooth Headset: A Bluetooth head set can be used by a caregiver, teacher or paraprofessional when receiving active consultation. Document Camera: A document camera is used to electronically display paper based material. Fax Machine: A fax machine is used to provide the on site team a paper copy of material or documents. ipad: An ipad is used to supplement electronic material, serve as a second monitor or display apps. J Mount Webcam: The J Mount is used for tele AAC to view the client s device as well as for environmental views of the therapy setting. Pen Mouse: A pen mouse is used in whiteboard activities in which the on site client is drawing, underlining, etc. This device mimics a pen/pencil that would commonly be used in an on site setting. Smart Board: A SmartBoard is used as a large monitor or to support gross motor and interactive movements from the on site client. SmartPhone: A smartphone can be used for communicate between the on and off site teams or as a secondary monitor. Rolling Cart: A rolling cart can be used to make the equipment portable and move from room to room. Broadband and Internet Connection A high speed internet connection is essential for high quality f2f services Recommended Internet Connection Live, interactive videoconferencing requires high quality and reliable Internet. High speed Internet connection with incoming/outgoing signal of at least 900 KBps. Take into account the internal network through which the external connection is accessed. Consider who else is on the system at the time of services & consult with onsite IT professional. Some degradation in video quality can be accepted, but a telepractice session will not work if the sound quality is poor. 12

Material Most activities that can be used for on site services can be used for telepractice services Material for Telepractice Many materials and activities that are used in on site treatment sessions can be modified to be presented in a telepractice environment. Clinicians and school based teams have access to a wide range of digital and electronic activities, games, books, and other material through the Internet. Document cameras and scanners can transform paper based into electronic materials that can be used for telepractice. Annotation and responding tools that can be used to enhance the digital material presented. Resources for Material There are free and fee based services enable the treating clinician to present interesting, highly interactive and grade/age/level appropriate material. Intervention session can be saved and reviewed multiple times (Towey, 2012). There are a number of Internet resources. Material can be simplified using the FIVES criteria described by Sean Sweeney (SpeechTechie, 2012): Free/fairly priced, Interactive, Visual, Educationally relevant, Speechie (i.e., programs that are rich in speech and language and can easily be repurposed for therapy use) 13

Resources for Material Through PowerPoint, SmartNote Book or Word most static activities (i.e., PDFs, flashcards, worksheet, etc.) can become interactive. Some resources include: Judith Kuster s website of materials that can be adapted for therapy http://www.mnsu.edu/comdis/kuster2/sptherapy.html BBC Short Stories http://www.bbc.co.uk/cbeebies/stories/page/all Internet4Learning http://www.internet4learning.com E Learning for Kids http://www.e learningforkids.org/index.html SmartNote Book Exchange http://exchange.smarttech.com/#tab=0 Considerations for Digital Material Large monitor (over 20 inches) or dual monitors support the dynamic exchanges between client and clinician. Visual cues and models, and use non verbal body language can and must be provided. Awareness of how to present cues/prompting Control of audio/volume of the treatment activities. Consider the Visual clutter that might be present on the screen. External visual stimuli that might distract the client from the content or intended purpose of the activity. When planning and preparing material, always consider how the client can interact with the activity. Helpful strategies Activity Schedules A consistent format to introducing the activities Helped with any language barriers Scaffolded Instruction Mini Lesson Multiple Representation of Information Graphic Organizers Modifiable depending on need Resource Guide 14

To provide high quality telepractice sessions, the environment of both the client General Overview of Environmental Requirements and the clinician must be considered Copyright Michelle Boisvert, 2014 Telepractice Room Considerations A telepractice room must have adequate lighting, physical privacy, comfortable furniture, and appropriate monitor/webcam placement. The telepractice room should be free of visual distractions and enable the on site helpers to provide supportive and supplementary assistance to the clients. A well thought out telepractice room design will accomplish two major functions: Clinical Interaction Create the visual and audio clarity and accuracy Support a connection where the focus in on student Visual Clarity Room Design Functions Audio Clarity Room Location and Size The size and location of a Room impacts the overall quality of the services Copyright Michelle Boisvert, 2014 15

Location and Size of Room The telepractice setting should be in a: Quiet location Minimizing exposure to environmental noise Environmental noise include: Busy corridors, stairwells, fans, parking lots, restrooms or other sources of noise. Environmental noise can be picked up by microphones which can make it difficult for the clinician at the remote site to hear. Size of the clinician s office can be smaller in size Room size also depends on the type of equipment and technology being implemented. Copyright Michelle Boisvert, 2014 Placement of Equipment there are optimal placements of the equipment that will be used for telepractice Copyright Michelle Boisvert, 2014 Placement of Equipment: Clinician Office The clinician s office will typically be smaller in size. Only one person is transmitting an image rather than a small group. The clinician must consider the camera viewing area, angle of the camera, lighting and microphone. Similar to individual settings Copyright Michelle Boisvert, 2014 16

Placement of Equipment: General Strategies Regardless of the setting there are optimal placements of the equipment that will be used for telepractice. Considerations for the equipment are: Position of the workspace Position of doors Position of windows Location of electrical outlets Existing telecommunication connections Copyright Michelle Boisvert, 2014 Webcam and Video Window direction Position The goal is to approximate natural eye gaze and facial Copyright Michelle Boisvert, 2014 Camera Positioning: Individual Setting Cameras need to be placed so that both participants are looking at each other. The clients (and clinicians) tend to look at the videoconferencing screen when receiving/providing services. This results in unnatural eye gaze and facial positioning when the image is on the side of the screen. To support (approximated) eye contact and expected facial positioning during a telepractice session place the webcam close to the video conferencing screen as possible. The clinician s webcam should be in this position for all settings. Copyright Michelle Boisvert, 2014 17

Lighting Good lighting supports the ability to see the client clearly with true color reproduction Copyright Michelle Boisvert, 2014 Lighting Fundamentals Use diffused soft light falling in front of the client Avoid backlighting from windows or overhead lights Avoid harsh lighting sources Consider full spectrum lighting Use supplemental lighting when necessary Windows or other light sources behind the client can cause deep shadows on the face that interferes with clinical services Copyright Michelle Boisvert, 2014 Preparation is key to the development, implementation and sustainability of an General Overview of the Needs Assessment effective telehealth program 18

What is a Needs Assessment? A systematic analysis (DOC, 2004)used to identify the needs of an underserved population and how those needs can be addressed. Consists of several steps to identify the gaps in services and identify potential strategies to address those needs. Current State of Practice Needs in the population Gap in Services Needs Assessment Organizational Resources Barriers Benefits of a Needs Assessment Clear understanding of the objectives of the program Identifying the target population and their need Determining appropriate candidates within the target population Identify organizational readiness for the program Potential barriers or considerations within the target population Identify strategies to overcome potential barriers/considerations Steps in the Needs Assessment Essential information must be assessed in the various steps of a needs assessment 19

Step 1: Objectives, Scope and Purpose The team must identify the objective, scope, target population and how the needs assessment will support the overall success of the telehealth project. Will this assessment be a sweeping overview of all clinical services within an organization and the collaborating agencies or will it be on a smaller scale with just a few previously identified individuals within a target group? It is important to limit the aim of the needs assessment and design it on a scale appropriate to the entire planning process (Eastmond, 1986). The goal is to maximize efforts, minimize redundancy and gather a solid understanding of the overall clinical need. Step 2: Identify the Assessment Team The program director should collaborate with professionals that will be directly involved in the services that are being assessed. e Clinician Telehealth Liaison or Coordinator IT support There should be a representative from each service area that has expertise or detailed knowledge about the problem and gaps that are occurring. Step 3: Assessment Approach The needs assessment team will collect information in order to obtain and clear view of the need and potential gaps in services. Primary/Secondary Data Qualitative/Quantitative Data The collection of this data commonly occurs through strategies such as: Focus groups/forums/surveys/interviews Secondary data analysis The collection of information must answer the following questions: What existing information is available? What information is needed? How did the data be analyzed and presented? 20

Step 4: Security of the Data When conducting a needs assessment, often team members are accessing confidential student information. The assessment team must ensure that all data collected as a part of this process is kept confidential and that FERPA laws are not violated. Security Checklist: The organization s student data policies have been reviewed. The assessment team is aware of the security data policies. Assessment team has a clear role for the use of the data. The administration is aware that the assessment team is reviewing student information. If accessing electronic information, the account automatically logs out after 20 minutes of inactivity. If accessing electronic information, the account is locked after 6 8 incorrect password attempts. If accessing paper documents, the documents are secured in a private and locked office. All files that are created are stored in a password protected file. The educational agency implements HIPAA and FERPA protocols for all student data. Step 5: Current & Preferred State of Services Evaluating the current state of services will generally focus on the clinical elements the organization currently provides or has access to along with how the provided services are delivered. The specific characteristics of support services, staff, and equipment will also be identified (Martin, 2012). The preferred state evaluation will identify the supplemental services, delivery capability, providers and other resources that can be supported by telehealth. Step 6: Organizational Readiness Organizational readiness is the willingness and ability of an organization to shift from its current way of operating to something new (Martin, 2011). Assessing organizational readiness will identify any major challenges that could delay or prevent your new program s successful start up. Leadership Resources Potential Barriers Creating buy in from others in the organization (host or remote) could impact the overall success of the program. Increased awareness of how telehealth will impact the target population. Increased awareness of how telehealth aligns to the overall mission of the organization. 21

Step 7: Identify the Gap The difference between the current and preferred state of services is considered the gap. The assessment team should use this information to identify how telehealth can be used to maximize current resources to address the need. The gap analysis should examine the specific service need along with the technology and infrastructure requirements (at all sites). Step 8: Identify Potential Barriers Once the specific needs of the organization and client(s) are identified the team must identify what barriers might hinder the success of the project. These include the following: Technology and infrastructure Location for services Support personnel Training, project support Confidentiality Step 9: Summarize and Make Decisions The components of the assessment should be prioritized. It should be determined which among the proposed services are the most important for the organization. What (if any) barriers can be overcome. Identify solutions based on: Identified Challenges Acceptable Practice Feasibility Present the findings to leadership who will make decisions based upon the information. 22

Functions and Roles of the Team Make the most of existing staff strengths and structure Key Functions Identify the functions that need to occur and then what personnel could fulfill these responsibilities. Typically, there are seven essential functions for a telehealth program. Program Director Project Manager Clinical Director Clinical Service Provider Site Coordinator On Site Helper or Liaison Technical Support Roles and Responsibilities Each function has a defined set of roles and responsibilities. Identifying these roles and responsibilities before the start of the project is important. Helps with the specific assignment to existing or new staff members In many programs one person may be responsible for or perform more than one function or role. 23

Program Director: Overview Most critical to a successful telehealth program. The person fulfilling this role should: Understand the benefits/limitations Understand the needs of the client and their team Ensure that organizations (at all sites) are ready Manage timelines/meetings Program director assures that clinical, operational and technical expectations and requirements are identified, met, or exceeded, therefore encouraging the successful outcome of the project. Program Director: Overview The responsibilities of the program director are different than ongoing project management. The program director is responsible for the overall project goals rather than the on going day to day operations. Often especially with smaller projects one person will take on the responsibility of the overall direction of the project and the day to day operations. Resources Benefits and Limitations Overall Goals Program Director Personnel Overall Needs Program Manager: Overview Responsible for the on going operational aspects of the telehealth program. Works in cooperation with service delivery clinicians, on and off site team members. Interacts with the organizational leadership Educated/updated on activities Overall quality/outcomes of services Program Manager Service Delivery Staffing Quality Assurance 24

Site Coordinator: Overview The On Site Coordinator s functions are related to operations and providing assistance as needed to the client at their location. Will be a different site coordinator for EACH location receiving telehealth Who will be the point of contact for the on site services Identify who will support the program on site Will help with buy in from other on site professionals The On Site Coordinator must be committed to the program and fully understand the benefits and purpose. Success of the program is related to the success of the clients. Site Coordinator Point of Contact ID Local Staff Educate Others Clinical Director: Overview The Clinical Director assures that there is adequate and appropriate clinical services. The person makes sure that the services are meeting the needs of the clients. Assures that the services are accessible without undue burden to the client. Clinical Director Services Meet Needs Services are Appropriate Services are Accessible Clinical Service Provider: Overview The telehealth clinician provides the direct and indirect clinical service to the clients. Direct services, consultation, supervision, meeting/administration responsibilities. The telehealth clinician has primary contact with the client. Frequent communication with the Clinical Director and Site Coordinator. First hand knowledge of how the client is responding to services and if changes or modifications are needed. Service Provider Direct Services Indirect Services Data Collection 25

On Site Helper: Overview The On Site Helper works with the remote clinician during the services. One or two trained individuals or the client s 1:1 or classroom paraprofessional or staff. The on site helper must be available during services and help with the transfer of information presented to general educational settings. On Site Helper Works with Clinician Collaborates with Classroom Available During Services Technical Support: Overview The Information Technician will ensure that equipment has minimal down time. Collaborate with the service provider, on site helper and service coordinator. Should know the schedule of the services. Should understand the purpose and goal of the telehealth program. On Site Helper Works with Team Minimizes Down Time Aware of Program Goals It is the responsibility of the intervention team to determine appropriate General Overview for Client Candidacy candidates for telehealth 26

Introduction Not all students, patients or clients are appropriate candidates for telehealth. It is the responsibility of the intervention team especially the treating clinician to determine and distinguish between ideal candidates for telehealth. Some individuals may need additional support and/or strategies. Overview of the Recommendations Clinical services are based on the unique needs of each individual client/patient, when providing telepractice services, the same holds true. The method in which services are delivered in a telepractice setting may not be appropriate in all circumstances or for all clients (ASHA, 2005). It is the treating clinician s responsibility to judge the appropriateness of telehealth to ensure that the client is able to receive maximum benefit from the services. Client Candidacy Candidacy for receiving services via telepractice should be assessed prior to initiation of services (ASHA, 2005). These guidelines are evolving based upon current clinical practices, strategies and research. There are several things that might impact the client s ability to benefit from telehealth services: Culture Education level Age Gender 27

Impact Factor: Physical/Sensory Physical and sensory characteristics that may impact the ability to provide telehealth: hearing ability visual ability (e.g., ability to see material on a computer monitor) manual dexterity (e.g., ability to operate a keyboard and/or mouse if needed) physical endurance (e.g., sitting tolerance) Impact Factor: Cognitive, Behavioral & Motivation Cognitive, behavioral, and/or motivational characteristics that may impact the ability to provide telehealth: level of cognitive functioning ability to maintain attention (e.g., to a video monitor) ability to sit in front of a camera and minimize extraneous movements to avoid compromising the image resolution willingness of the client/patient and family/caregiver (as appropriate) to receive services via telepractice Impact Factor: Communication Communication characteristics that may impact the ability to provide telehealth: auditory comprehension literacy speech intelligibility cultural/linguistic variables availability of an interpreter 28

Impact Factor: Client/Patient Support Client/Patient support resources that may impact the ability to provide telehealth: availability of technology access to and availability of resources (e.g., telecommunications network, facilitator) appropriate environment for telepractice (e.g., quiet room with minimal distractions) ability of the client/patient, caregiver, and/or facilitator to follow directions to operate and troubleshoot telepractice technology and transmission Modifying TeleHealth Based on Characteristics Research: Telehealth for Special Populations Deaf and Hard of Hearing Telepractice can be used to deliver early intervention, therapeutic, and educational services, for infants and toddlers, school aged students and adults. Considerations: Audio quality Higher speed internet (to support highest quality of audio signal) 29

Modifications: Physical/Sensory Characteristic: Physical and sensory characteristics Modifications: Hearing Ability: Enhanced audio, headphones, enlarged video to maximize visual cues, speech to text, material with closed captions Visual Ability: Enlarged text, text to speech output, chunking visual images (screen shades), contrast/background, magnified, reduce screen brightness, refreshable Braille devices, electronic and tactile material Manual Dexterity: Touch screen, switch/eye gaze, speech to text Physical Endurance: Touch screen, switch/eye gaze, speech to text Training of on site helper will help support modifications Modifications: Cognitive/Behavioral Characteristic: Cognitive, behavioral and/or motivational characteristics Modifications: Reduced level of cognitive functioning: epens to highlight, record sessions for review, hybrid of electronic and tangible rewards/activities Attention: Burst sessions, visual charts/schedules, visual timers, screen for notes, hybrid of electronic and tangible rewards/activities Inability to sit in front of camera: Motorized webcam, use of environment in sessions, SmartBoards Unwillingness from caregivers/clients: Increased education Training of on site helper will help support modifications Modifications: Communication Characteristic: Communication characteristics Modifications: Auditory comprehension: Eliminate audio distractions and visual clutter on screen, speech to text, whiteboards, epens, recordings for review Literacy: epens, animation, text to speech Speech Intelligibility: eflashcards, record audio/video for feedback, webcam (like a mirror) for placement of sounds 30

Role of e Helper The role of the e Helper is to ensure that the telehealth equipment is functioning properly. However, the e Helper can also assist the eslp with behavior management, managing paper based material, and serving as on site ears and hands. Careful attention must be made to ensure that the e Helper is working within her certified roles/responsibilities. The e Helper may not report clinical information. Confidentiality remains a priority when Conducting IDEA, HIPAA & FERPA telepractice Individuals with Disabilities Act, 2004 IDEA, 2004 mandates that children eligible for special education services receive the necessary services Telepractice is an evidence based service delivery that can be used for: Assessment/Evaluation/Screenings Direct Services in 1:1 or group setting Indirect Services (observation or consultation) Supervision (state regulations may differ) Administrative Meetings 31

Free Appropriate Public Education FAPE and LRE Telepractice can help schools with high speed Internet can receive IEP mandated direct services. Telepractice can provide additional, more consistent direct and indirect services in conjunction with an on site approach. Telepractice can facilitate collaboration between team members and caregivers. There is a growing evidence base for more complex disorders. Health Insurance Portability & Accountability Act The regulations of both HIPAA and the HITECH Act of 2009 have stringent guidelines for security and confidentiality. Strategies that increase data security: Secure firewall and have up to date anti virus software Any videoconference system used must have: Encryption for transmission of all files (128 bit AES) Access control (i.e., unique user identification, emergency access procedures, automatic log off) Audit controls & Entity Authentication Implement policies and procedures to protect student information. Back up data on regular basis Training of all Team members on security protocols Family Educational Rights & Privacy Act This mandate provides explicit regulations regarding the privacy and release of students educational records (Van Dusen, 2004; Toglia, 2007). When implementing telepractice programs it is recommended that: A consent form is obtained. A clear description of the differences between telepractice and on site services is provided (Boisvert & Hall, 2012). An outline positive and negative consequences are given. Telepractice team has established: Clear roles Clear procedures and policies 32

Clinical providers must be knowledgeable and trained in the specific skills required to General Overview of Clinical Procedures provide telehealth General Overview of Clinical Procedures Telepractice is not about technology. Telepractice is really about clinical interactions, rapport and forming a strong working relationship with the client and their team. Telepractice does not remove existing responsibilities in service delivery. Telepractice services must be the same quality as those delivered face to face. Getting Started eclinicians must learn the ins and outs of a videoconference system. This includes: Downloading software Schedule a meeting Invite participants Screensharing with clients Annotation features 33

Troubleshooting Most common issues Videoconference not working Poor incoming/outgoing audio Poor incoming/outgoing video Echo very common Internet connectivity Sessions can occur without video very difficult to conduct sessions without audio! Clinical Strategies Material Criteria for Appropriate Material The focus of the treatment material should be on the target behavior rather than details of the activity. Games and activities that are overly complicated are not a good choice for telehealth. The clinician should choose activities that are easily controlled, stopped/paused and have simple visuals. The audio of the activities should be controlled as well. The FIVES criteria is a way to evaluate if material is appropriate (Sweeny, 2013). 34

FIVES Criteria (Sweeny, 2013) Fairly Priced: There are many free/fairly priced resources online Interactive Visual Information Educationally Relevant CommonCore Standards Speechie Target goals Organization of Material Material should be organized before the session starts. The activities should be ready in separate tabs and enlarged so that only the activity is visual on the computer screen (to the best extent possible). Moreover, the clinician must prepare the activity so that the client does not see the advertisements (there are sometimes ads before games/activities). Organization of the Session It is helpful to create a visual schedule of the activities that will be presented. This helps with the overall flow of the session and creates a structured setting to help transfer from one activity to the next. Some students enjoy checking off the activities as they complete them and the use of a visual schedule provides a structure for the expectations within the session. Using a visual schedule and reviewing it with the client also provides a structured format to review any behavioral strategies or modifications that the client may need. 35

Display of Material The activity presented should be enlarged as possible and in a full screen. Clinician s should try to eliminate visual clutter. This includes address bars, chat boxes, adds, navigation bars, etc. Use the computer s zoom feature to make the activity larger and then use the computer s full screen option. Being aware of the display of the material achieves several goals: First, the larger image is easier to see Second, it reduces distractions on part of the client Third it eliminates the possibility that the client might click off of the activity to another website. Helpful Hints to Increase Visual Attention Cursor Size: In the size of the cursor can help draw the participants view to various parts of the screen. Ideally, the size of the cursor should be extra large. Location of Cursor: To orientate the participant s view of the cursor, Windows enables the location of the curser to be found when pressing the CTRL key. Ink Annotations in Word and PowerPoint: To be able to hand draw or highlight in any word or PowerPoint document the user must insert Ink Tools/Pen Tab feature. Premade and Clinician Made Material Premade or company made material Saves time Usually professional presentation of material Many resource lists/guides available (see next slide) Unable to customize Clinician made material can be made via PowerPoint, SmartNoteBook, Word Customize to meet the specific needs of client Can re use by making slight modifications Share with colleagues Takes time Must be proficient in the programs 36

Hybrid Approach The combination of premade and homemade material enables the clinician to take advantage of professionally put together videos and games along with the control and customization of homemade material. To effectively use both pre made and homemade material, the premade activities must have natural stopping points or features built in to pause/stop at predetermined points. The treating clinician can then use flashcards (or the like) or screen caps of the activity to modify, use annotation tools, stickers, etc. Clinical Strategies Articulation Language Behavior Collaboration Generalization General Strategies Intervention should be dynamic rather than static Majority of time spent on targeting skills Generalization considered from the beginning Scientifically based approaches should be implemented Most strategies that are used for on site can be applied in a telehealth setting Behavior can be addressed via telehealth Team collaboration supports client and overall telehealth program Data collection is essential! 37

Assessment and Screening Identifying the goals/objectives Research has shown that assessment/screening results are equivalent when comparing telehealth to on site. Can use digital screeners/assessments Purchase from Pearson Stimulability Assessment Same resources can be used as onsite Consider the use of on site recording if there is a concern about the overall audio quality ehelper can assist with this as well Examples of Materials Speech Sound Production Language Comprehension Social Pragmatics Rewards Rewards can be in the form of short games, stickers and or other traditional methods. Students will work for 2 minutes of free time at the end of the session or a short reward following stimuli. The reward should fit the developmental age of the student. http://www.poissonrouge.com/room.php www.funbrain.com http://www.lego.com/en us/games 38

Strategies for Behavior Management Situations often occur in which we need to redirect the client s behavior so that it is appropriate for therapy. e helper facilitates the client s behavior. Many of the strategies that work in person will work through telehealth. Reinforcement and Punishment: Kids earn playtime, tokens, activities, congratulatory notes to students, Tangible vs. electronic behavior management systems Token boards/star charts/stickers, Virtual high fives /Verbal phrase Structured therapy sessions/giving choices Screen Shades/Spotlights Attention breaks Strategies for Non Verbal Cueing There are many different types of nonverbal communication that a clinician can use to support the overall objective of the session. It is important to keep in mind that the cues provided must be within the visual range of the webcam. Some common non verbal cues include: Facial Expressions Body Movements Gestures Generalization Strategies Homework should strengthen the response and facilitate generalization Practice and existing skill Review during initial portion of the next telehealth treatment session Carryover should be built into the treatment sessions (same strategies as on site) Collaborate with on site staff some training may be needed Charting progress Audio/video for self awareness Self cues http://nces.ed.gov/nceskids/createagraph/default.aspx 39

Collaboration Strategies Collaboration supports program and generalization and increases knowledge of benefits from services. Integrates functional skills into therapy Borrow book and material from classroom ID themes and units Use class based websites/lesson plans/ehelper can facilitate this Consult on successful strategies, needed skills Weekly/bi weekly meetings, paras observe sessions Review/Share data with on site team Demonstrate materials/lessons Active Consultation/coaching Other Considerations Scheduling sessions Aware of Internet usage at the same time as intervention (i.e., lunch time, classes in the computer lab) Scheduling is very similar to that of as on site sessions Account for adequate set up time in the scheduling process. IEP Meetings Use online software to write IEP/IEP team review documents Fax/email report Attend meeting via secure videoconferencing Moving around the school Mobile Cart/laptop push in services or services in another location Conclusions High quality intervention can occur through telehealth Encourage mutual and shared responsibility for positive client outcomes Establish goals and inform the team of the goals Collaboration is a dynamic process The expectations of the therapy should be realistic Encourage/support professional training as needed Celebrate successes! 40