Words Without Walls A private practice trades bricks and mortar for an exclusive focus on telepractice and home and school visits. Can the new model work for its speech-language services and overall survival? Time will tell. And insurance reimbursement will be key. Features
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Features  |   December 2014
Words Without Walls
Author Notes
  • Bridget Murray Law is managing editor of The ASHA Leader. bmurraylaw@asha.org
    Bridget Murray Law is managing editor of The ASHA Leader. bmurraylaw@asha.org×
Article Information
Speech, Voice & Prosodic Disorders / School-Based Settings / Practice Management / Professional Issues & Training / Telepractice & Computer-Based Approaches / Features
Features   |   December 2014
Words Without Walls
The ASHA Leader, December 2014, Vol. 19, 40-47. doi:10.1044/leader.FTR1.19122014.40
The ASHA Leader, December 2014, Vol. 19, 40-47. doi:10.1044/leader.FTR1.19122014.40
Jack bops up and down in his seat, describing the funny YouTube videos he’s been watching to speech-language pathologist Molly Wallace. She’s waving to him on his computer screen—from another screen in another zip code.
Nine-year-old Jack can string together whole sentences now, which shows just how much progress he’s made since age 4, Wallace notes. That’s when she started working with this cherubic, curly-headed boy, who then had a diagnosis of autism spectrum disorder. At age 5 or 6, he would tell whole stories without using words. “He’d just use environmental signs and sounds, like the noise of a truck,” Wallace says. “So we had to use word-retrieval strategies to come up with the nouns and verbs to say what happened.”
Now, after three more years of speech-language treatment—the last two delivered online—Jack’s diagnoses are limited to receptive/expressive language disorder and articulation difficulties. Right now, Wallace asks him what’s wrong with a sentence that pops onto his screen: “Next year I be one year older.” And he’s quick to respond: “Next year I will be one year older.”
Wallace is used to seeing this sort of progress among her 10 telepractice clients. The rest of her clients she sees in person, visiting their homes. In fact, though employed by The Chesapeake Children’s Therapy Center, Wallace never sets foot inside a traditional office. That’s because Chesapeake’s 20 clinicians—SLPs and occupational and physical therapists—provide services where clients are or remotely. There is no brick-and-mortar center.
It hasn’t always been like this at Chesapeake, a Springfield, Virginia-based private clinic started by SLP and executive director Patricia Rogers in 1995. The practice had walls until six months ago, when Rogers and Mary Wood-Maloney, Chesapeake’s telepractice project manager, decided the practice’s financial structure had to change.
The problem? Too few private insurers were reimbursing for services adequately or on time. The fix? Cut costs by closing the traditional offices. Focus on expanding the center’s state-supported early intervention services—and continue telepractice services reimbursed by one reliable private insurer: CareFirst BlueCross BlueShield.
Time will tell how this new model works out—and if Chesapeake can deliver some of its early-intervention services via telepractice as it hopes to. Much, Rogers says, depends on what happens with insurance reimbursement, with public insurers leading the way.
Why no building?
Back in its brick-and-mortar days, Chesapeake employed 35 staff members who served 300 to 400 children every month in the Washington, D.C., area. When, in 2010 and 2012, Virginia and Maryland passed legislation paving the way for private insurers to reimburse for telepractice speech-language services, Chesapeake boldly forayed into this new e-treatment terrain
When you eliminate traditional offices, the cost savings are obvious: You no longer pay rent, upkeep or overhead, or to have someone manage office appointments and scheduling.
But what really dogged Rogers was the unpredictability of private insurance providers and how much time and expense it took to collect money from them. “It was costing us 25 cents on the dollar dealing with insurers and collections,” Rogers says. “It was just very expensive doing all those authorizations and reauthorizations so we didn’t miss payments.”
Unfortunately, reimbursement for telepractice services was just as dodgy, sometimes even more so: Even though CareFirst BlueCross BlueShield reliably paid up, its subsidiaries didn’t always, says Rogers. Still, she and Wood-Maloney decided to keep the telepractice going when they shuttered the brick-and-mortar operation.
Chesapeake now
Why keep telepractice? For one thing, enough of Chesapeake’s clients carry CareFirst to make it worthwhile. For another, telepractice is a potential growth area for Chesapeake’s early intervention services, which provide a practical solution for families living in remote areas, unreachable by clinicians.
The main reason early intervention works for Chesapeake is that Virginia guarantees payment for all early intervention services, even those contracted through private insurers. Chesapeake also wants to expand its involvement in public early-intervention programs.
So that’s the money part, but what about the clinical effectiveness part—do telepractice services actually work for clients? Absolutely yes they do, Wood-Maloney says.
“We thought we were going to have to select out kids for telepractice who couldn’t sit still or would have behavior problems, and we didn’t need to do that,” Wood-Maloney says. “There were no kids it wasn’t suitable for, and we were blown away by that. Kids are really interested in what’s on their screen, and really attend well to it.”
Chesapeake continues fine-tuning its use of telepractice in early intervention, moving the caregiver coaching model online. “Schools have telepractice down to an art—they know, for example, that having an e-helper involved is key,” says Rogers. “But we’re still working out how you involve the family in early-intervention telepractice services. That’s part of why we’re growing this slowly. We want to do this right.”
She and Wood-Maloney have invested in training their clinicians for the job. Molly Wallace, for example, received telepractice training and certification from the American Telemedicine Association—she’s a pro at steering clients through a session, first hooking them with some easy banter, then whisking them through screen after colorful screen of word activities and games. The pace is brisk, yet measured, the activities stimulating, yet educational. And if the technology falters, which it’s bound to (in the session I sat in on, I couldn’t get my video-camera to work), Wallace adeptly troubleshoots the problem and quickly gets the session back on track.
SLP Molly Wallace smiles on clients’ screens as she guides them through word games and other activities in her online sessions.
Will telepractice fly?
As a testament to Wallace’s telepractice prowess, she recently discharged three telepractice clients after they successfully met their articulation goals. Another example is Jack’s constant, consistent progress in his remote sessions with her. But clients aren’t the only ones to benefit, Wallace notes. Telepractice also saves both caregivers and herself the time, cost and hassle of traveling.
“I do my home visits in the morning and get home at 1:30 most days to do the telepractice sessions,” Wallace says. “So schedule-wise it’s great, because I completely miss the evening rush hour.” Meanwhile Jack’s mom has one less appointment to shuttle one of her three boys to.
But Chesapeake staff warn that telepractice won’t work properly if clinicians aren’t properly trained on telepractice clinical techniques and technologies. Clinicians need to ensure use of a secure, accessible technology platform and to customize clinical content and pacing for the client’s needs.
Also, clinicians encounter harder-to-reach, challenging children in telepractice treatment just like they do in regular treatment, Wallace says. “You have to tap into what interests them just like you do in face to face,” she says, noting her use of rewards as motivational tools: the YouTube video of “Let It Go” from “Frozen” for one challenging 4-year-old and vacation pictures for another.
“I’ve provided telepractice for feeding and to kids with autism, Down syndrome and Prader-Willi syndrome—I haven’t met an age or a disorder where it hasn’t worked,” Wallace says. “My philosophy is let’s try it, even if it takes three or four sessions to get it going, which it tends to for the toughest kids.”
In the end, the biggest barrier facing telepractice is insurance reimbursement, Wallace says, concurring with Rogers and Wood-Maloney. All hope for progress on that front. So far, state Medicaid programs have been slow to reimburse for telepractice services, they note. But Rogers hopes that, with persistent advocacy from the health care community, Medicare will lead the way. A Medicare change, she says, would spur a positive cascade, with Medicaid, Tricare and even private insurers following suit (despite state mandates requiring telemedicine reimbursement in Maryland and Virginia, insurers there have been slow to embrace remote speech-language services as an appropriate form of telemedicine).
Meanwhile, Rogers and her pioneering staff at Chesapeake plan to continue their small, but thriving, telepractice program. Only 10 to 20 families receive the services at any given time. But to Chesapeake staff, the program’s obvious benefits to clients like Jack make it worth continuing.
The child who once used grunts and gestures to tell stories is right now, per Wallace’s request, typing a silly sentence on their shared screen: “My brother painted my kitten blue this morning!” he proclaims with a laugh. Who knows? He just might be the next client to successfully graduate from Chesapeake’s telepractice progam.
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December 2014
Volume 19, Issue 12