It’s a Family Affair: Telepractice for Children Who Are Deaf Four telepractice experts share what you need to know about providing speech-language services remotely for children who are deaf or hard of hearing. Overheard
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Overheard  |   April 01, 2016
It’s a Family Affair: Telepractice for Children Who Are Deaf
Author Notes
  • Marge Edwards, MSP, CCC-SLP, is a speech-language pathologist at Sound Beginnings, Utah State University’s early intervention program. She is an affiliate of ASHA Special Interest Groups 9, Hearing and Hearing Disorders in Childhood; and 18, Telepractice. marge.edwards@usu.edu
    Marge Edwards, MSP, CCC-SLP, is a speech-language pathologist at Sound Beginnings, Utah State University’s early intervention program. She is an affiliate of ASHA Special Interest Groups 9, Hearing and Hearing Disorders in Childhood; and 18, Telepractice. marge.edwards@usu.edu×
  • Kim Hamren, MEd, is a teacher of the deaf and early intervention coordinator at Listen and Talk, a Seattle-based nonprofit educational program serving children who are deaf or hard of hearing. kimh@listentalk.org
    Kim Hamren, MEd, is a teacher of the deaf and early intervention coordinator at Listen and Talk, a Seattle-based nonprofit educational program serving children who are deaf or hard of hearing. kimh@listentalk.org×
  • Amy Peters Lalios, MA, CCC-A, is an audiologist and director of therapy, including the ConnectHear teleintervention program, at HEAR Wisconsin in West Allis. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood. alalios@hearwi.org
    Amy Peters Lalios, MA, CCC-A, is an audiologist and director of therapy, including the ConnectHear teleintervention program, at HEAR Wisconsin in West Allis. She is an affiliate of ASHA Special Interest Group 9, Hearing and Hearing Disorders in Childhood. alalios@hearwi.org×
  • Laura Moody, MSEd, CCC-SLP, is clinic supervisor at the University of Nebraska-Kearney, where she developed and coordinates telepractice services. moodyln@unk.edu
    Laura Moody, MSEd, CCC-SLP, is clinic supervisor at the University of Nebraska-Kearney, where she developed and coordinates telepractice services. moodyln@unk.edu×
Article Information
Speech, Voice & Prosodic Disorders / Hearing Disorders / Telepractice & Computer-Based Approaches / Overheard
Overheard   |   April 01, 2016
It’s a Family Affair: Telepractice for Children Who Are Deaf
The ASHA Leader, April 2016, Vol. 21, online only. doi:10.1044/leader.OV.21042016.np
The ASHA Leader, April 2016, Vol. 21, online only. doi:10.1044/leader.OV.21042016.np
Participant: What are the challenges of providing services via telehealth?
Kim Hamren: The greatest challenge we have faced over the years boils down to technology and connectivity. Even though we have improved our equipment and procedures over the years there, we can still face these challenges. The frequency has definitely decreased but it still exists. We have simplified the type of equipment we use and have built our IT support, which has had a huge impact on our services. Another challenge is sharing the benefit of virtual services with our state and county [Individuals with Disabilities Education Act (IDEA)] Part C stakeholders in order to build a process for reimbursement. We have spent a lot of time developing an understanding of the benefit of coaching through virtual technology and support for payment for services. Currently the counties approve payment for a combination of in-home and virtual services each month.
Amy Lalios: Additional challenges include funding and awareness.
Laura Moody: We find that the challenge of not being “in person” to provide tactile cueing also provides an excellent opportunity for family training, as we rely on e-helpers to assist during sessions.
Marge Edwards: I would agree with Kim. Connectivity is a big issue, particularly in more rural areas or in urban areas with high Internet traffic. Also, reimbursement for services is a challenge.
Hamren: I agree about the hands-on challenge, but since we are able to provide both in-home and virtual for most families, we are able to balance that out.
Participant: Can teletherapy be conducted via Skype or FaceTime if the family/patient signs permission? What does the HIPAA law require?
Edwards: There can be a learning curve, whereby families must take more of the lead role in the sessions. We have used both FaceTime and Skype (though Skype only by family request at this point). We are also using Zoom.
Hamren: We have been advised that we can use FaceTime but not Skype. There are a lot of factors that need to be considered in determining this. It is important to have your entire system evaluated as a process to decide on the platform. We also use VSee. No matter what platform you use, you should have them sign a consent form.
Lalios: We have provided services via Skype, at the participants’ request. We always have all participants sign a consent form. At this time we are primarily using Vidyo, but we have used other platforms as well.
Moody: Our university uses Zoom and we have experience using WebEx. The platforms we have used included a fee for our facility, but were free for families to access.
Participant: Skype and FaceTime are not HIPAA-compliant from all the regulations I’ve seen.
Edwards: HIPAA-compliance is a big topic and consistently moving target as new platforms become available. Know your employer’s policy regarding transmission of information over VoIP [voice over Internet protocol]. Know the risks and mitigate to the extent possible, and make sure you have signed informed consent from patients/families. This link provides a great description of risks as well as a checklist for possible risk assessment for tele-rehabilitation specifically.
Participant: The national Telehealth Resource Centers are a good resource.
Participant: Is there any recommended software (for Internet speed, windows, cameras, etc.) that helps more in intervention services for children who are deaf, specifically in regard to early intervention?
Edwards: Screen sharing is very useful for both parents and children. You can share diagrams, pictures and videos. I think 1-2 Mbps is adequate for bandwidth. Check the bandwidth speed test. I ask families to run this so we know for sure.
Moody: We use Windows-based laptops with built-in cameras in our facility. Families provide their own technology, which has ranged from desktop to laptop to tablet. Each has worked well, though we prefer computers to tablets for easier positioning of the camera. Internet connection has been a larger factor. Internet available in rural areas can be limited. When connecting between two computers, we have run into occasional difficulty sharing documents/visuals if one is a Mac and the other is a PC.
Lalios: I agree that Internet connectivity is the biggest factor.
Hamren: With families, we actually use the iPad or [other] tablets and a really nice, flexible stand. Because we are working with children birth–3, it works best to be able to move the equipment around the room/home.
Participant: I am working full time but am ready for some telepractice. What are the criteria for certification?
Anne Oyler (ASHA associate director of audiology professional services): ASHA doesn’t require a certification to do telepractice. You must be competent by virtue of training and experience, which is a requirement of the Code of Ethics for any area of practice.
Lalios: Currently there are various programs offering training and experience; however, there is no certification.
Janet Deppe (ASHA director of state advocacy): There are licensing requirements to provide services through telepractice in many states.
Edwards: It is very helpful to attend some form of training and/or have mentorship for getting started with telepractice.
Participant: When billing insurance, what code do you use in the place-of-service box?
Edwards: We do not bill insurance or Medicaid, either. Check in your state to see if Medicaid does cover telepractice. Several do! Check the following link from ASHA 2014 for states reimbursing for Medicaid.
Hamren: Our state does not yet allow to bill for insurance.
Oyler: Right, Medicaid is state-driven, and some states do allow for reimbursement for telepractice services. Many payers are still not familiar with telepractice and may need to be educated.
Lalios: We have used “other location” and “home,” however this is dependent on the specific funding-source requirement or statements regarding telepractice services.
Deppe: The state advocacy pages on the ASHA website have a map that we keep updated on the states that cover telepractice services under Medicaid. There are now 21 states.
Kate Ogden (ASHA health policy associate): Yes, the place-of-service codes may be payer-specific. I’d recommend checking with the insurance company you’re billing or the Medicaid agency for its policies.
Sam Hewitt (ASHA director of political and grassroots advocacy): Here is a link to see if Medicaid does cover telepractice in your state.
Participant: Do families receive initial services in office and then outreach services periodically?
Lalios: Whenever possible, we like to meet with families initially in person. However, there are times when this is not possible.
Hamren: We usually start with in-home services. That varies from family to family. Primarily we use a combination of seeing the family both in home and virtually. We have served families through virtual only, though under special circumstances.
Participant: Do you find it helpful to have a few face-to-face sessions before you initiate teleintervention, or have you found it just as effective to begin virtually?
Edwards: We typically try to coordinate audiology visits and initial assessments at our clinic. However, if this is not possible, we have initiated services until the family can come in for the initial appointment or we go to the home. It can be helpful to do several initial visits face-to-face but certainly not essential.
Deppe: We have been successful in states ensuring that face-to-face services are not required to engage in telepractice. It is important to establish a relationship with the clients, but we try to make sure that it is not required in state law. Requiring in-person visits would make serving clients across state lines almost impossible.
Hamren: Yes, we prefer that. Because we are in collaboration with the Part C process in our state, we typically see the family a couple times before the services start. I do agree, though, that services can be very effective when started with virtual out of the gate.
Participant: What criteria do you use when determining if a family would benefit from telepractice versus physically going into the home to provide services?
Edwards: Many of our families live remotely or in other states, so telepractice is necessary. We have also seen local families of children with health care concerns. The family must be comfortable with technology, willing to take the lead in sessions and willing to establish an optimal learning environment for parents and children. They also need to be on the same page in terms of commitment to using hearing technology and use of spoken language.
Lalios: For some families we serve, telepractice is the only option for access to specialized services. So they tend to be very motivated. Families need to have an adequate level of comfort with technology as well as have a full understanding of their role.
Hamren: Excellent question. We have an informal process as we look at each family and nothing that is published. There are many considerations, which include family familiarity with technology, family comfort levels, use of an interpreter, etc. I would say that typically it is much more about the comfort level of the adults rather than when a child is ready, but that could be because we are working primarily with the very young population. [And to] clarify about the use of interpreter: We actually provide Spanish interpreting through virtual. I was thinking of when a family is non-English speaking and requires an interpreter. It is more difficult virtually.
Participant: Can you tell us more about the issue of awareness? Awareness of parents knowing teleintervention is available or administrators believing it is effective?
Lalios: Many do not realize the potential outcomes and effectiveness of this type of service-delivery model. Of course, it is helpful when the person providing services has experience with coaching families in the use of strategies to increase the child’s skills as well as the use of technologies.
Oyler: This is also discussed at on.asha.org/tele-stakeholders.
Hamren: Over the past couple years, it seems parents in general are much more aware of the idea of receiving services virtually. They also are more likely to personally be communicating through FaceTime, etc., so it makes sense to them. A big challenge seems to be helping administrators understand the benefit. However, in our case, the administrator has been a huge advocate from the beginning. One of the efforts that has been beneficial is the understanding that coaching parents is key for child outcomes and when you are providing services virtually, you are naturally in a coaching mode.
Moody: In my experience, parents have been completely unaware that this option can be available for therapy. Some are thrilled, while others are hesitant. Both can be successful when willing to try it.
Edwards: I had expected telepractice to have grown more quickly. Hopefully, it will gain more recognition in this specific field. I think the reimbursement issue may play a role.
Deppe: We believe that the major barriers to telepractice gaining more traction are reimbursement and licensure issues.
Participant: Since early intervention is all about equipping parents to be their child’s first teacher, how are you measuring changes in parent behaviors of implementing the strategies to support the family’s desired outcome?
Lalios: We have developed our own tool for looking at parent behaviors. These behaviors have been taken from other early-intervention tools and adapted for our purposes. Telepractice really is a good avenue for parents to develop their own skills. In fact, we have observed a trend in parent skills increasing more readily and parents are more confident across a shorter amount of time than for in-person sessions.
Hamren: I agree with Amy. We are using the same measures we use for in-home services. Primarily we use child outcome measures and have been on the hunt for a good tool for parent behaviors. Just had a form of this discussion today.
Edwards: I agree as well! It seems that the parent, by necessity, must learn, practice and develop skills much more quickly! This is a great question. At Utah State University I participated in a study that used the Home Visit Rating Scales that look at both provider and parent behaviors.
Participant: Are any of the children and families you are serving through teleintervention also receiving their audiology services remotely?
Hamren: As far as I know, none of the children we work with have remote audiology. They are doing some on the east side of our state, but I have not been involved with these families.
Lalios: I do not know of any of the families receiving audiology remotely for their children.
Edwards: We are doing consultations and troubleshooting remotely but not audiological testing/implant mapping as of now.
Participant: How have you incorporated other professionals from your team in your ongoing telehealth sessions?
Hamren: We team with other professionals both within our program and with other agencies. As Marge mentioned earlier, we will do joint visits with vision specialists as well as other therapists. It is a nice way to be able to share expertise and can be easier to coordinate schedules. I have had an ongoing schedule with a PT where the last 30 minutes of my session and the first 30 minutes of her session are overlapped. She is in the home and I join in virtually. This has worked very well. It also works well when children have a lot of challenges and there are many therapists that go into the home. You can reduce the number of people in the visit by having one attend virtually. We have also used it as an opportunity to have our own team members join us for a session to give a different perspective for a challenging situation. We have also attended meetings virtually.
Edwards: When providing services under Part C, we would usually try to be in the home for team visits with other providers. We have connected remotely with several teams (OT, PT, vision specialist, IFSP [individualized family service plan] team) for more remote families to consult. It usually seems to go pretty smoothly and can be very beneficial to know the full picture.
Lalios: We also have conducted telepractice sessions with professionals outside of our agency. It is a great way to team, consult and learn. We have conducted [IDEA] Part C and Part B meetings, as well, using telepractice.
Participant: Can you hear the child’s speech productions effectively over telehealth?
Moody: We have had variations here. Generally, we have had great success. We believe this is somewhat dependent on the quality of the technology on the family’s side. We are in the process of investing in some microphones to send to families to see if we can make improvements.
Edwards: I would agree with Laura. Microphones can help as long as they do not over-distort the speech.
Lalios: Sometime yes and sometimes no. This, however, is another great learning opportunity for parents. At times I need to rely on asking the parents to model exactly what they heard the child say. It’s a great opportunity to coach the parents to be aware of speech production development and goals.
Hamren: This is a common concern and is sometimes a reality. This can depend on the type of equipment being used. One of the challenges that impacts child speech is when the equipment has voice-cancelling properties. There needs to be intentional effort toward reducing background noise, one person talking at a time, reducing over-talking, etc. This is best practice for working with children anyway, and especially for children with hearing loss. With that said, the same thing can happen in live home visits too. It is an opportunity for parents to listen and report what their child is saying.
For a full transcript of this chat, visit on.asha.org/telepractice-chat.
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April 2016
Volume 21, Issue 4