A Tale of Two Screens Two telepractice experts share advice on providing clinical services remotely. Overheard
Overheard  |   November 01, 2015
A Tale of Two Screens
Author Notes
  • Michelle Boisvert, PhD, CCC-SLP, is co-owner and head clinician at WorldTide, Inc., and specializes in telepractice for the delivery of direct and indirect clinical services. She is an affiliate of ASHA Special Interest Group 18, Telepractice. michelleb@worldtide.com
    Michelle Boisvert, PhD, CCC-SLP, is co-owner and head clinician at WorldTide, Inc., and specializes in telepractice for the delivery of direct and indirect clinical services. She is an affiliate of ASHA Special Interest Group 18, Telepractice. michelleb@worldtide.com×
  • Nerissa Hall, PhD, CCC-SLP, ATP, is co-owner of Communicare, LLC, and specializes in augmentative and alternative communication and assistive technology. She is an affiliate of ASHA Special Interest Groups 12, Augmentative and Alternative Communication; and 18, Telepractice. hall@aaccommunicare.com
    Nerissa Hall, PhD, CCC-SLP, ATP, is co-owner of Communicare, LLC, and specializes in augmentative and alternative communication and assistive technology. She is an affiliate of ASHA Special Interest Groups 12, Augmentative and Alternative Communication; and 18, Telepractice. hall@aaccommunicare.com×
Article Information
School-Based Settings / Telepractice & Computer-Based Approaches / Overheard
Overheard   |   November 01, 2015
A Tale of Two Screens
The ASHA Leader, November 2015, Vol. 20, online only. doi:10.1044/leader.OV.20112015.np
The ASHA Leader, November 2015, Vol. 20, online only. doi:10.1044/leader.OV.20112015.np
Participant: How do you discuss implementing telepractice at a school district that is [hesitant] and is presently using para-educators because it’s cheaper?
Michelle Boisvert: Some of the initial talking points would be discussing the benefits of a telepractice program, including the increased access to specialists and generalization, as well as simultaneous paraprofessional training. Also, we typically meet the coordinator or director of special education and school-based educators to explain how telepractice works and answer any questions they may have. We also like to provide examples of telepractice to give them a first-hand look at the experience their students would have.
Participant: Do you have any tips for staying organized while serving multiple companies?
Nerissa Hall: We use online organizational solutions to store files and support scheduling with multiple teams. Google Calendar and iCal allow you to color-code different calendars, and then programs such as ShareFile (www.sharefile.com) offer HIPAA-compliant file-sharing options.
Participant: If online therapy is being done with children in a daycare setting or a school where there is no SLP, what does the other setting need to know about assistance they need to have available during the session?
Hall: We use a variety of interactive websites that offer engaging graphics and manipulatives. Here are some of our favorites: ABC Teach (www.abcteach.com), Education.com, Family Learning (bit.ly/fam-learning), Kids Can Have Fun (bit.ly/kids-fun-books), American Girl (www.americangirl.com), Bananas in Pyjamas (bit.ly/bananas-pjs), Berenstain Bears (www.berenstainbears.com), Disney (www.disney.com), Nick Jr. (www.nickjr.com)
Boisvert: The setting should be aware that the onsite assistance should be available to set up, troubleshoot and supervise the session. With children this young, there should be someone there at all times. This person can also help with carryover or transfer of skills and also let the SLP know of events going on in the classroom.
Participant: I currently provide therapy via telepractice for school-aged children and am always searching for more interactive activities/games to use. Are there any resources that you can share?
Hall: Sure. Here are a few more: Scholastic (www.scholastic.com), UpToTen (www.uptoten.com), Coloring.com, ABCYa! (www.abcya.com), Busy Teacher’s Café (www.busyteacherscafe.com), Kelly’s Kindergarten (bit.ly/kk-phonics), E-learning for Kids (www.e-learningforkids.org), Enchanted Learning (bit.ly/el-dictionary), Into the Book (bit.ly/itb-reading)
Participant: Will you please discuss how assessment and therapy procedures and materials may need to be modified and adapted to accommodate for the lack of physical contact with the client/patient?
Boisvert: Many of the mainstream assessment materials are in a digital format. Through screensharing these can be implemented via telepractice. With some of the subtests that require pointing, we select a “spotlight” tool so that the student can use the mouse to point to their response. For the most part, through annotation tools and shared screen/keyboard/mouse, there is a high level of interactivity during the sessions.
Participant: Are there any platforms or apps I can buy to use if I wanted to do some independent telepractice? I have one client who wants me to see them via telepractice.
Hall: We both use GoToMeeting, but there are also other video conferencing programs, such as Microsoft Live, Vidyo, Polycom, Team Viewer and WebEx. The most important thing is to ensure they are HIPAA-compliant.
Participant: Which platforms have you found to be most successful in the population? Which ones lend themselves to easiest student navigation in terms of controlling shared “materials” or “applications”?
Boisvert: The one that we use is GoToMeeting. We have found that this program is very user-friendly for screen/keyboard/mouse sharing. It is also easy in this program to “take back” control if needed. The install and access to the program is simple as well.
Participant: I am currently at an early-childhood school doing teletherapy with 3- and 4-year-olds. I have not done teletherapy with this age in the public schools before. What are some good strategies/tips you can share for successful therapy sessions?
Boisvert: We use a range of material including e-books, PDFs, online games, software, media and videos. We primarily use materials that permit flexibility and that allow us to change up activities quickly according to students’ skill levels or behavior at the time. These include static materials (such as PDFs), virtual manipulatives, graphic organizers, stories and videos. We don’t use websites and games with lots of animation and sound to avoid delays in loading. The use of a visual schedule is very helpful as well. This is typically presented at the beginning of the session and each activity is checked off by the student as they complete it.
Hall: We have found that using telepractice for real-time consultation with parents/caregivers in the context of engaging in activities with young children is a really effective use. It allows us to really offer guidance in the moment and empower the caregiver to work effectively with the individual to address specific goals.
Participant: Can you give a little more detail on what a “virtual” manipulative might look like?
Hall: A virtual manipulative is really anything that can be moved within the shared screen. So, for example on LEGO.com you can build a house using virtual Legos. Through shared controls the student could “move” an item on the screen, or in response to certain directions, etc. There are also annotation tools that allow the clinician to highlight/circle/underline certain targets.
Participant: Are materials shared through duplicate materials with a facilitator, screen share, and/or document readers or are there any interactive apps available specifically for telepractice activities?
Boisvert: Most of the materials that we use are shared through screen sharing. We put them up on our screen and the student is able to interact with them through the video-conferencing software. There are many sites and programs online that can be used for telepractice. Some are free and some require a paid subscription.
Participant: What browsers are acceptable in terms of the right to privacy? Do they need to be HIPAA-compliant?
Boisvert: This question came up in the Community earlier this week. Mike Towey responded with a very insightful and helpful comment. I’ve reposted it below.
It is not the platform that is HIPAA-compliant.
It is the provider, based on the policies and procedures in place by the provider/organization, including not only HIPAA confidentiality requirements but HITECH ACT 2009 security features required not only in the platform (ZOOM and many others have those features) but also the provider/organization policies….management of unique user identification, emergency procedures, procedure for allowing allowed access to the platforms, screen management/security, emergency procedures, etc.
Participant: Are you able to play games with the client and share your screen at the same time you see the client?
Boisvert: Yes, with GoToMeeting you are able to play interactive games via screen sharing and using the video-conference system to view the client at the same time.
Participant: How do you appropriately train individuals who will be present at the remote site to assist the client/student?
Boisvert: An e-helper will have several aspects and responsibilities. A clear job description and outline of their roles and responsibilities is very important before intervention starts. Also, we do a mock session with the e-helper before the student is present to make sure that they know how to set up and use the technology.
Participant: How do you overcome the need for tactile cues for articulation therapy?
Hall: There are some programs that are designed to help with this (i.e., that have visuals to support with articulatory placement). One we are familiar with is from the University of Iowa (bit.ly/uiowa-speech). We also work on training the e-helper to support tactile prompting if necessary, and/or place a heavy emphasis on teaching the use of visuals. Lastly, we use the webcam as an interactive mirror.
Participant: Which speech and language disabilities benefit the most from telepractice, and for which ones is it least effective?
Boisvert: There is evidence to support that the majority of speech and language disorders/disabilities can be targeted through telepractice. We feel that a student’s candidacy for telepractice services depends more on the program’s resources and onsite helpers than on the severity or type of disability. It is very important to conduct a needs assessment to ensure that the individual client is able to receive telepractice (i.e., sit in front of a monitor and attend to a remote clinician; see, hear and understand materials presented remotely; operate the input devices, such as the keyboard, mouse, trackball or touch screen, etc.). Plenty of clients, however, might not meet all these criteria and still benefit from telepractice services—with some modifications. For example, students with low vision could access content via enlarged images and changes in screen contrast and brightness. Additionally, students with reduced cognitive functioning could process material when presented in small chunks.
Participant: The use of telepractice has skyrocketed as a service delivery model and the profession is in the midst of trying to establish empirical evidence (or evidence-based practice) regarding the efficacy of using a telepractice platform on various clients and communication disorders. However, highly controlled research is limited or lacking. I wonder if you can comment on the state of the empirical evidence regarding telepractice as a service delivery model and on whom (types of clients and disorders) telepractice has been demonstrated to date. Also, I wonder if you can elaborate on the scholarly journals that focus on telepractice research available to SLPs and audiologists.
Hall: Research is lacking, and [studies] are small in number and typically small in sample size. There is an article coming in the upcoming [March] SIG 18 Perspectives on telepractice that has a relatively large sample size. There are also a number of good articles in the September issue. The International Journal of Telerehabilitation is a good source too, as mentioned. Boisvert: There is growing research to support the use of telepractice in the field of speech-language pathology, audiology and special education. Research in telepractice in speech-language pathology spans more than two decades. The growing body of research on the use of telepractice for communication disorders includes many studies demonstrating the comparability of telepractice and in-person services. For example, in one study (Grogan-Johnson, 2011) students who received telepractice services made significant improvements in speech-sound production, and actually demonstrated greater mastery of their individual education plan (IEP) goals. Gains were measured by the Goldman-Fristoe Test of Articulation. In another by Mike Towey (2013), students receiving telepractice outperform control groups (same diagnostic and demographic profile) and national benchmarks.
Participant: How do you market your services to the schools? Do you know of any private-practice SLPs who have obtained school contracts?
Hall: Michelle and I are both in private practice and provide services through school-based contracts. Here are ways we established the collaborative relationship: We typically meet the coordinator or director of special education and school-based educators to explain how telepractice works and answer any questions they may have. We also like to provide examples of telepractice to give them a first-hand look at the experience their students would have. Educators have initial concerns that students will misbehave or fail to pay attention. They also question whether or not telepractice services are comparable to those that are onsite. Others have feared the technology might overstimulate students. Some were concerned about bringing the students to and from the session, as well as the level of supervision during the session and the person who would be offering such support. We listen to the issues and are mindful to address each of their concerns. We discuss the use of proactive strategies (such as visual scaffolding, built-in rewards and highly organized sessions) used to maintain the student’s attention. With respect to whether or not the services are comparable, we provide evidence cited in relevant research studies, and also detail the progress monitoring process used to ensure the success of the service-delivery method for each individual student. In terms of supervision of the students, we explain that classroom aides or other staff members are responsible for bringing the students to and from the sessions, and that we were careful about scheduling to ensure that the classroom staff are able to facilitate this process. When possible, in-class group activities are conducted so that supervision can occur in the classroom. We also describe the benefits of involving classroom staff in this way and how it facilitates generalize of specific target skills.
Participant: Are you able to show us a video clip of online therapy being done? Does the child or SLP need to wear a special headset to increase clarity?
Hall: Here is a video of Tele-AAC intervention. In this case the student didn’t tolerate wearing a headset, but it is oftentimes recommended depending on the environment of the clinician and the student. More often the clinician will wear a headset to reduce echo, etc.
Participant: What resources or strategies do you use to manage undesirable behaviors?
Boisvert: For students with significant behavioral needs, we work closely with their educational assistant or 1:1, who provides onsite support. We also try to use the strategies that have been successful within the educational setting during our sessions. These may include the use of tokens, stickers, rewards (i.e., music, drawing, etc.), earning free time or computer time, etc. We encourage students to choose various activities, such as a preferred book or video and/or method of answering questions (narrative or written). We also provide instructional breaks for rewards and use visual timers to ease transitions. To engage students, we use movable pictures and spotlights, verbal encouragement, “high-fives,” e-stickers on pages and electronic tally boards. Participant: Do insurance companies cover telepractice?
Hall: Some insurance companies do (or are starting to) cover telepractice. It varies from state to state. There was a recent discussion regarding this on ASHA’s Community discussion board.
Janet Brown (director of ASHA health care services): Regarding insurance, you need to investigate it on a case-by-case basis. Even though some states have mandates saying that covered services must be reimbursed if delivered at a distance, it is advisable to check with the health plan first to verify the appropriate code to use. You may need to educate the health plan about telepractice first—many may not be aware that it is being used for SLP services. The media mainly covers telehealth for medical issues.
Participant: Are any of the materials available on a per-session use or monthly subscription?
Boisvert: Most materials that we use are a subscription-based products. For example, we use: BrainPop, ReadingEggs, BigUniverse, News2You, The Social Express, Scholastic Printables, Boardmaker Online and Spelling City.
Participant: I assume that part of the telepractice protocol includes education time to a “speech aide” for the client. That is, an explanation as to the expectation of the aide’s degree of participation and delineation of the role to keep the therapy progress productive. How much time on the front end is spent training a speech aide that is present at every tele-session?
Boisvert: There certainly is time spent on training the aide to ensure that they are not over-cueing/helping the student. Often, clear expectations from the beginning of the therapy session (and sometimes reminders throughout the session) are helpful. We always like to meet with the aide at least once—at the beginning of the year—without the student present to go over the goals, strategies and level of prompting that will be used in the sessions. Participant: What are some problems and pitfalls in terms of clinical strategies?
Hall: One major challenge is not being able to provide tactic cueing, or to offer hands-on support. It is important to control for visual clutter on the screen, as well as having all of your activities lined up and ready to go to support student engagement and ensure that the session goes as smoothly as possible. Obviously there are also some technical challenges that are hopefully addressed early on in setting the services.
Participant: Any recommendations for strategies to organize your caseload to prepare for sessions?
Hall: Scheduling and time management are key. We typically send out email reminders the day before sessions (and sometimes an hour before) to ensure they start on time and don’t run over. In addition, scheduling sessions sharing similar goals back-to-back helps with organization of materials. We also create folders (either within online bookmarks or other systems) to make sure that all of our resources are in a consistent and organized location. Does this answer your question?
Boisvert: The email includes the time that the student is seen, a direct link to the virtual meeting room, notification of resources uploaded on a shared site, and the clinician’s contact information in case a student/staff cannot attend.
Participant: Who provides the equipment? Parent, school district, the independent provider? Who provides the technical support on site? How do you arrange the logistics for set-up and use?
Hall: It varies depending on the relationship with the contract agency/client. Typically the school district has the equipment they need. Sometimes with family we loan equipment (and have a signed agreement) so they can determine whether or not they want to continue with services prior to investing in the needed equipment. We typically use our own video-conferencing system (i.e., we host the session).
Boisvert: In terms of technical support online, if the issue is with the video-conferencing system, then we will utilize their tech support. If it is something to do with the school/organization firewall then we will contact IT support at the site. We will also troubleshoot common issues such audio/video problems. The logistics for set-up is done before the sessions start for the year.
Participant: Do you have ideas/tips to ease communication with parents and students’ teachers?
Hall: We like to meet in-person first to clearly detail the process and the typical set-up, and to show videos of the service if need be. We also communicate a lot via phone and email to establish and maintain a good working relationship. We try to make sessions fun and rewarding to keep the student engaged. We also check in in-person quarterly or twice a year to make sure everyone is satisfied.
Participant: Is there a computer that you find works better than others? Or can you use an iPad?
Hall: We use both Mac and PC. Oftentimes, the bigger the screen the better. We typically only use an iPad to screenshare apps to our computer for the purposes of intervention, or as a secondary webcam to offer a different view. The iPad screen is generally too small and doesn’t allow for shared control for the purposes of intervention.
Participant: Are you servicing one school or multiple schools in the same state or different states/time zones? Give a brief description of your typical service day.
Boisvert: We service multiple schools/clients throughout the day. For the majority of the day, the schools/clients are in EST. We do provide international services (China) in the morning (there is a 12- or 13-hour difference depending on daylight saving time). A typical day starts at 6:30 a.m. with services to China. From 8 a.m. to 3 p.m., we do direct services to different schools in EST. Then there are often several students who stay after school for services as well in EST.
Participant: How young a child (chronologically and/or developmentally) can benefit from telepractice?
Hall: With respect to direct intervention via telepractice, we have both worked with individuals as young as 4. There is research to suggest that telepractice can be helpful for students in pre-school. Telepractice for consultation to caregivers of young children can be extremely useful and effective, too.
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November 2015
Volume 20, Issue 11