the state of telepractice for delivering early ...€¦ · myths about telepractice ... note: 4...

The State of Telepractice for DeliveringEarly Intervention Services

ASHA 19005 1


Arlene Stredler Brown, PhD, CCC-SLP

University of Colorado

[email protected]

Disclosures

• Financial:

– Financial compensation from ASHA for this presentation

• Nonfinancial:

– None


ASHA 19005 2

Learning Objectives

Participants will be able to…

• Learning Objective 1: State common concerns about the useof telepractice

• Learning Objective 2: Identify the growing evidence thatsupports the use and efficacy of telepractice with youngchildren and families in early intervention programs

• Learning Objective 3: Describe the processes undertaken bystate early intervention programs and smaller nonprofitagencies as they have adopted and funded telepractice

• Learning Objective 4: Summarize the attitudes towardtelepractice of parents, service coordinators, providers, andadministrators

ASHA Strategic Objectives

• Expand data available for quality improvement anddemonstration of value

– Data is emerging, through an NIH-funded telepractice study,demonstrating the efficacy of telepractice with young childrenwho are deaf or hard of hearing

• Enhance service delivery across the continuum of care toincrease value and access to services

– Qualitative data suggests that telepractice increases access toservices, especially for clients in rural areas who seekexperienced professionals with knowledge of specific treatmentstrategies


ASHA 19005 3

Myths About Telepractice

Do These Ring True for You?

• “The technology always lets us down.”

• “Families don’t like telepractice.”

• “Telepractice is never as good as in-person sessions.”

• “Telepractice is a good option when there are no otheroptions.”


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Quick Polling #1

Rate the challenge, as you perceive it today, ofdelivering services via telepractice:

a. Not a challenge

b. Minimal challenge

c. Moderate challenge

d. Large challenge

e. Too much of a challenge to try it

A Recent Poll (n = 83)

Perceived Challenge % n

No challenge 0 0

Minimal 35% 31

Moderate 46% 37

Large 14% 11

Too much to try 5% 4


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Quick Polling #2

Best practice recommends the use of coachingbehaviors in early intervention treatment sessions.

Do you think EI providers use the same amount ordifferent amounts of coaching behaviors in telepracticesessions and in-person sessions?

% n

Same amount 85% 75

Different amounts 15% 13

A Recent Poll (n = 88)


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Early Intervention Colorado

Evolution of Telepractice in Colorado:A Program on a Mission; an Inter-Agency Effort

Year Initiative

2015 Colorado Medicaid funds telepractice (for selected disciplines;SLP included)

2015 Initial in-person telepractice training at one community Part Cagency (there are 20 agencies statewide)

2016 Online Telehealth Training Modules (4) launched (online; DIY)

As of January 2018, 5% of providers completed the training; asof January 2019, 271 (17%) have completed it.

2017 State law passes; supports insurance coverage of telepractice

July 2017–September

2018

440 telepractice sessions completed

<0.1% of all services delivered to Part C children in Colorado (EIColorado Data system, 2018)

~15,000 children receive services through Early Intervention Colorado (JBC Report, 2017)


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What is Working? What is Missing?

EI Colorado created a Padletwith practical suggestions,publications, policies, &legislation

For-profit therapy agenciesusing telepractice joinedtask force

Foundations supporttelepractice (particularinterest in serving childrenwho are deaf or hard ofhearing)

A sixfold increase in numberof providers billing fortelepractice sessions

What is Working? What is Missing?

- Not all disciplines (e.g., PT)can bill Medicaid

- Few providers (2%) are billingfor telepractice

- Not all state agencies are onboard (State School for theDeaf)

EI Colorado created a Padletwith practical suggestions,publications, policies, &legislation

For-profit therapy agenciesusing telepractice joinedtask force

Foundations supporttelepractice (particularinterest in serving childrenwho are deaf or hard ofhearing)

A sixfold increase in numberof providers billing fortelepractice sessions


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Why is Telepractice Underutilized?

• Surveys distributed to four groups

– Local program administrators (n=8)

– Service coordinators (n=39)

– Providers (n=112)

– Families (n=2)

• Follow-up focus groups with administrators and parents

Provider Results: Age of Respondents


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Provider Results: Child Progress

Provider Results: Parent/Caregiver Involvement


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Provider Results: Technology

Provider Summary

Positive Perceptions

• Most respondents supportthe use of telepractice toaddress:– Provider shortages

– Inclement weather

– Illness (provider and child)

– Travel burden

• Respondents like theflexibility telepractice offersto join a family during dailyroutines

• More family engagement

Negative Perceptions

• Attitudes:– Telepractice is not family-

friendly

– It’s impersonal

– It’s not as good as in-person visits

• Access to bandwidth


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Service Coordinator Results: Caseload

Service Coordinator Results: Acceptability


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Service Coordinators: Comments

• “Families don't get to know the therapist as well. Many of theEI therapy sessions are very hands on and hard to do over thecomputer.”

• “Being rural, I don't want families to think they are getting a‘lesser’ version of therapy.”

Some Parents are Very Comfortable UsingTelepractice

Video #1 here


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Each State is Unique: Part C Telepractice in NM

• Collaboration among agencies– NM Department of Health

– Medicaid

– Part C Inter-Agency Coordinating Council

– Providers and parents

• Infrastructure– Agencies required to have a provider in the home to help facilitate the

telepractice visit (being reconsidered)

– More common in rural areas (provider access)

– Some using a hybrid model

• Billing: Specialist in the home bills a higher home rate; specialist viatelepractice bills a lower center-based rate (they are not traveling)

• Satisfaction: Positive feedback from families, who are pleased tohave more access to services

Nuts and Bolts of Telepractice


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Hardware

• Screen size

• Loaner program

Software

• HIPAAcompliant

• Professionalversion

Bandwidth

• www.speedtest.net

Recommended Bandwidth Speeds


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IT Support

2000s: Essential

2010s: Mostimportant for

setting up hardwareand software

2020s: Decrease inneed; comfort in

having access to ITsupport

Practical Implementation Strategies for Providers

• Introducing telepractice: Explain to parents that they will bethe focus of family-centered intervention; you do not expectthe infant or toddler to work with you, for the entire session

• Before you start telepractice: Establish text or emailcommunication with the family

• Before the session: Identify props the parent can collect

• Communication: Set up a plan for reinitiating the call ifconnectivity is interrupted

• Modeling: Be prepared with alternative ways to model anactivity (e.g., props, pictures, a short video)

• After the session: Text or email ”homework” for practice


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Value Added: Coaching Practices

The Coaching Process(Rush & Shelden, 2011)

1. Joint planning

2. Action– Parent observes provider

(modeling)

– Provider observes parent

3. Reflection– Effect on child behavior

– Comfort of parent implementinga new strategy

4. Feedback


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Coaching

Video #2 here

Provider Coaching Behaviors

Action

• Model

• Facilitate

• Prompt

• 3-way interaction

• Teach child

Explain task andteach parent

Reflection

• Ask parent forinformation

• Provideinformation

• Listen

• Discuss child’sdevelopment

Observe parent-child interaction

Feedback

• Comment

• Problem solve

• Reflect

• Color commentary

Provider feedbackto parent

Provider feedbackabout child


ASHA 19005 18

Documenting Provider Coaching Behaviors(Behl & Blaiser, 2015)

http://www.infanthearing.org/flashvideos/teleintervention/Stir-Clips-Captioned.mp4

Thank you, Amy Peters-Lalios, AuD, CCC-A, LSLS Cert-AVT

Provider Coaching Behaviors: Action

• Model: “Oh, what should we use to mix it?”

• Facilitate: “Okay, let’s move it a little faster now, we’re losinghim.”

• Facilitate: “Okay get a spoon!”

• Model: “Audrey, as soon as he has a turn, then mommy’sgoing to say that it’s Audrey’s turn.”

• Teach parent: “And I want to see if he recognizes her name(sibling) and if he’ll let her have a turn.”


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Provider Coaching Behaviors: Reflection

• Observe parent-child interaction: Throughout

• Listen: Throughout

Provider Coaching Behaviors: Feedback

• Parent feedback about child: “Okay, that was at least an effort,okay now.”

• Provider feedback to parent: “Good.”

• Provider feedback to parent: “Good job.”

• Provider feedback about child: “And I liked the way he lookedat Audrey, like he was overhearing her model, which is perfect.”

• Problem solve: “Oh, that’s a good idea, Audrey! I heard Audreysay we should use a spoon!”

• Provider feedback about child: “Okay, there we go.”

• Provider feedback to sibling: “Good job!”

• Provider feedback about child: “Oh good, so he looked right ather.”


ASHA 19005 20

Coaching Practices Used in Telepractice:A Comparison Study (Stredler-Brown, 2017)

• Children participants– Deaf/hard of hearing (any type/degree of hearing loss; bilateral)

– Birth–36 months

– English as primary language in the home

– Any communication approach (although most children were learning to listenand talk)

• Providers– One session/provider

– Intervention offered via telepractice

– Each session was recorded and coded for coaching strategies

• Observation

• Direct instruction

• Provider feedback to parent about parent

• Provider feedback to parent about child

Observations

0

10

20

30

40

50

60

70

80

90

Telepractice In-person

Mean # Observations

Mean # Observations

79%

17%

Note: 5 in-person studies (range, 6–36%)


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Direct Instruction

0

2

4

6

8

10

12

14

16

18

20


Mean # Direct Instruction

Mean # Direct Instruction

12%

19%

Provider Feedback About Parent Action

Note: 4 in-person studies (range, 0.36–6%)

0

0.5

1

1.5

2

2.5

3

3.5


Mean # Provider Feedback to Parent

Mean # Provider Feedback to Parent

3%

2%


ASHA 19005 22

Provider Feedback About Child Skills

Note: 3 in-person studies (range, 0% - .36%)0

1

2

3

4

5

6

7

8


Mean # Provider Feedback about Child

Mean # Provider Feedback about Child

7%

0.5%

Additional Provider Behaviors

• These provider behaviors were noted, but not analyzed in thisstudy:

– Modeling a strategy

– Conversation with parent

– Triadic play: Parent + child + early intervention provider


ASHA 19005 23

Provider Report on Coaching Strategies(NCHAM Learning Community, 2019)

EI Coaching Practice(JCIH Supplement, 2013)

Rated asEssential

Same Easier Harder

Timely, authentic feedback 100% 73.91% 21.74% 8.70%

Respectful, reciprocalrelationships

100% 78.26% 4.35% 21.74%

Active listening 100% 86.96% 8.70% 4.35%

Family identifies concerns,priorities, resources

86.96% 82.61% 13.04% 8.70%

Strategies to promote parent-child interaction

100% 65.22% 17.39% 26.09%

Family involvement in session 91.30% 65.22% 21.74% 21.74%

Efficacy DataTACIT

(Teletherapy After Cochlear Implants Using Telemedicine)

Funded by NIDCD: #1U01DC013529

(Falcone et. al., 2018)


ASHA 19005 24

Longitudinal Development of P1 CorticalAuditory Evoked Potential (CAEP) (n=21)

Significant effectof therapy(p < 0.001)



ASHA 19005 25

Significant effectof therapy(p < 0.001)

No significanteffect by typeof therapy(p = 0.451)


PLS Change(n=19)


ASHA 19005 26

Significant effect oftherapy beyond theeffect of normal ageimprovements (p < 0.01)

PLS Change(n=19)


Average improvementin age-equivalenceof 10.41 monthsover a 6-month period

PLS Change(n=19)


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Average improvementin age-equivalenceof 10.41 monthsover a 6-month period

No significant effectof type of therapy(in-person or telepractice)(p = 0.890)

PLS Change(n=19)

Myth Busters


ASHA 19005 28

The technology could let you down, but there areresources and increasingly easy-to-use softwareplatforms.

Telepractice is different from in-person sessions,but may be efficacious; coaching practices may beused more.

Providers and service coordinators may be lesscomfortable with telepractice than the families.

Telepractice may be the best option, evenwhen there are other options.

Relationships: Parent and Therapist

Video #3 here


ASHA 19005 29

Benefits Conducting Sessions at Home

Video #4 here

ASHA Resources Supporting Telepractice

• https://www.asha.org/Practice-Portal/Professional-Issues/Telepractice/

– The “nuts and bolts” of telepractice implementation

• https://www.asha.org/Practice/reimbursement/Reimbursement-of-Telepractice-Services/

• https://www.asha.org/advocacy/state/


ASHA 19005 30

Go Do #1: Use the Family’s Props and Their Routines

• Routine-based intervention (McWilliam, 2010)http://fgrbi.fsu.edu/

– Everyday activities are basis for instruction; uses props alreadyin the home

– Supports use and generalization of strategies presented in asession

– More likely done in telepractice

Go Do #2: Notice Your Use of Coaching Practices

• Notice if your use of the telepractice platform promotes youruse of more family-centered and coaching practices


ASHA 19005 31

Go Do #3: Status of Telepractice in Your State

• Get information from your own state’s programs aboutsupport for, and utilization of, telepractice

– State Part C Early Intervention program

– State Medicaid program

– State laws that impact insurance coverage

• Current statewide Part C practices:

– Colorado

– New Mexico

– Texas

The State of Telepractice for Delivering Early Intervention Services, by Arlene Stredler Brown

ASHA Online Conference Birth to Three: Working Together to Serve Children and Their Families

References

Behl, D., & Blaiser, K. (2015). T-I 101 learning courses. Retrieved from: http://www.infanthearing.org/ti101/index.html Cole, B., Pickard, K., & Stredler-Brown, A. (2019). Report on the use of telehealth in early intervention in Colorado: Strengths and challenges with this service delivery method. Unpublished manuscript. EI Colorado Data System. Data collected on January 4, 2018. EI Colorado Report to the Colorado Joint Budget Committee Report. November 1, 2017. Falcone, J., Harris, N., Glick, H., Bell-Souder, D., Stredler-Brown, A., Elder, S., … Sharma. A. (2018, October). Central auditory development and language outcomes in children with hearing loss receiving aural habilitation: Preliminary findings. Poster presented at the Colorado Academy of Audiology Conference, Breckenridge, CO. McWilliam, R. (2010). Family-guided routines-based intervention. Retrieved from: http://fgrbi.fsu.edu/ Rush, D. D., & Shelden, M. L. (2011). The early childhood coaching handbook. Baltimore, MD: Paul H. Brookes Publishing Co. Sharma, A., & Glick, H. (2018, June). Cortical neuroplasticity in hearing loss: Why it matters in clinical decision-making for children and adults. Hearing Review, 1-13. Sharma, A., Martin, K., Roland, P., Bauer, P., Sweeney, M. H., Gilley, P., & Dorman, M. (2005). P1 latency as a biomarker for central auditory development in children with hearing impairment. Journal of the American Academy of Audiology, 16, 564-573. Stredler-Brown, A. (2017). Examination of coaching behaviors used by providers when delivering early intervention via telehealth to families of children who are deaf or hard of hearing. Perspectives of the ASHA Special Interest Group SIG 9, 2(Part 1), 25-42.

http://www.infanthearing.org/ti101/index.html

http://fgrbi.fsu.edu/

The State of Telepractice for Delivering Early Intervention Services, by Arlene Stredler Brown

ASHA Online Conference Birth to Three: Working Together to Serve Children and Their Families

Resources URL for Slide 35: http://www.infanthearing.org/flashvideos/teleintervention/Stir-Clips-

Captioned.mp4

ASHA’s Practice Portal: Telepractice: https://www.asha.org/Practice-Portal/Professional-Issues/Telepractice/

Reimbursement of Telepractice Services (ASHA):

https://www.asha.org/Practice/reimbursement/Reimbursement-of-Telepractice-Services/ Telepractice State by State (ASHA): https://www.asha.org/advocacy/state/ National Consortium of Telehealth Resource Centers:

www.telehealthresourcecenters.org Early Intervention Colorado. Part C Training Modules:

Contact Beth Cole at [email protected]



https://www.asha.org/Practice-Portal/Professional-Issues/Telepractice/



https://www.asha.org/Practice/reimbursement/Reimbursement-of-Telepractice-Services/

https://www.asha.org/Practice/reimbursement/Reimbursement-of-Telepractice-Services/

https://www.asha.org/advocacy/state/

http://www.telehealthresourcecenters.org/

mailto:[email protected]

the state of telepractice for delivering early ...€¦ · myths about telepractice ... note: 4...

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