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Connecting to Communicate: Designing Telepractice Services

Connecting to Communicate: Designing Telepractice Services
K. Todd Houston, PhD, CCC-SLP, LSLS Cert AVT
October 16, 2018

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Introduction and Overview

Thank you for joining us for the second installment of a three-part series on telepractice. Today, we will be discussing the logistics around launching a telepractice service, including the technology and equipment involved, as well as the planning process. At conferences and workshops, I am often approached by people who tell me, "I'm going to go home today and set up my Skype account to start working with patients." While I appreciate their enthusiasm, that's not what telepractice is about. You can't just jump in without doing some careful planning to understand the populations that you're serving and the technology required for telepractice. As Benjamin Franklin once said, "If you fail to plan, you're planning to fail." When beginning in telepractice, you have to think through a lot of details to make sure that you're compliant with licensure issues, with HIPAA, and that you abide by any and all privacy laws. Take your time and figure out how everything is going to come together for you. Hopefully after today, you'll have some more tools and ideas and strategies for making that happen.

Defining Telepractice

As defined by ASHA, "Telepractice is the application of telecommunications technology to the delivery of speech-language pathology and audiology professional services at a distance by linking clinician to client/patient or clinician to clinician for assessment, intervention, and/or consultation." ASHA goes on to state that, "the use of telepractice does not remove any existing responsibilities in delivering services, including adherence to the Code of Ethics, Scope of Practice in Audiology, and Scope of Practice in Speech-Language Pathology, state and federal laws (e.g., licensure, HIPAA), and ASHA policy." 

As we discussed in part one, telepractice can be considered another tool for you to use. It's another service delivery model that you can incorporate into what you're already doing. It gives you another option in terms of how you could potentially serve your patients and clients. Telepractice gives you more flexibility in providing the services that you're already providing.

Areas to Assess When Beginning Telepractice

If you are thinking about launching a telepractice program, there are some key issues that you should carefully consider as you build your operating plan to make everything happen.

Purpose and Scope of the Telepractice Program

Clinical population (number and type of patients/clients served). First, you need to determine who you are trying to serve. Will you be serving small children, or parents of children with hearing loss or autism? Perhaps you will be working with adults who have hearing loss. If that is the case, will you have to accommodate them in terms of how they hear instructions through the computer? Will they be able to connect directly to the computer through a direct audio input? Will you be interacting with the client directly, or will they require the assistance of a primary support person? If you are connecting to the client's home environment, the support person will likely be a parent or family member. If you are connecting to patients through a satellite center of a hospital system, the support person may include a paid employee, such as an eHelper, SLP aide or assistant. What additional needs will they have in order for them to have proper access to the information and assistance you are providing? How many patients are you going to try to serve? You may start off with a smaller number, but as you become more comfortable with telepractice, you can increase your caseload down the road.

Type of service. Are you going to be doing diagnostics? More and more tests that are used to diagnose are now available in digital format and can be administered from a distance. If you will be providing therapy, will it be based more on parent coaching and early intervention? Will it involve children with hearing loss who will need to work on auditory and verbal skills? Maybe you will be working with older children that have fluency disorders or voice disorders? You might work with adults that are going through cognitive rehabilitation because they've had a stroke or a brain injury. Are there special materials or special ways of adapting your type of therapy to make it accessible through the computer? Will you be involved in any supervision, such as supervising someone doing their CFY who's at another site? Are you going to be supervising speech pathology aides or an e-helper (i.e., someone on the other end who's going to assist you in providing telepractice services)? There may be a mentoring component, for example, if you are working with a student in their clinical fellowship year, or perhaps a younger colleague. You can use telepractice services to provide mentoring support virtually.

Delivery model. What will your delivery model be? Will it be synchronous, where you and the client have a live connection and can interact in real time? Or will you use a store and forward method? For example, you would receive video recordings of the client performing tasks or activities, which you would view and provide feedback, perhaps via email. After they have incorporated your feedback, they would make and send a new recording. You might choose to use a hybrid model, incorporating a mix of synchronous delivery, store and forward, and in-person delivery of services. For instance, you might see a client in person one week, and the next week use telepractice. There are many different ways that you can structure the program with regard to how you're going to deliver these services. It boils down to understanding what your patient needs, and putting together the best possible diagnostic and treatment model, using technology in different ways to promote success.

Current State of Services

The other thing you want to think about is the current state of services. How will your telepractice program meet unmet needs? How does it support better outcomes? Are there individuals that are underserved, or not being served at all, that might present a growth opportunity for your practice or for the center you're working in? For example, people who live in remote or rural areas may not have access to someone with your skill set. However, if they have the right equipment and a strong internet connection, telepractice might be an answer for them. 

Organizational Readiness

If you are considering telepractice, how ready is your organization/workplace to launch that type of program? There are several things to consider:

Who will deliver these services? Is it going to be a speech-language pathologist? Is it going to be someone with a great deal of experience or someone with less experience?

Training needs of the telepractitioners. How are you going to train people to deliver telepractice services? We do need more training institutions and training programs. While there are colleges and universities that are incorporating telepractice training and exposure into their SLP graduate programs, currently, there are a limited number of training opportunities for individuals who already have their CCCs or who are practicing in the field. If any of the participants in attendance today are interested in developing in-depth telepractice training for professionals in the field, please reach out to me, because I'm eager to work with others who want to set up those kinds of opportunities. 

Management support and buy-in. Do you have "buy-in" from management? Do the decision-makers and the key stakeholders support your efforts to launch telepractice? Do they understand what telepractice is and the flexibility that it will provide you as a clinician, as well as your clientele? Do they see that this could be a way to meet some unmet needs in the field or unmet needs of the potential patients that you could serve? Support and buy-in from management are going to be critical to getting your telepractice off the ground.

Patient/Client support and buy-in. Do your patients have an interest in the telepractice option being available to them? Do they know what telepractice is and the potential benefits it could provide to them? It's important to make sure that everyone is on the same page, and you have that level of buy-in from everyone on staff.

Facility requirements (physical space and privacy). What type of physical space within your facility will you use to deliver your telepractice services? It needs to be an area free of distractions from behind because when you're sitting at the computer, your clients will be able to see you and everything behind you. Do you have adequate lighting? Do you have enough privacy and security to make sure that the services you deliver can remain confidential? You need to maintain the same level of privacy delivering services via telepractice that you would provide in person. If you work in a hospital or center, you have to keep things confidential. Do you have a room that can be secure and private?

Availability of technical support. Do you have technical support available if there are issues that come up with technology equipment? For example, if the audio or video goes out on the computer, you will require some type of troubleshooting and technical support to be able to fix and resolve the issue. I strongly suggest you think through that before launching into telepractice, because I can guarantee you that at some point, things break. Technology will need repair, updating and eventual replacement. You need that tech support in place.

Potential Barriers

Reimbursement. Currently, one of the potential barriers to providing SLP services through telepractice is reimbursement. At the present time, reimbursement rates from private insurance and third-party companies are not where they need to be. It is getting better and going forward, I do think we will be seeing improvement probably in the next three to five years or so.

Initial and long-term costs. If you don't have the computers or the proper internet connections and the appropriate software and hardware, there could be some potentially significant costs to incur when starting a telepractice program. You need to budget for equipment, software, and training. In addition, what kind of costs are you going to have over time for things like maintenance of equipment, future training, ongoing service fees or therapy-specific materials? 

Licensure. If you're ASHA certified, you can certainly do telepractice, however, it does become challenging when you encounter a situation where you need to deliver services across state lines. Are you required to have a license to practice in the other state as well? Different organizations and professional associations are tossing around the idea of developing compacts, where you could be licensed in one state and be able to practice across states that are members of that compact. There are similar models that other professions have developed that may provide an answer for speech-language pathology and audiology as they increasingly provide more services via telepractice.

Bandwidth. For telepractice, you must have an excellent internet connection and good bandwidth in order to get an adequate signal that supports both audio and video. If you don't have reliable bandwidth, you're going to have some issues. We'll talk more about that in a moment.

Competition. As we start to see more people get into telepractice, you're going to encounter competition for services. My belief is that adding telepractice to what you're doing makes you more competitive. It provides another method of delivering services that might be more convenient to certain patients on your existing caseload. In fact, telepractice may provide an opportunity to help you grow your overall caseload or the overall number of patients that you're serving at your center. I see it as a competitive advantage to have telepractice as an option for your patients.

Data collection/evaluation. As you work with patients on a day-to-day basis, how are you going to measure their progress? How are you collecting data in each session? Furthermore, what data points will you collect to look at the overall success of the telepractice program? Perhaps you measure success by the total number of patients that you have. Or, you may measure success if you see a lower number of cancellations, which translates into seeing more patients over time. There are different metrics that you can use to evaluate the whole program itself. If you look at the initial costs of starting a telepractice, what's going to be the return on reimbursement, private pay and other ways of funding your telepractice program? 

In summary, when starting a telepractice program, it begins with a needs assessment and extensive planning. With the proper preparation and planning, your telepractice program will be more successful in the long run.

Getting Started

Recruit Providers

When you get started in telepractice, you have to think about which professionals are going to provide those telepractice services. I would caution you to not let age influence your decision. Certainly, the younger generation loves technology and many of them are excited to be doing telepractice. At the same time, they may not always know how to use technology to achieve the desired outcomes. While they may be comfortable with it, their focus on technology has been on a more social level. They may not have thought through how to use technology to influence the behavior of the patients they're working with. That's a learning process. I have young grad students who are tech-savvy, but they don't care for telepractice. They prefer to see patients in person. I also have older, more experienced colleagues who have jumped into telepractice and loved it so much they never looked back. You never know until you give them a chance to get some experience, and have some mentoring along with a little training to expose them to what telepractice is capable of doing. Keep an open mind when you're approaching professionals to provide telepractice services.

Select Patients

When selecting patients, I would recommend that you start off with a small caseload. Pick a handful of patients at first, because you're going to need to focus on putting some metrics in place to make sure you're capturing what they're doing. You may want to survey some patients to get a feel for their technological comfort level, as well as their comfort level with receiving services from a distance using technology. I would start with a small group of people who are already quite savvy with using technology.

You could also think about building confidence with patients before you enroll them in your telepractice program. When we have patients that are feeling a little reluctant, we set up mock telepractice sessions here in our center. In a mock session, I'm in one room at my computer and the patient is down the hall in another treatment room with a computer. I may have a grad student sit with the client as we go through an entire telepractice session. I'm coaching the parents and working with them "at a distance", but it's just down the hall. It gives them a feel for what it's like to receive services through the computer. It exposes them before they have to jump in and commit to it. There may be a way for you to build that confidence with patients or the families you're working with before you start actual services. Patients that feel successful with telepractice are going to be your biggest cheerleaders when you start to expand your client base. 

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k todd houston

K. Todd Houston, PhD, CCC-SLP, LSLS Cert AVT

K. Todd Houston, PhD, CCC-SLP, LSLS Cert. AVT is a Professor, speech-language pathologist, and a Listening and Spoken Language Specialist (LSLS) Certified Auditory-Verbal Therapist (Cert. AVT). For more than 20 years, his professional focus has been serving young children with hearing loss and their families who are learning to listen and acquire spoken language. Over the past decade, Dr. Houston has incorporated telepractice into his service delivery and continues to provide direct services each week, both in-person and through telepractice, to young children with hearing loss and their families. He has authored/edited three recent books through Plural Publishing: Telepractice In Speech-Language Pathology (2014), Assessing Listening and Spoken Language in Children with Hearing Loss (with Dr. Tamala Bradham, 2015), and Telepactice In Audiology (with Dr. Emma Rushbrooke, 2016). 



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