handout for telepractice presentation 2011

Telepractice Results with High-Risk

Preschoolers Using a Web-Based Approach

Waldo County General Hospital Belfast, Maine

Nathan H. Curtis, M.A., CCC-SLP Jennifer B. Whitcomb, M.A., CCC-SLP

Jessica L. Wilbur, M.A., CCC-SLP Erica E. Ricker, M.A., CCC-SLP

Introduction and Overview

Web-based approaches to telepractice

Bedrock clinical principles applied to telepractice

Techniques to engage preschoolers in telepractice

Clinician and e-helper competencies

Coaching within telepractice

Results: NOMS

Parent and e-helper feedback

Questions and Answers

Who We Are…

Introduction

Maine has many unmet needs

Geographical limitations

Long travel times to providers

How We Got Started

Worked to promote legislation in Maine to pay for telepractice services (Towey, 2009).

How We Got Started

Completed paperwork to become enrolled as telepractice providers.

Web-based Approach to TelepracticeWe looked for:

• Flexible system• Easily accessible• Low cost for each site• Utilization of authentic materials• Availability of e-tools to engage clients• Simplicity in establishing connectivity• Secure and confidential

Tech Requirements-Vendors

A number of low cost, web hosting applications are readily available including Adobe Connect (Adobe 2011), WebEx (Cisco 2011) and applications that integrate electronic medical records (iHAS 2010).

Tech Requirements-Security

Look for a vendor with:

• dedicated security department, including a GIAC- Certified Forensic Analyst,

• restricted site access,

• the ability to require all therapy sessions to have a password,

• an encrypted connection using the128-bit SSL encryption standard.

Requirements at Our Site

• Web based account• Computer• Web cam & Microphone• High speed broadband• Digital materials

Requirements at Each Site

• Computer • High speed broadband• Web Cam & Microphone• E-helper

Tech Requirements-Computer

Most computers purchased within the last several years have adequate processing speed.

It is helpful for the e-helper to use a computer with at least a 14 inch monitor.

Tech Requirements: Broadband

Check the computer speed to assure download speeds of 1 Mbps.

Tech Requirements-Audio

For most speech telepractice, the built in microphone will be adequate.

A separate USB microphone or the use of a headset will improve audio quality.

Tech Requirements-Video

There are a variety of webcams offering standard or high definition video. We utilized Logitech 9000 webcams.

But here is the important stuff:

• It is really NOT about the technology.

• Effective telepractice happens when relationships are built.

• Technology is the portal to establish that relationship.

Getting Started

Getting Started

Set up password protected meeting and email link to e-helper and parents.

Web-Based Telepractice

Our Point of View

Speech therapy telepractice should not be just an extension of traditional speech therapy by a “video conference.”

Assessed client and e-helper needs in first session.

Built digital materials to support child’s programming.

Web 2.0

Communicatively disordered patients live, socialize, learn and work in a digital age that continues to change society (Anderson and Rainie, 2010).

Bedrock Clinical Principles Applied to Telepractice

Techniques to Engage Preschoolers in Telepractice

Our Clients

• Patient selection

• Utilization of resources

• Options continue to change

Authentic Materials

• Requested a few pictures of clients to make materials.

• Set up routines to embed literacy opportunities.

• Personalized instruction based on interests of client.

• Engaged e-helper’s participation.

Welcome to teletherapy!

Today’s speech pathologist working with you isNathan H. Curtis, M.A., CCC-SLP. He can bereached at 338-9349 or [email protected].

You are on a secure connection meeting HIPPAstandards. Confidentiality is important to us.Please make adjustments on your site to protectyour student’s confidentiality of these services.

mailto:[email protected]

Layla Smith

I have a friend whose name is Layla and this is how she spells her name….

L a y l a L a y l a

L a y l a

That’s how she spells her name!

Team Work

Multiple therapists working with clients.

Building language literacy skills.

Utilizing e-helpers.

Two videos demonstrating these concepts.

The Rhyming Game

Have you heard of the rhyming man,

Who can change words in a short span?

He likes to make words sound the same,

And loves to play the rhyming game.

Tips When on Camera

• Remember you are always live!• Be aware of your space & your nonverbals. • Personal appearance: know what you are

comfortable with.• Be Prepared & Flexible.• Confidence: remember pace, intonation.• Understand the camera.• Avoid background clutter. Use privacy screen.

Clinician and E-Helper Competencies

Nathan H. Curtis, M.A., CCC-SLP, Jennifer B. Whitcomb, M.A., CCC-SLP, Jessica L.Wilbur, M.A., CCC-SLP & Michael P. Towey, M.A., CCC-SLP, 2011

Competencies for Speech Pathologists Completing Telepractice Services

Preparing for Session: Equipment

1. Clinician identifies and acquires needed equipment to establish a telepractice connection (computer, web cam, microphone, recording software, video conferencing account/software).

2. Clinician provides e-helper with list of needed equipment.



Set-Up Skills

1. Clinician can problem solve and correct audio, video and lighting problems on local computer and at distant site.

2. Clinician chooses location of telepractice equipment to reduce visual and auditory distractions on local computer and at distant site.

3. Clinician can assure privacy and confidentiality through careful location of computer and offer instructions to e-helper to do the same.



Technical Skills

1. Clinician demonstrates skills in adjusting video and audio quality.

2. Once a mutually beneficial schedule is established, clinician will e-schedule individual and recurring appointments and send email confirmation to e-helper.

3. Clinician demonstrates the ability to manage telepractice account including meeting settings, password protection, recorded materials and privacy controls.

4. Clinician can locate, open, load and share materials in a telepractice session.



Technical Skills (continued)

5. Clinician utilizes a variety of web-based tools within a telepractice session to enhance interactions with e-learner (text tools, pointer, eraser, and highlighter).

6. Clinician demonstrates skills in sharing web-based tools to engage e-learner with a variety of materials. (whiteboard, desktop, documents, web content, applications)

7. Clinician can record and archive treatment session video providing a store-forward link to patients and caregivers.

8. Clinician can create digital materials for use in a telepractice session.

9. Clinician can provide telepractice services using cross platform as well as mobile web-based devices.



Interpersonal Skills

1. Clinician can state expectations of clinician and e-helper roles in telepractice sessions.

2. Clinician develops rapport quickly within a telepractice session to engage each e-learner.

3. Clinician can establish a relationship to help coach the e-helper in providing support to the e-learner in the therapy process.



Clinical Skills

1. Clinician can locate and carefully screen which clients could benefit from telepractice services.

2. Clinician can document the need and rationale for providing telepractice services to each e-learner.

3. Clinician demonstrates flexibility in adjusting pre-planned lesson to meet a current need within a telepractice session.

4. Clinician uses appropriate vocal loudness, affect and pacing of presenting materials to match the need of the client within each session.



Clinical Skills (continued)

5. Clinician manages the e-therapy environment allowing for maximum and flexible use of the e-tools and e-materials.

6. Clinician uses strategies to aid e-learner with transitions.

7. Clinician provides opportunities for parents and teachers/support staff to observe and participate in telepractice sessions.

8. Clinician demonstrates coaching skills in working with parents, e-helper, teachers, and support staff.

9. Clinician can demonstrate deliberate practice within telepractice sessions.



Regulatory Information

1. Clinician understands scope of practice and complies with all requirements of ASHA within the delivery of services.

2. Clinician knows billing codes and billing practices of telepractice services.

3. Clinician demonstrates adequate documentation of telepractice services, written daily notes and progress reports.


Competencies for E-Helpers: Telepractice Services

Technical Skills

1. Can set up a schedule that provides an optimal and consistent time for the e-learner to offer his/her best work.

2. Can access email to locate the link for the telepractice session.

3. Can set up the computer and establish the video and audio connection for the telepractice session.

4. Can trouble shoot basic audio and video difficulties by listening to directions of the telepractice provider and accessing those sites/tools on the computer.



Technical Skills (continued)

5. Can assist the e-learner in accessing web-based tools (highlighter, pointer, text tools, color palette).

6. Can play an active role in offering feedback to clinician about quality of video and audio as well as the materials being displayed.

7. Can establish proper seating for e-learner allowing access to the computer and offering appropriate lighting to aid in video transmission of e-learner.



Instructional Skills

1. Can establish a distraction-free environment for the e-learner.

2. Attends solely to the e-learner’s needs during telepractice sessions with no other job requirements (supervising, monitoring, mentoring other students).

3. Can help e-learners transition from classroom activity to area for telepractice allowing time to settle into the space and be ready for work.

4. Can demonstrate awareness of the e-learner’s strengths and needs and acquisition of a basic understanding of the e-learner’s communication needs, and knowledge of the IEP goals.



Instructional Skills (continued)

5. Can provide a link for communication with school personnel, parents, and e-learner offering any pertinent updates before beginning a session.

6. Can demonstrate understanding of therapeutic strategies and provide cueing and strategies at the right times to help the e-learner become independent in responding to the telepractice provider.

7. Can provide accurate feedback about e-learners response to materials, restate the e-learners utterance if needed for clarification, and provide statements that will aid in completing tasks.

8. Assure privacy and confidentiality of telepractice environment.

Coaching Within Telepractice Response to Coaching (RtC):

An Innovative RtI Model

Jennifer B. Whitcomb, M.A., Nathan H. Curtis, M.A., Jessica L. Wilbur, M.A.

Coaching Consultation Collaboration

Partnership Provision of service Collegially working

Focused on teacher learning goals

Informs re: the child’s needs

Transdisciplinary

Non judgmentalTo improve child learning

Focus on common child goal

Action, Reflection, Planning, Evaluation

Focus individual growth

Sustained improvement

A Tool We CanOpen & Use

Coaching was once viewed a tool to help correct underperformance, today supporting top producers.

86% of companies used coaching with individuals identified as organizational leaders (Michelman, 2005).

Partnership

Coaching works best when it focuses on the entire person versus focusing on skill development alone.

Source: Harvard Business Review

The quality of the skill interacting with children is most closely associated with children’s positive development (Justice et al, 2008).

It’s impossible to make content relevant for students whom you don’t know (Littky, 2004).

Coaching Process

• Building trust

• Ensuring fit

• Strengthening voice

• Developing awareness

(Tomlinson, 2008)

Trust

Trust strengthens when coaches believe in e-helper’s capacity to succeed and work in their best interest.

Ensuring Fit

• Support e-helpers to do what they are ready to do to ensure success.

• Coach what the e-helper cares about.

• Differentiate coaching based on e- helper’s needs and skills.

Strengthening Voice

High quality does not happen if partners are unable to express their ideas, emotions, confusion, learning needs, biases. Only when people can speak their minds does real learning have a chance to happen (Palmer, 1998).

Developing Awareness

E-helpers understand how learning works for themselves and their students:

– They know what is really important. – They sustain focus on what matters. – They practice. – They reflect on what works and what needs to

change.

What do you start with?

• Choose a few vital skills to build.

• Listen to what the e-helpers want to do first.

• We chose emerging language literacy skills.

Modeling• E-helpers had a chance to observe us and the responses of the student

• Real-time coaching offered opportunities to give and get feedback

• E-helpers took what we did and made it their own

Coaching in Real Time

Create a process and environment where e-helpers feel safe to share and learn

Important Aspects of RtC

• We located key behaviors that had the largest impact.

• E-helpers had opportunities to describe what was going on in their own way.

• E-helpers were given strategies or materials they could use in their classroom the next day.

• Problem solving together rather than problem solving for them.

Important Aspects of RtC

• Coaching was “shoulder to shoulder”.

• We were greeted as full participants so feedback was accepted more readily.

• Teamwork: Multiple therapists sharing clients.

Results: NOMS

• Compared our facility’s telepractice results to our facility’s results for children seen in preschool settings, to national data from children seen in preschool settings.

• Setting limited to preschools

• 30 minute sessions

Considerations

• 55% had other Dx including: Hearing Loss, ADHD, ASD, Disruptive Behavior Disorder, Developmental Delay

• 45% had 1:1 support in educational setting

• 25% of the children attended a special purpose program for children with need for behavioral support

• 40% Attended Head Start

Articulation

30

35

40

45

50

55

60

65

One Level Multiple Levels

Telepractice

Facility

National

55%

Pragmatics

20

253035

404550

55606570


TelepracticeFacilityNational

25%

Spoken Language Production

20

25

30

35

40

45

50

55

60

65



85%

Spoken Language Comprehension

20

25

30

35

40

45

50

55

60

65



90%

Other Considerations

• Frequency of sessions– Tele 1-2x/wk (average 1.6)– Facility 1-3x/wk (average 2.3)– National 1-4x/wk (average 1.9)

• Total Time Seen (in 15 minute units)– Tele Average 62 units– Facility Average 85 units– National Average 68 units

6 Month Snapshot

01020304050607080 One Level

Multiple Levels

Average # of 15 minute units = 44Artic 50%Pragmatics 60%Comprehension 70%Production 80%

Parent and E-Helper Feedback

Parent Questionnaire

Overall Satisfaction Rating (4.82)

82% very satisfied

18% satisfied


Effectiveness (4.36)

45.5% highly effective

45.5% very effective

9% effective


Amount of progress (4.18)

36% much more than expected

46% more than expected

18% amount expected


Would you recommend teletherapy? (4.91)

91% highly encourage services

9% encourage services

Parent feedback

“My son went from saying maybe 1-2 words last November, to full interactive, understandable conversations. The progress has been amazing! His goal was 3 word sentences, and he far surpassed that.” (parent…)

Parent feedback

“It has worked well for us because of our location and even with my child's young age and short attention span he was engaged for the length of the sessions. It was very good for us!” (parent…)

Parent Feedback

“He is talking more, and before he wouldn’t and couldn’t talk to me. He now tells me

he loves me!” (parent…)

“I think this entire program is fantastic. I would recommend it to any parent who

has any concerns about their child.” (parent…)

E-helper Questionnaire

Before starting telepractice, prediction of these services being successful with client:

27% very apprehensive

67% not sure

6% confident of success


Amount of progress (4.27)

47% much more than expected

33% more than expected

20% amount expected


Effectiveness of Teletherapy (4.07)

40% highly effective

27% very effective

33% effective


Use of Strategies (4.13)

33% learn and use strategies weekly

53% use strategies regularly

7% use strategies occasionally

7% have tried strategies a few times


Quality of Audio & Video (4.13)

27% excellent

60% very good

13% okay


Comfort in Setting Up Sessions (4.87) 93% comfortable

7% somewhat uncomfortable

Baseline: 20% comfortable, 73% uncomfortable, 7% very uncomfortable


Would you recommend teletherapy? (4.71)

71% highly encourage

29% encourage

E-helper feedback

“I was very apprehensive about teletherapy in the beginning because my client is easily

distracted and very hyper active. I was worried that she wouldn't get much from the

service but I have definitely been proven wrong! I have been very pleased with the progress my client has made thus far and continues to make on a daily basis. Great

program!” (e-helper…)

E-helper feedback

“I have noticed that my client is much more verbal in every aspect of her day since starting

teletherapy services. My client has gone from not being able to say "open" when she wanted a door open to now being able to request things and label items very easily in 4-5 word utterances. My clients vocabulary had more than doubled and she enjoys going to speech and being able to interact during her sessions. Teletherapy has also helped her to

be more social. When you tell her that she is going to have speech her whole face lights up and she

goes running to the computer!” (e-helper, …)

E-helper Feedback

“Staff is excited to be able to understand the student and work with them on a more

personal level.” (e-helper…)

“More effective communication. Expanded vocabulary. Better behaviors because

other students understand them better.” (e-helper…)

E-helper Feedback

“My client gets very excited for his teletherapy sessions. He thinks getting on the computer is so fun and it turns into a “game” for him. He is learning and doing work without even realizing it! He enjoys

his therapist and has formed a good relationship! Teletherapy has been a HUGE success for my client!” (e-helper…)

“Living in an area where there are more needs than therapists, teletherapy has been a great way to reduce our unmet needs for 3-5 year olds. Also, transportation can be

difficult for some parents. With teletherapy, we have been able to offer services while their child is in school. This has also been very helpful for teachers and aides to be

able to carry over strategies in the classroom.” (case coordinator…)

Questions & Answers

Resources

More information can be found at:

www.mainespeechtherapy.org

References• Adobe Systems, Inc. (2011). Adobe Connect web conferencing [online]. Retrieved February 6 2011 from the

world wide web: http://www.adobe.com/ConnectWebConference

• Anderson, J. & Rainie, L. (2010). The future of social relations. Pew internet and American life research center. Social Capital Gateway [online]. Retrieved December 19, 2010 from the world wide web: http://www.socialcapitalgateway.org/content/paper/anderson-j-rainie-l-2010-future-social-relations-pew-internet-american-life-research-c

• Cisco Systems, Inc. (2011). Cisco WebEx conferencing and collaboration solutions [online]. Retrieved February 6 2011 from the world wide web: http://www.webex.com

• iHAS (2010). iHASMD integrated healthcare access [online]. Retrieved February 6 2011 from the world wide web: http://www.ihasmd.com/index.jsp

• Justice, L & Vukelich, C.(2008). Achieving Excellence in Preschool Literacy Instruction. New York: Guilford Press.

• Littky, D. & Gabelle, S. (2004). The big picture: Education is everyone’s business. Alexandria, VA: Association for Supervision and Curriculum Development (ASCD).

• Michelman, P. (2004). Methodology: Do You Need an Executive Coach? Harvard Management Update, 9 (12).

• Palmer, P. (1998). The courage to teach: Exploring the inner landscape of a teacher’s life. San Francisco, CA: Jossey-Bass, Inc.

• Tomlinson, C. (2008). The Goals of Differentiation. Educational Leadership, 66 (3), 26-30.

• Towey, M. (2009, September 1). Maine advocacy wins telepractice coverage. The ASHA Leader [online]. Retrieved December 19, 2010 from the world wide web: http://www.asha.org/Publications/leader/2009/090901/090101a1.htm

http://www.adobe.com/ConnectWebConference

http://www.adobe.com/ConnectWebConference

http://www.socialcapitalgateway.org/content/paper/anderson-j-rainie-l-2010-future-social-relations-pew-internet-american-life-research-c

http://www.socialcapitalgateway.org/content/paper/anderson-j-rainie-l-2010-future-social-relations-pew-internet-american-life-research-c

http://www.webex.com/

http://www.webex.com/

http://www.ihasmd.com/index.jsp

http://www.ihasmd.com/index.jsp

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handout for telepractice presentation 2011

Documents

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