Telepractice Results with High-Risk

Preschoolers Using a Web-Based Approach

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

Waldo County General Hospital Belfast, Maine

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 Telepractice

We 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 GIACCertified 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 ehelper needs in first session.

Built digital materials to support childs 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-helpers participation.

Welcome to teletherapy! Todays speech pathologist working with you is Nathan H. Curtis, M.A., CCC-SLP. He can be reached at 338-9349 or ncurtis@wcgh.org. You are on a secure connection meeting HIPPA standards. Confidentiality is important to us. Please make adjustments on your site to protect your students confidentiality of these services.

Layla Smith
I have a friend whose name is Layla and this is how she spells her name. La yla La yla La yla
Thats 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

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.

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

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 ehelper to do the same.
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

Technical Skills
1. Clinician demonstrates skills in adjusting video and audio quality. 2. Once a mutually beneficial schedule is established, clinician will eschedule 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.

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

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 storeforward 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.
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

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.

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

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.

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

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, ehelper, teachers, and support staff. 9. Clinician can demonstrate deliberate practice within telepractice sessions.
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

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

2.
3.

Clinician knows billing codes and billing practices of telepractice services.

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

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 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.

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 E-Helpers: Telepractice Services

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.

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 E-Helpers: Telepractice Services

Instructional Skills
1. Can establish a distraction-free environment for the e-learner. 2. Attends solely to the e-learners 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-learners strengths and needs and acquisition of a basic understanding of the e-learners communication needs, and knowledge of the IEP goals.
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 E-Helpers: Telepractice Services

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.
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

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
Partnership Focused on teacher learning goals Non judgmental

Consultation
Provision of service Informs re: the childs needs

Collaboration
Collegially working Transdisciplinary Focus on common child goal

To improve child learning

Action, Reflection, Planning, Evaluation Focus individual growth

Sustained improvement

A Tool We Can Open & 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 childrens positive development
(Justice et al, 2008)

Its impossible to make content relevant for students whom you dont know (Littky, 2004).

Coaching Process
Building trust Ensuring fit Strengthening voice Developing awareness
(Tomlinson, 2008)

Trust
Trust strengthens when coaches believe in e-helpers 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 ehelpers 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 facilitys telepractice results to our facilitys 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
65 60 55 50 45 40 35 30 One Level Multiple Levels Telepractice Facility National

55%

Pragmatics
70 65 60 55 50 45 40 35 30 25 20 One Level Multiple Levels

25%
Telepractice Facility National

Spoken Language Production

65 60 55 50 45 40 35 30 25 20 One Level Multiple Levels Telepractice Facility National

85%

Spoken Language Comprehension

65 60 55 50 45 40 35 30 25 20 One Level Multiple Levels Telepractice Facility National

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
80 70 60 50 40 30 20 10 0
A ul ic rt P P g ra C om e eh pr c du ro s ic at m n io at ito n n io

One Level Multiple Levels

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

ns

Parent and E-Helper Feedback

Parent Questionnaire
Overall Satisfaction Rating (4.82) 82% very satisfied
18% satisfied

Parent Questionnaire
Effectiveness (4.36)
45.5% highly effective 45.5% very effective 9% effective

Parent Questionnaire
Amount of progress (4.18)
36% much more than expected 46% more than expected 18% amount expected

Parent Questionnaire
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 wouldnt and couldnt 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

E-helper Questionnaire
Amount of progress (4.27) 47% much more than expected 33% more than expected 20% amount expected

E-helper Questionnaire
Effectiveness of Teletherapy (4.07) 40% highly effective 27% very effective 33% effective

E-helper Questionnaire
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

E-helper Questionnaire
Quality of Audio & Video (4.13) 27% excellent 60% very good 13% okay

E-helper Questionnaire
Comfort in Setting Up Sessions (4.87) 93% comfortable 7% somewhat uncomfortable

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

E-helper Questionnaire
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-internetamerican-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 everyones 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 teachers 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