In two rural Ohio school districts, 120 students are receiving their speech-language treatment via Internet-based videoconferencing. This pilot telepractice project, housed in the Department of Speech Pathology and Audiology at Kent State University (KSU), is one of several efforts seeking to reverse speech-language pathologist shortages in the state (The ASHA Leader, March 6, 2007; July 15, 2008).
The program's founders began it as a grassroots effort, without any previous experience with telepractice (Grogan-Johnson, Gabel, Taylor, Rowan, & Alvares, 2011). With funding from the Ohio Department of Education, they investigated other programs delivering similar services and then developed and in 2007 launched the KSU program with 34 students in the school districts of Montpelier Exempted Village and Greenfield Exempted Village. The program has since grown and thrived.
Based on the KSU program leaders' experience, following is an overview of the steps in creating program, along with practical advice—and anecdotal reporting of how it worked in the KSU program.
Step One: Investigate
A successful telepractice program begins with investigation and information gathering. Essential ASHA documents to read include Speech-Language Pathologists Providing Clinical Services Via Telepractice: Position Statement (ASHA, 2005b), Speech-Language Pathologists Providing Clinical Services Via Telepractice: Technical Report (ASHA, 2005c), Knowledge and Skills Needed by Speech Language Pathologists Providing Clinical Services Via Telepractice (ASHA, 2005a), and Professional Issues in Telepractice for Speech Language Pathologists (ASHA, 2010). These documents and other resources are available at ASHA's telepractice webpage. Another must is researching the evidence base for this type of service delivery—a good starting place is the telepractice articles section on ASHA's website.
Another article, "A Blueprint for Telerehabilitation Guidelines," outlines the provision of effective and safe telepractice services based on available evidence and technologies (Brennan et al., 2010). Initial pilot data suggest that school-age children receiving either type of service make similar amounts of progress (Grogan-Johnson, Alvares, Rowan, & Creaghead, 2010; Grogan-Johnson et al., 2011). Certainly, further study is needed.
Two areas of particular interest are the legal and ethical issues related to the service delivery model and choice of technology. Areas to read up on include:
- State licensure laws, clinician competence, privacy, informed consent, and the use of support personnel (Denton, 2003).
- Interstate telepractice, reimbursement, and confidentiality concerns (Cason & Brannon, 2011).
- Available technology and its possible application in intervention (Pramuka & van Roosmalen, 2009). A number of articles describe the commonly used voice-over-Internet protocol (VoIP) and related confidentiality and standards of care issues (e.g., Cohn & Watzlaf, 2011).
Observing telepractice in action and consulting with SLPs using the delivery model can help solidify a decision on whether or not to try telepractice. One easy way to access telepractice professionals is through the online community of ASHA Special Interest Group 18, Telepractice. Observing several different practitioners will help you compare different types of technology and videoconferencing options. Observation also may spark ideas for applying the service delivery model in your situation.
Finally, it is essential to determine whether there are provisions in the state licensure law or regulations regarding speech-language telepractice in your state and the state where you plan to provide services.
At the start of the KSU telepractice project in 2006, the project director traveled to Oklahoma City to observe the INTEGRIS Health System speech-language teletherapy program, which provided services to rural school districts in Oklahoma. The director also contacted researchers and authors of published articles to seek guidance and feedback about the KSU program. Many responded with words of encouragement and advice.
Following the investigation, the director conducted and videotaped a mock telepractice session, with family members posing as clients, to test the telepractice setup. We later used the videotape to demonstrate the service delivery model during the project's planning stage.
Step Two: Plan
In the next phase—defining the program scope and its essential elements—it helps to examine the challenges prompting the need for the program. For example, a school district is unable to hire part-time SLPs to help with large caseloads. Other motivating factors could include students who require services in their homes and intervention time lost to travel between distant schools. When possible, it is advantageous to start small and integrate telepractice services into an established traditional speech-language program. For example, an SLP in a rural district may continue to provide traditional services to the district's elementary school children while providing telepractice services to the middle and high school students.
After determining scope and focus, the next step is identifying participants for the project. This phase involves determining minimum selection criteria for the participants. Though children with a wide variety of communication impairments can benefit from telepractice services, some cannot participate due to limitations in vision, for example, or an inability to sit or stand for an intervention session.
Conducting a needs assessment is the important next phase of the planning process. This process, best done in collaboration with key district employees—including the information technology coordinator or technician, special education director, and classroom teacher—should determine:
- The technology needed.
- The instructional technology support needed and available.
- Building facilities available at both the distant and service-provision sites, including a dedicated room for treatment, desk, chair, fax machine, and phone.
- Intervention support personnel needed.
- District procedures and practices regarding, for example, software for paperwork, Medicaid billing (if available in your state), progress report schedules, and parent visitation dates.
- Parent/student/faculty education needed.
A caveat: The needs assessment process can lead to a perception that the project cannot be implemented until all possible factors have been identified and accounted for. Our experience revealed the opposite. No amount of planning can account for all potential snafus. While making a good faith effort to plan for the project, it is also important to determine a start date and make every effort to initiate the project on that date. Understand that some elements of the project will be learned as the project progresses.
In the spring of 2007, an informational letter sent to school superintendents introduced the KSU telepractice project to more than 600 public school districts. We also solicited participation at the Ohio Speech-Language-Hearing Association convention. To encourage districts to participate, the Ohio Department of Education agreed to cover the entire cost of the project during the first year. However, despite these efforts, no school districts initially expressed interest in the project.
Eventually, through repeated contacts with administrators and special education directors, we secured participation from four rural school districts with SLP shortages. After talking with the district SLPs and reviewing their caseloads, we decided to pilot the telepractice intervention with students in grades 1–5 who had speech and/or language impairments or specific learning impairments with co-occurring communication disorders.
Because of the model's novelty and districts' concerns about telepractice effectiveness, we decided that the participating students—selected by SLPs from their caseloads—would receive services via telepractice for only half the school year. The rest of the year they would receive traditionally delivered services.
Next, we conducted a needs assessment and established a start date in August 2007.
Step Three: Implement
Use the results of the needs assessment you conducted in Step 2 to generate a task list for the project. Prioritize the tasks and provide regular performance updates to the school district. As soon as reasonably possible, conduct a trial telepractice session with information technology personnel to identify technology glitches and assess video and audio quality.
It's also worth providing project orientations, either in person or via videoconferencing, to parents, students, and faculty. Also consider being available to meet and greet students and parents during school orientation at the start of the school year. If you launch the project during the school year, consider holding an open house and inviting students and faculty to visit the telepractice room. Offer to schedule appointments during parent/teacher conference nights and other after-hours events. Don't underestimate the importance of sharing facts and answering questions in these informational sessions and demonstrations. KSU project personnel discovered that parents and faculty members often have curious misconceptions about telepractice services that can be passed on if not identified and corrected. For example, faculty in one school district thought that students would receive speech-language services from on-site telepractice support personnel, rather than through live videoconferencing with the SLP.
Now that you've oriented participants and stakeholders, it's time to implement the program and help the district adjust to and embrace it.
After completing the KSU project needs assessment in May 2007, we worked through the task list it generated. We tested videoconferencing software and applications, purchased and installed equipment, and hired an SLP. At the start of the school year, the SLP met with other SLPs, faculty, administrators, students, and parents throughout the district to enlist support and provide information. Delays in obtaining parent permission forms and hiring support personnel pushed the start date back to October 2007. A complete description of the first year of the project and project results is available in print (Grogan-Johnson et al., 2010).
Step Four: Evaluate
Evaluation is key to improving your telepractice service delivery model. You can run a self-assessment and also survey students, parents, faculty, and administrators in your district (see sample survey below). After reviewing the survey and self-evaluation results, create a prioritized list of changes to make to your program.
After the KSU project's first year, we surveyed the students, parents, faculty, SLPs, telepractice support personnel, and building principals (Grogan-Johnson et al., 2010). Results from 29 of 38 students and 22 of 33 parents surveyed revealed that 93% of students and 82% of parents were very satisfied with the service delivery model and 95% of parents believed that the telepractice services provided "above average" or "very good" results in improving their children's communication functioning.
Results from 15 of 27 faculty members surveyed indicated that, in general, the teachers did not know or understand the program or the students' progress in intervention. An exception was students' reported attitude toward telepractice, which teachers rated as "very good" on a six-point rating scale ranging from "I don't know" to "very good." The SLPs and telepractice support personnel also reported satisfaction with the program, and three of four school principals reported being very satisfied with it. The fourth principal reported below-average satisfaction, citing faculty comments that limited amounts of treatment were provided in the project. However, on reviewing attendance records from the telepractice SLP and support personnel, we found that telepractice students received the amount of treatment required by their individualized education programs (IEPs).
Based on the survey results, we 1) developed a demonstration of the telepractice project specifically for faculty; 2) implemented a weekly checklist to provide teachers and parents with a review of the weekly treatment sessions; 3) built a weekly faculty consultation time slot into the telepractice schedule; 4) increased frequency of e-mail and phone contact with teachers and documented SLP contacts and responses; and 5) launched a monthly telepractice newsletter for students, parents, and faculty.
Step Five: Rework
Now it's time to make the changes identified in step four and continue to refine and improve your program. Over five years of telepractice service delivery and four cycles of evaluation and revision, the KSU team has learned several lessons to share with SLPs considering starting similar programs in schools.
Lesson One: Establish Faculty Cooperation and Collaboration
In our work with seven different school districts, faculty acceptance or "buy-in" has been gradual. Even with pre-project in-service training, faculty members reported limited knowledge and awareness of the program and student progress in year-end surveys. Our advice is to stay the course—because in the second and subsequent years, we find that faculty surveys reflect increased awareness, acceptance, and recognition of student progress. Key to building such buy-in is frequent e-mail and telephone communication with faculty members.
Lesson Two: Select the Right Students
A wide variety of students can benefit from telepractice services, but this model is not appropriate for some students. The KSU project has served 300 different children, from preschool through high school, and to date has asked that just one student be removed. This student had a cognitive impairment and significant communication impairment, and was transitioning to using an augmentative and alternative communication device. In addition, four parents requested that their children be removed from telepractice and returned to traditional service delivery, and two middle school students refused to participate in treatment entirely.
Lesson Three: Stay the Course Through Challenges
At the outset of the KSU telepractice project, program staff predicted that technology reliability and adequacy would prove the biggest barriers. There were some technical glitches, but the most significant challenges came from teachers, information technology personnel, and parents. Some resisted change in service delivery or felt the model would hurt student performance.
The KSU team remained committed to the project and demonstrated its effectiveness. In time, stakeholders' biases were largely overcome. Our advice is to anticipate—and not be discouraged by—initial resistance to telepractice, and to stay the course.