Social Mediating: Using Telepractice for Clients With Autism

shutterstock_265366694

I think most of us agree that technology changes our social interactions. The daily flurry of “tweets,” “likes” and “snaps” can make us feel more engaged with our world than ever. At the same time, we probably feel isolated sitting next to a person who has their face buried in a smartphone.

So what does a highly technological exchange like telepractice mean for individuals with autism spectrum disorder (ASD) who typically require social interaction guidance and have restricted behaviors?

The core characteristics of ASD include “deficits in social communication and social interaction and the presence of restricted, repetitive behaviors.” As a result, people with ASD struggle with a variety of behaviors like joint attention, verbal and nonverbal communication, restricted interests and routines, and high sensitivity to sensory input. That’s a wide range of things to cover in treatment.

In addition, speech-language pathologists use many different treatment methods with these clients. The National Professional Development Center identified 27 evidence-based interventions for ASD. Some of these approaches require physical assistance. Others focus on a client’s environment. Treatment might also target subtle skills such as interpreting a partner’s eye gaze and tone of voice.

The remote nature of telepractice versus the “hands-on” nature of some tools means that SLPs must evaluate each client’s needs, treatments already in use, and ways to modify treatments for telepractice, and look at options better suited for telepractice. Be aware and ready for potential obstacles—how to address eye contact when you’re using a webcam, for instance, or if the equipment accurately conveys subtle changes in body language and tone of voice—ahead of time.

However, there are also advantages.  Telepractice interaction may be less overwhelming to a client with ASD, for example, or using technology may hold his interest more so than an in-person session.


April is Autism Awareness Month and our entire April issue focuses on related issues.


Obviously, autism and its treatments require flexibility. Fortunately, telepractice offers just that. Researchers at the University of Pittsburgh outlined various technologies and clinical applications for telerehabilitation. These include more-direct “teletherapy,” to less-direct “teleconsultation,” “telecoaching,” and “teleplay.”

You can use some techniques—like social narratives, technology-aided instruction and video modeling—through telepractice without many extra steps. Interventions including peer-mediated instruction, parent-implemented intervention and pivotal response training already require indirect approaches, so modifying them for telelpractice won’t take much more effort than applying them for a specific client in face-to-face sessions.

Emerging research in telepractice treatment for ASD clients already shows success in both direct and indirect interactions. One case study gives positive results for two clients with ASD. One subject received services through “active consult,” in which a student clinician was coached  and monitored by a remote supervising clinician using Bluetooth technology. The other client received telepractice services and responded more favorably to those than he did to onsite intervention.

Another study compared traditional onsite intervention to a hybrid model of direct onsite and indirect telecoaching services. They found that gains made through traditional therapy could be maintained as well or better in a model that also incorporated telepractice.

We still have a lot to learn about how to use telepractice to serve clients with ASD. However, developing evidence reinforces something we know from other settings: We are most successful when we analyze and individualize our services to fit a specific client.

 

Nate Cornish, MS, CCC-SLP, is a bilingual (English/Spanish) clinician and clinical director for VocoVision and Bilingual Therapies.  He is the professional development manager for ASHA Special Interest Group 18, Telepractice; a member of ASHA’s Multicultural Issues Board; and a past president and vice president of ASHA’s Hispanic Caucus. Cornish provides clinical support to monolingual and bilingual telepractitioners around the country. He also organizes and presents at various continuing education events, including an annual symposium on bilingualism.  

nate.cornish@vocovision.com.

Of Language Barriers, Culture Gaps and e-Bridges

shutterstock_234152752

It certainly isn’t news that our country is becoming increasingly diverse. What may surprise us is that some of the biggest growth is happening in non-border, less-urbanized states. California, Texas and Florida continue to have the most residents who were born in another country. However, Alabama, Arkansas, Delaware, North Carolina and Tennessee all saw more than a 70% increase in foreign-born residents between 2000 and 2012.

This means that ASHA members probably find themselves with more and more English-language learners on their caseloads. These audiologists and SLPs likely also live in areas where there may not be many resources for serving ELL students. Our Code of Ethics states that we should provide culturally and linguistically appropriate services. ASHA also acknowledges that the ideal situation for ELL clients is to work with a bilingual service provider with specific language and clinical skills.

Telepractice offers an elegant solution for connecting colleagues with these competencies to our clients that need them.

The versatility of telepractice makes it useful in different settings. A school district might use several Spanish-speaking telepractitioners to manage its entire ELL caseload. A rural health clinic may create a limited agreement with a bilingual audiologist for follow-up care of a patient who communicates in a less-commonly spoken language.

Telepractice can be used for more than intervention. We can assess patients—even formally—through telepractice. Formal assessment via telepractice is getting easier because many well-known tests are now digitized. Even when a certified professional is not available through telepractice, an onsite team can use technology to connect with interpreters and cultural brokers to help provide appropriate services.

Telepractice licensing, however, remains a hurdle for taking advantage of remote services or becoming a telepractitioner. Most states don’t currently have regulations on telepractice for our professions. ASHA and local associations, however, advocate for states to formulate and adapt guidelines permitting telepractice.

In the meantime, associations advise telepractitioners to verify requirements and policies, as well as hold all appropriate credentials, both in the state where we reside and where the client receives services. This applies also to special credentialing for bilingual telepractitioners.

ASHA doesn’t certify bilingual service providers, but it provides guidelines for those who represent themselves as such. For example, we are ethically-bound to ensure that we speak or sign another language with native or near-native proficiency, and possess various clinical competencies.

To my knowledge, only Illinois and New York have a type of credential for bilingual practitioners, and these are specific to professionals working in schools. However, because policy changes frequently (and is difficult to track), SLPs and audiologists should verify any bilingual-specific requirements in states where they might practice before providing services.

Telepractice holds a lot of promise for serving clients with diverse needs. Even when there is some red tape to figure out, using technology to build bridges to communities that may not have many resources is one of my most rewarding professional experiences!

 

Nate Cornish, M.S., CCC-SLP is a bilingual (English/Spanish) SLP and clinical director for VocoVision and Bilingual Therapies.  He is the professional development manager for SIG 18: Telepractice, a member of ASHA’s Multicultural Issues Board, and a past president and vice-president of the Hispanic Caucus.  Cornish provides clinical support to monolingual and bilingual telepractitioners around the country.  He also organizes and presents at various continuing education events, including an annual symposium on bilingualism.  Contact him at nate.cornish@vocovision.com.

Our Profession’s Biggest Open Secret

shutterstock_163265117

What’s the biggest open secret in our field? Each of us might have slightly different answers. Here’s mine: the reason so many students are blocked from receiving needed services is because their home states have not updated their Medicaid telepractice policies.

Children who qualify for Medicaid coverage, by definition, are from low-income families. My experience is that these children are disproportionately affected by the shortage of SLPs and could therefore benefit a great deal from access to treatments delivered via telepractice.

In addition, many schools, when faced with tight budgets, simply do not have the money to hire additional SLPs–telepractice or not–without Medicaid funds.

This places an unfair burden on the rural and urban schools that need telepractice the most. They struggle more than their affluent peers to find qualified SLPs. One reason is that those wealthier districts can pay substantially more for treatment delivered via telepractice if state Medicaid policies haven’t been updated to reimburse for online services.

This isn’t the most surprising part of the secret, however. That honor goes to how easily states can make the change. Consider this:

  • The federal government, which partners with each state on its Medicaid plan, has already approved billing for telepractice. That’s right, the Centers for Medicare & Medicaid Services already has an approved billing treatment for treatment delivered via telepractice.
  • All reimbursements for telepractice are paid for entirely by the federal government. This means that states don’t pay for additional reimbursements out of pocket. Let me repeat that one more time: allowing reimbursement for telepractice increases access to services without requiring additional funds from your state’s Medicaid program.
  • For all states that PresenceLearning has researched—aside from Indiana—allowing reimbursement for telepractice is as simple as publishing a clarifying policy memo. The memo should say that online services can be billed with the same codes as traditional sessions as long as a “GT” telepractice modifier is included for tracking purposes.

It is important to keep in mind that telepractice is just a different delivery method for services already approved by CMS and reimbursed by Medicaid in schools.  SLPs provide online services using the same approaches and materials they would use if they were physically at the school site. 

What can you do to help students get the treatment they need by motivating your state to write that memo?

  • Speak to stakeholders to build a consensus. Stakeholders include: ASHA, state licensing boards, special education directors, state departments of special education and directors of child health programs for your schools.
  • Consult state-level billing agents on the best way to document services to ensure program integrity.
  • Network with colleagues using telepractice to find out which states currently approve Medicaid funding for telepractice.

There are eight states that reimburse for telepractice services. They include: Colorado, Maine, Minnesota, North Dakota, New Mexico, Ohio, Oregon and Virginia. In addition, reimbursement for telepractice services are pending in California and Michigan.[Note from ASHA editors: This list was published in July 2013, so it may have changed. Our December issue focused on telepractice and has a slightly different list of states offering reimbursement.] 

Contact state speech and hearing associations or state-level Medicaid directors to find out how you can assist in getting Medicaid reimbursement for telepractice services. Let’s work together to ensure students who need our services receive them and schools receive the appropriate funding from Medicaid.

Melissa Jakubowitz M.A. CCC-SLP, vice president of clinical services at PresenceLearning, is an SLP with more than 20 years of clinical and managerial experience, Melissa is a Board Recognized Specialist in Child Language. She is a past-president of the California Speech-Language-Hearing Association and is also active in ASHA, serving as a Legislative Counselor for 12 years. Melissa began her career working in the public schools and can be reached at melissa@presencelearning.com

On the Road Again: ASHA Convention and Telepractice

120914blog_206164252

I admit it. I am an ASHA convention regular attendee. I am the SLP you see year after year collecting large yellow tote bags, company pens and my new favorite—nail files. This year, I even lined up to have my professional photo taken for my LinkedIn profile. I take in all that the ASHA convention offers, and my schedule allows, year after year.

One reason why the ASHA convention is so important to me is that I rarely stay in one place very long. I am the spouse of an active duty military officer. Therefore, I move a lot. With each move (eight so far), I’ve attended ASHA with a new job title: Department of Defense school SLP, hospital SLP, staff SLP, Lead SLP… This year, I attended ASHA as an SLP that works via telepractice. I deliver services and perform assessments via an online, custom built platform. I’m several states away from my students but I am licensed in the state where they reside and the state in which I reside. Using my home computer(s), a headset, webcam and high-speed internet connection with plenty of bandwidth, I treat, assess and collaborate with other SLPs, school staff and parents daily.

At this year’s convention, I encountered some surprising conversations regarding telepractice. I was met with responses ranging from: “Telepractice. I’m not so sure how I feel about that,” to “Yes, I’ve been looking into doing that. How does it work?” When embarking on a career in telepractice as a service delivery model, I was skeptical too. Was it ethical, effective and authorized? After researching ASHA’s rules and state bylaws, I put my feet in the water. That was four years ago.

During the ASHA convention, I was pleased to attend an increasing number of sessions focused on telepractice. However, these sessions highlighted the work and research still to be done to prove the effectiveness of telepractice as a service delivery model (especially with regards to culturally and linguistically diverse populations).

I still wonder, does an increase in sessions and visibility at the ASHA convention translate to increased acceptance/adoption by SLPs on the ground?

Telepractice is established and has been used in the medical field for more than 40 years. The American Telemedicine Association states that “telemedicine is the use of medical information exchanged from one site to another via electronic communications to improve a patient’s clinical health status. Telemedicine includes a variety of applications including two-way videos, smart phones, tablets, wireless tools and other forms of technology.” According to ATA, “the use of telemedicine has spread rapidly and is now becoming integrated into the ongoing operations of hospitals, specialty departments, home health agencies and private physician offices as well as consumers’ homes and workplaces.”

I am looking forward to next year’s ASHA convention in Denver. I am already wondering about the sessions, networking opportunities and of course the pens and highlighters. Most of all, I’m looking forward to attending ASHA again as a SLP working via telepractice and the discussions that will surely follow.

Lesley Edwards-Gaither , MA, CCC-SLP, is a Speech-Language Pathologist in the Washington D.C. area.  She is a Lead SLP with PresenceLearning and an affiliate of Special Interest Group 18, Telepractice. She can be reached at legaitherslp@gmail.com

 

Beyond Skype for Online Therapy: Protecting Student Privacy

Privacy

 

The trend for kids online is sharing more, not less. Today’s kids consciously and unconsciously share so many aspects of their life using Facebook, Skype or even newer tech tools like Snapchat. But, as educators, we hold ourselves to a much higher legal and professional standard for protecting the information of these very same students. We’ve all heard about the laws—FERPA, HIPAA, COPPA— that set the standards for privacy of student records and personally identifiable information, but what do the laws mean in the context of delivering speech-language therapy online?

HIPAA: Protecting Individually Identifiable Health Information

Created by the Department of Health and Human Services in 1996, The Health Insurance Portability and Accountability Act (HIPAA) is a federal law that protects patient medical records. HIPAA specifically protects “individually identifiable health information,” which includes:

  • the individual’s name, address, birth date and Social Security number.
  • the individual’s past, present or future physical or mental health or condition.
  • the provision of health care to the individual.
  • the past, present or future payment for the provision of health care to the individual.

HIPAA gives patients a variety of rights regarding individually identifiable health information. With consent, HIPAA permits the disclosure of health information needed for patient care, such as speech therapy.

FERPA: Protecting Education Records

The Family Educational Rights and Privacy Act (FERPA) is a federal law that protects student education records. FERPA gives parents certain rights with respect to their children’s education records until they turn 18 or transfer to a school higher than the high school level, thus making them “eligible students.” The law applies to all schools that receive funds under an applicable program of the U.S. Department of Education. Under FERPA, parents or eligible students have the right to:

  • Inspect and review the student’s education records.
  • Request a school to correct records they believe to be inaccurate or misleading.
  • Prevent a school from releasing information from the student’s education record without written permission (with some exceptions).

COPPA: Protecting Children’s Personal Information

The Federal Trade Commission instituted COPPA (Children’s Online Privacy Protection Act) in April, 2000 to protect children’s personal information on websites and applications that target children under the age of 13. Under the legislation, websites and apps that collect this information must notify parents directly and get their approval prior to the collection, use or disclosure of a child’s personal information. The FTC describes personal information as:

  • A child’s name, contact information (address, phone number or email address.
  • A child’s physical whereabouts.
  • Photos, videos and audio recordings of the child.
  • A child’s “persistent identifiers,” like IP addresses, that can be used to track a child’s activities over time and across different websites and online services.

Recommendations for Online Therapy

Clinicians and educators often focus on the capabilities of individual pieces of technology, and, indeed, a secure therapy platform is highly recommended both to ensure the privacy of sessions as well as student data. However, it is the information, and the sharing of that information by the adults responsible for the care of each child, that these laws focus on. So educators need to focus on a systems approach that considers the end-to-end process of handling and securing student data.

While clinicians are trained in student identity protection, non-disclosure methods and the maintenance of student record confidentiality, it is ultimately the school’s responsibility to ensure agreements they have in place with online therapy service providers support them in protecting student privacy. So what are the practical considerations in this end-to-end approach to protecting the privacy of students receiving online therapy?

  1. Ask what type of security is in place. Solutions with bank-level security offer the strongest protection of data. This includes 256-bit encryption using TLS 1.0, restricted physical access to the servers on which data is stored, and 24/7 on-site security personnel.
  2. Use a secure platform for therapy. Secure platforms use an invite-only, encrypted, secure connection. In this model, only the online clinician and the student assigned to that particular appointment time are permitted to enter the password-protected “therapy room.” Parents may also view a session with a prior written request.
  3. Use a secure server to store data. Make sure all student files containing individually identifiable health information and education records are stored on a secure server using industry-leading security.
  4. Restrict access. Only online clinicians, authorized school administrators and parents should have access to this password-protected information, thus further protecting student privacy.

This “big picture” thinking will let educators take advantage of new online delivery models for therapy services AND stay compliant with privacy laws. And leave Snapchat to the students.

Melissa Jakubowitz, MA, CCC-SLP, is the Vice President of SLP Clinical Services at PresenceLearning. She is a Board Recognized Specialist in Child Language with more than with more than 20 years of clinical and managerial experience. She is the past-president of the California Speech-Language-Hearing Association and is active in ASHA, serving as a Legislative Counselor for 12 years.