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Service Delivery for Children and Adults with Cochlear Implants in the 21st Century: Telepractice

July 17th, 2012 by | Tags: , , , , , , | 1 Comment »

Kelly J. Brown, B.A
Anne M. Fleming, B.A.
K. Todd Houston, PhD, CCC-SLP, LSLS Cert. AVT
Telepractice & e-Learning Lab (Tell)
School of Speech-Language Pathology and Audiology
The University of Akron

Today, cochlear implant technology is allowing more children and adults with severe and profound hearing loss to access auditory information, learn to listen and use spoken language, and enhance overall communication.  While technology can improve the individual’s ability to hear both speech and environmental sounds, listening – by contrast – is an active process that requires increased attention and processing of what is heard (Beck & Flexer, 2011). Auditory-based intervention or rehabilitation, therefore, is required for children and adults who have received cochlear implants to develop, expand, and refine their use of the technology for communication.

For children with cochlear implants, professionals who are certified Auditory-Verbal practitioners are the most qualified to deliver listening and spoken language services. Similarly, audiologists or speech-language pathologists who have Auditory-Verbal or related knowledge, background, and experience typically are the professionals best suited to provide comprehensive aural rehabilitation services. Unfortunately, however, locating practitioners who are well-trained in Auditory-Verbal practice and/or aural rehabilitation remains a challenge for many cochlear implant recipients.

To combat these issues in Ohio, the Telepractice and eLearning Laboratory (TeLL) was established in the Hearing and Speech Center in the School of Speech-Language Pathology and Audiology at The University of Akron. Currently, the TeLL is providing both Auditory-Verbal intervention and adult rehabilitation services to a range of children (and their families) and adults with cochlear implants as well as others who use hearing aids.

“Tele” Terminology

For many families or individuals seeking services, the question may be asked:  “what is telepractice?”  The prefix “tele” is derived from the Greek root word that means “distant” or “remote” (Houston, 2012); thus, simply put, it means delivering services from a distance – usually through some form of distance technology. Because of the rapid expansion of these service delivery models, the prefix “tele” is being used in a variety of contexts across multiple disciplines, such as telenursing or telepharmacy as well as tele-speech, tele-therapy, and tele-audiology .

In an attempt to clarify some of the terminology, telehealth is usually used as a general term to describe a range of information or services provided; telemedicine refers to services provided at a distance by a medical professional (e.g., a physician or nurse); and telerehabilitation refers to the allied health professions, which includes speech language pathologists (Houston, 2012). The American-Speech-Language-Hearing Association (ASHA) chooses to use the term telepractice when referring to services of speech-language pathologists and audiologists.

ASHA defines telepractice as: “The application of telecommunications technology to delivery of professional services at a distance by linking clinician to client, or clinician to clinician, for assessment, intervention, and/or consultation” (ASHA, 2012). In addition, ASHA has developed a position statement that states: “Telepractice is an appropriate model of service delivery for the profession of speech-language pathology. Telepractice may be used to overcome barriers of access to services caused by distance, unavailability of specialists and/or subspecialists, and impaired mobility. Telepractice offers the potential to extend clinical services to remote, rural, and underserved populations, and to culturally and linguistically diverse populations. The use of telepractice does not remove any existing responsibilities in delivering services, including adherence to the state and federal laws, and ASHA policy documents on professional practices. Therefore, the quality of services delivered via telepractice must be consistent with the quality of services delivered face-to-face” (ASHA 2005).

Equipment & Getting Started         

For both the practitioner and the consumer, the minimum equipment needed for providing or receiving telepractice services is a computer, webcam, a headset with microphone, and a high-speed, broadband Internet connection. Additionally, an individual’s laptop may be connected to a wide-screen computer monitor or flat-screen television to provide a larger video image. As well, high-quality external computer speakers may be used if the patient/client receiving services is unable to use a headset due to their use of hearing aids or cochlear implants. With cochlear implants, the client may be able to direct connect their cochlear implant(s) to the computer and/or to the external speakers for improved audio fidelity.

Currently, the TeLL utilizes the distance learning software Elluminate, which is produced by Blackboard, to deliver telepractice services. While other video conferencing equipment and software were evaluated, Elluminate provided the flexibility that was required, and the University of Akron was able to provide technological support as needed. Because the software is designed for distance learning applications, it creates a “virtual classroom” whereby the “student” can enter and have access to complete audio and video of the “lecturer” in real time (i.e., synchronously). In the TeLL’s telepractice sessions, the client/patient can log into the virtual classroom using their laptop or desktop computer from their home. In a similar manner, the clinician can enter the classroom and can see and hear the client/patient clearly. The equipment requirements have remained minimal.

Auditory-Verbal Sessions

Through the TeLL, families receive weekly Auditory-Verbal telepractice sessions. Because the University of Akron has two Listening and Spoken Language Specialists and Certified Auditory-Verbal Therapists (LSLS Cert. AVTs) on faculty, Drs. Denise Wray and Todd Houston, a commitment exists in providing comprehensive listening and spoken language services to children with hearing loss and their families. Furthermore, the School of Speech-Language Pathology & Audiology remains one of only a few university training programs that incorporates Auditory-Verbal content in its courses and provides clinical practicum experiences in support of listening and spoken language. Thus, through the TeLL, graduate students in Speech-Language Pathology not only learn how to deliver effective Auditory-Verbal sessions, they also learn how to provide these services through a telepractice model.

Prior to each weekly 60-minute session, each family receives via email a lesson plan and materials that can be printed that were developed to meet the child’s current goals in speech, language, and listening. Many of the materials, such as colorful scenes to foster language use, can be posted within the virtual classroom as a Powerpoint file. The parent and the child can see these materials as images on their computer screen. Each session begins with a discussion of the speech, language, and listening goals targeted during the prior session and about how previously demonstrated communication strategies had been integrated into the child’s daily routines. The faculty member, graduate students, and parent discuss any new communication behaviors that might be relevant to the child’s progress, such as new or emerging speech sounds, words, or listening behaviors that have been noticed. Once these updates have occurred, the faculty member and graduate students introduce the goals for that day’s session, explaining the desired speech, language, listening, and interactive behaviors.

After discussing the materials and activities that would most engage the child, the SLP and graduate students demonstrate the activity before asking the parent to engage the child. The parent repeats the activity while the faculty member and graduate students observe. At this point in the session, the practitioner’s role shifts to that of a coach. The faculty member and/or graduate student provides positive reinforcement and constructive feedback to the parent based on how the activity was implemented and how the communication strategies that promote listening and spoken language are applied. This same scenario is repeated as one activity ends and a new activity is initiated. Throughout the session, the parent, the faculty member, and graduate students closely monitor the child’s attention level.

Following the session, the parent is given ample opportunity to discuss any concerns about the child’s progress, to ask questions about short- or long-term communication goals, or to seek input about troubleshooting the child’s hearing technology (e.g., digital hearing aids and/or cochlear implants, FM systems). The faculty member and graduate students summarize the goals and facilitation strategies that were modeled and practiced during the session. Based on the child’s performance and developmental level, new or additional communication goals are discussed that will be targeted in the home the following week.

The Auditory-Verbal telepractice model continues to be a viable means by which to support children with hearing loss who are acquiring listening and spoken language skills. As one mother of four-year-old son with bilateral cochlear implants explained, “what I’ve found is that telepractice has benefitted him in many, many ways. First, we have the consistency of weekly therapy back in place. Second, my son is more comfortable with telepractice than he was going to see a therapist and having more traditional services sitting at a table in a therapy room. With telepractice, he’s in his home, and I’m working with him. If he needs to get down and stretch his legs or grab a glass of water, he can. It is quite natural for him. Most importantly, because he feels more comfortable being at home, I see him talking more during the sessions. He doesn’t “clam up” like he used to when we visited the therapist. Another benefit of telepractice is the coaching I receive as the parent, and that I receive weekly lesson plans and other materials that I can refer to after the session. We’ll continue to work on the goals and do the activities throughout the week. Telepractice has been great for my son and our family!”

Aural Rehabilitation for Adults

For adult patients receiving services through the TeLL, each session is focused on the individual’s communication needs in the areas of auditory processing and overall conversational competence. The adult logs into the virtual classroom, and the faculty member and graduate students are able to interact directly with the patient. The session typically begins with a discussion of how the patient has performed over the past week since the previous session. Any noticeable changes in the patient’s communication – either positive or negative – are recorded in his/her file. Then, a discussion of the current session’s goals and activities occurs. Typically, most patients have goals that target auditory discrimination and identification tasks at the phoneme and word levels. That is, these activities provide “bottom-up” auditory skills that are essential for making fine discrimination of speech information.

Conversely, the patient also will have activities that target “top-down” activities that incorporate functional language and conversational skills. Throughout the session, the faculty member and graduate students are giving directions, asking questions, and commenting on the patient’s performance. Even when formal top-down strategies are not being targeted directly, these skills are being practiced indirectly. For each adult patient, top down language is tailored to their specific needs. That is, patients may share vocabulary or conversational phrases from their profession or work setting, and those are incorporated into each session. Additionally, many adults may also struggle with specific listening situations within the community, such as attending a worship service, a restaurant, a local business, or the gym. Context-specific phrases and vocabulary from these situations are also practiced within the telepractice session.

A 60 year-old adult cochlear implant user with an acquired hearing loss had these comments about his experiences receiving aural rehabilitation services through telepractice:  “As compared to in-person therapy, there’s no question that telepractice brings another dimension to this process. With in-person therapy, the clinician controls the entire situation – the therapy room, the materials, and how everything is presented. With telepractice, I’m connecting from my home office, so I feel that I’m more of a partner in this process. I know that I must be there at the computer ready to listen, and I believe that I’m taking greater ownership of my own rehabilitation. I believe that I’ve been able to establish great rapport with my telepractice team, and the results I’m experiencing are on par with those that I’ve achieved through in-person therapy.”

Barriers to Telepractice

Several barriers currently exist in regards to accessing and expanding the availability of telepractice services in Speech-Language Pathology and Audiology.  Two primary challenges are licensure and reimbursement. For example, in order to deliver services through telepractice, the treating clinician must be fully licensed both in the place (i.e., state) of origin and delivery.  This creates barriers to interstate practice, as obtaining multiple state licensures may be difficult and cost-prohibitive.  Regulations and licensure provisions for telepractice also vary by state, so it is important that practitioners ascertain the current requirements from their state licensure board before beginning services (ASHA, 2010).  Additionally, telepractice reimbursement varies among insurance providers.  Medicare currently does not provide funding for Speech-Language Pathology or Audiology telepractice services, and Medicaid coverage varies by state.  Coverage of telerpactice services through private insurance also varies, so it is recommended that advance approval is obtained prior to initiating services.

Conclusion

Telepractice service delivery models will most likely become standards of care for families seeking early intervention and/or speech-language services for their children with hearing loss. As well, adults who are utilizing digital hearing aids and/or cochlear implants will seek aural rehabilitation services to improve their auditory processing and communicative competence. While generational differences exist in the use of technology, those differences are beginning to diminish, especially as technology becomes user-friendly, lower in cost, and reliable. For audiologists and speech-language pathologists, models of telepractice provide exciting opportunities to connect with patients and to provide valuable services, such as Auditory-Verbal Therapy and Adult Aural Rehabilitation, that may not otherwise be available.

References:

American Speech-Language -Hearing Association. (2005). Speech-language pathologists providing clinical services via telepractice: Position statement. 

American Speech-Language-Hearing Association. (2010). Professional issues in telepractice for speech-language pathologists (professional issues statement). 

American-Speech-Language -Hearing Association (2012). Telepractice for slps and audiologists.

Beck, D. L. & Flexer, C. (2011, February). Listening is where hearing meets brain…in children and adults. The Hearing Review.  

Houston, K. T. (2012). Connecting to communicate: Using telepractice to improve outcomes for children and adults with hearing loss. 

 

Authors:

Kelly J. Brown, BA is a second year graduate student at The University of Akron studying Speech-Language Pathology.  She is a graduate assistant at the University helping with research and mentoring other students.  Her interests include telepractice and working with children with hearing loss and their families.

 

 

 

Anne M. Fleming, BA is a second year graduate student at The University of Akron studying Speech-Language Pathology.  She spent her first year as a scholar on the Auditory- Verbal Training Grant.  Her interests include telepractice and working with children and adults with hearing loss.

 

 

 

K. Todd Houston, PhD, CCC-SLP, LSLS Cert. AVT is an Associate Professor of Speech-Language Pathology at The University of Akron. His primary areas of research include parent engagement and communication outcomes in young children with hearing loss. As the director of the Telepractice and eLearning Laboratory (TeLL), he is also keenly interested in the use of telepractice to enhance service delivery to young children and adults with hearing loss. An avid user of social media, you can contact Dr. Houston at Houston@uakron.edu, follow him on Twitter (@ktoddhouston), or connect on LinkedIn or Facebook.

1 Comment

neethu

February 17, 2013 at 10:37 am

i would like to join for it.. can u tell how to start with it