Five minute warning, okay Welcome everyone to the first PLC for the 2019 2020 school year. I am Sarah Burns with Alberta Education Low Incidents team We are supported today by the great people of the film lab of Alberta education WizCAP for captioning and Tanya Adler for ASL interpretation Before I introduce our presenter, I'd like to make a note of a save the date On October 9th, we've been invited to a PLC With Dr. Nicole Grove from the UK to speak about the implications of adopting a holistic and multimodal approach to communications The webinar is based on the research and practice drawn together in the first ever text dedicated to the topic of Manual sign acquisition in children with developmental disabilities. I Will send out additional information at the beginning of next week So this this week's this month's PLC is the adoption of telepractice to support intervention with Dr. Stedler Brown And just to give you a little bit of information about Dr. Brown She provides consultation and technology assistance in programs working with children who are deaf and hard of hearing in the United States and Internationally She has a graduate degree as a speech language pathologist an educator of the deaf and hard of hearing and the Doctorate degree in special education Her research has focused on telepractice and she's a co-investigator for phase two clinical trial Funded by the National Institute's on health and National Institute on communication disorders and deafness to study services To children who are deaf and hard of hearing by a telepractice Dr. Stedler Brown works with initiatives promoting evidence-based early intervention practices and The use of individualized assessments to inform treatment She's a busy person. She also teaches at the University of UBC Sorry, the University of British Columbia and Holds a position as in the clinical faculty of speech language hearing clinics at the University of Colorado She has many other research interests and like many Albertans loves the outdoors camping and hiking and with that I'm going to switch it over to Dr. Brown Well, hi everyone. It's good afternoon. Do I sound okay? I Don't hear otherwise. I'll assume it's a go Lovely to be Working with you today, please Ask your questions as they come up. No need to save them for the end of the talk and Sarah or Elena should I just tell you when to advance the slide? I'm ready So a few things that I'm going to hit on today and again if you have questions for me Please ask them and I can spend more time on any of these topics but I'm going to look a little bit at how telepractice has gotten started and Some of the pros and cons that we hear around the world I'm going to look at how telepractice impacts Your team educational audiologists and teachers of the deaf and hard of hearing and speech language pathologists, of course as well I have some research to share that looks at the efficacy of telepractice and then its effectiveness when it's applied in schools and in early intervention and Some practical tips for professionals who are getting involved in telepractice Next slide The highlighted word there telepractice. I know is what Alberta or your project is Your system is using But you're going to see lots of terms relating to this idea of delivering services virtually It kind of all started with telemedicine because hospitals at least in the US got involved in it and the rehabilitation fields psychology speech language pathology audiology are kind of riding on the coattails if you will of the medical community and then education Came on board a little bit later in the US. So I'm happy to hear how Alberta and also Nova Scotia had a nice conversation this week with Suley at apse how schools are beginning to Launch into telepractice I might slip sometimes and say telehealth. That's the term we use here in the US And that or at least in Colorado, I should say that's tied to our reimbursement system for health care services whole different world from what's happening up there in Canada and We also hear terms like tele-service telecare Nova Scotia apse is calling it distance services and doesn't have telly in the name at all So as you read or listen to different people Read different articles. You're going to see all of these terms and best I can tell they're pretty interchangeable Next slide So there are some myths and we can stop there for a second and At the end of this presentation, I'm going to pop these same questions up or these same statements I'm calling these myths We've been hearing them for the last How long have I been involved since about? 2002 I've been hearing these types of statements. The technology always lets us down Next one Families don't like telepractice Next one telepractice is never as good as in-person sessions And the last one telepractice is a good option when there are no other options I don't want to say that these are unequivocably right or wrong But I do think that there's enough evidence to address all of them to maybe suggest that we've moved beyond them Next slide, please So in preparing for this talk today, I did some Investigation especially around school-age services and picked up some interesting quotes from what others have experienced. I love this Statement from an article. It's at the end all the references that I mentioned are at the end of this talk Tucker about seven years ago said Telepractice is going to happen anyway so let's prepare for this and I'll tell you this about our Study here at the University of Colorado that's funded by our federal government our project officers said to us Telepractice is going to happen Even if the federal government doesn't regulate it or write rules about it So we want to fund your study because we want to understand if it's effective or not So from a research perspective or from a federal government perspective in the US There the same thing as being said is what Tucker here said seven years ago. It's probably going to happen anyway So let's get ready Next slide Why should we jump into this I've spoken with Sarah a little bit Sarah Burns there in Alberta To understand your situation in general our experience in Colorado and many other places around the world say Next slide it reduces travel time and again from the Tucker article I love that one of their interventionist or therapist teachers I'm not sure who was said I can move 120 miles in 45 seconds Now that really resonates in Colorado. We have the Rocky Mountains going through our state Know about Alberta Not sure where the Rockies are up there in Canada, which province they're in but I do know that you have a huge geographic area and Moving 120 miles in 45 seconds is not such a bad idea We have weather considerations here in Colorado for sure that makes this appealing another reason for telepractice Kids can get more services Especially kids in rural areas where there aren't providers Especially in places where there's inclement weather which would keep someone from Getting to services keeping a itinerant teacher for instance or SLP from getting to the school and What I'm hearing around Colorado is people are very sensitive to spreading germs these days and kids and providers alike and Sometimes someone doesn't feel so bad that they can't work But they don't feel like they want to show up in person and spread their germs around I love this next purpose for telepractice and Suley in Nova Scotia reinforced it By telling me what one of her providers had to say which was very much as I'm quoting here from the Heinz et al article Telepractice provides new ways to practice and for some therapists They feel like they get more animated and they become more excited about it from the Tucker article They said providers have a chance to do something new and I've had huge professional growth because of it Someone else said we want to be cutting edge All of those definitely apply It's like being a surfer and being on the wave the top of the wave To get started at the very beginning of things um Another reason for telepractice is School-age children tend to be pretty motivated by technology, right not to mention your parents a lot of the Millennials are Absolutely fine with technology. That's a theme that's going to keep coming up Some school-age kids, especially the older ones like not being Let me just say it reduces the stigma of being pulled out for services because they're going to the computer lab or the room with a computer to do something virtual which is in vogue and Students also receive some reinforcement materials for practice or to take to their classroom And they can get those electronically and share them electronically and that's so appealing to young kids these days Another reason From the Tucker article when students are engaged through the computer they seem to be more responsive more engaged and more responsive more responses can increase a student's practice with the material and Hopefully increase student learning a couple more on the next slide. Maybe we as providers can learn more too. With the push of a button as Terry or someone did on your end for this webinar. You can record a session just like he's recording this webinar and I don't know if anyone has done this since their pre-service training at university, but if you ever watch yourself in a session, there's lots to learn so we as providers can learn more and the students Let me make another point as a provider. You can go back. I have my students in our clinic here do this all the time I say look at your session. Watch what you did collect the baseline data. Look at your progress notes sessions down the way Something that might be hard to do in session, but you can use that recording to Monitor kids progress and to watch yourself and that's to the second point Providers tend to do more coaching when they're working through telepractice and Sarah shared with me that you have a consultative model and a Consultative model is kind of the same as coaching. You're going to be teaching adults something that you have figured out with the student and That happens more frequently in the telepractice condition Since you have a teaming approach for kids with who are deaf and hard of hearing between educational audiologists Teachers of the deaf and hard of hearing and speech language pathologists This is an excellent way to collaborate. You can share recordings. You can Be in two different places students in a third place. You can do a session together Travel is not an issue so a lot of Added flexibility to our job In Colorado with our birth to three population with kids with all types of disabilities they got started in telepractice because We weren't able to get services to all kids as quickly as they needed to be delivered as soon as the child was Identified with a disability and our federal government gives us a timeline and says services must start in 28 days Well, we were not meeting that criteria and we were hoping telepractice would help to meet that and I don't know what your interpreter thinks but both for sign language interpreting and for other lang oral spoken language interpreting This is an easy way to include an interpreter so lots of Reasons to do telepractice, but there are issues when you're on the cutting edge of something new if you would go to the next slide Please and I'm going to start with changing attitudes about people. I Think that this has been a huge barrier. I think that it makes sense. It's logical We're telling people who were trained to work with people in person to change that service delivery approach to embrace it to give it a try and sometimes people are Uncomfortable with that change for a lot of good reasons. So let's look at some of the changes in attitudes that might need to happen again, please There you go In this Heinz et al article It they were saying that the providers they interviewed I Identified their initial feelings about starting telepractice and it fell into three conditions So I'm going to show you those and ask you just to think a little bit about Which of those three categories applies to you? So if you'd advance that there you go Are you excited about the potential I'll be it maybe you're uncertain about its effectiveness or Are you unsure how to do it? therefore, maybe not So comfortable with with starting Or maybe a mixture of those two If we were in person you'd be raising your hands, but I'll just let you think about it for now And if you'd advance to the next There you go Here's the good news Attitudes of therapists Are said to change Once that interventionist starts telepractice. So whichever category described you Chances are it's going to change once you start doing telepractice And a couple of quotes from these articles I've been looking at one person said I'm amazed how something so different That being telepractice Is so similar to in-person therapy at the same time And again this theme of Providers saying I saw new ways to practice And that's basically a good thing A couple more Points about attitude There you go The provider needs to be more flexible. That's true The provider needs to be a little bit more organized This whole idea of collaboration Starting with teachers of the depths, speech-language pathologists, educational audiologists for Kids who are deaf and hard of hearing Let's add in collaboration with the general education teacher Let's add in parents, especially for the young children in the u.s. That's birth to three I think in Nova Scotia it's birth to five I'm not sure about Alberta Um There's collaboration with the facilitator who might be bringing this Student from their classroom to the telepractice session In the literature. We're referring to that person these days as an e-helper I don't know if that terminology will last but I see it used a lot. I see facilitator used a lot too so You know best practice for in-person intervention is all that collaboration would happen anyway But there's something about telepractice that actually makes it a little bit easier You don't have to drive anywhere. You don't have to walk down the hall. You don't have to find out if the person is In the classroom and you have to come back later You just electronically arrange a time to meet and to collaborate or to sign into your session And it seems to be um telepractice seems to give us an advantage for that and um If you could do a couple more Or at least there you can keep going To that stop. Oops go back. Okay Let me say That besides just jumping in and doing telepractice There is A lot of evidence that some training Prior to starting might be advantageous And I like the way that the article by uh, Heinz et al Four years ago identified some of the priorities that providers Want before they start telepractice That would be training in the technology Like zoom Some practice with the hardware And the software is Maybe any online materials that you're accessing for your therapy sessions Or teaching sessions Observing colleagues who are already comfortable with telepractice They can record their session you as a person new to telepractice can watch it see what's the same what's different Which could become to the next point a formal mentor process if your agency were so inclined And uh assuring that Your access to resources Is different if you feel it needs to be different And we'll go into more detail about that later So when it comes to attitudes, I'm kind of looking at what is And uh What we might do to help And uh in the next few slides, I'm actually going to show you you can go to the next one the results of a recent study that um We a few of us published in the international journal of telemedicine or telerehabilitation about um the attitude of providers serving all types of kids with all types of disabilities All the children were birthed to three years of age and we surveyed providers And we have service coordinators who are kind of overseers of each child's Program, they they see the children when they start intervention and Periodically throughout the three years they might be in intervention We also surveyed parents and administrators, but we didn't get enough Return on those surveys. So i'm going to share with you the results of um What providers and service coordinators of children birthed three Said and this was in the state of colorado Now the next slide before you go there. Oops. Well, there it is. That's fine. Well, whatever. Um, I want to share that once colorado said all birth to three providers hundreds and hundreds of them could do telepractice And after three years now the next slide As of march 2008 That very small percentage of providers were actually doing it Now the state endorsed it The state paid for it state of colorado They promoted it They had online training modules But uptake was really low and we thought Okay, what's the problem? And it comes down to attitude if you'll go to the next slide, please Here were the positives Go ahead and there you go Let's stop there for a minute. The positives were It addresses provider shortages It's appropriate for rural families It's flexible In terms of scheduling and weather and illness like I was talking about earlier less travel another theme that keeps recurring The providers and the service coordinators like the flexibility Interventionists could uh Instead of going at one o'clock every thursday They might more easily be able to join a family during eating time or dressing time or transitioning to the car time Whatever was a challenge for a family They thought the families were more involved in the intervention and um They said that coaching strategies were used more And then there were the negative attitudes that'll be the next One thing is technology The next is It's less personal And the next is the perception that families didn't like it The next few slides might debunk some of those notions Next slide This is a slide from the interventionists. These could have been speech language pathologists occupational therapists physical therapists psychologists social workers any provider So we said, okay We asked this question one among many Compared to children you see in person The children I see in telepractice sessions make More progress eight percent Kids did better in telepractice Same amount of progress in person and in telehealth telepractice That would be the blue bar and that's 80 percent Make the same amount of progress And we have uh, what's the percentage there that think they make less Progress it would be about 12 percent next slide We also In the same provider survey Another question was compared to families I see in person The parents or caregivers Who are involved in the telehealth session are blue bar More than 50 percent say the parents were equally involved Green bar at the top 33 percent say that the parents were more involved In the telepractice condition And then we have about 14 percent that say parents were less involved This is another theme you're going to see Coaching seems to happen at least the same if not more In telepractice and what's the value of coaching? Well, if you as a provider are assigned to a child they speak language pathologists sees the child an hour A week or two 20 minute sessions a week But you teach the people the teachers other team members parents How to implement those strategies And that child that student is exposed to those strategies more often Maybe kids will do better We'll see Maybe maybe they do equally well That data comes later The next slide, please This was a question that we asked the service coordinators those people monitoring the children in the system and We have a problem here I think in terms of Why telepractice is not being used more How many said it was wonderful About 12 percent 53 percent the blue bar said It's okay in some situations That is not a resounding endorsement of telepractice The yellow bar Was um, I haven't recommended it, but I'm open to it. That's about 22 percent And the orange bar at the bottom 11 percent said Not interested I'm not going to recommend it And the next slide to that point Uh, again, please Said a service coordinator said being rural she Her area was a rural part of colorado. She said I don't want families to think they're getting a lesser version of therapy Another myth that hopefully by the end of this webinar You'll raise your eyebrows and maybe question We'll see So if we're going to actually before you go on any questions, I should be aware of I don't see that any You're there, but it's kind of a logical pausing point So if you have a question, please type it And it'll show up for me Okay, let's move on So who needs to be informed about telepractice and I couldn't help but put in this word in parentheses who needs to be convinced To engage in telepractice and it's kind of everybody school district personnel the students the parents the SLPs Maybe the teachers of the deaf and hard of hearing too or the educational audiologists Probably could have said just providers and this uh statement from article in 2010 dunkley and colleagues Said research has suggested The disparities exist between clinicians the providers and the clients students perspectives With the therapists often displaying more negative attitudes than others who are interested in Promoting telepractice or those who are receiving telepractice And that's what we see with the service coordinators in colorado Next slide So how do we convince everybody? Or influence them so with administrators and teachers and maybe parents How about watching a telepractice session? That might eliminate some preconceived ideas Or to administrators Let's train the providers that's shortlist. I showed you earlier. Let's train them on the technology Let's train them by having them watch others do it. Maybe create a mentorship program And that's in the bail and con article and also the Heinz article And establish your credibility So that providers can collaborate with parents e-helpers other teachers who are physically present with the student During a telepractice session If you're all set to go and you start We may have the provider convinced But we also need to be sensitive to the attitude of more naive people And since you're working in a consultative model there in Alberta It sounds like that orange bullet at the bottom pretty much applies Some tips on the next slide When you're getting started as a telepractice practitioner You might send some type of a letter of introduction To the student to the teacher to your colleagues Send it electronically however you want to do it Invite them to watch a session so that you can demonstrate what it looks like I think the idea of hybrid services is very popular hybrid being some in-person sessions some telepractice sessions and i'm going to Take a second to talk about our colleagues in australia Who are working with children who are deaf and hard of hearing and i can share melissa mccarthy dimity dorne ellen roads a bunch of people in the field of working with kids who are deaf and hard of hearing Have done a lot of work with telepractice And they really built some of their service delivery models on telepractice because of the size of the country and where the population live and where the providers were and They didn't do much of a hybrid model They were pretty much launched into telepractice 100 of their sessions with many of their families Because they just couldn't wait To organize in-person sessions But i find in the u.s Where that challenge is not quite as significant that It sometimes when practitioners can do some in-person sessions and some telepractice sessions. It's a way to ease into telepractice Just an fyi So once telepractice is underway you can have some informational sessions perhaps through email or webinars So that you can discuss telepractice and demonstrate To people who want to learn about it what it looks like um, you can send an email to teachers Or send a something printed out with the student that goes back to their classroom teacher You can report on how the child is doing um I don't think any of these are required. They're all optional And then over time If one is so inclined You can get some satisfaction surveys and I have some articles with great satisfaction questions that i'm happy to share with you And uh, I know how busy everyone is but even a very short occasional newsletter maybe not monthly maybe per semester might be a nice way to um share with your colleagues this whole idea of delivering services through telepractice Okay, next slide. What's different about telepractice from in-person sessions? And there's three areas that i'll hit on Engaging the recipient of the services the student selecting your materials managing the technology Let's look at the next slide engaging clients engaging your students For one Think about your eye contact. You have to establish eye contact not by looking at your camera Keep your eye on the students I suggest not watching yourself It can be very distracting um The next point is how do you give directions You might find you need to be more descriptive in giving directions to students Especially if they're old enough that they don't have an e-helper or a facilitator or another teacher with them and when it comes to these e-helpers Again in your situation, maybe it's a another teacher or a teacher's aide um Assign some tasks to those e-helpers like scheduling Bringing the student to the class to the room where the telepractice session is taking place Let them be trained in the use of technology and to handle any technology problems Uh, something you can't see just because of the way the slide was reformatted is a fourth point which is um The person sitting there with the student can help to be sure the student stays in the view Of the camera so that you can see them and i'm not going to go into great detail about this, but there are Devices, uh, for instance something called swivel swi Vl It's an acronym. It's or it's the name of a product uh that you can put an ipad on and it Moves to follow the voices or the action or Even thinking about Using an ipad versus a computer because ipads can be so easily Turned even if you're just holding it um When I was talking with su leh in oba skosha at apsee she was talking about the um facilitators that they have or whoever is there accompanying the student Can um Get more opportunities to be a good coach for that student By being engaged in the session so you can actually be teaching that person Some things to try right there while you're watching with the student Um, I see a question has popped up. I'm going to address that in just a minute Let me point out two more things about engaging clients on the next slide I've mentioned about giving directions and this quote kind of says it all We've learned to refine how we give direction and we're more descriptive Oh, I already said that actually and it can take place of being physically present. Sorry for the duplication Let me point out a word of caution And this applies maybe more to the little ones should any of you be working with young children in the home But I was at a presentation this summer and the presenter was from new zealand and she said that She felt like in a good way She was on call all the time And that the parents of these young children could check in with her all times of the day any day of the week during mealtime or Something they wanted to show the therapist that was just really special And this therapist was fine with that But I want to point out that while the technology might allow you to do that because you can zoom on your phone It's easy to get in touch It is not essential to telepractice to do that It was her preference her choice that particular provider's choice She liked it. She advocated for it. But i'm still going to suggest it is a personal preference of the provider or the teacher or the therapist So Something that people are doing but not necessarily something I want to you to think is required The question that's up. Maybe you can all see it Do I have experience using telepractice with indigenous families in remote locations? I don't we don't have We have a couple of what we call native american tribes in colorado They're small And uh, we have not used telepractice that i'm aware with them, but in my work with um, British columbia They have reported on its use the use of telepractice with indigenous families in remote locations and uh Here are the things that I learned and this is from my colleague noreen simmons at the bc family hearing resource society They work specifically with children who are deaf and hard of hearing birth through At least through elementary. I'm not sure if they go older than that And they have said that some of these things help them with indigenous families In remote locations and that is to be sure that you have An indigenous provider With the child um And I think there was some work that was done before they started the telepractice to be sure that the community embraced telepractice And I think that as with anyone that you're talking to about starting telepractice You need to individualize how you tell and maybe sell the idea uh This wouldn't be specific to indigenous families, but the more remote you get The more issues you're going to have You might have with bandwidth with having adequate bandwidth um I think zoom which we're using now has been fantastic Uh, that means the software is great but sometimes The bandwidth is not good enough or even accessible enough That to have a really good clear signal I'll talk a little bit more about what might be done about that But again talking with uh, Suley at apsee in Nova Scotia the other day She said that one of the issues they had is that the schools keep Creating firewalls for security purposes. And so their program needs to keep Getting permission to get through the firewall. Um, it's another access issue when it comes to remote areas And security issues So, um, those are some tips about uh, that I've learned about working with indigenous families the next question Uh, for students who are here hard of hearing using hearing technology, how can this be facilitated? Listening through a computer can be challenging. Have I heard of any issues with the auditory signal? Absolutely. Um, and I have more slides about that. Uh, when we get into the equipment But let me just say this for starters um There are remote microphones that can be used There are remote headphones that can be used Of course, you can't necessarily use headphones when you have hearing technology But there's bluetooth connection and whatnot so that you can have some wireless support for, um, kids who are hard of hearing Uh, and I don't want to say too awfully much because I'm stepping into the world of educational audiologists But I know you have them. So I would look it, uh To them for some suggestions on the best, um Uh, support that you can give for kids who are using hearing aids or cochlear implants To make the sound, uh clearer for them Uh, interestingly terry who's one of your tech people there and I did a test yesterday to make sure everything was working And I was using my microphone on my computer And then I said I happened to have a headset here with a noise canceling microphone Let me put that on and see if the quality of sound is any different And I don't know what you've got going there in alberta But he said the sound sounded great like I was next door to him and it did not change with the microphone or the headset Uh, at all. So, um, I think computers or help computer technology is helping us out because it's getting better and better all the time And the microphones are better and better all the time on the computers But still an important question for kids with hearing technology Uh, let's see hard of hearing educational audiologists here. Yay Uh, I've had great success with google meet for remote sessions. There's a captioning option Thanks for mentioning that and while it's not perfect It's extremely helpful and helps fill in the blanks of anything. I may not have heard It's the same technology as google translate. It's an android app Thank you, melanie Okay, I'll keep watching the box next slide and sarah or alaina if I don't look at the box just Speak up and Tell me to tell me to look or read the question Um materials What do we do for materials that's different in telepractice? Planning is kind of essential And i'm a kind of a spur of the moment kind of a interventionist, especially with little ones at home and I use whatever is in the home Uh, and with telepractice you need to plan what you're going to be using in the home When you're doing this via telepractice. Thanks for advancing the slide Um use what's readily available Uh In the melard rice and carter article they say we really have to be good at using what's there But in some other articles i've read that um, they just plan in advance put in a request to the classroom teacher or the principal for what they need Um, so that they have access that they want. I think the key is um plan plan in advance uh in some uh programs and certainly it's documented in articles that have been published Uh, there's duplicate materials in both places Where the provider is at the remote site and where the student is at their school um This is kind of a security measure Uh, it makes it easier to model something when you both have the same materials I think it's a personal preference. I don't think it's necessary Uh 15 years ago, uh the program at utah state university Actually had a lending library and they sent materials to the home And it was the same duplicate set of materials that they had that the therapist had on campus And then after a month the family would send those back and they'd get a new box of materials It's expensive shipping materials is expensive replacing materials is expensive buying duplicate materials is expensive There's nothing wrong with it. The question is is it necessary and for some providers it feels necessary And this last point if you're going to be using computer Based programs, which certainly is easy to do with school age children um have the tabs on the computer ready have it open and uh Don't close and you'll go open a new window and go searching for it during a session You'll be happy that you had them all in tabs before the session Next slide, please Managing the technology that people are so worried about. Um This is what the melard rice and carter recent article said about The skills of the provider who is the telepractice provider They think that the technology skills of the provider only need to be adequate With the expectation that what's hard today Is going to be okay tomorrow and eventually it's going to not even be an issue in the future Technology is just improving that quickly uh back in the early 2000s when I started uh telepractice at the university of colorado hospital We had a $20,000 piece of equipment and we had a full-time it person Now you can use your phone or an ipad or any kind of Notepad laptop computer And I'll talk a little bit more about this in a minute, but it support is minimal These days uh because the technology is so good But speaking of technology next slide We have as I've been mentioning hardware Including additional mics headsets software um And that's your zoom platform or the uh What was mentioned here google meat? um The hip of compliance probably doesn't apply to you that's a us issue Well, you may have the same concern about security and encrypted secure sites software for instance Right now we can't use skype if we're a government agency You can use it personally but not for a telepractice session with your employer because it's not been deemed secure And hippa is our security law um There are Free versions of zoom for instance. There's the professional version of zoom What's the difference besides? The um free version and the professional version costs about 10 american dollars a month Is that uh the free version Only allows you 45 a 45 minute session And then your session is over you would have to stop and call back If you wanted to do an hour session the professional version You can sign up for a 24 hour session if you were so inclined um, and then uh in the reformatting that we had to do today I'm not sure you can see this. I can't on my computer. Anyway, uh, maybe you can um There's a url there. Ah, yes. Okay. It was just Not visible because something else was popping up on my computer. Um, this w w w dot speed test net um, it'll identify the upload and download speeds On your computer and on the computer Uh that the student Or child is using and there are some guidelines about what are the ideal speeds Next slide Before you start telepractice Sessions In uh the literature they're calling it onboarding getting ready Make sure all the technology works and that it's all Where it's supposed to be just like terry and I did a sound check a technology check yesterday in preparation for today's call terry, I don't know if you're there, but I think we finished it in about three minutes in the other 10 minutes. We just chatted um Make sure your computer's ready to go webcams are in place uh Be ready Maybe before you launch telepractice for the first time to make sure everything's working well Uh next slide Additional equipment maybe one an additional monitor Uh, I was talking with a family that used a laptop and they Uh were showing the session on a very their large tv screen lcd screen They said well that didn't work. They thought it was a good idea. It was very distracting uh Phone it's pretty small uh But I know people have used their phones. Um, maybe there are a lot of options. I think in between Uh, do you want to use the computer the device camera or a separate camera? Uh, there are cameras that you can Uh move On the remote end you as a provider can be moving the camera That's with the student so that you can keep the student in view Uh, we've talked about mics And uh, here are some other ideas about materials. Do you want to use an interactive whiteboard? A document camera people find handy Uh, if the room has a lot of reverberation Do you need to adjust things? Can talk to your educational audiologist about that so that you can Make the sound quality better by changing the environment Next slide Uh, melard race and carter again said we typically have some sort of an e-helper with the students And oftentimes when there are technology issues the kids fix it They fix it faster than the e-helper can they know exactly what to do. They just say, oh, yeah, right Just click this button it fixes the problem. So uh I'd love that idea. I just thought it was a cute thing to quote Next So this idea of coaching that I keep bringing up um Kind of moving on here um Coaching applies both to early intervention and I'll show you some data from uh our Study of coaching and um coaching as I mentioned earlier also applies to your consultative model where your Teacher your slp. Let's say is teaching the teacher of the deaf and hard of hearing some strategies around auditory skill development or speech articulation Um, but let me show you the data if you would go to the next slide Um Good, uh, oh go back Thank you. I'm not sure I'm going to play this clip I'm not Going to um, but there's the url and you can see amy peters lalios in wisconsin There to the right Uh, and it's about a two and a half minute clip and it's quintessential teaching mom on the other end How to interact with her little? Guy there a little son on that monitor um There is no doubt the use of coaching practices increases with um Uh telepractice uh When I was talking with su le yesterday I think whenever earlier this week about uh coaching she said this and I totally agree She said my interventionist teachers who were good at coaching in person Telepractice is not a problem My providers who have not learned coach skills in coaching Other adults how to interact how to work with child Those who don't know how to be a coach Telepractice is going to be really tough.  They all had hearing loss And I compared the use of some coaching strategies in the in-person condition to the telehealth condition Telepractice condition and if you just advance to the next slide It shows you that Providers observe more in telepractice During a session than when they're in person They teach these were young kids under three years of age under 36 months of age We were teaching the parents how to interact with their kids The providers did a lot more observation When they were watching the parent interacting with their child Then uh in the in-person condition where the providers did more of the work with the child In the next one the next slide in the telepractice condition providers shared more about um The parents about what the parent was doing um They didn't do it much in either condition, but they did it more in telepractice And the next slide Would be talking to the adult that's with the child about um how the student is doing And uh in the telepractice condition There was a lot more feedback about the student about in my study about the children Seven percent compared to less than one percent in the in-person condition And the next slide was uh teaching the parents What to do with their child and uh there was more teaching being done in the in-person condition Then in the telepractice condition Uh so three of the four behaviors I studied were done more in the telepractice condition But let's advance to the schools And uh a study by Merza this year um Was talking about coaching kids and um Uh thought that the second bullet there the student can help to advertise Their participation in these virtual sessions as can the uh teacher facilitator whoever's with the child Um, and that's advanced beyond Coaching And just look at a little bit of research that i'm pretty excited about This is a uh study that is ongoing right now As was mentioned that i'm involved with at the university of colorado And this is with children who are deaf and hard of hearing and the ages of those children is six months to seven years And what we're doing now is we want to see What's the efficacy or effectiveness of telepractice compared to in-person On the child outcomes. So we're looking at testing the kids. It's a research study We test the kids with speech language tests and Another test uh of the brain which i'll explain in a minute We do all of that baseline testing. We give them six months of treatment half those kids have six months of telepractice therapy Half the kids have six months of in-person therapy And then we test them again So if you go to the next slide Let's see how this one looks when it got reformatted Can you um push return again Okay, well that's fine Um, let me explain the chart to you Well, I Well my pointer work Can someone say yes or no? Can you see my pointer? Nope. Okay. No pointer. Um every line on this graph is A child And every blue line The child is in the in-person condition And every red line the child is in the telepractice condition And that diagonal black line that goes from bottom right hand corner to upper right hand corner Is basically saying uh That's the normal developmental trajectory on the preschool language scale For kids at different ages and down at the bottom you'll see that we have two-year-olds four-year-olds six-year-olds And on the vertical axis is their their total score on the preschool language scale so Pick a line pick any line except for the one that's totally horizontal The one blue line is totally horizontal that child made no progress But every other line shows a very nice trajectory starting at the bottom ending at the dot Some lines are longer than others because some kids got more than six months of treatment We started the study with nine months of treatment. We changed it to six months But you can basically see how kids were making some really nice progress um, whether they were in person therapy or intelligent services Uh, there was no significant difference in the outcomes for kids And this was about 20 kids um Out of our total group of 70 Interesting point Over the six months average six months period in of uh intervention kids made almost 10 and a half months growth We were pretty happy about that and that was irrespective of which condition they were in Uh, next if you hit return, I think another Yeah, uh, no significant effect of the type of therapy The p value is insignificant Now let me show you the other measure and when I found out there were educational audiologists on the call I decided to toss this in I don't know if you're familiar with cortical auditory evoked potentials Where the p1 waveform that's been studied by dr. Anu Sharma also at university of colorado and her colleagues they're looking at The temporal cortex and looking at how the brain is listening And that's done with a um With electrodes pasted to the child's head The child's in the sound suite and the child is looking at a dvd. They're awake. They're looking at a dvd with no sound It has captions And the sound being emitted by the speakers in sound field is bop the syllable bop And every second Bop is emitted from the speakers and the electrodes are picking up The brain's response to that sound And um, if you go to the next slide This is a reference for What a response would look like? Um, you can see that the response differs by age. That's along the horizontal axis Those two bands with all the blue dots suggest a p1 waveform within normal limits By age and that's judged according to the brain's the Speed of the brain's response to the sound bop I'm not going to take more time to go over that But I do want to show you the results from our study on these 20 kids Next slide There you go um Look at each individual child Blue is a child in the in-person condition red is a child in the telet practice condition And look it's like every child's brain is heading toward quote within normal limits within those two black bands uh So all of this says that the therapy was significantly helpful And it didn't matter if you were in the in-person condition or the telepractice condition And this is the kind of information our federal government wants to know to prove To demonstrate the telepractice Not only does no harm, but outcomes are equally as effective as in-person services So some school age outcomes in the next um Slide for my study here that i'm involved in it's cu where we have Closed recruitment and we'll be analyzing our data for the next six months. So stay tuned for Outcomes on 70 kids and not just 20, but there's some nice work being done for kids in school Uh, a lot of these studies are on speech Production or speech articulation Sue grogan johnson in ohio Has published many studies looking at uh kids progress in the telepractice condition Similar progress to in-person on the goldman fristo test of articulation. The next study was um Looking at speech language therapy, not just articulation Similar progress in person in telepractice Next bullet is in Speech sound disorders again no difference in the two conditions and the fourth study Uh, the same and uh, these are all pretty recent Uh Studies well at least three of them are pretty recent, but sue grogan johnson has some new stuff out since 2010 So if you're looking at Is it effective? um There's a lot of data to suggest that it is if people are concerned about that So barriers if you go to the next slide um They kind of fall in these four these five areas and I feel like I've addressed attitudes sufficiently So let me look at the other four What about a technology failure? like Can't get through the firewall or During a session the modem stopped working Or the computer crashed or the audio failed or the mics didn't work Or because of a bandwidth problem the video freezes Or there's a difference in the delivery of the visual Information and the sound Basically the fix to all of this is having the information technology person on hand um If you have no tech support Addressing all of that becomes more difficult and you'll need to go to your colleagues another fix is training so that the teacher or the teacher the Facilitator the general education teacher teacher of the deaf and hard of hearing slp That they have some working knowledge remember the kids are good at it Maybe your facilitator has been received training on it um You can also have plans For technology failures And I think that that's really important to keep in mind because these things could happen A storm could come in and something happens um You're in a school and There's a classroom and everyone's on their computer and they're using up the bandwidth So that you don't have enough to have a good signal or a good synchronous signal things will happen Have a plan beyond having a fix and being prepared In the ways listed here have a plan at the beginning of your session say if we The connection is dropped. I'm going to text you Or if the connection is dropped you just disconnect wait for me. I'll reconnect Maybe I'll call you to let you know i'm back on in other words have a plan for a technology failure because It happens another area Next slide Um, let's say your facilitator didn't set up the equipment properly didn't get the student to the session on time Uh, couldn't manage the student's behavior didn't bring the therapy materials These are all things that you might be asking the facilitator or e-helper Or teacher that brings the child to the session to do for you Well, there needs to be some training about roles and responsibilities before you launch into telepractice Do your onboarding before your first session do a tech check make sure everything's working And Let them in on the plan for what should we do if we have a problem Both sign off sign back on i'm going to text you etc um And the next area The problem is not having training the fixes are training as we talked about a mentor practice a session with a friend um maintain contact with um The people that you're going to be working with calling emailing Send speech practice materials to the kids Send postcards home to tell them you send speech practice materials to the kids um It's good to get training in advance and it's good to have training as you go and with the environment um Next slide Be very careful about the feedback you give Talk about it Let them watch what you're doing um Stay in touch with the general education teacher or your team s lp educational audiologist teacher of the deaf heart of hearing um, I don't I'm kind of going quickly because I don't want to repeat myself too awfully much um, I'm going to advance uh A couple of slides You're welcome to read those practical tips, but uh again, please And one more time and stop in conclusion How about that technology? When I said at the very beginning The technology always lets us down Hopefully after this time together You might say well The technology could let me down But there are resources and increasingly easy to use software platforms To address that Before you show the next one The myth was families don't like telepractice And if you push return now Maybe it's providers and service coordinators from our experience here in colorado who are less comfortable with telepractice Maybe it's not that the families don't like it The next myth Telepractice is never as good as in-person sessions But the research is showing Maybe telepractice is no different than in-person Services When it comes to the outcomes That students are demonstrating And before you show the next one One of the myths was telepractice is a good option when there are no other options And what I'd like to propose after this talk if you would advance the slide Is telepractice Sometimes might be the best option Even when there are other options Because maybe it's motivating to the kids or maybe it's the way to develop a collaborative consultative approach I think that that's Maybe where we're heading But I think in the next few years We'll find out The next several slides you don't need to show but they're just all the references that I shared with you Which um I'm happy to send copies Or you can look them up if um You like and um I have practically used every minute of this hour and 15 minutes But if there are any questions find available And you also have my email address on the very last slide and you're welcome to contact me outside of This um Time might spend with you Thank you Arlene. I do have a question. Has there been this is sarah burns um Has there been any organization that required a certain percentage of their services be through telepractice And has was that successful? I the only place I can think of is australia where they have basically said this is our model And it's been very successful But not for a place like colorado Where it's we we don't require it We're simply supporting it and that's more typical Around the us and in other countries that I've been engaged with as well Did that answer your question sarah? Yes, it does. Um, there's one more question I don't know if it showed up on your No, okay. I'm having hard time seeing it. Sorry Um, are there rules in the united states about providing services outside of the provider's geographic zone of licensure? colorado licenses, but providing services in utah Um, yes for speech language pathologists and audiologists because that is governed by the american speech language hearing association, which I think canada Follows those guidelines at least british columbia does Asha requires speech language pathologists and audiologists to be licensed in the state in which the client resides So we do have uh providers speech language pathologists and audiologists who were licensed in multiple states Which is an issue. It's an issue for doctors as well And there's an initiative in the medical community With something called portability so that you can be licensed in several states under an umbrella license if you will And uh, I think ash is just standing by watching to see what happens there and is talking about doing something similar But that's not advancing quickly However for teachers of the deaf and hard of hearing there is not a governing body like that And we do have teachers of the deaf and hard of hearing um Seeing kids through telepractice in other states who are only licensed in the state in which they provider resides And I can't speak to occupational therapists or physical therapists. They just don't know Yeah, I'll see any other questions and I just want to thank you arlene for the review of the research and the practical suggestions and I hope this um plc inspires people to embrace these ideas and Oh after 34 years of driving I would like to get back into the practice with telepractice Thank you so much for your time. You're very welcome. A pleasure