October 17, 2006 Feature

Telepractice in the City

The Story of The Visiting Nurse Service of New York Home Care

Second in an Occasional Series of Articles Highlighting Telepractice Programs or Services Provided by Speech-Language Pathologists

The Visiting Nurse Service of New York Home Care (VNSNY), the largest certified non-profit home health care agency in the United States, faced the challenge of providing speech-language pathology services for a growing number of patient referrals given the shortage of speech-language pathologists in the workforce. In July 2002, the agency initiated a telepractice proposal for a project utilizing real-time interactive audio and visual telepractice technology to provide treatment interventions to meet the growing demand for services.

In May 2003, the Speech Telehealth Program was piloted and launched in Manhattan and now includes service in Brooklyn, Queens, and the Bronx. More than 200 patients have participated and received treatment in the speech telepractice program.

This collaborative model of speech services combines service delivery via telepractice as an adjunct to the traditional in-home speech treatment visits. The telepractice treatment interventions support the established plan of care initiated by the treating SLP.

The field clinician completes an in-home comprehensive evaluation and a telepractice screening. This screening assesses the home environment to accommodate telepractice equipment, evaluates patient and caregiver capabilities (such as visual and auditory acuity), and identifies speech clinical conditions (such as learning potential or functional receptive language skills) necessary to participate in speech telepractice. Patient willingness to participate in the program is established and written patient consent obtained. VNSNY clinicians report a Functional Assist Code Level for speech, language, swallow, and cognitive abilities and determine the level of care required for the patient based on the assessment results.

Patients who present with restorative and/or compensatory clinical potential can be considered for the program if treatment intervention techniques deemed appropriate for care can be delivered not only during in-home visits but also via telepractice. The clinical evaluation and the telepractice screening process are key components of the admission criteria and assist the clinician in making the decision about admitting patients for speech telepractice services.

Patients with stroke, transient ischemic attack, neurogenic dysfunction, and/or neuromuscular dysfunction have been admitted to the telepractice program. At VNSNY, patients with Parkinson's disease constitute 55% of the patients in the current program. Telepractice services also are beneficial to patients who have communication disorders following a stroke. A significant number of homebound patients who receive speech services present with aphasia and/or an associated dysarthria, which may require intensive treatment due to the sub-acute clinical stage. Telepractice treatment interventions allow the SLP to increase the patient care time to meet the care needs of the communicatively impaired homebound patient. Sub-acute patients with restorative clinical potential can benefit from daily intervention with the use of telepractice services in addition to in-home visits.

Patients receive telepractice interventions in the area of oral-motor exercise, language treatments, voice, dysphagia, and cognitive-communicative interventions. For example, telepractice treatment sessions may include oral motor exercises to improve the range of motion, strength, coordination of the articulators, and sound placement or articulation drills to improve speech production and intelligibility. Sessions also may include speech rate tasks and instruction in compensatory dysarthria techniques. Expressive language stimulation exercises, including generative and responsive naming exercises or verbal formulation treatments, can be effective treatments for patients at the appropriate time in the recovery process from stroke. Each telepractice session is designed to meet the individual needs of the patient's specific speech-language or swallowing problems. In addition to providing skilled speech treatment, telepractitioners place special emphasis on caregiver training and developing a speech home exercise program to facilitate carryover of learned skills to the functional home environment.

As the program evolved, it added a special focus on evidence-based voice treatment for individuals with Parkinson's disease. Telepractice sessions combined with home visits make it possible to offer the Lee Silverman Voice Treatment program that is recommended at an intensive treatment frequency of four times a week. Telepractice treatment options provide the homebound patient with the opportunity to receive evidence-based speech treatments despite the clinician's inability to provide intensive treatment due to caseload or other restrictions.

In 2004 VNSNY conducted a patient satisfaction survey on telepractice program services, assessing patient satisfaction in the following categories: easy to use, easy to learn, appropriate training received, improved overall plan of care, and staff knowledge and professionalism. Patient satisfaction ratings were summarized using a 1-5 point Likkert scale (1= strongly disagree, to 5 = strongly agree); results ranged from 4.2 - 4.8. Patient feedback was very positive about the experience of telehealth services. Subsequently, patients rated improvement in an overall plan of care at 4.3 on the scale.

Speech telepractice is an adjunct treatment service used to enhance accessibility, patient outcomes, efficiency, and cost effectiveness of speech-language pathology services at VNSNY. It is provided at no cost to the patient and is improving patient access to service. Further ongoing analysis of the Speech Telehealth Program and data metrics is underway and beneficial to meet and effectively manage program and agency initiatives. Enhancing patient care remains its core element.

Daniel J. Carpenedo, is a clinical specialist in speech-language pathology for the Visiting Nurse Service of New York Home Care. He provides diagnostic and treatment services for homebound patients, clinical supervision and education, and operates the Speech Telehealth Services Program in Manhattan. Contact him at dan.carpenedo@vnsny.org.

cite as: Carpenedo, D. J. (2006, October 17). Telepractice in the City : The Story of The Visiting Nurse Service of New York Home Care. The ASHA Leader.

Clinical Case Study

Mr. J.W., 82, was referred to speech services by the Visiting Nurse Service of New York due to decreased speech intelligibility related to Parkinson's disease.

During the evaluation in the patient's home, the speech-language pathologist also completed a speech telepractice screening protocol. She determined that the home environment, client/caregiver capabilities, and recommended treatment interventions could be delivered appropriately with a combination of home and telepractice visits. The patient and family consented to the delivery of service using both methods.

The field SLP established a plan of care with the patient and obtained orders from the physician for one home visit per week and three telepractice sessions per week for speech/voice treatments.

During the course of treatment, the field SLP obtained objective SPL levels for loudness on a weekly basis while in the home and established the home exercise program. The program consisted of LSVT® (Lee Silverman Voice Treatment) daily exercises and other transfer activities for carryover of improved speech and voice production in functional activities. The patient participated in interactive speech telepractice sessions conducted by the speech clinical specialist, which followed the identical plan of care as established by the field SLP.

The patient made excellent progress, achieving >95% intelligibility at discharge. Over a five-week period he received five in-home patient treatments with 12 speech telepractice treatments. The patient's satisfaction was 4.8 on a Likert scale of 1-5, with 5 indicative of a highly satisfied rating.

The patient and his wife reported that speech telepractice services positively affected his clinical outcome and plan of care. 



To Determine Care Level

  • Complete in-home speech-language evaluation
  • Identify speech treatment interventions
  • Assess home environment and patient/caregiver capabilities
  • Establish patient willingness to participate
  • Report Functional Assist Code Level 


References

American Speech-Language-Hearing Association. (2005). Knowledge and Skills Needed by Speech-Language Pathologists Providing Clinical Services via Telepractice.  Available at: www.asha.org/about/leadership-projects/archive/focused-initiatives/01-03-archive/telepractice.htm.

American Speech-Language-Hearing Association. (2004a). Speech-Language Pathologists Providing Clinical Services via Telepractice: Position statement. Available at: www.asha.org/about/leadership-projects/archive/focused-initiatives/01-03-archive/telepractice.htm.

American Speech-Language-Hearing Association. (2004b). Speech-Language Pathologists Providing Clinical Services via Telepractice: Technical report. Available at: www.asha.org/about/leadership-projects/archive/focused-initiatives/01-03-archive/telepractice.htm.

American Speech-Language-Hearing Association. (2002). ASHA Speech-Language Pathology Health Care Survey. Rockville, MD: Author.

Health Resources and Services Administration. (2002). Telehealth Technology Guidelines. Retrieved from http://www.hrsa.gov/telehealth/.

Vaughn, G.R. (1976). Tele-communicology: Health care delivery system for persons with communicative disorders. Asha, 18, 13-17. 



  

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