November 28, 2006 Feature

Telepractice Brings Treatment to Rural North Dakota

Fourth in an occcasional series of articles highlighting telepractice programs or services provided by speech-language pathologists

In the past four years, a successful pilot project has linked the St. Alexius TeleCare Network with patients in need of speech-language services at the Ashley Medical Center in Ashley, ND.

The project, which started in May 2002, grew quickly with the assistance of a grant awarded to the TeleCare Network by the federal Office for the Advancement of Telehealth (OAT). The OAT grant ended in August 2004, but during that time tremendous strides were made: 49 patients from western and central North Dakota received either evaluation or treatment.

In the past four years, major changes have taken place in areas of reimbursement and research. At the time the project was initiated, no reimbursement was available for speech treatment delivered by telepractice. Of the 49 patients treated, 86% were covered with funds from the OAT grant. As the end of the grant period approached, St. Alexius began requesting coverage from Medicaid, Medicare, and Blue Cross/Blue Shield. Medicaid began coverage, with prior approval, in the summer of 2002. Blue Cross/Blue Shield began coverage in October 2003, also with prior approval. Medicare continues to deny reimbursement of telepractice speech services.

The TeleCare Network utilizes real-time, two-way, interactive teleconferencing equipment over dedicated T-1 phone lines. A document camera, called an "ELMO," is used to view evaluation and treatment materials to facilitate patient learning. Although an evaluation may take one hour to complete, individual treatment sessions are typically 30-45 minutes and most often are scheduled two to three times a week for three to six months.

Clinicians from St. Alexius Medical Center treat pediatric through geriatric patients, with diagnoses that include global developmental delays, speech and language deficits, autism, voice disorders, cognitive deficits, aphasia, apraxia, dysarthria, dyslexia, and dysphagia.

At the time the pilot project was initiated, the Speech-Language Pathology Department at St. Alexius consisted of three full-time employees. These three speech-language pathologists (SLPs) were responsible for inpatients, transitional care, rehabilitation, outpatients, home health care, and outside contracts. To meet the increasing demands and the addition of telepractice patients, the department hired an additional full-time employee and two on-call staff. A telepractice specialist, the SLP, and the rural telepractice coordinator at St. Alexius—and a nurse, physician's assistant, physician or interpreter at the rural site—were all needed to ensure the telepractice session worked effectively.

Documentation for telepractice speech treatment follows the same requirements as outpatient visits. Initially a physician order is required from the referring provider for an evaluation and/or outpatient treatment. A telepractice request form is also needed from the rural health care facility. An evaluation is done by the SLP and is faxed to the referring physician. Initial certification is obtained before the first treatment session and then renewed every 30 days.

The SLP completes a daily flow sheet and charge ticket for each session. Upon discharge, a final report is faxed to the referring physician. Although there are no changes in the requirements for documentation, there are changes in the CPT codes. Telepractice charge tickets continue to have the same CPT codes for evaluation and treatment, but the modifier changed from GN to GT, indicating that the encounter was through telepractice rather than face-to-face.

Patient Response

Patients have responded positively to receiving treatment by means of telepractice. Speech treatment is not available in many rural health care facilities in North Dakota; telepractice allows rural patients the convenience and efficiency of staying in their own community for services. One of the first stroke patients in the pilot project stated, "I would not have traveled the 96 miles to Bismarck and was very pleased that services were provided using telepractice."

Patients appreciate receiving services two to three times a week without the expense of fuel, meals, and time off from work for the patient and/or family members. The wife of a recent telepractice patient with Blue Cross coverage said, "I wasn't sure how I would be able to maintain my health benefits if I had to stop working to drive my husband to Bismarck two or three times a week for treatment." In addition to reducing expenses, telepractice also eliminates the hazards of driving on winter roads in North Dakota.

St. Alexius SLP Kathie Beneke said, "Due to staffing and time limitations, we were not able to treat patients in their rural communities. With telepractice these patients now have access to speech-language services."

A school-based SLP treating a young patient with a brain tumor said, "Education-based speech treatment follows a specific curriculum to help the student participate in the classroom. I felt the telepractice services provided additional hours and focused on the dysarthria and aphasia, helping her to excel."

The future of the delivery of speech-language pathology services by telepractice looks promising. The willingness of the SLPs and the patients' continuing satisfaction indicate that telepractice has a definite future and value in rural communities. The Telemedicine and Speech Language Pathology departments at St. Alexius, along with ASHA, continue to advocate-with support from OAT and the Center for Telemedicine Law-for Medicare reimbursement for telepractice speech treatment. In addition, the SLPs at St. Alexius are working in conjunction with ASHA to study the effectiveness and benefits of telepractice speech services through the use of the National Outcomes Measurement System.

Patients in many rural settings have benefited from speech treatment delivered through telepractice. The success of this project over the last four years can be partially attributed to the willingness of skilled SLPs to reach out to those in underserved areas of central and western North Dakota by integrating telepractice into their schedules.

Bobbie Houn, is senior speech-language pathologist at St. Alexius Medical Center inBismarck, ND. She provides diagnostic and treatment services for hospital inpatients, outpatients including through TeleMedicine, and home health care patients. Contact her at

Kolette Trottier, is telehealth nurse coordinator for St. Alexius Medical Center in Bismarck, ND. She coordinates the TeleCare Network for clinical specialties and education. Contact her at

cite as: Houn, B.  & Trottier, K. (2006, November 28). Telepractice Brings Treatment to Rural North Dakota. The ASHA Leader.


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