Remote and underserved school districts across the country increasingly are turning to telepractice to meet the communication needs of their students—and finding success. "It's no secret that rural districts and small districts are having a difficult time recruiting qualified speech-language pathologists," said SLP Jeanne Juenger, who has completed two successful telepractice demonstration projects in Minnesota. Telepractice, "the application of telecommunications technology to deliver professional services at a distance" (ASHA, 2005), can incorporate a variety of equipment and software configurations, and schools fund its development in different ways.
Juenger emphasized that implementing telepractice does not require "tens of thousands of dollars. You just need to use readily available technology well." In Minnesota, for example, she had no sophisticated videoconferencing software; instead, she used two computers—hers and at the remote school—and Skype, free software that allows users to see and talk with each other.
But she also cautioned that a successful telepractice model involves "preparing a good implementation plan, recognizing your stakeholders and drawing on their strengths and enlisting their commitment, and preparing for the unique challenges involved in effective telepractice, including documentation management, working with virtual and co-located teams, and appropriately documenting roles and responsibilities."
Despite its challenges, Juenger views telepractice as having limitless potential. "You could even use the model within a district to reduce the amount of time wasted traveling among the schools," she said. "We should be using technology wisely to get the optimal benefit from our available resources."
In West Virginia, a private provider has joined the effort to extend services to students in remote and under-served public school districts.
LinguaCare Associates, Inc., has been providing speech-language services in West Virginia public schools since 1990, and has contracts with 10 districts located within 60-70 miles of its location in Hurricane. LinguaCare recently initiated telepractice because "we get calls every year from special education directors in remote areas of West Virginia requesting services for their students, and we can't provide them because of the travel time," said SLP Vickie Pullins, co-owner.
Officials from the state department of education agreed to a trial telepractice program. "Because of the established pattern of quality services that our company has already provided with face-to-face treatment, officials were confident that if we launched a telepractice it would be a quality service as well," Pullins said. "Therefore, support from educational administrators has been excellent."
To initiate the project, Pullins first reviewed ASHA's information on telepractice; researched and interviewed other SLPs already using the model; and researched available technology. She also contacted officials about Medicaid reimbursement for telepractice in the schools.
"After all that, I met with the state department of education to identify a school district that had the necessary equipment and a willingness to allow us to implement a trial project," Pullins said, "including the provision of a paraprofessional at the remote site."
Many districts in West Virginia already have computer hardware and software in place for long-distance learning, so LinguaCare purchased compatible equipment for its offices. Services began in late winter in a district in southern Ohio where the SLPs had extremely high caseloads and the district had been unsuccessful in recruiting additional staff.
"We do some testing of students in that county, so we already had a connection with them," Pullins said. "We are now serving 15 middle school students with speech, language, and fluency disorders with very good success."
A paraprofessional who is a retired curriculum specialist from that county works on-site with the students in an ancillary role, gathering materials, preparing homework received by fax, and accompanying students to and from class. "She was trained on the use of the equipment by the IT personnel in the school district," Pullins explained. "With her educational background, she is an excellent person to be observing and evaluating our service. She provides us with feedback weekly; her input resulted in changes after only three to four weeks into the project."
Pullins cites technical glitches and "not being able to get my hands on the students who need help with articulatory placement" as her biggest challenges so far. "I am learning so much about the technical side of this project, but I would really like to be able to concentrate on the clinical side," she said. She has traveled to the remote site every other week to work with students who need hands-on treatment before they can participate in telepractice—those with articulation disorders who cannot produce the target phonemes in isolation such as lateral /s/ and /r/.
These visits, however, offer additional benefits—Pullins is building rapport with teachers and administrators and working with the paraprofessional on homework distribution and treatment activities.
"Feedback has been excellent," Pullins said. "Five weeks into the program, I called the students' parents, and they were very positive. One parent who initially was not enthusiastic about telepractice reports that her son—who never talks about school—comes home on telepractice days telling her all about his session with the ‘lady in Charleston on the TV screen.' Teachers and administrators have been most supportive."
Pullins has developed an instrument for assessing the quality of services that students, parents, teachers, and administrators will complete at the conclusion of this project. The feedback "will help us improve our overall telepractice service," she said.
About a dozen school districts have already expressed interest in the program for the 2008–2009 school year, and Pullins has connected them with the teleconferencing equipment company to investigate grants for purchasing equipment.
"We are always looking for ways to address the shortage of SLPs in West Virginia," Pullins said, "and we are excited about the possibility of being able to provide services to children in our state who have limited or no access to speech-language treatment."
In Ohio, a telepractice initiative receives state funding as part of a multi-pronged effort to increase the availability of speech-language services statewide.
A 10-year-old program—the Ohio Master's Network Initiatives in Education-Speech Language Pathology (OMNIE)—works to minimize the shortage of SLPs in Ohio schools (see The ASHA Leader, May 6). Sponsored and supported by the Ohio Department of Education, OMNIE collaborates with the Ohio Speech Language and Hearing Association, the Ohio School Speech Pathology Educational Audiology Coalition, and universities in the state. The project has focused on distance-learning master's programs to boost the number of qualified SLPs in the state and on clinical internships in the schools that lead to employment upon graduation.
OMNIE recently added funding for a telepractice program to determine if the service delivery model is a viable way to bring speech and language services into rural districts. Now completing the first of a two-year pilot (which has been extended an additional two years), the telepractice program provides services to 36 students grades K–7 in four districts in rural Hardin County.
OMNIE funds purchased computers, Web cameras, and teleconferencing software for the four school districts of the Hardin County Educational Service Center (ESC) in the west central part of the state, according to Susan Grogan-Johnson, OMNIE telepractice coordinator. (In Ohio, ESCs provide educational support services to a coalition of smaller districts in a specific geographical region.)
"We consulted with technical experts and others already doing telepractice to determine what hardware and software to buy," Grogan-Johnson explained. "We wanted the best available technology, but we also want equipment that's easy to use." The project uses videoconferencing software that allows for data-sharing and collaboration.
The grant also pays the salary of an SLP, Robin Alvares, who provides telepractice services from an office in Kent State University's Department of Speech Pathology and Audiology. "We wanted to house the program in a university, because this pilot is really a research project," Grogan-Johnson said, "and because we thought graduate students could eventually participate as part of a practicum."
The pilot uses a split-half design, in which students in the study receive telepractice services for half the school year and traditional face-to-face services for half of the year. "We are comparing the students' progress through language samples, NOMS (National Outcomes Measurement System) ratings, and standardized articulation testing," Grogan-Johnson said. "Most of the students have articulation impairments, and we also have students with language and stuttering impairments."
Data are collected at the beginning, middle, and end of the school year, Grogan-Johnson said. "Our hypothesis is that students will make progress in both face-to-face and telepractice service-delivery models."
At the remote sites, "e-helpers"—similar to aides—transport students to and from the sessions and remain in the room but do not participate in treatment. They assemble materials as needed for the sessions and intervene with technical difficulties.
On-site SLPs from the Hardin ESC have assisted in the telepractice project and have also been instrumental in scheduling telepractice sessions. Paperwork is completed online with shared software; Alvares prints and sends it to the remote sites. Parents participate in IEP and progress meetings via videoconferencing.
"The kids like telepractice," Alvares said. "They like wearing the headphones and playing on the computer. However, we can't get into the classroom to work on classroom-based goals with push-in activities."
Technology glitches are sometimes a problem, she said, noting that "we haven't yet found software that has all the features we want." In addition, the video camera can capture only two students at once, precluding group treatment and complicating scheduling issues.
Alvares also said that "teachers have to buy into the model," noting that some e-mail her frequently about students, and some initiate no contact at all. "It's important that the stakeholders know who you are," she said. "I would suggest having an open house at the remote site early on to meet teachers and parents."
Grogan-Johnson agreed that the limited collaboration between Alvares and teachers is an unanticipated difficulty. "Faculty members are not embracing the model," she said. "Next year, despite travel costs, the SLP will visit the school and meet teachers. We hope this connection will extend the professional relationship."
"It's too soon for documented results, but our impression is that students love to come to telepractice," Grogan-Johnson said. "They like the individual attention, putting on the headset and microphone, and controlling the mouse. In general, we have the sense that students in the two groups are making similar progress."
Plans for next year include adding a second school district—about 40 students, including preschoolers—to the project.
"We're finding that telepractice is a wonderful service delivery model that has the potential to fill a niche in speech-language treatment in public schools," Grogan-Johnson said. "It has the potential to provide master's level speech-language treatment to students who wouldn't receive services otherwise. I'm excited that the Department of Education wants to gather data and determine if this method is reliable and feasible for Ohio's students."