This resource is designed to provide information about the range of service delivery models in schools, considerations for providing these services, and relevant resources. Information included will assist speech-language pathologists (SLPs) in meeting the tenets of the Individuals with Disabilities Education Act (IDEA; 2004) by delivering a free and appropriate public education program (FAPE) in the least restrictive environment (LRE) for students with communication disabilities in schools.
Service delivery is a dynamic process whereby changes are made to:
According to Part C of IDEA, services to children from birth to age 3 are to be family centered and provided in natural environments, such as the child's home and community settings, to the greatest extent appropriate to meet the individual needs of the child. For more information and resources on birth to age 3, see ASHA's Early Intervention resource.
Similar provisions are provided under Part B of IDEA for preschool and school-age students (ages 3–21 years). These provisions require that children with disabilities be provided with a FAPE and be educated in the least restrictive environment. LRE means being educated with children who do not have disabilities "to the maximum extent appropriate" to meet the specific educational needs of the student.
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Selecting the most appropriate service delivery model is a fluid process. While no single model is appropriate for all students, one must understand the range of service delivery models as well as the advantages and limitations of each model (Nippold, 2012). Student outcomes may be improved if a flexible approach to scheduling and service delivery is adopted. The frequency, location, duration, and intensity of services should be reviewed and revised based on various factors, including:
A number of evidence-based practice studies have been conducted using different service delivery models and approaches, including:
Combining service delivery models allows the SLP to focus on the individual needs of students, ensure the educational relevance of speech-language services, and reflect on treatment effectiveness.
Services provided in a separate room—away from the general education classroom—have long been the traditional location for speech-language service delivery. This location allows for focused individual or small-group service delivery but removes students from their peers who are typically developing, and some classroom instructional time is missed.
By providing integrated/in-class services, SLPs work closely with teachers and classroom staff—along with other specialized instructional support personnel (SISP)—to collaboratively address students' goals. This increases team coordination and competency to provide assistance and support to students. Research shows that when SLPs model and instruct on how to implement recommended accommodations and modifications, results include improved communication interactions within the classroom setting (Blosser, 2011).
Determining which model to use within the general education classroom is based on student need and collaboration with the teacher. A variety of in-class models are in use (Cook & Friend, 1995):
Speech-language services may be provided in a variety of educational settings, such as the playground, media center, lunchroom, vocational training site, music classroom, physical education room, and other classrooms. IDEA mandates that services be provided in the least restrictive environment and/or most natural setting.
Telepractice uses telecommunications technology to deliver speech-language services remotely (see ASHA's Practice Portal page on Telepractice). Technology allows the clinician to link to the student for assessment, intervention, and/or consultation. Studies have demonstrated that telepractice can be an effective service delivery model (Grogan-Johnson, Alvares, Rowan, & Creaghead, 2010; McCullough, 2001; Grogan-Johnson et. al., 2011; Lewis et al., 2008) and parents, students, and clinicians report satisfaction with this model (McCullough, 2001; Rose et al., 2000; Crutchley & Campbell, 2010). Factors to consider in schools when using telepractice as a service delivery option include:
The SLP schedules students for services on the same time/day(s) every week. The location and group size can and may vary; for example, the SLP may provide one session of individual pullout treatment per week and may alternate small-group pullout sessions with classroom-based service delivery every other week.
The SLP provides direct services in intense, frequent intervention for a period of time and then reduces direct services while increasing indirect services. For example, in the first semester, the SLP works with a student 90 minutes per week on individualized education program (IEP) articulation goals. In the second semester, the SLP provides 15 minutes of direct services and 30 minutes of indirect services per week to allow for independent practice of target sounds and opportunities to monitor generalization with teacher and family (Rudebusch & Weichmann, 2013).
The SLP first provides direct services to students for a period of time and then follows that up with no services—or indirect services—for a period of time. The focus in the first phase is on learning new skills; the focus in the second phase is on monitoring the stabilization of skills.
The 3:1 model is an example of a cyclical schedule. Direct services are conducted for 3 weeks in a row, followed by indirect services and activities in the 4th week. IEPs reflect the service frequency (e.g., [direct service × minutes 3×/month] + [SLP consult × minutes 1×/month]). The week of indirect services could be referred to as a "student support week" to document that services are still being provided during that week. Indirect services can include the following:
Sharing informational handouts with parents and staff can be particularly helpful. Doing so highlights the benefits of the 3:1 schedule and informs them of the scheduled student support weeks (indirect) for the school year (Lancia, J., Noble, G., & Sweeney, S.J., 2009; Strong-Van Zandt, S., & Montgomery, 2006.
Speech-language sessions are longer but less frequent, often reflecting a middle school's or high school's master block schedule, where there are fewer but longer classes every day or every semester. This schedule allows for fewer interruptions to the student's school day. Because class periods are longer, the SLP can provide a pullout session to practice a skill—immediately followed by in-class services to generalize the skills—all within the same class period (Rudebusch & Weichmann, 2013).
In this schedule, speech-language services are provided in short, intense bursts (i.e., 15 minutes 3 times per week). This model allows the SLP to provide (a) individualized services, with less travel time to and from the therapy room as services could be provided right outside the classroom, and (b) less out-of-class time (Kuhn, 2006).
Group sizes vary and fluctuate over time in response to dynamic service delivery. Considerations in grouping students includes grade level, abilities, similarities or compatibility of IEP goals. Student placement should be based on individual needs, where the most progress and benefit will occur. ASHA does not have a practice policy on determining group size in school based intervention. However, some states provide guidance based on third party payer mandates.
When providing indirect or consultative services, the SLP works with the student's teachers, staff, and family. Activities include the following:
Workload refers to all activities required and performed by school-based SLPs and other professionals. Caseload (or the number of students served) is just one part of the SLP's workload. Reasonable workloads allow for optimal service delivery to students to meet their individual needs as required under IDEA. The workload analysis approach is explained in ASHA's Caseload and Workload Practice Portal resource.
IEP documentation can influence the service delivery model that an SLP uses to provide services in schools. According to ASHA's Practice Portal Page on Documentation in Schools, services must be provided "according to what is agreed upon and documented in the IEP, including the frequency, type, duration, and location of services." Service considerations must be individualized according to IDEA. Caseloads that have a large percentage of students receiving the same amount and frequency of services (e.g., 2×/week for 30 minutes) may not be appropriately meeting the IDEA service provision requirements.
Some districts or states are more flexible in how services can be documented on the IEP. They allow "minutes per reporting period or semester" as acceptable means of recording frequency and duration of services. Documentation that allows for contact hours or services per month would allow SLPs to vary service provision while still providing appropriate services that meet the student's needs in accordance with IDEA. IEPs could also reflect changes in the frequency and location of services, depending on the individual student's needs and progress (e.g., start with more intensive services to teach a new skill and transition to less frequent or in-class services). Check with your state Department of Education or district regarding their policies for reporting services.
ASHA's 2010 professional issues statement titled Roles and Responsibilities of Speech-Language Pathologists in Schools suggests a framework for providing services in schools. Included in this professional issues statement is a list of the SLP's range of responsibilities; several of those responsibilities relate to service delivery:
The concept of "practicing at the top of the license" is gaining momentum within the speech-language pathology profession. It originated with providers in health care (e.g., physicians, nurses) to highlight the inefficiency of spending time engaged in unskilled and nonreimbursable activities. ASHA included the phrase, "Work at the top of the license" in the 2013 report titled Reframing the Professions of Speech-Language Pathology and Audiology Report [PDF]. Relevant content related to "working at the top of the license" is also provided in ASHA's 2010 professional issues statement titled Roles and Responsibilities of Speech-Language Pathologists in Schools.
Practicing at the top of the license has implications for SLPs in school settings. Many schools are experiencing tight budgets, large caseloads, and shortages of qualified providers; therefore, it is important that SLPs in school settings focus on providing professional services that (a) require the skills of an ASHA-certified SLP and (b) are within the Scope of Practice in Speech-Language Pathology.
Other routine tasks may be performed by other professionals (e.g., speech-language pathology assistants [SLPAs], aides) under the supervision of the SLP or in concert with other SISP on the school team. SLPs in school settings need to consider which service provider can best meet the needs of the students. Those considerations, in turn, may influence the service delivery model selected for a particular student.
For more information, view this course: Enhancing Service Delivery Across the Continuum (0.15 ASHA CEUs)
ASHA's Code of Ethics (2016) is a framework of principles and standards of practice for providing speech-language pathology and audiology services. Ethical practice is required for maintaining both the ASHA Certificate of Clinical Competence (CCC) and the state license, as well as most educational certifications. SLPs need to adhere to ASHA's Code of Ethics when making decisions regarding service delivery in schools. The most recent Code of Ethics, revised in 2016, devotes particular attention to interprofessional practice. Rule A of Principle IV states, "Individuals shall work collaboratively, when appropriate, with members of one's own profession and/or members of other professions to deliver the highest quality of care." Additional information on ethical issues in schools can be found on ASHA's webpage titled Ethics and Schools Practice.
ASHA's definition of evidence-based practice (EBP) includes three components—external scientific evidence, clinical expertise, and client perspectives. All three are considered when making decisions about services for students and are based on individual student needs. More information can be found on ASHA's webpage titled Evidence-Based Practice in Schools.
Making changes in service delivery may require advocacy on the part of the individual SLP at the local or state level. Here are some points to consider when trying to effect change in the school setting. Be prepared to support your case with data and facts, and consider these questions:
American Speech-Language-Hearing Association. (2016). Code of ethics. Rockville, MD: Author. Retrieved from /Code-of-Ethics/
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Blosser, J. (2011). Outcomes matter in school service delivery. Retrieved from /Events/convention/handouts/2011/Blosser-2/.
Cirrin, F., Schooling, T., Nelson, N., Diehl, S. Flynn, P., Staskowski, M...Adamczyk, D. (2010). Evidence-based systematic review: Effects of different service delivery models on communication outcomes for elementary school-age children. Language, Speech, and Hearing Services in Schools, 41, 233–264. Retrieved from https://doi.org/10.1044/0161-1461(2009/08-0128).
Cook, L., & Friend, M. (1995). Co-teaching: Guidelines for creating effective practices. Focus on Exceptional Children, 28(3), 1–16.
Crutchley, S., Dudley, W., & Campbell, M. (2010). Articulation assessment through videoconferencing: A pilot study. Communications of Global Information Technology, 2, 12–23.
Every Student Succeeds Act of 2015, Pub. L. No. 114-95, § 114 Stat. 1177 (2015–2016)
Ebert, K. A., & Prelock, P. A. (1994). Teachers' perceptions of their students with communication disorders. Language, Speech, and Hearing Services in Schools, 25, 211–214. Retrieved from https://doi.org/10.1044/0161-1461.2504.211.
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Individuals with Disabilities Education Improvement Act. (2004). Public Law 108-446, 20 U.S.C. 1400 et seq.
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Lancia, J., Noble, G., & Sweeney, S. J. (2009, November). 25 strategies to make 3:1 service delivery work for you. Paper presented at the ASHA Annual Convention, Philadelphia, PA.
Lewis, C., Packman, A., Onslow, M., Simpson, J., & Jones, M. (2008). A Phase II trial of telehealth delivery of the Lidcombe Program of Early Stuttering Intervention. American Journal of Speech-Language Pathology, 17, 139–149. Retrieved from http://dx.doi.org/doi:10.1044/1058-0360(2008/014).
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Rudebusch, J., & Wiechmann, J. (2013, August 01). Time block after time block. The ASHA Leader, 18(8), 40–45.
Strong-Van Zandt, S., & Montgomery, N. (2006, November). A comparison of service delivery models: What practicing professionals report. Paper presented at the ASHA Annual Convention, Miami Beach, FL.
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