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Considerations for Speech, Language, and Cognitive Assessment via Telepractice

This resource provides some guidance for speech-language pathologists (SLPs) conducting assessments of speech, language, and cognitive communication via telepractice. (Assessment of swallowing or feeding is not included.) Although many of these considerations may apply at any time, some are unique to the COVID-19 pandemic.  

There are many considerations to ensure that telepractice assessments are equivalent to those completed in-person. ASHA’s Practice Portal on telepractice identifies that audiologists and SLPs should

  • select clients who are appropriate for assessment and intervention services via telepractice;
  • select and use assessments that are appropriate for the technology and that take into consideration client and disorder variables; and
  • be sensitive to cultural and linguistic influences that affect the identification and assessment of communication disorders and differences in individuals receiving services via telepractice, which may include collaborating with interpreters.

ASHA recognizes that the COVID-19 pandemic is unprecedented and requires unique—and sometimes, less than ideal—measures to assess a person’s communication needs. It’s critical for SLPs to adhere to the ASHA Code of Ethics and federal, state, and district guidelines regarding telepractice to ensure, to the fullest extent possible, that they are providing high quality services. This includes consideration of the use of interpreters and translators during services to English learners, as needed, to provide effective clinical services.

SLPs in all practice settings should also verify state licensure requirements for telepractice and telesupervision to be aware of existing regulations and any recent telepractice policy changes [PDF] that may impact delivery of audiology and speech-language pathology services.

Evidence

The telepractice Evidence Map provides an overview of evidence on the feasibility of assessments via telepractice for various clinical populations. The systematic reviews and clinical practice guidelines cover audiology and speech-language pathology topics.

What to Consider When Performing Assessments via Telepractice

Prior to Initiating Assessment

Some ASHA members have expressed concerns about needing to perform evaluations and assessment in nontraditional ways without their usual fidelity. Clinicians may want to consider and discuss the following with employers and payers:

  • Any components of an evaluation or assessment procedure that is waived or revised, such as requirements for norm-referenced or criterion-referenced tools
  • Considerations for nonstandardized assessments should be reflected when the client does not fit the norming sample
  • Clinical opinion and functional information obtained by using the client’s natural environment, observation (live or recorded), and family/caregiver reports
  • Opportunity or benefit of pre-conferencing with families/caregivers to help gather materials needed for assessment, such as manipulatives or sample videos
  • Considerations for language used in the home, including any needs/requirements for collaboration with an interpreter/translator
  • Critical information needed to establish eligibility and/or develop a treatment plan, and aspects of the assessment that need to be deferred to a later time

In addition to the client’s clinical presentation, SLPs should consider

  • their skills/competency in techniques such as coaching families;
  • families’ understanding and feelings about telepractice services;
  • home/work life responsibilities of parent(s)/caregiver(s);
  • familial norms; and
  • access to technology.

Standardization

Some publishers of standardized assessments have developed guidance about administration of tests via telepractice or validated assessments for administration via telepractice. Other researchers have compared the validity of in-person and remote assessment protocols (Sutherland et al., 2016; Taylor, et al., 2014).

When using a test that has been validated for telepractice administration, document the interpreted scores as you would from in-person administration. Check with the test publisher if the assessment tasks show evidence of in-person vs. remote administration equivalency for administration via telepractice. Verify that your client falls within the norming sample of that instrument. 

If the test you’re using does not fall under this category, the reliability and validity of the test is in question for remote administration. Be sure to document this, including a discussion of modifications, such as collaboration with an interpreter/translator or modification of prompts. Use of a test in a nonstandardized manner may also impact billing of standardized assessment codes (see the Coding and Payment Policy section below).

Individual test publishers (e.g., Pearson) may offer free access to their digital products, including test stimuli, in response to clinicians’ needs during COVID-19.

Modification of Test Materials

Publisher permission is required to copy, scan, or modify test materials in any way. Permission is given on a case by case basis. Many publishers, including ProEd [PDF] and Pearson [PDF], have issued statements waiving certain requirements during this pandemic, but make sure to check with the publisher before modifying tests. Recording of test administration (such as recording a telepractice evaluation session) continues to be prohibited by most publishers.

Documentation of Assessment Results

SLPs must state modifications made to test materials, administration procedures, or other aspects of an assessment in the interpretation and documentation of the assessment. This may include skills observed by the clinician versus skills reported by others, use of an interpreter/translator, any behaviors that may have impacted performance and interpretation of results, and recommendations for reassessment.

Coding and Payment Policy

Coding and payment considerations for telepractice services are generally the same as in-person services. SLPs providing telepractice should report Current Procedural Terminology (CPT) codes just as they would if the services were provided face-to-face and follow the same guidelines for appropriate billing. For example, time spent administering nonstandardized tools for telepractice may not be reported using CPT codes requiring standardized tests. ASHA provides additional guidance on coding and payment for telepractice as well as extensive resources on CPT coding for speech-language pathology services. Always verify coverage and payment guidelines with payers before initiating telepractice services.

Population and Setting Considerations

Birth to Three

The decision to accept assessment via telepractice when determining eligibility is subject to facility/employer/state agency requirements, payer regulations/requirements, as well as independent SLP clinical judgment on a case-by-case basis. Considerations of the language used in the home are reflected in the treatment plan. See IDEA Issue Brief: Part C Cultural and Linguistic Diversity.

During this time, some early intervention (EI) programs have reported using assessment tools that include parent interviews. Some ASHA members have shared ideas for EI telepractice resources on the EI ASHA Community.

School Settings

The U.S. Department of Education (ED) provides the following guidance about IDEA timelines in its “Supplemental Fact Sheet: Addressing the Risk of COVID-19 in Preschool, Elementary and Secondary Schools While Serving Children with Disabilities” [PDF]:

“As a general principle, during this unprecedented national emergency, public agencies are encouraged to work with parents to reach mutually agreeable extensions of time, as appropriate.”

This statement supports flexibility in achieving timeline requirements as well as opportunities to prioritize evaluations. SLPs must follow state requirements, which include making determinations to inform school district decisions. To date, ED has not issued specific guidance on using telepractice for evaluations.

Similarly, when providing intervention via telepractice, it’s important to consider federal privacy laws like the Health Insurance Portability and Accountability Act (HIPAA) and Family Educational Rights and Privacy Act (FERPA). During this pandemic, the U.S. Department of Health and Human Services (HHS) relaxed requirements to comply with HIPAA for some videoconferencing platforms; however, relaxation of HIPAA does not impact compliance with FERPA. FERPA usually takes precedence over HIPAA when educational agencies or institutions receive direct funding from ED.

One consideration for your school district is whether a statement about allowing the disclosure of personally identifiable information to other parents and household residents during telepractice or virtual instruction should be included in a FERPA consent-to-disclose form. ED provides a sample FERPA consent to disclose form at the bottom of their “FERPA and Coronavirus Disease 2019 (COVID-19) Frequently Asked Questions (FAQs)” [PDF].

Health Care Settings

Telepractice in health care settings has not been extensively used in the United States due to the lack of reimbursement from both public and private third-party payers. With relaxed regulations and increased reimbursement options during the COVID-19 pandemic, SLPs in health care settings may have remote service delivery options for the first time. Before starting telepractice in health care settings, ASHA recommends the following considerations:

  • Ensure access to appropriate technology for both patient and provider. This may look different depending on the type of health care setting. For instance, in an acute care setting, there may be a selection of shared devices between different units or care teams. In home health, the clinician or provider may be using their own personal devices, and both access and ability to navigate software platforms should be ensured before initiating services.
  • Ensure availability of extenders who are appropriately and adequately trained. Extenders are crucial in facilitating access to and use of technology, troubleshooting technological issues, and assisting with repairing communication breakdowns. Depending on the setting, extenders could be nurses, nursing aids, rehabilitation assistants, family members, or other staff. Regardless of who is acting as an extender, they need to be adequately trained to facilitate remote assessment without impacting the validity of results.
  • Ensure linguistic access to services. Patients and extenders may require the assistance of an interpreter to appropriately access services. Like extenders, interpreters may need to be adequately trained on facilitation of clinical services. See Collaborating with Interpreters.
  • Be aware of any comorbidities that may impact a patient’s ability to participate. Across the continuum of care in health care, patients may present with various comorbidities that could impact their ability to fully participate. Concomitant cognitive, hearing, motor, or vision impairments could significantly impede a patient’s ability to participate in remote sessions and should be considered prior to initiation of assessment.
  • Ensure proper infection control protocols for shared devices. In the event that a care team is sharing devices between providers or patients, infection control policies and procedures should be in place and followed. See ASHA’s infection control resources page for additional information.
  • Promote frequent communication between care team members. As with the implementation of any new service delivery model, when initiating the use of telepractice in health care settings, communication between all stakeholders is key to successful use of remote service delivery. This is important for the episode of care, and to promote continuity of care and discharge planning as the patient moves through the continuum of care.

Additional Resources

References

American Speech-Language-Hearing Association. (2016). Code of ethics [Ethics]. Available from www.asha.org/policy/.

American Speech-Language-Hearing Association. (n.d.). COVID-19: Tracking of state laws and regulations for telepractice and temporary practice. Available from www.asha.org/siteassets/uploadedfiles/State-Telepractice-Policy-COVID-Tracking.pdf [PDF].

American Speech-Language-Hearing Association. (n.d.). Telepractice. (Practice Portal). Available from www.asha.org/Practice-Portal/Professional-Issues/Telepractice/.

American Speech-Language-Hearing Association. (n.d.). Telepractice resources during COVID-19. Available from www.asha.org/About/Telepractice-Resources-During-COVID-19/.

Dantuma, T. (2014). The similarities and differences of telepractice and in-person pediatric speech assessment results. Northcentral University.

Mullins, S., Lane, K., & Lowman, J. (2017, November). How a pink Post-It may improve diagnostic testing in a telepractice environment. Poster session presented at the Annual Convention of the American Speech-Language-Hearing Association, Los Angeles, CA.

Sutherland, R., Hodge, A., Trembath, D., Drevensek, S., & Roberts, J. (2016, September). Overcoming barriers to using telehealth for standardized language assessmentsPerspectives of the ASHA Special Interest Groups, 1(SIG 18), 41–50.

Taylor, O.D, Armfield, N.R, Dodrill, P., & Smith, A.C. (2014). A review of the efficacy and effectiveness of using telehealth for paediatric speech and language assessment. Journal of Telemedicine and Telecare, 20(7), 405–412. doi:10.1177/1357633X14552388

Waite, M. C., Cahill, L. M., Theodoras, D. G., Busuttin, S., & Russell, T. G. (2006). A pilot study of online assessment of childhood speech disordersJournal of Telemedicine and Telecare12(3_suppl), 92–94. doi: 10.1258/135763303779380048

Waite, M., Theodoros, D., Russell, T., & Cahill, L. (2010). Internet-based telehealth assessment of language using the CELF-4Language, Speech, and Hearing Services in Schools, 41, 445–448.

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