Stredler Brown Handout

The State of Telepractice for Delivering
Early Intervention Services

Arlene Stredler Brown, PhD, CCC-SLP
University of Colorado
arlene.brown@colorado.edu
Disclosures
• Financial:
– Financial compensation from ASHA for this presentation
• Nonfinancial:
– None
ASHA 19005 1
Learning Objectives
Participants will be able to…

• Learning Objective 1: State common concerns about the use
of telepractice
• Learning Objective 2: Identify the growing evidence that
supports the use and efficacy of telepractice with young
children and families in early intervention programs
• Learning Objective 3: Describe the processes undertaken by
state early intervention programs and smaller nonprofit
agencies as they have adopted and funded telepractice
• Learning Objective 4: Summarize the attitudes toward
telepractice of parents, service coordinators, providers, and
administrators
ASHA Strategic Objectives
• Expand data available for quality improvement and

demonstration of value
– Data is emerging, through an NIH-funded telepractice study,
demonstrating the efficacy of telepractice with young children
who are deaf or hard of hearing
• Enhance service delivery across the continuum of care to
increase value and access to services
– Qualitative data suggests that telepractice increases access to
services, especially for clients in rural areas who seek
experienced professionals with knowledge of specific treatment
strategies
ASHA 19005 2
Myths About Telepractice
Do These Ring True for You?
• “The technology always lets us down.”
• “Families don’t like telepractice.”
• “Telepractice is never as good as in-person sessions.”
• “Telepractice is a good option when there are no other

options.”
ASHA 19005 3
Quick Polling #1
Rate the challenge, as you perceive it today, of

delivering services via telepractice:
a. Not a challenge
b. Minimal challenge
c. Moderate challenge
d. Large challenge
e. Too much of a challenge to try it
A Recent Poll (n = 83)
Perceived Challenge % n
No challenge 0 0
Minimal 35% 31
Moderate 46% 37
Large 14% 11
Too much to try 5% 4
ASHA 19005 4
Quick Polling #2
Best practice recommends the use of coaching

behaviors in early intervention treatment sessions.
Do you think EI providers use the same amount or
different amounts of coaching behaviors in telepractice
sessions and in-person sessions?
A Recent Poll (n = 88)
% n
Same amount 85% 75
Different amounts 15% 13
ASHA 19005 5
Early Intervention Colorado
Evolution of Telepractice in Colorado:

A Program on a Mission; an Inter-Agency Effort
~15,000 children receive services through Early Intervention Colorado (JBC Report, 2017)
Year Initiative
2015 Colorado Medicaid funds telepractice (for selected disciplines;
SLP included)
2015 Initial in-person telepractice training at one community Part C
agency (there are 20 agencies statewide)
2016 Online Telehealth Training Modules (4) launched (online; DIY)
As of January 2018, 5% of providers completed the training; as
of January 2019, 271 (17%) have completed it.
2017 State law passes; supports insurance coverage of telepractice
July 2017– 440 telepractice sessions completed

September
2018 <0.1% of all services delivered to Part C children in Colorado (EI
Colorado Data system, 2018)
ASHA 19005 6
What is Working? What is Missing?

 EI Colorado created a Padlet
with practical suggestions,
publications, policies, &
legislation
 For-profit therapy agencies
using telepractice joined
task force
 Foundations support
telepractice (particular
interest in serving children
who are deaf or hard of
hearing)
 A sixfold increase in number
of providers billing for
telepractice sessions
What is Working? What is Missing?

 EI Colorado created a Padlet
with practical suggestions, - Not all disciplines (e.g., PT)
publications, policies, & can bill Medicaid
legislation - Few providers (2%) are billing
 For-profit therapy agencies for telepractice
using telepractice joined - Not all state agencies are on
task force board (State School for the
 Foundations support Deaf)
telepractice (particular
interest in serving children
who are deaf or hard of
hearing)
 A sixfold increase in number
of providers billing for
telepractice sessions
ASHA 19005 7
Why is Telepractice Underutilized?
• Surveys distributed to four groups

– Local program administrators (n=8)
– Service coordinators (n=39)
– Providers (n=112)
– Families (n=2)
• Follow-up focus groups with administrators and parents
Provider Results: Age of Respondents
ASHA 19005 8
Provider Results: Child Progress
Provider Results: Parent/Caregiver Involvement
ASHA 19005 9
Provider Results: Technology
Provider Summary
Positive Perceptions Negative Perceptions
• Most respondents support • Attitudes:
the use of telepractice to – Telepractice is not family-
address: friendly
– Provider shortages – It’s impersonal
– Inclement weather – It’s not as good as in-
– Illness (provider and child) person visits
– Travel burden • Access to bandwidth
• Respondents like the
flexibility telepractice offers
to join a family during daily
routines
• More family engagement
ASHA 19005 10
Service Coordinator Results: Caseload
Service Coordinator Results: Acceptability
ASHA 19005 11
Service Coordinators: Comments
• “Families don't get to know the therapist as well. Many of the

EI therapy sessions are very hands on and hard to do over the
computer.”
• “Being rural, I don't want families to think they are getting a

‘lesser’ version of therapy.”
Some Parents are Very Comfortable Using

Telepractice
Video #1 here
ASHA 19005 12
Each State is Unique: Part C Telepractice in NM

• Collaboration among agencies
– NM Department of Health
– Medicaid
– Part C Inter-Agency Coordinating Council
– Providers and parents
• Infrastructure
– Agencies required to have a provider in the home to help facilitate the
telepractice visit (being reconsidered)
– More common in rural areas (provider access)
– Some using a hybrid model
• Billing: Specialist in the home bills a higher home rate; specialist via
telepractice bills a lower center-based rate (they are not traveling)
• Satisfaction: Positive feedback from families, who are pleased to
have more access to services
Nuts and Bolts of Telepractice
ASHA 19005 13
Hardware Software Bandwidth

• Screen size • HIPAA • www.speedtest
• Loaner program compliant .net
• Professional
version
Recommended Bandwidth Speeds
ASHA 19005 14
IT Support
2010s: Most 2020s: Decrease in

important for need; comfort in
2000s: Essential
setting up hardware having access to IT
and software support
Practical Implementation Strategies for Providers
• Introducing telepractice: Explain to parents that they will be

the focus of family-centered intervention; you do not expect
the infant or toddler to work with you, for the entire session
• Before you start telepractice: Establish text or email
communication with the family
• Before the session: Identify props the parent can collect
• Communication: Set up a plan for reinitiating the call if
connectivity is interrupted
• Modeling: Be prepared with alternative ways to model an
activity (e.g., props, pictures, a short video)
• After the session: Text or email ”homework” for practice
ASHA 19005 15
Value Added: Coaching Practices
The Coaching Process

(Rush & Shelden, 2011)
1. Joint planning
2. Action
– Parent observes provider
(modeling)
– Provider observes parent
3. Reflection
– Effect on child behavior
– Comfort of parent implementing
a new strategy
4. Feedback
ASHA 19005 16
Coaching
Video #2 here
Provider Coaching Behaviors
Action Reflection Feedback

• Model • Ask parent for • Comment
• Facilitate information • Problem solve
• Prompt • Provide • Reflect
• 3-way interaction information • Color commentary
• Teach child • Listen Provider feedback
Explain task and • Discuss child’s to parent
teach parent development Provider feedback
Observe parent- about child
child interaction
ASHA 19005 17
Documenting Provider Coaching Behaviors

(Behl & Blaiser, 2015)
http://www.infanthearing.org/flashvideos/teleintervention/Stir-Clips-Captioned.mp4
Thank you, Amy Peters-Lalios, AuD, CCC-A, LSLS Cert-AVT
Provider Coaching Behaviors: Action
• Model: “Oh, what should we use to mix it?”

• Facilitate: “Okay, let’s move it a little faster now, we’re losing
him.”
• Facilitate: “Okay get a spoon!”
• Model: “Audrey, as soon as he has a turn, then mommy’s
going to say that it’s Audrey’s turn.”
• Teach parent: “And I want to see if he recognizes her name
(sibling) and if he’ll let her have a turn.”
ASHA 19005 18
Provider Coaching Behaviors: Reflection
• Observe parent-child interaction: Throughout

• Listen: Throughout
Provider Coaching Behaviors: Feedback
• Parent feedback about child: “Okay, that was at least an effort,

okay now.”
• Provider feedback to parent: “Good.”
• Provider feedback to parent: “Good job.”
• Provider feedback about child: “And I liked the way he looked
at Audrey, like he was overhearing her model, which is perfect.”
• Problem solve: “Oh, that’s a good idea, Audrey! I heard Audrey
say we should use a spoon!”
• Provider feedback about child: “Okay, there we go.”
• Provider feedback to sibling: “Good job!”
• Provider feedback about child: “Oh good, so he looked right at
her.”
ASHA 19005 19
Coaching Practices Used in Telepractice:

A Comparison Study (Stredler-Brown, 2017)
• Children participants
– Deaf/hard of hearing (any type/degree of hearing loss; bilateral)
– Birth–36 months
– English as primary language in the home
– Any communication approach (although most children were learning to listen
and talk)
• Providers
– One session/provider
– Intervention offered via telepractice
– Each session was recorded and coded for coaching strategies
• Observation
• Direct instruction
• Provider feedback to parent about parent
• Provider feedback to parent about child
Observations
Mean # Observations
90
80
70 79%
60
50
Mean # Observations
40
30
20
10
17%
0
Telepractice In-person
Note: 5 in-person studies (range, 6–36%)
ASHA 19005 20
Direct Instruction
Mean # Direct Instruction

20
18 19%
16
14
12
10
12%
Mean # Direct Instruction
0
Provider Feedback About Parent Action
Mean # Provider Feedback to Parent

3.5
3%
2.5
2
2%
Mean # Provider Feedback to Parent
1.5
0.5
0
Note: 4 in-person studies (range, 0.36–6%)
ASHA 19005 21
Provider Feedback About Child Skills
Mean # Provider Feedback about Child

8
7%
6
4
Mean # Provider Feedback about Child
0
0.5%
Note: 3 in-person studies (range, 0% - .36%)
Additional Provider Behaviors
• These provider behaviors were noted, but not analyzed in this

study:
– Modeling a strategy
– Conversation with parent
– Triadic play: Parent + child + early intervention provider
ASHA 19005 22
Provider Report on Coaching Strategies

(NCHAM Learning Community, 2019)
EI Coaching Practice Rated as

Same Easier Harder
(JCIH Supplement, 2013) Essential
Timely, authentic feedback 100% 73.91% 21.74% 8.70%
Respectful, reciprocal
100% 78.26% 4.35% 21.74%
relationships
Active listening 100% 86.96% 8.70% 4.35%
Family identifies concerns,

86.96% 82.61% 13.04% 8.70%
priorities, resources
Strategies to promote parent-

100% 65.22% 17.39% 26.09%
child interaction
Family involvement in session 91.30% 65.22% 21.74% 21.74%
TACIT
Efficacy Data (Teletherapy After Cochlear Implants Using Telemedicine)
Funded by NIDCD: #1U01DC013529
(Falcone et. al., 2018)
ASHA 19005 23
Longitudinal Development of P1 Cortical

Auditory Evoked Potential (CAEP) (n=21)

Significant effect
of therapy
(p < 0.001)
ASHA 19005 24

Significant effect
of therapy
(p < 0.001)
No significant
effect by type
of therapy
(p = 0.451)
PLS Change
(n=19)
ASHA 19005 25
PLS Change
(n=19)
Significant effect of
therapy beyond the
effect of normal age
improvements (p < 0.01)
PLS Change
(n=19)
therapy beyond the
Average improvement
in age-equivalence
of 10.41 months
over a 6-month period
ASHA 19005 26
PLS Change
(n=19)
therapy beyond the
Average improvement
in age-equivalence
of 10.41 months
over a 6-month period
No significant effect
of type of therapy
(in-person or telepractice)
(p = 0.890)
Myth Busters
ASHA 19005 27
The technology could let you down, but there are

resources and increasingly easy-to-use software
platforms.
Providers and service coordinators may be less

comfortable with telepractice than the families.
Telepractice is different from in-person sessions,

but may be efficacious; coaching practices may be
used more.
Telepractice may be the best option, even

when there are other options.
Relationships: Parent and Therapist
Video #3 here
ASHA 19005 28
Benefits Conducting Sessions at Home
Video #4 here
ASHA Resources Supporting Telepractice
• https://www.asha.org/Practice-Portal/Professional-
Issues/Telepractice/
– The “nuts and bolts” of telepractice implementation
• https://www.asha.org/Practice/reimbursement/Reimburseme
nt-of-Telepractice-Services/
• https://www.asha.org/advocacy/state/
ASHA 19005 29
Go Do #1: Use the Family’s Props and Their Routines
• Routine-based intervention (McWilliam, 2010)

http://fgrbi.fsu.edu/
– Everyday activities are basis for instruction; uses props already
in the home
– Supports use and generalization of strategies presented in a
session
– More likely done in telepractice
Go Do #2: Notice Your Use of Coaching Practices
• Notice if your use of the telepractice platform promotes your

use of more family-centered and coaching practices
ASHA 19005 30
Go Do #3: Status of Telepractice in Your State
• Get information from your own state’s programs about

support for, and utilization of, telepractice
– State Part C Early Intervention program
– State Medicaid program
– State laws that impact insurance coverage
• Current statewide Part C practices:

– Colorado
– New Mexico
– Texas
ASHA 19005 31
The State of Telepractice for Delivering Early Intervention Services, by Arlene Stredler Brown
References
Behl, D., & Blaiser, K. (2015). T-I 101 learning courses. Retrieved from:
http://www.infanthearing.org/ti101/index.html
Cole, B., Pickard, K., & Stredler-Brown, A. (2019). Report on the use of telehealth in early
intervention in Colorado: Strengths and challenges with this service delivery method.
Unpublished manuscript.
EI Colorado Data System. Data collected on January 4, 2018.
EI Colorado Report to the Colorado Joint Budget Committee Report. November 1, 2017.
Falcone, J., Harris, N., Glick, H., Bell-Souder, D., Stredler-Brown, A., Elder, S., … Sharma. A.
(2018, October). Central auditory development and language outcomes in children with hearing
loss receiving aural habilitation: Preliminary findings. Poster presented at the Colorado
Academy of Audiology Conference, Breckenridge, CO.
McWilliam, R. (2010). Family-guided routines-based intervention. Retrieved from:

http://fgrbi.fsu.edu/
Rush, D. D., & Shelden, M. L. (2011). The early childhood coaching handbook. Baltimore, MD:
Paul H. Brookes Publishing Co.
Sharma, A., & Glick, H. (2018, June). Cortical neuroplasticity in hearing loss: Why it matters in
clinical decision-making for children and adults. Hearing Review, 1-13.
Sharma, A., Martin, K., Roland, P., Bauer, P., Sweeney, M. H., Gilley, P., & Dorman, M. (2005).
P1 latency as a biomarker for central auditory development in children with hearing
impairment. Journal of the American Academy of Audiology, 16, 564-573.
Stredler-Brown, A. (2017). Examination of coaching behaviors used by providers when

delivering early intervention via telehealth to families of children who are deaf or hard of hearing.
Perspectives of the ASHA Special Interest Group SIG 9, 2(Part 1), 25-42.
ASHA Online Conference

Birth to Three: Working Together to Serve Children and Their Families
The State of Telepractice for Delivering Early Intervention Services, by Arlene Stredler Brown
Resources
URL for Slide 35: http://www.infanthearing.org/flashvideos/teleintervention/Stir-Clips-

Captioned.mp4
ASHA’s Practice Portal: Telepractice:

https://www.asha.org/Practice-Portal/Professional-Issues/Telepractice/
Reimbursement of Telepractice Services (ASHA):

https://www.asha.org/Practice/reimbursement/Reimbursement-of-Telepractice-Services/
Telepractice State by State (ASHA):

https://www.asha.org/advocacy/state/
National Consortium of Telehealth Resource Centers:

www.telehealthresourcecenters.org
Early Intervention Colorado. Part C Training Modules:

Contact Beth Cole at beth.cole@state.co.us
ASHA Online Conference

Birth to Three: Working Together to Serve Children and Their Families

Stredler Brown Handout

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Stredler Brown Handout

Uploaded by

Copyright:

Available Formats

The State of Telepractice for Delivering

Early Intervention Services

The State of Telepractice for Delivering

Participants will be able to…

ASHA Strategic Objectives

• Expand data available for quality improvement and

Myths About Telepractice

Do These Ring True for You?

• “The technology always lets us down.”

• “Families don’t like telepractice.”

• “Telepractice is never as good as in-person sessions.”

• “Telepractice is a good option when there are no other

Rate the challenge, as you perceive it today, of

A Recent Poll (n = 83)

Too much to try 5% 4

Best practice recommends the use of coaching

A Recent Poll (n = 88)

Same amount 85% 75

Different amounts 15% 13

Early Intervention Colorado

Evolution of Telepractice in Colorado:

July 2017– 440 telepractice sessions completed

What is Working? What is Missing?

What is Working? What is Missing?

Why is Telepractice Underutilized?

• Surveys distributed to four groups

• Follow-up focus groups with administrators and parents

Provider Results: Age of Respondents

Provider Results: Child Progress

Provider Results: Parent/Caregiver Involvement

Provider Results: Technology

Service Coordinator Results: Caseload

Service Coordinator Results: Acceptability

Service Coordinators: Comments

• “Families don't get to know the therapist as well. Many of the

• “Being rural, I don't want families to think they are getting a

Some Parents are Very Comfortable Using

Each State is Unique: Part C Telepractice in NM

Nuts and Bolts of Telepractice

Hardware Software Bandwidth

Recommended Bandwidth Speeds

2010s: Most 2020s: Decrease in

Practical Implementation Strategies for Providers

• Introducing telepractice: Explain to parents that they will be

Value Added: Coaching Practices

The Coaching Process

Provider Coaching Behaviors

Action Reflection Feedback

Documenting Provider Coaching Behaviors

Thank you, Amy Peters-Lalios, AuD, CCC-A, LSLS Cert-AVT

Provider Coaching Behaviors: Action

• Model: “Oh, what should we use to mix it?”

Provider Coaching Behaviors: Reflection

• Observe parent-child interaction: Throughout

Provider Coaching Behaviors: Feedback

• Parent feedback about child: “Okay, that was at least an effort,

Coaching Practices Used in Telepractice:

Note: 5 in-person studies (range, 6–36%)

Mean # Direct Instruction

Provider Feedback About Parent Action

Mean # Provider Feedback to Parent

Note: 4 in-person studies (range, 0.36–6%)

Provider Feedback About Child Skills