E F F E C T I V E LY U S I N G T E L E -

I N T E R V E N T I O N T O S U P P O R T

F A M I L I E S A N D C H I L D R E N

D I N A H B E A M S , M . A .

A L L I S O N B E I V E R , A U D

S A R A K E N N E DY

N A N E T T E T H O M P S O N , S L P, L S L S

TELE-INTERVENTION

Clinical Audiologist

Speech-Language Pathologist

Parent Advocate

Systems Administrator

DHH Teacher

TELE-INTERVENTION

Clinical Audiologist

Allison Biever, AUDRocky Mountain Ear Center

RECENT TELEHEALTH SESSION

• Toddler- Leah

• 351 miles

(6 hours) from our center

• Bilateral reprogramming visit

• 1 to 2 days of lost time off work for Leah and one parent

• Lost wages, gas, food, accommodation expenses

• Satisfaction of delivery model?

WHY TELEHEALTH MATTERS?

Improves access to

treatment and audiological

appointments

Allows for continuity of

care

Minimizes time away

from school and work

Cost savings approach to

receiving intervention

WHY USE TELEHEALTH?• Health status• Distance from implant center is

problematic• Time away from school and work

for both child and parent• Follow-up can be expensive• Weather can make travel for

follow-up impractical

• Parking is difficult and traffic is stressful

H E A LT H I S S U E S

D I S TA N C E

T I M E

E X P E N S E S

W E AT H E R

T R A F F I C & P A R K I N G

TELEHEALTH EFFICACY QUESTIONS

Could telehealth be delivered in a

feasible, inexpensive

model?

Would patients be satisfied with the delivery of

services?

Would clinicians be satisfied with the delivery of

services?

Could the service be

reimbursed?

DEMOGRAPHICS

Groups Subjects Age (Years) Child/Adult

Mean Distance From Implant

Center

MeanDuration of

Device Experience

Phase I(Remote Site) N= 17 Range: 1.5–77

Mean: 23 yrs 12/5 236 miles ~6.3 years

Phase II(Recipient’s

Home)

N=12 Range: 2.5-41Mean: 13 yrs 11/1 339 miles ~8.3 years

TOTAL N=29 Range: 1.5–77Mean: 19 yrs 23/6 280 miles ~7.1 years

QUESTION 1: AFFORDABLE MODEL• Can remote programming be delivered in a cost savings model?

– Windows 8 tablet: $400

– GoToMeeting: $468/year

– Pod with cables: $1,525 (assuming clinic doesn’t have extra pod and cables)

– FedEx charges: $20

QUESTION 1: TIME SAVINGS

15

26

19

0

5

10

15

20

25

30

Phase 1 Phase 2 All Subjects

Hou

rs

QUESTION 1: FINANCIAL SAVINGS

285

689

435

0

100

200

300

400

500

600

700

800

Phase 1 Phase 2 All Subjects

Mon

ey (

$)

QUESTION 2: PATIENT SATISFACTION

22

7

0 0 0

29

0

5

10

15

20

25

30

35

SA A N D SD Total

Subj

ects

QUESTION 2: TELEHEALTH OVER TRAVEL

21

53

0 0

29

0

5

10

15

20

25

30

35

SA A N D SD Total

Subj

ects

QUESTION 3: CLINICIAN SATISFACTION

10

0 0 0 0

10

0

2

4

6

8

10

12

SA S N D SD Total

Sess

ions

QUESTION 4: REIMBURSEMENT• Phone conversations with payers critical

• Use of GT modifier utilized (92602GT): Via interactive audio and video telecommunication systems

REIMBURSEMENT

Petition to have service added to the telehealth listPetition

Use of an ABN when insurance will not allow for session to be performed through telehealthUse

Need to be licensed in the state you are providing telehealth servicesNeed

FINDINGS• Telehealth could be administered in a feasible, inexpensive

model

• Patients were extremely satisfied with the service provided

• Telehealth session could be reimbursed through insurance in most cases

TELEHEALTH EFFICACY

University of North Carolina

University of

Michigan

Medical College of WisconsinRocky

Mountain Ear Center

DEMOGRAPHICS

• 40 subjects

• Experienced users

• Current programs

Gender F = 22 / M= 18

Age

Mean = 45.2 yrs(12-88 yrs)13 adolescents / 27 adults

SoundProcessor

Nucleus 5 = 17Nucleus 6 = 23

METHODS

CNCsRemote

programming (facilitated)

CNCsRemote

programming (unassisted)

CNCs

RESULTS

0

10

20

30

40

50

60

70

80

90

100

Familiar Facilitated Unassisted

Group Mean CNC Scoresp=<.001

1. Choosing telehealth over face-to-face programming

2. Using telehealth if you lived >2 hrs away, inclement weather, difficult transportation, or hours

3. Recommend telehealth to another CI recipient

SUBJECT FEEDBACK

Likely Neutral Not Likely

56% 39% 5%

Likely NeutralNot

Likely

80% 17% 3%

Likely Neutral Not Likely

90% 10%

01/2016 Telehealth Study Site Invitations

03/2016 1st Subject

Enrolled

04/2017Last Subject,

Last Visit

TELEHEALTH TIMELINE

01/2017 Enrollment

Closed

***11/2017 FDA approves telehealth

12/2015 Telehealth IDE Approved

TELEHEALTH CI PROGRAMMING

SETTING UP TELEHEALTH SERVICES

TELEHEALTH CAVEATS

Need a good internet connection

Best if you’ve met face-to-face initially

Difficult to provide test results (no booth testing) – but future applications will allow for testing remotely

Reimbursement questions

Equipment necessary for programming – plan ahead

TELE-INTERVENTION

Speech-Language Pathologist

Nanette Thompson, MS, CCC-SLPListening 2 Learn

TELEHEALTH AND EARLY INTERVENTION SERVICES

A perfect tool for helping children, and

families maximize early language

development skills.

Provides access to experienced providers to

individuals in rural areas

CONNECTION TO FAMILIES

Consistent information about child’s current skills

Consistent support and

encouragement to

family/patient

Consistent progress

monitoring

Increased sense of

teaming and connection to family/clinic/EI

services

TELEHEALTH: DIRECT EARLY INTERVENTION SERVICES

• Maximizes parent coaching• Increases parent involvement• Encourages parents to have a

hands-on approach to all aspects of habilitation and auditory skill development

Providing true parent-centered early intervention

Allows working parent to join session

EFFICACY OF TELEHEALTH: CHILD OUTCOMES

0255075

100125150175200225

PLS E

xpres

sive*

PLS R

ecep

tive*

PLS T

otal*

MBCDI

ASC*

TI In-Person

(Blaiser, Behl, Callow-Heusser, & White, 2013; Behl et al., 2017)

EFFICACY OF TELEHEALTH: COACHING

0 1 2 3 4 5 6

Provider Responsiveness to Family

Provider Relationship Family w/Family

Provider Facilitation of parent-child interaction

Provider Non-Intrusiveness & Collaboration

Parent-Child Interaction

Parent Engagement

Child Engagement

*

(Blaiser, Behl, Callow-Heusser, & White, 2013;

Behl et al., 2017)

IMPLEMENTATION

Set expectations of family, patient, and provider

Readiness checklist – NCHAM

Trial session to connect and review the lesson plan

Tele-intervention lesson plan

Materials needed for each session

Patience, a sense of humor, and deep respect for families

REIMBURSEMENT• Reimbursement resources are expanding every day.

• Many insurance companies and state Medicaid systems are reimbursing.

• Many State EI programs are supporting it’s use and supporting funding.

• Grant funding from a variety of resources. Federal agencies supporting agriculture and rural development.

• What’s happening in your areas?

LET’S TALK!

• Unexpected things happen

• Notice child might have additional challenges

• Child is always asleep

• Others:

RESOURCES GALORE!• www.telehealthresourcecenter.org

– Telehealth 101: The Basics

– Other Resources

• www.infanthearing.org/ti-guide– A Practical Guide to the Use of Tele-Intervention in

Providing Early Intervention Services to Infants and Toddlers Who are Deaf and Hard of Hearing

– Technology and Home Environment Tele-Intervention Checklist

– Parent Letter

STILL MORE RESOURCES!• ASHA Special Interest Group 18, Telepractice

• ASHA.org

– Telepractice Frequently Asked Questions

– Telepractice for SLPs and Audiologists: Key Issues

• American Telemedicine Association (online)

TELE-INTERVENTION

Systems Administrator

DHH Teacher

Early Interventionist

Dinah Beams, MA

BUILDING CAPACITY THROUGH TELEHEALTH

Direct service Consultation Mentoring

Trainings Team building Connections

BASICS TO CONSIDER • Always best for provider to have an opportunity to meet

face-to-face (not only virtual) – initially or at regular intervals

• Set clear expectations for all parties prior to virtual visit

• Prepare for the tele-intervention session

– Send reminder text or e-mail to family

– Send e-mail as to focus of session

– Sign on early

– Be aware of signs of fatigue/distraction

– Follow-up with electronic notes of session and next steps

WHAT’S IN A NAME?

Tele-Health Tele-Intervention

Virtual Visit

The name might be

determined by function of visit

and funding source.

TELE-INTERVENTION: DIRECT SERVICE

• Providing true parent-centered early intervention– Increases parent involvement immediately– Can’t rescue the parent or save the moment– Maximizes parent coaching

• Opportunity to involve parents/family members in other locales

– Family lives in another country for extended period of time– Parent who is deployed

TELE-INTERVENTION: TEAM-BUILDING• Team for a child and family can include professionals

in the community and professionals at a distance

• Permits the involvement of a highly skilled professional as part of the team

• Involvement of all team members in IFSP meetings, transition meetings, evals

• Aids in transition to school services

TELE-INTERVENTION: CONSULTATION• Training with a limited number of sessions (could

be as few as one) for a specific purpose– i.e upcoming CI

• Opportunity to provide follow-up consultations at set intervals to build capacity in the community

TELE-INTERVENTION: CONSULTATION

• Allows increased time with professionals with specific skill sets needed by child and family to aid in better intervention services

• Provides opportunity for second opinion when otherwise not available in the community

• Provides decreased time in the wait for services and assessments in the home for the family

TELE-INTERVENTION: TRAINING• Opportunities for training and real time support

to early interventionists in more remote areas or professionals with limited experience in this area.

• Regional trainings that include presentations from professionals and experts in other regions (in lieu of video recordings) providing the opportunity for focused live interactions

TELE-INTERVENTION: ENHANCED MENTORING

– On-going relationship– Increases opportunity for professional growth – Increases opportunities for individualization for both

child and provider leading to better outcomes• Provides specific learning opportunities honoring

what the provider wants and needs

• Training is related to child outcomes – Provides reflective professional learning opportunities

COLORADO EIREIMBURSEMENT MODEL• Early Intervention Colorado

– Providers must complete on-line TI course

– TI Certificate

– TI must be discussed as an available service model with families and must be listed on the IFSP

– Providers receive a slightly higher reimbursement rate for TI to cover technology expenses

BARRIERS LEAD TO CREATIVE THINKING! • Partnerships with agencies and organizations

when families do not have internet in their home

• Community funding to provide technology

• Partnerships with community providers

R O L E M O D E L S A N D D E A FM E N T O R SINCLUDING DEAF ADULTS AS PART OF THE TEAM!

TELE-INTERVENTION: DEAF ROLE MODELS• Face-to face interaction is always ideal, but if not available:

– Virtual visits provide families an opportunity to develop relationships with d/Deaf and hard of hearing adults

• (fewer than 25 states have Deaf Role Model Projects as part of their EI services)

– Opportunity to meet/interact with a variety of adults

– Assists families with young children in becoming comfortable with this technology – virtual visits will be important to their child as they grow.

SUPPORT FOR LEARNING SIGN

– INTERACTIVE!

– Opportunity to learn/practice ASL

• SignOn Project with American Society for Deaf Children provides interactive individualized virtual visits

– Allows an opportunity for more family members to participate as visits could be during evening hours or include family members who do not live in the same area

– Some states provide SRP or other programs virtually

TELE-INTERVENTION

Parent Advocate

Sara Kennedy

PARENT-TO PARENT SUPPORT

• Remote regions where opportunities to meet a family face-to-face are very limited

• Connecting families with similar needs and concerns

– Same language or cultural group– Children have similar diagnosis

• Regions where no trained parent guides are available

• Visual Language connection

MENTORING & TRAINING PARENT GUIDES• Joining a newer parent guide remotely on a family visit to

mentor and train

• “I do, we do, you do” teaching model

• Remote trainings through Zoom, Skype, Facetime, Loom, etc.

T I M E F O R Q U E S T I O N S A N D A N S W E R S !