The Five W's Meet the Three R's: The Who, What, When, Where, and Why of Telepractice Service Delivery for School-Based Speech-Language Therapy Services

Abstract

School-based speech-language pathologists (SLPs) are implementing telecommunication technologies for service provision. Telepractice is one among an array of service delivery models that can be successfully implemented in the public-school setting. While many school-based SLPs have been plunged into telepractice with the recent pandemic, this temporary shift to emergency instruction is not the same as fully implementing a telepractice service delivery model. SLPs who recognize the potential application of telecommunications would profit from additional training and experience to take advantage of the benefits of this service delivery model. The purpose of this article is to explore the concept of telepractice as a service delivery model, and to answer the who, what, when, where, and why questions of school-based telepractice. Telepractice is one of several service delivery models that school-based SLPs can confidently utilize to provide effective speech and language therapy services to school-age students.

Keywords

telepractice - school-based - speech-language therapy - service delivery model

Learning Outcomes: As a result of this activity, the reader will be able to (1) explain the benefits and challenges of the school-based telepractice service delivery model; (2) describe how to select candidates for telepractice; (3) explain a student-centered approach to technology selection; and (4) identify at least two resources for the school-based telepractice service delivery model.

The global pandemic has made telepractitioners of most school-based speech-language pathologists (SLPs). While the use of live, interactive videoconferencing and other telecommunication technologies, commonly referred to as telepractice, as a service delivery model for speech-language services has been growing over the last decade,[1] social distancing and remote learning mandates across the globe in 2020 have moved telepractice from the periphery to the forefront of our profession. Many SLPs have embraced telepractice, while others have denounced the service delivery model as inadequate, claiming that it is not possible to provide speech-language services effectively without physical, in-person interactions. Additional concerns include the validity of conducting assessments by telepractice; whether SLPs can establish rapport with this service delivery model; and whether therapy is as effective via telepractice as it is in person.[2] These reactions reflect a reluctance to change,[3] which occurs in most human endeavors. In our profession, this reluctance manifests in a hesitancy to adopt new and innovative technologies.

As an illustration, in 1995, Language Speech and Hearing Services in Schools published a Clinical Forum series on computer applications in schools. The introductory article reviewed the integration of computers into the professions of speech-language pathology and audiology through several periods: early adoption, an exploration phase, growing usage, and (as of the time of publication) nearly universal acceptance.[4] As the use of computers in the profession grew, concerns were regularly expressed that the computer would replace SLPs.[5] In an aptly titled article, “Not using a computer in language assessment/intervention: In defense of the reluctant clinician,” Cochran and Masterson argued that there were many good reasons for not using computers with school-age clients, including limited access to computer resources, lack of clinician training, concerns about student response, the time required to teach children how to use the computer, and doubts surrounding the efficacy of computer-based activities.[6] The forum concluded with recommendations to expand computer training and research as well as admonishments to make use of computers and computer applications only for tasks that could not be done well without computers.[4]

Twenty-six years later, the notion of reluctance to use computers is unthinkable, and the profession now completely integrates computer use in all facets of our work. Yet, simultaneously, SLPs are wrangling with similar concerns about telepractice. What is different this time is that school-based SLPs have been thrust into implementation of telepractice without the orientation and training that is a critical component of integrating new technologies. The natural reaction to such a sudden change is a sense of disorientation, and a tendency to find fault with the technology. Indeed, Venus et al suggest that, when faced with the necessity of change, efforts must be made to include a “vision of continuity.”[7] In other words, during significant change (like the current surge in telepractice), it is essential that the foundational elements of our practice, “what makes us who we are,” are preserved. Otherwise, resistance is a given, and failure in orchestrating change may occur. As a first step toward that vision of continuity, school-based SLPs can be helped by remembering that telepractice is just another method for delivering services. Rather than focusing with apprehension on the service delivery model, SLPs should instead focus first on those elements of therapy that remain the same.[4] For example, decide what evidence-based strategies will be used to intervene for a particular communication deficit, and then determine how those strategies can be implemented using telepractice.

With this vision of continuity in mind, the following sections provide an overview of the current state of the profession with respect to both in-person and telepractice service delivery models, followed by answers to the who, what, when, where, and why questions for implementing telepractice.

School-Based Service Delivery Models

Telepractice is one of an array of service delivery models utilized in the public-school setting, such as pull-out, in-classroom collaboration, and classroom consultation. Selecting a service delivery model should be based on the unique needs of the individual student with disabilities.[8] Selection of service delivery should be an adaptable, fluid process, which permits changes to the intervention setting, format (individual or group), intensity, frequency, and duration.[9] No one service delivery model is applicable for all students with communication disorders and, while the current pandemic limits or alters the service delivery models that can be utilized, it is important to recognize the advantages, limitations, and evidence base of the various available service delivery models.[10]

Telepractice is distinctive as a service delivery model. It permits the SLP to implement any of the other service delivery methods utilizing telecommunication technology.[11] At the same time, it requires a unique set of clinical skills, including engaging students over the internet, selecting or creating appropriate digital materials, and troubleshooting technology glitches.[12] A decision to provide services through telepractice typically involves a variety of stakeholders, including the school district, students, families, and SLPs. Prior to the pandemic, the primary motivation for implementing telepractice was a lack of access to services provided by an in-person SLP.[13] In the current state, telepractice has become a primary method for service delivery due to safety concerns. In fact, the American Speech-Language-Hearing Association (ASHA) is advocating increased use of the model during the pandemic.[14]

SLPs face significant challenges in selecting a delivery model apart from current pandemic restrictions, due to a lack of evidence comparing the models[15] as well as factors (e.g., large caseloads, number of school buildings served) which limit the delivery models that can be implemented.[16] While the best method for determining a service delivery model is based on the unique needs of the individual student, in actual practice, even in nonpandemic times, service delivery model selection is often guided by availability of services, the training and skills of the SLP, and student/family/district preferences.[11] Confounding the selection process is the limited data available comparing the service delivery models across communication disorders and grade levels. The following section provides a brief review of service delivery model effectiveness, including a summary of what is currently known about implementing telepractice as a service delivery model in the school-based setting.

Brief Review of School-Based Service Delivery Model Effectiveness

In a perfect world, a school-based SLP would utilize published research evidence, consider the student's/families' preferences, and his/her own clinical experience when selecting a service delivery model.[17] While published results are available for identifying the advantages of a single service delivery model for select language skills (e.g., preschool children generalized new vocabulary words better when services were provided in the classroom),[9] published comparisons across the range of school-based service delivery models and disorders are sparse. In their systematic review of language intervention services provided to young school-age children (preschool-age to 8 years of age) in pull-out versus in-classroom services, McGinty and Justice were able to identify only three published studies with adequate levels of evidence with which to evaluate this question.[18] While their results suggested a benefit for classroom-based vocabulary instruction co-taught by the SLP and the classroom teacher, the authors cautioned that the results cannot be generalized based on several essential considerations, including small sample size, restricted participant characteristics, and heterogeneity of intervention methods. The authors concluded that there is a dearth of evidence regarding in-person speech-language pathology service delivery models.[18] In a more comprehensive systematic review, Cirrin et al compared the effects of different service delivery models, as well as the frequency and intensity of services delivered within each model, on a variety of communication disorders (e.g., speech sounds, language, social communication), with school-aged children ranging in age from 5 to 11 years.[19] Once again, only five published studies were judged to have adequate evidence to be included. The authors concluded that the SLP practicing in the school setting does not have compelling evidence available for the advantages or disadvantages of any particular service delivery model.

The two previous evidence-based systematic reviews were conducted prior to widespread use of a telepractice service delivery model. Since that time, two systematic reviews pertaining to the use of a telepractice service delivery model within the school-based setting have been published. In their review and meta-analysis, Rudolph and Rudolph reported only six published reports that met the criteria for inclusion.[20] They posited that telepractice is a promising service delivery model for school-based speech and language intervention, but stated that sufficient evidence is lacking to confirm that results obtained from intervention delivered in a telepractice model are equivalent to outcomes obtained in a traditional in-person delivery model. Similarly, Wales et al identified seven published studies for inclusion in their systematic review of school-based telepractice service delivery.[21] They concluded that participants made significant and similar amounts of improvement in both in-person and telepractice service delivery models, suggesting promising but limited evidence to support a telepractice service delivery model. Findings of both meta-analyses pointed to the need for more robust research studies with larger sample sizes and more rigorous study designs to support the efficacy of telepractice for school-age students. In response, Coufal et al compared 1,331 students with speech sound disorders receiving services through a traditional in-person service delivery model with 428 students with speech sound disorders receiving services through a telepractice service delivery model.[13] They reported no significant difference in results for children with speech sound disorders receiving therapy in an in-person, as compared with a telepractice, service delivery model.

The review results highlight the essential need for additional research to help school-based SLPs make a reasoned decision regarding service delivery model selection. Interestingly, a common concern expressed by SLPs is the lack of evidence base for the telepractice service delivery model, when in fact there is a limited evidence base for any of the available service delivery models.[11] In the absence of a substantial evidence base, the practicing school-based SLP can utilize ASHA's Principle of Ethics I, “…to hold paramount the welfare of persons they serve professionally,”[22] as a guiding principle in making a determination regarding service delivery model selection.

For a school-based SLP to effectively employ telepractice, it is first necessary to return to the foundational elements of our practice: those components that characterize the practice of school-based speech-language pathology. There are many components of providing services in telepractice that are remarkably like traditional in-person service delivery. Accordingly, the following sections will provide the who, what, when, where, and why of the telepractice service delivery model. Included in the discussion will be a consideration of those elements that are utilized during both in-person and remote service delivery specific to telepractice. Exceptions in the telepractice service delivery model as result of the current pandemic, such as easing of security restrictions, will be incorporated where applicable.

The Who of School-Based Telepractice Service Delivery

Bearing in mind that service delivery model selection should be based on the unique needs of the student, it is axiomatic that telepractice may not be appropriate for all students. Yet, telepractice may be the only service delivery model available, a point driven home by the COVID-19 pandemic. Regulations for who can provide speech-language therapy services, and what services can be provided by telepractice, vary by state in the United States. In this section, we discuss factors related to client selection for telepractice, and considerations for the SLP entering the telepractice arena. Where appropriate, information about the telepractice project at Kent State University (KSU) is offered as an example of a successful implementation of this approach.

Client selection. The school-based speech-language telepractice project at KSU began in December 2006. Over 14 years, we have provided services to more than 500 school-age students through telepractice. Our clinical experience suggests that most school-age students are capable of successfully participating in this service delivery model.[23] In our project, students have ranged in grade from preschool through high school. Students with a variety of communication impairments have participated, as well as students with intellectual impairment, visual impairment, hearing impairment, autism, emotional–behavioral disturbance, specific learning disability, and students requiring augmentative–alternative communication modes. As a rule, we typically complete a trial of service using telepractice with the student, rather than predetermining that a student will or will not be able to participate in telepractice.

Published lists of factors to consider when determining if a child can participate in telepractice have been developed.[24] However, given the wide array of telecommunications technology now available, a better approach is to contemplate the specific characteristics of an individual client, and then determine what available technology would permit that client to participate in a telepractice session. Factors to consider include physical and sensory qualities (e.g., how will the student interact with the clinician, such as by using a keyboard/touch screen/switch?), cognitive and behavioral qualities (e.g., Can the student benefit from interactive materials on a computer screen?), communication characteristics (e.g., How can the student be cued to correct a speech sound disorder?), and environment and resource qualities (e.g., Does the student have reliable internet access? Is there a caregiver available to assist during the therapy sessions?).

SLP considerations. ASHA supports telepractice as an accepted service delivery model for school-based SLPs.[25] An SLP's ability to utilize the model is constrained by state regulations, ASHA, and applicable state codes of ethics. For convenience, ASHA maintains an updated state-by-state listing of licensure/regulations related to telepractice, web addresses for state speech-language pathology licensure boards, and published accommodations for telepractice permitted during the current pandemic (https://www.asha.org/uploadedFiles/State-Telepractice-Policy-COVID-Tracking.pdf).[26]

The SLP and ethical telepractice service delivery. Regardless of the service delivery model utilized, the SLP is required to abide by the ASHA Code of Ethics, including only engaging in services that are within their scope of education, training, and experience; utilizing technology consistent with professional standards; and keeping paramount the best interest of students being served.[27] In a recent article, Cohen and Cason summarized ethical telepractice under three guiding principles: practice in a lawful manner, employ ethical communication, and uphold the well-being of the client.[28] An example of unlawful telepractice service delivery is providing services to a student who resides or is temporarily residing in a state where the SLP does not hold a license to practice. An illustration of this principal involved a school-based SLP who was asked to continue to provide speech-language therapy services as identified in a child's individualized education plan (IEP) while the child and his family vacationed in another state for an extended period. The SLP's school district approved of the action as did the school district's attorney. However, the SLP did not hold a license to practice speech-language pathology in the other state. After consulting with the state speech pathology licensure board, the SLP correctly declined to provide services and offered to help locate local services for the student. To ensure lawful delivery of telepractice services, the SLP should review the published state telepractice guidelines or contact the state licensure board for guidance when established telepractice guidelines are not available.

In the realm of school-based telepractice service delivery, one example of utilizing the principal of ethical communications can be applied when explaining to parents how confidentiality will be maintained in the telepractice service delivery model. The SLP should review with parents the steps taken to ensure privacy in the SLP's physical location (e.g., providing services in a nonpublic setting and maintaining student educational data in a secure location) as well as the encryption and safety features of the videoconferencing platform utilized. Upholding the well-being of the client is paramount. Examples of maintaining client well-being during telepractice service delivery include ensuring a backup communication mode (e.g., phone) in case of technology malfunctioning, ensuring that the SLP maintains emergency contact information for the student's location in the case of an emergency, and transitioning the student to another service delivery model when needed services cannot be provided through telepractice.

The SLP and maintaining confidentiality. An important question, regardless of service delivery model, is “What should I do to ensure the confidentiality of school-age clients?” Telepractice introduces additional concerns, such as ensuring the safety and confidentiality of student data and information transmitted through telecommunications technology. Richmond et al developed guidelines for the provision of safe and confidential telepractice services based on currently available technologies and evidence.[29] Although these guidelines were developed through the American Telemedicine Association and are not specifically for school-based telepractice services, the principles provide an excellent foundation for understanding the issues of safety and confidentiality (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5716618/).[29]

Understanding what regulations must be adhered to is another important consideration. School-based services will fall under the Individual with Disabilities Education Act (IDEA)[8] and the Family Education Rights and Privacy Act of 1974 (FERPA).[30] The telepractitioner may also need to comply with the Health Insurance Portability and Accessibility Act (HIPAA),[31] the Health Information Technology for Economic and Clinical Health Act (HITECH),[32] and specific state and/or district regulations.

Considerations for maintaining student confidentiality and ensuring ethical telepractice service delivery will be differentiated based on the unique situations that school-based SLPs find themselves. To accomplish confidential and ethical telepractice service delivery, the school-based SLP is encouraged to complete continuing education in the area of telepractice, acquire hands-on practice, and consult with experienced telepractitioners.[28] A comprehensive review of confidentiality and security considerations related to school-based telepractice is beyond the scope of this article. However, ASHA and other professional organizations have developed continuing education opportunities and resources available online to support implementation of the telepractice service delivery model.[33] [34] [35]

The What of School-Based Telepractice Service Delivery

Commonly asked questions when considering telepractice include the following: “What telecommunications technology should I use?” and “What equipment should be purchased?” To answer these questions, it is helpful to correctly order the steps in the decision-making process. First, decide what evidence-based strategies will be used to intervene with a particular client, and then determine what technology and equipment can be harnessed to accomplish the task. Using this student-centered approach to technology, selection is likely to result in choosing equipment that best suits the needs of the caseload the SLP will be serving.[36]

Telecommunications technology. Telecommunications technology, which includes smart phones, tablets, computers, peripheral equipment, videoconferencing software and hardware, and secure web-based programs, is constantly changing. A starting point for implementing student-centered technology selection is to review the technology and technology-related information on the ASHA Practice Portal site.[37] The site contains a basic checklist of needed equipment and associated technology. Observing telepractice sessions and/or consulting with other SLPs who are using the service delivery model can inspire ideas for applying the model with an SLP's particular caseload.[23] ASHA sponsors the Special Interest Group (SIG) focused on telepractice. Membership in SIG 18 (telepractice) provides access to an online community, which is helpful in locating other telepractitioners. In addition, the online community offers a readily available venue for asking questions and soliciting feedback from other telepractitioners. Online communities, such as Facebook groups, and subscriptions to YouTube channels have provided immediate access for SLPs to pose questions and find resources and tips as they transitioned to telepractice during the pandemic (e.g., “teletherapy materials for speech-language pathologists,” “early intervention telepractice”). As with all internet-based materials, the SLP is cautioned to let professional and ethical considerations guide a decision to utilize items found through social media outlets.

Internet considerations. Telepractice requires that information is transmitted using a telecommunications connection, typically the internet. Internet connectivity plays an important role in the quality and quantity of information shared during a telepractice session. Internet connection speed affects the video and audio quality, and the ASHA Telepractice Portal[37] recommends a minimum upload/download speed of 3 megabytes (MB) for optimal connectivity and screen sharing; if the SLP intends to share a video source, such as a PowerPoint presentation or YouTube video, then the minimum upload/download speed should increase to at least 5 MB. Recent internet speed tests indicate that, in the United States, internet speeds typically exceed these requirements.[38] However, access to high-speed internet is not equally distributed in this country, and some estimates suggest that half of the U.S. population do not have access to even the most basic internet upload/download speeds.[38] As relates specifically to school-age children, the United States Department of Education[39] released a 2018 report showing 94% of 3- to 18-year-old children had internet access. Of those with access, 88% had access through a computer and 6% had access only through a smart phone. The remaining 6% had no access. However, the speed/adequacy of the internet service was not reported.

Implementation. Given the challenges with technology selection and availability, internet quality and access, and adhering to state and federal regulations for client safety and confidentiality, it can seem daunting to achieve compliance with ASHA's requirement that telepractice services must be equivalent to the quality of services provided in person.[40] Based on years of experience in school-based telepractice service delivery, spanning both nonpandemic and pandemic time periods, KSU has found that, with careful planning, vigilance, and on-going education, it is possible to meet the ASHA equivalency standard. The challenges associated with initiating telepractice—transitioning students to telepractice delivery, lack of control over technology selection, variable internet quality, and little time to transition therapy materials to digital equivalents—present significant barriers to establishing telepractice services that are equivalent to in-person services in the midst of the numerous other challenges presented by the pandemic. However, during the COVID-19 national emergency, the Federal Government has relaxed HIPAA enforcement of federal penalties, to facilitate provision of needed services to more Americans.[41] In addition, state licensure boards and departments of education are providing greater flexibility in order for school-age students to gain access to services. While it remains important to strive for equivalent services, Hodges provides a helpful perspective for service provision during the pandemic:

First and foremost, emergency remote teaching is a temporary shift of instructional delivery to an alternate mode due to crisis circumstances. The primary objective is to quickly provide temporary, reliable access to instruction and support during a crisis, not to re-create a robust educational ecosystem.[42]

The When/Why of School-Based Telepractice Service Delivery

For most SLPs, physical in-person interaction within a clinical setting is the “gold standard of care,” or the standard by which all other service delivery is measured.[43] However, even before the COVID-19 pandemic imposed telepractice on school-based SLPs, the growing evidence to support online intervention, and the potential for telepractice to permit intervention within a naturalistic context, has led to greater use of telepractice as a service delivery model. There is a growing body of evidence validating telepractice as comparable to in-person services for evaluation,[44] [45] [46] [47] for intervention with school-age students,[48] [49] [50] [51] [52] and for professional collaboration and consultation.[53] [54] [55] In addition, the benefits of reducing time lost to travel, increasing locations where services can be provided, and improving efficiency for SLPs who provide services to multiple schools have long been recognized.[56]

COVID-19 created a situation in which many SLPs could provide services either through telepractice or not at all. In this way, the pandemic has made the need for telepractice patently obvious. Provision of speech and language services is a vital component of education for many students, and telepractice is an important service delivery model, whether or not the community is under difficult circumstances such as a pandemic.

In evaluating when or why to utilize telepractice as an alternative, perhaps it is useful to conceptualize speech-language service delivery models as a buffet line. The SLP can select one, two, or more service delivery models to meet the needs of her clients and flexibly manage her workload. For example, a school-based SLP may choose to work in-person with a client with a speech sound disorder until the student can correctly produce the target sound. Then, the student could be transitioned to telepractice to practice the sound for mastery in a group setting. It is common for school-based SLPs to travel among school buildings to provide services. Incorporating telepractice could permit the SLP to establish remote group therapy sessions among students with low-incidence communication disorders such as stuttering, who otherwise would not be able to interact with each other. Telepractice could also be utilized for challenging situations such as when a student with a communication disorder is suspended from school and still needs to receive services or when a medically fragile student must receive therapy in their home. This service delivery model can also enable opportunities for parents/caregivers to participate in meetings. Strategically implementing telepractice is a logical step in facilitating clinical flexibility to meet the needs of a wide array of clients and the demands of a school-based workload.[57]

The Where of School-Based Telepractice Service Delivery

The ubiquity of telecommunication technologies may mislead one into thinking that telepractice services can be provided in most or any location. But there are important considerations for the setting in which the SLP provides telepractice services and in which the student receives those services. These notable considerations include the actual physical location (e.g., home, office), and environmental factors that safeguard the comfort, safety, confidentiality, and privacy of clients; ensure adequate video and audio data transmission; and minimize ambient noise and visual distractions.[41]

Environmental considerations. Lighting, room decor, and room size are examples of the factors the SLP must consider for the location where she provides telepractice services.[58] For example, consider the background that the students will view during the session. Utilizing a blank neutral colored wall and controlling natural outside lighting will minimize visual distractions and encourage the student to focus on the SLP and the therapy activity. On the student side of telepractice, where the child is seated in relation to the camera and microphone will impact audio and video quality. Consider a student with a speech sound disorder and the SLP's need to hear the child's speech production and clearly visualize their mouth. Advanced planning and practice will identify the physical setting factors to modify or accommodate. [Table 1] provides a detailed list of physical features and their associated considerations for telepractice service delivery.

Table 1 Physical Setting Feature Considerations for Telepractice Service Delivery

Setting feature	Consideration for telepractice
Is there a door?	Helps maintain confidentiality
Are their working electrical outlets and access to phone line and/or internet?	Helps ensure working technology
Is there adequate lighting?	Consider a light source above or in front of the SLP/client to reduce shadows and encourage a clear view of the face Consider using room darkening shades or use a room without a window to improve lighting
Are their visual distractions?	SLP background should be neutral such as a blank wall/door or closed cabinet
Are their auditory distractions?	When possible avoid using space near noisy environment (e.g., next to the cafeteria, game room) Consider headphones to minimize ambient room noise When possible limit other media in the surrounding area (e.g., television on in the adjoining room)
Is the room setup/placement of the SLP optimal for telepractice?	Does the SLP have adequate space to organize therapy materials for immediate access? Does the SLP have immediate access to a phone for alternative communication if there are technology glitches or safety concerns?
Is the room setup/placement optimal for the client's therapy?	Consider the materials and space needed for the session. For example, will the student be interacting with the SLP using online materials in a face-to-face video conferencing session or will the client be engaging in play while the SLP coaches the parent through wireless ear buds? Consider the camera angle for seeing the client
Does the telepractice equipment need to be stationary or moveable at the SLP site?	Consider dedicated equipment for telepractice to help maintain specific settings. If equipment needs to be moved, then consider a rolling desk or cart

Abbreviation: SLP, speech-language pathologist.

The How of School-Based Telepractice Service Delivery

Having discussed the who, what, when, where, and why of telepractice as a service delivery model, this final section reviews basic principles for how to provide intervention and assessment, considerations for reimbursement, and considerations for collaboration in the telepractice service delivery model.

Intervention. Delivering therapy services through telepractice requires the same clinical competencies as are required for in-person therapy services. SLPs trained in ASHA-approved graduate programs in speech-language pathology should possess these foundational clinical competencies. Developing skills specific to this service delivery model (e.g., screen sharing and transitioning among multiple digital materials) can be obtained through continuing education and observing other experienced practitioners. In addition, actual practice is essential to developing skill in delivering services through telepractice. [Appendix A] provides a list of skills specific to telepractice service delivery along with resources and tips for acquiring these skills.

Appendix A Skills specific to speech-language pathology telepractice intervention

Skill	Abbreviated list of resources and tips
Technology-related skills
Establish an audio and video connection and send a meeting invitation using the selected telecommunications platform	Telecommunication platforms provide instructions and instructional videos on their Web site (e.g., https://support.zoom.us/hc/en-us/articles/201362613-How-Do-I-Host-A-Video-Meeting )
Correctly utilize the features of the telecommunications platform, such as a white board, screen-sharing, participant access, and resizing of windows	Instructions are available at the telecommunications platform Web site (e.g., https://support.zoom.us/hc/en-us/articles/115005706806-Using-annotation-tools-on-a-shared-screen-or-whiteboard ) If your platform does not have a particular feature, a workaround may be provided in a user forum (e.g., https://support.google.com/meet/thread/42236750?hl=en )
Open and switch between shared materials without interrupting the flow of the therapy session	Practice is required to develop this skill. It can be beneficial to observe an experienced telepractitioner or collaborate with other telepractitioners to share tips and tricks
Prepare for glitches in shared materials and be flexible in adjusting preplanned activities within the session	Select Web sites and other materials to be shared and have them available on your computer prior to initiating telepractice sessions for the day. Create a file of alternate Web sites or activities. Social media SLP telepractice groups can offer suggestions (e.g., https://www.facebook.com/groups/SLPTelepractice )
Initiate simple troubleshooting procedures for audio/video difficulties or loss of internet connection	Your telepractice platform will offer basic troubleshooting tips on their Web site (e.g., https://support.zoom.us/hc/en-us/sections/200305593-Troubleshooting ) If available, discuss tips with an experienced telepractitioner and instructional technology personnel. Create a list of troubleshooting tips and make sure contact information for support is readily available
Recognize when the audio and/or video quality is not at an acceptable level for providing intervention	Audio and video qualities are often directly connected to internet speed for the telepractitioners, the client, or both. Check your telecommunications platform Web site for recommended internet speed, and then check the speed of your internet here: http://www.speedtest.net/ Attempt to troubleshoot and, if audio and video qualities do not improve, reschedule the therapy session and/or provide an alternative, such as consulting/coaching with a caregiver. If audio and video quality issues persist, then utilize a different service delivery model
Understand the safety and confidentiality features of your telecommunications technology	Your telecommunications platform Web site will provide information related to safety measures, encryption, and best practices (e.g., https://zoom.us/docs/en-us/privacy-and-security.html )
Skills related to engagement/interaction
Maintain eye contact with the client(s) rather than the computer screen during the session Develop rapport with the student(s) during the session Use effective vocal loudness, affect and pacing to match the needs of the student and the telepractice service delivery model	If using an external camera, situate the camera so that you can look directly at the student and use your peripheral vision and brief glances downward to control the videoconferencing session Practice is required to acquire these skills. It can be helpful to observe an experienced telepractitioner
Develop or find digital materials that are appropriate for the student and the telepractice service delivery model	This skill is challenging for many SLPs. You can consider a videoconferencing platform that has built in activities (e.g., Theraplatform https://www.theraplatform.com/). You can create online materials with authoring tools such as Lesson Pix (https://lessonpix.com/) or Boom Cards ( https://wow.boomlearning.com/ ) You can purchase materials from a variety of sources. Common resources include: Boom Cards ( https://wow.boomlearning.com/ ), and Teachers pay Teachers ( https://www.teacherspayteachers.com/# ). You can learn about Web sites and online games and activities through continuing education and social media telepractice groups (e.g., Teletherapy Materials for Speech-Language Pathologists: https://www.facebook.com/groups/420947961614606/ ).
Recognize the potential impact of cultural variables on the student's ability to participate in telepractice and provide modifications or accommodations if needed	This is a new area of clinical research in telepractice and the SLP is encouraged to stay up to date in this area. Developing cultural competence is an individual and ongoing process. ASHA provides a helpful cultural competence self-assessment tool ( https://www.asha.org/practice/multicultural/self )

Assessment. Like intervention, conducting assessments for school-age students through telepractice relies on the in-person evaluation competencies that the SLP already possesses. Unique challenges to assessment in telepractice include adapting the testing materials for on-line delivery, in some cases adapting the testing procedures for remote administration and summarizing and reporting standardized test scores. Eichstadt and Castilleja encourage the SLP to consider five environments when preparing for online assessment.[59] First, the SLP needs to consider the physical environment at both the student and clinician sites. Is the area quiet with reduced distractions, adequate lighting, and optimal orientation to the screen for the student? The second environment to consider is the availability of test materials and how they will be delivered to the client. For example, if the test requires a stimulus book, is it available in a digital format or can the hard copy be utilized with a document camera? If a test requires manipulatives, the SLP may provide the list of required items to the adult at the student site ahead of time so that the materials are available during testing. A recent article by Kester identifies key considerations related to the test materials utilized in online assessment.[60] The third environment to evaluate involves the student's behavior during the testing session. For example, is the child attentive and responsive? Does the child interact in the testing situation online as you would expect in person? Fourth, the SLP needs to examine his/her behavior during the assessment, including what adjustments were made to conduct the assessment. Was the SLP able to efficiently administer the assessment online? Did the student have an adequate view of the stimulus materials? Lastly, was a support person utilized in the assessment? How was that person prepared for his/her role? Did the support person appear to influence the child's behavior? When writing the evaluation report, the SLP should include information about these aspects of the environment in the analysis and interpretation of test results.

Collaboration. Collaborating with other educational professionals and assimilating into the school culture is an important variable in school-based telepractice, as it is for all school-based service delivery models. Early on in our school-based telepractice project at KSU, we discovered that parents and, in particular, faculty members had misperceptions about telepractice services. For example, one faculty member self-reported that, although she did not know what telepractice service delivery was, she believed that it was a cost-saving device used by the school district to provide inferior services to students.[23] It is likely that there is much less confusion about online service delivery since the shift to remote instruction and provision of speech-language therapy services due to COVID-19. Still, the SLP can engender enthusiasm among stakeholders and promote participation through an orientation/demonstration session. In our clinical practice, we found that responsibility rested with the telepractice SLP to not only initiate contact with classroom teachers, administrators, caregivers, and parents but to persist in initiating communication about student progress, concerns, and classroom content/assignments. Collaboration is an important consideration for all service delivery models to ensure effective intervention for students with communication impairments.[61]

Reimbursement. The cost of providing telepractice services and how these services are covered by insurance and Medicaid is an important consideration when deciding to become a school-based telepractitioner. The public schools are unique in that they are required to provide services and therefore have a financial obligation to offer specialized instruction to students who have been identified as handicapped under IDEA 2004.[8] In fact, public schools are the most common setting where speech-language telepractice services are provided.[35] In some states, school districts can receive Medicaid reimbursement for speech-language therapy services provided to children who are eligible for Medicaid services. To check for availability in your state and the relevant policies for reimbursement, go to ASHA's COVID-19: Tracking of State Medicaid Telepractice Policies & Emergency Telepractice Orders[62] as well as your state's Medicaid department Web site. The cost of service delivery using a telepractice service delivery model will vary and is dependent on a variety of factors, including how the SLP is employed (e.g., an employee of the district, a contracted private practitioner), who supplies the telepractice equipment and internet connection, who supplies the clinical materials, and who covers the other costs related to delivery of speech-language therapy services.

Conclusion

In 1985, Fitch remarked that, “There is much to be done before we can claim that the field of communication disorders is utilizing technology to its fullest.”[5] Dr. Fitch made his remarks in the inaugural issue of the Journal of Computer Users in Speech and Hearing. While the journal is no longer in publication, Dr. Fitch's call to action remains compelling as we integrate telepractice into the service delivery models in our field.

Telepractice has the potential to radically redefine how our services are delivered to better meet the needs of our school-age clients and is an important service delivery model for every practitioner to understand and implement, when appropriate.

Conflict of Interest

None declared.

Financial Disclosures

The author receives a salary from Kent State University, as a faculty member in the Speech Pathology and Audiology Department.

Nonfinancial Disclosures

The author has no relevant nonfinancial relationship to report.

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Publication History

Article published online:
16 March 2021