Using Telepractice to Improve Outcomes for Children and Adults With Hearing Loss

May 2012

K. Todd Houston, PhD, CCC-SLP, LSLS Cert. AVT

Rapid advances in the evolution of telecommunication and distance technology are creating new opportunities to provide direct services to meet the audiological, speech, and language needs of young children and adults with hearing loss. To this end, audiologists, speech-language pathologists, program administrators, and other service providers should be aware of the range of service delivery models–from telehealth and telemedicine to telepractice and teleintervention. Similarly, consumers–such as families of children with hearing loss and adults using hearing technology–are becoming more comfortable receiving a range of health care related services through the use of videoconferencing software and a secure Internet connection. The technology has become cheaper, more reliable, and widely available for use on laptops, tablet computers, and even smart phones. For example, in medical centers and private practices throughout the United States, physicians are providing diagnostic services, treatment, and patient counseling through models of telemedicine.

Audiologists and speech-language pathologists are embracing telepractice to provide services to a range of patients who have hearing and communication-related delays and/or disorders. Teleintervention, a specific model of early intervention provided through distance technology, provides family-centered services to infants, toddlers, and young children with hearing loss and allows the provider to model and coach parents in language facilitation techniques. As telemedicine, telepractice, and teleintervention become more common and are integrated into standards of care in some areas of the country, audiologists and speech-language pathologists will increasingly attempt to incorporate these services into their programs.

Defining "Tele" Terminology in Health Care & Service Delivery

The "tele" prefix is derived from the Greek root word "tele," which means "distant" or "remote." Therefore, any word attached to "tele" implies that service is provided at a distance, typically through some form of technology. According to the Agency for Healthcare Research and Quality (AHRQ), telehealth is the use of telecommunication technologies to deliver health-related services and information that support patient care, administrative activities, and health education (Dixon, Hook, & McGowan, 2008). Telemedicine, however, is defined as the provision of medical services over distance (Fong, Fong, & Li, 2011). While these definitions appear to overlap, telemedicine typically is used more narrowly to describe treatment or clinical services delivered by a physician, hospital, or medical center. However, use of these terms is inconsistent. Baker and Bufka (2011, p. 405) observed, "The terms are frequently used interchangeably as there is yet no universal definition or term used by legislators, policymakers, government agencies, and payers." Because of the confusion that exists among consumers and stakeholders, professionals of different disciplines often devise their own terminology to describe the services that are being provided, including, but not limited to, telemental health, telenursing, telepharmacy, telecardiology, telepathology, teleradiology, telepsychology, telerehabilitation (i.e., a broad term typically used with allied health professions), tele-audiology, tele-speech, and tele-therapy.

Telepractice in Audiology and Speech-Language Pathology

The American Speech-Language-Hearing Association (ASHA) defines this videoconferencing service delivery model as "telepractice" for practitioners in audiology and speech-language pathology (ASHA, 2005a, 2005b, 2010). Evaluating the use of telepractice in audiology, Swanepoel and Hall (2010) analyzed related peer-reviewed literature and found that hearing screening, diagnosis, and intervention were feasible and reliable across ages and patient populations. The researchers acknowledged that continued research was warranted, but held that tele-audiology showed significant promise.

A National Center for Hearing Assessment and Management (NCHAM, 2010) survey of state early hearing detection and intervention (EHDI) coordinators revealed that 42% had some type of telehealth efforts planned or underway. After teleintervention, the use of audiology telepractice to conduct diagnostic automatic brainstem responses (ABRs) remotely was the second most common service implemented or in the planning stages. In efforts to ensure timely delivery of services from properly trained professionals, EHDI coordinators reported ongoing plans to either expand or implement remote hearing aid programming and/or cochlear implant mapping through models of audiology telepractice.

Mashima and Doarn (2008) completed a review and described broad application of telepractice in speech-language pathology, including treatment of neurogenic communication disorders, fluency disorders, voice disorders, dysphagia, and childhood speech and language disorders. While further research is needed, a growing body of evidence in audiology and speech-language pathology supports positive outcomes with telepractice.

The Telepractice & eLearning Lab (TeLL) at The University of Akron

Families of young children with hearing loss often face challenges securing appropriate services from qualified providers. Evidence continues to illustrate the shortage of professionals with the necessary knowledge and skills to deliver evidence-based medical, clinical, and early intervention services to this special population (Houston & Perigoe, 2010; Houston, Munoz, & Bradham, 2011; Joint Committee on Infant Hearing [JCIH], 2007). Likewise, for more than a decade, the shortage of adult aural rehabilitation services has been raised in the literature (Montgomery & Houston, 2000) as well as the need to deliver these services to more adults with hearing loss who use both hearing aids and/or cochlear implants (Alpiner & McCarthy, 2000; Hull, 2010). To provide greater access to services, some practitioners and/or their programs are employing models of telepractice to address the habilitative and rehabilitative needs of children and adults with hearing loss, often with favorable results (Houston, 2011; McCarthy, Munoz, & White, 2010; Swanepoel & Hall, 2010).

In an effort to expand clinical services, provide opportunities for pre-service training, and further investigate the efficacy of telepractice models, the Telepractice and eLearning Laboratory (TeLL) was established in the School of Speech-Language Pathology and Audiology at the University of Akron in the fall of 2011. Building on a model of teleintervention (Houston, 2011) developed at Utah State University, families of children with hearing loss who were seeking services to support listening and spoken language were recruited to participate in the pilot project. Adults who wished to receive aural rehabilitation services were also recruited to expand the TeLL's range of telepractice services.

Currently, the TeLL utilizes the distance learning software Elluminate, produced by Blackboard, to deliver telepractice services. Although other videoconferencing equipment and software were evaluated, Elluminate provided the flexibility that was required and the University of Akron was able to provide technological support as needed. Because the software is designed for distance learning applications, it creates a "virtual classroom" whereby the "student" can enter and access complete audio and video of the "lecturer" in real time (i.e., synchronously). In the TeLL's telepractice sessions, the client/patient can log into the virtual classroom using a laptop or desktop computer at home. In a similar manner, the clinician can enter the classroom and see and hear the client/patient clearly. The equipment requirements have remained minimal. That is, the only additional equipment needed are a web camera (i.e., webcam) and microphone, which are typically standard features of most computers. When the webcam and microphone are coupled with a strong broadband Internet connection, clients/patients have had little difficulty accessing the sessions. Other centers have purchased high-end videoconferencing equipment ($5,000–7,000 per unit) to be placed in the homes of clients/patients; this practice has proved to be cost prohibitive in most situations. While this equipment may provide an optimal audio and video signal, it is not necessary to deliver effective telepractice services.

TeLL: Services to Young Children With Hearing Loss & Their Families

Families enrolled in the project receive weekly teleintervention sessions that last approximately 60 minutes each. Prior to each session, each family receives, via e-mail, a lesson plan and materials that can be printed that were developed to meet the child's current goals in speech, language, and listening. Many of the materials, such as colorful scenes to foster language use, can be posted within the virtual classroom. The parent and the child can see these materials as images on the computer screen.

Typically, each session begins with a discussion of the speech, language, and listening goals targeted during the prior session and about how previously demonstrated communication strategies had been integrated into the child's daily routines. The speech-language pathologist (SLP), graduate students, and parent discuss any new communication behaviors that might be relevant to the child's progress, such as new or emerging speech sounds, words, or listening behaviors. Once these updates have been shared, the SLP and graduate students introduce the goals for that day's session, explaining the desired speech, language, listening, and interactive behaviors. After discussing the materials and activities that would most engage the child, the SLP and graduate students demonstrate the activity before asking the parent to engage the child. The parent repeats the activity while the SLP and graduate students observe. At this point in the session, the practitioner's role shifts to that of a coach. The SLP and/or a graduate student provides positive reinforcement and constructive feedback to the parent based on how the activity was implemented and how the communication strategies that promote listening and spoken language were applied.

This same scenario is repeated as one activity ends and a new activity is initiated. Throughout the session, the parent, the SLP, and graduate students closely monitor the child's attention level. For example, if the child begins to lose interest, the parent may say, "Let's do it one more time, and then we'll get something else to play with!" By maintaining control of who (i.e., the parent) ends each activity, the parent is often able to move through several activities that reinforce listening and spoken language without losing the child's interest or seeing the session deteriorate.

Following the session activities, the parent is given ample opportunity to discuss any concerns about the child's progress, to ask questions about short- or long-term communication goals, or to seek input about troubleshooting the child's hearing technology (e.g., digital hearing aids and/or cochlear implants, FM systems).

The SLP and graduate students summarize the goals and facilitation strategies that were modeled and practiced during the session. Based on the child's performance and developmental level, new or additional communication goals are identified for targeting in the home the following week.

The teleintervention model continues to be a viable service delivery model for supporting children with hearing loss who are acquiring listening and spoken language skills. Children have obtained language outcomes that are consistent with or exceed developmental norms. Additionally, parents have become more confident in their role as the child's primary facilitator of language.

A parent with a 3-year-old boy with bilateral cochlear implants explained her experiences with teleintervention:

My son started Auditory-Verbal Therapy when he was much younger, which required us to travel to the therapist's office for weekly sessions. After we moved, we found another therapist, but he was quite a distance from our home. We could only see him one or two times each month. I realized that we were losing the consistency of weekly sessions, and I saw his speech and language start to regress just a bit. I was very concerned. With telepractice, I wasn't sure how he would do sitting in front of a computer and interacting with the therapist. But, what I've found is that telepractice has benefitted him in many, many ways. First, we have the consistency of weekly therapy back in place. Second, my son is more comfortable with telepractice than he was going to see [the] therapist and having more traditional services sitting at a table in a therapy room. With telepractice, he's in his home, and I'm working with him. If he needs to get down and stretch his legs or grab a glass of water, he can. It is quite natural for him. Most importantly, because he feels more comfortable being at home, I see him talking more during the sessions. He doesn't "clam up" like he used to when we visited the therapist. Another benefit of telepractice is the coaching I receive as the parent, and that I receive weekly lesson plans and other materials that I can refer to after the session. We'll continue to work on the goals and do the activities throughout the week. Telepractice has been great for my son and our family!

TeLL: Services to Adults With Hearing Loss

For adults with congenital or acquired hearing loss, improvement in auditory processing and comprehension can often be achieved when their use of advanced hearing technology (i.e., digital hearing aids, cochlear implants) is coupled with aural rehabilitation services that are delivered by well-trained practitioners. Several factors may impact an adult's performance with his/her hearing technology, such as the age of onset of deafness or duration of deafness, the remaining residual hearing the individual may retain, the amount of time hearing aids and/or cochlear implants are worn, and the opportunity to listen to or participate in conversations.

For adult patients receiving services through the TeLL, each session is focused on the individual's communication needs in the areas of auditory processing and overall conversational competence. The adult logs into the virtual classroom, and the SLP and graduate students are able to interact directly with the patient. The session typically begins with a discussion of how the patient has performed over the past week since the previous session. Any noticeable changes in the patient's communication–either positive or negative–are recorded in his/her file. Then, a discussion of the current session's goals and activities occurs. Typically, most patients have goals that target auditory discrimination and identification tasks at the phoneme and word levels. That is, these activities provide "bottom-up" auditory skills that are essential for making fine discrimination of speech information.

Conversely, the patient also will have targeted "top-down" activities that incorporate functional language and conversational skills. Throughout the session, the SLP and graduate students are giving directions, asking questions, and commenting on the patient's performance. Even when formal top-down strategies are not targeted directly, these skills are being practiced indirectly. For each adult patient, top-down language is tailored to meet his/her specific needs. That is, patients may share vocabulary or conversational phrases from their respective profession or work setting, and those are incorporated into each session. Additionally, many adults may also struggle with specific listening situations within the community, such as attending a worship service or visiting a restaurant, local business, or gym. Context-specific phrases and vocabulary from these situations are also practiced within the telepractice session.

A 60 year-old adult cochlear implant user with an acquired hearing loss made these comments about his experiences receiving aural rehabilitation services through telepractice:

As compared to in-person therapy, there's no question that telepractice brings another dimension to this process. With in-person therapy, the clinician controls the entire situation–the therapy room, the materials, and how everything is presented. With telepractice, I'm connecting from my home office, so I feel that I'm more of a partner in this process. I know that I must be there at the computer ready to listen, and I believe that I'm taking greater ownership of my own rehabilitation. I believe that I've been able to establish great rapport with my telepractice team, and the results I'm experiencing are on par with those that I've achieved through in-person therapy.

Future Directions

Telecommunication and distance technology continue to evolve and are becoming more pervasive in the provision of audiological, speech, and language services to young children and adults with hearing loss. Looking forward, we can foresee that telepractice service delivery models will most likely become standards of care for families seeking early intervention and/or speech and language services for their children with hearing loss. As well, adults who are utilizing digital hearing aids and/or cochlear implants will seek aural rehabilitation services to improve their auditory processing and communicative competence. While generational differences exist in the use of technology, those differences are beginning to diminish, especially as technology becomes more user-friendly, affordable, and reliable. For audiologists and speech-language pathologists, models of telepractice provide exciting opportunities to connect with patients and to provide valuable services that may not otherwise be available.

About the Author

K. Todd Houston, PhD, CCC-SLP, LSLS Cert. AVT, is associate professor of Speech-Language Pathology at The University of Akron. His primary areas of research include parent engagement and communication outcomes in young children with hearing loss. As the director of the Telepractice and eLearning Laboratory (TeLL), he is also keenly interested in the use of telepractice/teleintervention to enhance service delivery to young children and adults with hearing loss. An avid user of social media, Dr. Houston can be contacted at houston@uakron.edu; you can also follow him on Twitter (@ktoddhouston) or connect on LinkedIn or Facebook.

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