Season 7, Episode 6

[INTRODUCTION]

[00:00:13] ANNOUNCER: Welcome to SLP Learning Series, a podcast series presented by speechtherapypd.com. The SLP Learning Series explores various topics of speech-language pathology. Each season dives deeper into a topic with a different host and guests who are leaders in the field. Some topics include stuttering, AAC, sports concussion, teletherapy, ethics, and more. Each episode has an accompanying audio course on speechtherapypd.com and is available for 0.1 ASHA CEUs. Now, come along with us as we look closer into the many topics of speech-language pathology. 

Welcome to season 7. Telepractice: It's Not Just Screen Time. 

[INTERVIEW]

[00:01:15] KHK: Welcome to the podcast mini-series; Telepractice: It's Not Just Screen Time. Presented by speechtherapypd.com. Thanks for joining us for our sixth episode; Treating Medical Cases Through Telepractice. This audio course is offered for 0.1 ASHA CEUs. 

I'm your host, Karin Hartunian Koukeyan. I've been a speech-language pathologist for over two decades and working in telepractice for the past 12 years serving in both special education and healthcare. 

Before we get started, we have a few items to mention. We love and encourage questions from our participants. You can put your questions in the chat box for our guests to answer towards the end of the episode. 

As a reminder, if your state license requires CEUs, be sure to complete all course modules including the one that says quiz before the end of today on your speechtherapypd.com account. 

Here are the financial and non-financial disclosure. Karin Hartunian Koukeyan is the host of this podcast and receives compensation from speechtherapypd.com. And she's also currently the Clinical Program Director at SLP Tele. Her non-financial disclosures are that she is the current SIG 18 Associate Coordinator for ASHA. Dr. Kelli Uitenham receives an honorarium from speechtherapypd.com for this episode. She is the owner of Serenity Speech Therapy, owner of Kensington Academy, and an independent contractor for Great Speech. Her non-financial disclosures are that she is a member of SIG 18 for telepractice.

And now here's a little bit about our guest today. Dr Kelli is a medical SLP licensed in nine states that has been practicing for nine years. She is the owner of a private telepractice, Serenity Speech Therapy, and owns Kensington Academy, a private consulting firm for SLPs interested in starting a private practice, getting into telepractice, or travel therapy. 

Dr. Kelli's areas of interest include accent modification, dementia, dysphagia, aphasia, Parkinson's disease, and fluency. She has experience working in skilled nursing, assisted living, and independent living facilities. Dr. Kelli also has experience working in hospitals, home health, and as a travel therapist. She is a certified Compton PESL accent modification instructor, a Speak Out and Speech Easy provider. 

Dr. Kelli is also an adjunct assistant professor at St John's University, North Carolina, A&T State University, and Shaw University. She is a public speaker and has served as a guest lecturer for Purdue University as well as Howard University. Welcome back, Dr. Kelli. 

Dr. Kelli was our guest for episode 4 on accent modification through telepractice and we are excited to have her back to speak with us about treating medical cases through telepractice. There is a handout that goes with this course and it will be available beginning tomorrow for download. 

All right. The learner outcomes for this course are, that by the end of the course, participants will be able to identify appropriate therapy materials for telepractice, facilitate functional family caregiver training, understand safety measures for various medical cases via telepractice. 

All right. Welcome, Dr. Kelli. 

[00:04:57] KU: Thank you for having me back. It's an honor to be here. And hello, everybody, who's tuned in. 

[00:05:03] KHK: Wonderful. Let's get started. What are some examples of medical cases that you will be highlighting today for us? 

[00:05:09] KU: Well, I will be highlighting several, but I have a list of about eight different diagnoses that I'll go through quickly for those who are not as familiar with the medical terminology or don't have the medical SLP background. 

Okay. One will be stroke. That's a big one that I see in my practice. This is sometimes referred to as a brain attack. And it takes place when something blocks the blood supply in the brain. That could be if a blood vessel or a blood vessel bursts, or if there is a blockage. But either way, a part of the brain can become damaged or die. And this also causes lasting effects, which is why they, of course, require speech therapy. Another one that I see a lot in my practice is Parkinson's Disease. And this is a brain disorder that causes unintended and uncontrollable motor movements. An example of this would be like shaking, stiffness, tremor. You may see Ð they call it the pill-rolling movement where the client's fingers roll like this but it's not of their own volition. They're just doing it. 

Dysphagia is a big one. This is the medical term for swallowing difficulties. If you can recall back to grad school, there are several stages of the swallow, which means that there are different kinds of things that can go wrong with the different parts of the swallow. And that is dysphagia. TBI is another one, which is a traumatic brain injury. This can happen if there's been a jolt or some sort of injury to the brain, as well as if something penetrates the skull and enters the brain. That's another type of traumatic brain injury. Aphasia is a big one. That can be accompanied with other diagnoses such as stroke. This is the loss of language. This affects how a client can communicate. Either expressive communication or receptive communication. If they hear what you're saying, what you are saying to the client, it could be translated to them as something completely different and you may get a lot of, "What? What did you say?" 

Dementia is another one. This is characterized as the progressive or persistent loss of brain function. And this really impairs memory and problem-solving. It can change your client's personality. There's also a tracheostomy. And this is a hole that surgeons will put into a client or patient's neck to help them breathe better. The trach is a tube that goes into the opening. And one that I'm seeing a lot of now is unfortunately long COVID. This is a multi-system disease of unknown causes that manifest. And it is Ð they're exacerbated by other comorbidities. Brain fog is a big one that we'll talk about later on. But there is an estimate that there are approximately six, but to as many as 30%, of adults that are infected with COVID-19 that are currently experiencing long COVID symptoms. And we'll get into that more later on, I'm sure. 

[00:08:21] KHK: Well, thank you so much for the detailed definitions of those cases. It looks like it's going to be a very informative episode. Thank you. Let's start with the preliminaries. How do you effectively utilize therapy materials via telepractice for medical cases? 

[00:08:38] KU: Well, first, I would like to share with everybody that I was always taught that you should be able to do therapy with just your fingers and a pencil. That really helps with how creative you can be because you should be able to turn anything into therapy. When you do get the actual physical materials or digital materials, it really becomes a luxury and a welcomed addition to the skills that you've already established. And in saying that, I do use a combination of traditional materials. So like the walk resource books. I really like those. I do have them in Virtual form. So I do have them in a PDF which makes it great for screen sharing with my clients so they can interact with it and feel like they're really participating in the session, which I'll share more about later. 

I really like the Just for Adults Cards. That's a deck of cards. And I can show it here for those of you who can see it. It's a large deck of cards and it has pictures. And on the back, there are questions. So for those who are just getting into medical SLP treatments or you're transitioning, this is phenomenal. Because even on the back of the cards, they will give you the questions and the prompts until you kind of get your own flow of things. There's a second box just for adults for apraxia. They have a second deck that's available now. And if I think about some tech ones, I really like a particular set of apps. I think that they're really great and very functional. I like Constant Therapy or the CT app. That is excellent for cognitive exercises. It's free for the clinician. For the client, I believe they get a 14-day free trial. And after that, it's $29.99 a month for the clients. It always remains free for the clinician. But it's a great way for you to track the client's progress. It's a great way for you to see if they're doing the homework and carryover exercises. You can modify the challenge level. You can modify the number of repetitions. Recently, I just assigned it to one of my clients and just kind of did a trial so that they could get familiar with the app. But I was only having them do two or three reps of a particular exercise. But now that they're doing well, and I was able to check their accuracy through the app, I could see they were doing okay. And so, I bumped it up to a more challenging number. So between like 10 and 15. But I believe the app goes to 30 or more reps. I really like that one. 

I really like this app called EPICC Tech. And that's E-P-I-C-C. And you can download these on the Apple Marketplace or Google Play. And this also has really great functional tasks. I really like that it includes financial information. If you're needing to know, "Am I going to have enough money for something?" So they'll provide you with a menu of something. Maybe it's a sushi menu. It's an actual thing on there. It's a sushi menu. And they'll say what the different items cost. And they'll also show you currency. And then the client will have to determine if the amount of money that they have is enough. And so, they'll also have to do the math where they add, "Okay. Can I get a California roll and a shrimp tempura roll? Do I have enough money for that?" And this is another app that allows you to track how they're doing. 

I know they have 80-plus cognitive communication modules. This is great for clients with aphasia, stroke, TBI, dementia, MS, Parkinson's disease. And I know that this one has a free 30-day trial. And this one costs $19.99 for the month for the clinician and for the client. Or you could do the $199 for the year and just be done with it. Let's see. And I really like the EPICC app because it's actually made by an SLP. You can go and follow them and learn more about it. But that's one I really like. Another one is called TalkPath by Lingraphica. This is the most economical option because it's free for both you and the client. And it has variations of the different things that I listed for the previous apps. But you may experience more limitations just because of the cost being free. But it is a great tool to use if you would like to trial and see if your clients can utilize the device with the following directions and the different steps. And then if they do well with that, they may to graduate to something more challenging. 

There is an app called Aphasia Talks. I know they have multiple language options, which I really like. So English, Spanish, Mandarin, Hindi. And this is $9.99 to purchase in the Apple Store. 

And Ð oh, yes. So then, also, thinking about therapy materials or rehab devices that your client may need. I like to purchase my own version so that they can see me model the device. And an example of that would be the EMST device. And that is the exploratory muscle strength trainer. I have it here for those who can see. And so, I will just do the actual exercise with them. As you can see, there are pieces to manipulate and you can help them through it. Help them set it up. But it's easier if they can see you actually doing it. Okay. I also recommend incentive spirometers. Breathalyzers, that's another inexpensive device that can be purchased for clients, which means that you, the clinician, can also purchase it. 

And more pricey, but an NMES device. So a neuromuscular electrical stimulation device. The most popular on the market is the VitalStim. A lot of facilities or hospitals may purchase these. But there are NMES devices that are available for clinicians to purchase. And the one that I have is called the Aspire2 by The Guardian Way. Or vice versa, The Guardian Way by Aspire2. You can Google those, and they'll send you the pads and the device. They'll actually provide the training for you. But it's a great way for you to have the device in case your client would like to purchase it as well. I have worked with the company, and they will train your client. Allow them to purchase the device, which is Ð I have not heard of that of a medical device company actually allowing non-medical personnel to purchase it and train them. But they do. And so, having that on hand is beneficial when I'm doing those exercises with my clients. 

[00:15:25] KHK: Oh, excellent. That's a lot of really, really good resources. I am curious with these that require additional technology, have you had issues with the technology piece knowing that some of our adults may have challenges in that area? How have you worked through that? 

[00:15:45] KU: I always try to consider my client's limitations. If a client has a difficult time with following multi-step directions or difficulty with remembering the steps to either access the app or how it works, then that may be an exercise that we build up to. And I won't introduce the technical pieces just right away. 

But if clients are high-functioning enough to where they can operate the app, then I will have them use it. And that way, they're cognitively able to share if something goes wrong, or if they're having a difficult time, or if they want to change the challenge level with the exercises. It really depends on the client. But I won't recommend using something as advanced as the app for clients who can't handle it. Good question. 

[00:16:30] KHK: Definitely. And most of your clients, I would assume, either have a family member or access to the technology. Is that right? Most of them have smartphones? Or can you maybe like give us examples of some challenges that you were able to work through? 

[00:16:45] KU: With Ð I won't say most. Because a lot of my clients are in their 80s and 90s. So some will have like maybe their child or an actual caregiver to be present. And if they do need to access information with technology, either a phone or a tablet, then they will have a caregiver or a family member nearby to help with that. 

[00:17:09] KHK: Got it. Got it. And then are you having to like schedule kind of off hours? I was just curious. Because the family members might not be available during the day. Has that been an issue? 

[00:17:23] KU: For like training on the device? 

[00:17:24] KHK: Yeah. 

[00:17:25] KU: I like to do as close or as often as point of service as possible. So I will ask if the spouse or caregiver can be present for the first couple of minutes. And I'll dedicate that time. But if additional time is needed and they're not available, then, yeah, I can schedule a virtual meeting or speak with them on the phone or send them a detailed email that describes everything. I'm also good for sending links. I may send like a YouTube video with an example of something. But I always make sure that they know that I am available for questions whenever they need to. My office number also can serve as a text number. And so, if I always say, "If you can't reach me if I'm in session or anything, just text me and I'll respond." 

[00:18:06] KHK: Excellent. So you don't always have to have the family there 100% of the time in order to do therapy. 

[00:18:12] KU: Correct. But sometimes they just like to be there. 

[00:18:16] KHK: Of course. Yeah, definitely. 

[00:18:19] KU: We have fun. We have fun in sessions. 

[00:18:20] KHK: Yeah. And that's the beauty of telepractice. They don't necessarily Ð I mean, they may even be able to connect when they're not physically there. But, yeah, it opens up a wide variety of opportunity. Yeah. So let's continue to talk about some of these diagnoses and some of the exercises. Can you give us some examples of exercises for two particular most common diagnoses? 

[00:18:45] KU: Sure. A big one that I mentioned was aphasia. And some examples of exercises I'll kind of go through, what is less challenging, to intermediate, to more challenging tasks. And this can be an exercise that I start with a client. And as time progresses and they improve and demonstrate gains, then these are exercises that they can elevate to, if you will. For an Aphasia client, I may start off doing something very simple depending upon the severity of the diagnosis. But getting them to repeat the initial sound of their first name. Mine is Kelli. It could be just getting them to be able to control their tongue to get it to the back of their throat and have that air pressure and produce the "k, k" sound. Sometimes that could take an entire session depending upon what the reason for their aphasia when they were discharged from the hospital. If they receive speech therapy while they were hospitalized or prior to coming to my practice. 

After that, I would increase the challenge level once they're able to do that and start working on more functional words like their name or their birthday. In some cases, their address. That can be lengthy. But that's a good one once they start improving. And a more difficult one would be to produce a complete sentence like requesting what they wanted for breakfast, which is actually what I did in a session today. A client that I started with, we did start with his name and the city and state that he lived in. And that used to be very laborious for him. And now he is able to produce complete sentences. But sometimes he'll still need a model. 

But it can be challenging because of going from either a sound, or one or two words, or phrases. To complete sentences, you still have to remember where those parts of Ð or where your articulators are placed. The order of the words and not getting too confident and ahead of yourself. Because I do run into that too, where my clients with aphasia will get excited that they can say particular words, or phrases, or like automatic speech is coming back easier to them. And then they'll want to start speaking like they always have. But you have to remind them, "We're still working together. So remember to slow down." And reminding them to slow down their thinking. Because if they're thinking exactly what they want to say and getting it here, then you can have kind of a traffic jam. And helping them through that is a part of treatment. 

Another common diagnosis that I work with in my practice is dementia. So a simple or less challenging activity that I would facilitate would be to recall daily events. So it sounds like you're chatting with them and they're not feeling like, "Oh, this is therapy." Or she's asking me therapy questions. It really just sounds like you're shooting the breeze. I would say, "Tell me about your day. What'd you do today? You woke up and then what?" And so, then I want to see if they're able to recall. If they have caregivers or family present that can confirm, that's always helpful. Or you can ask later. I ask them about ADL. I ask, "What did you do to get ready?" And see how they do with listing that. Also, if there are any kind of medical or social interactions that they've had during the day, like, "Oh, like did your grandchildren come and visit you today?" Or, "What happened at your appointment?" And see if they can remember one thing or anything more than one. That's great. 

An increased challenge level for a client with dementia would be to recall either trivial or functional content, either visual or audio. So if it's something trivial Ð I like to use trivial tasks to help build confidence. Please keep in mind that mental health is still a part of this. If you have dementia, if you have aphasia, then your clients could be experiencing depression. And so, boosting their confidence that they're feeling better about their abilities is an important part of being in session and providing these exercises. I may show them a picture of a scene in a small town and ask them to memorize as much as they possibly can. I don't put the pressure of a time limit on for clients at this stage. That's more for higher-level functioning tasks. But I'll ask them, "Okay. Take your time and try to remember as much as you can." And then I'll take the picture away and then I'll ask them 10 questions about what they can remember. And as that progresses, I will ask Ð I will incorporate space retrieval intervals, which is the fancy speech-therapy term for a delay. I'll also incorporate some environmental distractors because the phone is going to ring, the doorbell, a television program that they want to finish could come on. And the goal is for them to be able to either view or listen to information and be able to hold on to it enough to get through a distractor like a phone call. 

If medical office contacts them and says, "Hey, we need to change your appointment from Tuesday to Wednesday at three." If they want to finish a news program or if their grandchild FaceTime's them and they can't get to a pen or a paper, then they should be able to have those skills to be able to retrieve, "Okay. I need to write down that my appointment got changed to a different day at 4." And a difficult task would be for them to independently recall great functional information. Like if it's a grandmother who likes to cook, then a recipe to something that she's famous for cooking within the family. Or medication management. And also, incorporating those space retrieval intervals and environmental distractors. 

[00:24:26] KHK: These are awesome. These are really wonderful. How do you actually build in those environmental distractors? Do you like text them or call them in the middle of your exercises? Is that how it works? Or Ð 

[00:24:39] KU: I will use more therapy activities if there's nobody else to help. Or I can ask a caregiver who's present to do something. So I may ask them to tap a client on the shoulder or offer them water or do something to get them away from what the actual task is. I may ask them to look at the therapy photo that I mentioned before and completely change topics after they look at the picture. And we could talk about Ð I have one client who very much is involved with her church. So I may ask her a church question, or ask her about the Bible, or ask her about what she's going to wear on Sunday. And then I'll go right back to the activity and see if she remembers. 

[00:25:23] KHK: Very interesting. And I'm curious, with these pictures that you choose. Does it make a difference if it's a novel scene versus a familiar scene? I don't know. I'm just curious. 

[00:25:34] KU: No. Not for visual or recall. They just need something for them to focus on and try to memorize the details. But it's also Ð I like to use those as the confidence boosters. Because if it's something that's functional, like their grandchild's birth date, or age, or something like that, that could really make them feel not great. And so, I try to shy away from those kinds of things until their memory is strong enough to do something like that. 

[00:26:00] KHK: Yeah, definitely. And I did want to ask a little bit about frustration or emotions because that definitely is part of this aphasia and all of it, right? Any comments on situations that might come up and how you've worked through them if a person gets frustrated or emotional? 

[00:26:19] KU: Yes. Had one today. I always try to remember what they are experiencing. Because if it's aphasia or dementia, like a huge part of your life, your personality, who you are has changed. It may never return to your prior level of function as we say on the medical side. And that can be scary. 

I always try to remain patient with my patients, with my clients. I try to keep high energy. I smile a lot. I offer rest breaks. I will tell them Ð I don't know if you can call it making deals. I will negotiate with them, like, "Let's try two more." I go for a small number. Because if you say, "Let's finish these 10 whatevers," that can be daunting especially if they are PO'd and don't want to participate at all. You give it a small number, "Let's try two more. Let's try one more and then we'll take a break." Or, "I'll let you go get some water." Or, "Then we'll talk about something else." And incorporate those times are planned for being able to talk about trivial information.

If the person is fussy and they really don't want to be in session, then talk to them about something that is important to them. If it's sports, talk to them about whatever's happening in their favorite sport. You can Google that. That's what's great about telepractice. You can quickly Google. Find information, scores, players. And you can still incorporate that as therapy. Because after you get them to start talking and get them to kind of teach you some things, then they feel better because they feel like they're socializing. But then, let a little bit of time go by. And then if it's a recall exercise or if it's somebody who has a memory goal, then you can say, "Hey, you said something about." And remember what they said and then see if they can tell you. Or say something incorrectly and see if they'll correct you. 

Or I like to do this one, which is great for memory. At the end of them teaching you something or talking to you about whatever it is that they're interested in, ask them to give you a quiz. You could say, "Could you ask me three questions? Give me a quiz. I'm always quizzing you. Now it's your turn. Quiz me. What are three things? Ask me three questions. I want to make sure I heard everything." It looks like they are becoming the teacher or the therapist. But they actually have to remember what the heck was I talking to her about to develop the questions for you. And also, remember, I'm supposed to be coming up with questions. Because sometimes they will just restate some things that they've said or mentioned. So you want to make sure that they're questions. 

[00:28:56] KHK: Excellent. Love it. What are some other ways to provide functional exercises to your clients? 

[00:29:03] KU: So similar to what I just said. So taking things that may appear as a game or a social communication, like puzzles, things like with television. Let's see. I have a deck of cards that I use that have three different decks. It's called a chill chat challenge. And there are three decks that come with it. And you just Ð each deck has multiple questions. It's great for teens and adults. It actually says that on the box. It's for teens and adults. 

And I make it interactive. So I will hold up the box and I'll say, "Which one are we doing today?" They'll pick. And then we'll just go through the different questions. And that kind of develops into a conversation where you get to learn more about the client. But then you get to go back and do the different tasks that I shared earlier. Asking them questions or asking them to recall the specific questions that were asked. If I ask five questions in a row, I may say, "Hey, can you think of three of those questions that I asked you?" And see how they do with that. 

[00:30:07] KHK: Excellent. All right. Well, thank you for all of that very practical information. Let's talk a little bit about safety, especially when we're working with our clients through telepractice. What are some safety measures to consider for various medical cases that you're working with via telepractice? 

[00:30:25] KU: Great question. Limitations. Be cognizant of your limitations. Providing services virtually. And also, be aware of your client's limitations as well as the caregiver's limitations. Because you don't want to ask the caregiver to do something that they're not comfortable with. You also want to be cognizant of Ð if you are providing swallow treatments, is the patient going to be safe to know the amount of liquid or what a small bite is? Is the caregiver present for that? And also, knowing that if you are not comfortable providing a service such as dysphagia treatment, then knowing your limitations and being comfortable enough to say, "You know, I'm not quite comfortable with this. I can refer you to somebody." Or provide them with a different recommendation. But if you do feel comfortable, then just making sure that all of the different steps are in place and all of the materials that are needed. I always explain what's going to be done before I do it. I also explain why. Because with adult clients, I find that having a better understanding of why they're doing a particular exercise or task makes them more receptive and included in the exercises. 

[00:31:46] KHK: Definitely. I would assume cooking or something like that would probably be off-limits if they're by themselves. 

[00:31:54] KU: For certain clients, yes. For some, I would not recommend pouring beverages or anything. 

[00:31:59] KHK: Got it. So let's talk a little bit about those swallow evaluations. How would you safely complete a swallow evaluation via telepractice? 

[00:32:08] KU: All right. Of course, consider your limitations. So you won't be able to do every single piece. But in any evaluation via telepractice, you want to make sure that you're documenting how you were able to obtain the information and describe the limitations. So if I Ð not swallowing. But if I present someone with an image and need to identify, then I will say, "Identified with finger virtually, or touched computer screen, or verbally indicated accurate answer." With swallowing, I would say make sure that you have a good clear visual of the client's neck. And depending upon preference and visibility, you can do it face-front. You can also ask them to turn to the side. If they have a more pronounced Adam's Apple, typically in gentlemen or male clients, then you can see when the swallow triggers. 

You can also ask the client to provide you with an indicator. If you have a harder time seeing when they swallow, you could ask them to give a finger, or some sort of nod, or some indicator that lets you know, "Okay, I've just swallowed." You can still do an oral motor exam. There are checklists that are available for free online if you Google bedside swallow evaluations. Of course, this is more like screen-side swallow evaluations. Yes, you want to do your oral motor exam. You'll still have them open their mouths and you'll be able to check the range of motion and the coordination of their tongue and lips and cheeks. You'll still be able to hear when they clear their throat. But it may be difficult for you to see into the oral cavity. More detailed view of the oral cavity. So you can either ask them to put a flashlight up close so that you can see. You can also ask them to take pictures beforehand. You can also ask the caregiver, if there's a caregiver present, to help with visualizing certain structures or asking like, "Does it look red?" And of course, that's subjective. But just you try to visualize the best that you can and then document the limitations you experience. 

All right. There are different swallow screenings and tests that are available online. You can search these. One is the Kayser-Jones Brief Oral Health status examination. And this is a way for you to visually assess what's going to ask you about the condition of the client's lips, about their teeth. These are all things that you can physically see. So if a client has missing teeth, or dentures, or if they're a dentulous, which means they have no teeth, you can document that. There is the GUSS, this is the Gugging Swallowing Screen. And this allows for indirect and direct swallow testing. It's a great tool. At the top, it'll ask you questions about their physical appearance. And then the bottom part of the screen will have you actually have them sample different consistencies. 

There's also the EAT-10. This is a great assessment tool. Some of these are great for the client to participate in as well. And then there's the Yale Swallow Protocol. This is a great one. There's been extensive research that's been done on this protocol. As well as there's a lot of research that's been Ð I just said that. Research. And there's been a lot that's been written about this tool. And you can use it in any setting. So telepractice is included. And for safety, I would also bone up on the IDDSI, which is the International Dysphagia Diet Standardization Initiative. This was released in 2019. It is used in a lot of medical facilities now. And they have moved away from just using regular, mechanical, soft puree, that sort of a thing. It's much more detailed and it's universal. All medical professionals around the world are using this. And it's quite detailed. So they do have cards. Or I would keep a print-off so that you can keep track. Because now it's like moist, moist-minced. Like they really break it down. Definitely educate yourself on the new IDDSI. 

[00:36:30] KHK: Just curious. Do you have the names of these screener tools on your handout by chance? 

[00:36:36] KU: I don't. But I can have them placed in the chat so that everybody can Ð 

[00:36:40] KHK: Yeah, that would be great. We had a question from the audience regarding the names, particularly of the first one you mentioned. But would you mind just kind of maybe repeating the different names for now? 

[00:36:52] KU: Yes. Okay. So the first one that I mentioned, I'm going to give you the acronym for it. It's BOHSE. And that one was the Kayser or Kayser-Jones Brief Oral Health Status Examination. And then the GUSS, that's GUSS. All caps. Gugging Swallowing Screen. Then there's the EAT-10. That's all caps. EAT-10. The Yale Swallow Protocol. And I saw someone request the spelling of IDDSI. That is IDDSI. 

[00:37:34] KHK: All right. Thank you. And I will take one of the questions that's pertinent to this part of the presentation. Somebody was asking, "Do you always make sure there's another responsible adult there during a swallow eval in case of emergency? Or how do you handle that?" 

[00:37:51] KU: For the clients that would require that, so like my clients who are older and may not be cognitively able to or Ð I would feel safe for them to complete the swallow evaluation, then yes. I always have a caregiver, a family member. Their child or their spouse who's present who can help. And I have had young clients with dysphagia who are in their 40s. And those clients who have not had a stroke and are cognitively able. They're able to retrieve their own materials and participate in the swallow evaluation without the assistance of a caregiver or family. Good question. 

[00:38:31] KHK: Yeah. Thank you. I was curious if you have to do anything to navigate the camera view or obtain necessary information to complete the evaluation when you can't actually palpate, right? When you can't physically be there to feel how the swallow is on the neck. How do you navigate that? 

[00:38:52] KU: So with that, I review the chart beforehand. If there isn't anything that describes an abnormal Ð like the physical act of swallow. So any deglutition. So if there isn't anything that the previous SLP or the doctor noted with their swallow, then I'm not as concerned about that piece. I mean, there is a limitation of the screen. I physically cannot be there. But I do try to mitigate that as best as I can by visually seeing the swallow. Again, providing a signal of some sort where they raise their finger. Make sure that they don't have anything covering, like any obstructive jewelry, or turtleneck, or anything like that. Make sure their hair is pulled back. But also, if they want to turn to the side, if that helps, then I will do that. But, I mean, there are just certain limitations that come with telepractice and a swallow evaluation. And not being able to palpate is unfortunately one of them. 

[00:39:49] KHK: Right. And then how do you work around if they only have a smartphone or if they come to the evaluation on a smartphone? Do you make it work? Or what do you do in that case? 

[00:40:02] KU: I will reschedule. Because with a phone, it's great if you're not doing a swallow evaluation. I like for my clients to be able to have therapy anywhere. That's what's great about telepractice. But I won't do a swallow evaluation when they just have their phone. I like to have kind of like a large view. And with the system that I have, when people use a phone, it's just a very limited scope. And I would prefer to have as much visibility as possible, which means that they're as large as possible.

[00:40:35] KHK: Yeah, definitely. And then, along those lines, do you have a particular type of camera that you require them to have? Or do you just work with their built-in camera? 

[00:40:45] KU: I work with their built-in camera. Luckily, technology has made it to where cameras that are built into computers, laptops, phones, iPads, tablets are high-quality enough. The main concern for that sort of a thing would be with their connection and their Wi-Fi being strong enough. 

[00:41:02] KHK: Right. Exactly. I was curious, you mentioned about reports coming in. Are you able to get access to external reports from their doctor pretty easily? How do you do that? 

[00:41:14] KU: So as the client onboards, I will have them complete my own medical onboarding documentation. But I also encourage them to share any notes from their former speech therapist or any kind of medical notes or medical history documentation that they have if they were hospitalized or if they were discharged from a skilled facility. 

[00:41:36] KHK: Okay. And are most of them connecting with you from their home? Or are some of them in other facilities? 

[00:41:44] KU: Some are in their home and some are in independent living facilities where either the facility doesn't offer speech therapy or they're not interested in the kind of speech therapy that's provided. And they will contact me that way. 

[00:41:59] KHK: Okay. Excellent. All right. Let's talk a little bit more about the family and caregiver's role in sessions. How do you incorporate family and caregivers into sessions and training? 

[00:42:12] KU: Always remain with the high-energy. But I physically include them, speak with them. It's great if you have a caregiver or a family member who is physically with the client throughout the session. I have some family members like I have a client whose daughter is in every session no matter what. And so, I will make sure that they get to participate in the session so they're not just sitting there. Sometimes sessions are 45 minutes to an hour long. And if you have no role, then it can be quite boring. But when I include them, then they look forward to therapy as well and they look for how they can provide carryover exercises and like what else can be done. But if the client needs a break, then I will provide a little lengthier break. So maybe three to four minutes. And I will engage with the caregiver or the family member. So I'll see how they're doing. I'll ask how the client did over the weekend or since our last session. If they're saying if they have something going on, positive or negative, I listen to that. 

And then with the client, I will ask, like, "Well, how do they do with this?" Or we talked about facilitating this kind of exercise while she's watching TV or something. How has that been going? And so, I'll receive verbal reports from them. This is great because that makes them want to share information with you. And it also gets them to tune in to the client and pay attention to different aspects that they wouldn't have known otherwise to pay attention to. 

That is for a client, for a caregiver or family member who is physically a part of the session. For those who can't Ð so there could be spouses that are working, or family members, or children who are not present all the time. So for that, I will set up either a call, a video call. Or I'll send a detailed email stating what client's gains are, or what we're working on, or if they had a tough time with something. And I will also share different cues and ways for them to facilitate exercises and carry over so that we are all working as one cohesive team. 

[00:44:14] KHK: Love it. So let's talk a little bit about maybe a case study or a case that you might have had. What would be the youngest person that you've treated with, let's say, a medical diagnosis such as traumatic head injury? Can you tell us a little bit about that and what was the outcome? 

[00:44:32] KU: Sure. All right. Youngest TBI client was a 23-year-old male. He went to celebrate the Super Bowl in 2019. Unfortunately, it was raining where he was and his car swerved off of the road. And the way his mother described it, his car was literally wrapped around a tree. He was hospitalized in the Intensive Care Unit. They did a craniotomy on him. And that is where they remove a piece of the skull so that the brain is able to expand while it's swelling. And he was in a coma for 11 days. And unfortunately, during that time, he did not receive speech therapy during his hospitalization. And he was in the hospital from mid-March to the beginning of June. That's a long time to have no rehabilitation services. And I feel like his mother said that he also did not receive physical therapy and occupational therapy. Don't quote me on that. I know he did not receive speech though. 

I actually started seeing this client after a colleague of mine who I went through my doctoral program with, she sold her practice. And she knew that I worked with adults and then I worked via telepractice. And so, when I first started working with him, he had already been working with my colleague. And so, he and I kind of picked up with the things that she and he were working on. So we worked on memory. He had a very, very difficult time with remembering even what happens five minutes ago. And so, through the exercises, and consistency, and making it fun and incorporating things that he liked. And for him, it's like we're having some fun. But he's also seeing the benefits of it because now he can do things like log into the session on his own, which was a huge deal. He was needing his mother to do a lot of things for him. 

Now he's 24 years old. And with his cognitive gains, he's talking about what he's going to do when he finishes Community College. Because he's in a program at a Community College. We work on functional things like utilizing the career portal through his Community College. He's talked about wanting to get a job and being able to move out of his mom's house. We are still working together. And I see the gains. He also wanted to work on Ð he's a private pay client. So he also wanted to work on his articulation. So he had a very hard time with producing his R's. And in his wanting to become more independent and be more of an adult without relying on his mom so much, he says he wants to be able to talk like a grown-up. He wants his R's to be as strong as possible. And he's doing well with that too. 

[00:47:14] KHK: Wonderful. What a great story. Thank you. Yeah. How long do you usually work with your adult clients in order to be effective and really see the changes? 

[00:47:25] KU: That is a loaded question. It really varies. It really varies. It depends on the client. It depends on the diagnosis. It depends on their motivation. It depends on if they're going to do the exercises and homework that I provide to help with the carryover. And so, it really can vary. A client with aphasia, that could be six months or longer depending upon the severity. Also, if it was a stroke, what kind of stroke? I've worked with clients who had a stroke and rehabbed in two months and we're back to using complete language. And I've worked with clients who have worked with me for close to a year.

[00:48:13] KHK: Okay. Wonderful. Good to know. We did touch upon COVID-related brain fog earlier. I would really like to talk a little bit about that before our time ends today. What is COVID-related brain fog? And what are some ways to combat it? 

[00:48:30] KU: Okay. I'm going to read this because I want to make sure I say it right for the listeners tuning in. Brain fog is one of several side effects of long COVID. It includes difficulty, thinking, concentrating, mood changes, difficulty sleeping, and fatigue. Post-COVID conditions are a wide range of new returning or ongoing health problems that people experience after being infected with COVID-19. 

Unfortunately, there are no specific diagnostic tests designed to diagnose post-COVID conditions such as brain fog. It's really what people are describing and experiencing the change in their cognition and how they're functioning in their daily lives. The best way to combat the symptoms is really to include a neurologist and a medical SLP into your medical team who's helping you to recover. And because there are no protocols or evidence-based treatments at this time, medical SLPs are really using stroke rehab exercises to help with treating brain fog. 

A lot of clients that I work with who have brain fog describe having memory deficits, problem-solving deficits, reading comprehension, auditory processing, word finding challenges. I've even come across clients who are having a very difficult time with typing, spelling, and sequencing. And through a convention that I just attended, I learned that brain fog affects women more than it affects men. And so, what they're finding is that this modifies how women are caring for themselves, caring for their children if they have them, caring for their home, their work. 

Females who are professionals are having a difficult time with like remembering content for meetings, speaking eloquently like they had before for different presentations. They have reported making a lot more errors and feeling embarrassed. Having decreased confidence. And even some are having decreased communication with others because they feel, since they can't really think fast enough to communicate how they used to, they don't want to.

[00:50:40] KHK: Wow. This is definitely up and coming. Your recommendation, based on what you learned, is that they should definitely seek out speech therapy services to help this.

[00:50:52] KU: Yes. 

[00:50:53] KHK: All right. And so, what are some of the symptoms and the newer symptoms associated with this? 

[00:51:00] KU: The memory deficits, problem solving, difficulty with typing, spelling, sequencing. Visual and executive functioning. Those are all symptoms that fall under a brain fog. 

[00:51:14] KHK: Pretty much all the cognition types of symptoms.

[00:51:16] KU: Yes. But these things are developing and new things are being reported daily. And so, the medical community Ð I've gone to conventions, and summits and focused specifically on COVID-19 and what's happening afterwards. And unfortunately, there is a big giant we don't know that's being presented at this time. And so, we're really just doing what we can to treat the symptoms. Because, unfortunately, this too is unprecedented.

[00:51:44] KHK: Yeah, definitely. And do you have an example of a client, maybe a case study that you could share with us on this? 

[00:51:51] KU: Sure. I have a client who is a professor. She's in academia. And she had COVID three times over the course of last year. And she kind of notated when she started having cognitive difficulties. With her first round of COVID, she did not. Her second round of COVID, she described it as her brain feeling exhausted. And then the last time that she had COVID was when she started noticing having a difficult time with typing, and spelling, and speaking. 

She said she's been mixing a lot of her words together Ð and a lot of her words together. And she also has been mixing her words up. So if she was going to talk to a family member and say, "Hey, I'm going to grandma's house." She would say, "Hey, I'm going to house grandma's." And she wouldn't realize that she said something backwards. She would have a family member to say, "Did you mean to say this?" And she very well Ð there were times where she said, "That's what I said." And they have to tell her that that's not what you said. 

But this is a woman who has her doctorate. She is very esteemed within her field. And she is having a very tough time because she's aware of all of the challenges that she's having. She is not a native of America. And so, her native language where she's from, they naturally speak rapidly. And so, part of how she's getting her words mixed up is she's speaking very quickly. But prior to having COVID, her brain was able to keep up and her brain and her mouth were coordinated just fine. But I have to remind my clients, with brain fog or any brain injury really, because you can't see it, people can either not take it as seriously or be less patient with themselves. 

If you think about if you sprain your ankle or you break your leg, you can physically see it. There's a cast or there's a brace or something. And you're going to be careful with it. You're going to keep your leg propped up. Or you're going to apply minimal pressure when you're walking. But people don't allow themselves the same courtesy because you can't see the brain, you can't feel the brain. And they get very frustrated with themselves. So I do encourage my clients to be patient with themselves. Understand that they have a brain that has been injured and that they should be patient with themselves as we rehab it back. 

[00:54:17] KHK: Great tip. What about functional exercises for this particular diagnosis? 

[00:54:23] KU: For the brain fog for this particular client or overall? 

[00:54:27] KHK: Yeah, just overall. If there's anything? 

[00:54:31] KU: Well, memory is a big one. Just like what we did, what I discussed with other cases. Have them try to remember small things with brain fog. A lot of times you may not see hospitalization because of it. Trying to keep them as independent in their daily lives as possible. 

I'm a huge advocate for artificial intelligence devices like Alexa, or Google Home, or Siri. I tell them, use that like a personal assistant. If you see that you're out of something, add it to a list and say, "Alexa, add milk to my shopping list." And you can use that for scheduling. And you can use it to set timers, reminders. 

If they're in the kitchen cooking, they love cooking for their family, but they're burning a lot of meals because they can't remember or they don't set the timer. Well, then, I get them in the habit of saying, "Alexa, set a timer for 15 minutes." Or finding out what the weather is so that they don't wear the wrong clothing for a presentation or a business function. Those are important things that I do. The artificial intelligence devices are great reminders for things. If they need to be reminded to take medication, that's important. And that also reminds me, I did find out at this convention that there are studies that are showing that incorporating antidepressants are helping to mitigate brain fog somehow. 

[00:55:56] KHK: Great tip. We do have some questions from the audience. First question, how do you handle the actual technology setup, especially for clients that have strokes or TBI? 

[00:56:09] KU: I'm guessing they mean the technical setup for the clients. 

[00:56:12] KHK: Mm-hmm. Like the onboarding. 

[00:56:14] KU: In those cases, they have younger family members who can help them with that. And if not, then I am happy to set up a call and walk them through how to do it. I've even Incorporated using or logging onto my system so they know how to get into the virtual waiting room. And I will send them multiple links just so that they can practice logging on. I get a lot of beeps on my end. But the repetition of them doing the act can help. And just being patient with them and knowing that older clients are going to need that. And once they get into the repetition of it, they will remember it better and it should be easier for them. Any client that I've worked with who has had a tough time, I incorporated it as a goal and then they become independent with it. It's great. 

[00:57:03] KHK: Okay. Wonderful. An additional question from this listener. What kind of safety protocols do you have for dysphagia if there's no caregiver especially if you suspect aspiration? Would you just not go through or move through with the screening? Or how do you handle that? 

[00:57:22] KU: If a client is like NPO or at risk for silent aspiration and there's nobody present, then I would not complete the evaluation and I would say Ð I would either refer or recommend that they get a swallow evaluation completed separately. And then we can do the exercises together. But I definitely take into consideration those limitations and that level of danger. Dysphagia is very dangerous. And so, I take that very seriously.

[00:57:52] KHK: Right. Okay. Additional question. Is it HIPAA-compliant to have clients or caregivers email medical history or charts to you? Directly to you? 

[00:58:02] KU: You have to have email set up that is HIPAA-compliant, which I do. But to keep things like that 100% secure, I make sure that I have them send them to me through my platform that I use, the client portal. And that is HIPAA-compliant. And so, what they'll do is they'll log in through their client portal. They will upload the documents in their attachments folder and then both of us can see them electronically and it's still HIPAA-compliant. Good question. 

[00:58:29] KHK: Is the platform you're referring to something that you could give like an example of? I don't know. 

[00:58:36] KU: Sure. Yes. 

[00:58:37] KHK: I mean, we're not promoting any particular company. I'm curious. 

[00:58:41] KU: Not promoting. But the platform that I use is called TheraPlatform. I really like that platform because, again, there is a speech therapist who is a part of the development. And so, all of the things that we, speechies, need are included. I also like it because they provide regular updates. And you can write the company and say, "Hey, this would be a great feature." Or, "I'm having a tough time with this." And a lot of times, on the next update, their rollout will include something that you've suggested. And it's HIPAA-compliant. It's great for pediatric SLPs as well as medical SLPs. I love it because it's a one-stop shop. You have your medical records there. You have your onboarding process there. They provide the client with reminders 10 minutes before your session. You can do all your documentation there. 

You can also Ð now they have a fax option for faxing plans of cares and various records to and from other medical providers. And you also do your billing from there. So you just click a button and your claim is sent off. You also can accept payments. So co-payments are done through the platform. And I really love it. I know that there are other ones out there. SimplePractice is another one. I did look into that one. And I think there's one maybe called Blink? But there are other Platforms in EHR systems that are available. You just have to Google them and see what works for you.

[01:00:07] KHK: Essentially, you have them email and it goes into this platform. Is that correct? 

[01:00:11] KU: No. They log into Ð you mean the client? 

[01:00:14] KHK: Yeah. Like how do you have them send the records into the platform?

[01:00:19] KU: Each client has their own portal. So they can come in. They can send me messages. It's kind of like a medical portal for your PCP. So you can send me messages. You can request information if I record a session, which is another feature that's a part of the platform. If I record a session, I can upload it. But they will log on to their own profile and upload it in their own section. 

[01:00:43] KHK: Got it. Got it. Okay. Wonderful. Thank you. All right. One final question, what kind of advice do you have for SLPs who are just starting off in medical SLP or if they want to make the switch and start doing medical speech pathology? 

[01:01:00] KU: Okay. I say, one, don't get rid of your textbooks. I hope that you haven't. I was told when I was in grad school to develop a Ð well, undergrad actually. Develop a professional library. I have all of my books from school. So if I need to reference anything, I know exactly where to look and I have it on hand. That's the most economical option because it should be on hand. You can also ask current SLP students if they'd be willing to let you take a glance. You can also observe or shadow. Taking CEU courses is great. And if observing and shadowing is a challenge, then I would just find out whatever avenue that you can to get the information that you need so that you feel more comfortable. And it could be finding someone who is willing to let you shadow but you may have to sign a privacy agreement or something like that. But don't take no for an answer and go about it the right ways. But definitely, find a way to transition if that's what you're interested in. 

[01:02:06] KHK: Wonderful. And any last takeaways before we wrap up here? 

[01:02:09] KU: Yes. I mentioned high-energy. Having high-energy is great. You can't physically be in the room with them and if you have a client who has aphasia, or TBI, or dementia, you may be the one bright spot in their day. And they may not be just as high-energy and jovial as you but they are receiving what it is that you are sharing with them. I also like to incorporate interesting things into the session. I mentioned I had a client who really likes church. I'll incorporate that into different exercises. Sports, fashion, grandchildren. Great topics for older clients. Pets. I like doing virtual high-fives. And that's just as simple as saying like, "Yeah, high five." And bringing your hand close to the camera and bringing it back. They will do it too. So it really feels like you're doing a high five. 

I'll do a virtual hug where basically I'll just kind of show my neck and go like this. It looks like a hug. But they see that you are being affectionate with them. And that if you were there, those are things that you would do with them. And the EMST devices, the different things that I shared, are good for you to have. That's another way for you to keep things interactive. And follow me on social media on Instagram and Facebook @SerenitySpeechTherapy and @KensingtonAcademyLLC. And I'd love to chat with you if you have more questions. 

[01:03:33] KHK: All right. Well, thank you, Dr. Kelli. We are out of time. We truly appreciate your research, education, and expertise you provided about treating medical cases through telepractice. Remember, there is a handout that goes with this course, and it will be available beginning tomorrow for download. As a reminder, if your state license requires CEUs, be sure to complete all course modules including the one that says quiz before the end of today on your speechtherapypd.com account. 

Stay tuned for more episodes of Telepractice: It's Not Just Screen Time coming in the fall. And also, look for more courses from Dr. Kelli on the topic of medical speech pathology. She has one coming up entitled Telepractice for the Medical SLP: Functional Treatment and Caregiver Inclusion. And of course, remember to follow speechtherapypd.com on Instagram. Have a great evening. 

[OUTRO]

[01:04:33] ANNOUNCER: Thank you for joining us for tonight's course. To complete the course, you must log into your account and complete the quiz and the survey. If you have indicated that you're part of the ASHA registry and entered both your ASHA number and a complete mailing address in your account profile prior to the course completion, we will submit earn CEUs to ASHA. Please allow one to two months from the completion date for your CEUs to be reflected on your ASHA transcript. Please note that if this information is missing, we cannot submit to ASHA on your behalf. 

Thanks again for joining us. We hope to see you next time. 

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[END]
SLPL S7E6		Transcript

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