SEASON 7 EPISODE 10 [INTRODUCTION] [0:00:13.9] KHK: 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 it is available for .1 ASHA CEUs. Now, come along with us, as we look closer into the many topics of speech-language pathology. Welcome to season seven. Telepractice: ItÕs Not Just Screen Time. [INTERVIEW] [0:01:14.9] KHK: Hello everyone and welcome to the podcast miniseries Telepractice: ItÕs Not Just Screen Time, presented by SpeechTherapyPD.com. Thanks for joining us for this episode, Tele-Assessments in the Clinic Setting. This audio course is offered for .1 ASHA CEUs. IÕm your host, Karin Hartunian Koukeyan. IÕve been a speech-language pathologist for over two decades with 13 years' experience in both special education and healthcare settings. Here are the financial and nonfinancial disclosures. [DISCLOSURE] [0:01:49.0] KHK: Karin Haartunian Koukeyan is a sole proprietor who consults on telepractice services and works with professionals on accent modification to enhance our communication skills. She is a regional manager at Parallel Learning. She is also the host of this podcast and receives compensation from SpeechTherapyPD.com. Her nonfinancial disclosures that she is the current associate coordinator for ASHA, special interest group for telepractice SIG18. Roxana Gonzalez receives an honorarium from SpeechTherapyPD.com for this episode and sheÕs also a full-time employee at SLP Tele. Roxana does not have any relevant, non-financial disclosures. [INTRODUCTION] [0:02:32.4] KHK: And now, hereÕs a little bit about our guest today. Roxana Gonzalez, MS, CCC-SLP is a bilingual speech-language pathologist with experience in hospitals and clinic-based settings. RoxanaÕs worked with pediatrics, adolescents, adults, geriatric populations, providing bilingual assessments and treatment services. Prior to pursuing a career in speech pathology, Roxana worked as a certified behavioral health case manager for children and adults with mental health disorders. Additionally, Roxana also has post-graduate training in data science and business analytics. Her diverse background and transferrable skills serves her well in meeting the everyday needs of clients. She is passionate about the idea of bridging technology, research, and clinical skills in telepractice. [INTERVIEW] [0:03:27.0] KHK: Welcome to our show today. [0:03:28.5] RG: Thank you, thank you for having me. [0:03:30.7] KHK: Now Ð absolutely. So, letÕs start with a little bit about you. Tell us about your journey as an SLP and how you came to doing telepractice. [0:03:40.6] RG: Definitely. So, my journey as an SLP began in 2015. I had obtained a bachelor's degree in psychology from Nova Southeastern University and I was working as a mental health targeted case manager after that. I worked with children and adults and if youÕre familiar with this field, you are basically advocating for underserved populations and linking them to resources in the community, primarily, their health needs. So, I came across speech-language pathologists and what they do as many of the kiddos that I served and some adults as well, they needed this service and I was able to participate in some sessions and observe their progress and collaborate over time, see where they were at and thatÕs when I decided, I love to talk. So, this is for me and I went home, I remember that day, still today, where I research what a masterÕs degree in speech-language pathology from Nova because I had already gone to Nova for my bachelorÕs. And now I saw the requirements and IÕm like, ÒI can spend two to three years here.Ó And Ôtill this day, itÕs definitely for me. I had various externships and internship experiences, primarily hospital-based. I went to Joe DiMaggio ChildrenÕs Hospital and was mentored by Dr. Tommy Braun from the cranial facial team. There was cranial facial, a very specialized area. After that, I had the opportunity of going to another externship at Memorial West. Memorial West is some shadowing at the NICU there and then, outpatient services for children and adults, and after I felt my skills had gotten stronger, I applied for an internship at the Veterans Hospital. To my knowledge, it was one of the only paid internships and I really needed to [inaudible 0:05:54.4] too. So, I was just flabbergasted to be accepted and have that opportunity to be an intern there. Where I worked under the mentorship of Aquilla Johnson at the Miami VA and I would say, these were my first practical experiences as a medical-based SLP. I was lucky enough to do MBS and you know, have these experience under guidance of course but after that, the clinical fellowship opportunity came at a private practice. The hospital asked me to stay at the VA but they wanted to start eight months later and I needed the money, Karin. So, I definitely looked for a private practice where I can be mentored and I worked at DNV for my 10 months there as a clinical fellow where I saw children and adolescents all the way up to the age of 18. A lot of medically fragile as well became my specialty there and after that, I was looking for a telepractice company where I can work and since I hadnÕt acquired any school-based experience, thatÕs where SLP Tele came up and IÕm still there. [0:07:16.5] KHK: Awesome. So, you are 100% medical speech pathologist with experience in telepractice as well as in person. Amazing. So, weÕre really fortunate to have you on the podcast today. So, today, our learner outcomes are as follows. By the end of the course, participants will be able to one, summarize current research on tele-assessments. Two, discuss tools that enable both standardized and informal telehealth assessments. Three identify the benefits and challenges of virtual assessments, and we are going to try to focus on the clinic-based aspect but certainly, weÕll try to cover some differences between the schools as well. Now, letÕs go ahead and dive into the body of this podcast here. What is the role of tele-assessments in the field of speech and language pathology? [0:08:16.0] RG: Yes. So, telehealth is the use of telecommunication technology and you use it to provide health services to people that are located at some distance from the provider. In this case, the SLP and the client is really meeting with you at a distance to access your services. You are a qualified specialist and they are seeking to have that consult. So, thatÕs really the purpose of the telehealth and being able to provide services through these means. Now, I want to dive into the benefits of that. In telehealth, you are able to improve access, to need the health services, and you are amongst one of the qualified specialists that individuals seek to connect with. Now, this is typically done in a video conferencing modality, what we call telehealth telepractice, and all those other synonyms you know. ItÕs very convenient, some clients will tell you that they really enjoy just coming to their session from the comfort of their home. So, decreased travel time, less time in traffic. If youÕre late, because you forgot your session, you can just hop on. ItÕs never too late to get something done and just eliminates barriers, so weather-related and geography. So, IÕm bilingual and geography is important because IÕm able to reach clients that need bilingual therapists or Spanish speaking is my other language, my primary language really, I like to call that, and even in the pandemic, right? Where we couldnÕt meet face to face and there were just a lot of mandates per state about stay at home or not. You know in Florida, there was a little bit of more noose in that sense but other states, I know like in California, you are asked to stay home for most of the time, and just family-centered. The opportunity to collaborate on the evaluation process, right? And being able to develop intervention goals with parent feedback in a natural environment. This is how they are at their home, this is how they present, this is the family dynamics, their life, youÕre able to observe, ask questions, that reflective listening, and active listening, right? Brainstorm with them and plan about what you would like your therapy sessions to look like if you have a need and thatÕs identified through tele-assessment. [0:11:05.4] KHK: And thatÕs definitely the beauty of the clinic-based where you have that option to do it from home as opposed to students that go to a brick-and-mortar building and that youÕre doing that assessment in their school environment. So, thatÕs wonderful. So, yeah, letÕs go ahead and talk about the research. What does the research say about tele-assessments for speech pathology? [0:11:32.8] RG: Yes, there is research out there and IÕm still learning and more and more each day as I navigate and going to this. So, just know research helps to guide your clinic with decision-making. It is a tool that we have as clinicians to be able to have this information, access it, and put it to use in the work that we do. The use of telepractice is where you can basically perform individualized assessments and practitioners were doing some of these before COVID-19 like LSVT. If youÕre familiar with the protocol for get louder and be able to for the stroke and ParkinsonÕs patients, thereÕs more research prior Ð research, IÕm sorry, prior to COVID. Now, it really came where the researchers found that it is not any more an option. The mandate was on and this was the only option for many, many people, and thatÕs when I feel like research accelerated in that area. And more people started looking at, ÒWell, we need to guide clinicians about what is valid.Ó What is valid because most of these standardized instruments, they had been validated in in-person administrations but not necessarily over telepractice. So, clinicians wanted to do the best for their clients. I think everyone has the best interest of the client at heart and it was just some matter of, ÒCan we use it through this medium?Ó What is the best way to administer it through this medium and best practice guidelines and how do we ensure the client does continue to get quality care? And so, with all the uncertainty, I feel like publishers started to look at that as well as researchers, and one of the biggest problems that evaluators faced was how is it that the presentation can mimic in-person administration as much as possible. So Ð and ensure that the results can still be compared to the norms that there are, without overgeneralizing or making significant modifications that throw off, where your instrument is really intending to measure, right? So, there were examples about what test started being validated and I do have something to share with you, let me know if you like me to go and dive into that. [0:14:19.3] KHK: Yeah, absolutely. [0:14:22.6] RG: Okay. So, I have shared just the general common issues that kind of stirred the thought of, ÒHow should we do this?Ó right? And one of the biggest issues was over-generalization. So, if you have an investigation or research study, where one particular test is chosen by the researchers and the research want to see if it is valid to be used over telepractice and this is done usually picking out one standardized instrument and matching individuals. So, one of those instruments that was study was a test of integrative language and literacy skills that many SLPs might be familiar with and so if you are familiar with this test, you know that it was administered in-person and norms were obtained for the population of six to 18 years of age. So, you are administering maybe about 15 sub-tests if I remember correctly it has, and then, you also get your core scores that create this profile strength and weaknesses for the client in literacy and language skills. So, in the traditional administration of it, you are the examiner, you have a hard copy of the stimulus book in front of you. ItÕs like a spiral-bound easel for many of the tests, not just this one, and you present it to your client or administration. Now, in Tele-TILLS, the research team had a close replica of that book but they used PowerPoint software and with screen sharing displayed in a manner that married the stimulus book, and for the nonword repetition portion, they embedded audio files into it. So, they use that technology and they were able to mimic as close as possible, right? The real work experience of having a client right in front of you but just the administration through screen sharing, and what they found was, well, itÕs a bit of a long test. So, letÕs work a 60 to 90-minute duration, and letÕs work with maybe two sessions at most if it needs to be broken into parts. So, Nelson and their team that assessed these 51 children and adolescents, they decided to divide it into age groups. So, the younger ones, six to seven year oldÕs, the middle group was like eight to 11 year oldÕs, and the older group, 12 to 18 years old, and the study found that there is preliminary evidence suggesting that the Tele-TILLS results can be equivalent to traditional, the traditional in-person administration format, and it supports the validity of administering that test to tele-assessment, as long as the guidelines are followed and the way that they learned about this is they sent an in-person rater to the clientÕs house. So, each client that was part of this study had an in-person rater listening to their responses and scoring it, and at the same time, there was a telehealth practitioner administering this exam, and then they compared agreement of results and the okay may rate was high at a 96.1%, which is pretty impressive if you look at it in terms of number. 49 out of 51 cases agreed on the outcome of the battery as it examined where it was looking for that. [0:18:19.0] KHK: Yeah, that is rich, impressive, yeah. [0:18:23.2] RG: The language was high. Then statistics was put into it in the CohenÕs Kappa Statistic. It showed .87, which is an excellent level of agreement. So, thatÕs pretty Ð [0:18:33.7] KHK: Yeah, and I would like to kind of clarify for those of us that took statistics a really long time ago, what is the difference between assessments that had been normed on certain populations? For example, norm-referenced and the research, what does, you know, the research about no statistical difference, if we hear those terms used, no statistical difference with in-person versus telepractice administration? If you could just briefly explain that to us, that would be amazing. [0:19:05.0] RG: Right. [0:19:05.6] KHK: Thank you. [0:19:07.5] RG: And as you Ð as you really consume research, youÕll see that itÕs always a term thatÕs well-defined and this helps us as clinicians to kind of navigate that as well. If you have a normative sample, you have chosen a group that you basically want to assess. You want to look at that group but you and I, if we were part of that group, weÕre so part of a larger population. So, when norms are used, they determine what is typical or normal behavior for that gain in population. But just know that the norm, the normative sample, or what we refer to the norms were obtained by looking accounting for who do you want to study, maybe what age is or what background, ethnicity, or Ð and if itÕs supposed to be diverse and account for cultural differences and youÕre maybe studying a diverse group but we are all part of that larger population. So, I think the biggest takeaway is a norm is a sample from Ð the normative sample is the sample from which norms are obtained and it consists of a group of individuals, sampled from a larger population. And statistical differences is different in the sense that it refers to whether the observed results are because of chance or some other factor of interest, what is known as your alternative hypothesis. If you have a norm, a bit of about statistics, your no hypothesis is something that was only occurred only by chance and not because of the claim that you made. So, no statistical difference, cannot be used to support a conclusion of, ÒThere was no difference in these groups.Ó Like, if we go back to the study I mentioned, that study of the TILLS, it does not mean that there was absolutely no difference or that the test was even Ð can say that it was equivalent but what it really means is that you are expected to be able to administer it with some level that itÕs a similar way to know that the results have a lot of agreement between in-person raters and the rater that is doing it on telehealth as long as the best practice guidelines are followed. So, does that help? [0:21:40.0] KHK: Yeah, absolutely, and one, I think, important question, because as clinicians, we often hear Ð there are times when we should not report standardized scores, and maybe if you can comment a little bit about when should we not report standardized scores or when should we report them with some qualifying statements, that would be amazing. [0:22:02.9] RG: Right, right. [0:22:03.5] KHK: Talk about that. [0:22:04.7] RG: Yeah. I definitely, when I started doing telehealth, I had this same question, ÒCan I report these scores and if I do, how do I let the person reading my report know that it was even done through this modality?Ó And now, a little bit more into it, I can say, you can report it as long as these guidelines are following. We are going to talk a little bit more about what those guidelines are. But the main takeaway is yes, and if youÕre searching for tools to aid your clinical decision-making for identifying language disorders or literacy or any other areas that we examine, just make sure that you make informed decisions about what instruments have been validated that exist and these instruments have best practices guidelines on how to use them and how they should be administered, even if they deviate from the traditional, in-person administration method that they were normed on or that we have norms from. So, clinicians who deliver telepractice services, you must have specialized knowledge and skills in selecting these assessments and interventions, right? That are appropriate and valid when administered remotely in. You can see in the ASHA practice portal, theyÕve really made a statement on how these instruments should be selected, and they kind of point you in the right direction but you do have to go into the instruments that are validated and read a little bit more in-depth about what the recommendations are. So, some publishers of standardized assessments have developed guidelines about the administration of tests as via telepractice and others have compared the validity of in-person and remote assessment protocols. So, while not everyone has gone the research route, at least thereÕs some guidelines about if youÕre going to use them, the publisher does tell you how they would like you to administer it to mimic those in person. But of course, I, having a research background, do like to use the ones that have been tested, even if thereÕs not a lot of research on it but have used the ones that have been tested in remote environments and where there was no major statistical difference found. So, just being cognizant also that any deviation from the administration guidelines of any standardized test should be noted, right? And I think one of the ways to let your client know and anyone who reads your report is if you did it through telehealth modality, you want to mention that because that is in itself already a deviation from the administration guidelines of most tests that have been normed for in-person. [0:25:06.6] KHK: Is there any other specifics that we should put as disclaimers into our report? Anything else that we can kind of make note of? [0:25:16.7] RG: Right. So, one of the disclaimers, and IÕll share the ones that I personally use as I encounter the situation, you can pick and think about what works for you. I really feel that we Ð first of all, know on the background that equivalency of in-person administration and tele-assessments cannot be assumed, right? And Ð but validated instruments help you to identify if there is deficits in a certain area that you're examining. But your clinical acumen, your clinical judgment is what is really needed to augment the empirical findings about equivalency of the test scores, and what that means is, even if a test is set out to, and sensitive enough to help you identify disorders that may exist or deficits or even, just say, with a normal range, you still have to use your clinical judgment and that is a final because we are trained, right? WeÕre trained SLPs and we have that way of making sense of all this data that those instruments give us but they are tools. Now, one of the disclaimers that I like to use, itÕs my most common and go to is this assessment was administered via telepractice modality and results should be interpreted with caution, right? There could be differences among SLPs of what was the best instrument and so maybe, sometimes you just want to say, to look at the results and really look at the whole report and see with caution, take a look and just see if it Ð you feel also that it makes sense for everything that was administered in within the time that you have. ThereÕs a lot of other factors that go into it. Another one is Ð another disclaimer that I use is a full comprehensive assessment battery, was able to be accompanied in one sitting with best practice guidelines followed in accordance with, and I put the developerÕs name and I put guidelines, ÒNonetheless, results should be interpreted with caution.Ó And I listen to Ð I always say caution because the researchers also use that word, interpret with caution, right? It really does come from the data that is out there and even they will caution you in their research. Interpret with caution, it doesnÕt mean itÕs equivalent, it doesnÕt mean. So, weÕre still learning even in that world in the research world about what works and we Ð I hope we grow in this area but also, if you administer portions of a sub-test, you might want to state that portions of X test was administered and scores should be interpreted with caution and not overgeneralized as a full comprehensive measure of the area that was assessed. [0:28:13.9] KHK: IÕm curious if youÕve ever gotten, you know, questioned by parents if this was done in a private practice setting or has insurance rejected or denied the claim because of these statements. Any comments about that? [0:28:30.6] RG: So, I personally have not had a denial that I was aware of but I have heard that in some odd cases, my colleagues have shared with me and they did say that the telehealth was denied and they were asked to provide in-person services and really, where that came from is maybe the parentÕs request as they communicate with their insurance about it and maybe they shared something or they were intending to be treated in person. And even though the disclaimers were there that we are a telehealth company and this is our way of serving you, when they communicated, it was denied. So, whether one was related to the other, not sure but I have heard that yes, it can happen, definitely. Even though itÕs just a modality, right? Telehealth is a modality but youÕre still clinic-based if you are providing services through this medium or school-based but we are not. IÕm talking about insurance reimburse clinics like mine. [0:29:39.2] KHK: Right, exactly. All right, thank you for that. So, letÕs talk a little bit about the tools that are being used. What are Ð what tools are being used and considered valid measures to administer virtual assessments? [0:29:54.0] RG: Good question. So, in the beginning, everything was thinking about, what way to serve your client and just see and hear them, right? The basics of fundamentals about having that face-to-face, which if you couldnÕt have, you were thinking about whatÕs next and it really Ð ASHA does do a good job of breaking it down into software-based technology that is encrypted or public domains. So, if youÕre a university, you might be set up with a lot of hardware, where you have computer terminals that serve the client and are not necessarily software-based but they are protected in ways that the clientÕs identity or information, health information will not be compromised and then you have the software-based technologies, so what do you contract with? Are you using Zoom for healthcare purposes? And if so, they do have what they call BAA, which is a business associate agreement that you can sign sometimes for years if one, two, three years, depending on the magnitude of your clinic and how you expect to see cases over telehealth and they do have encrypted software. So this, what it does is really protect the client's information and make sure that there is measures to safeguard the client. Now, there is even more levels of security and we donÕt have to go into it specifically but then you can set up your two-factor authentication or making sure that there is just even more layers, right? But the others are public domains that have not been validated as secure and often do not indicate how much level of encrypting technology they use like FaceTime or Skype or Google Hangouts, we just donÕt know. So, when you think about how to serve your client and security and making sure that their health information is safe to abide by HIPAA law, you would think of a software-based technology or what depending on your setting of course but like I said, just think about the level of security and public domains like I had mentioned are not the ones that we want to service through really and this is all meant to continue to be compliant and not violate HIPAA that can potentially place a set up liable for any leagues I would say. [0:32:33.9] KHK: All right, letÕs talk a little bit about some of the instruments to consider for assessments. [0:32:40.0] RG: Yes, so when I think about instruments for assessment, I think about what can facilitate what I need to do and need to get done but still answer the question that I have about whether itÕs client does warrant services or not and so you think about your instruments. My first go-to is the very traditional parent interview question format because this is powerful. You have an open unstructured dialogue. You can really establish rapport and get to know this client and listen, listen to their needs. Then the next thing I think about is what tests do not require manipulatives to administer and one of those, the PLS-5 is widely used but they have, as an example, a lot of manipulatives that accompany this test, which thereÕs very specific direction in which way they are supposed to be utilized to elicit independent responses from the individual rather than prompted. And so, if you have a parent using a little bear and theyÕre telling the child, you know, there is a lot of cues, right? In the whole environment, so even if you did find a way to get those to them, you can have your instrument and tools and validated just find a way that itÕs prompting responses. So, I steer away from that and I feel like this has been talked about as well in the research about finding ways to assess that donÕt have these manipulatives unless you have a facilitator that is trained in the house of the client. So, there are exceptions, I donÕt want to over-generalize either. Then I look at what publishers are there and what have they done to accommodate practitioners like myself that have to administer tests in digitized formats because we donÕt provide in-person services for the company that weÕre working for and some of these developers like WPS, Pearson, they have digitized their protocols and assessments and stimulus books and even scoring now, right? And take place in a digital format. So, I donÕt have much to share about each developer but I can tell you that WPS uses an online evaluation OES platform and Pearson uses Q-global digital assessments, where they have all of the stimulus books and just embedded and you can use it. ItÕs shown to the examinee in another location, they have a screen-sharing feature, so through teleconference and software. So, you want to make sure that if you are doing these digitized assessments, you can screen-share, right? And that your client has that ability to be able to use it according to the best practice guidelines. So, we do our due diligence and you have to be familiar with the various assessment types that are out there to mimic that in-person administration of these tests and some disclaimers from the publishers too. Like WPS, they have a statement on tele-assessments and it reads all and I quote, ÒAll of our currently individually administered assessments were standardized using in-person administration.Ó And just like I said earlier, I would say most of them were, right? ÒOr these tests and they go on tele-assessment methods would be considered an adaptation of the standardized administration and should be considered when reporting and interpreting the results of a remote administration.Ó So Ð [0:36:34.9] KHK: So, itÕs definitely important to include that in your report. [0:36:38.4] RG: Yeah, they do, so we should. [0:36:40.8] KHK: Yeah, but I did want to ask real quick before we go, I know we donÕt need a fancy platform that embeds these assessments, correct? Because of course, we have several out there that it does make it easier and I know, you know, weÕre both familiar with some systems that do that and they do it each differently but of course, the premises is similar. You are able to pull the assessment within the platform. But you donÕt need that necessarily. Like you said and I heard you say this, really itÕs video conferencing with screen share. Of course, itÕs better or itÕs convenient but if youÕre your own private practice or maybe youÕre a part of a smaller practice, you know not sharing the content with hundreds of providers, then you could in theory just do it, you know? [0:37:32.3] RG: Yes, absolutely. [0:37:33.7] KHK: Okay, good to know. [0:37:35.7] RG: Absolutely. [0:37:36.2] KHK: Yeah, so letÕs talk a little bit about some more examples that you had of specific assessments based on ages I think were helpful. [0:37:46.2] RG: Thank you. So, yes, Karin, like you said, not everyone has the ability or even the Ð you have to have negotiated that and maybe work at a larger scale, seen a lot of clients to have maybe Pearson work with you and embed their assessments into your platform. So, thinking on a smaller scale if you are in private practice like I am and you might serve maybe a client or two over your own and I know some clinicians do even if they work for another company. But you still can adhere the best practice guidelines, you still can assess absolutely. So, one example of that is your traditional parent interview format, like for early intervention, itÕs actually best practice because these kiddos donÕt necessarily have the attention or the ability to look at a screen for a 60-minute duration and you also want to capture their skills and see how they are across environments, right? How they communicate at home and if they go to daycare or if they go to school, you want to know as much as you can about them. So, one example is the receptive expressive emergent language test. You donÕt have to screen share up to three years old, commonly used, and it records parent observation of the childÕs behavior. You have in a similar format, The Rossetti Infant-Toddler Language Scale up to three years old, where you assess pre-verbal and verbal aspects of communication and interaction in young children. And itÕs not just looking at one area, they really assess interaction attachment or reciprocated interactions that the client is having with the parent or the caregiver, looks at pragmatics, the way that the child uses language to communicate with others but it really captures all of these skills like just their play, language comprehension, expression through the parentÕs lens and how they perceive abilities of their child. And so, if you really believe that the parent is the most knowledgeable about their child, then a parent interview using these assessments that give you a way of standardizing and being still a standardized tool, right? That you Ð does allow you to compare to other norms. Then you have your DAISY, which collects information as well and it does it through observation, parent caregiving interview, and direct assessment looking at cognitive communication. DAISY2, social, emotional, physical development, adaptive behavior, and I would say that for EI early intervention, these are very much my go-toÕs right now in that order, literally in that order. Then we have our school age and if youÕre familiar with Q-global, you have here involvement for still test of articulation, you have here self-five, you have the tools that we talked about earlier used as an example. If you serve adults, it really depends also the area that youÕre looking at, right? But you have your EAT-10 if you want to assess dysphagia. If youÕre looking at voice, you have the voice handicap index. The PeakD if youÕre looking at kind of linguistics screener, maybe short version, the MoCA has actually a lot of research tied to telehealth even and credible enough but even phone administration. So, looking at that, right? And seeing what they recommend to make sure you still have that instrument available and are using it in a way that could be valid through that medium. Then you have your Quick Aphasia Battery and this university from the Quick Aphasia Battery, they actually have their telehealth version and they have their in-person version and theyÕre working on creating versions that are extended. So, if you have more time on telehealth then you get to do the telehealth QAB, the extended version but if you have a limited time, then they have a limited time version, so I am grateful for that and I do get my clinic an hour, sorry, but not everyone does. I remember when I worked in the hospital, sometimes it was 30 to 45 minutes, so times vary where you work, and then you also have your Tikofsky 50-word Speech Intelligibility Test that applies to dysarthric adults as well. So, IÕve named a few and just ways of assessing that. You donÕt necessarily screen share in some of these that I mentioned, not all of course is screen share and the GFTA and the self and all of those with stimulus but in this list, thereÕs quite a bunch that you just really donÕt necessarily have to present a stimulus on screen to conduct the assessment. [0:43:03.0] KHK: Yeah, definitely. ThatÕs good to know because itÕs really no different than sitting across the table from them and administering it. [0:43:13.8] RG: Right. [0:43:15.1] KHK: Okay, so letÕs talk a little bit about the challenges and I know weÕre going to have time for questions towards the end here but please do continue to put your questions in the QA. What are the challenges of practicing speech-language pathologists who are conducting these virtual assessments? [0:43:36.1] RG: Yes, itÕs music to my ears. I face these challenges myself and I felt like I need to find solutions and problem solve it, especially if you are a telehealth and like meeting initially, sometimes you feel like you donÕt have that coworker to consult right away, right? I canÕt go next door and say, ÒWhat would you do?Ó right? So, thinking about client selection, thereÕs less options for standardized assessments for very young children. Maybe between the ages of zero to three, regardless of modality, right? And just thinking about the client and whether they can participate and whether this session can be productive and can I get the information that I need to make a clinical informed decision. So, assessments with early intervention population frequently require the use of manipulatives and I explained this earlier but to ensure standardization, sometimes we have to deviate from those that you may be very used to using in-person administration. And consider there are other options that exist and then really incorporating a parent or caregiver or the family into the assessment process to ensure spontaneous results but at the same time, make sure that they do not prompt the child. ThatÕs a challenge, right? A lot of prompting like they want to see them succeed and from a parentÕs perspective, which I am a parent of a six-year-old, like I think IÕd make that mistake too. When I go to the clinics where I take him or anything like that and I Ð theyÕre testing him for letÕs say, school readiness assessment and I was like talking. ItÕs like Hal is just like, ÒNo, mom, no, thatÕs not what you do.Ó And IÕll, ÒOh, I forgot.Ó And I will stick in like my capacity. That was me telling a parent to do that, right? And just the engagement in telepractice assessments, so how you orient the examinee or the parent to make sure that the guidelines are followed. So, they and both, you have the information that you need and sometimes I explain to them and what I share is if you help, the results are going to be so out of range that maybe the child is not going to qualify because it will show that they do not have a need when they do. So, that really is an eye-opener that IÕve, ÒOh, no, no, you know we want to make sure we capture their true skills, right?Ó So, thatÕs one of the main ones, client selection. The other one is referral question, why are they referring this client and what are the reasons for this modality? So, the client chose it, some clients have shared that they even chose it because they think it meets the needs and the circumstances of their family at the moment. They canÕt drive so far or the hours and just participation, being able to be there. And there are other challenges related specifically to the client. So, hearing and vision, cognitive ability, and tech literacy, thatÕs a big one, technological literacy like do you know how to set yourself up for your session and do you know how to connect to your audio and your video? So, I donÕt want to necessarily say that being a person that doesnÕt or has a hearing impairment disqualifies you automatically. I think we should think about technology and how it has evolved. So, if you are hearing impaired, which I have served them through telehealth, what I do is first, I need to know what is your last hearing exam that youÕve had and if you have a hearing aid, are you fitted appropriately and your hearing aid can connect to your audio, right? And if so, we may have a great session and I may be able to proceed with my assessment. But making sure that those questions are asked and that you know beforehand. So, one of my clientsÕ hearing aid stopped functioning and we did have to put therapy on hold for some time but obviously, for the assessment experience, it was great. There was no issue there but I was serving the deaf and hard of hearing and I have some clients in a very specialized niche that I can still serve through this platform and I was excited. Like, when she told me, ÒI have hearing aids on.Ó I was like, ÒDo you hear me? Do you hear me?Ó And sheÕs like, ÒI do, IÕm connected to the audio.Ó ItÕs like, ÒOh my God, this is wonderful.Ó And the environment is another challenge. Is it Ð hopefully you get to coach a client on the importance of a private space, minimal distractions. Minimal distractions also include putting the electronics far away from the child. So, the phones and the gadgets and all that, right? Then you have the technology, the hardware, software that they have and that you have should be appropriate because this is what youÕre set up to do but if youÕre the client, do they have a large screen, a small screen? Some of my own colleagues have shared the limitations of when clients connect through their phones, right? And how it changes slightly or a lot, depending on the circumstances of the assessment experience for them. But best practice is obviously the large monitor, 15 inch measured diagonally, your audio, and minimal environmental distractions like background noise, your family is snoring, youÕre laughing, your dogs barking. So, think about all of that as you set yourself up and your client for success and do you have screen-sharing capability. Do you have the ability to annotate? So, does your Zoom allow you to make selections for the assessment? And some assessments you do have to point, like if youÕre doing just the GFTA sometimes youÕre pointing to the shoe, right? So, even you as a provider, can you annotate? Can you point for your client? And ultimately, of course, the high-quality video is necessary. You want to see their mouths if youÕre doing an articulation exam, you want to be able to see the mouth movement, right? And making sure that even if they have this great microphone, itÕs not covering their mouth. So, things like that are challenges but we navigate them together and most of the times, I would say IÕm able to conduct most of my assessments. [0:50:22.3] KHK: Okay, so a question came up. In my mind, when you brought up the articulation, a pretty common question. So, how do you ensure that youÕre Ð you know, what about your oral motor exam, how would you do that? [0:50:38.8] RG: Yes. So, I love the Beckman protocol and obviously, I canÕt measure cheek strength or directly as I could when IÕm touching their faces, right? So, that is something that is a limitation but it doesnÕt mean I canÕt administer an oral motor exam. So, one of the things that IÕm like due to see, do they have good labial strength, right? Is say, ÒPuff up your cheeks with air and hold, hold, hold.Ó And we make silly faces but the client is able to hold and I see were they able to hold for five seconds, did they immediately go because they couldnÕt hold, right? That gives me an idea about strength. So, even if I am unable to touch it but I still can see whatÕs going on and if I think theyÕre being silly, IÕd say, ÒTry it again.Ó This time, I am being serious, ÒI want to see if you are strong.Ó And you know, they all want to be strong. So, they really give it a try until they get red. IÕm like, ÒOkay, okay, youÕre strong. Let it go.Ó Does that give you an example? Yeah, and then, of course, youÕre tongue up and tongue down and to the left and right and are they able to do their AMRs, SMRs, ÒSo, padica-padica-padica, now, letÕs do it, letÕs repeat it until I say stop.Ó And I give you five seconds. Can you do 12 to 15 repetitions in five seconds? IÕm hearing that, IÕm seeing that, and I am looking at their oral motor differentiation skills and IÕm like, ÒOkay, this is good.Ó They did Ð if itÕs not all thatÕs saying, they did 12 repetitions in five seconds, thatÕs awesome, and I really can measure it. I could have an informal measure but itÕs still pretty accurate. So, if you are doing the Newcastle dysarthria assessment, those are the norms youÕre looking at and youÕre hearing and seeing that. So, itÕs still valid. Does that answer your question? [0:52:27.0] KHK: Yes, that was very helpful. Thank you, and then letÕs talk about who would not be an appropriate fit because I know you mentioned that youÕve been able to work with hearing impaired but what would happen if their vision or you know, perhaps they are visually impaired or thereÕs significant cognitive issues, at what point do we say, ÒOkay, this is not going to workÓ even if there are no other options? [0:53:00.3] RG: Right. [0:53:01.1] KHK: When is I guess no service better than the service that you would provide? [0:53:07.2] RG: Right. No, thatÕs a good question. I feel that the type of parties is big and weÕve talked about it and if you think about a diagnosis doesnÕt automatically disqualify an individual. I have asked the client, ÒSo, youÕre visually impaired and youÕre not able to see the monitor very well, have you had contacted an ophthalmologist?Ó ÒNo, I see blurry but I havenÕt gone.Ó And if theyÕre hearing impaired and you need hearing aids, do you have them? Are they something that you can use and readily available to be connected to the audio and do you know how to do this? So, really looking at what their tech is like including if they have a disability, how they are up to date with their medical care, right? And educating them, so I might say, ÒFor now, I will put your assessment on hold and once you have this corrected and looked at, we can revisit.Ó ÒSo, definitely come back and consult this service. I really want to help you but we have to make sure that the medical part is needed is taken care of.Ó So, thatÕs very important and if they have the capability of mitigating that, we can revisit the assessment at a later time. [0:54:23.0] KHK: Absolutely, and I know one of the big issues in clinic-based services might be because of access issues and equity of you know, folks that all they have is a smartphone and so theyÕll show up to the assessment with a smartphone. Have you been able to conduct an assessment by phone? We frequently hear itÕs not best practice but if you are trying to navigate that fine line of providing the service and giving that access. And making it equitable, what are there Ð are there workarounds? What could we consider doing to make this work? [0:55:04.4] RG: Definitely. So, initially, when I was new in telepractice, I panicked. I was like, ÒDo I just stop here and say I canÕt help you?Ó Because I would ask the question, ÒDo you have a backup device?Ó ÒNo, this is all I have.Ó But in my heart, you know, doing the best for the client. I was like, ÒNo, I have to make this work.Ó So, I started thinking about methods or techniques where I can still get the data that I needed to make an informed clinical decision. And so, I wonÕt go into detail but for the sake of time but you have your parent interview, your play observation if theyÕre little, your clinical observation in general, then you have your chart review. So, do you have a clinical report from an outside provider available to you? Then you have your language sample, that very powerful spontaneous language as you try to elicit and not necessarily screen sharing. I can set up a scenario, ask a parent to grab some manipulatives, and talk about a topic, and really look at their syntax that they use one word or sentences. Do they ask questions? Do they answer yes and no? Their morphology, are they using tense markers, pronouns, right? Their vocabulary. My famous one is a 25 utter example if I canÕt do a 50, you know? And I find it to be pretty reliable each and every time as I go back and see my initial sample would have gave me and then where they are now. Then you have your semantics and how they use language socially. If they are older, I might do, well, still being Ð going back to the little ones, maybe an MLU calculation, speaking until it really connective speech, a phonetic inventory, so how they say their sounds and this consonant-vowel syllable shapes that they have. If itÕs literacy-based, IÕm like do Ð make phonological words test, like can you name your letters? Can you name the sounds associated with each letter? And I might not even be showing, sometimes I say, ÒA says.Ó And I am hoping they say, ÒAh.Ó And they get credit. Can you produce rhyming words like what word rhymes with cat? Bat, something like that, right? Your reading fluency, get a book nearby, and letÕs measure how many words per minute and I later ask the parent to send me a picture to see how many words and do that count, right? Spelling, so I am going to dictate some words for you, can you not make an error as youÕre spelling your grade-level words, right? And ultimately, community outreach, like what others have observed, their teacher, their doctor, their therapist. [0:57:37.8] KHK: Amazing. I was going to say I canÕt believe our time is almost up. WeÕre going to take one or two questions from the audience and the first one, if you could just repeat the assessment you mentioned for voice earlier, do you have that name? [0:57:53.0] RG: Yes. Yes, I do. I did mention the voice handicap index. If you want a more structured protocol, something like the LSVT is great. They have their own assessment and ways of doing this and thatÕs CAPE-V as well. Those are some of those assessments that I use, and is it voice for dysarthria or voice in general because there is voice for dysarthria and thatÕs a little different but then thereÕs voice in terms of standing alone and not related to that diagnosis. [0:58:29.8] KHK: Yeah, and I believe it was voice in general. [0:58:32.9] RG: Oh, okay. [0:58:33.9] KHK: And then one more question regarding validated assessments. ASHA has a list of validated assessments for tele-assessment administration. Does ASHA have a list of validated assessments for tele-assessment administration? Are you aware? [0:58:51.6] RG: Right, so ASHA, what they do is they provide the research and they do mention if you put tele-assessments validated, then they will pinpoint you in that direction. They donÕt have a list per se but they do point you towards them looking at the research about valid instruments. [0:59:08.4] KHK: All right, and I think one last important question that I wanted to ask before we wrap up was regarding emergencies because the unexpected does happen when you least expect it and it will happen over a telehealth session and so, what would you do if there was an emergency during your tele-assessment session? [0:59:31.8] RG: Yes, definitely. So, if there was an emergency, the first thing you want to know is, ÒHow can I easily access my clientÕs demographics, and what are the numbers to their residing state?Ó So, what are the numbers? So, if you dial 911 from your state, you might get your local police department, your local fire department and thatÕs not what you need, right? Your client is in, like myself, California. So, just make sure you know the numbers to their local agencies so if that ever happens, you know who to call right away and they could do a wellness check or mitigate any health issues that they are having as fast as possible. [1:00:12.2] KHK: And I believe one of the things to ensure that you can send that information over to the local agencies would be to verify their location, correct? [1:00:25.4] RG: Absolutely, yes. [1:00:26.5] KHK: Their address. [1:00:26.7] RG: Yes, and specifically county. What county they are in, right? And if they are in an apartment, like do you have the code or would they be willing to provide that information to you? So, itÕs very important to think about their self, yes. [1:00:40.0] KHK: Yeah, ahead of time for sure. All right, well, this was extremely informative and I think we have a whole lot of other questions that weÕll have to answer it in another possibly podcast. So, thank you so much, Roxana, we truly appreciate Ð [1:00:55.5] RG: Thank you for having me. [1:00:56.9] KHK: Education and expertise you provided this evening about tele-assessments in the clinic setting and be sure to join us for our next episode in this series, episode 11, where IÕll be speaking with Ta’na JimŽnez-L—pez, about the topic of best practices in telesupervision. Have a great evening. [END OF INTERVIEW] [1:01:16.3] ANNOUNCER: Thank you for joining us for tonightÕs course. To complete the course, you must log in to your account and complete the quiz and the survey. If you have indicated that you are a part of the ASHA registry and entered both your ASHA number and a complete mailing address and your account profile prior to course completion, we will submit earned CEUs to ASHA. Please allow one to two months from the completion date for your CEUs to be reflected on your ASHA transcripts. 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