Shaping the Future of Hearing and Speech Therapy - The Telehealth Revolution

Can you imagine a world where specialized help for hearing and speech therapy is just a few clicks away, even in remote and underserved areas? That's exactly what telehealth is doing and our esteemed guest, Nell Rosenberg, National Director of Teleservices at Clarke Schools for Hearing and Speech, has a wealth of insight to share with us. Nell passionately discusses how telehealth is providing language-rich environments for children, breaking down barriers due to distance and availability of professionals.

A critical part of these services is the involvement of parents in early intervention, especially from birth to the age of three. Nell shares her hands-on experience in coaching parents to become their child's first teachers, fostering a profound bond and ensuring high-quality care. We also address the emotional rollercoaster parents often find themselves on when dealing with an unexpected diagnosis. Listen in to learn more about virtual parent groups and referrals that build a welcoming and supportive community.

Lastly, we delve into the future of tele-services. Nell believes these services are here to stay and will continue to influence the lives of professionals, parents, and children alike. Nell's enthusiasm is infectious as she encourages practitioners to embrace telehealth fearlessly. Tune in for an enlightening chat as we explore the promising future of telehealth in hearing and speech services.

Transcript

Blaise M. Delfino: 0:06

You're tuned in to the Hearing Matters podcast, the show that discusses hearing technology, best practices, and a growing national epidemic: Hearing Loss. Before we kick this episode off, a special thank you to our partners. Sycle - built for the entire hearing care practice. Redux - Faster. Drier. Smarter. Verified. Fader Plugs - the world's first custom adjustable ear plug. Welcome back to another episode of the Hearing Matters podcast, and joining us again this week we have Nell Rosenberg, who is the National Director of Teleservices at Clarke Schools for Hearing and Speech. Nell, welcome back to the Hearing Matters podcast!

Nell Rosenberg: 0:50

I'm so happy to be back. I feel like we could have talked for hours last time, so a second episode is very welcome.

Blaise M. Delfino: 0:56

The week has gone by incredibly fast and we were really excited to have you back on the show because we really wanted to introduce our listeners to who Clarke is, how long you've been serving your community and now we're going to really dive in deep to telehealth, because this is really a huge passion of yours and your teams. Last week, we talked a little bit about the benefits of telehealth and the incredible statistics that you shared. When we talk about the positive impact, personally and professionally, how have you seen telehealth positively impact the accessibility of hearing and speech services for families in remote or even underserved areas? Because it has to have a major impact.

Nell Rosenberg: 1:46

This is one of the biggest things about teleservice is that it can overcome these barriers. So I mentioned in last week's episode the zip code lottery. We used to say it all the time that kids won or lost the zip code lottery based on where they happen to be born. Maybe they're by a major pediatric audiology center, maybe there happens to be one AVT in their county, maybe there is no one. There are states with no practicing teachers of the deaf child's born in that state, out of luck for services, right? Well, not anymore, but that was the reality for the vast majority of our field existence.

Nell Rosenberg: 2:29

It's only in recent decades that we've had the opportunity to utilize telehealth to reach families who are not specifically located very closely to a Clarke campus or another similar programs campus.

Nell Rosenberg: 2:43

Right, because we have many amazing colleagues in the field, but they're not everywhere. So we have served students in geographic areas with no specialists, all over the country and children and families outside of the USA. For example, right now we have three little girls under the age of three, all residing in Bermuda, not related to each other, but they happen to all have hearing loss, which is very rare for the population of that nation. They travel to the US for their audiological care, but there are no teachers of the deaf in Bermuda, nor are there SLPs with listening and spoken language background in their entire nation. And now these three children all have access to T visits and, in fact, are achieving beautifully meeting their language milestones. I recently tested one of them, who I see personally, and she exceeded the expectations compared to her same age hearing peers. So the benefits are endless. And when you mentioned those underserved areas like rural and urban both areas we see huge, huge benefits because in those rural areas there's now high speed internet whereas there did not used to be.

Blaise M. Delfino: 3:57

Right.

Nell Rosenberg: 3:58

Over COVID. We saw a huge improvement there and those families were driving hours and hours for services and can now get access. And then the barriers in intercity areas or just urban areas in general are the same but different. Right, we have other transportation challenges. Now we're relying on public transit with small children. Now, perhaps you know, there's other barriers involved and we may have families with alternative work schedules doing shift work who cannot maintain a regular schedule for center-based care. So the impact on accessibility is one of the biggest benefits to telehealth and I see no limits on it.

Blaise M. Delfino: 4:40

That is super exciting. I mean Bermuda. These three kiddos now again have access to a language-rich environment, not only at home, but now they're teamed up with professionals like you and your team that will give them the tools to communicate effectively. That is super exciting. Now that's got to make you just smile ear to ear.

Nell Rosenberg: 5:03

It does. It really does, you know, and it always takes work to figure out, you know. Can we practice in this nation? What are the regulations? Can SLPs do it? Can teachers of the deaf do it? But then you see the outcomes and it's all worth it.

Blaise M. Delfino: 5:17

Access to hearing health care. That is really what we believe in Breaking down those barriers. Who would have thought, you know, even when you were talking about how 2011, I believe you had said, was the first T-visit that Clarke did to now, 2011 does not seem that far away, but the advancements that have been implemented in this field and industry have been incredible. When we talk about, there has to be some challenges or considerations, right. So, like no service delivery model is perfect, we try to refine and get better every single day. But, you know, are there any specific challenges or even considerations when providing hearing services through telehealth compared to, like, in-person sessions?

Nell Rosenberg: 6:03

Yes, absolutely. Now I truly believe that we can provide appropriate services to any child via tele-service. I do not believe that there are children who quote unquote can't do T-visits. I don't believe that. I believe that it is on us as a professional to make it work, and that is why sessions are so highly individualized for the child's needs. Now, there may be some children who also need in-person services for other challenges. You know if they perhaps they also need physical therapy and some of that needs to be in-person. Or perhaps we have an oral motor component and we're going to need to do an in-person evaluation for that type of thing. But when we're really talking about oral, aural habilitation and rehabilitation, I believe that tele-services can work for any child if you put the right strategies in place. The challenges, which I don't want to consider them challenges, but what you need to be prepared for is that there's more planning involved.

Blaise M. Delfino: 7:02

Okay, tell us more.

Nell Rosenberg: 7:03

So, yeah, for there to be an effective telehealth session, you need to do more planning up front and the provider needs to have really, really strong coaching skills, and that is not something we're always taught. So you need to go into a session ready to coach whoever is there. So if that's the caregiver, which I'll use parents and caregivers interchangeably, anyone who's important in the child's life caregiver, school personnel, the child themselves if it's an older child, you need to know how to coach appropriately to that person. And we don't all know that right, because maybe we didn't learn much about adult learning theory. So our providers, before they start providing tele-services, go through quite a complex training process to increase their coaching skills and their knowledge of adult learning theory, and you really need to have multiple backup plans. You do for a center-based session too, right, like you don't know what a three-year-old's going to do.

Nell Rosenberg: 8:03

But you can't just think it now, because now you need to have communicated that to whoever's in charge of the session there, because they have to have everything ready. So you do need to communicate very effectively between sessions before and after. You know, let's have this ready. This is the goal we're working on. These are the strategies we're going to focus on. Please have XYZ ready. Are there any toys that she's been really into lately? Let me know and we'll incorporate those. So everybody in the session has to be ready to go on both ends, and you need to send updates, you need to send videos, you need to send whatever resources are needed for the parents or the school teams so that they can succeed, because now my role is not just to make sure the child succeeds, but to make sure every participant in the session succeeds.

Blaise M. Delfino: 8:51

And there's carryover there too. I love the implementation of adult learning theory and not many may think of that and understand how important that is. But for carryover, specifically, it's just ensuring that what you're teaching the child will be carried over in the home. That's interesting.

Nell Rosenberg: 9:14

And I think it's a huge gap in training preservice audiologists and speech pathologists, even though audiologists and many speech pathologists do work with adults in their day-to-day, not just as caregivers.

Blaise M. Delfino: 9:25

I would have loved to been trained on that and have a class on that for sure.

Nell Rosenberg: 9:29

There should be.

Blaise M. Delfino: 9:30

And.

Nell Rosenberg: 9:31

I've learned a lot now, but it's really important because we send parents or adult patients off thinking like, oh, we taught them all these things.

Blaise M. Delfino: 9:40

They've got it.

Nell Rosenberg: 9:42

They don't have it. Could you remember all of that? There's no way. So we have to reiterate, we have to send follow-up, we have to know what works for this adult a video clip, like a visual, a bulleted email? How are they learning best so that they can carry over? Because nothing that I do in the 30-minute session is changing the child's life. It's what everyone else is doing all the other hours of the week that matter.

Blaise M. Delfino: 10:57

But that 30 minute session really does matter and, to your point, making sure that you are prepared pre and post. Curious to know, with today's advancements in technologies and innovations, as we discussed last week, do your communications with the caregivers are a lot of those, because I know in speech language therapy like we would have maybe pre-written lesson plans for if you're working on the S sound or the Z sound. Do you have like automation tools that you're able to use and tap into and you can make selections to then create like an automated workflow?

Nell Rosenberg: 11:38

We do have some, but they're so highly customized to the children's needs that that's not primarily what we rely on. But we do use some of the same progress monitoring tools for all our kids and we can screen, share those and send PDFs of those to the parents so that they really develop a deep understanding of the developmental trajectory and exactly the gaps that we're trying to fill in our sessions.

Blaise M. Delfino: 12:05

That's excellent when we talk about carry over communication. Communication in the simplest form is the exchange of ideas. How do you, as a speech language pathologist, and how do you and your colleagues ensure effective communication and engagement with the child during telehealth sessions? Cause I'm sure not every single one is sunshine and rainbows?

Nell Rosenberg: 12:34

Oh, it sure isn't, and I have endured plenty of sessions with a 360 minutes of a three-nature, having a complete meltdown and hanging off.

Blaise M. Delfino: 12:46

You say three-nature.

Nell Rosenberg: 12:47

I sure did, but you know they're my favorite secretly. So yeah, there are challenges, but it is possible to do this at any age. And now, as I said, each team is highly customized because every individual student is different and has different needs and every family is different in terms of their learning needs, their culture, their home environments. We take all of that into account, right, but in general the model shifts in a pretty predictable way throughout the years to match the child's developmental needs. So I'll give kind of a high level overview of that. So for our birth to three, our early intervention population, we're following very strictly apparent or caregiver coaching model, those birth to three kids. I have seen kids as young as two weeks. That is not too young to be in speech therapy because, as you've mentioned, we are not learning to talk really, we are training the brain to hear and listen. All of that happens in the brain and it's never too early for that.

Blaise M. Delfino: 13:50

And it's never turned off.

Nell Rosenberg: 13:51

It's never turned off and it's never too early for parents to learn and to become advocates either. So, birth to three, we're using a parent coaching model in which I don't actually even want the child to pay attention to me on the screen. I am the coach or the provider is the coach. I'm the expert in the listening and spoken language content and the parent or caregiver is an expert in their child and they are the interventionist. They are the interventionist. They are there with the child, doing in-person developmentally appropriate activities with the child and I'm giving feedback and suggestions and coaching along the way to enable them to have those activities and interactions hit all of our goals. So the child, hopefully, is not engaged with their provider because it's not developmentally appropriate for a nine-month-old to chat with someone on Zoom.

Blaise M. Delfino: 14:41

Right, they're very advanced.

Nell Rosenberg: 14:45

And at times, even if it's distracting, I can turn my camera off and just talk to the parent, and if that becomes distracting, the parent may wear one like AirPod or something so that I'm coaching them in real time if the audio and visual is just too distracting for the child, and we can turn it on and off as we switch throughout the session. But for those early years, people worry about screen time and my baby can't pay attention to you. Well, I don't want your baby to pay attention to me. I want your baby to pay attention to you and I'm going to teach you how to be their first and best teacher.

Blaise M. Delfino: 15:19

Now, while you were speaking there, I kind of wrote down new parent and a couple of weeks ago we had Valley Gideons on the show and she said something that really, really profound. She says it's a grief for what you imagined, but this is true for all parents. You do not end up with the child you imagined. My gosh. The first thing I thought of was some of these parents you're working with and caregivers you're working with. They might be first time parents and trying to navigate this, the amount of stress level that they must have, but the work you're doing is taking their stress levels from 100, maybe I don't want to say all the way down to zero, but decreasing it significantly.

Nell Rosenberg: 16:05

That is a primary goal. Yes, those early T visits, for sure, the early sessions I would say most to all of the parents are going through some type of grieving process.

Blaise M. Delfino: 16:17

Right, whether they're first time parents. Can you stand on that a little bit more and talking about ensuring that caregivers and parents are being heard?

Nell Rosenberg: 16:26

Yes, and they often do not feel heard. These parents are going to so many appointments and if they're first time parents, they're also learning how to care for an infant, and if they're not first time parents, they're learning how to care for an infant while they have an older child, and it is so overwhelming. The vast majority of children with hearing loss are born to hearing parents with no history in the family. These parents rarely saw it coming and even if they did, there's a process. So there is a grieving process, not necessarily unique to hearing loss, but for any kind of identified issue. That was not what you expected at your child's birth, right? I mean, it's very shocking. You're expecting this one thing and then you fail your newborn hearing screening, you refer on it and then it's a whirlwind of appointments and APRs and all these things. And the parents are really, really struggling and I have the deepest empathy for them because they are asked to learn an incredible amount of information that is literally impossible to learn in that short of a timeframe. In very short appointments. They're usually seeing people for maybe 10 or 15 minutes in a million different specialties, while they are massively sleep deprived, trying to care for their infant, who they love deeply but who is not the infant they were expecting and trying to reconcile all of that.

Nell Rosenberg: 17:53

We have not set them up for success. We have not. And that's where I see one of our most important roles as their ongoing tele-service providers, because I'm someone they see every week, not like their ENT, who they see here and there, or their audiologist, who they see more at first but then maybe not for months or maybe they can't get in touch, or maybe they can't get in touch with their early intervention service coordinator. There's a lot of challenges. So they have a lot of questions because they heard this and they heard that but they can't quite remember. So they can bring all of those questions to their provider, who they see every week, because they come to really trust you. We form this very close bond and we do a lot of counseling and a lot of education and I want to be careful when I'm saying counseling, because we are offering a ton of emotional support and validating that what they're feeling is very much part of the process and is normal. We're often connecting parents to other parents who have gone through.

Blaise M. Delfino: 18:54

That's phenomenal, yeah.

Nell Rosenberg: 18:55

And I'll say, oh my gosh, this is so similar to a child.

Nell Rosenberg: 18:58

It's community. It's community and we've done virtual parent groups before and we look forward to doing more of those in the future. But connecting like oh, that's a really unusual thing that happened with your child. I had a kid like that three years ago Let me call their mom and then, at times, making referrals. And that's why I was so thrilled to hear about your partnership, because parents sometimes do need more support than that, because this is an incredibly stressful life event. Having a child is an incredibly stressful life event and having a child diagnosed with any disability is an incredibly stressful life event. And now we've done them at the same time. That's unusual. That's unusual. Most disabilities are not diagnosed at birth.

Blaise M. Delfino: 19:36

You cannot see the picture when you're in the frame, and empathy is a. It's so essential to just to implement empathy, because you don't know what someone's going through, and I personally can only imagine what that is like.

Nell Rosenberg: 19:52

Right.

Blaise M. Delfino: 19:53

And really sharing all of that really.

Nell Rosenberg: 19:54

My pleasure I have to say it's, it's one of my favorite parts of my job is working with new parents. They always apologize and cry and I say they all cry. Everyone cries Like it's and you know, every parent I meet with Christ, I do all of our intakes, so I meet all of our parents through the first time. There's never a dry eye and that's okay. I'm here to hear you through that.

Blaise M. Delfino: 20:15

It's essential to to measure progress, if you will and I remember when I was in graduate school, you had your pen and maybe your soap notes and your your- marks. And then you're, you're, you're calculating how well they did in the session, and that's important because you know you don't want piece of technology that's going to distract the child you're working with Right, so you need to implement a writing. Implement if you will, but what strategies or tools do you and your team use to assess and monitor a child's progress through telehealth?

Nell Rosenberg: 20:54

Yeah, so we definitely still do that. I'm definitely still marking down as I go taking, you know, taking data points. Yes, so we do do that. For sure you know how many childs, et cetera, using our old school markings. But we also use a combination of assessment tools at regular intervals and then an ongoing basis, because it is critical to to measure progress and to make sure the child is hitting expected milestones and then to adjust our our program if they're not right.

Nell Rosenberg: 21:25

Our goal is to close the gap Right, so we need to make sure we're doing that. The way we do that is we use norm reference assessments to compare the children to their same age hearing peers so we can see how much of a gap is there when we start and are we working toward closing that gap? Are we making more than month for month progress? If there's a gap, you need to make more than one month progress in one month's time, but there's always going to be a gap. So those we do every six months to ensure we are closing the gap or maintaining appropriate functioning or exceeding right. Our goal is for the child to meet their full potential, not just average right. It's for the child to meet their full potential, but that keeps us really making sure that they are hitting the level of their same age hearing peers so they can join a mainstream setting as early as possible. We also use a lot of criterion reference assessments. This is giving you flashbacks to grad school.

Blaise M. Delfino: 22:22

Yes, yeah, I felt my BP just go up a little bit there. Yeah, a little bit.

Nell Rosenberg: 22:28

I won't go into all of them, but of course we use the language measures, but we use a lot of measures for specific auditory skills and then we use a very detailed progress monitoring tool that looks at every domain of listening and spoken language, social communication, audition, speech.

Nell Rosenberg: 22:46

That breaks it down in three month developmental intervals and we do that with the parents to see which skills they have, which are they missing, and then with the parents, we jointly select from those missing skills what are our current goals, and when the child has mastered those we just update it again and pick new goals. So the parents really feel ownership in the evaluation, progress monitoring and goal setting process and we ensure that everything we're working on is functional for the family. And then for the school age students it's a little different, but we monitor progress on IEP goals, academic performance, and then we assess in accordance with every district's requirements. So whatever that district requires, we find a way to do it via tele-service.

Blaise M. Delfino: 23:32

Again, you cannot manage what isn't measured.

Nell Rosenberg: 23:37

Exactly.

Blaise M. Delfino: 23:38

And to share this data with the parents is so important, because any progress is progress and especially, to your point we were just talking about new parents when they see this progress being made and these progress reports. They're so important.

Nell Rosenberg: 23:50

You're tracking they're so important and that's why I love I can send them a PDF that shows, when I check the dates, that I checked off new skills. So even if we've only been working together a couple months and I probably saw a bunch of random new skills here- and there, right, or we talked about it. Then I can send them a PDF and say look for all of the October ones. That's everything new that he did just this month and they can really see that in context of typical development.

Blaise M. Delfino: 24:18

And if you think, let's just say, within this month maybe they've had, let's just say, one session per week, but the carryover that they're implementing, that's a huge win for the caregiver. That's so exciting. So we know where we are today with telehealth services. Let's talk about the future. In your opinion, professional and personal, what does the future of hearing, health care and speech services look like in terms of accessibility and advancements?

Nell Rosenberg: 24:48

What do you see the future is really bright, but it's going to take work to get there. That's what I see. I see more and more adaptation of an adoption of tele services across our field. I think that audiologists and manufacturers have really been at the forefront of this and I can't wait to see the developments that keep coming out of those spaces, to see some of the distance technologies and the apps that are being used by audiologists and manufacturers now. I don't see that slowing down.

Blaise M. Delfino: 25:22

I have to dovetail there. The caregiver is very important and what I think is really cool. So Starkey does have a caregiver app, which is wonderful and really it brings the caregiver along the journey with whether it be their mother or father or whoever, so it does create that accountability as well to walk with that individual on their road to better hearing. So I love that you brought that up because, yes, it is incredibly bright. We need to create greater access, but the access needs to ensure that the professional is still part of that equation, in this instance, the speech language pathologist very important.

Nell Rosenberg: 26:03

But also the audiologists we're very aware of that because I cannot do my job without optimal audiological care. I cannot. If we don't have optimal access, we will not have optimal speech and language. It's not possible. So I think to ensure that the future stays so bright for both audiology and tele-services, in terms of teachers of the deaf and speech pathologists, we really need to unite. I mentioned in last week's episode Ash's Interstate Compact. That's really important, but I also think that lobbying for insurance reimbursements for different states recognizing tele-services, recognizing out-of-state licenses we're going to need to do a lot of work in our professions jointly to ensure that we can use these amazing tools with appropriate reimbursement, legal backing, et cetera. That's where I see the biggest need and the biggest opportunity.

Blaise M. Delfino: 27:04

And I think that we're going to make a lot of noise now as we and fellow professionals continue to raise awareness of the importance of communication sciences and disorders. But before we sign off, today you brought up a really cool statistic about tele-services. You had a third-party run a survey. But this question has to do with maintaining strong rapport. I remember in grad school our professors would always ensure you build a strong rapport not only with your clients but also the caregivers as well. How do you do this during a tele-health session, because maybe the first session you might be meeting this person for the first time and everyone has a different personality style. Do you have any tips for other practitioners in establishing this connection?

Nell Rosenberg: 27:56

I do, because this is the cornerstone. Without that strong rapport, you're going nowhere in tele-health. I have to be honest with you. But here's the great news it is actually pretty simple to establish that rapport if you know what you're doing. So, as I mentioned before, you do need to get that education in adult learning theory and in coaching. You need that before you can start this. You cannot dive into teleservice without some type of training in that. Specifically. Now, in terms of establishing rapport, I believe the most important step is to set appropriate expectations from the very beginning, regardless of who you're working with. So that may be a school-based team, that may be parents or other caregivers, whoever it is.

Nell Rosenberg: 28:45

I always hold an introductory session without the child present because I want to set up that family or that school team for success. If they don't understand that we're going to be using a coaching model, well, that first session is going to be pretty rough, because they're looking at me like when are you going to start screen sharing for this two-month-old? And I'm looking at them like why don't you have toys out? So it's explaining in depth why do we use a coaching model? What is a coaching model? What is my role? What is your role? Giving them ample time to ask questions about that. They ask a lot of questions like what does that look like? What happens if the baby falls asleep? Or, like in a school, what happens if the para is out sick? What do you think, Because he's seven, could he do it on his own? Talking about talking through all of those things and really making clear what each person's role is going to be anyone who might be participating so that could include a grandparent or a nanny, and so the child's family or indoor school team truly understands what is this session going to look like? And so there are not surprises.

Nell Rosenberg: 29:53

If you go into this thinking like I'm going to do a parent coaching model, but you don't set the stage, it really falls apart and you want to get really granular. Where is this going to happen? I always do this on whatever platform we're going to use, like Zoom or whatever platform a school may require, and say, okay, let's go to where we're going to do this session, because the school may realize, oh, we don't have a room with high-speed internet connection that's not really noisy, and so then we're going to troubleshoot that. Or we may be in the home and we say, okay, we're right, by a window unit, so let's take a look around. And you troubleshoot all those technical and logistical issues before the kid is even there.

Blaise M. Delfino: 30:34

That's excellent. Now that probably saves you and the caregiver so much time and frustration, because it is setting those realistic expectations. Now I want to thank you so much for joining us on this two-part series. We have to have you back on the show in the near future. Before we sign off, what advice can you give to speech language pathologists, audiologists, who aren't there yet implementing telehealth, but want to take the next step?

Nell Rosenberg: 31:05

Don't be afraid, but do your homework. This has opened up a whole new world to me and, in fact, a whole new role for me, and it's been an incredible journey and I think this is the future of our field. I would strongly encourage you to learn more about tele services. We have on our website which we can send to you for your show notes, with a lot of resources for parents and for professionals. We have a recorded webinar that my colleague and I did on tele services across the age span from birth all the way to graduating high school. That can give you some more insight and there's a lot of related resources there that can set you up in the right direction. And if you are a pre-service professional, look for those tele service opportunities, look for those counseling and adult learning classes, if you can take them, to be ready when this comes your way, because this has been an incredible honor to be part of this movement and it is the future of our field.

Blaise M. Delfino: 32:04

You're tuned in to the Hearing Matters podcast. Today we had Nell Rosenberg, who is the National Director of Tele Services at Clarke Schools for Hearing and Speech. Until next time, hear life story.