Positive Outcomes for Speech Telepractice as Evidence for Reimbursement Policy Change Oklahoma has a large population living in rural areas where it is difficult to fill school speech-language pathologist (SLP) positions. To meet this need, telepractice has been used in rural Oklahoma school districts since 1999. Medicaid policies have allowed schools to receive reimbursement for speech therapy provided by onsite therapists; ... Article
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Article  |   April 25, 2016
Positive Outcomes for Speech Telepractice as Evidence for Reimbursement Policy Change
Author Affiliations & Notes
  • Lori Short
    INTEGRIS eHealth, Oklahoma City, OK
  • Tiffany Rea
    INTEGRIS eHealth, Oklahoma City, OK
  • Beki Houston
    INTEGRIS eHealth, Oklahoma City, OK
  • Sonya Scott
    INTEGRIS eHealth, Oklahoma City, OK
  • Pamela Forducey
    INTEGRIS eHealth, Oklahoma City, OK
  • Disclosures
    Disclosures ×
  • Financial: The authors have no financial interests related to the content of this article.
    Financial: The authors have no financial interests related to the content of this article.×
  • Nonfinancial: The authors have no nonfinancial interests related to the content of this article.
    Nonfinancial: The authors have no nonfinancial interests related to the content of this article.×
Article Information
Speech, Voice & Prosodic Disorders / School-Based Settings / Practice Management / Telepractice & Computer-Based Approaches / Part 1
Article   |   April 25, 2016
Positive Outcomes for Speech Telepractice as Evidence for Reimbursement Policy Change
Perspectives of the ASHA Special Interest Groups, April 2016, Vol. 1, 3-11. doi:10.1044/persp1.SIG18.3
History: Received April 14, 2015 , Revised June 9, 2015 , Accepted June 26, 2015
Perspectives of the ASHA Special Interest Groups, April 2016, Vol. 1, 3-11. doi:10.1044/persp1.SIG18.3
History: Received April 14, 2015; Revised June 9, 2015; Accepted June 26, 2015

Oklahoma has a large population living in rural areas where it is difficult to fill school speech-language pathologist (SLP) positions. To meet this need, telepractice has been used in rural Oklahoma school districts since 1999. Medicaid policies have allowed schools to receive reimbursement for speech therapy provided by onsite therapists; however, reimbursement for speech telepractice was excluded. The current project measured the effectiveness of a speech telepractice program so this policy could be revised. Speech and language skills of 578 children, grades PreK–12, were followed over one of two school years and were rated using Functional Communication Measures (FCM) established by the American Speech Language and Hearing Association (ASHA). Our data show that 67–87% of the children advanced by one or more levels on three common FCM scales. These changes are similar to, or greater than, what was reported in a large sample of students compiled by ASHA's National Outcomes Measurement System (NOMS) with clinicians who worked onsite in schools. Average weekly treatment time was also less in our teletherapy practice than what was reported in the reference database. Therefore, the current study demonstrates that speech telepractice is an effective and efficient method of delivery for the school age population.

Since 1990, the United States Department of Education has published the Teacher Shortage Area Nationwide Listing (U.S. Department of Education Office of Postsecondary Education, 2015). Speech-language pathology is one area of need that has been identified for Oklahoma frequently since the creation of that list. Sixty percent of Oklahoma's population of almost 3.8 million is distributed in two primary metropolitan areas while the remaining 40% of the population is located in rural areas dispersed across a large geographical area. Out of the 77 counties in Oklahoma, 63 are considered to be rural and 14 are designated as urban (Hackler, Landgraf, & Wheeler, 2014). There is an ongoing challenge to provide onsite speech-language pathology services for students with speech and language difficulties in the school districts located throughout the small communities in Oklahoma.
INTEGRIS Health is a community-based, not-for-profit health care system based in Oklahoma City, with clinics in smaller towns throughout the state. Since 1999 INTEGRIS Health has provided speech telepractice service in rural Oklahoma communities. The current speech telepractice service evolved from our prior efforts to evaluate the feasibility, efficacy, and satisfaction of the speech telepractice. We found that telemedicine (real time and two-way interactive video) was an efficient and cost effective method for delivering speech therapy. The initial pilot project at our center was conducted in 1999 with a rural school with which we already had an established relationship, had infrastructure to support teletherapy, and expressed willingness to continue teletherapy if it was successful (Scheideman-Miller et al., 2002). That initial pilot project lasted six weeks and included nine students. There were improvements in three cognitive domains (Social Interaction, Problem Solving, and Memory) that were measured on the Pediatric Functional Independence Measure (WeeFIM) outcomes management tool (Ottenbacher et al., 1999). Parents, students, and therapists all rated the program as successful and effective (Scheideman-Miller et al., 2002).
The current project was developed in response to a request by one of the rural school districts in Oklahoma that contracts for speech telepractice services. In December 2012, that school district asked the Oklahoma Health Care Authority (OHCA), the agency that disperses Medicaid funds in the State of Oklahoma, to perform a study of the effectiveness of speech telepractice. The primary reason for this request was that the rural school was unable to submit claims to the OHCA for speech telepractice but was able to receive reimbursement for onsite speech therapy. In response, the OHCA requested that INTEGRIS speech telepractice provide clinical outcome data to support a policy change that would allow schools to receive reimbursement for speech telepractice services. Thus, the current study was performed to measure the effectiveness of speech telepractice in Oklahoma using a larger sample size than our pilot work from 13 years prior. We used an outcome evaluation tool that is endorsed by the American Speech-Language-Hearing Association (ASHA, 2003) to measure the progress of Pre-K–2nd-grade students from multiple school districts over two consecutive academic years. To our knowledge, the current study has the largest sample size to date demonstrating the clinical effectiveness of speech telepractice with a school-based population.
Methods
INTEGRIS Health speech-language pathologists (SLPs) are certified by ASHA and licensed by Oklahoma Board of Examiners of Speech-Language Pathology and Audiology. Over the course of the two-year reporting period, speech telepractice was conducted over a secure Internet Protocol (IP) connection between an INTEGRIS Health facility in Oklahoma City and each of the participating rural Oklahoma school sites. Speech telepractice services were provided according to service agreements with the schools, and as outlined in the student's individual education plan (IEP). Each school appointed a paraprofessional to be present for treatment sessions in order to provide hands-on assistance with the student and speech therapy material/equipment. The speech services provided were the same as those that would be provided by onsite clinicians using current professional guidelines, including screenings, evaluations, treatment, parent and teacher meetings, and consultations.
The level of each student was rated using Functional Communication Measures (FCMs) for the K–12 population developed by the ASHA (2003) . The FCMs are comprised of 7 separate scales that rate speech language function in the areas of Fluency, Intelligibility, Pragmatics, Speech Sound Production, Spoken Language Comprehension, Spoken Language Production, and Voice. The scoring range for each scale is 1–7, for the lowest to highest competency, respectively. An example of the scale levels can be found in Table 1, a paraphrased version of the Speech Sound Production scale. FCMs were originally developed in 1999 to track outcomes of speech therapy services as part of the National Outcomes Measurement System (NOMS) database. The NOMS database is a compilation of data from three speech language pathology patient areas: adult, preschool, and standard school K–12 populations (Mullen & Schooling, 2010). National reporting for the standard K–12 school population was discontinued in 2010. However, ASHA still maintains and distributes the K–12 FCMs for schools for the purpose of compiling additional results for internal performance improvement and accountability. In order to use one scale and be consistent across our entire school-based caseload, we used the scale for the standard school populations K–12 to measure the performance of all of our students in grades Pre-K–12.
Table 1. Speech Sound Production FCMs Score Criteria (paraphrased).
Speech Sound Production FCMs Score Criteria (paraphrased).×
Level 1 Student is not producing speech sound(s) correctly and is distracting to the listener with no awareness of errors.
Level 2 With maximum cues, student can produce speech sounds correctly in words and rarely aware of errors.
Level 3 Student occasionally aware of errors and occasionally spontaneously produces sound correctly in words.
Level 4 Student is usually aware of the error and can produce the sound in sentences with minimal cues. Rarely self-corrects.
Level 5 Student is aware of errors and can occasionally self-correct. Student can produce sound with minimal cues in structured conversation.
Level 6 Student monitors speech and self-corrects in conversation. Speech is rarely distracting to the listener.
Level 7 Student's speech is not distracting to the listener. Student consistently monitors and self corrects without limits in conversation.
Source. National outcomes measurement system (NOMS): K12 speech-language pathology user's guide (ASHA, 2003).
Source. National outcomes measurement system (NOMS): K12 speech-language pathology user's guide (ASHA, 2003).×
Table 1. Speech Sound Production FCMs Score Criteria (paraphrased).
Speech Sound Production FCMs Score Criteria (paraphrased).×
Level 1 Student is not producing speech sound(s) correctly and is distracting to the listener with no awareness of errors.
Level 2 With maximum cues, student can produce speech sounds correctly in words and rarely aware of errors.
Level 3 Student occasionally aware of errors and occasionally spontaneously produces sound correctly in words.
Level 4 Student is usually aware of the error and can produce the sound in sentences with minimal cues. Rarely self-corrects.
Level 5 Student is aware of errors and can occasionally self-correct. Student can produce sound with minimal cues in structured conversation.
Level 6 Student monitors speech and self-corrects in conversation. Speech is rarely distracting to the listener.
Level 7 Student's speech is not distracting to the listener. Student consistently monitors and self corrects without limits in conversation.
Source. National outcomes measurement system (NOMS): K12 speech-language pathology user's guide (ASHA, 2003).
Source. National outcomes measurement system (NOMS): K12 speech-language pathology user's guide (ASHA, 2003).×
×
During the 2012–2013 and 2013–2014 academic school years, 578 students from 13 rural Oklahoma school districts were scored using the FCMs rating system. Students were rated only on the scales that matched their specific deficits, as determined from their initial speech-language evaluation and IEP. Thus, some students were rated on a single scale, while others were rated on multiple scales. The scales were used to score students that were designated with a speech and language impairment, developmental disability, or specific language impairment documented on their IEP. Although other students may be on our caseloads, we did not complete these scales for students who were classified with other diagnoses such as autism or intellectual disability because the NOMS database was not validated with children with those diagnoses. All speech students were scored at the beginning and end of the school year, unless they were determined to have made sufficient progress to be dismissed mid-year from the school-based speech telepractice program. In that case, the follow-up FCM scoring was performed at the time of dismissal.
Speech teletherapists completed onsite school visits at the beginning and end of the school year to conduct evaluations, review records, and meet parents and school staff. All other treatment sessions, typically once or twice per week, were conducted using real-time and two-way interactive video telecommunication technology between the INTEGRIS Health metropolitan site and the respective rural schools. All of the schools and students that participated in the current project received speech services only through teleconferencing; there were no onsite speech therapy services provided. Thus, it was not possible to directly compare onsite and telepractice speech therapy within the specific schools that were served.
Data were collected over two consecutive school years, and each school year was assessed separately. Data analysis was performed using paired t-tests to compare the students' pre- and post-FCM scores. Univariate correlations were used to measure the strength of association between the change scores for the FCM scales and educational grade level, teletherapy time per week, and initial score. A p-value lower than 5% was described as statistically significant.
Results
In the 2012–2013 (Year 1) and 2013–2014 (Year 2) school years there were 324 and 254 students, respectively, who received speech teletherapy and whose performance was rated on at least one the FCMs scale. The distribution of students by educational grade for each year is shown in Figure 1. The figure demonstrates that the majority of students were in the lower grades. Students were seen 36.6 ± 0.6 minutes per week in 2012–2013 (range 3–60 minutes) and 41.3 ± 0.8 minutes per week in 2013–2014 (range 5–60 minutes).
Figure 1.

Distribution of Students by Educational Grade in School.

 Distribution of Students by Educational Grade in School.
Figure 1.

Distribution of Students by Educational Grade in School.

×
The FCM evaluation results for the 2012–2013 and 2013–2014 school years are shown in Tables 2 and 3, respectively. For both years, significant improvement was shown by increased performance measured on five of the seven FCM scales: Intelligibility, Pragmatics, Speech Sound Production, Language Comprehension, and Language Production. There was also numerically improved performance on the remaining two scales, Fluency and Voice, but there were too few participants scored to demonstrate statistically significant changes for those scales. The magnitudes of improvement on the FCM scales were similar across both academic years. Likewise, the percentage of students who advanced by at least 1 or 2 levels on the 7-point scale was consistent in both years. The change in FCM scores over the course of the school year was not significantly correlated with educational grade level or duration of teletherapy time per week for Intelligibility, Pragmatics, Speech Sound Production, Language Comprehension, and Language Production (correlations were not analyzed for Fluency or Voice due to the small number of observations). There were also no significant correlations between the change in FCM scores and initial score for all scales except Pragmatics, which had a modest positive correlation (r = 0.308, p <0.05). However, there were relatively fewer students tested on this scale (34 total in the two school years) than for Intelligibility, Speech Sound Production, Language Comprehension, and Language Production.
Table 2. Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2012–2013 Academic Year.
Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2012–2013 Academic Year.×
Outcome [N=324 ] Initial score (range) Final score (range) P-value % of students improving 1 unit % of students improving ≥ 2 units
Fluency [4] 4.3 ± 1.3 5.5 ± 1.7 0.141 50 25
(3–6) (4–7)
Intelligibility [47] 2.4 ± 1.3 3.5 ± 1.5 <0.001 36 34
(1–6) (1–7)
Pragmatics [21] 2.7 ± 1.6 3.4 ± 1.9 <0.001 71 10
(1–6) (1–7)
Speech Sound Production [174] 2.3 ± 1.5 3.8 ± 1.8 <0.001 36 51
(1–6) (1–7)
Language Comprehension [150] 3.3 ± 1.5 4.3 ± 1.7 <0.001 60 21
(1–7) (1–7)
Language Production [175] 3.1 ± 1.4 4.1 ± 1.7 <0.001 63 18
(1–6) (1–7)
Voice [2] 4.5 ± 0.7 5.0 ± 1.4 0.500 50 0
(4–5) (4–6)
Note. The number of students that were scored for each Functional Communication Measures (FCMs) scale is shown in square brackets in the first column.
Note. The number of students that were scored for each Functional Communication Measures (FCMs) scale is shown in square brackets in the first column.×
Table 2. Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2012–2013 Academic Year.
Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2012–2013 Academic Year.×
Outcome [N=324 ] Initial score (range) Final score (range) P-value % of students improving 1 unit % of students improving ≥ 2 units
Fluency [4] 4.3 ± 1.3 5.5 ± 1.7 0.141 50 25
(3–6) (4–7)
Intelligibility [47] 2.4 ± 1.3 3.5 ± 1.5 <0.001 36 34
(1–6) (1–7)
Pragmatics [21] 2.7 ± 1.6 3.4 ± 1.9 <0.001 71 10
(1–6) (1–7)
Speech Sound Production [174] 2.3 ± 1.5 3.8 ± 1.8 <0.001 36 51
(1–6) (1–7)
Language Comprehension [150] 3.3 ± 1.5 4.3 ± 1.7 <0.001 60 21
(1–7) (1–7)
Language Production [175] 3.1 ± 1.4 4.1 ± 1.7 <0.001 63 18
(1–6) (1–7)
Voice [2] 4.5 ± 0.7 5.0 ± 1.4 0.500 50 0
(4–5) (4–6)
Note. The number of students that were scored for each Functional Communication Measures (FCMs) scale is shown in square brackets in the first column.
Note. The number of students that were scored for each Functional Communication Measures (FCMs) scale is shown in square brackets in the first column.×
×
Table 3. Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2013–2014 Academic Year.
Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2013–2014 Academic Year.×
Outcome [N=254 ] Initial score (range) Final score (range) P-value %of students improving 1 unit % of students improving ≥ 2 units
Fluency [1] 3.0 ± 0.0 4.0 ± 0.0 n/a 100 0
(3) (4–4)
Intelligibility [39] 2.5 ± 0.2 4.3 ± 0.2 <0.001 46 38
(1–6) (1–7)
Pragmatics [13] 2.4 ± 0.4 3.4 ± 0.5 0.004 54 15
(1–5) (1–7)
Speech Sound Production [139] 2.4 ± 0.1 4.2 ± 0.2 <0.001 28 55
(1–6) (1–7)
Language Comprehension [110] 3.3 ± 0.1 4.5 ± 0.2 <0.001 50 29
(1–6) (1–7)
Language Production [133] 3.1 ± 0.1 4.2 ± 0.2 <0.001 41 26
(1–6) (1–7)
Voice [2] 4.0 ± 1.0 5.0 ± 2.0 0.500 0 50
(3–5) (3–7)
Table 3. Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2013–2014 Academic Year.
Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2013–2014 Academic Year.×
Outcome [N=254 ] Initial score (range) Final score (range) P-value %of students improving 1 unit % of students improving ≥ 2 units
Fluency [1] 3.0 ± 0.0 4.0 ± 0.0 n/a 100 0
(3) (4–4)
Intelligibility [39] 2.5 ± 0.2 4.3 ± 0.2 <0.001 46 38
(1–6) (1–7)
Pragmatics [13] 2.4 ± 0.4 3.4 ± 0.5 0.004 54 15
(1–5) (1–7)
Speech Sound Production [139] 2.4 ± 0.1 4.2 ± 0.2 <0.001 28 55
(1–6) (1–7)
Language Comprehension [110] 3.3 ± 0.1 4.5 ± 0.2 <0.001 50 29
(1–6) (1–7)
Language Production [133] 3.1 ± 0.1 4.2 ± 0.2 <0.001 41 26
(1–6) (1–7)
Voice [2] 4.0 ± 1.0 5.0 ± 2.0 0.500 0 50
(3–5) (3–7)
×
Due to the lack of availability of onsite speech therapists at the schools we served, it was not possible for us to make a direct comparison between teletherapy and onsite therapy within our school population. Table 4 shows a comparison between the current study and the NOMS database (Mullen & Schooling, 2010) for the weekly contact time and the percentage of students that advanced at least 1 unit for Sound Production, Language Comprehension, and Language Production. Each of these comparisons demonstrates that the INTEGRIS speech telepractice program matched or exceeded the reference standard; a greater proportion of children in the current study advanced at least 1 unit than in NOMS, and the average speech therapy time per week was less than what is reported in NOMS. Thus, the data demonstrate similar or greater efficiency of therapy time spent to achieve clinically meaningful advancements in treatment goals.
Table 4. Comparison of INTEGRIS Speech Telepractice With NOMS Database.
Comparison of INTEGRIS Speech Telepractice With NOMS Database.×
INTEGRIS Speech Telepractice INTEGRIS Speech Telepractice NOMS Database
Academic Year 2012–2013 Academic Year 2013–2014
Number of Students 324 254 14,852
Minutes Seen/Week 36.6 (average) 41.3 (average) 42–60 (76%)
Speech Sound Production
1+ level 87% 83% 74%
Spoken Language Comprehension
1+ level 81% 79% 56%
Spoken Language Production
1+ level 81% 67% 57%
Table 4. Comparison of INTEGRIS Speech Telepractice With NOMS Database.
Comparison of INTEGRIS Speech Telepractice With NOMS Database.×
INTEGRIS Speech Telepractice INTEGRIS Speech Telepractice NOMS Database
Academic Year 2012–2013 Academic Year 2013–2014
Number of Students 324 254 14,852
Minutes Seen/Week 36.6 (average) 41.3 (average) 42–60 (76%)
Speech Sound Production
1+ level 87% 83% 74%
Spoken Language Comprehension
1+ level 81% 79% 56%
Spoken Language Production
1+ level 81% 67% 57%
×
Discussion
The main new finding in the current study is that our speech telepractice services resulted in improved speech and language skills in Pre K–12th-grade students attending nine rural schools across the state of Oklahoma. We showed that the magnitude of improvement during both of the academic years examined matched or exceeded the progress reported for students that received onsite speech therapy in the Mullen and Schooling report (2010) .
Since we were unable to make a direct comparison between onsite and speech teletherapy services within the schools we serve, we compared our results to the NOMS database. The NOMS database for the K–12 scale was last updated in 2010, and consists of 14,852 K–12 students from 597 schools across 106 school districts within 37 states (Mullen & Schooling, 2010). Our speech telepractice students were seen for an average of 39 minutes per week with 46% seen for 40–60 minutes per week. In the NOMS database, the majority (74%) of students were seen for 42–60 minutes per week. As shown in Table 4, a higher percentage of students in the current study advanced at least 1 unit on the three most common FCM scales compared to the NOMS database, and the teletherapy time per week was less in the current study compared to the average reported in NOMS. Our results demonstrate that speech telepractice sessions are as time-efficient as onsite speech therapy for NOMS students. Therefore, treating students with communication, language, or articulation disabilities via teletherapy should not prevent those students and their teachers from addressing other learning needs and academic objectives within their classrooms.
Speech telepractice also enables students at their respective schools to receive speech therapy services, even when inclement weather or transportation barriers might prevent an onsite speech therapist with multiple school assignments from arriving for scheduled speech therapy visits. For example, rather than taking time and travel risks to see students at a distant site during a snowstorm, a connection can be made via teleconferencing safely in a matter of seconds. Since teletherapy sessions are on average shorter than average onsite sessions (as reported in the NOMS database) the amount of time a student spends away from their regular classroom instruction may also be reduced for students receiving speech therapy by teletherapy. Thus, the current study shows that teletherapy appears to be as clinically effective and efficient as onsite therapy.
Our findings are in agreement with the limited previous studies with school-aged children that directly compared speech teletherapy with onsite speech treatment. In 2010, Grogan-Johnson, Alvares, Rowan, and Creaghead  reported that four months of telespeech resulted in similar progress with 34 children who received speech therapy intervention onsite and via telepractice. These authors also reported that parents and students completed surveys that confirmed they were very satisfied with speech therapy delivered via telepractice. Likewise, a study conducted in Australia indicated that CELF-4 assessment scores improved by a similar magnitude for students treated by telepractice or onsite for 25 students aged 5–9 (Waite, Theodoros, Russell, & Cahill, 2010). More recently, Grogan-Johnson et al. (2013)  found that teletherapy was as effective as onsite therapy for 14 students aged 6–10 in a 5-week summer program focused on speech sound improvement. These prior studies had fewer students or were conducted for a shorter duration than the current study, but the effectiveness of speech telepractice has been consistent in both assessment and intervention.
In our experience, satisfaction with the clinical outcomes and practical implementation of speech telepractice has been mostly favorable. However, occasional technology disruptions may occur due to disconnections or breakdowns with technology. In our practice, the most common technology challenge has been packet losses (when only part of the video stream reaches its destination) over the Internet between the hub site in Oklahoma City and the school sites. Packet losses present as a blurry or pixelated picture, or in worst case, a complete termination of the video call. In our experience, the best approach for preventing packet loss is to use a dedicated connection, as is used for a T1 for video conference. Unfortunately, this may not be possible for some rural schools that lack financial resources for costlier connectivity and increased bandwidth. In an effort to overcome the packet losses, it is paramount that a strong relationship exists between the speech telepractice professional, information technology professional at the hub site, and the school-based clinical and technology professionals. The team should share the goal of proactively performing service and maintenance checks on the telemedicine equipment and transmission lines and addressing needs quickly as they arise.
Secondly, some parents or staff members may be reluctant to utilize new technology and different delivery methods to address the speech and language needs of the students. To overcome these concerns, the speech telepractice providers should provide early comprehensive and ongoing education, and share evidence for program success to all stakeholders, including the school administrators, special education staff, teachers, paraprofessionals, students, and parents. In some cases, speech telepractice is the only viable option when schools can't recruit onsite speech pathologists, or have more students than their onsite therapists can accommodate. Without using speech telepractice and the teleconferencing equipment that connects the students to the speech therapist, students may go without speech services for prolonged periods, which may have long-term detrimental impact on their speech language development and education. Since speech telepractice providers are not present onsite at the school, an ongoing and concerted effort needs to be made to stay in close communication with the school staff by e-mail, telephone, or using the telemedicine technology system to respond to needs as they arise at the school setting. A well-trained speech para-professional can also serve as a liaison and proactively advocate for the students' needs and concerns.
Conclusion
Clinical outcomes from our INTEGRIS speech telepractice program demonstrate that speech telepractice is at least equivalent in effectiveness and efficiency as traditional onsite speech therapy. Students served via two-way interactive telecommunication technology improved their speech and language skills while spending less time out of the classroom, which demonstrates speech telepractice sessions are efficient and allow students with communication difficulties and their teachers to address other learning needs and academic objectives. For schools that are unable to recruit and/or retain SLPs, this modality of speech therapy allows students to receive speech therapy regardless of inclement weather or transportation barriers. Outcomes from the speech telepractice program overall have been well received by parents, teachers, and students.
As requested, the clinical outcome data for the 2012–2013 academic year was submitted to the OHCA in the summer of 2013 for consideration of making regulatory revisions. Those revisions, had they been accepted at that time, would have enabled Oklahoma schools to receive Medicaid reimbursement for speech telepractice services beginning in the 2014–2015 academic year. Unfortunately, OHCA took no action for that academic year. A follow-up report with additional clinical outcome data for the 2013–2014 academic year, similar to what is presented in the current report, was submitted to OCHA in the summer of 2014. In February 2015, the OHCA released a proposed revised policy to expand the scope of telemedicine for all disciplines, including speech language pathology. The proposed permanent rule change was presented to the Medical Advisory Committee and the Board of Directors in March of 2015. The rules have been approved and went into law September 2015, and will be the first step in the process of allowing schools to bill professional fees to the OHCA for speech telepractice. This rule change will apply to both rural and urban schools. We anticipate that the clinical outcome data in the current study will help support policy changes for speech telepractice reimbursement for other Medicaid offices in other states, the Centers for Medicare and Medicaid Services (CMS), and private insurers across the United States.
Acknowledgements
The authors thank the speech telepractice students, para-professionals, and school administrators from the 2012–2013 and 2013–2014 academic years from participating Oklahoma public schools in Cottonwood, Felt, Forgan, Guymon, Haywood, Keyes, Tyrone, Vinita, and Wyandotte.
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U.S. Department of Education Office of Postsecondary Education. (2015, March). Teacher shortage areas nationwide listing 1990-1991 through 2015-2016. Retrieved from http://www2.ed.gov/about/offices/list/ope/pol/tsa.doc ×
Waite, M., Theodoros, D., Russell, T., & Cahill, L. (2010). Internet based telehealth assessment of language using the CELF-4. Language, Speech, and Hearing Services in Schools, 41, 445–448. [Article]
Waite, M., Theodoros, D., Russell, T., & Cahill, L. (2010). Internet based telehealth assessment of language using the CELF-4. Language, Speech, and Hearing Services in Schools, 41, 445–448. [Article] ×
Figure 1.

Distribution of Students by Educational Grade in School.

 Distribution of Students by Educational Grade in School.
Figure 1.

Distribution of Students by Educational Grade in School.

×
Table 1. Speech Sound Production FCMs Score Criteria (paraphrased).
Speech Sound Production FCMs Score Criteria (paraphrased).×
Level 1 Student is not producing speech sound(s) correctly and is distracting to the listener with no awareness of errors.
Level 2 With maximum cues, student can produce speech sounds correctly in words and rarely aware of errors.
Level 3 Student occasionally aware of errors and occasionally spontaneously produces sound correctly in words.
Level 4 Student is usually aware of the error and can produce the sound in sentences with minimal cues. Rarely self-corrects.
Level 5 Student is aware of errors and can occasionally self-correct. Student can produce sound with minimal cues in structured conversation.
Level 6 Student monitors speech and self-corrects in conversation. Speech is rarely distracting to the listener.
Level 7 Student's speech is not distracting to the listener. Student consistently monitors and self corrects without limits in conversation.
Source. National outcomes measurement system (NOMS): K12 speech-language pathology user's guide (ASHA, 2003).
Source. National outcomes measurement system (NOMS): K12 speech-language pathology user's guide (ASHA, 2003).×
Table 1. Speech Sound Production FCMs Score Criteria (paraphrased).
Speech Sound Production FCMs Score Criteria (paraphrased).×
Level 1 Student is not producing speech sound(s) correctly and is distracting to the listener with no awareness of errors.
Level 2 With maximum cues, student can produce speech sounds correctly in words and rarely aware of errors.
Level 3 Student occasionally aware of errors and occasionally spontaneously produces sound correctly in words.
Level 4 Student is usually aware of the error and can produce the sound in sentences with minimal cues. Rarely self-corrects.
Level 5 Student is aware of errors and can occasionally self-correct. Student can produce sound with minimal cues in structured conversation.
Level 6 Student monitors speech and self-corrects in conversation. Speech is rarely distracting to the listener.
Level 7 Student's speech is not distracting to the listener. Student consistently monitors and self corrects without limits in conversation.
Source. National outcomes measurement system (NOMS): K12 speech-language pathology user's guide (ASHA, 2003).
Source. National outcomes measurement system (NOMS): K12 speech-language pathology user's guide (ASHA, 2003).×
×
Table 2. Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2012–2013 Academic Year.
Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2012–2013 Academic Year.×
Outcome [N=324 ] Initial score (range) Final score (range) P-value % of students improving 1 unit % of students improving ≥ 2 units
Fluency [4] 4.3 ± 1.3 5.5 ± 1.7 0.141 50 25
(3–6) (4–7)
Intelligibility [47] 2.4 ± 1.3 3.5 ± 1.5 <0.001 36 34
(1–6) (1–7)
Pragmatics [21] 2.7 ± 1.6 3.4 ± 1.9 <0.001 71 10
(1–6) (1–7)
Speech Sound Production [174] 2.3 ± 1.5 3.8 ± 1.8 <0.001 36 51
(1–6) (1–7)
Language Comprehension [150] 3.3 ± 1.5 4.3 ± 1.7 <0.001 60 21
(1–7) (1–7)
Language Production [175] 3.1 ± 1.4 4.1 ± 1.7 <0.001 63 18
(1–6) (1–7)
Voice [2] 4.5 ± 0.7 5.0 ± 1.4 0.500 50 0
(4–5) (4–6)
Note. The number of students that were scored for each Functional Communication Measures (FCMs) scale is shown in square brackets in the first column.
Note. The number of students that were scored for each Functional Communication Measures (FCMs) scale is shown in square brackets in the first column.×
Table 2. Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2012–2013 Academic Year.
Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2012–2013 Academic Year.×
Outcome [N=324 ] Initial score (range) Final score (range) P-value % of students improving 1 unit % of students improving ≥ 2 units
Fluency [4] 4.3 ± 1.3 5.5 ± 1.7 0.141 50 25
(3–6) (4–7)
Intelligibility [47] 2.4 ± 1.3 3.5 ± 1.5 <0.001 36 34
(1–6) (1–7)
Pragmatics [21] 2.7 ± 1.6 3.4 ± 1.9 <0.001 71 10
(1–6) (1–7)
Speech Sound Production [174] 2.3 ± 1.5 3.8 ± 1.8 <0.001 36 51
(1–6) (1–7)
Language Comprehension [150] 3.3 ± 1.5 4.3 ± 1.7 <0.001 60 21
(1–7) (1–7)
Language Production [175] 3.1 ± 1.4 4.1 ± 1.7 <0.001 63 18
(1–6) (1–7)
Voice [2] 4.5 ± 0.7 5.0 ± 1.4 0.500 50 0
(4–5) (4–6)
Note. The number of students that were scored for each Functional Communication Measures (FCMs) scale is shown in square brackets in the first column.
Note. The number of students that were scored for each Functional Communication Measures (FCMs) scale is shown in square brackets in the first column.×
×
Table 3. Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2013–2014 Academic Year.
Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2013–2014 Academic Year.×
Outcome [N=254 ] Initial score (range) Final score (range) P-value %of students improving 1 unit % of students improving ≥ 2 units
Fluency [1] 3.0 ± 0.0 4.0 ± 0.0 n/a 100 0
(3) (4–4)
Intelligibility [39] 2.5 ± 0.2 4.3 ± 0.2 <0.001 46 38
(1–6) (1–7)
Pragmatics [13] 2.4 ± 0.4 3.4 ± 0.5 0.004 54 15
(1–5) (1–7)
Speech Sound Production [139] 2.4 ± 0.1 4.2 ± 0.2 <0.001 28 55
(1–6) (1–7)
Language Comprehension [110] 3.3 ± 0.1 4.5 ± 0.2 <0.001 50 29
(1–6) (1–7)
Language Production [133] 3.1 ± 0.1 4.2 ± 0.2 <0.001 41 26
(1–6) (1–7)
Voice [2] 4.0 ± 1.0 5.0 ± 2.0 0.500 0 50
(3–5) (3–7)
Table 3. Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2013–2014 Academic Year.
Scores for INTEGRIS Health Speech Telepractice Outcomes During the 2013–2014 Academic Year.×
Outcome [N=254 ] Initial score (range) Final score (range) P-value %of students improving 1 unit % of students improving ≥ 2 units
Fluency [1] 3.0 ± 0.0 4.0 ± 0.0 n/a 100 0
(3) (4–4)
Intelligibility [39] 2.5 ± 0.2 4.3 ± 0.2 <0.001 46 38
(1–6) (1–7)
Pragmatics [13] 2.4 ± 0.4 3.4 ± 0.5 0.004 54 15
(1–5) (1–7)
Speech Sound Production [139] 2.4 ± 0.1 4.2 ± 0.2 <0.001 28 55
(1–6) (1–7)
Language Comprehension [110] 3.3 ± 0.1 4.5 ± 0.2 <0.001 50 29
(1–6) (1–7)
Language Production [133] 3.1 ± 0.1 4.2 ± 0.2 <0.001 41 26
(1–6) (1–7)
Voice [2] 4.0 ± 1.0 5.0 ± 2.0 0.500 0 50
(3–5) (3–7)
×
Table 4. Comparison of INTEGRIS Speech Telepractice With NOMS Database.
Comparison of INTEGRIS Speech Telepractice With NOMS Database.×
INTEGRIS Speech Telepractice INTEGRIS Speech Telepractice NOMS Database
Academic Year 2012–2013 Academic Year 2013–2014
Number of Students 324 254 14,852
Minutes Seen/Week 36.6 (average) 41.3 (average) 42–60 (76%)
Speech Sound Production
1+ level 87% 83% 74%
Spoken Language Comprehension
1+ level 81% 79% 56%
Spoken Language Production
1+ level 81% 67% 57%
Table 4. Comparison of INTEGRIS Speech Telepractice With NOMS Database.
Comparison of INTEGRIS Speech Telepractice With NOMS Database.×
INTEGRIS Speech Telepractice INTEGRIS Speech Telepractice NOMS Database
Academic Year 2012–2013 Academic Year 2013–2014
Number of Students 324 254 14,852
Minutes Seen/Week 36.6 (average) 41.3 (average) 42–60 (76%)
Speech Sound Production
1+ level 87% 83% 74%
Spoken Language Comprehension
1+ level 81% 79% 56%
Spoken Language Production
1+ level 81% 67% 57%
×
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