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OTS 56: Telehealth Guidance, Practice, & Research

Updated: Jun 28


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Welcome to the show notes for the Episode 56 of the OT Schoolhouse Podcast.


In this episode of the OT Schoolhouse Podcast, I share guidance, research and practical strategies related to providing telehealth occupational therapy services as a School-Based OT. We will look specifically at AOTAs guidance on telehealth, state laws to be mindful of, and the considerations to be mindful of when providing OT services via a teletherapy model. I also provide a few of my favorite teletherapy treatment ideas and how I have been adapting them. This is the first in a 2-part series on teletherapy.


View the second episode in this teletherapy series at otschoolhouse.com/episode57


Earn a certificate for 2 hours of professional development by listening to episode 56 & 57 and purchasing the Professional Development Podcast Course!

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Episode 56 of the OT Schoolhouse Podcast is sponsored by Learn Play Thrive

View the free Learn Play Thrive webinar by clicking the image below

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Be sure to subscribe to the OT Schoolhouse email list & get access to our free downloads of Gray-Space paper and the Occupational Profile for school-based OTs.


Have any questions or comments about the podcast? Email Jayson at Jayson@otschoolhouse.com

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Thanks for visiting the show notes for Episode 56! If you enjoyed this episode be sure to subscribe on Apple Podcasts, Google Podcast, Spotify, or wherever you listen to podcasts



Episode Transcript


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Jayson Davies   

Hello, my favorite, OTPs. Before we dive into today's content for the podcast, I want to share with you an up and coming podcast from a previous guest of the OT school house podcast, Meg proctor hosts the two sides of the spectrum podcast where she interviews researchers, OTs and people on the spectrum. The two sides of the spectrum podcast is changing ot practice to reflect new research and to help us shift our perspective so that we can better understand and serve our neurodiverse students. You can find the two sides of the spectrum, podcast wherever you get your podcast, or at learn, play, thrive, slash podcast. Now let's Cue the intro. 

 

Amazing Narrator   

Hello and welcome to the OT school house podcast, your source for school based occupational therapy, tips, interviews and professional development. Now to get the conversation started, here is your host, Jayson Davies, class is officially in session.  

 

Jayson Davies   

Hey everyone, and welcome to episode 56 of the OT school house podcast. My name is Jayson Davies, and I am so excited to be here with you today, wherever you're listening. Just I really appreciate you being here, and I'm so happy to be with you in your ears today. All right, okay, that just sounded really weird that I said to be in your ear today. Anyways, we're gonna continue on. I'm just excited for today. Today is probably the podcast that has been most requested over the last weeks, if not months, and that is teletherapy. Today is the first of a two part series all about teletherapy. And today we're going to dive into the guidance of teletherapy, as far as like what a ot A says, as well as a few others, we're going to dive into the actual practice of the therapy sessions. And then I also have a few pieces of research to share with you today in Episode 57 which will be coming up here in two weeks, I will be moving into more of the actual evaluation side of teletherapy, and we'll also talk about some ethical considerations regarding teletherapy. This two part series on telehealth will be available for purchase at ot schoolhouse.com, forward slash podcast, and just a reminder, because it's been a little while since I made one of these episodes a professional development opportunity. When you purchase a podcast professional development opportunity, you will receive a opportunity to take a quiz and earn a certificate of completion for listening to these two episodes, that certificate of completion can then be used for your mbco T certification and potentially your state licensure, depending on your state regulations for this particular podcast, teletherapy professional development opportunity, you will also receive the PowerPoint presentation that I have put together that goes along with the podcast episodes. To learn more about that, you can head on over to OT schoolhouse.com/episode 56 All right, so let's go ahead and dive into the content. Just a reminder, we are talking about teletherapy as it pertains to school based occupational therapy. I want to start off by saying, I'm probably going to be intermixing the terminology telehealth and teletherapy in this podcast. I'm going to use those terminologies interchangeably and to mean the same thing, which is basically the way that a ot a identifies the term telehealth. A ot a defines telehealth as the application of evaluative, consultative, preventative and therapeutic services delivered through information and communication technology, also known as ICT, that is information and communication technology. So like I said, I'm going to use telehealth and teletherapy interchangeably, even though teletherapy may more just be the actual therapy provision, where telehealth takes on the evaluation, consultative and preventative means in order to provide occupational therapy services. That definition that I just reviewed actually comes from the A ot a position paper, telehealth in occupational therapy from 2018 in that article, a ot also mentions that ot occupational therapy can be provided in both synchronous and an asynchronous model. We're going to talk a little bit about that later, but for now, just know that asynchronous is what we think of, such as like an email, where I send you an email now and you respond to it later. Versus synchronous is more what we think about when we're on a zoom call that what I'm doing you are seen in or very close to real time and responding to in real time within the position paper, a, OT, a also makes it very clear that they feel occupational therapy providers can make achievable outcomes with clients in every area that they can when providing traditional in person services, a, ot A does not explicitly mention pandemics as being a reason for teletherapy to be used widely, but they do note that teletherapy will allow clients. To access the necessary services in sub optimal conditions, such as in rural areas or when a client is unable to go to occupational therapy services during normal business hours. That might be a prime example for when an asynchronous model may be used, such as you might create a video or some form of text to send to the client, and then later at night, when they have an opportunity, they could then follow the routine that you gave them, or whatever else you might have provided, and then might send you back some feedback on how that went. Therefore you can then make changes and send something back to them. So that's a little bit about what a ot a things. Now, let's talk a little bit about at the state level. What do we need to know at the state level when it comes to providing occupational therapy services in a telehealth model, we need to start by understanding that regulations vary from state to state, so you need to be sure to check your state's board of occupational therapy for guidance on what is and is not allowed in your state regarding teletherapy. If you don't see anything on your state board of occupational therapy website about teletherapy, your best option is to probably call them or email them and ask for some guidance and ask, Am I allowed to provide teletherapy services within the state of whatever state you're in, that's probably going to be the easiest and most direct answer you will receive, unless they do, of course, have a website that talks about teletherapy and what you can and cannot do. Fortunately, by the time that this podcast is coming out in September, more than likely, your state has developed some form of guidelines for teletherapy, even if they may be temporary due to the current pandemic going on right now. One issue that has risen out of everything going on right now is the need for occupational therapy providers to provide services to students in another state or clients in another state. Currently, if you want to provide services to a client that is in a state that is not your own or not that you are actually practicing from, then you might need to be licensed in both that state as well as the state that the student is in or that the client is in. Currently, a ot A is working with state licensing boards to work on what is called a licensure compact, which may prevent this from being needed in the future. You might be okay if you have a California license to provide services to a student in another state, but at this time, that has not gone through yet, and so you need to be sure to check with the board of the occupational therapy board that you live within, as well as the board of the state that the client is in to see if it is okay for you to to be providing services for that student. This has become, actually a fairly common issue with schools being closed. Occupational Therapy providers may be providing services outside of the state that they usually live in. Maybe they're living at a long term Airbnb, or they're living with their parents that's in another state than the school district that they provide services to. Or maybe the student has moved because, for the same reason, because they don't have to go to school every day, so they're living with grandma and grandpa in the state next door as a way to continue to be on computer, because they have a guardian there with grandma and grandpa, but they're no longer in that state that they usually receive your services in, that is a circumstance where you probably need to address the boards and ask for guidance. Be careful with just asking your district, because your district may not understand occupational therapy, like they so often do not they. They are not the ones looking at the Board of occupational therapy to see if you can provide these services. They're looking at the board, or, sorry, not the board, the Department of Education, and seeing what they say, but sometimes the Boards of Education and the Department of occupational therapy, or board of occupational therapy, they don't always talk to each other, and so we have to work both under the guidance of the district and the Department of Education, but also the board of occupational therapy, who provides us with our license, another factor that You are going to need to check in on with your board of occupational therapy is the permission required from the client or the parent in order to provide therapy services. Now, again, in the case that we're currently in, this isn't a huge issue, because everyone wants some form of therapy, and they're likely to accept teletherapy if they can't receive typical therapy because the schools are just closed down, but you still need to check with your board to see what is needed. In regards to permission to provide teletherapy services. In California, we need permission to do that, but it's very general. It doesn't say there must be written permission. And it doesn't say you need to check in with the parent or the client at the beginning of every therapy service to get permission. It's very general. We just need permission. And so for me, I have gotten email permission from all of my students or all of the parents, and I'm working with that, along with them signing on to my zoom or Google room, that's also kind of giving permission, right? But in some states, that's not the case. It's very specific on exactly what type of permission is required before you can provide those teletherapy services you might need at the beginning of every single session to ask the parent, do you comply, or do you agree to this teletherapy session you might need in writing and with the signature in the child's documentation or the child's folder at the school site that the parent has given permission for that to occur. So be sure again, I would just put together an email template and just send this to the states that you work in and you have these specific questions, do you need permission in order to provide services. Can you provide services? And what if my student is living in another state? Potentially, the last state specific item that I have here regarding occupational therapy services in the school is reimbursement, and in the schools, typically reimbursement from Medicaid is a supplemental, not deposit, but it's a supplemental income for the district they are receiving state and federal funds, and the ability to build Medicaid is supplemental to that, and goes straight back into special education, which is awesome, But unfortunately, not all states will allow occupational therapy providers, in specific, the ability to bill for teletherapy services. Now this is changing, probably on a week to week basis, as this COVID 19 pandemic continues to go on. I know several states have already made the change and are now billing for teletherapy services, and some states might bill for individual teletherapy services, but not group teletherapy services. They might bill for evaluations over a teletherapy model, but not treatments over a teletherapy model. This is very unique state to state, and to be honest, what we're doing is we're just billing for everything, and we are letting the program that we use, the district contractors that we use, to weed out what is and what is not billable. It doesn't change the system that we're going to put into place. We're still going to provide services whether it's billable or not. And so we're just doing the best that we can and allowing the contractor on the other side to basically submit what's billable and not submit what is not billable. If your district happens to be a little bit smaller, and maybe they don't have a contractor that does the billing for them, and maybe they do rely on you to be taking on that initiative, I would definitely let your director know, or your coordinator know whoever you need to work with and let them know that you're not sure of these regulations and that you need to talk to someone so that you know what is worth your time to be billing. If no teletherapy is really billable, then is it really worth your time to be doing it? I know with insurance and with Medicaid, sometimes it's better to do the work now, because in the future, they may go back and say, Oh yeah, teletherapy services is back, or as far back as maybe 2019 are now billable, and we will give all the the schools money for the services that they build back then. So that might be a reason to continue billing. But again, you you should probably talk to your director and see what is billable, what is not billable, and if they don't know, then the district probably needs to get outside support from someone to look that up for them. All right. All right. So now I want to jump into the ethical decision making process when it comes to determining when to or when not to provide occupational therapy services over a telehealth model. Now, things are a little more black and white right now, because it's either a for many people, at least a receive occupational therapy services via a telehealth model, or don't receive occupational therapy services at all because the school is closed or B schools open, so we're going to provide ot services on campus and not provide virtual ot services or teletherapy services. That's pretty black and white. But what about when that's not the case? And maybe you are given the option to provide distance teletherapy services or on campus services. That might be the case when we go hybrid. If that, if your district is going hybrid, are you getting the option to either a see kids when they're on campus, or B do a distance learning program? We're not at the hybrid model, so I'm not quite sure about that yet. But what if that's the case? How do you decide what students can get a. Occupational Therapy Services through a teletherapy model, and which ones is that not appropriate for in general, we need to weigh the pros and the cons for teletherapy When making this decision. Like I said, things are a little bit more black and white right now, but when things open up, it might be a little bit different right now. As I'm saying this, I can think of those kids that are on my caseload that are just barely benefiting, if benefiting at all, from this teletherapy service model. And I just really want to bring those kids on campus, and hopefully those will be the first kids that we can bring back on to campus for services. Right now, California is in the works of putting together guidelines to bring some of our special education students who have high needs back on campus, and I'm sure other services, or, sorry, not other services. I'm sure other states are looking into similar opportunities. But I want to challenge you to kind of think about which students can and which students will probably not benefit from teletherapy services, and maybe need to be the first students to come back on campus. And maybe it's not just about the student's ability to attend to the to the computer screen for services, but also we need to consider the parent and family circumstances. Which of your families have the ability to be there when it's time for teletherapy services. Are your parents able to be there? Or is an older brother or sister able to be there during teletherapy? Maybe it's grandma or grandpa, but for many of our students, everyone's gone back to work, and now maybe it's the 12 year old sister at home alone with the five year old brother or whatnot, and you're trying to provide services for that five year old brother while that 12 year old sister is trying to attend to her what is that? Maybe seventh grade math lesson or whatnot. And that's not fair. That is not optimal, and it's very likely that the student is not going to benefit from occupational therapy services when there's no one there to help be your eyes and ears and hands. So if you're given the opportunity to potentially help the special education teachers decide which students to put into what cohort or for which students to come back first from distance learning back onto campus, definitely consider what's going on in the family. What did you and the special education teacher learn about the family, about the home circumstances for Student A versus Student B, back in the spring when we were all doing this, what students need to be on campus to truly benefit from their education? Those probably are the students that need to be back on campus the most. All right, so we're going to take a quick break right here, but when we come back, we're going to talk about a few different types of teletherapy models. But right now, I'd like to introduce you to my friend, Meg proctor from learn, play thrive. Hi. Meg.  

 

Meg Proctor   

Hey, Jayson. 

 

Jayson Davies   

Hey and welcome and thank you for joining us. I really appreciated all the content in your learn, play Thrive approach to autism. Course.  

 

Meg Proctor   

Yes, it was so much fun having you in the course. I actually have a new free 45 minute master class that I think your listeners will love. It's called autism specific strategies that transform ot practice. 

 

Jayson Davies   

That sounds great. Tell me more about it. 

 

Meg Proctor   

Well, even though the training is only 45 minutes, it goes really deep. I talk about why so many OTs are floundering in their work with students on the spectrum. Then I go over in detail the latest research on how kids on the spectrum think and learn. Finally, I teach really specific strategies that we can use right away to generate more meaningful and effective interventions. 

 

Jayson Davies   

From my experience. In your course, you always have fantastic research, so that sounds super exciting. 

 

Meg Proctor   

Yeah, you know, my goal is to really help therapists feel more confident and effective in their work, and also to empower more therapists to help our clients find joy, independence, connection and acceptance in their lives. This free training is a great place to start for both new and experienced therapists. 

 

Jayson Davies   

Awesome. Where can people learn more about this master class?  

 

Meg Proctor   

Well, they can check out, learn, play, thrive.com/masterclass. To start the free training right away. 

 

Jayson Davies   

Awesome. Thank you for that. And anyone interested in learning more about this can either use that link, or you can head on over to OT schoolhouse.com, forward slash episode 56 to learn more about the course. Thanks again, Meg, and we will catch up with you later. Thanks, Jayson, All right, welcome back. So before we jump into the three different types of teletherapy options that I really want to talk about today. I first want to briefly address a research article, and that is an article by Daniel wartveld and Karen Jacobs. I once had the chance to meet Karen Jacobs, actually, since the pandemic came about, it was actually a group of podcasters that had met together, and she happened to be on that Zoom. Call, and I briefly got to talk to her, but just from that short interaction, I can tell she is just very energetic and loves occupational therapy, and so I was happy to see this article from her. All right. Before I continue talking about it, let me make sure I get this title right. The article was titled perspectives of the use of telehealth service delivery model as a component of school based occupational therapy practice designing a user experience. Titles always tend to be long, but there's a reason for that. In this article, and they published it in 2018 I believe the research was actually in 2017 they interviewed more than two dozen occupational therapy practitioners on their perspectives related to telehealth or teletherapy. As a result of this article, some of the respondents actually reported some key benefits, being logistics, MTSS and classroom observations, support for homebound students, and collaboration, consultation and supervision. All of those were perceived as benefits. Let me explain just a little bit. First, you have logistics. They thought maybe with the idea of telehealth, it would mean less traveling for the for the therapist, maybe a better use of the therapist time because of that, less traveling, also because information could be delivered more quickly. Then maybe you could see more students in a day. They also perceived it as that they may be able to get more information out to more people more quickly, which that's a huge benefit, really. I mean, this is kind of nice about a podcast, right? I'm able to get a lot of information out to a lot of people relatively quickly, and that's all through the help of well, not teletherapy, but technology therapists also believe that telehealth, or teletherapy could be beneficial when it comes to the MTS, S and classroom observation side of occupational therapy within the schools, and they felt that because they thought it would be beneficial to to have parents and teachers understand more about occupational therapy, and they could do that through maybe recorded, recorded modules or something where parents and teachers could then better understand occupational therapy and could then help the kids that they work with. And that leads right into the whole collaboration, consultation and supervision benefit that could potentially be there with telehealth, you are only ever a zoom call away, or whatever program you're using. And so talking to a teacher, talking to a parent, is really simple. You don't have to physically walk across campus or drive across an entire district, right? And then also the supervision idea of it, it sounds like therapists really liked the idea of being able to supervise a therapist over a Google meet or Zoom call. The same thing was actually said for mentoring new occupational therapists. And I can't agree with that more zoom Google meets, Microsoft Teams, whatever it might be FaceTime, or whatever they call FaceTime for Google on Google phones, I don't know, but yeah, that is all a fantastic way to help more people in a quicker and easier format. I mean, people can mentor people across the state, let alone across a district or in the same same school. So that's really, really a great benefit of telehealth and teletherapy, all right. So whenever there are benefits, there are also typically some barriers. And so some of the barriers that were found as a result of still this same article, are logistics. And if you remember right, we had some logistics as a perceived benefit, but now we're going to talk about some of the logistics as a perceived concern. Also a lack of physical content was also considered a barrier. There were student factors, and I'll go over those in just a second. And then there are also just general concerns with evaluations as a whole. A few other perceived barriers that I will also go over, but those were the big ones. First, let's go ahead and talk about logistical barriers. Two of the highlighted logistical barriers included the lack of training related to telehealth for the occupational therapy providers. And yeah, I can imagine that was a huge logistical concern in 2017 and it still is today. You know, granted, we all have about three months of teletherapy now under our belt, even though we weren't planning for it. So things are a little bit better, maybe, but I still know that a lot of people are asking for teletherapy help, so there's still a need for training. As far as I'm seeing, we'll get more into that in a moment. But the other logistical concern was also about students being supervised wherever they are, and that is going to probably always be a concern. You know, we can't physically be there if we're doing or for providing teletherapy. Services, and we need to make sure that that student is safe, that that student is not in any sort of danger, that the student is not running away from the computer, right? Are they actually participating in therapy? So the ability to have someone supervising the student is definitely a key factor. And remember, this article was looking at the school based realm. So they're looking at, potentially, the supervision of a student within the school based realm. I can talk from my experiences, typically, when a student was was being provided a teletherapy service of some form, whether it was OT or speech, there had to be an aide in the room with the with the student. And that is not only a logistical concern about how that's going to happen, but that's also a financial concern for the district, because now they're not only paying for the therapist, but they are also paying for that aid that's going to be with the student. Just something to keep in mind. The next perceived barrier to discuss is that of student factors, and we're going to talk a little bit more about ethics next time in part two of this teletherapy series, we got going on here, but really quickly, there was a perceived barrier about student factors such as cognitive ability or behavioral concerns, and how that might play a role into teletherapy being effective. And you know, if it takes a lot of communication skills in order, at least that's what I'm learning, that it takes a lot of communication skills when you are working via teletherapy, you need to be able to communicate exactly what you're thinking, exactly what you want the student to do, as well as exactly what you want the parent to do, or whoever is working with the student on the other end of the screen. And so there's a lot of factors that go into teletherapy, including those student factors that we need to weigh when we're trying to decide if teletherapy will be an effective means for providing therapy services to this child, I think right along with that goes what is also an article lack of physical contact as a perceived barrier. As occupational therapists, we tend to provide not just visual and verbal prompts, but also maybe a slight physical prompt to a wrist or a slight physical prompt to some hands or two fingers or whatever that might be during a treatment activity. And so without that ability to have physical contact with the student and guide them in the in the way to whatever it might be, if you're working on Crossing midline or whatnot, you You lack that ability when you are in this teletherapy space, which just kind of goes back to what we were just discussing communication and how key that is. I mean, I was just working today with a student on some crossing midline, and one of the ways that I had to describe, describe to this student was, all right, I want you to touch the wall on this side of you, and then on this side of you, tap your mom's shoulder. And I mean, I've never had to use that ever in my therapy career, reach across, touch the wall, reach back and touch mom's shoulder. And that was just like a little warm up physical activity. And so imagine how much more complex that can be if you're getting into a real occupation of of writing, of using scissors, whatever it might be, in the classroom, getting organized. There's so much, I think there's a lot more physical contact than we actually realize in our jobs. And I think communication. There's more communication in our job as well, and when you add a third party involved that you have to communicate. I mean, whether it's the teacher or a parent or someone, it's just difficult, and you really have to be mindful of how you are speaking, and not only how, but who you're giving the direction to, to the parent or to the student. In that instance, of course, you can't really talk about teletherapy without there being some form of privacy concern. And that was also brought up in this article, of course, you know, back in March and May, the first thing that kind of popped up was zoom bombing and people getting into zoom calls. And you know what? There's always going to be people out there finding a way to get into a place that they shouldn't be that's going to be there. I think that as time goes on, you know, we're going to minimize that. And I think there's also a weighing of the cons and benefits, you know, is it worth the potential risk of someone bombing a zoom call to have therapy week after week after week. You know, if you just got to weigh those pros and cons, I think the idea of having weekly therapy outweighs the risk of potentially having someone sneak into a room. And you know, a lot of times that ends up actually being user air and zoom as well. The other platforms have gone a long way in fixing that by making sure that there's a password enabled, by making sure that wait lists are turned on or waiting rooms are turned on so that you know who's in your room before you actually let them into your room. So I think we're coming a long ways in that, but I understand that privacy is always going to be a concern, and then the last one on here that I really wanted to discuss was evaluations. Now I'm just putting it in in this segment, because it was a perceived concern. One of the things that is on the concerns list, but not on the potential benefits, is that evaluations. There was no potential benefit for evaluations. It is here under the barriers people. I mean when I say people, I mean occupational therapy providers are concerned about evaluations through teletherapy means. And I didn't really need this article to tell me this. You guys are telling me this in your emails that you sent to me, so I get it. Evaluations are definitely a concern to many of you, it is to me as well. So we'll talk more about that in the next episode. But today we're going to focus on the actual treatment within teletherapy. Okay? So we're going to talk about asynchronous, synchronous and the ability to provide consultations and collaborations. So I think the best way to start talking about the different models, different locations, if you want to call them or temporal spaces within teletherapy, and the different aspects that we have to consider when it comes to teletherapy. Therapy Services, first we got to talk about the traditional services when we are on campus. What are we looking at when we are deciding what type of services a student needs. If you've taken the A to Z school based ot course, or maybe if you've listened to some of the previous episodes of the OT school house podcast, then you know that there's three main areas that we look at, and that is the location of services, the model of services, and the frequency of services. But when it comes to providing teletherapy services, we have to add one more, and that is the temporal aspect of services when it comes to helping our students. What I mean by temporal aspect is that asynchronous versus synchronous aspect, whether or not we are providing the service, live with the child on the other end of a zoom call or a Google meet call, and they can see us and we can see them in live time, or via an asynchronous temporal model, in the sense that we are creating a video, or we are putting together an email that we're sending to the parent, and then the parent is doing that activity with the student at a later time. That's what I'm talking about when I talk about asynchronous model. All right, not to be confused with in synchronous model. That's a that's an NSYNC bye bye bye song. But now I want to dive into each of those aspects. Like I said, there's three original aspects, but we're adding that fourth temporal aspect when it comes to developing the type of services that our student needs. So let's first look at the location of occupational therapy services in a teletherapy model. If you're working in a full teletherapy model right now, because your district is completely on distance learning mode, then this is pretty straightforward. There's not much control you have over this. The location is the student's home, or wherever they might be receiving services. It might be the daycare. It might be, I don't know, at Grandma's house, and your location is either a somewhere in your school district, in a lonely office all by yourself, or maybe it's your desk at your home office, when we're at school and when everyone's at school, I should say, we often consider whether or not a a session would be best inside the classroom or inside our OT room or hallway or closet, wherever that might be. But when it comes to teletherapy, there is one location. Now I'll talk a little bit about whether or not a service can be in a quote, unquote classroom as far as like a Zoom Room or in their Google meet classroom. I'll talk more about that when we get to model. But as far as location, there's not a lot of options. So that does bring us to the model, the delivery service model, and how we are going to provide that service. So let's go ahead and talk about that. Now, I have four models listed here that we would use traditionally, and these same four models can be used in a teletherapy model that is individual services, group services, collaborative services and consultative services. So let's go ahead and start with, I think, one that most of you are most commonly using and most frequently, most frequently writing on IEPs, and that is individual services. Individual services are probably the most likely to occur during this teletherapy model, because it is just easier. Honestly, you are there on the computer screen. It's just you and it's just the student and hopefully the student's parent. It's simple. There's less distractions. There's not five different faces on the screen. It is you and the student. So. You can be over Google meets, it can be over zoom it can be over Microsoft Teams, whatever it might be. But that is probably the way that most people are doing teletherapy right now, just because of its ease. And you can just simply transition from seeing a student in a direct model in the schools to a direct individual model via teletherapy. The next model would be in a group. And now there's a few different ways to provide a group. You can provide a group within a classroom, or you can provide a group outside of a classroom. And that still holds true when it comes to teletherapy, you can either push into that preschool classroom and provide a group for all the students in there. It's tricky, but it can be done. If you're going to do that, you need to make sure that you are letting all the parents and everyone know what materials they're going to need way before you're actually going to do that. For me, I provide a group and a preschool classroom on Fridays, and so I make sure that either the Friday before or Monday at the latest, I am getting them a list of materials that they need, and not just the materials that they need, but how those materials should be set up. I've already learned that if you just send a picture of the activity that you're going to be doing, they are going to set it up like that picture. So even though I didn't want the rubber bands on the muffin tin already, they already had the rubber bands on the muffin tin. Well, that takes away part of my strengthening and finger manipulation exercise of actually putting the rubber bands onto the muffin tin. So make sure that you are being explicit in what they need and how you want them to be set up. And that goes for individual services as well, just like with providing group services in a well, brick and mortar type of classroom, you know, at school, not over teletherapy model. You need to also ensure that the that the students that you're working with have similar goals and similar ability levels, and that what you are are providing for that group is actually going to be helpful for every student, and not only two of the four students, or whatever it might be. So when you're going to think about groups, you need to consider what students can work well in a group together. And the last thing I really want to address as far as groups that you have to be mindful of is HIPAA and FERPA laws. Be sure that you are talking to your district about groups. Can groups even happen? Is your district willing to allow that to happen or not because of privacy laws at this point in time? I think people understand that it's more beneficial right now than it causes harm in order to be providing those group services, even though a parent from Student A might see Student B or vice versa and understand that they also have an IEP and they also have occupational therapy services. I think that is outweighing the consequence of not having services at all. Some students need that group service when it comes to the communication skills and those social skills involved. That's especially true when it comes to speech and language services. Oftentimes they are working in a group to develop those social and communication skills. For us, it's still true, especially with social skills. Maybe you're working on like the zones of regulation program or something where it works best in a group, or maybe you're just trying to get the students engaged through play, and more cooperative play, as opposed to isolated play. So definitely groups can be fantastic, but make sure that your district is all on the same page as to whether or not you are able to provide group therapy services. The last two models that I have here go hand in hand, and they are collaboration and consultation. I first want to start with collaboration and kind of share with you how I'm providing collaborative type of services right now. Maybe in the past, you've been able to go into a classroom and you can kind of sit near the student and kind of work with the student in the classroom as well as with the teacher a little bit well. Now that's very difficult, because if you speak in a Zoom Room, every single kid in that Zoom Room is going to hear you, right? So how am I doing that? This is what I'm doing a little bit differently. I'm going into the student's Zoom Room or Google meet classroom, and I'm simply observing, and I might observe for 15 minutes to 30 minutes, and now, before everyone gets started, I do not condone this type of collaboration when we are actually on campus, you should not be going in and just observing a student and calling that collaboration. But let me finish here. When it comes to teletherapy, I'm going to go in. I'm going to observe that student for 1520, 30 minutes, whatever I've kind of decided needs to be done. I'm also going to make sure that I'm going in during the right time of the day, determined by what their goals are. I'm not going to go in during math time if that's in the middle of the day, and we're trying to work on that getting started in the morning routine. That's not how it's going to work. So I'm going to go in at the right time, and then on top of that, I'm also going to schedule a debriefing time, if you want to call it. At and I'm going to, I'm going to debrief with the teacher, maybe later that afternoon, after School's out. I may also debrief with the with the parent or the student, depending on the level of the student, to use the example that I just kind of started down the road with, and a student's ability to get ready for their day and get started with that morning routine in a classroom? Well, I'm actually working with a student right now on exactly that, that morning routine right now, a lot of kids are having difficulty, especially, I mean, our kids, maybe they're they're getting up in the morning, they're still in their pajamas, they're showing up to zoom in bed. Maybe they're eating breakfast or whatever it might be. Well, that's not quite how it should be. You know, we want the students to be in classroom on time, and so I might go in observe a student from the time that school starts at 8am and then go through to 820 and then later in the day after school is over 130 or whatever that might be, I can then schedule that call with the teacher and with a parent and with the student again, if their ability level is there, and we can discuss some options, some potential strategies to try whether it be a checklist or a schedule. So that is one way that you could potentially collaborate. Other ways that you can collaborate is by going in and maybe you see some handwriting difficulties. Maybe then you meet up with the parent and the student later, and you let the parent in on some strategies that they can try. Or maybe you provide them with a handwriting checklist that they can take to their desk. Another example might be a student who has some sensory concerns, or maybe is easily distracted and needs a fidget that is something that maybe you see during that 30 minute period, and then later in the day, you collaborate with the teacher and the parent on some different strategies that we can use to keep them from getting distracted so much and keep them attending to the computer. Everything is different right now, so everything's on the table. Goals that might have been put in place last year may no longer be relevant, and you may need to potentially work on different goals. So keep in mind that services may look different now than they did when the student was on campus. When they were on campus, we barely talked to the parents as far as collaboration, yeah, we let them know how their student was doing on goals, and we talked to them at the IEPs. But now those parents are our eyes, our hands and our ears, and they're the ones that can actually implement change in the home where the student is for their education. So you're going to have to really help and really collaborate with the parents. Similar to collaboration, consultation is another way that you can provide services. And my only real difference between a collaboration in this sense versus a consultation, is that maybe you don't need to go into the classroom earlier that day in order to provide that consultation. Maybe it is happening in a one to one direct session, but you're really working with the parent on how to help their student in the quote, unquote, Zoom classroom, or whatever you want to call it. So consultation versus collaboration? I think collaboration is making sure you're getting into the classroom, versus consultation is more of talking to the parent, hearing their concerns, or talking to the teacher, hearing their concerns and giving them solutions to trial out. All right, so now we've gone over location and model. The next area that we must consider is frequency, and just like I was talking about a moment ago, how things can change because students are now in a complete different location for their learning, frequencies might have to change. Students who may have been able to attend to you for 30 minutes may only be able to attend to you for 15 minutes now, or maybe students that could only attend for 15 minutes now. Maybe computers work great for them, and you can get more done with them in a 30 minute period. You need to be consistently monitoring whether or not the frequency is the right amount of frequency for that student to make progress toward their goals. And as I also mentioned earlier, maybe their goals are different now, because they are on a distance learning program, every district is is taking this a little bit differently. Some districts are revamping the entire IEP versus others are kind of modifying the IEP slightly in an interesting way. And so depending on how your district is doing it, that can really change how your services look. And this now brings us to the fourth and additional aspect to consider when we're looking at teletherapy, and that is synchronous versus asynchronous. Type of therapy services, as I mentioned earlier, synchronous teletherapy services are those that we typically think of in a zoom call, where we are speaking and we are making actions with our hands, and the person on the other end of the computer can hear and see us in either live or very close to live time asynchronous or store and full. Word model is when you are creating something, you are sending that to the parent to the student, for them to do at a later time. So why might we choose either synchronous or asynchronous type of services? Well, because some students do better when they can be with you live, and other students do better when they can do that activity, potentially with their parent at a different time. There are so many aspects to consider when trying to decide whether or not a synchronous or asynchronous model will be best. Some of these factors include the student's ability to attend to a computer, whether live or in an asynchronous model. Another factor may include who's at home with the student, and at what time is older brother there and can actually help the student. Is a parent, grandparent or other Guardian available at the time that you need to see the student during the school day? For some of our students, that's not the case. Mom and Dad are at work. Sibling is on the computer in another room, attending to their high school curriculum, and there's simply no one there to be the therapist assistant, in a way, just as well. There could be the case where, yes, the parent is home, but there's also three kids that the parent is trying to help. They're trying to make sure that their teenager with ADHD is logged in. They're trying to make sure that their middle schooler is accurately getting from one class to another, because they're trying to figure out Google. And then there's the student that you work with who maybe the parent just can't get to at at the time that you need them to or maybe they just don't have time to do that. The parent is just frustrated and overwhelmed with everything they're trying to to make sure everyone's on the computer for class, they're trying to make sure that lunch is prepared. They're trying to make sure that the that the dishes are clean from breakfast, whatever it might be. But it's just hard for these parents, and so sometimes it might be easier to use an asynchronous model when working with our kiddos. So how do you prepare for when you have some kids on an asynchronous model and some kids on a synchronous model? Well, a synchronous model is pretty similar to seeing a kid directly in an OT room or in the classroom whatnot. You are there live with them. It's similar in the sense that you have to prepare your materials ahead of time. And like I mentioned earlier, you have to make sure that the materials are planned ahead of time at the at the house for the student. So make sure that you are sending in advance the materials that the parent will need. When you're looking at providing services in an asynchronous model. It's similar, but slightly different, because you're not going to be working directly with that student. You're not going to be able to, in live time, tell the parent how to adapt an activity that maybe that student's having difficulty with. And so what you can do is create a video or create a document that not only shares what the activity is and how to complete it, but also gives exactly the different types of accommodations that can be put in place if a student is struggling with a a specific part of the activity. So what does the parent do when their student is struggling to use tongs? Is there another way to go about doing this activity without tongs? Or what happens when the student will absolutely not touch the shaving cream that you were recommending in this activity. Is there a way to potentially put plastic over it so that they don't actually feel the shaving cream? There's just so many different activities and so many different ways to adapt the activities that we are going to be sending to our parents when using an asynchronous model. Recently, my go to method for creating asynchronous content for the parents is by developing a video. And I do this actually just simply using zoom or Google meets and I share a document camera so that the parent can see what my hands are doing while I'm speaking to them and telling them exactly how to model or to have their student create this activity that I've been doing. Some of my favorite activities so far have been helping the students to create mosaic art, where they're using a ruler and a pencil to draw lines, and then going back and coloring in those different shapes to kind of create a mosaic like art. And then they get to write their name on it, of course, or something on it in a nice, dark, bold marker. You can actually see an example of that on my Instagram account at ot school house. So then, after I've created a 10 minute or so video that has exactly what the activity is, how to complete it, and even several accommodations or adaptations to that activity. In case they need it, I go ahead and send that activity out via an email or the cloud or however, I can get it to them. Oftentimes, I upload it into the Microsoft cloud, and then I send them a link to it, and then they can view it and send me back some feedback after they've tried the activity with their kid. And so that's where. Out pretty well. I have also been using the zones of regulation program in a digital format in order to help my students. Using Google Slides, I've created a PowerPoint in a way that I work through with them. Now, before you email me right now and ask for that material, because I have had a few people asking for that as I did mention it in another episode. I can't share that with you for copyright and trademark reasons, but it is something that you can create. If you have the downloads or the materials from zones of regulation, you can actually kind of turn that into a PowerPoint and work that with your students. Many of the activities that I complete over teletherapy are very similar to the activities that I would complete in a traditional format, such as making a jellyfish to work on different ways of cutting and folding paper, or poking toothpicks into cardboard to match colors or letters or whatnot. A really fun one for the students was where they used their sandals to trace their feet or their shoe print onto a piece of paper, and then we put the shoe prints on the ground, and they got to jump from one shoe print to the next shoe print, making sure that their body was turned the correct way. I've also used American Sign Language as a way to work on visual processing and discrimination skills, as well as finger isolation and fine motor skills. Directed drawings have also been a huge success with my students, and I think the parents appreciate it, because it's so easy for them to replicate at a later time. Once I do that activity with them in person or even in an asynchronous model, they then understand how they can find a YouTube video that is a directed drawing video, and how they can press pause and help their student with imitating and visually replicating a picture from a YouTube video. Currently, I'm looking forward to actually putting together an activity where students are going to have to, well, the parents are going to have to help me with this, because we're going to take a toy, we're going to freeze it in an ice cube container, and then we're going to use some bilateral hand skills in order to get the toy out of the ice cube. So that's a fun one. I'm looking forward to it, but I'm definitely going to have to reach out to the parents in advance to make sure that they have the tools necessary to do that. So that wraps up the different considerations for teletherapy. Remember, we have location, we have the model of service delivery. We have the frequency and the temporal consideration of asynchronous or synchronous therapy, as I was talking about some of those different treatment activities. I'm sure there are several of you listening out there saying, Well, how am I going to do that when I don't have hands on capabilities with my students. You don't understand Jayson, I have students in a moderate to severe autism classroom, or students in a very low functioning, medically fragile classroom, and you know what? Well, here's what I have to say to that we have to learn how to transition from a hands on model to a communication based model. And what I mean by that is that our parents are going to be our eyes, our hands and our ears. They are going to be the people that we rely on, and we're going to have to learn how to communicate, not only to our students, but also to the families or the parent or the Guardian that is working with the student in that time, whether or not you're providing a synchronous teletherapy service or an asynchronous teletherapy service, you're going to need to learn how to communicate, and this is only going to help you even more when we actually come back to a physical school site, I already talked a little bit about how important It's going to be to make sure that you're communicating with the teacher and the parents in advance of your group or your individual session to ensure that they have the materials available. But also my advice to you and to myself, really is to slow down and remember that the parent and child cannot hear your thought process unless you speak it out. And so make sure that what you're saying to yourself in your head often, you need to say that out loud. You need to make sure that you're verbalizing those thoughts so that you can even let the parent know what you're thinking and maybe what you're thinking two steps ahead. Why are you telling them to get a different pair of tongs. Why are you giving them an instruction to hold their students wrist a little bit while they're coloring? As I say this, I think back to when I was a little kid, and my question was always, Dad, why do I need to do it this way? Mom, what do you mean? I need to do it that way. As adults, we question everything, and we want to know a little bit about what's going on and why we're doing what we're doing. Your parent is more likely to do something the way that you want them to do it and even do it later in the day, the way that you ask them to do it right now, if you explain to them why you're doing that, what is your process? What is your thinking? As far as why you're having them place their hand on their students wrist as they're writing, or why you're asking them to break apart their crayons, or why you're asking them to put a sticker on the kid's fingernails so that they can see their thumb when they're cutting all these are important not just to have the student do but also to explain to the parent why you're doing that. It may also be beneficial to send the parent a quick wrap up summary of what you did during teletherapy and how they can continue to build upon that over the next week, or until you see their student again. I know that takes a lot of work, but even if that is in some way, a copy of your documentation for the day. Maybe that is enough to help them continue the process. Okay, so that wraps up today's primary content. But before I let you go, I want to share with you a research article that's slightly more recent than the previous one that I shared. This article is from 2019 entitled parent perspectives of an occupational therapy telehealth intervention. It was published in the International Journal of tele rehabilitation. The article by Anna Wallace, Lauren Lytle, Ellen Pope and Winnie Dunn found that parents appreciated the collaborative telehealth model because they felt that the services were compatible with their daily life in the sense that they were more convenient and that they actually fit into their daily life. It was more about how the therapy services were in tune with what was going on in the house. Now, to be completely fair, these services were not provided from a school based model, nor were they provided during a pandemic. This was from 2019 and so I'm going to assume that maybe the actual research occurred during 2018 per se, and technology was a lot different. The current situation was definitely a lot different. And maybe they were working on school based occupations, but more than likely, they were working more on home based occupations because it wasn't school based. With that said, What is the educational environment these days? What is the home based environment these days? Where is the line drawn between home and school right now, everything's a little bit meshed together, and as long as students are receiving their education from home in a teletherapy model, it's going to be difficult to distinguish what is what and what school based occupations affect home based occupations, and what home based occupations affect school based occupations. Never before have the lines between school based and clinic based or home based occupational therapy been so blurred. What I can say from reading this article is that the parents really appreciated the collaborative relationship with the therapist. Some parents noted that it was helpful to have someone simply to talk about their child's occupations with and what their child was struggling as well as what they were struggling in in regards to how to help their student. They appreciated the ability to ask questions of the occupational therapist, and they felt more empowerment in their ability to problem solve activities within the house. They had a better understanding of maybe what an occupational therapist might be thinking, what an occupational therapist might do, and therefore they felt like they could better problem solve different occupations within their own home. So the next time that you are providing therapy through a teletherapy model, just remember that that parent is not only your hands, your eyes and your ears, but they are also the one that's going to be with that student the entire day for the foreseeable future. They are the ones that can carry out different things that you provide for them. They are the ones that can adapt their learning environment right now. They are the ones doing everything, and they need your support. Okay, so that is going to wrap up this episode of the OT school house podcast. Remember, this is part one of our two part teletherapy service. And yeah, I hope you enjoyed this first one. Next time, we are going to jump into a little bit about Medicare, Medicaid reimbursement. We're going to talk about evaluations, especially, that's going to be the key aspect for episode 57 and we're also going to talk a little bit about ethical considerations. We touched on it slightly today, but we're really gonna dig deep into it in Episode 57 and one last thing before I let you go, if you felt like I missed something in today's session, let me know, because I want to make sure that I've covered everything for you, and if I haven't well, then maybe this will turn into a three part series. But please let me know if I missed something, did I miss on what technology you need in order to provide teletherapy? Did I miss out on what software you need? Did I miss out on something? Let me know so I can get back to you and we can improve this. All right, take care. Have a great rest of your Monday or whatever date you're listening to this. I can't wait to see you in. Again or hear from you again in Episode 57 All right, if you'd like to see the resources for today's episode, check them out at ot schoolhouse.com forward slash, Episode 56 we will see you next time. Bye, bye. 

 

Amazing Narrator   

Thank you for listening to the OT school house podcast. Now that you've listened to this episode, head on over to OT schoolhouse.com, forward slash, PD, as in professional development to earn your continuing education certificate until next time class is dismissed. 



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