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Telehealth/Remote Therapy: Useful Tips, How-to and Forms

Updated: Mar 26, 2020


Telehealth in Early Intervention Covid-19

This guideline is a summary of information on the use of Telehealth or Teletherapy in early intervention and information on best practices on Telehealth and Teletherapy, Family-Centered Care, and Parent Coaching for early intervention. Please use this to help you prepare, structure and conduct your virtual therapy sessions with the families you are working with in early intervention to ensure successful and effective delivery of services.


Background


Teletherapy or telehealth is the remote provision of services through virtual means that include both audio and video components (e.g. videoconferencing). Because of the COVID-19 pandemic and the subsequent declaration of national emergency, the New York State Department of Health Bureau of Early Intervention has made Teletherapy temporarily reimbursable method for providers to deliver early intervention.


Teletherapy as a form of ongoing care will only be reimbursable from March 18, 2020, to April 6, 2020 or until the time when the current state of emergency is no longer in place. After that time, telehealth will no longer be a reimburseable service.


The following reminders apply:


  • Teletherapy is not required for all providers but is made as an available option in case ongoing care is interrupted due to the COVID-19 pandemic.

  • Teletherapy should reflect the mandated amount of services in the child’s Individualized Family Service Plan (IFSP)

  • Virtual therapy sessions should be at least 30 MINUTES in duration

  • Providers must maintain all required documentation of the therapy service in their session notes, with a note specifying that the session was done virtually.

  • If technology fails and the full authorized session is not delivered, the session is NOT BILLABLE.


Before Beginning Telehealth Services


Before teletherapy or telehealth services can be started, the following steps should be completed:


  1. The Service Coordinator has discussed the option of teletherapy or telehealth to the child’s family.

  2. The child’s parent or guardian understands that they must be present for the entire duration of the virtual session and will be an active participant throughout the whole session.

  3. If the family wants to have all communication done through e-mail, make sure they have signed and submitted the Early Intervention Parent Consent to use E-mail

  4. The Service Coordinator has completed the Family Checklist for Telehealth with the child’s family and has ensured that the child’s family has the adequate technology at home to support virtual therapy sessions (e.g. internet connection, laptop, desktop, webcam, smartphone and etc.)

  5. The family has signed the Consent for the Use of Telehealth During COVID-19

  6. The Family Checklist for Telehealth and the Consent for the Use of Telehealth During COVID-19 should be uploaded by the Service Coordinator to the child’s integrated case on NYEIS.

  7. Provide your parent a filled out Telehealth Service Log


Please carefully review the information needed for each required document.

You cannot start Telehealth or Teletherapy sessions unless the required documents are signed and uploaded on NYEIS.


The family has the option to sign or complete the required documents through fax, postal service, or e-mail (provided that the family has given consent to the use of e-mail).


Collaborate with the case’s assigned Service Coordinator to ensure these documents are completed in a timely manner.


Technology Requirements for Telehealth Sessions


The following are considerations when deciding on a Telehealth or Teletherapy technology to be used by a provider during the sessions (Cason, 2011).


  • Confidentiality (security, privacy)

  • Integrity (Information protected from changes by unauthorized users)

  • Availability

  • Cost-benefit ratio

  • Socioeconomic considerations

  • Leveraging existing infrastructure (equipment and personnel)

  • Technology connection requirements (e.g. broadband)

  • Sound and image quality

  • Equipment accessibility


To ensure proper delivery of virtual therapy sessions, New York State Department of Health Bureau of Early Intervention recommends that the provider and the child’s family has the following:

  • access to a stable Internet or Wi-Fi Connection

  • a smartphone, tablet or computer with webcam and speakers (Apple, Android, or Windows)

  • a bandwidth of at least 1.5Mbps, which can be checked by the family through www.Bandwidthplace.com or other options.

  • an experience in video conferencing (not required but can help determine the parent or caregiver comfort level)

  • a complete understanding of their role during the virtual therapy session.


According to the New York State Department of Health Bureau of Early Intervention, any non-public facing remote communication product that is available to communicate with families for the entire duration of the authorized EI visit is permissible during this state of emergency.


The Office of Civil Rights at the Department of Health and Human Services (HHS) will not impose penalties for non-compliance with the regulatory requirements under the HIPAA Rules against covered health care providers in connection with the good faith provision of telehealth during COVID-19 nationwide public health emergency.


With regards to telehealth for early intervention, the following applications or software have been recommended as options (Cason, 2011; AOTA, 2018). Other software not mentioned may be used as long as there is an audio and video component to the software being used:

  • Skype

  • Oovoo

  • Zoom

  • Vsee

  • Doxy.Me

  • Tandberg

  • Movii

  • Chat

  • Google Video Chat


Preparing for Your Virtual Session


Here are some things that you need to do before you start your first Telehealthy session:


Ensure that all required documents are uploaded to NYEIS by the service coordinator before starting the session.


Set Expectations

Before conducting the first virtual therapy session, you can conduct a phone call with the child’s parent/guardian to accomplish the following:


  • Set expectations for telehealth and teletherapy (strategies to be used, roles expected from the caregiver present during the session).

  • If starting a new case, introduce yourself as the provider and confirm the identity of the child with the information you have.

  • Confirming the parent/guardian who will be present during the session and his or her relationship to the child.

  • Explore concerns they currently have and expectations for their child that can be addressed during the virtual sessions.

  • Devices, materials, and other modalities the family might have that can help enrich the virtual therapy session.

  • Discuss comfort levels with regards to the videoconference and identify special accommodations that the family might need (e.g. a translator during the session, visual aids)

Prepare your space


  • Ensure that you (the provider) has space that is conducive for the session and free from distractions (e.g., noise, other people in the space).

  • Ensure that you (the provider) and the family have all equipment available and well-functioning to support visual and auditory interactions during the session. Providers can test the software with the parent or guardian when scheduling the therapy session with the family.

Pick a Schedule that Fit's the Child's Routine


  • Ensure the schedule of the session is conducive to the child’s function and/or family routine with regards to the IFSP goal targeted (e.g. addressing feeding during the mealtime routine of the child).



Strategies for an Effective Telehealth Session


The following strategies or approaches can be used to help guide you or give you ideas on how to carry out your virtual therapy sessions with the family you’re working with.


Family-Centered Care


Family-Centered Care involves developing collaborative and working relationships when working with families. This approach can be used to model virtual therapy sessions. Moeller et al (2013) have described behaviors as best practices when partnering with families. These behaviors can be applied when conducting your holding telehealth or teletherapy sessions.


  • Focus on facilitative family-child interactions Example: Therapists can use videoconferencing to teach a parent how to effectively use manual prompting to direct the child’s actions when completing a simple puzzle.

  • Focus on family-identified concerns (priorities, hopes, needs, goals, and wishes) Example: Through videoconferencing, the therapist and the child’s parent or guardian can discuss and review the family’s current priorities and hopes relating to the child’s development and collaboratively come up with strategies on how to support the child in achieving these goals.

  • Building on individual family strengths to meet family needs Example: Through videoconferencing, a service provider can build on the child’s mother’s active and playful tone of voice to encourage the child to complete a play activity that the child easily gets frustrated with.

  • Working with adults to enhance their confidence and competence in fostering their children’s development Example: During the videoconference, the therapist can observe a specific routine at home such as performing vestibular ball exercises to facilitate the infant’s sitting balance. The provider can then provide feedback on how the parent did during the routine and suggest tips to help the parent comfortably and confidently perform the exercises with his or her child at home.


Coaching Strategies for Virtual Therapy Sessions


Coaching strategies can be used during Virtual Therapy Sessions. The following are coaching strategies with parents in early intervention (Friedman, Woods, & Salisbury, 2012) and examples on how to incorporate them in Telehealth and Teletherapy.


  • Conversation and Information Sharing The provider asks how the family’s morning routine has been going and following up on the last strategy discussed with the parent.The parent shares a new routine they’ve added to support the child’s development. The provider shares with enthusiasm and asks how it went, and celebrates with the parent on the positive impact the new routine has helped the child. The provider asks the parent on what activities they have done at home to help occupy the child during their time at home.

  • The provider asks about how the child and the parent have been dealing with prolonged stays at home and limited opportunities to go outdoors.

  • Observation Through the video conference, the provider can observe the family when performing their routines or when performing the strategies that were taught to the family from previous sessions. Examples:

  • Observing the caregiver when feeding her infant

  • Observing the parent and the child playing the shape sorter or completing a puzzle activity at home

  • Direct Teaching The provider can provide verbal instructions through the videoconference on how to perform a specific strategy and why it is important. Example: Explaining how to position toys for the infant to help facilitate the child’s reaching skills.

  • The provider can share a video and watch it together with the parent or caregiver during the videoconference. Example. Watching a video of a parent performing vestibular ball exercises aimed at supporting sensory-integration skills and balance skills and explaining what are the critical parts the parent is doing and how it is important for the child.

  • Caregiver Practice with Feedback The caregiver demonstrates or tries out the new strategy with the child, the provider then provides feedback about the caregiver’s performance. During the videoconference, the provider will ask the caregiver to demonstrate the new strategy with their child such as performing pelvic exercises with the child. The therapist will then provide feedback by commending the areas or parts the parent successfully and skillfully carried out and by suggesting areas that can be improved or further worked on.


Sample Questions to guide your feedback


  • What went well?

  • How did the child respond?

  • What can be done differently?

  • What other materials can be used instead?

Problem Solving and Reflection


  • This strategy in coaching directs itself to the adult learner’s (the parent or caregiver) need to translate the new learning into his or her own language and apply it to his or her everyday experiences. The provider encourages the caregiver to generate new ideas for how to enhance the use of the strategy and how to generalize the strategy into new routines.


Sample Activities for Problem Solving


  • Identifying different areas of the family routine wherein the new strategy can be applied.

  • Identifying ways on how to modify the strategy when in a different context.


Sample Questions to guide parents reflection


  • What do you think went well?

  • What was different?

  • How did the exchange or the interaction feel?

  • What do you think could be improved?

  • What do you think could you have done differently?


Teaching Strategies for Virtual Therapy Sessions

To further enhance the quality of the virtual therapy session, strategies for online teaching can also be used.


Sharing helpful website links for additional resources Therapists can provide the parents with helpful online resources that they can browse through together during the virtual sessions. Therapists and parents can go over these resources together, and therapists can guide the parents to navigate these resources.


Using the share-screen option during teleconferencing to add visual aids to the session. If you think it’s difficult to just verbally discuss or instruct the parent with a strategy you’ll be coaching them with, you can make use of the share-screen option that most video conferencing software has. With this, you can make use of a simple PowerPoint presentation to guide your audience when teaching or coaching them with the new strategies.


Using different media such as videos and pictures. During the virtual therapy session, you and the parent can also watch videos or pictures of the topic of the session to help supplement the adult learner’s idea of what is being discussed. It is also a way to make the sessions interesting for the parent to be more engaged.


Notes on Proper Documentation of Telehealth Sessions


Based on the guidelines for Teletherapy Sessions from the New York State Department of Health Bureau of Early Intervention, the requirements for session notes and progress notes remain unchanged for virtual therapy sessions. Providers should make sure to indicate on their session notes that the specific session was done virtually or online.


With regards to acquiring signatures for session notes to be able to bill for the virtual session, the New York State Department of Health Bureau of Early Intervention requires the providers to have parent’s signatures on a service log (NOT ON THE SESSION NOTE).


The service log must document that the service was received by the child on the date and during the period of time as recorded by the provider. To obtain the necessary signatures, the provider can maintain the list of sessions furnished virtually for the week and send the child-specific service log to the parent for signature via US mail.


The signed service log can be returned to the provider either via US mail or electronically (scanned/returned via email or the parent can take a picture of the signed document and return it electronically). The session notes that documents the service furnished must be maintained by the provider and both the signed service log and the session note must be available on audit. Note: A typed signature is not acceptable.


Ethical Considerations


To ensure ethical practice in virtual therapy sessions, please review the ethical guidelines on Telehealth from each of your professional organizations.


Information for Occupational Therapists

American Occupational Therapy Association, telehealth resources https://www.aota.org/Practice/Manage/telehealth.aspx

Occupation-Based Coaching by Means of Telehealth for Families of Young Children with Autism Spectrum Disorder

https://ajot.aota.org/article.aspx?articleid=2670866


Information for Physical Therapists

American Physical Therapy Association, telehealth resources

https://www.apta.org/telehealth/

Telehealth in Physical Therapy in Light of COVID-19

https://www.apta.org/PTinMotion/News/2020/3/16/TelehealthCOVID19/


Information for Speech-Language Pathologists

American Speech-Language-Hearing Association, Telepractice

https://www.asha.org/Practice-Portal/Professional-Issues/Telepractice/

Information for Psychologists, ABA’s and Special Instructors

Telehealth for ABA’s

https://bsci21.org/telehealth-abas-new-frontier/


Information for Vision Therapists

Teaching students with Visual Impairments, Online Instruction

https://www.teachingvisuallyimpaired.com/online-instruction.html


REFERENCES


New York City Department of Health and Mental Hygiene, Division of Family and Child Health, Bureau of Early Intervention Guidance for Service Session and Evaluations during COVID - 19. March 18, 2020.

Cason, J. (2011). Telerehabilitation: An Adjunct Service Delivery Model for Early Intervention Services. International Journal of Telerehabilitation, 3(1). https://doi.org/10.5195/IJT.2011.6071

Friedman, M., Woods, J., & Salisbury, C. (2012). Caregiver Coaching Strategies for Early Intervention Providers: Moving Toward Operational Definitions. Infants & Young Children, 25(1), 62–82. https://doi.org/10.1097/IYC.0b013e31823d8f12

Little, L. M., Pope, E., Wallisch, A., & Dunn, W. (2018). Occupation-Based Coaching by Means of Telehealth for Families of Young Children With Autism Spectrum Disorder. American Journal of Occupational Therapy, 72(2), 7202205020p1. https://doi.org/10.5014/ajot.2018.024786

Moeller, M. P., Carr, G., Seaver, L., Stredler-Brown, A., & Holzinger, D. (2013). Best Practices in Family-Centered Early Intervention for Children Who Are Deaf or Hard of Hearing: An International Consensus Statement. Journal of Deaf Studies and Deaf Education, 18(4), 429–445. https://doi.org/10.1093/deafed/ent034

Telehealth in Occupational Therapy. (2018). American Journal of Occupational Therapy, 72(Supplement_2), 7212410059p1-7212410059p18. https://doi.org/10.5014/ajot.2018.72S219


Below is a the checklist that service coordinators are required to complete prior to the start of Telehealth services.


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