A Tale of Two Worlds: Meshing Telepractice with Head&Neck Cancer populations

Title: Using Telepractice to Support the Management of Head and Neck Cancer: Key Considerations for Speech-Language Pathology Service Planning, Establishment, and Evaluation

Author: Burns, C.L., Wall, L.R.

Journal: Perspectives of the ASHA Special Interest Groups. 2

Year of Publication: 2017

Design Type: Descriptive Review

Purpose: “This paper provides a review of current evidence and key professional policy documents to assist clinicians in the development of speech-language pathology HNC telepractice services.”

Population: Head & Neck Cancer patients


My friends, I am right there with you. Well, right now I’m stuck in my apartment luckily being accompanied by my adorable pup, but soon I’ll be back in the hospital doing the things I’ve done so many times before. But this time, with an eerie sense of awareness and caution. I have to admit, before things started getting ‘too’ crazy and before all the distancing away from others, at times while at work I’d forgotten that anything was all that different since a majority of precautions can be pretty standard in most medical facilities. Soon enough, things changed..

While so many are scrambling, searching, and being socially aware, I still have to believe evidence can continue to be a crucial guide, since evidence guides us to evidence-based practice, which ultimately helps our patients the most, which is needed the most now. While unfortunately I have no evidence on how to guide us through this time, luckily others have stepped up and provided great resources already. While I’m stuck in a similar situation too many can relate to, I can offer an unplanned review for those stuck at home or others who need to read something new. So please feel free to skim, share, and hopefully keep our determined and passionate heads & hearts open.❤❤

“Telepractice is emerging as a viable option for the delivery of speech-language pathology head and neck cancer (HNC) services to assist in addressing the demands of a growing population requiring specialist speech-language pathology intervention, and to offer patients more convenient and flexible models of carep.140


While I have to be 100% honest that this population is not one I can begin to claim immense expertise in (but one I hope to continue to gain more knowledge about!), I was still surprised to know that not only has this mode of service delivery already been dipped into, but that there is actually some general practice advice for those interested.

But what is telepractice anyway?

There are so many amazingly helpful resources, blocks, podcasts, groups etc. doing such an incredible job sharing this exact fastly-researched topic (I am sure some are overwhelmed with the information overload🤯🤯), so here is a simple reference from ASHA:

“The American Speech-Language- Hearing Association (ASHA, n.d.) defines telepractice as “…the application of telecommunications technology for the delivery of speech-language pathology … services at a distance by linking clinician to client/patient or clinician to clinician for assessment, intervention, and/or consultation.” p.140

Pretty general? Yes. So let’s get a bit more sticky with it, because there are also different types of telepractice delivery:

  • synchronous” models=real-time/interactive (videoconferencing, teleconferencing)
  • asynchronous” models=delayed delivery, where you save/foward things for later use
  • Hybrid model= (self-explanatory, using mix of both models)

https://www.google.com/search?q=office+space+Yeah,+if+you+could+tell+me+what+to+do+with+that+information,+that%27d+be+great+meme&client=ms-android-sprint-us-revc&prmd=ivmn&sxsrf=ALeKk02NJfY8aSPMuR6BHkLv4qkqtJA7Sw:1584652154064&source=lnms&tbm=isch&sa=X&ved=2ahUKEwj32vCluafoAhXPCTQIHXVrARkQ_AUoAXoECA4QAQ&biw=360&bih=617&dpr=3#imgrc=msrOXSvF4c6fnM
So how exactly can you use this for the HNC population though? If you thought the above modes are merely for specific exercise or compensatory interventions, think again!

The article gives some evidence for using these models for the following, with positive results “related to patient satisfaction and uptake, improved service efficiency, and cost savings…increased flexibility and convenience for the patient, eliminating barriers of distance and travel, whilst providing structure and support to maintain treatment fidelity and therapy adherence.”

  • Post-Laryngectomy
  • Dysphagia
  • Intensive prophylactic swallowing therapy
  • Voice
  • Speech
  • Counseling
  • Multidisciplinary team consultation/referrals

If you have experience with these areas, GREAT!! If you think you can just dive in head first (or maybe a cannonball) doing the above while using a telepractice-type of delivery system, think again (and maybe again if you’re thinking you can dive beautifully into this with a swan dive). There are many things to think about and consider before moving forward.🤔🤔


  1. Follow whatever your local, state, and national guidelines and laws. That might mean a bit more research for you to look into, but better safe than ‘sorry, I didn’t know it was illegal‘ when it comes to knowing the cans and the can’ts. (See ASHA for Telepractice guidance). 
  2. Get an expert on board who has been there, done that to help with all the techno-parts that I for one, would have less clues about than I do about electrical engineering (See a Live Facebook chat 3/22/20 @8pm  EST for information with an HNC SLP using telepractice in the Facebook HNC SLP group!)
    • **this may mean using specific systems, equipment, or applications that may be commercially or custom-made, but anything that can work at both locations for the cliniciand and patient is crucial**

      3.   Think about bandwidth!

boy band  No, not boy bands. 

“Bandwidth (a measure of the capacity of a communications channel to transfer information) influences the transmission, and presentation of audiovisual information for synchronous telepractice services..Published studies validating the use of live telepractice services for adult swallowing assessments used relatively low bandwidth), however as some sessions were affected by image pixilation, audio delays, and sound drop out, the use of higher bandwidths is recommended.” p.141

If you’re planning on doing something highly intricate, the higher the better. If it’s something more simple and doesn’t need to have very detailed imaging (e.g. speech/voice therapy), lower or a broader range of bandwidths may do the job

4.  To see and hear what’s going on, examples such as ‘pan/tilt/zoom and/or free standing mobile‘ may work for face/oral cavity inspections for swallowing, speech, and voice specialties (specialized medical-purpose videocameras may be required for TEP management**). Don’t think too small! Being able to control the camera from the other side might even be worth it in the end specifically for inserting prostheses).

5.  Microphones that can cancel out noise (not sure about any studies for Airpods?🤔🧐🎧) as well as pinning close to the mouth for accurate perceptual voice and physiological readings can be helpful (while not the ‘end-all-be-all,’ throat clearing and coughing can still play a role 😉 ). While bigger may not necessarily be better when it comes to the size of screens, anything that can let you see what’s going on while also being a split or extra views (screen sharing is the new thing guys!) can only benefit your patient and their safety. 

6.  And if you thought your patient wouldn’t have to do anything different–sorry, you were wrong. Some studies have used white tape placed on the patient’s thyroid notch to assist in visualizing laryngeal movement, clear cups/utensils to facilitate bolus amounts, and the debated pulse oximeter to give some additional physiological information (sometimes you gotta use what you can/got, BUT outside of this context please be sure to review the truth about Pulse Oximetry). 

7.  Finally, our favorite educational handouts not only for therapy, exercises, and informational, but also for any equipment that might be used (i.e. gel cap loading kit, adhering bandages, hygiene, etc.). This may also include “a written ‘how to’ guide with troubleshooting information, and/or access to phone support.

“To date, there is a comparative paucity of literature discussing the technological specifications required for delivering quality speech-language pathology HNC services via asynchronous technologies.” p.142

Wait! don’t give up!!!! It seems there has been some research done with simpler systems and modalities, and our expert clinical instruction and feedback along with out-of-the-box thinking may be the most important factor in its effectiveness (see article for research references).

In this world where HIPAA is no longer a light-hearted joke to some, in light of recent events (please visit CDC and/or cms.gov for additional information, or likely many other great resources posting current updates), specialized software that allows clinicians to gather data after-the-fact for review and treatment plan, create profile and individualized goals can be especially useful if done in a safe, ethical, and legal manner, the article recommends. 

hipaa


So that’s all that YOU have to do. It may seem like a huge mountainous task. And some may not be able to check off everything, others hopefully may be able to investigate to see what may be possible in their setting. 

But what about the patient?

warningCOMBINING THESE 2 WORLDS ARE NOT SUITED FOR EVERYONE! ! !

So how do you know if it might be feasible for someone? After ensuring all the above recommendations and requirements are met, there are some patient requirements that have been used in past research to figure this out (sorry I tried to figure out a flowchart for this for ya’ll, but my brain just #couldn’t at that point😩😓).

Patient requirements:

  1. High levels of computer literacy (particularly for asynchronous services)
  2. Motivated/engaged (i.e. patients who want to be active participants in their care )
  3. Access to needed technology (I’m talkin about internet and computers folks, rural areas as well as low-income can be vulnerable for this)

Additional things to consider before launching your real-time videopractice rocket:

  1. Physical ability
  2. Cognitive functioning
  3. Speech intelligibility (yes, this may be a goal but also can be a larger barrier)
  4. Language skills 
  5. Hearing/visual abilities
  6. Additional caregivers/family/friends etc. to support and facilitate therapy tasks and also ensure patient safety and health is maintained

Why are all of these critical? Because just like this unplanned, unknown, and ‘under-understood’ puzzle we are finding ourselves in, the last thing we, as professional clinicians, want to do is create more complexity and uncertainties with our at times, extremely vulnerable patients.  

Some trial-and-error navigation may need to take place, as well as creating some sort of assessment for your own practice to determine who appropriate candidates might be. 


tenor-5

~ Clinician+Patient+Staff Training ~

In case you are not a sole pracitioner, there are some studies that have also looked at how other staff may be involved (checkout the following podcast with Dr. Joanne Patterson about telepractice counseling with HNC patient!)

“For synchronous telepractice HNC services, SLPs have been trained to support complex clinical tasks (e.g., voice prosthesis insertion), while speech-language pathology assistants/nursing staff have supported patients during swallowing assessments and counseling sessions , all under the direction of the online SLP.” p.143

In addition to appropriate license and credentialing, all staff should be adequately trained in all the technical and mechanical operations of all systems, protocols, and procedures (e.g. software, sound pressure level meters, cameras, etc.). On-call or an IT system setup would also be ideal for any troubleshooting technical issues (these people are literally my gods whatever building I’m in, and I often have to resort to bringing baked goods for all the times my needy butt has to bug them🤓😅).

documentation

Definitely the opposite there guys, we’re not thaat far into the future with this stuff yet. While they do give reference to consent and attendance records, every practice, every setting, every clinician may have their own specific guidelines, software systems, and staff, all typical telepractice/telehealth rules and regulations are likely to apply, if not more so (for further guidance on any documentation, coding, etc. refer to ASHA and local/state organizations). Confirming outcomes from beginning to end, as well as modifications along the way are also likely to be a must (this’ll probably include functional outcomes as well!!). 

Dayreaming what a session might look like? A much regarded HNC SLP expert Megan Nosol also gives a 👍 for the following to aide in technical troubleshooting time:

“Synchronous HNC telepractice services to date have reported an average 1-hour SLP appointment has allowed for adequate clinical intervention while accommodating time for technical setup,positioning changes, and interaction between participating sites.” p.144

A huge, HUGE, H-U-G-E part after doing all of this, is to ‘test it out‘ with lots of trials, practices, simulations, and piloting. Suggestions for having copies of clinical/operational manuals, “patient simulation” sessions, multiple hands-on training, and piloting at a few/small sites before wide implementation (depending on your setting) are all recommended prior to actively involving our sometimes desperate and support-seeking patients. 


While this may be new news, or something old and only dreamed about, I can’t help but face the fact that we don’t know. What keeps my brain more awake at night, is that our patients are there knowing even less that we do. The old adage, ‘Where there’s a will, there’s a way‘ seems slightly comforting while also overwhelming. We all want to do what’s best for our patients. Sometimes, there may be nothing. Other times, we can only offer comfort and other caring gestures. Hopefully, there may be a time where we are able to offer more, fight for more, and do more. The above information may not have ever been thought about before, and may never be utilized again after all of this, but it also may be worth considering or at least keeping an option, because 

In strange and uncertain times such as those we are living in, sometimes a reasonable person might despair. But hope is unreasonable and love is greater even than this. May we trust the inexpressible benevolence of the creative impulse. ~ Robert Fripp

 

How can you use this article?!?

Does this population and mode of service delivery speak to you?

Are you someone already implenting this??! Please share your guidance and input!!! 🙂 🙂

Do you have other questions as it relates to this population? (See below for additional articles collected thus far)

What other programs have you started or are aware of similar to this? (e.g. tele-support groups?)

Now’s the time to share, care, and dare to do what we can & need to do. ❤️❤️❤️❤️❤️

giphy-3
I am fully aware of the corny-ness of this, but it was the first thing that came to my mind🤦‍♀️🤷‍♀️

giphy-4 giphy-5

 



Takeaways:

  • “When establishing speech-language pathology HNC telepractice services, regardless of mode or therapeutic intention, a range of key requirements must be considered in order to preserve efficacy and quality of care”
  • “Telepractice services should be developed based on current evidence-based practice and
    be compliant with professional guidelines and relevant national, state, and local laws so that the telepractice service provided is at least equivalent to face-to-face speech-language pathology care”
  • “As directed by professional guidelines, patient suitability to participate in the telepractice
    service should be determined on a case-by-case basis”
  • “To date, clinician and consumer perceptions of speech-language pathology HNC
    telepractice services have been very positive. Patients have reported that telepractice services provide them with a greater opportunity to be active participants in their healthcare, and have stated their preference for telepractice over traditional care models”

Be safe, be healthy, be strong!

**A BIG thanks to Megan Nosol for giving input and sharing her expertise with this article 👏👏🙌



Article Referenced: [ASHA FREE ACCESS]

Burns, Clare & Wall, Laurelie. (2017). Using Telepractice to Support the Management of Head and Neck Cancer: Key Considerations for Speech-Language Pathology Service Planning, Establishment, and Evaluation. Perspectives of the ASHA Special Interest Groups. 2. 139. 10.1044/persp2.SIG13.139.

https://pubs.asha.org/doi/10.1044/persp2.SIG13.139

 

Additional resources:

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

https://www.asha.org/Practice/reimbursement/Payment-and-Coverage-Considerations-for-Telepractice-Services-During-Coronavirus/

https://www.asha.org/Practice/reimbursement/Reimbursement-of-Telepractice-Services/

https://www.asha.org/EvidenceMapLanding.aspxid=8589944872&recentarticles=false&year=undefined&tab=all

https://www.asha.org/Certification/COVID-19-Use-of-Telepractice-and-Telesupervision/

https://www.asha.org/SIG/18/

https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589934956&section=Resources

https://www.asha.org/Advocacy/state/default/

https://higherlogicdownload.s3.amazonaws.com/AMERICANTELEMED/618da447-dee1-4ee1-b941 c5bf3db5669a/UploadedImages/NEW%20Practice%20Guidelines/2017%20Practice%20Guidelines/NEW_ATA%20Blueprint%20for%20Telerehab%20Guidelines.pdf

https://www.spohnc.org/

https://www.facebook.com/groups/HNCSLP/?multi_permalinks=586568462053502&notif_id=1584663228640278&notif_t=group_activity

 

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