Tele-AAC: Case Studies:
Working With What You've Got
Module 1: The Basics of Tele-AAC
Critical thinking questions and prompts for this module are:
Explain candidacy for tele-AAC and how it is like a feature-matching process
Detail the main difference between synchronous and asynchronous service delivery models
Describe how to address privacy and security
1.1 Tele-AAC, Services, Privacy and Security
What is telepractice?
Telepractice is a way of providing various speech and language services that is approved by the American Speech-Language-Hearing Association (ASHA). Services are provided at a distance using videoconferencing technology to link a client and clinician.
And, what is tele-AAC?
Tele-AAC is the use of telepractice specifically for individuals using augmentative and alternative communication (AAC) and the teams supporting them. Tele-AAC involves the use of AAC systems, simulations and replicas, and it is an extension of the broader field of telepractice in that the clinician needs to have “eyes on” the system in order to provide clinical input, guidance and teaching.
Tele-AAC services can happen in real-time or over time. These are called synchronous versus asynchronous services. Via tele-AAC one is able to offer intervention, assessment, and consultative services. Intervention servicesare real-time, synchronous services that replicate in-person on-site sessions. Assessment services can be synchronous or asynchronous depending on the individual being evaluated, but should generally involve an on-site component, especially in order to present the individual being assessed with a varying number of AAC systems and tools. Consultative services are the most flexible class of tele-AAC services and can be useful for individuals and/or team members with varying experience and comfort using and supporting AAC.
Each of these tele-AAC service types support the involvement of team members. By being able to “tune in” to a virtual session, irrespective of one’s location can support collaboration, generalization, more widespread and targeted implementation and more. Additionally, the virtual environment can enhance efficiency by reducing travel time, and support attendance by offering more flexible scheduling and timing options.
Privacy and security:
As this is a clinical service, privacy and security are critical components of tele-AAC. Various video-conferencing tools have built-in HIPAA compliance elements, but it is important to determine which services include the appropriate level of encryption and that there is an established (and oftentimes signed) Business Associate Agreement - BAA.
Securing protected health information (PHI) in both the virtual and on-site environments of everyone involved in a tele-session is essential. The HIPAA Privacy Rule is a federal protection in the United States that enforces protection of such information (by de-identifying PHI by removing information such as name, location, dates aside from the year, and more, for example). Additionally, there are environmental considerations, such as:
using a private treatment area
being aware of who can hear
being aware of who can see
being careful about how content from the session is shared, stored, and/or secured
For clinicians working within schools it is important to be familiar with FERPA (Family Educational Rights and Privacy Act), a federal privacy law designed to protect a student’s privacy, by generally requiring schools to ask for written consent before disclosing a student’s personally identifiable information to individuals other than parents.
1.2 Tele-AAC Candidacy
It is also important to think about who is an appropriate candidate for what kind of tele-AAC service. It is important to complete an initial intake surveying process (like a Needs Assessment) to determine:
the players (i.e., the individual, their communication partners, and other service providers when applicable),
the environment (where the service is being provided and received), and how it can be arranged,
the technology and platform available for use, and
the best ways to connect (synchronous, asynchronous, scheduled, etc.)
This intake process serves as a tele-AAC “feature-matching” process. It is not a “yes” or “no” answer about whether or not someone meets the pre-requisite criteria for tele-AAC services, but rather how are they going to be best served, and how are we going to provide the service. If we think about our fundamental understanding of successful use of AAC we can reflect on the 3-way process of communication between the individual, their communication partner, and the AAC system or systems.
Depending on the individual’s proficiency with the AAC system, the communication partner may offer more or less modeling, recasting, rephrasing, and language expansion to support the communicative process. The more the individual can do on their own managing their AAC system (and the technology necessary for tele-AAC), the more likely they could access direct synchronous and asynchronous tele-AAC service.
Conversely, the more support needed by the communication partner, the more likely synchronous and asynchronous tele-AAC consult will serve as a more appropriate model of service delivery.
Similarly, If we think about service delivery as a continuum of support ranging from direct, synchronous services to indirect asynchronous consultation, one is better able to visualize how someone can be supported in various ways in the context of tele-AAC, and how one may move across services types depending on the goal of the task.
The most important thing is to be transparent and clear about what can and cannot be done via tele-AAC. It is advised that clinicians obtain informed consent from the client and/or family regarding offering tele-AAC services from and to a private environment, as well as factors pertaining to the security of the Internet connection and other environmental factors.
1.3 Equipment and Software
Lastly, the Internet is an important component and should be hardwired whenever possible, and should be:
150 kbps for screen sharing with video thumbnail,
600 kbps for video calling, and
1.5 mbps for video calling with many people/seats (using a 2nd camera counts as a seat)
As previously noted it is important to keep the threshold of technical complexity low so as not to take away from the service being provided and the overall sharing of information. Given the added nature of AAC, it is suggested that the games played, materials shared, and software programs used are as simple yet targeted as possible. Some suggestions are:
Word processing/presentation tools
The equipment will vary depending on the tele-AAC service being provided and what is available at the location of the client and the clinician, but the fundamentals are as follows:
A way to see information (video and content)
A way to share content (Internet, video-conferencing software, cameras and tripods)
Relevant and appropriate content to share (AAC emulation, images, tutorials, videos, etc.)
With respect to seeing the content (the display screen) it depends what you want to share. The more you plan to share, the larger the recipient’s display should be. Common display screen options are a smart phone, tablet, laptop or desktop computer.
The software and equipment used to share content (the display software) needs to be HIPAA compliant, and should include the ability to share the screen and possibly annotate content shown on the screen. If you plan to demonstrate your own use of a tool, or to see how an individual is engaging with a tool you might need to have additional camera views (and therefore additional participant “seats” within your software program). Lastly, built-in recording features will help with sharing of information.
Regarding the cameras, one is necessary for synchronous video-conferencing. You may want two camera views depending on the service being provided. If there is only one computer then the user will need to toggle back and forth between the built-in camera on the computer and the external webcam. If there are two display systems (such as a phone and an iPad) then two views can be run at the same time. You may want more depending on the service.
Telepractice (American Speech Language Hearing Association (ASHA) Practice Portal)
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