PREVISIONES E INFORMACION PARA PREVISIBLES TRABAJOS POSTERIORES

Another way that speech pathologists attempt to improve access to speech pathology is by utilising alternative modes of treatment. The traditional mode for speech pathology services has been individual face-to-face mode, where one client meets with one clinician in the same room for the consultation. Alternative modes may vary the number of clients, such as in group treatment (discussed more fully in ‘Dose parameters’ above). Other variations in mode include less-traditional clinician roles, such as occur with transdisciplinary treatment, where multiple allied health inputs are provided by one clinician, or with multidisciplinary treatment, where several allied health providers provide services to the same client. One popular modification of treatment mode is the use of technology to allow the client and clinician to connect, such as is used in telehealth treatment. The following section discusses the use of various telehealth modes of treatment.

1.3.2.1 Telehealth

The last decade has seen a significant increase in research and practice demonstrating the use of telehealth modality for speech pathology services. Telehealth is ‘the application of telecommunications technology to deliver clinical services at a distance, by linking clinician to client, caregiver, or any person(s) responsible for delivering care to the client, for the purposes of

assessment, intervention, consultation and/or supervision’ (Speech Pathology Australia, 2014b, p. 4). Telehealth is variously known as telespeech, telecare, telerehabilitation and telepractice (Mashima & Doarn, 2008; Theodoros, 2013). Telehealth fits within the broader category of e-health, which encompasses all electronic processes and communication technologies that support healthcare, such as electronic medical records, stand-alone technology-based therapy, and digital collection of data for assessment and treatment (Speech Pathology Australia, 2014b).

Telehealth applications can be synchronous, where information is sent and received in real time such as videoconferencing, or asynchronous (i.e., store and forward) such as email and purpose-built computer applications. Although various telehealth platforms are available, such as teleconference, video, email and videoconference, this thesis focuses mostly on videoconferencing. During a videoconference, visual and auditory information is transferred in real time via the Internet. Videoconferencing enables the clinician to directly conduct activities with the client and provide feedback in real time despite significant physical distance between the client and the clinician (Theodoros, 2008). During a speech pathology videoconference, the speech pathologist is most commonly located at their workplace (e.g., clinic or hospital) and the client is located at home or an accessible place in the community (e.g., school or community centre; Hill & Miller, 2012).

The main advantage of telehealth for service delivery is the ability to address the geographical barrier to accessing services that disproportionately affects people living in rural and remote locations (American Speech Language Hearing Association, 2005; Lowe, O'Brian, & Onslow, 2014; Speech Pathology Australia, 2014b; Theodoros, 2011). Services provided by telehealth decrease clients’ travel time and associated costs (Mashima & Doarn, 2008) and increase convenience (Hill & Miller, 2012; Theodoros, 2013). Telehealth also saves clinicians’ time, as it can eliminate the need for travel to outlying areas (Hill & Miller, 2012). Although many videoconferencing studies use custom-built systems, it is possible to use personal computers or

tablets with inbuilt webcams, and for families with existing Internet connections, set-up costs are low (Speech Pathology Australia, 2014b).

The benefits of telehealth are not limited to clients in rural and remote areas. Telehealth has application for metropolitan clients who find it difficult to attend face-to-face sessions (Lowe et al., 2014; Theodoros, 2013). It can enable metropolitan clients to receive weekly services that would otherwise have been impractical due to lengthy travel time resulting from traffic congestion (Verdon et al., 2011). In many cases, clients prefer telehealth to the face-to face modality due to the convenience, time savings and reduction in transport costs (Mashima & Doarn, 2008;

Theodoros, 2011). Telehealth treatment can have stronger generalisation gains than traditional face-to-face clinic-based treatment (Burgess et al., 1999; Mashima & Doarn, 2008; Theodoros, 2011).

1.3.2.2 Use in speech pathology

Telehealth is used in many countries around the world, including the United States of America, Canada, Greece, Ireland, the UK and Japan, for a variety of impairments, from neurogenic communication disorders and paediatric speech and language impairments to dysphagia and stuttering (Molini-Avejonas, Rondon-Melo, Amato, & Samelli, 2015). Consequently, many speech pathology professional organisations have published position statements regarding telehealth (e.g. American Speech Language Hearing Association, 2005; Canadian Associaion of Speech Language Pathologists and Audiologists, 2006; Speech Pathology Australia, 2014b).

Telehealth is more commonly used in rural areas than metropolitan areas (Molini-Avejonas et al., 2015), and most speech pathologists who use telehealth are based in regional or rural areas (Hill

& Miller, 2012). However, despite Australia’s vast rural landscape, telehealth use is not universal, with only 13% of Australian allied health professionals using telehealth at the beginning of the decade (Australian Government Department of Health, 2012). Even when telehealth is used, it is generally only for a small proportion (e.g., 0%–30% of the caseload; Hill & Miller, 2012).

Historically, telehealth has been used more with paediatric clients than with adult clients and in treatment more than in assessment sessions (Hill & Miller, 2012).

1.3.2.3 Efficacy

In general, telehealth has similar efficacy to that of face-to-face treatment (Speech Pathology Australia, 2014b). There has been a steady increase in investigations of telehealth efficacy since the first two comprehensive reviews of the literature reported that telehealth holds great potential for application in speech pathology assessment and treatment (Theodoros, 2008, 13 studies:

Mashima & Doarn, 2008, 40 studies). The most recent comprehensive literature reviews (Molini-Avejonas et al., 2015, 103 studies; Speech Pathology Australia, 2014b, 77 studies) revealed more extensive research across the breadth of speech pathology range of practice areas for both assessment and treatment. Speech Pathology Australia (2014b) reported that personal-computer-based (PC-personal-computer-based) videoconferencing is valid and reliable for the assessment and treatment of childhood speech and language, acquired neurological impairments and hearing impairment and for the treatment of stuttering, provided the technical capabilities of the signal permit high audio and visual quality. Videoconferencing was also reported efficacious for the assessment and treatment of dysphagia, voice, craniofacial and head and neck disorders; however, this was demonstrated by researchers using custom-built systems with features and technical capabilities beyond that of PC-based systems (Speech Pathology Australia, 2014b). No research has been published investigating the efficacy of videoconferencing for treatment of children with CAS.

1.3.2.4 Other considerations

Telehealth service delivery requires specific hardware, software, connectivity and clinician and client skills and attitudes (Keck & Doarn, 2014). Custom-built videoconferencing systems, although technically superior, are expensive and not widely available. Even PC-based systems have minimum specifications (Keck & Doarn, 2014), and not all homes have access to sufficient or sufficiently powered hardware. Although free or low-cost videoconferencing software is

available via programs such as Skype, clinicians have concerns about security, privacy, reliability and confidentiality, and many workplaces prohibit use of these programs for clinical services (Hill & Miller, 2012; May & Erickson, 2014). Although Internet connectivity in Australia is relatively good, and improving year on year (Akamai, 2016), access to high speed Internet is not universal (Australian Government Department of Health, 2012), and poor telecommunication connectivity is one of the main barriers to telehealth use (Behl & Kahn, 2015; Hill & Miller, 2012). There is limited evidence supporting the use of PC-based video conferencing for conditions that require high fidelity audio signal, such as speech and voice (Keck & Doarn, 2014;

Speech Pathology Australia, 2014b) and, by extension, CAS. For families, telehealth treatment can be more expensive than the equivalent traditional service, as there are limits on financial reimbursements for telehealth services under some government schemes (e.g., NDIS) and private health insurers.

In addition to hardware and software requirements, effective telehealth delivery requires specific clinician skills and attitudes (Hines, Lincoln, Ramsden, Martinovich & Fairweather, 2015; Wade

& Eliott, 2012). Clinicians may require training to develop technical proficiency with the specific telehealth system and may need technical support during the implementation of telehealth treatment (May & Erickson, 2014; Speech Pathology Australia, 2014b). Some assessment and treatment materials require modification for use in telehealth modality (Hill & Miller, 2012).

Lastly, it has been argued that the clinician’s positive attitude to telehealth is integral to the success of telehealth treatment (May & Erickson, 2014; Wade & Eliott, 2012).