Use of Virtual Care for Treatment, Assessment, and Management of Dysphagia

Kyle Mamiya, MS CCC-SLP

VA, Puget Sound Healthcare System

Trish W. Cavanagh, MS, CCC-SLP, BCS-S San Francisco VA Health Care

System

Disclosures

• No relevant financial or non financial relationships to disclose

• The views discussed are based on personal experiences and opinion, and do not necessarily reflect those of the Department of Veterans Affairs. The information is not intended to substitute for or provide specific treatment recommendations.

Things to Discuss

• Modalities of virtual care

• Benefits for use of CVT

• Evidence for use in assessment, treatment and management of dysphagia

• Practical applications for use of CVT

• Next generation of CVT devices

Chefs for Seniors, Madison WI

• Drop-In Chefs Help Seniors Stay in Their Own Homes

– A million seniors may be malnourished in their own homes, and 50% in long-term care facilities

• Leads to illness, frailty and falls

• Chefs go to client’s home and cook healthful meals and avoid assisted living and poss improved health

Jaffe, I. (Narrator). (2015, April 27). Drop-In Chefs Help Seniors Stay in Their Own Homes [Radio broadcast episode]. In E. McDonnell (Producer), Morning Edition. Washington, DC: National Public Radio.

Chefs for Seniors, Madison WI

• Impetus was Nathan Allman’s grandmother that was in an assisted living facility

• Clients pay 45-75$ per week on ave for the service

– 15$ for grocery shopping

– 30$ for cooking and cleaning

• Provides services for those with severe disabilities or that are on hospice care

Jaffe, I. (Narrator). (2015, April 27). Drop-In Chefs Help Seniors Stay in Their Own Homes [Radio broadcast episode]. In E. McDonnell (Producer), Morning Edition. Washington, DC: National Public Radio.

Chefs for Seniors, Madison WI

• What other things might we be able to provide in the home?

• “Health Buddies” and CCHT monitoring replaced by new CVT Tablets

– Vital signs monitoring

– CVT to home via one button access

• Nursing care

• Rehab Therapies

• MD

• Mental Health

Virtual Care

• eHealth

– Telehealth • CVT, Store and Forward, Mobile health

– Electronic medical records • VA Blue Button, MyhealthEvet

– Tech supported consumer education and training

– Secure Messaging

Ward, E. C., and van As-Brooks, C. J. (2014). Head and neck cancer: treatment, rehabilitation and outcomes. San Diego: Plural Publishing.

Delivery of Telehealth Modes

• Synchronous

– Clinical Video Telehealth (CVT)

• Asynchronous

– Store and forward

– Shared drives

– VA Intranet

– Email and Secure Messaging

– Home/Remote monitoring

– Apps both for patients and providers

Ward, E. C., and van As-Brooks, C. J. (2014). Head and neck cancer: treatment, rehabilitation and outcomes. San Diego: Plural Publishing.

Clinical Video Telehealth (CVT)

• Teleconsultation

– Guidance for procedures requiring specialized skills/knowledge

– Interface with cohorts/colleagues

• Telerehabilitation or Telemedicine

– Provision of treatment/assessment using clinical video telehealth services

• Store and Forward

Some Applications for Speech Pathology

• Aphasia

• Motor speech/

Voice Banking

• Voice Therapy

• Fluency

• Dysphagia

• Cognitive rehab

• Social Communication

http://roadwidows.com/2013/02/22/dinner-date-across-the-pond

Mashima , P. A. and Doarn, C. R. (2008) . Overview of telehealth activities in speech-language pathology. Telemedicine and e-Health, 14(10): 1101-1117

Is there a Need for CVT in Management of Dysphagia?

“Tele-dysphagia management has the potential to increase patients’ survival, enhance the expertise of primary, local clinicians, and reduce healthcare costs. Even a modest reduction in either hospital admissions for aspiration pneumonia, or in the length of stay for AP, could save the US health care system hundreds of millions of dollars each year. Wide spread tele-dysphagia management offers significant opportunities for prevention, cost-savings and advanced training, and is therefore worthy of consideration by stakeholders in the health care system and university training programs.” Coyle J. (2012). Tele-dysphagia management: An opportunity for prevention, cost savings and advanced training. Int J Telerehabilitation; 4:37–39.

Is there a Need for CVT in Assessment, Treatment and Management of Dysphagia?

• A clinical report describes a method to address geographic challenges and gaps in training and skill sets

– University of Kansas SLP to rural site

– Rural site SLP had little training with VFSS

– Emulated Perlman and Witthawaskul (2002) • Remote interactive VFSS with CVT viewing the image from

fluoroscope

Georges, J. , Belz, N. & Potter, K. (2006, November 07). Telepractice Program for Dysphagia : Urban and Rural Perspectives From Kansas. The ASHA Leader.

Potential Benefits

– COMFORT Willock, S., Cavanaugh, P. (2015) TeleProvider Hot Topics and Best Practices: CVT into the Home. Lecture during EES Conference call April. Tacoma, WA and San Francisco, CA.

– Saves time, energy, money, emotional reserve

– Increases access, reduces delay, provides opportunity to treat in the home (natural environment)

Schwamm, L. H., Holloway, R. G., et al. (2009). A Review of the Evidence for the Use of Telemedicine Within Stroke Systems of Care: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke, 40(7), 2616-2634.

Potential Benefits

• Able to visualize facial expression and gestures to enhance communication and build therapeutic rapport

• Useful for observation of home environ for distractions and to optimize or modify the environment if needed

• May increase opportunities to provide training for family and caregivers unable to come to sessions, physically

• It might be “green” as some consider carbon footprint

Potential Benefits

• CVT may already be in place if a patient is seen as part of interdisciplinary team, or we may already be using CVT for other treatment purposes

• May be conducted from off-site location to patient’s home to free up treatment space at facility, and providers may be more inclined to offer more flexible hours for clinics

• Evidence that CVT may be used to train metacognitive strategies, and behavior patterns

Ng, E. M., Polatajko, H. J., Marziali, E., Hunt, A., & Dawson, D. R. (2013). Telerehabilitation for addressing executive dysfunction after traumatic brain injury. Brain injury, 27(5), 548-564.

Potential Barriers

• Patient preference and comfort

• Reduced resolution/sound/flexibility

– Bandwidth

– lighting

• Tech support

• Tech acumen or skill

• Paperwork Barrier

Patient Preferences Re: CVT Use During Assessment of Dysphagia

• Sharma et al. addressed perceptions of 40 pts with dysphagia before and after CVT sessions

• Assessed comfort and satisfaction, perceived benefit, and pt’s ultimate choice in tx modality

• Most felt comfortable with CVT, but about half then indicated preference for face to face assessment

Sharma, S., Ward, E. C., Theodoros, D., and Russell, T. (2013). Assessing dysphagia via telerehabilitation: patient perceptions and satisfaction. International Journal of Speech-Language Pathology 12(2): 176

CVT and Clinical Swallow Evaluations

• Feasibility and validity of doing a CSE via CVT

• Ward et al. noting good agreement during CSE when comparing face to face and online

– Decisions for oral/non-oral intake and safe food and fluid consistencies had high levels of agreement

– The levels of agreement remained despite varying severity of dysphagia

– Stressed the import of flexible camera and zoom and high fidelity sound recording

Ward E.C., Sharma S., Burns C., Theodoros D. G., Russell T. (2012) Validity of conducting clinical dysphagia assessments with patients with normal to mild cognitive impairments via telerehabilitation. Dysphagia; 27:460–472.

Ward, E. C., Burns, C. L., Theodoros, D. G. & Russell, T. G. (2014). Impact of dysphagia severity on clinical decision making via telerehabilitation. Telemedicine and e-Health, 20 (4). Advance online publication.

CVT and Instrumental Swallow Evaluations

• Perlman and Witthawaskul (2002) – PC and web cams and speaker phones

– Clinicians viewed and directed VFSS remotely

– Concluded adequate ability to provide remote care, and to provide training

Perlman, A.L., & Witthawaskul, W. (2002). Real-time remote telefluoroscopic assessment of patients with dysphagia. Dysphagia, 17, 162–167.

• Malandraki et al. (2011) – 32 pts with dysphagia

– Found some tech limitations at 2002 might have affected ability to accurately interpret VFSS

Malandraki, G.A., McCullough, G., He, X., McWeeny, E., & Perlman, A.L. (2011). Teledynamic evaluation of oropharyngeal swallowing. Journal of Speech Language and Hearing Research, 54, 1485-1496.

CVT and Instrumental Swallow Evaluations: Store and Forward

• Store and Forward, and Teleconsultation Malandranki (2013)

• VFSS in face to face with novice clinician and later reviewed by expert clinician

• Disparity in judgement highlighted value in using asynchronous teleconsultation in evaluation of VFSS and subsequent tx planning

Malandraki, G.A., Markaki, V., Georgopoulos, V.C., Bauer, J.L., Kalogeropoulos, I., & Nanas, S. (2013). An international pilot study of asynchronous teleconsultation for oropharyngeal dysphagia. Journal of Telemedicine and Telecare, 19, 75-79.

CVT and FEES

• Dorrian et al. (2009) trained two PC MDs to pass endoscopes, while Otolaryngologists were observing online between Shetland Is. and Aberdeen

• 42 patients seen, no dx were altered

• 20 patients seen 2 mos and 6 mos after initial for safety

• Olympus laryngoscope images via s-video through Tandberg videoconferencing unit at 384 kbit/s

Dorrian, c., Ferguson, J., Ah-See, K., Barr, C., Lalla, K., van der Pol, M., Mckenzie, L. Wooton, R. (2009). Head and neck cancer assessment by flexible endoscopy and telemedicine. Journal of Telemedicine and Telecare, 15, 118-121.

Dysphagia Rehabilitation via CVT

• Burns et al. 2012 noting CVT facility to facility for dysphagic pts after H&N Ca tx including laryngectomy

– Using a medical cart unit with an exam camera to view close ups of the oral cavity, tongue/palate, stoma and TE Puncture regions

– Novice on pt side and expert on other site

– 15 Patients reportedly managed succesfully

• EL training, voice restoration management and for some dysphagia rehabilitation

Burns CL, Ward EC, Hill AJ, Malcolm K, Bassett L, Kenny LM, Greenup P. A pilot trial of a speech pathology telehealth service for head and neck cancer patients. J Telemed Telecare 2012; 18: 443-446

Dysphagia Rehabilitation via CVT

• Current study is underway using Burns model 2012

– Multisite telehealth service with H & N CA patients

– Incorporating dysphagia assessment and management

• Implement, monitor and review – Oromotor exercises

– Trismus tx

– Swallowing exercises

Expansion of our CVT Program

• Completed encounters working with folks inside and outside our catchment area via CVT to other facilities

– Seattle to Walla Walla, VAMC and Lewiston, ID CBOC

• Exploring use of CVT in the home

– In our catchment area

– With folks in other states

Some Practical Uses for CVT • Store and forward to share findings and

discuss recommendations with other sites and providers, and during Otolaryngology and Speech Pathology Rounds

– Aids in education for all involved, and gets everyone on the same page in a low key atmosphere and manner

– Results in consolidation of more resources, and fosters motivation to problem solve collaboratively

Some Practical Uses for CVT

• Swallow follow up visits, and use of QOL outcome measures

– Patients with chronic or neurodegenerative dz processes (ALS, MS, Parkinsons, and etc…) that we know will decline in function or that might need long-time support

– In conjunction with other procedures, LSVT, use of AAC or AT, and cognitive issues, and for education of caregivers

Some Practical Uses for CVT • Receipt of training and education

– Use of Swallow Strong with Ray Heller and Jacqueline Hind, Lingraphica Touch/All Talk

– Grand Rounds discussions and teleconferences

• Provision of training and education

– Swallowing exercises in patient’s environment

• Use of instrumental biofeedback

– Safe swallow guidelines in patient’s environment- the dining experience

– Pre and post medico-surgical intervention counseling and education

Some Practical Uses for CVT • Nurture intrinsic motivation to engage in

therapeutic endeavors

– Patients may be isolated, and/or may feel misunderstood

– Patients may need more opportunities in their environment to:

• Practice to transfer/implement their skills

• Exhibit their competence

• Counseling to address psychological barriers to progressing with treatment

Some Practical Uses for CVT

• Groups and inclusion of folks with difficulty traveling

– Voice Message Banking, Cognitive Skills Groups, H&N CA groups

• Co-treatments

– Inter and intra disciplinary

What is Around the Bend?

• CVT Patient Tablet

– Cellular service

– Table top

– Clinician generated calls via Jabber and SIP or alias, user friendly, screen share

– Peripherals

• Exam cam, pulse ox, blood pressure cuff, stethoscope

• CVT Patient Tablet M

– Portable tablet

References

• Burns CL, Ward EC, Hill AJ, Malcolm K, Bassett L, Kenny LM, Greenup P. A pilot trial of a speech pathology telehealth service for head and neck cancer patients. J Telemed Telecare 2012; 18: 443-446

• Coyle J. (2012). Tele-dysphagia management: An opportunity for prevention, cost savings and advanced training. Int J Telerehabilitation; 4:37–39.

• Dorrian, c., Ferguson, J., Ah-See, K., Barr, C., Lalla, K., van der Pol, M., Mckenzie, L. Wooton, R. (2009). Head and neck cancer assessment by flexible endoscopy and telemedicine. Journal of Telemedicine and Telecare, 15, 118-121.

• Georges, J. , Belz, N. & Potter, K. (2006, November 07). Telepractice Program for Dysphagia : Urban and Rural Perspectives From Kansas. The ASHA Leader.

References

• Jaffe, I. (Narrator). (2015, April 27). Drop-In Chefs Help Seniors Stay in Their Own Homes [Radio broadcast episode]. In E. McDonnell (Producer), Morning Edition. Washington, DC: National Public Radio.

• Malandraki, G.A., Markaki, V., Georgopoulos, V.C., Bauer, J.L., Kalogeropoulos, I., & Nanas, S. (2013). An international pilot study of asynchronous teleconsultation for oropharyngeal dysphagia. Journal of Telemedicine and Telecare, 19, 75-79.

• Malandraki, G.A., McCullough, G., He, X., McWeeny, E., & Perlman, A.L. (2011). Teledynamic evaluation of oropharyngeal swallowing. Journal of Speech Language and Hearing Research, 54, 1485-1496.

• Mashima , P. A. and Doarn, C. R. (2008) . Overview of telehealth activities in speech-language pathology. Telemedicine and e-Health, 14(10): 1101-1117

References

• Ng, E. M., Polatajko, H. J., Marziali, E., Hunt, A., & Dawson, D. R. (2013). Telerehabilitation for addressing executive dysfunction after traumatic brain injury. Brain injury, 27(5), 548-564.

• Schwamm, L. H., Holloway, R. G., et al. (2009). A Review of the Evidence for the Use of Telemedicine Within Stroke Systems of Care: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke, 40(7), 2616-2634.

• Sharma, S., Ward, E. C., Theodoros, D., and Russell, T. (2013). Assessing dysphagia via telerehabilitation: patient perceptions and satisfaction. International Journal of Speech-Language Pathology 12(2): 176

• Ward, E. C., and van As-Brooks, C. J. (2014). Head and neck cancer: treatment, rehabilitation and outcomes. San Diego: Plural Publishing.

References

• Ward E.C., Sharma S., Burns C., Theodoros D. G., Russell T. (2012) Validity of conducting clinical dysphagia assessments with patients with normal to mild cognitive impairments via telerehabilitation. Dysphagia; 27:460–472.

• Ward, E. C., Burns, C. L., Theodoros, D. G. & Russell, T. G. (2014). Impact of dysphagia severity on clinical decision making via telerehabilitation. Telemedicine and e-Health, 20 (4). Advance online publication.