ROUGHLY EDITED COPY

2015 EHDI CONFERENCE

A Report on the Effectiveness of Tele-Intervention Using Real-Time Embedded Coaching

March 10, 2015, 1:45 P.M.

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Welcome to 2015 EHDI!"A Report on the Effectiveness of Tele-Intervention Using

Real-Time Embedded Coaching.">> BETSY MOOG BROOKS: I'm going to go ahead and get started.

My name is Betsy Moog Brooks. And I'm from the Moog Center for Deaf Education, which is a private school in St. Louis that teaches children with hearing loss to talk. And we serve children between birth and around 9 years old.

We're also a model program for six other programs in the United States and a program in South America, and what that means is that we develop curricula and then disseminate it to those programs and they provide services similar to what we do in St. Louis. One of the things we pride ourselves in is being innovative and progressive, so related to teleintervention, we decided that we should investigate it and evaluate its efficiency and whether or not it could be an appropriate means of service delivery.

And one of the reasons why I was so interested in it is because I was absolutely sure that there was no way that we could be as effective via the internet as we are person to person. So we had lots and lots of experience, for many, many years, providing service face to face, and as people became -- became popular to try to implement teleintervention, we couldn't imagine it wouldn't be a good idea if we could touch the children or help the parents by being there physically.

The end of the story is, I was completely wrong, and it is not only a great means of providing service but we actually, as I'll tell you towards the end of the presentation, we've changed some of the ways that we do our face-to-face services as a result of what we learned by providing teletherapy.

So we engaged in a project that was funded by the Oberkotter Foundation, and what I'm going to do is go over the purpose of the project and describe the project. One of the key ways that we deliver service is real time embedded coaching, so we'll explain that concept, talk about the results, the lessons learned, and then some of the parent perspectives, and some of the parents who actually participated in it are here, so if the questions are appropriate, perhaps they'll be the ones answering them. That was a shock to them. They're now shaking.

All right. The purpose of the project is, as I said, we really wanted to investigate, could we come up with a means of service versus the internet that could be effective and have quality outcomes for the children. So we were pilot testing the program as we made up as we went along for children 0 to 3 and their families. And as a part of it, we were measuring progress in children and in parents. I'm mostly today going to report on the progress of the children and the progress of the parents is

reported in their comments, though they're here, so they can tell you if they achieved progress. And it was, as I said, to determine in teleintervention would be an effective measure of service.

So we embarked on the project, thinking it would be a 12-month project, but on the front end, it took longer to engage families, so it ended up being a 15-month process. So there were ten families that participated, and in order to get the project started, we had the families come to the Moog Center in St. Louis from wherever they lived and we spent two days with them, and I'll tell you a little bit about that in a minute.

The teleintervention was provided to match the service that we provide face to face in the sense that for children who are between 12 and 18 months old, we typically are providing one hour of face to face parent support, including that coaching piece, and for children 0 to 3, most are interesting a center-based program and the parents come once a week and get 30 minutes of coaching and so we took that 30 minutes once a week and it's two hours, you know, it comes out to be two hours a month, so we made that be two times per week to try to match the same amount of service. The children coming to the center were getting an hour of therapy from a teacher plus 30 minutes a week of parent coaching. So there was more service to the children coming to the center.

And then at the end of the project, we did a wrap-up session with all the parents coming to St. Louis, and we did post-testing on the children and met with the parents. And I'm not going to really talk about the -- I'm going to talk about the results of the children but not really describe the wrap-up session. If someone is interested, you can talk to me about it.

The sessions, all of the online sessions lasted about 60 minutes. Sometimes they were a little bit shorter, depending on if something went awry. All involved realtime-embedded coaching, which I will describe, and in addition to that, they met to discuss how it was going because I imposed my bias on them saying, I don't think this will work, so it was to troubleshoot our bias about the project and figure out a way to make things work.

So we went into the project not knowing how the parents were going to engage their children in activities when we couldn't be there to support that. So in face-to-face sessions, those of you who provide those know, if a child gets fussy and you're trying to explain something to the parents, as the provider, you just take the child and engage the child and play while you're talking to the parents, so you're not distracted by the child, but then neither is the parent, because you've engaged the child.

So now we have a situation where the parent and the child, you know, you can't get to them, so the parent is going to have to keep the child engaged. Otherwise, the child will get up and leave. So those are the things that we were worried about on the front end that actually, quite quickly, were dispelled and somehow the parents figured it out and we learned more from them than they learned from us because they learned the ways to keep the children engaged since they had to do that.

So for the realtime-embedded coaching, the concepts, most of them come from Rush and Sheldon, and Rush and Sheldon have a specific protocol for how they suggest that people do interactive sessions for providing parents support. And many years ago, we switched over to this approach, or most of this approach, about eight, maybe nine years ago. And at that time when we switched over to coaching the parents in this way, I actually thought that I was brilliant and I had an idea that no one else had. And then in 2011, Rush and Sheldon came out with a book, and they had all my ideas but came out with a book, so I don't get any credit. In any event, they do have some great ideas that they've written about that we hadn't thought of and that we weren't doing at the time. And one of them is this reflection piece and the other is the feedback and joint planning.

So we, in our face-to-face sessions, have always engaged the parents in joint planning, though if we had video or audio recordings to go back and analyze, I think we were very specific about guiding that joint planning, that we weren't willing to give up the responsibility. And what we've had to learn when people talk about adult learners is a trust of our learner, that, you know, people do a lot of talking about that these are adults, we should treat them like adults, but nobody ever goes into that what actually means.

And I think one of the biggest components of that is trusting your parents. If you ask them to bring an activity to the table, you should trust that they'll show up with an activity. If they don't show up with an activity, what we should do historically is rescue them, to pull something out of the bag to do what they did with the child, because we really don't trust them, because if we did trust them, we wouldn't have brought the activity, okay?

When we talk about adult learners, we need to go down that route of, if you trust them, they will be responsible. It's a little bit like your children. If you let them go, they will be okay. So I think that when we talk about the adults, that is one of the flaws that we had is that some of the providers were still hiding things in their bags, just in case.

So what happened is, with the teletherapy families, there is no opportunity for that. You cannot send them the materials via the internet while talking to them. So if they decided to show up without materials, they would have been sunk. And I think that the participants in the project were so interested in helping us, I think one piece was to help us, the services were provided for free, because it was a project, so I think there was some level of participation on their part to be good participants.

We didn't ask much, but we did ask them to come to St. Louis twice, so that's kind of a obligation, and I think the relationships developed so quickly because we had one on the front end, and there was a responsibility not to let us down. So we didn't say, we're not going to be able to help you so you need to be prepared, and everyone did. I don't know how to tell you how to make that happen, although they did. I think it was the trust, we conveyed, we're going to believe in you and whatever you bring will be fine and we made that work.

Besides that, we've always done joint planning, as I said, for these eight years and making sure with the parents that we have planned with them is going to be okay. So you sort of have to have an agenda to your session. The agreement is to tell the parent the agenda and then to move forward.

In the case of these sessions, what happened was, we could not have an agenda. After probably the first or second session with most families, when the computer went on and if the family logged on or however they were doing, the child was already at the table, so there was not a moment for discussion because if we started talking, we would lose the child. So the parents had four items lined up on a table adjacent to wherever they were working, outside of reach of the child, and the computer would come on and we would just have to get started. That's how it happened. And the parents figured it out. All ten parents did the exact same thing. They all came prepared. They all had the items on a table. They were all lined up in order. It just happened.

The reflection piece is something that is written extensively in Rush and Sheldon and it's something that we were not doing. I think mostly because I was afraid of how parents liked it, I wouldn't like the answer, so I didn't impose it on my staff, if we didn't like the answer or just avoid it and then you don't have to worry about it. So we avoided it for a long time until I did a lot of reading and decided this was a huge component that they were really, really missing. So the reflection became a mandate in this project. And we've only been doing it since January of 2013. Yes. January of 2013.

And with that reflection, then, comes following the parents' reflection comes the feedback from the provider.

Okay. And I'm now going to go through each of these and show video to -- to illustrate, thank you, to illustrate each of the comments. It's after lunch, I ate a hamburger, now I want to go to sleep. I'll try to keep you awake by interspersing video. The computer pops on, the family says hello, and right away, the provider is asking, what do you have planned for today? And the parent describes what the activities are and what they want to work on.

So I'm going to talk, before we get to the videos, I'll talk about the kinds of things that the parent might be saying that he or she is going to work on. But this is the -- the onset is telling us the activity and then telling us what they're going to work on, and that might be a language structure, but it might not be. It might be behavior, just managing the child's behavior. It might be working on, for a child who hasn't yet established it, it could be turn-taking, it could be wait time, it could be eye contact. So there are a lot of other things besides just modeling appropriate language and trying to get that language from the child.

And some of the time you'll see in the examples that after the parent provides what she is intending or he is intending to do, then the provider will add other things on, to remind the parent that these are things that he or she could be working on.

So in my message to you, you need to decide the focus of the session before you start. Remember, the child's seated there, and it's just like if you're on the phone. Once you start talking to each other and ignoring the child, all the bad behavior is going to start because the child wants your attention. So the parent has to have already figured out before you arrive at the session what it is that he or she is planning on doing. So once you get this process started, it becomes a cycle.

At the end of the session here, you joint plan for the following session, and we always send notes. You'll see in one of the videos, the provider is actually talking while she's talking and the camera is over her shoulder, so you can see she's typing. So she's taking notes on what's happening so at the end of the session, she can send the notes to the parent and they can do a joint planning session via e-mail so when it comes up, they don't have to have a full discussion. They had that discussion a few days before or a week before.

One of the things we really changed in the last three or four years, but it really became obvious in some other things unrelated to teletherapy is that when one is trying to train an adult how to do something, we really need to be very focused on

only teaching that person one thing at a time. And I think that when you think about, if you were a student teacher or you have student teachers now, that what happens is we feel so hurried to teach them everything we know that we can't teach them one thing at a time, and if we taught them one thing at a time, we could add to acquisition of skills by stair stepping rather than giving them so much at one time.

We have a program in South America, in Argentina, and I can understand the Spanish, but I can't conjugate the verbs fast enough to explain, and there's a woman with Spanish as her native language, so she travels with me as the interpreter, but in this function, she only says what I tell her to say because she was functioning as the interpreter. So we were trying to teach coaching to some advisory staff, so you can imagine, the teacher is teaching, the supervisor is sitting here, but in order to do that, the interpreter has to say what comes out of my mouth, into her mouth, into the coach and into the teacher.

So the time delay is actually worse than teletherapy, okay? And this is really how it happened. It was so apparent that if we tried to focus on more than one thing, we couldn't. Because for the time for me to have an idea to get it through all the people to get to the person, we had lost the moment. And it became a great example of how hard that is because it caused us to stop doing it and we decided, okay, we can only work on one thing because we can't make the message go through four people fast enough. And immediately, it became crystal clear that working on one thing was so apparent rather than working on more than one thing.

So the coach would pick a second thing and I couldn't talk fast enough to the interpreter. No is no, but the person who had already said it -- so I just started hitting her. So by the time in Argentina, my leg, my leg! She was smacking the person next to her and when we met with the teachers afterwards, right away, they said the greatest change was only working on one thing. That it increased their confidence significantly by only working on one thing and focusing on one thing, and it allowed them to learn it and get so much positive feedback because they only had to focus on one thing.

So we have a rule, you know, you can only focus on one thing, but the thing to know is, if you only focus on one thing, you will absolutely focus on two. Nobody can help themselves. So you have to tell yourself, I'm only going to focus on one thing, and maybe you'll be able to focus on only two. You see an opportunity and you can't turn it down, but you should. Trust that your learner can learn, as long as you don't overwhelm them.

So I think that's important to state, to keep your focus, and in doing so, you will build the parent confidence, and in doing so, to build the child's confidence, because you will see so much more success.

When we talk about deciding what to focus on, another thing that you need to do, because we're going to embed the coaching in the actual activity, you need to be careful to explain to the person you're coaching to tell them what to say. If you think about that chain of four people, if I give a big, long explanation, by the time I say something, the moment is lost. The same thing is going to happen in teletherapy. The parent can't stop while you're getting your thoughts together, so you need to make sure you've addressed what you need to say ahead of time.

An example would be if for the activity you've decided the parent says, look, I just really want to practice my modeling. I feel like we were doing eye contact before and I did a great job doing eye contact, but I feel like I'm hyper focused trying to get my child to watch and I'm not modeling the words. So I want to provide a model. As a coach, I would be saying, okay, here's what we need to do. If you forget to model a word, I'm simply going to say "model." So very quickly, you'll know, I need to give a model. Or "be sure to model." If I can see in your eyes that you're looking hesitant. Or I might give you the word. If I'm afraid the moment is going to leave, I might say "model" and then the word. If you tell them what's going to happen, they won't jump out of their skin, that you'll be supporting them. That's very, very important.

If you were focusing on encouraging the child to talk, like the parent says, I feel like I'm doing a great job modeling, but I'm not getting anything back. I really want the child to give me something back. The first thing we would think of is you're not waiting long enough. So you would be able to say at the front of the lesson, then we'll work on wait time. Wait. Wait. Don't talk. Wait. And remind you that it's okay not to say anything. That would help you, wait, and then hopefully something will happen and you'll see the benefit of that. So it's those kind of instructions, if you say don't talk, some might burst into tears because you told them to talk and they're all anxious. If you set that up ahead of time, that will help them.

When we talk about the areas to address, I've broken language up into some categories. So you have the child who is prelingual, so there are no words. This is not going to be an exhaustive list. If you want an exhaustive list or a semi exhaustive list, send me an e-mail and I'll send it to you. But for a child with no words, work on positioning. That might be

figuring out where the best place to be in certain situations and that might be what you're focusing on. They're going to do four different activities and you'll give them the access to the sound or if it's for lip reading, whatever it is that you're trying to do.

It may be that you're going to focus on eye contact, that that's something that the child hasn't yet established. Or it may be that you want the parent to be modeling or labeling using single words. So those are the kind of things you might be doing with a child with no words. For a child with single words and two-word combinations, when you think about the age of the child, this might be a behavior. The child may not stay as long as you want to model the activity, so they might be working on behavior.

You might be helping the parent model whatever they want to say, whether a single or a two-word combination. And you might be working on wait time. Those are things you could be doing.

The next level is simple sentences, so they're stringing words together and you might be helping the parent just insert a verb. That may be what you're wanting to do, using a subject or verb and this is the point where parents starts to say, mommy juice, and leave out the other part of the English language that make that a correct utterance, so you might be sure that the model is grammatically correct.

It may be that the child has great vocabulary and really what you need to do is switch the parent over to using higher-level vocabulary, so working on alternate words for whatever the parent is doing.

Or you might be working on turn-taking, and that would go back to the pausing and the wait time.

At the simple and the complex level, you'll probably be working on filling in the missing pieces and working on the child's utterance to get it up to six words, okay? You might also be trying to expand that to complex language and working on conjunctions.

So as I said before, you're going to explain the expectations and explain them clearly on the front end before you start the coaching session. So you're going to state exactly what you're going to do. We're going to work on managing behaviors, you're going to provide examples of the words you use, as I said before, and you want to make sure you provide an example before the activity begins of what you're expecting the parent to do. If you're expecting the parent to withhold a toy, you need to tell them that before so you're not putting things on them in the midst of what's going on. And another reminder, stay focused and concentrate on only one thing.

So this is going to be joint planning. So this is going to be the camera comes on, the mom said hello, and now we're going to move into what she has planned for her activities. So this little girl is Hattie. She is 29 months old in this video. She was bilaterally implanted at ten months. And I don't know her IQ, but I'm guessing it's above average, based on what you're going to see happen, although you're not going to say anything in this tape. You're not going on see it. For the captioner, the video is captioned.

(Video)>> BETSY MOOG BROOKS: Okay. So that is an example of doing

what she's going to do, very quickly, and I respond how I'm going to react or guide her.

The next one is with Harrison. He's three years old at the time of this. He has a mild to moderate hearing loss and is using hearing aids and I'm telling you that so you'll understand more about what it is she's going to be doing.

(Video)>> BETSY MOOG BROOKS: Okay. So let me explain about the

teacher. What she has done, using the computer, she's communicating via the computer, but she's brought up a Word document on the computer which is allowing her to take notes of that's going on while the event is going on. Not everybody is able to type while this is going on simultaneously, but for those who are, it's a huge time-saver. I can almost transcribe the session so at the end, I just have to go back and analyze them what's going on. If I've typed down the utterances, I can analyze them for the mom and say, okay, look, she produced four new adjectives that she hadn't used or the last three weeks, I've only been typing, go back and look at your notes, she had three-word combinations and this week, she did four-word advantages. If you can type, it's a great advantage, but not many can type and do the coaching and get all that accomplished simultaneously, but that's what she's doing in this particular event.

So you can see that the mom came to the event with an idea of what she wanted to do. She had all the materials ready, but she wasn't exactly sure of the language. So the teacher allowed her to say what she wanted to do and then helped guide her beyond that. At one point she said, what else? So she gave her an opportunity to think about it and know that there was more to what she was doing and that's the training process. You can't expect the parents to come, understanding all the things they're going to say about what they want to do, so you have to guide them through that.

All right. This is going to be Megan at 33 months old. Megan had meningitis at 21 months and then was bilateral

implanted immediately thereafter. (Video) that was it. The provider didn't have anything else to add on, the provider came, mom knew it. We're done. Sometimes it takes a minute. Sometimes it takes a few seconds to get that started. In the case of Harrison, it would have been better if we started it in a few seconds. You could see, right away, the behaviors were starting because the parent and the provider were having a conversation.

Let's talk about the realtime-embedded coaching. The idea of providing supporting through suggestions while the parent is engaging in an activity with the child, okay? So it's going to happen while the parent is talking to the child. And the purpose of it is to increase the independence within the individual or the parent, therefore reducing the parent's reliance on professionals to teach their child.

And I think this second point is just so important. That the parents are with their children, theoretically, all the time, and in our traditional sort of coaching or parent support, we sort of swooped into the house, gave a 60-minute session, interacted a lot with the child, maybe gave some information with the parent, and then with the toys that we just demonstrated, we left the house, left the parent without -- there was no way to imitate or continue to practice what we just did because we brought the materials and then we took the materials.

Then we sort of got better about that, someone wrote that that we weren't able to bring toys into the house anymore and we kept them in the trunk of our cars unless we needed them, and then we went and got them. So we got better, but we didn't change our delivery style. So we came in and decided what we were going to use within the house. We still picked the activity and did it, I guess thinking that when we left, they could do what we did. But we still weren't telling the parents how to do it. We were talking at them, and worse than that, talking about how knowledgeable we were, and the parent is very proud of all the things their child can do in our presence, and then we leave, and I'm guessing in many houses across America, mothers sat and cried because they couldn't do what we just did when we were in their home, which of course they couldn't, because we went to school to learn how to do that and by the act of showing them, they should get it in two years of graduate school and I'm not sure why it's taken us 100 years to figure out that wasn't a good approach, but it has, and at least now we know.

And as the speaker -- was that just this morning, let's not use the stuff we learned in the '80s when it's 2015 -- doesn't it seem like that was a week ago? So just this morning, that

was just hours ago, I think that's the way we need to be thinking. It's okay to move on. It's okay to move on. There are better ways, and more effective ways, and so now, you know, we need to lock the trunk so we don't actually have access to the toys if we feel compelled to carry them and let the parents take control. I think by letting them take control, there's a lot more accountability.

The parents are going to want the children to be significantly more successful if they decide what to do with the child, and if we allow them to have a lot of activities and not just one activity, they can switch it up a little bit. We as therapists know, if this isn't working, put it away. But what we model for the parents, this is what you should be doing in my absence, and if it doesn't work, good luck, because next week I'm going to watch you do it because this is what we thought we were going to do. So this allowing the parent to be accountable will allow them to develop much more independence than how we had previously been doing.

So the goal as a coach is to build the parent confidence and self-esteem. And I don't think this is new. I think we always thought they were building confidence and self-esteem. I think our approach might have been askew. To build parent self-confidence. That's going to help automatically if they interact with the child rather than you interacting with the child and they watch.

And then to help the parents recognize their skills and strengths. So you're going to hear the coach say, that was a great job, you did a really good job, to remind the parents, those are good things. You should keep doing those. And then I think one of the most interesting things to me throughout the whole process was both of the parents with whom I worked with for this project were incredibly talented in implementing whatever I suggested. They really did trust me and respected what I said and implemented anything that I told them to do. They were very, very talented, had two different kinds of children, but both were actually good with the children.

At the end of many sessions, probably a third, as many as a half, they apologized for it not being a good session, and I think that it was their perspective that for instance in the video like where Harrison cried or was acting out a little bit. I'm guessing at the end of the session the only thing his mother thought was it didn't go well. So for me, because I was typing everything that happened at the end of the session I was able to say, you crack me up you think you didn't go well. Let me tell you all the amazing things that you did, because I was able to type those in, and all the amazing things that your child did. And every single time they were amazed that had happened.

And I bring that up because the old method was coaching was, we talked about it at the beginning, we observed and took notes, and then we talked about it in the end and for those parents doing incredible jobs and children making incredible progress, they perceived that everything in the middle didn't go well. By the time it was over, if we had talked about it at the end and I say, remember when you did X, Y, and Z? Here's a place you could have done P, D, and Q.

By the end of the session, they didn't remember X, Y, and Y or how to implement P, D, and Q. But they could fix it and at the end I could say, you remember when I said, do X, Y, and Z, you did this, and he did this, and they say, oh, my gosh, you're right, it was a good session. So the old way isn't an effective means of changing behavior, and it's obvious once you start doing it the other way.

So just as a review, you're going to coach a predetermined lesson. Now, of course, the parent has decided what that is. You're going to have goals and explain those goals so the parents are going to give you their goals and you might add on to those. You're going to provide the coaching throughout the activity and at the end, summarize and provide some positive feedback, and really, the parent is going to be doing the summarizing by talking about -- by reflecting.

Okay. So regarding making the suggestions, just to remind you, the parent has stated the focus at the beginning. The therapist is going to explain how they're going to make the corrections or make suggestions. It's very important to be clear and to be succinct. You can't give a big, long, eight or nine explanation or the moment will be lost. Use short phrases and sentences, make one suggestion at a time and be sure to focus on one element.

You need to be very specific when you're telling the directions. Tell the parent what to say or feed the parent the language, and if you can previously explain why, and I'm going to show you some examples. So our inclination is to say, good job, nice. And that's reaffirming. If in your head you thought that holding the toy in your hand and not giving it up was good and you said "good job" and the parent thought the model they provided was good, you haven't actually connected very well. It's a disconnect. So what you need to be careful to do is to provide that quick, positive comment followed by an explanation, so these are the explanations, he imitated the model, you corrected yourself, he provided a two-word model. Those kinds of things are what you want the parent to know. He provided a two-word model.

When you're doing face-to-face sessions, the timing is important, but you lean in to make a comment and the person

starts talking. There's all that body language that helps with the turn-taking. When you're doing teletherapy, the parent is usually not looking at you. You have to get your timing going or get your mojo going. There's got to be a connection. We had the advantage of meeting the parents two days before this and part of that two-day visit, we didn't simulate it, we actually did it.

We took the parents and the child in one room, the teacher in the other room, with the door closed between the rooms just to work on the synchronicity of getting the timing down, and a teacher got to go into the room and figure out what the child could be pushed to do so when the parent left, we know a starting place. And she also was able to provide two and sometimes three parent-support sessions face to face, providing this coaching. So a lot happened in those two days so sort of set the stage.

Now, since this project, we've engaged many other families in teleintervention, and we don't have the advantage of the two-day intro meeting, but I think everyone would say, this would sure be easier if we'd had a two-day intro meeting. It just sort of gets things going.

Okay. So this is going to be Harrison again, same videotape, just a different part of it, and now the teacher will be providing some coaching.

(Video)>> BETSY MOOG BROOKS: Okay. You saw she wasn't saying

anything for a while because the mom was doing a fine job. She was being coached for 12 months. But then there was a missed opportunity. He was saying messy and the parent wasn't pushing for it, so the therapist said, "make him say it." This was about expanding his utterances, and here the therapist was reminding her, this is what you wanted, so commit to it.

This is Hattie. What did she tell us she was going to do? They're playing with Play-Doh. Oh, yeah, expanding the utterances, three to four-word utterances. We'll watch that.

(Video)>> BETSY MOOG BROOKS: Okay. So you see how that's working,

I was giving hints, she was responding, and then when I was reinforcing the mom, I was saying, this is what you did something. and one time I told her to do something, and she never looked at the computer, she just said okay and implemented it in the next sentence.

So here comes the tough part. I wasn't good at using reflection before because I was afraid of it, but using it now, it has never backfired. Sometimes the parents aren't great at figuring out what they want to say. When you're doing it via teletherapy, there isn't a lot of time. Sometimes the

strategies that we use it when we're finished it we know we're to the point of reflection, sometimes we let the child down and the child can play, if the parent is comfortable with that. Sometimes we let the child eat or let them to have toys to keep them occupied while we're having a short conversation at the end of the session.

This is time to summarize what went on, if the parent thought it didn't go well, to summarize it. Ask the parent how they feel about the session, what was tricky. Maybe talk about what you're going to practice between now and the next session, and we need to plan at the end of this session what's going to happen for the next session so we don't have to suck up a lot of time when the child is ready to go talking about that.

So this is going to be the reflection, and I think the thing to get from that is how much information the parents are actually able to provide about what they say their child do or how they feel about what they did.

(Video)>> BETSY MOOG BROOKS: Okay, the teacher started to tell her

why it went well and caught herself.(Video)>> BETSY MOOG BROOKS: Okay. So you could see that the

provider was giving back a lot of positive things that had gone on. All right. I'm going to skip this one. I'll go back to it if at the end I'm not out of time. So when we talking about measuring output, it was the PLS-5 and the MacArthur-Bates Communication Development Inventories. All of the children made more than a year's progress in a year's time, which is what we want to happen, because we want to close the gap. Except one child that was already in the average range before the project started. The standard scores at the beginning of the project ranged from 60 to 102, and at the end of the project they ranged from 81 to 114. So that's quite nice. Shows some nice progress.

The PLS-5, of course, is not the greatest measure of what our children really can do, so we also looked at the MacArthur-Bates at the expressive component, and at the beginning the range of the children's expressive vocabulary, single-word vocabulary was between -- some of the children had 0 words and the highest child had 173. And at the end, the range was 206 to 606. So that's a nice change in the level of vocabulary.

The lessons learned, some of these, as I said on the front end, we did discover that teleintervention can be an effective means of service delivery. We also learned that we need a separate time to talk to the parents, that the time during the session, of course, we can't talk, and the parents agreed that we needed another opportunity to figure that out or to have a

conversation, and we still today are struggling to figure that out. If we have a 60-minute session, do we use 45 minutes of it for the teletherapy and schedule 15 minutes for another time? How do we balance that?

And as I said at the front end, what it did was force us to change our face-to-face sessions. One thing, we were sending them written notes after every session. In the face-to-face, we don't give them nearly the written note that we're giving to the teletherapy families, and by the nature of the beast, we were forcing the teletherapy families to be more accountable and we needed to change what we were doing face to face and make our face-to-face parents more accountable.

I'm going to go back. I think I'll -- well, does somebody have questions? Or would you rather see the video? You want the video? Okay. So here's this video.

(Video)>> BETSY MOOG BROOKS: Okay. So I'll just put this up.

These are just some comments from the parents that just can help you understand sort of their perspectives. So two of the parents are here, if you have any questions for them as well. But it's late in the day. Nobody fell asleep, so that's good.

Yes. So the question is funding, basically, how is this funded. So what happened in the state of Missouri -- right now, I don't know the exact number, but within the past six months, there have been at least seven states that have authorized teleintervention as an approved service from birth to three, and I worked it to be an approved service. So by the time the project ended and we ended in June and on June 1st, the state of Missouri made teleintervention an approved service for birth to three.

So it's not just for teachers of the Deaf or speech pathologist, it's all disciplines -- OTPT and everything. There are some things going on, and my guess is that in the next three years, everyone will have teletherapy as an approved service. The problem is, we can't wait three years. It wasn't an approved service. We had two grants that allowed us to give therapy to the families and now it is an approved service. I'm working on a different project now, training people to provide teletherapy and -- I don't know, four or five different states, and this is going to be very shocking, but it happened.

In Alabama, we're talking to a state School of the Deaf to start an oral classroom, so she is now a part of this teleintervention project. She went to the state School of the Deaf to ask for spoken language to be via in the state of Alabama and we're this close to getting it passed. I think there's something going on in New York as well.

There's -- what would you call it, a paper? What would you call the results from the multisite study? So there's NCHAM, had a report -- thank you. So NCHAM -- we were part of a multisite study with NCHAM, and there's a report of that study, so if you contact me, I might be able to get you the report, although I learned from the lead on it that the -- some of the tables, the numbers are wrong, so she has to get it reprinted with the right numbers before people start taking it to their states saying we want to get approved, because you would know the numbers are wrong because they don't make sense.

I think it's worth trying. When I called our state person to ask, how do I help other people make this happen, she said, literally, the thing to do is have a conversation. She said, just call the person that you think is the person you should be talking to about it. So in our state I went to the person responsible for our early intervention program, and I just said, what is this stand, what stand does Missouri have? She said, we don't have a stand. I said, we need to have one because we need to explain this service. So I wasn't the first person. I was just the worker bee that was going to help her collect her information to make a case. So I started feeding her information and it took about a year. So contact me if you --

>> AUDIENCE MEMBER: (Away from mic). Al.>> BETSY MOOG BROOKS: All right. Thank you.(Applause).I'm sorry, say it again? No, I won't be able to off the top

of my head. Okay. So Missouri is approved, Utah is approved. Oh, my gosh. I can't believe I don't know this off the top of my head. I do, but you shouldn't have asked me under pressure. Illinois is definitely not approved. Actually, I'm going to -- I have -- you know, quote, friends in Illinois who keep saying, please help us. So I just keep promising, responding by e-mail, oh, yeah, I'm on my way, and nothing happens. If I just had a fire lit under me, I would go straight to the governor's office and we could probably make it happen.

>> AUDIENCE MEMBER: (Away from mic).(End of session at 2:50 p.m.)

ROUGHLY EDITED COPY

2015 EHDI CONFERENCE

An AuD Practicum Experience that Addresses EHDI ProgramLost to Follow-Up Issues

March 10, 2015, 3:00 P.M.

REMOTE CART CAPTIONING PROVIDED BY:ALTERNATIVE COMMUNICATION SERVICES, LLC

P.O. BOX 278LOMBARD, IL 60148

***

This is being provided in a rough-draft format. Remote CART, Communication Access Realtime Translation, is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.

***

Welcome to 2015 EHDI!"An AuD Practicum Experience that Addresses EHDI Program Lost

to Follow-Up Issues.">> JULIE BEELER: Okay. We'll go ahead and get started.

Welcome, everybody, I'm glad you all came this afternoon. I'm one of the last standing. I was hoping because we were close to the snacks and the drinks for the afternoon that we would bring in more people, okay, I'll sit in this room close to the food. Anyway, I'm prepared for this. How about you, Claudia?

I'm Julie Beeler, I'm an audiologist with the Tennessee EHDI program, and my cohort is Claudia Weber, and we'll chat in tandem and talk about an AuD experience that focuses only on lost to follow-up and lost to documentation. Kind of a unique experience we'll share with you today. There's some acknowledgements. Claudia is at the top of the list, but it couldn't happen without Jacque Cundall supporting us and I want to give a shout-out to someone in the room making our phone calls for us. Hello, Kelly! She's newer, but we love what she does for us and are appreciative every day. So Patti Johnstone is the director of Clinical Education, and career -- Clinical Education and Services in Audiology.

Welcome. Hey, if you want to talk, you've got a microphone there too.

Let me give you all an idea of kind of where we've come from on Tennessee's EHDI program and how we've addressed the follow-up in the state. Traditionally, all along, our Part C program has been an integral part of the follow-up piece, so we've addressed, however, how we've done that follow-up very, very differently over the years. Okay? So I've given you just a few examples of in the beginning, not the beginning of EHDI for Tennessee, but in the beginning when we paid attention to what happened, after that screen, we have non-Part C districts in our state and the referrals went to the non-Part C districts and they got a clump of names they were expected to make follow-up calls on.

You can see my icon that I've got there. They were somewhat a part of the EHDI team, but were apart, so they're standing front word "team" but the system didn't work too well because they weren't involved with our EHDI team itself. So we want to a new system, we took a small team of centralized staff of people that were doing the follow-up calls at that point. But then we found somebody named Claudia Weber, and Claudia Weber is already working for the part-C program. She was not doing anything like that now, she was working in contracts, and we could take up the rest of the half hour about how boring that was. So when she had the chance to do something with us, she was like, I'm all about this. So that's our new approach. She

said she was a true -- you know what? When you turn -- you turn me off. So we're coming up with creative ways to supplement what she does because it's an absolute huge job.

In Tennessee, we have approximately 3,000 babies, give or take, who are referred to the Newborn Hearing Screening each year, so Claudia as a follow-up coordinator, she gets a sizable amount of those to track down, so I'll turn the floor over to Claudia for a second and she'll give you an idea of what living in her shoes is like.

>> CLAUDIA WEBER: Okay. I would say on a weekly basis, I am faced with about 200 people to call in a month. So give or take 50 calls a week and just to back up, giving you an overview of the state, we have a volunteer aspect to our state in which the department of health -- and thank you, Pam Isom for coming, she was with the Department of Health, and Pam and Jacque Cundall decided to shake hands with the lead agency for the Department of Intervention. So we share data, and in these phone calls I make, I am able to enter directly into the Department of Health database the results of what a parent or a provider tells me, whether it was a pass or whether it was another refer, so without having to make another spreadsheet, Julie knows at UT, they had a contract with the Department of Ed, and they did due diligence on these but they had to create their own reports and there's a lot of intensive time and effort on that. But I can just click into the Department of Health data and just sort of actually really closing a lot of kids that they passed. They passed their follow-up, did their follow-up, you know what it was. We put in that information.

But again, it's work intensive. It's data entry. The best part of the job of phone calls is to talk to parents and hear the little babies in their arms going coo, coo, ga, ga. I love those sounds. But the mothers don't remember leaving the hospital, much less that they had a piece of paper telling them where to go next. That's kind of like the volume to set you up for where you're talking about, the help that we're getting, volunteer wise.

>> JULIE BEELER: Thanks. You got it. So the idea of partnering with the university program to enlist assistance had really been considered in the past, and she's the one who thought of it in the past. We just took it to the next step. I had ties with the university. That's where I used to work. So I had a pretty good relationship with that clinical director of audiology and she happened to sit together as a conference in 2013, and she said, have you got any needs for our students? And I said, oh, yeah, I've got a need for the students. So what she explained, then, was that the new Casa, the knowledge and skills acquisition list includes competencies for graduate

students, and what better way through the EHDI project. So we have a way to focus loss to follow-up and lost to documentation efforts in Memphis, in the Western portion of our state and it's a unique area, and we have some concerns about getting babies back in for services in that region.

We also, of course, had the federal push in the most recent guidance EHDI-wise, saying, you know what, you've got to figure out quality improvement strategies to try to address lost to follow-up in documentation issues and partner with stakeholders in doing so. And then the other thing, we just had a sheer willingness. Everyone was open to the idea and the students -- we couldn't get them in fast enough.

What were some of the goals for the students themselves? We wanted to make sure we were offering an experience that was very meaningful, wanted to conduct effective follow-up calls with families and EHDI stakeholders with ease. We wanted them to use the clinical knowledge base that they had to field questions and educate families. We weren't using green students. We were using second and third-year students, to document effectively and maintain a database. This was an internal database, not the internal Newborn Hearing Screening database. It was something we came one ourselves to keep up with the input that we were receiving and develop a deeper understanding of the audiologist role. More than anything, we want them to take this away and work with the QI challenges that we were being faced with as to think about as they were developing this practicum along with me. It was a brand-new practicum experience. I wanted them to feel empowered by being a part of that. As they had hunches on ways to make some of the procedures that we were coming up with better, we just encouraged that and we taught them how to do the small test of change to do this more effectively.

So what were some of our considerations? We had to consider the student. What was the ideal year of the student, the time per week required, we had to think about the practicum, the time space available, resources available, was there a phone they could use, how about a filing cabinet and access to a computer, a fax machine, and a scanner? Those did seem like simple things, but I did have to consider them in advance. I was the supervisor. I had to be certified to do that. And what kind of time would it take? Would I be able to supervise a little bit more heavier in the beginning but be able to sit at my desk and have them do their work while I was multitasking? The other thing is, we did have to think about that region for phone calls. These are students who are located in Knoxville, Tennessee, which is in east Tennessee. We did not want them making calls on families that were from east Tennessee because we didn't want anybody looking at us as an EHDI program saying,

now, wait a minute, all of a sudden, UT audiology has this real burst of new appointments for newborn hearing follow-ups. Okay. We really wanted to reduce the chance that anybody could critique us and eliminate all possible conflicts of interest, so they called people on the opposite end of the state, and the opposite end of the state was having problems are loss to follow-up.

How did we implement this? Quickly. Once we got the okay, we couldn't do to fast enough. We had two students, spring and fall semester of 2014, but one student volunteered her time over the summer. So we had pretty much year-round coverage for this task, and although the student in the summer did not sign up for a practicum, and I was not assigned any students in summer, that's something we'll be thinking about in the future is how to get summer coverage for the notifications. We don't want to leave them sitting that long.

We worked very quickly and collaboratively with the UTHCS clinical faculty, because there's one person that does all the scheduling, so I had to work with that person to make sure the students coming didn't have a clinical -- another assignment, another clinical assignment during that time, so we had to work out and make sure we had no conflicts. So we had a second-year paired with a third year student. I'm going to use you as an example, Kelly? Kelly came in this semester as a first-timer to the practicum, but she's a second-year student. So I will get to keep her into the next semester. Okay? And so she worked under, not only me, and in cooperation with Claudia and Jacque, getting some input and training, but under the third-year student who had already done it for a semester. So we hope it will minimize our training and we'll be able to bring the students up to speed quicker by having that kind of a model.

We did an orientation, as I mentioned, and it was dually led by myself and Jacque Cundall, the coordinator, and we followed up verbal and in writing and went through a couple of situations really quick where I would model how we do something and they would come behind me and replicate it. These students are really, really savvy students. We didn't have green students. They had engaged with families before. This wasn't something new to them.

How do we process the referrals? They were received snail mail through the EHDI program and logged on to the Excel spreadsheet created just for this practicum experience, but the students would write notes on the hard copy of the notification, and then we turn around when it's a completed file and send it back to EHDI. Now, one of the tests of change is that Claudia reported back to -- it's hard to read those faxes. So we very quickly devised a change and said, let's scan them and encrypt

them with a password and see if you can read them better, and sure enough, it led to improvement. So she was able to see the notifications much clearer, and I think it was easier because our fax machine oftentimes is persnickety so I don't like dealing with it anyway.

So we were pressing the students and encouraging them and we will press the students that continue in this practicum to think of small ways that they can improve this process.

This is kind of a disaster of a slide. I don't like sitting in a presentation where I am expected to read something like this, but most of you all came today because you're familiar with the process of follow-up. I don't think I need to go through this, but of course, as you all know, when you make that first call to the family, there's a lot of different answers that you can get. There's a lot of different scenarios that will occur immediately and might be a disconnected phone number, it might be a mom that says, I have an appointment in two weeks. It can be many things. So I've outlined the path of that. But the ultimate goal is that we can come to some conclusion, and that conclusion is, that we either got an answer and the baby did go for follow-up. If the baby didn't go for follow-up, we offer some essence of support, and it can be just reminding them who it is they need to call, or going ahead and facilitating an appointment in some circumstances. We do offer that.

And then if we run into roadblocks, what do we do? Obviously, on the right-hand side of that chart, when we run into some roadblocks, we have some access to some partners for lack of better word, but they really are our partners, that we call. And say, okay, we don't have a phone number that works. Tell us a little bit about this baby. And sometimes it's a PCP that we call and get that information from. But we also do have kind of an insider connection at the health department, so because we're Department of Health, permissions are granted, everything is confidential, we're safe and she can access databases that we can't access to get second phone numbers, second points of contact, then those are really fruitful.

Okay. So where did we collect data? We did collect data. We've been very intentional in this process. Obviously, the number of files received, active days, number of time to complete a file, and I was interested in completing this because we do want to expand and offer this to other university programs, so I want to, in sharing our model, say, it takes about this much time to do this. We have final dispositions that we have been tracking over time, a completed report is a successful report of a successful outcome. A completed report is also one that we were unable to reach. We got our job done. We determined we could not reach the family. We exhausted all

measures in doing so. Completed could be nonresponsive. We got to the mom first but then she wouldn't answer the phone after that. We made a recommendation for support or follow-up and she didn't go. Okay? We qualify that as a nonresponsive. We did our part, but we can't control what the parent does or doesn't do. And then we've got some pendings. We track loss to documentation on this. It wasn't extremely scientific, but let me tell you how we did it. Basically if our students call and upon the first time that they call they get mom or dad that says, oh, we went for that rescreen. We went on this date, and here were the results. But yet we have a notification from the Department of Health that they have no information about that rescreen, we put a tick in our log sheet that says, lost documentation. So I'll give you the data on that in just a minute, okay?

I don't expect you to read this, but what this is a report. Our Excel spreadsheet, we sponsored with the fiance of one of our previous students and he came up with a Cadillac of our first basic spreadsheet of students and it tells us all kinds of things now. What does it tell us? Let me tell you. 417 total referrals in 2014, and you can see we send out from January to May, June to September, and October to December. So we got a steady support and the students completed in tandem with me 88% of those. So we feel good about that. And I'll share a little bit more about the final dispositions in just a minute.

How long did it take to complete these referrals? An average number of days, and this is very interesting, because it didn't take them longer in the beginning than it does most recently. Look. In January and May, on average, the number of active days was three. Now, that's not three subsequent days, though, that could be three days where the mom said, I've got an appointment in three weeks and we called them back in three weeks and we don't get them on that second call and we call them again and get that answer. That's three active days, okay?

Estimated time spent on a referral. This is per file. So you can see that the largest majority of them take one to four minutes. Not long at all.

What about the disposition of follow-up calls? Ooh, that looks ugly. Something didn't transfer there. Hmm. Let's see if the final answer was. Okay. The large blue, I can go ahead and tell you -- I'm not sure why my data is not there, but the large blue piece of the pie were completeds. So you can see the piece that did come up, 51% were successful with the parent reporting status, 12% were -- we were able to reach that the parent was nonresponsive. Okay? The smallest piece that's gray was there our pending. They were the ones that -- no, the orange is pending and the gray is that we were simply unable to

reach the family. Sorry that I don't have the data on that. I'm not sure why it didn't pop up.

Okay. Loss to documentation after a referral. Now, this is in 2014. You can see that in -- these are numbers for Memphis, okay? Excuse me. This is the loss to documentation, they're all from Memphis, but it's from within, just the files that we process. So these were the ones where the family said, oh, yeah, I went for follow-up, okay? Hung up the phone and they gave us the results, okay? But we at DOH didn't have any indication that they had gone for follow-up. So truly, LTD, I'm hoping that it's close to scientific, but this is how we did it. So what you can see is of those, almost 500 files, 40% of them from May to June, 36% from June to September, and 32% from October to December. So you can see on average, about 35% were lost to documentation. They had gone for the follow-up.

Okay. This is support to family to facilitate rescreen appointment, and it might seem like a very insignificant data piece, but let me tell you why it's important. Like I said, the students were trained on how to, in certain circumstances, to give the family some support on scheduling an appointment, okay? We couldn't do it necessarily with every hospital, but we do it in some cases with private practice in Memphis, they will take an appointment without the doctor referral, okay? So they don't have to have that in information. So we could go ahead and facilitate appointments. Well, at first, the students were doing it 8% of the time. So not a whole lot of the time were they offering up support. However, look at the big drop. Well, what happened in the time where I've got the little star indicated is that the largest birthing hospital in Memphis, they wrote up a PDSA task plan as a result of a regional meeting and all the sudden the families the students were talking to were saying, I know exactly what I'm to do. I have an appointment in two weeks. Or I've already been to my appointment. So they had a lot more clarity, the families, and the students weren't giving as much support in those areas.

So here's some Memphis Delta follow-up area as a whole city, and that's where you all get notifications from, from the entire city, but there's lots of things going on, not just the 80 practicum experience to address lost to follow-up, we have lots of TDSA work plans that have been developed. You can see in 2012, lost to follow-up numbers were around 44%, and then in 2013, they leveled out about 40%. 2014, quarter one was 41%, but then we have a drop, when a lot of our PDSA work plans kicked in and the practicum experience had gotten rolling, we saw a drop in loss to follow-up. In quarter 2 of 2014, down to 21%.

So here's some of the feedback that we got from students that are already participated in the practicum. They just got a behind-the-scenes picture on what it takes to make an EHDI system kind of work and kind of click and what are the mechanics of that program and how do these things work. And so the other thing, too, is kind of -- it gave this particular student, and you can see I've gotten some of the more salient parts of her -- the quote that she shared, that that process that brought the family to our office. How did they get to my office? How did they get to this diagnostic appointment? It really gave for a new appreciation of that. And the other thing, too, I really like is this last piece that I've underlined is that she really felt like the experience allowed her to be more confident when she was making some recommendations to families in other practicum experiences.

And the other student that gave some feedback, she just really felt like she was making a difference in a new and unique way, as she never had this opportunity, obviously, she had never been associated with the EHDI program before this and didn't really even know what the EHDI program was all about past the one lecture that I gave in pediatric audiology, that was pretty much the only exposure that they'd ever had. So it made her feel like she was making a difference in a way. And I go back to that comment you made, Claudia, about hearing that baby in the background, and that's what she was feeling.

So in summary, we maximized our resources. We looked around as an EHDI program and said, you know, Claudia Weber could use some help. So we had opportunities that we did take advantage of, and I don't want the students ever to feel like we're using them. I feel like we are partnering with them. And we're giving them a new and unique experience. And the second note that I've made here is we do really feel that they're acquiring new skills, new and unique skills that they would not have had the opportunity to do had they not been a part of this practicum. And the other thing, too, we are seeing these partnerships grow. And I'll go ahead and say, this is a university program that I left years ago when I started EHDI, and I was a little worried about the program because I didn't feel like they knew a whole lot about EHDI. I think they were very good about what they did but they worked very much in a silo. Now we have a beautiful partnership that I hope to in the future expand to other AuD programs.

So what does the future hold? We're going to continue the practicum to come one creative solutions in the summer because we don't want all of those going back to Claudia. We want to keep her plate as clear as possible. She's got enough on it already. But we do want to expand to another university and we

have another university interested in participating in this. And we are going electronic someday. And so this process will really become easier when we are electronic because at that point our students would be able to do what Claudia does right now and enter it directly into our metrics database. And the other thing too, I want to extend this as an invitation for anybody who is a part of an EHDI program who might want to partner with the university AuD program, come to me and I'll tell you how to do it. It's not hard. We did it pretty easily.

Acknowledgement, Association of Deafness on the University of Tennessee. I recently changed jobs so that's where the host site used to be, but now it's at UT and the students came with me. We're not going to end this practicum experience, but we have lots of partner agencies that really come into play to make this happen, and we always get great technical support from some of our team members. Okay. Any questions? Yes.

>> JULIE BEELER: Yes, we do. No. The only thing I can add to that, there have been times when we have had that confirmed, they'll get a cross report that's come in in the meantime from that exact provider who confirms they did go. We don't go back and cross-reference that intentionally, but we do take appearance work. We ask, what day did you go, and do some checks and balances. Okay. What did they do to the baby when they work? When they say, they put a probe in their ear or stickers on the forehead, we know they did go. By and large, we have honest parents. We don't have another alternative to check it out either. So good point. Yes.

The university came to me with the idea because of that's casa standards, they have casa standards that are for program development and the students have no other opportunity to meet those standards. There's not many of them, Patricia, but there's enough to be a motivating force, hey, we're going to partner with you. And it's only a few students that get to do it. Not many. Kelly is a lucky duck. But the other thing, too, now, Claudia, early on when she had this idea, she did encounter some hesitation, but it wasn't from the university.

>> CLAUDIA WEBER: No, it's from the government. The government is very protective and worried about confidentiality and FERPA and all that. There's Memorandums of Agreements involved and all that. There is an umbrella of the Department of Health and Department of Education working together, results of the hearing rescreen, so I don't know the whole answer to that, but people decided to shake hands on this and say that we wanted to get to babies as early as possible and we weren't doing that. So we needed more man and woman power to make that happen. And we didn't have money to pay, you know, and to contract with others pretty slim budget in our state right now,

but we thought that if there was a meaningful experience for students that we could test it out with UT and then hopefully spread it to Vanderbilt University, which we're in the process of talking about, and so we'll get a lot more help that way. Also, with phone calls, that's a special skill, a coaching skill, it's a social work skill, it's a -- it's key to -- the students were trained to introduce themselves first and foremost and tell where they were calling from because when you see a readout on your phone and it says the Department of Education or the department -- University of Tennessee or something, you're going to wonder why somebody is calling you. So they were quick to learn that, I'm Meredith, blah, blah, blah, representing the Department of Health. Did your baby get a follow-up hearing test or very identified, very early in the phone call so that people were set at ease that you weren't collecting a bill or any -- for any other reason. They're very good at learning that and knowing that that works. And we're getting success.

>> JULIE BEELER: The two students don't come in as much as they used to. The first round of students came in two days a week and now Kelly comes in one day a week and the other student comes in one day a week for -- it's three hours but it's give or take. You know, sometimes they'll sit there a little bit longer if they have more time and they've gotten a new stash of information. They're committed students. Committed. Thank you all so much. If you have questions, I'll be here after. (Applause).

(End of session at 3:37 p.m.)

ROUGHLY EDITED COPY

2015 EHDI CONFERENCE

Pediatric Audiology Learning Opportunities for 2015

March 10, 2015, 3:45 P.M.

REMOTE CART CAPTIONING PROVIDED BY:ALTERNATIVE COMMUNICATION SERVICES, LLC

P.O. BOX 278LOMBARD, IL 60148

***

This is being provided in a rough-draft format. Remote CART, Communication Access Realtime Translation, is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.

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Welcome to 2015 EHDI!"Pediatric Audiology Learning Opportunities for 2015">> DR. KAREN MARKUSON DITTY: Okay, we're winding down and I

appreciate you coming. How many were here last year when I tried to do a part on pediatrics? Everything locked up, and I swore I'd never do it again, but I'm back, and they're promising me I won't have the issues, but I brought my backup laptop just in case. The problem, is I need to hook it up.

So thank you for coming to the conference. I know many of you. I'm Karen Ditty, I'm a pediatric audiologist, and I work out of the Houston, Texas, area. I've been involved with NCHAM the last 15 years and have been doing EHDI work most of that time. I thought everybody was and I got ahead of my stuff there. I laugh because people call NCHAM other things and I think it's important that we know how to say it, and the website is infanthearing.org.

How many of you have been there, to the infanthearing.org site? How many are audiologists? Welcome. This is the group that came. How many Deaf educators, interventionists, EHDI coordinators? Excellent. So I know who I'm talking to.

Because you're here, you know what the goal of NCHAM is. It's kind of neat that we've been doing this as many years as we've been doing. One of the areas we focused on is newborn hearing screening. How do we get started? And we learned, we're a part of the entire network of EHDI, Early Hearing Detection & Intervention, and we got newborn screening and this was our focused, then we thought, audiologists aren't ready to see these babies, and we focused on that. But it's hard, because audiologists are working on little silos, and we all work individually wherever we are and it's hard to keep up with technology.

Heard a great talk today by Lisa how to do diagnostic ABRs and I learned after doing this as many years as I have. So how do you do this without running to every single conference or workshop? I kind of came up with some ideas, what you can do to be a better pediatric audiologist. How many would you consider yourselves pediatric audiologists? Fantastic. Fantastic. If you're not, go ahead and join the game. It's fun. We like working with the babies.

One of the first places we've learned that we can get some good information is the C.D.C. website. I have a handout. I'll pass it out in just a second, okay? Which has all of these links, so you don't have to be writing a bunch links down. Has anybody been to the new site? It's updated and really pretty. Well, go to it. It's got great information and been updated with new statistics. You know what's happening in your state, and they have information on "A Parent's Guide to Hearing Loss."

Thank you. Babyhearing.org. Tell me you've not been there. Yeah? Some of you have?

This is a great site, great for parents, yes? It's going to be on that piece of paper, right there. That's why I did it. Yeah.

It's a great website for parents, newly diagnosed parents, and it's in English and Spanish, and I'm surprised some of you may not have been to it, but it's great for resources for professionals, and there's a whole nice section that gives you parent education, fact sheets, everything you need to know.

I know we all try to be a teacher and hand them all the materials, and it's not the best way to communicate a hearing loss to a family, but at least you'll have the materials ready when they're ready to hear it. You may have given it to them a couple of times, but why reinvent the wheel? We have accurate information that will not give inappropriate information.

Have any of you been to supporting success children with hearing loss? I'd like you to think you're learning something new today. It's been out a couple of years. Karen Anderson put this together. It started out simple. My goodness, it is packed with a wealth of information. So if you're more of an educational audiologist but a pediatric audiologist, it has great information for parents and professionals.

So, again, you sit back in your jammies with your cup of coffee and I know you'd rather be watching "Scandal" or something, but I've been impressed with this website, always a family focus. As a pediatric audiologist, we need to embrace some of our family-focused opportunity.

Hands and Voices, obviously, being one. How many of you have Hands and Voices in your state? It's really taken off. I'm on the board of ours in Texas, and really good, caring people, who just want to make a difference, and they're doing it on a dime, and the American Society for the Deaf. Some of these you've seen before.

And Hands and Voices now, and how many sites there are, and they continue to grow, even internationally.

Finally, something for parents that is unbiased. That is the goal, that it's unbiased and not pushing one methodology or another, but it gives families a place to go, again, vetted material, referring your families to it, and I had pointed out that the American Society for Deaf Children, A.G. Bell, and this has continued to grow, and they have teenagers who want to talk to teenagers with the same situation they're living in.

How many have signed up for EHDI-PALS? How many are pediatric audiologists? Now there's not as many in the room. EHDI-PALS is where you go and let people know that you live in that state and your interest is working with children. You have

the equipment. You're ready to go with it. Now, it's not individual names, it's brick-and-mortar locations. But they're the only ones who have the names of the audiologists, but it will show parents, other professionals who are not interested in doing babies where they can go and locate you.

So when a child does not pass a hearing screening -- we have issues in Texas that there are places where families have to travel up to two hours to get to an audiologist, and that probably wouldn't matter, even if they looked it up, they would still have to travel two hours. This is great. If you open up in between, you'll be able to see these babies.

So go to the website, sign up. The only people who see it are the EHDI coordinators, your name, but the others, you know what I mean by brick and mortar, where they need to go to get services. So those who are not pediatric audiologist, sign up so you can do that again.

And it also has fantastic links and information. It's got JCIH, rules, knowledge, and skills for the audiologist. So it helps you, too, to go to that website, provide you with some amazing information. So please, I do encourage you to just go sign up and let them know that you exist.

We obviously have a lot of position statements, and we've known about the JCIH since 2007, and it truly is the standard of care. And when you work in your silos but you get referrals from hospitals, you should assess, is that hospital doing all the protocols that does reach that standard of care? There are hospitals out there, one that I used to work at that has quit doing ABRs in the NICU for some reason, but you should know that about that and what standard of care, what are the recommendations for monitoring children at risk for hearing loss.

More documents on the Academy of Audiology website, and you'll notice those are specific to pediatrics, pediatrics diagnosis and that kind of thing on this same website, you can have access to all the current position statements. Practice guidelines. So if you're not sure and you didn't get a good study in college on that, these are -- built by your colleagues that, again, have been reviewed thoroughly.

ASHA also has position statements and you can access these without necessarily being a member of ASHA, too, if that's a thing with you, but they do have some excellent documents on that website that will help you in your private practice, much less working with pediatrics.

Why are these documents important? What -- it's best practice, and when somebody tells you, you don't need to be doing those things, right? How do you back it up? You have got best practices documents to back it up. This is our standard of

care. No longer are we going to be knocked around by those people that tell us we can't do those things, right? Yeah! Thank you, thank you.

And there's a new edition to the JCIH, it's the Early Intervention After Confirmation That a Child is Deaf or Hard of Hearing. It's pretty detailed for early interventionists, so when you're working with the hearing interventionists who are Deaf educators, they may not always be aware of some of these things because it's not always -- you know, I -- my sister is like one door over and she's a Deaf educator and I have to tell her about these things, so that's pretty bad. Please look this up and share it with your colleagues, and they can read it when they're drinking their coffee at home with their legs up, and this is what is looks like in the website and you can get all of this by going to JCIH.org, again, will be on that document.

There's a lot of resources on the NCHAM website, infanthearing.org. If you're wondering what's going on in your state, or you think you know what's going on in your state but there's some changes, you can go to your state, pick whatever state you're living in and you might want to see what their guidelines are, and again, a busy slide, but look at all the information. When the law was passed -- do they require screening? I think most every state does now but there was a time when they didn't. Is informed consent necessary?

So you can get all this information, and what the bill looks like and everything from your site. And it's important to be informed. Because every time the legislative session goes in, something can change. Somebody will surprise you, pop up and try to make a change that may change that proper standard of care. So be aware of it.

How many of you are from states with hearing aid legislation? A few of you? I think there's about 20 now in the United States. With the advent of the Affordable Care Act, it kind of affected us trying to pass legislation. Texas has been trying to do it for four years, actually six, but four years really hard.

This year, we've got a bill in. It didn't have everything I wanted in it because it got stripped by the legislative people. Why? Because it has to match your Affordable Care Act benchmarks. So whatever insurance plan is going on in your state that you use as a benchmark, that would be the plan to decide. Yes. Should I bring this over to her?

>> AUDIENCE MEMBER: We got legislation passed last year, but what they did was put the funding in like the hearing aid program for special health needs for kids rather than putting the legislation on insurance companies for just that reason. So --

>> AUDIENCE MEMBER: Just a quick cautionary note, if you're in a state working on trying to get this legislation passed, be very careful to make sure that you, you know, indicate what constitutes a qualified provider. What we observed in our state, I guess not surprisingly, a lot of interest in serving children with hearing aids from audiologists and even hearing aid dealers who had not previously been interested in serving this population. So it gets back to your point about having, you know, best practices, well defined, so it doesn't look like you're just trying to promote. Because even audiologists in some cases were not serving children or young children, at least, would like a piece of that action, which is fine, as long as best practices is followed.

>> DR. KAREN MARKUSON DITTY: And again, that's another problem in Texas we're hearing, because unfortunately, hearing aid dealers can't work with children. There's no legislation that stops them, but they typically do not work with children. A battle, a hard battle. I think you know what I'm talking about. I'm going to use Kentucky as a benchmark plan. You can find this on the website, so it's also on the website, infanthearing.org and you can see that Infant Plans of Kentucky is the one they use.

In Texas, Blue Cross/Blue Shield, it will play $1,000 a year, every three years. I tried to put in the legislation more specifics and the legislators completely stripped it out. We're going to go forward because I want something in there, and next time around, we'll fight to make it a little bit better. Sometimes that's the best you can do. But please work on this. If we can get this in -- there's a lot of changes coming down the front, but our children -- I had an audiologist -- I'm ranting. I had an audiologist tell us the other day, there's not a lot of complaints about kids getting hearing aids. They can get them through those charitable organizations. The churches can raise the money. I said, what are you talking about? That delays the initiation of getting services to that child. He says, I do see babies. But obviously not many! And that's a terrible attitude. I really think it's important.

We understand it's a developmental emergency. Parents shouldn't have to -- that could be for C.I. parts, batteries, or something like that, but not the initial cost of the hearing aid, and in our state, Medicaid pays for it. If Medicaid pays for it, all babies should have it. That's enough ranting.

And I think, Jack, you had something to do with this? You didn't? Tell, I was giving him credit where I didn't need to. But they're good talking points when you go to the legislature that you can give to parents that they do have on the website, fairly new, a hearing aid loaner bank, and it has a list of all

different kinds of organizations, you can get assistance with for purchasing hearing aids, and it depends on your law and if your hearing aid breaks you can replace it a year later, depending how your law was written, and it's a comprehensive list of services for families if you're in a state like I am. Yes.

Should have brought my scooter. One of the really frustrating things that we found with the legislation, while we got it covered, any employer that was self-insured was opted out and that was frustrating. As we looked at it -- I think we're five years in -- it did start the big employers a step to the plate. They said, we don't have to, we don't have to, and they were humiliated into it in some cases. We thought, all these kids were going to have coverage, and a huge amount of them don't.

>> DR. KAREN MARKUSON DITTY: I tried to build on our legislation on everybody else's mistakes, and I think everybody and their brother is going to have to pay for it as we try to

get that aspect covered. So good point. Good point.How many have looked at the Newborn Hearing Screening

Training Curriculum? Couple of you. How many manage hospitals for Newborn Hearing Screening? I think it's important to look at it because it tells you what hospitals have to go through and you can do this without doing a CEU and doing all the work. You might just want to view it. Randi Winston talked about it early, but it's interactive to talk about what Newborn Hearing Screenings are required to do, how HIPAA controls safety and all of that, and it's also on the website, if you're ever in a situation where you're managing a Newborn Hearing Screening.

Now, this is where I'm praying that these will work. We also have some filming. How many of you have ever been to a pediatric audiology workshop by NCHAM? A few of you. We've tried to do as many states as possible.

Our last one was last year in Coeur d'Alene, Idaho, and money was drying up for these workshops, typically, it's a five-to-eight-week online chat and everybody is on the same page, show up at the two to four-day on site where you gets hands on with the equipment from the manufacturers, we've had wonderful support from the manufacturers, and when you get to the workshop, everybody who has not had a lot of experience or really even experienced people are all on the same page.

We started filming back in 2012, we started filming the presentation so that others can learn. I was woefully saddened that there weren't many people who signed up for this and it was more of a communication and it didn't work last year when I tried to show everybody, but we in Idaho, they did a five-week

online class, a scholarship and a one-day hotel, and we did a two-day on site and it was very good.

She discussed the electrophysiological, electroacoustical and we had some interesting videos. This was done by otometrics. We've had different people support it, but they did this for all of you to be able to watch it, and we're going to see if it actually works.

(Video)Now, what do we know about -- they're about 70% larger than a

click. Smaller. Other way around a timber, when we start to get close to the threshold, we're probably going to have a harder time seeing a response on. If they're already harder to see, when we get to threshold, they'll be smaller to see.

So at times, remember, it may take you a lot longer to see this response relative to the background noise. And it can take you maybe twice as long. So don't be surprised if you're sitting there and you're not seeing much at 1,000 hertz and around 2,000, something looks like it's appearing, at 3,000, you're saying, by gosh, it's there or 4,000. When you're at 500 hertz and close to threshold. So don't be afraid to let it run out. You can't just stop at 2,000 hertz all the time and say, I've got the response. You're going to be fooled. It's a smaller response. If you have any kind of background noise going on, it's going to be harder to see. So now need to let your suites run out and that's particularly true for your smaller frequencies, closer to threshold.

>> DR. KAREN MARKUSON DITTY: Does everybody know what a chirp is by now? As you heard today, most of the equipment is coming out with having chirp added in, either the room chirp, their version of the chirp, their unique way of making a chirp or there's the standard chirp, which is the CE chirp, and what in essence you're trying to do is stimulate more of the brain by having those low frequencies in first, trying to stimulate more apical part and then your higher frequencies last. So that you are getting information across the whole basal membrane.

So you're starting at the basal end and those neural responses to the basal end, and what we're trying to do now is we're trying to get more apical information by stimulating using the low frequencies first, almost like reversing things, you're trying to stimulate those lower frequencies first, then the higher frequencies and lo and behold, you're getting information across the whole basal membrane. What do you think is going to happen if you have a stimulate chirp?

>> AUDIENCE MEMBER: (Away from mic). The low to high frequency.

>> DR. KAREN MARKUSON DITTY: What do you think the result of that will be? With the way the cochlea work, we are getting

response to the higher frequencies first and we're already stimulating the higher frequencies. We're not getting much from the low frequency, even though we think we are. So when we get a chirp, we're trying to get a response through the whole basal membranes.

>> Those are my teasers. We try to keep up to date on the readings and all that kind of thing. It is not there yet, but that's an excellent question. I just got through editing. It will be up within the week. I will show you on the website, and I think I might have put the connection, but it -- yes, it's under resources under eLearning and you can find it under there on the infant, and even more, Lisa is here, but let's see what Diane has to say about wide band reflectance. If I can find the mouse.

>> What we're seeing is we can get information about the ear, but we don't always have to pressurize the ear. You can use pressure or not use pressure. But what you're doing is really getting information across different frequencies. All at the same time.

So it uses a broadband stimulus, and it's usually done, most of what we've been seeing is done as ambient pressure, and it takes a few seconds to record the response. We don't know, but it looks like it may be a little bit more sensitive and specific to abnormal middle ear function in young babies is infants and there's been enough studies done, Hunter, Lisa Hunter in Cincinnati has done probably a lot of work on babies using reflectants and screening results on how to maybe use this. It was first looked at in 2000 in the publications that came out in the big study on otoacoustic emissions and the group out of Boystown did a lot of that and now we're seeing a resurgence to help us understand a little bit more about what might be going into -- be involved in the baby's ear.

The thing that I still question, even if you know you have an abnormal reflectance measure and an abnormal screening result, you still need to get a diagnostic test done because we don't know if you have a sensorineural component on top. So I think it's added information. I'm not sure where we're going to fit it in in terms of screening. It may be supplemental to the metric findings for our older kids. I think, again, this is another place where we're seeing new information coming out, trying to help us understand how to use it, but I don't think we have enough information yet to say we can replace one test for another or use it specifically for screening or for diagnostic.

>> DR. KAREN MARKUSON DITTY: Okay. So that's a little bit more new information and we're trying to do it. We tried to identify speakers who are current, knew what was new in the field of pediatric audiologist. Does anybody know Terry Foust,

Dr. Terry Foust from Utah? He's pretty funny and good and this is just a short clip. We don't all -- for all of you who are audiologists in the room.

>> I'm going to go on to the next one here. The Department of Education just completed another large study, and I'm just going to move ahead to that one, but this looked at kids that were as young as two years old and found they do play, touch, and learning using touch screen devices, that the apps need to be -- this seems like a no-brainer to us, but they need to be age an appropriate for their developmental levels and use the intuitions as they move through the app. This is a key summary of their findings as they look at 3 to 4-year-olds, 5 to 6-year-olds, 7 to 8-year-olds but when you look at these, you might keep these guidelines in place because it looks at the motor skills that they would need on to concepts of games to be able to participate appropriately and so forth.

Okay. So I told you that I'm just going to categorize these apps into these four areas, but let's just go right into those. So what I was thinking about tools, I was thinking about tools to help you, as an audiologist, such as sound level meters, speak to see -- speak to see is more of a dictation and puts it into large letters, so if you're working with someone you want to caption, maybe you're not a fluent signer and they rely on sign language, you can use this to caption what you say, okay?

And then these different sound level meters, work differently, and there's -- there's, I think, more than 25 apps that are of different sign languages.

>> Do you know of any in different languages?>> The question is, does Speak to See translate to other

languages, and as far as we know, Spanish is available, English to Spanish. There's another one, Sprint and those will have captioning apps that I think are actually better than Speak to See, but you need to be a hearing impaired person and then you get that app for free. So they can bring the iPad, turn that app on, and use it. Google translator has a lot of languages there. Yeah.

>> DR. KAREN MARKUSON DITTY: So that just tells you a little bit, we try to keep you up to date with what's available on iPads and iPhones and things like that. Erica Blanchard spoke about coding.

>> So today I'm going to talk to you about correct coding and reimbursement. Initially, the talk was going to be just focused on ICD 10 and documentation for ICD 10 as ICD was going to go live on October 1st of this year. As most of you are aware, for several reasons, they decided to push that deadline out again until 2015. ICD 10 has been used in the rest of the world since 1994, and we're not there yet. So plus correct coding equals

quality of care, compliance, and reimbursement, and that's what we'll be talking about today.

>> DR. KAREN MARKUSON DITTY: We try to cover a number of areas and you can take each of these modules individually, if you wish. Currently, these are not CEU ready, but they will be. We just wrapped up the editing and all that. Typically, they're also captioned. So if you have trouble following the laws, it will be captioned.

Back in 2012, we did a workshop in Meridian, Idaho, with numerous manufacturers of the equipment, so it's a little higher quality and even though it's from a few years back, it's still very relevant, and I think you would enjoy observing this one. You get a number of CEUs available for this and it goes over all the aspects of doing electrophysiological and electroacoustical in a manner that probably you haven't heard before and it's good to understand. There are clinical aspects of OE that you can utilize and that's the way he approached it. I tried to just take fun little snippets. This is Dr. Hall.

>> Now, I'm going to show the diagnostic information and it's going to take ten times longer than it takes to get the information. Don't waste time on the click. I'm always very cautious how much time is passing and I'm doing an ABR. I always feel like I'm on the treadmill.

When we do the demos tomorrow morning, we'll get something here, none of you, I'm sorry to say, lay them down quietly, and I'll do an ABR, we'll have the computer hooked up to the screen and I'll show you how quick we can get a quick ABR. That's it. Great use of your time. If you happen to have a child with reasonably good hearing and they're quiet, that click ABR will jump out at you and after 500 sweeps, if it's repeating and everything looks normal, you don't needs to waste any more time there.

>> DR. KAREN MARKUSON DITTY: So that's a nice little overview, and there are several videos and no hesitation. Then we did some filming in Arizona when we had the EHDI conference there and we had a pre -- before the EHDI conference, and Dr. Sabo spoke at that one. I don't know if I've got that in here.

>> Let's get back to the question about whether or not -- (no audio).

We also have live webinars that we've done, and there's a huge list of EHDI-related webinars that you might be interested in going online to see. These are short, maybe an hour in length. Many of them have CEUs, but it's free. I would stress that. It's free. What we did with Dr. Sabo, we viewed about an hour of her behavioral video and came on and talked about current philosophies, things that she's learned and new documents she's come up with.

For the workshops, most of the workshops, we do have associated readings. We try to make it as much of an educational experience as possible.

And these are some of the other EHDI-related webinars. You see Dr. Hall. We changed his into a short webinar as well. I was hoping this would come up better. Down at the bottom, the behavioral audiological one. So there are a number of things, readability, if you're working EHDI, good articles, and those are continuing on, something that NCHAM offers, pretty much for free. This is just a snippet, I don't think it's long. I'm doing this so you'll watch when you get out of here. I messed up. That's too bad.

>> One of the things that we want to do today to tie into Dr. Hall's talk, when we start talking about OAE testing in pediatric assessment mode, we talk about what you should use for that, types of protocols and discussions that should be available on any clinical device that you have, so it's not specific to any machine.

Some machines have a lot more options than others. But for the most part, what we're going to do it keep it very simple, because as we start looking at OAEs now in a new sense as we see more and more pediatric assessments coming up, we need to look at these as a field, so when your test is seen by someone else, we know that the accuracy is credibility is there across the board, and that will just be a short discussion today but I hope it will help you focus in on what we consider to be a wish list if you're doing a traditional clinical diagnostic pediatric assessment.

>> DR. KAREN MARKUSON DITTY: And again, it doesn't drag like that on the site. And I edited down raw data, raw copy, so again, they're captioned, so you'll just know.

How many of you work with Head Start a couple of you are? How many work with Echo website, kidshearing.org or get to it through the NCHAM website. It's very comprehensive, a lot of free material there and videos, and you can go into a center and use all these videos as part of a training to improve hearing screening in Early Head Start. You can actually stream it live from the website when you're teaching and doing your instructions and it gives you copies of materials you might use for training, everything you possibly need is on this website, and it's a really cool site for those of you who work with Head Starts, it's called the Echo initiative, and just to go through,

we have a Practical Guide to the Use of Teleintervention, what you need to do.

Does anybody do any teleintervention audiology at all? I think it's coming down the pike. We've got some bugs to work out, but you may want to learn a little bit, and it has all the links to all the information you may need to know, and this was pulled together by a bunch of audiologists who are doing it. I'm watching my time. We started late, but I know you probably want to get out earlier.

These are coming, Dr. Shane Moody, he does a section on DSL and how to do this with infants and toddlers and hearing aid fittings, and this will be coming soon. And these are some other videos that are available right now that you might find informational for you as a pediatric audiologist.

What's also neat is we've been doing EHDI conference works for 14 years. This is our 14th one. Many of these are archived on the website and you can pull up old PowerPoints that might be applicable to something that you're working on now that you weren't working on at the time. And that's great. How many of you know about the eBook on the NCHAM website? Great.

We realized there were a lot of people not know what EHDI even was. They thought it was EDDY or something. And we've pulled together a number of authors that work in the field, and I'm not talking about just audiology but all the way through the intervention part. I think we're up to 41. The newest version is up now. I think -- okay. 38. 38 articles that you can use. This is really good for students and Au.D. programs, but it's really good to update your skills, your knowledge with the current thought of the world in EHDI.

These are updated so they're always current. They're updated on an annual basis. You can click them out, print them if you're old-fashioned like me or read them on the website, but every year they get updated with new articles, so it's a great resource for pediatric audiologist, financial, sustainability, grantsmanship, those kinds of things.

Again, infanthearing.org. So we do have quite a bit up there and it's just a lack of knowledge. What I would ask you to do is share this with your colleagues, all your colleagues, who want to know. I don't know about that.

Well, there's a web resource center and they have all that information. You can access it pretty much all for free. This is all on the webinars. As you can see, there's a number of them. What I've done also is I know that it's hard, as an audiologist, to search all over the web trying to find websites and sites for information and documents and PDFs.

On that handout you've got, the very last link will take you to a website for those who attended this and on that website

will have all these articles that you can download yourself or go to the correct website and download the articles so you're not having to search all over the website for this information so that's sort of a gift for you to have for bearing with me during this. So if you'll go to the last resource on that handout that I gave you that is the website that you can download all of this good information, and much of it can be found on the sites I provided you as well.

We do plan to do more workshops in the future. We're always looking for new ideas, new speakers, how to present them. On that link that I gave you is a place you can sign up if you'd like to be notified of future workshops. It's also on the NCHAM website if you browse and you'll see a link. It doesn't commit you to anything. It just said, it's okay, send the information in there's something in my part of the world.

We've done them all over the United States. Never gotten one in Texas, but we're working on that. And we want to keep this information as updated and as current as possible and to make it as easy as possible. As I said, these workshops, we do it online most of the time for about five weeks. We provide all the reading materials and everything. You get a whole lot of CEUs out of these as well, and it's two to four days depending on the workshop we're performing. So sign up and you can get there from the link on the handout or when you browse through the website.

I'm going backwards. So navigating EHDI from home is easier than it ever has been. I hope you've seen there's lots of resources out there. Much more than 15 years ago. We know so much more than we knew 15 years ago and I hope you found it useful to improve your skills as pediatric audiologists or signing up to be a pediatric audiologist for those who didn't have your name on the EHDI website. Any questions?

Kind of glazed over now, are you? Okay. Well, thank you so much for coming and I hope that information is helpful. Just a minute. Lisa.

>> LISA: This is such a great overview of all the resources. I've learned some things today too. On the hearing screening training curriculum, do you know if anybody is using that to sort of certify hearing screeners or --

>> DR. KAREN MARKUSON DITTY: It doesn't certify them because we don't have the hands-on component, but there's sign-offs, training, what they should do. You can utilize all of that for your quality assurance in the hospital and you're going to have to provide the hands-on component. If you have an E program at the hospital or some kind of eLearning programming, you can get it and load it. We just want you to use it. You can get that for free. Any other questions? Well, thank you guys for

coming. I hope this was helpful, and thank goodness the videos worked this time so I didn't have to make it up.

(Applause).(End of session at 4:34 p.m.)