Telehealth guidance

Telehealth guidance

This guidance is for speech and language therapists using telehealth. It includes information on considerations for service delivery and the use of telehealth and updated links to relevant research evidence and resources.

Last updated: December 2022

Introduction

Defining terminology

Telehealth is defined as the: 

“Delivery of health care services, where patients and providers are separated by distance… (it) can contribute to achieving universal health coverage by improving access for patients to quality, cost-effective, health services wherever they may be” (World Health Organization, 2016).

We are aware that other terminology including telepractice, telemedicine and teletherapy is also used to describe remote healthcare services but, for consistency, the RCSLT will refer to the use of remote services as ‘telehealth’ throughout this guidance.

Telehealth and the COVID-19 pandemic

Telehealth is not a new concept. National policy and guidance from across the UK referenced terms such as ‘digitally-enabled care’ and had proposed a vision for service delivery where ‘digital first’ consultations were routinely utilised across services. The emerging COVID-19 pandemic accelerated this vision and resulted in the rapid adoption of telehealth across healthcare.

Telehealth was successfully used in speech and language therapy prior to March 2020 but in relatively few services or clinical areas. In March 2020, due to the emerging COVID-19 pandemic and the general disruption to the delivery of healthcare services, many more speech and language therapists turned to telehealth to enable them to continue to work with service users in the context of public health restrictions.

Many SLTs are continuing to use telehealth to assess and provide intervention for service users as well as utilising the principles of videoconferencing to support meetings, training, supervision and student placements. This guidance is designed to support an evidence-based approach to the use of telehealth. Where appropriate, telehealth should be embedded within long term service delivery in a way that ensures effective, patient-centred care.

Please note:

  • Our guidance will be periodically reviewed and updated as needed.
  • For further consistency throughout this guidance, we will use the phrase ‘service users and others’ to indicate ‘service users and their families and carers’.
  • The resources throughout this guidance are provided for informational purposes only. No endorsement is expressed or implied, and while we make every effort to ensure our pages are up to date and relevant, we cannot take responsibility for pages maintained by external providers.

The scope of this guidance

This guidance is aimed at all SLTs, regardless of setting, client group or previous experience with using telehealth and is intended to:

  • provide practical guidance and examples of best practice for delivering speech and language therapy remotely; and
  • enable individuals or organisations to understand telehealth options, help to justify their decision making and support the implementation at a local level.

This guidance is not intended to:

  • identify or address every individual risk that may be associated with using telehealth in your speech and language therapy practice;
  • provide recommendations about specific data management processes, platforms and tools; or
  • replace local and national guidance.

Please contact us if you have any suggestions or feedback on these pages.

Last updated: 15 December 2022

Service delivery

Telehealth compared with a traditional ‘in person’ model of service delivery

Moving forwards from the pandemic, many services will likely choose to continue to use telehealth in some form as part of a hybrid model of service delivery.

In person care

This describes what many think of as ‘traditional’ care where SLTs meet with service users in a face-to-face appointment.

Telehealth

This may encompass:

  • synchronous telehealth services where service users are seen remotely in real time via audio or video connection to mimic a traditional in-person encounter
  • asynchronous telehealth services where images, audio and videos can be transmitted between the SLT and service user. This allows the SLT or service user to view the content without the need for the other to be present, outside of a face-to-face or remote session.

Hybrid

A combination of traditional in-person care and synchronous and/or asynchronous telehealth to best meet the needs of individual service users.

Decision making

When services are deciding about using telehealth or a hybrid approach to service delivery, there are several areas of consideration needed. These considerations centre on the benefits and limitations of telehealth as well as factors surrounding implementation of telehealth.

Benefits of telehealth

There are several broad benefits of using telehealth including:

  • improving accessibility to services, particularly for individuals affected by limited mobility or access to transport;
  • assisting in caseload prioritisation, allowing for intensive treatment regimes, reduced length of stay in hospital, longer term rehabilitation management;
  • supporting relationships with families in certain settings such as school-based speech and language therapy services;
  • supporting with gaining increased observations of service users using asynchronous telehealth; and
  • offering a cost-effective use of healthcare funds.

In addition, helping people who are digitally excluded to access and use digital health services and tools can:

  • improve their health literacy and help people to better manage their health and care;
  • offer people a better choice and convenience of service that suits their day to day lives;
  • improve our relationships and how we communicate with patients; and
  • reduce the cost and burden on frontline services (NHS England, 2020)

Limitations of telehealth

While we have outlined the benefits of using telehealth, we also appreciate that there are risks associated with the use of telehealth and that these vary across clinical settings.

We suggest that you access our guidance on managing risk and review the guidance relating to individual clinical areas in our clinical guidance A-Z as well as information contained in the remainder of this guidance.

There is a specific decision making tool to support with making decisions about telehealth for service users with dysphagia.

At a service level, the following factors need to be considered when deciding to use telehealth:

  • The purpose – consider whether it is appropriate for:
    • triage;
    • assessment (including formal and informal assessment);
    • intervention (including direct, indirect and/or group intervention);
    • multidisciplinary team assessment and/or intervention;
    • provision of advice and support;
    • provision of, or support with a piece of equipment, for example, a high-tech AAC device;
    • patient, family and/or other professional education;
    • staff supervision
  • Availability of appropriate device/software to carry out telehealth consultations and training to use such device/software
  • Risk evaluation for specific client group/clinical setting
  • Any relevant local, national, or professional regulations and policies governing telehealth

As with in-person care, the appropriateness of telehealth alone or as part of hybrid care for an individual should be decided on a case-by-case basis and will need to consider service user eligibility. It is important to consider:

  • diagnosis and clinical judgement concerning risk;
  • urgency of care;
  • age;
  • language skills and/or cultural background;
  • communication skills;
  • level of literacy;
  • hearing and visual abilities;
  • cognitive skills;
  • technological skills, availability of technology devices and access to internet;
  • service user’s informed choice and preference;
  • consent to participate in remote consultations and
  • availability of others to provide support and facilitate consultations if needed

NHS England recently published ‘Choosing how to consult with your secondary care patients’; guidance which was co-produced with clinicians and service users and informed by a review of existing guidance and relevant research to prompt thought when making decisions about which mode of service delivery is most appropriate.

Meeting HCPC standards

Meeting HCPC standards is important regardless of your method of service delivery. Visit our website section on guidance to meet HCPC standards for more information on adhering to the standards of the regulator, the Health Care Professions Council (HCPC).

Key sections of the standards include:

  • Promote and safeguard the interests of service users and carers
  • Communicate appropriately and effectively
  • Delegate appropriately
  • Respect confidentiality
  • Manage risk

The standards also highlight the importance for all SLTs to:

  • Understand the legislation
  • Act as resource investigators
  • Build supportive infrastructure
  • Work in partnership

Insurance

One of the benefits of being an RCSLT member is that your annual membership includes professional indemnity/medical malpractice cover as part of the insurance provision under the RCSLT’s group policies.

If you have insurance additional to that provided by your RCSLT membership, we suggest that you inform your insurance company if you provide services via telehealth and ensure these are covered, particularly if you work with service users with dysphagia.

Digital inclusion

Over recent years the use of digital services has significantly increased within our society but there are still individuals within the UK who have limited or no access to new digital technology.

Data collected in 2020 by the Office of National Statistics (ONS) estimates that 92% of adults in the UK can be described as recent internet users (ONS, April 2021).

Some sections of the population are more at risk of digital exclusion than others, these include people:

  • In specific age groups (such as older people)
  • With disabilities
  • In lower income groups or without a job
  • Living in rural areas
  • In social housing or homeless people
  • Whose first language is not English (NHS Digital, 2020)

There is a clear and strong relationship between groups that are digitally excluded and those at greater risk of poor health. People from excluded groups or living in deprived areas often lack the skills, ability and means to get online.

An evaluation of the NHS Widening Digital Participation Programme demonstrated that digital inclusion interventions showed a return on investment of £6.40 for every £1 spent (NHS Digital, 2020).

It is therefore important to consider access to technology when considering use of telehealth with your service users. NHS England (also see further reading for UK wide information on digital inclusion) have provided some suggestions for how organisations can support digitally excluded patients by:

  • Training their staff to be digital health champions who can support patients with using digital tools
  • Connecting with local community organisations providing access and digital skills support, for example, libraries, Online Centres
  • Working with and enabling local charities who already engage with deprived communities, for example, homeless charities, social housing groups, charities supporting older people etc.
  • Socially prescribing digital interventions and establishing digital health hubs in the community where people can go to get help and support to use digital health tools

Individuals accessing speech and language therapy services may be at increased risk of digital exclusion. RCSLT has published guidance on addressing health inequalities.

Further reading on digital inclusion

NHS publications

Other publications

Consent

Before commencing with telehealth, it is important to gain informed consent from the service user and/or others as you would for an in-person session.

You should also consult any relevant local and national guidelines related to consent for telehealth that are relevant and applicable to your service.

As part of the usual process of obtaining consent, we suggest that you inform service users of:

  • their rights and responsibilities when receiving assessment, intervention or training using telehealth (including their right to refuse this mode of delivery);
  • the principles of telehealth and the evidence to support its effectiveness to support their decision making;
  • the key aspects to be aware of related to security (PDF), and;
  • the alternative service provision options, should the service user decline, or is unable to access, therapy sessions via telehealth.

On gaining consent, ensure you have documented this in your clinical notes. Informed consent to telehealth can be given in verbal or written form.

We also encourage you to consider the following:

  • If your service user is under the age of 16 years, please refer to Age appropriate design: a code of practice for online services guidance from the Information Commissioner’s Office, which is applicable UK-wide. Other guidance related to consent may be available for your local context, such as NHS consent guidelines.
  • If there are safeguarding concerns, regardless of the service user’s age, we recommend you follow your existing protocols and guidelines.
  • If your service user lacks the capacity to consent, a telehealth session may still be carried out in their best interests in line with the Mental Capacity Act.

Information governance

This section provides guidance for SLTs around information management and data protection when implementing telehealth.

More detailed information can be found in the RCSLT information governance guidance. This guidance is kept up to date with relevant national guidance and legislation.

This section details best practice to enable individuals/organisations to understand options and justify their decision making. It is not intended to replace or override local context, service, organisational or government guidance. Instead, the focus is on practical, profession-relevant strategies to translate existing guidelines into clinical practice.

Key policies and authorities on information management

This section highlights some key policies and national authorities providing guidance on information management, which is relevant when using telehealth. It is not designed to explore this in detail.

Information Commissioner’s Office (ICO)

The ICO is the UK’s independent authority set up to uphold information rights in the public interest, promoting openness by public bodies and data privacy for individuals.

National Cyber Security Centre (NCSC)

The NCSC is the UK’s independent authority on cyber security.

Assessing and managing risk

Throughout their practice, including when using telehealth, SLTs are responsible for complying with the data protection law. As part of the accountability principle, individuals are required to take responsibility for processing personal data, and this includes assessing and managing risk.

This follows the key principles of the GDPR Data Protection Impact Assessment (DPIA) (PDF) process. This process is designed to support the systematic analysis, identification and minimisation of data protection risks related to a project or plan involving telehealth.

The ICO has created templates to support with undertaking a DPIA:

The data protection officer within your organisation can assist with assessing and managing risk, as well as advising on completing a DPIA. Depending on the size and type of your employing organisation, you may also have a dedicated department to support with completing and signing off DPIAs (eg an IT or information governance department in the NHS).

When completing a DPIA for using a specific platform to deliver speech and language therapy services remotely, you will need to have a detailed knowledge of:

  • the client group;
  • the requirements of the telehealth activities; and
  • the capability of the chosen platform.

A separate DPIA will need to be completed for each platform used but information on specific client groups can be included within the same DPIA.

Maintaining security during telehealth sessions

A DPIA supports individuals to undertake an assessment of the risks and identify measures to reduce risk before starting to use a specific platform or new piece of technology.

However, assessing and managing risk will be a continual process when delivering speech and language therapy via telehealth.

RCSLT has put together some practical considerations (PDF), designed to support SLTs with maintaining security during telehealth sessions.

Selecting a platform

Please note: The RCSLT cannot recommend specific platforms, apps or resources. There may be platforms approved by your employer. Follow local guidance for approved platforms or discuss this with your health informatics/IT department.

There are many platforms available to support videoconferencing and telehealth. We recommend considering the following factors when making a decision about which platform will best meet your needs.

Platform basics

  • Cost – some platforms have different pricing structures depending on how many participants you want to support within a call. You may need to consider additional cost implications if you need to support a larger number of participants which may be important if you are planning group sessions or training.
  • Integration with clinical records systems or calendars
  • Account requirements for both the host and the client
  • Availability of the platform as a desktop app, mobile app and access via a web browser

Platform functionality

  • Screen sharing
  • Remote control for participants
  • Chat function
  • Whiteboard feature
  • Maximum number of participants
  • Differences in functionality may require you to consider your system and bandwidth requirements and those of your client. Ofcom’s checker can be used for broadband testing.

Privacy settings

  • Ensure that you understand all the security features of your chosen platform prior to your first telehealth session.
  • Check the level of encryption. Ensure that the site name begins with ‘https://’ and has a padlock symbol next to the URL in the browser bar. There are a variety of online website encryption checkers to check that any platforms and website resources you share are secure.
  • More information about a company’s privacy settings and use of data can be found through Polisis.
  • The UK Safer Internet Centre provides information on some commonly used platforms when considering video conferencing options for use with children and young people.

Recording

Should you wish to record a telehealth session, we encourage you to do the following:

  • Gain consent as per current guidelines
  • Check the privacy settings of the platform you are using for your consultation
  • Refer to relevant local information governance policies
  • Ensure that the recording is saved to a secure local drive (eg a drive on your computer rather than ‘cloud storage’). Consider whether this needs to be uploaded to the service user’s electronic record.

Carrying out a telehealth session

Once you have made the decision that using telehealth is appropriate, the following should be considered when planning to carry out a session using telehealth.

Carrying out a session using telehealth

Before your telehealth session

  • As with an in-person session, ensure you gain consent. Consent may be provided verbally or in a written format. More information can be found in the consent section of this guidance.
  • Share any relevant handouts with the service user about getting set up to access their session via telehealth. This may include information on the platform and helpful tips for setting up the ideal environment for the session.
  • Ensure you have given the service user an opportunity to ask any questions and share any concerns about using telehealth.
  • Jointly agree expectations for the assessment or therapy appointment including support needed from family/carers and reducing background distractions. Ensure targets are appropriate and meaningful and adapted to a virtual session as needed.
  • Ensure appropriate resources are available as needed (eg toys for carrying out an assessment with a child, or thickener and/or prepared foods for a dysphagia assessment or review).

Carrying out your telehealth session

Tip: Have the service user’s telephone number to hand if technology fails and you need to guide them through setting up the platform or troubleshooting.

Once the session is underway you can support your service user and others by doing the following:

  • Clarifying the expectations and aims of the session, as you would in any therapy session, especially if these have been adapted when carrying out the session virtually.
  • Allowing time for discussion and questions, at the beginning and/or end of the session including any concerns about the use of telehealth.
  • Checking that they can hear you well and can see the same thing as you if you are sharing resources via screen share
  • Being explicit and not assuming that the service user and others can interpret what you are saying or doing. Telehealth may limit the amount of non-verbal communication we typically use in-person.

After your telehealth session

  • Complete your clinical notes specifying that the session was carried out via telehealth.
  • Confirm the details of the next appointment and share a video link as needed.
  • As with in-person sessions, remember to raise any safeguarding concerns with the appropriate safeguarding lead or organisation.
  • We recommend you request feedback on the therapy to help you to refine future sessions. Online questionnaires are useful for collating feedback and this feedback could ultimately help the growing evidence base for telehealth.

Guidance has been developed by a group of AHPs from across Northern Ireland and collates available resources on virtual consultation including the evidence base, patient selection, the consultation and evaluation – AHP virtual consultation guidance.

You can also review existing guidance on management and intervention when planning telehealth sessions.

Assessments

Administering assessments via telehealth

Best practice when administering assessments via telehealth is to try and ensure your assessments align with the following standards:

There are different options available when assessing a service user via telehealth including:

  • using informal assessment;
  • using digital versions of the assessment where available (be mindful of licensing requirements with digitised assessment and materials);
  • scanning assessments if this is not in breach of copyright;
  • careful manipulation and handling of physical assessments; and
  • using a visualiser.

Always consider licensing, copyright and intellectual property when making a decision about how to assess remotely.

Consider if a telehealth assessment is appropriate for the individual you are wanting to assess. Gather relevant information about the service user that may influence the suitability of the assessment process (eg any linguistic, cultural or communication barriers). Also consider that a telehealth session may be preferable in certain situations such as a child feeling more comfortable in their home with their parents present. See the previous section of the guidance for further considerations. You may also wish to undertake a risk assessment.

Prior to the assessment session you may want to practise administering the assessment via telehealth if you have not previously done so, for example, with a colleague.

Prepare carefully for the assessment as you would usually do, including:

  • Ensuring that you have all of the materials available
  • Keeping the administration of the assessment as similar as possible to how it would be administered when carrying it out in-person.

After administering the assessment remotely, we then suggest that you consider the following:

  • Clearly document that the assessment was completed remotely in the health and care record and in any reports, including the duration it took to complete the assessment. Also note if the administration of the assessment was adapted and how this might have impacted the results.
  • Overtly discuss and address the validity of the data gathered, using professional judgement to determine whether it was a true representation of the service user or whether further information gathering is required. See below about normative scores.

Normative scores

There are normative score data considerations when moving from an in-person to telehealth administration. A normative score is only useful when:

  • You can administer the assessment in a standardised fashion
  • The service user is cooperative and responds to the assessment
  • The assessment environment supports an optimum performance from the service user

As with all assessments, the SLT will need to use professional judgement to determine whether it is appropriate to use norms when administering a formal assessment remotely.

The following differences can have a detrimental impact on the validity of the assessment norms:

  • A weak connection results in not being able to see or hear the service user clearly
  • The service user is distracted and/or not in optimum conditions
  • The SLT has had to deviate from the standardised procedure
  • The service user has to respond differently from the standardised response requirement

Conclusions or decisions based on data that are skewed are likely to no longer represent an individual’s abilities or functioning. We suggest that these factors are considered when deciding whether to:

  • proceed with modified assessment procedures in the specific situation;
  • use alternative measures that are available to use in a remote format; or
  • postpone until an in-person assessment can be arranged.

Download the key considerations infographic (PNG).

Please note: The RCSLT cannot recommend specific assessment products or publishers. Any resources related to specific products in this guidance are provided for informational purposes only. No endorsement is expressed or implied.

We suggest that SLTs check on publishers’ websites for more information about specific assessments.

Considerations when assessing specific client groups

This section sets out some key considerations for specific client groups. Please note, it is not exhaustive, and members are also encouraged to review the following RCSLT guidance:

  • Clinical guidance A to Z – Contains specific information about assessment for the different clinical areas found within speech and language therapy
  • Managing risk – Provides some useful information that could be relevant to undertaking telehealth assessments

Dysphagia assessment considerations

Dysphagia assessments for adults and paediatric service users have been documented via telehealth in many clinical areas.

You can access our telehealth decision making tool to support with making decisions about whether or not telehealth is suitable on an individual basis.

Remote dysphagia assessments require a risk assessment to be done. Risks include:

  • loss of video connection during assessment meaning that the therapist cannot see the assessment;
  • instructions not followed/heard by assistant;
  • change in patient status;
  • aspiration/respiratory changes;
  • choking; and
  • need for emergency procedures for the above risks.

We also suggest that you clearly outline emergency procedures and troubleshooting (Word). Below are some considerations for developing these:

  • Who is responsible in an emergency?
  • Are all the relevant parties involved, informed and do they understand their role?
  • What process(es) should be followed should an issue arise (eg choking, altered health state of service user)?

You may also need to consider:

  • Procedures for access to thickener for assessment (eg sending out sachets or thickener tubs before the assessment with instructions for family members or a video consultation to take an assistant/family member through the instructions).
  • Providing training and supporting resources to staff/carers and families. This will help them with understanding the assessment process and their role in supporting, enhancing diagnostic accuracy and reducing risks for the service user.

Speech assessment considerations

When completing speech assessments we suggest that SLTs:

  • can see the service user’s mouth clearly — if the service user is wearing a headset, make sure that the microphone is not obstructing the view of their articulators;
  • check that the audio is clear with no background noise. Noise cancelling headphones may be helpful to support this;
  • ensure adequate lighting conditions to view the user’s face while avoiding strong sources of light from behind the user;
  • assess the quality of images and audio, as this can impact the confidence of your assessment results (if recording the session please also ensure that you have consent for this).

Developing digital skills

Digital literacy has been defined as “those capabilities that fit someone for living, learning, working, participating and thriving in a digital society” (Health Education England, 2022).

The use of digital technology within healthcare continues to grow and evolve and is becoming more fully integrated into the ways we work as speech and language therapists. Speech and language therapists have a responsibility to ensure they feel competent, confident and capable when using digital technologies in the workplace and have the requisite digital skills to support their work, specific to their area(s) of clinical practice. We aim to support therapists with this and ensure they keep their skills up to date.

Resources

National programmes supporting digital literacy and competency that are available to speech and language therapists:

Other resources:

Evidence-based practice

Finding evidence

This section contains evidence from the research literature. You can gain access to research articles through the RCSLT journals collection, and find more resources to support using evidence-based practice in our research centre. You can find other evidence about the use of telehealth within the case studies linked throughout the guidance and in the resources section.

This section contains a list of relevant articles about telehealth. Please note that this list is not exhaustive. As this is an emerging evidence base, we would encourage SLTs to continue to support with the development of evidence in this area. Please contact us with any suggestions of additional articles or resources to be included.

Articles

This section highlights some key research articles relating to telehealth generally and within specific clinical areas.

General

Publications pre-COVID-19

Publications post-COVID-19

Adults

Aphasia

Autism and neurodiversity

Children and young people

Deafness

 Dementia

Dysfluency

Dysphagia

Head and neck cancer

Parkinson’s disease

Traumatic brain injury

Voice

Resources

Please note: The resources throughout this guidance are provided for informational purposes only. No endorsement is expressed or implied, and while we make every effort to ensure our pages are up to date and relevant, we cannot take responsibility for pages maintained by external providers.

National guidance and policy

An up-to-date list of relevant UK-wide legislation and guidance can be found in our technology guidance.

Some relevant information to telehealth in the UK can be found below:

UK wide

A plan for digital health and social care

England

Technology enabled care services England

Northern Ireland

Digital Strategy 2022-2030

Scotland

A changing nation: how Scotland will thrive in a digital world

Technology enabled care Scotland – Telecare

Wales

Digital Health and Social Care Strategy for Wales

Technology enabled care Cymru – Telehealth

Telehealth professional network

Our telehealth professional network has been developed as a place for members across the UK to discuss the use of telehealth in their speech and language therapy services.

The forum can be used as a place to ask specific speech and language therapy related questions about telehealth, discuss and share new resources and opportunities, as well as your experiences of using telehealth.

You can join the network via the professional networks’ webpage.

Consent to use telehealth

Example consent forms:

Information governance and telehealth

How to and user guides

  • Conducting CEN meetings online – RCSLT CEN organisers may wish to host meetings over an online forum, with members participating remotely. The Computers in Therapy CEN has put together tips for hosting an online CEN meeting.

Carrying out a telehealth session

Remote assessments

Example risk assessments and decision-making tools

Contributors

This guidance has been developed by the Royal College of Speech and Language Therapists (RCSLT).

Supporting authors:
  • Rebekah Davies
  • Charlotte Gower
  • Rachel Radford
Acknowledgments:
  • Rafiah Badat
  • Shermeena Rabbi
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