JCPSLP Vol 23, Issue 1 2021

and processes involved. Both SLPs provided in-person and telehealth therapy weekly. Intervention BUSHkids implemented two telehealth service models by two different SLPs located at BUSHkids clinics. In the first model, children received therapy at a telehealth room in a community centre in a small town (population approximately 3,000). The telehealth computer had been previously provided by a local primary health network. In the second model, children received therapy in their homes which were more than 30 minutes’ drive from a rural service hub (population approximately 30,000) and used their own devices. The videoconference software was Zoom Meetings by Zoom Video Communications, Inc. (San Jose, California). Before beginning telehealth practice, the SLPs were trained in telehealth technology, and risk and distress management guidelines. Training was provided by the IT manager of BUSHkids and the first author of this study using training modules developed in consultation with BUSHkids clinical managers and reviewed by two members of the research team experienced with telehealth provision (DB, TR). Training covered how to use Zoom, strategies to maintain therapeutic alliance, strategies to identify alternatives to physical touch, and speech-language pathology telehealth guidelines and evidence. The SLPs also observed at least one telehealth therapy appointment by another clinician and completed one or more mock therapy appointments via Zoom with a colleague. A total of 70 telehealth therapy appointments were conducted during the data collection period (mean 7.77 per client, range 4–10). In-person participants were also observed and interviewed to compare in-person and telehealth practice. In-person participants were recruited from the in-person clinic caseload of the two SLPs during the same period as telehealth provision. A total of 68 in- person sessions were conducted (mean 9.71 per client, range 8–10). Participants Participants included two BUSHkids SLPS, six BUSHkids managers and 17 parents of child clients. The two SLPs were aged 18–29, female, with 1–2 years in their profession. Both had heard of telehealth but had no experience with it. The six manager participants were a clinical supervisor, line manager, IT manager, clinical manager, and two executive leaders (three males, three females, aged 30–44 (n = 3) or 45–50 (n = 3). Three were experienced with telehealth and three had no experience with it. Telehealth participants included nine parents, most of whom were aged 30–44 (89%) and women (89%). These parents were the parents of nine child clients (mean age 4.7 years, range 3–6 years, five boys and four girls). Three families received therapy at the community centre and six received telehealth in their home. In-person participants included eight parents (six aged 30–44, two aged 18–29, seven women, one man), who were the parents of eight children (mean age 5.1 years, range 3–7 years, four boys and four girls). Recruitment A list of two SLPs able to take on telehealth clients in addition to their current caseloads were provided by BUSHkids. SLPs were provided with detailed verbal and written information about the research by the first author via email and phone. They were assured that their participation

than being passive consumers of therapy, parents can take active and effective roles in therapy. A Cochrane systematic review of the effectiveness of speech-language therapy for children with primary speech and language delay/ disorder found no significant difference between clinician- implemented and parent-implemented intervention when parents were trained to deliver the intervention (Law et al., 2003). Parents are known to take on a co-therapist role when doing home speech-sound practice with children (Sugden et al., 2019) and can provide high dosage speech and language home programs when they receive direct training (Tosh et al., 2017). Other systematic reviews have found preliminary evidence for parent-mediated interventions. Parent-mediated intervention training may increase parent knowledge, intervention fidelity, and improve social behaviour and communication skills for children with ASD, although a low number of RCTs and other limitations limited the generalisability of the findings (Parsons et al., 2017). Parent-implemented interventions for late talkers are potentially more effective that clinician- directed therapy, although generalisability is limited by variations in parent training procedures and unclear ecological validity of parent training (Deveney et al., 2017). Given the importance of parents in these therapy approaches, it is likely that parents will also be key stakeholders in telehealth speech-language therapy. Despite this, the roles of clinicians and parents in such therapy are as of yet not clearly described in extant literature. In summary, while there is evidence for the efficacy of telehealth speech-language therapy and parents are likely to be key stakeholders in such therapy, there is, as yet, limited understanding of clinician and parent practice changes and other supportive factors needed for telehealth adoption. This study aimed to explore clinician and parent practice changes involved in implementing telehealth SLP therapy in an existing service for rural children. Methods Setting This research was conducted at BUSHkids, a not-for-profit organisation providing free allied health and education services to rural families in Queensland, Australia. BUSHkids funded the first author’s PhD scholarship and provided funding for transcription. Ethical approval was obtained from the University of Queensland Human Research Ethics Committee B (2017001829). Approach A pragmatist paradigm was used with the intention to create knowledge that could be practically applied in daily clinical work. A qualitative exploratory case study design was used. Case study design is appropriate when describing a case bounded by time or place that can inform a problem (Creswell et al., 2007). This case study examined the key activities of speech-language therapy conducted in-person and via telehealth by two BUSHkids SLPs. Telehealth was a new service for BUSHkids. The case was bound by time (the first six months of telehealth (TH) provision 2 May 2018 March – 1 January 2019) and place (services provided from BUSHkids Emerald and Mount Isa clinics). Telehealth and in-person speech-language therapy were examined using two data sources: (a) observations of SLPs and families during telehealth and in-person therapy; (b) interviews with SLPs about their experience of therapy

Nicole Hartley (top) and Nicole Gillespie

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JCPSLP Volume 23, Number 1 2021

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