Nell Rosenberg on Access and Teleservices Programs

On this episode of the Getting Smart Podcast Rebecca Midles is joined by Nell Rosenberg, National Director of Teleservices at Clarke Schools for Hearing & Speech. 

Clarke, an organization established in 1867, has evolved to support children with hearing loss by teaching them to utilize hearing technology like cochlear implants and hearing aids to access sound, develop spoken language, and acquire literacy skills. Originally a single boarding school, Clarke has adapted to significant technological advancements and societal changes, transitioning to operating multiple-day program sites and offering teleservices across the East Coast. This shift responds to the earlier detection of hearing impairments due to universal newborn screenings and the improved accessibility of hearing technology, allowing for a more inclusive and flexible service model that supports children in their natural environments and mainstream schools.

In addition to physical locations, Clarke has expanded its support through a structured teleservices program, which aims to provide consistent and high-quality education and support from birth through high school graduation. This program emphasizes a strong parent-caregiver coaching model, regardless of the service setting, to ensure that families are equipped to support their child’s development continuously. The introduction of virtual services, or “T-visits,” has been crucial in overcoming geographic and accessibility barriers, commonly referred to as the “zip code lottery,” which affects the availability of specialized services. Through these initiatives, Clarke not only addresses the critical shortage of qualified professionals but also enhances the flexibility and reach of their services, demonstrating significant success in educational outcomes and parental satisfaction. This conversation touches on aspects of this journey and how education leaders can learn from this evolution. 

Nell Rosenberg

Nell is the National Director of Teleservices at Clarke Schools for Hearing and Speech. She served as a speech-language pathologist, speech/language supervisor, and assistant program director of Clarke New York for seven years prior to assuming her current role in 2021. In New York, Nell served as the campus tVisit early intervention program coordinator and discovered her passion for overcoming access barriers through teleservice. Nell received her bachelor’s in Human Development and Special Education from Boston College, her Master of Education in Early Childhood Special Education from the University of Florida, and her Master of Science in Communication Sciences and Disorders from Florida State University. Prior to joining Clarke, she was a speech-language pathologist in the auditory/oral program of Duval County Public Schools, and for children with a wide range of needs at the Gillen Brewer School and The Churchill School. 

Links:

• LinkedIn
• Clarke School for Hearing and Speech
• tVisit Teleservices Program
• National Center for Hearing Assessment and Management,

Transcript

Outline:

• Clarke’s Evolution and Program Overview (00:10 – 02:44)
• Teleservices Program Structure and Support Levels (02:44 – 04:27)
• Impact of Virtual Services and Language Support (04:35 – 08:16)
• Challenges and Solutions in Implementing Virtual Services (10:40 – 13:27)
• Success Stories and Data Analysis (15:34 – 19:27)
• Addressing Shortage in Specialized Support (19:41 – 22:58)
• Advocacy Efforts and Public Awareness (23:57 – 25:45)

Clark’s Evolution and Program Overview

Rebecca Midles: You’re listening to the Getting Smart podcast. I’m Rebecca Midles. Today, I’m joined by Nell Rosenberg, Clarke’s National Director of Teleservices. Good morning.

Nell Rosenberg: Good morning. I’m happy to be here.

Rebecca Midles: Can you tell us a little bit about Clarke’s journey? I think they started in 1867, supporting children with hearing loss. Can you tell us a little bit about that?

Nell Rosenberg: Yes. So Clarke has a very long history. What has remained constant since 1867 is that we teach children who are deaf or hard of hearing the listening, learning, and spoken language skills they need to succeed in school and life. So children who attend Clarke use hearing technology, such as cochlear implants or hearing aids, to access sound, and Clarke’s specialists help them learn to interpret the sound and then learn spoken language and literacy skills they need based on that auditory input. So that has always been the case. What has changed over time is the technology, and then the models have changed that. So in 1867, Clarke was one boarding school, and that is reflective of our field at large.

Children who are deaf and hard of hearing, have a low incidence disability, and it was the only option for a long time to send your child to a boarding program, unfortunately, to get those centralized services. But hearing technology has changed immensely, so the kids have better access to sound. The advent of universal newborn hearing screenings meant that children were being identified earlier and had earlier access to hearing technology. In response to those changes in our society and technology, we transitioned away from running one residential campus to having five-day program sites along the East Coast. That was around the 1990s.

So it took change; it took a while to come, and then it came fast, because now we’re serving children still at our five campuses, also in mainstream schools, in the natural environment, and anywhere children who are deaf and hearing hard of hearing are through teleservices. So though our mission has remained the same, what it looks like to receive services has changed a lot over the years.

Rebecca Midles: That’s wonderful. So you’ve probably seen an increase in services that might be similar, maybe with a different mission across the country. Is that accurate as well?

Nell Rosenberg: Absolutely, yes.

Teleservices Program Structure and Support Levels 

Rebecca Midles: What are the different levels of support through the teleservices program that are available in the field, and maybe how do they differ?

Nell Rosenberg: Well, our goal is for them to differ minimally, to be honest. When we look at the continuum of birth through high school graduation, the child and family’s needs change a lot, right? Of. So our youngest children are birth to three kids and a little older. We use a very strong parent-caregiver coaching model, and that would be the same if you went on campus at a Clarke site or if you visited teleservices. And that’s the gold standard in our field. So anywhere that children are accessing services, our colleagues across different programs are providing those caregiver coaching modeled sessions so that families learn to implement the strategies all the time, not just in one little session. And then it kind of evolves as the child’s educational and developmental trajectory goes on.

We start working with school teams still using a lot of coaching with people in the child’s school. And then as they get older and older, it transitions more to a direct service model where a child can log on and receive a direct service with a provider because they don’t need an adult helping them anymore. And at that point, we’re doing consult services with school and family teams so that everyone is still in the loop. And that is the gold standard in our field. Everywhere we say “T-visits” all the time. That means Clarke’s “t visit” teleservices. But many amazing organizations are providing teleservices not under that specific name.

Impact of Virtual Services and Language Support

Rebecca Midles: What has been the impact of the introduction of virtual services like T-visits, and how has that impacted the accessibility of language and speech support for families?

Nell Rosenberg: That has been huge. The zip code lottery is often discussed in education at large, but for children who are deaf and hard of hearing, it is even more complicated. What’s the same is that virtual services are critically important for families in rural areas, families that live in areas impacted by severe weather, children with additional medical needs, and families who are in urban areas with poor access to realistic transportation options. That probably sounds similar to what we’re used to talking about for our population because it is so low incidence and because there’s a real dearth of provider preparation programs and a huge shortage, therefore, of providers in our field.

You’d be shocked by what the zip code lottery looks like because there are mid-sized suburban areas, large urban areas, and school districts with outstanding schools, and even excellent special education programs that happen not to have a single professional with expertise in listening and spoken language. So you may have planned very specifically to live in this great school district with great programs for everything, and then you have a child born with a hearing loss, and there’s no one there to serve you. So the zip code lottery feels, at times, quite random. Some areas have great programs for children who use ASL, but not for listening and spoken language. Some have the opposite. So depending on what communication modality the family chooses their options may be limited, or there may be nothing at all. 

Rebecca Miles: It’s really helpful for that to be highlighted. Often the zip code lottery conversation has some bias in there, so it’s really helpful for us to share that difference. You’ve made me think about ASL, American Sign Language. Do you often have students who want to transition? Let’s say they had ASL, but they wanted to have more spoken language. Is that an option? And is there a time when that matters?

Nell Rosenburg: There is a time frame where that matters, and we see every iteration of that. Right. So Clarke focuses on listening and spoken language. That is our area of expertise, and we don’t practice outside of our area of expertise. So I am not going to present myself on it as an ASL expert, and I’m not going to provide direct service. However, if a family does want to pursue ASL in addition to listening and spoken language, then we are very happy to refer them to our excellent colleagues in the field who can give them that support. And we see various iterations of this. Some families want to do a bilingual approach where they’re learning both spoken English and ASL, which is a real commitment on the part of the family. Right. Because everyone’s going to have to learn those.

We have some families who were presented with biased information at birth. This is a huge problem in our field, where maybe they only heard about ASL or they only heard about listening in spoken language. And it is our strong belief that both of those are wrong. We are a listening and spoken language program, but I don’t think it’s the one right approach for all children because there’s no such thing as one right approach for all children. So we do get kids who have been learning ASL, and then their parents learn. They can perhaps learn to listen and speak, and they want to come to learn how to do that at Clarke, and we are very much on board with that. And then we have families that say they want to keep listening in spoken language, but we’re worried.

40% of children who are deaf and hard of hearing have additional disabilities, and perhaps they have a significant motor challenge that may affect speech production. And they say, maybe our kids should learn ASL, too, and then we help them get those services, or if they’re not making sufficient progress in listening and spoken language, we will never advocate for language deprivation if it is not working for a child. We will help the family find a program that does, whether that be ASL or a completely different communication modality, like alternative and augmentative communication.

Rebecca Midles: I can imagine there are lots of different ways that people and families find out about you, but I’m also thinking about. I currently live in Washington, used to live in Colorado at one time, Alaska. Have to get that in there. But a lot of those states have, like those mentioned, kind of an overarching BOCES is what it’s called in Colorado, or an overseeing ESD. Yeah. And then in Washington, it’s called an ESD, you know, educational service district. But with those organizations that kind of oversee multiple districts, I can imagine that what you offer is very attractive to those systems. Is that something that happens frequently, or is that something that probably would make sense if it was out there and understood?

Nell Rosenburg: Both. So it’s happening with increasing frequency, and we’re hoping to increase public awareness and knowledge that this is an option because for so long, it wasn’t. And the answer was, this is what we have, and this is the best we can do for your kid. And families had almost no choice but to accept that. But with the advent of tele services expanding, that is no longer the case. So it is critical for both school districts and, you know, large organizations like BOCES and so forth to know about the options and also for parents to know so they can advocate that. Okay, I hear you saying your BOCES doesn’t have a teacher of the deaf. I understand that, but my child needs a teacher of the deaf, and therefore, we need to contract with a program that can provide one virtually. Yeah.

Challenges and Solutions in Implementing Virtual Services

Rebecca Midles: What have been the major challenges in transitioning to or implementing virtual services? How have you overcome those challenges?

Nell Rosenburg: Yeah, well, we’re fortunate because we received some large grants beginning in around 2011 to pilot teleservices for young children, children ages birth to three. So we started figuring this out and refining our approach long before the field at large was forced to pivot to virtual due to COVID and so forth. So we had a long time to figure out what the challenges were. At that time, a lot of them were technology people not having comfort with video systems and so forth. That’s not a challenge anymore. Families and schools are very comfortable using video conferencing platforms and so forth. So that has become the last of our concerns.

And that was what we learned, that someone can be an excellent teacher or therapist in person, but not have the skills related to parent and caregiver coaching and adult learning styles to do well in teleservice, because you’re not there to save the session, and you shouldn’t be. You should never be stepping in to save the session. But we’re. We realized we had to step up our training, and we have. So now, before people are providing teleservice, we have developed training protocols where they learn about adult learning styles, they learn about coaching, and they become comfortable with that model. And then the other challenge we encountered was everyone having inappropriate expectations of what a session was going to look like. And that’s everyone, from the teacher to the parent to the kid to the provider.

And we’ve solved that by having, starting with family and/or school consults, an introductory session when the child is not present. We are specific in explaining the roles of the caregivers, the teachers, and the provider, and we establish who’s going to participate in the session. Where will they occur? We troubleshoot things like, “Oh man, you’re saying it’s going to occur here, but there’s a very loud radiator right here that’s going to affect auditory access. Let’s look for a new space,” and we troubleshoot all those logistical and technical issues before the child is present. And that time when the child comes in, everyone knows what to expect, everyone knows what their role is, and we’re ready to go.

Rebecca Midles: So many things I think listeners can relate to in even different contexts. That makes so much sense.

Nell Rosenburg: Yes. Yeah. I would recommend that for anyone doing teleservices with any population.

Rebecca Midles: Yeah. And so thoughtful. Well, can you share some success stories or maybe key findings?

Nell Rosenburg: Absolutely, yes. So, we have done data analysis. Specifically, the most robust data we have is from our birth to three programs. We do have some from our older populations as well. We worked with an outside data analysis agency, and they analyzed both parent surveys and parent input, as well as standardized language testing. Our outcomes found that children receiving teleservice performed just as well on norm reference language tests as children receiving the same in-person services on Clarke sites, which we all hoped for. But way back in 2011, or whenever we started, it seemed like an impossible goal, and it happened nearly instantaneously. So we saw that children were performing on par with kids receiving in-person services, and then the parent satisfaction data just blew us away.

Over 95% of parents surveyed said that teleservice visits were either effective or very effective in helping caregivers learn to interact more effectively with their child, increasing the strategies they use to build their child’s communication skills, monitoring, and tracking their child’s progress. What hit me, is because the resistance to teleservices is often relationships, people think we won’t connect. The same 100% of our parents surveyed said teleservice visits were effective or very effective at developing and maintaining a relationship with their provider and receiving the emotional support that they need. Yeah.

Rebecca Midles: And I can imagine that level of support for the family isn’t always included in in-person. Right. So, yeah, and so, yeah. That speaks to that piece. That’s the benefit.

Success Stories and Data Analysis

Nell Rosenburg: Yeah. And in terms of success stories, yes, I can share some. Some fun success stories. One thing that’s been exciting is that we’ve been able to harness technology to make virtual services an even better option for some children. One development in our field recently across the board has been for children with single-sided deafness with normal hearing in one ear. Some of them can now receive a cochlear implant on the other ear so they can have true binaural hearing with both sides, just like we do. That has traditionally been hard to habilitate because they can hear with the other ear. Right. So it’s harder to isolate.

And then we coach their parents on how to use those direct connection strategies in their homes and other settings. And we’ve seen these kids make progress that is much faster than we would expect with their new devices than is typical for a child with single-sided deafness. We have several kids like that in our program now, and three of them are making very exciting progress with their new devices. What I’d like to say about success stories is that sometimes they’re complicated and they often require quite a bit of problem-solving. I could tell you a lot of great stories about kids getting t-visits and being ready to join their mainstream peers with typical hearing at age three for preschool. I have countless stories like that, and they make my day every time.

But what I take even more pride in is the complicated ones. So, for example, right now I work personally with a four-year-old who lives in a rural area with no specialists and also no local pediatric audiologist, which is a big challenge. So they were traveling for audiology, and it wasn’t pediatric-specific. She has bilateral cochlear implants. She is one of the 40% of kids that have additional disabilities. She was hitting a wall with speech production, and it was kind of being written off as well. You know, she has motor delays, etc. So I sat down with her mom virtually, and we went through her audiological reports and realized she’s not having her cochlear implants mapped optimally. Mapping is a term that means programming for cochlear implants.

And so I had to do some work because, without optimal auditory access, this child’s never going to have a chance to make the right kind of progress. So I contacted colleagues in the field in that general area. I contacted some alumni families. I found pediatric audiologists who came recommended, still a distance, right, but not much farther of a drive than they were currently doing, helped them get set up with a new audiologist, who, after one appointment, identified significant mapping issues, remapped the cochlear implants. Whereas previously, the next time that child would have received any kind of intervention would be three months later at follow-up at that center. Now I can see her and her mom every week, and she is already making faster progress with her auditory skills, which precede speech development.

So those are the kinds of success stories that are really exciting for me.

Rebecca Midles: Yeah, you’re meeting them kind of at the intersection. Right. Of services, and what a great resource to be able to catch those pieces. Kind of that whole-child approach.

Nell Rosenburg: It’s really a whole child approach, and we have to be so open to collaboration, and that’s the key to success.

Addressing Shortages in Specialized Support

Rebecca Midles: So I’m thinking about this, and in the intersection and all the people involved. How does Clarke start? Do teleservice programs contribute to mitigating the nationwide shortage of teachers and speech-language support that specialize around hearing loss?

Nell Rosenburg: Yeah, there’s a critical shortage of teachers of the deaf. So those are teachers who’ve gone through a specialized program. There are not enough programs, which is a challenge, but there are not a lot of teachers of the deaf. Teleservices can really help with this shortage because it’s such a low-incidence disability that teachers of the deaf were found to be spending up to 50% of their days driving. After all, they’re driving to see one kid in one school district, and then 2 hours away to see the next child in the next closest district who has a hearing loss is often only one kid in a district. So they’re spending a lot of their time in the car. 

So when we can use teleservices, we can optimize their time, sometimes by up to 50%, which is just wild if you think about the impact on the number of children who can be served. You know, not always, not everyone spends that much time in the car. But they were spending a ton of time in the car. And every hour in the car is a child who is deaf or hard of hearing, who does not have a teacher of the deaf. And that really stuck with me when I really thought about it. How many kids were not able to serve? And how many more could we serve if we’re doing teleservices instead of driving all over different states? And the same with speech pathologists with expertise. We don’t want them driving around either.

And also, I think one really interesting way that it’s helping mitigate this nationwide shortage is providing flexible employment options. We see in our field with TODs, teachers of the deaf, and SLPs, and I suspect in many areas of education as well, that a lot of times it’s a female-dominated field and a lot of times people leave the workforce when they have children and/or move, and we lose a specialist. And what we’ve done is now started hiring back some people that used to work at Clarke. Right. And they moved. They had children. They wanted to dedicate some time at home when their children were young. I now have two outstanding SLPs and one TOD on my team who worked at different Clarke campuses prior to having children.

And now they’ve moved and they can now work flexible hours from home while doing the work that they love and the work that they’re trained to do. And I think this is one of the biggest untapped markets there is because this is a group of highly skilled providers. And I plan to continue to leverage this flexibility option to mitigate that nationwide provider shortage.

Advocacy Efforts and Public Awareness

Rebecca Midles: Yeah. Particularly with supportive services, there’s a pretty high, what some people reference as a burnout rate in the system. And what I’m hearing is higher levels of satisfaction with their time and work. And so that’s another great way to retain. So makes so much sense other than today. Finally, what is the role that you guys are playing in raising public awareness and advocating for the needs of children with hearing loss? And how can we listeners and the public support these initiatives?

Nell Rosenburg: That’s a great question. Clarke advocates at many levels, and I will not go into the finer detail points because, as I said, we have programs operating in five states and we have national programs. And as I’m sure you are well aware, education laws and regulations differ from state to state and from county to county and so on. So we are advocating at our local levels very much as well as nationwide for things like the ASHA Interstate Compact, which may be something listeners are familiar with, where Asha, the licensing board for speech-language pathologists, is really pushing to have more interstate reciprocity for licensing, which would help significantly with teleservices, right? Yes.

So Clarke is doing a lot of different advocacy work and trying to get the message out there about the critical importance of virtual services because we know our population is low incidence and many people have never even heard that children who are deaf and hard of hearing can listen to talk. That’s still a big thing that we have to overcome. I would encourage listeners to educate themselves more about the low-incidence population. We’re going to include links in the show notes to a couple of different places, certainly to Clarke’s website, which has some great resources, including free educational webinars that were recorded for families and professionals on a variety of topics, including but not limited to teleservices. We have a lot of other topics as well.

And then for some really nice, unbiased resources for all audiences, we’re going to refer you to the National Center for Hearing Assessment and Management, often referred to as NCHAM, which has everything from short video clips to information about teleservices to information about how to get services for your specific child, specifically where you are in your state and your county. So those are great starting points for people who are just learning about these possibilities.

Rebecca Midles: Thank you so much, Nell, and to the team, for sharing Clarke’s journey, but also highlighting the challenges from the field, the success stories, and other services that are out there and provided. We look forward to sharing those show notes with others so that we can support this work. Thank you so much for joining us today.
Nell Rosenburg: Thank you so much for highlighting the work of our field. I love it. I am passionate about teleservices and serving children who are deaf and hard of hearing, and we love to get the message out there.