Swallowing and Feeding Services in Schools via Telepractice During COVID-19

During the COVID-19 pandemic, many students, including those who have feeding and swallowing disorders, are receiving special education services virtually through telepractice. This page is designed to guide school-based speech-language pathologists (SLPs) who are pivoting to effectively provide these services via telepractice.

On this page:

School-Based Swallowing and Feeding Services
Responsibilities of the School District
USDA Food Services Program and Meal Modifications
When Swallowing and Feeding Is a Concern
Virtual Assessment of Swallowing and Feeding
Preparing for Swallowing and Feeding Services via Telepractice
IEP Goals
Service Delivery Scenarios
Role of the Facilitator
Monitoring and Documentation

School-Based Swallowing and Feeding Services

Services for students who have an established swallowing and feeding plan in the school setting typically include the following:

Implementing a safe swallowing and feeding plan during mealtimes at school.
Providing education and training to students, families, and school staff on safe swallow strategies.
Training classroom or cafeteria staff to modify student’s food and liquids to meet the swallowing and feeding plan recommendations.
Maintaining safe mealtimes at school with ongoing monitoring and consultation with classroom staff.
Training classroom staff to (a) recognize signs and symptoms of aspiration as well as changes in a student’s feeding and swallowing skills and (b) immediately report those changes to the team.
Training students to self-advocate for appropriate food and liquid consistencies.
Revising a swallowing and feeding plan when changes are warranted.
Collaborating with parents, physicians, related service providers, and food services staff.
Intervening therapeutically, when indicated, to improve functional eating skills and to ensure a safe swallow.

Responsibilities of the School District

According to the U.S. Department of Education, if a local educational agency (LEA) continues to provide educational opportunities to the general student population during a school closure, the school must ensure that students with disabilities also have equal access to the same opportunities, including the provision of a free appropriate public education (FAPE). For more information, see 34 CFR §§ 104.33 (Section 504) and 104.4, as well as 28 CFR § 35.130 (Title II of the Americans With Disabilities Act of 1990 [ADA]). State educational agencies (SEAs), LEAs, and schools must ensure that, to the greatest extent possible, each student with a disability can be given the special education and related services identified in the student’s individualized education program (IEP) developed under the Individuals With Disabilities Education Improvement Act of 2004 or can be given a plan developed under Section 504 of the Rehabilitation Act of 1973 (see 34 CFR §§ 300.101 and 300.201 [IDEA] and 34 CFR § 104.33 [Section 504 of the Rehabilitation Act]).

The U.S. Department of Education understands that there may be exceptional circumstances that could affect how a particular service is provided. In addition, an IEP team and—as appropriate to an individual student with a disability—the staff members responsible for ensuring FAPE to a student for the purposes of Section 504, would be required to make an individualized determination as to whether compensatory services are needed under applicable standards and requirements.

It is the school district’s responsibility to provide all students equal access to the educational curriculum so that they may learn alongside their peers. Students should also be safe while attending school.

When students with swallowing and feeding disorders are participating in school virtually in the home setting and not on campus, the requirement to implement safe feeding no longer falls on the school district but, rather, on the parents. The services that students receive via telepractice, however, continue to be consistent with their IEP.

Telepractice services may be not be appropriate for some students. When a student is not a candidate for services via telepractice, missed sessions can be made up when they physically return to school. Services may be modified to include goals targeted to assist the child in maintaining some level of skills until services are resumed at school.

Services may be refused or ineffective because the delivery of telepractice services require a facilitator. If the parents/caregivers or their surrogate are unable to participate and support the student during the session, then the SLP will document all attempts to provide support and education to the family. Services will resume once school resumes in person. Schools—not parents/caregivers—are required to provide a FAPE. Parents have the right to refuse services at any time (see §1401 of IDEA 2004).

When a school district goes completely virtual, it typically has a plan for how to implement virtual instruction. Therapists and school teams should comply with the directives of their school district; however, in situations where the therapist is concerned about a student’s safety during mealtimes or an ethical concern arises, the therapist should meet with the district supervisor to inform them. The school district should document all safety and ethical concerns in writing—along with how such concerns will be addressed.

When swallowing and feeding services are not provided during virtual school, the SLP may do the following, if supported by the district:

Discuss with the parent(s) that these services will not be offered during virtual classes but will resume once students are on campus.
Provide the parent(s) with a copy of the student’s swallowing and feeding plan, and offer to explain the plan to parents for follow through at home.
Contact the parent(s) periodically to answer questions and to offer support.
Document all contacts and services provided virtually.

USDA Food Services Program and Meal Modifications

The U.S. Department of Agriculture (USDA) School Food Services Program issued a waiver during COVID-19, targeting students whose in-person school programs were halted. According to the USDA School Food Service Program waiver, school lunch programs will be provided for all of the children in a family if at least one child attends a school that is closed due to COVID-19. See the USDA Food and Nutrition Service COVID-19 Questions and Answers for States.

If a student requires a modified diet, then the school district’s food services program is required to offer the meal accommodations recommended on that student’s swallowing and feeding plan during the time period of school closure. More information can be found in the document titled Guidance Q&As for Accommodating Disabilities in the School Meal Program.

Therapists should consult with their schools’ food services supervisors to determine the current status of the federal meal waivers in their school district and to ascertain how distribution is being handled now that school districts are using hybrid models that provide some on-campus classes and some virtual ones.

When Swallowing and Feeding Is a Concern

A teacher, parent, or therapist may have a concern about a student’s swallowing and feeding skills during virtual instruction. If the parent or a team member has an immediate safety concern for the student eating at home, then a meeting with the parents/caregivers (either virtually or in person) is recommended so that teachers, SLPs, and administrators can hear concerns, offer support, and advise the parents/guardians/caregivers to bring these concerns to the attention of the student’s physician.

According to IDEA 2004, the school district has the responsibility of continuing to conduct evaluations for eligibility as well as reevaluations. If a student has a suspected swallowing and feeding disorder during the evaluation process, then the report should indicate that once the student returns to on-campus instruction, the swallowing and feeding team will (a) identify the student’s swallowing and feeding concerns and determine how the student can be safely fed at school, (b) establish a plan, and (c) train staff according to the procedures followed by the school district’s food services team.

Virtual Assessment of Swallowing and Feeding

An assessment via telepractice should be equivalent to an in-person assessment. Given the nature of a swallowing and feeding assessment, SLPs should carefully consider whether students are appropriate candidates for virtual assessment. Dr. Georgia Malandraki and associates from the I-EaT Research Lab at Purdue University have developed a set of guidelines titled Telehealth Recommendations for Dysphagia Management During COVID-19, which includes information on telehealth evaluation and treatment procedures. Part C, Table 3 of this resource includes a chart designed to help determine appropriate candidates for assessment and services via telepractice. At present, there are varying degrees of positive research for swallowing assessment and treatment via telepractice.

Preparing for Swallowing and Feeding Services via Telepractice

When the IEP team determines that a student will receive feeding and swallowing services via telepractice, preparation and planning are essential. See ASHA’s Telepractice Checklist for School-Based Professionals [PDF]. When the school swallowing and feeding team (SLP, occupational therapist [OT], nurse, and physical therapist [PT]) is training the parents on the student’s swallowing and feeding plan, per the IEP, and is serving the student via telepractice for swallowing and feeding monitoring and/or therapy, a few things need to be in place prior to the first session.

Arrange for the parents/caregivers or facilitator to gather adaptive feeding equipment noted on the student’s IEP—equipment such as low-flow or cut-out cups, suction bowls, utensils, Dycem mats, and positioning equipment needed for safe feeding. This is required if documented on the student’s IEP.
Arrange for the parent/caregiver or facilitator to have the appropriate food and drink consistencies needed for each session.
Obtain a signed, parental informed consent form for each student (see sample FERPA and COVID -19 consent form found on page 9) [PDF].

IEP Goals

When one of the goals on a student’s IEP is to improve functional eating skills and swallow safety, the SLP works with the family to schedule sessions. The facilitator (typically the parent/guardian/caregiver) is trained to work with the SLP to provide the therapy service with the student. In many cases, it may be necessary to make adaptations to accommodate the new service delivery model. There may be some limitations as to what the facilitator, SLP, and student can work on together via telepractice.

Suggestions for goals are as follows:

Begin where the student is already demonstrating success, and expand those skills.
Use plain language to describe goals. Educate and train the facilitator (parent/caregiver) on their role in providing the exercises with the student and the purpose of each exercise.
Use the student's IEP swallowing and feeding plan, referred to in the IEP, to guide intervention. For example, if the student’s plan includes cues for pacing bites, train the facilitator to gradually fade the cues so that the student becomes more independent.
Adjust or delay goals that you determine cannot be done effectively using a facilitator, such as those that require the therapist to manipulate the oral mechanism.
Send a written notice to parents/caregivers regarding services that may be impacted during virtual learning, based on each student’s individual needs and circumstances.

When parents are unable to participate or provide a facilitator for the therapy session, then the SLP documents the effort and provides the therapy when the student returns to campus or when the family can provide a facilitator.

Services and supports provided to students with disabilities may also include parent/caregiver training for safe swallowing and feeding, such as:

appropriate food textures and consistencies;
ways to modify food and liquids for safe intake;
appropriate positioning for safe swallow;
proper use of feeding equipment such as low-flow cups and curved spoons for safe intake. The district must provide adaptive equipment for the student regardless of whether they are attending school on campus or virtually.

Service Delivery Scenarios

School districts may offer students three service delivery scenarios: all instruction is delivered virtually via telepractice, instruction is delivered in a hybrid model (a combination of in-school learning and virtual learning) or all instruction and support services are delivered in person.

Students receive all instruction virtually via telepractice

When students receive their education program via telepractice, it is important to do the following:

Discuss with the parents/caregivers and teacher how the student’s services will be delivered according to stipulations on the student’s IEP. Changes to the IEP may be necessary to implement the new service delivery model, and/or a new distance learning IEP plan may be put into place.
Share the student’s swallowing and feeding plan with parents/caregivers. This includes:
- positioning and special equipment (provided by PT);
- positioning of the feeder relative to the student;
- utensil selection (provided by the OT or school team);
- diet/food preparation, including food and liquid consistency;
- sensory modifications; and
- feeding plan techniques and precautions.
Provide education and training to parents/caregivers—or, if they were already trained, a refresher—to implement the student’s swallowing and feeding plan at home.
Encourage parents/caregivers to video record the student eating a meal to provide additional information for the therapist and the school team or to problem-solve situations that occur. Parents/caregivers may need to sign release-of-Information forms.
When the parents/caregivers are not able or willing to follow the plan, document on the IEP the fact that although the parents/caregivers will not be implementing the student’s swallowing and feeding plan at home, when the student returns to the school campus, the parents/caregivers will follow the plan.
Consult with the parents/caregivers at scheduled times to troubleshoot and respond to questions or concerns when training and consultation are included on the student’s IEP.

When the school district provides school meals to a student who has a modified or mechanically altered diet, either the school-based swallowing and feeding team or the SLP collaborates and communicates with the food services staff to provide meals that meet the requirements of the student’s swallowing and feeding plan.

Students are educated in a hybrid model (combination of in-school learning and virtual learning)

In most cases, the swallowing and feeding services will be provided when the student is on campus with service providers who are also on campus. In some situations, the SLP may be virtual while the student is physically attending school. The following list details the various scenarios present in a hybrid model:

The SLP is virtual, and the students are in the school building; the classroom teacher or paraprofessional in the student’s class serves as facilitator.
The SLP and/or swallowing and feeding team members familiarize the facilitator with the telepractice platform.
Teachers and paraprofessionals are trained virtually to safely feed the student according to their particular swallowing and feeding plan.
Paraprofessionals and/or cafeteria staff are trained to modify the student’s school meal to meet the recommendations listed on that student’s particular swallowing and feeding plan.
Parents/caregivers are trained and are supported virtually to implement the student’s safe swallow plan on days when the student is at home engaging in virtual learning.

Students receive all instruction and support services in person

Swallowing and feeding services are provided on campus with direct services by the school swallowing and feeding team. When the students receive in-person, face-to-face services, school staff should follow all health and safety recommendations set by the local school district and state. Utilizing personal protective equipment (PPE), such as masks, gowns, gloves, or face shields, are essential to prevent virus spread during aerosol-generating procedures such as swallowing assessment and treatment.

Role of the Facilitator

In order to effectively work with a student virtually, a facilitator must be present at all times to help the student engage and participate in the session. Parents/caregivers or other designees are now stepping into this role without training or experience. Therefore, the onsite facilitator should be trained and prepared to help the student benefit from the session.

Facilitators should be:

physically present with the student during their session with the SLP;
trained and prepared by the SLP to monitor the student during meals and to implement the student’s swallowing and feeding plan at home; and
able to share information about the student with the SLP, including their observations and health issues.

Facilitators also:

assist the student with communication if that student cannot communicate independently with the SLP;
meet virtually with the SLP prior to each session to discuss the session, materials, feeding equipment, and goals; and
prepare the food prior to the session if the student is being observed during a meal.

See the ASHA Facilitator Checklist for Telepractice Services in Audiology and Speech-Language Pathology [PDF] for step by step considerations when working with facilitators, from preparation to implementation.

Monitoring and Documentation

Ongoing monitoring of the implementation and carryover of a student’s established swallowing and feeding plan is essential, regardless of the service delivery option being implemented. Because some if not all monitoring and consulting may be done through telepractice, it is important to set a schedule for monitoring and observing each student who has a swallowing and feeding plan when services are provided virtually. Frequency will depend on each student’s individual needs in the classroom and at home. Observations should be timed with intake of food or liquids, as appropriate.

Progress monitoring is also an important component of every swallowing and feeding plan. Swallowing and feeding team members should routinely document data and anecdotal observations for each session to determine student progress and safety.

Documentation is necessary to ensure compliance with IDEA (2004) as well as state and local mandates. Communication, services, and results should all be well documented. Telepractice involves some additional important steps that require documentation—such as obtaining informed parental consent with a signed consent form. See sample consent form on pg. 9 of FERPA & Coronavirus Disease 2019, Frequently Asked Questions (FAQs) [PDF], training facilitators, and reviewing and revising the IEP. ASHA’s Telepractice Documentation Data Checklist for School-Based SLPs [PDF] is a useful tool for organizing your documentation efforts.

ASHA thanks Emily Homer, MA, CCC-SLP, F-ASHA for this content. Some information within this document was provided through consultation with an attorney.