Hearing Health Care for Adults Priorities for Improving Access and Affordability (2016) / Chapter Skim
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3 Hearing Health Care Services: Improving Access and Quality
3 Hearing Health Care Services: Improving Access and Quality
Pages 75-148
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From page 75... ...
These services are provided by a range of hearing health care professionals. Hearing health care is facing challenges similar to those being addressed in many other facets of health care in the United States.
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From page 76... ...
. Hearing Instrument Specialists Also referred to as hearing aid specialists, hearing instrument specialists are qualified to identify individuals with hearing loss, assess their need for hearing aids, dispense hearing aids, and educate individuals and their family members about hear ing loss.
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From page 77... ...
. Primary care providers can be the first to assess and diagnose patients with hearing loss and, in some cases, may be able to treat the patient without a referral to a hearing health care professional.
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From page 78... ...
Hearing health care ranges from the identification and management of diseases or conditions that may cause hearing loss, which sometimes require advanced medical or surgical care, to rehabilitation and the use of hearing aids and hearing assistive technologies to minimize the psychosocial and quality-of-life consequences of permanent hearing loss. As a result, the consumers of hearing health care services may require services from physician or nonphysician professionals, depending on the cause of the hearing problem, the ability of modern medicine to treat any underlying condition (if present)
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From page 79... ...
Under optimal conditions, hearing health care is a coordinated system, capable of addressing hearing loss from both a medical/disease focus and a functional/rehabilitative focus. Thus, the key to offering efficient and effective hearing health care services is assessing hearing-related problems from both a disease and function perspective and accessing the right services and technologies for the specific needs of the individual, at the lowest cost.
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population, little is known about the factors or types of symptoms or complaints that make individuals more likely to seek hearing health care. It is well recognized that the prevalence of hearing aid use is quite low in the United States compared with the prevalence of hearing loss.
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From page 81... ...
. Evaluation and Diagnosis Individuals presenting for a hearing evaluation may be seeking audiological services for several reasons, including self-recognized concerns about the ear and hearing; a referral following signs of poor hearing found during a medical evaluation; the request of family members or friends who suspect hearing loss; or as part of routine health care.
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From page 82... ...
When hearing loss is the result of damage to or disease of the ear canal, eardrum, or middle ear, air conduction thresholds will be higher than bone conduction thresholds -- termed a "conductive hearing loss." When air conduction and bone conduction thresholds are similar but fall outside the limits of normal hearing, the hearing loss is called a "sensorineural hearing loss." Speech audiometry In the United States, speech audiometry uses simple, two-syllable words presented via headphones to each ear individually to determine the lowest intensity level at which 50 percent of the words are correctly repeated, termed a speech reception threshold. Speech reception thresholds ranging from −10 to 20 dB HL are considered within normal limits.
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From page 83... ...
Functional Communication Assessment The aims of a functional communication assessment are to define an individual's audiologic and nonaudiologic needs related to hearing and communication, establish the impact of hearing loss on the individual and his or her communication partners (e.g., family) , and to determine from which services and technologies the individual may derive benefits (ASHA, 2016f; Valente, 2006)
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From page 84... ...
, although not every person with hearing loss is a candidate for a hearing aid or other assistive technologies. Medical and surgical treatments are not part of this report's statement of task and will not be discussed.
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From page 85... ...
, which includes hearing aid selection, fitting, verification, and validation within the context of the functional communication assessment (for best practice guidelines for audiologic management of hearing loss in adults, see ASHA, 2016f and Valente, 2006; for a review of the components of hearing aid fitting management across worldwide guidelines, see Oh and Lee, 2016)
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From page 86... ...
Increased attention to hearing assistive technologies is needed in hearing health care professional training to enable these professionals to provide individuals with hearing loss information on the range of technologies available and to help individuals determine what technologies might be useful to them given the nature and extent of their specific hearing loss and communications needs. Tables 3-1 and 3-2 provide the distribution of hearing health care professionals who fit hearing aids and the distribution of venues that provide hearing aids, respectively, from one survey of the field.
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From page 87... ...
Programs have been designed for an array of individuals with varying degrees and types of hearing loss and across all age groups. These programs may be focused on individuals who are new to using hearing aids, those who are experienced hearing aid users, or those who have hearing loss but do not use hearings aids.
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From page 88... ...
Some auditory rehabilitation programs combine both of these strategies to maximize the opportunities for positive outcomes for individuals with hearing loss. Although an indi idual's family may be included in consultations and v hearing aid orientation, auditory rehabilitation is typically designed to enhance the speech recognition of the individual with hearing loss and does not involve family members or other communication partners (some programs may incorporate family in home-based practice or in communication strategies training)
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From page 89... ...
The researchers found that participation in auditory training resulted in increased word recognition and that it reduced the cognitive effort required to identify words in the presence of background noise, a common complaint of people with hearing loss. Of the 10 studies reviewed by Chisolm and Arnold in 2012, the authors concluded that only 1 study provided evidence and methodologies that were sound enough to be considered for clinical implementation -- the 2006 study of the computer-based auditory training program, Listening and Communication Enhancement (LACE)
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From page 90... ...
Unlike the case with auditory training, which can be evaluated using objective measures, the outcomes measured in these studies tended to be more subjective, assessing individuals' selfperceived changes in personal adjustment/coping, limitations related to their hearing loss, and overall satisfaction with hearing aids. Based on an evaluation of 12 studies (out of 22 identified)
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From page 91... ...
used a randomized controlled trial design to test an Internet-/computer-based educational intervention for new hearing aid users. Some of the more integrative counseling-based rehabilitation programs have actively incorporated spouses, communication partners, and family members and have identified possible positive outcomes for both the person with hearing loss and the family member participants (Caissie et al., 2005; Habanec and Kelly-Campbell, 2015; Preminger and Meeks, 2010; Scarinci
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From page 92... ...
, take the needs of family members into account, and are intended to increase awareness and enhance communication for everyone who is touched by the hearing loss within the family. Using randomized controlled trials, both Preminger and Meeks (2010)
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From page 93... ...
with 203 new hearing aid users. Internet-based education and rehabilitation programs offer a promising opportunity to extend the reach of limited resources, engage people with hearing loss and their families, and bolster knowledge and confidence.
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From page 94... ...
, may maintain the beliefs that hearing loss is a natural part of aging and that hearing aids and other treatment options have low l evels of efficacy (Gilliver and Hickson, 2011; van den Brink et al., 1996; W allhagen and Pettengill, 2008)
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From page 95... ...
One challenge that hearing health care professionals and patients face is ensuring that there is plenty of time for the discussion of options and next steps, particularly regarding the purchase and fitting of hearing aids. The patient may be asked to make a large investment in hearing aids at the same time that the patient is adjusting to a new diagnosis of hearing loss.
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From page 96... ...
. Hearing health care professionals -- as with other health are rofessionals -- need to engage in best practices in patient- c p interaction processes and take the necessary time to understand the atti tudes, concerns, health literacy needs, and priorities of individuals with hearing loss; discuss all available treatment options, not just hearing aids; know what community-based education and support resources are avail able both locally and online; educate individuals about the use, operation, and maintenance of hearing aids and hearing assistive technologies at an understandable level; and manage user expectations and beliefs.
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From page 97... ...
As part of the Patient Protection and Affordable Care Act,4 the Medicare Initial Preventive Physical Exam and the Annual Wellness Visit include provisions for reviewing patient hearing status in the primary care setting. To make the best use of these provisions and the opportunity to detect hearing loss in any primary care visit, regardless of the type of insurance, studies are needed to identify the most effective methods for improving the likelihood and ease of detecting hearing loss in patients when a patient presents in the office of a health care professional who is not a hearing specialist.
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From page 98... ...
Among other stipulations, FDA's regulations require that prior to obtaining hearing aids, a patient must provide the hearing aid dispenser with a "written statement signed by a licensed physician that states that the patient's hearing loss has been medically evaluated and the patient may be considered a candidate for a hearing aid" (see Box 3-3)
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From page 99... ...
(2) of this ection, a hearing s aid dispenser shall not sell a hearing aid unless the prospective user has pre sented to the hearing aid dispenser a written statement signed by a licensed physician that states that the patient's hearing loss has been medically evalu ated and the atient may be considered a candidate for a hearing aid.
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From page 100... ...
use of hearing aids could mask an ongoing health condition that could go untreated and possibly cause further detriment to hearing or health. To determine whether the above-mentioned concerns were significant enough to justify keeping the medical waiver regulation in place, the committee assessed the data available in the scientific literature on the incidence and prevalence of the eight conditions and others that could relate to hearing loss.
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From page 101... ...
hearing aids; middle ear surgery Cholesteatoma 3.7–13.9/100,000/ Not provided Generally unilateral yearc Symptoms: hearing loss, ear (Kemppainen et al., pain, drainage, dizziness/ 1999; Tos, 1988; for vertigo a review, see Kuo et Treatment: surgery al., 2015) Sudden 10.21–27/100,000/ ~0.2/1,000/year Unilateral sensorineural year (N = NA)
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From page 102... ...
Symptoms: hearing loss, (also known as Lin et al., 2005; (DoD) e vertigo/imbalance, facial acoustic Propp et al., 2006; weakness, difficulty neuroma)
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From page 103... ...
In weighing the rareness of the medical conditions, the incidence of hearing loss in adults, the widespread need for hearing health care, and the wide use of the medical waiver, the committee recommends removing this regulation to serve consumers' best interests. Access to and Portability of Hearing Health Care Records Access to hearing aid–related records (including audiograms and programming history)
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From page 104... ...
(An additional challenge to changing providers is that hearing aids have proprietary software that can only be programmed by dispensers who have a relationship with the manufacturer of that particular hearing aid. See Chapter 4 for further discussion.)
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From page 105... ...
For example, evidence-based clinical practice guidelines and standards of practice can be used to educate health professionals, inform practice patterns, and facilitate widespread adherence to best practices. Performance metrics can be used to standardize and incentivize high-quality care, assess quality in specific areas of care, and compare care across providers.
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From page 106... ...
In addition to the National Guideline Clearinghouse, several professional organizations maintain standards of practice and clinical guidelines for public reference. Box 3-4 provides examples of clinical practice guidelines and standards of practice for hearing loss in adult populations.
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From page 107... ...
○ Clinical Practice Guidelines Adult Patients with Severe-to-Profound Uni lateral Sensorineural Hearing Loss (AAA, 2015) • American Academy of Audiology, American Speech- anguage-Hearing L Association, and Department of Veterans Affairs: Audiological Clinical Prac tice Algorithms and Statements (Joint Audiology Committee on Clinical Practice Algorithms and Statements, 2000)
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From page 108... ...
Furthermore, efforts to widely disseminate revised guidance; teach students and health care professionals, including primary care providers, about the existence of the guidelines and how to implement them; and modify practice patterns will also be required to ensure that patients fully benefit from evidence-based practices. Performance Metrics Another mechanism for ensuring and promoting high-quality health care is the development, implementation, and analysis of performance metrics, which may also be tied to clinical practice guidelines.
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From page 109... ...
. As with the discussion of the clinical practice guidelines and standards above, it is difficult to know how these indicators are applied and what impact they have on quality, and it appears that they have not been revisited in more than a decade.
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From page 110... ...
. In 2016 health care professionals and group practices are required to choose and report on at least nine individual measures and one crosscutting measure from a list of available measures for at least half of all Medicare patient appointments.
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Continuous Quality Improvement Continuous quality improvement (CQI) is a process- and data-oriented mechanism that is used to enhance the quality of health care delivery and promote excellence.
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From page 112... ...
. Summary Measuring and improving the quality of hearing health care necessitates buy-in and collaborative effort among researchers, health professionals, health systems, insurers, advocacy organizations, people with hearing loss and their families, and experts in performance metrics and health care quality improvement.
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From page 113... ...
. Further more, many adults who have hearing loss and may benefit from using hearing aids are not using the devices (see Chapter 4)
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. An additional challenge for staff and family members is to distinguish miscommunication related to hearing loss from miscommunication related to dementia (Haque et al., 2012; Slaughter et al., 2014)
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From page 115... ...
. Given the potential association between hearing loss and social isolation in older adults (Mick et al., 2014)
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. Equally important to improving access to care is the promotion and support of increasing the number of providers in underserved communities.
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From page 117... ...
population with hearing loss for the foreseeable future. Recruitment and retention of diverse students to professional training programs in hearing health care would likely boost the diversity in the hearing health care workforce over time.
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From page 118... ...
. Improve and Expand Use of Auditory Rehabilitation Programs Although consumer organizations (e.g., the Hearing Loss Association of America and AARP)
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From page 119... ...
. This ariability may be the result of v individual differences (e.g., baseline performance, functional abilities, communication needs, age, severity of hearing loss, motivation, support)
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From page 120... ...
Where evidence-based programs are available, audiologists, health professionals, and advocacy organizations need to be aware of them and be encouraged to recommend them to their patients and constituents. Develop and Evaluate Innovative Models of Hearing Health Care Delivery As described earlier in this chapter, obtaining treatment for hearing loss in the United States generally follows a medical model of clinic-based care in which an individual visits a hearing health care professional for diagnostic evaluation, assessment, and care.
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From page 121... ...
. Community health workers have the potential to play a role in helping an individual and his or her family cope with hearing loss as a chronic condition, potentially by teaching them about hearing strategies and effective communication skills, maximizing the use of hearing aids by pairing them with other assistive products and with other communications and emergency alert systems (see Chapter 4)
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From page 122... ...
Given the prevalence of hearing loss in the United States and the multiple follow-up visits that are often needed for comprehensive hearing health care, community health workers offer a potentially beneficial mode of extending hearing health care to a broader segment of the U.S. population, and additional research is needed to further explore this model.
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From page 123... ...
. However, just as each individual's hearing loss and hearing needs are unique, a self-fit or pre-programmed option may work well for some and not for others.
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From page 124... ...
Current teleaudiology technologies provide capabilities for audiometry, obtaining case histories and completing self-report questionnaires, Web-based support groups, professional-to- rofessional communication, hearing screening, p auditory rehabilitation programs, video otoscopy, and the programming of hearing aids.
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From page 125... ...
. Among the innovative tele-audiology technologies that may increase access in the future are home hearing tests, the scanning and transmission of ear canal images, and the programming of hearing aids in the home through smartphones or tablet computers.
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From page 126... ...
. Within the realm of hearing health care, retail clinics are beginning to explore opportunities to gain a share of the market and expand services for hearing loss.
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From page 127... ...
necessitates research to investigate the relative risks and benefits of these new approaches in comparison to the traditional models of hearing health care delivery, which include hearing aids that are dispensed by hearing health care professionals. A 2009 IOM report that identified priorities for comparative effectiveness research highlighted the importance of investigating and understanding different hearing loss treatments as a priority (IOM, 2009)
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From page 128... ...
Nor is any care related to obtaining a hearing aid covered by Medicare because of the explicit exclusion in the Social Security Amendments of 1965.12 Other federally funded programs with hearing health care coverage provisions include the Federal Employees Health Benefit plans (plans approved through the Office of Personnel Management and offered by individual carriers) , the Department of Defense Medical Health System, and the Veterans Health Administration.
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From page 129... ...
, ensuring that a physician or nonphysician medical practitioner stays involved with and informed of a patient's hearing ability and any diagnosis may be important for overall health. The medical home model ensures that older adults with hearing loss receive coordinated care for their hearing loss, and also ensures that providers are aware of communication limitations with their patients to whom they must convey critically important health information (such as instructions for medications, etc.)
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From page 130... ...
. The association of hearing loss with these conditions may indicate that the primary care provider should be an integral part of the initial episode of care related to any diagnosis of hearing loss, and thus direct access, which bypasses general medical providers, may not be in the patient's best interests.
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From page 131... ...
Goal 3: Remove FDA Regulation for Medical Evaluation or Waiver to Purchase a Hearing Aid Recommendation 3: The Food and Drug Administration should re move the regulation that an adult seeking hearing aids be required to first have a medical evaluation or sign a waiver of that evaluation and should ensure consumers receive information about the medical condi tions that could cause hearing loss through continued inclusion of that information in hearing aid user instructional brochures. Goal 4: Empower Consumers and Patients in Their Use of Hearing Health Care Recommendation 4: Hearing health care professionals, professional asso iations, advocacy organizations, and relevant government agen c cies such as the Office for Civil Rights at the Department of Health and Human Services should ensure patients are aware of, and understand how to exercise, their rights of access to information about themselves under the Health Insurance Portability and Accountability Act Privacy
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From page 132... ...
. Specifically, • Use patient visits to assess and discuss potential hearing difficulties that could affect doctor–patient communication and overall patient well-being, to encourage individuals and their family members and caregivers to discuss hearing concerns, to raise awareness among older adults about age-related hearing loss, and to encourage refer ral when appropriate; and • Develop and disseminate core competencies, curricula, and con tinuing education opportunities focused on hearing health care, particularly for primary care providers.
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From page 133... ...
2015. Clinical practice guidelines: Adult patients with severe-to-profound uni lateral sensorineural hearing loss.
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From page 134... ...
1996. American College of Radiology appropriateness criteria hearing loss and/or vertigo.
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From page 135... ...
2003. Screening and management of adult hearing loss in primary care: Clinical applications.
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2013. Learning to listen again: The role of compliance in auditory training for adults with hearing loss.
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From page 137... ...
2014. Impact of advanced hearing aid technology on speech understanding for older listeners with mild to moderate, adult-onset, sensorineural hearing loss.
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From page 138... ...
2010. Guest editorial: Accessible and affordable hear ing health care for adults with mild to moderate hearing loss.
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From page 139... ...
2013. Efficacy of individual computer-based auditory training for people with hearing loss: A systematic review of the evidence.
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From page 140... ...
2011. A comparison of gain for adults from generic hearing aid prescriptive methods: Impacts on predicted loudness, frequency bandwidth, and speech intelligibility.
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From page 141... ...
1991. Hearing loss and hearing aid use in Hispanic adults: Results from the Hispanic Health and Nutrition Ex amination Survey.
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From page 142... ...
2010. Communicating in a healthcare setting with people who have hearing loss.
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From page 143... ...
2015. Options for auditory training for adults with hearing loss.
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From page 144... ...
2015. Aging America and hearing loss: Imperative of improved hearing technologies.
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From page 145... ...
2004. Health status attributes of older African-American adults with hearing loss.
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From page 146... ...
2015. Community health workers bridge gap to hearing loss treatment.
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From page 147... ...
2014. Final recommendation statement: Hearing loss in older adults: Screening.
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2006. Sudden sensorineural hearing loss: Evidence from Taiwan.
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