1 That phrase “Reach out and touch someone” sounds familiar. Did you steal it from somewhere?
Well, let's say borrow. “Reach out and touch someone” probably rings a bell with those of you old enough to remember commercials from the 80s. The popular jingle refers to improving communication among family and friends, which, of course, is also the goal of audiologists and other hearing healthcare providers. The jingle, however, was used to promote the products and services of the American Telephone and Telegraph Company, better known as AT&T.
The ad continues with an emphasis on communication over distances: “Reach out and touch someone, wherever you are, you're never too far. They're waiting to share your day.” Although audiologists tend to focus on helping persons hear those in relatively close proximity, I like to use the “Reach out and touch someone” theme as a reminder of the technology that audiologists may consider to aid communication with someone who may be across a large room or across the world. If you'd like to sing along, the complete jingle can be heard at http://www.porticus.org/bell/bellsystem_ads-1.html.
2 We all certainly can use catchy reminders, but what exactly should I be using to “touch” my patients?
Just as AT&T connected families around the world, we also have an ATT acronym for hearing healthcare providers. This ATT is short for: the Audiogram, TELEGRAM, and Treatment plan. Together, these three components lead to the kind of comprehensive patient care that should result in improved communication.
The process to facilitate communication, of course, begins with an audiogram in order to determine the patient's need for assistive technology. Following that, we can obtain more information regarding a person's communication difficulties in the environment by using the TELEGRAM.1 Information is combined from these tools, along with other diagnostic tests, to determine the treatment plan. This may include hearing assistive technology, development of communication strategies, increasing awareness of public accommodations, and involvement of family members.
3 Well of course we need an audiogram, but what is the TELEGRAM?
As you know, a telegram was a message that could be sent over long distances by means of a telegraph device that interrupted an electrical signal in a coded format that could be translated into words.
Just as the telegram addressed the challenge of communicating over distances, the acronym TELEGRAM was coined to represent the many challenges in communication that persons with hearing loss face. The letters represent the following communication challenges: Telephone, Employment, Legislation, Entertainment, Groups, Recreation, and Alarms. In order to facilitate communication, it is also important to know the Members of the family with whom the person with hearing loss will be interacting.
4 Don't we already have several other excellent tools for evaluating patient communication difficulties?
Yes, a variety of tools can be used to determine the communication difficulties that a person is experiencing. For example, one popular scale is the Client Oriented Scale of Improvement (COSI). Consider, however, that when using the COSI, patients report five communication difficulties that are specific to their particular experiences. In doing so they may focus on verbal communication and therefore fail to mention that they can't hear a smoke alarm or alarm clock.
There is no inventory at this time to assess a patient's knowledge of, for example, legislation that may significantly affect the beneficial services provided through the Americans with Disabilities Act (ADA). This law requires employers and public facilities to provide accommodations for persons with impaired hearing. Therefore, using both the COSI and TELEGRAM would allow for complete assessment of your patient needs.
5 That all sounds fine, and I already do the COSI. But how am I going to find time to fit the TELEGRAM into my busy clinic schedule?
The timesaver is the efficient format of the TELEGRAM. It is designed to prompt the practitioner to ask probing questions and record the responses in a sort of shorthand format. The TELEGRAM involves questions that address auditory challenges in six situations, knowledge of legal issues related to hearing improvements, and family arrangement.
The format of the TELEGRAM (See Figure 1) is such that a simple score is assigned in each auditory area to represent degree of difficulty. Because the form is similar to that of the audiogram, it allows us to stay in our left brain, which saves time! The areas of assessment are represented in a graphic format to be attractive to the personality traits of the typical audiologist.
6 Wait, you're talking about my personality? Don't you have to spend an hour or so answering questions to find out your personality type?
There are elaborate tools to determine personality types that involve multiple questions and yield complex personality types. However, such in-depth assessments are sometimes less revealing of personality traits of certain groups, such as audiologists. I like the simple system described by Smalley,2 which includes only four categories that are represented by animals for easy reference.
7 Animals? You're kidding, right?
Not at all. I've found that audiologists can easily be characterized by this system, which includes:
- Lions—The leaders who take charge of organizations and events! Lions are confident, strong-willed, independent, bold, and competitive.
- Golden retrievers—The caretakers who send greeting cards! Golden retrievers are loyal, sensitive, warm, patient, sympathetic, and undemanding.
- Otters—The partiers who are ready for any social event! Otters are enthusiastic, risk-takers, energetic, friendly, group-oriented, visionary, and spontaneous.
- Beavers—The detail-oriented data keeper who likes to graph things, read the instruction manuals, and quantitative! Beavers are analytical, conscientious, consistent, precise, orderly, and practical.
Although most of us have all of these traits to some degree, it's quite obvious from the tasks we do that many of us are predominantly beavers. For more regarding these four personality types, go to http://www.smalleyonline.com/articles/i_discoveringpersonality.html.
8 Okay, you're right, I do sense a little beaver in me. But why do you care and how does that relate to the TELEGRAM?
I'll get to that in a moment, but first let's examine the evidence regarding patient satisfaction to determine if we need to consider suggesting improvements in service delivery. A 2005 survey indicated that only 29% of hearing aid users were satisfied with their instruments in noisy situations.3
One conclusion this might suggest is that most hearing aid users could benefit from devices that facilitate communication in noise, such as remote microphone technology. It has been proposed that overall customer satisfaction with hearing aids will not reach a respectable 80% until consumers are satisfied in 70% of the listening situations that are important to them.4 The technology to accomplish this through ear-level instruments and remote microphones has been available since 1992. Yet, some 15 years later, surveys show that most consumers are still dissatisfied with available technology to listen in noise.
Although there could be multiple reasons for the limited use of this technology to solve listening in noise problems, a significant one may be that hearing healthcare providers focus primarily on the hearing instrument and fail to investigate additional solutions for listening difficulties, which they view as merely an accessory or “assistive listening device.”
9 Are you saying that we tend to ignore ALDs?
Well, that's sort of what the data say. Although Prendergast and Kelley reported that more than 80% of audiologists provide information regarding ALDs,5 Mark Ross states, “The vast majority of hearing aid users who are queried directly do not recall receiving information about any hearing assistive device other than hearing aids.”6 He concludes, “In brief, it seems we have gotten very good at managing hearing aids, but other services that are germane or potentially helpful to a hearing aid user seem to be on some back burner.”
Moreover, improving listening in noise is only one example to illustrate the need for audiologic services that go beyond fitting hearing aids. Ross points out that there are critical areas to explore in the audiologic evaluation and summarizes them in a one-page Communication Needs Profile.6 However, it seems that we need alternative tools to the questionnaire format, since these have not been routinely incorporated into hearing healthcare practices.
10 I'm glad you got that off your chest, but I was asking about animals and the TELEGRAM?
I'm getting there! So, based on the assumption that many audiologists have the “beaver” personality and are accustomed to graphing results on the audiogram, the TELEGRAM was developed as a tool for audiologists to conveniently address all the areas Ross suggests in the Communication Needs Profile.
As shown in Figure 1, the areas to be assessed are represented along the abscissa with a rating scale to reflect the assessment on the ordinate. Just as an audiologist wouldn't think of doing an audiologic assessment without an audiogram, I believe that the TELEGRAM should be assigned equal importance in the assessment.
11 Do you mean that after completing the audiogram, I should complete a TELEGRAM?
Absolutely! You are completing your assessment of the patient's perceptual system through a variety of tests that are documented on the audiogram, and then on one convenient form you can begin to document the impact of those abilities on the person's daily functioning at home, at work, and in social situations. The format is specifically designed to avoid the linguistic format that seems to have failed to be integrated routinely over the years. Instead, it emphasizes the degree of difficulty that beaver audiologists like to quantify in a numerical format on a rating scale.
12 So how does this rating scale relate to the topics referenced in the TELEGRAM?
The scale is provided so that each of the important areas of the Communication Needs Profile recommended by Ross6 can be assessed. Practitioners know in general what areas should be explored, but the TELEGRAM provides a format to ensure that none are forgotten.
To administer the TELEGRAM, ask probing questions, as suggested in Table 1. Most areas are rated from 1 meaning “no difficulty” to 5 meaning “great difficulty.” The areas of Legislation and Members of the family require a different response set as shown in Table 1.
The symbols may be customized to represent an individual's specific challenges. For example, SC may be used to refer to “sewing club,” where a person has great difficulty because there are five women and machine noise. Or T could stand for “tutoring” where there are only two children working in a small room. These notations can be made below the graph to facilitate reassessment during follow-up appointments to see if the hearing aids and/or assistive devices have resulted in less difficulty.
13 Once I have the audiogram and TELEGRAM completed, what's next?
The next phase of the process is the treatment plan, which begins with recommendations that are briefly mentioned below the graph. For example, if the patient has difficulty on the telephone, a notation may be made to explore an amplified telephone. Or if the person reports great difficulty in groups, a plan to explore use of an FM system may be in order.
The purpose of the treatment plan is to provide suggestions to reduce the patient's communication difficulties through assistive technology or perhaps by attending auditory rehabilitation sessions with a spouse. Since these suggestions appear right on the TELEGRAM, it can be used as a quick reference guide during follow-up visits to discuss the patient's progress.
14 That's great. So with ATT for audiologists, can my patients “connect with others,” as the song goes.
The use of the TELEGRAM will start the process of reducing communication difficulties, but the impact must be determined through follow-up assessments. So, whether your patients will really be “connecting with others” through communication must be assessed in follow-up evaluations.
Therefore, the treatment plan should include a recommended time for re-evaluation. The recommendations can easily be made for assistive technology, but guiding the patient in securing that technology is part of the evaluation process and should be part of the follow-up. When the patient returns for follow-up, you can repeat the questions and make the appropriate notations.
15 Don't we need to know how much change is a significant change on the TELEGRAM? (There's my “beaver” personality showing again!)
Let's consider some evidence that we've collected with the TELEGRAM when we used it in our auditory rehabilitation program. The TELEGRAM was used to measure improvements with 10 adults who had been enrolled in our 4-week program known as AALTA or Application of Advanced Listening Technology for Adults.7 For all 10 adults, improvements in at least two categories were noted. On average, the improvement of at least one rating occurred in five of the seven possible categories. The average improvement was a change in rating of 1.88.
These results suggest that individuals experienced a reduction in communication difficulties in the majority of the areas assessed. Whether or not this was a significant improvement would have to be determined with a larger number of participants. It would also be informative to explore content validity through the use of some corresponding measures, such as quality-of-life scales.
16 It seems as if I've had some patients with those different animal personalities? Should I consider that when I go over the results of the TELEGRAM with my patients?
Certainly! You are now beginning to see how personality types may affect many of our interactions. For example, it is very possible that the patients with “beaver” tendencies will be interested in their assessment and treatment plan as documented on the TELEGRAM. For such patients, the audiologist might want to share the actual results that document the improvements.
Other patients with more “otter-like” tendencies may be more interested in discussing social events in their personal lives or the media than in seeing the rating values on the TELEGRAM. In either case, the practitioner can reinforce the progress patients have made in reducing communication difficulties by following the recommendations that were given.
17 I hate to bring up billing, but is there a CPT code to cover the administration and treatment associated with using the TELEGRAM?
The diligent work of the ASHA Health Care Economics Committee has led to the long-awaited outcome that auditory rehabilitation evaluation can be billed by audiologists. The CPT codes approved in 2006 are:
- 92626: Evaluation of auditory rehabilitation status; first hour.
- 92627: Each additional 15 minutes, on same day as 92626.
It is important to note that these new codes apply to evaluation, whether for the purposes of hearing aids or cochlear implants. In particular, the AMA provides a further description of 92626: “The objective of this assessment is to determine current abilities to instruct the use of residual hearing provided by a cochlear implant or hearing aid. The assessment addresses, in children and adults, dimensions of impairment, activity limitation, participation restriction, and applicable environmental and contextual factors.”8 At this time, the codes for audiologists limit services to diagnostics; services for auditory rehabilitation must be billed by speech-language pathologists.
18 This all sounds good, but how can I incorporate into my busy practice all the hearing assistance technology that the TELEGRAM might suggest.
This has been a concern for many audiologists because of the variety of devices that would need to be stocked and the repair service that would need to be provided for those that are sold.
In a Hearing Journal article a few years back, Donna Wayner reviewed the sequence of events that led to the development of a demonstration center within an Albany audiology clinic.9 She recommends that after determining a patient's needs, the audiologist should refer the person to the most accessible and cost-effective distributor, either locally or through web sites or even catalog mail order, for purchase.
There is one exception. Because of possible connection to personal amplification and the need for guided instruction, she recommends that it is most efficient to dispense FM systems. Just as with amplification, the time the audiologist spends in orientation and follow-up to ensure appropriate use of the FM should be included in the cost of the device.
There has been a common misconception among audiologists that assistive devices have limited mark-up. The concern should not be with the profit margin, but with the bundled price, which includes the professional services required for the consumer to benefit from the FM and any other assistive device.
Another solution Wayner suggests is to have volunteers staff an assistive device demonstration center so that patients can determine what is helpful and then purchase it from a recommended source. Such volunteers are now being trained through an online program offered by a component of the Hearing Loss Association of America. For more information on their training and certification by the Academy of Hearing Loss Support Specialists, go to www.hearingloss.org/academy/overview.asp.
Another option for developing specialists to manage assistive equipment within a hearing care practice is through the Peer Mentoring Certification Program offered at Gallaudet University as part of the Rehabilitation Engineering Research Center (RERC) on Hearing Enhancement. The 13-credit distance-learning program was designed for laypersons with hearing loss to develop skills to support the use of hearing assistance technology and several other services. More information about the program can be found at www.hearingresearch.org/Projects/Bally.htm.
19 I think I'm understanding the pieces, but I don't see how the whole thing would fit into my standard protocol. Can you explain?
Let me first talk in general terms, as I believe it's not only important to discuss how this can be implemented in your protocol, but also to consider how to make this aspect of auditory rehabilitation a part of the AuD clinical training programs. It is one thing to convince audiologists in practice of the need for this comprehensive assessment beyond the audiogram, but it is the students in training programs who have the greatest potential to incorporate this into their routine assessments.
From the beginning of their training, if AuD students experience the importance of providing comprehensive patient care, they will see the difference they can make in the success of the treatment they provide. Ultimately, overall patient satisfaction with hearing instruments should improve as patients and their family members are guided through a series of technology options and communication strategies to address their total communication difficulties—from group conversations to hearing the smoke alarm.
Now, to answer your question more specifically, I think one way to incorporate this into a routine audiologic practice is to include it in routinely used software packages, such as hearing aid programming software and database programs. The bottom line is that the more convenient it is to use the assessment tool, the more likely it is to be incorporated in busy clinical settings.
20 Before that software arrives in my mailbox, where can I get the TELEGRAM forms?
The TELEGRAM may be downloaded from www.utdallas.edu/∼thib so that identifying clinic information may be added. Forms may also be self-generated and customized for a particular population, such as the residents of a retirement community.
“Apatient waiter is no loser.” A sentence from the HINT or QuickSin test perhaps? No, not quite. We'll get to its connection with this month's Page Ten article in just a moment.
As we've discussed several times on these pages, there is much more to auditory rehabilitation than fitting hearing aids. We've had various articles on such topics as assistive technology, individual counseling, group rehabilitation classes, and even individualized auditory training. It requires some organization, however, to develop a treatment plan that meets the specific needs of each patient. Often, a casual case history just isn't enough.
That takes us back to our opening sentence, which some of you probably recognized as the first message sent by telegraph back in 1838, from Alfred Vail to Samuel Morse. While the Vail/Morse code and the telegraph aren't being used much these days for communication, in the audiology field we do have a way to communicate with our patients using the TELEGRAM. Linda Thibodeau, PhD, came up with the TELEGRAM acronym to assist audiologists in developing a treatment plan. It also can be used as an outcome measure, and it addresses eight communication challenges experienced by people with hearing loss. The TELEGRAM has undergone some revisions over the years, and we thought it was time for Linda to provide us an update.
Dr. Thibodeau is a professor at the University of Texas at Dallas, where she is head of the AuD program and the Pediatric Aural Habilitation Training Specialist Project. She has published extensively on topics related to the speech perception of listeners with hearing loss and auditory processing problems as well as evaluation of amplification systems and hearing assistance technology to help those persons. She currently serves as the editor-in-chief of the Journal of the Academy of Rehabilitative Audiology, and is associate editor for the American Journal of Audiology.
When not spending weekends working on an ANSI committee, an AAA Task Force, or one of her many forthcoming book chapters, you'll probably find Linda at her daughter's volleyball games, where she's been known to roam the sidelines with a sound level meter measuring the intensity of the referees' whistle (I'm not making this up).
Like the “patient waiter” mentioned above, you'll likely be a winner with your patients if you use the concepts of the TELEGRAM in developing your audiologic rehabilitative treatment plan.
Page Ten Editor