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Cover Story: Integrating Vision and Hearing Care: Providers Speak to Benefits, Risks

Lowry, Fran

doi: 10.1097/01.HJ.0000432403.62584.06
Cover Story
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When done right, combining vision and hearing services under the same roof offers an excellent model for good and cost-effective healthcare, proponents of the approach say. But, they caution, providing the best patient care should be the main motivation for setting up such a multispecialty practice. Increasing one's cash flow should not.

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Figure. Vic

Joining the two service types is “a very good solution to help with what I consider a crisis in American healthcare,” said Victor Hugo Bray Jr., PhD, dean of the George S. Osborne College of Audiology at Salus University in Elkins Park, PA.

“I think it will become very common as a way for optometrists and audiologists to partner together.

“Optometrists and audiologists are trained to be point-of-entry primary caregivers for our two most important sensory systems in the body. Both of our professions are trained to treat patients holistically and evaluate them beyond just their eyes and their ears, and to screen and identify problems that need referral to specialists.”

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QUESTIONS TO ASK

Visual impairment and hearing loss often occur together. Between 1999 and 2006, about 1.5 million Americans 20 years or older had concurrent hearing and vision loss, with 11.3 percent of adults 80 or older coming under that category (JAMA Intern Med2013;173[4]:312-313). Only 19 percent of individuals in that age group were without a loss in either sense.

“Either you are going to find hearing loss in patients with vision loss, or you are going to find vision deficits in patients with hearing loss,” Dr. Bray said. “We see this routinely in our audiology clinics.

“Often the source of the vision loss and the hearing loss is the same. It can be a genetic mutation or a syndrome that is affecting both sensory systems, and it always calls for referral to a physician such as an ear, nose, and throat (ENT) specialist for intervention to get at the basic cause.”

While the common coexistence of vision and hearing loss lends medical and practical support for a combined approach, there are important questions to ask before joining such a practice.

“In the optometry–audiology model, this is a peer-to-peer relationship,” Dr. Bray said. “Both are professions with doctoral degrees with similar hours of training in their area of specialty and knowledge of how to refer. This is the preferable model. So the first question I would ask is, ‘Am I coming in as your partner or an employee?'”

Another key point to consider is whether the eye care professional has been screening for hearing loss and referring patients to qualified audiologists throughout the professional's career. If that is the case, bringing in an audiologist to extend good patient care makes sense.

But, if it appears that the eye care professional now wants to generate additional income by adding hearing loss screening to the services offered, that should be a warning sign not to join the practice, Dr. Bray said.

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MORE TIME FOR PATIENTS

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Being part of a practice that includes ophthalmologists allows Susan A. Turner, AuD, director of audiology at Houston Eye Associates Hearing Center, to spend as much time as she feels is necessary to examine her patients, she said in an interview. Dr. Turner has been with the ophthalmology practice—the largest in the country—for three years.

“I have been in other practices where people were being moved through at a very high rate and I didn't have the time to give my patients the individual attention they needed,” she said. “In this practice, I am not tied in with someone who is knocking on the door telling me they have three audios waiting.”

Houston Eye, which only hires doctors of audiology as hearing healthcare providers, takes a holistic approach to patient care, she said.

“Having audiologists in the same building is great for both the patients and the doctors. If an eye doctor is going to do surgery on the patient and that patient can't hear the doctor's post-op instructions for care, and if the patient with impaired hearing can't see well enough after the surgery to read instructions, it's easy to see that hearing becomes even more important to the good care of the eyes.”

Her advice to hearing healthcare professionals who are thinking of joining an eye care practice is to make sure that the doctors in the practice are on board with the idea.

“I've known people who have joined an eye care practice, and it has not worked out, but that was because the eye doctors themselves didn't really want the audiologist to join or didn't understand what their role was, and they just weren't accessible and didn't send them patients,” she said. “Under those circumstances, working in such a practice would not be satisfying.”

The situation at her practice is different, Dr. Turner said.

“They are supportive of allowing us to do our thing. They don't try to micromanage how we handle our patients.”

Dr. Turner believes that similar practices will be set up across the country but has one caveat—the shortage of audiologists might impede the integration of hearing health services into eye care practices, she said.

“There aren't a lot of audiologists. In fact, the one thing an audiologist can find is a job. They can really have their pick because there are so few of us.”

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TWO COMPETING ISSUES

Frank R. Lin, MD, PhD, assistant professor in the Division of Otology, Neurotology, and Skull Base Surgery at Johns Hopkins University School of Medicine and core faculty member in the Johns Hopkins Center on Aging and Health in Baltimore, has mixed feelings about the incorporation of hearing healthcare practices into eye care practices, he told The Hearing Journal.

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“On the one hand, I realize that two of every three adults over the age of 70 have a clinically significant hearing impairment and that we increasingly are understanding that hearing loss is a public health issue in terms of its impact on cognition and dementia,” Dr. Lin said. “Therefore, I applaud any way that we can improve access and affordability of hearing treatment.”

On the other hand, treating hearing loss is complex, he emphasized.

“It's not just ‘here's your hearing aid' and you're cured. It's very much a process of comprehensive rehabilitation, counseling, and using the right technologies, and these may or may not include a hearing aid at all. So, I am concerned that the model of care in these hearing and eye care practices might stress that all the patient needs is a hearing aid, and that is not the right model of care.”

Approaches to broaden the accessibility and affordability of hearing healthcare are desperately needed, Dr. Lin added. Combining the two specialties seems logical and natural from that point of view, as long as the proper level of care is delivered, he underlined.

“This is a huge issue, given the number of people with hearing loss. A pair of hearing aids costs between $3,000 and $5,000, and that is a huge amount of money. Even if people want to do something about their hearing loss, they may not feel that it is really worth spending that much money, especially because they may feel that the hearing loss minimally affects their lives.”

And then there is the patient access issue, he said.

“The current gold standard model of hearing healthcare is making repeated visits to an audiologist or dispenser for fitting and adjustments. Such visits are necessary, but what if you are a 75-year-old living on a fixed income and do not have a car? This makes that gold standard model of care inaccessible.

“So there are two competing issues: you want the best quality care, but, at the same time, you want accessibility and affordability. There's got to be some type of middle ground, but I'm not sure what that is yet.”

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‘BEEN THERE, DONE THAT'

Kenneth Smith, PhD, vice president and director of operations at the Hearing Center of Castro Valley in Castro Valley, CA, tried operating with an eye care practice and found the experience wanting.

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“Been there, done that,” he said in an interview. “It didn't work. Most audiologists are not so busy that they do not need patients, which is why they explore new avenues of association. You would think that having a hearing aid audiology practice in an eye center would be a good source of patients.”

About 15 years ago, Dr. Smith said he had “the bright idea” of running a clinic with an optometrist.

“She was screening people for visual problems, and we were screening people for balance problems, and it was a bust. It didn't generate enough interest to make it worthwhile, and we did not get a good quality of patient through that.

“We had another experience even further back with an optometrist in a small town where one of our rural clinics was located, and we ended up stopping because it was a waste of time,” he said.

Dr. Smith said he even went so far as to do basic eye screening himself for a while.

“We had the ophthalmologist train us in screening for eye disease, but there wasn't much interest from the people who came in for vision problems or with hearing problems. It wasn't worth my while as an audiologist, nor was it worth it for the ophthalmologist.”

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MAINTAIN HIGH STANDARDS

Steven M. Silverstein, MD, of Silverstein Eye Centers in Kansas City, MO, is an ophthalmologist who has experience integrating vision and hearing care.

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“We were one of the first six practices in the country to put hearing services into our practice,” he said. “We've had hearing integrated into Silverstein Eye Centers for eight years.”

Incorporating the care of these two sensory systems makes use of already established relationships, he noted.

“The merger and integration of hearing centers into an ophthalmology practice makes tremendous sense, as they serve a common demographic,” Dr. Silverstein said in an interview.

“Patients already come to their eye doctor based upon a relationship of trust, so they would prefer to have their audiology needs be cared for within a medical environment they've already come to know and trust.”

The highest ethical standards must be maintained when vision and hearing services are combined, Dr. Silverstein said.

“There are going to be patients who do not require any type of hearing services, and the testing will reveal that. There are going to be patients who have hearing deficits who will not be benefited by hearing aid devices and would potentially be better suited by seeing an ear, nose, and throat doctor for a treatable medical or surgical condition. And then there are patients who really do benefit from today's digital hearing aid technology, and they enjoy being able to take care of their visual sense and their auditory sense under one roof.”

The key is to find a qualified hearing healthcare professional who has the patient's best interests at heart, Dr. Silverstein emphasized.

“This is absolutely crucial. It can completely destroy you and the success of the program if you do not have a capable, skilled, and ethical hearing specialist or audiologist.

Drs. Turner and Silverstein mentioned that ear, nose, and throat specialists can sometimes feel uncomfortable with the idea of integrating hearing healthcare into eye care practices.

“They feel threatened, and they shouldn't because we are not playing ear doctor,” Dr. Silverstein said. “We don't diagnose ear conditions, we don't treat ear conditions, and, in fact, we refer out dozens and dozens of patients a year from our centers to ear, nose, and throat specialists, whereas before we put hearing into the practice, we never sent them any referrals.”

Integration is a good thing for all parties involved, he added.

“It's a benefit to the ENT; it's a benefit to the patients. We don't charge anything at all for the hearing exam—it is completely complimentary—and we are equally happy to tell patients that they are doing just fine and do not need any ancillary treatment or hearing aids.”

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