Of course, differentiation isn't the only reason audiologists should provide auditory rehabilitation. Comprehensive AR includes sensory management, education, counseling, and auditory perceptual training (Trends Amp. 2007;11(2):63). Amplification alone cannot address cognitive factors related to working memory and speed of processing in older listeners (Int Jour Aud. 2003;42:11). Hearing aids can't fix communication with partners who mumble or speak from the other side of the house or in noisy environments where it's difficult to hear even for those with perfect hearing. The education, counseling, and auditory training components of aural rehabilitation are critical to patient acceptance of and long-term success with amplification. Aural rehabilitation should therefore be a part of our standard treatment protocol.
Why then is comprehensive AR being offered only by a few hearing care providers? The most commonly heard reasons include lack of time, lack of confidence (“we are not visited by the ‘AR rep’ for free training and support”), lack of reimbursement, and lack of patient compliance. As an audiologist in a busy ENT practice, I've faced these challenges and devoted the last decade to developing strategies and tools to overcome them. My recent acquisition of the audiology side of the practice has given me an additional opportunity to test and revise these strategies in a hectic private practice setting. In my opinion, comprehensive AR is a moving target; there is no one-size-fits-all solution. However, given a simple framework, some readily available tools, and encouragement, even the busiest clinical practice can provide comprehensive AR.
1. It all starts with the assessment. We need to shift our assessment focus from hearing concerns to communication concerns. This change should be reflected in the questionnaires we use and even in the way we refer to the initial consultation. The term “hearing aid evaluation” puts all emphasis on technology and does nothing to differentiate us from the commodity options. Let's follow the recommendation of Robert W. Sweetow, PhD, from more than a decade ago and modify the name to reflect a broader treatment plan (Hearing Journal. 2007;60(9):26). Functional Communication Assessment and Communication Needs are a couple of options (SIG 7 Perspectives. 2015;22:15). Many assessment tools are available for communication needs. My favorite is the Patient Assessment of Communication Abilities (Hear Rev. 2016;23(3):20). I have the patient and the communication partner complete this simple, closed-set questionnaire pre- and post-treatment to make sure we're meeting the goals of all involved parties.
2. K.I.S.S. Keep it super simple! This strategy cannot be over-stated. Clinicians are busy and our patient visits are consumed by instructions related to technology, leaving little time for counseling on communication and coping strategies. Patients are also busy and don't want to be burdened with time-intensive activities once they leave our office. They are also often overwhelmed by all the new technology and may not remember the verbal education received during clinic visits. We must keep our education, counseling, and training simple to increase both clinician and patient compliance with aural rehabilitation.
3. Have a written plan. Create a document that lists your clinical procedures, from the initial visit through the end of the trial period. Include procedures related to patient intake, diagnostics, treatment, patient education, auditory training, and follow-up. List these procedures by visit. For example:
Visit 1: Communication Needs Assessment
- Have patient and communication partner complete intake forms
- Determine top three communication/hearing goals
- Complete diagnostics: air/bone, speech, Quick SIN, MCL/UCL
- Provide educational materials on communication strategies and consumer resources
- Introduce treatment options
The written plan can be as basic or as detailed as you choose to make it. The goal of the written plan is to keep providers accountable for following best practices. In the craziness of our daily lives in the clinic, it can be easy to skip an important step, especially those procedures related to patient education. The written plan should be posted in the front of the patient's chart so that each step can be checked off as the clinician performs it. A written plan can be easily converted into an electronic document, such as a fill-able PDF, and stored in the patient's electronic chart for clinics using electronic medical records.
4. Know your tools and use your resources. When it comes to hearing aids, most hearing care providers feel confident about the products and wireless accessories they recommend to their patients. We receive excellent training from the manufacturer reps on products and software, and we get useful support materials such as brochures, colorful placemats, and displays. However, the story is much different when it comes to patient education, counseling, and auditory training. Tools for critical AR components are available, but they are not dropped on our laps as readily as the hearing aid tools. Hearing care professionals need to do a little digging to find them, and this is where that “lack of time” excuse comes into play. Allow me to do some of that dirty work for you. Please note that the following tools do not constitute an exhaustive list. They are simply the tools that I'm most familiar with and can act as a starting point for you.
EDUCATIONAL TOOLS AND RESOURCES
- Hearing Loss Association of America (HLAA): This organization's sole purpose is to support people with hearing loss. Our patients should be introduced to HLAA from the very beginning. It literally takes one second to hand the patient an HLAA brochure. But I would encourage providers to go one step further. In my practice, I include a one-year membership to HLAA with every hearing aid purchase. The small $35 membership fee is rolled into the mark-up on my hearing aid sales so the cost is easily covered. I give patients an HLAA brochure and instruct them to complete the short form on the back and return it to me at their next visit if they'd like to take advantage of my generous offer. This way I'm only providing the benefit to those who've shown serious interest by completing and returning the form. In addition, many cities have local HLAA chapters that hold monthly chapter meetings. These are a wonderful source of education and support for our patients, and they take absolutely no time or effort on the part of the provider. The day, time, and location of the local HLAA meetings are listed on the HLAA website so patients can easily be directed there. I have created a flier that lists the meeting information as well as the email address of the chapter president, and give this flier to every patient along with the HLAA brochure. With this simple task, we give every patient the opportunity to connect with a community of people who are dealing with similar challenges. And it literally takes no time or effort on the part of the clinician.
- IDA Institute: The IDA Institute is a non-profit organization located in Denmark that creates educational and counseling resources based on patient-centered care. All of the tools are available online at no charge to the clinician as the institute is funded by a grant from the Oticon Foundation. The tools are incredibly user-friendly and can be used for pre-appointment assessment of communication needs as well as during the treatment process for education and counseling. Some of the tools include Living Well with Hearing Loss, My Turn to Talk, Why Improve My Hearing?, and Everyday Life with Hearing Loss. There are resources for individual and group sessions, and all tools include instructional videos.
- 5 Keys Communication: There are three parts to this simple program: education, action, and follow-up. The education occurs with a patient handbook that discusses the importance of family member involvement and realistic expectations of hearing aids. It then provides communication strategies that are organized into the 5 Keys to Communication Success: speaker, listener, environment, technology, and practice. These five keys are systematically applied to the most commonly reported difficult listening situations around the house, in the car, on the phone, dining out, and at public events. The action step of the program is a communication plan worksheet that is included in the book and can also be downloaded at no charge from the website. The worksheet provides patients with a written plan that is personalized to their unique goals. The follow-up step of the program occurs via weekly e-tips that provide patients with a review of the communication strategies, a simple homework, and a tip related to hearing aid use and maintenance. The e-tips are provided at no additional charge for clinics purchasing the patient handbooks. As with the IDA tools, the 5 Keys system can be adapted for individual or group use.
AUDITORY TRAINING TOOLS AND RESOURCES
- clEAR: This is a relatively new computer-based auditory training program (JSLHR. 2016;59(4):871). It can be played on any computer or tablet with an internet connection and presents customized and adaptive learning exercises in a game format. clEAR is the first program that allows the patient's most frequent communication partners to record stimulus words, thus enabling the patient to train with the voices that matter most. Clinician cost for the program is a maximum of $75 per patient and the suggested retail cost is $150.
- Listening and Auditory Communication Enhancement (LACE): LACE is an auditory training program that has been available for many years (Hearing Journal. 2004:57(3):32). It has evolved into an online application that can be used on any device with an internet connection. Providers can purchase “Session Codes” for a maximum of $40 each and the suggested retail price is $79.
- Angel Sound Training: This is a PC-based program that can be obtained as a free download via the Emily Shannon Fu Foundation (Trends Amplif. 2007 Sep;11(3):193). There is also an app called iAngel Sound that can be purchased from iTunes.
- Hear Coach: This is a free mobile app that patients can download from iTunes or Google Play. No account set-up is required. This is a good option for patients who might not be compliant with the more formal training programs listed above.
- Clinician-directed training: For some patients, computerized training is not an option. However, resources are available that can be used for individual or group training. A.C.E. (Active Communication Education) is a proven program for teaching communication strategies (Ear Hear. 2007 Apr;28(2):212). Home heARing is a new tool developed by Geoff Plant and available through the Hearing Rehabilitation Foundation. Harriet Kaplan's classic book, Speechreading, is another important tool that can be used for clinician-directed training (Kaplan. Gallaudet University Press, 1985).
These tools are only a sampling of the many great AR resources available to clinicians. My hope is that the strategies and tools presented here will give providers the motivation and confidence to add at least one new resource to their treatment protocol. As hearing care providers, it is our responsibility to provide education, counseling, and training beyond amplification. I promise you, it is worth the effort. Clinicians who provide comprehensive AR are reimbursed through fewer returns, more repeat purchases, and increased patient referrals. The need is clear, the tools are available, and we are the professionals trained to provide this critical service.
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