Since the founding of the Veterans Health Administration (VA) Rehabilitation Research and Development (RR&D) National Center for Rehabilitative Auditory Research (NCRAR) in 1997, a focus of research has been the development of protocols for the clinical management of tinnitus, which affects 10-15 percent of the adult population.1, 2 These efforts have resulted in the development of Progressive Tinnitus Management (PTM), a multidisciplinary, stepped-care method for providing tinnitus clinical services, and its telehealth version called Tele-PTM. Large randomized controlled trials completed for both PTM (N = 300)3 and Tele-PTM (N = 205)4 have demonstrated the effectiveness of each method.
The COVID-19 pandemic has resulted in physical distancing and stay-at-home orders worldwide, impacting all forms of clinical care. Audiologists have been particularly impacted because they schedule predominantly in-person visits, which have generally ceased during this crisis. Even before this current crisis, there has been a movement within the VA system to expand telehealth services and increase access to care. Early adoption has targeted services, such as those for mental health care, that do not typically require physical proximity between the health care provider and the patient. These efforts have been expanding to provide more services either facility-to-facility or directly to a patient's home. This movement toward telehealth is echoed in other health care systems outside of VA.5
Whereas much of the audiologists’ usual scope of practice may not translate readily into a telehealth approach, tinnitus care can. Audiologists regularly encounter patients reporting tinnitus, and they are often the primary link between these patients and the health care community. For many reasons that have been described elsewhere,6 audiologists are well-positioned to assess tinnitus and provide an intervention if needed. When people with tinnitus cannot meet with an audiologist in person, telehealth options can provide not only continuity of care but also evidence-based treatment. Our Tele-PTM program is an option to fulfill this need.
PTM has been described in detail in numerous publications.3, 7-9 Tele-PTM, the telehealth version of PTM, essentially delivers the higher levels (3-5) of PTM remotely. Table 1 outlines the features and differences between the two modalities of PTM.
Prior to receiving Tele-PTM services, patients would ideally first see an audiologist in person to receive the PTM Level 2 Audiologic Evaluation. This would include administering the Tinnitus and Hearing Survey (THS) and dispensing hearing aids as needed.9 The Tele-PTM audiologist will confirm that these needs have been adequately met, and that the patient has habituated to any new devices during the initial audiology telehealth screening. In situations where an in-person hearing assessment may not be completed in a timely manner (e.g., during a global pandemic), the Tele-PTM audiologist would need to set expectations about what problems could be addressed via Tele-PTM counseling and what problems (e.g., hearing difficulties) must be tended to with hearing aids or other hearing-focused rehabilitation programs.
A patient referred to Tele-PTM would also be evaluated by a mental health care provider to rule out risk factors such as active suicidal ideation and to determine any mental health conditions that require treatment or for which telehealth would not be a suitable modality. If the patient is determined to be a qualified candidate for Tele-PTM after completing audiology and mental health screenings, then he/she is scheduled to receive the five sessions that comprise Level 3.
Ideally, some form of video telehealth counseling takes place between the clinicians (audiologist and mental health care provider) and the patient. A phone can be used if video telehealth is not.4 Within the VA system, the VA Video Connect (VVC) application allows clinicians to easily connect with veterans on their smartphone, tablet, or computer for video telehealth. The program is user-friendly and has been set up to coordinate with the VA scheduling and medical records systems. VVC makes secure video telehealth delivery available to any veteran with an internet connection and a webcam or a smartphone. In response to the COVID-19 crisis, U.S. states are providing temporary expanded telehealth coverage for health services such as behavioral health services, making telehealth an option for providers outside the VA as well.
The audiologist provides two sessions of training on how to use sound as therapy for tinnitus, and the mental health provider delivers three sessions using CBT. If the patient requires further intervention, additional sessions can be provided, most of which would involve teaching additional skills from CBT. As for PTM Level 5 Individualized Support, the counseling can involve acceptance and commitment therapy (ACT),10 mindfulness therapy,11 and tinnitus retraining therapy (TRT).12
ADVANTAGES OF TELE-PTM
A challenge in providing multidisciplinary tinnitus care is engaging a mental health care provider for PTM Levels 3 to 5. Having such a provider available and trained to offer these services is uncommon. The lack of on-site mental health care providers is one of the main barriers to establishing PTM programs in VA and non-VA facilities.13 Tele-PTM can provide a means for access to services by expanding the reach of a few well-trained mental health care providers to include tinnitus patients, thereby filling the gaps left by the lack of on-site mental health support for tinnitus care. Tele-PTM has potential applications for regional or even nationwide provision of tinnitus services, making these services available to many people who otherwise do not have access to evidence-based tinnitus care. The “Anywhere to Anywhere” legislation (38 CFR Part 17 effective June 11, 2018) allows for the provision of care across state lines within the VA system. While many logistical issues remain, this legislation and the VVC platform allow the VA to expand the use of remote care to reach more veterans. Telehealth services are also being used by other health care systems,9 which could make Tele-PTM available to their patients. Tele-PTM, therefore, is an evidence-based telehealth service that is poised to be made accessible to the millions of Americans affected by tinnitus. Under normal circumstances, implementing Tele-PTM programs serve to expand care to those who live in remote areas or have mobility issues. With the ongoing COVID-19 pandemic, these also provide flexibility in broadly transitioning care to telehealth.
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