Editor's note: This is part one of a two-part series. Part two will appear in the February issue.
Life as we knew it changed in 2020. With an unprecented pandemic upending the economy, medical care, and national elections, among many other issues, it doesn't come as a surprise that the Oxford English Dictionary decided not to name their traditional “Word of the Year,” noting that 2020 is “a year which cannot be neatly accommodated in one single word.” Indeed, there's much to be said about lessons learned, goals, and hopes as the world, including audiology, look to the future.
To kick-start 2021, The Hearing Journal (HJ) hosted an online roundtable discussion with leaders from the American Academy of Audiology (AAA), Academy of Doctors of Audiology (ADA), and American Speech-Language-Hearing Association (ASHA) to discuss key issues and the organizations’ goals and strategies to support members in the new year. In this month's cover story, ADA President Victor Bray, PhD, ASHA's Vice-President for Audiology Practice, Sharon A. Sandridge, PhD, and AAA President Angela Shoup, PhD, along with HJ’s Editorial Board Chair Fan-Gang Zeng, PhD, as the discussion moderator, share critical insights into reframing challenges within evidence-based silver linings.
HJ: As of this recording (Nov. 2020), we are seeing record-high increases in COVID-19 cases in the United States. Although many hearing health care practices and medical facilities have developed good safety protocols, many patients may still be hesitant to seek hearing care. What does your organization plan to do to promote and develop public confidence in seeing an audiologist amid this pandemic?
Dr. Bray: The COVID-19 pandemic numbers are truly frightening, with new daily cases over 100,000, more than 60,000 Americans hospitalized, and over 1,000 people per day are dying. ADA has provided a resource on our website and at our recent Audacity 2020 virtual conference for all things COVID. ADA practitioners have implemented and continued their best practices for infection control to protect patients and colleagues from this transmissible disease. While many of our audiology patients are in higher risk categories due to their age and health conditions, audiologists have successfully transitioned their parking lots, curbsides, and offices into managed-risk environments.
The important communication to the public is that audiologists are essential health care workers because hearing health and balance are essential to maintain and participate in daily activities, prevent injury, and promote a high quality of life. Patients who are at risk for or living with hearing loss and balance issues should not delay seeking and obtaining audiological assessment and treatment just as they should not delay seeking care for other conditions.
Dr. Sandridge: ASHA hosted an online conference that is hitting a lot of what is happening now and what is happening in the future for the practices. It features a series of talks and a panel discussion, so I highly recommend checking it out.
From a personal standpoint, I work at the Cleveland Clinic, where audiology is a very small part. There's a huge push to make sure that patients feel comfortable and safe to come in for care, with extensive thermal screening and questions I think patients are realizing it is safer to be in the Cleveland Clinic than it is probably anywhere else. As long as we as health care providers and workers maintain our level of safety with social distancing and masking, which all of us are required to wear when we are in contact with our patients, then we are setting the examples. Our governor is also very strict about making sure that the state of Ohio wears masks.
Dr. Shoup: The Academy has also developed a very rich COVID-19 resource section on our website, and this provides information and recommendations about safety when providing services during COVID-19 for our members as well as for consumers. It includes materials that were developed by the Academy and links to information from the CDC and relevant materials developed by our colleagues and other organizations like the ones represented here. We also send out a weekly COVID-19 newsletter and update the website with new links about the latest and greatest information. We have integrated the theme of being essential in light of COVID-19 into our public awareness campaigns, including May's Better Hearing Month, October's National Audiology Awareness Month, and the weekly COVID-19 newsletter I mentioned.
In addition, we have been working very hard to update and better organize our consumer content, integrating it with Google word searches and indexing the content into Google to make it easily accessible for consumers who are concerned about hearing and balance. The Academy is encouraging all of our members to update their profiles on the public-facing “Find an Audiologist” directory. Members have the opportunity here to share information about their services, including contactless options as Victor referred to, and pre-appointment safety precautions they are taking in their practices to make consumers feel a little more confident seeing the provider in person if they need to. They can also point to their practice website from that directory for easy consumer access toward specific practice information. We have included enhancing the robustness of their profiles so that we have specialty and symptom selection criteria, which will include the ability to select, as a provider, that you provide curbside services and/or telehealth so that the consumer can recognize that as another offering in your practice if that is important for them in selecting a provider.
Dr. Bray: It is very impressive to me how all three organizations have responded to their members’ needs. These organizations ramped up rapidly at a time when all of us were asking questions and guidance. I just want to applaud all the audiology associations for what they have done.
HJ: Agreed. Since the beginning of the pandemic, your organizations have been instrumental in updating professionals on critical issues such as Medicare changes, HIPPA compliance, and telehealth—which many have approached with much creativity. But amid all the strategies, adjustments, and advancements in teleaudiology, what do you feel remain the top barriers and challenges, and how does your organization plan to address these issues?
Dr. Bray: We must recognize the successful collaboration among audiologists, device manufacturers, and other suppliers. Their prior work and product design supporting the provision of audiology services without face-to-face client interactions has been a boon to the continuation of hearing health care services during the pandemic. It is not uncommon in a crisis to create a new environment where what was an optional, low-utilization tool suddenly becomes a critical high-utilization tool. Such is the case for the practice of audiology and telehealth, especially in regard to the remote assessment and programming of hearing devices.
ADA is working on multiple challenges with reimbursement for audiological services provided by telehealth. One, it is important to secure reimbursement for services to a profession that in many cases has not been on the list of professions that provide telehealth. Two, we need the creation of reimbursement codes that are audiology appropriate. Three, we need to secure a short-term emergency approval regarding licensure regulatory issues, and seeing the obvious value of audiology telehealth, ensuring the short-term changes becomes long-term changes. And four, [we need to] work with Medicare, either through their internal decision-making process or external legislation, to remedy the inappropriate classification of audiologists as diagnosticians and suppliers to the proper category of practitioners. Such a change is the most comprehensive and easiest method to fully open audiology telehealth in hearing health care.
Dr. Sandridge: Earlier this year, ASHA was successful in securing temporary coverage of services delivered via telehealth by both public and private payers. Unfortunately, audiology is not the greatest recipient of that because we just don't have the codes. We have four codes covered by Medicare for cochlear implants—that's all we have. Fortunately, ASHA has joined forces with AAA and other allied stakeholders, and I encourage audiology organizations to continue working together. It is probably one of the greatest things that have happened in the last couple of years: Our organizations are no longer working against each other but instead coming together and working as one unit to promote audiology—so we can get permanent telehealth coverage for audiology services under Medicare, get recognized, and get services delivered via telepractice.
Dr. Shoup: It is also very important for us as audiologists to stay involved in national discussions about the barriers to telehealth and the ways that we can increase the applicability of telehealth. It would be good for us to review and look at things like the report published by the National Committee for Quality Assurance, the Alliance for Connective Care, and the American Telemedicine Association. When we think about our patient population, broadband can be an issue for them. Also, the trust issue, which is one that we need to address individually with our patients—trust that you are actually receiving quality care through telehealth. And more importantly is the digital literacy gap. As an audiologist, I spend a lot of my time educating and training on the appropriate use of technologies. It is incumbent on all of us to recognize when we have opportunities for face-to-face time or through telehealth—if patients have somebody assisting them—that we spend some of the time addressing the digital literacy gap and helping them become more effective users of the technology necessary to access our care remotely.
Another thing has been touched on briefly is the fact that when it [teleaudiology] was first introduced as technologies that could allow us to address our patient needs remotely, it wasn't just our patients who were resistant; there was a lot of provider resistance as well. Several technologies have become available, but many of us thought, “It may be good idea someday,”—and that “someday” never came. We were busy, and we were comfortable with what we were doing. I think we need to be extremely vigilant about not falling back into that and make sure we utilize any time when we are no longer as stressed due to the pandemic to fully evaluate efficient and effective ways to implement telehealth practices on an ongoing basis within our clinical care routines.
I do have a strong concern that we have the tendency to backslide—back to no longer pushing the envelope as soon as it's comfortable—because I think there are still a number of people who continue to be resistant to fully embracing it.
Dr. Sandridge: We never think about digital proficiency of adult patients. How many times do we assume they know how to download the app to use the remote programming? We really do need to implement a type of digital proficiency assessment before we go down the road of trying to do remote programming, and not assume they know how to do it like we typically do. As Angela said, it is now time to change. We have been reluctant although we've known about all these things—OTCs, telehealth models, etc.—for many years. COVID-19 just gave us a smack in the back to move forward. It is time to change how we do audiology.
Dr. Shoup: We've been focusing very much on telehealth applications for remote and contactless patient care. As we push this envelope and continue to work on making sure providers and patients are comfortable and getting reimbursements for the remote care, we also need to look at the limiting factors on our services. As what Victor referred to, our manufacturers have done a great job trying to think ahead on how we could provide services remotely. But one of the most important aspects of providing quality habilitation and rehabilitation is a truly good diagnostic evaluation, but we haven't corrected that. So, research and innovation from the manufacturers on ways to provide greater access to technologies that can be used remotely for diagnostics and supply chain—such as calibrated units that could be shipped to patients, some supply chain options that offer reasonable prices for calibrated solutions that can be sent for one-time use, or shipping and distribution patterns that audiologists and private practices could access inexpensively and efficiently—would be necessary for us to deliver diagnostic services to patients who could participate in a remote session on their own.
We have to look at reimbursement models for remote care using a single provider, but we also need to look at how to structure appropriate reimbursement models to support remote care that requires a technician on the other end, a satellite office set up with additional equipment, and/or personnel cost so that we can do ABRs on complex babies from a distance or remote vestibular evaluations on older adults at risk for falls with the support of a technician who can do hands-on patient work for us while we guide, direct, interpret, and provide the knowledge base during the patient encounter. This is definitely a different reimbursement model than just paying for an individual sitting there providing remote care to a person who's logged on to their website.
Dr. Zeng: I will amplify the importance and power of working together. As what Angela said in the beginning, hearing and balanced services were initially excluded from Medicare's telehealth initiative, but by the end of April 2020, most of these services were included. This shows the power of working together.
HJ: What specific business areas do you think should practice owners focus on as we continue to see more COVID-19 cases and have sustained pandemic-related safety measures?
Dr. Bray: I want to keep two things separate. One is the response to the pandemic, and the other, which is a little different, is business trends and managed care in group practices.
With regards to business sustainability, audiology private practices can survive the pandemic. There are a lot of business operations failing, including indoor dining restaurants and clothing companies that produce business attire. Audiology and private practices are surviving by means of meeting a human communication need. While there are short-term hardships for many of us, historically the long-term demands for audiology services are consistent and have moved through the fluctuations in the business cycle. The crisis like the current pandemic—or any crisis that impacted business operations—will always bring to the foreground the focus of how operations can improve. The crisis has all of us stepping up our game in infection control, the use of PPE, and methods of patient contact that maintain physical distancing guidelines such as using audiology telehealth. But there are other areas where audiologists have focused on, such as alternative scheduling policies for patients, physical re-arrangement of our facilities, the hours of operations, and business relationship contracts with our vendors. Once the pandemic is over, I believe some of the new processes developed today will become standard operating procedures of tomorrow.
As for managed care and forming group practices, these activities have been going on for decades and will continue to do so. As we purely see where new players and new practices come forward, some will have improved operations and will succeed, and there will be others that fail. This will continue pandemic or no pandemic. The important thing to remember is that audiologists who focus on their full scope of practice are best prepared to survive any time of change. Legislation that supports audiologists working at their full scope of practice will contribute to the strength of the profession needed during times of crises.
Dr. Sandridge: We need to think about how we are doing our business. There are all kinds of evidence and research to support pre-educating patients before they come in for an appointment. For example, Melanie Ferguson's C2Hear program can be used to prime patients about hearing aids so they become better consumers and informed of what happens during a hearing aid evaluation. Why not do this for every appointment? We are in the process of doing that at Cleveland Clinic—breaking it apart, dissecting it, and re-evaluating every domain of audiology. We start with an introduction, then we prime the patient. We ask them to bring their significant other. If this is not possible, we will spend money to get a monitor so they can see their loved ones, which is going to be easy for the significant others because they don't have to take off work. They can just zoom in and zoom out. We can do so much more in pushing the family-centered approach because we all do it to some degree, but we don't embrace it to the level that we need to do. We concentrate on health and reading literacy because there's so much literature out there that says these are correlated with success. We also need to go back to our roots and figure out that we are working with people who have communication issues; it's not just about a pair of ears and/or devices. That's where private practices are going to either make it or break it—if they go back to their roots.
Dr. Shoup: When we look at the focus that the audiologist need to have, it is definitely about making sure we practice our full scope of practice, going back to our roots, recognizing that we are communication and balanced specialists who work with individuals who need our guidance. Each one is a complex unique individual who has different needs than the person you saw 30 minutes earlier. As an audiologist, we must continue embracing models that allow us to limit in-person service requirements and adjust those areas to deliver optimum care. Just like any other health care provider, we must prioritize those services that can be provided by telehealth and offer them that way even if you are starting to open up your practice to in-person or if you have already been doing so. Try to think carefully: Is this something you can use for telehealth? It is important because it could potentially give you a much more cost-effective model for value-based care. In addition, it allows you to practice more safely in-person right now because it decreases the volume of patients who physically have to come to your clinic. We could start this process, as Sharon referred to, by educating the patient to start with.
There are definitely a lot of conversations around the impact of COVID-19 on private practices. We are seeing a lot of information in the news about rural and/or smaller hospitals closing or consolidating. For health care in general, this has pushed something that was already a weakness for many and driven more consolidation of practices. But the concern we need to keep in mind is sometimes it could lead to decreased choice and increased cost because with decreased competition, you will have people who will no longer push to offer better services. And sometimes it could lead to an increase in health care costs overall because you no longer have competitive fees. As a society in general, we need to be looking at options to continue to support private practitioners and provide them with the resources necessary to re-tool practices in supporting remote care and telehealth.
HJ: We've been seeing increasing case reports of sudden hearing loss, tinnitus, and vestibular issues among COVID-19 patients. What do you envision will be the role of audiologist in the continuum of care for these patients?
Dr. Bray: Hearing loss, vestibular dysfunction, and/or tinnitus associated with COVID-19 are comorbidities of the viral attack. Doctors of Audiology are health care providers concerned with whole body health as well as ear health. The role of audiologist will be the same with COVID-19 as with other disease processes. Audiologists will contribute to and monitor the emerging evidence base, come to understand the pathophysiology of SARS-CoV-2, and continue to participate as an integral part of interprofessional collaborative health care teams.
Dr. Sandridge: Every day we learn something new about COVID-19. The sad thing is we still are having deaths. The good news is the death rate is decreasing because we now know how to treat it. We also know it attacks just about every single system in our body, and nothing is immune from it. Who knew that a rash and the toes would be involved? That alone, we know our ears can be involved, too. We are going to treat tinnitus regardless of where it comes from.
Dr. Shoup: I agree with both of you. As any public health issue that comes up, audiologists are going to be involved with education with other health care providers and how the health issue impacts the auditory and vestibular systems. They should start early on with discussions about otoxic and vestibulotoxic effects so they can help with monitoring patients and making sure they receive appropriate education at the right point of care to understand the issues they may encounter once they are released from care. Audiologists are going to be providing the same type of care to any patient with hearing and balance dysfunction. Increasing awareness of the potential otoxic and vestibulotoxic effects of the drugs being used is a very important responsibility of audiologists. We've been very active in assisting people with increased difficulties in hearing and understanding speech due to masking. We've also been heavily involved in helping patients who don't have COVID-19 but are increasingly distressed due to their tinnitus by assisting them with good sleep hygiene, stress management, and other related strategies.
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