In high school, I played varsity soccer for four years. During that time, my coach repeated many times that to progress forward, sometimes we had to move backward. When the team wanted to attack and score, often it was more beneficial for a player to look behind to supporting teammates than forward at those trying to steal the ball. When individual players worked together as a team, we evolved and met our goals, both figuratively and literally.
Audiology can take the advice from my coach: Look backward to continue moving forward. After World War II, the U.S. Navy set up aural rehabilitation (AR) programs for returning soldiers.1 Raymond T. Carhart, PhD, is often given credit for initiating AR programs that included hearing aids.2 He further developed speech audiometry, expanding the diagnostic testing available.3 The Veterans Administration (VA) took functional hearing loss seriously and created a comprehensive diagnostic protocol.4 Prior to 1977 when many audiologists began dispensing hearing aids, the evaluation of an individual's auditory system was critical to selecting a proper treatment device. Today, it seems the diagnostic evaluation has morphed into simply ticking off a “checkbox” before fitting a hearing aid. However, rather than looking at a portion of a patient's treatment plan (a widget), I argue that hearing care professionals ought to look backward to the diagnostic process with a functional and communication needs assessment (F&CNA).
BENEFITS OF NEEDS ASSESSMENT
A needs assessment is not a new idea and has come by many names over time, such as Needs Assessment, Functional Communication Assessment, Communication Needs Assessment, and Auditory Needs Assessment. As early as 1998, professional committees have convened, and peer-reviewed articles, including notable works by Cynthia Compton-Conley, PhD,5 and Robert Sweetow, PhD,6 have been published regarding a needs assessment. Compton-Conley reviewed the four areas of a needs assessment for hearing enhancement: (1) face-to-face, (2) reception of electronic media, (3) telecommunications, and (4) alerting. She also stressed that the individual's needs should inform the technology, not vice versa.7 The outcomes revolve around better hearing. Sweetow, who also focused on auditory function, created a plan that includes education, counseling, communication strategies, auditory training, and devices.8
In the book, Health Design Thinking, Ku and Lupton challenge medical providers to ask, “How might we find an alternative solution to an issue?”9 In the context of audiology, how might audiologists evaluate the whole person to create a comprehensive plan of care? The answer is an F&CNA. This 30-40 minute diagnostic/screening protocol looks at the entire person and creates a comprehensive treatment plan that may or may not include the use of a traditional hearing aid with a traditional delivery model.
The F&CNA begins with questionnaires before a patient is seen for an appointment. Although quality of life (QoL) questionnaires are meant to determine if further evaluation is needed, addressing anxiety, depression, dizziness, hearing, hyperacusis, motivation, and tinnitus are also vital for positive outcomes. The results will influence referrals, follow-up appointments, and actual treatment protocols. Some QoL questionnaires are in the public domain (e.g., PHQ-210) for health care providers, while others require permission from their respective authors to reproduce.
Patient observation commences when the patient enters the practice. Vestibular screening with minimal equipment can be done using the Timed Up and Go (TUG11) test. The audiologist compares the time it takes for an individual to complete the movement with published normative data and may suggest additional testing and/or referral. Vestibular screening, which can be easily implemented in an audiology practice, expands the role of an audiologist from only hearing to hearing and balance. This is an easy first-step with an F&CNA.
While many in the profession are working to prevent hearing loss and demonstrate the value of hearing and balance to younger individuals, the average age of those seeking hearing health care services is still retirement age and beyond. Vision loss among this population plays an important role in safety (falls risk) and treatment options. A Snellen eye chart, which can be used to screen for both near- and far-sightedness, is practical in spaces as small as 10 feet and inexpensive (less than $25). The results can suggest how well a patient may be able to handle large or small treatment devices (e.g., cochlear implants), related accessories (e.g., remote controls), and assistive devices (e.g., captioned telephones). A referral to optometry and/or ophthalmology may still be required.
A thorough case history includes a Review of Body Symptoms and an informed patient will report cardiovascular issues and medications. Safety is of utmost importance and as more hearing aids incorporate artificial intelligence, alerting/monitor systems, and health trackers in the ear, screening protocols need to be implemented to justify the recommendation, when truly needed. Audiologists can screen for blood pressure with an automated machine. A “Good, Fair, or Refer” criteria can be measured against the U.S. Preventative Services Task Force for adults 18 years and older.12
A dexterity screening is the last portion before a patient is placed in the sound booth. Dexterity screening tools, such as the Purdue Pegboard Test,13 will likely need to be purchased (approximate cost of $100-$200) for consistency and normative data. The measurement typically has at least three sub-tests, providing information with the user's dominant hand, non-dominate hand, and a combination task requiring the use of both hands working together. Similar to vision screening results, treatment options may need to be larger for those with impaired dexterity, regardless if they are over-the-ear, in-the-ear, and/or an accessory.
The F&CNA continues with the patient inside the sound booth. Regardless of the order of audiologic testing, most comfortable listening levels (MCLs) with recorded and monitored live voice and uncomfortable listening levels (UCLs) need to be obtained for the right ear, left ear, and bilaterally. HARL's Contour Test,14 when followed closely, can assist in diagnosing hyperacusis, which, if present, needs to be treated early in the plan of care. Diving further into the auditory system, measurements for noise tolerance (e.g., acceptable noise level15), binaural interference, speech in noise, and cochlear dead regions are straightforward to obtain and the test materials are now being incorporated in audiometry diagnostic equipment. An auditory processing disorder (APD) screening is likely the most time-intensive component of an F&CNA, requiring the purchase of screening/diagnostic materials and a two-channel diagnostic audiometer. Results not only suggest whether or not diagnostic APD is required but also the treatment of communication strategies and formal aural rehabilitation programs, such as Listening and Communication Enhancement (LACE).16
Cognitive screening tools need to be administered after audibility is verified. While systems such as Thrive by Cognivue17 are becoming more popular, simple paper and pencil tools or auditory instruments can be used to get a snapshot of the patient's cognitive function and help clinicians decide if additional testing is warranted from a medical provider. Incorporating working memory protocols (e.g., Word Auditory Recognition and Recall Measure18) completes the screening/testing F&CNA appointment.
A care plan is mandatory for each F&CNA appointment and must address additional audiologic-vestibular testing, follow-up with other medical and/or health care providers, alerting systems, APD rehabilitation, aural rehabilitation needs, cerumen management, swim molds, hearing protection, lifestyle modifications, music protection, phones, public venue accommodations, workplace modifications, support groups, osseointegrated devices, amplification, and related accessories and supplies. A visually appealing and well laid-out care plan can be developed with the help of a graphic designer. Valuing the expertise and time to complete an F&CNA appointment ensures providers are reimbursed fairly and allows the patient to seek treatment from their preferred provider and/or system.
When implementing new procedures like an F&CNA, providers must guarantee that each testing and screening protocol is within the state-defined scope of practice. If licensure law is vague or not addressed, the decision needs to be obtained in writing prior to administering any part of an F&CNA. Additionally, owners and clinical managers need to ensure all members are on board with an F&CNA as the goal changes from selling widgets to providing treatment care plans. Pricing has to be determined and possibly adjusted (reduced from hearing aid cost), and the appointment cost is reimbursed every time. Pricing is important as an F&CNA is not covered by third-party entities. Staff members who schedule patient appointments need to be comfortable introducing an F&CNA and its associated cost and cease the use of terminologies that focus on hearing aid evaluations. Finally, a referral procedure is needed should any screening or test require services not offered or within the scope of practice of an audiologist.
The concept of F&CNAs will continue to evolve as new measures are added to provide patient-centered care and patient outcomes from these measures are evaluated and reported. As hearing care professionals look forward to the emergence of over-the-counter (OTC) hearing aids, reduction of third-party coverage, and evalution of third-party administrators, we can also take some time to look back at our device consultations and consider whole-patient care for a functional and communication needs assessment.
EDITOR'S NOTE: For more on F&CNAs, check out Dr. Spoor's AuDaCITY 2020 presentation at https://audiologist.org/archive/audacity-2020-archive and materials at https://www.practicegrowthbydesign.com.