Interventional Audiology Services: Serving More Patients | October 2016 Hearing Review
Moving toward the Life-course Health Development Model being adopted by physicians
When hearing care professionals look beyond their traditional clinic-based testing and hearing aid fitting approach, new interventions valued by a large swath of patients with unmet needs are likely to emerge. As our field finds its way in the consumer-driven, integrated healthcare system, interventional audiology is likely to become a guiding principle of our profession.
Over the next 10 to 15 years—mainly due to the aging Baby-boomer generation—the demand for hearing care services is likely to grow by upwards of 50%.1 Although it may be tempting to passively wait for this surge of aging Baby-boomers to find their way to our clinics for testing and hearing aid fittings, it is quite possible this group will have different expectations and service demands compared to previous generations. If studies from other healthcare specialties are an indicator, many Baby-boomers are more likely to want greater involvement in the decision-making process with their doctors, appreciate a wide range of choices and exhibit a stronger preference for direct access to treatment options without seeking the guidance of their physician. The vision care industry, for example, was utterly transformed 15 to 20 years ago when aging Baby-boomers demanded an over-the-counter solution for the condition of farsightedness. Opticians, optometrists, and ophthalmologists adapted and never looked back.
The current model for delivering hearing healthcare relies on clinic-based testing, hearing aid selection, and a series of face-to-face follow-up visits. This model, which has been popular for more than 40 years, is considered to be the gold standard of care. And, for some patients, the model is effective, especially if you’re a motivated individual with a complex hearing loss and the financial means (or insurance coverage) to purchase hearing aids and services.
Unfortunately, the majority of adults with hearing loss of gradual onset do not seem to value the current delivery model, as up to 86% of adults with hearing loss do not own or wear hearing aids.2 In fact, many adults with hearing loss, often seeking help for the first time, report that the current delivery model is “disconnected,”3 relying upon a series of isolated events that are product-focused and fixated on hearing aids.4
On its own, the traditional hearing healthcare delivery model, and the poor hearing aid uptake associated with it, is not necessarily detrimental to patients. After all, if age-related hearing loss were inconsequential and simply a normal part of the aging process, then the current model for care is probably sufficient. However, several recent studies5 suggest hearing loss of gradual onset in adults is associated with more rapid cognitive decline, physical aging, depression, social isolation, and overall poorer quality of health. This research, much of it conducted over the past 5 years, indicates age-related hearing loss is a significant public health concern. Thus, efforts must be made to provide adults with easier access to more affordable options for hearing healthcare, especially for those in underserved and vulnerable populations.
NAS Report on Accessibility and Affordability
The NAS’s 12 Recommendations for Improving Hearing Healthcare
On June 2, 2016, the National Academy of Sciences (NAS)2 made 12 recommendations for improving hearing healthcare in their report, “Hearing Health Care for Adults: Priorities for Improving Access and Affordability.”
1) Improve population-based information on hearing loss and hearing healthcare;
2) Develop and promote measures to assess and improve quality of hearing healthcare services;
3) Remove FDA’s regulation for medical evaluation or waiver of that evaluation prior to hearing aid purchase;
4) Empower consumers and patients in their use of hearing healthcare;
5) Improve access to hearing healthcare for underserved and vulnerable populations;
6) Promote hearing healthcare in wellness and medical visits for those with concerns about their hearing;
7) Implement a new FDA device category for over-the-counter wearable hearing devices;
8) Improve the compatibility and interoperability of hearing technologies with communications systems and the transparency of hearing aid programming;
9) Improve affordability of hearing healthcare by actions across federal, state, and private sectors;
10) Evaluate and implement innovative models of hearing healthcare to improve access, quality, and affordability;
11) Improve publicly available information on hearing health;
12) Promote individual, employer, private sector, and community-based actions to support and manage hearing health and effective communication.
The urgency to address the unmet need of those with age-related hearing loss swelled to greater heights when, on June 2, 2016, the National Academy of Sciences (NAS),2 after more than a year of careful study and deliberation by its 17-member committee, issued three key findings about the current state of hearing healthcare in the United States:
1) The sense of hearing is vital to communication, active participation in daily living and overall quality of life;
2) Treatment and management of age-related hearing loss involves a wide range of services and technologies; however, many people do not have access or cannot afford them; and,
3) Age-related hearing loss is a public health and societal concern that warrants changes to the current delivery system, and all stakeholders must take an active role in addressing these concerns.
Based on these three overarching considerations, the NAS issued 12 recommendations for improving access and affordability (see sidebar). For workaday hearing care professionals, perhaps the most critical question surrounding the NAS recommendations is, how do we better meet the needs of the aging population without compromising the productivity of our current business? Interestingly, the dual issues of affordability and accessibility are also affecting the broader US healthcare system; many of the NAS recommendations mirror the current changes in the American healthcare system (see the October 2016 Dr John Bakke article for more details).
To fully appreciate the potential far-reaching effects of the NAS recommendations, let’s more closely examine how hearing healthcare is delivered today, how it reached this point, and why it needs to adapt to changes in marketplace demands.
The Evolving Healthcare System: Life-course Health Development in Hearing
Since the 1960s, when audiology became a sustainable profession, the biomedical model of disease and illness has driven much of healthcare. Focusing on the “diagnosis & treatment” of acute conditions, such as infectious diseases, the biomedical model has been a cornerstone of the US healthcare system for decades. With its emphasis on site-of-lesion testing and the fitting of hearing aids on patients with long-standing, often complex hearing loss, hearing care professionals also have relied on the biomedical model of delivering care to patients.
Subsequently, as evidence mounted indicating the role of lifestyle and behavior contributed to disease and illness, the broader healthcare system began to design programs to manage chronic medical conditions over long periods of time, and to try to modify the behavior of patients who make unhealthy lifestyle choices. Hearing care professionals must follow suit, and intervene in different ways, if they expect to maintain a vibrant profession in the new era of consumer-driven care. Several articles in the October 2016 issue of Hearing Review, including this one, address these emerging intervention strategies.
More recently, the term Life-course Health Development Model has been used by Davis et al6 in the audiology literature to describe the interconnectedness of an individual’s genetics, lifestyle choices, social, psychological, and environmental factors, and how these might impact short and long-term health outcomes. By definition, according to Halfon et al,7 the life-course health development model (LCHD) is a multidisciplinary paradigm that attempts to better understand the risks associated with developing a chronic condition within the context of an individual’s lifestyle, genetic predisposition, and social history. The LCHD includes ideas and observations about the individual from an array of disciplines, notably sociology, demography, developmental psychology, biology, and economics.
Using an LCHD approach, the hearing care professional (HCP) would examine more closely the history, environmental conditions, and personal experiences of each patient. Say, for example, you are seeing two different people who present to your clinic in their early 50s: Patient A and Patient B. Both patients present with similar hearing within the range of normal, but because of different life experiences the two individuals are on “very different underlying hearing health trajectories.”6 For Patient A, with a history of smoking and noise exposure, his trajectory involves more vigilant annual hearing screenings. In contrast, Patient B, without co-morbidities but who nevertheless happens to be expressing some concerns about his hearing in specific workplace listening situations, would be managed in a much different way. Perhaps even the recommendation of a PSAP without a regimented follow-up plan with the HCP would be warranted.
Thus, it is important for the HCP to consider the hearing health trajectory of each patient and intervene in an appropriate manner. Further, the term “trajectory” implies the HCP carefully examine the patient’s entire history in order to make the right recommendation at the right time—a core principle of integrated medical care. This requires a broad assortment of interventions to be used at various points on the aging continuum.
The evolution of healthcare from examining all medical problems through the lens of the biomedical model to examining each individual’s health throughout their lifespan in the context of their social, emotional, economic, and psychological experiences, has the potential to change the way hearing care and audiology is practiced. Rather than focusing on the individual’s audiogram, trying to identify the cause of their hearing impairment, and waiting for that person to use hearing aids, the LCHD approach focuses on tailoring the intervention to the immediate, real-world needs of the patient. Unlike the biomedical model, which emphasizes the diagnosis and treatment of hearing disorders—often identified in its latter stages when the hearing disorder is more complex—the LCHD model emphasizes highly targeted, often less complicated interventions. The term interventional audiology has been used to describe this shift in preventive, early, and alternative management of hearing loss, oftentimes conducted outside the walls of the sound booth.8
Three Branches of Interventional Audiology
In practice interventional audiology takes on three forms. The first is direct involvement with patients, often younger in age with milder hearing loss to help them stave off the effects of age-related hearing loss (ARHL). This involves preventing or minimizing hearing loss. The second branch of interventional audiology involves embracing alternative products and treatments for those with “situational” communication problems, often coinciding with a visit to their medical care provider. These alternative products may address the immediate need of many individuals and, in addition, may lead to a more comprehensive assessment by the HCP in the clinic. Finally, the third branch of interventional audiology involves offering help-seeking patients, already in your clinic for services, alternative solutions for their hearing difficulties. Some of these alternative solutions may provide a gateway to traditional hearing aid use when the patient is psychologically ready for more elaborate care or when the hearing loss declines.
Branch One: Raising Public Awareness About Prevention and Minimizing Risk for Hearing Loss
Rather than passively waiting for adults to find their way to a clinic for a hearing test, eventually to be fitted with hearing aids, a cornerstone of the first branch of interventional audiology is educating the public about the importance of good hearing being a central component to a vibrant and active lifestyle. Even though the US Preventive Services Task Force9 indicated there was insufficient evidence to warrant universal hearing screenings for adults over age 50, there is growing evidence since their 2011 report to encourage healthy adults over the age of 50 to obtain a periodic hearing screening. Further, common co-morbid conditions, such as Type II diabetes and hypertension,9 may warrant more frequent periodic hearing screenings at younger ages for individuals affected by these conditions.
Although it is tempting to simply create some catchy new marketing slogan to capture the attention of a younger audience, hearing care professionals can practice interventional audiology by engaging in public awareness and hearing loss prevention campaigns. Here are three examples of how public awareness can be raised so that hearing loss of adult onset can be minimized and even prevented:
1) Hearing conservation and public awareness. Noise-induced hearing loss, including that caused by personal music players, continues to be a global problem.10 Hearing care professionals are advised to become involved in public awareness campaigns that not only make people aware of the risks of noise and loud music on hearing, but also the broader effects noise exposure has on sleeping, mental health, workplace productivity, and cardiovascular function. These public awareness campaigns could include messages about developing the habit of using proper hearing protection, limiting time exposure to loud music and using earbuds that automatically limit the intensity of music being delivered to the ear canal.
2) Hearing care apps. Another component of preventive interventional audiology care is the use of smartphone apps for self-screening of hearing. One example is Marshall Chasin’s Temporary Hearing Loss Test ($2.99 at the Apple App Store), which allows the user to measure hearing thresholds before and after music or noise exposure.10 It is believed that such self-screening apps raise awareness of noise-induced hearing loss and its long-term deleterious effects by getting individuals directly involved in their own healthcare without having to take the time to schedule an appointment with a professional.
3) Normalize hearing loss and its association with healthy living. Davis et al6 refer to this as the “hearing health trajectory,” which takes into account each individual’s risk factors for hearing loss (eg, history of smoking, noise exposure, etc) as that person ages. Given the American health system’s movement toward integrated care, hearing care professionals need to consider the individual’s entire health history and provide insights and guidance on how hearing impacts “healthy and successful aging and active participation in society.”6 Ultimately, this involves partnering with primary care physicians and Accountable Care Organizations to become part of their preventive care teams. Early involvement in the identification of hearing loss is bound to reduce the overall costs of care, especially for patients with multiple morbidities.
Adding these interventions to your current clinical armamentarium is likely to lead to greater patient engagement. It also puts your practice in alignment with the NAS recommendations of promoting hearing healthcare in wellness and medical visits for those with concerns about their hearing, improving population-based information on hearing loss and hearing healthcare, and making information about hearing health publicly available.
Branch Two: Going Where No HCP has Gone Before—Testing & Dispensing Outside Your Clinic
It’s a famous line from Star Trek, but you don’t have to be a Trekkie to appreciate the power of working directly with hearing-impaired patients in settings other than the confines of your own clinic. Considering the importance of good hearing to the physician-patient relationship, there are ample opportunities for the HCP to intervene in the care of patients at-risk for not hearing the directives and advice of their physician.
For example, the physician who sees many geriatric patients is likely to encounter several individuals each day who have some degree of hearing loss, affecting their ability to communicate. Many of these individuals, even though they have significant hearing loss, do not wear hearing aids. The post-trauma care center, the senior living center, a retirement condominium are all places with a large number of individuals at-risk for hearing loss who might benefit from situational hearing improvement with a medical care giver.
Since high-quality PSAPs offer off-the-shelf, “one-size-fits-all” capability, it is thought they could be a viable alternative technology in situations where face-to-face communication with a caretaker is required. Further, by providing an off-the-shelf amplification solution for those in need (in addition to training front-line physicians and nurses to recognize patients in need of them), the focus is on offering immediate help for communication, rather than referring for a hearing test and waiting several more weeks for the patient to be fitted with hearing aids. As Zitelli & Palmer suggest,11 interventional audiology and integrated healthcare go hand-in-hand, as referrals for more comprehensive audiological services increase when HCPs intervene with immediate solutions outside their own clinic to improve hearing in at-risk populations.
Another type of intervention involves community-based outreach services. Although no good data is yet available to support its effectiveness, community-based intervention involves care delivered with a supervising audiologist working with trained community health workers and/or medical technicians to provide a high-quality “starter hearing aid” or PSAP-like device and basic aural rehabilitation services (eg, hearing loss education and communication strategies). In addition to providing hearing services, community-based interventions could provide additional instruction for aging patients with various forms of dementia in need of communication services.
Branch Three: The In-clinic Functional Communication Assessment
Interventional audiology does not have to be restricted to alternative products and services offered outside the clinic. According to studies,12-14 between 39% and 48% of patients seeking hearing help from a clinic fail to accept the HCP’s recommendation of hearing aids.
Among the theories used to describe patient behavior is the Transtheoretical Stages of Change Model. Commonly abbreviated to “Stages of Change,” it is a framework for understanding how individuals progress toward adapting and maintaining behavior change for optimal health. For HCPs, the stages of change model involves understanding five key stages that individuals with hearing loss of adult onset are believed to move through over time as they seek solutions for hearing difficulties.15 These stages include:
1) Pre-contemplation (lack of awareness of possible hearing difficulties);
2) Contemplation (ambivalent about hearing difficulties);
3) Preparation (searching for information with the intention of addressing hearing difficulties and changing underlying behaviors stemming from hearing loss);
4) Action (overt act of changing behavior); and
5) Maintenance (sustained behavior change).
Identifying the Pre-contemplation Stage During the Initial Patient Visit
Studies have shown that the patients who are in the “pre-contemplation stage” of the Stages of Change Model are highly unlikely to accept a recommendation for a hearing aid and could instead benefit from other forms of intervention. The patient is likely to be in the pre-contemplation stage if:
- During appointment the patient attributes hearing difficulties to the listening environment and/or third parties.
- Displays low concern about hearing difficulties.
- Minimizes or denies hearing problems exist.
- When asked, “On a scale of 1 to 10 (with 10 being ready today), how ready are you to get help?”, the answer is 6 or less.
- When you ask the direct question: “What best describes your thinking about getting hearing aids…”, the patient’s response is number 4 listed below:
- I am ready today.
- I have been thinking I might need hearing aids.
- I have started to seek information about hearing aids.
- I am not ready to get hearing aids, even if you recommend them to me.
The Stages of Change Model proposes that adults will seek help, accept an intervention, and adhere to it only when they are in one of the latter stages (Preparation or Action) of change.
Previous research by Laplante-Levesque and colleagues12 indicated that the Stages of Change Model, specifically identifying patients who may be in the pre-contemplation stage of change, has good clinical validity. More recently, Ekberg et al13 determined that 27% of patients visiting a clinic for help were in the pre-contemplation stage of change, and 100% of the pre-contemplators within this group did not accept the recommendation of hearing aids. Moreover, Ekberg et al concluded that patients in the pre-contemplation stage of change were likely to meet the recommendation of hearing aids with significant resistance, while patients in the contemplation or preparation stage of change were much more likely to move into the action stage of change by the end of the appointment and commit to using hearing aids.
Thus, identifying patients in the clinic who may be in the pre-contemplation stage, and desire broader discussions that raise awareness of a hearing problem to the patient (and family’s) would be beneficial. This counseling approach with pre-contemplators could prove a useful intervention compared to the current service delivery model.
This vein of research on help-seeking behavior has practical implications for HCPs who wish to embrace several of the NAS recommendations and/or practice interventional audiology. First, HCPs would be wise to find ways to quickly and effectively identify help-seeking patients who may be in the pre-contemplation stage of change. Some of the key tactics for identifying these patients are listed in the sidebar. Second, rather than attempt to convince pre-contemplators—even those with significant hearing loss—into a trial with hearing aids, offer an alternative solution. These solutions could include a high-quality vetted assistive listening or PSAP-like device, communication tips, aural rehabilitation, or support groups.
Further, there is some evidence suggesting help-seekers who refuse hearing aids may benefit from the use of a smartphone-based app to improve their overall attitude and outlook towards hearing aids.16,17 This would have the added benefit of speeding their progression to the action stage of change. Additionally, hearing care professionals could charge a fee for the various types of service they offer patients, depending on the scale and scope of each intervention.
The practice of interventional audiology in the clinic, one that moves away from the exclusive use of the biomedical model and embraces the Life Course Health Development approach, begins with conducting a functional communication assessment on all help-seekers. Rather than conducting the usual and customary hearing aid evaluation, which by its very nature suggests the patient has the binary choice of using hearing aids or nothing, the functional communication assessment (FCA) places the emphasis on the immediate needs and desires of the patient. Moreover, the goals of the FCA are to assess the day-to-day functional ability of the patient by conducting speech in noise tests, validated subjective communication assessments, as well as screenings of cognitive and fine motor (haptic) ability.
In addition to a standard set of measures of functional communication ability, a substantial part of the FCA must be a thorough assessment of the individual’s Stage of Change. When HCPs look beyond their traditional clinic-based testing and hearing aid fitting approach, new interventions valued by a large swath of patients with unmet needs are likely to be uncovered. As HCPs find their way in the consumer-driven, integrated healthcare system, interventional audiology is likely to become a guiding principle of our profession.
National Academy of an Aging Society. 2007 Report: Aging Baby Boomers. Available at: http://www.agingsociety.org/agingsociety/publications/public_policy/cqboomers.pdf
National Academy of Science. Hearing Health Care for Adults: Priorities for Improving Access and Affordability. June 2, 2016. Available at: http://www.nationalacademies.org/hmd/Reports/2016/Hearing-Health-Care-for-Adults.aspx
Laplante-Lévesque A, Hickson L, Worrall L. Factors influencing rehabilitation decisions of adults with acquired hearing impairment. Intl J Audiol. 2012;49(7):497-507.
Grenness C. The nature of communication throughout diagnosis and management planning in initial audiologic rehabilitation consultation. J Am Acad Audiol. 2015;26:36-50.
Oyler AL. Untreated Hearing Loss in Adults—A Growing National Epidemic. January 2012. Available at: http://www.asha.org/Aud/Articles/Untreated-Hearing-Loss-in-Adults
Davis A, McMahon CM, Pichora-Fuller KM, Russ S, Lin F, Olusanya BO, Chadha S, Tremblay KL (2016) Aging and hearing health: The life-course approach. Gerontol. 2016;56(Apr)[Suppl 2]:S56-S67.
Halfon N, Larson K, Lu M, Tullis E, Russ S. Lifecourse health development: Past, present and future. Maternal & Child Health Jour. 2014;18:344-365.
Palmer C. Interventional audiology: When is it time to move out of the booth? September 14, 2014. Available at: http://www.audiologyonline.com/articles/interventional-audiology-when-it-time-15226
Sanju HK, Kumar P. Annual audiological evaluations should be mandatory for patients with diabetes. Hearing Review. 2016;23(1)[Jan]:14. Available at: http://www.hearingreview.com/2015/12/annual-audiological-evaluations-mandatory-patients-diabete
Chasin M. A temporary hearing loss test app. Hearing Review. 2016;23(6)[June]:32. Available at: http://www.hearingreview.com/2016/05/temporary-hearing-loss-test-app
Zitelli L, Palmer C. An example of interventional audiology in an inter-professional post-trauma clinic. Audiology Practices. 2015;7(3):8-15.
Laplante-Levesque A. Stages of change in adults with acquired hearing impairment seeking help for the first time: application of the transtheoretical stages of change in audiological rehabilitation. Ear Hear. 2013;34:447-457.
Ekberg K, Grenness C, Hickson L. Application of the transtheoretical model of behavior change for identifying older clients’ readiness for hearing rehabilitation during history-taking in audiology appointments. Int J Audiol. 2016. In press. Available at: http://www.tandfonline.com/doi/full/10.3109/14992027.2015.1136080
Ridgway J, Hickson L, Lind C. Decision-making and outcome of hearing help seekers: a self-determination theory perspective. Int J Audiol. 2016;55[Suppl 3]:S13-22. Available at: http://www.ncbi.nlm.nih.gov/pubmed/26750770
Taylor B, Tysoe B. Forming strategic alliances with primary care medicine: interventional audiology in practice: How to leverage peer-reviewed health science to build a physician referral base. Hearing Review. 2014;21(7):22-27. Available at: http://www.hearingreview.com/2014/11/interventional-audiology-part-3-changes-primary-care-health-belief-systems-opportunities-hearing-healthcare
Amlani A. Improving patient compliance to hearing healthcare services and treatment through self-efficacy and smartphone applications. Hearing Review. 2015;21(2):16.
Amlani A, et al. Effectiveness of smartphone-based hearing-aid applications to change attitudes in impaired listeners about amplification and hearing loss. Poster presented at: Annual meeting of the American Academy of Audiology. April 2016: Phoenix, Ariz.
Brian Taylor, AuD, is senior director of clinical affairs at Turtle Beach Corp, San Diego, and serves as a clinical advisor for Fuel Medical Group in Portland, Ore.
Correspondence to Dr Taylor at: [email protected]
Original citation for this article: Taylor B. Interventional Audiology Services: Intervening in the Care of More Patients: Beyond Clinic-based Testing and Fitting. Hearing Review. 2016;23(10):20.?
Other Articles in This Special Edition about Interventional Audiology Services:
Introduction: Interventional Audiology Services: Meeting the Demands of Today’s Consumer, by Brian Taylor, AuD, Guest Editor
What Hearing Care Professionals Need to Know About Today’s Healthcare Economics, By John Bakke, MD, MBA
Intervening in the Care of More Patients: Beyond Clinic-based Testing and Fitting, by Brian Taylor, AuD
Incorporating Health Literacy into Your Hearing Care Practice, by Jennifer Gilligan, AuD, and Barbara E. Weinstein, PhD
Patient Complexity and Professional Time: Improving Efficiencies in the Service Model, by Dan Quall, MS, and Brian Taylor
Thinking Outside the Booth: Three Overlapping Categories of University Audiology Outreach, By Melanie Buhr-Lawler, AuD
Image credits: © Rafael Ben-ari | Dreamstime.com