20Q: Audiological Rehabilitation - Back to the Future

From the Desk of Gus Mueller

Today, when thinking about the overall hearing aid fitting process and attempting to follow best practice, we have guidelines from all the major audiology organizations, and a standard soon will be available from the Audiology Practice Standards Organization (APSO). But let’s go back to the beginning, 75 years ago, when Captain Raymond Carhart published his protocol, which had been used successfully for several years for military personnel at Deshon General Hospital in Butler Pennsylvania.

Carhart stated three specific goals: 1) To secure for each patient a hearing aid having optimal efficiency in everyday situations; 2) To give the patient an understanding of hearing aids, establish habits of efficient use and initiate auricular training; and, 3) To foster in the patient a full psychological acceptance of hearing aids.

Note that Carhart’s goals were heavily weighted toward what today we would call “audiologic rehabilitation.” It seems that over the years, however, our focus toward the hearing aid fitting process has shifted more toward the devices themselves, rather than the patient’s successful use of these devices. But what happens when these devices come from Aisle 7 of the neighborhood Big Box store?  What then is the role of the audiologist?

To remind us of the importance of audiologic rehabilitation, we’ve brought in one of leaders in this area for this month’s 20Q, Joseph Montano, PhD. Dr. Montano is internationally known as co-editor of the best-selling book on this topic, Adult Audiologic Rehabilitation, now in its 3^rd Edition from Plural Publishing.  

Dr. Montano is Professor of Audiology and Director of Hearing and Speech at Weill Cornell Medicine, New York City. He is a fellow of the American Speech-Language Hearing Association (ASHA), and has served as the ASHA Vice President for Standards/Ethics in Audiology. He also is a Past President of the Academy of Rehabilitative Audiology and holds Honors of the New York State Speech Language Hearing Association (NYSSLHA). His numerous awards include recipient of the ASHA New York State Clinical Achievement Award and the Nitchie Award for Adult Aural Rehabilitation from the League for the Hard of Hearing.

In his 20Q article, Joe addresses several areas to consider regarding today’s AR services, and sums up his hopes for the future as follows:  “. . . the hearing aid will no longer be the focus of our practices but rather just another tool in the arsenal we already have to help patients manage their hearing loss . . . we will begin to shift our focus back to the communication needs of our patients through the provision of counseling, therapies and group interventions”. I’m pretty sure that Captain Carhart would agree.

Gus Mueller, PhD
Contributing Editor

Browse the complete collection of 20Q with Gus Mueller CEU articles at www.audiologyonline.com/20Q

20Q: Audiological Rehabilitation - Back to the Future

Learning Outcomes 

After reading this article, professionals will be able to:

1. Discuss the implementation of audiological rehabilitation (AR) in audiology clinical practice
2. Identify ways to include family members in the AR process
3. Identify resources for group AR intervention in practice

   Joseph Montano

1. Do you think audiologic rehabilitation should be an important component of most audiology practices?

Audiologic rehabilitation (AR) most definitely is the foundation and background of audiology. However, issues exist when attempting to implement AR in practice. One of the major factors is trying to identify the meaning of the term AR. While we may acknowledge its importance and advocate its use, how AR is defined can be misunderstood and difficult to implement. There have been numerous definitions of AR over the years, some stressing fundamental aspects of therapeutic intervention such as speechreading and auditory training while others focused on the psycho-social impact of hearing loss and counseling. McCarthy and Alpiner (2021) looked back on the history of AR, its roots, and its influence in the creation of the audiology profession. One of the questions they address is the specific terminology. Historically, AR was referred to as aural rehabilitation and performed by speech-language pathologists. Ross (1997) described the aural rehabilitation services he received as an in-patient with hearing loss at the U.S. Army Walter Reed Hospital in 1952. He attended a program of therapeutic intervention for eight hours per day for eight weeks. The aural rehabilitation staff consisted of acoustic technicians, lipreading instructors, auditory training instructors, speech correctionists, psychologists and social workers, and operated through the Department of Otolaryngology. Ross believed as audiology developed as a profession, it took on an increased diagnostic role and there was a decline in AR services provided by audiologists. While AR is included in the scope of practices for both speech-language pathologists (SLP) and audiologists, the SLP tended to take the lead in AR service provision. So while it is important that AR be a part of audiology practice, we need to have a sense of what that really means.

2. Since both audiologists and speech-language pathologists provide AR services, how do their roles differ?

In 1984, ASHA published a paper on the competencies necessary to provide services in aural rehabilitation. While it did acknowledge that both professions (SLPs and audiologists) were designated to provide AR services as specified in their scopes, the paper did not delineate any distinction between the two professions. It merely provided the academic background necessary to achieve competency in therapeutic delivery and provided a general definition of the term. It was not until 2001 that the roles of SLPs and audiologists in the provision of AR services were delineated. ASHA (2001) published the AR skills and knowledge paper developed by an ad hoc committee on audiological rehabilitation. The committee was comprised of both audiologists and speech-language pathologists. The paper was designed in such a way that each profession had designated sections; Skills and Knowledge for audiologists necessary to provide AR services and the same for Speech-Language Pathologists. For example, the document states that SLPs can identify the need and refer to an audiologist for evaluation and fitting of personal and group amplification systems and sensory aids, while audiologists conduct appropriate fittings with and adjustments of these devices and technologies.

3. How has the definition of AR changed over the years?

As you read the literature regarding the evolution of the definition of AR over the years, the most obvious change is conceptual. Early definitions stressed the clinical provision of service. They were task-specific and often stressing services to individuals with severe to profound hearing loss, focusing more on deafness than perhaps milder levels of hearing loss. Later definitions began to focus on the impact of hearing loss on function and included more aspects of the psycho-social elements of hearing loss and its impact on an individual’s functioning ability in daily life.

The World Health Organization published a landmark paper in 2001 on International Classification of Function, Disability and Health (ICF).  Most of the AR definitions published following the WHO’s 2001 paper included concepts highlighted in the ICF report. Primarily, an important element was the break from considering hearing loss as a disease and rather, viewing it as a health condition that may limit activities and restrict participation in society. Relating the ICF paper to hearing loss allows us to focus our AR on what a person with an impairment can do or is capable of doing rather than their disability. Some recent definitions even use specific terminology from the ICF such as “activity limitations” and “participation restrictions” instead of disability and handicap when referring to an individual functioning with hearing loss.

4. Is there a definition of AR that you personally prefer?

My AR definition, recently published in the 3^rd edition of a book I authored with Jaci Spitzer, is influenced by the WHO ICF paper and stresses certain concepts pivotal to managing hearing loss. “AR is a family-centered approach to assessment and management of hearing loss that encourages the creation of a therapeutic environment conducive to a shared decision process, which is necessary to explore and reduce the impact of hearing loss on communication, activities, and participation” (Montano, 2021, p. 27).  The definition stresses the practice of family-centered care and focuses its emphasis on improving communication function within the context of communication environments; this is similar in many ways to the concepts guiding the WHO’s International Classification of Function.

5. While most audiologists acknowledge the importance of counseling, there often is not time on the schedule to allow for this. Can you address this?

The importance of counseling in audiology is both my belief and the rule that guides my practice. While I may have an academic title, I am a working clinician seeing a full caseload of patients in our Cornell faculty practice. I take a counseling approach with every patient. Ordinarily, my patients have already had diagnostic testing performed either in my facility or by an outside audiologist. The concept of performing a counseling-based audiologic consultation is really a matter of shifting of the emphasis of the meeting from an audiologist talking about an audiogram, to a patient talking about his or her hearing loss. In fact, unless my patient requests an explanation of his/her audiogram, I do not even discuss it. Instead, I use open-ended questions to elicit the patient’s story and work with the individual and family to figure out the best possible solutions to the communication issues they have identified. A counselor, therefore, is more of a listener rather than a talker. It is important for audiologists to reject the techno-centric model of service delivery (Montano, 2012).

I have heard many audiologists report they are limited by time constraints and counseling frequently cannot be performed. My response is always the same, counseling does not require additional time in your schedule, it requires a different emphasis on how you manage the time. To me, it is far more important to learn the patient story than it is to talk about the audiogram.

6. What do you mean by techno-centric?

By techno-centric, I am saying that the services we provide focus primarily on technology. We tend to put our emphasis on the devices such as hearing aids and their accessories rather than on the hearing loss, thereby minimizing our counseling and treatment focus. Instead, it should be the patient and family that is the focus of our treatment with technology being one of the possible solutions to some communication issues. As most audiologists will agree, the hearing aid (or other amplification) alone will not solve all of life’s communication problems. As reported in a qualitative study by Grenness and colleagues (2014), when patients work with an audiologist, technical competence is assumed but interpersonal relationships are valued.

7. It seems you are implying that the actual audiology service delivery system interferes with audiologic counseling?

Many times it does. Erdman, Wark and I (1994) reported on the service delivery models in audiology. Frequently, audiologists assume a medical model of service delivery, meaning, it becomes a top-down curative process as though we want to rid the person of his/her hearing loss. The authors advocated for a rehabilitative model that would be a more horizontal process where the patient becomes an equal partner in the treatment process. Erdman (2021) refers to this rehabilitation model as a biopsychosocial service delivery, which embraces counseling.

8. Earlier you mentioned family-centered care. Don’t we all already do this?

I happen to agree with your assumption that indeed most audiologists believe they perform family-centered care (FCC) in their practice. However, the literature seems to suggest otherwise. Ekberg, Schuetz, Timmer, & Hickson (2020) have demonstrated that while most audiologists acknowledge the importance of FCC, there are few who have incorporated it into the daily function of their practices.

9. Maybe then I need to know how you define family-centered care?

FCC is an invitation to patients and their families to participate in the management of a person’s hearing loss. As I have heard my friend Dr. Sam Trychin, a noted psychologist with severe hearing loss, say, “It is not a hearing loss, it is a communication loss.” By family, I mean anyone a person with hearing loss invites to participate in his/her care; that might be a communication partner, spouse, child, sibling or friend.  Together, the audiologist, person with hearing loss and communication partner, form a therapeutic relationship that allows for the development of shared decision goals. The inclusion of family in medical treatments increases positive outcomes (Rathert, Wyrwich, & Boren, 2013) and even improves satisfaction with and uptake of amplification (Singh & Launer, 2016). My therapeutic interactions take place in a comfortable environment that welcomes family to participate in the process. There is room at the table for all and I do not sit behind a desk. Rather, we sit together around a table as equals. This seating sends a message that we are equal partners in this process. What message do you think we send when we wear a white lab coat and sit behind a huge desk? All you need to do is think back to that medical model I mentioned earlier.

10. What components of family-centered care do you think can be easily integrated into the average audiology practice?

Singh, Hickson, English and colleagues (2016) published a practical article that described FCC, gave it a definition and listed steps toward implementation in audiology practices. I would emphasize that, in order for a practice to adopt an FCC approach, it requires a buy-in from the entire staff including appointment clerks, secretaries and all audiologists. The first and arguably the most important step is to invite families to participate in the first place. This is accomplished easily by including the invitation with every scheduled appointment. This is a welcoming gesture and sends a positive message to the patient.  Ultimately, it is the patient’s decision to include family in the rehabilitation process but without an invitation they may not have considered it at all. Once scheduled, it is critical that the environment be welcoming and that family is welcomed “to the table”. There can be nothing more counter-productive than to invite family to a rehabilitation session and leave them in the waiting area while the audiologist meets with the patient. The basis of FCC is that rehabilitation goals will be decided together as a team. Inclusion of family does not end with the initial consultation, but rather is encouraged for all the subsequent AR meetings.

11. What about the current pandemic? Many practices are limiting the number of people who can attend an audiology session.

Our practices have certainly changed a great deal in the last year. We have been struggling to re-invent ourselves and modify our practices to allow for safe treatment options with social distancing and proper infection control. Perhaps there is no patient population that has been more affected by use of face masks than people with hearing loss. The distortion of speech and lack of visual cues have made communication particularly difficult for our patient base. Here at Cornell, we actually have a policy that restricts the patients from bringing an accompanying person to medical appointments if they are capable of participating independently. This policy can certainly restrict our efforts to include family in the AR process.

If I have to find a positive aspect to the pandemic, it is the fact that audiologists have now begun to embrace telepractice. They are holding Zoom appointments and using manufacturers' distance support software to program or adjust hearing aids. I have found that the use of video visits has actually helped in the provision of FCC. I recently had an elderly patient whose son lives in Virginia and was able to participate in all her hearing related appointments. In fact, this particular patient had rejected the use of hearing aids in the past, but having her son encouraging her during the appointment resulted in her finally accepting hearing aids and wearing them on a daily basis. The use of Zoom, or even FaceTime or Skype, can allow family participants who would not ordinarily be able to participate in their loved one’s treatment because of distance, work responsibilities or even illness to be a part of the rehabilitation process.

12. Aren’t there issues regarding reimbursement for audiologists providing AR services?

Reimbursement has always been a problem for audiologists. As a health care field, audiology is classified as a diagnostic profession. As a result, the provision of audiologic rehabilitation, being a treatment service, is for the most part, non-reimbursable. Speech-language pathologists, who are classified as both diagnostic and rehabilitative professions, can be reimbursed for AR. There has been a major push in recent years for this to change, but it requires legislative action that can take many years to achieve.

There has been a great deal of work in this area and now, as the American Academy of Audiology, The American Speech-Language Hearing Association and the Academy of Doctors of Audiology have begun working together on legislative efforts, I am beginning to feel some optimism for a change in future reimbursement for AR for audiologists.

13. How can audiologists provide AR services without third-party reimbursement?

It certainly would be great if third party reimbursement for AR could be available to audiologists. This however, does not mean that we cannot charge directly for the services. Still today, the most common model for hearing aid dispensing is bundling all services with the cost of the hearing aid. As a result, the patient believes they are paying for the hearing aids and thereby undervalues the services that audiologists perform. Many audiologists are already providing AR built into the hearing aid process. The ongoing counseling, training and support are all important components of the process. The problem is, patients do not realize that these services have value.

14. This sounds like you are recommending that we unbundle audiologic services?

Yes. I certainly acknowledge how difficult it is to shift from a bundled to an unbundled model of hearing aid dispensing. I am sure many audiologists experience it every day; a patient offers to pay for a follow-up appointment even though it was included in the cost of the hearing aid. That, of course, is determined by the professionalism of the practice. If a patient believes they are going to a store to buy a product, like perhaps the big box store model, they do not expect to pay for the service. However, when the patient believes they are receiving professional services, the value is increased. Many audiologists have begun itemizing the services they provide which then allows patients to have a better understanding of the process and cost.

15. How do you think this will be impacted by over–the-counter (OTC) hearing aids?

OTC hearing aids have been the talk of audiology non-stop for the past several years. I have never felt threatened by the push for new methods of hearing aid distribution; in fact, I see it as a great opportunity for audiologists and audiology. I am sure you all remember the report from the National Academy of Science, Engineering and Medicine (NASEM) in 2016 that lead to the OTC legislation in 2017. Recommendations from that report included increased insurance coverage for hearing aids and that Medicare should increase access to assessment for and delivery of (AR) including reimbursement for audiologists. This is our invitation and opportunity to distinguish ourselves from those who “sell” hearing aids to those who provide rehabilitation and management of hearing loss. My advice is to embrace the new avenues for amplification and provide the services that make us audiologists.

16. If I want to begin to offer some AR services, where should I start? 

I believe that most audiologists are already providing some form of AR. Certainly, counseling is a huge part of everything we do. I always say that counseling begins the moment we greet our patient in the waiting room and the relationship starts when the first appointment is booked. I still think that many people consider traditional therapeutic interventions like speechreading and auditory training as AR. While some may offer these services, it certainly is the minority of providers. Frequently patients are referred to online training programs like clEAR (Tye-Murray, Spehar, Sommers, & Barcroft, 2016) and LACE (Sweetow & Sabes, 2006). Research in the areas of auditory training and speechreading is not very strong and there is a lack of evidence and outcomes. However, group AR intervention has been shown to improve outcomes and has evidenced-based research to support its implementation (Hawkins, 2005; Chisolm & Arnold, 2012).

17. Most of us do not have any experience offering group therapy, where can we obtain resources?

There are many resources available to audiologists that can help with the creation and implementation of group AR. The Active Communication Education program (ACE; Hickson, Worrall, & Scarinci, 2007) is an evidence-based group treatment program that is available free through the University of Queensland, Australia. Audiologists can have access to strategies and actual lesson plans for administering the program. Another excellent resource available, also free, is on the Ida Institute website (idainstitute.com). They established a program referred to by the acronym GROUP that stands for "group rehabilitation online utility pack". GROUP allows users access to videos, sample lessons and suggestions for short or lengthy group programs. While most audiologists are apprehensive about running groups, one only has to try it to experience how rewarding it can be for patients, families, and providers. When we provide group AR at Cornell, our feedback is always positive and frequently results in word of mouth referrals.

18. How do you implement groups in your facility?

At Cornell, we use the ACE evidenced-base group AR program as the basis for our service. We advertise in our building lobby and office areas and keep a list of patients who have expressed interest in participation. We refer to it as a communication group and not a hearing aid group. Participants do not have to be hearing aid users nor even existing patients at Cornell. We do, in fact, charge for participating in the AR group, and it is not included in the price of the hearing aids. While the charge is minimal, it adds value to the service. We offer the program twice a year one evening a week for five weeks. Just recently, during the COVID, we held a well-received Zoom AR group. Our patients are always encouraged to bring a communication partner to all meetings. Prior to COVID restrictions, we held the meeting in our conference room and participants sat in a circle. Every week we covered a different topic about living with hearing loss.  I refer you to the Ida institute GROUP site for specific suggestions on some activities you can implement.  I have always taken a “field of dreams” attitude on offering group intervention, “If you build it, people will come.” 

19. Do you also include other outside services?        

In my facility, I am fortunate to have both audiologists and speech-language pathologists (SLPs) on my staff. We have the ability to refer to our SLPs when our patients need traditional AR services like speechreading and auditory training. In addition to offering group intervention for our patients with hearing loss, we are fortunate to have a local chapter of the Hearing Loss Association of America (HLAA) nearby. Many of our patients participate in the chapter and are grateful for the peer support they receive at the meetings and on the HLAA website.  

20. Are you optimistic about the future of AR and Audiology?

Most definitely! We currently only reach a small percentage of people with hearing loss who can benefit from our services. As technology increases and more people begin to avail themselves of amplification options, the opportunity to provide audiology care will only increase. What I am most hopeful for is that the hearing aid will no longer be the focus of our practices but rather just another tool in the arsenal we already have to help patients manage their hearing loss. I am hopeful that AR services will soon become a reimbursable treatment option for audiologists and we will begin to shift our focus back to the communication needs of our patients through the provision of counseling, therapies and group interventions. I believe the future is indeed bright and encourage all audiologists to set forth on the AR road.

References

American Speech-Language-Hearing Association. (1984). Definition of and competencies for aural rehabilitation. American Speech-Language-Hearing Association.

American Speech-Language-Hearing Association. (2001). Knowledge and skills required for the practice of audiologic/aural rehabilitation [Knowledge and Skills]. Available from www.asha.org/policy.

Chisolm, T., & Arnold, M. (2012). Evidence about the effectiveness of aural rehabilitation programs for adults. In L.Wong and L. Hickson (Eds), Evidence-based practice in audiology: Evaluating interventions for children and adults with hearing impairment (pp. 237-266). San Diego, CA: Plural Publishing.

Ekberg, K., Schuetz, S., Timmer, B., & Hickson, L. (2020). Identifying barriers and facilitators to implementing family-centred care in adult audiology practices: a COM-B interview study exploing staff perspectives. International Journal of Audiology, 1-11.

Erdman, S.A., Wark, D., & Montano, J.J. (1994). Implications of service delivery models in audiology. Journal of the Academy of Rehabilitative Audiology, 27, 45–60.

Erdman, S.A. (2021). Biopsychosocial approaches to audiologic counseling: patient- person-family, and relationship –centered care. In J.J. Montano & J.B. Spitzer (Eds.), Adult audiologic rehabilitation (pp. 159–206). San Diego, CA: Plural Publishing.

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Hickson, L., Worrall, L., & Scarinci, N. (2007). A randomized controlled trial evaluating the Active Communication Education program for older people with hearing impairment. Ear and Hearing, 28(2), 212-230. doi: 10.1097/AUD.0b013e31803126c8

Ida Institute. (2012). Group rehabilitation online utility pack (GROUP). Available from www.idainstitute.com

McCarthy, P.A., & Alpiner, J.G. (2021). History of adult audiologic rehabilitation: A map for the future. In J.J. Montano and J.B. Spitzer (Eds.), Adult audiologic rehabilitation (3rd ed., pp. 3–22). San Diego, CA: Plural Publishing.

Montano, J.J. (2012). Overdependence on technology in the management of hearing loss. In R. Goldfarb (Ed.), Translational speech-language pathology and audiology. San Diego, CA: Plural Publishing.

Montano, J.J. (2021). Defining audiologic rehabilitation. In J.J. Montano and J.B. Spitzer (Eds.), Adult audiologic rehabilitation (3rd ed., pp. 23-36). San Diego, CA: Plural Publishing.

National Academies of Sciences, Engineering, and Medicine. (2016). Hearing health care for adults: Priorities for improving access and affordability. Washington, DC: The National Academies Press. https://doi.org/10.17226/23446

Rathert, C., Wyrwich, M.D., & Boren, S.A. (2013). Patient-centered care and outcomes: a systematic review of the literature. Med Care Res Rev, 70, 351-379.

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Singh, G., Hickson, L., English, K., Scherpiet, S., Lemke, U.,...Launer, S. (2016). Family-centered adult audiologic care: A Phonak position statement. Hearing Review, 23(4),16.

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Sweetow, R., & Sabes, J. (2006). The need for and development of an adaptive Listening and Communication Enhancement (LACE) Program. Journal of the American Academy of Audiology, 16(7), 494-504.

Tye-Murray, N., Spehar, B., Sommers, M., & Barcroft, J. (2016). Auditory training with frequent communication partners. J Speech Lang Hear Res, 59(4), 871–875. doi: 10.1044/2016_JSLHR-H-15-0171

World Health Organization. (2001). International classification of functioning, disability and health. Geneva, Switzerland: World Health Organization.