The demographics of the aging population in the United States are changing rapidly. In 2008, an estimated 37 million people, 13% of the U.S. population, was 65 years of age and older. By 2030, it is projected that number will rise to approximately 71.5 million people, or 20% of the U.S. population. The fastest growing segment of the U.S. population is people over 85 years of age, also known as the "oldest-old" (Roberts & Gross, 2008). At any point in time, approximately 5% of the U.S. population resides in a nursing home (Weinstein, 2000). The number of nursing home residents is expected to double over the next 30 years and, by 2040, will exceed 5 million in number (Ouslander, Osterweil, & Morley, 1991).
According to the 2003 ASHA Omnibus Survey, only 2 % of audiologists provide services in nursing homes (Janota, 2004). This is despite the fact that audiology services can be provided effectively and efficiently to the nursing home population. The key for success is to provide integrated and consistent services in a professional manner. Possible enhancement of reimbursement for audiology services delivered in nursing homes may happen over the next several decades as the aging demographics in the United States change. In the future, it may become more financially feasible to provide hearing health care services to this critically underserved population.
The incidence of hearing loss in nursing home residents has been reported to range from 70% - 80%, as compared to 50% - 60% of community-based elders (Show & Nerbonne, 1980). There are several possible reasons for the high incidence of hearing loss in the nursing home population. Many frail, elderly, people tend to have hearing problems as well as other medical conditions. There are also higher identification rates in nursing homes due to the mandatory comprehensive assessments that must be conducted on each resident.
Weinstein (2000) noted that 50% of nursing home residents have cognitive impairments, such as dementia. Weinstein and Amsel (1986) reported a relationship between hearing loss and dementia. They found that hearing loss tends to be more severe in nursing home residents and, the more severe the hearing loss, the more likely the resident is to have dementia. Identification of hearing loss is critical in this population, as undetected and untreated hearing loss can mimic dementia, and other cognitive impairments, and reduce the resident's quality of life.
Specific goals have been established for the care of nursing home patients. The Omnibus Budget Reconciliation Act of 1987 specifies that "all persons living in a nursing home setting should receive or have access to comprehensive and integrated services for the purpose of attaining and maintaining the highest practical level of physical, mental and psychosocial well-being" (OBRA, 1987). OBRA (1987) also specifies that, at all times, there must be a focus on maintaining the resident's functional autonomy, quality of life, comfort, and dignity.
Patient Assessment
In order for a nursing facility to be eligible for Medicare funding, the staff must conduct comprehensive assessments of each resident. Such assessments must be completed on a schedule that includes multiple evaluations: the first upon admission to the facility, then quarterly for the first year, and annually thereafter. A resident also must be assessed when there is a significant change in status, or if the staff identifies a significant error in a prior assessment (OBRA, 1987).
The Resident Assessment Instrument (RAI) consists of two multidimensional assessments known as the Minimum Data Set (MDS) and the Resident Assessment Protocols (RAPs). The MDS contains two questions related to hearing loss under the Communication/Hearing Patterns heading: staff is asked to rate the residents hearing ability (with a hearing apparatus, if used), and to note whether the resident has and uses a hearing aid. The assessment of the resident over the first 14 days is coordinated by a registered nurse. The RAPs is designed to guide the nursing staff in the identification of rehabilitation goals and the development of resident care plans.
The MDS is a useful tool for the identification of patients who use amplification, or who should be referred for a hearing screen. Due to time constraints, the MDS is not typically completed by an audiologist. It is usually completed by a speech-language pathologist or registered nurse in the facility. Upon identification of a resident in need of audiology services, the audiologist should be contacted to determine the course of action.
The majority of services that can be provided in an outpatient audiology facility also can be offered to nursing home residents in their residential facilities. While more convenient for the patient, the audiologist must be mindful that this is not an ideal situation because, in most instances, there will not be a soundproof booth for testing. The audiologist must also remember that, with this population, some testing procedures may need to be modified due to physical and/or mental impairments. A valid and reliable comprehensive audiological evaluation can be conducted at the nursing facility, as long as the test environment meets the ANSI Standards for Maximum Permissible Ambient Noise Levels for Audiometric Test Rooms (ANSI, 1999). This is more cost effective than having residents transported to an outpatient audiology practice.
Evaluation Procedure
The first component of any audiological evaluation is the case history. The case history for this population can be abbreviated as a great deal of information, such as diagnoses and medications, is available in the resident's chart. The focus of the case history should include balance function, as well as the patient's hearing health, as falls in this population are very common. Individuals at risk for falls due to balance issues should be identified and appropriate referrals made.
Following the case history, an otoscopic examination should be performed. Impacted or excessive cerumen is a large issue in nursing homes, and can significantly impact the timeliness of hearing health care services. If the audiologist plans to see a large number of residents in a facility, then it may be productive to conduct an otoscopic examination on every resident. If a large number of residents are identified with excessive or impacted cerumen, a protocol can be put into place for removal prior to the initiation of audiology services.
Comprehensive audiologic evaluations should include air and bone conduction threshold testing. Speech audiometric testing is highly recommended. Tympanometry can be done using a portable device if an air-bone gap is present, or if there is a history of middle ear involvement. Whenever feasible, a hearing handicap scale should be administered. There are several hearing handicap scales that have been developed for the nursing home population, including the Nursing Home Hearing Handicap Index (NHHI): Self Version for Resident, and an accompanying scale for staff, Nursing Home Hearing Handicap Index (NHHI): Staff Version (Schow & Nerbonne, 1977). The results from a hearing handicap scale can yield information about the patient's perception of the impact of hearing loss on daily activities. If the resident reports a significant handicap, then there is a greater likelihood that auditory rehabilitation will be recommended. Nursing home staff who are very familiar with the communication style of the resident can also complete a hearing handicap scale. The results of the hearing handicap scales can provide important information on how others perceive the resident's hearing loss, and the need for audiologic intervention.
Once it is decided that a resident may be a successful hearing aid candidate, the hearing aid selection and verification process should begin. Hearing aid selection must take into account both the physical and cognitive abilities of the resident. The best advice is to keep the hearing instruments as simple and automatic as possible, while being fiscally conservative. The complexity of the hearing devices that are recommended will depend on a variety of issues. For some individuals, it may be feasible to recommend an assistive listening device in lieu of hearing aids, especially if auditory processing problems are suspected. Although there are numerous advantages to bilateral fittings, it may be more advantageous, when working with certain members of this complex population, to recommend one hearing aid. This may keep costs reasonable while contributing to the resident's ability to be a more independent hearing aid user. Objective hearing aid verification can be accomplished using real-ear measurements. In addition to real-ear measures, it is recommended that the resident be observed in a variety of informal listening situations with staff and family members.
Tips for Successful Hearing Health Care Service Delivery in Long-Term Care Facilities
The following are some suggestions to help integrate comprehensive audiology services into a long-term care facility.
Understand the organizational structure of the facility. It is critical to have a professional relationship with the medical director, nursing home administrator, and the director of nursing. These professionals are responsible for the development and implementation of policies and procedures for the facility. Obtain an organizational chart for the facility and get to know the key professionals, as they will be excellent sources for referrals.
Work in tandem with the staff of the rehabilitation department. Members of the rehabilitation team may include speech-language pathologists, physical therapists, occupational therapists, and physiatrists. These professionals are excellent sources for referrals, and can assist with hearing aid follow-up, as they typically have regular contact with the residents. These therapists can benefit from communication tips to work more effectively with patients who are having communication breakdowns due to hearing loss. In addition, many therapists and nursing staff would welcome using an assistive listening device, such as the Pocketalker, during the therapy sessions to reduce vocal abuse and maintain patient confidentiality.
Provide ongoing staff training about hearing health care. It is highly recommended that there be consistent and ongoing opportunities for educating the nursing facility staff about hearing loss and audiology services. With each hearing aid dispensing, the audiologist should conduct an individual hearing aid orientation for that resident's nursing staff and family members. Staff turnover tends to be very high in nursing facilities, so it is critical that each new staff member receive a hearing aid orientation. According to ASHA Guidelines for Audiology Service Delivery in Nursing Homes (ASHA, 1997), the following are topics for an effective in-service training:
- Overview of age related hearing loss
- Psychosocial effects of hearing loss on quality of life
- Types and styles of hearing aids;hearing aid components
- Realistic expectations for hearing aids
- Basic troubleshooting techniques
- Benefits of speechreading and communication strategies
- Procedures to report lost or damaged hearing aids
It is advisable to demonstrate how to use and care for the hearing aid on a resident, or show a videotape of a resident using a hearing aid. If time permits, have several volunteers practice insertion, removal, and manipulation of the hearing aid controls. It is also recommended that, when visiting the facility, a "spot-check" be conducted on residents who are not independent hearing aid users to see if their hearing aids are inserted and working properly.
Refer to other professionals in the facility. When necessary, refer residents for other professional services. This will have a twofold benefit of building relationships between the audiologist and other professionals on staff, as well as the resident benefiting from needed services. An example would be to refer the resident for an optometry evaluation if vision problems make hearing aid use challenging or makes speechreading difficult. Dual sensory loss is common in this population, and residents may benefit from the services of a low vision specialist. A referral to occupational therapy may be warranted if the resident has the potential to be an independent hearing aid user. The occupational therapist can work with the resident on hearing aid use as an Activity of Daily Living (ADL), and may be reimbursed for such services. The audiologist should attend at least one patient care planning meeting, especially if hearing loss is having a significant impact on a patient's care.
Establish a formal contract with the facility. A formal contract with the nursing facility is recommended. The contract should address, in detail, all policies and procedures related to hearing health care services. A description of services and their associated costs also should be included in the contract. Terms of severance of the business relationship should be specified. The contract should be reviewed and revised on an annual basis, more frequently if necessary. The staff of the facility will be more likely to comply with the audiology policies and procedures if there is a written contract in place. The following are some areas that should be included in the contract.
Referral for audiology services
This section should focus on defining the primary referral sources. This is necessary in order to be reimbursed by some third parties, such as Medicare and Medicaid. There also should be a staff member assigned to complete the Minimum Data Set (MDS) if the audiologist is not available. Information on how the audiologist will be notified if a resident needs services should be included as part of the formal contract. Whenever possible, it is recommended that there be one coordinating professional for referral such as the director of nursing.
Cerumen management
Given the high incidence of excessive or impacted cerumen in this population, it is critical that a protocol be established for cerumen management. The audiologist should have extensive experience in removing cerumen from medically-complex patients. If the audiologist is not comfortable with cerumen management then arrangements should be made for medical personnel in the facility to be responsible for this task.
Location of testing
The testing location should be consistent for each visit to the facility. The contract should stipulate where the testing will take place and an acceptable alternative site if the primary location is not available. The facility should make every attempt to ensure that the surrounding areas are as quiet as possible.
Transportation to testing location
The contract should specify the party responsible for transporting the residents to the testing location. The audiologist should negotiate with the staff to have the transportation service take the residents to and from the testing site whenever possible. This will expedite the testing process so that more time can be spent counseling residents and their families.
Documentation of services in chart
The type of documentation required and its location in the patients' charts should be identified. Documentation is critical for resident auditing: for accreditation purposes and reimbursement of services. It is best to specify the type of documentation necessary for each patient and where it will be located. This will help the staff to locate any pertinent information in the audiologist's absence.
Accountability for loss of hearing aids or assistive listening devices
The contract should identify who will be held accountable if the resident's hearing aids or assistive listening devices are lost. In some facilities, the nursing staff is held accountable while, in others, the patient is the responsible party. This becomes an important issue when a family questions the loss of or damage to a hearing aid or assistive listening device. An extended warranty is highly recommended for each hearing aid, as loss and damage is a significant issue for this population.
Fees for services
The contract must contain information about billing procedures, such as who will be responsible for billing third party payers. The facility's billing staff should be aware of the pricing structure for audiology services so they can respond to any inquiries. A pricing list should be included as an appendix to the audiologist's contract. Prior to providing services, the audiologist must ensure that the resident or the individual who holds Power of Attorney has signed a release for service provision.
In-service training
The type and frequency of in-service training for the staff should be stipulated. Any associated fee should be listed in the contract.
Summary
Audiology services can be delivered in a cost-effective manner to older adults in long-term care facilities. Audiologists need to consider providing services in settings outside of the office or hospital, such as retirement communities, assisted living facilities, adult day care facilities, and senior centers. The keys to success are integrating hearing health care services into the facility in a consistent and professional manner. Along with the audiologist, the staff and family are essential to successful hearing health care service provision. The diagnosis and management of hearing loss will improve the resident's functional independence and quality of life. The audiologist who works with this challenging population can achieve professional satisfaction and financial success.
References
American National Standards Institute (1999). Maximum permissible ambient noise levels for audiometric test rooms (ANSI S3.1-1999). New York: Author
American Speech-Language-Hearing Association (1997a). Guideline for audiology service delivery in nursing homes. American Speech-Language-Hearing Association, 39 (Suppl. 17), 15-29.
Janota, J. (2004, March 30). Audiology data show trends. The ASHA Leader, 24-25.
Omnibus Budget Reconciliation Act (1987). 42 U.S.C.A. § 1396 (Supplement 1989).
Ouslander, J., Osterweil, D., & Morley, J. (1991). Medical Care in the Nursing Home. New York: McGraw-Hill.
Roberts, S. & Gross, J. (2008, October 2). New census data: Aging America. Posted to NY Times New old age - caring and coping blog, archived at newoldage.blogs.nytimes.com/
Schow, R. & Nerbonne, M.A.(1977). Assessment of hearing handicaps by nursing home residents and staff. Journal of the Academy of Rehabilitative Audiology, 10, 2 -12.
Schow, R.L. & Nerbonne, M.A. (1980). Hearing level among nursing home residents. Journal of Speech and Hearing Research, 45, 124-132.
Weinstein, B. (2000). Geriatric Audiology. New York: Thieme.
Weinstein, B. & Amsel, L. (1986). Hearing loss and senile dementia in the institutionalized elderly. Clinical Gerontologist, 4, 3-15.
