Getting Back to Life Clients retreat from the world when hearing aids stay in the drawer. Moving them forward to adoption and social connection often takes ongoing audiologic follow-up, or rehab. But how does an audiologist do this when clients resist and clocks tick? Features
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Features  |   July 01, 2014
Getting Back to Life
Author Notes
  • Dusty Ann Jessen, AuD, is an audiologist for an otolaryngology clinic in Littleton, Colo. She is the founder of Cut to the Chase Communication, LLC, which develops counseling tools for hearing care professionals. info@CutToTheChaseCommunication.com
    Dusty Ann Jessen, AuD, is an audiologist for an otolaryngology clinic in Littleton, Colo. She is the founder of Cut to the Chase Communication, LLC, which develops counseling tools for hearing care professionals. info@CutToTheChaseCommunication.com×
Article Information
Hearing Aids, Cochlear Implants & Assistive Technology / Features
Features   |   July 01, 2014
Getting Back to Life
The ASHA Leader, July 2014, Vol. 19, 36-42. doi:10.1044/leader.FTR1.19072014.36
The ASHA Leader, July 2014, Vol. 19, 36-42. doi:10.1044/leader.FTR1.19072014.36
“Today is the big day! Are you ready for your new hearing aids?” I ask my patient, Sam, with perhaps too much enthusiasm. A polite nod indicates he is. But he shares none of my zeal.
Sam’s reason for being here is more about his wife than about himself: His hearing loss has caused tension between them and she’s pushed him to get hearing aids. At our first appointment two weeks ago, I performed the usual testing. Today I’m doing the fitting and programming. But I’ve barely had a chance to explain how to use them, when I realize our time is up. I hand Sam a packet filled with great information on realistic expectations and effective communication strategies, and dash off to my next appointment.
Two weeks later, at his first follow-up, Sam reports disappointment with his hearing aids. He claims he still can’t hear his wife around the house. I ask if he’s practiced the communication strategies discussed in the packet and he admits that he hasn’t had time to read any of the handouts yet. I attempt to address a few communication strategies as I review how to use and care for the hearing aids.
Over the next three months, Sam expresses continued dissatisfaction with the hearing aids but reluctantly decides to keep them, mainly because his wife will have it no other way. In an effort to ease his frustration, I invite Sam and his wife to attend my group aural rehabilitation class, but the date and time don’t work for them. So I’m not surprised when, six months later, Sam sheepishly admits that he wears his hearing aids only occasionally, and that his hearing loss remains a problem for him and his wife.
As is obvious from this experience, patient success with amplification is unlikely without audiologic, or aural, rehabilitation—education and support to help patients and their families work with hearing loss and adapt to use of hearing aids (“A Whole Lot of Hearing Going On,” March 2014).We know that the hearing aids themselves are only one piece of the rehabilitation puzzle.
Yet how do we make AR work? Clearly, patient education should start right after the initial audiologic evaluation. But as Sam’s example illustrates, we audiologists face many challenges when it comes to audiologic rehab, including lack of time, lack of patient compliance and, at least to some degree, lack of reimbursement.
I have found an approach that works well in the face of such challenges. Twelve years as the director of audiology in a busy otolaryngology practice have given me lots of time to experiment with different AR approaches and develop this unique method that works across patient populations and clinical settings.
Let’s start with three simple components that must be present for AR to be successful.
  • Education. Obviously we must educate our patients about hearing loss, communication strategies and appropriate hearing aid expectations.

  • Action. Patients must take personal responsibility for what they learn by acting on it.

  • Follow-up. Patients simply won’t retain and use everything we teach them for their first several months with hearing aids, so they need regular reminders.

Education
Initially, education seemed to me like the easiest part of this process. Readily available books, handouts and websites provide fantastic consumer education. However, sources tend to provide too much information—to the point that it becomes confusing and overwhelming to the consumer. Today’s patients are busy, distracted and sometimes already overwhelmed by new information about the hearing aids themselves. They’ve been led to believe that hearing aids will fix their communication problems, and they aren’t interested in investing much more time or energy into the process.
So how do we educate today’s patient? It’s simple.
Yes, simplicity is the key to effective patient education. Education should be engaging, efficient and, most of all, simple. Audiologists can certainly create their own simple system that feels comfortable to them. That is exactly what I did last year when I wrote and published my patient guidebook, “Frustrated by Hearing Loss? 5 Keys to Communication Success.”
My book breaks down communication into its five essential components: speaker, listener, environment, technology and practice. It provides a simple framework that helps the patient remember what we’ve talked about. This education should start the first time we meet the patient, and continue throughout each follow-up visit. I make it very clear that the patient and the spouse must read the guidebook before they return (together) for the hearing aid fitting.
Now that we’ve properly educated our patient, our job is done, right? No way! Even simple and efficient education will go in one ear and out the other if we don’t help patients apply it to their own lives. That’s why the action step is so critical.
Action
I’ve found that most patients are concerned only about themselves when it comes to AR. They don’t care much about research findings or what works well for others. They want to know how it will help them. This perspective is the basis for the patient-centered treatment approaches that have become increasingly popular in recent years and also, I believe, why group AR programs aren’t always successful.
Today’s patients feel that they have paid enough money to warrant individual attention, and they want this attention at a time that has been set aside specifically for them. They don’t want to waste valuable time listening to the problems of others. Rather, they want to do what is necessary to address their own problems, and move on with their busy lives. To this end, it is imperative that we help all patients apply what they have learned to their own lives.
At the hearing aid evaluation, I help patients identify their top three challenging listening situations. We then focus on these environments for the remainder of the fitting and follow-up process. Narrowing the challenging situations down to three (or fewer) helps keep everyone on task and provides a structure and purpose for each visit. I require patients to write out an “action plan,” which defines the speaker and listener strategies, environmental modifications, and technology to be used for each challenging situation. I keep a copy in the chart, and the patient takes a copy home to post where he or she will see it every day.
It’s also critical to enlist participation of the patients’ main communication partners. The act of writing out a personalized plan reinforces to patients and their loved ones that communication is like a puzzle. All pieces must be present to ensure a successful communication exchange. I’ve found that this simple and action-oriented approach to patient education reduces the number of costly follow-up visits. Patients who are empowered with the right tools for success don’t rely on the hearing aids or the hearing care provider to fix every problem.
Follow-up
So we’ve properly educated our patients and helped them to apply that education to their own lives. Now our job is done, right? Not quite. Can we really expect our patients to retain everything they’ve learned during the trial period? They must wrap their minds around heaps of information on their new hearing aids: proper insertion and removal, cleaning brushes, wax guards, domes, batteries, indicator tones, volume controls, program buttons, wireless streamers, TV transmitters, and phone clips, to name a few. Even the most engaging, efficient patient education cannot negate the fact that our patients are often overwhelmed.
This enormous amount of information is why it is so critical to implement a long-term follow-up program for each patient. This follow-up should reinforce the information you presented during the education step. It should be consistent in appearance, engaging and, most important, simple. Several companies provide newsletter templates that you can customize with educational tips and mail to patients at regular intervals following their trial period. Some hearing aid manufacturers offer this service as well. I’ve had more success with follow-up emails. Yes, some patients aren’t computer-savvy, but in my experience, this is becoming rare.
Most of my patients, regardless of age, come in sporting smart phones and tablets and busily check e-mail or play games as they wait for appointments. E-mail has become the norm, and I suggest using it to field questions from patients and to schedule and remind them about follow-up appointments. I send out patient “eTips” weekly for an entire year following the hearing aid fitting. These weekly e-mails offer much more than continued education. First, they keep your clinic at the top of patients’ minds (remember, they are bombarded daily by advertisements from your competition). Second, they show patients you are committed to their long-term success.
Implementing a structured, patient-centered aural rehab program is our professional responsibility, and though insurance reimbursement can be challenging and not guaranteed, the good news is that there are billing codes for aural rehab assessment (92626 and 92627) and aural rehab therapy (92630 and 92633; see below for more information).
Lack of reimbursement is truly not an issue when your patients have been well-educated, empowered with a personalized action plan, and receive long-term follow-up. You are “reimbursed” by reduced return rates, increased word-of-mouth referrals, and repeat purchases. I truly believe that a simple, fun and engaging aural rehab program is the key to patient and clinician satisfaction and success.
Sam comes back to see me two weeks after his six-month appointment. Based on a conversation we had at that appointment, he brings his wife with him this time. He now understands that she is equally responsible for making his hearing aids work for both of them. They report that they both read the patient guidebook and have a better understanding of what they must do to address their communication challenges.
We work together on creating a personalized action plan for their communication breakdowns around the house. Sam agrees to wear his hearing aids at home, and to ask his wife to rephrase sentences or words he has missed rather than hastily saying, “What?” His wife agrees to make sure she is face-to-face with Sam before she begins speaking so that he can see her lips. They both agree to turn off the television during meals so that they can talk without that distraction. They promise to post their written action plan on the fridge as a daily reminder to practice the new habits. I keep a copy of their plan in my chart so I know exactly what to address at their one-year follow-up appointment—to keep them accountable.
They leave this appointment 10 minutes early with plenty of time to grab a coffee before their exercise class. As I jot some quick chart notes, I reflect on how pleased I am that Sam and his wife are now equipped to keep Sam’s hearing aids on his ears. I’m confident that I’ll be meeting several of their friends in the near future.

Telepractice for Cochlear Implant Follow-Up? Yes!

Cochlear implantation surgery is only the beginning of a person’s hearing journey, not the end. CI recipients require many follow-up visits after surgery, possibly spanning many years. Clinicians typically conduct medical follow-up and initial processor fitting—called mapping—a week or two after surgery. Patients must return for fine-tuning of CI processors six or more times over the next year.

Some patients also require multiple audiologic (re)habilitation sessions, speech-language treatment and additional processor mapping appointments—not to mention yearly visits thereafter. Many have to travel long distances, which can be burdensome for their families. In response, researchers have investigated telepractice’s feasibility for providing remote, clinical CI services.

Initial studies, which focused only on processor programming for adults, found that the maps were generally similar for remote versus traditional in-person methods. More recently, our laboratory evaluated the use of remote technology to provide clinical services beyond processor programming in a relatively large group of CI recipients that included adults and children.

Remote testing of individual electrode function, physiological measures of the auditory nerve, and perceptual measures of soft and loud yielded results similar to those of traditional in-person tests. But speech understanding was poorer for the remote condition, due to higher levels of background noise and reverberation at the remote site. These issues typically are avoided with traditional testing conducted in a sound-treated booth.

Recently, we received a new research grant from the National Institute on Deafness and Other Communication Disorders. With it, we will validate the use of telepractice for processor programming with young children, who require different audiological testing techniques than adults. We will also develop and evaluate alternative methods for remote testing of speech perception, which our earlier study found to be poorer in remote conditions. Last, we will determine whether a clinician-administered audiologic rehabilitation program via telepractice is equivalent to that conducted in traditional, in-person rehabilitation—and if it’s superior to a computer-based, self-administered program.

Michelle Hughes, PhD, CCC-A, is coordinator of the Cochlear Implant Program and director of the Cochlear Implant Research Lab at Boys Town National Research Hospital. michelle.hughes@boystown.org

Audiologic Rehab Resources

ASHA offers a range of patient handouts and fact sheets to help audiologists with AR, including:

AR Billing

There are four CPT (Current Procedural Terminology, © American Medical Association) codes related to audiologic/aural rehabilitation that apply to both audiologists and speech-language pathologists.

Evaluation Codes

92626, evaluation of auditory rehabilitation status (first hour), and 92627 (each additional 15 minutes) may be billed by audiologists and speech-language pathologists, and are reimbursed by Medicare and most private health plans.

Treatment Codes

There are two codes for auditory rehabilitation—92630 (prelingual hearing loss) and 92633 (postlingual hearing loss)—but neither code has been assigned a value by Medicare, rendering them unbillable by Medicare. Medicare instructs SLPs to bill CPT 92507, the general speech-language treatment code, for auditory rehabilitation; Medicare does not, however, allow audiologists to bill for AR, as Medicare coverage of audiology services is limited to diagnostic testing only.

Private payers may follow Medicare guidelines, but not always. For example, UnitedHealthcare’s policy includes all four codes in its speech-language pathology services, and lists them specificially. Clinicians should check with non-Medicare payers regarding use of these codes.

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July 2014
Volume 19, Issue 7