Dimensions of Care Model and Pediatric Audiology With the advent of universal newborn hearing screening programs as a standard of care and continuing technological advances, enhanced early intervention experiences for children who are deaf/hard of hearing and their families may be an attainable goal. The last two decades have brought much progress, but parents still have a ... Features
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Features  |   June 01, 2010
Dimensions of Care Model and Pediatric Audiology
Author Notes
  • Nannette Nicholson, PhD, CCC-A, is an associate professor and director of audiology in the Department of Audiology and Speech Pathology, a consortium program at the University of Arkansas for Medical Sciences/University of Arkansas at Little Rock. Contact her at NN@uams.edu.
    Nannette Nicholson, PhD, CCC-A, is an associate professor and director of audiology in the Department of Audiology and Speech Pathology, a consortium program at the University of Arkansas for Medical Sciences/University of Arkansas at Little Rock. Contact her at NN@uams.edu.×
  • Kathy L. Shapley, PhD, CCC-SLP, is an assistant professor in the Department of Audiology and Speech Pathology, a consortium program at the University of Arkansas for Medical Sciences/University of Arkansas at Little Rock. Contact her at klshapley@ualr.edu.
    Kathy L. Shapley, PhD, CCC-SLP, is an assistant professor in the Department of Audiology and Speech Pathology, a consortium program at the University of Arkansas for Medical Sciences/University of Arkansas at Little Rock. Contact her at klshapley@ualr.edu.×
  • Patti F. Martin, PhD, CCC-A, is the director of Audiology and Speech Pathology at Arkansas Children’s Hospital, and holds an adjunct appointment in the Department of Audiology and Speech Pathology, a consortium program at the University of Arkansas for Medical Sciences/University of Arkansas at Little Rock. Contact her at MartinPF@archildrens.org
    Patti F. Martin, PhD, CCC-A, is the director of Audiology and Speech Pathology at Arkansas Children’s Hospital, and holds an adjunct appointment in the Department of Audiology and Speech Pathology, a consortium program at the University of Arkansas for Medical Sciences/University of Arkansas at Little Rock. Contact her at MartinPF@archildrens.org×
Article Information
Hearing Disorders / Special Populations / Early Identification & Intervention / Features
Features   |   June 01, 2010
Dimensions of Care Model and Pediatric Audiology
The ASHA Leader, June 2010, Vol. 15, 16-19. doi:10.1044/leader.FTR2.15072010.16
The ASHA Leader, June 2010, Vol. 15, 16-19. doi:10.1044/leader.FTR2.15072010.16
With the advent of universal newborn hearing screening programs as a standard of care and continuing technological advances, enhanced early intervention experiences for children who are deaf/hard of hearing and their families may be an attainable goal. The last two decades have brought much progress, but parents still have a range of experiences with newborn hearing screening. As their statements attest, Parent A’s experience was less than desirable and Parent B’s experience was quite positive.
Parent A: “As we were being released from the hospital, the nurse who was discharging us just randomly said, ‘Your daughter hasn’t passed the newborn hearing screening. We gave it to her yesterday and she didn’t pass so we gave it to her today and she isn’t responding.’ She said it as if she was saying something off of her grocery list. It was just like—’Okay when you go home, do this, this, this, this, and by the way your daughter failed her newborn hearing screening.’ When I left the hospital I was shocked. I mean, we had no idea that that was coming. I had the feeling that something was wrong and she had a lot more wrong than just that but the initial feeling was disbelief.”
Parent B: “I found out about my daughter’s hearing loss from her newborn hearing screening. She failed one ear in the hospital when she was born and we were told to go to Children’s Hospital to get more tests run…and so as soon as we could we took her…and that’s when we were told that she had a severe loss in her right ear and a profound hearing loss in her left ear. When we found out, she was automatically fitted for hearing aids and we got those ordered and we got them put in and she started wearing those. Then she received speech-language treatment, and then they did more hearing tests just to kind of note her progress to see if it was getting worse or if it was staying the same. Then, probably the second or third hearing test that they did, her hearing loss had gone from severe in one ear and profound in the other ear to a profound hearing loss in both ears.”
Family difficulties like these challenge us to strive for continuous quality improvement in the implementation of early hearing detection and intervention (EHDI) processes.
Assessing Quality of Services
The Agency for Healthcare Quality and Research (AHQR, 2003) defines quality in health care as safe, timely, patient-centered, efficient, and equitable service delivery with full consideration of a patient’s preference and values—and certainly this is our goal as audiologists and speech-language pathologists. In a broad sense, this definition applies to patient interactions and relationships as well as to the continuum of clinical services provided by audiologists and SLPs. The ultimate goal of our diagnostic and/or intervention plan is to provide the right services at the right time and in the right way.
The classic Donabedian structure-process-outcomes model provides a framework for assessing the quality of health care, with each component having a direct influence on the next. Simply stated, highly qualified providers (structure) affect best practices (process) and result in improved health status (outcomes). However, this linear model fails to integrate the dynamic, interdependent, and interrelated dimensions of health care that affect quality of services and outcome (e.g., personal belief systems, family dynamics, interpersonal relationships, cultural norms). The need to include these other dimensions is especially true in the case of complex multidisciplinary systems of care, such as EHDI services/programs.
Dimensions of Care Model
The Dimensions of Care model (Figure 1 [PDF]) provides a paradigm for conceptualizing diagnostic and management outcomes in early intervention. This paradigm explores the balance of three critical interdependent and interrelated dimensions of care that affect quality of services:
  • Systems of care

  • Clinical decision skills

  • Experiential/relational processes

The authors offer an expanded Dimensions of Care quality model that posits interpersonal process aspects of care for use as a quality tool for assessing EHDI services.
This expanded model theorizes that interpersonal process aspects of care are dimensions that influence quality of care (i.e., outcomes) and that can be evaluated by examining them within these three nested components. As an example, a systems conceptualization focuses on the structure and organization of EHDI and highlights how the processes are operationalized. Experiential aspects of the EHDI process include cultural sensitivity, environment of care, and family-centered practices. Clinical considerations inform the science of service delivery and include evidence-based practices, protocol development and test selection, and individual professional competencies. It is important that audiologists and SLPs recognize the impact of these relational components in order to understand the multifaceted complexity of service delivery required to ensure continuity of care, enhance family satisfaction, and improve outcomes.
Systems Dimension
Screening, diagnosis, intervention, and education are the systems of care components necessary to consider when evaluating EHDI using the Dimensions of Care model. The implementation of these EHDI components is a complex process with multiple levels. At the national level are the Joint Committee on Infant Hearing (JCIH), composed of representatives from professional organizations with an interest in children with hearing loss; the Centers for Disease Control and Prevention (CDC); and the National Center for Hearing Assessment and Management (NCHAM). For the past 41 years, JCIH has issued position statements regarding early identification of children with hearing loss. The CDC provides funding and collaborates with federal, national, and state agencies as well as with organizations to develop, modify, and implement EHDI programs. NCHAM is a multidisciplinary center that serves as the national resource for providing technical assistance for the implementation and improvement of comprehensive and effective EHDI systems.
The Dimensions of Care model accounts for the multiple levels and individual elements that have the potential to influence health outcomes and that must be considered when evaluating quality of care. At the state level, advisory boards assist in the implementation of state guidelines regarding their EHDI program. Screening, diagnosis, intervention, and education at the state level require coordination and collaboration across a number of professionals working in a variety of settings (Alberg, Wilson, & Roush, 2006). Viewing the EHDI system of care through this model would not only give insight into the EHDI component processes, but also capture the collaborative efforts among agencies.
In Arkansas, for example, the EHDI program is housed in the Department of Health. Medical, audiology, and speech-language pathology services for children diagnosed with hearing loss are accessed through the Individuals With Disabilities Education Act (IDEA) Part C (for children from birth to 3 years of age), a division of Developmental Disability Services within the Department of Human Resources. In Arkansas, if children are Medicaid-eligible, funding for these services is processed through Medicaid first; if these children are not eligible for Medicaid, then Part C becomes the funding source for services after other sources of funding have been exhausted. Education and intervention services under IDEA Part B (for children ages 3 to 21 years old) are under the purview of the Department of Education. Although other states may be organized differently, navigation through state systems is a common challenge and recognized as a barrier to timely and appropriate services. This daunting challenge can be overwhelming for seasoned professionals and even more so for parents who have just embarked on a journey with a very steep learning curve.
A single point of entry with a seamless system of service delivery is an admirable target. One entry point into the system that is empowered to share information quickly and efficiently with all service providers has the potential to streamline the process for families, reducing their frustration as well as enhancing the potential for service coordination to achieve the best outcomes. North Carolina and Connecticut have systems in place to facilitate this process. For example, the Beginnings program in North Carolina works with the state EHDI/early intervention programs and educational systems to accomplish this goal. Families in Connecticut may choose one of three centers that specialize in the coordination, management, and provision of services from birth to 21 (American School for the Deaf; CREC/Soundbridge; and the New England Center for Hearing Rehabilitation).
Clinical Dimension
Who coordinates collaboration among clinical providers—the otolaryngologist, audiologist, SLP, occupational therapist (OT), physical therapist (PT), developmental therapist, early childhood educator, general educator, special educator, or primary care physician? Management of various elements of clinical care—including provider qualifications, implementation of standards of care, development of practice guidelines for establishing partnerships, and maintenance of communication between and among providers and patients—has proven to be an ongoing challenge. Families continue to receive services from multiple providers with little, if any, communication or collaboration among the professionals. To deliver true quality of care, all providers involved with a patient must, at a minimum, be aware of one another and the services being provided. The ultimate goal would be coordinated services with a long-term multidisciplinary plan designed to maximize outcomes aligned with family choice.
The term “medical home” refers to a patient-centered approach to comprehensive care (AAP, 2002). A quality improvement initiative, the idea is for pediatricians and parents to act as collaborative partners to identify and secure access to all the medical and non-medical services needed to help children and their families achieve their maximum potential. Care provided through a medical home is considered accessible, family-centered, continuous, comprehensive, coordinated, compassionate, and culturally competent (AAP, 2002).
In an expansion of the idea of a traditional “medical home” from the perspective of allied health professionals, the parameters of evaluation and treatment would be addressed. As depicted in Figure 1 [PDF], the idea of a medical home would include systems of care, wrap-around services, and evidence-based practice. In this context, “systems of care” refers to team dynamics (transdisciplinary, interdisciplinary, multidisciplinary) as well as methods (face-to-face, phone/e-mail, reports) and frequency of communication among the various allied health professionals (audiologist, PT, OT, SLP, etc.) involved in the client’s care.“Wrap-around” is a team-based planning process intended to provide individual, coordinated, family-driven care to meet the complex needs of children who are involved with several child- and family-serving systems (e.g., mental health, child welfare, juvenile justice, special education) and who are at risk for or may be experiencing emotional, behavioral, or mental health difficulties. Through the wrap-around process, a family and its team develop, implement, and fine tune an individual plan of care to achieve positive outcomes for the family. Regardless of the discipline or service model, the goal is to deliver services that are evidence-based.
Experiential Dimension
Experiential aspects encompass cultural sensitivity, family-centered practices, and the environment of care (i.e., home-based versus center- or school-based services). The experiential component recognizes that the patient/family experience begins upon entry into the building and does not end until exit. It includes every aspect of the family and patient experience, including their relationship with the provider, supports in the community, and involvement with other families and peers.
Some aspects of quality can best be assessed when viewed through a patient’s eyes; patient experience surveys may be more informative than patient satisfaction surveys because they may uncover concerns that could bring quality improvement needs to light. How did the patient/family feel during the visit? Were they treated with understanding, respect, and consideration? How did they feel when the visit was over? If the visit was diagnostic and test results were not what the family had hoped, did the family feel that all their questions had been answered and did they know the next step in the process? Clients may observe and articulate deficiencies that busy providers do not notice.
Experiential aspects of EHDI focus on service provision that recognizes the potential disconnect between the priorities of health care and educational agencies and the priorities of families of children with hearing loss and attempt to fill this gap. Professionals can enhance their experiential perspective in activities that promote shared learning opportunities and connections with families. Participating in groups or activities such as Hands and Voices, AG Bell, EHDI Conference, or Investing in Family Support help strengthen the partnership between families and professionals. One opportunity for pre-service training in team assessment and management is provided through the LEND program (see sidebar below).
Tools for Families
More than 12,000 children with hearing loss will be born in the United States in 2010. Fortunately, children born today will reap the benefits of the improvements in both processes and outcomes for children who are hard of hearing or deaf (White, 2006). For example, the number of infants screened annually in the United States has increased from 38% in 2000 to 95% in 2007 (JCIH, 2007). The effectiveness of early intervention services depends to a great extent upon their reception by the family (Young et al., 2009). In addition to being qualified and competent, providers need to be sensitive to family and generational learning styles. Current tools and technologies—social networks, electronic formats, and face-to-face and written communication—should be used to communicate with and provide support for families.
Audiologists and SLPs play an integral part in assuring continuous quality improvement in EHDI. Valuing the importance of supporting families through active participation and communication with everyone involved in the care of the client leads to compassionate, family-focused, multidisciplinary care and results in enhanced outcomes for children identified with hearing loss and their families. As EHDI components and services continue to be refined over the next decade, the focus toward quality improvement will continue to evolve. Tools such as the ‘Dimensions of Care’ model proposed in this article may offer one framework for assessing quality of care and help move us one step closer to “a perfect world” (see sidebar “In a Perfect World”).
Putting Theory Into Practice

The true value of a theory is in its application. In our clinical practices, we have attempted to use the proposed model as a framework for quality improvement initiatives. For one of our quality improvement projects, “Parental Perceptions of the Hearing Aid Fitting and Adjustment Process,” we elicited parental perspectives across systems, clinical, and experiential aspects of diagnosis through the initial hearing aid fitting. We specifically wanted to focus on parent knowledge, skills, and feelings of self-efficacy.

From a systems perspective, we addressed concepts related to benchmarks established by the Joint Committee on Infant Hearing, such as time from diagnosis to initial hearing aid fitting, as well as quality of the EHDI and early intervention information and materials shared with the family at diagnosis and during the first few weeks of adjustment to the hearing aids.

Clinically, we wanted to know the parental perception of the qualifications of the provider, the “family-friendly” feeling of the clinical environment, and the parents’ take on information, expectations, and understanding of the hearing loss and potential benefit of amplification.

Finally, the parent experience was paramount. We wanted to measure parental self-efficacy through the constructs of how comfortable, concerned, or confident a parent was about an aspect of his or her experience. For example, we asked: How confident were parents that their child would benefit from hearing aids? How comfortable were they placing and removing the hearing aid/earmold from their child’s ear? How concerned were they about what other family members and friends might say or think?

Developing our survey around the Dimensions of Care model allowed us to delve further into the parent experience and perspective rather than calling our program successful based only on how competently we were able to plot an audiogram from an auditory brainstem response study or how savvy we might be with programming strategies for infants. Rather, it allowed us to incorporate additional opportunities for parents to practice skills hands-on while in the clinic with us, reminded us that parents don’t start out seeing their relationship with the audiologist as an equal partnership, and encouraged us to work toward providing additional opportunities for parents to interact with other families from the outset.

—Nannette Nicholson, Kathy L. Shapley, and Patti F. Martin

Association of University Centers on Disabilities (AUCD) LEND Programs

The federally funded Leadership Education in Neurodevelopmental and Related Disabilities (LEND) programs provide long-term, graduate-level interdisciplinary training as well as interdisciplinary services and care. The purpose of the LEND training program is to improve the health of infants, children, and adolescents with disabilities. It prepares trainees from diverse professional disciplines to assume leadership roles in their respective fields and ensures high levels of interdisciplinary clinical competence.

LEND programs operate within a university system, usually as part of a University Center for Excellence or other larger entity, and collaborate with local university hospitals and/or health care centers. This structure gives them the expert faculty, facilities, and other resources necessary to provide exceptional interdisciplinary training and services.

There are 38 LEND programs in 31 states and the District of Columbia. Collectively, they form a national network that shares information and resources and maximizes their impact. They work together to address national issues of importance to children with special health care needs and their families, exchange best practices, and develop shared products. They also come together regionally to address specific issues and concerns.

Although each LEND program is unique, with its own focus and expertise, they all provide interdisciplinary training, have faculty and trainees in a wide range of disciplines, and include parents or family members as paid program participants. LEND is funded under the 2006 Combating Autism Act and is administered by the Maternal and Child Health Bureau of the U.S. Health Resources and Services Administration.

References
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Schmeltz, L.R. (2009). Parent counseling in the Internet age: The rules and roles have changed. In NCHM E-Book: A Resource Guide for Early Hearing Detection and Intervention. pp. 5–1–5–8. Retrieved from http://infanthearing.org/ehdi-ebook.
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June 2010
Volume 15, Issue 7