A Whole Lot of Hearing Going On Clients who undergo audiologic rehabilitation get more from their hearing aids and improve their overall hearing. But to take advantage, clinics need to find the AR model that works best for them. Features
Features  |   March 01, 2014
A Whole Lot of Hearing Going On
Author Notes
  • Jennifer Henderson-Sabes, MA, CCC-A
    is vice president of audiology and research and development at Neurotone, Inc., and a research audiologist at the University of California San Francisco. ■jhs@neurotone.com
  • Becky Bingea, AuD, CCC-A
    is director of clinical outreach and development at Neurotone, Inc. ■rbingea@neurotone.com
Article Information
Hearing & Speech Perception / Hearing Aids, Cochlear Implants & Assistive Technology / Audiologic / Aural Rehabilitation / Features
Features   |   March 01, 2014
A Whole Lot of Hearing Going On
The ASHA Leader, March 2014, Vol. 19, 42-47. doi:10.1044/leader.FTR1.19032014.42
The ASHA Leader, March 2014, Vol. 19, 42-47. doi:10.1044/leader.FTR1.19032014.42

Sheila is quietly listening to her audiologist discuss the next steps in the process of getting her first set of hearing aids. They have decided on the style and color of the devices and the audiologist is discussing the logistics of the fitting process. She begins to outline Sheila’s options for additional rehabilitation. Sheila finally stops the audiologist, asking for clarification. “Rehabilitation? For hearing aids?” Sheila imagines the weeks of rehabilitation after her knee surgery and can’t imagine what audiologic rehabilitation might be.

The truth is that if you ask 10 audiologists what audiologic/aural rehabilitation is, you are likely to get almost as many answers. If you ask how and when to implement it, you are likely to find even more variety. In the case of AR, it may be true that variety is the spice of hearing loss remediation.
Audiologic rehabilitation’s purpose is to counteract the psychosocial, communicative and lifestyle effects of hearing loss. AR began as a basic component of the amplification process, but as hearing aids have become more advanced, the amplification process has become more technology-driven. Advances in digital signal processing address tough fitting issues such as background noise, loudness recruitment and challenging hearing losses.
So why the need for AR? Because even though customer satisfaction with amplification rose consistently from 2000 to 2008, more than 15 percent of hearing aid users are dissatisfied with their hearing aids, with most of them leaving the hearing aids “in the drawer.” The reasons for dissatisfaction vary, from the way they feel to perceived lack of acoustic benefit, especially in difficult listening situations, like listening to speech in noise or without visual cues.
Sheila’s audiologist realizes Sheila’s confusion and potential dissatisfaction in difficult listening situations and has implemented audiologic rehabilitation as part of the plan to maximize the benefit Sheila has with her hearing aids.
Studies have demonstrated that AR can have many benefits, including better and more effective hearing aid use, better communication skills, better speech in noise perception, improved self-efficacy, reduced disability related to hearing loss and reduced participation limitations (see sources). Audiologists and speech-language pathologists are trained in audiologic rehabilitation in university programs, and many audiology students take part in facilitating AR as part of their curricula.
Realistically, however, audiologic rehabilitation is not a component of most hearing aid fittings, and anecdotal reports suggest that many clinicians are not confident in their ability to implement AR in a way that works for their patients or their clinics. In fact, there are many ways to implement AR, including group, home-based and individualized methods, and most clinics can find a model that works. Finding the right model involves understanding the differences between the programs and then determining which model or models work best with the resources, patient population, interests and personality of the practice. For example, an audiologist with an outgoing and energetic personality might relish a group program, while another colleague in the practice may enjoy the analytic coordination of home-based programs.
Group AR
In group AR programs, people with hearing loss and their partners learn skills—such as effective communication strategies and speechreading—and they find support from facilitators and others in the group. The group experience helps to alleviate the social and emotional effects of hearing loss. Group program models are varied, from a single session to many sessions over months, and often include spouses or family. The curriculum and content can be driven by the group dynamics and needs, but obviously are not individualized to each participant.
Benefits to group programs include better use of hearing aids, a more rapid adjustment to the amplification process, and reduced participation restrictions. Considerations include the time-cost to the clinician without third-party reimbursement; however, clinics that provide this service not only enhance the rehabilitative process for their patients, but also decrease hearing aid returns and return visits to the clinic.
In 2012, the Ida Institute—an independent, nonprofit organization that fosters a better understanding of the dynamics of hearing loss—developed a Web-based tool to encourage audiologists and SLPs to provide group audiologic rehabilitation and to provide clinicians the tools to do so in their practices (see sources). The program, Group Rehabilitation Online Utility Pack (GROUP, www.idainstitute.com), includes free content, resources, videos and evidence that are useful to clinicians new to or experienced in leading group AR.
Another good resource for clinicians providing AR to older adults is the ACE (Active Communication Education; Speechmark Publishing Ltd., available for purchase at bit.ly/active-comm) program. The program, developed by Louise Hickson, Linda Worrall and Nerina Scarinci, outlines a six-module curriculum that has been shown to have a positive effect on disability related to communication and hearing (see sources).
Individualized AR
Individualized AR provides a patient-oriented and personalized approach to the process. Individual sessions allow the clinician to focus on areas that are likely to provide the greatest outcomes for each patient and flexibility in the AR course and timeline. For example, if intensive communication repair strategies and personal-adjustment counseling is most beneficial for a patient, sessions can focus primarily on these areas. Interestingly, studies have indicated no observed benefit to individualized AR over the group experience.
“Learning to Hear Again” (Hear Again Publishing, available for purchase at bit.ly/hear-again), a curriculum designed for audiologists and SLPs, is used for individual and group programs and is an excellent resource for clinicians. The Ida Institute also has helpful free content for developing a therapeutic AR plan.

What Goes Into Audiologic Rehab?

Audiologic rehabilitation can be done with groups or individuals, in person or using a home-based computerized model, or in some combination of these. AR can include:

  • Informational counseling (providing information about hearing loss, its consequences and hearing aids)

  • Communication strategy training

  • Auditory training in quiet and in noise

  • Speechreading training

  • Psychosocial, stress mediation and relaxation exercises

  • Problem identification and problem solving

  • Referrals to appropriate support groups

  • Advocacy information

Home-based audiologic rehabilitation/training programs and some of their features.
Home-based audiologic rehabilitation/training programs and some of their features.×
Home-based audiologic rehabilitation/training programs and some of their features.
Home-based audiologic rehabilitation/training programs and some of their features.
Home-based audiologic rehabilitation/training programs and some of their features.×
Home-based individualized AR
The last several years have seen an increased focus on home-based individualized AR. In this model, a patient can perform certain aspects of AR over the course of days, weeks or months outside of the clinic. This model allows for some aspects of individual AR—like training and informational counseling—to be provided in a more cost-effective manner than face-to-face in the clinic. It also allows hearing aid users to spend more time on aspects of AR that have traditionally been difficult to implement in the clinic, such as auditory and speechreading training. Research investigating home-based AR programs has yielded variable outcomes that illustrate the challenges of patient compliance and differences in individual benefit (see sources).
In fact, few home-based programs have published robust studies to support their efficacy. But in the published studies, researchers have observed objective and subjective improvements. Objective benefits are strongest for on-task training, with more variable results for off-task benefits. Robert Sweetow and Jennifer Henderson-Sabes (see sources) showed significant improvements on subjective measures, comparable with group audiologic rehabilitation, but subjective data for other programs have not typically been reported in the literature.
Examples of commercially available home-based programs include LACE (Listening and Communication Enhancement, Neurotone, Inc; available for purchase at www.neurotone.com), Read My Quips (Sensesynergy, Inc; available for purchase at www.sensesynergy.com), Sound and WAY Beyond (Cochlear Corp; available for purchase at bit.ly/sound-way-beyond) and Seeing and Hearing Speech (Sensimetrics; available for purchase from www.seeingspeech.com). Angel Sound is a free program available at http://angelsound.tigerspeech.com.
Sheila’s moderate-to-severe hearing loss has affected her participation in once-regular social events as well as her speech understanding. As a part of her rehabilitation, Sheila’s clinician recommends a home-based auditory rehabilitation program that she can use on her computer. The program allows Sheila to practice using her hearing aids with difficult listening challenges, and provides informational counseling, communication strategies and tips for managing her expectations. The audiologist also recommends that Sheila attend the next two-session group audiologic rehabilition program that the private practice clinic offers every other month.
In this case, the clinician is implementing two of the most common models of AR, which are also the models that work best in a private practice. Because of reimbursement issues, namely that the Centers for Medicare and Medicaid Services—and, thus, many third-party payers—do not reimburse audiologists for audiologic rehabilitation, group and computerized AR are the most common implementations among audiologists. Some clinicians charge the patient for audiologic rehabilitation services. Others provide it at no cost to the patient (and may or may not bill a third party). And others provide an incentive to participating in audiologic rehabilitation. (SLPs may be reimbursed under Medicare for audiologic rehabilitation using CPT 92507 [Common Procedural Terminology ©American Medical Association]).
As illustrated in Sheila’s case, audiologic rehabilitation has evolved to keep pace with changing technology and health care needs. There are multiple models available to the clinician in private practice, and the opportunity is available to find the option that works best, with support from available resources or commercial programs.
Home-based audiologic rehabilitation/training programs and some of their features.
Home-based audiologic rehabilitation/training programs and some of their features.×
Home-based audiologic rehabilitation/training programs and some of their features.
Home-based audiologic rehabilitation/training programs and some of their features.
Home-based audiologic rehabilitation/training programs and some of their features.×
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March 2014
Volume 19, Issue 3