Overcoming Barriers to Adult Aural Rehabilitation

April 2015

Carrie Spangler, K. Todd Houston, and Tamala S. Bradham

Introduction

Hearing loss continues to be a defining health condition for many individuals as they age. In fact, from 2001 to 2008, there were an estimated 30 million Americans (or 12.7% of the population) ages 12 years or older who had bilateral hearing loss, and this estimate increased to 48.1 million (or 20.3% of the population) when individuals with unilateral hearing loss were included (Lin, Niparko, & Ferrucci, 2011). Lin and colleagues also found that hearing loss increases with every age decade (i.e., as people age into their 40s, 50s, 60s, etc.). Furthermore, the study demonstrated that, for individuals 12 years and older in the United States, nearly 1 in 8 has bilateral hearing loss, and nearly 1 in 5 has a unilateral or bilateral hearing loss. By 2050, individuals in the United States with hearing loss will exceed 40 million (Kochkin, 2005) with about 80% experiencing irreversible hearing loss (Tye-Murray, 2009).

The effects of hearing loss on the individual can be dynamic and significant, especially in older adults. Lin, Thorpe, Gordon-Salant, and Ferrucci (2011) discuss the impact of hearing loss on older populations and how hearing loss is associated with various conditions or situations, such as incident dementia (e.g., driving or walking difficulty), social isolation, cognitive and functional decline, and falls. More importantly, the prevalence of hearing loss is expected to rise because of the aging of the population, and research is needed to understand the impact of hearing loss on cognition, communication, and other functional domains (Lin, Niparko, & Ferrucci, 2011). Furthermore, the researchers support continued study of the role that aural rehabilitation (AR) has in mitigating these effects.

Unfortunately, barriers exist to the delivery of effective AR services. Tye-Murray (2009) discussed how individuals with hearing loss are usually underserved or unserved due to a scarcity of available AR services, the attitudes of service delivery personnel, a lack of reimbursement for these services, and communication or environmental factors. Montgomery and Houston (2000) would add one more factor to this list: the lack of well-trained personnel who can deliver effective AR services. Thus, while the number of adults with hearing loss who could benefit from comprehensive AR services is significant and increasing, obstacles remain. Three specific steps, however, could be taken to drastically increase the availability of these services: improve the efficacy of the rehabilitation; secure reimbursement rates for these services, especially for audiologists; and increase the number of competent practitioners who can deliver AR services.

Defining Aural Rehabilitation/Audiologic Rehabilitation

The American Speech-Language-Hearing Association (ASHA; 2001) has delineated the basic knowledge and skills audiologists and speech-language pathologists (SLPs) should possess prior to providing comprehensive adult AR services. As well, several noted clinicians and researchers have described preferred practices in the delivery of AR services (Alpiner & McCarthy, 2000; Hull, 2010; Montano & Spitzer, 2014; Tye-Murray, 2009).

Over the years, different terms have been propagated within the communication sciences and disorders discipline. Typically, aural rehabilitation is the term used by most SLPs, and audiologic rehabilitation or rehabilitative audiology are the preferred terms of audiologists. Similarly, the definition of aural rehabilitation has evolved. Montgomery and Houston (2000) described AR as services that "increase the probability that successful communication will occur between a hearing-impaired person and his or her verbal environment" (p. 379). Tye-Murray (2009) stated that AR is aimed at restoring or optimizing a patient's participation in activities that have been limited as a result of hearing loss and also may be aimed at benefiting communication partners who engage in activities that include persons with hearing loss. The goals of AR are to alleviate the difficulties related to hearing loss and minimize its consequences (Gagne, 2000; Tye-Murray, 2009).

Similarly, but more expansively, Montano and Spitzer (2014) describe these services as:

...a person-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 participations. In order to achieve this, the audiologist must be mindful of the factors that influence a person's sense of being. This includes, but is not limited to, interactions with communication partnerships in environmental conditions, with concurrent or acute health conditions, and the readiness for self-management of hearing loss. (p. 27)

For many audiologists, a technocentric model of service delivery is often established with their patients (Montano & Spitzer, 2014). For example, the audiologist provides services that are focused on and revolve around the patient's use of hearing technology (e.g., hearing aids, cochlear implants, assistive listening devices). While the proper use of hearing technology is essential to mitigate the impact of the hearing loss and to provide improved audition, such myopic attention to the technology may cause the audiologist to miss the patient's broader outcomes in listening, communication, and functional well-being.

Over time, evidence has mounted in support of comprehensive AR, which can involve individualized communication/listening therapy and counseling, one-on-one telepractice sessions, computerized auditory training sessions, group sessions, or a combination of all of these. The appropriate route must be individualized and based on the patient's specific communication needs. Today, the integration of spouses and other family members into the AR process is not only expected but necessary. The benefits of providing comprehensive AR are significant and include the reduction of the perception of hearing difficulties, improvement in perceived quality of life, better use of hearing technology and successful communication strategies, and improvement in personal adjustment (Hawkins, 2005).

Reimbursement

Today, even when audiologists want to provide AR services, many are reluctant to do so due to limited or absent reimbursement for services. Currently, Medicare recognizes audiology as a diagnostic service and not a treatment service, which excludes payment to audiologists for AR services. (CPT codes 92626 and 92627 are for diagnostic services, and 92630 and 92633 are for AR services). However, neither 92630 nor 92633 is a covered audiology benefit under Medicare Part B. Because Medicare views audiology as diagnostic in nature, audiologists may not be able to offer services that cannot be billed or aren't reimbursed by Medicare or private insurance. Many older patients may be on a fixed income, and paying out of pocket for AR services may not be possible. Currently, SLPs are allowed to bill for AR services through the Medicare program (CPT code 92507), but many SLPs may not be working with adults with hearing loss or have the necessary training to be effective. Although some SLPs may have the knowledge and skills to help children develop listening and spoken communication, the treatment plans are often different for adults who have acquired hearing loss gradually.

With the passage of the Affordable Care Act (ACA) in 2010, which was upheld by the Supreme Court in 2012, payment for health care services is changing. The ACA lists 10 benefit categories that must be covered as essential by new individual and small group plans. Under the benefit category, Rehabilitation is defined as: "Health care services that help a person keep, get back, or improve skills and functioning for daily living that have been lost or impaired, because a person was sick, hurt, or disabled" (Hasselkus, 2011). These services may include physical and occupational therapy, speech‐language therapy, and psychiatric rehabilitation services in a variety of inpatient and/or outpatient settings. In addition, the Department of Health and Human Services (HHS) recognizes that each state may have slightly different needs and is allowing each state to choose from a set of plans to serve as the benchmark plan in that state. These benchmark plans must include the minimum of 10 required categories, but each state may exercise its rights differently. For example, for rehabilitation services, one state may allow a total of 20 sessions that can be used for occupational therapy, physical therapy, and/or speech-language therapy. However, another state may allow for each discipline to provide 20 therapy sessions per year.

As the ACA emphasizes efficiency and effectiveness to reward providers for better coordination of care, payment reform is inevitable. With the ultimate goal of reducing health care costs by improving both quality and efficiency, payment for services will be linked to quality outcomes. HHS, for example, has announced that it will reward quality health care and phase out payments based solely on volume. Specifically, HHS is aiming to tie 85% of Medicare fee-for-service payments to quality or value by 2016 and 90% by 2018. The Center for Medicare & Medicaid Innovation—designed to encourage innovative payment models for health care coverage—has funded 34 states, three territories, and the District of Columbia through its State Innovations Models Initiative, with many proposing a model called the bundled payment for care improvement (BPCI). BPCI creates episodes of care based on conditions, such as diabetes or stroke, and a single payment is made to the hospital and/or the post-acute care facility to manage the medical needs of the patient. Quality measures and outcomes reporting are requirements of the BPCI model. TennCare, Tennessee's form of Medicaid, is using the BPCI model and implementing 75 episodes of care over the next 5 years. Because audiologists are often recognized in Medicaid programs for AR services, they are well positioned to fully participate in the bundled model. Even if the audiologist doesn't provide AR services directly, partnering with an SLP will be key to maximize reimbursement and to ensure quality outcomes. Demonstrating how quality of life has improved through comprehensive AR services will be critical. Incorporating AR into hearing aid service programs will result in patients' having higher functional outcomes, which will impact the payment for that episode of care.

Audiologists and SLPs can effectively advocate for potential coverage of rehabilitation at the state level. By demonstrating the impact of their collaborative partnerships on outcomes, audiologists and SLPs will have the ears of state policy makers and insurance companies. ASHA members are encouraged to contact their State Advocates for Reimbursement (STAR) representatives to find out about advocacy efforts in their respective states in relation to the ACA and AR. ASHA has provided members with a variety of tools to educate, advocate, and, hopefully, gain reimbursement for these critical services.

Training and Interprofessional Aural Rehabilitation

To move forward, one must look back. The World Health Organization (WHO, 2010) stated, "...after almost 50 years of enquiry, the WHO and its partners acknowledge that there is sufficient evidence to indicate that effective interprofessional education enables effective collaborative practice. Collaborative practice strengthens health systems and improves health outcomes" (p. 7). In 2001, the Institute of Medicine called on the United States to redesign its health care system. "Tens of thousands of Americans die each year as a result of preventable mistakes in their care" (National Academy of Sciences [NAS], 2000, p. 2). Health care needs to be safe, effective, patient-centered, timely, efficient, and equitable (NAS, 2000). Many professionals remember Dr. C. Everett Koop, the U.S. Surgeon General, for raising awareness of AIDs and the dangers of secondhand smoke; he also was a strong advocate for hearing health and made it one of the goals for Healthy People 1990, the national public health agenda. Interprofessional coordination of hearing health services was a concept waiting to be fully implemented. Since Dr. Koop's public focus on hearing loss, significant advances have occurred in hearing aid technologies, cochlear implants, osseointegrated implants, and FM systems. Similarly, improvements in adult AR that incorporate interprofessional collaboration have emerged and continue to be refined.

For both audiologists and SLPs, having the appropriate professional preparation is critical when providing evidence-based AR services. Most university training programs offer a single course in AR with limited practicum; this may not be enough for students to gain an appropriate level of competency in service delivery. As seen with the BPCI payment model, effective AR will involve interprofessional collaboration—combining the knowledge and skills of the audiologist—who can focus on ensuring that the patient is maximizing his or her effectiveness and performance with the prescribed hearing technology— with those of the SLP—who can target the development of functional listening and communication skills as well as target strategies to reduce communication breakdown. Both professionals can be instrumental in either individual or group counseling sessions that often lead to their patients' improved quality of life. Because the demand for AR services is expected to increase, university training programs and professional associations must redouble their efforts to ensure that students in training gain experience in the interprofessional delivery of AR services. Practitioners in the field must have access to university course work, workshops, conferences, and other venues to improve and expand their knowledge and skills.

At The University of Akron, faculty members in audiology and speech-language pathology have teamed up to offer an interprofessional approach to AR. Through an adult support group, coined "Hear No Fear," the expertise of both the audiologist and SLP is utilized to provide support for adults with hearing loss. At monthly meetings, topics that relate to hearing technology, communication barriers and strategies, and social-emotional challenges are discussed. Graduate students in both professions participate in the planning and facilitation of meetings, which revolve around the needs and concerns of the participants and their significant others. As health care embraces interprofessional models of care, comprehensive AR services that combine the expertise of audiologists and SLPs will be more effective at helping a person with hearing loss build, improve, and maintain communication function for daily living.

Moving Forward

Professional and consumer advocacy are necessary to change the existing system to ensure that a range of adult AR services are available to meet the communication needs of adults with hearing loss. In fact, several professional associations and consumer organizations have included comprehensive hearing health care services in their mission statements or public policy agendas. For example, ASHA has initiated its 2015 ASHA Public Policy Agenda, which includes an effort to expand Medicare coverage for a range of services provided by SLPs and audiologists. Other professional groups and organizations, such as ASHA's Special Interest Group 7 (Aural Rehabilitation and Its Instrumentation), the Academy of Rehabilitative Audiology, the Academy of Dispensing Audiologists, and the American Auditory Society have supported and advocated for the availability of AR services. Consumer organizations, such as the Hearing Loss Association of America and the Alexander Graham Bell Association for the Deaf and Hard of Hearing have missions to support the communication needs of individuals with hearing loss through information, education, advocacy, and support. By carefully coordinating advocacy efforts, professional and consumer organizations can combine resources and dramatically increase their impact, which could lead to more widely available AR services for individuals with hearing loss.

Conclusion

The numbers of adults with hearing loss will continue to rise rapidly over the next decade, and these individuals will be prescribed hearing aids and/or receive cochlear implants to lessen the impact of their hearing loss. Likewise, most of these individuals could benefit from comprehensive AR services that incorporate the interprofessional knowledge and skills of both audiologists and SLPs. AR services—including the management of the hearing technology, individual and group sessions, communication therapy, online auditory training programs, telepractice, and counseling that includes spouses and other family members—are structured to meet the individual listening and communication needs of the patient. When delivered appropriately and supported interprofessionally, these services can foster better communication, greater self-confidence, and an improved quality of life and general well-being. Barriers remain, but issues such as a lack of reimbursement and a shortage of well-trained providers are solvable. Through well-coordinated advocacy efforts that include professionals and consumers, changes in the reimbursement schedules are likely to occur in the near future. By then, we hope there will be enough qualified professionals who can provide effective, evidence-based adult AR services.

About the Authors

K. Todd Houston, PhD, CCC-SLP, LSLS Cert. AVT, is a professor in the School of Speech-Language Pathology and Audiology, College of Health Professions, at The University of Akron. His teaching, clinical, and research interests include listening and spoken language outcomes in children with hearing loss, adult aural rehabilitation, cochlear implantation, telepractice as a service delivery model, and the use of social media and social networking to engage patients in health care. He is the current editor of Perspectives for ASHA Special Interest Group 9, Hearing and Hearing Disorders in Children. Contact him at houston@uakron.edu.

Carrie Spangler, AuD, CCC-A, is clinical preceptor and instructor in the School of Speech-Language Pathology and Audiology, College of Health Professions, at The University of Akron. Her teaching and clinical interests include educational and pediatric audiology, hearing assistive technology, and aural habilitation/rehabilitation, including specialized support groups for teens with hearing loss. In addition, she brings a personal perspective to the field of audiology, navigating successfully with severe to profound hearing loss. She is the former chairperson of the ASHA School Finance Committee. Contact her at cls132@uakron.edu.

Tamala S. Bradham, PhD, CCC-A, is a quality consultant for quality, safety, and risk prevention at Vanderbilt University Medical Center, where she is at the forefront of health care reform and population health and practice management. Her research interests include auditory, speech, and language outcomes in children with hearing loss; cochlear implants; and family-centered practices in health care. She is the former coordinator for ASHA Special Interest Group 9, Hearing and Hearing Disorders in Children. Contact her at tamala.bradham@vanderbilt.edu.

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