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Aural Rehabilitation in Private Practice

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Oral rehabilitation is a crucial, patient-centered approach that goes beyond simply fitting hearing aids, aiming to comprehensively address the impact of hearing loss on a patient's communication and quality of life. Private practices can differentiate themselves and improve patient outcomes by adopting a clinician-centered model of oral rehabilitation.

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thanks for joining us today my name is

Dr Dusty jessen and I am an audiologist

in a private practice ear nose and

throat clinic in the Denver area and I'm

also the founder of cut to the chase

communication which is a company

specializing in oral Rehabilitation

products and services for hearing care

providers I have a financial

relationship with Asha for this

presentation in the form of a speaker

honorarium and I also have a financial

relationship as the owner of cut to the

chase communication because we provide

products and services related to the

content of this presentation and I have

no non-financial relationships to

disclose so the purpose of this

presentation is to dig into what oral

rehabilitation really is and why it is

so very important in a private practice

setting and then we'll really get into

how we can make oral Rehabilitation work

in a private practice setting so let's

start by defining oral

Rehabilitation Montano and Spitzer

define oral rehab 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 is kind of a mouthful in

2007 Dr Arthur booy defined oral rehab

as the reduction of hearing loss induced

deficits of function activity

participation and quality of life

through sensory management instruction

perceptual training and counseling so he

took it a step forward to explain the

components that should be incorporated

in an oral rehab program but really oral

rehab is just the comprehensive services

that we as Hearing Care Providers give

to our patients or offer to our patients

and so it can include all of the

following components calair implants

hearing aids auditory training group

sessions patient centered care assistive

listening devices counseling education

speech reading communication strategies

all of that is Incorporated in oral

Rehabilitation that is what a

comprehensive oral rehab program should

include unfortunately in private

practice we're faced with certain

challenges that leave us to um use a

more technocentric model of oral rehab

rather than a clinician centered model

of oral rehab so in this figure you can

see the model that's very commonly used

and the technology being the hearing

aids and the Wireless accessories is the

focus of this model and then the

arguably possibly more important

components of education and resources

communication strategies are kind of

tucked in as afterthoughts so I would

like to propose a different model and

this is a model that puts the clinician

at the Forefront so as you can see at

the base of this model the clinician is

Prov providing education resources

communication strategies and group

classes and this needs to be provided to

every single patient that comes to us

because if they're seeking our services

that means they're experiencing some

perceived difficulty and so we need to

be addressing those difficulties whether

or not they need hearing aids or want

hearing aids and then the next step in

this model is to provide audibility for

those patients who need it who have in

loss and that can be provided in the

form of hearing aids assistive listening

devices or personal sound amplifiers and

then there are some patients who need to

go a step further where hearing aids and

the education is not quite enough for

them and that's when we get into the

auditory training so there are two forms

of auditory training the first is

computerized auditory training and that

is nice for a busy Clinic situation

because the patient typically does

computerized train training on their own

at home but there are those patients who

need a more one-on-one approach and so

clinician directed auditory training

serves that

purpose so why is it so important that

we as private practice practice

clinicians are providing oral rehab for

every single patient well first of all

hearing aids just can't do it all for

patients who have deficits in spectral

and temporal resolution and also for our

aging popul who are experien

experiencing age related cognitive

changes in their working memory and

their speed of processing hearing aids

cannot address those issues on their own

and from a business standpoint hearing

aids are really starting to be seen as

commodity items hearing aids can be

purchased at big box stores like Costco

they can be purchased from online

retailers from storefront retailers and

so the patients have a lot of options

when it comes to purchasing hearing aids

and so there's a growing need as

professionals to set ourselves apart

from those commodity options and also

oral rehab really brings the

professional back to the Forefront

because we're focusing on service versus

technology so it's so very

important now most Private Practice

audiologists do understand how important

oral rehab is to our to our practices

and to our patients however we do face

unique challenges that may not be faced

in other settings so this um flowchart

here gives you an idea of the challenges

that I face on a regular basis these are

the tasks that I have to complete in my

practice on a daily

basis I know that each audiologists may

have a different organization in their

practice but this is what I face on a

regular basis so I am responsible for

the Diagnostics in the form of the

diagnostics for the ENT as well as

diagnostics for hearing aid evaluations

I'm responsible for the treatment the

oral reab and the provision of hearing

aids I'm also responsible for office

tasks like going through the mail going

through our emails returning phone calls

going through invoices and I'm also

responsible for trainings both the

manufacturer trainings that I receive as

well as trainings that I give to our

staff on various topics and finally I'm

responsible for the marketing so I have

to put out social media posts and I'm

also responsible for all community

outreach so I have a lot on my plate

Private Practice audiologists have a lot

on our plates and so sometimes it's hard

to fit in the oral Rehabilitation that

we know is so important and sometimes

that leads us to treating our patients

in a way that we're not so proud of so

I'm going to give you an example of a

not so proud moment this patient was a

67-year-old male

he had a mild sloping to severe sensory

neural hearing loss above 2,000 Herz he

had no self-perceived difficulty he

didn't feel like he had any hearing

trouble at all and he believed that his

difficulties were exclusively the

problem of his wife who always talked to

him from another room and mumbled and on

and on so he agreed to a trial with

hearing aids just to Plate his spouse so

that she would leave him alone so here

is our not so proud process that we use

for this patient because of a scheduling

mistake this patient was scheduled for a

hearing aid evaluation appointment for

just 45 minutes and this really cut down

on our time with this patient so we had

to rush through this visit so this was

the process that we followed we gave him

one intake questionnaire which was our

hearing Health assessment and this

questionnaire just asked Basics about

ear history and hearing health for

Diagnostics we only had time for a

screening audiogram versus a diagnostic

audiogram our plan was simply a trial

with hearing aids because that's what

the patient come in came in expecting

and so we went ahead and followed his

expectations and fit him with hearing

aids that very day and the result of all

of this was that he returned 3 days

later and returned the hearing aids for

credit it was kind of an awkward

situation really kind of a waste of time

on his part and ours so what did I learn

from this well number one I learned that

patient centered care does not mean

patient dictated care so just because

the patient came in with certain

expectations didn't mean that I

necessarily had to meet his expectations

so I learned that we can't cut Corners I

really needed to be the professional in

that situation and I needed to come in

and tell him my expectations let him

know how the process was going to work

so that he could make a decision of

whether we were the right practice for

him or not and perhaps this would have

been a good situation for a referral out

to someone else he was looking for more

of a retail experience and we are don't

we don't want to provide that we are

wanting to provide an oral

Rehabilitation experience so maybe he

would have been happier at a retail

store or a big box store so luckily as

clinicians we learn from mistakes and so

I'm going to take you through a proud

process and this is the process that we

now use with every single one of our

patients that come in it's our

comprehensive oral Rehabilitation

process so this patient was a

65-year-old female she had a mild

sloping to moderate sensory neural

hearing loss above 1,000 Hertz and only

mild self-perceived difficulty as you'll

see in a moment here she was not at all

excited about getting hearing aid AIDS

her spouse however was very excited

about her getting hearing aids he was a

university Professor very techsavvy he'd

been doing lots of research about

hearing aids and he knew all the latest

and greatest on the devices he was also

a very fast speaker and we knew that

because he was there with us and it was

great to have him at this appointment

and he truly was the main motivation for

this visit she wasn't really interested

in hearing aids but he was is very

interested in having some help for her

so here's our proud model or the proud

plan that we use with every patient now

it starts with the initial or the name

of this initial appointment so if you'll

remember back to our not so proud

process we scheduled a hearing aid

evaluation well this time we have

changed the name of that initial

appointment to a communication needs

assessment or a

CNA and we've scheduled this appointment

for 90 minutes Dr Robert swedo was

calling for this change clear back in

2007 and I'm hoping that I can help him

to get it to start catching on in

clinics because a communication needs

assessment really more accurately

describes what we're assessing and what

we're hoping to help these patients with

and from a business standpoint it's

going to set your practice apart right

from the get-go because chances are that

not many other clinics are scheduling

communication needs assessments but

they're instead scheduling hearing aid

evaluations or hearing aid trials so

when a patient calls your office to

schedule an appointment and you schedule

them a communication needs assessment

they're going to be impressed that

you're looking at more than just selling

them hearing aids so the first part of

our assessment process are the in intake

questionnaires and the first three question

question

are given to the patient prior to the

appointment we actually have them on our

website and so the patient can download

them and fill them out from home or they

can fill them out in the waiting room

before their appointment the three

questionnaires are our basic intake

questionnaire which gets basic patient

information our hearing Health

assessment which we used with our first

case it just takes in information about

ear and hearing Health family history of

hearing loss that sort of thing and then

the Paka which we'll go over

next so the Paka is the personal

assessment of communication abilities

and this form can be downloaded at the

website at the bottom of this form at er tr.com

tr.com slaka

slaka

paca I like to use closed set

questionnaires like this in the

beginning because it gets patients

thinking about different communication

environments and it encourages them them

to rate their level of difficulty in

these different environments so it gives

them a lot of ideas without having to

think too hard and I always have the

patient fill out this form as well as

their spouse if the spouse is with them

and as you'll see in a second here the

spouse had very different responses and

so that gives us a good basis for some

more in-depth counseling so in this case

the patient was reporting moderate

difficulty in large groups concerts and

movies places of worship and in the car

and only slight or no difficulty in all

other situations but as you'll see from

this next slide her spouse her husband

had a very different view of her

difficulties he perceives her having

much more difficulty than she perceives

her having himself and this is very

common for the spouse to be more

frustrated with someone's hearing with

their their partner's hearing loss than

the patient themselves because they're

the ones having to repeat themselves and

speak louder and and so it's important

to get this information from the spouse

so you can see that all of his responses

are shifted to the right showing that he

is rating her difficulty much

higher and then the final step of this

assessment process actually happens in

person so those first three assessment

forms were completed before I even met

the patient so I have a wealth of

information before even having the

patient step foot in my office and

that's great because the name of the

game in private practice is efficiency

and we are trying to fit a lot of

information into a short amount of time

so the more that we can do with our

patients outside of the actual office

visit is really helpful but the coce or

the client oriented scale of improvement

is something that I feel needs to be

completed with the patient because it

takes a little more prompting and

discussion this is where the patient

actually identifies his or her most

difficult communication situations I

like for them to choose their top three

and we rate them the Cozy can be

downloaded at no charge from the website

at the bottom of this

slide and then after we've intake taken

in all of that information and we'll

come back to the cozine a little bit

here it's important to create our plan

but first of course we do our

Diagnostics and so in a typical

situation like this we do a diagnostic

audiogram we do a quick sin testing and

mcl's and ucls and this gives me basic

audibility information the patients's

ability to process speech in the

presence of background noise as well as

any loudness sensitivities so only 45

minutes into our appointment I feel like

I've got a really great and

comprehensive view of this patient's

hearing and communication needs so we'll

move on to our plan the first step of

our plan is education and then we get

into a little more specific personalized

plans for each individual patient and

this is where we go back to the proposed

model that we discussed earlier so this

is where we start with the education

resources communication strategies and

then we work our way up the model

through audibility and then possibly

auditory training and the most important

part of this is that this

model cannot happen without the

clinician so this really is a

professional clinician centered model

and it shows that we cannot be helping

our patients our patients problems

cannot be fixed without the professional

there with them they can't just go

online and purchase some hearing aids

and think that everything is going to be

okay so that's why this model following

this model in your plan is so

important so the education starts with

providing the patient with some

important information now education is

something that I feel should be kept

very simple because the patients are

overwhelmed sometimes with all of the

information that we're giving them at

this initial appointment especially if

we're talking to them about hearing aids

as well they are just overwhelmed by the

care and use of the hearing aids how to

change the batteries all of the

technical aspects and so the other parts

of the education that are probably more

important sometimes times get you know

pushed to the back of their mind and

they forget them so the three aspects

that I really try to focus on with my

patients are realistic expectations the

importance of communication partner

involvement and communication strategies

for this particular patient we use the

five keys to communication success

handbook but there are lots of

educational resources available out

there you just want to make sure that

they really are um short and to the

point and fun for the patient to read

and so the way that I assign this

education is I give them the handbook on

the way out the door of their first

appointment but I don't give it to them

as an afterthought it's really important

the way that we assign this information

to our patients because if we give it to

them as an afterthought they're going to

think of it as an afterthought but if we

tell them how important this education

is we tell them that we are going to

follow up on what they've read at their

next appointment and we give give it as

an assignment versus just a suggestion

then they're more likely to read this

when they get home and have have this

information in their brains when they

get back for their next

appointment the next step is to plug our

patients into the local and national

resources that are available in your

area and so the local resources will

include University oral rehab classes

many universities put on community oral

rehab classes that the faculty and the

students put these on at libraries and

community centers and so it's really

great to plug our patients into those

and then the local hearing loss

associations have chapter meetings

usually on a monthly basis and so these

are great because the these allow the

patient to connect with other people who

have hearing loss and understand what

they're going through now I realize that

depending on your location you may not

have a university nearby and you may not

be in a big city that as local um

monthly hearing loss Association

meetings but I still encourage you to

look into these options because you

might be surprised how far a patient is

willing to drive to connect with people

who are understanding what they're going

through so definitely look into the

cities in your area and see if they have

oral rehab classes and hearing loss

Association meetings happening and then

on a national level no matter where you

live you can be plugging your patients

into the hearing LW Association of

America um this is a wonderful

organization the membership to the

hearing loss Association of America is only

only

$35 per year and so it is such a cheap

easy way to provide our patients with

awesome education and that membership

includes the bimonthly hearing loss

magazine and that is like an oral

Rehabilitation class in a bright pretty

shiny magazine that they get in their

mailbox every other month so it is

really worth it in this particular case

my patient was not interested in being

plugged into the local classes she

didn't want to go hang out with other

people with hearing loss although I

think her husband wanted to but she

wasn't interested in that she was

however thrilled with our gift

membership to the hlaa so in our Clinic

we purchase a $35 membership for every

single patient who purchases hearing

aids through us and she loved

that okay so now that we have educated

our patients and we have given them the

resources that they need if they're

wanting to plug into a group class or a

group meeting now it's time to kind of

bring this into a personalized plan for

this individual patient based on the

specific needs that they put forth at

the very beginning and so we use the co-

the goals that they put forth on the

Cozy as our guide for our personalized

plans we use something called the

successful communication plan which goes

along with the five keys to

communication success handbook that I

mentioned earlier these plans can be

downloaded at no charge from the website

at the bottom of the

screen and so we choose those use those

cozy goals we choose three of them and

we add them to our successful

communication plan so in this case I'm

going to go through her goal of hearing

her husband better around the house so

as we complete the successful

communication plan we have to identify

the challenging situation which in this

case is around the house and of course

we need to identify the communication

Partners involved in this case it's her

husband and then we're going to take

them through stepbystep communication

strategies to help them overcome their

communication challenges in in this

environment so this program breaks

communication strategies down into five

different components or keys and the

first key is the environment modifying

the environment so my patient and her

husband have agreed to turn off the

television unless they're actively

watching it because they both said that

it's hard to hear each other when the

TVs on in the background the speaker key

is for the husband he's the speaker in

this case and he agrees to speak slower

he also agrees to go to the same room

that she's in or call her name before he

starts talking to her The Listener key

in this case is for our patient and she

is taking on the responsibility of

asking her husband to rephrase versus

saying what and also to repeat what she

thought she heard rather than saying

what because in our initial assessment

it came out that she says what all the

time even if he hasn't even finished his

sentence so we're going back to what we

learned and discussed in our assessment

as we fill out this form she also agrees

to go to the same room as him before she

starts talking now this is where

auditory training would come in and

we'll get to that in a little more

detail in a second here the technology

key is the next piece of this puzzle the

five keys and so the patient was fit

with hearing aids and she originally

came in saying that she only needed the

hearing aids when she goes to church or

when they go out to eat but after some

counseling and now she has it written in

a plan she has agreed to wear her

hearing aids around the house as well

because that is one of her top

challenging situations and then we also

fit her with a remote microphone and we

discussed when that might be appropriate

around the house as well and then the

fifth key is practice because we know

that none of these tips are going to

sink in right away way so we know they

have to practice these and so we

assigned them the finger touch before

talking practice and this just means

that our patient and her husband have to

touch fingertips before they start

talking to to each other around the

house and this is something that we

assign to couples often it's kind of a

fun game that they play and they they

think it's nice but it really gets them

in the optimal distance from each other

and it also makes them be face to face

before they start talking to to each

other and so it's it's a great practice

strategy okay so let's talk about

auditory training for just a moment

Arthur broid in

2007 defined auditory training as formal

listening activities designed to

optimize speech perception so auditory

training can be clinician directed

meaning the clinician is sitting with

the patient and going through the

training exercises and there are

wonderful clinician directed auditory

training programs some of the resources

for those are the hearing Rehabilitation

foundation and the Ida Institute and

then the next form of auditory training

is computerized auditory training and as

I mentioned earlier this may be a more

feasible option for the busy Private

Practice clinician because it can be

done by the patient at home and doesn't

have to take up Clinic time a couple of

options that we use in our clinic and

that we offer to the patient are the

lace or the listening and communication

enhancement program and the rmq which is

read my quips which is a more of a

game-based auditory training program so

some patients will want to do auditory

training they're very excited about it

but honestly most feel like they don't

have time maybe it's not necessary so

when it comes to auditory training if we

have patients who we feel would benefit

from it either because they are

reporting difficulties in background

noise or difficulties with comprehension

or because they have very poor speech

and noise scores or speech recognition

scores we need to have some auditory

training options in our back pocket

ready to offer these patients and the

way that we deliver it to our patients

is very similar in the way that we

deliver our education it cannot be

thrown out there as an afterthought like

oh yeah if you have time maybe you

should do this program but rather

something that we recommend highly we

think it's really going to help them and

we we give it to them as an assignment

versus an

option so the final part of our

successful plan here is followup now our

patients have been inundated with

information information about the

hearing aids about how to care and use

the hearing aids um information about

education the resources we've been

plugging them in into effective

communication strategies their brains

are on overload and we cannot expect

them to remember all of this on their

own and really followup is so important

long-term consistent followup is

critical for long-term satisfaction and

success so if we are wanting our

patients to do really well with their

treatment to remember what we taught

them to use their hearing aids to

recommend us to their friends and family

members to come back to us for their

next set of hearing aids or if they're

having any difficulties we need to make

sure that a follow-up program is in

place and follow-up can come in the form

of phone calls it can come in the form

of snail mail or traditional paper mail

and it can come in the form of

electronic mails or

emails in our Clinic we have chosen to

use electronic mail or email as our form

of followup we find that email is a

really nice and convenient way to reach

a lot of patients at once and email is

also relatively inexpensive there are

commercially available email programs if

you're wanting to create your own

follow-up emails you can use Constant

Contact or MailChimp and I know there

are others but those are a couple of

suggestions and then there are also

commerci commercially available email

follow-up programs for audiologists and

Hearing Care Professionals so we use the

etip program that goes with the five

Keys communication program and that's

what you see on the screen here it

includes one communication strategy tip

in this case it's a technology tip and

then it includes a homework assignment

for them to help them apply that

strategy to their own life that week and

then finally it ends with the hearing

aid tip also there's a big bold message

at the end of every email that says

please return to your hearing care

provider if you need anything at all so

if even if the patient doesn't open

these e tips they at least have to

delete them and they when they do that

they are thinking about their hearing

care provider and so they think hm that

hearing aid that is sitting in the

drawer over there probably should be on

my ear and I probably should contact my

hearing care provider so we send these

we send these out to our patients on a

weekly basis and they receive them for

an entire year and this really just

helps to keep us connected to our

patients for the long run they're also

very easy for our patients to forward to

their family and friends because

sometimes the tips that we're talking

about are problems that their family

members do like talking from another

room or mumbling or talking with a

napkin near their mouth and so it's kind

of an easy way for our patients to

educate their family members about

fixing these communication issues

without having to say something to them

in person so it's it's a nice way to to

share the education with their family and

and

friends so before I conclude here I have

a question for you what is the most

annoying word to the family members of

someone with hearing

loss and as you'll see on the next slide

what is the most annoying word to the

family members of someone with hearing

loss so it truly is all about focus and

if we focus on hearing aids and

Technology we just aren't able to reach

the patients on a level that makes us

stand apart from the commodity options

that are available out there but if we

focus on communication communication

breakdowns fixing those breakdowns and

the communication need needs of our

patient and their family members we are

solving a much bigger problem than if

we're just fixing the problem of hearing

because we know that hearing loss is

only one part of communication and so if

we're really doing our job correctly we

will be providing a comprehensive oral

rehabilitation program that addresses

all of the communication needs that our

patients come to us with so I hope that

you'll be able to take this information

and use the strategies that I've

provided and some of the tools and the

websites and implement this in your own

clinics as soon as you can thank you for

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YouTube Transcript:Aural Rehabilitation in Private Practice