Threats and Opportunities to Audiology

1. Threats and Opportunities to Audiology Catherine V. Palmer, PhD School of Health and Rehabilitation Science Department of Communication Science and Disorders School of Medicine, Department of Otolaryngology Director, Audiology, UPMC

3. Introductions Director, Audiology for a large integrated health system. 24 locations, 51 audiologists (pediatric and adult) Director, University of Pittsburgh Auditory Processing Research Lab (5 PhD students) Clinician AuD program Director

4. What is good for the patient has to be good for the profession… THREATS OPPORTUNITIES OTC HAs (devices separate from services; differentiating ourselves) 3rd Party Contractors (defining reasonable pay structures) Medicare Coverage (opt out to provide choice for patients and audiologists) Practicing across the scope Extending our reach Outcome measures Plan for needed practice data • OTC HAs • 3rd Party Contractors • Medicare Coverage • Specializing • Not utilizing assistants • Lack of Outcome measures • Not having our own data Disclaimer: I could be wrong

5. What did you do this week?

6. What did you do this week? Did you reduce hospitalization and general health care use?

7. What did you do this week? Did you lower mortality in community-dwelling older adults?

8. What did you do this week? Did you reduce the odds of your patient falling?

9. What did you do this week? Did you reduce the chance of your patient suffering from depression or social isolation?

10. What did you do this week? Did you decrease the burden of disease on your patient and the health system?

11. What did you do this week? Did you decrease hospital readmissions?

12. What did you do this week? Did you reduce caregiver burden?

13. What did you do this week? Did you increase adherence to treatment recommendations?

14. What did you do this week? Did you reduce accidental injury and adverse medical events?

15. What did you do this week? Did you insure accurate oral questionnaire based assessments given to patients?

16. What did you do this week? Did you reduce total medical expenditures?

17. What did you do this week? Did you decelerate brain atrophy?

18. What did you do this week? Did you increase satisfaction with overall quality, accessibility, and receipt of information related to health care?

19. What did you do this week? Did you reduce the amount or rate of cognitive decline?

20. What did you do this week? Did you insure that a child will fully access educational and employment opportunities?

21. Identifying hearing loss is important and under-treatment may be costly for the patient, the family, and the health care system Short term associated risks Long term associated risks • Increased odds of falling • Poor adherence to treatment recommendations • Increased accidental injury and further medical difficulties • Increased preventable adverse medical events • Increased readmission to the hospital • Dissatisfaction with overall quality, accessibility, and receipt of information related to their healthcare • Independently associated with lower ratings patient-physician communication and overall healthcare • More vulnerable to and tended to suffer more from the ill effects of depression • Prevalence of depression increased as untreated hearing loss became worse • Associated with an increased odds of social isolation in women aged 60 to 69 • Linked to higher rates of mortality in community dwelling older adults • Increased rates of hospitalization • Increased rates of general health care use • Poorer overall health and burden of disease

22. Negative Consequences $3.30 Billion in excess total medical expenditures CMS now bases 25% of hospital payments on patient satisfaction Increased hospitalization 3 times more likely to experience a preventable adverse event 1/3 requiring readmission to the hospital Decreased satisfaction with overall quality, accessibility and receipt of information related to their health care

23. Disclaimer • Focus on older adults today • Pediatrics • Speech and Language Outcomes • Yoshinaga-Itano et al (Pediatrics, 102(5) 1161-1171, 1998) • Outcomes of Children with Hearing Loss Study (factors that moderate the relationship between hearing loss and longitudinal outcomes) • Education and Income Loss (tax base loss)

24. Untreated HL

26. “…although hearing loss and cognition are linked, untreated hearing loss drives the association”

27. What has been our approach?

28. Audibility

29. Quality of Life

30. Does treating hearing loss improve health outcomes Therefore saving money – for the individual, for the health care system, for the healthcare insurer (Different from does the person hear better…) Our colleagues focused on balance already do this well. The Larger Question is…

31. 60% Over the age of 65 have hearing loss 18% People with hearing loss wearing hearing aids

32. Hearing loss: under-recognized ~50% Of health providers recognize hearing loss ~40% Of people who have hearing loss recognize it Data from Mormer et al

33. Something to consider, we are very good at identifying hearing loss in babies, but we expect adults to self-identify Expected, but no benign

34. Thinking out of the booth: Interventional Audiology Go to where the patient is Improve communication when hearing loss is not the primary concern Meet the health care provider where they are

35. Example Programs • Inpatient • Interdisciplinary Clinics • HearCARE • EAR Program

36. Inpatient Setting

37. Inpatient – Joint Commission on Accreditation of Health Care Organizations (JCAHO) • Full participation in decision making • Patient and family centered care • Provision of Care, Treatment, and Services • PC.02.01.21 The hospital effectively communicates with patients when providing care, treatment, and services. • Rationale: this standard emphasizes the importance of effective communication between patients and their providers of care, treatment, and services. Effective patient-provider communication is necessary for patient safety.

41. “We don’t get paid for these services.” • Means “we are not reimbursed by insurance providers for these services” • Presumably, if you bill a person or system, you will get paid.

42. Does an audiologist need to deliver these services? Does an audiologist need to oversee these services?

43. Letting health care providers know about our services… • Systemwide Extra Title: Can You Hear Me Now? • Clinical Screensaver Do you know if your patient has hearing loss? It might not be easy to spot. Search for the video “Disabilities Debunked 102: Hearing Loss” on Infonet to learn more. Thanks to Sarah Katz with Internal Communications who guided us through this process. • Video • Disabilities debunked

44. The primary goal of our Head & Neck Cancer Survivorship Clinic is to identify and treat unmet needs among our survivors. Note that audiology is listed first Untreated hearing loss can negatively impact healthcare interactions and outcomes.

45. Audiology Protocol for all Survivorship Patients Screening Intervention Otoscopic examination • Other audiology services available: • Cleaning & checking hearing aids • Comprehensive hearing tests • Wax removal (referred to otologist) • Discussion of hearing protection Recommendations

46. Head & Neck Cancer Survivors are not “average” Americans. ENT Survivorship patients with hearing loss (as of 7/12/18) Americans with hearing loss (Lin et al, 2011) 20% 77% ENT Survivorship patients reporting tinnitus (as of 7/12/18) Americans with tinnitus (Kochkin et al, 2011) 15% 31% 1/3 accepted amplifier

47. Survivorship Follow-Ups (19%) (54%) (50%) (62%)

48. The Post-Trauma Clinic’s goals are to consolidate rehabilitative resources and facilitate optimal recovery following a traumatic incident which requires the services of our primary hospital’s Trauma Unit. Green = go! Normal Hearing – no communication adaptations necessary. Yellow = be careful! Pt with hearing loss. Remember: clear speech, face-to-face, good lighting, reduce noise. Pt with significant hearing loss. Please use amplifier for appt. Remember: clear speech, face-to-face, good lighting, reduce noise. Red = potential danger zone! Pt with significant hearing loss. Pt to use personal hearing aids for appt. Remember: clear speech, face-to-face, good lighting, reduce noise.

49. Americans who can’t pass a 25 dB hearing screening (Lin et al, 2011) Post-Trauma Clinic patients who can’t pass a 25 dB hearing screening 20% 40% 8% accepted amplifier

50. Silos of Intervention • 2014 Census Bureau’s American Community Survey • 36% of older adults reported some type of participation limitation with many reporting more than one impairment (8) • CDC estimates that 59.8% of individuals 65 and older have complex activity limitation related to multiple impairments