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Family-Centered Care:Successful Strategies in

Adult Aural RehabilitationK. Todd Houston, PhD, CCC-SLP, LSLS Cert. AVT

ProfessorThe University of Akron

Learning Objectives

u Define family-centered aural rehabilitation and related service delivery models;

u Identify at least three aural rehabilitation strategies and explain how they can be implemented;

u List three outcomes that positively benefit adults with hearing loss after they’ve enrolled in family-centered aural rehabilitation.

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Disclosure Statement Dr. Houston has no relevant financial or nonfinancial relationship(s) with the products or services described, reviewed, evaluated, or compared in this presentation.

Dr. Houston is the author/co-author of Telepractice in Speech-Language Pathology (2014), Assessing Listening and Spoken Language in Children with Hearing Loss (2015), and Telepractice in Audiology (2016), all published by Plural Publishing.

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Current Hearing Loss Statistics by Age

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Hearing Loss Statistics

1 in 6 U.S. adults ages 18 & over report trouble

hearing

=37.5 million U.S. adults

28.8 millionU.S. adults could

benefit from using hearing aids

Only 1 in 4 U.S. adults ages 20 & over who could

benefit from hearing aids has them

1 in 6 adults (16%) ages 20 to 69

1 in 3 adults (30%) ages 70+

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What is Aural Rehabilitation?

“Adult aural rehab is the reducing of hearing loss induced deficits of function, activity, participation, and quality of life through a combination strategies.”

Boothroyd, 2007

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Overall Goal of Aural Rehabilitation

“…to increase the probability that successful communication will occur between a hearing-impaired person and his or her verbal environment.”

(Houston & Montgomery, 2000)

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Status of perceptual training (or auditory brain training) in audiological practices ASHA’s 2012 survey of 2,000 ASHA-certified audiologists from a variety of work settings:

u 17% provide ‘auditory training’ u 4% provided speech reading/lip reading

“There is much current focus on the instrument and so little on the rehabilitation of the user”

(“We Must Return to Our Rehabilitative Roots” Maurice H. Miller, Ph.D, Hearing Review, Mar 2015)

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Technocentric Model of Service Delivery u Audiologists diagnose hearing loss

and prescribe/fit appropriate hearingtechnology

u Technology without aural rehabilitation treatment is not sufficient to produce a successful outcome

u Need a well-rounded approachu Industry is slowly moving in this

direction; AR treatment is taking patient’s life & desired outcomes into consideration and spouses & family members are seen as partners in the process 9

Cognitive Declineu Without proper hearing

intervention, cognitive decline can occur

u When hearing is difficult, the brain requires greater cognitive resources to process auditory signals

u Case studies hypothesize that HL leading to social isolation and decreased quality of life also impacts cognitive decline

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Andragogy = Adult Learning

According to Malcolm Shepherd Knowles, andragogy is the art and science of adult learning, thus

andragogy refers to the art and science of helping adults learn.

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Lecture(5%)

Reading(10%)

Audiovisual (20%)

Demonstration (30%)

Discussion Group (50%)

Practice By Doing (75%)

Teach Others / Immediate Use of Learning (90%)

Average RetentionRate after 24 hours

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Most people forget at least 60% of training delivered within the first 24 hours!

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Knowles’ 4 Principles of Andragogy (that are applied to adult learning)

1. Adults need to be involved in the planning and evaluation of their instruction.

2. Experience (including mistakes) provides the basis for the learning activities.

3. Adults are most interested in learning subjects that have immediate relevance and impact to their job or personal life.

4. Adult learning is problem-centered rather than content-oriented.

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Adult Learning Theory

u bring knowledge, skills, attitudesu bring experienceu like to solve problemsu like to apply what they learn to real situationsu like to have choicesu like to share in the setting learning objectivesu have variety of learning styles/preferencesu do best in an environment where they feel safe, accepted, and

respectedu want and need feedbacku need to have their abilities and achievements honored

Adults …….

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Adult Learning Principles

ubring knowledge, skills, and attitudes

ubring experience

Adults …….

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Adult Learning Principles

uLike to solve problems

uLike to apply what they have learned to real problems

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Adults …….

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Adult Learning Principles

uLike to have choices

uLike to participate in the setting of goals and objectives

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Adults …….

Adult Learning Theory

uHave a variety of learning styles & preferences

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Adults …….

Adult Learning Theory

u Do best in an environment where they feel safe, accepted, & respected

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Adults …….

Adult Learning Theory

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Adults …….

u Want and need feedback

u Need to have their abilities & achievements honored

Patient/Family-Centered Core Concept

u Patient- and family-centered care is working with patients and families, rather than providing services “to” or “for” them.

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Patient/Family-Centered Care:Core Concepts

u People are treated with respect and dignityu Health care providers communicate and share complete

and unbiased information with patients and families in ways that are affirming and useful

u Patients and families are encouraged and supported for participation in care and decision-making at the level they choose

u Collaboration among patients, families, and providers occurs in policy and program development and professional education, as well as in the delivery of care

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Why Patient/Family-Centered Care?

u Individuals who are most dependent on health care are most dependent on families:u Those with chronic conditionsu The very young

u The very old

u Families are allies for quality and safety by:► Providing constant support across settings

and assisting with transitions of care

► Participating in developing care plans and supporting patients in following plans

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What is Family-Centered Care?

u Supports the whole family as a unitu Includes spouses, children, close family friends

u Empowers family choice and decision-makingu Establishes a collaborative relationship between the

provider and family membersu Encourages support group attendance for all family

members

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The Importance of Family-Centered Care

uThe World Health Organization describes the impact of hearing loss on families as a third party disability.

uWhen one person is affected, those around them are affected as well

uSpouses report:uFeeling the burden of communicationuFrustrationuA change in their relationship, loss of intimacy uThey avoid socialization and daily activities

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Benefits of Family-Centered CareuMore effective than patient

centered careuProvides more relevant

functional therapy activities that address the individual and family needs

uReduction in the impairmentuBetter communication outcomesuAn improvement in family

relationshipsuGreater family engagementuHigher patient satisfaction 34

Creating Family Centered Careu Arrange the physical environment to accommodate the familyu Inform the family that you are seeking and value their inputu Obtain case history and questionnaire assessments from both the patient as

well as their family u Acknowledge communication challenges for both partiesu Develop goals that address the needs of both the individual and their spouse,

family or caregiveru Goals should address the needs of both the patient and spouse, family

u Encourage spouses or family members to join therapy sessionsu Provide ongoing counseling

u Acknowledge emotions, ask open ended questions, re-state concerns, and wait

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Role of the Family

u Practice good communicationu Be patientu Attend audiologist appointments togetheru Provide your inputu Be flexibleu Participate in the aural rehabilitation process

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Client/Family Educationu Vital for patient to understand their level of hearing loss and what to expect in

the future

u Spouse or family member should tag along in the meeting to become educated on the patient’s needs

u Discuss topics regarding HA or CI with the audiologistu How to work the device

u What to do if technology is failing

u What will the device do/not do

u Rearrange household u Have furniture face each other

u Use lighting in conversational areas

u Carpet absorbs noise

u Background noiseu Request table away from kitchen/walk in area in restaurant setting

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Lois’ Journey

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Adult Aural RehabilitationAudiology & Speech Center

School of Speech-Language Pathology & Audiology

The University of Akron Akron, OH 39

12 Principles of Aural Rehabilitation

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1.Treatment should always adjust to the specific needs of the patient

2.Educate to empower patients to advocate for themselves3.Model effective communication4.Work together with the patient to develop communication

goals & definition of success5.Provide individual and group therapy options, support

groups6.Offer opportunities for successful communication in

therapeutic activities as well as “real world” settings

12 Principles of Aural Rehabilitation

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7. Promote clinician-patient rapport through counseling8. Discuss realistic expectations9. Role-playing for functional communication events10.Incorporate hearing assistive technology11.Provide listening strategies for various situations12.Incorporate active involvement of communication

partners (i.e. spouse, family members) in every step

Assessment and Beginning Therapy

u Determine Strengths and Weaknessesu Formalized tests, checklists, interviews

u Determine where they are in the listening hierarchyu Detection, Identification, Discrimination, Comprehension

u Discuss needed supports, therapy model for intervention, and counsel the family

u Develop family centered goals and determine functional activities for intervention

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Questionnaires for Assessment of Listening Difficulties

u Communication Confidence Profile (CCP)u EXAMPLE: If you are having trouble understanding, how

likely are you to ask a person you are speaking with to alter his or her speech by slowing down, repeating or rephrasing? (1-5, Extremely-Not at all)

u Qualitative Outcomes Assessment for clEAR (QOAC)u EXAMPLE: We are having dinner at a restaurant. There is

background music. I have to ask my partner to repeat something: (1-7, None of the time-All of the Time)

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Adult Aural Rehabilitation Strategies As Boothroyd (2007) describes, the four components of

aural rehabilitation include:

• Sensory management -- to target & enhance auditory function

• Instruction – to increase the probability of positive outcome from sensory management

• Perceptual training – to target activity, by supplementing the learning opportunities provided by everyday communication

• Counseling – to target issues of participation & quality of life that result from residual deficits of function & activity.

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Sensory Management & Instructionu Types of hearing technology you

may needu Cochlear Implantsu Hearing Aids

u Behind the Ear Hearing Aids (BTE)u In the canal (ITC)u Completely in the canal (CIC)u Receiver in the Canal (RIC)

u Bone Anchored Hearing Aids (BAHA)

u Hearing assistive technology45

Sensory Management & Instruction: Hearing Assistive Technology

u Assistive technology can help individuals with hearing loss in difficult situations and improve quality of life

u Assistive devices may include:u Cell phone adaptationsu Personal amplification u Alert systemsu Home amplification systemsu Hearing loopsu Closed captioning

u Hearing assistive technology can be used as a support to make communication more effective.

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Perceptual Training

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Goals: • Enhance auditory perception skills, • Increase conversational confidence and

fluency

Patients differ in how they improve in these skills

• Some learn spontaneously• Some need the help of a family member or

close friend• Some need guidance with encouragement to

have the confidence to improve their perceptual skills and have the confidence to use these new skills

Many patients can benefit from active perceptual training

“Adult Aural Rehabilitation: What is it and does it work? Arthur Boothroyd, PhD., Trends in Amplification, Volume 11, No.2, June 2007, 63-71.

Are hearing and listening the same thing?

uHearing allows you to receive acoustic information (speech)

uListening requires your brain to attend to and interpret speech

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Can’t hearing aids or cochlear implants solve all listening problems?

Hearing technology reduces listening problems, but alone they cannot develop the listening and mental skills that are necessary for comprehension.

We need to help the brain interpret the information it is receiving!

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Top-Down vs. Bottom-Up Strategies

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• Bottom-up Strategies– Analytic Training– Segmental and

suprasegmental level– Pitch, intonation,

stress, timing– Phoneme level

• Top-Down Strategies– Synthetic Training– Sentence & phrase

training– Relies on linguistic

context, conversation– Communication

breakdown/repair

Aural Rehabilitation Testimonial

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Instruction: Self Awareness & Self Advocacy

u Important to not be afraid to ask for the communication partner to repeat their statement or question

u Explain your hearing loss to the communication partner, othersu Type of equipment you ownu How to work itu Why you are wearing it

u Close family members and relatives must advocate for the person who has a hearing loss in all environments u Explain person has hearing lossu Ask for repetitionu Not polite to discriminate

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Repairing Communication Breakdowns

u Ask the speaker to repeatu Ask the speaker to face youu Ask the speaker to slow down u Ask the speaker to rephraseu Listen for keywords when there is a topic

changeu Repeat back what you heard u Ask questionsu Mention that you are interested in what was

said, and you would like for them to repeat 53

UA Continuum of Aural Rehabilitationu Individual Aural Rehabilitationu Community Therapy

u Taken out of speech room, to a natural environment

u Working on phone conversations

u Role-playing u Listening in noise u Using normal, everyday items in

functional situations u Teaching self-advocacy

strategiesu Telepracticeu Support Group: Hear No Fear

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Bottom Up, Community Therapy, & Counseling

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We are here to provide a supportive group environment for adults with hearing loss and their families to learn and share their unique experiences. We strive to provide a place for communication opportunities, growth, education and encouragement from others.

Hear No Fear: A Hearing Loss Workshop For Adults with Hearing Loss and their Families

u Introductionsu Educational Topicu Sub-groups

u Family members/supportu Adult with Hearing Loss

u Discussion Pieceu Strategiesu Advocacyu Journeyu Assistive Technologies

u Game/Social Breaku Wrap up/Share Take Aways

Hear No Fear:A Hearing Loss Workshop For Adults with Hearing Loss and their Families

Hear No Fear: Sample Topics

u Anatomy & physiology of hearing

u Audiogram & speech perception

u Caring for hearing technology: hearing aids & cochlear implants

u Candidacy – Cochlear Implantsu Assistive Listening Devices,

Loop Systemsu Auditory learning/training

u Coping with hearing lossu Conversational Repair

Strategiesu Implications of the ADA & other

policies/lawsu Cognitive Issues / Reinforcing

Brain Healthu Insurance & Medicare Issues

related to hearing loss coverageu Deaf Culture vs. Hard of

Hearing

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Hear No Fear: Support Group

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Hear No Fear: Meet Jim & Jean

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Telepractice: Jim

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Reimbursement for Aural Rehabilitation

u Medicare will reimburse for audiologic diagnostics, but not audiologic treatment (i.e. aural rehab provided by audiologists)

u The Affordable Care Act includes rehabilitation as part of 10 essential benefits for health care plans

u SLPs and Audiologists can cooperate to create better outcomes and reimbursement levels for clients

u Continued advocacy to state and national legislators is necessary to keep reimbursement for aural rehabilitation services

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Charging for Aural Rehabilitation

uBundled PricinguIncluded with hearing aid sales

uUnbundled Pricing uIncluded in a service package

u Itemized uIndividually

u Community Support 63 64

Trends for the Futureu Individuals are living longer.u Technology:

u Increased number of individuals who can now benefit from digital hearing technology and cochlear implants.

u More individuals are embracing technological solutions to augment or enhance their lifestyles.

u Increased movement to interprofessional collaboration and person-centered/family-centered service delivery models.

u Greater emphasis on outcome-based solutions that are evidence-based; insurance companies want higher valuate for their funding.

u Shifting focus to prevention (cognitive issues) and improved quality of life.

ResourcesAdmin, B. (2014, January 29). Communication repair strategies for smooth conversation. Retrieved November 03, 2016, from

http://www.captel.com/news/hearing-loss/communication-repair-strategies-smooth-conversationBoothroyd, A. (2007). Adult Aural Rehabilitation: What Is It and Does It Work? Trends in Amplification, 11(2), 63-71. doi:10.1177/1084713807301073.Cochlear Implants | NIDCD. (2016, May 3). Retrieved November 12, 2016, from https://www.nidcd.nih.gov/health/cochlear-implants Dowd, K. (June 2015). When Hearing Loss Goes Unnoticed. The ASHA Leader, Vol. 20, 44-49. doi:10.1044/leader.FTR2.20062015.44.English, K., Jennings, M. B., Lind, C., Montano, J., Preminger, J., Saunders, G., Singh, G., Thompson, E. (2016). Recommendations for moving

forward a family-centered model in hearing healthcare. Family-Centered Audiology Care: Working with Difficult Conversations. Hearing Review. Hearingreview.com/2016/07/family-centered-audiology-care-working-difficult-conversations/.

Family Support: What is my role as an audiologist and speech-language pathologists? (2013.) Accessed November 3, 2016, fromhttp://www.asha.org/Events/live/04-30-2013-Family-Support/

Fin, F. R. (2011). Hearing loss and cognition among older adults in the unites states. J Gerontol A Biol Sci Med Sci. 2011 October;66A(10):1131-1136 doi:10.1093/gerona/glr115

Grenness, C., Meyer, C., Scarinci, N., Ekberg, K., & Hickson, L. (2016). Functioning, disability and health as a framework for providing patient- and family-centered audiological care for older adults and their significant others. Seminars in Hearing 37(3). 187-199.

[Hearing Aids]. (2015, May 14). Retrieved November 3, 2016, from https://prezi.com/hqpzvhzd-yym/hearing-aids/ Hickson, L., Worrall, L. & Scarinci, N. (2015). ACE: Active Communication Education – A program for adults with hearing

loss. The University of Queensland: AustraliaIncidence of Severe and Profound Hearing Loss in the United States and United Kingdom. (2013, May 10). Retrieved November 12, 2016, from

http://www.audiology.org/news/incidence-severe-and-profound-hearing-loss-united-states-and-united-kingdom Infographic: Hearing Loss and Hearing Aid Use | NIDCD. (n.d.). Retrieved November 03, 2016, from https://www.nidcd.nih.gov/shareable-

images/infographic-hearing-loss-and-hearing-aid-use

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ResourcesInclusive Hearing - Auris Hearing Loops. (n.d.). Retrieved November 03, 2016, from http://aurisloops.com/ Kaland, M., & Salvatore, K. (2002, March 19). The psychology of hearing loss. The ASHA Leader, 7(5), pp. 4–5, 14–15.Kramer, S. E., Allessie, G. H., Dondorp, A. W., Zekveld, A. A., & Kapteyn, T. S. (2005). A home education program for older adults with

hearing impairment and their significant others: A randomized trial evaluating short- and long-term effects. International Journal of Audiology, 44, 255–264

Knudsen, L. V., Öberg, M., Nielsen, C., Naylor, G., & Kramer, S. E. (2010). Factors Influencing Help Seeking, Hearing Aid Uptake, Hearing Aid Use and Satisfaction With Hearing Aids: A Review of the Literature. Retrieved November 12, 2016, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4111466/

Montgomery, A. A. & Houston, K. T. (2000). The hearing-impaired adult: Management of communication deficits and tinnitus. In Alpiner, J.G. & McCarthy, P. A. (Eds.), Rehabilitative Audiology: Children and Adults. Third

edition. Lippincott Williams & Wilkins: Baltimore.Oyler, A. L. (2012). Untreated Hearing Loss in Adults-A Growing National Epidemic. Retrieved November 11, 2016, from

http://www.asha.org/Articles/Untreated-Hearing-Loss-in-Adults/ Peyrot, M. (2013, November 25). DAWN2: A multi-national, multi-stakeholder study and strong action platform to promote person-centred diabetes care. Retrieved November 03, 2016, from http://www.idf.org/diabetesvoice/issue-4-2013/peyrot Resolve to support your spouse with hearing loss. (2014, January 28). Accessed November 3, 2016, from

http://www.healthyhearing.com/report/51764-Resolve-to-support-your-spouse-with-hearing-lossState, B. (2016). Resolve to support your spouse with hearing loss. Retrieved November 03, 2016, from http://www.healthyhearing.com/report/51764-Resolve-to-support-your-spouse-with-hearing-loss

Scarinci, N., Meyer, C., Ekberg, K., & Hickson, K. (). Using a family-centered care approach in audiologic rehabilitation for adults with hearing impairment.http://perspectives.pubs.asha.org/

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ResourcesI

Tye-Murray, N. (2009). Foundations of aural rehabilitation: Children, adults, and theirfamily members. Third edition. Delmar: New York.

Wynn, R. (2015, April 14). Hearing Aids and the SLP. Accessed November 3, 2016, from http://graymattertherapy.com/hearing-aids-and-the-slp/

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Comments…Questions…

Ideas…

Thank You for Listening!K. Todd Houston, PhD, CCC-SLP,

LSLS Cert. AVTEmail: houston@uakron.eduOffice: (330) 972-6141Facebook: K Todd HoustonSnapChat: KToddHoustonTwitter: ktoddhoustonLinkedIn: www.linkedin.com/in/toddhoustonLinkedIn Groups: 6 Sound-Off

Telepractice In Speech-Language PathologyTelepractice In Audiology

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