1.  ASSESS PATIENT PRESENTING PROBLEM AND NEEDS

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 Expected Outcomes

• Identification of factors in the patient’s background that may put him at risk for hearing problems.

• Identification of FDA red flags that would require a referral for medical evaluation.

• Identification of other medical problems that may have an impact on the methods used for procedures and/or expected outcomes of hearing aid fitting.

• Identification of family members’ concerns regarding patient’s hearing difficulties.

• Exploration of patient attitudes and expectations of amplification.

• Identification of problems with hearing and understanding.

• Identification of daily activities and impact of hearing loss on lifestyle.

• Identify impact of hearing loss on family, friends, and in the workplace.

 

Indication for Procedure

• Individuals being seen for either hearing screening or hearing evaluation.

 

Procedure Methods

• Typically consists of a combination of written answers to a series of questions, elaboration of those answers by oral questioning, and behavioral observation.

• Areas covered include but are not limited to:  family history of hearing loss, incidence and duration of childhood hearing-related illnesses, information regarding dizziness, loss of balance, or tinnitus, current medication/drug history, history of noise exposure and acoustic trauma.  In addition it is critical to elicit family members concerns about patient’s hearing difficulties, the patient’s attitudes and expectations regarding amplification, and the patient’s own assessment of their hearing difficulties.

• Additional areas that must be covered include but are not limited to questions regarding history of ear surgeries, diseases and treatments, information regarding past experiences with amplification, questions and observation regarding ear deformity, pain, sudden hearing loss, ear infection, disease, drainage or blockage requiring medical referral. 

 

 

 

2.  TEST AND ANALYZE HEARING

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Expected Outcomes

• Basic hearing evaluation is conducted to quantify and qualify hearing loss on the basis of perceptual responses to acoustic stimuli and to describe any associated communication disorders.

• Results of the evaluation may result in recommendations for more advanced testing, medical referral, amplification consultation, assistive listening device consultation, or follow-up recommendations.

• Speech discrimination tests are performed for additional information about a hearing loss.

• Evaluation may result in recommendation for a medical referral, amplification, aural rehabilitation, and/or counseling.

• Determine need for medical referral based on audiometric air-bone gap results.

• Determine degree, type, and configuration of hearing loss from test results.

• Hearing instrument efficacy will be determined by pre-post audiometric measures.

 

Indications for Procedures

• Hearing evaluation may be done when a hearing screening is failed.

• Hearing evaluation is generally prompted by self-referral, family referral, failure of an occupational hearing test, or referral from other professionals.

 

Procedure Methods

• Hearing evaluation is preceded by eliciting the hearing history and assessing the hearing problem.  This is followed by examination of the external ear canal and cerumen management, if necessary.

• The standard audiometric tests consist of pure-tone air and bone conduction testing with appropriate masking using the TDH-39 standard.  It is our recommendation that all providers move to the EAR-3 or equivalent insert earphones standard by July 1, 2005.  Some professionals also choose to do loudness growth testing at this time.

• Speech testing includes speech awareness and/or speech reception threshold tests, speech discrimination tests, and establishing MCL and UCL thresholds (appropriate masking used as required).  In addition further information can be gained by doing unaided and aided sound-field discrimination tests and by testing binaurally as well as monaurally.

• Special audiometric tests are performed for additional information about a hearing loss.

• Evaluation may result in recommendation for a medical referral, amplification, aural rehabilitation, and/or counseling.

• Procedures such as immittance audiometry (tympanometry and reflexes) are quite common.

• Evaluate the reliability and validity of the test results.                     

• Evaluate test results to determine the presence of collapsed ear canals.

• Evaluate aided sound field measures and/or real-ear aided performance measures or Live Speech Mapping.                             

                                                            

                                                                       

 

3. ANALYZE HEARING AIDS 

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Expected Outcomes

• In consultation with the patient and family, taking into account their lifestyle, special needs, hearing aid style, technology, and price category preferences, selecting the hearing aid that will best fit their needs.

• Provide measurable results of improved hearing thresholds and ease of communication.

• The appropriate specifications for the hearing aid will be selected.

 

Indications for Procedure

• Individuals identified with hearing loss who have reached a level of acceptance regarding their loss that they are ready to seek help from amplification.

 

Procedure Methods

• Determine hearing aid needed for severity, type, and configuration of hearing loss, keeping in mind the patient’s history, lifestyle, and audiogram.

• Discuss with patient the various levels of technology and their different price categories to aid in determination of hearing aid selection.

• Identify physical limitations affecting hearing instrument selection. 

• Prior to dispensing the hearing aid, verification of hearing aid performance is conducted via a listening check to rule out excessive circuit noise, intermittency, and/or poor sound quality. 

• Perform electroacoustic analysis to determine if hearing aid is performing according to manufacturer’s specifications.

• Confirm telecoil function.

• Programmable and digital hearing aids should be programmed prior to patient’s arrival to ensure integrity of programming system and hearing aids.

 

 

 

4.  FIT, ADJUST, AND SERVICE HEARING AIDS

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Expected Outcomes

• Appropriate earmold/hearing aid shell configuration and material will be selected for maximum comfort and hearing aid performance.

• Alleviation of a problem with physical or acoustic comfort (i.e., occlusion, loudness, discomfort)

• Restore the aid to manufacturer’s specifications.

 

Indications for Procedure

• Patient is being fitted for new amplification.

• Patient or family report a problem with the function, comfort, or benefit being received from the hearing aid.

 

Procedure Methods

• Assess ear canal for ear impression vis-à-vis size, length, and direction.

• Perform proper ear impression procedures, e.g. otoblock placement.

• Determine earmold/hearing aid shell configuration and material.

• Examine surface of earmold and instrument for damage and sharp edges.

• Perform physical fitting of coupler and instrument.

• Appropriateness of physical fit should be assessed through ease of insertion and removal, cosmetic appeal, comfort, absence of feedback, placement of microphone port/ports and ease of volume control use when present.

• Program selected hearing aids to patient’s baseline audiometric data.

• Adjust/modify hearing instrument electronics based on patient feedback.

• Make venting modifications as needed for reduction of occlusion effect and or to control feedback.  Modify shell or ear mold for improved, more comfortable fit.

• In the event the patient returns with a malfunctioning hearing aid, conduct in-office internal inspection of ear mold and instrument and take appropriate corrective action (suctioning wax and debris from receiver and microphone ports, cleaning corrosion from battery contacts, replace earmold tubing, etc.). Conduct electric current drain measurement of hearing aid.  If in-office repair is not possible return aid to manufacturer for repair and offer the patient a loaner hearing aid to use while his is being repaired.

• If the hearing aid needs to go to the factory for repair, and it is out of warranty, inform the patient of the charges and repair warranty.

• Validation of fitting should be done either with sound field testing using frequency specific thresholds and/or aided speech discrimination and speech reception thresholds or with real ear aided measurements or with Live Speech Mapping.

• Reprogram hearing aids based on patient feedback.

 

 

 

5.   COUNSELING AND AURAL REHABILITATION

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Expected Outcomes

• Dispensers assist patients in coming to grips with the reality of their hearing loss and in the process of accepting amplification or other assistive listening devices.

• Dispensers educate the family and the patient in the ramifications of a hearing loss and what is a reasonable expectation for improved communication with amplification.

• To facilitate listening in various acoustic environments.

• To provide alerting systems.

• To augment the benefits of the hearing aids.

• To establish procedures for follow-up.

• To provide information to allied health-care professionals.

 

Indications for Procedure

• Individuals who have had their hearing evaluated.

• Individuals who are being fitted with amplification.

• Individuals who need more help than their hearing aids can provide in various situations.

 

Procedure Methods

• Explain otoscopic examination and audiometric assessment to patient.

• Discuss patient’s reactions to hearing instruments.

• Discuss with patient various treatment options e.g., different levels of technology, different styles of hearing instruments.

• Provide patient with hearing rehabilitation exercises (several of the manufacturers have good programs for this as well as programs found in the literature).

• Explain hearing instrument use in different listening environments.

• Instruct patient on proper instrument insertion and removal techniques.

• Counsel patient on cerumen management.

• Counsel patient regarding care and use of instrument.

• Counsel patient on battery life and insertion/removal techniques.

• Counsel patient on telephone usage with hearing instruments, and assistive listening device coupling as necessary.

• A hearing aid usage schedule is determined.

• Counsel patient on amplification expectations and limitations.

  • Discussion of appropriate expectations for amplification include: improved communication, freedom from unwanted feedback, minimization of the occlusion effect, and more auditory benefit in quiet than in noise.

  • Patient is advised of their legal rights for hearing aid adjustment, replacement and return.

  • Self-assessment tools that measure degree of hearing handicap, and/or pre- and post-fitting satisfaction are an appropriate tool for measuring patient satisfaction.

• Instruct patient/family in effective listening techniques with hearing aids.

• Counsel family members about patient’s adjustment and use of hearing aids.

• Provide patient with information concerning environmental modifications that can ease communication.

• May provide patient with information on speech reading or other aural rehabilitation classes.

• May also include demonstration and information on devices to enhance:

                          - telephone usage

                          - listening to television

                          - listening in church

                          - listening in restaurants and other difficult listening environments

                          - listening in the classroom or auditoriums

                          - telephone, doorbell, smoke alarm alerting systems

• Formulate long-term treatment program

• Establish methods for recording care from treatment to rehabilitation.

• Counsel patient on importance of follow-up visits.

 

 

 

6.  OFFICE AND PRACTICE MANAGEMENT

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Expected Outcomes

• Equipment will be maintained according to sanitary guidelines and manufacturer’s specifications.

• Records will be maintained in an organized and efficient manner.

• Clinical/ professional knowledge and skills will be current.

 

Indications for Procedure

• To standardize professional standards and practices.

 

Procedure Methods

• Maintain equipment to standards of sanitation and cleanliness.

• Supervise sanitization and cleanliness of office personnel.

• Maintain equipment according to manufacturer’s specifications.

• Conduct biologic check of audiometric equipment.

• Perform cerumen management procedures using standard techniques/equipment.

• Recruit, train and develop professional and administrative staff.

• Establish supervisory procedures to ensure quality care.

• Develop marketing and advertising plans.

• Provide certification to patient to receive amplified telephone systems where appropriate.

• Identify sources of patient referrals.

• Establish and maintain quality assurance procedures.

• Adopt and follow a professional code of ethics.

• Maintain adequate professional liability protection.

• Design, implement, and monitor hearing care/conservation programs.

• Know governmental laws and guidelines affecting the dispensing profession.

• Update clinical/professional knowledge and skills.

• Attend professional seminars, conferences, and association conventions.

• Maintain patient records in accordance with governmental regulations.

• Develop and maintain effective patient/business information systems.

• Formulate short and long range business plans.

• Upgrade office computer systems (hardware and software).

 

If you have any questions, or would like additional information, please contact me at 734-522-2900 or email me at the email address below.

 

Regards,

 

Linda K. Jackson

Executive Director, NBC-HIS