In part 1 of this email exchange between Elaine Saunders and Brian Taylor, Dr. Saunders shared her thoughts on self-fitting hearing aids and how her company, Blamey Saunders Hears, is shaping the future of hearing healthcare. In part 2, they discuss the integration of tele-audiology with traditional face-to-face care, and how the combination of the two approaches can reach more people in need of hearing care services.
BT: How does Blamey Sounders Hears triage patients?
ES: Blamey Saunders has adapted the Goldstein and Stephens (1981) model to incorporate teleaudiology. This provides the triage pathway through a comprehensive evaluation of the client’s attitude towards digital health and their audiological complexity. In our team we have trained teleaudiologists to be expert in triage management with the primary role to help the client identify their most suitable or preferred path forward, with a focus on empowerment and enablement. This role can be likened to a coach.
We map our triaging against Stephens’ Types:
Type 1 people are positively motivated without complicating audiological factors.
From a teleaudiology perspective these people are motivated, self-sufficient and will be keen to control their own healthcare. Any tools, systems and processes in an eHealth model should provide ease of access for these people to self-help.
Type 2 people are positively motivated but have complicating audiological factors.
In an eHealth model these people require a blended service approach. They need to build trust and confidence in their own ability to make decisions – along with the role of the clinician as coach. A mixed model should enable these clients to drop in and out of moderate-to-low service needs as their confidence peaks – tools should focus on online help in tandem with verbal confidence boosting via phone a low-touch face-to-face clinician service provision.
Type 3 people want help but reject the idea of hearing aids, lacking the effort or understanding and persistence that sometimes is needed to cope with hearing loss.
Teleaudiology offers interesting prospects for this group – it is almost the “tale of two cities” – on one hand it could be argued that this client needs the assistance and assurance of a clinician face-to-face. On the other hand this client could do very well with a “circuit breaker” approach that shifts attitudes from the old, tried, and not trusted, to a new approach. Of critical importance, as with each of the segments yet more so here, will be the ability to bring the client’s family along the journey. True family centered care via video counselling – right into their living room! Type 3 provide an interesting challenge for clinicians but one well worth tackling through an innovative service model that respects their view point.
Type 4 are the biggest challenge, as this group denies any personal hearing problem.
This group requires education and facilitation that would be best handled face-to-face. Little can be gained via a teleaudiology intervention.
(For more on the four patient types described above see this recent article.)
BT: What is the scientific evidence underpinning this approach you describe?
ES: David Goldstein and Dai Stephens collaborated in the early 1980s to improve the integration of the various aspects of auditory enablement with the needs of patients. This led to the development of a ‘management model’ of audiological rehabilitation (Goldstein and Stephens, 1981). The model was developed further with collaboration with Patricia Kerr and later Sophie Kramer. Indeed, the authors also acknowledge input from Louise Hickson, and inspiration from the renowned William Burns. These studies and incremental developments ultimately lead to the publication of “Living with Hearing Loss: The Process of Enablement”, where the authors also note the influence of the theories of neurological rehabilitation, developed by Derrick Wade.
The resulting book is thus a very well-rounded text and incorporates research from over a 25-year period. Stephens and his colleagues use the term “auditory enablement”, as being an active, rather than passive, role for the patient.
From the work of David Wade, enablement is “not a passive process” and could refer to the patient achieving or having:
- More skills
- A wider behavioural repertoire
- A better environment and
- More appropriate expectations
BT: Today, with several options for service delivery, how does a potential hearing aid user know what is the right option for them? How does an audiologist know what is the right option for the client?
ES: After seeking a structured and reasoned model of care, the Goldstein and Stephens model was applied, refined and evaluated and has provided a robust framework at Blamey Saunders Hears.
We offer a home based, and self-fit model, that provides choices in the amount of face to face interaction with a clinician and indeed in the degree of autonomy. It is consistent with an emphasis with the client being on what they can do rather than what they can’t do. It provides a framework to match the process to the client’s want or needs.
BT: How could a clinic that currently does not use tele-audiology implement the approach to care you describe?
ES: At the essence of teleaudiology sits client-centered choice and care. Family centered care could be seen as a subset of this. There are models operating in the world today under the auspices of “teleaudiology”. Typically, they place a remote Audiologist in full control of the appointment, requiring a teleaudiology Clinical Technician to be physically present in the room with the client.
Generally, the Audiologist makes all diagnostic and clinical decisions, performs all testing and verification, and prescribes hearing devices with the Technician on site in a support role. We would call these technicians partnering models.
In effect these models still use a traditional audiogram, operate with the clinician in complete control, and ensure that when the client goes home they cannot fine-tune adjust or manage their own health any better than they could coming to an audiologist rooms. They do present a way that a clinic could start thinking about remote health provision.
Effective teleaudiology is not as simple as digitizing traditional health delivery.
It requires a bespoke approach, one built from the ground up. This demands agility and innovation in a health delivery model. We believe this should be a model where:
- Clients can access the tools for hearing self-assessment. Most importantly they must be able to personally understand the results of their hearing assessment. What does it tell them about their ability to hear speech? By default, this cannot require clinical rooms, hearing booths, or expensive specialist equipment. Nor should it as this is far from a real-world experience and is really most relevant for differential diagnosis.
- Clients can then choose how they interact with a hearing care professional – some are 100% independent and happy to self-manage on-line, others want face-to-face care.
- This type of approach dictates a delivery model that is agile, bespoke and supportive. It must maximize technology, data and truly place the client in the driver’s seat.
- Hearing health support teams should be multidisciplinary – triaging experts, communication coach, counsellor, skills in family centered care, hearing aid advisor, and have an understanding of diagnostics. Teleaudiology teams must add to this the ability to conduct clinical work by video or other e-communication, and be very comfortable with a variety of digital technologies, and almost unfettered access from the client.
- Most critically, in a teleaudiology model, the hearing aids must be self-programmable, designed for eHealth. The opportunities that provided are significant, from empowerment to the utilization of data tracking tools with proficient distance counselling support.
A clinic wanting to be part of a teleaudiology eHealth ecosystem would need to team up with a company such as ourselves from the research and analysis we have done of the current marketplace.
BT: The approach you describe is one I hope audiologists and hearing instrument specialists pay close attention to. I can see how your approach using Goldstein and Stephen’s methodology leverages current self-fitting technology and tele-audiology to bring a new level of service to adults who struggle with their hearing. This new model of care you describe is especially valuable when you realize something close to 80% of individuals with hearing loss fail to take action using the traditional face-to-face service model. Providing vetted choices to patients is a good thing and hard to argue against, I think.
One last question: Even though patients are savvier and better informed than ever before, in the US still see quite a bit of misleading hearing aid product claims in local newspapers and on-line advertising. Could you provide us with some of the independent research supporting your tele-audiology service model?
ES: Sure. Here is a list:
- Goldstein, D.P., Stephens, S.D.G. (1981) Audiological Rehabilitation: management model, Audiology 20: 432–52.
- Hickson, L., Worral, L., Scarinci, N. (2007) A randomized controlled trial evaluating the Active Communication Education program for older people with hearing impairment. Ear and Hearing 28: 212–30. High,
- Stephens, D.P., Kramer, S.E., (2010) Living with Hearing Difficulties: the process of enablement. Wiley Blackwell
- Wade, D. (2003) Enablement: The new rehabilitation! Paper presented to the Royal Society of Medicine: Wales meeting, ‘The power of belief’, Cardiff, 12th May 2003.
- Vestergaard-Knudsen, L. Öberg, M., Nielsen, C, Naylor, G. and Kramer, S. E,(2010) Factors Influencing Help Seeking, Hearing Aid Uptake, Hearing Aid Use and Satisfaction With Hearing
- Aids: A Review of the Literature. Trends in Amplification. 14(3) 127–154