Downstream Consequences of Aging is a bi-monthly series written by guest columnist Barbara Weinstein, PhD. Today’s post is especially timely, coinciding with yesterday’s announcement of a bipartisan bill being introduced by U.S. Senators Elizabeth Warren (D-Mass.) and Chuck Grassley (R-Iowa) entitled the Over-the-Counter Hearing Aid Act of 2016 which aims to reduce cost and increase access of hearing technology for those with hearing loss.
The National Academy of Sciences recently released a report focusing on directions the health care system must begin to move to address the needs of older adults whose numbers are increasing dramatically. The major concern expressed is that the health care system does not have the capacity to meet the challenges faced by older adults, the majority of whom suffer from multiple morbidities (Rowe, Fulmer, & Fried, 2016).
The four recommendations listed in the report are of direct relevance to audiologists who are already dealing with the question of affordability and accessibility of hearing health care for older adults.
Vital Directions Central to the Health and Well-being of Older Adults (Rowe, Fulmer, & Fried, 2016)
Developing new models of care delivery
Strengthening and augmenting the workforce with competency in geriatrics
Fostering and promoting social engagement of older adults
Transforming delivery of care to persons in advanced stages of illness and at the end of their lives
Priority Number 1: Optimizing Care for Persons with Multimorbidity
Strengthening delivery of care to vulnerable older adults with multiple morbidities and focusing on outcomes which matter most to patients and family caregivers has the highest priority. Emphasis was placed on evolving strategies for care delivery which add value. This priority resonated for me given the centrality of effective communication to the health care encounter.
We need to get the word out to primary care doctors and other stakeholders within the health care system that when hearing loss goes unrecognized and untreated, implications are profound in terms of health care expenditures, health care burden, hospitalizations, and quality of physician patient communication. Throughout the continuum of care, be it outpatient, acute hospital care, geriatric rehabilitation, home care, nursing home or end of life care, the ability to communicate effectively with health care providers is integral and central to care delivery and transitions.
Regrettably, the ability to hear is rarely considered an important aspect of physician patient communication. In a recent systematic review of research on physician patient communications, fewer than 25 percent of papers on the topic mentioning hearing acuity and hearing loss. (Cohen, Blustein, Weinstein, et al., 2016)
Priority Number 2: Strengthening the Workforce
Bottom line, there is a shortage of professionals across all health care professions from direct care workers (e.g. home health aides) and public health professionals to physicians with experience and expertise in geriatric care delivery. Management of older adults requires a unique set of skills and audiologists by dint of their course work and clinical exposure are well positioned in this regard. HOWEVER, we remain a very low visibility profession.
I asked first semester AuD students to conduct informal surveys of a sample of New Yorkers to determine to which professional they would turn if they suspected a hearing loss. The results were humbling. Out of 60 respondents, 53% responded that they would go to their PCP, 27% to an ENT, 15% would go to an audiologist (most of those respondents had relatives going for a degree in audiology!), and 5% were not sure. When asked how they would locate a professional when they had concern about their hearing, most respondents said they would search the internet or ask their insurance company! Primarily millennials and baby boomers, the overwhelming majority of respondents felt strongly that hearing should be screened routinely as part of an overall health exam.
We must address our identity crisis more effectively to ensure that we are a credible and recognizable health profession for all stakeholders, be they health care providers, young adults, baby boomers and older adults.
Priority Number 3: Promoting Social Engagement
This topic of course is near and dear to my heart so I was glad to see it as a priority. Social factors and diversified social networks are critical to the well-being and health of older adults (Rowe, Fulmer & Fried, 2016). Social support systems, social ties, and engagement serve as buffers against crises and stress (Hawthorne, 2008; Lubben and Gironda, 2003).
Interestingly, social support and social isolation are rarely assessed in routine practice even for older adults considered at risk (Sansoni, et al., 2010). Additionally, there is a dearth of evidence based studies on efficacy of interventions to promote social engagement, increase social participation and to optimize social functioning (Sansoni, et al., 2010). Of the few studies which have been completed, data on efficacy of social support interventions are equivocal.
Let’s begin to discuss with our patients the importance of social participation and the improvements in the quality of interpersonal relations that they experience thanks to our hearing health care interventions. Group rehabilitation with communication partners is a wonderful way to optimize use of communication strategies and help keep older adults engaged. Providing intergenerational opportunities for persons with hearing loss to interact with children, adolescents, and older adults can yield substantial benefits, as well.
Priority Number 4: Transformation of Care of those with Advanced Illness and End-of-Life Care
Rowe, Fulmer, & Fried (2016) highlighted the importance of focusing on improving communication between patients and care providers as one way of improving quality of care at end of life. Our roles should be painfully obvious in these settings. Promotion of communication, shared decision making, and empowerment, even in the case of people with mild cognitive impairment, can enhance patient autonomy and dignity, helping to improve the quality of remaining life (Feinberg, 2014). Hearing and communication are so critical to dignity at the end of life because it is at this stage and phase, where the need to communicate with family, physicians, and other caregivers becomes paramount.
In my view, we should take a leadership role in helping to optimize how our colleagues in geriatrics and palliative care communicate with these vulnerable older adults.
In sum, the focus of health care for older adults in the 21st century is delivery of integrated patient centered care with a focus on wellness and outcome metrics which highlight the clinical benefits and value of interventions. Let’s begin to place some of our focus on positioning hearing health care interventions as high value services (those related to managing chronic conditions) which have the potential to promote effective, efficient and affordable health care (Chernow & Fendrick, 2016).
Chernew, M. & Fendrick, M. (2016). Improving benefit design to promote effective, efficient and affordable care. JAMA. Published online September 26, 2016. doi:10.1001/jama.2016.13637.
Cohen, J., Blustein, J., Weinstein, B., et al., (2016). Studies of physician-patient communication with older patients: How often is hearing loss considered? Submitted for publication.
Feinberg, L. (2014). Moving toward person- and family-centered care. Public Policy Aging Rep. 24(3):97-101.
Hawthorne, G. (2008) Perceived social isolation in a community sample: its prevalence and correlates with aspects of peoples’ lives. Social Psychiatry & Psychiatric Epidemiology. Vol. 43, pp. 140150.
Lubben, J. and Gironda, M. (2003) Centrality of social ties to the health and well-being of older adults. In: Berkman, B. & Harootyan, L. (eds.). Social work and health care in an aging society. New York: Springer, pp. 319350.
Rowe, J., Fulmer, T., & Fried, L. (2016). Preparing for better health and health care for an aging population. JAMA. Published online September 26, 2016. doi:10.1001/jama.2016.12335
Sansoni, J., Marosszeky, N., Sansoni, E., Fleming, G. (2010) Final Report: Effective Assessment of Social Isolation. Centre for Health Service Development, University of Wollongong.
Vital Directions for Health and Health Care (2016). An Initiative of the National Academy of Medicine. JAMA. 316 (7):711-712. doi:10.1001/jama.2016.10692.
Barbara E. Weinstein, Ph.D. earned her doctorate from Columbia University, where she continued on as a faculty member and developed the Hearing Handicap Inventory with her mentor, Dr. Ira Ventry. Dr. Weinstein’s research interests range from screening, quantification of psychosocial effects of hearing loss, senile dementia, and patient reported outcomes assessment. Her passion is educating health professionals and the public about the trajectory of untreated age-related hearing loss and the importance of referral and management. The author of both editions of Geriatric Audiology, Dr. Weinstein has written numerous manuscripts and spoken worldwide on hearing loss in the elderly. Dr. Weinstein is the founding Executive Officer of Health Sciences Doctoral Programs at the Graduate Center, CUNY which included doctoral programs in public health, audiology, nursing sciences and physical therapy. She was the first Executive Officer the CUNY AuD program and is a Professor in the Doctor of Audiology program and the Ph.D. program in Speech, Language and Hearing Sciences at the Graduate Center, CUNY.
feature photo courtesy of shannon christy