New Pathways to Care: How Self-Directed Care Could Change Audiology….For the Better Part 2

Hearing Health & Technology Matters
October 22, 2018

Two broad categories of patients – help seekers with hearing devices and help seekers without hearing devices – will benefit from new forms of counseling and customization in a market landscape where persons with hearing loss can self-direct their care.

Part 1 examined self-fitting hearing aids and the role audiologists could play in their selection and use. Part 2 takes a wide-ranging look at self-directed care and some of the emerging opportunities for audiologists to expand the demand for their services.


Brian Taylor, AuD

Historically, people who suspect a hearing problem had one recourse, if they wanted help or support: Make an appointment with a licensed professional for a hearing assessment or consultation. Today, thanks to technological breakthroughs like AI-based automated hearing testing, self-fitting hearing aids and smartphone apps, a growing number of people can choose to self-direct their care. Although there are plenty of reasons to be optimistic about the future of conventional hearing aids, as this recent commentary attests, these innovations give the audiologists more tools to broaden the demand for hearing-related services.

To accomplish the task of broadening demand for hearing-related services, however, involves implementation of new business models focused on patients who choose to self-direct their care.

Broadly defined, self-directed care is a philosophy and practice that assumes individuals can assess their own needs, determine how and by whom those needs are met, and evaluate the quality of the services they receive.

Self-directed care is an emerging trend in health care that allows certain individuals to plan and receive medically-related services from the comfort of their own homes. Given many of the factors related to the affordability and accessibility of hearing care, especially in view of a savvy, aging baby-boomer population, self-directed care is likely to gain traction within the profession of audiology.

The trend has already begun. Automated hearing screening tools, self-fitting hearing aids, as well as other non-custom amplification devices sold directly to consumers all fall under the rubric of self-directed care. A primary challenge for audiologists in a time when persons with hearing loss can self-direct their care will be providing the right type of service at the right time.

Undoubtedly, there will be help seeking patients who make their first point of contact for hearing care with an audiologist that will be able to self-direct their care, and audiologists will need tools to determine what patients can effectively self-fit their own hearing aids. Concurrently, there will be patients who first choose to self-direct their care, perhaps by purchasing OTC devices and then for assorted reasons eventually find their way to an audiologist for help and support. Given the changes in the way persons with hearing loss are expected to enter the service pipeline, audiologists need to create assessment tools and processes that meet the needs of patients who choose to self-direct their care and wind up needing personal support.

The objective of this article is to review some of the burgeoning self-directed and self-fitting hearing aids (SFHA) literature and provide some initial thoughts and guidance on the role of audiology in a marketplace where patients can self-direct their care. Another objective of this article is to identify opportunities to customize the treatment or rehabilitation plan of the individual.

By focusing more on the social, emotional and day-to-fay functional needs of the individual, audiologists can offer services that complement devices purchased elsewhere or enhance the benefit of devices purchased through the clinic. To better understand the challenges and opportunities associated with self-directed care, let’s step back and evaluate the dual role of audiology in the larger healthcare system.


How Will Audiologists Continue to Make a Difference?


Audiology is one of the few healthcare professions that works in two distinctly different healthcare arenas: diagnostics and rehabilitation. Another defining feature of audiology is its strong retail bend. Many clinicians have incentives to meet a unit commitment to earn a bonus or commission that shape their decision-making process in unintentional ways. Because many audiologists have a foot in both the medical and the retail, and work in the diagnostic and rehabilitative arena, a wide range of divergent skills are needed to be a proficient, well-rounded clinician.

Published data indicate audiologists, when following best practice clinical protocols, can effectively identify (and refer to otolaryngology) medically complex cases. However, these findings are based on the execution of a systematic, evidence-based series of tests, including tympanometry, ipsi and contralaterally stimulated acoustic reflexes, otoacoustic emission, speech understanding tests and thresholds testing via air & bone conduction audiometry.

There is solid reason to believe many audiologists fail to conduct these procedures routinely. Although not directly related to diagnostic audiology, we know, for example, there is considerable variability in the consistent use of evidence-based hearing aid selection and fitting protocols. If audiologists are inconsistent in their application of evidence-based hearing aid selection and fitting protocols, it is likely this inconsistency carries over to their work in the diagnostic arena. (Case in point: The popularity of monitored live voice testing at +30 or 40 dB SL relative to the SRT, a procedure debunked several years ago as ineffective that, nevertheless, by many accounts, is still widely used.)


Precision and Accuracy in Diagnostics Remains a Staple of the Profession


Not only are audiologists who fail to complete the entire comprehensive audiological assessment battery using evidence-based procedures at-risk for missing medical problems requiring referral (look no further than the Valente’s Adult Audiology Casebook and the Jerger’s 1981 text, Auditory Disorders for cases in which precise and accurate testing uncovered sometimes obscure medical conditions), they also might be leaving money on the table because they are not completing (and billing for) all the necessary tests to accurately triage patients. Correct identification of medically complicated, non-benign ear problems, completed in the most cost-effective manner, will benefit everyone. Further, the use of AI-driven algorithms that diagnose and predict ear disease, as well as advise audiologists and physicians on treatments will demand that clinicians conduct and interpret comprehensive test batteries to exacting standards.

In an era of direct-to-consumer hearing aid sales, precise diagnostic work by audiologists will be more important than ever.  

Another case in point: Clinicians could see an increase in the number of younger adults (60 years of age and younger) interested in purchasing self-fitting hearing aids.  With a potentially increasing number of younger adults dabbling with amplification devices sold over-the-counter, it could increase the probability of individuals trying amplification that have an unidentified medical condition. For example, note the prevalence of vestibular schwannoma in adults under the age of 60 relative to older adults.  

Although cases of ear disease are rare relative to benign hearing loss, in a future with direct-to-consumer self-fitting hearing aids, there is an even greater need for accurate and precise diagnosis of medical conditions involving the ear. Once these individuals find their way to the audiology clinic for an evaluation, it is imperative that any medically complicated ear problem is correctly identified and referred on to a physician.


Rehabilitative Audiology and The Chronic Care Model


Let’s turn to the rehabilitative side of audiology where tremendous changes are in store as result of OTC hearing aids legislation. An immense challenge for the profession is the ability to juggle the skills needed to practice at a high level as both a diagnostician and a rehabilitative specialist.

The skills needed to be a proficient diagnostician, namely accuracy and precision, are not all that useful for working with patients that have a chronic condition, like age-related or other forms of benign hearing loss. We know, for example, that the degree and etiology of hearing loss has very little to do with how the individual is affected by the condition. There are a variety of factors that impact the disabling effects of the individual’s hearing loss. Moreover, studies demonstrate audiologists spend too much time discussing the audiogram and hearing aid technology and are perceived as emotionally distant.

These findings imply many audiologists attempt to use what works effectively in the medical model (exact execution of a test battery, repeatedly) to their work with patients who have the chronic condition of benign hearing loss.

From a chronic care perspective, a primary role of audiology is to help patients become more effective self-managers of their condition. Much of the groundwork defining the role of audiologists as facilitators of self-management skills is being conducted by a group of researchers at the University of Queensland in Australia. Helping patients become better self-managers requires audiologist develop effective counseling and communication skills.


Helping Patients to Become Better Self-Managers


Self-management skills for adults with hearing loss is defined as the patient independently demonstrating the following behaviors: 

  1. Active participation in the goal setting and treatment planning process
  2. Adherence to an agreed upon treatment plan
  3. Ability to recognize and manage changes in condition or treatment plan
  4. Use of proactive coping strategies when communication becomes challenging or treatment plan falls short of expectations

When audiological rehabilitative is viewed through the lens of improving hearing loss self-management skills, the provision of a hearing device from the audiologist is not necessarily needed. That is, it is entirely possible that some patients will opt to self-fit their hearing aids and find their way to an audiologist who will help the patient learn these self-management skills.

When audiologists improve the self-management skills of adults with hearing loss, several benefits are likely to occur: Individuals, who can effectively self-manage their condition, are less likely to show up unannounced in the clinic looking for additional help, they are more likely to keep their scheduled appointments and to experience improved outcomes. All of which help a practice operate more efficiently.

It is likely that many adults with hearing loss, regardless of where they purchased hearing devices, will benefit from becoming better self-managers of their condition. If a primary role of audiology is to guide patients through the process of becoming better self-managers, the necessary services provided by the audiologists can probably be placed into one of these three categories:

  1. Information gathering and exploratory dialogue
  2. Goal setting and treatment planning
  3. Monitoring progress and assessing outcomes.  

The foundational skills needed to perform these services are motivational interviewing, shared decision making, and other types of skills directly related to communication and counseling. It’s a positive development, for example, to see collaborations between audiology and psychology that are encouraging the use of these skills.

Another model that can help audiologists become better counselors is the application of the International Classification of Functioning (ICF) framework. Created by the World Health Organization in 2001, the ICF provides a foundational roadmap for understanding the contextual factors that limit activities and participation by individuals in their daily lives. The ICF framework reminds us that hearing loss affects much more than bodily structures and functions; the entire individual, including their social environment, personality and other attributes need to be considered during the assessment process. When the audiologist utilizes validated in-take and outcome measure, such as the Hearing Handicap Inventory for the Elderly and engages in dialogue with a patient to better understand contextual factors, such as the emotions associated with hearing loss, motivation, locus of control and self-confidence, the process of customizing a treatment plan – regardless of where hearing devices are purchased– can begin.


Two Types of Help Seekers


In a marketplace where individuals have the option to self-direct their care, audiologists should be prepared to offer services to two distinct types of patients:

  • Help seeking individuals who do not own hearing devices, and
  • Individuals who own hearing devices seeking help from a professional

Additionally, it’s worth acknowledging there will be some patients who will choose to self-direct their care who won’t ever see an audiologist, either because they are successful in the self-fitting process and don’t need the help audiologists provide or have been unsuccessful and have given up on the process. (More research will be needed to better understand these patients.)

For help seeking individuals who do not currently own hearing devices, a primary objective of the communication assessment is to separate patients who view their condition of low importance from those who view their condition to be of high importance.

A basic tenet of working with patients with chronic conditions is they have a choice as to when to begin treatment. Knowing if the patient believes the condition is important enough to begin treatment is a critical initial step in the appointment process for individuals who are seeking help but do not own hearing aids.


Help Seekers Without Devices: Importance to Treat is a Touchstone


Most clinicians probably encounter the following situation more than a few times per year: A older adult with a moderate, bilateral hearing loss – an audiogram crying for help, who perceives the problem to be “no big deal” or believes his hearing is near-normal. Even for the patient with significant hearing loss who is a hearing aid candidate, if the problem is considered by that patient to be of low importance to treat, spending an hour convincing them to try hearing aids is usually an ineffective tactic. On the other hand, for patients who view their condition to be of high importance to treat, spending an hour or more with that patient is more likely to result in a set of well-planned treatment goals and the purchase of hearing devices.

To separate patients of low importance from those that consider their condition to be of high importance, the use of a simple scaling question, “On a scale of 1 to 10, ten being the most important priority for you today and one not important at all, how important is getting help for your hearing loss?” is extremely helpful.

It’s important to remember patients with a chronic condition need to buy-in to the treatment process for it to be effective, therefore, understanding the patient’s perspective is paramount. Asking about how convinced they are that their condition is important to treat is a useful starting point.

For the “importance to treat” question, if the patient provides a number lower than, say, five, it is an indication that the patient’s awareness of their condition and its impact on daily activities needs to be raised.

When patients who view their condition to be of low importance to treat it does not make sense to convince them to accept a recommendation of hearing aids – even when significant hearing loss is present. Rather, the focus of the initial appointment with the audiologist should be to increase patient awareness of the consequences of their condition on daily communication. This process begins at the initial appointment, but treatment may not begin for some time later when the patient is ready to move ahead. Thus, patients who view their condition to be of low importance to treat usually require less face-to-face time with the clinician at the initial appointment and should be encouraged to schedule another appointment at a later date to monitor the patient’s perception of the condition and their willingness to move ahead with goal setting and treatment planning.

Much is still to be learned about the best approaches to working with persons with hearing loss who view their condition to be of low importance to treat. Currently, in the units-based business model in which revenue is generated only when hearing aids are dispensed and services are bundled into the price of each sale, persons with hearing loss who view their condition as low importance to treat receive professional services, but often receive those services for free.

For first time help seekers without hearing aids, when this initial appointment is viewed as “counseling time” in which the clinician is guiding the patient through the self-discovery process using effective information gathering tactics and exploratory dialogue, it might be perceived by patients as a high value service that warrants a nominal fee. Additionally, it is possible that patients who perceive their condition to be of low importance to treat might be amenable to a use of low cost PSAP as a low-risk starter device.

In a recent University of Iowa study that used realistic listening conditions, the researchers found that while three the PSAPs evaluated in the study did not outperform professionally fitted hearing aids, the PSAPs did offer significant improvement compared to the unaided condition, and thus could serve as a budget-friendly option for those who cannot afford or do not want to try traditional hearing aids.

Contrast individuals with low importance to treat with those who consider their hearing loss to be of high importance to treat. It is likely these patients would provide a much higher rating on the scaling questions posed above, and therefore require more time with the audiologist during an initial appointment. During this initial appointment treatment goals could be targeted, and agreement could be reached on a treatment plan, usually involving hearing aids.  

Regardless of a patient’s self-rating on the importance to treat scale, the time spent with the patient by the audiologist warrants a fee. For the patient who self-rates low on the importance to treat scale, a 30-minute appointment might be sufficient, while the patient who self-rates higher on the importance to treat scale is apt to require one full hour of time during which time several variables such as speech understanding in noise ability, motivation, family support, self-efficacy, and other factors addressed below are assessed.

Besides using the importance to treat scaling question to guide the flow of an appointment, audiologists need to identify mechanisms that accurately identify patients who might be able to successfully self-fit hearing aids. Many of the controls used by audiologists to program and fine tune hearing devices will be handed over to patients via a smartphone app. Thus, in the future, audiologists need mechanisms in place that help them separate who are good candidates for self-fitting hearing aids from candidates for audiologist-driven, conventional hearing aids.


Determining Candidacy for Self-Fitting Hearing Aids (SFHA)


It is possible help seekers could purchase SFHAs from a clinic following an evaluation. Assuming SFHAs meet performance standards, similar to conventional hearing aids, the advantages of a SFHA purchase could benefit both the patient and the clinician. For the patient, a SFHA could be less expensive, require fewer visits to the clinic, and provide less personal risk, while for the clinician the recommendation of a SFHA for the appropriate candidate could save time on follow-up visits, thus freeing up appointment space to see more new patients.

Although much is still to be learned about SFHA candidacy requirements, some recently published reports suggest audiological variables such as degree of hearing loss and speech understanding ability may not be key predictors of SFHA success. Rather, other non-audiological factors, readily accessed by the clinician, which could determine SFHA candidacy.


Locus of Control: Locus of control is the degree to which people believe that they have control over the outcome of events in their lives, as opposed to external forces beyond their control. Individuals with a strong internal locus of control believe events in their life derive primarily from their own actions.

For example, when learning a new skill, people with an internal locus of control tend to blame themselves and their abilities, if they cannot successfully master the task. Moreover, people with a strong internal locus of control believe they have the will power and fortitude to overcome challenging situations. On the other hand, individuals with a strong external locus of control tend to blame external factors, such as clinicians or teachers, if things go wrong. That is, those with a strong external locus of control believe other people or other forces control their fate.

It is possible individuals with a strong internal locus of control, what some may call grit, have the resolve or perseverance to see a new skill is learned.


Self-efficacy: Related to locus on control is self-efficacy, or the ability for a person to belief in one’s ability to succeed in specific situation or accomplish a task. It is the ability to belief that you have the confidence to complete a task or learn a new skill. Previous studies have shown a relationship between self-efficacy and success with conventional hearing aids.  Given the requirements of fitting and adjusting SFHAs self-efficacy may be a critical component in the recommendation of them.


Problem-solving Ability: Another attribute that could identify successful SFHA users is the ability to problem solve. There are four basic steps to solving problems:

  1. Defining the problem 
  2. Generating alternative solutions
  3. Evaluating and selecting alternatives
  4. Implementing a solution

These basic steps to solving any problem occurring when trying to learn a new task require normal cognitive or executive function. Considering SFHAs involve several potentially new learning processes, such as inserting the devices into the ears, conducting an in-situ hearing test and programming/adjusting the device via a smartphone app, it would be logical to evaluate an individual’s ability to be an effective problem solver prior to use of a SFHA.

Other variables, such as motivation, cognitive status, physical ability and family support are other considerations when evaluating SFHA candidacy. In the future, audiologists will need to develop assessment tools that evaluate these attributes to determine who is an appropriate candidate for SFHSAs.

To summarize, the following services could be offered to individuals who seek help from an audiologist, but do not currently own or use any type of hearing device:

  • Diagnostic audiological assessment to identify possible medical complication that requires a physician referral
  • Basic communication assessment for individuals who deem their communication problem to be of low importance
  • Comprehensive communication assessment for individuals ready to proceed with the development of goals and a treatment plan
  • Treatment plans could include the following:
  • Self-fitting hearing aids or non-custom amplifier, no additional follow-up service
  • Conventional hearing aids with basic follow-up service package (finite number of office visits)
  • Conventional hearing aids with comprehensive service package (unlimited number of office visits over a finite period)


Individuals with Hearing Devices Seeking Help


Unlike help seekers who do not own hearing devices, the second category of patients, help seekers who own hearing devices, is not commonly seen in clinics today, but their numbers are expected to grow. With the expected launch of self-fitting hearing aids and other direct to consumer hearing devices, this second category of patients could benefit from service provided by an audiologist are individuals who have already purchased SFHAs or OTC hearing devices and are now seeking additional help or guidance. The type of help they are seeking could take many forms, however, a couple of recently published studies might shed some light on the role audiologists play in providing services directly to this group.

Humes et al (2017) used conventional multichannel hearing aids in a randomized, blinded study that compared the device across three different conditions:

  1. Hearing aids pre-set to mimic devices sold over-the-counter,
  2. Professionally fitted devices that matched a prescriptive target and included face-to-face guidance and support from a clinician, and
  3. A placebo control in which the hearing aids were set to match the characteristics of the open ear canal.

Among the key findings was that 20% of those fitted with the OTC-like devices benefited from help by the audiologist during the evaluation period. Following the intervention by the audiologist, of the patients who requested help with their OTC-like fitting, approximately half of this group wanted to keep their hearing aids at the end of the evaluation period.

These results indicate that a substantial number of individuals who first opt to self-direct their care by purchasing OTC hearing aids would benefit from the assistance of an audiologist.

In another recent study examining factors associated with self-fitting hearing aids, Convery et al (2018) asked a group of 60 middle-aged to older adults to follow a 9-step task to self-fit a pair of hearing aids. The self-fit hearing aids used in the study were receiver in the canal devices programmed and adjusted with a smartphone app. Additionally, part of the self-fitting task involved an in-situ hearing test.

Several variables, including cognitive status, self-efficacy, problem solving ability and locus of control that could have impacted participants’ success with the self-fitting hearing aid process were evaluated. Results showed that 68% of the study participants were able to successfully complete the entire self-fitting process either independently or with the assistance of a trained non-audiologist. Of the group that could successfully self-fit, 37% of them did so independently, while 63% sought help from the non-audiologist assistant. Two variables, locus of control and problem-solving ability had some limited predictive value, suggesting that both traits should be evaluated before someone purchases self-fitting hearing aids. More interestingly, study participants who did not use a smartphone were more likely to need assistance with the self-fitting process, suggesting that smartphone use is a lead indicator of SFHA candidacy. Finally, those that did need assistance with the self-fitting process received effective help from a non-audiologist assistance.

Together, these two studies, even though they used slightly different OTC delivery models, indicate any self-fitting device should provide access to trained support personnel that can assist the patient with the self-fitting process. And, this support service can be provided successfully by non-audiologist either in a face-to-face manner or using video conferencing tools, such as Skype.

Help seeking individuals who have already purchased hearing devices elsewhere or in an audiologist’s clinic might need follow-up care that can be placed into one of two categories: device mastery skills and self-management skills. Each category of service could require the audiologist (or a trained non-audiology assistant) to customize the fitting, counseling or educational support of the person in need of help. Let’s examine these two categories of service.


Device Mastery Skills: Any service delivered by an audiologists that depends on the patient’s interaction with their hearing devices themselves can be placed in the device mastery skills category, including:

  • Customization of device performance using real ear measures to ensure a prescriptive target is being matched
  • Insert & removal of hearing aids from ears
  • Basic orientation – how to use features and accessories of devices
  • Care and maintenance of devices
  • Expectations of initial use of devices
  • Pairing device to mobile device and adjustment of SFHAs with app
  • Auditory training exercises that include use of hearing devices during the training

Once a device mastery plan has been customized for the individual (and when permitted by state regulations) audiologists should consider the use of a well-trained, competent non-audiology assistant to deliver all or part of the patient support of these device mastery skills.


Self-Management Skills: Moving beyond education of hearing loss and device use, teaching individuals to actively identify challenges and solve problems associated with their hearing loss describes the term self-management. For audiologists, providing self-management skills training could be an opportunity to offer a tangible service that stands apart from the delivery of a device. (Note a previous section of this article describes some of the basic attributes of hearing loss self-management training.) Given the movement toward more over-the-counter purchases of hearing devices, it seems reasonable to offer this type of service to help seekers who already own a device.

To customize a hearing loss self-management plan for these individuals, Convery and colleagues are developing a self-management interview process centered around assessing the patient’s knowledge of their condition and treatment options, actions that can be taken to improve or cope with their condition and coping strategies for difficult communication challenges.

To complete the self-management interview, the audiologist asks the following questions to the patient:

  1. Overall, what do you know about your hearing loss?
  2. In general, what do you know about your treatment/management options?
  3. How likely are you to manage my hearing loss as asked by your hearing care provider?
  4. How likely are you to attend appointments as asked by your hearing care provider?
  5. How likely are you to keep track of changes in your condition (e.g., sudden change in hearing, pain, hearing aids stop working)?
  6. How likely are you to work with your hearing care provider to get the services you need?
  7. How do you manage the effect of your hearing loss on how you feel (e.g., emotions, well-being)?
  8. How do you manage the effects of your hearing loss on your social life (e.g., participate in activities, mix with other people)?
  9. How confident are you that you can self-manage your condition effectively?

Clinicians should be cautious about utilizing this interview format, as research is still being gathered on how it might apply to persons with hearing loss, especially those who have attempted to self-direct their care. However, responses to these interview questions could form the basis for a customized self-management treatment plan used with anyone in need of help, regardless of where they purchased their devices or what type of devices they are using.

The patient’s responses to the interview can be used to create a plan with the goal of assisting the patient become an independent self-manager of his condition. The plan can focus on improving one of the three components of self-management:

  1. Knowledge of condition and treatment options,
  2. Actions that improve the patient’s condition, and 
  3. Psychosocial issues resulting from the hearing loss that need to be overcome or addressed

In summary, the following types of services could be offered to help seekers who already own hearing devices:

  • Diagnostic audiological assessment to identify possible underlying medical complication that requires a physician referral
  • Basic communication assessment to identify extent of problem followed by one of the following services:
  • Device customization and/or device mastery training, possibly delivered by a non-audiologist
  • Hearing loss self-management skills training


Overcoming the Tyranny of Free Tests and Unit Margins


Ultimately, the onus of addressing the unmet needs of those with hearing loss falls to the profession. It’s incumbent upon all of us to find innovative approaches to service device provision that get more individuals suffering the ill-effects of untreated hearing loss involved in the process of improving their own hearing and communication.

This is the essence of the chronic care model: To help these patients become better, more effective self-managers of their own condition.

For decades it was sustainable business practice to provide free hearing tests and dispense, on average, 15 to 20 hearing aids per month to be profitable. Even if you provide the very best patient care, the units-based business model is unlikely to be sustainable over the long haul in a profession that will see shrinking margins resulting from OTC devices and third-party insurance contracts.

By focusing on the emotional, psychosocial and functional impact that hearing loss has on the person’s ability to self-manage their condition, audiologists can provide a full range of counseling and customization services –beyond the traditional bundled approach to delivering audiologist-driven care.  These new services could be appealing to a broader range of persons with hearing loss who choose to self-direct their care and could complement current clinical practice.


**All references are embedded in the links found in the article.  The opinions in this article reflect only those of the author and not any of the organizations in which he is affiliated.


Brian Taylor, AuD, is the director of clinical audiology for the Fuel Medical Group. He also serves as the editor of Audiology Practices, the quarterly journal of the Academy of Doctors of Audiology, and editor-in-chief of Hearing News Watch for HHTM. Brian has held a variety of positions within the industry, including stints with Amplifon (1999-2008)  and Unitron (2008-2015). Dr. Taylor has more than 25 years of clinical, teaching and practice management experience. He has written and edited  six textbooks, including the third edition of Audiology Practice Management, recently published by Thieme Press. He lives in Minneapolis, MN and can be reached at [email protected]


*feature image courtesy of Cambridge in Color

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