Guidelines for Audiology Service Delivery in Nursing Homes
Ad Hoc Committee on Audiology Service Delivery in Home Care and Institutional Settings
About this Document
These guidelines were developed by the Ad Hoc Committee on Audiology Service Delivery in Home Care and Institutional Settings and approved by the ASHA Legislative Council in November 1996 (LC 27-96). Members of the Committee are Denise Brantley; Susan A. Logan; Carol Whitcomb Lozier; Kumar Nandur; Barbara Weinstein, chair; Maureen Thompson, ex officio; and Lawrence Higdon, monitoring vice president. These guidelines are an official statement of the American Speech-Language-Hearing Association. They provide guidance on the use of specific practice procedures but are not official standards of the Association.
All persons living in nursing home settings should receive or have access to comprehensive and continuing integrated audiology services for the purpose of attaining and maintaining the highest practicable level of physical, mental, and psychosocial well-being (Omnibus Budget Reconciliation Act, 1987). With the increasing number of older adults in our society and the high percentage of hearing loss documented in this population, there is a need for a well-defined hearing management protocol for nursing home facilities. The protocol should encompass identification, evaluation, management, and caregiver education. The challenge for audiologists is to provide quality audiology services given the changing health care climate, personnel shortages, public policy initiatives, economic considerations, and reductions in provider reimbursements. Rehabilitation specialists in general and audiologists in particular have to provide appropriate care in a cost-restricted environment.
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With changes in demographics and in the structure of the total health care delivery system, long-term care services emerge as viable and vital to the safety, well-being, and quality of life of older adults. Community-based long-term care in the United States typically is delivered informally by a host of individuals, including family, friends, and neighbors who provide health, social, and personal care services. Home health agencies provide for the health and daily living needs of homebound persons when they are too ill to be cared for by family members (Hegner & Caldwell, 1994). Third-party reimbursement for community-based long-term care services generally is fragmented and often difficult to coordinate (Ouslander, Osterweil, & Morley, 1991). The home health care programs that do list speech treatment services as a benefit also list audiology within the rubric “speech therapy.” When community-based long-term care alternatives fail, older adults and their families seek formal long-term care services through different types of facilities that provide such services.
Formal long-term care refers to the organization, delivery, and financing of a broad range of services and assistance to people who are severely limited in their ability to function independently on a daily basis over a relatively long period of time. Several different terms are used when referring to a long-term care facility: skilled nursing facility, rehabilitation facility, nursing facility, assisted living facility, or adult home (Hegner & Caldwell, 1994). In general, people who need long-term care for a sustained period of time are: (a) those who need restoration or rehabilitation; (b) those who cannot care for themselves because of ill- ness or disability; or (c) those who are old and infirm and need continuous care (Hegner & Caldwell, 1994). Over 90% of nursing home care is paid either by out-of-pocket expenditures or by Medicaid, with Medicare supporting less than 3% of the cost (Ouslander et al., 1991). Medicaid, the major source of nursing home payments, covers over 70% of residents (Kane, Ouslander, & Abrass, 1994).
Within nursing facilities, nursing home residents can be characterized broadly on the basis of their length of stay: “short,” 1–6 months, or “long,” more than 6 months. Short-term stayers enter for short-term rehabilitation after an acute illness such as stroke or hip fracture or if they are medically unstable or terminally ill. In contrast, long-term stayers fall into these categories: (a) primary cognitive impairments; (b) primary physical impairments, such as severe arthritis or endstage heart disease; or (c) both cognitive and physical impairments (Ouslander et al., 1991). Both categories of residents may require audiology services; health status, economics, and time constraints dictate the extent of service required.
Hearing health care professionals must become familiar with the goals of nursing home care; these goals influence the purposes and approaches to audiologic evaluation and management. The goals that pertain to hearing health care professionals (Kane, Ouslander, & Abrass, 1989) are:
to restore and maintain the highest possible level of functional independence;
to preserve individual autonomy;
to maximize quality of life, perceived well-being, and life satisfaction; and
to stabilize chronic medical conditions.
The nature of care delivered in nursing homes is dictated in large part by the Omnibus Budget Reconciliation Act (OBRA, 1987). Nursing facilities must comply with OBRA to qualify for Medicare and Medicaid reimbursement. The OBRA guidelines specify residents' rights within nursing facilities and dictate components of the resident assessment. With regard to resident assessment and quality of care, facilities must provide all services necessary to maintain the highest practicable physical, mental, and psychosocial well-being. Within this context, vision and hearing services are required, when appropriate.
Under OBRA, all nursing home residents covered by federal funds must be assessed using a standardized form known as the Minimum Data Set for Nursing Home Resident Assessment and Care Screening (MDS). The MDS, designed as an interdisciplinary tool, summarizes the resident's behaviors, problems, and special care needs, including functional levels, psychosocial well-being, and nutritional status (Kane et al., 1994). The nationally mandated MDS must be completed within 14 days of admission and updated when a major change in status takes place. Several sections must be updated on a quarterly basis (Kane et al., 1994). A variety of disciplines must take part in the assessment and care planning process; the extent of each discipline's involvement depends on the nature of the resident's problems. Most states require assessment by dental, pharmacy, podiatry, audiology, ophthalmology, and nursing professionals. Medical evaluation and treatment must be complemented every step of the way by assessment and care planning processes that involve a number of disciplines including audiology (Kane et al., 1994).
Problems identified on the MDS trigger more detailed assessments called Resident Assessment Protocols (RAPs). If the RAPs identify problems in communication, psychosocial well-being, and cognitive status, the next level of assessment begins. The RAPs drive the care plan; the care plan must be individualized and treatment integrated with assessment of all aspects of patient status (Kane et al., 1994; see Appendix A for sample items that identify problems in communication/hearing patterns and communication devices and techniques).
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The U.S. Bureau of the Census reports that one in eight Americans is elderly, which is defined for federal regulation purposes as 65 years of age and older. In 1990 more than 31 million Americans were over 65 years of age. By the year 2020 more than 50 million Americans will be over 65, and by the year 2040 that number will exceed 75 million. The proportion of the total U.S. population over age 65 is projected to increase: by 2040 one in five persons will be over 65 years of age (US Bureau of the Census, 1992; Ouslander et al., 1991). At this time approximately 13% of the total population is over 65 years of age; by the year 2040 this group will make up 21% of the total population. Also, the older population is getting older: within the over-65 age group, approximately 10% are over 85 years and this proportion is expected to rise to 17% by 2040. The “oldest-old” population is the fastest growing segment of the U.S. population. The growth of the “oldest-old” population will have a marked impact on the health care system in general and on the population needing long-term care in particular. Specifically, the number of persons with acute and chronic conditions requiring nursing home admission and the per capita cost of medical services is on the rise (Ouslander et al., 1991; Abrams, Beers, & Berkow, 1995).
It is estimated that 5% of elderly Americans reside in the 19,000 nursing homes across the United States. This translates into a need for 1.5–2 million nursing home beds, almost triple the number of acute care hospitals, and double the number of acute care hospital beds (Ouslander et al., 1991). The number of nursing home residents is expected to double over the next 30 years, exceeding 5 million by the year 2040. The majority of nursing home residents are over 85 years of age and have multiple chronic conditions. About 63% of elderly nursing home residents exhibit disorientation or memory impairment; nearly half are diagnosed with some form of senile dementia (Kane et al., 1994).
The presence of hearing loss and related changes in auditory processing is well documented in persons 65 years and older (Adams & Benson, 1991; Gulya, 1991; Hull, 1995; Ventry & Weinstein, 1983). Approximately 30–40% of persons over 65 years present with some degree of hearing loss, with the prevalence rising to 70–80% among persons over 80 years of age (Gates, Cooper, Kannel, & Miller, 1991; National Health Interview Survey, 1994). Among nursing home populations, the incidence of hearing loss is over 80% (Schow & Nerbonne, 1980). Some investigators have reported that approximately 92% of persons who live in health care facilities have hearing impairment that interferes with the communication process (Chafee, 1967; Hull, 1995). The high prevalence of disabling hearing loss reflects the fact that the majority of residents are over 80 years of age. A person's hearing loss may interfere with attaining or maintaining the highest practicable, physical, mental, and psychosocial well-being. Adverse changes in cognition and quality of life (such as poor health, depression, and reduced independence) also have been associated with hearing loss in older adults (Bess, Logan, & Lichtenstein, 1989; Mulrow et al., 1990). Hearing aid use can have a positive effect on a person's health and well-being. It has been demonstrated that hearing aids are a successful treatment for reversing social, emotional, and communication dysfunction caused by hearing loss (Mulrow et al., 1990). In addition, hearing aids may improve cognition and functional health status, and decrease depression.
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Audiologists who work in nursing facilities often are asked to conduct diagnostic services and administer treatment plans in nontraditional test environments. The heterogeneity of the population and facilities must be taken into account when developing treatment plans. For example, the classification of residents of nursing facilities as “short stay” or “long stay” will influence the nature of services provided. Audiology assessment procedures and decisions to intervene must be moderated by the resident's length of stay, the overall goals of nursing home care, and OBRA requirements. Identification and treatment of chronic conditions such as hearing loss are important goals, with the focus of care at all times remaining on functional independence, autonomy, quality of life, comfort, and dignity of the residents (Kane et al., 1994).
The standard protocol for audiology evaluation and management traditionally requires an acoustically treated test environment in accordance with American National Standards Institute (ANSI) standards (ANSI, 1991) and the ASHA Preferred Practice Patterns for the Professions of Speech-Language Pathology and Audiology (ASHA, 1993). Alternative test environments and protocols are the rule rather than the exception when providing audiology services in nursing homes. Restrictive reimbursement policies further dictate certain patterns of care in nursing homes. Because of the dearth of data validating evaluation and management protocols within nursing facilities, this document does not attempt to prescribe protocols. The guidelines below are outcome-oriented and the role of the audiologist, at every stage of intervention, is to gain an understanding of the patient's function and the patient's perceived needs, abilities, and limitations (Lesner & Kricos, 1995). It is anticipated that the experienced audiologist can apply standard procedures in nonstandard settings to attain a complete picture of the resident's current hearing status and audiological rehabilitation needs.
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The general purpose of providing hearing screenings is to distinguish apparently healthy individuals from those with a greater probability of having a disease or condition and to refer these individuals for appropriate diagnostic testing (ASHA, 1994). For residents of nursing facilities who may present with a hearing deficit, the audiologist's goal should be to identify those in need of audiological or medical services necessary to ensure their health, safety, and maximal functioning (Ammentorp, Gossett, & Poe, 1991). Hearing screening and referral for audiology services or medical management should occur within the first 2 weeks of entry into the long-term care system (OBRA, 1987). The referral can be made by hospital discharge planners, intake personnel, nurses, social workers, speech-language pathologists, audiologists, physicians, or home health care providers. The screening results and any referrals should be documented in the resident's medical record.
The MDS is administered routinely to all nursing home residents to obtain a comprehensive approach to assessment, problem identification, and individualized care planning. Section C of the MDS, “Communication/Hearing Patterns,” contains two questions that are used to determine the functional adequacy of the resident's hearing. Item C-1 requires the examiner to rate hearing ability (with a “hearing appliance,” if used) and item C-2 asks the examiner to indicate whether the resident has and/or uses a hearing aid (see Appendix A). OBRA requires a registered professional nurse to conduct or coordinate the assessment with the appropriate participation of health professionals, including audiologists and speech-language pathologists. Where applicable by state statute or facility policies and procedures, the audiologist or speech-language pathologist is responsible for completing Section C, certifying accuracy of this portion of the resident assessment, and signing/dating an RAP. For each RAP, the audiologist/speech- language pathologist must indicate if he or she is proceeding with a care plan. If so, an appropriate care plan must be completed and updated accordingly. A registered nurse must sign and certify completion of the entire assessment (Lubinski & Frattali, 1993). To ensure accuracy of the MDS and RAP concerning the resident's functional, medical, mental, and psychosocial status, the Committee recommends that the examiner consider the behaviors listed in Table 1 and that personal amplifiers be available to facilitate the interview/screening process.
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The purpose of an audiological assessment is to: (a) determine the need for medical and/or rehabilitative intervention; (b) identify residents with hearing loss who have been misdiagnosed as “senile” or “depressed”; and (c) assess the rehabilitation potential of residents (Kane et al., 1994). Identifying and managing hearing loss often can reverse the diagnosis or lessen the severity of a confusional state. Decisions regarding the nature and severity of hearing loss generally can be reached using routine behavioral audiometry and immittance tests. Often, nursing facilities are not equipped to allow audiologists to administer electrophysiologic tests such as auditory brainstem evoked response testing or vestibular evaluations. If additional diagnostic evaluations are indicated, the resident is typically referred out for these services.
The components of the comprehensive audiological assessment should take into account the resident's functional and cognitive ability, cost and time effectiveness, and efficiency. A standard approach cannot be dictated, given the social, psychological, and physical diversity of older adults receiving long-term care services. It is the responsibility of the audiologist to ensure that audiometers, audioscopes, and immittance instrumentation are calibrated biologically on a daily basis and electroacoustically on an annual basis. Committee members consider the following protocol to be representative of an appropriate audiological evaluation protocol:
Otoscopic examination of the external ear canal and tympanic membrane. At the time of the otoscopic examination, the audiologist should check carefully for collapsed ear canals; their prevalence increases with increasing age, especially when supra-aural earphones are used. Collapsed ear canals may interfere with the validity of air conduction testing. Although cerumen management is within the audiologist's scope of practice, assuming appropriate knowledge and skills (ASHA, 1992a), caution should be exercised when removing cerumen—many nursing home residents are frail and have complex medical conditions. In addition, nursing facilities may regulate which professionals are permitted to perform cerumen management. Audiologists performing cerumen management should follow specific measures to prevent disease transmission. The Occupational Safety and Health Administration (OSHA) determined that a significant health risk is faced by employees exposed to blood and other infectious materials that may contain bloodborne pathogens. The regulation Occupational Exposure to Bloodborne Pathogens (OSHA, 1991) should serve as the basis for infection control procedures.
Air conduction testing at 250, 500, 1000, 2000, 3000, 4000 and 6000 Hz. The use of insert earphones is recommended if a sound-treated booth is not available. The 250 and 500 Hz test tones may be omitted if ambient noise levels exceed the ANSI standard (ANSI, 1991) or if acoustic immittance testing is done (ASHA, 1994). The audiologist should take into account the need for calibration and maintenance of equipment.
Bone conduction should be tested from 250 to 4000 Hz or at those frequencies for which ambient noise levels are within ANSI standards (ANSI, 1991). Following bone conduction testing, the audiologist again should check carefully for collapsed canals in the event that an unexplained high frequency air-bone gap presents.
Speech recognition or detection thresholds to determine a recognition level for speech information.
Suprathreshold word recognition testing using face valid materials such as sentence materials or simple questions presented in quiet and/or noise. The primary purpose of word recognition testing for residents of nursing facilities is to identify persons who need assistive technology, which would promote communication among residents, residents and caregivers, and residents and family members. Functionally relevant test materials are recommended because the adequacy of the resident's functional communication capacity is of primary importance in the evaluation of hearing status. The secondary goal is uncovering peripheral or central auditory processing difficulties.
Assessment of most comfortable and uncomfortable listening levels if the individual is considered a hearing aid candidate.
Immittance testing in the presence of air/bone gaps and/or when bone conduction thresholds may be contaminated by excessive ambient noise levels.
A reliable and valid functional communication assessment scale standardized on institutionalized individuals should be administered to determine candidacy for and benefit from hearing aids. If the resident is too confused to provide valid self-report data, a simple questionnaire regarding communication abilities could be completed by a formal or informal caregiver. For adults likely to return to or for adults living in less restrictive environments, the screening version of the Hearing Handicap Inventory for the Elderly (HHIE-S) or the Self-Assessment of Communication (SAC) may be considered (ASHA, 1992b). These instruments have been standardized on noninstitutionalized older adults and therefore are ideal for those in less restrictive settings. (See Appendix B and C.)
The audiologist should monitor functional status annually to determine whether any significant change in resident status has taken place.
Note: For those residents who are already using amplification when they enter a facility, the audiological assessment should, at a minimum, include a visual inspection of the hearing aid(s), earmold(s), and tubing, an electroacoustic evaluation of the hearing aid(s) with real ear measurements and/or self-report data.
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As a result of the audiological assessment, the audiologist has one of three referral options, as presented in Figure 1.
If otoscopic examination and/or audiometric tests suggest a possible medical condition requiring treatment, immediate referral to a physician is indicated. If medical clearance is necessary for a potential hearing aid fitting, the referral should take place prior to the hearing aid evaluation session. If an annual audiological reevaluation is indicated, it should be noted in the chart and a recall schedule should be established. Finally, a referral for audiological rehabilitation should be made if audiometric findings or cognitive, physical, and psychosocial conditions suggest that the resident can use and benefit from a hearing aid and/or assistive device. The decision regarding candidacy for rehabilitation should take into account the audiologist's data, input from the nursing staff, and input from the resident. It is not within the scope of this document to prescribe specific audiological or nonaudiological criteria for candidacy for intervention. A primary caregiver (e.g., nurse, aide, family member) should be included to provide information regarding the resident's background, cognition, or daily living skills that might affect the audiologist's management strategy.
Audiological rehabilitation should be restorative and maintenance-oriented. Restoration in long-term care settings implies assisting residents to do as much as they can, as well as they can, for as long as they can (Hegner & Caldwell, 1994). Maintenance is aimed at preventing further loss and limitation and helping the resident achieve as high a level of wellness and independence as possible (Hegner & Caldwell, 1994), using a holistic approach that considers physical, sociological, psychological, cognitive, and communication capabilities.
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Empirical studies have demonstrated that hearing aids can have a positive effect on the physical health, psychological well-being, and cognitive status of an older adult (Mulrow et al., 1990; Weinstein, 1996). The prevailing FDA regulations, Professional and Patient Labeling and Conditions for Sale of Hearing Aid Devices (FDA, 1977) should be followed when dispensing amplification. Table 2 lists the factors that should be considered when recommending a hearing aid.
Table 2. Factors to Be Considered When Fitting Hearing Aids
Table 2. Factors to Be Considered When Fitting Hearing Aids
The appropriate electroacoustic characteristics of the hearing aid should be determined at the time of the prefitting using standard procedures (e.g., audiometric data; real ear measures, when available; loudness judgments). Studies have indicated that hearing aid users over age 60 prefer less amplification than various fitting strategies recommend. Care should be taken to recommend an earmold or hearing aid that the resident or staff can easily maintain, insert, and remove. When taking earmold impressions, universal precautions and sterilization procedures for objects, surfaces, and people should be in place.
The caregiver should be included in the rehabilitation process and should be encouraged to attend the hearing aid orientation sessions. A successful hearing aid fitting depends in large part on the resident's level of dependency and the availability of a caregiver to assist the resident in inserting and adjusting the hearing aid. To establish realistic expectations, the limitations of hearing aid use should be explained to the user and caregiver.
At the time of the hearing aid fitting, it is important for the audiologist to verify the hearing aid response using one or more of these techniques: (a) real ear measures of insertion gain and output when the necessary instrumentation is available; (b) functional gain measures when patient or physical variables permit; (c) valid speech measures; and/or (d) informal questionnaires to verify adequacy of the hearing aid settings. At the postfitting session, which should take place within 2–3 weeks of the fitting, the adequacy of the hearing aid fitting should be verified electroacoustically, with real ear measures, speech tests, and/or self-report data. Electroacoustic measures verify that the hearing aid is functioning according to manufacturer specifications; real ear data verify audibility and loudness characteristics; self-report data often confirm perceived communication and psychosocial benefit. When the perceived benefit is at odds with real ear data, the audiologist must make a decision as to the adequacy of the response, paying attention to input from the resident and caregiver as well as the real ear data. Safety and infection control procedures should be in effect before, during, and after the hearing aid fitting as well as between residents. Audiologists are encouraged to wear latex gloves when handling hearing aids and earmolds, but glove use should be discouraged when taking silicone earmold impressions. The audiologist should maintain a list of residents who obtain hearing aids (see Appendix B). At a minimum, the list should include the resident's name, hearing aid make and model, battery type, serial number, and which ear(s). The nursing unit at the facility should receive a revised hearing aid list each time a resident is fitted with a new hearing aid. The nursing unit's hearing aid list should be updated monthly. The volume control setting for each resident should be marked in red and the hearing aid(s) should be imprinted with the resident's name to help prevent loss.
As part of the prefitting and fitting, ongoing hearing aid orientation sessions should be scheduled to optimize the benefits of hearing aid use. A staff caregiver or family member should participate in the orientation and counseling sessions when feasible to ensure carryover of information into daily life. It is critical that the orientation sessions be client-centered, with particular attention to the resident's communication needs within the given facility or listening environment. The audiologist must be aware that cultural/linguistic factors influence the orientation and direction of these sessions.
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Hearing aid use is limited among residents of nursing homes: approximately 5–10% per facility at any one time. Hearing aids are underutilized because of a variety of nonaudiological and audiological factors. Foremost among the audiological factors is the high incidence of central auditory processing disorders (CAPD) that, according to Stach, Spretnjak, & Jerger (1990), tend to increase in prevalence with age. Older adults with CAPD tend to derive minimal benefit from hearing aids partly because of the interference posed by external distortions such as noise. Nonaudiological factors include lifestyle variables, financial considerations, manual dexterity, listening needs, and cognitive status, and also interfere with successful hearing aid use. Cognitive impairment associated with dementia, delirium, depression, amnestic syndromes, or benign senescent forgetfulness may render residents dysfunctional and unable to use hearing aid devices. Older residents who are withdrawn, isolated, and rarely interact with others may be adverse to hearing aid use but may benefit from assistive listening devices. Personal amplifiers are less costly than hearing aids and may provide sufficient auditory benefit for individuals with limited financial resources or because of audiologic or non-audiologic considerations do not warrant full-time hearing aid use.
Assistive listening devices improve the signal-to-noise ratio of the primary message by transmitting speech directly to the listener's ears free of external distortion such as noise or reverberation. A broader, more descriptive, and inclusive term for these devices is “audiological rehabilitation technology.” Audiological rehabilitation technology can be classified operationally according to functional category (Leavitt, 1989). The four functional categories include sound enhancement technology, television enhancement technology, telecommunication technology, and signal/alerting technology.
Sound enhancement devices are available as hardwire, wireless, FM, or audio-induction systems. These listening devices are ideal for one-on-one, large or small group situations, and television or radio listening. Hardwire systems, which couple directly to the sound source via a microphone, amplifier, and external receiver to the listener, are ideal for the nursing home setting. They can facilitate resident-to-resident, resident-to-staff, or informal caregiver-to-resident interactions. These systems, which are inexpensive, durable, and easy to use, make communication exchanges easier and more meaningful; it is difficult and tiresome to communicate with residents who need but do not use amplification or assistive listening devices. An additional advantage of hardwire systems is that they represent a visible symbol of hearing loss, signaling to other residents and staff that it is necessary to modify communication techniques to ensure understanding. This minimizes misunderstandings and the tendency to ignore people who have significant hearing loss.
Wireless devices such as infrared systems are ideal for residents who enjoy television viewing. These devices enable the signal from the television to be delivered directly to the listener's ear free of interference and distortion. If the nursing facility's lounge area is equipped with a television, nursing facilities should make sure to include a transmitter along with several receivers to enable residents to enjoy television viewing. Infrared systems have been installed successfully in large listening areas such as auditoriums, activity rooms, and places for religious observance, enabling large numbers of residents to follow the speaker free of noise or the disadvantage posed by distance.
A variety of telecommunication technologies that enhance speech understanding over the telephone are ideal for use in nursing facilities. Given the high prevalence of hearing loss among residents of nursing facilities, it may be desirable to have in-line amplifiers installed in each resident's telephone. Staff members in regular contact with residents, family members, or potential residents also should have in-line amplifiers installed in their telephones. All telephones should be compatible with hearing aids. All coin-operated telephones should be hearing aid-compatible and contain in-line amplifiers. At least one coin-operated telephone should incorporate a text telephone. According to the Americans with Disabilities Act (ADA) of 1990, Public Law 101-336, residents who do not have sufficient hearing to use a regular telephone with an amplifier or have a speech impairment that precludes use of standard telephones should have access to text telephones. Telecommunication technology facilitates contact with loved ones and is critical to the quality of life of residents of nursing facilities.
A variety of signal/alerting devices should be used throughout the nursing facility, especially in large areas where residents congregate. Personal rooms of residents with significant hearing loss should be equipped with telephone alerting devices and smoke detectors with strobe lights or vibrotactile stimulation. Some smoke alarms emit a pungent aerosol spray into the air when visible or audible alarms are not effective. In all cases, devices must be in compliance with state regulations or guidelines.
Individuals with hearing loss, nursing facility staff, family members, and administrators should be informed of the availability and advantages of audiological rehabilitation technology. Audiologists need to inform administrative staff that these devices can and should be used to bring facilities into compliance with the ADA and create a barrier-free environment for individuals with hearing loss. It is our professional responsibility to insure that this law is implemented so that people who are hard of hearing and deaf have equal access to services in nursing facilities. Audiologists should consult with the administration to ensure that the facility is in compliance with the ADA.
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Audiology restorative treatment and maintenance recommendations (i.e., audiological rehabilitation, hearing aid orientation, maintenance programs) for nursing home residents with hearing loss should be included in the resident's comprehensive care plans (CCP). The degree of assistance necessary from nursing staff/caregivers also should be specified (e.g., full assist, partial assist, supervised use, etc.).
New hearing aid users should be given a set of large print instructions (if cognitive level and vision permit) describing the care, maintenance, use, and operation of the hearing aid. A hearing aid list should be posted on each nursing unit to provide a quick and easy reference, particularly for new and “floater” nursing staff. The hearing aid list should include:
resident's name and room number;
hearing aid make, model and serial number;
hearing aid battery size;
level of assist; and
any other pertinent comments (e.g., high-risk for loss of aid, volume control setting).
Each nursing unit at the facility should receive a revised hearing aid master list whenever a resident is fitted with a new hearing aid. The unit's list should be updated monthly.
Other tools to help reinforce monitoring and nursing assistance with hearing aid use might include a hearing aid sign in/sign out log (see Appendix C) and nursing assessment/assignment records that capture information regarding the resident's physical and mental status and needs (e.g., Nursing Orders/Nursing Assistants' Accountability Record [NONAAR]).
When a resident is placed on a hearing aid maintenance program, the audiologist or designated staff member should conduct bimonthly checks to ensure that the aid remains clean and in good working order. Zinc air batteries are recommended because they are less toxic than mercury batteries and have a longer battery and shelf life. Extended warranties and/or supplemental insurance for loss and damage should be considered. Nursing home facilities and state medical programs have different arrangements for paying for lost or damaged hearing aids and assistive listening devices. When possible, the audiologist should investigate the purchase of loss and damage insurance and incorporate that coverage into the cost of the hearing aid.
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The audiologist should provide regular and periodic in-service training for nursing home staff to support the rehabilitation program designed for the resident and to provide carryover of therapeutic aspects into their daily lives (Hull, 1995).
The in-service program should include:
cause and functional effects of presbycusis;
psychosocial effects of hearing loss;
realistic expectations about hearing aids;
hearing aid troubleshooting procedures;
methods to facilitate communication; and
procedures to report lost aids.
In-service training programs should be as practical and relevant to the attendees as possible. Handson experience, adult learning principles, and interactivity are the key to successful sessions. It is helpful to use residents known to the caregivers as examples of the types of problems residents may have (e.g., Resident A uses a hardwired system because he is too confused to use a hearing aid; Resident B, with a moderate sensorineural hearing loss, uses an in-the-ear hearing aid). Adult learning principles suggest that when a caregiver can relate to a resident and a particular problem, understanding of the responsibility for hearing aid/assistive listening device use, function, and communication with the resident increases.
Lost hearing aids are a significant concern of audiologists working with nursing home populations. Although there is no guaranteed method of prevention, resident orientation, staff education, quality improvement (QI), spot checks, and appropriate reporting to nursing supervisors and administrators can help keep the problem at a minimum. The extent of QI measurements is for the most part dictated by the nursing home facility. When a QI program exists, assessment of the quality of care should be outcome-oriented. Basic indicators (e.g., working battery, hearing aid worn, volume correctly adjusted, hearing aid present/lost) serve to verify consistent and appropriate usage. Assessments should focus on ensuring that residents with hearing loss receive proper treatment and assistive technologies to: (a) maintain hearing abilities; (b) effectively communicate their needs and requests; and (c) participate in social communication.
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It is critical that all contacts with residents be documented in the appropriate place in the resident's chart. This includes, but is not limited to: (a) screening results that assess the rehabilitative potential or need for services; (b) RAP documentation notes, which correspond with the MDS+ assessment periods; (c) diagnostic summaries and recommendations; and (d) entries regarding pertinent telephone contacts or patient conferences. Comprehensive care plans must be completed to reflect individualized management and interventions for the resident.
If the resident is to be placed on a rehabilitative program, the type (i.e., restorative or maintenance), frequency, duration of session, and long-term/short-term goals to be addressed should be described and updated as needed in progress notes. If the resident is not considered an appropriate candidate for intervention, an explanation should be provided. If the resident's potential for rehabilitation is questionable, a trial period should be worked out with the resident and nursing staff. Seeger and Holt (1996) found that trial periods facilitated decision making in questionable cases. The responsibilities of the formal caregivers also should be documented in the chart.
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As part of the multidisciplinary team caring for the resident, the audiologist should be involved in the assessment of the individual's continuing care needs after discharge, and should contribute to a written plan for meeting those needs. Audiological summaries, professional and self-help resource listings, educational literature, and instructions for families should be made part of the resident's discharge packet to ensure carryover of information and inclusion of recommendations into the resident's daily life and routines.
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The delivery of audiology services in nursing home facilities is dependent on the availability of third party reimbursement. Medicare as well as private health plans have specific coverage and medical review guidelines for audiology services.
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Medicare will reimburse audiologists working in independent practices directly for diagnostic tests rendered in any nursing facility. For reimbursement to occur there must be a physician referral and the procedures performed by the audiologist must be within the Medicare scope of coverage. The physician referral should state “testing for the purpose of obtaining additional information necessary for evaluation of the need for or appropriate type of medical or surgical treatment for a hearing deficit or a related medical problem” ( Medicare Carriers Manual, 1975). Reimbursement is not determined by the setting in which the services are provided.
When an audiologist is reimbursed directly by Medicare, the amount of reimbursement is linked to Common Procedural Terminology (CPT) codes and determined by the Medicare Fee Schedule. Reimbursement for audiologic services also can be handled through a Medicare intermediary if the resident is covered under Medicare Part A (i.e., within first 100 days of stay). In this situation, reimbursement is based on “reasonable costs,” not the Medicare Fee Schedule, and payment is made directly to the nursing facility. When an audiologist is reimbursed directly, it typically results in a lower reimbursement rate; however, the audiologist retains the right to bill Medicare directly (and receive direct payment) for residents covered under Medicare Part A.
As in non-nursing home settings, aural rehabilitation services are not covered for audiologists. If an audiologist works under the supervision of a speech-language pathologist (subject to limitations of state regulation), Medicare will pay for speechreading services. The specific requirements for this coverage vary from intermediary to intermediary.
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Many private health plans provide coverage for communication disorders associated with illness or accident, but often exclude those disorders that have a developmental or congenital etiology. Reimbursement for audiologic services may be restricted to certain provider settings (hospitals or clinics) or to licensed practitioners. In addition, the insurer may require a physician referral. The majority of private health plans cover audiologic diagnostic services when they are required by a physician to establish a diagnosis. Evaluations performed by an audiologist for the purpose of prescribing amplification and/or assistive listening devices are seldom covered.
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The increasing number of older adults in society as well as changing consumer preference and health care delivery systems have led to more frequent activity of audiologists in the delivery of services in nursing homes. The nursing home setting presents a number of challenges for the audiologist. It is anticipated that this document will provide audiologists with a comprehensive hearing management protocol and facilitate audiologists to confront the numerous challenges of the nursing home setting and provide quality audiology services.
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1. Hearing—Resident's ability to hear (with hearing appliance, if used) during the LAST 7 DAYS. (Check the correct response.)
2. Communication Devices/Techniques—(Check all that apply to the resident during the LAST 7 DAYS.)
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