Roles and Responsibilities

Roles and Responsibilities of Audiologists

Audiologists, by virtue of academic degree, clinical training, and license to practice, are qualified to provide guidance, development, implementation, and oversight of hearing screening programs. See ASHA's Scope of Practice in Audiology (ASHA, 2018).

Appropriate roles and responsibilities for audiologists include the following:

• Selecting screening protocols appropriate for the given setting, population, and screening personnel.
• Selecting, upgrading, and calibrating screening equipment and applicable software.
• Completing hearing screenings and providing oversight to hearing screening programs.
• Training and supervising screening personnel.
• Selecting and/or developing educational materials for patients and families.
• Developing and implementing written policies and procedures on issues such as infection control, screening process, and documentation.
• Communicating screening results to patients and their families, appropriate program representatives, primary care physicians, and diagnostic audiology centers.
• Providing counseling and education.
• Completing rescreening and diagnostic evaluations.
• Referring for medical and/or other professional services.
• Collaborating with other professionals to ensure appropriate follow-up and outcomes.
• Educating medical professionals about the importance of hearing screening and the impact of chronic diseases and ototoxic medications on hearing.
• Remaining informed of research in the area of adult hearing screening and adult hearing loss.

As indicated in the Code of Ethics (ASHA, 2016a), audiologists who work in this capacity should be specifically educated and appropriately trained.

Roles and Responsibilities of Speech-Language Pathologists

Speech-language pathologists (SLPs) play a role in the hearing screening process. They also offer speech, language, and communication assessment, as well as (re)habilitation services to individuals with hearing loss. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).

Appropriate roles and responsibilities for SLPs include the following:

• Completing hearing screenings.
• Reviewing and considering auditory status and use of communication devices in advance of speech, language, and cognitive assessment.
• Communicating screening results to patients and their families.
• Providing counseling and education.
• Referring for audiologic, medical, and/or other professional services.
• Collaborating with other professionals to ensure appropriate follow-up and outcomes.

As indicated in the Code of Ethics (ASHA, 2016a), SLPs who work in this capacity should be specifically educated and appropriately trained.

Hearing Loss Risk Factors and Associated Conditions

Hearing loss risk factors and associated conditions include

• advanced age;
• chronic health conditions (e.g., diabetes, cardiovascular disease, kidney disease);
• disorders of the ear (e.g., Ménière's disease, otosclerosis, autoimmune inner ear disease);
• exposure to ototoxic and vestibulotoxic medications, such as those prescribed for the treatment of cancer, infection, and pain;
• exposure to recreational noise (e.g., personal listening devices) and/or occupational noise (See the U.S. Department of Labor Occupational Safety and Health Administration (OSHA) standards for occupational noise exposure, the National Institute for Occupational Safety and Health (NIOSH) criteria [PDF], and the World Health Organization-International Telecommunication Union standard [PDF] for recommendations);;
• genetic factors;
• head trauma (see ASHA Practice Portal page on Traumatic Brain Injury in Adults);
• history of ear infections;
• history of falls;
• speech, language, cognitive impairments (see ASHA Practice Portal page on Dementia);
• stroke; and
• tinnitus.

Hearing Screening Settings and Situations

Adult hearing screenings may take place in a variety of settings and situations, including the following examples:

• Routine primary care or post hospitalization medical visits may include a hearing screening.
• Residential facilities (e.g., skilled nursing, long-term care) may have protocols for hearing screening or assessment (e.g., CMS Long-Term Care Facility Resident Assessment Instrument 3.0 [CMS, 2015; PDF]).
• Speech language pathology visits may include a formal or informal screening or assessment of hearing.
• Health fairs often offer hearing screenings.
• Occupational hearing conservation programs, although details are outside the scope of this page.
• Remote access hearing screening is available through a number of landline, cell phone, and online tools, including The National Hearing Test, ASHA's Self-Test for Hearing Loss, and the Better Hearing Institute's (BHI) Online Hearing Check. Results may vary among the many online tests available.
• Telepractice may be used in a variety of audiologic applications (see ASHA Practice Portal page on Telepractice).

Screening for Disorder, Impairment,and Disability

A comprehensive protocol for adult hearing screening uses a three-pronged approach with the following components ( Schow, 1991; Ventry & Weinstein, 1983):

• Screening for disorder (health condition) includes a brief case history (e.g., review of chronic diseases, medications, and family history) and a visual or otoscopic inspection to identify any significant otologic history or obvious anatomic abnormalities of the ear.
• Screening for impairment (body structure and function) includes the use of calibrated pure-tone signals to identify a loss or abnormality of function of the auditory system.
• Screening for disability (activities and participation) includes the use of self-report questionnaires to identify any perceived difficulties related to hearing.

Completing each step of this process allows for more targeted, appropriate referrals/recommendations and for more patient-appropriate counseling.

Screening for Disorder (Health Condition)

Case History

A brief case history should include questions designed to identify individuals with possible hearing or related disorders. Participation of significant others in the case history process can be valuable. A case history may include the following questions:

• Do you have a hearing loss? If so, is it in one ear or both ears?
• Do you have difficulty understanding speech?
• Have you ever had a sudden or rapid progression of hearing loss?
• Do you hear ringing or noises in your ears and/or head?
• Do you have pain or discomfort in your ear(s)?
• Have you had any recent drainage from your ear(s)?
• Have you had problems with dizziness and/or impaired balance?
• Do you have any chronic diseases?
• What medications (including prescription, over-the-counter, and herbal) are you currently taking?
• Do you have a family history of hearing loss?
• Do you have a history of head injury or concussion?
• Have you ever been exposed to loud sounds or noises through occupational and/or recreational activities?

Otoscopy/Visual Inspection

Otoscopy completed by a trained examiner (e.g., audiologist, audiology assistant) allows for visualization of the tympanic membrane and inspection of the external ear canal for drainage, foreign bodies, impacted cerumen, infection, fluid, or structural abnormalities. A screener who is not trained in otoscopy can perform a general visual inspection of the outer portion of the ear and make note of any anomalies. The information obtained during visual inspection or otoscopy may have an important impact on screening results and/or referral to medical personnel for further evaluation.

Pass/Refer Criteria: Screening for Disorder (Health Condition)

• Pass/Unremarkable —if ­no concerns are reported during case history that have not been previously evaluated (e.g., by a physician or audiologist), and no abnormal results are observed during otoscopy.
• Refer —if concerns are reported from the case history for which the individual has not received medical/audiological consultation or if otoscopy identifies outer ear, ear canal, or tympanic membrane abnormality or cerumen impaction.

Screening for Impairment (Body Structure and Function)

Pure-Tone Screening

Pure-tone screening is typically accomplished with the use of a pure-tone audiometer. Pure-tone stimuli are usually routed through either TDH supra-aural earphones or insert earphones.

Handheld audioscopes allow for otoscopic visualization and pure-tone screening. Some of these devices will utilize tones at a variety of presentation levels (e.g., 20 dB HL, 25 dB HL, 40 dB HL).

There are a growing number of online and smartphone applications for hearing screening; however, caution is warranted when using these applications due to variability in the results obtained.

Otoacoustic emissions (OAEs) can be used to screen for hearing loss, particularly for populations who may be difficult to test, and for monitoring cochlear damage due to noise or ototoxicity ( Engdahl, Tambs, Borchgrevink, & Hoffman, 2005; Jupiter, 2009).

Pass/Fail Criteria: Screening For Impairment (Body Structure And Function)

• Pass —if responses are obtained in both ears to pure-tone air-conduction stimuli at 25 dB HL at 1000 Hz, 2000 Hz, and 4000 Hz.
• Fail —if there is an absent response to pure-tone air-conduction stimuli at 25 dB HL at any screening test frequency in either ear.

Because the incidence of hearing loss increases with age, many older adults will likely fail a pure-tone screening at 25 dB HL, particularly at 4000 Hz. Hearing loss in excess of 25 dB HL can negatively affect communication and, therefore, may reflect a clinically significant hearing loss. Some clinicians have advocated for use of higher screening levels (i.e., 30, 35, or 40 dB HL) when screening older adults. These higher screening levels will result in lower fail rates but may miss milder degrees of hearing loss and opportunities for further assessment, counseling, and education. Further studies are needed to determine whether different screening levels might be more appropriate for different age ranges.

Screening for Disability (Activities and Participation)

Self-Assessment Tools

Self-assessment tools (questionnaires/inventories) for disability screening can be used in conjunction with screenings for impairment and disorder to help identify those who would benefit from more comprehensive audiologic evaluation, counseling, and management (Ventry & Weinstein, 1983). Hearing disability screening measures can be administered in a verbal, written, or computerized format. Some patient report measures can be completed by family members or significant others. In the absence of an audiometer or other screening technology, these questionnaires can be useful in the identification of individuals at risk for hearing loss and requiring audiologic follow-up.

Examples of hearing screening self-assessment questionnaires include the following:

• Hearing Handicap Inventory for the Elderly–Screening Version (HHIE-S [PDF]; Newman, Jacobson, Hug, Weinstein, & Malinoff, 1991)
• The Speech, Spatial and Qualities of Hearing Scale (SSQ; Gatehouse & Noble, 2004)
• Self Assessment of Communication (SAC ; Schow & Nerbonne, 1982)
• Significant Other Assessment of Communication (SOAC; Schow & Nerbonne, 1982)

Pass/Refer Criteria: Screening For Disability (Activities And Participation)

Before using a self-assessment questionnaire, it is important to review the background publications related to the administration, scoring, and interpretation associated with that specific tool.

Referrals and Recommendations

Referrals and recommendations may involve counseling and education, comprehensive audiologic assessment, and/or other examinations or services as indicated. For example:

• Positive findings on the case history or otoscopic inspection will result in a referral for audiology and/or medical evaluation.
• A failure on the pure-tone screening will result in a referral for comprehensive audiologic evaluation.
• When hearing disability scores fall outside the normal range, recommendations should include counseling, referral for audiologic assessment, and/or other examinations or services.
• Failure on both pure-tone and hearing disability screening will result in a referral for comprehensive audiologic evaluation.

Follow-Up

There is limited information in the literature as to how often adults follow referral recommendations after hearing screening or the long-term outcomes of those referrals (e.g., auditory rehabilitation, hearing aids). Some adults may appreciate the hearing screening opportunity but may choose not to take action on the referrals or recommendations. Hearing screenings offer the opportunity to educate older adults about the full range of rehabilitative options available to those with hearing loss (e.g., environmental modifications, auditory training, amplification, counseling). A wider range of options may increase the chance that an individual will pursue some follow-up services.

Program Management

Equipment Calibration

Audiometric equipment must meet applicable specifications of the American National Standards Institute (ANSI)/Acoustical Society of America (ASA) S3.6-2010 (ANSI, 2010) and/or manufacturer recommendations to ensure accurate results. Calibration should be performed annually using instrumentation traceable to the National Institute of Standards and Technology. Functional inspection, performance checks, and biologic listening checks should be conducted to verify equipment performance prior to each use (ANSI, 2010). Visual inspection should be completed to check for any obvious equipment damage. All calibration activities should be conducted by a trained audiologist or an external company/individual properly trained in performing such tasks.

Screening Environment

Hearing screening should be conducted in a clinical or natural environment that is conducive to obtaining reliable screening results and that is free from auditory and visual distractions and interruptions. In addition, the location should allow for privacy and confidentiality.

Perform daily listening checks to rule out defects in major pure-tone screening components. Ambient noise levels may exceed ANSI standards for pure-tone threshold testing in audiometric test rooms (ANSI, 2013) but must be sufficiently low to allow accurate screening. A sound level meter, if available, may be used to establish maximum permissible noise levels at 25 dB HL for the earphone to be used during screening (i.e., supra-aural or insert earphones). However, when a sound level meter is not available, a biologic check is suitable.

Universal Precautions

It is important to ensure that adherence to universal precautions and appropriate infection control procedures are in place during screenings. Instrumentation that comes into physical contact with the patient must be cleaned and disinfected after each patient use (and per manufacturer's instructions), and clinician hand washing or use of sanitizing gel between patients should be routine (Siegel, Rhinehart, Jackson, Chiarello, & the Healthcare Infection Control Practices Advisory Committee, 2007). Disposable equipment, such as insert eartips, should be discarded after each patient use. See OSHA standards relating to occupational exposure to bloodborne pathogens and the CDC's Universal Precautions for Preventing Transmission of Bloodborne Infections.

Personnel Training

When audiologists oversee other screening personnel, initial training and refresher training is provided to ensure proper screening skills and knowledge. It is beneficial for the results of new screeners to be validated by an audiologist.

See ASHA Practice Portal page on Audiology Assistants for information on the training, educational standards, and roles/responsibilities of these paraprofessionals.

Documentation

Documentation typically includes the date of screening, patient demographics, medical and medication history, positive concerns from the case history, screening results, and recommendations and referrals. Any educational resources should be written in plain language (see ASHA's Health Literacy web page) and with culturally and linguistically appropriate translations provided as needed. For a hearing screening template for adults, see Hearing Screening (Adults) [PDF].

Reimbursement Considerations for Adult Hearing Screening

Although screenings are important to maintain the hearing health of adults, they are not a covered Medicare audiology benefit. The "Welcome to Medicare" preventive visit, Medicare Advantage plans, private plans, and Affordable Care Act–compliant plans may include screening as part of well visits, but these screenings may not be separately billable.

A failed hearing screening, a positive history of chronic diseases, ototoxic/vestibulotoxic medication use, or a genetic illness with comorbid hearing loss may support medical necessity for a referral to an audiologist. When referred by a physician, most plans will cover diagnostic exams for hearing and balance that are performed by an audiologist.

ASHA Web Resources

• ASHA analysis of Medicare audiology coverage
• ASHA's analysis of private plan coverage of audiology services
• ASHA-Self Test for Hearing Loss
• Hearing Aids For Adults- Portal Page
• Hearing Assistive Technology
• International Classification of Functioning, Disability, and Health (ICF)
• Patient Information Handouts
• Practice Considerations for Dispensing Audiologists
• Stark/anti-kickback FAQs
• Summary of Self-Referral and Anti-Kickback Regulations
• Using Automated Technology and Telehealth for Adults With Mild to Moderate Hearing Loss

Other Resources

This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.

• Better Hearing Institute Hearing Check
• CMS Long-Term Care Facility Resident Assessment Instrument 3.0 [PDF]
• Healthy People 2020: Hearing and Other Sensory or Communication Disorders
• International Classification of Functioning, Disability and Health (ICF)
• Medicare Information on Hearing & Balance & Hearing Aids
• The National Hearing Test

American National Standards Institute. (2013). Maximum permissible ambient noise levels for audiometric test rooms. (Rev. ed.; ANSI S3.1-1999). New York, NY: Author.

American National Standards Institute. (2010). Specification for audiometers (ANSI S3.6-2010). New York, NY: Author.

American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. Available from www.asha.org/policy/

American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of practice]. Available from www.asha.org/policy/

American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. Available from www.asha.org/policy/

Blackwell, D. L., Lucas, J. W., & Clarke, T. C. (2014). Summary health statistics for U.S. adults: National Health interview survey, 2012. National Center for Health Statistics Vital Health Statistics, 10, 1-161.

Centers for Disease Control and Prevention. http://www.cdc.gov/nchs/data/databriefs/db214.htm NCHS Data Brief, 2015.

Centers for Medicare and Medicaid Services. (2015). Long-term care facility resident assessment instrument 3.0 user's manual, version 1.13. Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/MDS-30-RAI-Manual-V113.pdf

Engdahl, B., Tambs, K., Borchgrevink, H. M., & Hoffman, H. J. (2005). Otoacoustic emissions in the general adult population of Nord-Trondelag, Norway: III. Relationships with pure-tone hearing thresholds. International Journal of Audiology, 44, 15–23.

Gatehouse, S., & Noble, W. (2004). The Speech, Spatial and Qualities of Hearing Scale (SSQ). International Journal of Audiology, 43, 85–89.

Jupiter, T. (2009). Screening for hearing loss in the elderly using distortion product otoacoustic emissions, pure tones, and a self-assessment tool. American Journal of Audiology, 18, 99–107.

Kochkin, S., & Rogin, C. M. (2000). Quantifying the obvious: The impact of hearing instruments on quality of life. Hearing Review, 7, 6–34 .

Lin, F. R., Metter, J., O'Brien, R. J., Resnick, S. M., Zonderman, A. B., & Ferrucci, L. (2011). Hearing loss and incident dementia. Archives of Neurology, 68, 214–220.

Newman, C. W., Jacobson, G. P., Hug, G. A., Weinstein, B. E., & Malinoff, R. L. (1991). Practical method for quantifying hearing aid benefit in older adults. Journal of the American Academy of Audiology, 2, 70–75.

Schow, R.L. (1991). Considerations in selecting and validating an adult/elderly hearing screening protocol. Ear and Hearing, 12, 337–348.

Schow, R. L., & Nerbonne, M. A. (1982). Communication screening profile: Use with elderly clients. Ear and Hearing, 3, 135–147.

Siegel, J. D., Rhinehart, E., Jackson, M., Chiarello, L., & the Healthcare Infection Control Practices Advisory Committee. (2007).Guideline for isolation precautions: Preventing transmission of infectious agents in healthcare settings. Retrieved from www.cdc.gov/ncidod/dhqp/pdf/isolation2007.pdf

U.S. Preventive Services Task Force. (2012). Final Recommendation Statement, Hearing Loss in Older Adults: Screening, August 2012. Retrieved from http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/hearing-loss-in-older-adults-screening

Ventry, I. M., & Weinstein, B. E. (1983). Identification of elderly people with hearing problems. Asha, 25, 37-42.

Yueh, B., Shapiro, N., MacLean, C. H., & Shekelle, P. G. (2003). Screening and management of adult hearing loss in primary care: Scientific review. The Journal of the American Medical Association, 289, 1976–1985.

Acknowledgements 

Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Adult Hearing Screening page: 

• Kathleen Cienkowski, PhD, CCC-A
• Deborah Culbertson, PhD, CCC-A
• Kathryn Dowd, AuD, CCC-A
• Wafaa Kaf, PhD, CCC-A
• Anna Kharlamova Meehan, AuD, CCC-A
• Anne Olson, PhD, CCC-A 
• Gabrielle Saunders, PhD
• Pamela Souza, PhD, CCC-A
• Barbara Weinstein, PhD, CCC-A 

In addition, ASHA thanks the members of the Ad Hoc Committee on Screening for Impairment, Handicap, and Middle Ear Disorders (Technical Report on Audiologic Screening) and the members of the Panel on Audiologic Assessment (Guidelines for Audiologic Screening) whose work was foundational to the development of this content.

Members of the Ad Hoc Committee on Screening for Impairment, Handicap, and Middle Ear Disorders were Robert Nozza (chair), Judith Gravel, Joan Martilla, Michael Nerbonne, Diane Scott, Thayne Smedley, and Jo Williams (ex officio). Guidance on the report was provided by Jean Lovrinic, vice president for governmental and social policies (1991-1993).

The Panel on Audiologic Assessment was led by Chie Craig (chair). The adult working group included Sabina Schwan (coordinator), Gary Jacobson, and Wayne Olson. Evelyn Cherow served as ex officio. Larry Higdon served as the monitoring Executive Board Officer.

Citing Practice Portal Pages

The recommended citation for this Practice Portal page is:

American Speech-Language-Hearing Association (n.d.). Adult Hearing Screening (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Professional-Issues/Adult-Hearing-Screening/.