Below are real-world practical examples showing the benefits of audiologists and speech-language pathologists actively involved in value-based care.
Thomas is being seen for an initial hearing test as ordered by his primary care physician (PCP). He has not had his hearing tested since being diagnosed with type 2 diabetes. He reports that he has progressive hearing loss in both ears, that he has difficulty hearing when there is background noise, and that family members tell him that his TV is reportedly too loud. He states that he’s able to manage his type 2 diabetes with medications. Thomas reports recent balance issues with blurred vision. He denies falls and he admits that his last eye exam was 5 years ago. He denies discussing changes in vision and balance issues with his PCP. An audiologic exam reveals a mild sloping to moderately severe sensorineural hearing loss in both ears. Bedside vestibular evaluation indicates that his peripheral balance system is intact. The audiologist recommends hearing aids, and Thomas is referred to an optometrist for an eye exam.
People who have diabetes are more than 2 times as likely to have hearing loss, and those who are pre-diabetic have a 30% greater rate of hearing loss than those with normal blood glucose. Yet, audiology is not routinely included in the management of diabetes. Although the connection between diabetes and hearing loss remains unknown, mitochondrial dysfunction, changes in microvascularization, and other reasons may attribute to this connection. These changes can impact both the hearing and balance systems.
Audiologists need to know about this connection—and to routinely ask patients if they have diabetes. By asking a few questions and completing a comprehensive evaluation, you may be the first provider to (a) identify that patient’s risk factor for diabetes and (b) make that referral to their PCP for further investigation.
Abigail is a 2-year-old girl who presents to the Emergency Department with complaints of fatigue, fussiness, and poor intake. An X-ray reveals an abdominal mass, and the liver biopsy is positive for hepatoblastoma. Abigail’s oncologist initiates chemotherapy and refers Abigail to audiology for a baseline audiologic evaluation. The mother denies concerns for hearing loss but notes that her daughter has been receiving speech and language therapy services through the Infants and Toddlers Program for speech delay. Abigail passed her newborn hearing screening in both ears following a healthy, full-term pregnancy. Abigail’s mother denies any family history of hearing loss.
Abigail’s audiologic evaluation reveals that she will likely have difficulty hearing in many listening situations. The hearing loss is expected to negatively impact further speech and language development as well as educational performance. The audiologist recommends bilateral amplification and relays the evaluation results to Abigail’s oncologist. Her care team determines that they will continue to monitor Abigail’s hearing throughout chemotherapy treatment and beyond. After discussing amplification options with the audiologist, Abigail’s mother orders hearing aids for her daughter.
Regarding baseline evaluations, audiologists give priority to patients with newly diagnosed cancer and accommodate these patients with overbookings whenever possible. The oncology providers have a direct line of communication to the audiology administrator/scheduler. Ideally, patients are seen for the audiologic evaluation prior to the initiation of treatment; however, sometimes that is not possible due to the imminent nature of the treatment. Access to in-house medical records makes the medical history easy to review and allows for efficient communication between providers. Consultations via telephone are frequent—especially if hearing loss is present. The team approach (e.g., collaboration between audiology, oncology, and speech-language pathology) is helpful and ensures that the family adequately understands and adheres to the care team’s results and recommendations.
Susan is a 78-year-old woman with a 5-year history of Parkinson’s disease. Within the last year, an associated mild cognitive impairment is diagnosed. Living alone in her two-story home, Susan experiences a fall and a right hip fracture while preparing her dinner. After hospitalization for a surgical repair, Susan is admitted to a skilled nursing facility (SNF) for rehabilitation. Her personal goals are to return to her independent lifestyle of living alone in her home, gardening, caring for her dog, and driving to the market for groceries each week. Her results from the Minimum Data Set (MDS)—which is a required post-hospitalization admission assessment for all Medicare beneficiaries—give evidence of Susan having mobility challenges and needing assistance for activities of daily living. In addition, the MDS assessment results indicate that Susan needs to have a full cognitive assessment and that she has lost 5 pounds in the last month. There is no evidence of delirium or depression. Susan is referred to a speech-language pathologist (SLP) for a speech-language pathology evaluation (“speech eval”). The speech eval indicates that Susan has a moderate cognitive impairment, low vocal volume, shallow breathing, and occasional slurring of words. Review of the medical record indicates that Susan has eaten little since admission to the SNF. The SLP requests orders for a dysphagia evaluation.
Despite the presence of a progressive neurological disease, such as Parkinson’s, an aging patient with a recent fracture may not automatically be referred for a speech-language pathology intervention. A referral to an SLP is often overlooked because of mobility issues and difficulty with activities of daily living. Because of the many different payment models emerging in post-acute care, patients are best served by the SLP, who has educated the caregiver staff regarding symptoms of communication and swallowing disorders. Advocacy for evaluations of those who have comorbidities that may not be the direct reason for the admission to the facility not only sheds light on what an SLP offers to the care team, but it also facilitates patient safety and positive patient outcomes.
Marcus is a 6-year-old boy who is referred to outpatient rehabilitation for feeding therapy services. He has a complicated medical history significant for prematurity and fetal alcohol syndrome. He receives 100% of his nutrition via gastrostomy tube (G-tube). A recent modified barium swallow study has revealed Marcus does not present with any pharyngeal deficits that impair his ability to safely consume thin liquids or regular textures. He has begun accepting small bites of crunchy foods and water. Marcus’s mother has expressed a desire to decrease oral residue after eating foods. During his recent feeding reevaluation, his SLP observed decreased lateralization of foods. Marcus also holds food in his mouth after chewing and before initiating a swallow. He has an increased amount of food residue in his lateral sulcus and buccal cavity that he will spit out if he feels that he cannot swallow. His current medical team includes his parents, a physical therapist, an occupational therapist, an SLP, a gastroenterologist, and a developmental pediatrician.
It is important to ensure that the entire care team (including the parent or parents) agrees with the ultimate goals for the child. If the long-term plan is for transition to full oral nutrition and hydration, it would be important to have a dietician be a part of the medical care team. The SLP and dietician can work very closely together as the child safely increases their oral intake while maintaining appropriate nutrition and hydration. In this example, the child would also be best served by an SLP who can provide education to all members of the care team across settings (e.g., clinic, home, school, community) so that everyone is approaching the child’s goals in a similar manner—in order to provide consistency and continuity of care.