What hearing healthcare levels do you supply as an Independent Practice?
I had a really good conversation with Gary Holland recently in relation to service levels and testing processes that were offered within the Independent Hearing Healthcare sector. The conversation was based around the introduction of AQP (Any Qualified Provider) in the UK. AQP is the system whereby private hearing healthcare providers supply and fit public service hearing instruments under contract. Several companies are already offering AQP services in the High Street side by side with their private offerings.
In order to supply this service, companies have to provide a basic level of testing process and service to AQP Patients. Basic in this case is an interesting word, there is nothing basic about the assessment and aftercare that needs to be supplied. As you would expect for a government contract, the requirements are quite in-depth and the testing process and aftercare service are based on best practice principles. The issue here though is that this is now in place in the high street, free of charge.
It will and probably already is, changing the expectations of Patients in the United Kingdom. Their future expectations of what is a good test procedure, what is good after care service processes will be shaped by their contact with this programme. But what does that mean to the Independent Hearing Healthcare provider? It means that in order to differentiate, Independent Hearing Healthcare professionals will have to offer testing processes over and above what is being offered. Just to keep on the same playing field Independents will have to offer at the very least exactly the same as is being offered by an AQP supplier. Most Independents would probably be currently undertaking a similar level of procedure.
A similar level of process and service offering may not be enough though. If a Patient perceives that the free service is as similar to or more comprehensive, what will that do to the Independent Hearing Healthcare sector. I think it is time that all Independent Hearing Healthcare professionals took a strong look at their testing procedure. They also need to take a strong look at their testing equipment and facilities. Again, if your facilities and equipment are not as good as your AQP counterpart, what does that tell a Patient?
We need to begin to consider this and change our processes in order that they reflect where we have positioned ourselves. We also may need to re-invest in equipment, sound booths, integrated test equipment like the Aurical and the Affinity. We will need to consider the introduction of speech audiometry, quick SIN, tympanometry as standard. Below you can find the outline pertaining to requirements on AQP providers:
The Provider should ensure patients have an adequate understanding of the hearing assessment process before the appointment, by providing information (in a suitable language and format) in advance (either via the referrer or to be received by the patient at least 2 working days before the appointment) that explains the purpose of the assessment, what it involves and the possible outcomes.
During the assessment appointment, the practitioner should ensure that communication with the patient is effective enough to be able to work in partnership with the patient to reach jointly agreed goals/outcomes, undertaking the following:
· A clinical interview to assess hearing and communication needs – this should establish relevant symptoms, co-morbidity, hearing needs, auditory ecology, dexterity, and cognitive ability, significant psycho-social issues, lifestyles (including driving, use of mobile phones, TV, etc) expectations and motivations
· Full otoscopy
· Measurements of pure-tone air and bone conduction thresholds – if there are contra-indications to performing Pure Tone Audiogram (PTA) – for example, occluding wax, discharging ear, exposure to sustained loud sound in the 24 hours preceding test – the patient must be informed of the reason for non-completion and rebooked or referred back to the GP for treatment as necessary. Such events should be recorded as ‘Incomplete Assessments’
· Assessment of current activity restrictions and participatory limitations – using a formal validated self-report instrument – that will enable an outcome measure to be documented for both the individual patient and also the service. The Glasgow Hearing Aid Benefit Profile (GHABP) or Client-Orientated Scale of Improvement (COSI) or International Outcome Inventory for Hearing Aids (IOI-HA) are the preferred outcome measures for this service
· Assessment of loudness discomfort levels – where required
· Integration of assessment findings with patient expectations – to enable patients to decide on appropriate and suitable interventions (i.e. hearing aids, communication support, education etc)
Where the patient has already had a hearing test performed elsewhere, the provider will still offer an initial assessment to complete a full assessment of the patient. A reduction of x% of the tariff will be agreed by the commissioner for patients who meet the criteria to avoid a double payment where the cost of the tariff is included in the ENT tariff.
Following the assessment, the practitioner should:
Explain the assessment, including the extent, location, configuration and possible causes of any hearing loss and the impact hearing loss can have on communication e.g. poorer speech discrimination and sound localisation and the impact this can have on a personal and societal level.
Discuss with the patient the management options available to address their hearing loss and whether a hearing aid would be beneficial, exploring the psycho-social aspects of the hearing loss, as well as the physical aspects (e.g. audibility of sounds and speech)
Work collaboratively with the patient to establish realistic expectations for the management suggested providing all relevant literature (in a suitable language and format) to facilitate discussions
Where hearing aids are expected to be beneficial and the patient wishes to accept provision of hearing aids, at the same appointment:
Undertake pre-fitting counselling, managing expectations as necessary
Develop a written Individual Management Plan (IMP) with the patient which defines the patients’ goals and hearing needs and how they are going to be addressed
Discuss and document hearing aid options and agree types and models with the patient based on their suitability to the patients’ hearing loss*
Discuss and document whether a unilateral or bilateral fitting is appropriate. Any decision in this respect must be based on clinical need and not financially driven. Bilateral fittings are not clinically appropriate where:
One ear is not sufficiently impaired to merit amplification
One ear is so impaired that amplification would not be beneficial (and should be referral back to the GP for onward referral to complex audiology or other support services)
The patient declines bilateral aiding where offered as appropriate (this should be confirmed in a signed statement by the patient)
Other reason (e.g. manipulative ability, otological)
Proceed to fitting (where appropriate – see sections B1_2.3.2 and B1_2.3.3) using open ear technology or take impressions and decide on choice of ear mould type and characteristics
Provide patient information (in a suitable language and format) and ensure that the patient has understood the major points arising from the assessment including details of the hearing aid(s) which have been, or will be, fitted and any follow-up arrangements
Electronically record details of the assessment appointment, including any comments by the patient.
At the fitting appointment (if separate from the assessment) the following should be provided and discussed with the patient:
A review of the patient information and outcome measures (GHABP/COSI/IOI-HA)
Selection and programming of hearing aids*
Education of patient in order to reach a shared understanding of the benefits of hearing aid provision
Objective measurements (e.g. Real Ear Measurements (REM)) to verify fitting by agreed protocol (e.g. BAA/BSA recommended procedure) and adjustment of hearing aid output to match target exceptions to be reported in the Individual Management Plan
Modification of ear moulds/venting if necessary and repeat of objective measurements for verification
Evaluation of subjective sound quality (including own voice) and fine tune if necessary
With patients own aid(s) worn and switched on, teach the patient (using same model) how to:
Change battery – observe insertion and removal and correct processes for maintaining battery life
Switch between programmes
Insert and remove aids
Take care of aids, including cleaning, re-tubing and what to do if the aid is damaged or appears not to be working
Advise on acclimatising to the use of hearing aids and amplified sound
Advise on battery warnings, battery supply, repair/maintenance service
Supply cleaning wires if open ear fit
Explain the purpose and function of hearing aid data-logging
Advise on lost/damaged hearing aid charging policy
Issue a copy of the audiogram, information (in a suitable format) on the aids, ear moulds, local services, and update the IMP and provide a battery issue book if appropriate
Discuss patient’s wider needs and provide signposting to any relevant support services (including lip-reading classes and assistive technologies), as agreed with the patient, in accordance with agreed local protocols
Arrange a follow-up appointment – the patient should be offered a choice of face to face or non-face to face follow-up and given the option to bring a relative/carer
Within the follow-up the provider should:
· Discuss with the patient whether the outcomes agreed within the IMP have been met and if not how to resolve residual needs and update the IMP as necessary
· Check on use of hearing aid(s) in terms of comfort, sound quality, adequacy of loudness, loudness discomfort, noise intrusiveness, telephone use, battery life, cleaning, use of loop and different programmes
· Confirm patient’s ability to remove and insert aid and provide further help if needed
· Review hearing aid data-logging
· Fine tune hearing aid (if necessary) based on patient’s comments
· Continue usage of the preferred validated outcome measure (GHABP/COSI/IOI-HA) plus any additional measures used to assess the effectiveness of the intervention and respond to result
· Conduct objective measurements e.g. REM (if necessary)
· Provide information (in a suitable language and format) and sign-posting to any relevant communication/social/rehabilitation support services
The Provider should:
· Update the IMP in conjunction with the patient to ensure that any residual need has a plan of action
· Maintain confidential electronic records of the follow-up appointment including completed copies of the outcome tool, any adjustments made to the aid(s) and comments made by the patient
The Provider should provide on-going aftercare and equipment maintenance to patients for 3 years after fitting.
Aftercare services should include:
· Cleaning advice and cleaning aids for patients with limited dexterity
· Battery removal devices for those with limited dexterity
· Replacement of batteries, tips, domes, wax filters and tubing, where required
· Replacement or modification of ear moulds
· Repair or replacement of faulty hearing aids on a like for like basis
· Provision of information (in a suitable language and format) about wider support services for hearing loss
Patients should be able to access aftercare services (via face to face or non face to face methods) within 2 working days of the request.
As you can see the requirements are comprehensive, can you say that you are offering this level of test and aftercare? If the answer is no on even one of these requirements you need to consider just how good your service will be viewed.