Patient Engagement Through Interventional Counseling and Physician Outreach

Interventional Audiology Services: Physician Outreach  | October 2016 Hearing Review

A unique window of opportunity for outreach to physicians and their patients

By Robert Tysoe

People are awash in information, but oftentimes are unable to use it. These limitations are clearly hazardous to health. Hearing healthcare now has a unique window of opportunity to provide the latest clinical research about individuals with hearing loss to primary care physicians, including the latest patient education and literature about patients with age-related hearing loss to the medical assistant, so that patients (and their friends and family) become more actively engaged in seeking care for their hearing loss.

Hearing loss is one of the most common untreated chronic health conditions, and without doubt this has important implications for patient quality of life. Age-related hearing loss, however, is substantially under-detected and under-treated.¹ Just as the unrelenting growth of the co-morbidity of diabetes and pre-diabetes (which is an independent risk factor for hearing loss) has caused the World Health Organization (WHO) to recently categorize both diseases as pandemics—health problems so large that they could overwhelm the healthcare systems of all the developed countries—untreated age-related hearing loss can now be added to the list of chronic conditions contributing to skyrocketing healthcare costs.

The WHO has declared that hearing loss ranks third among all of the chronic diseases on earth in terms of years lost to living with a disability. Given the age of the first-time wearer of hearing aids ranges somewhere between 63 years and 70 years of age,^2,3 this should not come as a surprise. Due to the hidden nature of hearing loss as a disabling condition, at-risk adults are often dismissed by physicians, other allied healthcare professionals, and even the lay public’s stereotypical attitude about hearing loss of gradual onset being confined to “old people.” Although the industry’s marketing efforts have been largely confined to getting senior adults to make an appointment to see a hearing care professional, statistics reveal other populations for outreach: 20% of the US population 12 years of age and above cannot pass a 25 dB hearing test in their worse ear. This means that 48 million plus US citizens may suffer from a communicative disorder that could be detrimental to their overall health.⁴

While 75% of the US population state that the first person they ask about treatment for hearing loss is a primary care provider, calculations from available consumer data^2,3 suggest only one binaural hearing aid fitting per month, per US hearing healthcare provider, is fitted with new devices as a result of a physician referral. Elective care, as opposed to obligatory care, is hardly the right strategy to manage a condition of epidemic proportions that can profoundly affect the health and quality of life of the general population.

Relationship-building Marketing to Physicians for Improved Patient Access

There are too few adequately trained professional physician liaisons­—people who actively market a practice’s services to medical clinics and hospitals—employed by hearing healthcare practices. The need to assess an individual’s hearing difficulties, diagnose and refer medical conditions, evaluate a patient’s hearing loss and treatment needs, and provide counseling and services are all central to supporting hearing health. Additionally, there are few professional training programs for representatives of audiology clinics that embrace the pharmaceutical marketing model and that teach patient-centered relationship marketing strategies. Yet, this “educate to obligate” marketing strategy is necessary if significant improvement in physician referral behavior for the hearing-impaired patient is to occur.

The bell-curve of adoption with this marketing strategy shows that the return on investment (ROI) is not immediate; it often takes 1 to 2 years (and as many as 3 years, depending on the area) to maximize market share, but the use of physician liaisons results in many more patients receiving the hearing care they need to maintain an active and healthy lifestyle. New patients, referred by their primary health care provider, enable a long-term, sustainable, more profitable revenue stream to hearing care practices that engage in relationship-building marketing strategies with physicians.

Patient Engagement Strategies

Patient engagement simply means providers and patients working together to improve health in a more efficient manner. Typical patient engagement strategies attempt to get the patients more actively involved at the earliest stages of onset of a medical condition in order to prevent the condition from worsening and becoming more complicated (and expensive) to treat. A patient’s greater engagement in their own healthcare is thought to contribute to improved health outcomes, and new Information Technologies (IT) can support this process. Patients want to be engaged in their healthcare decision-making process, and those who are engaged as decision-makers in their care tend to be healthier and have better outcomes.

Stated differently, patient engagement is defined as combining the patients’ knowledge, skills, ability, and willingness to manage their own health and care with interventions designed to increase activation and promote positive patient behavior. Hearing healthcare providers can leverage patient engagement strategies—a hot topic with third-party payers and healthcare organizations—to build stronger bonds with physicians and other medical gatekeepers.

“Risk vs Benefit” Counseling

One approach to leveraging patient engagement in the relationship-building process with medical gatekeepers is to utilize risk vs benefit counseling. An increasingly common part of the information exchange between a patient and their healthcare provider, it is important to understand how risk vs benefit counseling works.

Physicians and hearing care professionals are trained to provide detailed information about potential risks and benefits associated with a treatment plan, a product, or a medication. In addition, they provide information about the probability, potential harm and magnitude, and other risks associated with treatment and, importantly, non-treatment. This can lead to an increase in hearing healthcare interventions that improve overall patient outcomes.

For example, it is common to review with the patient in a face-to-face consultation the potential risks of not using hearing aids, and during that same conversation discussing the potential benefits of amplification within the context of the individual’s audiological evaluation results and daily communication demands and expectations. Most would agree this is a standard part of the consult appointment with most adult patients. Taken one step further, interventional counseling can be employed by the loved one of the patient who is not ready to have the discussion with the professional about the risks and benefits of getting help.

Interventional Counseling

One type of risk vs benefit counseling is interventional in nature. Consider, for example, the parallels between the alcoholic and the adult with hearing loss. Although it may seem like an unlikely parallel, it is common for individuals suffering from both to lack awareness of the condition and the impact it has on relationships. Further, it is common in both chronic conditions for the patient to adamantly resist or even refuse care.

To succeed with an intervention, we need to rely on the hard work, dedication, and perseverance of every concerned family member or close friend. These are strong words, and for people who live in families that have been touched by the negative consequences of untreated hearing loss, they are easy to take to heart. Each time a family bands together and holds an intervention, that family is taking a step toward a better future for a hearing-impaired person in need.

Holding an intervention might not be easy, as these types of actions often take a significant amount of planning. Discussing a sensitive subject with someone who is upset, angry, depressed, anxious, paranoid, withdrawn, or in cognitive decline, can be difficult to accomplish.

Preparing a script can be a good first step. When the conversation is mapped out in advance, the stress level for all participants can drop, and conversation can flow more easily. The hearing care professional may facilitate the interventional counseling process by offering the following guidance with patients and their loved ones. In this sense, the clinician is acting as an interventionist by facilitating the process:

Step 1: Open with affection. Interventions can be confrontations in which emotions run high. Lead off with expressions of love, support, and concern from people who truly love and respect the hearing-impaired person.

Step 2: Describe specific behaviors. Denial is a common part of coping with gradual onset hearing loss. Denial or lack of awareness can even keep people from getting the help they need in order to improve relationships. The dialogue between patient and loved ones should concern behaviors that family members, friends, and co-workers have witnessed on a first-hand basis. When hearing-impaired people are shown that their behavior is both obvious and distressing, they might begin to think more critically about seeking treatment.

Step 3: Detail the physical problems hearing loss can cause. The emotional and financial damage caused by hearing loss might compel some people to change, and there are people who might be more likely to address their hearing loss if they are forced to think about the health issues that can develop as a result of inaction. In some cases, families might be wise to hire a family mediator who can work with the hearing care professional to develop a list of specific health problems that are associated with certain types of hearing loss. It should be factual and precise, providing the person in denial with information that is hard to ignore.

Step 4: Outline treatment options. At the end of a successful audiological intervention, the person who needs care may go directly to a hearing clinic for evaluation, testing, and treatment. Family members need to find the right hearing healthcare professional to help smooth the first appointment process for the person they love. At this point in the intervention, the family, friends, or co-workers can begin to outline how treatment works and why it is beneficial.

When instructing a family or loved ones on conducting interventional counseling it is important to inform them about both device and non-device treatment options. Although the minority of hearing care professionals offer stand-alone aural rehabilitation options, these options do exist and individuals in need of help should know about all possible treatment options. Furthermore, treatment options involving a device include more than hearing aids. Patients need to know about assistive listening devices, PSAPs, as well as other assistive technologies that might be beneficial—in addition to the value of seeing a dedicated hearing professional who can help sort through the myriad options.

Step 5: Express love and support. Providing facts and figures may be persuasive, but simply expressing how much the hearing-impaired person is loved is persuasive on its own. It is appropriate for family members to talk about how much they love, admire, support, and respect the person who needs care, and how much they want their loved one to overcome their denial of care so that they can move forward with a healthier and happier life. Family members can outline how they plan to help them cope with their new devices or listening skills. Family members who promise support can help newly treated patients feel more comfortable with amplification and accepting care.

Optional Step 6: Set consequences. If the individual does not agree to seek hearing care, families may choose to outline specific consequences that will take place if treatment for the hearing loss does not go forward. It might seem harsh to threaten someone who is dealing with the negative consequences of untreated hearing loss, but it is important to remember that this can cause people to make decisions that can be difficult for the family members to endure. People with untreated hearing loss might:

• Place other family members or others at risk due to poor hearing (eg, when caring for children, driving, etc);
• Place themselves at greater risk for falls, which could result in hospitalization, surgery, and endanger their life;
• Deprive other family members of enjoyable social outings due to the self-isolation of the hearing-impaired person, thus risking further alienation, loneliness, and depression;
• Suffer from a life-long learning handicap or disability associated with untreated hearing loss that deprives them of opportunities in life;
• Place the family in significant financial hardship should the person deny amplification, which may lead to a greater or more rapid decline in cognitive function, and thus require care in an expensive memory care facility.

These aren’t minor problems, and they could cause the family to experience a significant amount of distress. When put in this context, it’s easy to see why families might choose to place harsh and negative consequences on the person they love. Without audiological intervention, the person refusing treatment could threaten or even destroy their family life. An audiological interventionist can outline the risks and benefits of this step and help families make the right decision.

Putting it all together. Create a script or key talking points that contain all the proper elements of persuasion, and share this script with family and loved ones who desire to intervene. Practice sessions can also allow family members to advise one another on their scripts, and how to tweak individual messages until they seem perfectly crafted to reach the person who is in obstinate denial about their hearing impairment, and who clearly needs help.

Interventions for people who have hearing loss can be complicated, and if family members are feeling overwhelmed, there is help available from experienced hearing healthcare providers and family mediators who can handle the conversation with polish and skill so that there is more opportunity for a positive outcome.

Interventional Counseling by Primary Care Providers

Alarmingly, a random cross-sectional survey of general practitioner activity in Australia between 2003 and 2008 identified that approximately 3/1000 (0.3%) consultations for older adults included hearing loss management.⁵ Why is this rate, when the Australian government provides no-fee hearing aids for those who are 26 years and younger and 65 years and older, so abysmally low?

Several studies, many of which were outlined in the recent National Academy of Sciences report,⁶ indicate high levels of unmet need for hearing health services, and poor use of prescribed hearing aids. Denial or non-acceptance of hearing loss, and the stigma associated with hearing loss in adults are factors associated with this reluctance to seek help. Other reasons include an underestimation of the negative impacts of hearing impairment on overall health by general practitioners (GPs), leading to poor referral to hearing healthcare providers.

There are three potential critical roles for the GP in hearing health:

1) Early identification of patients with hearing loss, and recognition of resulting negative consequences/disabilities;

2) Assistance in reducing the stigma of hearing loss and counseling/motivating patients to seek help; and

3) Appropriate referral of these patients to hearing care providers.

This could be achieved by sensitizing GPs to recognize at-risk individuals, and use targeted questions to identify hearing loss disability. The challenge that remains for hearing care professionals is to effectively increase GP knowledge and practice behavior in this area.

Physicians need to consider whether the risk of not treating hearing loss in a given patient is reasonable in relation to anticipated benefits. A risk to the patient is considered minimal where the probability and magnitude of harm or discomfort anticipated are not greater, in and of themselves, than those encountered in the daily lives of the general population.

Clearly, research shows that adults with gradual onset hearing loss may benefit from collaborative interdisciplinary care between audiologic and primary care providers. Consider the following findings:

• Depression. The prevalence of unipolar depression in untreated hearing loss is 11.4% compared to those who reported good to excellent hearing (5.9%).⁷
• Psychological disorders. Psycho-social disorders, such as anxiety, paranoia, social isolation, loss of community, anger, and irritability, are reported to be present in the elderly with untreated hearing loss.⁸
• Falls. Identifying modifiable risk factors for falls in older adults are of significant public health importance. The magnitude of the association of hearing loss with falls is clinically significant, with a 25 dB hearing loss (equivalent of going from normal to mild hearing loss) being associated with a nearly 3-fold increase in odds of reporting a fall over the previous year.⁹ The average length of time an elderly person survives following a fall that results in a broken hip is 11 months. This is typical of the patient who falls into the “5% category” and who contributes to the generation of 50% of the $3 trillion dollars spent annually on US healthcare (see the October 2016 article by John Bakke, MD).
• Cognitive decline. Age-related hearing loss has been found to be independently associated with poorer cognitive functioning and incident dementia. Compared with individuals with normal hearing, those with mild, moderate, and severe hearing loss have a 2-, 3-, and 5-fold increased risk of developing dementia, respectively.¹⁰
• Social isolation. Declining social engagement in older adults with a hearing impairment is a key determinant of overall morbidity and mortality in later life with direct causal and neurobiological pathways linking loneliness and physiologic pathology.¹¹

Frequently, the physician’s clinic staff is less than adequately trained to effectively guide or advocate for hearing healthcare on behalf of the patient. Further, the training program curricula of medical assistants does not include education about the care of the adult with hearing loss.

Patient education literature about the treatment of hearing loss is sorely needed in physician’s offices, and a routine hearing screening, while rarely performed in the age of production-based medicine should be part of primary care medicine’s best practices because of new Medicare guidelines.¹² Additionally, improving population-based information on hearing loss and hearing healthcare, while promoting hearing in wellness and medical visits for those with concerns with their hearing are among the 12 National Academy of Sciences recent recommendations.⁶

The Risk of “Poor Health Literacy”

This leads to the troubling paradox of poor health literacy in the United States, and its impact on both quality and cost of hearing healthcare. A 2006 report notes that only about 12% of US adults had a proficient state of health literacy, defined as individuals who can obtain, process, and understand the basic health information and services they need to make appropriate health decisions.¹³

The paradox is that people are awash in information, but oftentimes unable to use it. These limitations are clearly hazardous to health. Research has linked limited health literacy to a cascade of suboptimal health outcomes, including worse overall health status and increased mortality rates in elderly persons.¹³

However, this same disconcerting research by Berkman also provides the answer: “Over the past 2 decades the lens of health literacy has widened greatly. In addition to focusing on the needs of individual patients, the field now brings the promise of greater commitment and shared responsibility from clinicians, institutions, and care systems.”¹³ This is an opportunity for hearing care professionals to provide the latest clinical research about individuals with hearing loss to primary care physicians, including the latest patient education and literature about patients with age-related hearing loss to the medical assistant, so that patients become more engaged in seeking care for their hearing loss.

New Preparation; New Training

What kind of new training is necessary for a new era of shared responsibility in patient care between audiologists and hearing care professionals, primary care, and institutions such as Medicare, Medicaid, and health insurance companies? Hearing care professionals need to invest in certified “Physician Liaisons” training programs that work directly with universities, community colleges, and private sales and marketing coaching companies.

Physicians will benefit by completing a training rotation through audiology during medical school that enhances their diagnostic capabilities, and their “risk vs benefit” patient counseling skills. Audiologists in the US are already volunteering their time in respected university medical residency programs to help ensure the quality of future interventional interdisciplinary care for deaf and hard-of-hearing patients.

Audiologists may be trained in collaborative patient care partnerships with primary care physicians at universities, with guest lecturers provided by physician specialists from local medical schools. Whenever the adult patient with hearing loss seeks help, the hearing healthcare specialists will altruistically find a way to be part of their PCP’s patient care team, to minimize impairment and maximize function, provide timely interventions, the right counseling, the right care, and be there for them—at the right time (sooner rather than later)—so that the hearing-impaired patient has the best opportunity for improved outcomes.

We have arrived at a unique time in hearing healthcare, with ample opportunities for enhanced relationship-building marketing to physicians and patient engagement strategies. We are all in this together, so let’s collaborate!

References

1. Bogardus ST Jr, Yueh B, Shekelle PG. Screening and management of adult hearing loss in primary care. JAMA. 2003;289(15)[Apr 16]:1986-1990.

2. Kochkin S. MarkeTrak VIII: 25-year trends in the hearing health market. Hearing Review. 2009;16(11):12-31. Available at: https://hearingreview.com/2009/10/marketrak-viii-25-year-trends-in-the-hearing-health-market

3. Abrams HB, Kihm J. An Introduction to MarkeTrak IX: A New Baseline for the Hearing Aid Market. Hearing Review. 2015;22(6):16. Available at: https://hearingreview.com/2015/05/introduction-marketrak-ix-new-baseline-hearing-aid-market

4. Lin F. Hearing loss and cognition among older adults in the United States. J Gerontol A Biol Sci Med Sci. 2011; 66A(10)[Oct]:1131–1136.

5. Karpa MJ, Gopinath B, Beath K, Rochtchina E, Cumming RG, Wang JJ, Mitchell P. Associations between hearing impairment and mortality risk in older persons: The Blue Mountains Hearing Study. Ann Epidemiol. 2010;20(6):452-459.

6. Committee on Accessible and Affordable Hearing Health Care for Adults. Hearing Health Care for Adults: Priorities for Improving Access and Affordability. Washington, DC: National Academies of Sciences. June 2, 2016. Available at: http://www.nationalacademies.org/hmd/Reports/2016/Hearing-Health-Care-for-Adults.aspx

7. Li CM, Zhang X, Hoffman HJ, Cotch MF, Themann CL, Wilson MR. Hearing impairment associated with depression in US adults, national health and nutrition examination survey 2005-2010. JAMA Otolaryngol Head Neck Surg. 2014;140(4)[Apr]:293-302.

8. National Council on Aging (NCOA). 1999. The consequences of untreated hearing loss in older persons. Washington, DC: NCOA. Available at: https://www.ncoa.org/wp-content/uploads/NCOA-Study-1999.pdf

9. Lin F, Ferrucci L. Hearing loss and falls among older adults in the United States. JAMA Arch Intern Med. 2012;172(4):369–371.

10. Lin FR, Yaffe K, Xia J, Xue QL, Harris TB, Purchase-Helzner E, Satterfield S, Ayonayon HN, Ferrucci L, Simonsick EM, Health ABC Study Group. Hearing loss and cognitive decline among older adults. JAMA Intern Med. 2013;173(4):293-299.

11. Lin FR, Thorpe R, Gordon-Salant S, Ferrucci L. Hearing loss prevalence and risk factors among older adults in the United States. J Gerontol A Biol Sci Med Sci. 2011;66A(5)[May]:582–590.

12. Taylor B, Bakke JN, Tysoe R. Interventional Audiology, Part 3: Changes in primary care and health belief systems are opportunities for hearing healthcare. Hearing Review. 2014;21(12):14-19. Available at: https://hearingreview.com/2014/11/interventional-audiology-part-3-changes-primary-care-health-belief-systems-opportunities-hearing-healthcare

13. Agency for Healthcare Research and Quality (AHRQ). AHRQ Health Literacy Universal Precautions Toolkit. 2nd Ed. Rockville, Md: AHRQ. Available at: http://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/index.html

Robert Tysoe is the owner of the Hearing Healthcare Marketing Company, LLC, Portland, Oregon.

Correspondence to Robert Tysoe at: [email protected]

Original citation for this article: Tysoe R. Patient Engagement Through Interventional Counseling and Physician Outreach. Hearing Review. 2016;23(10):30.?

Other Articles in This Special Edition about Interventional Audiology Services:

Introduction: Interventional Audiology Services: Meeting the Demands of Today’s Consumer, by Brian Taylor, AuD, Guest Editor

What Hearing Care Professionals Need to Know About Today’s Healthcare Economics, By John Bakke, MD, MBA

Intervening in the Care of More Patients: Beyond Clinic-based Testing and Fitting, by Brian Taylor, AuD

Incorporating Health Literacy into Your Hearing Care Practice, by Jennifer Gilligan, AuD, and Barbara E. Weinstein, PhD

Patient Engagement Through Interventional Counseling and Physician Outreach, by Robert Tysoe

Patient Complexity and Professional Time: Improving Efficiencies in the Service Model, by Dan Quall, MS, and Brian Taylor

Thinking Outside the Booth: Three Overlapping Categories of University Audiology Outreach, By Melanie Buhr-Lawler, AuD