Aural Rehabilitation

The definition of aural rehabilitation? (AR), as well as the terminology used to describe the practice of AR, has varied and evolved over the years. Montano (2014) defined AR as

a person-centered approach to assessment and management of hearing loss that encourages the creation of a therapeutic environment conducive to a shared decision process which is necessary to explore and reduce the impact of hearing loss on communication, activities, and participations (p. 27).

Boothroyd (2007) defined AR as

the reduction of hearing-loss-induced deficits of function, activity, participation, and quality of life through sensory management, instruction, perceptual training, and counseling (p. 63).

Ross (1997) included in his definition of AR

any device, procedure, information, interaction, or therapy which lessens the communicative and psychosocial consequences of a hearing loss (p. 19).

The impact of hearing loss and/or related disorders on a person’s quality of life, and the quality of life of their family/significant others, may be substantial. The AR process takes into account a person’s interpersonal, psychosocial, and educational functioning, among other factors.

Aural rehabilitation? is also referred to as audiologic rehabilitation?, auditory rehabilitation, hearing rehabilitation, and rehabilitative audiology. Some terms are more commonly used to refer to services offered by audiologists, whereas some encompass services offered by audiologists and/or speech-language pathologists (SLPs).

Roles and Responsibilities

Aural rehabilitation? falls within the scope of practice of both audiologists and SLPs. Audiologists and SLPs often collaborate in the AR process.

Roles and Responsibilities of Audiologists

Audiologists play a central role in the screening?, assessment, diagnosis?, and treatment of persons with hearing loss. The professional roles and activities in audiology include clinical services (diagnosis, assessment, planning, and treatment), prevention, advocacy, education, administration, and research.

Appropriate roles for audiologists include the following:

• Educating the public and other professionals on (a) the needs of persons with hearing loss and related disorders (e.g., tinnitus, CAPD) and (b) the role of audiologists in the prevention, identification, and management of hearing loss and related disorders.
• Advocating for the communication needs of all persons, including advocating for the rights of—and funding of services and devices for—those with hearing loss and related disorders.
• Conducting a comprehensive auditory assessment.
• Developing and implementing an AR plan of care in collaboration with the person receiving services as well as with family/significant others and other professionals (e.g., physicians, SLPs).
• Providing evaluation and fitting services for hearing aids, cochlear implants, other sensory aids, and hearing assistive technology.
• Providing device and technology support, including programming services.
• Educating the person receiving services and the family/significant others on hearing loss and device use and care.
• Providing information and training in the areas of
  • listening skills and communication strategies;
  • managing the listening environment;
  • communication with significant others;
  • strategies for addressing quality of life;
  • hearing protection/noise hazards; and
  • self-advocacy.
• Counseling persons with hearing loss and their family/significant others on factors related to hearing loss, device use, and tinnitus/hyperacusis (e.g., impact on quality of life).
• Providing referrals to other appropriate professionals to ensure access to comprehensive services.
• Providing information about local and national consumer resources.

As indicated in ASHA’s Code of Ethics (ASHA, 2016a), audiologists who serve this population should be specifically educated and appropriately trained to do so.

Roles and Responsibilities of SLPs

SLPs play a role in the screening?, assessment, and rehabilitation? of persons with hearing loss. Professional roles and activities in speech-language pathology include clinical services, prevention and advocacy, education, administration, and research. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016b).

Appropriate roles for SLPs include the following:

• Educating the public and other professionals on the communication needs of persons with hearing loss and related disorders.
• Advocating for the communication needs of all persons, including advocating for the rights and funding of services and devices for those with hearing loss and related disorders.
• Conducting a speech and language screening? and/or comprehensive assessment as indicated, including review of functional auditory skills.
• Defining speech and language goals for an AR plan of care.
• Developing and implementing an AR plan of care in collaboration with the person receiving services as well as with family/significant others and other professionals (e.g., audiologists).
• Providing individual or group training in the areas of
  • listening and communication behaviors and strategies (e.g., conversational strategies);
  • modifying the listening environment;
  • communication with significant others;
  • strategies for addressing quality of life;
  • hearing protection/noise hazards; and
  • self-advocacy.
• Counseling persons with hearing loss and their family/significant others on factors related to hearing loss, device use, and tinnitus/hyperacusis (e.g., quality of life).
• Providing referrals to other professionals to ensure access to comprehensive services.
• Providing information about local and national consumer resources.

As indicated in ASHA’s Code of Ethics (ASHA, 2016a), SLPs who serve this population should be specifically educated and appropriately trained to do so.

Interprofessional Education/Interprofessional Practice

Interprofessional education (IPE) and interprofessional practice (IPP) are important considerations in the field of AR. Collaboration between audiologists, SLPs, and other professionals (e.g., psychologists, social workers, physicians) benefit the person receiving services and allow for improved outcomes.

Person- and Family-Centered Care

AR truly begins during the first contact with the person seeking/receiving services and/or their family/significant others. Individualized person- and family-centered care is an approach to the planning, evaluation, and delivery of clinical services based on collaboration among the person receiving services, their family/significant others, and the clinical provider (Johnson et al., 2008). The inclusion and involvement of family/significant others in the AR process is important and may benefit the person receiving services in a variety of ways (Hull, 2005; Scarinci, Meyer, Ekberg, & Hickson, 2013).

Integral concepts of person- and family-centered care include the following (Johnson et al., 2008):

• Dignity and respect—honoring the priorities and choices of the person and their family/significant others while incorporating their values and cultural background.
• Information sharing—providers communicating with the person and their family/significant others accurately, completely, and in a health literate format so that the person and their family/significant others can fully participate in decision making.
• Participation—supporting participation by the person in their care and their family/significant others at the level they choose.
• Collaboration—enabling the person and their family/significant others to collaborate with health care professionals in a variety of ways.

Assessment for AR

The goals of an AR assessment include identifying the impact of hearing loss and/or other auditory complaints (e.g., tinnitus, CAPD) on communication, activities, participation, interactions with communication partners, and quality of life. Assessment may be ongoing or periodic depending on the person’s evolving needs and goals and the initiation of device use (e.g., hearing aids, cochlear implants). Assessment may result in a recommendation for a variety of AR options and/or referral to other professionals.

Case History

A detailed and individualized case history is taken with attention to the following factors:

• Priorities and communication goals of the person receiving services and/or their family/significant others
• Primary communication modality
• Medical history, including medication use (both prescribed and natural/homeopathic)
• History/etiology of hearing loss (prelingual or postlingual)
• Type of hearing loss
• Duration of hearing loss
• Description of other auditory complaints or diagnoses (e.g., tinnitus, hyperacusis, CAPD)
• Use and type of hearing device
• Challenging communication situations
• Cognitive considerations
• Cultural considerations
• Available supports
• Results from any client and/or family surveys or questionnaires
• Hearing technology expectations of the person receiving services and/or their family/significant others
• Educational/vocational implications

See the ASHA Practice Portal page on Cultural Responsiveness for more information regarding gathering a case history. A variety of hearing-related self-report tools are available (Bentler & Kramer, 2000; Bentler, Mueller, & Rickets, 2016, pp. 447–496; Cox, 2005; Erdman, 2001; Weinstein, 2015).

Comprehensive Assessment

An AR assessment may include the following measures and/or tests, depending on the person’s needs:

• Needs assessment, which may include subjective self-report measures completed by the person receiving services and/or their family/significant others (e.g., functional impact, psychological factors, quality of life).
• Screening? measures, as appropriate, which may include the following:
  • Cognitive screening? (Shen, Anderson, Arehart, & Souza, 2016)
  • Speech-language screening?
    • Functional listening skills (e.g., everyday situations at work, school, etc.)
    • Use of verbal and nonverbal communication strategies
    • Maladaptive communication behaviors (e.g., avoidance of phone communication)
• Assessment measures, as appropriate, which may include the following:
  • Audiologic evaluation
    • CAPD-specific measures, as appropriate (e.g., electrophysiologic tests; see ASHA’s Practice Portal page on Central Auditory Processing Disorder for more details)
    • Tinnitus-specific measures, as appropriate (e.g., pitch matching, loudness matching; See ASHA’s Practice Portal page on Tinnitus and Hyperacusis for more details)
  • Speech-language evaluation
  • Skills assessment: detection, discrimination, recognition, and comprehension
    • The ability to characterize sound presence, duration, and suprasegmental features (e.g., loud vs. soft, high pitch vs. low pitch, vocal inflection)
    • Speech recognition/comprehension at various presentation levels (e.g., words, sentences) with and without competing noise
  • Speechreading assessment at perceived, analytic, and synthetic levels (Seal, Wilson, & Gaul, 2013)
• Device assessments, as appropriate, which may include the following:
  • Assessment of the person’s current hearing device use (e.g., type, regularity of use, personal and family/significant other satisfaction with device)
  • Evaluation of differential listening abilities with various amplification options, including the use of hearing assistive technology systems
  • Determination of candidacy for hearing aid(s), cochlear implant(s), another implantable device (s), and/or hearing assistive technology systems
• Outcome measures for tracking treatment progress and benefit.

International Classification of Functioning, Disability and Health

The World Health Organization (WHO) published the International Classification of Functioning, Disability and Health (ICF) in 2001 as a classification of health and disability based upon functional status. This classification system can be used to assist clinicians in establishing goals and in determining specific outcomes that can be measured through client report.

Aural Rehabilitation? Plan of Care

The use of person- and family-centered care is now an area of focus in the development of an AR plan of care (Ekberg, Meyer, Scarinci, Grenness, & Hickson, 2015; Grenness, Hickson, Laplante-Levesque, & Davidson, 2014; Laplante-Levesque, Hickson, & Worrall, 2010; Meyer, Scarinci, Ryan, & Hickson, 2015). A person- and family-centered AR plan of care may include one or more of the following approaches:

Counseling

Effective counseling in AR is paramount (Sweetow, 2018) and is applicable not only to hearing loss but also to related disorders (e.g., tinnitus, CAPD). Fundamental skills in counseling are important for the implementation of an individualized person- and family-centered AR plan of care (Hull, 2005; Jessen, 2015; Johnson, Jilla, & Danhauer, 2018). “By shifting the focus to our patients and attending to the actual reasons they seek audiologic intervention, the foundation on which to base relevant counseling emerges” (Erdman, 2009, pp. 190–191).

Types of counseling in AR may include one or more of the following:

• Informational counseling—focuses on providing education to the person with hearing loss (or related disorders) and their family/significant others about the disorder, associated symptoms, prevention and wellness, and the rationale for specific treatment interventions.
• Personal adjustment counseling—focuses on the person’s psychological, social, and emotional acceptance of the hearing loss and/or related disorders.
• Support groups—provides support from a community, practice with speech in noise, training for conversation partners, work on auditory comprehension, and discussion of other concerns that may arise.

Topics of AR counseling may include but are not limited to

• the nature and effects of (a) hearing impairment, (b) tinnitus and/or hyperacusis, and (c) CAPD;
• care and management of hearing technology;
• use of hearing assistive technology systems;
• realistic expectations for using hearing technology;
• adjustment to hearing technology;
• use of hearing protection;
• the rights of persons with hearing loss and/or related disorders;
• interpersonal and psychosocial implications of hearing loss and/or related disorders;
• self-advocacy;
• educational and vocational implications of hearing loss and/or related disorders;
• impact on family/significant others;
• issues regarding the use of telephone, television, and other technology;
• access and availability of resources and accommodations;
• effective coping and compensatory skills; and
• any other quality-of-life concerns voiced by the person receiving services and/or their family/significant others.

Sensory Aids

The AR provider may assist the person receiving services with maximizing the use of a current hearing device or guiding the process of selection and fitting for a new device. Instruction and demonstration will be provided for the most effective use of the sensory aid(s). Devices may include hearing aids, cochlear implants, other implantable devices, and/or assistive listening devices.

Environmental Modifications

Another focus of an AR plan of care may be to inform the person receiving services and/or their family/significant others of environmental modifications that may be helpful for their specific hearing needs and then to support them in implementing these changes. Examples of these modifications include the following:

• Choosing optimal seating arrangements
• Improving room acoustics and minimizing background noise
• Improving lighting for speechreading
• Installing visual alerting systems
• Using nonwearable masking devices (for tinnitus)

A vocational counselor may assist in defining and implementing specific accommodations and/or modifications for the workplace and educational settings.

Training

Training is provided in a variety of areas and in selected modalities to maximize communication skills in environments relevant to the person receiving services. Training includes participation of the family/significant others, as appropriate. There are a variety of commercially available training programs and mobile applications that may be useful in an AR plan of care.

Auditory Training

“Auditory training is a process designed to enhance the ability to interpret auditory experiences by maximally utilizing residual hearing” (Sweetow & Sabes, 2009, p. 267). The approach to auditory training may be analytic, synthetic, or a combination of both (Sweetow & Sabes, 2009). Auditory training may be provided in individual or group sessions and may involve the use of computer programs and mobile applications (Olson, 2015; Sweetow & Sabes, 2007). In some cases, auditory training may be part of an intervention plan for persons with normal peripheral hearing (e.g., CAPD, tinnitus). There are two main approaches to auditory training—analytic and synthetic—both of which are discussed below.

• Analytic Approach
  • Uses the smallest distinguishing linguistic features of acoustic cues (i.e., bottom-up processing).
  • Uses small segments of speech such as phonemes or syllables.
  • Focuses on how perception (hearing) influences communication.
  • Follows the auditory skills hierarchy:
    • Sound awareness (determine if sound is present or absent)
    • Auditory discrimination (distinguish sounds as same or different)
    • Auditory identification (label the sound)
    • Auditory comprehension (understand the meaning of the sound)
  • Uses tasks progressing from easy to difficult and/or from a quiet environment to an environment including background noise.
• Synthetic Approach
  • Focuses on the overall meaning of discourse (i.e., top-down processing).
  • Uses segments of speech such as words, phrases, sentences, or conversation.
  • Includes all areas of auditory comprehension.
  • Pulls analytic targets into functional practice to address the use of strategies in real-world situations.

Communication Skills Training

Communication skills training may range from improving articulation to managing conversation. Group AR may be helpful in this area (Hawkins, 2006). Areas of focus may include the following:

• Articulation
• Communication strategies
• Conversational repairs
• Pragmatics
• Self-advocacy
• Voice (e.g., resonance, loudness)

Speechreading

Speechreading refers to processing speech using visual information, such as movements of articulators, facial cues, and gestures. Including speechreading in an AR plan of care supports the idea that “cross-modal stimulation from optical and acoustic events contribute to multisensory enhancement in speech perception” (Lansing, 2014, p. 253). Training may be provided to both the speech reader (i.e., listener) and the communication partner (i.e., talker). For example, the speech reader may engage in perceptual practice activities while the talker learns to modify speech and use proactive behaviors to reduce miscommunications. See Wickware (2014) for a description of four approaches to speechreading training: analytic, synthetic, pragmatic, and holistic.

Sound Therapy

Sound therapy refers to the use of sound to relieve bothersome tinnitus. It uses strategies and products to mask, habituate, or neuromodulate perceived subjective tinnitus. Both wearable and nonwearable devices may be helpful. Tinnitus retraining therapy is an approach to intervention that includes both sound therapy and counseling.

Outcomes

A person’s progress in the AR process may be measured in several ways and may require documentation by more than one professional (i.e., audiologist and SLP). Outcomes may be tied to the ICF framework and may include measures related to functional progress, activities, and participation.

Examples of outcome measures may include

• functional listening skills;
• clarity of speech;
• use of communication strategies in daily activities;
• use of self-advocacy skills; and
• overall quality of life.

Outcomes and treatment progress may be documented in a variety of ways. For example:

• Periodic review of short- and long-term treatment goals and objectives (which are functional in nature and have been determined by interactive and collaborative decision making).
• Description and reasons for appropriate modifications to the treatment plan.
• Self-assessment questionnaires.
• Surveys or questionnaires completed by significant others.

Service Delivery

In addition to determining the optimal treatment options for each person receiving AR services, the provider also considers service delivery variables. Examples of variables that may affect treatment outcomes include format, provider(s), dosage?, timing, and setting.

Reimbursement

Medicare Billing

AR services provided by an SLP may be a Medicare-covered benefit as long as the services are medically reasonable and necessary to improve patient function and that a plan of care is approved by the treating physician.

The Social Security Act defines audiology services as “hearing and balance assessment services,” limiting the ability for audiologists to bill the Medicare program for treatment. The law only applies to the ability to bill, not to the scope of practice of an audiologist. The limitation, therefore, is based on the coverage of the benefit. An audiologist may provide AR services to a Medicare beneficiary, but the beneficiary must understand that treatment services provided by an audiologist are not covered by the Medicare program.

Medicaid Billing

The coverage of AR varies from state to state. For assistance with questions related to state Medicaid, contact reimbursement@asha.org, or contact the appropriate State Advocate for Reimbursement (STARs) Liaison.

Private Insurance

Coverage of AR varies across individual health plans. Audiologists and SLPs need to review third-party payer contracts and have the patient provide documentation of their health plan’s coverage.

For more information, see ASHA’s page on Billing and Reimbursement, and the ASHA Practice Portal page on Documentation of Audiology Services.

Other Resources