Editor's Message: Moving Away from the Binary Service Delivery Model

Author: Brian Taylor, Au.D.

In most audiology practices, once an underlying medical problem has been ruled out, clinicians have a tendency to treat all individuals with hearing loss as hearing aid candidates. We tend to sort them into one of two categories: A.) Hearing aid users (those that accept our recommendation to use hearing aids on the day of their appointment), or B.) Hearing aid candidates (those that have some type of objection to using hearing aids who often get labeled as “tested not sold”). In this binary service delivery model the patient is either an immediate hearing aid user or a future hearing aid user who is likely to be flooded with letters, direct mail pieces and other forms of advertising until they eventually purchase hearing aids.

A big challenge associated with our current binary service delivery system is inefficiency. When the same group of services and procedures (for example, the hearing aid evaluation) are bundled with the sale of a pair of devices, as they usually are today, the more routine cases subsidize the more complex cases. In other words, in a bundled model, patients who need just one or two relatively short appointments to become successful hearing aid users are paying more for the same thing than patients with complex problems that typically require more time and expertise to successfully remediate. When the goal is simply to fit as many hearing aids as possible in order to generate sustainable revenue for a practice, as it is in the binary model, we lose opportunities to deliver more varied and sophisticated types of services that can be unbundled from the devices we fit.

One path to the provision of services that could be delivered separate from the fitting of a pair of hearing aids can be found in the work of Sophia Kramer and the late Dafydd Stephens. (An excellent starting point is their 2010 book, Living with Hearing Difficulties: the Process of Enablement). In much of their work they discuss the process of hearing enablement, a term loosely defined as the clinician’s ability to help a person with hearing loss become more active and engaged in daily living by overcoming the emotional obstacles associated with their chronic condition. Their work does a good job of focusing on the need to discuss with patients their particular communication problems, their reactions to their communication problems and the reasons behind such reactions. It is a significant departure from our current binary approach where we try to fit the individual into our service delivery model.

Stephens and Kramer suggest clinicians sort patients into one of four categories and provide the right kind of counseling and remediation, depending on how the clinician classifies their condition.

Type 1: Positively motivated without complicating factors
Type 2: Positively motivated with complicating factors
Type 3: Wants help, but rejects a key component of your recommendation
Type 4: Deny any problems with hearing or communication

According to Stephens & Kramer, about 80% to 90% of patients fall into the first two categories. Let’s look more carefully at each type, what each type looks like clinically, along with some of the service that need to be provided by the clinician for ear respective type.

Type 1: Positively motivated without complicating factors
The individual readily accepts your recommendation for hearing aids and rapidly and effectively passes through the system, needing only one of two appointments with the audiologist

Type 2: Positively motivated with complicating factors
The individual requires more time and attention to successfully use hearing aids or to acquire necessary communication skills. Thus, a Type 2 patient needs three or more appointments over a 6 month time period. Time spent at each of appointment would address issues related to complicating factors such as the patients’ lack of confidence, physical or cognitive decline, and/or lack of family support.

Type 3: Wants help, but rejects a key component of your recommendation
The individual requires additional personal adjustment counseling and involvement of significant others to improve their acceptance, understanding and expectations relative to the rehabilitation process. Type 3 patients are likely to need more “talk therapy” that allows them to gain confidence and independence with respect to accepting the clinician’s recommendation. Oftentimes because a device is not involved in the rehabilitation, the clinician’s role is to providing guidance on the patient’s underlying reasons for not accepting treatment recommendations.

Type 4: Deny any communication or hearing problems
Because the individual is in denial or unaware of a communication problem, no intervention can be started at this time. Significant others may require support and advice during the time of the appointment. Type 4 patients likely need to be monitored over a long period of time, and with the support of family, encouraged to visit the clinic periodically for a re-assessment of their hearing along with their motivations for accepting help.

Triaging patients into one of these four categories, using patient centered counseling skills has the potential to unlock new service delivery models that benefit more patients and allow clinicians to charge fees for specific services, many of which do not have to be coupled with the sale of hearing aids. As audiologists grapple with changes in product regulation and the rise of third party Medicare Advantage programs, it imperative we engage with patient’s on a deeper level. The model proposed by Stephens and Kramer is a good starting point toward achieving that goal.