Functional & Communication Needs Assessment Translating Results into Recommendations

Author: Alicia D.D. Spoor, Au.D.

"It’s an epic story of enduring appeal across generations.” The description of Margaret Mitchell’s Gone With the Wind could also accurately describe the presentation of Functional and Communication Needs Assessment (F&CNA) at AuDaCITY 2020. The three-hour long (not including Intermission), Tier-1 ABA talk is a thorough review of the literature, hearing aid evaluations, each F&CNA testing/screening procedure, and recommendation. The recording is available below and includes pictures of the equipment used in each assessment and videos of a patient completing each task. A recorded, condensed 90-minute F&CNA presentation is available through AudiologyOnline. [Videos can also be accessed at https://DesignerAudiology.com/AOvideos] This article introduces and summarizes key points about the F&CNA.



Moving from HAEs to CNAs
Alicia Spoor, Au.D.

Completing each procedure of an F&CNA efficiently and accurately is necessary, but not sufficient. Being able to interpret the results and create a plan of care (sometimes referred to as “care plan”) is what will differentiate audiologists who complete F&CNA appointments versus those providing a hearing aid evaluation and non-traditional methods of amplification treatment such as over-the-counter hearing aids.

An F&CNA encompasses an audiologist’s entire of scope of practice. It includes audiologic and vestibular testing and also screening procedures to look at the entire person. “Functional” is a commonly used term in healthcare relating to musculoskeletal/neuromusculoskeletal capacity. Diagnostic evaluations of the vestibular system (e.g. 92540) determine if an individual has an impairment or loss of physical function related to this capacity1. Without the term “functional” in the name, the appointment appears to focus only on the hearing portion of the audio-vestibular system (e.g. Communication Needs Assessment, Auditory Needs Assessment). Audiologists need to expand their definition of communication beyond hearing to encompass the exchange of information via any medium2 (e.g., sign language, alerting signals). Perhaps most importantly, licensure laws need to be reviewed prior to implementing an F&CNA appointment. Licensure laws, while similar for audiology, are not uniform in all 50 states and the District of Columbia. Some states are intentionally vague, allowing the state’s Board of Examiners to make decisions about what is included within audiology licensure. This contrasts with licensure laws in other states which name each and every procedure allowed and, therefore, require a change in law to include any new field of audiology and/or screening procedure. Each test and screening used with an F&CNA must be within the scope of practice for an audiologist to offer it. In the case where licensure is vague, it is essential the audiologist ask the Board whether or not s/he can perform the procedure and obtain the answer in writing. While it sounds simple, this task may take months to complete since many Boards of Examiners are required to meet (commonly monthly) to discuss such topics, state lawyers may be involved, and a public announcement is often posted.

The literature around needs assessments, both communication and functional, is limited. Today, the two most commonly referenced materials are those by Cynthia Compton-Conley, Ph.D. and Robert Sweetow, Ph.D. Dr. Compton-Conley expands the traditional role of communication to include the four areas for hearing enhancement: (1) face-to-face, (2) reception of electronic media, (3) telecommunications, and (4) alerting. She also stresses that the individual’s needs should inform the technology, not vice versa3. Dr. Sweetow was one of the first to discuss a care plan, noting that it should include education, counseling, communication strategies, auditory training, and devices4. National associations and peer-reviewed literature may provide additional insights about needs assessments, although the body of work is scarce.
F&CNA Testing/Screening Procedures
A comprehensive F&CNA is non-trivial. An entire hour was devoted to the procedures of an F&CNA appointment in the AuDaCITY presentation. In practice, a 30-45 minute F&CNA protocol is completed for one reason: to create a comprehensive plan of care. The plan of care may or may not include a recommendation for hearing aids via a traditional delivery model (e.g., via an audiologist, physician, or hearing aid dispenser) and must provide recommendations for all concerns noted by the patient and outcomes from the procedures. This is not a simple task and requires an ethical and knowledgeable provider.

There are numerous testing and screening instruments available for an F&CNA. Quality of Life (QoL) questionnaires should be dispensed to the patient prior to the appointment to allow for completion and proper reflection from the patient and/or caregivers, family, and friends. Each QoL questionnaire should address an area of possible concern: anxiety, depression, dizziness, hearing, hyperacusis, motivation, and tinnitus. Screening for dizziness/vestibular difficulties can be accomplished using the Timed Up and Go (TUG5) with minimal equipment. These two procedures can be an easy first step towards a comprehensive F&CNA. Vision loss, among the affected population, plays an important role in safety (falls risk) and treatment options. A Snellen eye chart can be used to screen for both nearsightedness and farsightedness, is practical in spaces as small as 10 feet, and is inexpensive to purchase. Blood pressure screening is likely best completed with an automated screening (e.g. Easy@Home digital upper arm blood pressure monitor,6,7) to rule out cardiovascular issues. ADA has long advocated for elevating the profession of audiology to a doctoral-level. A thorough case history with the Review of Body Systems is key to providing comprehensive care to an individual, not just their ears. [Purchase the ‘Adult Case History’ from the Forms Library8.] A dexterity screening tool (e.g., the Purdue Pegboard Test9) may need to be purchased, if only to obtain consistent, evidenced-based results to compare with normative data.

Irrespective of the order of audiologic testing, most comfortable listening levels (MCLs) with recorded and monitored live voice and uncomfortable listening levels (UCLs) need to be obtained for the right ear, left ear, and bilaterally. Diving further in to the auditory system, measurements for noise tolerance (e.g. Acceptable Noise Level10), binaural interference, speech in noise, and cochlear dead regions are straightforward to obtain and the test materials are now being incorporated in audiometry diagnostic equipment. An auditory processing (APD) screening is likely the most time-intensive component of an F&CNA, requires the purchase of screening/diagnostic materials, and requires a two-channel diagnostic audiometer. Cognitive screening – assuming it is within the scope of practice – needs to be administered after audibility is verified. This is becoming more widely recognized with emerging literature around hearing loss and cognition. Incorporating working memory protocols (e.g. Word Auditory Recognition and Recall Measure11) completes the screening/testing F&CNA appointment.
Results to Recommendations
Since the goal of an F&CNA appointment is to provide a comprehensive treatment plan, the purchase of hearing aids is not essential; however, a take-home plan of care document is required. The plan of care will naturally commence from results obtained during each procedure of an F&CNA. Documentation may easily be two or more pages in length when customized to a patient. The care plan needs to be aesthetically pleasing and handed to each patient at the end of the appointment. Not only does this treatment plan show value for the cost of the appointment (an out-of-pocket expense), it also allows the patient to choose his or her treatment path with an audiologist, another provider, or no provider. Table 1 shows the general outcomes that are derived from each of the tests/screenings completed.
Table 1
                                                                  
Additional Testing Referral Treatment Plan Follow-up/Return Timeline
Questionnaires X X X X
Vestibular Screening X X X X
Vision Screening X X  
Blood Pressure Screening X X
Dexterity Screening X X X
Most Comfortable Listening Levels X X X X
Acceptable Noise Level Test X X X X
Speech in Noise Test X   X X
Binaural Interference Test X   X X
Cognition ScreeningX X  
Auditory Processing Screening X X X X
Tolerance Test X X X X
Cochlear Dead Region Test X X X  
Working Memory TestX X  
Questionnaires
A variety of relevant questionnaires are available to inform the patient’s overall assessment. A hearing-related QoL questionnaires may suggest additional testing (e.g., otoacoustic emissions) that needs to be completed to determine or rule-out a diagnosis, treatment outcomes (e.g., communication strategies), and the timeframe for a patient to return (e.g., 1 year) for follow-up testing. Dizziness QoL questionnaires may suggest additional testing (e.g., positional testing) or a referral to a vestibular audiologist, referral to another provider for further testing (e.g., imaging), vestibular treatments (e.g., Canalith Repositioning Testing), and the timeframe (e.g., 30 days) to return to the clinic. A tinnitus QoL questionnaire may suggest additional testing (e.g., tinnitus evaluation) or a referral to an audiologist who specializes in tinnitus, referral to another provider for further testing (e.g., dentist), tinnitus treatments (e.g., tinnitus masker), and the timeframe (e.g., 6 months) to return to the clinic. A limited number of hyperacusis QoL questionnaires are available and results may suggest additional testing (e.g., UCLs), referrals to an audiologist specializing in hyperacusis/misophonia and/or another provider (e.g., medication management), and the timeframe to follow-up (e.g., 1 month). Motivational QoL questionnaires may indicate treatment options (e.g., alerting devices) and the timeframe to return (e.g., 4 months). Depression QoL questionnaires are often in the public domain for healthcare professionals (e.g., PHQ-2). A positive screening result will require a referral to a provider who can further evaluate, diagnose, and treat the individual as needed (e.g. psychologist). Anxiety QoL questionnaires (e.g., GAD) may suggest treatment options (e.g., working in small steps with devices over the course of a year, rather than an osseointegrated device the first month), and referral to another provider (e.g., psychiatrist).
Vestibular Screening
Using the Centers for Disease Control and Prevention’s (CDC) Timed Up & Go (TUG) criteriav, a positive screening is a result longer than 12 seconds. In such situations, further vestibular evaluations are required which may require a referral to another practice. Depending on the patient’s history, a referral to another provider may also (or instead of) be needed, such as a physical therapist or optometrist. A home hazard evaluation (e.g., Johns Hopkins Falls Risk Assessment Tool) should be completed to ensure safety in the patient’s primary residence with suggestions for improved safety made. Treatment recommendations may include assistive devices such as a walker, more consistent use of an assistive device, and may warrant fall detection alerts within or separate from hearing devices.
Vision Screening
Depending on the results of both the nearsighted and farsighted vision screening, and whether or not the screening was completed with corrective lenses (e.g., contacts), a referral to an optometrist or ophthalmologist may be required. Audiologic treatment options such as hearing aids may need to be significantly larger than usual, have direct power sources (e.g., TV Ears), and/or visual text (e.g., captioned phones) for full benefit. Accessories could also be warranted for optimal control, if amplification/osseointegrated devices are needed.
Blood Pressure Screening
Vestibular testing may be impacted by high or low blood pressure and medication from a prescribing physician could be required. Cardiovascular treatments require a referral to another provider (e.g. cardiologist). Follow-up testing and treatment can also be affected by the blood pressure screening results. If amplification is warranted, technology that incorporates body/health measurements should be recommended when available.
Dexterity Screening
The Purdue Pegboard Test (PPBT) has four different conditions and results are timed to compare with normative data. Depending on the needs and wants of the patient, treatment may need to be adjusted based on the results. For example, if a patient cannot adequately feel small objects such as the pins in the PPBT or #10 batteries, the plan of care should have recommendations that meet the patient’s needs, not wants. Treatment options should be considered with smartphone compatibility, hearing aid accessories/remote controls, raised and onboard program buttons and volume controls, rechargeable batteries, coupling options, and extended-wear devices. Non-traditional devices may also play a role in treatment: alerting devices (e.g., Sonic Boom alarm clocks), television amplification (e.g., TV Ears), and even non-traditional amplification (e.g., iPad with Live Listen and headphones).
Most Comfortable Listening Levels
Most Comfortable Listening Levels (MCLs) can identify non-organic hearing loss, which would require a referral to another provider such as a psychiatrist. Additional testing (e.g., auditory brainstem response) may also be warranted to confirm measurements. Results from MCLs will provide a starting point for hearing aid programming and, if MCLs are low, the timeframe to return to the clinic to properly adapt to amplification will be evident.
Acceptable Noise Level Test
Along with a thorough case history, the Acceptable Noise Level Test (ANL) can estimate if an individual will be successful with treatment. For those unlikely to be successful, support groups (e.g. Hearing Loss Association of America) are a common recommendation to help cope or share information about hearing loss. Local, national, veterans, and online organizations provide such services with minimal cost. ANL results of less than 7 dB suggest good success with amplification; individuals with results between 7 dB and 13 dB can still be successful, but will often need professional involvement. A traditional dispensing model needs to be recommended for these patients and gain may be minimal for the first few months (or year!). Follow-up treatment may also need to occur more often to increase the gain in the hearing aid and support the patient in the process.
Speech in Noise Test
Speech in Noise (SIN) testing can help to diagnose non-organic hearing loss and the need for additional audiologic testing such as otoacoustic emissions. Poor SIN results may also indicate poor auditory processing and suggest a full auditory processing (APD) test and/or referral to a provider who completes APD testing. Pure tone thresholds within normal limits and poor SIN results verify a patient’s complaint of difficulties hearing and may be the first indicator of a “hidden” hearing loss. Follow-up testing may be indicated sooner than initially anticipated (e.g., 1 year) with poorer than expected SIN results. Treatment options for those with more than a 3 dB signal-to-noise ratio (SNR) loss should include communication strategies and possible aural rehabilitation. Along with questionnaire results, amplification for specific listening environments (e.g., large meetings, restaurants) may be recommended as a part of the care plan. SIN scores greater than 10 dB SNR loss may warrant accessories for optimal communication, in addition to high-level technology amplification with directional microphones, and noise reduction. Such accessories include a television streamer, remote microphone, phone clip, and/or FM system. Treatment options for SIN scores 6-10 dB SNR loss need to include devices, size/style with directional microphones, noise reduction, multiple listening programs, automatic program adjustments, technology levels (minimum mid-level technology), phone connectivity, and upgradability.
Cognitive Screening
Depending on the screening tool used, the cut-off for a “positive” result will vary. Some tools (e.g. miniCOG) have different cut-offs for cognition (less than 4) versus dementia (less than 3). Referrals to appropriate providers for any positive results are essential. Follow-up timelines will be influenced by the results. For example, an individual may need to have more appointments to learn communication strategies if s/he has poor cognition/memory. Support groups can also be helpful for both the patient and caregivers. Assistive devices which incorporate visual cues can be helpful and treatment devices may need to incorporate a smartphone. Amplification treatment options may incorporate rechargeable batteries, automatic controls, extended-wear devices, and/or smartphone compatibility. Accessories could also be helpful, such as a smartphone app, television streamer, or remote control. Extended warranties may also need to be discussed.
Auditory Processing Screening
The plan of care may vary depending on which subsection(s) of the APD screening indicated difficulties. Additional APD testing, or a referral to an audiologist who performs APD testing, is required when screening results specify refer. Treatment options may require communication strategies, aural rehabilitation, and use of a device. A decision must be made for personal amplifiers, low-gain hearing aids, directional microphones, and/or noise reduction.
Uncomfortable Listening Levels
Measuring speech and tonal Uncomfortable Listening Levels (UCL) will screen for sound tolerance issues. Hyperacusis and/or misophonia can be measured with the Hearing Aid Research Lab (HARL) Contour Test12. Treatment for hyperacusis must be completed prior to consistent amplification use. A referral may be warranted to an audiologist who is specifically trained in hyperacusis/misophonia and/or another provider to help with sensitivity issues (e.g., sleep medication). The follow-up timeline will be more frequent with these individuals compared to the average patient. Hearing protection devices (e.g., musician earplugs with filters) may be needed to help the patient acclimate to environmental sounds. UCL and Contour Test results will also be utilized to program amplification (which may not be available via over-the-counter devices), Maximum Power Output (MPO) levels, and (automatic) adaptation settings.
Cochlear Dead Regions
Additional testing, or referral to a provider who can provide testing for osseointegrated devices, may be needed with a significant (4 or more) number of cochlear dead regions. With any number of cochlear dead regions, hearing aids need to have a frequency transposition, frequency compression, or frequency lowering features to ensure audibility of sounds.
Cost to Implement F&CNA
Implementing a well-thought-out Functional and Communication Needs Assessment requires investment. The largest cost is the need for a 2-channel audiometer to provide auditory processing screenings. The remaining equipment is relatively inexpensive, likely less than $1,200. Audiologists who wish to pursue comprehensive auditory processing, musician, tinnitus, hyperacusis, and misophonia, and vestibular training can expect to pay $10,000 for additional workshops. However, even considering this $11,200 investment and an average audiology hourly rate, the clinic may break-even with less than 120 F&CNA appointments.
Additional Information
For more details and information, the epic AuDaCITY 2020 presentation is available through the AuDaCITY convention website. AudiologyOnline hosted the 90-minute, shortened presentation. A plan of care patient handout can be customized with a clinic’s logo and is available for purchase from High Definition Impressions (HDI).    
Dr. Spoor owns and operates Designer Audiology, LLC, a private practice located in Highland, Maryland. She holds a Doctor of Audiology (AuD) degree from Gallaudet University and a Bachelor of Arts (BA) degree from Michigan State University in Audiology and Speech Sciences.
References
1 2020 MIPS Measure #182: Functional Outcome Assessment. Accessed 11/29/2020. [https://healthmonix.com/mips_quality_measure/2020-mips-measure-182-functional-outcome-assessment/]

2 Oxford Languages. Accessed 11/29/2020. [https://languages.oup.com/google-dictionary-en/]

3 Compton-Conley, C. Needs Assessment for Hearing Enhancement©. Academy of Doctors of Audiology [presentation]. 2015, Nov.

4 Sweetow, R. Instead of a hearing aid evaluation, let’s assess functional communication Ability. The Hearing Journal. 2007; 60(9): 26-31p.

5 Centers for Disease Control and Prevention (CDC) Stopping Elderly Accidents, Deaths & Injuries (STEADI). [Internet] Available from: https://www.cdc.gov/steadi/pdf/STEADI-Assessment-TUG-508.pdf

6 Accessed 11/29/2020. [https://www.aafp.org/afp/2016/0215/p300.html]

7 Accessed 11/29/2020. [https://www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-blood-pressure-at-home]

8 Academy of Doctors of Audiology. Accessed 11/29/20201. [https://audiologist.org/practice/forms-library]

9 Shirley Ryan Abilitylab. Purdue Pegboard Test. [Internet]. Available from: https://www.sralab.org/rehabilitation-measures/purdue-pegboard-test

10 Interacoustics. Acceptable Noise Level. 2017 May. [Internet]. Available from: https://www.interacoustics.com/guides/test/audiometry-tests/acceptable-noise-level-anl-test

11 Smith, S., Pichora-Fuller, K., Alexander, G. Development of the Word Auditory Recognition and Recall Measure: A Working Memory Test for Use in Rehabilitative Audiology. Ear & Hrg. (2016); 37(6):360-376p.

12 Accessed 11/29/2020. [https://harlmemphis.org/contour-test/]