A Case Study in the Use of Cognitive Screening

An Interview with Al Turri, Au.D.

AP Let’s start by telling us your path to private practice.
AT I feel like I’ve built three different successful practices over the years and had a couple major fails intertwined with the successes over the last 20 years. Audiology is a second career for me and I was drawn to it quickly after shadowing a few private practice audiologists that fit patients with aids while I was with them (thank you Dennis Uken for making this almost-SLP grad student shadow AuDs). The immediate improvement that was reported by patients and the hearing smiles hooked me, as did the ability to hang my own shingle one day since I had been self-employed in my previous career.

Larry Hagen, of MicroTech fame really gave me my start when he acquired five retail locations in AZ and hired me as an operations manager. I really cut my teeth and learned a lot, as SoundPoint Audiology grew from five locations in Tucson to over 20 in four states prior to me moving back to Florida and hanging my own shingle, which ultimately became Harmony Hearing Centers of America in Central Florida.
I sold those nine locations in 2015 to focus on my current project as the audiology director of The Villages Health System, which is the premier health system in the largest retirement community in America. It started as one of my physician contracts while I was in private practice and has morphed into a team of eight audiologists embedded in eight medical practices throughout the community.
AP Where is your current practice and how long have you operated it?
AT The Villages Health LLC is located in the Villages Florida (an hour north of Orlando) and has been around for almost nine years. I’ve been involved since the beginning as their director of audiology. Additionally, I am a member of the LLC, and a member of its leadership cohort.

AP With OTC hearing aids looming, what do you see as some of the opportunities and threats to audiologists in clinical practice?
AT The only threat I see to audiology are audiologists, unfortunately. For whatever reason we refuse to band together and utilize our numbers, buying power and expertise to own our scope of practice. OTC will increase the number of people raising their hand asking for help and at some point many of them will seek the professional services of audiologists. I’m ready and doing everything I can to position myself as the local expert in the villages.

AP I know Florida is one of the most competitive commercial hearing aid markets in the country. What are some of the strategies you use to differentiate your practice from the competition?
AT And, I might add, the Villages is probably the most competitive in Florida with over 50 locations to acquire hearing devices in and around the Villages.

Primarily, we stay away from focusing on the widget and devote our energy on educating the community that hearing loss is a progressive degenerative disorder that needs to be identified and treated as early as possible by doctors of audiology utilizing best practices. We devote significant resources to screening cognition and educating the community on ear to brain health.

AP I understand you are an early adopter of computerized cognitive screening. Could you tell us what that is?
AT In my opinion, computerized cognitive screening tools are a game changer. I’ve been screening cognitive ability since 2016, with paper and pencil batteries, but finding it hard to translate those results into meaningful conversations with patients regarding their ear-to-brain health. Now, using an automated cognition screening tool, I have data on three cognitive domains and two speed performance parameters that translate well to cognitive ability. The results of this screening changes the direction of my conversations with patients and their treatment plan.

AP What is your take on the value of conducting cognitive screenings in an audiology practice?
AT It’s huge! Audiologists are on the front lines when it comes to cognition. Performing cognitive screenings provides the opportunity to identify potential cognitive decline early and refer the patient appropriately for assessment. Additionally, it stimulates incredible conversations with patients and referring physicians. I have also found that it increases the likelihood that the patient will seek help to address their hearing loss.

AP Take us through the process you use with the cognitive screener. How have you implemented it in your practice?
AT We have a screener in every location and all of our new patients and annual check-ups receive a screening. Additionally, new fittings also receive a screening four months post fitting to assess any improvement to cognition. Some providers, including myself have the screener in their suite and incorporate the screening into the consult. Other providers have their support staff conduct the screening before seeing the patient and simply review the results along with the hearing assessment. The key is to make sure that the patient understands that neither the screening tool nor the audiologist can diagnose cognitive decline and that the results today will be used to direct treatment recommendations. We are seeing improved memory and executive functions results regularly in my clinic, following four or more months of hearing aid use.

AP Could you share with us how you bill for it? Is it bundled with the sale of hearing aids or more of a fee-for-service?
AT Some clinics charge an unbundled fee, while others incorporate it into their functional hearing assessment. I have opted to bundle it in and not charge for it.

AP What has patient feedback been like for cognitive screening?
AT They love it and can’t wait to take their four month screening post fitting. For many, it puts their mind at rest since they pass the screening, while others are finally motivated to speak to their physician about a subject that they have been avoiding.

AP I am really curious about how cognitive screening affects patient benefit with hearing aids. What have you observed in your clinic with respect to hearing aid benefit with cognitive screening as part of your process?
AT It changes the conversation and helps people move towards treatment like nothing else I’ve ever implemented. It keys me into patients that are going to need more counseling, slower compression speed, assistive devices and family involvement immediately as opposed to several visits after the initial hearing aid fitting. Most significantly, it reinforces the ear-to-brain message that we have been discussing with patients in our practice since 2017, especially when coupled with incredible research from the realm of cognitive hearing science.

AP What is your approach with patients who score poorly on the cognitive screening?
AT Poor results prompt referral back to the primary care physician or neurologist for further assessment. If hearing aids are part of the patient's treatment plan, I use technology with slower compression speed, counsel with written materials and frequently reinforce the need for aural rehab. I also incorporate TV devices and remote microphones more frequently as part of the treatment plan for these patients. Finally, I try to make sure to involve the patient's family in the entire process..

AP Beyond cognitive screening, what other tests or counseling tools do you routinely implement in your practice that contribute to patient outcomes and business success?
AT Speech-in-noise testing, aided as well as unaided is hands down the most important test that I perform, especially when coupled with memory and executive function scores from the cognitive screening. For years I focused on the widget and got away from aural rehab, but today aural rehab is integral to my patients’ success. Additionally, I love questionnaires and use them pre- and post-fitting as well as at routine follow-up visits.

AP Thanks for the insights, Dr. Turri.
AT My pleasure.    

Dr. Turri can be reached at [email protected].