Community-Based Health and PSAPs: What Clinicians Can Learn from Research



Author: By Sara Mamo, Ph.D. and Brian Taylor, Au.D.

Dr. Sara Mamo is a post-doc researcher at John Hopkins University School of Medicine in the Otolaryngology Department. Prior to her time there, she obtained her PhD from the University of North Carolina in Chapel Hill. In January, 2017 she will take a faculty position in the Audiology Department at the University of Massachusetts-Amherst. As she explains in her interview with Brian Taylor, she has been involved in studying the public health aspects of hearing loss in adults, which has included the provision of PSAPs for some patients.

AP: Tell us about your clinic and some of your research projects.

Mamo: Currently, I am a post-doc researcher at John Hopkins University School of Medicine in the Otolaryngology Department. I am working on three intervention-based research projects. All three projects rely on over-the-counter amplification and basic education and training in age-related hearing loss and communication strategies.
  1. We provide basic aural rehab in a community-based setting. Presently, we work with three independent-living residential buildings for low- and middle-income older adults. The intervention is a one-time, 2-hour training session with an interventionist, a communication partner, and an adult with hearing loss. The pilot study manuscript is under review and we have been developing new materials as well as developing a ‘train-the-trainer’ curriculum. The next phase of the research project will test an audiologist supervised community health worker approach to providing this service.
  2. We have done a feasibility study and are working on a proposal for a randomized clinical trial to provide a basic aural rehab intervention at a specialty clinic for memory disorders. We have done this work in collaboration with the Johns Hopkins Memory and Alzheimer’s Treatment Center. The intervention is provided at the memory clinic with the person with dementia, a caregiver, and an interventionist. To date, the interventionists have been an audiologist, a geriatric fellow, and a trained research assistant. The purpose is to reduce dementia-related problem behaviors through simple amplification and communication strategies.
  3. The third project is set to be tested this summer and it translates the memory clinic project into a group care setting for older adults. Aspects of the intervention for the group setting include staff training, acoustic modifications to the activity hall, and small group communication therapy to adjust to the use of a personal amplification device. The goal of the intervention is to increase engagement in activities and with peers among participants with hearing loss and cognitive impairment.
AP: Affordability and accessibility of hearing aids has been a hot topic for a few years now, how has the research being conducted at Johns Hopkins contributed to this debate?

Mamo: Epidemiological research from the Lin Research Group, as well as others, in recent years has shown the broad impacts of age-related hearing loss (ARHL) on healthy aging—across such domains as cognitive function/dementia, physical function/mobility, and health resource use/hospitalizations. Previously, audiology has focused on the speech communication and psychosocial impacts (e.g., depression, social withdrawal) of ARHL, but these findings position age-related hearing loss at the heart of big issues in aging research. If it is the case that ARHL actually accelerates some of the negative health outcomes with which it is associated, then the importance of ARHL becomes much more significant than the attention it tends to receive. Hearing loss among older adults is so common that many people feel it doesn’t matter—“my hearing is normal for my age.” Importantly, that’s what many primary care, internists, and geriatric physicians think too.

The question as to whether or not treating hearing loss changes the trajectory of cognitive and physical health declines is under active investigation. In the meantime, we have a massive under treatment problem among adults with hearing loss. More than 80% of adults with hearing loss report not using hearing aids. We also know that even if hearing aids are free, as in some European countries, hearing aid adoption rates remain low.

So, while affordability is a big deal, I would argue that accessibility is a huge deal too. The challenges of accessibility cross many fronts, including knowing who to go to, having transportation to get there, and having the means to repeatedly visit one or more specialists. As it turns out, many people do not want to address their hearing loss, and so, it takes very little in terms of barriers to result in not pursuing treatment.

AP: You’ve been involved in evaluating PSAPs, please share with us the findings of your research in this area.

Mamo: We have started evaluating PSAPs via electroacoustic analyses, simulated- and real ear measures (REM), speech-in-noise measures in the sound booth, and intervention-based research. As expected some devices are poor quality. For example, with the $30 drug store device, adults with hearing loss actually performed worse than their unaided score on a speech-in-noise test in the sound booth. However, increasingly, there are a number of good options in the $150-350 price range. Most PSAPs have a set gain configuration designed to match the most typical mild to moderate ARHL configuration. As such, this can serve as a reasonable assistive device that is something, certainly better than nothing. Perhaps more exciting is these devices are increasing in their sophistication. In one very good device, you can take an in-situ hearing test through the device (coupled to a smart phone), and it uses the responses to program a prescriptive algorithm customized to the user. As it turns out, via REM analyses, this process generates a fitting that reasonably matches NAL-targets.

AP: How do you see PSAPs being utilized in medical clinics?

Mamo: I see PSAPs as an important part of person-centered care. Not everyone wants hearing aids, and not everyone who comes to the clinic with hearing-related complaints needs hearing aids. One of the new PSAPs on the market, looks like a Bluetooth earpiece, functions as a Bluetooth device, has multiple channels of gain set based on user preference, and has a remote microphone. What’s wrong with using a device like that to meet the needs of an adult who complains of difficulty hearing in restaurants, in the car, and on the phone? If practices are unbundled, as the field has been discussing for more than a decade, then the clinician has the freedom to consult on products like these.

AP: I believe your medical center has been involved in community-based hearing services. Could you tell us about your efforts in the area of community outreach?

Mamo: So far, our community-based hearing services have all been done under the umbrella of research. Concurrently, Drs. Lin and Nieman have established a non-profit organization to develop a distribution channel for providing our community-based intervention as a service. These are early days of this process, but the idea is to have a sliding-scale fee, use a good PSAP device, and couple provision of the device with a basic aural rehabilitation session (e.g., device care and maintenance, hearing loss education, and communication strategies). We envision this approach delivered with an audiologist as a supervisor and with trained community health workers and/or medical technicians as the intervention providers.

AP: What are some of the lessons private practices and small independent medical clinics can learn from your team’s research and foray into community-based audiology?

Mamo: I hope that our work starts to build new models that private practices and small clinics can adopt that will allow them to reach more people in need of communication support. Using audiologists as supervisors of community-based teams and technicians can drastically increase the number of individuals who receive intervention. I believe this approach eventually brings more people through the clinic door, and in the meantime, it provides improved communication to more people without them having to make it to the clinic multiple times to see multiple specialists.

The entire mindset of affordable and accessible models of care is not about replacing the clinic-based services that we’ve relied on to-date; it’s about finding the 80% of the people that we are not serving under our current model of care.    
Sara Mamo, PhD can be reached until December, 2016 at smamo1@jhmi.edu.