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Implementing New Clinical Services

Implementing New Clinical Services

Jason Baker, AuD

Although this entry is intended for new professionals, the message and the information provided is actually applicable to all audiologists. As a new professional, I would like to share my experience as it pertains to ear canal management.

As we all know, in order to perform the majority of audiological assessments, the ear canal(s) must be free of debris. In a study looking at the effects of cerumen occlusion on pure-tone thresholds, the authors report a prevalence of cerumen occlusion in 10% of children, 5-8% of adults, 34-57% of elderly adults, and 22-36% of those with developmental delays (Roeser et al., 2005). When we are faced with an occluded ear canal, we have two options:

  1. Perform cerumen management OR
  2. Send them out the door (PCP, ENT, Otologist, etc.).

Many state licensing boards do not allow audiologists to perform cerumen removal. According to the American Speech Language Hearing Association (ASHA), twenty-two of the fifty U.S. licensing boards allow audiologists to perform cerumen management. However, in some settings, it may be “easier” or the protocol is to send the patient to the ENT or otologist for a “quicker” removal. Rules and regulations on who can perform ear canal management is an entirely different conversation.

I am interested in hearing from audiologists that recognize the need for ear canal management, are allowed to perform cerumen removal under the scope of practice in that particular state, but do not perform the procedure. I am curious to know the reasons why some audiologists simply are not performing ear canal management. Reasons I’ve heard include:

Charging for Services:

  • Does the audiologist not want to charge the patient for these services? – At the very least, the patient should be made aware that the removal procedure may not be covered by insurance if performed by an audiologist. Dr. Kim Cavitt (2011) states that if the patient has Medicare and does want the cerumen impaction resolved, an Advance Beneficiary Notice (ABN) can be submitted and the patient can pay out-of-pocket. Some patients might actually prefer to have the procedure completed at that point and time and are willing to pay for it.

Duration of Services:

  • Does the audiologist think it will take too long? – Is it quicker and easier to send the patient over to ENT if the physician is down the hall? What if it would be a quick removal? According to the American Academy of Otolaryngology (AAO) Clinical Practice Guideline, it should take less than 5 minutes to instill cerumenolytic drops, less than 30 minutes for irrigation removal (including prep time), and only a few minutes for manual removal (Schwartz et al., 2017).

Confidence in Skills:

  • Throughout clinical training, is there limited exposure to and practice of cerumen removal?

The last question is what I am going to continue focusing on. Just like any skill, practice makes perfect. In the classroom, I was provided with knowledge regarding various ear canal management techniques. In clinic, I had some opportunities for ear canal management, but it was usually dependent on the setting and the comfort of the preceptor. In addition to regular clinical rotations, I was able to further develop my cerumen removal abilities while on various humanitarian trips to South Africa and Brazil. In these instances, the need was there and if we were not going to perform removal procedures, no one was.

When I began my job at the Callier Center for Communication Disorders, which is affiliated with UT Dallas, I knew there was a need for an Ear Canal Management (ECM) Clinic. I knew this would greatly benefit the local community and the graduate students participating. For the most part, none of the attending students had any previous experience with cerumen removal – mechanical or irrigation. However, even after a half day in the ECM Clinic, the students reported increased confidence in their cerumen removal abilities. I know one day in clinic will not make someone an expert, but when it comes to cerumen management, it is necessary to build-up confidence in this particular skill. The idea is to continue providing hands-on experience to graduate students and to increase their exposure to cerumen removal. For many of us, cerumen removal is a necessary procedure that we are allowed to perform. Ear canal management is an important part of audiology and as a profession, we must ensure that it is a skill that is implemented clinically and taught to future audiologists.

References

Roeser, R., Lai, L., & Clark, J. (2005). Effect of ear canal occlusion on pure-tone threshold sensitivity. The Journal of the American Academy of Audiology, 16: 740-746.

American Speech Language Hearing Association (2019). State Cerumen Management Requirements. https://www.asha.org/Advocacy/state/State-Cerumen-Management-Requirements/#TX

Cavitt, K. & White, S. (2011). Billing for cerumen removal under medicare. AudiologyOnline, https://www.audiologyonline.com/ask-the-experts/billing-for-cerumen-removal-under-40

Schwartz et al. (2017). Clinical practice guideline (update): Earwax (cerumen impaction). Journal of Otolaryngology – Head and Neck Surgery, 156(IS): S1-S29.

CEU Breakdown: Tips and Tools to Track CEUs

CEU Breakdown: Tips and Tools to Track CEUs

For many new professionals in the field of Audiology, continuing education hours seems to be a frequent source of confusion. How many do I need? Are CEUs different for licensure and membership to professional organizations? Is there anything out there that can make keeping track of all of this easier? Often, these questions are not answered as a part of an AuD program because, let’s face it, it’s difficult enough to get in all of the information needed just to see patients independently and successfully. There often is not much time left to discuss what happens AFTER graduation and how to keep up with your licensure, certifications, and professional memberships.

Fortunately, both the American Academy of Audiology (AAA) and the American Speech, Language, and Hearing Association (ASHA) provide information about CEUs on their websites, as well as options to track the hours you earn through conferences, webinars, etc. Information about AAA’s CEU policy can be found within AAA's professional development resources and information about ASHA’s CEU policy can be found on ASHA's continuing education web page. For additional tips and tools, refer to The New Professionals Guide to Continuing Education.

First, let’s start with the Academy. Through AAA, there are no set CEU requirements to maintain membership. However, the American Board of Audiology (ABA) requires 60 CEU hours in a 3-year period, with 15 Tier 1 CE hours and 3 hours in professional ethics, to maintain certification status. Tier 1 CE hours have a few requirements: 1) approval by AAA, 2) a minimum of 3 hours (one 3-hour sitting or two 1.5-hour sittings) on the same subject area, 3) include an interactive component (i.e., polling or clinical demonstration), and 4) participants need to indicate to the CE Provider that they are ABA certified and are seeking Tier 1 credits. Visit the ABA's web page for more information.

If you are a member of AAA, you are automatically given access to a CE Registry at no additional cost. The registry stores and organizes all reported CEU activities from Academy approved CE providers and also indicates if ABA Tier 1 hours have been earned. The transcript can be obtained two different ways. It can be printed from online through your member profile or you can complete a Transcript Request Form and have a transcript dated back to 2012 mailed or faxed to you. A transcript older than the past two years can be requested this way and costs $10 per calendar year requested. If you are not a member of AAA, don’t fret!  You can still obtain CEU hours through AAA if you join the annual CE Registry, which costs $60 per year. An AAA CE Transcript meets most state licensure regulatory requirements.

AAA additionally offers ways to obtain CEUs other than by attending conferences or watching webinars. One of these is through the completion of an independent study, and the other is through the Peer-to-Peer Mentoring Program. More information on how to set up either of these options, how to apply, and the cost can be found on the Academy website.

Now, on to ASHA. ASHA requires a minimum of 30 CEUs every 3 years to maintain certification. These hours must be tracked on a Compliance Form to be submitted on or before 12/31 of the year the interval is completed (i.e., the end of the 3-year period), but the hours can be submitted any time within the 3 year interval. In order to obtain ASHA CEU’s, you need to attend a course registered for ASHA CEUs and fill out the ASHA participant form.

Like AAA, ASHA also offers a CE Registry. The annual cost of the ASHA CE Registry is $28 if you are a member, and $38 if you are not. If you have the ASHA CE Registry, it automatically notifies the certification department when you have reached 30 hours; no need to submit a Compliance Form. Additionally, you can view your CE Transcript online at any time and you can request an official transcript. You are entitled to one free transcript each year you pay the CE Registry fee, and any additional transcripts are $15 for members and $20 for non-members.  You can sign up for the CE Registry when you renew your ASHA dues annually, online, by phone, or by mail. An ASHA CE Transcript meets all state licensure regulatory requirements. If you have your CCC’s and are ever audited in regards to your certificate maintenance, your ASHA CE Transcript will be considered proof of attendance for the 30-hour requirement.

When it comes to required hours, maintenance period, and costs associated with state licensure, every state is different. If you are unsure of what is required for your specific state, we encourage you to visit your state’s website and verify what you need in how many months/years.

 

 

Flying Solo After Graduation

Flying Solo After Graduation

Nicole Denney, AuD

When I accepted my first job following my externship year, I knew I was in for a very sink or swim life change. I accepted a position in a private practice as the sole provider in a new city right after graduation. I’d have my own office, my own PCC, and all the patients and responsibilities of managing an office would land on my shoulders. However, this is not all that unique in our profession. Many recent graduates choose to start out in a more independent setting rather than a multi provider office. After working at my current practice over a year now as the only provider, I’d like to share some advice on how to swim rather than sink when starting out on your own.

Before you accept, make sure this is right for you. Do a fair amount of soul searching, list making, and talking with mentors. I was fortunate in that my externship experience provided me with a great sense of the type of environment I’d be working in; we were part of a large practice group with typically only one audiologist and one PCC at each location. Knowing how to run an office and manage your schedule is very important and something we don’t exactly learn in school. For me, I spoke to other friends who started out on their own as a first job. They were able to give me a lot of honest pros and cons and it really helped me determine if this was something I could do. Likely, if you are thinking about taking a job being the sole provider, you know someone who has already been through this and would be willing to talk with you about the experience. 

Always have someone you can ask for advice. This was very important to me during my interviews for all jobs. I wanted to make sure that even though I would be 60 miles from the closest practice in our group, I could still call on other audiologists if needed. And let me tell you – I did need this, especially in the beginning! My corporate office is in Lubbock, Texas, and I’m all the way out in Southern Colorado, so there is a huge distance between us. However, I can always call or email the main audiologists there and they get back to me within the day. Besides that, I also use my mentor/externship supervisor for advice when I need it. It was very important to me to be able to talk to someone within the company when needed and also to get an outside opinion. This way, when I first started out in my office, I didn’t feel completely alone, but I also didn’t feel like someone was watching me or holding my hand. It made me really own up to who I am as a provider and still have that comfort of a safety net.

Which leads me to my next point – you have to own it. Being a 26-year-old doctor fresh out of school, we tend to look like our patient’s grandchildren. While the “wow you are so young” comments can throw you off, just remember you know your stuff! Holding yourself to a higher level of professionalism and making honest and educated recommendations and treatment plans for your patients will get you far when you are just starting out on your own. Being on my own actually gave me more confidence that I could not always find in my externship. Decisions are now mine and I know the reasons for why I’m making them. It’s a mental game that personally worked well for me.

While I made sure I still could call on other audiologists through my practice group for advice, I knew in advance it would be hard to not see and regularly discuss topics with peers. For this reason, I chose to involve myself more with the Academy by applying to be on the New Professionals Committee. There is a plethora of engaging committees within the Academy that are always looking for new members. This gives me a connection to collogues with similar interests and a fun way to stay invested. Another way is to become more involved with your state academy group! This one is a little harder for me personally due to where I live but I know they have in person meetings and that the Colorado Academy of Audiology is planning a really impressive conference this year! Being involved at the state level can connect you with audiologists in your area and lead to a rewarding experience.

I am very content and happy with my choice to work in a private practice as the only provider. If you are considering a similar choice, I’d be more than happy to discuss the pros and cons about my own experience. You can contact me via email at ndenn511@gmail.com

We are not the only profession to have new graduates start out solo. A similar advice article was written for law professionals and published on Americanbar.org. The part that I found most influential was, “you are more qualified to practice law than you give yourself credit for.” Same goes for audiology. You know way more than you think you do, and your patients are coming to you because YOU are the expert.

Resume Review Tips

Resume Review Tips

As a new professional, having a strong resume can mean the difference between a job you like and a job you love. We all have experience with similar areas of audiology like hearing aids, vestibular, or pediatrics. But what makes you unique? Did you complete a research fellowship?  Participate in a hearing mission? Or is there something else you did recently that makes you stand out? Regardless of what it is, below are a few tips to help your resume go from a draft to professionally polished in no time!

Revise Your Resume
As with any paper or article, make sure spelling and grammar are correct. If a hiring manager is reviewing your resume with spelling errors, it can appear unprofessional. Also, make sure your experiences do the talking rather than graphics, odd fonts, or color. Check out the Academy’s  resume do’s and don’ts for additional guidance.

Review Your Resume
Have someone, such as the Academy’s Resume Review Subcommittee  or a peer, look at all your application materials – resume, cover letter, even thank you notes – before submitting. They will check for spelling errors, professional jargon, formatting, and any other errors commonly seen in the field.

Post Your Resume
Audiology is a smaller field and organizations searching for employees will often ask their network of peers if they know anyone first. Aside from updating your LinkedIn profile, another opportunity to be proactive in your job search is to create a job seeker profile on  HEARCareers, a job board focused solely on audiology opportunities. Creating a profile and posting your resume on HEARCareers makes you visible to employers actively searching for their next job candidate!  

Having your resume or CV prepared in advanced will make it easier to apply to the positions you want when it becomes available. Keeping it updated after you get a job will help you be prepared for unexpected opportunities. Happy searching!

Serving as a Clinical Preceptor

Serving as a Clinical Preceptor

Serving as a clinical preceptor as a new professional is a unique job, which has both advantages and disadvantages. Being a new professional can be beneficial because the new professional can apply their recent experience as a student to effectively teach other students. For example, a new professional may better remember the aspects of masking that are confusing to students and be able to clearly explain those concepts while a more experienced audiologist may not remember the learning process and have a harder time breaking down those concepts. Although recent experience as a student is helpful when precepting, it does not make a new professional qualified to function in this role. The preceptor must be able to simultaneously perform as an educator and as a clinician, which takes knowledge, skill and continuing education. A new professional should not take on this task until they feel they have been properly educated.

There are many resources available to help professionals become equipped to precept students and anyone who precepts should view the role as a subset of audiology, which requires ongoing education. The following are useful resources:

Regardless of how educated the new professional is on the topic of precepting, there are inherent barriers to being a new professional, which can be overcome as long as the new professional recognizes that they exist. The first barrier is that in many instances, there is virtually no age gap between the student and the new professional. This can be an advantage because it eliminates generational differences in learning and teachings styles. However, the small age gap can also create issues when the roles of preceptor and student are not defined because the line between friendship and professional relationship may be blurred. This issue can be eliminated by setting boundaries, goals and expectations on the student’s first day. 

Another barrier that exists as a new professional is lack of experience. No amount of knowledge can make up for the amount of clinical experience that a senior audiologist has obtained simply due to their number of years in practice. A new professional must be able to recognize the scope of their experience and know when to seek help, especially when they are working with a student. 

The “Characteristics of Effective Preceptors” self-assessment tool is a great way for a new professional to recognize their strengths and weaknesses and recognize what they need to do in order to build upon their precepting skills. The tool is quick to complete and can be repeated periodically throughout one’s career.

Precepting can be a fun and challenging job but earning an AuD does not automatically make someone qualified to be a clinical preceptor so a new professional must understand what it takes to precept a student before they agree to the task. 

Professionalism in Social Media

Professionalism in Social Media

Remember that awesome party from sophomore year of college? Not so much? Well, Facebook remembers. As we transition from college students to graduate students to professionals, the way we portray ourselves in the online world can have significant impact on the trajectory or our careers.

While almost everyone utilizes some type of social media, and a presence on the internet is a positive thing, the content can either benefit or work against you when viewed by colleagues. As you gain more professional friendships and acquaintances, it is always a good idea to review your social media presence and determine if the image you are projecting is an accurate representation of who you are.

Knowing the right type of content to post on each platform is imperative to maintaining professional relationships and protecting your reputation.

Facebook: Think of Facebook like the backyard BBQ of social media. This is where you share family photos, videos of your dog chasing a squirrel, a recipe that you made last night, etc. The people seeing what you post on Facebook should be personal friends and family. Sometimes your work peers become your personal friends, so should you befriend them on Facebook? Well that depends, are they in a position of authority? Would you be embarrassed or could you get in trouble based on a post (even if it is from several years ago)?

What about building a reputation in the community? If you’re in a practice that is utilizing Facebook for marketing purposes, and your face is visible to patients or the community, it may be smart to create an additional profile for professional purposes only. This is an opportunity for you to reach out and participate in the Facebook community with less risk of exposing your privacy (or embarrassing photos from 10 years ago).

Twitter: Twitter is a huge platform to communicate information, and although you’re limited a just a few characters, what you type can say a lot about you. If you are using Twitter professionally, make sure you keep your tweets professional. This account is not the one to discuss what happened on last night’s episode of The Bachelor, or angrily tweet at the airlines for a delayed flight. Oftentimes, professional networking events will encourage and even host competitions for tweeting, and this is potentially an opportunity for you to really stand out (in a good or bad way).

LinkedIn: It is pretty well-accepted that LinkedIn is the place for professional social networking. Should you have a LinkedIn profile? Absolutely! This is a great way for you to share articles, find information, and build your network of peers without the fear of your weekend activities being broadcast to all your connections.

There are obviously many other avenues of social media today, Instagram, Snapchat, and even things like Pinterest and Musically. If you are applying for a job, you should definitely assume that your potential employer is looking at your social media footprint, and an innocent photo from ages ago can portray an entirely different message to a stranger. If you have to question it, delete it.

Social Media is great way to share information with others, keep up with our friend’s busy lives, and show off all the awesome things you are doing- just make sure you are communicating the right message to the right people!

New Professionals Guide to Continuing Education

New Professionals Guide to Continuing Education

A continuing education unit (CEU) is a unit of credit that equals 10 hours of participation in an accredited education or training program. CEUs are designed for professionals who have obtained certification or licensure to stay up to date with current practices in their field, typically on an annual or biennial basis. As a recent graduate, the topic of CEUs is new and unfamiliar yet extremely important, as it is now required as a newly practicing professional. Below you will find the answers to some of the questions many new graduates have about CEUs.

How many credit hours are needed each year to continue practicing?
The number of required CEU credits varies between states and organizations. For example, there is no CEU requirement to maintain American Academy of Audiology membership; however, there are CEU requirements for state licensure and American Speech and Hearing Association certification. Specific CEU requirements can be found on the states’ government speech and hearing website or on the websites of various professional organizations.

What are some opportunities to obtain CEUs?
CEUs can often be obtained at national organization conferences such as AAA or ASHA. Additionally, CEUs may be offered at state conferences or at the local level including university courses, seminars, or lectures. If traveling to state or national conferences isn’t feasible, there are other ways to acquire CEUs. For instance CEUs may be earned online through organizations, including, but not limited to:

  • eAudiology web seminars (live or on-demand) to members for $109/year and $399/year for nonmembers.
  • The JAAA CEU Program provides learning assessments available in the 2018 issues of JAAA for $95/year.
  • The Academy’s Ethics in Audiology “Green Book” program offers in-depth information on common ethical issues faced by audiologists in a variety of different settings such as practice management, teaching, and research for $15/CEU for members and $25/CEU for nonmembers.
  • Peer-to-Peer Mentoring through the Academy. Participants pay a one-time application fee of $75 and can earn up to 0.6 CEUs per year.
  • AudiologyOnline which offers unlimited CEUs for $99/year.
  • Available CEU courses can be found on the ASHA CEFind website where you can search thousands of courses that are offered by a wide variety of approved CEU organizations.
  • Seminars in Hearing (journal) by Thieme Publishing offers self-assessments that can be taken for CEUs.

How can one track earned CEUs?
Proof of credits earned is often necessary in order to renew licensure or certification. CEUs can be tracked in different ways. One option would be to create a simple spreadsheet that includes pertinent CEU information (name of course, date completed, type of credit, number of credit, etc.) and an attachment of the certificate of completion. Various electronic CEU tracking applications are available such as CE Broker. CE Broker has partnered with several state speech and hearing boards, offering a free basic account and simplifying the licensure renewal process. Additionally, some organizations offer a CEU tracking and recording service. For instance, the Academy’s CE Registry is an efficient way to track and organize your completed CEUs from Academy approved providers. Additionally, at the end of each year, an official transcript of your coursework is available to download. The Academy CE Registry is free for members and $60/year for nonmembers.

Mentorship

Mentorship

Do you have a mentor? Are you a mentor? Do you even know what a mentor really is? 

Every successful person in the world has had someone show them the ropes along their way to success at some point. In fact, a survey from the Association of Talent Development (ATD) found that 75% of private-sector executives credit their mentors for where they are now in their careers. The survey also showed that 71% of Fortune 500 companies use mentoring programs to help train new employees and develop new leaders. So it must be important, right?

As new professionals, we have much to learn. So why is it then that most of us don’t actively pursue a mentor to help advance our professional careers?

The benefits are clear for both the mentor and protégé - the most obvious being personal and professional growth. However, there are other advantages including the development of leadership skills, getting access to a larger professional network through the mentor, and being exposed to new perspectives.

It is up to you and the other person as to how formal or informal you want the mentor relationship to be but being clear and deliberate about your goals for the relationship and what you want to achieve is imperative for a successful mentorship.

When looking for a mentor, you’ll want to find someone who not only knows what you want to know but is also willing to take time to guide you. Hopefully you also chose someone who you get along with since you will be spending some time together.    

On the other side, as new professionals, we also have much to contribute. Just because we’re ‘new’ or young doesn’t preclude us from being able to act as a mentor to others. If you consider that we’re all on a spectrum of knowledge and that on one side of us are people with more knowledge and on the other side are people with less, we will always be in a position to learn from those ahead of us while contributing to the growth of those behind us.  This is how we as a profession can become stronger.

So how do you get started? Perhaps you already have someone in mind and just haven’t taken that first step to ask. Maybe you don’t think you know anyone who would be willing to be a mentor. Luckily, audiology has many willing mentors out there ready to pass their knowledge along.  If you need more help, there are hundreds of books on the subject to help you find your path. The key is to just get started.

If you’re interested in being a part of a mentor program, the Academy recently launched a Peer-to-Peer Mentoring CEU Program. Contact Katy Sidwell for more information.

Find a mentor, be a mentor, and find success.

TeleHealth and Licensure

TeleHealth and Licensure

Do you know if your state license regulates the services you may provide via telehealth or tele-audiology?  Do you know what telehealth is?  Telehealth is the concept of providing healthcare services remotely via technology such as high-speed internet, webcam, and smart phone.  This technology is evolving rapidly and becoming a part of daily audiology practice today.  The Veterans Health Administration (VHA) utilizes clinical video telehealth to provide real-time video appointments between audiologists and veteran patients at remote clinical sites.  Beyond the VHA telehealth program there are now various hearing aid manufacturers providing remote programming options for their devices.  This will allow the audiologist to make programming adjustments through an app on the patient’s phone.  What this means is that tele-audiology is closer to becoming a daily part of your practice than you may realize.  Does your license support it?

In September of 2017 the State of Illinois passed a new version of the Speech Pathology and Audiology Practice Act which became effective January 1, 2018.  These changes are thanks in part to the advocacy efforts of the Illinois Academy of Audiology.  Among many improvements to the licenses of Illinois audiologists this act included provisions allowing an audiologist to provide services through telehealth modalities.  The practice act specifies that the practice of audiology may be conducted with video conferencing.  It further explains that the use of telephone, email, messaging, and store and forward technology should be used in conjunction with or supplementing the use of video conferencing.  Additionally, this act regulates that an audiologist outside of Illinois but providing services to a patient in Illinois is subject to the rules and regulations of this act.

On the federal level the Medicare Telehealth Parity Act (H.R. 2550) has been introduced and identifies audiologists as eligible providers of telehealth services for Medicare patients.  As it currently stands an audiologist is not reimbursed by Medicare for telehealth related services.  Within the VHA a new rule has been proposed which will allow providers employed by the VHA to provide telehealth services (including tele-audiology) anywhere in the country regardless of the location of provider and patient.  There is also companion legislation to this rule (S.925) which has passed the Senate and is now in consideration with the House which allows VHA providers to practice across state lines, via telehealth, without restriction by individual states.

As advancements in telehealth continue and telehealth becomes more widely adopted by health care providers, it is important that audiologists understand licensure requirements and our scope of practice in the state or states in which we practice.  If you are unsure about your license consult your practice act and read it thoroughly.  Contact your state audiology licensure board or look for resources from within your state association if you have questions or concerns about your specific situation.

Perkins Loan Forgiveness

Perkins Loan Forgiveness

Did you receive Federal Perkins loans during your undergraduate or graduate education? As an allied health professional, you may be eligible to have all or a portion of your Federal Perkins loans canceled! An application, including proof of licensure and full time employment, must be submitted to the holder(s) of your Perkins loans. If approved, loan payments will be postponed for 12 consecutive months of eligible full time employment. Upon subsequent documentation of eligible employment, a portion of the loan is canceled. This postponement/cancellation cycle is repeated for a minimum of 5 years, during which time up to 100% of Perkins Loans may be canceled.

Contact the holder of your Perkins loans (either your university or their designated 3rd party servicer) to submit a request for postponement/cancellation. Keep in mind that if you attended multiple universities, you will need to submit multiple applications to whichever institutions hold your loans. Reach out to your university or visit the student aid website to learn more.