By Jason Leyendecker
Starting a tinnitus clinic or incorporating tinnitus management into your busy practice can be a challenging task that keeps audiologists from moving forward with helping an underserved population within the scope of practice of audiology. After practicing tinnitus management for 10 years, we have discovered how to create a successful tinnitus clinic. This article is designed to give insight on how to make the process easier.
Start with Why
When asked to write this article, the question that immediately arose is why? Why would someone want to work with patients who have tinnitus? Author and speaker Simon Sinek professes, “people don’t buy what you do, they buy why you do it” (2013).
My “why” is to increase access to care and to use best practices. There are not enough qualified tinnitus professionals in the country, which means patients may be consulting unqualified people, or even worse, they are not consulting a professional at all. Our clinic was developed to serve this patient need.
According to the National Health and Nutritional Examinations Survey completed in 2011–2012, close to 20 million people experience tinnitus regularly and approximately two million people struggle with severe or debilitating tinnitus.
The tinnitus patient is like no other, as they have a unique feeling toward a sound that no one else can hear. As audiologists, we are best equipped to treat these patients. They have most likely explored all methods to make the sound go away and no “magic pill” has helped them.
Working with a patient with tinnitus takes a strong will, the ability to be patient and knowledgeable, and the ability to emotionally support someone going through confusion, anxiety, and, sometimes, pain. When implementing tinnitus care into your practice, be sure to remember your “why.”
Up Your Tinnitus Training
When looking into training, there are several different avenues. Henry (2005) surveyed 60 accredited audiology programs to document what training for tinnitus management was included in the curriculum. Forty-one schools agreed that tinnitus management should be included in the audiologist’s scope of practice, but 34 schools did not offer a dedicated course for tinnitus management in their curriculum.
Seeking outside training is a good idea and there are some great training programs available. Becoming an expert in tinnitus management requires a great deal of continuing education and there are many options.
The option that serves as the baseline structure of treatment in our clinic is the Tinnitus Retraining Therapy (TRT) program produced by Pawel Jastreboff, PhD (1999, 2007). This program focuses on understanding the models of tinnitus and how to explain these models to patients in a way they can understand.
In addition to TRT, there are several other training classes and organizations focused on tinnitus and sound-sensitive care, such as the Tinnitus Practitioners Association (TPA), Tinnitus Activities Treatment (TAT), and Progressive Tinnitus Management (PTM).
The American Board of Audiology (ABA) also has a comprehensive tinnitus management education program providing essential information for assessing and managing patients with tinnitus or decreased sound tolerance. The ABA Certificate Holder-Tinnitus Management (CH-TM) is an assessment-based certificate program offered in a combination video and interactive online self-study program.
When beginning a tinnitus clinic, there are different options to consider. Tinnitus therapy can complement your current clinic and, for ease of logistics, can be integrated into your current schedules, which adds more value to your clinic.
You can either bill for your services and charge for a consultation fee separately or you can set up a separate limited liability company (LLC) to provide tinnitus treatments without accepting insurance contracts.
There are pros and cons to each option but, because laws may vary across states, it is best to consult with an attorney and an accountant to determine the best option for your practice.
It is important to establish a network of other professionals in your area to aid in tinnitus management.
Establish Your Network
Audiology is not the only profession with tinnitus management in its scope of practice. However, audiologists should be leading the multidisciplinary approach to tinnitus management (Henry, 2005).
It is important to establish a network of other professionals in your area to aid in tinnitus management. First, establish a good relationship with an otolaryngologist for medical management of tinnitus. Often, he or she will be the first provider in the patient’s journey in tinnitus care. Establishing relationships within the ear, nose, and throat (ENT) community will let the ENT know about the important role of audiologists in the care of the tinnitus patient and reduce the number of “you’re healthy, go home and live with it” situations.
Next, establish a pool of psychologists in your area that express interest in tinnitus management. One resource, suggested by a local psychologist, that can help in finding psychotherapists is the Psychology Today website (www.psychologytoday.com). Other resources include the American Psychology Association (https://locator.apa.org/) and the National Institute of Mental Health (https://www.nimh.nih.gov/health/).
You will want to find psychologists who have a background in chronic-pain management, mindfulness-based stress reduction, cognitive behavioral therapy, dialectical behavioral therapy, and, possibly, eye-movement desensitization and reprocessing (EMDR) experience. EMDR is showing great results with phantom-limb pain and this is being translated into success with tinnitus management (Rikkert, 2018).
Speak with these professionals directly and gauge their interest and commitment to tinnitus therapy. Once the relationship is established, the therapist may wish to attend a consultation to better understand TRT and how the neurophysiologic model of tinnitus affects the patient’s reaction to tinnitus.
Because every provider has their own methodology and personality, identify several therapists in your area to enable your patients to find a professional with whom they can form a good, trusting connection. The size of your community will determine how many providers to have in your network. For patients who travel, we use the resources listed above to identify a local therapist who specializes in treatments that will be helpful for the patient, as follow-up appointments will be necessary.
Reaching out to other professions such as neurology, physical therapy, and ophthalmology/optometry is also helpful in creating a good solid network of referral sources for your patients.
Our office sees a great deal of patients with traumatic brain injuries, so establishing a relationship with brain-injury clinics is very helpful. In my experience, tinnitus is one of the last brain-injury symptoms addressed in a brain-injury clinic. As a result, establishing a referral base for these clinics could offer tinnitus relief to many patients.
Challenges You Will Face
Establishing yourself as a tinnitus practitioner does not happen overnight and takes a great deal of extra work. The training can be time consuming, but it is a good investment toward your future. Once you have tackled that challenge, it may take time to get patients in the door. Patience during this process is difficult but essential in creating value for the patient.
One of our biggest challenges has been creating a true, separate clinic for our tinnitus patients and defining what a tinnitus patient is versus a patient with tinnitus. Our clinics are separate on paper and digitally; however, when someone calls and asks what clinic they belong in, it may be difficult to differentiate their needs when there is overlap.
The easiest way to determine the clinic in which a patient should be served is by conducting a tinnitus questionnaire, which can help you establish a cut-off score for the two clinics. There are several peer-reviewed questionnaires that can be used, including the following:
- Tinnitus Reaction Questionnaire (TRQ) (Wilson et al, 1991)
- Tinnitus Handicap Inventory (THI) (Newman et al, 1996)
- Tinnitus Functional Index (TFI) (Meikle et al, 2012)
- Tinnitus Questionnaire (TQ) (Hallam, 2008)
- Tinnitus Handicap Questionnaire (THQ) (Kuk et al, 1990)
These questionnaires will help you to document when tinnitus is affecting the patient’s quality of life.
A difficult component of tinnitus is that it is not objective; determining how tinnitus affects a patient requires more information than a questionnaire can provide. Our team asks patients questions, including how long have they been having trouble, how is the tinnitus affecting sleep and concentration, and what are their priorities. We lay out our fee schedule and what the consultation will entail. Most patients who call our tinnitus clinic need a tinnitus consultation.
Another challenge when adding a tinnitus clinic to your office is time. Tinnitus patients require a significant amount of time due to follow-up care, collaboration with other clinics, and report writing. In addition, tinnitus cases can end up in litigation because of head injuries from car accidents and workers’ compensation situations.
More work will be required if the provider is asked to serve as an expert witness for the patient. You are allowed to bill, and you should bill, for your time. However, this work takes away from time you would be serving other patients. Choosing to take insurance or even billing for workers’ compensation and auto insurances will add more work to having a tinnitus clinic.
Tinnitus treatments are considered experimental and require documentation as to why they should be covered by insurance. You may need to work with the treatment creators to provide data, as well as compile a literature review, to have enough data to support your recommendations.
Overcoming the challenges of adding a tinnitus clinic to your practice is not easy, but you can be successful by establishing your billable hours, your follow-up schedule, and, when you have a separate tinnitus clinic, one person to determine patient criteria for each clinic.
Benefits and Rewards from a Tinnitus Clinic
Despite the difficulties of adding tinnitus therapy to your clinic, there are several great benefits of tinnitus management. Providing a niche to your practice can bring additional revenue to your clinic.
You will be serving an underserved market. With approximately 50 million patients with tinnitus, and two to three million of those people needing a tinnitus assessment and consultation, there are not enough qualified providers available (American Tinnitus Association, 2021).
Approximately 50 percent of the patients will need some sort of treatment device (Schwartz, 2014). If you build your treatment costs into the device costs, the revenue can cover your costs and provide the appropriate level of profit.
To reiterate, there are not enough qualified tinnitus professionals in the country, which means patients may be consulting unqualified people or, even worse, they are not consulting a professional at all.
Currently, it is common for patients to travel long distances to get adequate tinnitus treatment and, while telehealth tools are available, they are still not widely accepted and may be limited by each state’s licensure laws.
Most hearing aid technologies have remote-care options, but limit the ability of programming the tinnitus program. Providing the best care must be timely and must include the full scope of what we can do. Including evidenced-based tinnitus care in your area will make treatment more accessible and result in better outcomes for your community.
Tinnitus Management Continuing Education Resources
Adding tinnitus management to the scope of your practice can be both rewarding and challenging. Because there are not enough qualified tinnitus providers in the country, there is a great need for this service.
To add tinnitus management to your practice, obtain the necessary training, network with practicing audiologists, and establish your multidisciplinary referral network. It is extremely rewarding to help a tinnitus patient become a patient with tinnitus.
This article is a part of the July/August 2021 Audiology Today issue.
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