Intro to Aural Rehabilitation: Interview with Raymond H. Hull, PhD
Douglas L. Beck, AuD, speaks with Dr. Hull about his new book, Introduction to Aural Rehabilitation.
Academy: Good Morning, Ray. Nice to speak with you.
Hull: Good Morning, Doug. Thanks for the kind invitation.
Academy: Ray, I have a copy of your new book, Introduction to Aural Rehabilitation, and I was very happy to get it! I know you are a prolific author and I applaud you for this all new addition to your body of work, including multiple editions and texts on aging and communication disorders as well as adult and pediatric aural rehabilitation.
Hull: Thanks, Doug.
Academy: Ray, please tell me how the book is structured?
Hull: Excellent place to start! The book is divided into four sections—The Nature of Aural Rehabilitation (AR), Introduction to AR—Pediatrics, Introduction to AR—Adults, and then finally, Considerations for Older Adults with Impaired Hearing.
Academy: And, I must admit dividing the book into sections based on “stage of life” is great. The needs change quite dramatically from learning language and learning to listen, building vocabulary, etc., all the way to cognitive problems that are rather common and associated with older adults.
Hull: Yes, well obviously, we could’ve organized the book in many ways, but our arrangement seems intuitive and helps make the content easy to access.
Academy: Agreed—the list of authors and chapter titles is excellent. In fact, if you don’t mind we’ll insert the list of authors and chapter titles at the end of the interview. I think it’s wonderful that you’ve got some 15 appendix items of tremendous value for audiologists
Hull: Yes, thanks for noticing that. I believe having all those tools available in one-easy-to-find location makes it easier for the audiologist to access and use these tools, and, of course, if it is easy, people are more likely to use them.
Academy: Yes—if it is really, really easy, I might even do it! Ray, do you have a preferred definition of aural rehabilitation?
Hull: Well, the specific definition would, of course, vary with the individual and their specific situation, desires, and abilities. However, in general, one could say the aim, or the goal of aural rehabilitation (and habilitation) on behalf of children and adults is to overcome the handicap.
In this context, handicap refers to the relationship between hearing-impaired people and the acoustic environment, whereas their disability would be the actual type and degree of hearing loss. Nonetheless, handicaps can arise from disabilities, and disabilities can arise from handicaps…again, it goes back to the individual and his or her specific situation.
Academy: Yes, and I believe the definitions and distinctions about handicap versus disability go back to the World Health Organization’s articles on those topics?
Hull: Yes, I believe that may have been the origin. And again, it is a rather fascinating discussion as I’m sure you’ve worked with people, as have I, that have a moderate or moderately-severe sensorineural hearing loss (SNHL), and they get along without amplification, and sometimes without apparent difficulty, and the converse is true, too. Some people with a mild high-frequency SNHL may be terrifically disabled by it, and may indeed be despondent due to their hearing loss.
Academy: Excellent point. In some respects, it reminds of the Alzheimer’s study on nuns from a decade or two ago. A researcher studied hundreds of nuns. The nuns all agreed to donate their bodies to science after their death. What he found was that many of the nuns had anatomic anomalies associated with (and perhaps causing) Alzheimer’s disease, yet many showed no cognitive signs of dementia. So, they certainly had the handicap, but the majority had no disability.
Hull: Yes, that’s a good analogy. It reminds me of the Boothroyd notes from 1982, in which he stated the disability from a severe SNHL in children may cause handicaps (more or less) related to perceptual problems, speech problems, communication problems, cognitive problems, social problems, emotional problems, educational problems, intellectual problems, vocational problems, parental problems, and societal problems, too! And, these problems represent a natural progression for pre-lingual, untreated hearing loss.
Academy: Ray, I suspect the reason AR is rarely performed maximally by private practitioners in audiology is that we are prohibited from accessing appropriate CPT codes. Seems to me, it just boils down to dollars and cents. Specifically, if we cannot bill and get paid for a particular service, we’re just not very likely to offer and perform that service. I wonder if you have any thoughts or guidance for people in private audiology practices with regard to how to bill for AR services?
Hull: Well, this is a very real issue, and I don’t have a one-size-fits-all solution. I suspect it depends on the definition of AR and the AR process in a given situation. For example, AR might be a simple and quick informational counseling session, perhaps 10-15 minutes for an adult receiving his third set of hearing aids in 15 years. However, it could be a highly detailed and time-intensive session, too, such as working with the parents of a child identified through a newborn hearing screening program. In fact, given the second scenario, it could take multiple visits and multiple hours. So again, the definitions, the individuals, and the time and place will matter.
But to address your specific question, audioliogists may indeed “bundle” AR services to accomodate the most typical scenarios, and other times, when unrelated to Medicare—the audiologist may bill for his or her time and expertise. In some situations, I have billed successfully for AR—but as you note, that is not typical. Of course, speech-language pathologists (SLPs) are allowed to bill for those services through the Medicare program and so referring to a local SLP is sometimes an option, although certainly not an ideal solution.
Academy: What do you think about offering once a month group AR services for post-lingually hearing-impaired adults?
Hull: I think that’s very useful for the participants and the professionals. Often in those situations, you might charge a nominal fee, something like $25 or so for a 90-minute group session with coffee and tea and soda, so people in similar situations such as adults, or older adults, can all meet, review, participate, and share their stories, thoughts and solutions. In that case, I think you could have 10-12 people in a group session and they would each pay privately as they enroll in the AR class. Such a nominal fee should be affordable, but the numbers of those who are paying make up for the small individual dollar amount.
Some members of such a group may come with specific personal hearing/communication difficulties to be resolved, or situations about which he or she may need help because they are causing so much difficulty in communication. Others may want at least several sessions. These sessions, however, generally revolve around communication counseling and problem-solving. The discussions generally benefit all members of the group. However, I have had a number of patients who requested individual sessions to talk about situations that may be ones that they do not feel comfortable discussing in a group environment.
Those sessions will cost the patient more, but they are generally willing to pay. Further, the number of these sessions may involve perhaps only one or two for an hour each. An example involves an older practicing physician who wanted to work to resolve the difficulties he was experiencing hearing his patients in his examination rooms. The rooms appeared to be essentially “reverberation chambers,” and so we worked to identify some ways in which he could redecorate attractively to make the rooms less of a difficult listening environment.
Academy: Yes, that’s a reasonable way to offer AR. As Mark Ross says, group AR sessions offer an excellent “value proposition.” However, we all realize that there are situations in which individual sessions are also important as you discussed above. Are you a fan of the “take-home DVDs” that address AR?
Hull: Excellent question. I know these DVDs are popular and they certainly are much better than having no AR services at all. Nonetheless, if the option is available, I prefer face-to-face AR programs if at all possible, as it gives a more meaningful and personal session, and it can change as needed to better address the individual’s needs as they occur.
Academy: Thanks, Ray. I appreciate your time and I really enjoyed the book.
Hull: Thank you, too, Doug. I appreciate your interest in our work.
Ray Hull, PhD, is a professor of Communication Sciences and Disorders Audiology / Neurosciences at Wichita State University, Kansas. He is also the is the author of Introduction to Aural Rehabilitation, published by Plural. Click here to access the book’s Table of Contents.
Douglas L. Beck, AuD, Board Certified in Audiology, is the Web content editor for the American Academy of Audiology.