8

Collaborative Strategies for the Future

A wide range of organizations are involved with issues related to hearing loss, many of which were represented at the workshop. In the workshop’s final session, representatives of three of these organizations described some of the ways in which they are working on hearing loss, providing examples of ways in which organizations can produce progress on the issue. Workshop participants then closed the workshop by offering their perspectives on the 2 days of deliberations.

THE AMERICAN PUBLIC HEALTH ASSOCIATION

Regina Davis Moss American Public Health Association

The public health implications of age-related hearing loss go far beyond the immediate threat to the individual, said Regina Davis Moss, associate executive director of public health policy and practice for the American Public Health Association (APHA). Age-related hearing loss has been linked to social isolation, depression, and anxiety, which can lead to other public health and safety issues. Yet many people seek treatment too late in the United States and worldwide.

Public health is a community-based approach that makes use of various settings for reaching different populations. These settings include not just physicians’ offices, hospitals, and nursing facilities but also places of worship, community-based programs, and retirement communities, among others.



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8 Collaborative Strategies for the Future A wide range of organizations are involved with issues related to hear- ing loss, many of which were represented at the workshop. In the workshop’s final session, representatives of three of these organiza- tions described some of the ways in which they are working on hearing loss, providing examples of ways in which organizations can produce progress on the issue. Workshop participants then closed the workshop by offering their perspectives on the 2 days of deliberations. THE AMERICAN PUBLIC HEALTH ASSOCIATION Regina Davis Moss American Public Health Association The public health implications of age-related hearing loss go far beyond the immediate threat to the individual, said Regina Davis Moss, associate executive director of public health policy and practice for the American Public Health Association (APHA). Age-related hearing loss has been linked to social isolation, depression, and anxiety, which can lead to other public health and safety issues. Yet many people seek treatment too late in the United States and worldwide. Public health is a community-based approach that makes use of vari- ous settings for reaching different populations. These settings include not just physicians’ offices, hospitals, and nursing facilities but also places of worship, community-based programs, and retirement communities, among others. 85

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86 HEARING LOSS AND HEALTHY AGING The APHA has issued several policy statements related to hearing. It advocates for early and cost-effective screening programs for at-risk populations, followed by careful evaluation and treatment. It also supports public education about conditions, warning signs, and the importance of seeking treatment. This public education includes preventive measures, such as hearing protection among younger people, said Moss. In addition, the APHA promotes a research agenda that includes such issues as screening for asymptomatic individuals. THE AMERICAN GERIATRICS SOCIETY James Pacala University of Minnesota Medical School Although representing the American Geriatrics Society (AGS) at the workshop, James Pacala, distinguished teaching professor at the University of Minnesota Medical School, offered his personal impressions of the issues surrounding hearing loss. He works in an underserved community in South Minneapolis at a busy clinic that trains residents, mental health workers, and pharmacists. The average age of his patients is about 85, and over the course of the day he is likely to use three different interpreters. “It is a chal- lenging setting to deliver care.” Pacala identified six hurdles to providing good hearing health care. First, everything in medicine is predicated on patient visits, he said, but most of the things that happen to patients occur outside visits. Second, the demand for evidence ignores the fact that many things done in medicine do not have a solid evidence base but are still important. Third, he described “the tyranny of the acute” in which the physician focuses attention on a patient’s immediate problems and tends to overlook longer-term issues such as hearing loss. Fourth, addressing chronic diseases such as diabetes can consume all of the time available for physician-delivered care. Fifth, shifting focus to prevention and health maintenance adds to the number of things that need to be covered in a family medicine practice. And, sixth, many important health problems are neglected in medical education and training, and hearing is one. Acting alone, physicians cannot overcome these hurdles, he said; in- stead, health policies need to change to remove the barriers to better hearing health care. For example, structural and financial barriers around the way care is provided and organized can stymie hearing health care. Innovations such as patient-centered medical homes and accountable care organizations are moving in a positive direction, said Pacala, but “we have a long way to go.” Also, in the area of policy, the financial burdens of as- sisted listening devices and hearing aids need to be reduced, he said.

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COLLABORATIVE STRATEGIES FOR THE FUTURE 87 Awareness is another important issue. “We need to continue to pound the pavement and increase awareness about this problem,” he said. For ex- ample, the AGS, through its Health in Aging Foundation, provides an Aging and Health A to Z webpage through which patients can access information on hearing loss and related issues.1 Finally, much more research is needed on how to partner medicine, public health, and technology to come together to create better environ- ments and better ways of solving the problem, Pacala said. Research into implementation is also critical to figure out how best to provide help for older adults. AARP Charlotte Yeh AARP Charlotte Yeh, chief medical officer for AARP Services, Inc., began her presentation by noting that her life’s experiences added to her thoughts about hearing loss: her role at AARP Services is to improve the experience of care for individuals over the age of 50, her experience as an emergency medicine physician reinforced the importance of communication, and her father’s experience with progressive hearing loss gave her personal insights. (See Box 8-1.) BOX 8-1 The Difference That Hearing Can Make Throughout the workshop, presenters and other participants offered ac- counts of the effects that hearing loss has had on their lives and on the lives of their family members. The story told by Charlotte Yeh, chief medical officer for AARP Services, Inc., was a good example: “My father spent 15 years with progres- sive hearing loss. . . . Finally, he got his hearing aid, and all of a sudden he wasn’t shuffling. He was walking with confidence. All of a sudden he wasn’t bent over. He was animated; he was telling jokes. He wasn’t sitting quietly in the corner; he was part of the family. He was telling jokes, laughing, enjoying his children and grandchildren in a way I haven’t seen since I was a child. As you can tell, I have a lot of personal thoughts and passion about this vision of what we can do with hearing and hearing loss.” 1  See http://www.healthinaging.org/aging-and-health-a-to-z (accessed March 31, 2014).

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88 HEARING LOSS AND HEALTHY AGING The major message delivered by Yeh is that consumer engagement is the key to changing the conversation. The rest of health care is already pursing such aspects of consumer engagement as behavior change and motivation. Those involved with hearing issues need to do the same thing, said Yeh, and this effort needs to encompass not just consumers but industry, researchers, and other stakeholders. According to Yeh, changing the conversation has three components. First, the conversation needs to be about the heart and mind of the con- sumer. Consumer retail does this well, she observed. It does not focus on loss but what is to be gained. Similarly, conversations about hearing loss could focus on the gain from social interactions, family connections, and workplace productivity. Hearing loss “is not a standalone disability. It is integral to everything we do every single day.” According to a study of adults with a Medicare Supplement plan (Hawkins et al., 2012), hearing loss has a greater impact on quality of life than diabetes, heart disease, coronary artery disease, hypertension, or any other medical condition, Yeh reported. Similarly, a survey conducted in 2011 of people older than 50 found that 85 percent said that hearing is very important to their quality of life, 76 percent said it is personally important to their lives, and 68 percent said that not enough attention is paid to hearing loss as an important health care concern (AARP/ASHA, 2011). Yet conversations about medical issues tend to revolve around conditions other than hearing. “More people have had colonoscopies than hearing tests,” said Yeh. “What is wrong with this prevention message, if you think about it?” The same survey (AARP/ASHA, 2011) also asked about issues of stigma, and Yeh said it is time to “blow away that myth.” In fact, 64 per- cent of respondents said that they did not think that having hearing aids meant a person was getting old. Two-thirds said that having a hearing aid did not matter to others, and 71 percent said they would not worry if other people saw them with the hearing aid. “The paradigms are shifting,” said Yeh. About two-thirds also said that they would get a hearing test if their hearing were hurting their relationships with their family, and 59 percent said they would be tested if their hearing was becoming a burden on the family. According to AARP research, said Yeh, the top things on people’s minds are their relationship with others, whether they are a burden on their family, and their mental alertness. Emphasizing the importance of good hearing is not a negative thing, said Yeh. It offers the promise of a good life. Yeh also pointed out that the conversation about hearing needs to reflect the fact that hearing needs range along a continuum, as does accep- tance of the issue. The conversation should be about “where you are on the stage of acceptance, what are the products and capabilities, and how do we help people adjust and move through that continuum,” she said. This facet

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COLLABORATIVE STRATEGIES FOR THE FUTURE 89 of the conversation also entails behavior change, motivation, patient activa- tion, and readiness to change. “Those are things that we are talking about in health care. We should be talking about them in hearing loss as well.” Finally, Yeh discussed the issue of affordability, including costs, cover- age, reimbursement, and “respect for the time and convenience of the con- sumer.” Industry needs to continue to work on how to make the technology easier to use, better in noisy situations, and less costly, she said. Baby boomers are used to getting things done, she concluded. “We are the ones who brought civil rights. We put a man on the moon. We had rock and roll, which is why we have hearing loss, and we brought Woodstock. If this isn’t a generation that can bring about that change, I don’t know what else is.” PARTICIPANTS’ REFLECTIONS ON THE WORKSHOP At the end of the workshop, speakers and participants were asked to provide their reflections on the 2 days of presentations and discussions. James Firman, National Council on Aging, began by calling attention to the need to tie hearing to quality-of-life issues. Policy makers are concerned that people be able to continue to contribute to society, whether through work, volunteer activities, or involvement with their families and communi- ties. Good hearing is essential to that connection, said Firman. He also pointed out that so many older adults have hearing loss that the only way to address the problem comprehensively is through universal design. Loops and other devices to improve hearing need to be the rule rather than the exception, he said, just as closed captioning on television has become common. Wen Chen, National Institute on Aging, emphasized the importance of communicating about age-related hearing loss to the older adult commu- nity in general. Many options are available for older adults with hearing loss, but some of those options are bound to be confusing, especially in areas where technology is advancing rapidly. Perhaps an emphasis on the outcomes of technology—such as hearing better in noise—would be a more powerful message than one that centers on the technologies themselves, such as telecoils and loops. James Appleby, Gerontological Society of America, recommended that more research be conducted to demonstrate that hearing interventions have value not only in improving health and economic outcomes but also in re- directing the trajectories of people’s lives. Such outcomes can help make the case for greater investment in hearing interventions. He also recommended that more attention be given to the issue of reducing stigma by reframing the issue of hearing loss around engagement and the need for action. Anna Gilmore Hall, Hearing Loss Association of America, urged chang-

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90 HEARING LOSS AND HEALTHY AGING ing the conversation to focus on ways of living successfully with hearing loss. There are many different ways to live successfully with hearing loss, she noted, especially given the many new technologies that are becoming available. Robert Burkard, University at Buffalo, said that hearing health care should become an essential health benefit within the broader context of health care reform. Burkard also urged the FDA to push harder on enforc- ing honesty in advertisements about hearing technologies. Composer Richard Einhorn emphasized the need for hearing health care and hearing devices to be affordable, adding that addressing the issue requires fundamental changes in the FDA regulations. Although many play- ers are involved in regulations, he added, change is possible that would ben- efit all stakeholders, including consumers and companies. He also wondered why age-related hearing loss is not higher on the agenda of gerontology, public health, and other health disciplines. One beneficial product of the workshop could be raising the profile of the issue, he said. Barbara E. Weinstein, Graduate School and University Center of the City University of New York, recommended that the hearing health care delivery system be reframed to put the patient at the center of the audiologi- cal assessment. People come to audiologists because they have difficulties in certain areas, and they need to leave audiologists’ offices with solutions. Someone may not be ready for a $6,000 hearing aid; they may only have problems with the television. That person may need just an infrared system for the television or one of the many varieties of personal amplifiers that are inexpensive and may increase the loudness enough to contribute to the enjoyment of television viewing. Both policies and medical practices should encourage those kinds of solutions, Weinstein said. Author Katherine Bouton pointed to the need to get the entire popula- tion involved in the conversation, not just those with hearing loss. “They need to understand that this is, if not a universal problem, close to it.” Part of the solution will be making hearing aids as affordable, ubiquitous, and effective as glasses. People today often see hearing loss as a sign of aging and view correction as complicated and ineffective, so they keep their dif- ficulties to themselves, she said. Valerie Fletcher, Institute for Human Centered Design, thought that many vignettes could be compiled of successful efforts to counter hearing loss involving collaborative efforts among clinicians, patients, and technolo- gists. Such a compilation “would go a long way toward eradicating the assumption that nothing works very well.” Steven Barnett, University of Rochester, called for research on the con- ditions associated with hearing loss. His patients are concerned about what other consequences hearing loss might have, yet he has little information for them today. In addition, much more needs to be learned about the con-

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COLLABORATIVE STRATEGIES FOR THE FUTURE 91 dition through more detailed questions on surveys and through increased surveillance, he said. Sergio Guerreiro, University of Miami School of Medicine, and Alicia Spoor, Academy of Doctors of Audiology, both said that hearing health care should be a standard part of care for everyone. Hearing tests should be routinely given to patients, Guerreiro said, just as other tests are given. Physicians should ask their patients about hearing in the same way they ask about smoking, added Spoor. Chris Roberts, Cochlear Limited, discussed the possibility of creating a disconnect between chronological aging and biological aging. With regard to hearing, reduced exposure to noise can prevent hearing losses, and au- diological training can reduce loss of function. “There is a lot more that could [be done] to affect the biology of what is happening.” Brenda Battat, retired executive director of the Hearing Loss Associa- tion of America, pointed out that baby boomers express a desire to stay in their homes as they get older, but they will not be able to do so unless they address hearing problems. Hearing health care thus can have benefits for older individuals, families, and health care costs. She also agreed that the FDA regulations are out of date and that hearing aid manufacturers need to produce devices that allow individuals to hear better in noise. Paul Mick, University of British Columbia, wanted more evidence of not just associations but also causal links between hearing loss and the physical and psychosocial effects associated with hearing loss. Such evi- dence would enable physicians to provide better advice for their patients and would be a force for greater funding and services. Outcomes data on interventions could have the same effect, he said. And identification of at- risk populations would help focus attention on these groups. Finally, planning committee cochair Frank Lin noted that many orga- nizations and perspectives were represented at the workshop, yet everyone there was focused on the issue of how to improve hearing health care for older adults. “The conversation has begun,” he said.

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