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Figure.  Patient Appointment Events, Locations, and Equipment
Patient Appointment Events, Locations, and Equipment

The blue boxes indicate the events that occur at each appointment. The white boxes indicate the location of that appointment and the source of equipment. HAVS indicates hearing aid verification system; PCP, primary care physician; and UMHS, University of Michigan Health System. See Introduction section for a description of Hope@UMHS.

1.
Darnell  JS.  Free clinics in the United States: a nationwide survey.  Arch Intern Med. 2010;170(11):946-953.PubMedGoogle ScholarCrossref
2.
Gertz  AM, Frank  S, Blixen  CE.  A survey of patients and providers at free clinics across the United States.  J Community Health. 2011;36(1):83-93.PubMedGoogle ScholarCrossref
3.
Felt-Lisk  S, McHugh  M, Howell  E.  Monitoring local safety-net providers: do they have adequate capacity?  Health Aff (Millwood). 2002;21(5):277-283.PubMedGoogle ScholarCrossref
4.
Shuman  AG, Aliu  O, Simpson  K,  et al.  Patching the safety net: establishing a free specialty care clinic in an academic medical center.  J Health Care Poor Underserved. 2014;25(4):1810-1820.PubMedGoogle ScholarCrossref
5.
Shuman  AG, Kupfer  R, Simpson  K,  et al.  Implementation of a novel otolaryngology clinic for indigent patients.  Laryngoscope. 2013;123(9):2142-2147.PubMedGoogle ScholarCrossref
6.
Choi  JS, Betz  J, Li  L,  et al.  Association of using hearing aids or cochlear implants with changes in depressive symptoms in older adults.  JAMA Otolaryngol Head Neck Surg. 2016;142(7):652-657.PubMedGoogle ScholarCrossref
7.
Chen  DS, Betz  J, Yaffe  K,  et al; Health ABC study.  Association of hearing impairment with declines in physical functioning and the risk of disability in older adults.  J Gerontol A Biol Sci Med Sci. 2015;70(5):654-661.PubMedGoogle ScholarCrossref
8.
Chisolm  TH, Johnson  CE, Danhauer  JL,  et al.  A systematic review of health-related quality of life and hearing aids: final report of the American Academy of Audiology Task Force on the Health-Related Quality of Life Benefits of Amplification in Adults.  J Am Acad Audiol. 2007;18(2):151-183.PubMedGoogle ScholarCrossref
9.
Rosenberg  E, Seller  R, Leanza  Y.  Through interpreters’ eyes: comparing roles of professional and family interpreters.  Patient Educ Couns. 2008;70(1):87-93.PubMedGoogle ScholarCrossref
10.
Kochkin  S.  MarkeTrak VII: obstacles to adult nonuser adoption of hearing aids.  Hear J. 2007;60(4):24-51. doi:10.1097/01.HJ.0000285745.08599.7fGoogle ScholarCrossref
11.
Ng  JH, Loke  AY.  Determinants of hearing-aid adoption and use among the elderly: a systematic review.  Int J Audiol. 2015;54(5):291-300.PubMedGoogle ScholarCrossref
12.
Williams  TR, Alam  S, Gaffney  M; Centers for Disease Control and Prevention (CDC).  Progress in identifying infants with hearing loss—United States, 2006-2012.  MMWR Morb Mortal Wkly Rep. 2015;64(13):351-356.PubMedGoogle Scholar
13.
Noble  W, Gatehouse  S.  Effects of bilateral versus unilateral hearing aid fitting on abilities measured by the Speech, Spatial, and Qualities of Hearing Scale (SSQ).  Int J Audiol. 2006;45(3):172-181.PubMedGoogle ScholarCrossref
Original Investigation
September 2017

Comprehensive Hearing Aid Intervention at a Free Subspecialty Clinic

Author Affiliations
  • 1Department of Otolaryngology–Head and Neck Surgery, University of Michigan Health System, Ann Arbor
  • 2Department of Neurosurgery, University of Michigan Health System, Ann Arbor
JAMA Otolaryngol Head Neck Surg. 2017;143(9):876-880. doi:10.1001/jamaoto.2017.0680
Key Points

Question  Is it possible to provide free, comprehensive audiologic services to indigent patients?

Findings  In this observational cohort study at a preexisting free clinic, 34 patients were identified as eligible for a free hearing aid and 20 of these patients (59%) received hearing aids. The value of services provided was estimated to be $2260 per patient.

Meaning  It is feasible to provide free, comprehensive audiologic care, including hearing aids and fitting, in a well-established, free clinic model.

Abstract

Importance  Providing a model of a comprehensive free audiologic program may assist other health care professionals in developing their own similar program.

Objective  To describe the structure, feasibility, and outcomes of a free subspecialty clinic providing hearing aids to develop a paradigm for other programs interested in implementing similar projects.

Design, Setting, and Participants  A retrospective case series was conducted from September 1, 2013, through March 31, 2016. In a partnership between a free independent clinic for indigent patients and an academic medical center, 54 indigent patients were referred to the clinic for audiograms. A total of 50 of these patients had results of audiograms available for review and were therefore included in the study; 34 of these 50 patients were determined to be eligible for hearing aid fitting based on audiometric results.

Exposures  Free audiometric testing, hearing aid fitting, and hearing aid donation.

Main Outcomes and Measures  The number of hearing aids donated, number of eligible patients identified, number of patients fitted with hearing aids, and work effort (hours) and start-up costs associated with implementation of this program were quantified.

Results  A total of 54 patients (31 women [57.4%] and 23 men [42.6%]; median age, 61 years; range, 33-85 years) had audiograms performed, and 84 hearing aids were donated to the program. The patients were provided with free audiograms, hearing aid molds, and hearing aid programming, as well as follow-up appointments to ensure continued proper functioning of their hearing aids. Since 2013, a total of 34 patients have been determined to be eligible for the free program and were offered hearing aid services. Of these, 20 patients (59%) have been fitted or are being fitted with free hearing aids. The value of services provided is estimated to be $2260 per patient.

Conclusions and Relevance  It is feasible to provide free, comprehensive audiologic care, including hearing aids and fitting, in a well-established, free clinic model. The opportunity for indigent patients to use hearing aids at minimal personal cost is a major step forward in improving access to high-quality care.

Introduction

Free clinics play an important role in providing health care to uninsured and underinsured individuals. A 2010 survey reported that there are more than 1000 free clinics providing health care to approximately 1.8 million Americans annually.1 These clinics often provide primary and urgent care that would otherwise default responsibility to emergency departments.2 Specialty care required by this vulnerable patient population is difficult to access, frequently involving long waits and up-front expenses.3

Hope Clinic, a nonprofit organization in Ypsilanti, Michigan, provides medical and dental services to uninsured individuals in southeastern Michigan. Hope@UMHS is a novel partnership between the Hope Clinic and the University of Michigan Health System that was started in 2010 to provide access to specialty care for patients of Hope Clinic. Included specialties are otolaryngology, audiology, plastic surgery, ophthalmology, neurology, and dermatology. Descriptions of the structure and success of this partnership have been previously published.4,5

As success of Hope@UMHS continues, our group sought to expand the available services provided. The detrimental and widespread effects of hearing loss on mental health, physical functioning, and quality of life have been established.6-8 Age-related hearing loss increases overall health care expenditures and the risk of depression; hearing rehabilitation can reduce depressive symptoms and fundamentally improve quality of life.6,8 However, hearing aids are expensive and not covered by Medicare and many other insurance policies; thus, many indigent patients are unable to attain them.

In 2013, intramural funding was secured from the University of Michigan to pilot the HeAR-U (Hearing Aid Recycling at Hope@UMHS) program, renamed Hope for Hearing. The mission of this program is to provide comprehensive hearing rehabilitation to indigent patients at the Hope@UMHS clinic.

We hypothesize that our nascent experience may serve as a paradigm for other programs interested in implementing similar projects. The aims of this study are to describe the structure, feasibility, and outcomes of a free subspecialty clinic providing hearing aids to assess the success of the Hope for Hearing program.

Methods

The Hope for Hearing program began by securing donated hearing aids, which were obtained by placing advertisements and through direct purchases via funding provided by a $5000 intramural grant. Advertisements included flyers in the audiology clinic in the Department of Otolaryngology, University of Michigan Hospital, Ann Arbor, and requests for donations in departmental and alumni newsletters. The Department of Otolaryngology agreed to repurpose a fully depreciated hearing aid verification system (RM500; Audioscan of Etymonic Design Inc) for use at the Hope Clinic. The intramural grant was also used to purchase a dedicated laptop computer enabled with audiologic software for use at the Hope Clinic. This study was evaluated and granted a formal exemption by the University of Michigan Institutional Review Board, who waived the need for patient consent.

Adult patients with hearing deficiencies were referred to the Hope@UMHS clinic by their primary care physicians at Hope Clinic. All involved otolaryngologists, audiologists, clinical support staff, and interpreters volunteered to participate in the Hope for Hearing program. At least 3 visits to the clinic were required for a patient to complete the process of obtaining an appropriately programmed and verified hearing aid. The first visit occurred at the quarterly Saturday morning Hope@UMHS clinic at the University of Michigan Health System. Additional audiologist-only clinics took place on site at the Hope clinic to shorten the time required to complete the process of fitting the hearing aid. These additional clinics were referred to as Hope for Hearing clinics. The specific name helped to avoid location scheduling errors.

The specific criteria to be eligible for a hearing aid from the Hope for Hearing program included the following: no health insurance (Hope Clinic requirement), bilateral permanent hearing loss of any degree or configuration, and some degree of self-perceived disability secondary to the hearing loss. All patients were also provided information on other programs that provide assistance in obtaining hearing aids (Michigan Rehabilitation Services, the Starkey Hear Now program, and the local Lions Club; Michigan Rehabilitation Services and Lions Club have multiple locations throughout Michigan, and the Starkey Hear Now program is a national and international foundation with their office located in Eden Prairie, Minnesota). These options require that patients transfer their care to the participating clinic and typically involve some out-of-pocket expense and/or long delays in the approval process. Patients were also given the option of using a Hope for Hearing program hearing aid as a “gap” device while they waited for another program. The Hope for Hearing option was the only truly free option, and all eligible patients selected the Hope for Hearing option despite the ability to obtain a new set of binaural hearing aids through other programs.

Initial assessment included a formal audiogram and screening evaluation. If audiometric testing suggested significant hearing loss and an otolaryngologist determined that a patient was medically cleared for hearing aids, he or she was referred back to Hope Clinic audiologists for hearing aid counseling and fitting. There was no specific pure-tone average threshold or minimum speech discrimination standard. Because speech discrimination was not required for eligibility, language barriers did not affect patients’ candidacy for a hearing aid, nor did we formally assess discrimination for non-English speakers.

The third visit was for conformity and follow-up (Figure). Patients were provided with an initial supply of hearing aid batteries and wax filters. This structure parallels the workflow and clinical trajectories of patients with traditional insurance. Owing to our desire to maximize the benefit of a scarce resource, patients were provided with only 1 hearing aid at a time, but bilateral aids were considered on a case-by-case basis depending on patient eligibility and supply. This process was meant to provide the best-quality hearing aids to every qualifying patient, thus conserving the highest-quality hearing aids so that more patients could benefit from them. In addition, this process conserved our budget for ear molds.

Data were abstracted from clinical records, deidentified, and maintained in a password-protected database compliant with the Health Insurance Portability and Accountability Act. Descriptive statistical analyses were performed using Excel, version 15.22 (Microsoft Corp).

Results

A total of 84 hearing aids were donated from September 1, 2013, through March 31, 2016. Seventeen hearing aids (20%) were purchased with grant funding; the remainder were donated. Supplies required to make ear molds were also purchased with grant money. All other audiologic equipment used was the property of the University of Michigan audiology clinic, which is located adjacent to where the Hope@UMHS clinic is hosted.

Since 2013, a total of 54 patients (31 women [57.4%] and 23 men [42.6%]; median age, 61 years; range, 33-85 years) have had audiograms performed; 50 audiograms (93%) were available for review for this study. Of the 50 patients with reviewable audiograms, 41 (82%) were identified as candidates for a hearing aid; 34 of these patients were determined to be eligible for the free hearing aid program. Of these 34 patients, 19 have been successfully fitted with hearing aids and 1 patient is scheduled for further audiologic assessment at the next clinic visit. Thus, to date, 20 patients (59%) eligible for this program have taken advantage of it. No hearing aid malfunctions or other complications have been reported.

Six patients were diagnosed with profound unilateral hearing loss. Thus, they were eligible for a contralateral routing of signal hearing aid but not for the free hearing aid program because we did not have any contralateral routing of signal devices donated, nor did we have access to free bone-anchored hearing aid implants.

A total of 14 patients were identified as eligible for the Hope for Hearing program but have not used it to date. Six of these patients were not interested in hearing aids at the time of their last visit, and another 5 patients have not returned for follow-up appointments. Of the 3 remaining eligible candidates, 1 individual chose to purchase hearing aids, and 2 (both with <20-dB hearing up to 2000 Hz) had no documentation recorded of a discussion regarding hearing aids.

An attempt was made to evaluate the monetary value of the items and services provided. Regarding donated work hours, audiologists spent approximately 3.0 to 3.5 hours with each patient (30 minutes for an audiogram, 1 hour each for a hearing aid evaluation and fitting, and 30-60 minutes for the conformity test). University of Michigan Health System audiologists are salaried employees, with a mean salary including benefits of $47 per hour, or $150 per dispensed hearing aid, for a total of $2850 of audiologic service provided in the program to date. This amount does not include the cost of clinical and technical support staff or the initial clinic appointment with an otolaryngologist at Hope@UMHS.

With respect to direct patient costs, a comprehensive audiogram, tympanogram, and acoustic reflex study would cost $350 out of pocket. The University of Michigan Health System offers a 40% discount on any service that is not covered by insurance, making the discounted price $210. The discounted cost for a hearing aid evaluation and conformity check was $300. A basic hearing aid costs about $700; however, the mean cost for a new equivalent version of a hearing aid distributed by the program would be $1750, because volunteer audiologists were choosing the best available recycled hearing aid at the time of each patient’s fitting. Nonetheless, new devices include warranties that increase their cost when compared with the estimated value of a recycled device that does not have any warranty. Thus, it would cost the average Hope for Hearing patient about $2260 to obtain an equivalent hearing aid or $1210 for the most basic hearing aid available at the University of Michigan Health System.

Discussion

We describe a novel adult hearing aid recycling program directed toward indigent patients and based in an academic center partnering with a free clinic. The Hope for Hearing program can be used as a model for other academic centers interested in providing access for vulnerable individuals in need of otherwise prohibitively expensive services. This hearing aid program began in an established, successful partnership between an academic center and a community program providing otolaryngology and audiology specialty care. This was an important factor in the success of the program, because enthusiastic audiologists and otolaryngologists were already invested in and volunteering regularly at clinics. In addition, a robust referral base and existing workflow were already established, obviating many of the inevitable logistical hurdles of any such endeavor. Finally, an intramural grant of $5000 and donation of a fully depreciated hearing aid verification system were critical in implementing the program.

There have been challenges in implementing Hope for Hearing that should be explicitly addressed. The first is the need for interpreter services. Many patients in this program have required an interpreter to successfully perform an audiologic evaluation and hearing aid fitting. Our program has been fortunate that a family member or friend with bilingual abilities has always been available to serve as an interpreter for Hope for Hearing appointments. However, family members serving as interpreters is not ideal for health care services.9 Other institutions considering a similar program should consider the target population’s cultural needs and their access to professional interpreter services.

A key factor in this collaboration was our ability to keep many of the additional follow-up appointments at the primary care Hope Clinic (Figure). Many patients expressed a preference for the primary care location rather than traveling to the specialty clinic for each appointment. The donated hearing aid verification system and purchased laptop computer were required to make appointments at the primary care Hope Clinic possible. If this equipment were to break down, we would need to reassess our current patient appointment flow. Another consideration is the need for continuous funding for ear mold and other hearing aid supplies. Although these supplies require less funding than the initiation of such a program, some degree of ongoing funding will always be needed as these expenses persist for the lifetime of the program.

The patients who chose not to partake in the program shed light on areas for improvement. When considering barriers to use of the program, cost, ability to attend multiple appointments, and barriers to hearing aid adoption are contributing factors. The only costs to the patient are hearing aid batteries and transportation to the clinics, which can be significant if someone has little to no income. Attendance at 3 appointments may be too great a travel burden for some patients. Finally, hearing aid adoption rates for the public are estimated to be less than 25% for reasons that have been described elsewhere.10,11 Thus, patient selection is critical and underscores the need to ensure that we are providing a resource that will indeed be used rather than expending resources better geared to other individuals. Despite this finding, these barriers could be mitigated if open dialogue and problem-solving occurs between patients and their health care professionals, who are very motivated to assist patients in accessing heath care services.

The Hope for Hearing program targeted only adults eligible for hearing aids because Michigan has robust services for children requiring audiologic testing and hearing rehabilitation. In Michigan, access to hearing aids for children at little to no cost is possible through Medicaid and Children’s Special Health Services. Local and national efforts to increase public knowledge of such programs and reduce patients lost to follow-up are instructive when considering improvements to the Hope for Hearing program.12

Future goals of the Hope for Hearing program are to develop a sustainable source of funding for hearing aid supplies and to increase exposure of the program in the community. Increasing community awareness of the services that Hope for Hearing offers is critical to increasing the success of the program. There is also potential for program growth by working with community physicians to identify a greater number of patients who can benefit from this program, especially since 82% of patients referred for audiogram were identified as candidates for a hearing aid.

Whether to fit binaural aids on patients is an area of active consideration. To date, the number of donated hearing aids and hearing aids purchased via grant funds (84) has more than exceeded the number of hearing aids dispensed (20). The decision for binaural fitting, however, is more complicated than the raw numbers make it appear. For example, a disproportionate number of donated hearing aids were power hearing aids that would not be applicable for many eligible patients. As mentioned previously, the patients to date have received relatively modern and sophisticated aids. Fitting binaural aids would require the use of older, lower-quality aids. Binaural fittings would also ideally require more donations of matched pairs of hearing aids. In addition, ear molds are a significant portion of our budget that would increase if binaural fitting was performed for all patients. Despite the wealth of research demonstrating the benefits of binaural hearing aids,13 we continue to reassess binaural candidacy on a case-by-case basis because of the logistical factors.

Limitations

This study is limited by its retrospective nature. It is also limited by the small sample size. The main limitation for other health care professionals wishing to implement similar programs is that our program was started within an established free clinic, which provided preexisting infrastructure.

Conclusions

Comprehensive audiologic care including donated hearing aids can be effectively delivered to indigent patients in a well-established free clinic and academic medical center collaboration. The opportunity for low-income patients to benefit from hearing rehabilitation at minimal personal cost can represent an effective extension of safety net services.

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Article Information

Accepted for Publication: March 22, 2017.

Corresponding Author: Aileen P. Wertz, MD, Department of Otolaryngology–Head and Neck Surgery, University of Michigan Health System, 1500 E Medical Center Dr, 1904 Taubman Center, Ann Arbor, MI 48109 (aibutera@med.umich.edu).

Published Online: June 15, 2017. doi:10.1001/jamaoto.2017.0680

Author Contributions: Dr Wertz had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Mannarelli, Shuman, McKean.

Acquisition, analysis, or interpretation of data: Wertz, Shuman.

Drafting of the manuscript: Wertz, Mannarelli.

Critical revision of the manuscript for important intellectual content: Shuman, McKean.

Obtained funding: Shuman, McKean.

Administrative, technical, or material support: All authors.

Study supervision: Shuman, McKean.

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Funding/Support: This work was supported by a University of Michigan Fostering Innovation Grant.

Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: We thank the individuals (audiologists, physicians, nurses, administrators, and support staff) from the University of Michigan Health System and the Hope Clinic who have generously donated their time and expertise to this multi-institutional collaboration providing compassionate care to our underserved population.

References
1.
Darnell  JS.  Free clinics in the United States: a nationwide survey.  Arch Intern Med. 2010;170(11):946-953.PubMedGoogle ScholarCrossref
2.
Gertz  AM, Frank  S, Blixen  CE.  A survey of patients and providers at free clinics across the United States.  J Community Health. 2011;36(1):83-93.PubMedGoogle ScholarCrossref
3.
Felt-Lisk  S, McHugh  M, Howell  E.  Monitoring local safety-net providers: do they have adequate capacity?  Health Aff (Millwood). 2002;21(5):277-283.PubMedGoogle ScholarCrossref
4.
Shuman  AG, Aliu  O, Simpson  K,  et al.  Patching the safety net: establishing a free specialty care clinic in an academic medical center.  J Health Care Poor Underserved. 2014;25(4):1810-1820.PubMedGoogle ScholarCrossref
5.
Shuman  AG, Kupfer  R, Simpson  K,  et al.  Implementation of a novel otolaryngology clinic for indigent patients.  Laryngoscope. 2013;123(9):2142-2147.PubMedGoogle ScholarCrossref
6.
Choi  JS, Betz  J, Li  L,  et al.  Association of using hearing aids or cochlear implants with changes in depressive symptoms in older adults.  JAMA Otolaryngol Head Neck Surg. 2016;142(7):652-657.PubMedGoogle ScholarCrossref
7.
Chen  DS, Betz  J, Yaffe  K,  et al; Health ABC study.  Association of hearing impairment with declines in physical functioning and the risk of disability in older adults.  J Gerontol A Biol Sci Med Sci. 2015;70(5):654-661.PubMedGoogle ScholarCrossref
8.
Chisolm  TH, Johnson  CE, Danhauer  JL,  et al.  A systematic review of health-related quality of life and hearing aids: final report of the American Academy of Audiology Task Force on the Health-Related Quality of Life Benefits of Amplification in Adults.  J Am Acad Audiol. 2007;18(2):151-183.PubMedGoogle ScholarCrossref
9.
Rosenberg  E, Seller  R, Leanza  Y.  Through interpreters’ eyes: comparing roles of professional and family interpreters.  Patient Educ Couns. 2008;70(1):87-93.PubMedGoogle ScholarCrossref
10.
Kochkin  S.  MarkeTrak VII: obstacles to adult nonuser adoption of hearing aids.  Hear J. 2007;60(4):24-51. doi:10.1097/01.HJ.0000285745.08599.7fGoogle ScholarCrossref
11.
Ng  JH, Loke  AY.  Determinants of hearing-aid adoption and use among the elderly: a systematic review.  Int J Audiol. 2015;54(5):291-300.PubMedGoogle ScholarCrossref
12.
Williams  TR, Alam  S, Gaffney  M; Centers for Disease Control and Prevention (CDC).  Progress in identifying infants with hearing loss—United States, 2006-2012.  MMWR Morb Mortal Wkly Rep. 2015;64(13):351-356.PubMedGoogle Scholar
13.
Noble  W, Gatehouse  S.  Effects of bilateral versus unilateral hearing aid fitting on abilities measured by the Speech, Spatial, and Qualities of Hearing Scale (SSQ).  Int J Audiol. 2006;45(3):172-181.PubMedGoogle ScholarCrossref
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