Leveraging the age friendly healthcare system initiative to achieve comprehensive, hearing healthcare across the spectrum of healthcare settings: an interprofessional perspective

Abstract

Objective

Hearing loss is associated with multiple physical, cognitive, and psychosocial co-morbidities. Achievement of safe healthcare in the context of these complex co-morbidities necessitates accurate hearing and coordination across specialties. This paper discusses the potentials for and barriers to an interprofessional approach to integrating hearing screening and treatment across all healthcare settings.

Design

The paper reviews the relationship between hearing loss and other health care concerns to emphasise the need for an inclusive, coordinated, interprofessional approach; discusses interprofessional and patient/family centred coordinated care as essential to achieving quality care; and introduces the Age Friendly Health System initiative as a framework that could be leveraged to move towards comprehensive hearing healthcare.

Results

The literature highlights prior work identifying gaps in quality care and the need for new and innovative approaches to evolve interdisciplinary and interprofessional collaborations to achieve comprehensive healthcare. The literature also provides support for using the Age-Friendly initiative as a point of leverage.

Conclusion

Bringing together thought leaders from the health care provider community, World Health Organisation, age-friendly cities movement, and field of architecture to coordinate the integration of hearing healthcare into Age Friendly Health Systems initiatives has potential to achieve comprehensive hearing healthcare across healthcare settings. (198)

Keywords:

• Hearing healthcare
• age-friendly
• interprofessional
• well-being

Introduction

Hearing loss as a multi-disciplinary concern

Many attempts to explain the relationship between sensory decline and cognitive functioning have been made, recognising the complexity of the ageing process itself and the large number of factors that are influenced by age (see Grady 2012 and Rachel, Wayne and Johnsrude, 2015 for reviews.) For example, in the early 1990s, the “common cause hypothesis” gained interest as an explanation for this association, suggesting that age related hearing loss occurred concurrently with other deficits because of a common underlying neurodegenerative mechanism (Baltes and Lindenberger 1997; Kiely and Anstey 2015; Wallhagen, Strawbridge, and Shema 2008). Although the common cause hypothesis received mixed research support over the years, it continues to be considered of one possible mechanism underpinning the association between hearing loss and cognitive impairment (Lin 2015; Pichora-Fuller, Mick, and Reed 2015). What is noteworthy, however, is that this theory conceptualised hearing loss as linked to other changes that occurred with age and supported the importance of sensory function to functional status.

At the same time, data continued to accumulate linking hearing loss with multiple other psychosocial and functional problems. Yet it is only recently that hearing loss has become more widely recognised as an essential concern to general health and well-being, especially for older adults (National Academies of Sciences, Engineering, and Medicine, 2016), as reflected in this current supplement. Situating hearing loss within the larger context of health and well-being has important implications for the current health care system and for practitioners across a range of disciplines, especially if the intent is to provide person and family centred holistic care. It also helps to raise the awareness that hearing loss is a public health concern because hearing loss is the fourth leading contributor to years lived with disability worldwide and has enormous economic and personal consequences, particularly in low-income and middle-income countries (LMICs) where more than 80% of people with hearing loss live (Reavis, Tremblay, and Saunders 2016, Cunningham and Tucci 2017, Wilson et al. 2019; Ruberg 2019) . However, currently, few people who can benefit from hearing care actually use it. For example, among adults aged 70 and older with hearing loss who could benefit from hearing aids, fewer than one in three (30 percent) has ever used them. Even fewer adults aged 20–69 (approximately 16 percent) who could benefit from wearing hearing aids have ever used them (NIDCD, 2016).

For the reasons mentioned above, the purpose of this paper is to provide a perspective on the implications hearing loss has for the health care system, and to suggest how incorporating it into an interprofessional age friendly health systems framework may address some of the barriers to comprehensive hearing health care. The paper is divided into three major sections and a discussion. First, the relationship between hearing loss and other health care concerns is briefly reviewed to emphasise the way hearing and hearing loss is integral to health and the need for an inclusive and coordinated interprofessional approach. Next, interprofessional and patient/family centred coordinated care are discussed as essential to achieving quality care. Included is a brief discussion of the current barriers or gaps to achieving such an approach to care, especially as it relates to hearing health. Following this, the concept of an Age Friendly Health System is discussed with emphasis on how this framework could be leveraged to move towards interprofessional comprehensive hearing health care. Finally, the discussion will summarise what might be next steps.

The need for a new vision and strategy

Hearing loss and the health connection

The capacity to hear accurately plays a vital role in promoting safe health care though its role in effective communication. Hearing loss can result in misunderstandings, inadequate assessment of health needs, misunderstandings of cognitive status, loss of personalised care, and possibly higher rates of readmissions to hospitals (Chang et al. 2018; Cudmore et al. 2017; Henn et al. 2017; Wallhagen, Ritchie, and Smith 2019). This can be seen as especially significant when it is realised that hearing loss is associated in various ways with such a wide array of health-related concerns where effective communication is essential. It is a risk factor for a range of socio-emotional-psychological conditions, such as isolation and loneliness, depression, and altered interpersonal relationships; and functional as well as pathophysiological conditions such as falls and delirium (George, Bleasdale, and Singleton 1997; Jiam, Li, and Agrawal 2016; Keidser et al. 2015; Ramage-Morin 2016; Viljanen et al. 2009; Wallhagen et al. 2004). Hearing loss is also associated with a number of co-morbid conditions such as cognitive impairment, diabetes, cardiovascular disease and HIV/Aids, possibly because of common under lying vascular pathologies (Abrams 2017; Besser et al. 2018; Deal et al. 2017; Lin et al. 2013; Loughrey et al. 2018; Wallhagen and Strawbridge 2016).

In addition to its association with multiple health conditions, medications used to treat many problems, such as antibiotic and chemotherapeutics, can be ototoxic and contribute to hearing loss as well as tinnitus and vestibular damage that results in balance problems (Baguley and Prayuenyong 2020; Miaskowski, et al, 2018a; Miaskowski, et al, 2018b). Hearing should therefore be assessed before chemotherapy is initiated (Bass et al. 2013; Paken et al. 2016). Further, hearing loss becomes one of the many sequalae related to cancer therapy that can result in permanent handicaps even if the cancer is resolved. These can include ability to return to normal life, work, and communication with loved ones during vulnerable times of treatment. Hearing loss must thus be considered in developing long term care regimens to support quality of life.

There is also data suggesting that medications not normally considered ototoxic but that are used long term at standard doses, such as nonsteroidal anti-inflammatory drugs and loop diuretics, may, in fact, be associated with hearing loss (Joo et al. 2020). The fact that hearing loss is linked to such a range of health and social concerns supports the need for safe, efficient health care that includes hearing as well as coordination across specialties.

Interprofessional, coordinated, person/family centred care

In 2001, the Institute of Medicine (now the National Academies of Science, Engineering and Medicine), published “Crossing the Quality Chasm: A New Health System for the 21st Century.” Following on a prior publication that highlighted significant problems and gaps in the current health care system (Kohn et al. 2000; Institute of Medicine (US) Committee on Quality of Health Care in America et al. 2001), the report defined quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge” (Institute of Medicine 2001, 232) Six characteristics were determined to be essential to health care quality – it had to be safe, patient-centred, timely, effective, efficient, and equitable. This was followed in 2018 with Crossing the Global Quality Chasm: Improving Health Care Worldwide (National Academies of Sciences, Engineering, and and Medicine 2018). This latter report emphasised that there needed to be a deliberate effort made to improve the quality of health care services globally and incorporated the same six quality indicators.

These two seminal reports emphasised the critical nature of health care improvement with the newest report highlighting the important roles that community and population health play in promoting health and well-being. Of central importance, however, is the emphasis on how the health care system needed to change to achieve the goals of true quality care because health care practitioners and organisations within the current system usually operated in silos without complete information about an individual’s complex health needs (Institute of Medicine 2001). To bridge this gap, the report emphasised that it was essential that clinicians and institutions collaborate and communicate to ensure an appropriate exchange of information and coordination of care. For hearing health care, the Committee on Accessible and Affordable Hearing Health Care for Adults also emphasises the critical nature of a comprehensive assessment that includes, in additional to an individual’s hearing and communication difficulties, auditory rehabilitation, counselling, and the identification of any underlying medical conditions (National Academies of Sciences, Engineering, and Medicine, 2016). This is the essence of interprofessional care.

Defined, interprofessional care is when “multiple health workers from different professional backgrounds provide comprehensive services by working with patients, their families, carers and communities to deliver the highest quality care across settings” (World Health Organization 2010, 13). This incorporates a person-centred philosophy that is meant to be central to collaborative care. Examples of person-centred and person-family-centred care can be found within the field of audiology. Thus, while at the first level (family involvement), research is limited, there is some evidence that family members are interested in being involved (Ekberg et al. 2015). However, audiologists who wish to include family members report difficulties in achieving this goal, such as arranging appointment times to include family members, family members not seeing the need to get involved, and discrepancies between patients and family members as to what should be done (Meyer et al. 2015). Unfortunately, examples of holistic, interprofessional and across specialty care, are, however, extremely limited.

Several factors make interprofessional care challenging. One relates to health professional education itself – each profession has its own professional scope of practice and legal authority, which can vary by state and impacts the delivery of services which is not inherently conducive to cohesive integration (D’amour and Oandasan 2005). Blueprints and frameworks have been put forth to promote interprofessional education with the acknowledgment that this would involve a true transformation of the educational systems currently in place (Greiner and Knebel 2003; World Health Organization 2010). However, while some data suggest such education can have a positive impact (Guraya and Barr 2018), there are few good data supporting the positive impact of variously designed interprofessional approaches to care (Reeves et al. 2017), partly because the data remain insufficient to allow clear conclusions to be drawn. What does appear clear is that good communication based on trust and a shared vision is central to interprofessional collaboration as it lays the foundation for building effective teams (Nancarrow et al. 2013; O’Daniel and Rosenstein 2008).

The difficulties encountered in developing and implementing interprofessional collaborative teams relate to a number of barriers encountered in clinical settings, including the structure of health care systems, which often makes smooth communication difficult. This can be exacerbated by financial constraints, regulatory processes and concerns about medico-legal issues (Gilles et al. 2020; Lahey and Currie 2005).

Developing effective teams may be especially challenging in relation to the provision of comprehensive hearing healthcare. Health care providers and hearing health care specialists tend to practice in separate domains. Hearing health is not routinely considered in primary care where it is underassessed and can be discounted. Studies indicate that only approximately 20–30% of practitioners screen for hearing loss (Abrams and Kihm 2015; Wallhagen and Pettengill 2008). These statistics are consistent with recently published data collected in the U.S.A by Stevens et al. (2019). Ninty-three percent of respondents surveyed indicated that they sometimes or often let their primary care providers know about their hearing loss. However, despite providing this information to the primary care provider, 29.3% of all respondents also reported that no follow up arrangements were made to address their communication needs. This was true even though their hearing loss posed difficulties such as hearing their name being called in the waiting room and communicating on the telephone. Hearing loss is also rarely considered in studies on physician-patient communication (Cohen et al. 2017) and is not considered in programs designed to teach practitioners how to engage in sensitive conversations with persons with a serious illness (e.g. Villagran et al. 2010; Kaplan 2010). Although the literature includes discussion of the potential value of physician – audiologist collaborations (Taylor and Tysoe 2013; Weinstein and Taylor 2015), few interventions appear to have resulted in lasting or widespread impact and those reported usually focus on building a physician referral network (Kochkin 2004).

If there is little formalised communication between hearing health care specialists and practitioners in other health care specialties team building and collaboration is less likely, especially if the different professions lack a shared vision. At the same time, persons with chronic conditions or other health care problems often prioritise hearing loss as of lower concern than their other health care needs and thus not raise the issue, especially if they do not realise the significant impact hearing loss can have on their overall health and it’s not discussed by their health care provider. Given the impact of hearing loss on multiple domains of an individual’s life, strategies are needed to overcome current barriers and promote interprofessional, collaborative practices that incorporate hearing health care into an overall comprehensive approach to the promotion of health and well-being. One strategy could include leveraging the current efforts to promote Age Friendly Environments, including Age Friendly Health Systems.

Leveraging the age friendly health systems initiative

The seminal reports noted earlier set forth a vision for both a transformed health care system that would provide comprehensive, coordinated and person-centred care, and a transformed educational system that could prepare practitioners to function effectively in this new model of care. However, achievement of these goals remains elusive, even while the health care needs of an aging population and the related costs continue to expand. In an attempt to address this continued need to re-envision the health care system, The John A Hartford Foundation partnered with the Institute for Health Care Improvement (IHI) along with experts in health care redesign as well as key stakeholders to synthesise key elements of prior best practices and evolve and test an age friendly approach to use in health systems (Fulmer and Berman 2016).

The Age Friendly Health System (AFHS) includes the goal of providing evidence-based care that should be seamless during transitions across care settings and into the community. It also should incorporate the ongoing, meaningful engagement of patients and families. The Age Friendly vision was in line with the earlier reports on the need for system transformation and depends on collaboration and coordination of care across professions and disciplines, or interprofessional care.

The development and scaling up of AFHS are being initiated through “Action Communities” that adapt an essential set of evidence-based practices called the “4Ms Framework” into their health care setting (Institute for Healthcare Improvement 2019a, 2019b and 2020). The 4Ms target four areas deemed especially critical to providing quality of care to older persons: knowing and aligning care with the individual’s specific health outcome and care preferences (“What Matters” or person centred care); assuring the medications are appropriate (“Medication”); preventing, or, if necessary, early recognition and appropriate treatment of alterations in cognition or mood states such as dementia, depression or delirium (“Mentation); and ensuring that individuals maintain function (“Mobility”).

While possibly appearing disparate to the development of comprehensive hearing health care, these targeted areas do, in fact, provide critical points of leverage. Accurate hearing is essential to meeting these 4 targets and, thus, hearing screening for and correction or mitigation of hearing deficits should be integrated into the overarching framework. For example, hearing loss affects the quality of palliative care by complicating the determination of goals or care (What Matters) (Smith, Ritchie, and Wallhagen 2016; Wallhagen, Ritchie, and Smith 2019). Hearing loss is a risk factor for delirium, depression and both cognitive impairment and misinterpretation of cognitive status (Mentation). Hearing loss is also a risk factor for falls and functional decline (Mobility). And finally, medication can cause hearing loss and hearing acuity should be assessed prior to many medication regimens (Medication). Given that hearing loss can lead to misunderstandings, prescribed medication regimens also may be misinterpreted leading to medication errors and hospital readmissions.

Prior efforts to integrate hearing assessments have generally been very localised and the impact of hearing loss on all domains of health and well-being have not been well-developed. Linking to health systems that are attempting to become Age Friendly provides an opportunity to make this larger connection by emphasising the potential impact of including hearing as a consistent and essential component of an older adults’ health assessment on outcomes in each of the 4Ms domains. This can be important to the health system given the value placed on being recognised as Age Friendly Health System (Institute for Healthcare Improvement 2019b). Further, age friendly initiatives and related recognition is occurring with various specialties. For example, Geriatric Emergency Department Accreditation Program (2020) is a specific initiative aimed at developing age-friendly emergency departments that are well prepared to provide appropriate care for older adults (American College of Emergency Physicians 2019; https://www.acep.org/geda/). These initiatives allow for permeation of best practices related to hearing health care into specialty practices.

An additional point of leverage includes the fact that the Age Friendly movement is not new. The World Health Organisation initiated a movement to stimulate the development of age friendly cities and communities as early as 2002 (https://www.who.int/ageing/projects/age_friendly_cities/en/; WHO Global Network 2018). Given the emphasis on a seamless transition into the community as a component of AFHS, using this framework allows for the instillation of the value of hearing friendly environments into the broader community within which the health care system is situated, thus facilitating the achievement of the goal of putting hearing health care in the context of healthy living and well-being (Saunders et al. 2021, current supplement).

Discussion

The current paper argues that hearing is central to both safe, effective health care across a spectrum of health conditions and settings and to the promotion of health and well-being. It further argues that interprofessional care is key to the provision of comprehensive, coordinated, and person-centred care. However, achieving such care, especially one that integrates consideration of hearing health, has been elusive. A new approach is needed.

One approach that has potential is to develop strategies that leverage the Age-Friendly Health Systems movement, especially linking the impact of hearing loss to each of the 4Ms. This would involve working with the key leaders in the AFHS movement, including the JAHF and IHI as well as the American Hospital Association, while also focussing on local initiatives. Complementary suggestions have recently been developed by the WHO as part of a community focussed, redesigning care for older people, project designed to preserve physical and mental capacity (World Health Organization 2017; Thiyagarajan et al. 2019). Termed the ICOPE (Integrated Care for Older People Guidelines), the guidelines focus on areas that are similar to the 4Ms – improving musculoskeletal function, maintaining sensory function, preventing cognitive decline and mood disorders, treating age related conditions, and supporting caregivers.

Bringing thought leaders together from these various complementary efforts along with leaders from the age-friendly cities movement and experts in the field of architecture to coordinate the development of age friendly health care and community environments provides the potential for a major world-wide initiative. Such an initiative that not only includes the presence and support of leaders from across a spectrum of specialties while leveraging an on-going broad based can address the lack of awareness of the importance of hearing to health, minimise the stigma attached to hearing loss and the use of technology, and move the agenda of hearing health care as critical to health and well-being.

Acknowledgements

We would like to acknowledge all the insights about hearing loss and how it impacts experiences in the healthcare system that we have gained from fellow members of the Hearing Loss Association of America (HLAA) and other persons with difficulty hearing.

Declaration of interest

Dr. Wallhagen was a prior Board member of the Hearing Loss Association of America (HLAA) and is currently on the Board of the Hearing Loss Association of America, California State Association (HLAA-CA). She has no financial disclosures.

Dr. Strawbridge has no financial disclosures.

Dr. Tremblay is currently on the Board of Directors of the Hearing Loss Association of America (HLAA), not paid, and provides consultation services for Lend an Ear, Inc.

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.