age-related hearing loss (PCAST, 2015), the Food and Drug Administration (FDA) held a series of meetings on streamlining regulations for good manufacturing practices for hearing aids (FDA, 2016). Representatives from various professional and consumer organizations such as American Speech-Language-Hearing Association (ASHA), American Academy of Audiology (AAA), American Academy of Otolaryngology—Head and Neck Surgery (AAO-HNS), and Hearing Loss Association of American (HLAA) presented their opinions on OTC hearing aids and included statements stressing the importance of AR in the hearing aid attainment process. There seemed to be no disagreement as to the importance of rehabilitative efforts in the management of hearing loss. The challenge for all of us, then, is to increase the inclusion of AR in audiology practice.
Many practitioners still believe AR to be the roots of our field and thus have pursued research and practice in this area. Alpiner and McCarthy (2014; also see Chapter 1 in this edition) discuss the evolution of AR in the field of audiology. As we study the history of AR from its origins through the establishment of professional organizations such as the Academy of Rehabilitative Audiology (ARA), ASHA and the latter’s Aural Rehabilitation and its Instrumentation Special Interest Group (SIG 7), and the evolution of professional organizations like the AAA and the Academy of Doctors of Audiology (ADA), we are able to understand better the development of the definitions that provide important clinical direction.
Perhaps reviewing the existing definitions of AR can shed some light on the process and attempt to unify the perceptions of audiologists. With this in mind, the purpose of this chapter is to explore the variety of definitions of AR and identify barriers to the provision of AR services.
Who Provides Services in AR?
Many consider AR to be the true marriage of audiology and speech-language pathology, particularly with respect to service delivery for children with hearing loss. Membership in both ARA and ASHA SIG 7 consists of both audiologists and speech-language pathologists (SLPs), with many holding degrees and certification in both professions. Given the nature of AR, the roles of SLPs and audiologists can be complementary and cooperative (ASHA, 2001). This overlap, however, may have contributed to confusion and misunderstanding among many audiologists. AR falls within the scope of practice of both professional groups (ASHA, 2018) and although knowledge and skills may have been delineated (ASHA, 2001), third-party reimbursement for service provision in AR is distinctly different. Audiologists are rarely, if ever, reimbursed for providing these services. In fact, it is often cited as the reason audiologists do not provide AR. Within the realm of third-party reimbursement, many AR services are covered only when performed by SLPs because this field of practice is classified as both diagnostic and rehabilitative while audiology is considered an exclusively diagnostic profession through the Centers for Medicare and Medicaid Services (CMS) (https://www.cms.gov).
Strides have been made to improve the reimbursement of AR services for audiologists, and as a result, the current procedural terminology (CPT) codes were established in 2006. Kander and White (2006) described the following codes: 92626: evaluation of auditory rehabilitation status, first hour; 92627: each additional 15 minutes, on same day as 92626; 92630: auditory rehabilitation of children; and 92633: auditory rehabilitation of adults. The codes developed for adults are more specifically aimed at adult cochlear implant recipients.
Reimbursement for audiology services provided under Medicare is limited to diagnostic services only, with limited coverage for treatment. Procedures for auditory training and speechreading are still not covered under Medicare for audiologists, even though the SLP can apply for reimbursement for these services by using the treatment code of 92507. Efforts are continuing to expand Medicare coverage for audiology services that would include the provision of AR and are included as part of the current ASHA Public Policy Agenda (ASHA, 2019a).
Not only is there confusion about who provides AR services, but basic nomenclature is also at issue. What should this process be called? Alpiner and McCarthy (2014) discuss the terminology paradox that is currently present in our field. The terms aural rehabilitation, audiologic rehabilitation and, most recently, auditory rehabilitation, are often used interchangeably. SLPs prefer to use the term aural rehabilitation, while audiologists have more consistently referred to these services as audiologic rehabilitation. One need only refer to the ASHA Preferred Practice Patterns (PPP) for the Professions of Speech-Language Pathology (ASHA, 2004) and Audiology (ASHA, 2006) to illustrate the difference. PPPs for speech-language pathology refer to services provided to individuals with hearing loss as aural rehabilitation; meanwhile, the audiology PPPs use the term audiologic rehabilitation. It is for this reason that the acronym AR was employed in the ASHA(2001) knowledge and skills publication on aural/audiologic rehabilitation. Currently, within the ASHA Practice Portal (2019b), adult aural rehabilitation is identified as an area of practice for both audiologists and SLPs with practice delineations provided.
What Is AR?
This question leads to a discussion of defining AR. A review of the literature reveals an abundance of definitions that seem to vary significantly historically. Gagné and Jennings (2009) reported that, while some definitions stress the activities associated with the rehabilitation of hearing loss, others focus on the reduction of associated disabilities and handicaps. The emphasis of AR has shifted from procedure-specific to a more patient-centered concept. Schow et al. (1993) reported on a trend of decreasing traditional treatments in AR (auditory training and speechreading), but an increasing perception by audiologists that their clinical duties included both diagnostic and rehabilitative services. Prendergast and Kelley (2002) postulated that this change was primarily due to a shift from traditional procedural AR approaches toward services designed to address emotional and social aspects of hearing loss. This belief can be substantiated when we compare the definitions used to describe AR throughout the years.
In 1971, Sanders published the first edition of his seminal book, Aural Rehabilitation. This text, along with subsequent editions, introduced a generation of audiologists to AR. The common thread throughout the chapters of this book was the importance of an individual’s overall communication ability. He reported that approaching assessment from a theoretical framework that encouraged rehabilitation was just as critical for individuals with mild to moderate hearing loss as it was for those with severe to profound loss. This was a change in thinking at the time since the lion’s share of AR services were offered only to those with more severe hearing impairments. Assessing individual areas of strengths and weaknesses would help identify abilities that were in need of improvement, making it possible to “circumvent the weaknesses through the development of the use of compensatory channels” (Sanders, 1971, p. 5). Included in this text were chapters dedicated to various topic areas: auditory and visual perception, amplification and hearing aids, auditory training, visual communication training, and the integration of vision and audition. Sanders stressed the importance of not limiting our services to just the assessment of hearing.
ASHA (1984) published a position statement that discussed the definition of, and competencies for, aural rehabilitation. Developed by the Committee on Rehabilitative Audiology, the paper revisited the American Speech-Language-Hearing Association’s 1974 legislative council resolution that supported the audiologist as the primary provider of AR services and their role in the supervision of such services. It was felt that in practice, however, the SLP was providing a significant proportion of AR services for individuals with hearing loss. As a result, the committee created a new definition of AR and included the components necessary for service provision: “Aural rehabilitation refers to services and procedures for facilitating adequate receptive and expressive communication in individuals with hearing impairment” (ASHA, 1984, p. 23). The authors went on to describe the elements necessary to accomplish the goals of AR. These included evaluation of sensory capabilities, fitting of auditory and sensory aids, counseling, and referral. The importance of counseling both the individual and family regarding the impact of hearing loss began to become a prominent message in the definition of AR.
While this position statement acknowledged the interdisciplinary nature of AR, it did nothing to help delineate the difference between the audiologists and SLPs in service delivery. In fact, it appeared that one of its purposes was to negate the audiologists’ primary role in AR that had been established earlier in 1974. Although perhaps unintentional, the use of the terms expressive and receptive communication within the core context of the definition, while certainly accurate, may have created the appearance that AR is more directly associated with speech-language pathology. The terminology, while not exclusive to speech and language, is often associated with child language development or adult neurologic language processes. The paper appeared at a time when audiologists were seeking a more independent professional identity and was probably indirectly responsible for the increased popularity of the label audiologic rehabilitation.
Not long after the publication of this position paper, the creation of Special Interest Divisions of the ASHA (now referred to as Special Interest Groups or SIGs) became a reality. These divisions were established to meet member needs for specialized areas of professional practice. Division 7 (Aural Rehabilitation and its Instrumentation) was among the first groups developed. The Steering Committee of Special Interest Division 7 (1992) contributed an article to the ASHA magazine that focused attention on some of the beliefs of their Division and stated simply that “Audiologic rehabilitation was Audiology” (p. 18). The implication, of course, was that the entire field of audiology was designed to be rehabilitative in nature. Their definition includes the importance of the impact of hearing loss on function within the context of the family and environment. These concepts would soon become primary objectives for AR.
Erdman (1993, 2000) stated that the “ultimate goal of rehabilitative audiology is to facilitate adjustment to the auditory and non-auditory consequences of hearing impairment” (p. 374). This brief description of AR begins to show the shifting emphasis in rehabilitation models from procedure-specific definitions to more function-driven descriptors. Here, the author places equal value on the auditory (e.g., hearing loss degree and nature, speech perception, etc.) and nonauditory (e.g., emotional, psychosocial, vocational, etc.) implications associated with the loss of hearing ability and goes on to discuss the importance of counseling in the rehabilitation process. In fact, Erdman (2000) remarks that counseling is the “essence of successful rehabilitation” (p. 435) of AR.
It became important that our profession begin to expand its definition of AR beyond the evaluation and management of hearing loss to include the impact of psychosocial functioning (Ross, 1997). The increase in popularity of self-assessment measurement tools, such as the Hearing Handicap Inventory for the Elderly (HHIE) (Ventry & Weinstein, 1982), the Hearing Performance Inventory (Giolas et al., 1979), and the Communication Profile for the Hearing Impaired (CPHI) (Demorest & Erdman, 1987), provided the audiologist with an arsenal that could be used to quantify the impact of adult hearing loss. The measures could yield a basic classification function; for example, the HHIE could be used to determine a level of hearing handicap or, more broadly, the CPHI could be used to provide a profile that is an effective counseling tool. Regardless of measurement focus, the direction of assessment for AR was tending to shift more toward the implications of a loss of hearing on numerous domains of function.
Ross (1997) reported that the process of AR includes “any device, procedure, information, interaction, or therapy which lessens the communicative and psychosocial consequences of a hearing loss” (p. 19). Like Erdman (1993), Ross seems to place equal emphasis on issues related to the auditory and psychosocial aspects of functioning. Without specifying further, he relegates any procedure appropriate to lessening the impact of hearing loss on communication function to AR. Certainly, one could include traditional activities such as speechreading and auditory training as treatment components, but one could just as easily consider counseling, vocational assessment, and family intervention.
Gagné (1998) continued to emphasize function over procedure when he defined AR as the process designed to “eliminate or reduce the situations of handicap experienced by individuals who have a hearing impairment and by persons with normal hearing who interact with those individuals” (p. 70). The author was quite specific about the inclusion of others within the communication environment of the individual with hearing impairment, an approach that can be directly related to a landmark publication under development at the time by the World Health Organization (WHO).
The World Health Organization and Its Impact on the Definition of AR
In 1980, the WHO published its first classification of disability with the International Classification of Impairment, Disability, and Handicap (ICIDH). It attempted to unify related terminology in the realm of handicap and disability. This original paper identified “impairment” as having an impact on the organ level and “disability” as related to activities and handicap referring to one’s role in society. During the late 1990s, WHO began to revisit this classification system and subsequently published the International Classification of Functioning, Disability, and Health, commonly referred to as the ICF, in 2001. The impact of the WHO classifications is covered in depth in Chapter 3 of this text.
The ICF described both health and health-related domains in relationship to the body, the individual, and to society at large. The primary areas of concern within the ICF are body functions and structures and what is referred to as activities and participations. The ICF describes “what a person with a disease or disorder does do or can do.” While the ICIDH seemed to highlight the negative consequences of impairment, the ICF emphasizes the positive (Boothroyd, 2007).
The influence of the WHO ICF can be directly observed in a publication prepared by the ASHA Working Group on Audiologic Rehabilitation (ASHA, 2001). This group was charged with the task of updating the ASHA’s 1984 position statement (discussed earlier) on the definition of, and competencies for, AR. The interdisciplinary nature of AR was evident in the group membership, which consisted of both audiologists and SLPs. Unlike the 1984 document, this group decided to directly address the issues related to the provision of services by two distinct professions and, essentially, created two documents within one.
The format of the 2001 publication consists of an introduction that defined AR and provided background and history. The specific areas of basic knowledge and specific knowledge and skills are divided into two sections: (a) knowledge and skills for audiologists providing AR services, and (b) AR knowledge and skills for SLPs. The paper specifically delineates the roles of the two professions; while collaborative, these roles are distinctly different.
The authors emphasize that AR no longer refers to simply procedure-specific treatments such as auditory training, speechreading, or even hearing aid dispensing, but rather, it is a broad process with tentacles reaching into all aspects of a person’s functioning. With this in mind, the working group proposed a definition of AR: “Audiologic/aural rehabilitation (AR) is an ecological, interactive process that facilitates one’s ability to minimize or prevent the limitations and restrictions that auditory dysfunctions can impose on well-being and communication, including interpersonal, psychosocial, educational, and vocational functioning” (p. 2).
The WHO ICF (2001) terminology includes descriptors such as activity and activity limitations, and participation and participation restrictions. In addition, this publication stresses the importance of contextual factors, such as environmental and personal influences, on an individual’s ability to function with an impairment. Inclusion of such terms as ecological, interactive, minimize or prevent limitations (activity), and restrictions (participation) reinforce the impact of the ICF on this ASHA (2001) document.
The knowledge and skills for audiologists providing AR services addressed by ASHA (2001) include areas of general knowledge, such as psychology, human growth and development, cultural and linguistic diversity, and quantitative research methodologies. Within the area of basic communication processes, those recognized are knowledge of anatomy, physiology, speech and hearing sciences, linguistics, psycholinguistics, and dynamics of interpersonal skills.
Table 2–1 includes the special areas of knowledge and skills identified in the ASHA (2001). The skills described are meant to educate the audiologist on the specific areas one should develop to practice AR. As is evident through a review of this table, the list is quite inclusive and does not distinguish between services for children and adults. A similar presentation of information was developed for SLPs, but will not be covered in the context of this chapter.
Building on this definition, the ASHA (2006) referred to AR in its preferred practice patterns for audiology as
a facilitative process that provides intervention to address the impairments, activity limitations, participation restrictions and possible environmental and personal factors that may affect the communication, functional health and well-being of persons with hearing impairment by others who participate with them in those activities. (Section 15, p. 40)
Boothroyd (2007) advocated a holistic approach to AR. He defined this as “the reduction of hearing loss-induced deficits of function, activity, participation and quality of life through a combination of sensory management, instruction and perceptual training and counseling” (p. 63). The WHO ICF is acknowledged as a major influence on the purpose of his paper. As was evident in the ASHA (2001) definition, specific terminology (e.g., function, activity, participation) directly aligns Boothroyd’s philosophy with the trend in the profession to an expanded view of AR: a shift from primarily procedural activities to the therapeutic process aimed at reducing the impact of hearing loss on function (ASHA, 2001; Erdman, 1993; Gagné, 1998; Ross, 1997).
A New Definition of Audiologic Rehabilitation
As we continue to expand the scope of services we include in the process of AR, our definitions will need to be reviewed and revised to allow for changes occurring in our professional practices. The following, which appeared in the second edition of this text, is what is believed to represent the current state of AR: “AR is a person-centered approach to assessment and management of hearing loss that encourages the creation of a therapeutic environment conducive to a shared decision process, which is necessary to explore and reduce the impact of hearing loss on communication, activities, and participations” (Montano, 2014, p. 27). As we review trends in audiology practice, there is a growing body of evidence to expand the concept of person-centered care to family-centered care. The inclusion of family in the rehabilitation process has been shown to improve health-related and audiologic outcomes (Laplante-Lévesque et al., 2010; Meyer et al., 2014; Rathert et al., 2013; Singh & Launer, 2016). As a result, a slight modification to the Montano (2014) definition of AR would be the influence of family-centered care rather than limiting it to patient-centered care.
Table 2–1. Special Areas of Knowledge and Skills for Audiologists Providing Audiologic Rehabilitation (AR) Services
1APD = Auditory Processing Disorder.
Source: Adapted from the American Speech-Language-Hearing Association (2001).
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