Association of VA Association of VA AudiologistsAudiologistsLucille B. Beck, Ph.D.Lucille B. Beck, Ph.D.

Chief Consultant, Rehabilitation Services and Chief Consultant, Rehabilitation Services and Director, Audiology and Director, Audiology and

Speech Pathology ServiceSpeech Pathology Service

2

VA MissionVA Mission

• To serve America's veterans and their families with dignity and compassion and to be their principal advocate in the ensuring that they receive the care, support and recognition earned in service to this Nation.

• VHA core missions: – Health Care– Graduate Medical Education– Research– Emergency Preparedness

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The Veterans We ServeThe Veterans We Serve……

• 24 million veterans and 37 million spouses and dependents of veterans

• About a quarter of the nation's population, approximately 74.5 million Americans are potentially eligible for VA benefits and services.

• Vietnam Era veterans are the largestgroup (7.9 million).

• Median age=60 years (61 for men and 47 for women)

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VA Medical CareVA Medical Care

• The largest integrated healthcare system in US:– 155 hospitals– 135 nursing homes– 209 veterans counseling centers– 872 outpatient clinics– 210,000 health care employees– 7.9 million total enrollees

• 5.7 million patients treated in FY2007. Over 64 million outpatient visits and 800,000 inpatients treated.

• Manages the largest medical education program in the U.S, partnering with 107 medical schools, 55 dental schools and 1,200 other schools. Over 90,000 health care professional train in VA each year.

• In FY07, VA collected nearly $2.2 billion in insurance and co-payments.

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VA Benefit ProgramsVA Benefit Programs

• More than half of the annual VA budget is paid to veterans in the form statutory benefits ($86 billion).

• 2,725,824 veterans received service-connected disability benefits in FY2006 ($25.6 billion) and another 329,856 veterans received pension benefits ($2.7 billion).

• VA processed over 825,000 disability claims and added over 250,000 new beneficiaries to its Compensation and Pension rolls in 2006.

• Other benefit programs (FY2006):─ Education (489,229 recipients)─ Vocational Rehabilitation (53,000 recipients)─ Mortgage guarantees (147,708 loans, $24.6 billion)─ Life insurance (7.2 million policies, $1.3 trillion in face value, 6th largest life insurer)

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Veterans Receiving DisabilityVeterans Receiving Disability

Period of Service NumberWorld War I 2 World War II 328,042Korean Conflict 159,804Vietnam Era 947,598Peacetime 595,565 Gulf War Era 694,813

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Best Care AnywhereBest Care Anywhere

• RAND study found that VA outperforms all other sectors of American health care across a spectrum of 294 measures of quality in disease prevention and treatment.

• A comprehensive Harvard study in Archives of Internal Medicine concluded that federal hospitals, including those run by VA, provide the best care available anywhere for some of the most common life-threatening illnesses such congestive heart failure, heart attack, and pneumonia.

• For the 7th straight year, VA received significantly higher marks than the private health care industry on American Customer Satisfaction Index (ACSI).

• VA won the prestigious “Innovations in American Government” Award from Harvard University’s Kennedy School of Government for its advanced electronic health records system and performance measurement system.

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AccomplishmentsAccomplishments

• IT Roadmap—audiometer interface to CPRS• Bluetooth technology waiver• Hybrid Title 38 conversion• Renegotiated Audiology Online• Audiology Role in TBI • ROES Automated Progress Notes• Hearing aid directive• Certification Program for C&P Examiners

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Challenges for AudiologyChallenges for Audiology

• Emerging foci for audiology: noise-induced hearing loss, tinnitus, and TBI─ Compensation and pension─ Increasing prevalence of hearing loss and tinnitus─ Revised TBI disability rating─ Evaluation of TBI-related symptoms (hearing loss,

dizziness, tinnitus, processing disorders)• Rapidly changing treatment technologies and

paradigms• Rapidly changing information technology and

systems• Best Practices and Standardization• Aging workforce--mentoring

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Disability CompensationDisability Compensation

• Auditory system disabilities (including tinnitus and ear diseases) are the second most common disability by body system—908,676 veterans (11.2% of all disabilities).

• Hearing Loss is the most common individual disability (444,583 veterans), followed by tinnitus (395,324 veterans).

• Of new claims in F2006, tinnitus and hearing loss were the top two disabilities awarded:

─ Tinnitus--51,360 (9.7% of all new claims)

─ Hearing Loss--38,330 (7.2% of all new claims)

• From 20024-2006, VBA made 419,323 hearing loss decisions and 304,773 tinnitus decisions. Favorable decisions: 39.5% for hearing loss and 58.6% for tinnitus

Source: 2006 Annual Benefits Report, VBA

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Disability by Period of ServiceDisability by Period of Service

PERIOD HEARING TINNITUSWWII #1 #3KOREA #1 #2VIETNAM #3 #4GULF #6 #2PEACE #4 #5GWOT #3 #1

Source: VBA

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Audiology Staffing and Workload (FY2007)Audiology Staffing and Workload (FY2007)

• 647 audiologists (increased 102% since 1996)

• Audiology encounters: 1,000,279─Outpatient visits increased 98% since 1999─Hearing aid issues increased 375% since 1996

• Unique veterans (outpatient)─ 564,445 (all veterans)─ 25,398 (OEF/OIF ~ 4%)

• Audiology services in 220 VHA sites of care

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Growth in Audiology Staffing (1996Growth in Audiology Staffing (1996--2007)2007)

AUDIOLOGY STAFFING

0

100

200

300

400

500

600

700

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

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Audiology Outpatient Visit GrowthAudiology Outpatient Visit Growth

0

200000

400000

600000

800000

1000000

1200000

FY99FY00FY01FY02FY03FY04FY05FY06FY07

VISITSUNIQUES

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VA Hearing Aid TrendsVA Hearing Aid Trends

(FY96-FY07)Source: VA Denver Acquisition & Logistics Center

0

50,000

100,000

150,000

200,000

250,000

300,000

350,000

400,000

FY96 FY97 FY98 FY99 FY00 FY01 FY02 FY03 FY04 FY05 FY06 FY070

20

40

60

80

100

120

140

UNITSSALES (000)

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VA National ContractsVA National Contracts

• Best technology anywhere.

• Digital Hearing Aid Contract:─ ITE (60%) and BTE (40%) hearing aids─ Open ear digital BTE

• Other national contracts:─ Cochlear Implants─ Assistive listening devices─ FM wireless systems─ Special niche devices (e.g. CROS, BICROS, eyeglass hearing aids)

• DoD Centers use VA national contracts

• Contract-mandated training

• New digital hearing aid contract in November 2009

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FY2007 Hearing Aid StatisticsFY2007 Hearing Aid Statistics

• 348,920 hearing aids issued ─ Up 12% compared to FY06

• Net sales: $122,350,812 ─ Up 14% compared to FY06─ Average cost: $350.66

• 30 million hearing aid batteries issued ($3.9 million)• 279,246 repair services ($14 million)

─ November 2005-October 2007—704,970 issues, 13% repaired once, 3% repaired twice, and 1% repaired three times

• 1 of every 7 hearing aids sold in the U.S. is issued by VA

Source: DALC

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2007 Prosthetics and Sensory Aids 2007 Prosthetics and Sensory Aids Satisfaction Survey ReportSatisfaction Survey Report

• Paper self-report instrument with web-based response option• 90 multiple-choice questions• Data collection: September 19 to November 15, 2007• Sample--9,776 contacted, 7,148 responded. 73.1% response rate

• Veteran Health Service Standards─ Access─ Coordination─ Courtesy─ Device As Good As Anywhere─ Emotional Support─ Information/Education─ Overall Quality – Last 12 Months─ Overall Quality of Device─ Overall of Last Visit─ Preferences─ Wait 20 minutes or less to be seen

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Prosthetics Trending FY2003 vs. FY2007Hearing Aids

National

50

55

60

65

70

75

80

85

90

95

100

AXC

S

CO

RD

CTS

Y

DA

GA

A

EMO

T

INFO

OQ

12

OQ

D

OQ

V

PREF

WA

IT20

Scor

e FY2003FY2007

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Cochlear ImplantsCochlear Implants

• Increasing number of implant centers and programming sites

• 17 implant centers, 4 programming sites, and 4 DoDcenters

• 120 implants and 49 speech processors ordered in FY2007

• Net sales: $2.8 million

• Other surgical implants: BAHA®

Source: Denver Acquisition and Logistics Center

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PerformancePerformance——Access to CareAccess to Care

• Audiology is tracked on national performance measures and is accountable for meeting national performance goals. Goal: all veterans seen in 30 days.

• FY2007 Performance (June-August):Target—New=89%, Established=92%─ Waiting times: 85.5% of new patients and 98.1% of established patients were seen

within 30 days. ─ Average waits: 19.3 days (new patients) and 5.2 days (established patients)

• Missed opportunities--improving clinic utilization by reducing no shows and cancellations (August)

• Target-- 8%─ Missed opportunities: 7.3% ─ 12.% cancelled by patient and 0.8% cancelled by clinic after date/time of appt.─ No Show Rate—5.0%

• No show rate varies by clinic:─ Audiology clinic rate—6.9%─ HA Fitting clinic rate—2.2%─ Audiology C&P clinic rate—11.2%

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PERCENT APPOINTMENTS <31 DAYS (FY2007)

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23

NEW

EST

Percent Appointments Seen in <31 Days Percent Appointments Seen in <31 Days (FY2007 Performance)(FY2007 Performance)

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MI SSED OPPORT UNI T Y RAT E ( FY2007)

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

9.00%

10.00%

1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23

MISSOP RA

Missed Opportunities (FY2007)Missed Opportunities (FY2007)

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PerformancePerformance——Access to CareAccess to Care

• FY2008 Performance Goals:

─ Waiting Times (New Patients)=94%

─ OEF/OIF Waiting Times (New and Established)=95%

─ Missed opportunities target-- 7%

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PERCENT APPOINTMENTS <31 Days

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23

%Appts <31 Days

Percent New Appointments Seen in < 31 Percent New Appointments Seen in < 31 Days (January FY2008)Days (January FY2008)

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PERCENT OEF/OIF APPOINTMENTS <31 DAYS

0.00%

20.00%

40.00%

60.00%

80.00%

100.00%

120.00%

1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23

NEW

EST

Percent OEF/OIF Appointments Seen in <31 Percent OEF/OIF Appointments Seen in <31 Days (January FY2008)Days (January FY2008)

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MISSED OPPORTUNITY RATE

0.00%

2.00%

4.00%

6.00%

8.00%

10.00%

12.00%

1 2 3 4 5 6 7 8 9 10 11 12 15 16 17 18 19 20 21 22 23

MISSOP RATE

Missed Opportunities (January FY08)Missed Opportunities (January FY08)

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Professional EducationProfessional Education

• FY09 Traineeships:─ 51 Doctoral Audiology Externships (12 months)

awarded to 30 sites─ 56 Doctoral Audiology Clinical Rotations (350 hours)

awarded to 22 sites─ Geriatrics and ASP settings

• Competitive site selection using automated standards of excellence

• Training to full scope of practice• Inter-professional education

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Hybrid Title 38Hybrid Title 38

• Special, one-time boarding continues• 927 employees, 920 completed (99%)• Grade Distribution:

– GS-13 audiologists increased from 51 to 116 employees (2006-2008)

– GS-14 audiologists increased from 3 to 12 (2006-2008)• 210 employees received special advancement for

professional achievement (23%)

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Mentoring and Succession PlanningMentoring and Succession Planning

• Leading edge of the “Baby Boomers” is now reaching retirement age.

• In a 2007 report to the American College of Healthcare Executives, Dr. Kussman indicated that as much as 53% of the senior VHA leadership will retire between now and 2012.

• 38% of the individuals in leadership positions ASP programs are now eligible for retirement.

• 24 employees selected for mentoring program• 20 others participating in the program

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Improved Information TechnologyImproved Information Technology

• Audiometer Interface Project:– Survey of all equipment used in VA– Automated collection of audiometric data

• Patch released and implementation is in progress nationwide.

• Interfaces send audiometric data (pure tone thresholds and speech recognition scores) into a national database.

• Hearing loss national database (562,795 audiograms).

• Audiograms available in electronic health record and ROES.

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ProductivityProductivity

• Collaboration with Office of Productivity, Efficiency, and Staffing

• National report developed (with Rehab)– National roll-up of procedures – Cost analysis– Basis for national productivity and staffing models

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TinnitusTinnitus

• Second most common service-connected disability.

• Most common SC disability in OEF/OIF veterans.

• Significant association with brain injury, noise exposure, hearing loss, ear disease, and medications use.

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Tinnitus InitiativesTinnitus Initiatives

• National Center for Rehabilitative Auditory Research is investigating effectiveness of various tinnitus treatments.

• ASP Education Committee developing tinnitus clinical protocols and patient education materials.

• Meetings with tinnitus treatment companies to investigate efficacy and identify new opportunities for treatment and clinical research

• ASP clinics receiving training on special techniques (Tinnitus Retraining and NeuromonicsTinnitus Treatment)

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Strategic PlanStrategic Plan

I. Succession Planning

Implement Mentoring Program for new Service Chiefs, Service Line managers or individuals seeking Audiology & Speech Pathology Leadership positions.

Primary Goals:• Ensure future Leadership of Audiology/Speech Pathology Programs by participation in

a formal Mentoring program. Match Mentors and Mentees to establish a year long formal training relationship and long term opportunity for exchange of corporate knowledge.

• Evaluate the success of the program through a periodic formal assessment and modify for presentation in future years.

• Provide opportunity for upward mobility in conjunction with educational programs.• Update Audiology/Speech Pathology website to ensure content reflects the needs of

new Chiefs

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Strategic PlanStrategic Plan

II. Telehealth Opportunities

Investigate opportunities in which Audiologists & Speech Language Pathologists can make increasing use of Telehealth system to provide service to patients in remote settings or to patients with travel barriers.

Primary Goals:• Identify opportunities for diagnostic consultation or remote methods for testing of

hearing ability through a thorough review of relevant literature.• Assess current viability of a process for remote programming of hearing aids and or

cochlear implants.• Revitalize Telehealth Task Force to aid in expanded use of telehealth by speech

language pathologists• Review relevant technology for web based treatments such as CNS Vital Signs and

virtual radiology.

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Strategic PlanStrategic Plan

III. Evidence Based Measures

Acquire and evaluate outcome data in audiology and speech language pathology to assess, modify, and improve patient treatment.

Primary Goals:• Collaborate with the Denver Acquisition and Logistics Center (DALC) to

develop and implement an electronic version of the IOI-HA in the Remote Order Entry System (ROES) website.

• Work with DALC to have alternate outcome measures available for local site use, e.g. APHAB, HHIE and/or COSI.

• Develop data collection and report strategies in both ASP disciplines.

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Strategic PlanStrategic Plan

IV. OEF/OIF Polytrauma – Traumatic Brian Injury

Provide on-going training to assure that audiologists and speech-language pathologists identify veterans with TBI and provide appropriate intervention.

Primary Goals:• Promote excellence in treatment of veterans with polytrauma • Provide educational opportunities for understanding the effects of blast injuries to the auditory

system.• Via research efforts identify an appropriate audiological test battery for OEF/OIF patients to assess

complaints of tinnitus, word recognition and balance.• Development of patient education materials• Develop Team relationships including OT, Neuropsychology• Disseminate information regarding assessment instruments and treatment strategies through a

variety of modalities, including conference calls and shared web sites.• Approach DALC to include cognitive communication devices on contract• Promote research in Audiology & Speech Pathology to contribute to the evidence base for diagnosis

and treatment in TBI.

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Strategic PlanStrategic Plan

V. System Redesign

Continue to work with the system redesign program to promote best practice for timely patient access for services.

Primary Goals:• Test Productivity algorithm which was developed in FY 2007 as a

method to model; clinic staffing.• Provide specific assistance to sites that experience ongoing difficulty

in meeting national performance measures.• Develop and publish standards of practice for audiology heath

technicians.

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Blast Injuries and PolytraumaBlast Injuries and Polytrauma——The Role of The Role of the Audiologistthe Audiologist

Washington Post, Nov 04Washington Post, Nov 04

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Current Conflict DemographicsCurrent Conflict Demographics

• Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF)

• Longer time in combat than any other US military conflict

• 37% (299,585) of total separated OEF/OIF veterans have obtained VA health care since FY 2002

• 799,791 OEF/OIF veterans who have left active duty and become eligible for VA health care since FY 2002*─ 49% (391,094) Former Active Duty troops─ 51% (408,697) Reserve and National Guard

• 57,589 service connected for tinnitus (#1 disability)**• 46,761 service connected for hearing loss (#3 disability)

Source: Environmental Epidemiology Service, through November 26, 2007*VBA Office of Performance & Analysis (through May 2007)**

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Improvised Explosive DevicesImprovised Explosive Devices

• Currently, 68% of wounded in action caused by blast injuries and 28% to 31% of troops evacuated to Walter Reed Army Medical Center had brain injuries

• Signature injury of OIF/OEF is the mild Traumatic Brain Injury (mild TBI)

• Complex, polytrauma injuries (amputation, burn, fractures, pain) are adding to the challenge

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Blast Injuries: Auditory Blast Injuries: Auditory and Vestibular Symptomsand Vestibular Symptoms

Ear ache Aural fullness Tinnitus and hyperacusisDizziness and vertigoLoudness sensitivityDistorted hearingHearing impairmentCentral auditory processing disorders related to TBI

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Auditory Damage from BlastAuditory Damage from Blast

• Immediately following blast injury, patients may experience transient hearing loss and tinnitus.

• Hearing loss may be transient, lasting for hours─ Some may experience prolonged hearing loss. ─ In some patients, there is permanent damage, usually with symptoms of HFHL,

tinnitus, and hyperacusis.

• Inner ear damage following explosions results from combination of blast wave and the following impulse sound.

• Ear plugs appear to be protective.

• Central auditory regions can be injured by blast exposure. Auditory brain injuries are not fully understood.

• Complex association with cognitive, memory, and executive function disorders.

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Traumatic Brain Injury and PolytraumaTraumatic Brain Injury and Polytrauma

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Symptoms of TBISymptoms of TBI

DizzinessLoss of BalancePoor coordinationHeadachesNauseaVisual disturbanceLight sensitivityHearing difficultyNoise sensitivityBody/extremity numbnessAltered taste or smell

Appetite changePoor concentrationForgetfulnessDifficulty making decisionsSlowed thinkingFatigueInsomniaFeeling anxiousFeeling depressedEasily irritatedPoor frustration tolerance

Cicerone: J Head Tr Rehabil 1995;10(3):1-17

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Invisible Wounds

• Constellation of symptoms many of which have interdependence and are exhibited by subtle and confusing behaviors

• Invisible injuries include: ─ Mild TBI─ Hearing loss and tinnitus─ Vision loss and visual disturbances─ PTSD─ Pain─ Fatigue─ Cognitive impairment and processing disorders─ Memory loss─ Musculo-skeletal disorders

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Demographically DifferentDemographically Different

• Younger • Technologically savvy • Tastes and preferences• Family composition and dynamics• Employment and education

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Provision of Comprehensive Provision of Comprehensive Rehabilitation CareRehabilitation Care

Polytrauma Rehabilitation Center

Brain Injury Program

PainManagement

PTSDProgram

RehabilitationAnd

OrthopedicPrograms

Audiology Program

AmputeeProgram

Head Injuries

Pain

Emotional Shock

Soft Tissue Trauma

Amputations

HearingLoss

Blind Rehabilitation

Program

Vision Loss

Spinal Cord InjuryProgram

Cord injury

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The Role of AudiologistsThe Role of Audiologists

Blast InjuryPolytrauma

Program

TreatmentAnd

Management

ResourceAnd

Registry

AssessmentAnd

Diagnosis

PreventionAnd

Education

Audiology Case History, Assessment, Diagnosis, Communication Plan

Audiology Treatment & Management (Hearing Aids, Cochlear Implants, Aural Rehabilitation, Tinnitus Management)

Hearing Conservation TBI Assessment Tool

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Thanks for ListeningThanks for Listening

With malice toward none, with charity for all, with firmness in the right as God gives us to see the right, let us strive on to finish the work we are in, to bind up the nation's wounds, to care for him who shall have borne the battle and for his widow and his orphan, to do all which may achieve and cherish a just and lasting peace among ourselves and with all nations.

Abraham Lincoln, Second Inaugural Address, March 4, 1865