Editor: An organization called the Delmarva Foundation for Medical Care Inc recently led an effort to establish guidelines for health care standards for people with hearing loss. Here are the results of that effort. Please direct your comments and questions to Dr. David Boan at dboan@dfmc.org
Guidelines for Services to Deaf and HOH Adults as Modified by the Conference on Standards of Care for Deaf and HOH, March 31, 2000
A project of the Delmarva Foundation for Medical Care, Inc., Gallaudet University, and the Health Care Financing Administration.
Introduction
This document reflects the consensus of a set of standards, guidelines and recommendations proposed by a virtual panel of experts and revised by a second panel. These standards assume that there is a gap in the quality of care received by deaf and hard of hearing adults (Deaf /HOH) as compared to the general population. Further, that there is a crisis in health care services for Deaf/HOH that raises the issue of whether we as a society will guarantee that all Americans have a right to a minimum level of health care. The following guidelines and standards also assume that equity in the quality of health care is a civil right for all people. The following guidelines and standards are proposed as the conditions that must be met if a Deaf/HOH adult is to receive the same quality care as a patient who is free from hearing loss or impairment.
You will see that the standards and guidelines do not focus upon providers. They were proposed from one simple question: What conditions must exist to eliminate the gap in quality between Deaf/HOH and the general population.
Further, these are not all strictly standards. Some are standards and their inclusion here is expected to lead to further work to adopt them as regulations. Other statements are better seen as recommendations, program guidelines, and policy statements rather than standards of care. The goal was not to develop standards to address the gap in care, which is a more comprehensive goal.
Revised May 3, 2000
1. Equal Access
1.1 It is the responsibility of the provider and/or health care organization to insure that communication does not create a barrier to the equal access to services. This must include;
– assessing the communication needs and preferences of the Deaf/HOH patient and
– assurance that all systems of access in that setting can accommodate the patient’s communication needs.
1.2 Determination of communication needs must be done by individual assessment of the patient’s needs and preferences. While existing law allows for a variety of means to accomplish effective communication, the patient’s needs and preferences should be paramount in determining the most appropriate method.
1.3 Advocacy services are basic to insuring equal access to treatment and quality of service, and therefore special attention is needed to insure the needs of Deaf/Hard of Hearing adults are adequately addressed by the existing advocacy services that are available in a timely manner.
2. Identification:
2.1 Three dimensions need to be addressed in identifying the communication and access needs of Deaf/HOH adults:
functional hearing status and preference (does the patient rely on visual or auditory communication, or both),
language use (American Sign Language, English, Foreign Language, etc) and communication skills.
2.2 Standards and guidelines should address the needs of the following groups:
Hard of Hearing
Deaf
Late Deafened
Deaf and Blind
Hearing Children of Deaf Parents
Deaf and Minimal Language Skills
2.3 People should always be asked their preferred mode of communication. Check lists should be made available to standardize this process.
2.4 When developing regulations, guidelines, or any printed materials, the following terms should be avoided due to their negative connotation:
deaf-mute
deaf-mutism
deaf-dumb
hearing impaired
3. Education
3.1 Provider Education. Programs of education for providers should address at least the following issues and concepts:
– Providing an interpreter for Deaf/HOH patients is only appropriate when that is the language preference and communication preference of the patient.
– Use of an interpreter is not all that is needed to bridge the gap between medical professional and patient. Providers need to be aware of how hearing loss can potentially impact other communication skills.
– Providers should be familiar with the use of various modes of communication, including but not limited to the use of an interpreter, how to acquire their services, judging the quality of services, and the various types of services available.
– Hearing loss has multiple forms and etiologies, and communication styles and communication needs can be unique to the individual. Diverse, individualized strategies are necessary to achieve effective communication.
– The elderly have varying levels of hearing loss and are particularly susceptible to “hearing” information but not really registering all that has been said.
– Assistive devices do not restore full hearing. Effort must still be made to confirm communication and comprehension.
– Communication can be more demanding physically and emotionally for Deaf/HOH patients, making fatigue a factor in assessing and communicating with Deaf/HOH patients.
3.2 Professional organizations and licensing/certifying boards should give credit for CEUs to be earned for Deaf/Hard of Hearing health related studies.
3.3 Staff Education. Programs for educating staff members in health care settings should cover at least the following topics:
– Require training for staff on communication requirements and the resources available to meet these requirements.
– Make sure staff have access to the technical and information resources required for Deaf/Hard of Hearing patients.
– Make training in effective communication and Deaf/Hard of Hearing issues part of certification and licensing for auxiliary and support medical staff.
3.4 Consumer Education. Programs for educating consumers should include at least the following topics:
– Appropriate use of the primary care physician as an advocate and organizer of information from various specialties.
– Appropriate use of specialists for medical problems that are relevant to the specialty.
– How to provide a clear history of medical problems, symptoms, allergies, surgeries, medications being used and why each medication was prescribed.
– How to clearly express needs – this would include needs for adequate communication.
– Appropriate use of emergency services (ambulance, ER). This requires understanding of medical problems – what can wait for the regular MD and what needs immediate attention.
– Appropriate use of medications as prescribed.
– Knowledge of rights as a consumer.
– Increase education of consumers regarding health care system, assertiveness, and in general how to be an effective Deaf/HOH consumer.
3.5 Other Education
– Health education schools should include Deaf/Hard of Hearing related subjects in the curriculum.
– Increase public awareness of Deafness/Hard of Hearing as public health issues and cultural awareness issues.
– Health Care as a career option for Deaf/Hard of Hearing people should be promoted. Barriers to Deaf/Hard of Hearing entering into health careers should be identified and addressed.
4. Provider Guidelines
4.1 Hearing loss can complicate the communication process, making it necessary to allow additional time for assessment and treatment, including the verification of comprehension.
4.2 Systematically checking comprehension by questioning the patient is important with all patients, but more so with Deaf/Hard of Hearing patients due to the higher risk of poor comprehension.
4.3 Incorporate visual aids into the discussion. Use of visual aids is more important with people who are more visually oriented or have less experience with health care system.
4.4 Make communication accommodations as appropriate to the patients’ needs.
4.5 Patient communication needs should be clarified when an appointment is setup so any necessary preparations can be made in advance.
4.6 Family members should not be used to provide communication access.
4.7 Patients may not be aware of their hearing loss. Therefore, medical professionals should know the signs and symptoms of hearing loss and take the initiative to assess the patient’s hearing.
4.8 Medication side effects that impact hearing (ototoxic) will be especially significant to HOH patients and should be carefully considered with the patient before prescribing such medications.
4.9 In assessing the patient, note the following:
– The patient’s self-identification;
– The medical description of the patient’s condition;
– The preferred method for getting information to the patient;
– The preferred method for getting information from the patient.
5. Interpreting Guidelines
5.1 Modify billing procedures, including the creation of an interpreting CPT code, to allow billing of a third party for interpreters’ services.
5.2 Patients have a choice of using a professional interpreter or an alternative, including a friend or family member or technology. Providers should advise the patient if they believe the patient’s choice as not in the patient’s best interest. Patients will not be required to use services against their wishes.
5.3 Patients should sign a release whenever they surrender a right to communication assistance or services.
5.4 Communication services are not only for the patient. Providers may also require interpreting or other assistive services and should negotiate the best solution with the patient, where possible. In some cases a provider may elect to obtain interpreting services apart from the patient’s need.
6. Facility Guidelines
6.1 Hospitals and especially Emergency Rooms need to have interpreting services available on short notice.
6.2 Hospitals need to provide more extensive accommodations for full communication than would be necessary in an outpatient office. Some examples of accommodations should be:
* The ability to interact with the nursing station from the hospital room,
* Closed caption TV,
* Clear labeling of needs on the chart and other places to ensure continuity of care as a result of staff changes, etc.
6.3 Information on communication rights and responsibilities should be posted prominently for both staff and consumers.
6.4 Standardized notation should be used to identify Deaf/Hard of Hearing patients on charts and in conspicuous areas around the patient, with the patient’s permission.
6.5 Larger facilities, especially with an ongoing census of Deaf/HOH patients, should have an office for Deaf/Hard of Hearing services.
6.6 Settings with exceptional communication needs may include hospice and mental health facilities. Special skills may be needed from an interpreter or additional or more stringent guidelines for staff and providers regarding the unique features of these settings. (For example, the recommendation to avoid use of a family member as an interpreter is especially important in a mental health setting where the family member could also become the subject of treatment.)
6.7 Facilitating communication and reducing isolation is especially important in programs where communication is part of the milieu, such as mental health and hospice.
6.8 Special interpreting skills may be necessary in specialized settings. Facilities should ensure that interpreters have the skills required for their setting and type of service.
6.9 When a Managed Care Organization reaches a certain size or if the population it serves carries a certain percent of Deaf/HOH persons, they should develop and implement a plan to meet the communication, education and access needs of these patients. System wide interpreting services could be deployed for in-office appointments, in-servicing staff across their provider network. They would have TTY’s available that would be placed in provider offices, etc. Rather than burdening the patient or doctor, it would become a responsibility of the MCO or provider network.
7. Miscellaneous
7.1 Support research into the use of alternative technology for communication, such as voice recognition, Video Remote Interpreting, and Remote CART.
7.2 A system needs to be created, perhaps through State Licensing Boards, through which information on rights and obligations related to Deaf/Hard of Hearing, ADA, and related communication issues can be disseminated to providers.
7.3 Affirmative Action should address opportunities for Deaf/Hard of Hearing.
7.4 Hearing aides are essential to the quality of life and quality of health for hard of hearing people of all ages. HCFA should undertake to determine the feasibility of covering the services of audiologists and hearing devices under Medicare and Medicaid.
7.5 HCFA should explore the impact of designating Deafness/HOH as a complicating condition and allowing additional compensation when additional time is required to provide services.
