Lacking insurance coverage for the purchase of hearing aids, individuals may seek the assistance of a Vocational Rehabilitation program. Audiologists, likewise, may refer patients to a vocational rehabilitation program for funding of hearing aids and other accommodations. Audiologists who are able to articulate the impact of hearing loss in the workplace for a specific worker, will facilitate eligibility determination and the rehabilitation process, resulting in improved patient outcomes.
What is Vocational Rehabilitation?
Vocational Rehabilitation (VR) is a program designed to assist people with disabilities, illnesses, or injuries, in acquiring and or maintaining suitable employment. VR services are funded by federal and private sources, and are provided either through state administered programs, Indian tribes, workers' compensation programs or private insurance (i.e. auto insurance). Because many of these programs are mandated by federal and/or state law, there are specific parameters to which programs must comply. Within these parameters, each program may have its own unique policies, protocols and eligibility requirements. Because of these variables, the audiologist is urged to check with the VR office administering the program for the most up-to-date and accurate information.
The Department of Veterans Affairs (VA) also administers the "Vocational Rehabilitation and Employment Service" for veterans with service-connected disabilities and for those recently separated from active duty. The VA also offers special rehabilitation services for dependents of veterans who meet eligibility requirements (see website address in references).
Eligibility & Vocational Needs Assessment
As the name implies, an Eligibility Assessment determines whether an individual meets the program eligibility criteria. A Vocational Needs Assessment, which may be conducted concurrently by the VR counselor, determines the goals, nature and scope of rehabilitation services to be included in the individual's plan for employment.
To assist the counselor in conducting the Eligibility and Vocational Needs Assessments for a person with hearing loss, the audiologist should submit the usual hearing evaluation detailing the type and degree of hearing loss. In addition, the audiologist's report should specify the vocational impact of the hearing loss, including the client's specific, job-related, communication needs. Most important, the audiologist should detail recommendations for accommodating the hearing loss to meet the vocational needs of the individual.
These detailed recommendations from the audiologist are important because people with hearing loss are rarely able to articulate the exact nature and extent of their on-the-job communication difficulties. Further, not all VR counselors are savvy to the vocational implications of hearing loss. Therefore, it is important that the audiologist effectively communicate to the VR counselor the impact of hearing loss on the worker, including suggestions and recommendations regarding management of these hearing loss related difficulties in the job situation.
The following are some questions and observations that audiologists might address when corresponding with counselors on the specific needs of clients who are hard of hearing. Keep in mind that VR decisions must always be based on vocational necessity
Examples of Vocational Considerations
What type of communication is required of you on the job on a daily basis? Are you occasionally required to attend meetings or conferences where important information is presented? Does the type of work you do require communication while driving, using the telephone, working outside, or while doing other activities?
All levels of hearing loss can produce communication problems. The level of hearing loss, by itself, may not be a sufficient criterion for evaluating eligibility for services, effects on communication, job selection, and job performance. Hearing loss must always be evaluated in terms of the communication requirements of the job, and the communication needs of the individual. All communication requirements should be considered, including face-to-face conversations, telephone usage, monthly staff meetings, infrequent training sessions, and informal sources of information, e.g., chatting around the coffee pot.
Hearing ability is affected by a number of variables in work settings. For example, if telephone use is part on the employee's responsibilities, special telephone equipment may be considered. FM systems and hearing aids are extremely useful for one-on-one communication situations. Environmental accommodations such as good lighting, noise-absorbing wall, floor and ceiling coverings, and reducing background noise, are essential for employees who are hard of hearing. For frequent group meetings, FM, sound-field systems and directional hearing aids offer significant benefits.
How dependent, skilled, and comfortable are you with speech reading? Does your work environment facilitate or hamper speech reading? Must you communicate while engaged in other activities that interfere with speech reading? Would training to improve speech-reading skills be helpful?
Hearing is often supplemented by visual information such as facial expressions, speech reading, context, and visual aids.
Speech reading (or lip reading) may be an important adjunctive tool for some workers with hearing loss. Keep in mind that even a highly skilled speech reader, under ideal conditions, may only be able to see 30 to 40 percent of spoken content. This is because many speech sounds appear identical on the lips and mouth, or are not visable. Carrying on conversation while walking, driving, or otherwise moving about in space reduces the ability to see the speaker's face and further impairs speech reading comprehension. Speech reading classes or individual speech reading training is advised for many people who are hard of hearing.
If ambient light in the work place is too bright or too dim, eye fatigue may make it difficult to sustain the necessary visual attention to understand speech. Changing the ambient light in the work area can be a significant accommodation.
If the VR candidates' vision is poor, resulting in low ability to see the speaker's face, there may be problems in understanding speech. Therefore, a comprehensive eye exam is recommended for persons with significant hearing loss.
Is the voice quality of the candidate an issue? Does the VR candidate appropriately modulate voice volume when speaking? Is his or her speech clear and easy to understand?
Depending on the age of onset and the severity of the hearing loss, speech may be distorted and difficult for others to understand. The person who is hard of hearing may, depending on the type of hearing loss, talk too loudly or too softly. People tend to match the voice volume of whoever is speaking. If the VR candidate speaks softly, others may lower their voice in response producing additional problems in understanding speech. If, on the other hand, the individual with hearing loss speaks loudly and/or is difficult to understand, co-workers may avoid him or her. In either case, VR candidates may need speech therapy to learn to adjust the volume level of their voice or to speak more intelligibly. Hearing aids or personal amplifiers often allow people to better hear and modulate their voice volume levels.
Balance and Vertigo:
Does the client have balance problems or vertigo? If so, does it affect his or her mobility? Does the job require standing or otherwise maintaining balance? Does the job require being in high places or working in the dark or other difficult or dangerous locations?
Hearing loss due to Meniere's Disease, endolymphatic hydrops and other inner ear conditions may significantly impact the worker's balance and sense of proprioception. People with inner ear based hearing loss may also have difficulty with balance in the dark, or non-ideally lighted rooms and work areas. If these conditions exist and are related to job requirements, the VR counselor should be informed.
Does the VR candidate respond appropriately when asked open-ended questions? Is there possibly a cognitive or Auditory Processing Disorder (APD) involved?
People who are hard of hearing often need additional time to integrate and retain spoken information. Increased time and energy is often required to ensure accurate understanding. It may be easier to understand when others speak slowly. Rapid speech is more often misunderstood because the hard of hearing person, while checking or verifying what has just been said, may miss the next spoken utterance. Further, the person with hearing loss may invest so much energy in comprehending a specific word that the overall meaning of the sentence is missed. These difficulties can be "figure-ground" or "speech-in-noise" issues, and if they are apparent, are worthy of investigation. Additional factors may play a role in cognitive and auditory processing disorders. If problems are suspected, consider appropriate evaluations such as an APD evaluation by an audiologist, a cognitive evaluation by a psychologist, or, perhaps a speech-language evaluation by a speech-language pathologist.
Hearing Technology Maintenance and Usage:
If the VR candidate already has a hearing aid(s), is he or she comfortable changing batteries, using a "dry aid" kit, and caring for and cleaning the hearing aid(s)? Does he or she have a T—coil on the hearing aid(s) and know how to use it? Is this individual capable of handling hearing aids, FM systems, or other technology independently?
Does he or she have the ability to properly use an assistive listening system, and/or alerting devices, and to trouble-shoot and adjust equipment when inevitable problems arise?
Hearing technology use, care, and maintenance is essential to successful rehabilitation. If this ability is not ensured and equipment problems arise, the tendency is to stop using the devices. Local chapters of Self Help for Hard of Hearing People (SHHH), or individual members of SHHH, the audiologist and staff are all possible resources for people who need coaching with hearing aids and assistive hearing technology. Clients with hearing loss may benefit from hands-on training with a variety of assistive devices.
Does the person bring someone else to the appointment? How much does he or she rely on this person for clarification or to answer questions?
Some people who are hard of hearing have become dependent upon family, friends, and/or coworkers, for clarifying spoken information. This can be a burden on others, who then become resentful, causing relationships to suffer. Dependence on coworkers, such as asking a fellow worker to provide information that was missed during a meeting, can be a cause of friction at work. Conversely, learning to be appropriately assertive regarding hearing needs will significantly improve independence in the workplace. Support groups and professional counseling may be beneficial. Counseling aimed at acceptance of hearing loss and its effects, coupled with training in managing hearing loss, are often necessary to overcome these issues.
Does the VR candidate interact appropriately with friends and colleagues?
The employee who is hard of hearing may respond appropriately when someone talks to him or her, but may be reluctant to initiate conversations. This can be taken as a sign of unfriendliness, lack of initiative, low motivation or psychological problems. Others with hearing loss may talk too much in an effort to control the conversation and their understanding. Some people who are hard of hearing have difficulty establishing and maintaining relationships. Frequently asking, "Huh?" or "What?" will not endear oneself to others. Pretending to understand what is being said is problematic in establishing and maintaining relationships at home or work. Blaming others for not speaking clearly can further interfere with relationships.
Coworkers may tend to avoid the person who is hard of hearing because of communication difficulties. Supervisors may give unsatisfactory evaluations and not recommend promotions or salary increases. Sometimes, people who are hard of hearing leave jobs they are competent to perform because of a negative interpersonal climate. In some cases, they may have inadvertently created the problems themselves. In any case, it is important that these problems be identified and addressed.
A Note about Hearing Instrument Recommendations:
Most VR programs are mandated to seek the least cost service for clients. Counselors must document rational for higher cost purchases. Therefore, it is essential that audiologists articulate the rationale for a specific hearing aid recommendation, options, and services. Taking the time to explain the benefits and purpose of digital circuitry, directional microphones, and other features will save time and money, and best serve the patient. Again, state the benefits in terms of the individual's work requirements.
Several years ago, we reviewed the summary of case-closure data from vocational rehabilitation offices around the United States. Several facts of importance appeared in that data.
- Clients who were hard of hearing were older. The average age of clients who were hard of hearing was about 45, whereas the average age for all other clients was about 30 years old.
- Most clients who were hard of hearing already had jobs they wanted to maintain.
- The average cost of providing services to the clients who were hard of hearing was $1,200, about the cost of a hearing evaluation and hearing aid(s) at that time.
- The clients who were hard of hearing were seen once or twice on average, which indicated an initial interview, prescription for a hearing evaluation, and, perhaps, a follow-up visit.
This review concluded that the VR service most often provided for clients who are hard of hearing is the provision of hearing aids. However, clients who are hard of hearing will often need additional support in order to function to their potential on the job. Many people who are hard of hearing underachieve in the workplace because they are unaware of strategies and equipment that can enable them to function at a higher level. Comprehensive rehabilitation services can play an important role in combating underemployment for people with hearing loss. The audiologist is in an ideal position to recommend and advocate for these additional services.
The audiologist can perform a valuable service for the VR client by providing a comprehensive audiometric evaluation and an in-depth needs assessment. The latter should be based on a personal interview, focusing on some or all of the questions presented in this article and any others as deemed appropriate for the given situation. A clear and informative report, including specific recommendations for suggested services and accommodations, will result in better services for the VR client, additional VR referrals, and also satisfied employers. Providing comprehensive reports and a range of services will ultimately benefit the professional community.
Rehabilitation Services Administration
Vocational Rehabilitation State Offices
Veterans Administration Vocational Rehabilitation and Employment Service http://www.vba.va.gov/bln/vre/index.htm
Sam Trychin, Ph.D., is the former director of training at the Rehabilitation Research and Training Center for Persons Who are Hard of Hearing or Late-Deafened, California School of Professional Psychology. Currently teaching at Penn State-Erie, Dr. Trychin is a licensed psychologist who developed the renowned Living with Hearing Loss program, which includes a series of videotapes and guidebooks. He lives in Erie, Pennsylvania, with his wife, Janet Trychin, Au.D., who co-presents the Living with Hearing Loss workshops with Sam. Dr. Trychin welcomes your comments and can be reached at ,a href='mailto:firstname.lastname@example.org'>email@example.com. Additional information, books, and videos related to hearing loss are on Dr. Trychin's web site at: www.trychin.com.
Julie Eckhardt, MA, LPC has worked for Michigan's VR program as both a rehabilitation counselor and consultant. She currently serves the state VR program as a consultant on Deaf and Hard of Hearing Services. Ms. Eckhardt also conducts training and writes for organizations and individuals seeking to improve services to people who are deaf and hard of hearing. She is editor of the E-Michigan Deaf and Hard of Hearing People website at www.michdhh.org. Ms. Eckhardt may be reached at: firstname.lastname@example.org.