Adult Aural Rehabilitation: Indications and Assessment

Editor’s note: This text-based course is a transcript of the webinar, Adult Aural Rehabilitation: Indications and Assessment, presented by Lindsay Zombek, MS, CCC-SLP, LSLS Cert AVT.

Learning Outcomes

After this course, participants will be able to:

• List at least one indication for aural rehabilitation for adults who have received cochlear implantation.
• Describe at least one typical challenge or area of concern for an adult with a cochlear implant.
• List 1-2 skills that are tested during an aural rehabilitation assessment.

What is Adult Aural Rehabilitation?

This particular definition is from the American Speech-Language-Hearing Association: "If you are an adult, aural/audiologic rehabilitation services will focus on adjusting to your hearing loss, making the best use of your hearing aids, exploring assistive devices that might help, managing conversations, and taking charge of your communication." 

I like this definition as it captures a lot of different information and features about aural rehabilitation. In addition to just training specific sounds, we're going to be working on adjusting to a hearing loss. We will ensure the person is making the best use of their hearing aids or cochlear implants, and explore the types of assistive listening devices that might be available. In addition, we will help the person to manage conversations in general, and most importantly, to take charge of communication. Adult aural rehabilitation includes empowering people to be able to make the best possible listening environment and to promote their best possible communication. It is professional interactive processes that actively involve the client with hearing loss. In general, we're trying to limit the negative effects of hearing loss and teach ways of compensating for a hearing loss to facilitate a sense of wellbeing, and to improve quality of life. 

Aural rehabilitation encompasses many different areas, including counseling, auditory training, communication skills training, environmental modification, technology training, and more. 

Counseling is a major component of aural rehabilitation. We can counsel the person and their communication partner regarding many different topics. Auditory training refers to training on specific listening skills. Communication skills training is teaching the client on how to set themselves up to have the best possible communication experience. And then when things don't work as intended, working on what they can do to make the situation better and repair what had happened. Technology training encompasses what technology is available to use with amplification, and even how to use their amplification to the best of their ability and to get the most out of it. Some people with hearing loss may not be familiar with or comfortable using all the features and accessories that are available with their amplification.

That's just a fraction of what we can do in aural rehabilitation. Aural rehabilitation meets the needs of a particular person, and each person's session or plan of care can look completely different from anyone else's. 

It's important to know when to refer to audiology, otolaryngology (ENT), or other professionals. If there are technology or device concerns such as repairs needed, decreased performance over time, or concerns with an individual's hearing status, a referral to audiology is indicated.  If there are medical concerns, referral to ENT or a physician is indicated. 

With a person who uses a cochlear implant (CI) and reports facial nerve stimulation, such as twitching around the eye area on the side of the CI in response to sound, you would refer that to the ENT and/or audiologist. If there is redness on the skin around the magnet or surgical site, that would indicate a referral to the ENT. Audiologists may be able to address issues by reprogramming the CI.  They can also try different magnet sizes if there is an irritation issue. So when we refer we want to be sure to loop in the appropriate professionals.

Evidence for Aural Rehabilitation

We need to provide gold-standard care and follow evidence-based practice, so let's consider the evidence on whether or not aural rehabilitation is effective for adults. There are a lot of studies on aural rehabilitation, but you won't find one that just states that "aural rehabilitation works".  What we do have, however, is that various target areas that fall within aural rehabilitation are effective. Aural rehabilitation is diverse and covers many different areas. Most of the research focuses on individual target areas, and there is ample evidence to suggest that people can make great progress with aural rehabilitation.

Not everything that we do in aural rehabilitation has been measured in the research yet. There are a lot of opportunities for good research projects in this area. Also, some of the areas can be very hard to measure, such as counseling. Just because we don't have a study that specifically says that aural rehabilitation works doesn't mean it's not effective. There is plenty of research that indicates that therapy for specific target areas is effective.

Sweetow and Palmer (2005) did a systematic review of auditory training in adults and concluded that aural rehabilitation should contain synthetic training (practice with meaning). We want functional practice that relates to people's worlds; we don't just want to do drill work although there is a place for drill work, such as therapy that focuses on specific sound elements. Research shows that aural rehabilitation that contains more synthetic training ends up having better outcomes and is more effective.

When people have hearing aids they do not typically have trouble identifying environmental sounds around them, although this is often a challenge for people when they first get a CI. There is research that shows an improvement in identifying environmental sounds by 15.8 percentage points after aural rehabilitation with computer programs targeting this skill (Shafiro, Sheft, Kuvadiya, & Gygi, 2015). Research shows sentence recognition can be positively impacted by aural rehabilitation (Bernstein, Bakke, Mazevski, et al., 2012). In this study, speech tracking exercises helped people with sentence recognition by increasing their performance 15 to 20%. Zeh & Bauman (2015) showed that people are able to recognize consonants and vowels better after aural rehabilitation; they reported people had 20 percentage points higher than baseline when they formally worked on this in an aural rehabilitation program. Some adults with hearing loss may be interested in working on their articulation, although this isn't what we see in the majority of adults coming in for aural rehabilitation, and there is research to show efficacy. Production of individual speech sounds with aural rehabilitation can increase between 12.7 percentage points to 83.3 percentage points, which is a vast improvement (Pomaville & Kladopoulos, 2013).

There is plenty of evidence that people who use cochlear implants can get better with music appreciation when it is specifically targeted in aural rehabilitation. Many aspects of music can be improved through aural rehabilitation: melody recognition, timbre identification (the "voice" of the instrument, which tells us what instrument we're listening to), sound quality, pitch recognition, comprehension of lyrics, and general music enjoyment. One study to note in this area is by Gfeller, Guthe, Driscoll, & Brown, 2015 and there are others listed in the handout.

We also know that people can do better communicating on a telephone if they receive specific training through aural rehabilitation. Both land line and cell phones filter pitches; they have a narrow frequency response so speech is filtered when it is transmitted over the phone. It can be especially challenging for people with hearing loss to hear and understand what is being said over the telephone. People who practice listening to either unfiltered speech or filtered speech over a telephone reported significant benefit from training. A study by Ihler and colleagues (2017) showed that people understood both words and sentences better on the phone after training. There is evidence that working on telephone skills in aural rehabilitation can make a big difference for people with hearing loss.

In summary, there is a lot of research out there showing that much of what we do in aural rehabilitation is beneficial, and evidence that these areas can improve when we target them. Please refer to the Reference list in your handout for the full citations for the studies mentioned and refer to them for more information.

Indications for Aural Rehabilitation

Aural rehabilitation for adults hasn't always been the first referral for adults with hearing aids or with cochlear implants. It was often people who had had their amplification for a long period of time, who were continuing to be unhappy with the outcomes, or had continued areas of concern, that would be sent for aural rehabilitation. For example, someone would get a cochlear implant and they would not be happy. The audiologist might make some programming changes, mapping changes, and the person would return in three months and was still unhappy. After more adjustments to the technology, if the person was still unhappy, then they would be referred for aural rehabilitation. It may have been six months or a year, or even longer that they had been frustrated; there's no reason to wait that long. If you do have someone who's unhappy with outcomes with amplification, then we certainly can refer for aural rehabilitation, but there's also the opportunity for other people with hearing loss to benefit. Aural rehabilitation can be considered for someone who is visiting audiology frequently and needs constant reteaching, for those who have trouble using their amplification, for those who need help with assistant listening devices, and for people who just aren't hearing as well as they could be. It's important to remember that just because someone owns a piece of technology or amplification, even when it is physically attached to their person, it doesn't necessarily mean it's functioning optimally.

I advocate for anyone who's receiving new amplification or new technology to be considered for aural rehabilitation. We can always look for opportunities to maximize their outcomes and maximize the benefit they're receiving through their technology.

Common Concerns of Adults with Hearing Loss

Common concerns of adults with hearing loss are listed in Figure 1.

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Figure 1. Common concerns of adults with hearing loss to help determine when aural rehabilitation may be indicated. 

These concerns are great indicators of people who should be coming in for aural rehabilitation, and those who have the opportunity to benefit from aural rehabilitation. In addition to communication challenges, people with cochlear implants may be concerned with how music sounds to them. People may be concerned about using their amplification or using the telephone.  You do hear some concerns from people about their job security. such as, "I don't want to get fired." People in school may be concerned with failing or having academic challenges.  And, people with hearing loss might not know some of their rights.

I hear a lot of concerns about how partners talk with them. For example, "I'm trying to have a conversation, but somebody always starts the conversation from the other room, and I can't hear what they're saying, and then they get mad at me." I also hear a lot of, "I wish I could hear the minister or pastor or priest at church," and, "When I'm in meetings, I can never hear what the presenter is saying." These concerns can come from adults who are doing really well by audiology standards. Even those who are deemed "successful" with hearing aids or with cochlear implants can still have these concerns as success is often defined by aided test results in audiology.  People can have very good aided speech perception testing and aided threshold testing results, but still have trouble in functional environments. The list of common concerns can help you determine if there is something else you can work on to make listening easier for an individual.  

I categorize the common concerns into four themes: comprehension, technology, advocacy, and communication promotion + repair.  Comprehension obviously refers to being able to understand conversations. Advocacy refers to the person knowing their rights and knowing how to make sure that there is a level playing field at work and in school environments. Technology refers to knowing the technology available for the individual's hearing loss and how to use it. Communication promotion and repair refers to being able to set up the best possible communication situation and then repair it if it doesn't go well.

Areas to Assess

It's important to note that today we don't have formal standardized tests for each of the different areas that we can look at in aural rehabilitation. The very nature of aural rehabilitation and the fact that it's so diverse in what we cover requires the use of additional informal assessment. We may end up piecing together information from many different sources and doing thorough interviews to create the best possible plan of care that will have the biggest impact for an individual.

Some areas to assess for general adult aural rehabilitation are: Case History, Subjective Perception of Performance, Auditory Skills, Specialty Areas of Concern, and Technology Knowledge and Use.

Case History

I encourage you to look at your case history as it exists now and determine if it is asking the right questions about hearing. Many of our standard forms ask great questions about swallowing, reflux, cognition and memory, but they don't always ask a lot of good, specific questions about hearing. Additionally, it's important to think about whether we are asking the right questions. Are you asking questions that will provide you with the types of information you need for a thorough plan of care? Figure 2 shows an example of the written form that I use for collecting information when someone comes in for aural rehabilitation. I collect a lot of information about how they are hearing (Figure 2).

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Figure 2. Questions to ask during case history for adult aural rehabilitation. (This is small so I would see if she would give it to you as a PDF handout)

The questions I ask include: How long have they had their hearing loss? Is it something that's been since birth? Did it happen very suddenly for them, or is it something that happened over time? I want to know approximately when it started. Is this somebody who has had a hearing loss for a month, or is this somebody who has had a hearing loss for 60 years?

The type of hearing loss and the duration of the hearing loss might impact outcomes, so that's information to obtain. I try to gather information about what types of amplification they're using. If they're using some form of hearing aid, cochlear implant, I want to know when they received it and how often they wear it. It's very telling if they tell you that they're not wearing it very often; that in itself indicates some problems and gives you an opportunity for some counseling to dig deeper in to why they're not wearing it.

I also like to get information on how much talking is required in the person's daily routine. Some of our adults are going to need to talk all day long. Other adults might not really have any communication partners and might not spend a lot of time talking. Not that we don't want to help people who aren't talking as much at home, but it's important to know what type of talking the person is doing. Are they on the phone all day? Is it face to face communication? What are their communication needs?

I then ask a lot of questions about how they're hearing functionally, such as "Are you having difficulty hearing sounds around you? When you hear sounds around you, do you know what they are?" I ask if they can determine what directions sounds come from, if they're able to understand what other people are saying by listening alone, or whether they have to read lips. I question if they are using the phone and feel confident using the phone, and whether they are able to understand when it's noisy. I ask questions about music. I also ask if there are any additional audiology concerns, like tinnitus or balance issues.

What are their personal goals? I want to have a statement in their own words of what they're hoping to achieve and what they want to see happen. When I get to my followup questions, I will ask them about what kinds of things they're able to hear. I don't necessarily ask this for people with hearing aids as much as with cochlear implants. Sometimes this is a really good starting place for people who get a cochlear implant, for them to notice that they are hearing some things. People tend to be very excited if they're hearing a sound that they haven't heard in a long time. It also gives me information about the types of sounds they do hear, and whether or not they're able to identify the sound.

I also want to know if there's anything that's hard to hear. People can usually identify some situation that's challenging for hearing, whether it's hearing the cashier at the grocery store, or hearing in a restaurant. It's important to find the situations that they're feeling like they're struggling in. I ask about where they need to listen during their week. That gives good information for determining later on if there are assistive listening devices that might help, or auditory skills that we need to build. If they have an accessory or assistive listening device, I ask them if they've used it yet and try to get some information about whether or not they feel it's working. I'll ask about using the phone and how phone calls go. And then I might ask about specific situations, especially if they're not reporting that anything is challenging to hear. For example, "If you're in a noisy place like a restaurant, how do you do with communicaton?"

We also spend a lot of time talking about their goals. What would make them feel successful with the amplification? This is important because aural rehabilitation is an investment for adults - there's a cost factor, a time factor, often a travel factor, and a motivational factor. There's the whole concept of having to be open and honest and admit to your deficits, which is challenging for a lot of adults. These are all resources that people have to use to participate in aural rehab so we want it to be worth their while. If we understand their goals and can show them how the plan we're developing together is going to help them achieve these goals, it's more likely they will feel invested and willing to participate in the therapy process.

Subjective Personal Assessment

We know that listening in a sound booth doesn't give us the whole story about how people are hearing. It doesn't tell us functionally how they are doing in their everyday activities. There are many different ways that you can get someone's personal impression of how they're functioning.

TELEGRAM. One of the most common measures used is the Hearing Handicap Inventory Screening Questionnaire for Adults, also referred to as the HHIA. It has a series of questions that ask about hearing in certain situations such as movies, restaurants, TV.  The person can indicate how frequently they experience a certain situation, and can rate whether they have difficulty in those situations. In my place of employment, our audiologists administer that so I have that information on most of the adults I see for therapy. I like to supplement that with the TELEGRAM, which is another subjective personal assessment. The acronym TELEGRAM stands for: telephone, employment, legislation, entertainment, groups, recreation, alarms, and members of the family.  I like this because it is comprehensive and takes into account many topics, and people can rate the level of difficulty with those topics. There is also a series of questions you can ask to prompt each individual area to get more information. It gives a functional, big picture perspective in a lot of different areas that we might want to work on in aural rehabilitation. The TELEGRAM was developed by Linda Thibodeaux at the University of Texas at Dallas (UTD) and can be found at the UTD Hearing Health Lab website.

Auditory Skills

After conducting subjective measure, I move on to auditory skills: suprasegmental features, open set comprehension, vowel and consonant identification, and listening in noise. I want to see how people are listening with their amplification, so I can develop an appropriate home program and a plan of care that isn't too easy or too challenging, but at the right level to address their needs. 

Suprasegmental features. The first thing I look at is duration, intensity, and pitch. These are areas that are most likely to be troublesome for recipients of cochlear implants as well as people who have had longterm hearing loss but little or no amplification. It isn't as common a challenge for someone who has spent most of their life hearing well and who now use hearing aids.

I spend the most time looking at duration, so I'm looking at the length of a sound, a word, a phrase, sentence, or paragraph. Duration is very important and has a lot of implications. Duration plays a role into our identification of consonants, because we know the length of a vowel sound. Following a consonant, for example, the duration will be longer or shorter depending on whether that consonant is a voiced or voiceless consonant. Duration also helps us to follow sentences and paragraphs. It also provides a lot of pragmatic information in terms of pauses and length of sounds in conversations. Duration does not, on its own, provide comprehension, but as we apply it there are a lot of implications for understanding. This is a foundational skill, so we need to develop and make sure that the person has the ability to identify duration before we build their additional skills. It is one of the earliest skills that emerges developmentally, and it's one of the earliest skills we develop when we start listening in a different way, like through a cochlear implant.

To assess duration, I like to use the Pre-Feature Identification Contrasts, or PREFICS. It looks at the ability to detect sound. It looks at the ability to identify something long, like the sound "aaah", versus something short, like "ouch". It looks at the ability to identify a continuous sound, like "aah", versus a broken sound, "ah, ah, ah". It looks at the ability to identify words of varying syllable length, and at words with the same number of syllables.

I also look at phrase and sentence length. When provided with a carrier phrase, is someone able to pick the ending from a closed set when each ending choice has a different number of syllables? For example, if the carrier phrase is "I went," some options could be "shopping," "to the movies," or "to the football game on Friday." Each one of those has a different number of syllables. In theory, you should be able to figure out which of those choices was said based only on the number of syllables. So if I said, "I went hmm, hmm, hmm hmm" you would be able to guess "to the movies," even if you didn't hear those exact sounds and comprehend it. A similar activity would assess sentence length based on duration using closed sets. Given four sentences that have different lengths, which sentence was said? and the person has to pick the sentence. The Cochlear Corporation Rehabilitation Manual and Screen has a section on this that I think is pretty easy to administer, and does a nice job with checking this area.

Open set comprehension. I also assess comprehension of phrases and sentences without written/visual materials. For this, I use the Common Phrases Test. In this test, a phrase is presented auditory-only, and the participant repeats the phrase that they heard. It has multiple lists, each one consisting of 10 sentences. You can use similar types of sentences across multiple sessions or in a test-retest situation. I like to do some listening and noise testing with this, and it gives me extra lists for that. It is a good resource to find out a person's ability to understand phrases and sentences without context. Also, in conversation, you can see how people follow directions, follow a paragraph, and follow the conversation, especially if you do something to interfere with their ability to read your lips. 

Vowel and consonant identification. Vowel and consonant identification impact comprehension of words. If we hear a word incorrectly, it impacts our ability to use contextual cues to figure out what's being discussed. Adults often struggle when they come into a conversation and don't necessarily know what the topic is and they're trying to figure out quickly what people are discussing. They might pick up on one word, "cable" for example, and they jump into the conversation by discussing how they discontinued cable service in their household and moved to streaming. They get funny looks from the group because they're completely off topic and nobody knows what they're talking about. Maybe the word was actually "table", and they were talking about a new table that had been purchased for a dining room. When you have the wrong words, you tend to get the wrong context, and it leads to what many adults have reported to be very embarrassing situations. The perception is that maybe they weren't really listening or that they were pragmatically inappropriate, and jumping to an unrelated topic. I like to assess vowel and consonant identification using minimal pairs testing to help identify patterns, to see whether someone is hearing vowel place, vowel height, consonant manner, consonant voicing, and consonant place of articulation.

Oftentimes, especially when someone has a cochlear implant, you can see that they're missing an entire target area, or they're not hearing one of these features. In that case, there is an entire class of consonants or vowels that they're not necessarily hearing correctly. My go-to assessment is the Minimal Pairs Test. The test involves giving two pictures of minimal pair words, and the participant is asked to tell you which word you said. The words are selected because they're very similar - one example from the test are the words "shoe" and "two". The results are useful for gathering general information on patterns, and if we find patterns, we can target a whole class of sounds rather than trying to target each specific sound.

Listening in noise. The final auditory skill we are going to talk about is listening in noise. We know the world is noisy. There's a lot of background noise. There's music playing in most stores. In meetings, there are people rustling papers, and moving around. In offices, you've got computers running, lights humming, and other noises. In situations like church or leisure activities, there are often a lot of people. Sometimes the main speaker isn't close by, and in a lot of situations, such as like restaurants, you have competing speakers. You have many people talking at the same time. We know it's hard for all of us to understand in these environments, whether or not we have hearing loss. When someone does have hearing loss, it has an impact on listening and noise. Amplification alone isn't always sufficient for listening in noise. Amplification generally does a good job of making voices louder, so you can hear them, but it doesn't always know which voice you are listening to, and it may make other sounds louder as well.  Practicing listening in noise, determining appropriate assistive listening devices, and environmental modification training can help people with hearing loss. The ability to listen in noise is a predictor of conversational communication, and this is because our conversations almost never happen in truly ideal (quiet) listening environments. If someone struggles with listening in noise, they're going to struggle with conversational communication in real-world environments.

I use an open-set-assessment task with the Common Phrase Test I mentioned earlier.  I use those lists and add noise.  I ask the person to repeat back a phrase or sentence that they hear presented auditory-only using environmental noise, and then using competing speech noise. Environmental noise will be noises around the room. If I am in the office and don't have access to an audiology booth, I use an app called White Noise HD.  It includes a restaurant simulation, with sounds like plates, glasses, and silverware clanking as well as the din of somebody talking. For competing speech noise (multiple speakers), I use a conversational sound file available on Karen Anderson's website, www.successforkidswithhearingloss.com (Copy and paste the link into your browser. Some tools may require a paid membership). 

The sound file is part of the functional listening evaluation and is a good option if you don't have access to another competing speech sound file.

Specialty Areas - Telephone Use and Music Appreciation

Telephone use may be challenging for people with hearing aids or cochlear implants, while music appreciation tends to be more challenging for adults who get cochlear implants.

For telephone use, I ask the person to demonstrate how they make a call. I can't tell you how many times they will hold the receiver of the phone directly to their ear, regardless of where the microphone of their hearing aid or cochlear implant sound processor is located. When the telephone is held against the ear, the microphone of their amplification is not picking up the sound.  Having people demonstrate telephone use will give you a lot of information.

I like to know whether or not they're even trying their amplifications for phone calls at this point or not. Their phone needs, so are they talking on the phone throughout the day or do they just talk maybe once a day? Whether it's changed since they've gotten their new amplification, whether they're trying any assistive listening devices, whether that's a streaming option, whether they're using some kind of caption service or TTY-service for phone calls, whether they feel that they're understanding things when people call, and even if the phone rings, are they willing to answer the call, that tells you a lot. If they're not going to answer the phone because they're nervous about how they're going to communicate, that tells you some great information. Do they call family members, or friends, or strangers? And then I ask things like, "Are you feeling comfortable enough to call a doctor's office to make an appointment? Are you willing to make those important phone calls or are you more interested in getting information, or only talking to people who you know well, and having somebody else make the important phone calls?" And then how successful they feel they're being when they do have phone calls. Do they feel like they're understanding most of the time, some of the time, none of the time? Are they having to ask for a lot of information? So with music appreciation, for assessment, again, this is generally for cochlear implant recipients, it's important to remember that to understand and appreciate music, you've really gotta be able to identify rhythm, tambour, and pitch. So again, tambour is the voice of the instrument, of which instrument it is. And those are all things that don't necessarily come through really well through a cochlear implant, due to how the cochlear implant processes and shares information with the brain.

When assessing music appreciation, I use more informal measures. I try to get information about the percentage of the time that people feel they appreciate music, what percentage of the time they feel like they can identify a song, and so forth. For people who are very serious about music like professional musicians, the Munich Music Questionnaire is very detailed with dozens of instruments and music skills. It's a very lengthy questionnaire, and it's one that is available in multiple places online (simply search by "Munich Music Questionnaire"). It's probably too much for the average person walking in, but for people whose life and world are centered around music, it provides valuable information.

Technology Use Assessment 

In terms of technology, determine if the person really understands the features and buttons on their amplification, what they do and if they feel comfortable using them. I commonly hear people say that they've got these new $6,000 pair of hearing aids, or they've gone through all the surgery and finally gotten this cochlear implant, and they're scared to touch something because they're afraid of breaking it. We do not want people to feel afraid of their technology. We want them to know the capabilities and settings of their amplification and how to use it. Do they know how to set up their hearing aid for noisy situations? Do they know, for a cochlear implant, which setting is the best if they're in a quieter environment? Do they know how to pair their assistive listening devices (if they have them) with their amplification? Rather than just ask them these questions, I have them show me how they use them. If someone says they have a feature or assitive device but "it doesn't help much",  I want to make sure that they're using it correctly. I often see that they may not have turned something on appropriately or are incorrectly streaming sound with an assistive device.  I want to be sure they can use it to the best of its ability. I also conduct an informal assessment to see if they know when and how to maximize technology options. Do they know, in any given situation, what they can use and what they can do to create the best possible listening environment for themselves? 

Summary

In summary, adults should be receiving aural rehabilitation with any form of new amplification. We know that adults do show benefits from aural rehabilitation, so it's worth their while to invest in aural rehabilitation. Candidates for aural rehabilitation are not only people who have had hearing loss for a very long time and are still struggling and haven't made progress. It can also include those people who just received new amplification in order to help ensure their success with it. Our testing should include many different measures and areas to get a full picture of their current performance.

Questions and Answers 

Where can we access the Cochlear Corporation Rehabilitation Manual and Screen?

You can find it at www.cochlear.com - if you don't see it in the Store, you can contact Cochlear via the Contact page on their website.

How do you locate aural rehab services for a patient, or should you just direct them to a hearing aid center?

Unfortunately, there isn't one directory of aural rehabilitation services for various states and cities. Some organizations might be able to guide you in the right direction, like the Hearing Loss Association of America. You likely will need to do some research in your area to find out what is available in your community. Talk to your local hearing aid providers and cochlear implant teams and ask who they're referring to. If they don't know of a center that sees adults, I ask who would they send a child to. A lot of times, people who are working with children and have expertise and specialization in rehabilitation of hearing loss are able to transfer those skills to the adult population.

Can aural rehabilitation be done via telehealth?

Aural rehabilitation services can be done through a telehealth model. There are some providers that are providing this service. It's more commonly offered for the pediatric population, but there are people who are doing it. A lot of university programs are doing that. There are challenges providing services across state lines but there are some providers who are able to provide telehealth services in multiple states.