Over a million ears in AZ

VA Hearing Healthcare

Steve Huart, Au.D.

VA Eastern CO Health Care System

Denver

http://www.tucson.va.gov/about/

Who has served?

Air Force

Army

Marines

Navy

National Guard

Coast Guard

Thank you for your service!

Disclaimer

Information is public

Opinions are mine, not the VA’s

Agenda

Audiology in the VA

Auditory disabilities in the VA

Audiology services in the VA

HA, HAT, and a whole lot more

“Eligibility”

Vets in AZ

Vets then vs. Vets now

How can you serve those who have served

…and I hate agendas so please ask ???

Audiology in the VA

The Origin of the VA Motto 1865 – in a month the Civil War would

end, Lincoln would be assassinated

“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…”

With the words, “To care for him who shall have borne the battle and for his

widow, and his orphan,” President Lincoln affirmed the government’s obligation

to care for those injured during the war and to provide for the families of those

who perished on the battlefield.

March 4th, Lincoln’s second inaugural address..

VISN:

Veteran’s Integrated Service Network

ECHCS:

Eastern CO Health Care System

ECHCS - 11 locations in CO

Denver – main hospital*

Move to Aurora 2015

10 CBOCs (Community Based Outpatient Clinic)

Alamosa

Aurora

Burlington

CO Springs*

Golden (*2014)

Jewell (Aurora)*

La Junta

Lakewood

Lamar

Pueblo (*TH)

Salida

*Sites w/ audiology

13 Auds

4 sound booths

~400,000 Vets

2013

4234 comp/pen exam

2900 hearing exams

>7000 HA for 3663 Vets

3 medical

centers in AZ

Las Vegas

Auditory disabilities

How much is too much?

In most cases, the sound level from firing a weapon is sufficient to

require the use of hearing protection, even if the weapon is fired only

one time. Recent National Institute for Occupational Safety and

Health (NIOSH) studies of sound levels from weapons fire have

shown that they may range from a low of 144 dB SPL for small

caliber weapons such as a 0.22 caliber rifle to as high as a 172

dB SPL for a 0.357 caliber revolver.

http://www2a.cdc.gov/hp-devices/huntershooters.html

http://www.hearforever.org/quiz/fact-or-fiction-hearing-loss

85dB

Ouch!

90dB

115dB

Hair cells

in the

cochlea

Normal

Noise

damage

AGE

NOISE

Impact on hearing

All Vets don’t have Hearing Loss

Audiograms for

National Health and

Nutrition Examination

Survey respondents

(1999–2006) by age

category. Statistically

significant contrasts are

indicated by stars

FOLMER et al. Audiometric thresholds and prevalence of tinnitus among veterans

JRRD, Volume 48, Number 5, 2011

4K

500

The odds ratio for the association between

veteran status and tinnitus is 2.3

FOLMER et al. Audiometric thresholds and prevalence of tinnitus among veterans

JRRD, Volume 48, Number 5, 2011

HL is immediate, can recover, not latent

FINDING: The evidence from laboratory studies in humans and animals is sufficient to conclude that the most pronounced effects of a given noise exposure on pure-tone thresholds are measurable immediately following the exposure, with the length of recovery, whether partial or complete, related to the level, duration, and type of noise exposure. Most recovery to stable hearing thresholds occurs within 30 days.

FINDING: There is not sufficient evidence from longitudinal studies in laboratory animals or humans to determine whether permanent noise-induced hearing loss can develop much later in one’s lifetime, long after the cessation of that noise exposure. Although the definitive studies to address this issue have not been performed, based on the anatomical and physiological data available on the recovery process following noise exposure, it is unlikely that such delayed effects occur.

Institute of Medicine, Noise and Military Service

http://www.nap.edu/openbook.php?record_id=11443&page=61

Listen to your mom*

Hearing damage is the No. 1 disability in the

war on terror

70,000 of the more than 1.3 million troops

who have served in the two war zones are

collecting disability for tinnitus

58,000 have ‘disability’ for hearing loss

True toll could take decades to become clear

*Protect Your Ears, Not Just Mom Advice

Stars and Stripes | March 11, 2008

Department of Defense

Hearing Center of

Excellence

Lt. Col Mark Packer, MD,

Director

?

Audiology services

HA, HAT, and a whole lot more

Hearing Aids and Hearing Assistive

Technology

Hearing aids and batteries

8 Manufacturers on contract

Complete array of Hearing Assistive

Technology

Baha and Cochlear Implant

Vet’s get the best

Audiologic Rehabilitation

Tinnitus

Workshop Group

Counseling Hearing Evaluation Individual

Counseling

Referral

Progressive Tinnitus Management

http://www.ncrar.research.va.gov/

J. Henry, 2013

Implantable solutions

VNG (Videonystagmography )

Rotational Chair

Other

Peer support

Multidisciplinary teams

Polytrauma

TBI

Service dogs

‘Disability’/Eligibility

USS Vogelgesang

(DD-862)

BLDG 215

1

2

VHA DIRECTIVE 2008-070

PRESCRIBING HEARING

AIDS AND EYEGLASSES

October 28, 2008

http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=1789

VHA DIRECTIVE 2008-070

(1) Ensuring access to audiology and eye care services including preventive health (care) services and routine vision testing for all enrolled veterans and those veterans exempt from enrollment. Eyeglasses and hearing aids must be provided to the following veterans:

(a) Those with any compensable service-connected disability.

(b) Those who are former Prisoners of War (POWs).

(c) Those who were awarded a Purple Heart.

(d) Those in receipt of benefits under Title 38 United States Code (U.S.C.) 1151.

(e) Those in receipt of an increased pension based on being permanently housebound and in need of regular aid and attendance.

(f) Those with vision or hearing impairment resulting from diseases or the existence of another medical condition for which the veteran is receiving care or services from VHA, or which resulted from treatment of that medical condition, e.g., stroke, polytrauma, traumatic brain injury, diabetes, multiple sclerosis, vascular disease, geriatric chronic illnesses, toxicity from drugs, ocular photosensitivity from drugs, cataract surgery, and/or other surgeries performed on the eye, ear, or brain resulting in vision or hearing impairment.

(g) Those with significant functional or cognitive impairment evidenced by deficiencies in the ability to perform activities of daily living.

(h) Those who have vision and/or hearing impairment severe enough that it interferes with their ability to participate actively in their own medical treatment and to reduce the impact of dual sensory impairment (combined hearing and vision loss). NOTE: The term “severe” is to be interpreted as a vision and/or hearing loss that interferes with or restricts access to, involvement in, or active participation in health care services (e.g., communication or reading medication labels). The term is not to be interpreted to mean that a severe hearing or vision loss must exist to be eligible for hearing aids or eyeglasses.

(i) Those veterans who have service-connected vision disabilities rated zero percent or service-connected hearing disabilities rated zero percent if there is organic conductive, mixed, or sensory hearing impairment, and loss of pure tone hearing sensitivity in the low, mid, or high-frequency range or a combination of frequency ranges which contribute to a loss of communication ability; however, hearing aids are to be provided only as needed for the service-connected hearing disability.

Congressional Medal of Honor

VHA DIRECTIVE 2008-070

(2) Ensuring that hearing aids are provided in accordance with the following policies:

(a) Hearing aids must be issued only to eligible veterans who are otherwise

receiving VA care or services in accordance with 38 CFR §17.149 and this Directive.

(b) Veterans meeting the eligibility requirements to receive health care are eligible for diagnostic audiology services. Eligibility rules are the same for both inpatient and outpatient medical services. Veterans must not be denied access to audiology services covered by the Medical Benefits Package (38 CFR §17.38) because they do not meet the eligibility criteria for hearing aids.

(c) Audiologists must utilize the Remote Order Entry System (ROES) to review and request eligibility for hearing aids; by requesting the hearing aid in ROES, the audiologist stipulates that medical need exists based on the evaluation. Veterans in Priority Groups 1-5 are eligible for hearing aids.

(d) Non-service connected (NSC) veterans (Priority Groups 6, 7, and 8) must receive a hearing aid evaluation (HAE) prior to determining eligibility for hearing aids to establish medical justification for provision of these devices. These veterans must meet the following criteria for eligibility based on medical need:

VHA DIRECTIVE 2008-070

1. Be enrolled or exempt from enrollment and receiving a vested

level of care from a VA medical facility; and

2. Have hearing loss that interferes with or restricts communication

to the extent that it affects their active participation in the provision of

health care services as determined by the audiologist (see

paragraph 4.c).

3. Eyeglasses

4. Replacing hearing aids and eyeglasses in accordance with VHA

Handbooks 1173.7 and 1173.12, to include: NOTE: Hearing aids or

eyeglasses are not to be replaced solely for cosmetic purposes.

VHA DIRECTIVE 2008-070

(a) Hearing aids or eyeglasses are to be replaced when the device proves to be ineffective, irreparable, or the veteran’s medical condition has changed and a different device is needed.

(b) Hearing aids or eyeglasses are to be replaced if the device was destroyed or lost due to circumstances beyond the control of the veteran.

(c) Hearing aids or eyeglasses are not to be replaced because of availability of newer technology, unless there is evidence that the replacement will significantly benefit the veteran.

(d) For hearing aids, replacement may be based on age of the device, whether they are beyond economical repair, technical performance is reduced, parts or accessories are unavailable, or the device is no longer sufficient for the veteran’s communication needs.

(e) Replacement hearing aids can be prescribed at any time that change of amplification characteristics are required to maintain or improve communication function. Hearing aids have an expected life span of 3 to 4 years depending on the model of the instrument, daily hours of use, wear and tear, frequency of repair and maintenance, ear conditions, and user lifestyle.

VHA DIRECTIVE 2008-070

c. Audiologist. The audiologist is responsible for applying all the following in prescribing hearing aids: (1) To mitigate the impact of hearing impairment on quality of life and participation, the

following degree of impairment is considered disabling and establishes the basis for consideration of hearing aid candidacy, subject to evaluation by an audiologist: hearing thresholds 40 decibels (dB) HL or greater at 500, 1000, 2000, 3000, or 4000 hertz (Hz); or hearing thresholds 26 dB HL or greater at three of these frequencies; or speech recognition less than 94 percent (38 CFR §3.385). This degree of impairment is disabling is considered justification for hearing aids.

(2) When determining candidacy for amplification, audiologists must consider the effect of impairment (i.e., activity and participation) using well-established, patient-centered clinical practices. It is the effect of impairment, specifically participation restrictions (e.g., access to health care), that is the justification for eligibility based on medical need. In making decisions about candidacy for amplification, audiologists must apply evidence-based clinical practices guidelines and recommendations including, but not limited to:

(a) Audiology Clinical Practice Algorithms and Statements. Joint Committee on Clinical Practice Algorithms and Statements. Statement 3 and Algorithm 3. Joint Audiology Committee Statements on Hearing Aid Selection and Fitting (Audiology Today, Special Issue, August 2000).

HA Eligibility

Priority Group 1-5

Any compensable service-connected disability

Former POW

Purple Heart

Medal of Honor

Receiving Title 38 US Code 1151 benefits Benefits for people disabled by

treatment or vocational rehabilitation

Increased pension for permanently housebound in need of aid and attendance

VHA Directive 2008-070, 38CFR17.149, CFR, 38 CFR §3.38

HL resulting from disease or condition for which Veteran is receiving care from VHA, and/or surgeries performed on eye, ear, or brain resulting in hearing loss

Significant functional or cognitive impairment evidenced by deficiency in ability to perform activities of daily living

HL severe enough to interfere with their own medical treatment and to reduce impact of dual sensory impairment

Service connected hearing loss (even if 0%)

“Service Connected”

Compensation and Pension

Vet reports problem

Exit physical

Veteran’s service officer

Claim filed

Exams performed

Service connection awarded or denied

Eligibility

Hearing thresholds 40

dBHL or greater at .5, 1,

2, 3, or 4 kHz

Hearing thresholds 26

dBHL or greater at 3 of

these frequencies

Speech recognition less

than 94%

Priority Group 6 - 8

VHA Directive 2008-070, 38CFR17.149, CFR, 38 CFR §3.38

Be enrolled or exempt

from enrollment and

receiving a vested level of

care from VA

HL interferes with or

restricts communication

to the extent it affects

active participation in

health care services

( 2010 SC = 3,210,261 Up 144,480 )

Compensation for hearing

benefits not limited to SC

Vets

NSC Vets are eligible too if

they meet certain criteria

Vets in AZ

Percent of the Civilian Population 18 Years and Over Who are Veterans

Arizona Estimate: 11.9 Percent (universe = 4,631,972 people)

United States Estimate: 10.1 Percent (universe = 307,006,550 people)

Source: http://factfinder.census.gov (2009)

Vets by state by period (x1000)

U.S. Census Bureau, Statistical Abstract of the

United States: 2011 *132+181=313,000 (56%) from VN and GWOT

* *

Vets then vs. Vets now

Most Prevalent Disabilities by Period of Service

at end of FY 2011

Most Prevalent Disabilities by Period of Service

at end of FY 2011

Most Prevalent Disabilities by Period of Service

at end of FY 2011

As Viet Nam Vets age this could change.

Most Prevalent Disabilities by Period of Service

at end of FY 2011

Most Prevalent Disabilities by Period of Service

at end of FY 2011

3

1

2

Vets then compared to Vets now

Most reported disability?

HL and tinnitus – since gunpowder!

Has history changed the problem?

NO

What has changed?

Survivability!

Viet Nam

OEF/OIF

Next War?

“Even as I support the troops, I work diligently for a world where

their role is unnecessary.”

The real goal of Veteran’s Day should not be only to honor

veterans, but to commit ourselves to have fewer veterans to

honor. The soldier’s duty is to follow orders. The citizen’s duty is

to hold leaders accountable for the orders they give.*

*http://theaffirmationspot.wordpress.com/tag/veterans-day-affirmations/

Please let me be wrong.

Bumpersticker: It'll be a great day

when our schools have all the

money they need and the Navy has

to hold a bake sale to buy a

battleship

(circa 1970)

Front line to hospital in minutes

Results?

What used to be fatal is not

Survivors have greater injuries

POLYTRAUMA

Tinnitus

Hearing loss

TBI w/ co morbidities

Physical, Cognitive, Psychological

Amputations

How to serve those who have

served

Vets in the private sector

The majority of veterans in the United States

do not use VA medical centers or clinics for

healthcare and do not receive VA

compensation payments.

FOLMER et al. Audiometric thresholds and prevalence of tinnitus among veterans

JRRD, Volume 48, Number 5, 2011

VBA Regional Office

3333 North Central Avenue

Phoenix, AZ 85012-2405

1-888-827-1000

PHX:

http://www.phoenix.va.gov/

Phoenix VA Health Care System

650 E. Indian School Road

Phoenix, AZ 85012

602-277-5551 | 800-554-7174

TUC:

http://www.tucson.va.gov/

Southern Arizona VA Health Care System

3601 S 6th Ave

Tucson, AZ 85723

520-792-1450 | 800-470-8262

PRE:

http://www.prescott.va.gov/

Northern Arizona VA Health Care System

500 Hwy 89N

Prescott, AZ 86313

928-445-4860 | 800-949-1005

VHA home page:

http://www.va.gov/healthbenefits/online/

http://www.va.gov/healthbenefits/vhbh/

All states:

http://www.dvnf.org/resources/veteran-affairs-facility-

locator/?gclid=CJaT79PboLkCFZBAMgodc3wAGw

AZ:

Locations: Only going to use one site, use this one!!!

http://www.va.gov/directory/guide/state.asp?STATE=AZ

http://www.azdvs.gov/

http://www.military.com/benefits/veteran-state-

benefits/arizona-state-veterans-benefits.html

References

http://www.va.gov/vetdata/veteran_population.asp

http://www.va.gov/vetdata/Quick_Facts.asp

http://www.va.gov/vetdata/veteran_population.asp

http://www.va.gov/vetdata/docs/quickfacts/Populatio

n_slideshow.pdf

http://www.va.gov/vetdata/docs/QuickFacts/Utilizatio

n_trends_FINALv5.pdf

https://www.facebook.com/HeroesWithHearingLoss

http://www.vba.va.gov

/REPORTS/abr/2011_

abr.pdf

Thank you for your time!

Thank you for your service!