VHA PROSTHETIC CLINICAL MANAGEMENT PROGRAM

> **CLINICAL PRACTICE RECOMMENDATIONS FOR PRESCRIPTION OF FM SYSTEMS AND
> PERSONAL AMPLIFIERS FOR**
>
> **HEARING IMPAIRED VETERANS**

## I. PURPOSE

> The purpose of these clinical practice recommendations is to assist
> practitioners in clinical decision-making and delivery of services, to
> standardize and improve the quality of patient care, and to promote
> cost-effective prescribing. This clinical practice recommendation
> focuses on Personal Assistive Listening Devices (Personal FM systems
> and personal amplifiers). These devices are defined as:

1.  [PERSONAL AMPLIFIERS]{.underline}: These devices provide
    amplification for most listening situations and are issued when
    hearing aids are deemed inappropriate for the patient. The devices
    are often used while patients are in the hospital, or for those who
    have difficulty inserting or managing hearing aids. These devices
    can include hardwired or wireless technology.

2.  [FM SYSTEMS]{.underline}: These devices are used to increase the
    signal to noise ratio, thus improving performance in the presence of
    background noise. These devices are especially helpful for patients
    who are exposed to a wide variety of listening environments (e.g.,
    meetings, houses of worship, etc.) in which hearing aids alone are
    less effective. These devices can be used with and without hearing
    aids and can be either hardwired or wireless technology.

## II. ELIGIBILITY

## Eligibility for Communication and Assistive Listening Devices and Assistive Devices is determined by Prosthetics and Sensory Aids Service in accordance to VHA Handbook 1173.7 -- 7.b.(1) and (2) that states:

> 1\. Prescriptions and requests for special function and/or
> communication electronic devices will be developed by the audiologist
> or speech pathologist. The special needs of each patient will be
> documented to clearly establish that the special function device
> provides superior performance over any of the more common and
> conventional appliances.

3.  Telecaption television decoders and other assistive listening
    devices to overcome the handicap of deafness may be provided to
    veterans who are profoundly deaf and entitled to compensation on
    account of a hearing impairment. *NOTE:* This should not be confused
    with all assistive devices, which are commonly used in auditory
    rehabilitation which take the place of, or are used in conjunction
    with, a hearing aid, e.g., telephone amplifiers, amplified headsets,
    etc., which may be provided to eligible veterans.

## III. BACKGROUND 

[]{.mark}

> The Under Secretary for Health directed VHA's Prosthetic and Sensory
> Aids Service Strategic Healthcare Group to establish a Prosthetic
> Clinical Management Program (PCMP). The objectives are to coordinate
> the development of clinical practice recommendations for prosthetic
> prescription practices and contracting opportunities to assure
> technology uniformity and ease of access to prosthetic prescriptions
> and patient care that will lead to valid outcome measures and analysis
> for research purposes.

** **

> A work group with input from selected audiologists and prosthetic
> personnel convened to develop clinical practice recommendations for
> the prescription, use, training and issuance of Personal Amplifiers
> and FM Systems to assist veterans with hearing impairment.
>
> Currently, 135 Audiology clinics exist within the VA wherein
> audiologists are responsible for identifying, assessing, and managing
> disorders of audition, balance, and other neural systems. Many
> veterans with hearing impairment who are served within the VA system
> are currently eligible to receive hearing aids, which primarily serve
> to make speech audible. In addition, veterans with severe to profound
> hearing losses are frequently helped with the provision of FM and
> personal amplification devices. Moreover, there are occasions when any
> veteran, no matter what the degree of hearing loss, may benefit from
> the use of Personal Amplifiers and FM Systems. There must be
> documentation about the justification for and evidence of appropriate
> patient training in use of Personal Amplifiers and FM Systems to meet
> VHA outcome measures.

## IV. CANDIDACY FOR FM SYSTEMS

> The following criteria must be met for veterans to receive FM systems:

A.  Determined by a licensed audiologist to have all of the following:

    1.  Documented hearing impairment;

    2.  Appropriate communication situations suggesting the use of FM
        systems;

    3.  Ability to use and maintain the device; and

    4.  Support available from significant others to appropriately use
        the device.

B.  Completed audiological assessment which includes but is not limited
    to comprehensive hearing evaluation, observations of auditory
    performance, consultations with the veteran or others knowledgeable
    of the user's performance, questionnaires and scales, hands on
    demonstration, and a trial period. ***\[Exception: veterans with
    dual sensory impairment (i.e. visual and hearing loss) may be
    considered for a personal amplifier prior to an audiometric
    evaluation to prevent isolation and facilitate communication with
    health care providers. The devices will be acquired through
    Audiology and can be disseminated through the Visual impairment
    Services Team Coordinator trained in the use of personal
    amplification systems. Veterans with dual sensory impairment
    receiving such devices must be consulted to Audiology for a complete
    audiometric evaluation.\]***

C.  Had a stated goal(s) that required the use of FM system.

D.  Expressed an interest in using the FM system to accomplish the
    goal(s).

E.  Demonstrated the ability to independently and safely use the FM
    system to effectively meet the stated goal(s).

G. The FM system must prove to be the most efficient and effective means
of utilizing the veteran's residual hearing to accomplish the stated
goal(s).

H.  FM systems must be prescribed by an audiologist.

## IV. CLINICAL PRACTICE RECOMMENDATIONS FOR EVALUATION 

## AND TRAINING OF PERSONAL FM SYSTEMS

A.  The FM system/personal amplifiers may be prescribed through an
    outpatient or inpatient program, contracted non-VHA agency, or
    affiliated community service providing the FM system/personal
    amplifiers at no charge to the veteran. Prosthetic and Sensory Aids
    Service will be responsible for batteries (initial dispersement of
    spares, cadmium/lithium, or rechargeable), whether they stock the
    batteries or procure them on an as needed basis. The only exception
    is batteries for hearing aids or other rare cases that are currently
    maintained by the Denver Distribution Center (DDC). In each setting,
    the following criteria must be in place to provide VHA issuance of
    FM system/personal amplifiers. The outpatient or inpatient program
    must have:

> 1\. A clearly defined hearing evaluation program, including a policy
> and procedure manual that outlines procedures for evaluation and
> training on FM systems and training performance goals.
>
> 2\. Provided audiological evaluations that meet nationally published
> standards of care.
>
> 3\. Documented evidence of an ongoing program of quality assurance in
> order to maintain the highest level of care.
>
> 4\. Appropriate documentation in the medical record that clearly
> identifies the training provided and the veteran's ability to achieve
> the stated goal(s).

B.  Performance of the personal FM systems should be verified alone or
    in conjunction with compatible hearing aids. The audiologist should
    include consideration of ergonomics, comfort, health status, and
    patient preferences in addition to performance level in
    determination of efficiency and effectiveness.

C.  When the veteran presents with vocational, educational, and/or
    activities of daily living goals requiring communicative skills that
    cannot be adequately accomplished with a standard hearing aid, then
    the appropriate alternative FM system may be evaluated.

D.  Once an FM system is ordered, appropriate verification and
    performance measurements should be completed by the audiologists and
    should include, but not be limited to real ear measurements,
    electroacoustic measures in a 2-cm^3^ coupler, and/or speech
    recognition testing. Outcome measures are suggested as a
    supplemental tool to measure benefit and satisfaction with the
    system.

## V. REFERENCES

American Speech-Language and Hearing Association. (1994, March).
Guidelines for fitting and monitoring FM systems. *Asha*, 36
(*Suppl.12*), 1-9.

Davidson, S.A., & Noe, C.M. (1996). Assistive listening devices and
hearing aids: Coupling considerations. *Folia Phoniatr Logop,* *48*(3),
143-9.

Hawkins, D. (1987). Assessment of FM systems with an ear canal probe
tube microphone system. *Ear & Hearing, 8*, 301-313.

Hawkins, D., & Schum, D. (1985). Some effects of FM-system coupling on
hearing aid characteristics. *Journal of Speech and Hearing Disorders*,
*50*, 132-141.

Kaplan, H. (1996). Assistive devices for the elderly. *JAAA, 7*(3),
203-11.

Lesner, S.A. (2003). Candidacy and management of assistive listening
devices: Special needs of the elderly. *Int J audiol. 42 Suppl 2*,
2S68-76.

Lewis, D.E., Feigin, J.A., Karasek, A.E., & Stelmachowicz (1991).
Evaluation and assessment of FM systems. *Ear & Hearing, 12*(*4*),
268-280.

Salzbrenner, L.G., Newman, C.W., & Goldstein, B.A. (1991). Probe-tube
measurements of ALDs: Uniformity, linearity and frequency response
differences. *Br J Audiol. 25*(2), 85-92.

**APPROVED**/DISAPPROVED**:**
\_\_\_\_\_\_\_\_\_\_\_\_[Signed]{.underline}\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

> Jonathan B. Perlin, MD, PhD, MSHA, FACP

Acting Under Secretary for Health

Date: \_\_\_\_[9/24/04]{.underline}\_\_\_\_\_\_\_\_\_\_