OTE 28                Transcript
EPISODE 28


[INTRODUCTION]


[00:00:00] ANNOUNCER: Do you enjoy listening to On The Ear, but wish you could earn ASHA CEUs for it? Start today. Speechtherapypd.com has over 175 hours of audio courses on-demand, with an average of 19 new audio courses released each month. Here's the best part, each episode earns you ASHA Continuing Ed Credits. Oh, no wait. This is the best part. As a listener of On The Ear, you can receive $20 off in annual subscription when you use code Ear21. Just head to speechtherapypd.com to sign up and use code Ear21, E-A-R-2-1 for $20 off your annual subscription.


[00:00:48] DS: You're listening to On The Ear, an audiology podcast sponsored by speechtherapypd.com. I'm your host, Dr. Dakota Sharp, Au.D, CCC-A, audiologist, clinical professor and lifelong learner.


While I primarily work with pediatric cochlear implants and hearing aids, I am absolutely intrigued by the many areas of audiology and communication in general. This podcast aims to explore the science of hearing, balance and communication with a variety of experts in hopes of equipping you to better serve your patients, colleagues and students. Let's go. We are live and On the Ear, brought to you by speechtherapypd.com.


[INTERVIEW]


[00:01:36] DS: When the pandemic hit in early 2020, clinicians in all disciplines had to rethink their service delivery models. Audiologists who had never before considered telepractice scrambled to connect with their patients in this new way. With some growing pains, we are certainly seeing that telepractice, at least in some form, is here to stay.


One population that has been subtly overlooked during this transition is newborns. Babies in low-access areas with few audiologists have historically been more likely to fall through the cracks of care in the early hearing detection intervention system. With COVID making access even more difficult, an unknown number of babies are not receiving adequate diagnostic and follow-up care.


Today's guest is going to explain what we can do to improve the situation. Dr. Melanie Morris, Au.D, is a Pediatric Audiologist, who graduated from the University of Memphis with her Au.D in 2015. She now works as a pediatric audiologist with Georgia’s Mobile Audiology Program, with a goal of improving access to audiological services across the state.


Melanie's background has been in clinical audiology, with the majority of her work experience being at a children's hospital. Melanie has a strong interest in providing and promoting services to underserved populations, as well as educating others about the need for early intervention. In an effort to improve access to audiological services, Melanie has started a roving Tele-ABR Program.


Just a couple of financial disclosures. I am the host of On The Ear, and receive compensation from speechtherapypd.com. Melanie was the first ever guest of On The Ear, and now she's our first-ever returning guest. Just in the spirit of audiology, and as I'm sure she's going to point out when it comes to Tele-ABRs, this is actually our fourth attempt to record this due to technical difficulties. I think, she can speak to some technical difficulties in a Tele-ABR sense. Hey, Melanie. Thank you so much for joining me.


[00:03:14] MM: It's great to be here, and glad to see that things are working this time. We always just got to go with – roll with the punches.


[00:03:23] DS: Absolutely. I imagine that's a big part of working with Tele-ABR is just in a world where Zoom and teleconferencing is everything, an ABR is not the place where you want your Internet to be spotty, or cut in and out. You don't want any tech issues when there's a baby who you're trying to keep asleep, and oh, I cannot imagine the pressure has ever been higher.


[00:03:45] MM: Yeah, it's funny. We'll talk about it today. Yeah, there have been a lot of little glitches and not necessarily glitches, but just constant little hurdles trying to figure out which software to use, which equipment to use, all these different things. We have had plenty of errors. Hopefully, you guys can learn from some of not necessarily mistakes, because nobody really has a playbook for this, but hopefully, I can share some of that knowledge.


[00:04:12] DS: Absolutely. Okay, so before we get into the Tele-ABRs then, in our last episode, you were sharing about how you're in Georgia. Georgia is a very large state area-wise. You have your metropolitan areas, where there's fairly good access to care, there's multiple options, but then, you can drive in Georgia for what, five straight hours and still be in Georgia and nowhere near a metropolitan city, or where there's access to care.


One of your goals when you started that mobile audiology program was you had this truck. It was all outfitted. It was ready to go. Then COVID hit and then it was like, “Now what do we do?” I'm curious since we last talked to you, it's been a little over a year now, what's been going on with the mobile audiology program and what led you to transition into Tele-ABR?


[00:04:57] MM: I'm really proud of our program, because we really did just pivot. We were like, okay, we don't know what COVID is going to bring to long-lasting situation. I'm really glad that we started looking into teleservices at the beginning of COVID, because I don't think any of us imagined that we would still be here. Now, we're up and running with teles, so we're able to see a lot more patients than we were at the beginning of the pandemic.


We are still using our big, old truck, primarily for school age population. We have contracted with a few different school districts. They just basically pay our travel funds, or our travel fees, and then we can do their IP, their valuations for IP and various management there. That's mostly my colleague who focuses on the educational audiology side.


Then I was like, “Okay, we're shut down. I can't drive and go see these babies. How are we going to fix this?” Really, I think a lot of people are going to find this, but with COVID, we were doing things in a very different way before. Now, we're finding that use of technology is actually in some ways, making things more efficient. We are just writing that, and maximizing the fact that now parents are used to Zoom. They're used to tele-appointments. We’ve had a lot of success with it.


[00:06:16] DS: That's awesome. That's a really good point, too. I still feel like, I'm one of those people who is a little bit hesitant to take the plunge. I've done some trainings, when it comes to hearing aid companies on like, here's some ways you can implement these things. I'm like, “Well, my patients, they wouldn't get how to do the video call while we do it.” That kind of thing. It's really encouraging that you're right, everybody has had to transition to this. Not just me and my professional and also personal space, just connecting with family through video calls, everybody's doing that. It's a really good reminder that it's not so foreign to everyone else who's not in the audiology world.


[00:06:51] MM: I know. I think, it's just going to become more and more part of our daily routine. I know personally, I would prefer, I prefer virtual appointments, so I don't have to take off work and do all these things. I am lucky that I work for the state. I'm seeing things from a much bigger lens. I used to work in a hospital, where I just saw what happened within that hospital. Now that I work for the state, I'm seeing how many babies we have missed in the state.


It does not make any sense for me to physically drive everywhere and see them, because I can see only a portion of them that way. Our goal is really to see a large, large quantity of babies. I know, most audiologists who probably see babies, I prefer to be in person. I love to be with my patient, have hands-on and do all that. When I'm seeing these numbers, and I don't really know of another way to – we have 2,000 babies between 2019 and 2020 that have no reported diagnostic ABR.


[00:07:51] DS: Stop. Oh, my gosh.


[00:07:53] MM: It's at this point, it's like, okay, it doesn't matter what I prefer. We just need to get out there [inaudible 00:07:59].


[00:08:00] DS: You got to do something.


[00:08:01] MM: Exactly.


[00:08:02] DS: Yeah. Oh, my gosh. Oh, my gosh. Okay, so it sounds like, you're starting to blend a little bit of the technology that we've all had to adapt into our lives into this mobile program, which I guess, when you guys first started, that was probably never in the cards, right? Did you even see telepractice being a part of this mobile program?


[00:08:20] MM: I don't think so. Maybe the people above me did know. We really didn't. It's been great that we have the flexibility and we've had the support from Department of Education to help us make this happen and see the need and then go for it. Our program now, so it's Georgia Audiology, but we have two wings of it. One is really the Georgia mobile truck services. Then the other one is the tele.


Right now, I'm only doing tele infant testing, so Tele-ABR. We do have some plans to do some other testing, so like behavioral testing, and things like that, more of a triage. At this point, triaging, figuring out, okay, for screenings and for these things. Do you have flu? Do you have a conductive loss, where you need to go see a medical professional before we do that? We do have some long-term goals.


[00:09:15] DS: Very cool. Very cool. It sounds like, there's even room to expand that, too. Okay, so thinking of Tele-ABR then, which if first, you want to break down what that means. There might be people listening who have never even heard of this concept before. I know how to blend the words tele and ABR together, but there might be people who don't even know what those two words initially are. Could you break that down? Is this brand-new? Are you literally the forefront of people who have ever done this? Or is there a little bit to base it on? How did we get to this point?


[00:09:44] MM: I actually think that there have been some people doing this for, I mean, 20 years, 15 years. For a while, but very few. It's not a very widespread thing. It's these little pockets of states that have been doing them. Then COVID is actually like, NCHAM, they got some funding from CARES Act, I believe, to try and bring audiologists together and learn and expand that knowledge and create this learning community. NCHAM was really helpful for me, because then I could join these calls that actually talks about Tele-ABR, hearing aids, all sorts of things.


Then, we have an online resource library, and so everybody can put in different resources that they use to get it started. That was definitely like, I was not starting totally from ground zero. I would highly encourage anyone who is interested in any degree of teleservices to look at the NCHAM resource library. You can just Google it, but they do have a special thing online. That was definitely helpful.


In Georgia, we do have – there was Department of Public Health did partner with Children's Healthcare of Atlanta, which is our one pediatric hospital in the state to do tell us. They've been doing tele for about five years, but their model is slightly different. They have one site, one audiologist in Atlanta, and then they have one trained person down in South Georgia health department. Then they have a clinic once a month at that one site.


Ours is a little bit different. We have the flexibility to travel. What I have done is we've created, right now, I think we have about seven different clinics. We have our equipment, and our equipment can travel from one clinic to the next clinic. With the test assistant, they are able to move it to these different clinics within a region, and so it's not just in one specific spot. I'm calling it a roving Tele-ABR program, because me as audiologist, I stay stationary, I'm in Atlanta, but then I have a test assistant who has the portable equipment, which was really key, portable equipment to have that flexibility to then move around. Then, we hold standard clinics at set dates.


[00:12:04] DS: Wow. I feel like, I want to just jump – I want to jump so far ahead into like, what's going on in a day? I guess, okay, so that model. Okay, help me out. I know, I've heard of spoke and wheel –


[00:12:15] MM: Spoke and hub.


[00:12:16] Okay. Spoke and hub. I’ve never heard of that before. What are the models you can approach here? I guess, you have this roving idea where someone's jumping from clinic to clinic, versus more a fixed. Could you breakdown some of that lingo a little bit for us?


[00:12:30] MM: Well, so most of the, I guess, models or tip for this are typically, going to be spoke and hub. They would be the hub. They are at the center of the wheel. Then, you would have a spoke site. You would be drawing, imagine drawing a line from the center of a circle out. Then, those spokes sites, or each of those outer sites. It's really just a matter of how many spokes sites are you going to add.


Then, the other thing is, is some people talk about synchronous, versus asynchronous. At this point, I can't really imagine doing any of this asynchronous. That would mean somebody is running it and then the audiologist is evaluating it and –


[00:13:09] DS: Like interpreting waves?


[00:13:11] MM: Yeah, interpreting it after.


[00:13:12] DS: Oh, my gosh. I can't imagine that, because so much of an ABR is like, what you do in the moment to reflect what you're seeing. Oh, my gosh.


[00:13:19] MM: For sure. I do wonder about asynchronous, like a screening, or something like that. In Georgia, we actually have this unusual law that only audiologists and physicians can do OAEs over the age of three months. That means, anybody over the age of three months, like nobody can do OAEs.


[00:13:39] DS: Oh, wow.


[00:13:40] MM: I know. We're actually trying to get that law changed, just to open access. We have a lot of stipulations of like, we need a training module. You need to be able to – there's no interpretation. It's past it. That is one thing that I think could be done asynchronous is like, somebody runs it and then an audiologist can evaluate the OAE responses, but I am not seeing any of that in ABR.


Our model is a spoke and hub model, but then we just add this element of roving. Instead of our spoke sight being stationary, which is what exists in a lot of places, so it's big equipment. There is a whole video platform. Everything is stationary. It’s only in one place. We pick up our stuff and that test assistant drives from various places to do it.


[00:14:25] DS: Got you. I'm picturing like a moon traveling around the planet, I guess, because it's –


[00:14:29] MM: Yeah. That’s exactly right.


[00:14:30] DS: - not one fixed bloke. It's more moving all over the place. Cool. Cool. Okay, so when it comes to what that looks like, so physically when you are sitting down to test someone, or I guess, I should say a baby, because probably most of them are children maybe. Or, I guess, not even children, like infants.


[00:14:51] MM: Yeah, they're all infants.


[00:14:52] DS: What is happening? Someone is in a room? Are they in the home of the baby and they've got a computer? If you were going to it explain this to someone who has literally never heard of this concept, how would you explain what's going on?


[00:15:04] MM: Okay. The most important part of this is not the audiologist. It's like, where is the family and where is the test assistant? They are together. The test assistant is going to be the crucial piece of this, because anyone who's done infant testing knows, you have to be a calm presence. There are things that you cannot put on a piece of paper that are like, “This is what we need.” You just need somebody that is confident with babies, and is calming, keeps the parent calm, can keep the baby quiet and asleep.


We have test assistant who's with the family, and the caregiver and the baby. Our model is we have worked very closely with Department of Public Health. There are health departments in every single county. What we've done is we've then contacted our – we have district EDI coordinators, which not every state does. We have 18 districts in our state divided up into 18 health districts. Each of those has an EDI coordinator, which is what I've learned is not common in a lot of states. We have that upper hand.


Each of those EDI coordinators, they then help us find a space and health department that maybe is two counties over. What we've done is we've looked at the data and we figured out okay, which counties have the highest no-show rate, or is not getting diagnosed on time? Also, where does our staff live? We have a coworker who lives down in South Georgia, so we started a clinic down in South Georgia. Then we just hired a test assistant, or an audiology assistant who lives in Central Georgia. Now, we're creating those clinics around there.


Anyway, I digress. What it looks is either in a health department, so we the EDI coordinators helped us get a space or a room. All we need, whenever they ask, like, “What do you need?” It can be a closet, but I need two chairs. I need an outlet, and I need Internet, and that's it. We've done health departments and in some cases, some of the health departments won't let us in, because we're Department of Ed, not Department of Public Health.


[00:17:05] DS: Oh, my gosh. Oh, my gosh. It's like an episode of Parks and Rec.


[00:17:09] MM: Yes. Okay. Exactly. Yes. To on point. We have partnered with the libraries, which if you think of a library, it's –


[00:17:18] DS: That’s awesome.


[00:17:18] MM: This makes perfect sense.


[00:17:19] DS: It’s awesome.


[00:17:19] MM: One, it's quiet, which then I'm like, “Okay, make sure it's okay if a baby’s screaming in your library. You need like, hide somewhere in the corner.” They have Internet, and it's all about literacy. That's ultimately our goal, and it align. We have chosen health department and library, because they are public service entities, they have bathrooms, they're mostly pretty open to us coming in.


The test assistant will meet the family at the health department, or the library, for instance. They'll have all of our equipment. They'll have everything set up. Then, they will join on Zoom. We do use Zoom, but there are different HIPAA-compliant options. I'll be in Atlanta, so the audiologist will be at wherever, at their home or whatever, on camera. I'll introduce myself. Will explain how this appointments going to look. I mean, everything that you would say for a normal in-person appointment, like what to expect and how long it's going to take, and those different things. One of the best things is that these families have driven five or 10 minutes.


[00:18:25] DS: Yeah. Baby didn't fall asleep on the car ride. Yeah.


[00:18:27] MM: Baby didn’t fall asleep. Parents are already – they are not stressed out, because they didn't just have to sit in a car with a screaming kid for an hour. It's their community. I don't know. It has been a much more pleasant environment and experience.


[00:18:45] DS: That's really interesting.


[00:18:45] MM: Yeah, it really is. I think, our no-show rate is 2% or something crazy.


[00:18:51] DS: Oh, my gosh. On non-sedates. That is crazy. That's probably the best ever. You really can't beat 2%. Oh, my gosh.


[00:19:01] MM: No. I'll have the camera. I make sure that they can see me at the beginning of the appointment. We do have an external camera, because I wanted – because we were using the one in the laptop and I'm like, I need to see this baby the whole time on testing, because otherwise, I don't know – we –


[00:19:16] DS: Electrode falls off. Insert falls out. Yeah.


[00:19:19] MM: If we need a little bit of control. We have an external camera and it's just pointing towards the baby. Sometimes, if I'm like, okay, I'm not getting a response where I think I need a response. I'll ask the test assistant to take a picture of the answer and the ear, or do something, so I can really check that everything is good.


Anyway, okay, so then I start the testing. Then, the test assistant is crucial during the appointment as well, because they've been trained on okay, the electrodes are popping off. When do you need to put it back on? Or, oh, the insert is falling out. We need to trim it, all of that. We have a very comprehensive training program that we actually developed as well, and it's a free resource and I'll share with you, so that you can share it with others.


[00:20:02] DS: Oh, my gosh. Yes. Yeah.


[00:20:03] MM: Yeah. Actually, it's online. Anyway, that was really nice to get everything in one place.


[00:20:09] DS: I'm assuming, before we go into the testing, so the test assistant is doing the prep, they're scrubbing. Then, do they feel confident enough, they can check impedances and then they know how to troubleshoot, inevitably when one is really high, but also you scrub that one, and then it's still – you know what I mean? You just run into the circle of – non-sedates are cursed. You just can’t not run into this weird stuff at least once a month with these things, at least in my experience.


[00:20:35] MM: 100%. No, totally. It's like, everyone knows it can be very stressful. One thing is, I feel pretty strongly about having a very small pocket of test assistants. They need to be almost their entire job is their, or prep, that this is what they are doing, so that they are confident, they are used to this. They are not just doing it once a month. They are doing it six times a week, at the minimum.


Definitely, they feel confident with that. I do check the impedances, because I just can – I remote in. Once we get set up, I talk to the family. I then take over. They share their screen, I take over remote control. I pull up the equipment. I tell them whether we're going to start with temps, or OAEs, or ABR. Every audiologist has their own preference. Also, some babies come in completely asleep. I'm like, “Well, let's just go straight for the ABR.” Various things like that.


It's a lot of communication back and forth between the audiologist and the test assistant. You have to call things out, like, okay, he failed the left ear, so we are going to start with the left ear. Very clear conversation of which side. It's very much, the audiologist is the one who has to lead that. Then the impedance thing, yep, we actually – we just had a major issue with – we had all these really high impedances. I'm like, what is happening? I just used this equipment, virtually.


It ended up being, we just got a bad batch of electrodes. I know. It was really devastating. I actually, I have the flexibility that if I have a really weird case, then I can go travel and I can go see that kid. That's what I did. I saw three babies on a Monday via tele, all the impedances were so high. It was acting really crazy. I was like, I'm just going to – I don't want to waste these family's time. I'm just going to go there. I drove there on the Thursday, and then I saw them all in-person. Then we discovered, okay, it's an electrode issue. Yeah, that was my first time that we actually had a lot of technical issues. Prior to that, things were running so smoothly. I was like, “It’s about to happen.”


[00:22:48] DS: You were overdue for it, I guess.


[00:22:49] MM: Exactly. Yeah. Once I do the testing, then I typically will pull up within NOAA or within our specific electronic medical records, I'll pull up, I'll plot the audiogram on there and show them and show them where the speech spectrum is. Then, also, the test assistant will have the speech spectrum, or the audiogram, familiar sounds audiogram, and she will then plot exactly what I have written on the screen, just so the family can also see it in person. Then they get a full report and everything. It's been better than I thought it would. I thought it would feel a little bit just not personal, but it's not. It's been really good.


Okay, so another one variable that all these things pop up, and they’re like, “Oh, I didn't think about that.” Our interpreting service that we use is an on-demand interpreting service. It's video and phone for just prior to Tele-ABR. I just assumed like, okay, well, they can just call into the Zoom. Luckily, I thought ahead, and I was like, let me just have a fake Zoom. I had my husband in a Zoom room. We called an interpreter. Asked them to get in the room and they were like, “No, we can't do that. You have to have this different service where you can – we get the link beforehand. We call in.” We had to redo our contract with the interpreting companies.


[00:24:14] DS: Oh, my gosh.


[00:24:15] MM: Yeah. Just make sure that you have the ability, the accessibility for interpreting, because I mean, it's a legal thing that you need to be able to provide. We now can schedule it in advance. We send them the link to the room, and then they join. This one time we had, okay, I was in Atlanta, we had the family and the test assistant in Valdosta, which is South Georgia, almost to Florida. Then we had a Spanish interpreter, who was in Argentina. It was so fun. It was really cool. Yeah.


Definitely think about interpreter and how you're going to do that, and what your system looks like. Then, the other thing was counseling. I do think there are some things I want to iron out on how do I effective counsel virtually. That's something that I'm still working out.


[00:25:06] DS: Maybe I missed this, but did you say how you're communicating with the test assist in the moment? Do they have headphones in and you're on a Zoom call? How are they hearing you?


[00:25:14] MM: No. We've tried this a couple different ways. Mostly, it's just like, I will mute myself when I'm testing and then I'll unmute myself when I want to ask a question. I will mostly, it's just like, parents will hear us, we're just talking. I feel like, that's the best way, because a tele-appointment is supposed to be nothing really different. They're not supposed to miss out on anything that they would be getting in person. It feels a little bit odd to be secretly talking to them. I don't know.


[00:25:47] DS: I get what you mean. Yeah.


[00:25:48] MM: Yeah. Then it's like, okay, if the baby is really sensitive to going to wake up, or things like that, we have our cellphone. I mentioned that the insert, I'm like, okay, this is not totally normal, but they had normal OAEs. Let me see a picture of how far you put them in certain. We'll do that thing, or I'll give a warning like, “Hey, I'm going to get bone conduction ready, and I'm going to want to do it on the left side.” The attacks, but also just open in the Zoom.


[00:26:19] DS: Wow, this sounds amazing. Because the most stressful part of doing an ABR is all of that in the moment, “Oh, is the electrode right? Is the insert in?” The little dance, where you go back and forth. The easy part is just running the waves and looking at that. Oh, my gosh. That does sound nice.


[00:26:35] MM: I always tell them that they have the hardest job. I can tell real briefly, so we have – I'm very organized. Maybe too organized. I created this training guide or competency thing. We have an online – we partnered with a foundation called Access to Language. They actually helped build this online training curriculum for newborn hearing screening. Just doing that, so it'd be for the technician, or the nurse in the hospital, or whoever. Then also, a tele-audiology clinical training program.


There is this 90-minute thing that they go in online, and they learn all about OAEs, all about the equipment, everything. Then, the training plan, what we do is we actually used a really busy health department site in Atlanta to be our training site. Because there was an audiologist going to be there, I could meet there, and we just had – I actually trained three people at the same time. They all came there. We saw babies all day long. This clinic is so busy, and it's a very unique clinic. That, if a baby fails the screening, they move straight into a diagnostic.


We mostly just like, we just went straight into diagnostic at the screening, just to have this practice, with this test assistant. I have this whole training guide. Basically, they observe me, or the audiologist, while I do three different patients. They practice on each other. Then, I observe them prepping. Then the final step, it's like, I'm slowly removing myself. The final step is I'm just in another room, or on another floor, but I'm in the building. We run it for a whole day of clinic of them prepping and doing it as if I wasn't there. Then ultimately, I'm not there. 


[00:28:24] DS: Wow. That's really cool. Okay. I think, your organization sales have really worked for you here, because that sounds like a great way to approach it. I think, if it were me and I had no experience with any of this, that'd be a really comfortable way to progress through all of those skills. That's great.


[00:28:40] MM: Yeah, for sure. I do think, having the audiologist who is going to be working with the test assistant, or the audiology assistant, just having a good – I was lucky that I was involved in the training. I did the training. I do think, to build that relationship, it would be important for the audiologist who is going to be –


[00:28:57] DS: Oh, yeah. To have trust that they're doing it. Yeah. I'm curious, was this an open job thing? Are these people who were already in an audiology assistant role? How do you find someone who has to learn? Because they have to understand what an ABR is on a deeper level and impedances and things like that. How do you find this person?


[00:29:16] MM: It's so interesting. One of these talks that I went to with NGM, it was a bunch of different – North Dakota, I think, is doing this as well. I forget a couple of the other states. Everyone was talking about how they chose their test assistants. One chose a DHH teacher. It was somebody who's very well-versed in deaf and hard of hearing lingo, everything. Then another one shows a – I think, she actually was a nurse. She had the medical record.


[00:29:43] DS: That’s a great one. Yeah.


[00:29:45] MM: Yeah. She is super comfortable with scrubbing and putting things in the ears. Then ours, it’s funny, because we have both. We have a deaf and hard of hearing teacher, because she's on our staff as a family engagement specialist. She does a lot of family education. This is just, we've now thrown a Tele-ABR at her, basically. Now, she does this one day a week. She has a deaf and hard of hearing teacher. She has that background. Then we hired an audiology assistant.


We got really lucky in that she is an audiology assistant. She has never done infant testing at ENT clinic that she used to work at, but she's very well-versed in audiology. Those are the two people on our team. Then, I have trained within the Department of Public Health, a couple EDI coordinators, because they're doing it with Children's Healthcare of Atlanta, and I've just offered to do the training. It's a little bit of a mixed bag. I don't think there's one right or wrong answer, but it definitely – I mean, this is an interesting topic. Hopefully, I don't get sued over this. We needed a female, because there are a lot of women who are breastfeeding. Actually, Dakota, you may have some insight on that. I'm curious the impacts. I know. Sorry.


[00:31:01] DS: It's something I have to consider all the time. I mean, as a dad who's gone through breastfeeding with two children, not the person who did the breastfeeding, but was in that world. I feel like, I have to delicately walk a line of professionalism. I mean, there are plenty of pediatricians who are males and lactation consultants. I try to be very mindful and respectful of whatever a mom would prefer by saying, usually my question is, do they normally feed before they go to sleep? If they say yes, I’ll say, “If you're breastfeeding, I'm happy to step out, or I can step over here to the side.” I give them that space to decide what they want me to do there.


Yeah, I definitely have to walk that line pretty regularly with my non-sedates. Totally. Oh, you mean, like you have to have somebody who can be flexible in that moment, and I see a female being much better.


[00:31:52] MM: Yeah. Maybe it doesn't need to be a female, but it needs to be somebody who has that ability to –


[00:31:57] DS: The tact, right?


[00:31:58] MM: Yeah, as a tact. It still is, even as me being a female asking, I give parents, on the mother option, of course, whether they want to feed before, or whether they are comfortable. Many times they're like, “Go ahead and just do it.” I'm in there, getting the baby prepped while they're eating. Anyway, it just was an interesting thing, where we were like, “How do we even advertise? We need somebody who is comfortable, who's going to make a parent comfortable.” It's a hard role to fill.


[00:32:26] DS: It’s a good point. That's a really good point. Hadn't considered that. Wow, yeah. That's a really interesting breakdown. I do see how all of those roads lead. They are a high school student who was interested in audiology and it's like, “Whoa. Okay. That's a lot for you to take on.” All these people have a background in this world, at least a little bit. I see the connections and I think that's really cool.


Okay, circling back around then to the Wi-Fi, because that might be – as someone who like – I consider myself to be really tech savvy. Still Internet connections make me so nervous. No matter where I am, I'm like, I don't want to do anything that totally relies on an Internet connection, because you never know. It'll just drop out, or somebody else starts using it and it slows. There's a lot of things that can go wrong. I'm curious what your experience has been from just an Internet connectivity standpoint and what you guys are doing to troubleshoot, or what you're hoping to do in the future about it.


[00:33:20] MM: Yes. When I started this, I was like, “Well, I got to have a hotspot as a backup.” I need to have all these different things. It's actually, well, knock on wood, it has not been as challenging as I thought it would be. One of the things, we are in a lot of rural communities. Since we are going to a library, or a health department, like we're not going to somebody's house. I think, that in itself builds in some infrastructure and they have Internet there. At first, I was thinking all Wi-Fi. Then, I'm like, “Wait. Ethernet cord.” We have an ethernet cord. We just connect it directly to the wall.


[00:33:50] DS: Well, there you go.


[00:33:52] MM: Yeah. Then it's not an issue at all.


[00:33:55] DS: That's awesome.


[00:33:56] MM: Yeah, Ethernet. I did get a hotspot for – I did Cricket, where I could pay for one month just, so I could figure out, do we need this as a backup? Really, I mean, it worked the same as my hotspot on my phone, which I have unlimited data through work. In really, like, I think one time we had to change rooms and they didn't have an Ethernet port. We were actually hotspotting off of the test assistant’s phone. It was not like I always want a speed test, so that is another thing. Every time we're about to set up a clinic location, we physically go there. We check the Wi-Fi, we also check the Ethernet speed. Then we Google speed test, Internet speed test and it tells us if it's sufficient or not.


In this one case, they had a last-minute meeting or something in the room that we always use, so she had to go to another room. There was no Ethernet port. She was hotspotting on her phone. I was like, “We have to turn our videos off.” In order to get the ABR, so we turn our videos off to help the speed. I was able to control her screen and get the whole ABR and then we FaceTimed after that. It was not ideal, but we just got creative. Ethernet port.


[00:35:12] DS: It sounds like a very safe bet to use that for sure. It does sound like, you guys have some flexibility should you need it, which is awesome. Yeah. Okay, so you go through the ABR, you fix, you get through the troubleshooting, you get through the hard stuff, you've got your results. Can you break down, because honestly, I would say, I do non-sedative ABRs pretty regularly, at least once a week. Those conversations are not easy, especially if you're diagnosing hearing loss for the first time, and it's unexpected. Could you tell me a little bit, I know you said that's one of the things you're working on is that counseling via Tele-ABR, but what have those conversations been looking like for you?


[00:35:53] MM: Okay. I mean, the counseling looks very similar to in-person counseling. We are going to be doing a qualitative, like asking parent, like surveys of like, okay, what was your experience like? Some of this, I can't really answer. I can tell you what we're doing. I can't tell you that parents feel one way or the other about it. I do think that's going to be some valuable information and we definitely plan to do that.


Our program is also really, really lucky and very special, because the family engagement specialist and the test assistant that we have, they do a lot of training on just talking with families about the next step. It's parent navigation. That's what we do. It's like, I make this diagnosis. I don't live anywhere near this family. We do not do the hearing aids. Then, that test assistant, or that parent navigator, or the family education specialists, they then are caught – They work with this family for a long time to figure out okay, we need to help you get a script and go here, we need to get you into ENT.


It's not just a one-off thing. They have our work cellphone number, so they can text us, they can call us. We are very unique in that aspect where it's really like, we will give the information, we will give it all, but that's not the only conversation we have with them. We have a lot of follow-up.


[00:37:15] DS: Got you. Got you. Okay, that's really cool. I didn't realize you guys weren't also doing follow-up. I mean, I guess it makes sense. How could you provide follow-up care for every kid around the state who ends up diagnosed with a hearing loss? Have you had any really positive, or maybe not so positive experiences through Tele-ABR when you've had to give a diagnosis, or anything like that?


[00:37:39] MM: I had a really challenging one last week. Okay, so this brings up the other thing. I mentioned the model of that one – it's Fulton County Health Department. It's in Atlanta. That one health department that's really busy. The model that they use is – and this is all in-person ABR, but they do a screening and they move straight into a diagnostic. That might be common in a lot of places, but that's not common anywhere that I've worked, but it is so incredibly helpful. It prevents the next appointment for this family.


That has been our long-term goal is to have my – the test assistant, or both the test assistants do screenings and then okay, if a baby fails or refers, they then call the on-call audiologist. Then I sign in and I do a diagnostic, so we prevent the family from having to come back. We are working through, because that sounds like, just such a magical, magical plan. It’s like, how is that actually going to work? I’m figuring some of that right now.


I had a patient, we had two diagnostics on the schedule. The EDI coordinator was doing a screening next door, so we had all these things going on. That baby failed. She's like, “Could y'all just squeeze him in, because I finished early?” We squeezed him in and I started a diagnostic. It's like, okay, I've got 40 minutes and we're doing this via tele. I knew I wasn’t going to get the whole thing, but it was like, “Okay, can I at least tell you that your child has some hearing, or?” Okay it's sensory. Various things.


I was able to provide some information. I knew, okay, I've ruled out neuropathy. I see a beautiful 135, but then there's like, I was thinking as mild to moderate hearing loss. The dad was like, he was crying. I couldn't even really tell that he was crying, because with the camera and with the sound. The test is this, I mean, it was mostly on her. She called me after. She was like, after we hung up with you, we talked for another 45 minutes.


That was a challenge. Then, I brought them back and he was really totally fine the next time and the child ended up having mild hearing loss, and just in one year. It's a little bit complex. This just shows how important that test assistant, or audiology assistant, whatever you want to call them is, because anyone who's going to talking with the family, you want to make sure it's consistent messaging and that they are saying the right thing, that they have the ability to say, “Oh, I don't know how to answer that. Let me call the audiologist.” That is that I guess, that was a challenge. I think we're going to learn a lot more as we as we grow this.


[00:40:17] DS: Yeah. Thank you for sharing that. I know that sounds like a really difficult one to navigate. I think, it's a really helpful reminder of – I mean, I think of some of the conversations, I have some family who were – they work in hospitals. One who's a nurse, who's worked with COVID patients, and they do family phone calls for someone who's has COVID in the hospital, and they're on their last breath, and having those difficult conversations through FaceTime.


We're just not used to that being our primary mode of extremely emotional, deep conversation. I think, as our world is more connected and more digital, eventually, that's not going to be that strange. Right now, I can't imagine, that's a difficult way to have a conversation like that.


[00:41:02] MM: That brings up, like I wonder, this is why we plan to survey the parents of like, I wonder, is it harder for the provider? Do we just assume that that patient is having a different and worse experience? Because I know, therapy is done on virtual capacity. I think that's pretty good. I'm just curious. I will report back to see, and it's hard to really qualify like, was it better or worse? Because they've only had this one experience. I know for a fact, these families that I am seeing, they knew that the closest place they could go was going to be four hours away.


They are so appreciative, or even a two-month waitlist or something. Incredibly, appreciative of just the service. I don't know. I feel that, he makes a huge difference. I am not doing Tele-ABR if that family is 30 minutes away from my house. I'm going to go in person and do that testing. It's really just the, I don't know. I think, some of these families are just so appreciative that they get the service that I don't necessarily think that – 


[00:42:14] DS: That’s a good point. The whole conversation starts differently. When I have somebody who's driven three hours, and they're exasperated, and they're tired, and then we get through this, and it was already an emotional day. Then that's even more emotional. That's very different than someone who comes in already, grateful. I mean the whole attitude of the appointment is probably really different. I see what you're saying there, for sure.


[00:42:34] MM: Yeah. I think that that plays out a lot longer, or has a lot more value than we may realize.


[00:42:40] DS: Yeah. That's really cool. I know you said you, you all aren't providing the follow-up hearing aids, or cochlear implants, or if the family is going with ASL. I don't think you guys are teaching that. I'm curious, how that follow-up works. I know, I think this is such a cool – I don't know if this was a coincidence, or if this was a part of the plan. One of the first things that you did, that I have since been trying to do where I am, one of the first things you did was create this amazing map of almost every practice in the state, but especially those that see pediatrics.


I guess, you can use that information for your referrals. Are you finding that in these – by the way, is there is there a term that we use, like a little piece of lingo for an area that has very little access to healthcare? I think, I've heard a term for it before, not a healthcare desert. I've heard of food deserts, where people don't have access to food, but do we have that for healthcare? We have a word?


[00:43:33] MM: There probably is. I know, we call it the zip code lottery, which shows all throughout the health system of your outcomes are going to be much higher if you live in this zip code, if you're in a metro, that sort of thing. 


[00:43:46] DS: I'm googling it. It looks like, it's called a medical, or a care desert. Medical deserts, or care desert. It's the same idea. I'm assuming that there might not be people who do pediatric hearing aids in that town, either. Maybe they don't have to drive four hours. I'm not sure.


[00:44:00] MM: That was one of the first things we did. It's very intricate. We went around right when we started this program, and we met with all these providers all over the state. We got to know them. I have this network, where anybody who sees kids is joined on this network, or has the invitation to join.


What we've done, for instance, the last – I've diagnosed a few kids in the last week. We then figure out, okay, we'll send everything to the pediatrician. A lot of this also relies on the pediatrician. It goes back to them. Some of them have preferences on ENTs that they want them to go see. Our parent navigator will then work with the family on calling the pediatrician to get the scripts, that then they can go see ENT. Typically, if it's not a super complex case, I don't know, we will just like, okay, there's an ENT that's close by. We've created this relationship with different pockets of the state.


Now we're like, “Okay, great. They have a really smooth process on getting kids in and they don't have to wait.” That sort of thing. We then get them into ENT. Then, I will call the audiologist who's nearby, if I've never spoken with them or met them, and just talk with them about what ages do you see. That's also on our map. I created this Google map that's on our website, which we can share.


I went through and it tells us basically, do you take Medicaid? Do you take the CMOS? What insurance do you take? What ages do you do hearing aids? Everything. Yeah. Then, if a family does want to go to Atlanta, that's an option, too, and we help figure out how to get there. We're not telling them where they have to go, but we do – Largely, we point them in the direction of a community – somebody who's near their community. If it's an hour away, versus five hours away.


[00:45:58] DS: That's great. I think, that that makes sense for your program, too. It's mind-blowing to me that you guys do stick with them through all of that. I'm glad to hear it. It's definitely for the best. It's so cool that it's happening. Because I would expect, well, we give them the diagnosis. We say, here's your local resources, and we're out of here. I also can't get over the fact that you guys are the mobile audiology program, but the acronym spells MAP. That was one of the first things you did, right? Is that a coincidence? I don't know.


[00:46:28] MM: Okay. It wasn't really a coincidence. Then we branded everything, made an email that was MAP. Then, we found out that there's another program in Department of Ed that's MAP and we're not allowed to use MAPS.


[00:46:39] DS: Oh, my gosh. That's so funny.


[00:46:41] MM: Now we're GMA, like Grandma. Georgia Mobile Audiology.


[00:46:48] DS: That’s so funny.


[00:46:49] MM: Yeah. We are programmed. Half of our team, they're not audiologist. They're parent navigators. They have this expertise. One of them was a deaf and hard of hearing teacher for 17 years. We find that there is so much value in helping the family get from point A to point B, because and C and D and E and F. Our system is very much set up to be provider hands it to the next provider, to the next provider. Like the family, there's nothing really consistent, at least in our area.


It saves the audiologist time, and then the audiologist can spend more time testing and doing what their expertise is in. I used to do a lot of case management when I worked at the hospital. Now, I don't do that. Sometimes I miss it. Then I'm like, no, I need to be seeing these babies, because I can see them. I can do the testing. Yeah. We value and we really need our parent navigators. It’s a huge piece.


[00:47:51] DS: Wow. I just love the infrastructure that y'all have set up for your program. I think, it's a really great model. I know, y'all are still learning it. You've picked it up from some other people, too. I think, the work you all are doing is really, really cool.


[00:48:02] MM: We appreciate it.


[00:48:03] DS: Okay, so if there is someone in a state where they notice a medical desert, or a care desert, and they are interested in establishing something like this, I know you guys are doing it through a state-based agency. I mean, do you think that's required to set up the infrastructure for this? Or could someone start small? I know you've invited some people in to learn more about this, me being one of those people who’s just interested. Like, I don't know if I can actually do this, but this is interesting to me. What does it take to get started with this?


[00:48:31] MM: No. I definitely think, figuring out – Honestly, I think, most states could probably benefit from this. There is a lack of access to diagnostic ABRs all over the country. One thing would be like, okay, where does the audiologist work? Because that's going to determine the billing. If they work for a hospital, just talking with their hospital, or if they work for public health, or whatever, figuring out okay, what are the bounds of billing? Because I know all of this is going to come down to billing, in many cases. Or just get a grant, because that's what we're doing, and then we don't have to build, but that's a separate topic.


Just looking at that, and then figuring out, okay, what infrastructure already exists? I would highly recommend talking with your state's EDI program and figuring out, okay, because what if they're also applying for a HRSA grant for this or something? Making sure and just letting them know that you're interested in it. Because they need the audiologist and you need somebody onsite, a health department, or a library –


[00:49:37] DS: To refer the babies. Yeah.


[00:49:39] MM: Exactly. Then, a lot of health departments have telemedicine programs and have the equipment in the health department. I know, Georgia has a lot of it. We have genetics, we have all these different things in various health departments that I never knew anything about. I would start by figuring out, okay, where do you as the audiologist work? What bounds are you under, in terms of billing for the hospital and that thing? Then, I would work with the EDI coordinator, or the state, just to see, start there, and the health departments, because that just – it makes sense. It's like, okay, this is a health aspect.


[00:50:19] DS: Yeah. It impacts the whole state when we catch these babies early, and we follow EDI guidelines. Yeah, I see how that could definitely work to an advantage in that way. Okay. That's really great advice. In terms of, we'll call them instead of mistakes, as you mentioned before, we'll call them learning opportunities. What do you feel is some pretty critical advice you would give to someone who is in those early stages of starting a program like this?


[00:50:46] MM: Give yourself some time. Give yourself the startup time. Do not immediately start scheduling patients that actually need a diagnostic ABR. Bring in your kids, your friends’ kids, bring in babies that's no – that's not super high stakes. Or do what we did, where we brought – We did the practice and the setup on babies that just needed that rescreen, because then, you can see tons of babies and you're like, you haven't wasted an appoint – in case they don't pass or something, it's not like, if your mistake is going to then change the trajectory of the meeting these 136.


Just give yourself time. I think as audiologist, we like to just get everything right the first time and we like to be productive, and we to move fast. I know, I do. Just giving yourself that freedom a little bit to make some – not errors. Learning makes them. Opportunities for learning. Then, just also, look at the NCHAM stuff and figure out, is anyone even doing this in your state? Because maybe they are and you just don't know about it. If they are, then see about coordinating with them, rather than starting something new.


I am all about working together, rather than all in these different silos. I mentioned that Department of Public Health had been doing this with Children's Healthcare of Atlanta. I very much have been working with both of them. Then, I ended up doing the training program for Department of Public Health, who's going to be working with [inaudible 00:52:20]. I don't want to have two separate teleprograms. I want it all to be working together, so that yeah. Those would be my recommendations.


[00:52:32] DS: That's great. I think, the idea of slowing down is you're right, hard for many audiologists, but in a situation like this, you definitely want to have it all worked out ahead of time. You don't want to figure this out on the fly when the baby's sleeping. No.


[00:52:47] MM: You want that test assistant to see tons of babies. It was really nice when I was starting to learn ABRs and seeing a bunch of normals, you know what I mean? You see a bunch of normal hearing, so then you know if something's abnormal, or atypical. I would, I think, the same concept goes for this.


[00:53:08] DS: Yeah, that's a great reminder for that. In this process, have there been any professionals you've worked with, or collaborated with that have surprised you? Did you establish some close connections with some pediatricians, or state agency people? You know what I'm saying here? Have any professionals you wouldn't expect it been a big part of this process for you?


[00:53:27] MM: Nothing too intriguing. I mean, the libraries, that was definitely an interesting one, where I was like –


[00:53:34] DS: That is a good one.


[00:53:34] MM: - that makes sense. Okay. They’re just so kind and it's like, I don’t know if anyone’s been into a library recently. It's just like, feel good vibes. Really, just lovely. Then I mean, nurses through the health department. Also, the health department's awesome. They've got otoscopes there. They have everything that you really would need. That also makes perfect sense. No, nothing –


[00:54:02] DS: I guess, that’s surprising to me, too. I picture a health department building as very administrative. The people who work at the health department, you know what I mean? The people who are writing papers and things. But no, there's a clinic in there.


[00:54:14] MM: They’re seeing that in clinics. Yeah, it's all patient care. Yeah.


[00:54:17] DS: That's really, really interesting to me. That's a really cool – that those two places have been able to meet your needs is really, really interesting to me. When it comes to that journey for families after diagnosis, how far into that are you still with them? It sounds like, you're at least getting them set up with their follow-up care. I mean, I know your program is in the beginning stages of some data, but I know that's ultimately where it came from, is this understanding of literacy and literacy impacts. Are you following these babies, because now you know, the date they were diagnosed and the date they were fit and you can track all of those data points to the point where, I think, you – remind me, but was it third grade literacy that was the big marker when I talked to you?


[00:55:02] MM: Yup. Our milestones in Georgia, it basically measures third-grade literacy.


[00:55:09] DS: That's seven years of tracking a kid. You've only been doing this for less than a year, I guess, or about a year?


[00:55:15] MM: Yeah. About a year.


[00:55:20] DS: Busy years don’t account anymore.


[00:55:21] MM: Yeah. I think it's been honestly, six months of actually fully up and running tele. Prior to that, it was training and doing all of that. Our program is birth to 21. We do the whole span. As far as tracking, really, the state has a system to track. Most states do. That's one thing that I want to make sure I make a point to get to know what your state's notification, notifiable situation is. Do you have an online system that you go in and you enter when a baby fails, or passes, or gets diagnosed with hearing loss? And understand, what happens with that information.


For Georgia, they're tracking all of that. If a child gets diagnosed with hearing loss, then they get a specific ID number, a Georgia test identification number. Then, they are going to be able to look at that data at third grade to figure out which kids had hearing loss and what were their literacy scores, versus what –


[00:56:15] DS: Oh, interesting. Interesting.


[00:56:19] MM: We are doing some data tracking, but mostly, we put everything into our state system. We upload everything. Yeah, what we are looking at more on our side is more of the like, okay, how many kids did we see? Where did they live? Figuring out like, okay, how many kids were getting diagnosed before we were in here, and that thing.


Our parent navigator, they have a set schedule of how often they reach out to the family. We get the kids. Our state system also, is how we alert early intervention services. When I go in, and I enter a diagnosis, then it automatically generates referrals to our early intervention programs, which is really awesome, and I understand that's not the case in every state. At that point, we're like, okay, this child is an early intervention. We make sure the family knows, like they can contact us at any point. If the kid’s going to school, and now we have a bunch of questions, or the kid starts crawling, and they're like, “Oh, shoot. What do I do now?” They can contact us. Our parent navigator does – just like, we'll send a text three months out, six months out, just to check in.


[00:57:24] DS: Got you. Got you. Okay. It sounds like, you aren't doing all the data management, but you do have a program in place to at least in those early stages, through those – yeah, that consistent communication. That's great.


All right, so we're just about at the end of our time. I was curious if there was either one experience in doing these Tele-ABRs that's really going to stick with you, that was either really positive or whatever. Or, if you just had one thing, if like, there was someone out there who's like, “I think I'm interested in this, but it sounds like it's too much to chew.” I'll let you pick which of those you want to leave us with.


[00:57:56] MM: Oh, man. I'll go with the second one. It does seem a lot. It is a lot. I would say, I mean, truly, having this perspective from the state side of things. Getting to know your state agencies and who are these people who are at the state level that would have some say in this, I would start there. Because once you figure out like, okay, is there truly a huge need? What is our state's data look like? We’re like, oh, we have 2,000 babies. Okay, this is a lot to chew, but we got to figure this out. It's a collaborative effort for sure, and so I would really encourage you to look at your state agencies and collaborate with them, so that you're not just doing something on your own. That would be my biggest.


[00:58:48] DS: Yeah, that's great advice. That's great advice. I mean, if you work in the pediatrics world, you have to have some connection, but you might not really know the people you're emailing. In our state, you have to rely on them for non-Medicaid hearing aids and the newborn hearing screening programs. At the same time, they might be just a faceless entity that you're faxing records to, you know what I mean, and looking for auth. I think that's really great advice. Even if you're not interested in this kind of a program, just to have a better connection with those people who, at the end of the day, whether that baby is hitting the 136 markers or not, they're the ones keeping track of all that.


[00:59:24] MM: 100%.


[00:59:25] DS: It's good to know who those people are. I totally agree. Awesome. Well, Melanie, having you back, our first ever returned guest, I'm so grateful that you agreed, even though this was our fourth attempt to do this, we got through it. We did it. If people wanted to reach out to you, if they had specific questions, or wanted to see more of these resources, what's the best way to get in contact with you?


[00:59:44] MM: Let me give you my email address, but I also want to give you our website, because it has that training program module on there that's free and it has a bunch of printouts that you can laminate, if you're a type A like me, put on your test assistance equipment. Our website is www.gamobileaudiology.org. Then my work email is melanie.carter@doe.k12.ga.us.


[01:00:22] DS: Got it.


[01:00:23] MM: If anyone is really interested in this and wants to live in Georgia, email me, because we just applied for a very large grant, and we are going to get this and expand it a lot more. We’ll be likely, hiring a couple people, which would be fantastic.


[01:00:43] DS: That's awesome. Well, we'll keep our fingers crossed for your grant. That's really great. Thank you so much for sharing that. I mean, this is invaluable information. I know, after your last episode, I had multiple people reach out to me and be like, “This is something I've been thinking about for a long time. This is so exciting that there are people really doing it.” I have a friend who did a similar program in Maryland, not at the state level, but more for adults. Hers is up and running now. That episode was the catalyst for her to really take the plunge.


I really, really appreciate you joining me and all the work you're doing down there in Georgia, and we'd love to have you back in the future, if you've ever got something new to share, because it sounds like, the services are changing all the time.


[01:01:21] MM: Absolutely. Well, thank you so much for having me. Yeah, anyone, feel free to reach out.


[01:01:26] DS: Awesome. Thanks, Melanie.


[01:01:27] MM: All right. Bye-bye.


[END OF INTERVIEW]


[01:01:29] DS: That's all for today. Thank you so much for listening, subscribing, and rating. This podcast is part of an audio course offered for continuing education, through Speech Therapy PD. Check out the website if you'd like to learn more about the CEU opportunities available for this episode, as well as archived episodes. Just head to speechtherapypd.com/ear. That’s speechtherapypd.com/ear.


[END]
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