The International Classification of Functioning, Disability and Health as a Framework for Providing Patient- and Family-Centered Audiological Care for Older Adults and Their Significant Others

Abstract

Hearing impairment is highly prevalent in the older population, and it impacts communication and quality of life for both the people with the hearing difficulties and their significant others. In this article, typical audiological assessment and management of an older adult is contrasted with a best practice approach wherein the World Health Organization's International Classification of Functioning, Disability and Health (ICF) framework is applied. The aim of the comparison is to demonstrate how the ICF expands our focus: rather than merely focusing on impairment, we also consider the activities, participation, and contextual factors for both the person with the hearing impairment and his or her family. A case example of an older patient and her spouse is provided, and their shared experience of the patient's hearing impairment is mapped onto the ICF framework. Family-centered hearing care is recommended for individualizing care and improving outcomes for older patients and their families.

Learning Outcomes: As a result of this activity, the participant will be able to (1) describe how the World Health Organization's International Classification of Functioning, Disability and Health can be used in audiological assessment and management planning to facilitate patient- and family-centered care when working with older adults and their significant others; and (2) integrate the World Health Organization's International Classification of Functioning, Disability and Health into clinical audiology practice when working with older adults and their partners.

Recent advances in our understanding of factors influencing help seeking, uptake, and success with hearing interventions have highlighted the importance of psychosocial and sociocultural factors in hearing rehabilitation. For example, support from significant others, confidence in hearing aid use, attitudes to hearing aids, and self-reported hearing impairment were found be significantly predictive of hearing aid use and benefit.^{1 2 3 4} That is, to provide optimal hearing rehabilitation and obtain optimal outcomes, hearing care providers should consider factors beyond a patient's audiometric thresholds. This article will propose a holistic model of hearing rehabilitation and use the World Health Organization's International Classification of Health, Disability and Functioning (ICF) as a framework for providing optimal hearing rehabilitation (Fig. 1).

Figure 1.

The World Health Organization's International Classification of Functioning, Disability and Health.¹³

Patient- and Family-Centered Care in Audiological Rehabilitation for Older Adults and Their Significant Others

Older adults with hearing impairment are likely to experience negative consequences as a result of their impairment, including: poorer psychosocial health,⁵ cognitive decline,⁶ and reduced successful aging.⁷ These secondary consequences of hearing impairment are important factors to consider in planning older adults' hearing rehabilitation. Moreover, older adults with hearing impairment report a preference for audiological rehabilitation that is based on individualized care, active participation, and a strong relationship with their audiologist.⁸

An individualized model of service delivery is consistent with a patient-centered care approach,⁸ and it is widely advocated due to its positive influence on patient health outcomes such as satisfaction and adherence to treatment.^{9 10} Patient-centered care applies several interpersonal skills, including skilled verbal and nonverbal communication, eliciting patients' perspective, empathy, and shared decision-making.¹¹ One limitation of the concept of patient-centered care is that it typically focuses only on the patient–practitioner dyad. That is, the patient-centered care perspective does not explicitly acknowledge the contribution of close family or friends of the patient to the therapeutic process, nor does it acknowledge the impact of a health condition on these family members or friends. The ICF terms this impact “third-party disability.”¹²

Third-party disability is defined as the impaired functioning of family and friends due to the health condition of their significant other.¹³ A growing body of literature links this concept to hearing impairment.^{12 14 15} That is, due to the impact hearing impairment has on communication, manifestations of functioning and disability extend beyond persons with hearing impairment to their significant others.¹⁶ Moreover, given the important influence significant other support has on older adults hearing rehabilitation outcomes,² consideration of the role significant others play in the rehabilitation process is warranted.

To address third-party disability and effectively engage significant others in the rehabilitation process, the practitioner's focus must extend beyond the patient–practitioner dyad to include appropriate significant others. Such a model of care is termed family-centered care. Family-centered care acknowledges the importance of partnerships between clients, significant others, and service providers in intervention planning and success.¹⁷ Importantly, in family-centered care, the needs of significant others also are recognized, with both the patient and significant other considered central in any clinical exchange.¹⁷

The ICF As A Framework for Providing Patient- and Family-Centered Audiological Rehabilitation

As a biopsychosocial approach, the applicability of the ICF to hearing impairment and audiological rehabilitation has been advocated for many years.^{14 18} Despite this advocacy, recent evidence exploring the nature of interactions between older adults and audiologists suggests that current models of service delivery are not consistent with ICF principles.^{19 20 21} For example, history taking (an important time for building a holistic picture of the patient and significant other) tends to be audiologist-led through the use of close-ended questions.¹⁹ Furthermore, patient statements relating to their motivations and readiness are often left unrecognized during the history-taking process.²² This phase of the consultation is short relative to time spent on assessment and management planning.¹⁹ Examination of the management-planning phase of clinical appointments also revealed that interventions were rarely holistic; rather, the focus was on providing amplified sound to overcome the sensory loss alone.²⁰ In addition, family members who attended appointments were not typically invited to contribute to the interaction, despite displaying an interest in doing so.²¹ When family members did participate in the interaction, audiologists typically responded by shifting the conversation back to the client.

A possible reason why patient- and family-centered care principles are poorly implemented in audiological rehabilitation for older adults and their significant others is due to a lack of clear strategies for implementation. It is argued here that the ICF offers a means of operationalizing patient- and family-centered hearing care by ensuring that all components, including body function and structure, activities and participation, and environmental factors and personal factors are addressed in the assessment and management of individual cases. Therefore, the aim of this article is to describe how the ICF can be used to operationalize patient- and family-centered care as a contrast to typical clinical practice.

Clinical Use of the ICF

Although the ICF offers broad structures and perspective on how audiological rehabilitation should be provided to older adults,¹⁸ less has been published on the clinical use of the core sets for hearing loss.²³ The ICF contains over 4,000 codes for the description of the various aspects of body functions and structures, activities, participation and environmental factors, and the core sets include those codes most likely impacted by hearing loss. The comprehensive and brief core sets for hearing loss, as described in Meyer et al (this issue), offer a standard for hearing health professionals to document patients' functioning and a system for policy makers and researchers to quantify profiles of health conditions.²⁴ To date, just one publication purposefully linked the brief core set for hearing loss to audiological assessment.²³ In this article, we will use the core sets for hearing loss to describe the functioning and disability of an older adult with hearing impairment and a significant other.

Case Study

The description of the following case aims to guide the reader through audiometric assessment, management planning, and problem solving in the context of a typical older patient and her spouse, one of whom presents at an audiology clinic for a hearing assessment. This case has two parts: part A illustrates the scope and limitations of working without the guidance of the ICF framework; part B illustrates how use of the ICF facilitates holistic and ultimately patient- and family-centered audiological rehabilitation. Throughout this case, the reader will be asked to reflect on his or her own clinical practice and is encouraged to consider how to use the ICF in the workplace.

Part A—Typical Approach

Case Presentation

Maggie, an 82-year-old woman, attends the clinic today. Maggie walks unassisted and with reasonable confidence from the waiting room. She is carrying her own handbag and a full shopping bag. Maggie is sitting next to a man and appears to know him, but she enters the clinical room alone. Maggie is able to slowly maneuver herself into her chair. This is the first time the audiologist has met Maggie and the first time she has attended an audiology clinic.

Case History

A standard history discussion, combined with responses to a checklist questionnaire conducted in the waiting room, reveal the following information about Maggie. Maggie has no history of medical problems with her ears nor has she seen an ear specialist for any reason; Maggie has no history of significant noise exposure, and she has some concerns with wax buildup and an awareness of high-pitched but soft ringing in her head. In response to the opening prompt: “Tell me about the hearing difficulties you're experiencing,” Maggie replies that she has noticed that she seems to need the TV to be at a higher volume than her husband does, and she is generally aware that she mishears words and misunderstands conversations with family and friends. Maggie reports that conversations with friends usually take place in quiet to slightly noisy places (such as friend's units, cafés, or the activities hall at her residential facility) and conversations with family often occur in her own apartment, her children's homes, or over the phone. These reported concerns have developed gradually over the past 10 years and, although Maggie admits they cause some frustrations to her husband and family, she reports her main worry is being able to comfortably watch the TV with her husband.

Questioning regarding Maggie's dexterity, general health, and living arrangement reveal that she is physically well despite some arthritis, particularly in her right hand (she is right-handed). It is noted that she has put on a pair of glasses to see the audiologist's face clearly but did not have these on when she entered the room. Maggie lives with her husband in an independent living facility located centrally in the medium-sized regional center in which the clinic is located.

Audiometric Assessment

Audiometric findings reveal a bilateral, symmetrical, moderate to severe sensorineural hearing loss with bilateral tinnitus commensurate with the hearing loss. Maggie's speech perception score is consistent with the audiogram, and her spatial processing thresholds are outside the normal range observed for people with normal hearing (although these norms are not applicable to her age group). Immittance results suggest air-filled middle ears with type A tympanograms with normal compliance and an acoustic reflex pattern consistent with a reduced sensation level given her audiogram, that is, absent reflexes at 2 kHz in both ears.

As a summary, all information obtained up to this point of the consultation is superimposed onto the ICF in Table 1. By summarizing information about Maggie in this way, the gaps in our understanding of her circumstances are clearly evident. After conducting a history and a typical audiometric assessment, sufficient information has been obtained regarding the body functions and structures implicated in Maggie's hearing impairment; some information has been gathered about Maggie's activity limitations and her contextual factors.

Table 1. Part A Typical Approach: Summary of Maggie's Information from Case History and Assessment Mapped on to Each Component of the ICF and Relevant Codes.

Component	Information	Code
Health condition	Aging
Body functions and structures	• Moderate to severe sensorineural hearing impairment bilaterally  • Tinnitus	b230, s260, s110 S260
Activity limitations	• Listening to conversations with family and friends  • Receiving spoken messages (mishearing)  • Participating in conversations (regularly asking for repeats)	d115, d310 d310 d350
Participation restrictions	• Unable to watch TV at a shared volume (Maggie's preference too loud)  • Finds conversations with family and friends challenging	d360 d310, d350, d760
Environmental factors	• Lives in assisted living apartment with husband	e310, e580
Personal factors	• Female  • 82 y old  • Some arthritis, particularly in right hand (right-handed)  • Some vision impairment (wears glasses for close up)	NA

Abbreviations: ICF, World Health Organization's International Classification of Functioning, Disability and Health; NA, not available.

Management

Maggie's audiometric results are explained to her by describing the layout and purpose of the audiogram and speech perception testing along with reassurance that there are no blockages in her ears. Maggie is informed that she has a moderate to severe hearing loss that explains her need for higher volumes and likelihood of mishearing conversations, particularly in noise. This feedback is coupled with a recommendation and explanation of how hearing aids would be able to help overcome these difficulties. After Maggie is presented with a recommendation for hearing aids, she is asked how she feels about this option. Maggie reveals that she knows little about hearing aids and so does not want to make the decision for herself. Maggie encourages the audiologist to tell her what she should do.

Audiologist Clinical Decision-Making

Clinically, Maggie's hearing thresholds deem her appropriate for any style of hearing aid; however, her arthritis would likely preclude her from use of a small receiver in the ear or completely in-the-canal device. The configuration of Maggie's hearing impairment (i.e., moderately sloping) suggests that a device with multiple channels will be needed for appropriate fitting and fine-tuning of gain across the frequency range. The most appropriate style is likely a behind-the-ear device with a skeleton mold or a larger custom aid such as an in-the-ear device. To simplify use of the devices, the audiologist concludes that some automatic function is required for program switching and microphone adaptation; moreover, it is unlikely that a volume control/program button would be of use or usable. Given Maggie's different listening environments, she may benefit from noise reduction features that act in separate processing channels.

Client Orientated Scale of Improvement (COSI) goals are defined after the assessment phase to inform which device and level of technology is required.²⁵ When Maggie is asked to prioritize her goals, she chooses to be able (1) to watch the TV at the same volume as husband and (2) to follow more of conversations with friends and family.

Decision-Making Outcome

The audiologist accepts Maggie's request to make the decision and recommends bilateral middle range technology behind-the-ear devices with skeleton molds. Maggie chooses a color to match her hair and impressions are taken on the spot.

Outcome

Maggie leaves the clinical room thanking the audiologist for his kindness and expertise. She understands that she is to return to see you in 2 weeks to pick up the hearing aids. When Maggie meets the older man in the waiting room, he asks how the appointment went. She says that the audiologist was delightful and that the audiologist is giving her hearing aids to help with the TV volume. The older man is Maggie's husband; he has not played a role in Maggie's hearing rehabilitation other than driving her to the consultation.

Maggie returns to the clinic in 2 weeks and is fitted with her hearing aids. Her audiologist is able to match the aids close to the National Acoustic Laboratories - Non Linear 2 (NAL-NL2) target in the clinic room.²⁶ Maggie is taught how to insert the hearing aids and remove them, and she is invited to return in a few weeks to discuss cleaning and other management. The COSI is revisited at 6 weeks postfitting and results reveal a significant reduction in disability (i.e., Maggie reports degree of change for both goals as better). At her annual review, 12 months later, Maggie is happily wearing her hearing aids while she watches the TV at home and it allows the TV volume to be at her husband's preferred level. Maggie's International Outcomes Inventory—Hearing Aids (IOI-HA) results reveal that she is satisfied with her hearing aids, wears the devices less than 4 hours a day, and experiences significant benefit.²⁷ Maggie has stopped attending social events over the last 12 months and communicates with family less frequently. Because Maggie is not wearing her aids regularly, the audiologist inserts the aids for Maggie at the audiology appointment for testing. Overall, the audiologist considers Maggie's audiological rehabilitation a success in her own opinion. Maggie's husband on the other hand, is dissatisfied and is becoming increasingly irritated at Maggie.

Part B—Applying the ICF

In this version of the same case, the audiologist uses the ICF and functional tools that address the ICF components to implement a more patient- and family-centered approach. The reader will note two differences: the depth of information obtained about Maggie, and the change in outcomes when her husband is including in the rehabilitation process.

Case Presentation

Maggie, an 82-year-old woman, attends the clinic today. Maggie and her husband Frank, who was invited to attend today's appointment, are welcomed in the waiting room. As Maggie and Frank walk to the room, it is noted that she carries her handbag but asks her husband to carry a shopping bag in her left hand and holds his arm while walking. Maggie is able to slowly maneuver herself into her chair and greets the audiologist with a smile. Frank looks tired but glad to be here. This is the first time Maggie and Frank have attended an audiology clinic.

Patient Narrative

A history discussion combined with responses to a checklist questionnaire conducted in the waiting room reveal the same medical information as reported in part A. In response to the opening question, “So what prompted you to come along today?” Maggie replies that her husband strongly suggested that she get her hearing checked as he is often angry with her—she wants to make him happy. The audiologist follows this comment up with a conversation about why Maggie thinks her husband is often angry, and similarly, the audiologist seeks Frank's input on the topic. This conversation reveals that Maggie is aware of a difference in preference for the TV volume and she is generally aware that she mishears words and misunderstands conversations with family and friends; however, she is unaware that Frank feels he is always accommodating Maggie's listening needs, is fixing relationships where Maggie has misheard and hurt others' feelings, and is feeling unable to enjoy social events in the presence of these stressors. Similar information is captured regarding Maggie's listening environments as in part A. However, key information regarding the couple's reduction in attendance to social events (dinner with friends, attending table tennis competitions) also is revealed. Moreover, Frank's input prompts a discussion about family: Maggie and Frank have three adult children and five grandchildren; two of the children live nearby and the third lives out of town and therefore mostly communicates over the phone.

The reported concerns have developed gradually over the previous 10 years and, although Maggie admits they cause some frustrations to her husband and family, she reports her main worry being embarrassment at mishearing. Frank, on the other hand, reports that his main concern is Maggie's ability to interact with family and friends and his ability to enjoy social events; he feels that Maggie's personality has changed as a result of her hearing, and her family is losing patience. Both Maggie and Frank's concerns and priorities are reflected in the COSI and Goal Sharing for Partners (GPS) tools,^{25 28} which are conducted as part of a comprehensive preassessment conversation in contrast to the postassessment goals in part A of this case. Maggie's individual goals are: (1) to feel less embarrassed about mishearing conversations; (2) to be able to follow and enjoy conversations with family and friends; (3) to be able to understand conversations with familiar people on the telephone. Their shared goals are: (1) to be able to watch the TV together comfortably; (2) to increase attendance and enjoyment at social events; and (3) to manage miscommunications better around the house. Frank's personal goals are: (1) to increase independence and enjoyment at social events and (2) to feel less frustrated at Maggie.

Questioning regarding Maggie's dexterity, general health, and living arrangement reveal similar information to that reported in part A.

Assessment

Similar objective audiometric assessments are undertaken as reported in part A. Additionally, Maggie is given the Hearing Handicap Inventory for the Elderly-Screening questionnaire and Frank is given the Significant Other Scale for Hearing Disability (SOS-HEAR) questionnaire to complete.^{16 29} The questionnaire results add the following information to the results described in part A: Maggie reports mild to moderate hearing activity limitations and participation restrictions; Frank reports the greatest third-party disability in the domains of communicative burden, relationship changes, and going out and socializing.

A summary of all information obtained up to this point of the consultation is superimposed onto the ICF in Table 2. Moreover, an ICF model has been created and summarized for Frank. In this table, the reader will note that greater depth of information has been obtained from Maggie; new information has been added and the audiologist has an understanding of the impact on Frank. All of this information will shape management planning (Table 3).

Table 2. Summary of Maggie's Information from Part B Patient Narrative and Assessment.

Component	Information	Code
Health condition	Aging	NA
Body functions and structures	• Gradual decline over 10 y  • Moderate to severe sensorineural hearing loss bilaterally  • Tinnitus  • Poor attention when in background noise	b230, s260, s110 S260 b140
Activity limitations	• Mishearing words in conversations with family and friends  • Unable to hear clearly on the phone  • Regularly asking for repeats	d115, d350, d310, d760 d360 d310, d350
Participation restrictions	• Unable to watch TV at a shared volume (Maggie's preference too loud)  • Finds conversations with family and friends challenging; people have been hurt by instances of mishearing  • Reduction in attendance at social events (dinner with friends, attending table tennis competitions)  • Mild-moderate impact score in the emotional scale of HHIE-S  • Feels embarrassed when mishears	d360 d350, d760, d910 d760 d760, d350, d910 d240 d240
Environmental factors	• Lives in assisted living apartment with husband  • Communicates with one adult child and grandchildren over the phone  • Family, including husband are losing patience with Maggie's hearing	e310, e580 e125 e310, e410
Personal factors	• Female  • 82 y old  • Some arthritis, particularly in right hand (right-handed)  • Some vision impairment (wears glasses for close-up viewing)  • Three adult children; five grandchildren  • Two children live nearby; one out of town  • Feels embarrassed when mishears	NA

Abbreviations: HHIE-S, Hearing Handicap Inventory for the Elderly-Screening; NA, not available.

Table 3. Part B ICF Approach: Summary of Frank's Information from Patient Narrative and Assessment.

Component	Information	Code
Health condition	NA
Body functions and structures	NA	NA
Activity limitations / participation restrictions	• Communicative burden:   • Has to participate in conversations with Maggie to ensure she hears appropriately   • Unable to enjoy social events because has to be Maggie's ears and maintain relationships for Maggie   • Reduction in attendance at social events (dinner with friends, attending table tennis competitions)  • Regularly feels angry and frustrated with Maggie	d115, d310, d350 d350, d760, d910, d240 d350, d760, d910, d240 d240, d760
Environmental factors	• Wife has a hearing impairment  • Relationship changes:   • Wife's personality has changed as a result of hearing impairment   • Losing patience at wife	e310, e410 e310
Personal factors	• Male  • Around 80 y of age  • Physically healthy and sociable	NA

Abbreviations: ICF, World Health Organization's International Classification of Functioning, Disability and Health; NA, not available.

Management

Maggie's audiometric results are explained in the context of the everyday difficulties reported by her (e.g., TV volume, asking for repeats) and by Frank (e.g., difficulty understanding speech in noise, impact on attention and enjoyment of social activities). Maggie and Frank are asked for their perspectives on these results; Frank reports being unsurprised and somewhat relieved that he has not been imagining Maggie's hearing difficulties, and Maggie reports feeling a little shocked, but can see how it explains her concerns. Maggie promptly asks if there is anything she can do about her hearing impairment.

The audiologist offers four mutually inclusive options to Maggie and Frank: (1) hearing aids for both ears, which will help with ability to hear sounds; (2) assistive devices for TV use; (3) an amplified telephone (or use of video calls); and (4) a group communication training class for both to attend. Both Maggie and Frank are keen to learn more about hearing aids and interested in attending communication education. Frank, in particular, insists that he will need to help look after the devices and so would like to understand how they work.

Audiologist Clinical Decision-Making

As discussed in part A, Maggie's hearing does not preclude her from any style of hearing aid. Nevertheless, the audiologist understands the importance of being able to use the phone effectively and easily given Maggie and Frank's needs. The audiologist is keen to ensure that Maggie and Frank understand that the hearing aids are just one part of the solution.

Decision-Making Outcome

The audiologist discusses the different style options with Maggie and Frank and they decide on in-the-ear aids to minimize interruption with glasses and ease of use of the phone. Maggie reveals that she is glad Frank is present to help her remember the details and contribute to the decision-making process. Maggie is offered a choice between two levels of technology. Maggie and Frank choose a color to match her hair and impressions are taken on the spot. Overall, Maggie and Frank participate equally in all parts of the decision-making process. After hearing aids are discussed, the audiologist provides details of the communication training and offers some specific communication advice coupled with a handout for the family regarding how to be heard and how to listen well. This conversation raises the issue of how Maggie and Frank cope with miscommunications around the home, and it is clear to the audiologist that there are some underlying reactions to communication problems at home, which will require attention (i.e., Frank gets frustrated and leaves the room). The audiologist discusses some alternative strategies with the couple. Finally, the audiologist asks Maggie and Frank if they have any concerns or questions.

Outcome

Major differences are observed in the outcome for part B of this case in contrast to part A. Maggie and Frank leave your clinical room thanking the audiologist for understanding them and showing them a way forward. Frank takes the pamphlet for the communication education group and aims to attend this group as soon as possible.

The couple returns together in 2 weeks to be fitted with the hearing aids. As in part A, the audiologist is able to match the output of the aids close to the NAL-NL2 target in the clinic room; however, when listening to Frank's voice, a decision is made to allow for acclimatization to occur (i.e., gain is reduced). Maggie and Frank are taught how to insert the hearing aids and remove them, and they are invited to return in a few weeks to discuss cleaning and other management.

The COSI and GPS are revisited 6 weeks postfitting.^{25 28} Maggie's final ability to avoid embarrassing mishearing is better, and a significant reduction in disability is reported for the TV volume and participating in conversations with family and friends including over the telephone is much better. Only minor residual difficulties are reported in communicating with family and friends (specifically in background noise); otherwise, Maggie reports hearing much better 95% of the time. Frank's goals have been met as well. Frank reports a reduction in social restrictions and concern for his relationship with Maggie. Both Maggie and Frank agree that the problems they experience with communication have been reduced, and, because of their education about communication, they both feel that they are getting on better and have an improved understanding of each other's needs.

Maggie's IOI-HA results reveal that she is satisfied with her hearing aids, wears the devices more than 8 hours a day, and experiences significant benefit. Maggie has started catching up with friends and family outside the house more often, and she and Frank attend more social events. Maggie reports that Frank seems to be happier. Frank's SOS-HEAR responses reveal a significant reduction in communicative burden and improvement in their relationship. Importantly, Frank also reports improvements in Maggie's relationship with others (e.g., friends and family). Frank reports that despite them implementing communication strategies, the couple experiences some residual participation restrictions in that Maggie still mishears people in noisy places. The audiologist discusses realistic expectations and reviews some important communication techniques. An International Outcome Inventory–Hearing Aids–Significant Other was conducted,³⁰ and Frank's reports of the outcomes of hearing aid fitting corroborate Maggie's positive results.

At Maggie's annual review, Maggie is happily wearing her hearing aids almost every day. Frank reports that he is in charge of maintaining the aids and helping her insert and remove them, as Maggie has trouble getting the right aid in due to arthritis. The couple has implemented successful communication strategies around the house and Frank is more understanding of Maggie's needs.

Overall, Maggie, Frank and the audiologist consider the audiological rehabilitation a success.

Discussion

In the case example, the ICF was used to illustrate how patient- and family-centered care can be implemented into audiological rehabilitation of older adults and their significant others. Specific strategies used were:

• The audiologist sought a large amount of contextual information (environmental and personal factors) alongside functional information (activity limitations and participation restrictions).

• Information was sought from both the older adult with hearing impairment and her significant other, which highlighted the impact of the hearing impairment on both parties.

• Shared goal setting was used to identify the focus of audiological management.

• Self-report questionnaires were used to supplement objective assessments.

• The person with hearing impairment and significant other were involved in the decision-making process with the audiologist.

• Outcome measures explored functional outcomes for the person with hearing impairment and significant other.

Ultimately, a more individualized and appropriate outcome was achieved with high levels of satisfaction for the person with hearing impairment and the family member.

The case example illustrated how each component of the ICF framework represents an important contribution to understanding the experience of a person with hearing impairment and significant others. Specifically, the ICF reveals that audiometric assessments form only one part of patient assessment in that they provide information about body functions and structures only, and although this information is vital for appropriate management planning, it is no more valuable than other aspects, such as conducting a thorough case history. In part B, the focus on impairment, activity limitations and participation restrictions, and contextual factors shaped the management planning phase and also engaged Maggie in the process of decision-making, a key aspect in health behavior change and adherence to health recommendations.³¹

The ICF specifically facilitated a family-centered approach in this case when used as a guide to involving and engaging Maggie's husband, Frank. Given the third-party disability experienced by significant others, family members can provide important insights into the impact of hearing impairment on everyday communication. Recent research has demonstrated that family members display an interest in being involved in audiology appointments; however, they are rarely provided the opportunity to do so, with audiologists more likely to be patient-focused in their interactions.²¹ Furthermore, even when family members contribute to the discussion by expanding on the answers provided by the patient, answering questions directed at the patient, and asking the audiologist questions, audiologists most often respond by directing the conversation back to the patient, hence ignoring the family member's contribution.²¹ By involving both Maggie and Frank throughout the process, the audiologist in this case was able to offer management strategies that reduced disability for both of them. That is, there was a shared reduction in activity limitations and participation restrictions. Reinforcement from others and helping relationships that support efforts toward change are two key factors that influence the success of long-term behavior change.^{32 33} Furthermore, studies in other areas of health care have found that including family members in interventions for adult chronic conditions can improve health outcomes for both the clients and their family.^{34 35}

Challenges for Implementation

Implementation of patient- and family-centered approaches via use of the ICF framework is not without challenges. The large number of categories in the comprehensive core set for hearing loss (n = 117) can be daunting. Fortunately, the brief core set is more clinically friendly.²³ As highlighted in this case, the brief core set covers the commonly experienced functional and contextual factors relating to hearing loss. Nevertheless, the core sets are limited in that they do not currently consider or code the activity limitations and participation restrictions and contextual factors of significant others. This is a key area for future research.

Several common barriers exist for implementing change in clinical practice. For example, issues relating to clinicians' capability (e.g., confidence to undertake and having the know-how), motivation (e.g., attitude to change, realization of need for change), and opportunity (e.g., time, equipment, organizational demands) often need to be addressed for successful clinician behavior change.³⁶

Recommendations for Clinical Practice

There are several possible ways that audiologists working with older adults could facilitate use of the ICF and a patient- and family-centered approach to audiological rehabilitation. First, audiologists might consider including the ICF framework as a template for keeping their case history notes for both the patient and family member, and such notes could be simplified and summarized for the client and significant other to take home to discuss. Activities could be described as difficulties clients experience because of their hearing loss; participation as impacts of their hearing loss on their lifestyle; and contextual factors as the barriers and facilitators to their ability to hear and communicate as they would like.

Second, shared goal setting could be included in clinical encounters by having both the older person with hearing impairment complete the COSI and/or by using the GPS.²⁸ Finally, many measures of hearing disability and hearing aid outcomes offer significant other versions, which can be used with family members in a family-centered care approach, for example, the International Outcomes Inventory–Hearing Aids–Significant Others and the Significant Other Assessment of Communication.^{30 37} In addition, there are two third-party disability measures available specifically for family members of adults with hearing impairment: the SOS-HEAR¹⁶ and the Hearing Impairment Impact-Significant Other Profile.¹⁵

Conclusions

The aim of this article was to present a rationale for the application of the ICF framework to the audiological assessment and management of an older adult with hearing impairment and the significant other. A case example was used to illustrate how this could occur and to demonstrate the value and relevance of such an approach in audiological rehabilitation. By presenting two versions of the same case (the first using standard practice, the second using an ICF-led model), this article illustrates how audiologists can implement patient- and family-centered care when working with older adults and their significant others. We encourage clinicians to reflect on their own practice and consider how they can implement the ICF in clinical practice:

• What components of the ICF are covered in their audiological rehabilitation appointments now?

• What else do they need to know about their clients and their families?

• How will they find out the perspectives and experiences of clients and families?

• Do they invite family to join the conversation during appointments?

• How can they change their practice to be more patient and family-centered?