APSO Standards: Implementing Hearing Aid Needs Assessments and Measuring Related Outcomes

Abstract

The proportion of individuals who pose to benefit from the use of hearing aids is much smaller than those who adopt them. Likewise, many adults who try hearing devices abandon using them after a short period of time. Most factors related to hearing aid use are unrelated to a patient's hearing loss severity. Hearing loss treatment requires more than the provision of hearing aids as a sole intervention. Adoption rates could be improved through the implementation of evidence-based clinical protocols which maximize patients' success. Recently, the Audiology Practice Standards Organization (APSO) released evidence-based, formal standards of practice addressing hearing aid selection, fitting, and rehabilitation for adult and geriatric patients. Notably, the standards acknowledge the importance of an amplification needs assessment, including hearing aid outcomes measurement. In this brief narrative, we describe Standards 3 and 14 ( Needs Assessment and Hearing Aid Outcomes Measurement ) and offer an example of the clinical implementation of a comprehensive needs assessment and hearing aid outcomes measurement currently being used in a multisite, longitudinal clinical trial.

STANDARDS DISCUSSED

• 3. A needs assessment is conducted in determining candidacy and in making individualized amplification recommendations. A needs assessment includes audiologic, physical, communication, listening, self-assessment, and other pertinent factors affecting patient outcomes.

• 14. Hearing aid outcome measures are conducted. These may include validated self-assessment or communication inventories and aided speech recognition assessment.

Hearing loss is a chronic condition with high prevalence among older adults in the United States. Overall, approximately 25% of adults older than 65 years and over 50% of adults older than 75 years have significant hearing loss. ¹ Numerous studies have demonstrated that untreated hearing loss negatively and significantly impacts quality of life and is linked to increased risk for all-cause dementia, depression, anxiety, and reduced social contacts in older adults. ^{2 3 4} As the U.S. aging population grows, the need for age-related hearing loss intervention will increase, particularly given the heightened awareness of the associations between hearing loss and other comorbidities noted earlier.

In most cases, the negative impact of hearing loss can be effectively remediated using hearing aids. Hearing intervention has been demonstrated to significantly improve symptoms of hearing loss and quality of life in users, ^{5 6} and studies have demonstrated hearing aid use being positively associated with cognitive functioning. ⁷ Although evidence is growing for not only the communicative benefit of hearing intervention but also for general healthy aging and physical functioning, the proportion of individuals who pose to benefit from the use of hearing aids is much smaller than those who adopt them. ^{7 8} Likewise, many adults who try hearing devices abandon using them after a short period of time, resulting in what audiologists coin, “in-the-drawer” or “ITD” hearing aids. ⁹ Systematic reviews of the literature on help-seeking and hearing loss suggest more than 20 probable factors related to hearing aid adoption and regular use. ^{10 11} Some of the most common factors include perception of need (such as severity of functional hearing difficulties or self-perceived hearing handicap), stigma (particularly related to aging and loss of function or independence), and demographic and other socioeconomic variables (such as gender/sex, age, household income, and years of education). Most of the aforementioned factors related to hearing aid adoption and regular use are unrelated to the measured degree of hearing loss, indicating that hearing loss treatment requires more than the simple provision of hearing devices as a sole intervention.

One way in which to address low adoption rates and discontinuation of use of hearing devices is through the implementation of evidence-based clinical protocols which maximize patients' success with amplification. Recently, the Audiology Practice Standards Organization (APSO) released formal standards of practice addressing hearing aid selection, fitting, and rehabilitation for adult and geriatric patients. ¹² The APSO standards are evidence-based, drawing upon both high-quality research and expert opinion, and reflect the most up-to-date clinical protocols for dispensing audiologists. Notably, the standards acknowledge the importance of an amplification needs assessment , including hearing aid outcomes measurement , for adult hearing aid candidates and users. Specifically, these related standards are as follows:

Standard 3 : “A needs assessment is conducted in determining candidacy and in making individualized amplification recommendations. A needs assessment includes audiologic, physical, communication & listening, self-assessment and other pertinent factors affecting outcomes of the patient.”

Standard 14 : “Hearing aid outcome measures are conducted. These may include validated self-assessment or communication inventories and aided speech recognition assessment.”

The purpose of this special issue is to provide guidance on how to carry out the recently approved APSO standards included in S2.1: Hearing Aid Fitting for Adult and Geriatric Patients. In this brief narrative, we will describe Standards 3 and 14 ( Needs Assessment and Hearing Aid Outcomes Measurement , listed earlier) and offer an example of the clinical implementation of evidence-based, comprehensive needs assessment and hearing aid outcomes measurement in line with Standards 3 and 14, currently being used in a multisite, longitudinal clinical trial entitled “Aging and Cognitive Health Evaluation in Elders (ACHIEVE; ClinicalTrials.gov Identifier: NCT03243422).

NEEDS ASSESSMENT

Previous research has highlighted the importance of a needs assessment beyond the basic audiological evaluation for optimizing patient success with amplification, such that both the American Academy of Audiology (AAA) ¹³ and British Society of Audiology (BSA) advocate for inclusion of procedures which address both auditory and non-auditory needs in their most recent practice guidelines for audiologic rehabilitation for adults. ^{13 14} Each of these professional organizations highlights the importance of a bio-psycho-social approach when assessing patient needs for hearing intervention. Biological needs consist of auditory factors, such as the physical status of the external and middle ear, measured audiometric thresholds, speech perception ability in quiet and in noise, central auditory-processing ability, and coexisting medical conditions (among other factors). The APSO standards address auditory needs in detail, stating that a comprehensive valid audiologic assessment (Standard 1) and assessment of speech recognition in noise and frequency-specific loudness discomfort levels (Standard 4) should be included in pre–hearing aid selection and fitting protocols (see Messersmith and Benson, this issue, for a detailed discussion). In addition to auditory needs listed earlier and detailed in Standards 1 and 4, Standard 3 also addresses patient-specific needs beyond the audiogram. With regard to the bio-psycho-social framework, psychological and social needs consist of non-auditory factors, including but not limited to perceived hearing difficulty or hearing handicap, motivation to use hearing aids, family and social supports, home environment, and employment needs.

The clinician's understanding of both auditory and non-auditory needs is important for offering a patient-centered approach to hearing loss rehabilitation. What is needed is a method to quantify the audiologic and non-audiologic characteristics that may influence HA use. An “income” tool would provide a means to determine which devices may be optimal. As suggested by Johnson and Danhauer, attention to income measurement variables at the beginning of the HA fitting process ultimately results in better patient outcomes. ¹⁵ Tools such as the Hearing Aid Needs Assessment (HANA; Schum) ¹⁶ and the Expected Consequences of Hearing Aid Ownership (ECHO; Cox and Alexander) ¹⁷ provide information about how the patient's perceived communication needs and expectations influence outcome; yet, neither instrument assists in the selection of specific devices. In response to this need, Jacobson, Newman, Fabry, and Sandridge developed the Three-Clinic Hearing Aid Selection Profile (HASP) to assess patient's perceptions and attitudes about issues related to both HA and non-HA use to direct the clinician to the most appropriate class of devices (e.g., style, level of technology). ¹⁸

While there are no agreed-upon “best practices” for conducting a needs assessment for the purposes of selecting and fitting hearing aids with adult patients, various procedures and protocols have been suggested in the literature. A protocol suggested by Sweetow ¹⁹ incorporated objective measures, subjective measures, and combined methods. Possible objective measures included speech-in-noise tests such as the QuickSIN, tests of binaural interference, and other central auditory indicators such as tests of listening span. Subjective measures included primarily self-report questionnaires. Finally, the combined method included the Performance-Perceptual Test, ^{20 21} which involves measuring speech perception in noise in terms of number of words repeated correctly at various SNRs and comparing the SNR-50 to the patient's subjective opinion over whether s/he understood every word that was said in the sentence.

A more recent needs assessment battery was suggested by Hotton and Gagné. ²² They describe a procedural “checklist,” the Québec Audiological Assessment Protocol for Younger and Older Adults (QAAP-YOA), a best-practices, evidence-based protocol designed to incorporate audiologic needs, living conditions, personal factors, and patient goals and expectations to design an individualized hearing rehabilitation plan. The authors stress that the QAAP-YOA is not solely a tool for hearing aid selection; rather, other rehabilitative options might be the most appropriate depending on the patient's needs. However, tools such as the QAAP-YOA can serve as valuable clinical resources for dispensing audiologists.

HEARING AID OUTCOMES MEASUREMENT

Hearing aid outcomes measurements are a necessary, but often overlooked, component of hearing aid dispensing. ^{23 24} This is unfortunate, as outcomes are used in healthcare to demonstrate treatment efficacy and effectiveness, justify third-party (insurance) reimbursements, and assess costs and benefits. ²⁵ As hearing loss intervention often involves more than the provision of hearing aids (i.e., person-centered, joint decision-making, self-management and communication skills training, and counseling for psychosocial adjustment are also provided), it is difficult to rely on a singular outcome to represent changes in hearing ability. This is because communication ability, self-perceived hearing difficulties, and other psychological and social aspects of a patient's life are impacted by hearing loss. Thus, both objective and subjective hearing aid outcomes are recommended to best portray pre- and post-hearing aid intervention differences.

Clinically, several tools are available to measure hearing aid outcomes. Objective measures include aided sound field thresholds and aided speech recognition ability in quiet and in noise. Speech-in-noise testing can be utilized to compare unaided versus aided performance, which is particularly salient for new hearing aid users, ²⁶ and can also be used to compare different hearing aids, or different hearing aid program settings. Not only does this provide the clinician with data regarding performance differences, aided speech-in-noise testing also provides the patient with an opportunity to listen under different conditions and select which devices or settings most appropriately meet their needs and preferences. ²⁵

Numerous subjective hearing aid outcomes measures are available and can be readily administered in clinical settings, with little additional time investment on the part of the audiologist. Established, validated, independent instruments are preferred over questionnaires developed by clinicians or hearing instrument manufacturers. ²⁷ There are several benefits of using validated and established measures: patient results can be compared with normative data, the use of reliable and valid measures ensures that change scores are likely a result of improvement and not due to a faulty instrument, and using an established instrument takes the “guess work” out of scoring and interpretation, all of which can assist with device fine-tuning or follow-up counseling. While detailed descriptions of all of the available self-report hearing aid outcomes measures is beyond the scope of this article, the reader is directed to studies by Bentler and Kramer ²⁷ and Bentler et al ²⁸ for excellent in-depth reviews.

CLINICAL IMPLEMENTATION OF NEEDS ASSESSMENT AND HEARING AID OUTCOMES MEASUREMENT IN THE ACHIEVE CLINICAL TRIAL

The ACHIEVE clinical trial study design and pilot outcomes ^{29 30} and comprehensive hearing intervention ³¹ have been described in detail previously. In short, the purpose of ACHIEVE is to determine if delivery of an evidence-based best-practices, person-centered hearing intervention can slow down the trajectory or prevent the onset of all-cause dementia, including Alzheimer's disease. A large body of research supports the independent association between untreated hearing loss and cognitive decline ^{32 33 34} such that a recent statement by the Lancet Commission identified age-related hearing loss as the primary modifiable mid-life risk factor for Alzheimer's disease. ³⁵ The proposed mechanisms underlying this association include the effects of poor audition and distorted peripheral encoding of sound on cognitive load and/or reduced social engagement. These pathways may be modified through delivery of comprehensive hearing rehabilitative treatment consisting of the use of hearing devices. To date the ACHIEVE study is the largest randomized clinical trial investigating whether hearing loss treatment could reduce cognitive declines in older adults.

Needs Assessment in the ACHIEVE Clinical Trial

In line with the APSO standards for Hearing Aid Fitting for Adult and Geriatric Patients, the ACHIEVE hearing intervention requires a comprehensive audiology assessment, assessment of communication needs, and assessment of non-auditory factors which can influence the technical aspects of intervention, as well as the measurement of subjective and objective hearing aid outcomes for ongoing counseling and amplification validation purposes. While the ACHIEVE hearing intervention is delivered as a part of a manualized research protocol, the procedures reflect those commonly delivered in clinical settings. The specific ACHIEVE activities for the needs assessment and related hearing aid outcomes measurement are described in the following section.

In the ACHIEVE clinical trial, the objective of the audiology assessment is to quantify the type and magnitude of hearing loss and confirm that the participant is a candidate for amplification. The audiology assessment primarily addresses biological needs. In addition to a comprehensive audiometric exam consisting of otoscopy, tympanometry, pure-tone air and bone conduction thresholds, word recognition in quiet, speech understanding in noise assessment, and measurement of loudness discomfort levels, audiologists also inspect the physical integrity of the outer and middle ear via otoscopy and assess patients' manual dexterity via direct observation and self-report. Physical elements of the ear and the patient's fine motor capabilities in part determine the style of hearing aid dispensed and/or the acoustic coupling (e.g., open fit vs. earmold).

An important aspect of needs assessment is determining a patient's ability to hearing and understand in challenging listening environments, as these are the scenarios most often cited by those with hearing loss to be troublesome. The other components of a comprehensive audiologic assessment cannot be used to adequately reflect a patient's ability to hear in complex listening environments, nor their perceived handicap in these environments. ^{36 37} Therefore, measuring speech-in-noise performance directly is required. ^{38 39} Despite solid justification, measuring speech-in-noise ability is an often-overlooked component of a comprehensive audiologic assessment. ^{26 40} In this issue, Messersmith and Benson discuss speech-in-noise testing as part of dispensing and fitting hearing aids in detail.

The ACHIEVE clinical trial includes the Quick Speech-in-Noise Test (QuickSIN) ³⁸ to assess speech-in-noise recognition performance using standardized materials in sound-field. The QuickSIN consists of a series of lists of six sentences spoken by a woman, mixed with multi-talker speech babble that increases in 5-dB increments with each sentence presentation, for a signal-to-noise ratio (SNR) varying from 25 to 0 dB. The most homogenous lists were selected for use and a practice list followed by two-test lists was presented. ⁴¹ The test is administered unaided in a sound-treated booth with the patient positioned between two sound speakers that are at least 1-m away from the patient's head. The standardized sound files are routed through the calibrated audiometer, with channel 1 presenting the sentences at 0-degree azimuth using a fixed level of 70 dB SPL, and channel 2 presenting the multi-talker babble noise at 180-degree azimuth ( Fig. 1 ). The audiologist manually adjusts the presentation level of the noise to achieve the SNRs from 25 to 0 dB in 5-dB increments. Patients repeat back what they heard, the target words are scored if correctly repeated, and the total correctly repeated words are used to calculate the “dB SNR Loss” using the average performance from the two-test lists. Most patients comment how the test resembles real-life listening scenarios they commonly encounter, and they have the opportunity to reflect on this communication challenge.

Figure 1.

A schematic of a possible sound field setup for aided speech-in-noise testing.

Psychological and social needs are assessed using self-report assessments, direct observation, and validated hearing-specific questionnaires. As a starting point, the audiologist reviews the participant's history and makes observations during the initial appointment that can inform technical decision-making regarding hearing aids and other devices. The Hearing Handicap Inventory for the Elderly—Screening (HHIE-S) questionnaire ^{42 43} is administered to measure patient's self-perceived hearing handicap and to determine if improvements in self-perceived hearing difficulties are evident following hearing aid intervention. The HHIE-S is a 10-item validated questionnaire that is highly reliable ( r  = 0.97). Items address social and emotional aspects of hearing loss, with scores ranging from 0 to 40 (higher scores indicate greater self-perceived hearing difficulties). Scores greater than 8 suggest significant functional hearing problems. ⁴⁴

To establish patient-specific communication needs and realistic expectations from treatment, patient-centered fitting goals are identified. Goals are critical to quantify the benefits of intervention. In a joint process, the audiologist and the patient complete the Client Oriented Scale of Improvement (COSI), ⁴⁵ a clinical tool developed by National Acoustic Laboratories (NAL) for hearing aid outcomes measurement. The COSI is an open-ended self-report outcome assessment that focuses on patient-set goals and subsequent attainment. Specific, hearing-related goals are defined and prioritized by the patient, with the intent to revisit goals after a sustained period of hearing aid use. Patients then estimate their degree of improvement and final communication ability for each of their identified goals. The COSI is a reliable clinical outcome measure (improvement r  = 0.73; final ability r  = 0.84) that is correlated with other measures of hearing intervention benefit such as the HHIE and the Profile of Hearing Aid Benefit. ⁴⁵

In the ACHIEVE clinical trial, the audiologist administers the baseline COSI assessment to guide technical intervention selection and fitting of hearing aids and other assistive technologies. The audiologist asks the patient to identify three specific listening situations in which s/he would like to improve hearing. Patients are encouraged to be as specific as possible, as improvement or change is more likely to be noticeable and impactful in specific listening scenarios. ⁴⁵ In the event a patient identifies a vague goal (e.g., “ I would like to hear better when in a crowd ”), the audiologist prompts him/her with follow-up “ Wh- ” questions, including (1) Who or What would the patient like to hear; (2) Where is the listening scenario located; and (3) When is the listening scenario taking place. Table 1 provides examples of specific versus nonspecific COSI goals. Finally, once goals are identified and prioritized by the patient, the audiologist assigns each goal to one of nine COSI categories (shown in Table 2 ).

Table 1. Examples of Specific Versus Nonspecific COSI Goals.

Nonspecific COSI goal	Specific COSI goal
“Hear better in noisy places”	“Hear the cashier better when in the checkout lane at the grocery store”
“Hear better on the telephone”	“Hear my sister better when we talk on the telephone”
“Hear better at dinner”	“Hear the conversation better at the table when my children and grandchildren come over for Sunday dinner”
“Hear better at meetings”	“Hear better at my weekly neighborhood association meeting when I am sitting in the back of the room”

Abbreviation: COSI, Client-Oriented Scale of Improvement. ⁴⁵

Table 2. COSI Goal Categories.

COSI category no.	COSI category description
1	TV/Radio at normal volume
2	Conversation in noise
3	Conversation in quiet
4	Church/Meeting
5	Telephone conversations
6	Hear traffic
7	Phone/doorbell ring
8	Social/emotional goal
9	Other

Abbreviation: COSI, Client-Oriented Scale of Improvement. ⁴⁵

ACHIEVE audiologists use information from each patient's needs assessment (biological, psychological, and social) as defined by his/her audiometric profile, speech-in-noise deficit, physical needs, case history, HHIE-S results, and COSI goals to select the most appropriate hearing aids, with regard to style, acoustic coupling, and level of technology. For example, in patients who report a variety of challenging and diverse listening scenarios among their COSI goals (e.g., reverberant environments, regular needs to communicate when driving, goals related to music listening, or goals related to outdoor activities where wind is noted as a problem), the highest level of manufacturer technology (in the case of ACHIEVE, the Phonak B-R 90 receiver-in-canal hearing aid) is selected. Furthermore, all patients have the opportunity to select from a variety of hearing-assistive technologies (HATs) to supplement hearing aid use, including those who are using the lowest level of technology. As another example from the ACHIEVE trial, if patient indicated listening goals included wanting to improve conversations in quiet and hearing the TV at a normal volume, then a lower-level hearing aid technology option coupled with a HAT to stream the TV at the patient's preferred volume would likely be selected as the appropriate selection to meet that patient's individualized needs.

Needs assessments are required for more than hearing aid selection. As a supplement to the hearing aid needs assessment, a HAT needs assessment is also completed to determine what additional assistance ACHIEVE patients receive based on their individual needs, history, hearing loss including unaided QuickSIN score, and COSI goals (see Table 3 for HAT suggestions based on COSI categories). Audiologists review the patient's unaided QuickSIN score, and those who score a +7 dB SNR-50 or greater are offered at minimum some type of HAT to help improve signal to noise ratio such as a remote microphone or FM system. ⁴⁶ As needed, the audiologists use the Line and Box Motivation Tools, developed by the Ida Institute, to obtain patient feedback on his/her thoughts and feelings about the suggested HAT(s). ⁴⁷ The objective is to motivate participants who are uneasy about HATs to try using at least one device in their most difficult listening situation(s); however, motivational interviewing is not necessary for patients who are eager or willing to use HAT(s).

Table 3. Suggested HAT Based on COSI Goal.

Listening category	Suggested HAT(s)
Conversation with 1 or 2 in quiet	Remote microphone
Conversation with 1 or 2 in noise	Remote microphone FM system
Conversation with group in quiet	Remote microphone
Conversation with group in noise	Remote microphone FM system
Television/Radio at normal volume	Infrared TV listening device Bluetooth streamer
Familiar speaker on phone	Telephone or telecoil program Bluetooth streamer
Unfamiliar speaker on phone	Telephone or telecoil program Bluetooth streamer
Hearing phone ring	Bluetooth streamer
Place of worship or meeting	Remote microphone Telecoil program (if looped) FM system

Abbreviations: COSI, Client-Oriented Scale of Improvement ⁴⁵ ; HAT, hearing-assistive technology.

Hearing Aid Outcomes Measurement in the ACHIEVE Clinical Trial

To validate the hearing aid fitting, ACHIEVE audiologists assess outcomes at numerous time points during the hearing intervention period. ³¹ Both objective and subjective outcomes are measured. Hearing aid benefit is objectively measured through comparing aided speech-in-noise ability with unaided ability. Using the same procedural setup as described earlier for the unaided assessment of speech-in-noise performance, patients are tested again with the QuickSIN test while using their hearing aids. Patients are positioned the same between the two speakers and novel QuickSIN tests are presented. The aided performance is expected to improve, with a lower dB SNR Loss score, compared with the unaided performance. For example, if the unaided performance was 11.8-dB SNR loss and the aided performance was 6.8-dB SNR loss, then the patient achieved a 5-dB SNR improvement indicating a clinically meaningful improvement with the hearing aids. If less than expected improvement is seen, then the audiologist and the patient would have the opportunity to discuss the performance which might lead to adjustments in technology, motivation to try HAT to further improve ability. Data logging using the manufacturer fitting software (Phonak Target, in the case of ACHIEVE) is also used to quantify hearing aid outcomes in terms of mean hours of daily wear. For patients who are utilizing hearing aids less than 4 hours per day, the audiologist engages in questions and counseling designed to identify reasons for low use, and offers strategies to increase wear.

For subjective outcomes, the HHIE-S is re-administered to determine whether a reduction in self-perceived social and emotional hearing handicap is evident. A decrease in total score is the desired outcome; if scores are not improved, this provides the audiologist an opportunity to engage with the patient to determine what additional supports can be provided to maximize his/her benefits from amplification. The COSI is also readministered to assess “degree of improvement” and “current ability” for each goal identified by the patient prior to the hearing aid selection and fitting. ⁴⁵ Again, if improvements are not seen or the patient continues to struggle meeting their identified listening goals, the audiologist can provide additional counseling, HAT intervention, or self-management skills training to address the perseverating problems and concerns. Re-administration of the COSI also allows for the patient to identify new listening goals that might have come up during the hearing aid intervention period, particularly when maximum benefits have been achieved with the initially set goals. Prompt cards are used for ease of administration for each COSI goal outcomes attainment measurement ( Fig. 2 ).

Figure 2.

Prompt cards used for administering the Client-Oriented Scale of Improvement (COSI) outcomes measurement. Prompt cards are provided to the patient for selecting a response for the question, “ Rate the degree of change in your hearing ability since your first visit for this goal ” ( A ); and “ Please rate your ability to hear in [state patient's COSI goal] now ” ( B ).

The International Outcome Inventory for Comprehensive Hearing Intervention (IOI-CHI), adapted from the International Outcome Inventory for Hearing Aids (IOI-HA), ⁴⁸ is another self-report hearing aid outcome measurement used in ACHIEVE. The original IOI-HA is a self-report measure of change often administered clinically due to its ease of completion, translation in a wide variety of different languages, and availability of versions. Multiple versions of the IOI are available which are used to assess amplification outcomes: (1) outcomes specific to hearing aid use (IOI-HA); (2) outcomes specific to alternative interventions, such as HATs (IOI-AI) ⁴⁹ ; and (3) communication partner's or significant other's perception of hearing aid outcomes (IOI-Significant Other, IOI-SO). ⁴⁹ In line with all of the previously developed IOI versions, the IOI-CHI used in ACHIEVE includes seven items assessing use, benefit, residual activity limitation, satisfaction, residual participation restriction, impact on others, and quality of life. The IOI-CHI asks the ACHIEVE patient to consider the entire comprehensive hearing intervention when answering each question. Items are scored on an ordinal scale from 1 to 5, with higher scores signifying better outcomes, with a possible total score range from 7 to 40. As with the other self-report hearing aid outcomes measurements used in ACHIEVE, low scores on the IOI-CHI afford the audiologist the opportunity to provide additional supports for patients who continue to struggle, even with the use of hearing aids.

CONCLUSIONS

This review was written to describe APSO Standards on Hearing Aid Needs Assessments and Measuring-Related Outcomes. We offered examples of how these standards were implemented in an ongoing clinical trial that is providing more than 900 older adults with best-practiced hearing intervention across multi-site locations. Implementation of standards is required in evidence-based practice, although sometimes can be the most difficult step to change clinical practice. With the use of examples, suggested scripts, and provided clinical tools, adoption of new standards is more likely. Standards are created as guidelines to support the majority, but the art of providing audiology intervention is rooted in individualized care. The theme centered around individualized approach to hearing intervention should be embraced. Having individualized needs assessments and measuring each patient's outcomes with the intervention provides the best chance of improving uptake and use of hearing aids.