Paediatric hearing aid management: a demonstration project for using virtual visits to enhance parent support

International Journal of Audiology ISSN: 1499-2027 (Print) 1708-8186 (Online) Journal homepage: http://www.tandfonline.com/loi/iija20 Paediatric hearing aid management: a demonstration project for using virtual visits to enhance parent support Karen Muñoz, Kristin Kibbe, Elizabeth Preston, Ana Caballero, Lauri Nelson, Karl White & Michael Twohig To cite this article: Karen Muñoz, Kristin Kibbe, Elizabeth Preston, Ana Caballero, Lauri Nelson, Karl White & Michael Twohig (2016): Paediatric hearing aid management: a demonstration project for using virtual visits to enhance parent support, International Journal of Audiology, DOI: 10.1080/14992027.2016.1226521 To link to this article: http://dx.doi.org/10.1080/14992027.2016.1226521 Published online: 09 Sep 2016. Submit your article to this journal Article views: 67 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=iija20 Download by: [Fudan University] Date: 04 December 2016, At: 12:53 International Journal of Audiology 2016; Early Online: 1–8 Original Article Paediatric hearing aid management: a demonstration project for using virtual visits to enhance parent support Karen Muñoz1,2, Kristin Kibbe1, Elizabeth Preston1, Ana Caballero1, Lauri Nelson1, Karl White2,3 & Michael Twohig3 1 Department of Communicative Disorders and Deaf Education, Utah State University, Logan, UT, USA, 2National Center for Hearing Assessment and Management, Utah State University, Logan, UT, USA, and 3Department of Psychology, Utah State University, Logan, UT, USA Abstract Objective: The purpose of this study was to explore the use of virtual visits to monitor hearing aid use with data logging measurements and provide parent support for hearing aid management. Design: A 6-month longitudinal case study design was used. Study sample: Four families and two providers participated. Results: Average hours of daily hearing aid use increased 3.5 h from the beginning to the end of the study period. Prior to receiving virtual visits, the parents and the clinicians generally indicated they were hopeful about the benefits of virtual visits including the frequency and convenience of the appointments but had some concerns about technical difficulties. These concerns diminished at the conclusion of the study. Conclusion: Virtual visits provided benefits to families including flexibility and timely access to support. The ability to collect data logging information more frequently was important for effective problem-solving to increase hearing aid use. Both parents and clinicians were accepting of tele-support. Parents and professionals would benefit from technology that allows them to access data logging information more easily and frequently. Key Words: Tele-audiology, hearing aid use, data logging Early identification of hearing loss and consistent use of wellfunctioning amplification are crucial for spoken language development for children who are deaf or hard of hearing (DHH). The implementation of universal newborn hearing screening has led to earlier diagnosis and amplification fitting for many children (Muñoz et al, 2013). Recommendations indicate amplification fitting should occur within 1 month of diagnosis (Joint Committee on Infant Hearing [JCIH], 2007), and children who were fit with hearing aids earlier and wear hearing aids 10 or more hours per day have been shown to have better speech and language outcomes (Tomblin et al, 2014, 2015). Parents are central to the intervention process (Jackson et al, 2008; Muñoz et al, 2014), although most do not have experience with hearing aids as almost 95% of children with hearing loss are born to hearing parents (Mitchell & Karchmer, 2004). Support for parent education is critical to assist parents to learn new information and skills to address their child’s needs and for problem-solving challenges that arise. Audiologists have an important role in partnering with parents to support them as they learn to effectively manage their child’s hearing aids day-to-day. Parents have reported encountering a variety of challenges with hearing aid management and use, including problems with hearing aid care and maintenance, recognising benefits of amplification, child behaviour, activities, and feelings of frustration with management (Sjoblad et al, 2001; Walker et al, 2013; Muñoz et al, 2015). Parents of children birth to 3 years of age have reported varying hours of hearing aid use, with many using hearing aids only some of the day (Muñoz et al, 2013, 2015), and others reporting use of 8 h or more per day (Marnane & Ching, 2015). Inconsistent hours of hearing aid use has also been identified through data logging measurements, objective information obtained from the hearing aid software about the number of hours the hearing aid has been on during the measurement period. For example, Jones (2013) found that children 0–4 years (N ¼ 2162) were wearing their hearing aids, on average, only 4 h per day. Muñoz et al (2014) found that children under 5 years of age (N ¼ 25) were wearing hearing aids 4.6 h per day on average. Walker et al (2013) found that parents of children 0–7 years reported an average of 10.84 h, while data logging showed an average wear time of 8.3 h (N ¼ 251), and when parentreported hearing aid use and data logging were compared, it was Correspondence: Karen Muñoz, Department of Communicative Disorders and Deaf Education, Utah State University, 2620 Old Main Hill, Logan, UT, 84322, USA. Tel: (435) 7973701. E-mail: Karen.munoz@usu.edu (Received 16 April 2016; revised 20 June 2016; accepted 16 August 2016) ISSN 1499-2027 print/ISSN 1708-8186 online ß 2016 British Society of Audiology, International Society of Audiology, and Nordic Audiological Society DOI: 10.1080/14992027.2016.1226521 2 K. Muñoz et al. found that 84% of parents overestimated wear time by 2.6 h on average (range ¼ 2–10 h). Recalling hours of use and estimating average use over time for young children can be challenging for parents. Young children often present behaviour challenges that interfere with hearing aid use, resulting in considerable variations in wear time for good and bad days (Muñoz et al, 2015). Data logging provides a way for parents and providers to have an understanding of cumulative use and can be an effective tool for identifying problems with use and determining effective solutions. Objective feedback about hours of use can raise parent awareness and in some cases, this may be enough to resolve the problem and increase hours of use (Muñoz et al, 2014). Although data logging provides important feedback for monitoring and problem-solving, the ability to measure data logging is currently limited to visits with the audiologist, because hearing aids need to be connected to the programming software to access data logging. This limitation may result in problems with hearing aid use not being identified and addressed in a timely manner. For parents to provide effective daily hearing aid management, audiologists may need to provide an array of support including addressing hearing aid retention, confidence with skills and parent emotions (Muñoz et al, 2014), and support needs are likely to vary over time. Telehealth Other areas of healthcare, such as diabetes management, chronic heart conditions, and mental health treatment have used telepractice to address behavioural change to improve health outcomes, and tele-practice has been found to provide similar or improved outcomes compared to in-office visits (Nesbitt et al, 2006; Emme et al, 2014). More frequent access to services is one factor that has contributed to improved outcomes with tele-practice (Verhoeven et al, 2010; Fjeldsoe et al, 2014), and patients have reported positive reactions to this mode of service delivery (Levy & Strachan, 2013). For example, Young et al (2014) found on the diabetes empowerment scale that people who participated in nurse telehealth coaching had higher self-efficacy in diabetes self-management than those participating in typical care. Tele-practice is beneficial in reducing the number of appointments cancelled due to travel constraints or illness, allowing for more family participation (Hofstetter et al, 2010; National Center for Hearing Assessment and Management [NCHAM], 2012). While there are advantages to the use of tele-practice, there are also potential challenges with the use of telehealth programmes. Some services may require additional equipment, Internet connections, and a confidence in working with technology by both the patient and provider (Jarvis-Selinger et al, 2008; NCHAM, 2012). Privacy and ethical issues are also a challenge that must be considered when providing services through telecommunication (Watzlaf et al, 2010, 2011). The American Speech-Language-Hearing Association (2016) recognises tele-practice as a service delivery approach. To date, tele-practice in audiology has been explored for provision of diagnostic testing (Givens & Elangovan, 2003; Lancaster et al, 2008; Swanepoel & Hall, 2010), hearing aid programming and cochlear implant mapping (McElveen et al, 2010; Hughes et al, 2012; Eikelboom et al, 2014) with findings revealing test results similar to those obtained for in-office procedures. In addition, telepractice has been successful for intervention with children who are DHH (Blaiser et al, 2013; Houston et al, 2013). Use of tele-audiology to expand caregiver education and support for daily hearing device management is an area of practice that has not yet been explored. The purpose of this study was to explore the use of virtual visits to monitor hearing aid use with data logging measurements and provide parent support for hearing aid management. Method A longitudinal case study design was used to describe the use of virtual visits in audiology practice to enhance parent support for addressing challenges with hearing aid use and management. Utah State University Institutional Review Board approval was obtained prior to data collection. To access data logging remotely, the researchers partnered with Phonak to use a tele-practice prototype built into the hearing aid programming software, Phonak Target. This tool was not commercially available at the time of this study. Participants Participants (families and providers) were recruited from an early childhood listening and spoken language programme in Utah. Four families were invited to participate in the study; they each had a child aged birth to 5 years with a permanent hearing loss using Phonak hearing aids with data logging capability that could be accessed remotely, and were either experiencing challenges with hearing aid use, or the child was recently fitted with hearing aids. Families were paid an incentive of $10 at the beginning of the study for their time to complete study forms, and $20 at the end of the study to encourage retention for the full 6-month study period. All four families remained in the study for the full time period. Two providers participated in the study. A paediatric audiologist who has been practicing for 9 years, and an audiology graduate student clinician, who is a physician and a native Spanish speaker. Equipment and procedures Each family was provided with a Lenovo laptop computer for use in their home. Two families who did not have Internet and were provided with Verizon hotspot access, for the 6-month study period. The families that were provided Internet service received training on how to operate the computer and connect to the Internet. The client software was pre-loaded onto the computers and the families were provided with a wireless device for remote connections to read data logging results. The clinician virtually connected with the families’ computers from the clinic computer via the hearing aid programming software, Phonak Target. Virtual visits were incorporated into the service delivery plan to provide more flexible contact with families as they worked through challenges related to hearing aid use and management. The schedule included more frequent visits initially as problems were identified and addressed, followed by less frequent visits to monitor progress and identify further support needs. The provider verified each child’s hearing aids in the office, as part of routine practice, to ensure that the hearing aids were fit to prescriptive targets for hearing aid gain and output. Procedures varied somewhat to accommodate family preferences. Two families met initially with the audiologist at the audiology clinic to ensure connectivity, and for the other two families, one clinician was at the family’s home and the other clinician connected from the office to set up the connection and Paediatric hearing aid management explain the process to the family. Reminders were provided (i.e. phone call or text message) for the families 1 or 2 days before each virtual appointment. Communication during virtual visits was conducted over the phone or via video conferencing. Future visits were scheduled at the end of each virtual visit. Families were counseled about data logging and the value in having objective information about hours of hearing aid use to assist with problem-solving. Clinicians emphasised with parents that data logging is a tool that can help identify when problems are occurring and when solutions are being effectively implemented. When participating in a virtual visit, the clinician would begin the videoconference or phone call, and then the family would connect to the client software on the provided laptop. The audiologist would then enter the serial number specific to a family’s wireless device and connect to the software to gather the data logging information. Parental concerns related to hearing aid management were addressed during the visit. Instruments Prior to beginning the virtual visits the primary caregiver completed a family demographic form and a pre-questionnaire about their attitude towards virtual visits. At the conclusion of the study, parents completed a post-questionnaire about their attitude towards virtual visits. All parent questionnaires were available in the family’s native language (i.e. English, Spanish). The providers completed a hearing loss and amplification characteristics form for each child, a log sheet at each visit, a practice demographic form, and a pre- and post-questionnaire about their attitude towards virtual visits. All of the questionnaires were developed for this study by the researchers. FAMILY DEMOGRAPHIC FORM A brief 12-item questionnaire to obtain information about family demographics, including primary mode of communication, race and ethnicity for child and primary caregiver, primary caregiver relationship to child, language spoken in the home, family members with hearing loss, number of children in the home, who the child lives with, primary caregiver educational level, and family income. HEARING LOSS AND AMPLIFICATION CHARACTERISTICS A questionnaire to provide information about the child’s hearing loss including degree, type, and configuration, and to record information on hearing aid verification. PRE- AND POST-ATTITUDE QUESTIONNAIRES Separate but parallel 10-item questionnaires for the parents and the audiologists to collect opinions on virtual visits, hearing aid use, and perceived concerns and benefits of virtual visits. AUDIOLOGIST PRACTICE QUESTIONNAIRE A 7-item survey to gather information about audiologist demographics and practice characteristics, including questions about age and gender, paediatric services and hearing aid management practices. VISIT LOG The visit log documented if the visit was virtual or in person, data logging details (i.e. date range, total hours, average hours per day), 3 parent perception of hearing aid use, concerns raised, problemsolving considerations and plan of action. Analysis Descriptive statistics were calculated for each child and family to identify trends in hours of hearing aid use. Qualitative responses were analysed to identify emergent themes within families. Results Each family participated for the full 6-month study period that consisted of an initial period to observe or better understand family issues, followed by a period of more active problem-solving or education, and then a final monitoring period to determine if additional concerns remained. The families all used spoken language as their mode of communication. Information about child and family demographics, and hearing aid visits are described for each family in Table 1. At the initial visit, the average hearing aid use time of the four children was 7 h (see Figure 1). There was marked improvement during the first 2 months of virtual visits, with an increased average use time of 9.1 h. Hearing aid wear time continued to improve through months 4 and 5 to 9.5 h on average. Hearing wear time plateaued during months 5 and 6 to an average of 9.1 h, and increased again to 10.5 h on average by the final visit, for a total average increase of 3.5 h. Family experiences FAMILY #1 The child was 2 months of age when tele-support was offered, at the time of the hearing aid fitting, to assist the parent with learning hearing aid management tasks and skills needed for consistent hearing aid use, and to address questions and challenges. The mother reported challenges with hearing aid use during feeding due to positioning limitations, and strategies (e.g. toupee tape) to help keep the hearing aid in place were not effective, resulting in lower hours of use for one hearing aid compared to the other. Other issues that arose were resolved in a timely manner by checking in more often with the virtual visits. For example, data logging measurements revealed unusual increases and decreases in hours of hearing aid use, and through discussion with the clinician, the parent realised she forgot to turn the hearing aid off some nights by not opening the battery door. At other times she was not fully closing the battery door when she put the hearing aids on in the morning, so the hearing aids were not turned on. In addition, intermittent hearing aid function was identified because hours of hearing aid use were lower than expected by the parent. The mother subsequently checked hearing aid function throughout the day and discovered intermittent hearing aid function that was promptly repaired. The hours of ‘‘use’’ were influenced by the periods of time when the parent forgot to turn the hearing aids off at night, did not fully close the battery doors, and when the hearing aids were functioning intermittently, resulting in an inaccurate reflection of the actual hours the child was receiving amplification during that period of time. Parent report of daily hours of hearing aid use remained at 10 h per day for every visit, and tended to underestimate use when compared to data logging. Data logging ranged from 2.5 to 19.2. Review of the visit pattern for this family revealed the initial two 4 K. Muñoz et al. Table 1. Child and family demographic and hearing aid visit information. Family Child Agea Gender Ethnicity Additional disabilities Hearing loss Length of time since HA fittinga Primary caregiver Relationship to child Ethnicity Education level Number of children in the home Hearing aid visits Total number of vistis Virtual visits (n) Mean length in minutes 1 2 3 4 2 months Male White Yes Mild-moderate bilateral 2 weeks 24 months Male White No Moderate-severe bilateral 22 months 64 months Female Hispanic No Severe bilateral 40 months 37 months Female Hispanic Yes Mild unilateral 20 months Mother Non-Hispanic College degree 4 Mother Non-Hispanic Some college 3 Mother Hispanic Some high school 4 Grandmother Hispanic Some high school 3 13 54% (7) 12 16 44% (7) 21 11 91% (10) 35 15 87% (12) 33 a Age at entry to the study; HA: hearing aid. Figure 1. Average hours of daily hearing aid use based on data logging measurements for the children combined (N ¼ 7 hearing aids) for the 6-month period of the study. visits were longer (M ¼ 45 min, range 30–60) given the hearing aid fitting and orientation components of the appointments. The following monitoring visits were primarily virtual (7 of 8 visits) and were shorter in length (M ¼ 13 min, range 7–20). The final three visits were in the office and were longer in duration because they were combined with testing to monitor hearing (M ¼ 50 min, range 30–60). FAMILY #2 The child was 24 months of age when tele-support was offered to help the family address challenges they were experiencing with hearing aid use. Even though this family had previous experience with hearing loss and amplification from other family members, they were struggling with having their child wear his hearing aids. The clinician initially focused on technical issues and challenges, such as addressing earmold fit and hearing aid function, and while this was helpful for the family, no change in hearing aid use was observed. When support targeted the child’s behavioural challenges, hearing aid use increased within a few weeks. The parent required several visits close together to learn how to incorporate new behaviour management strategies, coupled with data logging feedback, she was able to modify her responses to her child’s behaviour. The virtual visits provided a mechanism to work through the challenges in a supportive environment that helped her gain confidence in addressing her child’s behaviour. The mother appreciated the support, and expressed this in a letter she wrote after the study: Communication with the audiologist has alleviated a lot of frustrations . . . Thank you for providing an environment for my husband and I to address any and all of our concerns. Parent report of daily hours of hearing aid use tended to underestimate use compared to data logging; however, reports at times overestimated use, and less frequently, were similar to data logging measurements. Data logging ranged from 6.2 to 12.2 average hours of daily hearing aid use. Review of the visit pattern for this family revealed fairly equal distribution throughout the study of virtual and in-office vists, with slightly more in the office. The length of the visit time decreased over the study; the initial period had the longest visits (M ¼ 37 min, range 25–60), and during the middle of the study the visit length was similar to the end of the study (M ¼ 17 min, range 10–15). FAMILY #3 The child was 5 years of age when tele-support was offered to this family to help engage the father and to support his learning needs related to understanding his child’s hearing loss, and how to manage the hearing aids, as his job interfered with his ability to attend inoffice visits. The father was not having his daughter use her hearing aids on weekends, when he was the primary caregiver, and did not understand the importance of amplification use every day. Virtual visits with data logging feedback facilitated conversations with the family about the ramifications of inconsistent hearing aid use and helped the family realise the impact of their decisions and hearing aid use quickly increased. In addition, issues related to excessive battery drain, feedback and otitis media were addressed. The virtual visits enabled the parents to communicate with the clinician about these issues and address them in a timely manner. Parent report of daily hours of hearing aid use tended to underestimate use compared to data logging, and less frequently, Paediatric hearing aid management 5 Table 2. Parent attitude questionnaire responses. Pre-responses Post-responses Question M (SD) Range M (SD) Range Access to support will be/was a valuable option. It will be/was easy to connect my child’s hearing aids to the computer. Virtual visits will be/were more convenient than in-office visits. The quality of the conversation will be/was just as good via a virtual visit as an in-office visit. It will be/was helpful to get feedback about how many hours per day my child was wearing the hearing aids. The audiologist will listen/listened to my concerns. The audiologist will help/helped me to find solutions. I will feel/felt comfortable talking with the audiologist about our challenges. 5 4.3 5 5 5 5 5 4.8 5–5 3–5 5–5 5–5 5–5 5–5 5–5 4–5 5 5 4.8 5 5 5 5 5 5–5 5–5 4–5 5–5 5–5 5–5 5–5 5–5 were similar to data logging measurements. Data logging ranged from 9.4 to 14.9 average hours of daily hearing aid use. Review of the visit pattern for this family revealed predominately virtual visits (10 out of 11 visits). The first visit was the longest in duration (60 min), with the remaining visits lasting 30 min. (0.0) (0.8) (0.0) (0.0) (0.0) (0.0) (0.0) (0.4) (0.0) (0.0) (0.4) (0.0) (0.0) (0.0) (0.0) (0.0) Parents also provided feedback about their perceptions of benefit and their concerns through responses to open-ended questions at the end of the survey. Prior to receiving virtual visits the parents generally indicated they were hopeful about the benefits of telesupport. The aspect of tele-support that was initially most concerning to parents was connecting the hearing aids to the computer, although this was not a concern at the end of the study. FAMILY #4 The child was 3 years of age when this family was offered virtual visits to address challenges they were experiencing with hearing aid use and to support learning needs of extended family members. The grandmother was a primary caregiver during the day and she lacked confidence in managing the hearing aid. Virtual visits were scheduled when the mother, grandmother and other family members could be present to help everyone better understand hearing aid management and to address their challenges. For example, the grandmother struggled with how to manage putting the hearing aid on when the child resisted, and frequently gave up. Virtual visits with data logging feedback helped the family realise the impact of allowing the child’s behaviour to dictate her hearing aid use. As the family learned more effective strategies, they were able to see the influence on hearing aid use, and this feedback was motivating and helped them recognise the strategies that were working. Parent report of daily hours of hearing aid use underestimated, overestimated, and was similar to data logging meausrements on an equal basis. Data logging ranged from 2.2 to 8.3 average hours of daily hearing aid use. Review of the visit pattern for this family revealed predominately virtual visits (12 out of 15 visits). The first visit was the longest in duration (60 min), and all remaining virtual visits were 30 min in length. Virtual visit feedback Parents and audiologists completed a pre- and post-questionnaire related to their attitudes and perspectives about virtual visits and hearing aid use (see Tables 2 and 3). Responses were recorded using a 5-point Likert scale (1 ¼ strongly disagree; 2 ¼ disagree; 3 ¼ not sure how I feel; 4 ¼ agree; 5 ¼ strongly agree) to indicate extent of agreement with each statement. PARENT FEEDBACK Parent responses to the pre-attitude questions suggested a high level of motivation to participate in virtual visits and expectations that it would be helpful for them, as indicated in the positive ratings. The post-attitude responses indicated parents felt positively about the experience. AUDIOLOGIST FEEDBACK The audiologists’ pre-attitude responses indicated generally positive expectations for virtual visits, but there were some initial concerns about connecting to the equipment, the convenience and the quality of services. The post-attitude questions suggested that both audiologists were optimistic about providing services virtually. Clinicians also provided feedback about their perceptions of benefit and their concerns through responses to open-ended questions at the end of the survey. Prior to providing virtual visits the clinicians indicated they were hopeful that the visits would be more frequent and more convenient for the parents. The aspects of tele-support that were most concerning initially to the clinicians were technical difficulties and building a rapport remotely. These concerns diminished at the conclusion of the study, although there was still some concern about scheduling and equipment set-up. Discussion Establishing a parent–professional partnership that supports parents’ ability to implement and sustain effective daily hearing aid management has significant implications for child developmental outcomes. This study provided supplemental virtual visits for four families to track data logging, for children wearing Phonak hearing aids using a non-commercially available software prototype, and to address challenges related to hearing aid use and management. Because data logging is an objective measure that provides average hours of hearing aid use over a period of time, it can serve as a gauge to help identify when problems are interfering with auditory access. Even though the small sample size of this study is a limitation, this in-depth review provides important insights into the benefits of virtual visits and more frequent data logging measurement to help resolve hearing aid use problems. Unfortunately, in current clinical practice, data logging is gathered in the clinic limiting how often hours of use can be monitored and shared with parents – significantly limiting parent ability to identify the impact of hearing aid use problems over time. Benefits and challenges were identified in this study and provide insights related to how data logging, coupled with counseling and 6 K. Muñoz et al. Table 3. Audiologist attitude questionnaire responses. Pre-responses Post-responses Question M (SD) Range M (SD) Range Access to support from home will be/was a valuable option. It will be/was easy to connect to the parent’s computer. Virtual visits will be/were more convenient than in-office visits. The quality of the conversation will be/was just as good via a virtual visit as an in-office visit. It will be/was helpful to get feedback from data logging. I will listen/listened to parent concerns. I will help/helped parents find solutions. I will feel/felt comfortable talking with the parent about their challenges 5 3 4.5 3.5 4.5 4.5 5 4 5–5 3–3 4–5 3–4 4–5 4–5 4–5 4–4 5 5 4.5 5 5 5 5 5 5–5 5–5 4–5 5–5 5–5 5–5 5–5 5–5 support, can help identify problems, provide feedback about progress in addressing challenges, acceptance of delivery via virtual visits, and opportunities technology offers for meeting the needs of families. Lessons learned The virtual visits, coupled with data logging measurement, revealed three primary advantages to families in this study that would not have been as readily available with only in-office appointments. For example, offering flexible support at the time of an infant hearing aid fitting, facilitated parent learning (e.g. fully closing the battery door) that increased the consistency of auditory access for the child, critical for spoken language development. Second, virtual visits provided a way to support families in a more flexible manner to address challenges that arose. Even a parent who has previously gained hearing aid management skills can have their confidence shaken by a difficult situation. A child who does not want to wear hearing aids is not an uncommon occurrence for parents of toddlers and is an often reported as interfering with hearing aid use (Muñoz et al, 2015). As parents learn new strategies and gain confidence in managing the situation, data logging provides important objective feedback about what works. Third, virtual visits could be scheduled at a time that allowed multiple family members to be involved, providing an opportunity to address their learning needs. Having data logging feedback helped other families recognise the impact of their hearing aid management decisions that were detrimental (e.g. not using hearing aids on weekends), and make changes that increased the child’s auditory access. Children often have multiple caregivers; however, audiologists report that they most frequently teach mothers during in-office visits and it is much less common to work with other caregivers directly (Meibos et al, 2015). As a result of this study, an audiologist checklist for virtual visits was developed as a tool to recognise when virtual visits may be a beneficial option, and is available in the Appendix. (0.0) (0.0) (0.5) (0.5) (0.5) (0.5) (0.0) (0.0) (0.0) (0.0) (0.5) (0.0) (0.0) (0.0) (0.0) (0.0) longer wear time! The providers also reported they found the ability to follow-up more frequently and give consistent feedback to the families beneficial. Patients in other areas of healthcare have reported similar benefits, including diabetes and dermatology (Hofmann-Wellenhof et al, 2006; Levy & Strachan, 2013). Physicians and other healthcare providers that have participated in virtual healthcare visits have also had generally positive views after participating in tele-practice, and many reported being open to the idea of using telemedicine (Whitten et al, 2005). Tele-support access Access to tele-support in this study relied on technology that was not readily available to all families. Because the mobile Internet is now nearly ubiquitous in the USA, with 90% of people ages 25 years and older (U.S. Department of Commerce National Telecommunications and Information Administration, 2014), hearing aid manufacturers have the opportunity to offer smart phone applications that would provide broader access to virtual support. Families in this study were optimistic about virtual visits, they thought it would provide them with benefits and it did. Virtual visits could be enhanced with advances in wireless technology, to help families with a wide range of needs and that live in disperse geographical locations. Tele-support offers families the opportunity for access that has the potential to increase hearing aid use, and improve child developmental outcomes. Conclusion Virtual visits provided benefits to families including flexibility and timely access to support. The ability to collect data logging information more frequently than would typically be available with traditional, in-office visits was important for effective problemsolving to increase hearing aid use. Both parents and clinicians were accepting of tele-support. Parents and professionals would benefit from technology that allows them to access data logging information more easily and frequently. Tele-support acceptance Both parents and clinicians viewed tele-support positively, indicating that it was beneficial. Parents particularly appreciated the convenience offered by tele-support, and expressed satisfaction with a tele-support delivery to address their concerns. In fact, two families chose to access most of the support via virtual visits in place of in-office visits. One family expressed: If my child is ill, I could still hold our visit. We also did not have to make an extra trip in our already busy schedule! It was convenient! This program was very helpful in aiding me with useful information to implement Acknowledgements We would like to thank Phonak for their support of this study by providing funding and the necessary software. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article. Paediatric hearing aid management References American Speech-Language-Hearing Association. 2016. Telepractice. Available from http://www.asha.org/Practice-Portal/ProfessionalIssues/Telepractice/. 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Support considerations Never Client has access to Internet Client is Interested in virtual support services Client has difficulty coming to clinic for services Hearing aid programming can be accessed remotely: ____ Yes ____ No Current need, concern or challenge: Person(s) needing support: Name: Relationship to client: Name: Relationship to client: Name: Relationship to client: Type of support needed (describe): Education/information: Skill development: Problem-solving for hearing aid management challenge: Sometimes Often Always