Healthcare and Face Coverings: Reducing Communication Barriers for Deaf and Hard of Hearing Patients

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Global pandemics, such as COVID-19, and the increased use and requirements of face coverings, have created greater communication challenges for people who are deaf and hard of hearing. This communication issue is especially problematic in healthcare settings. This guidance sheet provides tips and strategies for effective communication, and is intended to assist healthcare providers, family members, and advocates of people who are deaf and hard of hearing.

Hearing Loss Statistics

In the U.S., about 1 out of every 8 people of all ages have hearing loss and it is the third most common physical condition behind arthritis and heart disease. (Source: HealthyHearing.com) Hearing loss is most significant amongst seniors. The National Institute on Deafness and Other Communication Disorders states "approximately 1 in 3 people in the U.S., between the ages of 65 and 74 has hearing loss, and nearly half of those older than 75 have difficulty hearing."

Effective Communication

People who are deaf and hard of hearing have varying degrees of hearing loss and rely on a variety of communication tools and strategies, such as American Sign Language (ASL) and ASL interpreters, captions, written/printed materials, amplification, and/or assistive technologies. Everyone has different needs, but visual cues, such as mouth/lip movements and facial expressions play a critical role in communication for many in this population. (Source: The University of Alabama at Birmingham) When healthcare providers must wear face coverings, auditory cues are reduced and visual cues are nearly eliminated, creating a frustrating barrier to effective communication.

As with any national emergency or disaster, civil rights laws that address communication access remain in effect during a pandemic, such as COVID-19. This includes Section 504 of the Rehabilitation Act, Section 1557 of the Affordable Care Act, and the Americans with Disabilities Act (ADA). The ADA gives people who are deaf and hard of hearing the right to effective communication in healthcare settings. In summary, healthcare providers must:

• Ensure effective communication and provide appropriate auxiliary aids and services (at no cost), such as qualified interpreters and information in alternate formats to afford an equal opportunity to benefit from the service and;
• Provide reasonable modifications to policies, practices, and procedures, such as a visitation policy, when necessary to avoid disability discrimination.

To determine what will be an effective communication method, providers should consult and actively partner with the person (and/or an appropriate family member/advocate, particularly if the person cannot communicate for themselves). For best practice, honor the request of the patient. Here are examples of auxiliary aids and services, strategies, and tips to reduce communication barriers caused by face coverings in outpatient and inpatient settings:

No-Tech Methods

• Use a face mask with a clear window at the mouth. Currently, the Safe N’Clear Communicator and ClearMask are the only FDA-approved clear masks available for use in a healthcare setting. However, these masks are not N95-style masks and therefore are not safe enough to use with COVID-19 patients and in certain inpatient settings.
• Provide qualified ASL interpreters upon request. For some situations, Video Remote Interpreting (VRI) may be effective. In other situations, an in-person interpreter may be more effective, especially for Deaf-blind consumers. Personal protective equipment should be available for interpreters.
• Check for mutual understanding. Use teach-back techniques. This is particularly important for critical information.
• Provide placards with written and/or pictorial procedures. This can be especially helpful for front-desk staff who assist in routine procedures, such as patient check-in. Laminate these materials so they can be disinfected between patients.
• For simple communication, use dry erase white boards (or writing tablets/pads) and write in large bold letters so words can be read from several feet away.
• Encourage patients to bring their family members/advocates with them for communication assistance. (Note: Family members or advocates are not to be used in place of qualified interpreters.)
• Allow extra time for the communication.
• Use gestures to enhance spoken communication.

Assistive Technology

• Provide video-remote interpreting (VRI), and follow the standards for effective VRI.
• Offer Communication Access Realtime Translation (CART) as an option (live captioning). This can be done remotely.
• Use mobile iPad carts for VRI and CART.
• Use Assistive Listening Devices, such as an FM System, Pocket Talker, etc.
• Patients may have text and/or speech-to-text apps on their smartphones, tablets, etc. Train healthcare providers to oblige patients’ requests to communicate through the patient’s smartphone or other device.
• Consider HIPAA compliant video calls (i.e. have the doctor go to their office where they can safely remove their mask and talk via videophone, or text/email). Patients may also waive HIPAA rights, if necessary, to support their communication needs.
• Upon permission, allow a family member/advocate to listen in by phone and then videoconference with patient or email/text the information. (Note: This option is allowable so long as the patient and provider agree that it is the best way to effectively communicate, e.g. the patient doesn’t use ASL, etc.)
• Healthcare providers can set up post-visit video conferencing with their patients in an area where no mask is required. (Check for HIPAA compliance.)
• Ensure a reliable internet connection, or Wi-Fi environment, for VRI and remote CART, as well as use of communication apps, smartphones, etc. Be sure all devices are charged, regularly checked for functionality, and easily accessible.  
• For smartphone or other handheld options, place on a stationary surface to minimize video movement.
• If the provider and the patient are in different rooms, human-based speech-to-caption conversion can be used with telephone relay services such as Innocaption.

Virtual Health (Telemedicine)

Telemedicine services may offer mask-free communication and should be considered as an alternative. Also, be prepared to arrange three-way video visits (to allow interpreters to participate) or Zoom calls (for CART or interpreting).

Two online articles that further explain VRI resources, communication apps, and other communication strategies are: “COVID-19: Deaf and Hard of Hearing Communication Access Recommendations for the Hospital” by the National Association of the Deaf and “How Do I Communicate with Doctors, Nurses, and Staff at the Hospital During COVID-19?” by the Hearing Loss Association of America.

Advocate for and Empower Deaf and Hard of Hearing Consumers

• Encourage patients to tell every healthcare team member about their hearing loss.
• Arrange accommodations; double-check prior to appointment.
• Promote the use of a Communication Access Plan (CAP).
• Get to know Automatic Speech Recognition (ASR) apps (captioning), such as Ava, Google Live Transcribe, Otter.ai, Interact Streamer (Note: Depending on the microphone, ASR apps may not work well when people are maintaining a 6-foot physical distance.)
• Be aware of texting apps such as Big Note, Cardzilla, and Sorenson Buzz Cards.
• Use communication aids, such as these print-outs or visual tools

(Source: National Academies of Sciences, Engineering, and Medicine webinar, Best Practices for Patient-Clinician Communication for People with Disabilities in the Era of COVID-19)

Signage

Signage can be helpful to inform clinicians and staff, especially if the patient is sleeping, unresponsive, or intubated. Signs can be printed with hearing loss icons or text and posted in highly visible areas in the patient rooms (e.g., over bed or patient room door). Signs can help reduce assumptions that the patient is able to hear and communicate effectively and encourage the arrangements of necessary accommodations.

(Source: Journal of the American Medical Association)

Continuous Quality Improvement

Providing effective communication to patients with disabilities is an ongoing responsibility of healthcare providers and should be a part of a provider’s Continuous Quality Improvement process. As communication access barriers, needs, and solutions change, healthcare providers can stay informed of this important topic by:

• Consulting with and including deaf and hard of hearing healthcare professionals, as they may be used to innovating communications solutions or can provide communication-concordant care.
• Seeking guidance within your institution, nearby, and nationally
  • Association of Medical Professionals with Hearing Loss
  • Hearing Loss Association of America
  • National Association of the Deaf
  • ADA National Network
• Making sure that arrangements are in place to secure assistance, that contacts are current, that equipment works, and that staff are trained on procedures.
• Knowing the procedures for contacting a qualified interpreter before a deaf patient arrives; and knowing how to access alternatives, such as video remote interpreting (VRI).
• Documenting the individual’s communication needs prominently in the medical record and elsewhere, e.g., wrist band, on bed.
• Re-assessing the effectiveness of communication as necessary.

As a reminder, always ask the person who is deaf or hard of hearing what communication strategies work best for them. Their hearing loss severity, language, and communication preferences, and existing physical, mental, and cognitive limitations may vary. (Source: Journal of the American Medical Association)

Additional Resources

• Health and Human Services (HHS) Office for Civil Rights
• Overcoming Additional Barriers to Care for Deaf and Hard of Hearing Patients During COVID-19
• Communicating with Masks During Coronavirus, National Association of the Deaf (NAD)
• Chad Ruffin, MD, chadruffinmd.com
• Knowledge Base, Strategies for Deaf and Hard of Hearing Communication, connect-hear.com
• Deaf/Hard of Hearing/Deaf-Blind Medical Placard, Telecommunications for the Deaf INC. (TDI), tdiforaccess.org
• List of Technology Tools (for people with hearing disabilities), Telecommunications for the Deaf, INC. (TDI), tdiforacces.org
• COVID 19 Picture Communication Board (PowerPoint file), University of Colorado Denver, Center for Inclusive Design and Engineering, 1ucdenver.edu
• Hearing Loss Association of America (HLAA)
• Connect-Hear.com knowledge base on communicating with speech to text apps, masks and face shields, and videoconferencing.

Transparent Masks

• Safe N’Clear Communicator
• ClearMask

Sources

• National Academies of Sciences, Engineering, and Medicine webinar, Best Practices for Patient-Clinician Communication for People with Disabilities in the Era of COVID-19
• Best Practices for Patient-Clinician Communication for People with Disabilities in the Era of COVID-19: A Webinar, The National Academies of Sciences, Engineering, and Medicine
• More Speech Degradations and Considerations in the Search for Transparent Face Coverings During the COVID-19 Pandemic, Audiology Today
• Overcoming Additional Barriers to Care for Deaf and Hard of Hearing Patients During COVID-19