REVIEW ARTICLE
Overcoming barriers to low-vision rehabilitation services: improving the continuum of care Walter Wittich, PhD, FAAO, CLVT,* Antonio Canuto, OD,* Olga Overbury, PhD†,‡ ABSTRACT ● RÉSUMÉ Objective: Low-vision rehabilitation is beneficial for patients with uncorrectable vision impairment, specifically in tasks such as reading and activities of daily living. However, referral to and use of these services remain less than optimal. Inspired by the findings of the Montreal Barriers Study, this article reports on an alternative way of introducing low-vision rehabilitation to clients within an ophthalmology department through the presence of an optometrist. Design: The Department of Ophthalmology at the Jewish General Hospital and the 2 Montreal low-vision rehabilitation agencies established a shared satellite office within the department to overcome administrative barriers, reduce the need for travel, and provide services within a familiar environment for patients. Participants: From June 2011 to December 2012, 35 patients with low vision were seen by 1 of the optometrists within the ophthalmology department. Methods: The optometrist was available on a part-time basis for a total of 20 half days. Results: Seven patients (20%) were already clients of a rehabilitation agency and were seen for follow-up, whereas 3 (9%) did not qualify for rehabilitation based on their level of visual function. A further 6 patients (17%) were treated whereby their needs were met within that appointment, and 19 clients (54%) received initial examination and were referred to the rehabilitation agency for additional services. Conclusions: The presence of a vision rehabilitation agency in an ophthalmology department through its optometrists helps triage patients, increases the integration of this service, and facilitates the continuum of care. Further fine-tuning will focus on increasing staff awareness and expansion of assistive technologies available at the satellite office. Objet : Le redressement de la déficience visuelle est bénéfique pour les patients qui ont des problèmes de vision, concernant particulièrement la lecture et les activités quotidiennes. Il arrive cependant que la référence et le recours à l'utilisation des services pertinents demeurent moins qu'optimaux. Inspiré par les données de l'Étude sur les obstacles à Montréal, le présent article traite d'une autre façon d'introduire le redressement de la déficience visuelle chez les patients d'un département d'ophtalmologie par l'intervention d'un optométriste. Nature : Le Département d'ophtalmologie de l'Hôpital général juif de Montréal et les deux agences montréalaises de redressement de la vision ont établi un bureau satellite partagé au sein du Département, afin de surmonter les barrières administratives, réduire les besoins de déplacement et offrir des services dans un environnement familier pour les patients. Participants : De juin 2011 à décembre 2012, 35 patients ayant une faiblesse visuelle ont été examinés par un des optométristes au sein du département d'ophtalmologie. Méthodes : L'optométriste a été disponible à temps partiel pour un total de 20 demi-journées. Résultats : Sept patients (20 %), qui étaient déjà clients de l'agence de redressement visuel, ont fait l'objet de suivis, alors que 3 (9 %) n'étaient pas qualifiés pour le redressement selon le niveau de fonctionnement visuel. Six autres (17 %) ont été traités pour leurs besoins au moment même du rendez-vous et 19 clients (54 %) ont été référés, suite au le premier examen, à l'agence de redressement pour plus amples services. Conclusions : La présence d'une agence de redressement visuel dans un département d'ophtalmologie par ses optométristes aide à la sélection des patients, accroît l'intégration de ce service et facilite le suivi des soins. Un plus ample affinement sera centré sur l'accroissement de la sensibilisation du personnel et sur l'expansion des technologies d'assistance disponibles au bureau satellite.
A recent systematic review has highlighted that low-vision rehabilitation services improve functional ability, specifically for tasks such as reading and activities of daily living (ADLs), and that patients highly value the use of the assistive aids and training they receive.1 These services include, but are not limited to, the use of compensatory techniques, psychological support, and assistive
technologies, such as strategies for completing ADLs, counseling and mobility skills, or magnification devices.2,3 To assure this success, low-vision rehabilitation service delivery relies on an intricate interplay of numerous professions, making this a prime example of a truly multidisciplinary and interdisciplinary domain of health care. However, the transitions within the continuum of
From the *MAB-Mackay Rehabilitation Centre–Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitaine; †School of Optometry, University of Montreal; and ‡Department of Ophthalmology, McGill University, Montreal, Que.
Can J Ophthalmol 2013;48:463–467 0008-4182/13/$-see front matter & 2013 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2013.05.013
Originally received Feb. 4, 2013. Final revision Apr. 30, 2013. Accepted May 23, 2013 Correspondence to Walter Wittich, PhD, MAB-Mackay Rehabilitation Centre–CRIR, 7000 rue Sherbrooke West, Montreal QC H4B 1R3; [email protected] CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
463
Low vision continuum of care—Wittich et al. care across the spectrum of vision health services are not always as smooth and automatic as they could be. Availability, awareness of, as well as access and referral to, low-vision rehabilitation services have been discussed internationally. Depending on the region, the challenges vary greatly, from the complete absence of services in some developing countries, to limited availability, access, and use,4–6 to models where referral to nongovernmental organizations is required,7 or private practice fee-for-service models,8 all the way to fully government-funded “Cadillac” models of low-vision rehabilitation, such as the Veterans Affairs inpatient model in the United States9 or the multidisciplinary rehabilitation services in Quebec,10 to name only a few. The consensus is that services are available only in a limited fashion where financial resources are sparse. In countries where they are available, eligible individuals are not always informed about their existence, and referral practices require substantial improvement.4,5 In Quebec, the Montreal Barriers Study was able to quantify an interesting obstacle to rehabilitation access, whereby 50% of patients, who were informed about the possibility of rehabilitation services at no cost to the client, chose not to avail themselves of this opportunity.11 This finding indicated certain reluctance on the part of the clients toward wanting this service. A qualitative study was able to elucidate details about these perceptual barriers involved in accessing vision rehabilitation from the client’s viewpoint. At the level of the individual, gradual vision loss left many participants unaware of a need for rehabilitation as long as they were still able to engage in most of their ADLs.12 At the level of their interaction with their eye care professionals, numerous participants reported that they were not well informed or educated, a finding that had previously been described elsewhere,13 in addition to reports of problems with transportation to and from rehabilitation service providers. This last point is particularly relevant in the context of service delivery in spacious countries such as Australia and Canada. Should an eligible client want to access rehabilitation for vision loss, the path can vary greatly, starting from the detection of visual loss (perceived or not) by an eye care professional or the clients themselves, the examination of the cause and eventual diagnosis, all the way through the referral process to professionals such as low-vision therapists, orientation and mobility specialists, rehabilitation teachers, occupational therapists, psychologists, social workers, and many others. Given the complexity of this interplay throughout the care delivery process, there are, nonetheless, instances where administrative regulations can create additional obstacles. In Quebec, for example, optometrists are not part of the Conseil des Médecins, Dentistes et Pharmaciens (Council of Medical Doctors, Dentists and Pharmacists) in a hospital. Under the directorate of professional services, membership in this council is mandatory to be recognized as a professional in the hospital in case they are not paid by the hospital directly, but via the Régie de l’Assurance Maladie du
464
Québec (RAMQ, the Quebec Medicare System). Therefore, the Quebec Ministry of Health does not currently have a billing code for optometric services within a hospital under RAMQ. The situation is entirely different within the private sector, whereby, theoretically, optometrists and ophthalmologists are free to combine their services as they see fit; however, in Quebec, such team efforts in service provision are relatively rare. This regulation creates a particularly interesting barrier in the case of low-vision rehabilitation service delivery because ophthalmologists need to complete a referral to a rehabilitation agency at a different physical location for clients eligible for such services. Once the clients arrive at such an agency (if they choose to follow through on the referral), they undergo an optometric examination to establish their level of eligibility (rehabilitation services only vs additional eligibility for assistive devices at no cost to the client), based on visual acuity, visual field examinations, and functional impairments.14 In addition, the low-vision optometrist then issues further recommendations for services within the agency (e.g., orientation and mobility, provision of and training with assistive devices, counseling), based on the individual needs of the client. This process could, however, be substantially streamlined if such optometric examinations would be available within the ophthalmology department where the referral was initially issued, thereby reducing waiting times and eliminating inappropriate referrals that may block the system. Ideally, this “triage” could be conducted immediately, in an environment familiar to the clients, and without need for an additional appointment or travel. In addition, the presence of such services in an eye clinic would further the legitimacy of low-vision services and integrate them directly into the spectrum of care, thereby facilitating and improving patients’ access. Therefore, a university-based hospital and 2 rehabilitation centres decided to implement a pilot project to facilitate the continuum of care for patients with low vision, and describe its effect on patient flow and referral.
METHODS This article reports on an alternative way to introduce low-vision services through a branch operation of a rehabilitation agency directly within an ophthalmology department. In the Greater Montreal Area, vision rehabilitation services are available through 2 agencies: the MAB-Mackay Rehabilitation Centre and the Institut Nazareth et Louis-Braille. Given the geographic distribution of Montreal on an island and its surrounding regions, these agencies have established 6 satellite service points to facilitate access for clients and reduce travel distance to appointments. These satellite offices are only open on specific days on a part-time basis but provide the basic services available at the agencies’ main sites. They are placed within a variety of locations, such as the School of Optometry of the University of Montreal, the
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
Low vision continuum of care—Wittich et al. Jewish Rehabilitation Hospital (an adult rehabilitation centre that does not offer vision-related services), or other community-based health centres. In collaboration, the 2 agencies opened a satellite office within space provided by the Department of Ophthalmology of the Jewish General Hospital, a McGill University–affiliated teaching hospital. Within this office, the agencies have placed their respective optometrists on a part-time basis, to provide optometric low-vision examinations for clients referred from the ophthalmologists of the department. Because these optometrists are not being employed by the hospital but by the rehabilitation agencies, the regulations of the hospital policy have not been violated while the service through optometry within an ophthalmology department is still made possible.
RESULTS During the period from June 2011 to December 2012, on 20 half days of appointments, a total of 35 referred clients from within the ophthalmology department had been seen by 1 of the optometrists. Of those, 7 (20%) were already clients of the rehabilitation agency and were seen for follow-up within the clinic. Three clients (9%) did not qualify for rehabilitation services based on their level of visual function at the time (acuity and visual field); however, they were informed in more detail about the services offered, should their condition worsen with time. A further 6 clients (17%) were treated at the satellite clinic whereby their rehabilitation needs were met within that appointment, through magnification devices or other immediately available assistive technologies. Finally, 19 clients (54%) received initial examination and rehabilitation services at the satellite office and were then referred to the rehabilitation agency’s main office for additional services, such as orientation and mobility, among others. All eligible patients automatically became clients of the rehabilitation centres. On a qualitative note, several clients commented on the convenience of accessing reahbiliation services in the same place where they receive their regular medical care, mostly because of familiarity with the environment. The optometrist noticed, however, that his direct presence within the department did not spark an immediate flow of referrals.
DISCUSSION This pilot project aimed to facilitate the continuum of care for patients with low vision and describe its effect on patient flow and referral. The results indicated that this new approach to low-vision rehabilitation referral and service delivery is feasible within the regulations of the RAMQ system, practical in terms of reaching and informing the targeted clientele (and their ophthalmologists), and promising in terms of facilitating patient flow and strengthening the cross-disciplinary collaboration and interaction
among eye care professionals. The decision to initiate this new path in service delivery was based on the qualitative and quantitative results of previous studies linked to the Montreal Barriers Study database11,12,15,16 to address the question as how best to facilitate the continuum of lowvision care. The administrations of the rehabilitation agencies interpreted from these studies that awareness of and access to low-vision rehabilitation could be improved through a direct presence of the agencies’ clinicians within the ophthalmology departments. The Montreal Barriers Study was initially partially funded by both rehabilitation agencies, in collaboration with the Vision Research Network of the Fonds de la Recherche en Santé du Québec; however, for the funding cycle 2012/2013, the rehabilitation centres decided to invest their contribution instead toward the salary of the optometrists providing the services within their satellite office. Therefore, a change in service delivery was directly effected as a result of translating evidence-based knowledge, following a previous example of close collaboration of ophthalmologists and optometrists in low-vision rehabilitation service delivery within a hospital setting in Scotland.17 This change of funding allocations is specifically of interest for low-vision service providers in times where resources are sparse and many health organizations find themselves providing more services with fewer resources. Limitations and future directions
The further development of this new type of introduction to low-vision rehabilitation within an ophthalmology department still requires additional fine-tuning. For example, not all ophthalmologists are fully cognizant of the eligibility requirements for these services, or they are still unaware or forgetful of the possibility of referring within the department. Over time, this will be addressed by raising awareness among staff through reminders at internal clinical meetings. As a result, it is anticipated that the number of hours during which the optometrists will be on-site will increase, according to demand and waiting lists. This could also result in an expansion of the services and assistive technologies available at this satellite office, to eliminate the need for agency referral to a different location or for return appointments. Furthermore, the level of visual loss at the time of referral has been problematic. Rarely, the referral arrives early, when the impairment is not advanced enough to pass the RAMQrequired eligibility criteria. More often, the services are introduced late, at a stage where the ophthalmologist has exhausted all treatment possibilities, whereas the client could have benefitted from compensatory strategies and assistive technologies in the meantime. In the research literature, this has been described as “nothing more can be done” from the ophthalmologist’s perspective.13,18 In addition, it has become apparent that, until now, the rehabilitation agencies provided only limited feedback information to the ophthalmologist after the client had
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
465
Low vision continuum of care—Wittich et al. been referred. This is of particular interest because clients with vision loss still remain patients of their ophthalmologist, often for the rest of their lives, for continuing followup examination to maintain ocular health, even if the client may eventually lose all sight (the structure of and around the eye may still require attention). This process of returning information to the ophthalmology file may be able to address several issues: (i) the ophthalmologist is reminded of the existence of rehabilitation services by returning clients who have used the services and by the agency report available in their chart, leading to increased awareness among eye care professionals; (ii) the ophthalmologist can engage the patient in conversation about the success of the rehabilitation process, leading to a better understanding of the client’s current functional status; and (iii) the communication link between the rehabilitation centre and the eye care professional is strengthened, leading to optimized information exchange and improved services. Given the variety of low-vision rehabilitation service delivery around the globe, efforts to overcome access barriers differ as well. For developed countries, such as Canada, efforts to overcome access barriers focus on bringing clients to services or vice versa. The United Kingdom, for example, has succeeded in introducing a new facilitator profession, eye clinic liaison officers, that assist clients in their quest for appropriate information and resources.19 Recent follow-up evaluation has indicated that eye clinic liaison officers primarily provide educational information and emotional support, in addition to referral for further appropriate services.20 Interestingly, in South Devon, an example has been reported whereby the lowvision rehabilitation services were moved out of a hospital setting and into what was termed a more “holistic” environment.21 This move was intended to make clients more comfortable and to provide access to a multiagency and multidisciplinary team.22 With regard to this report, this is comparable with the full services available within the 2 rehabilitation centres. The example in South Devon required patient referrals through the ophthalmology department, but no information was provided as to whether this change in location created access barriers, because the focus of the publication was on the evaluation of patient satisfaction and compliance to assistive device use. In the United States, some of these tasks are often taken on by ophthalmic nurses;23,24 however, the current time constraints within a hospital setting do not always allow for in-depth consultations. The present example of uniting optometric and ophthalmic services within the same hospital department provides an alternative of how to strengthen the continuum of care and how to facilitate access. Undoubtedly, service access will require the ongoing collaboration and exchange of information among all professions and service providers involved. Within Canada, awareness of these services and their benefits to
466
clients is increasing among eye care professionals, which is, in part, reflected in the increasing number of scientific publications in the domain of low-vision rehabilitation in the past decade.25,26 The number of Canadian publications in this field has dramatically increased in recent years, whereby more than 100 articles have been published since 2000. This level of visibility will increase communication and awareness among all stakeholders, and pave the way for increased access to and use of low-vision rehabilitation services, thereby improving the continuum of care.
Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article.
REFERENCES 1. Binns AM, Bunce C, Dickinson C, et al. How effective is low vision service provision? A systematic review. Surv Ophthalmol. 2012;57:34-65. 2. Faye EE. Clinical Low Vision.2nd ed. Boston: Little, Brown; 1984. 3. Corn AL, Erin JN. Foundations of Low Vision : Clinical and Functional Perspectives. 2nd ed. New York: AFB Press; 2010. 4. Chiang PP, O’Connor PM, Le Mesurier RT, Keeffe JE. A global survey of low vision service provision. Ophthalmic Epidemiol. 2011;18:109-21. 5. Chiang PP, Xie J, Keeffe JE. Identifying the critical success factors in the coverage of low vision services using the classification analysis and regression tree methodology. Invest Ophthalmol Vis Sci. 2011;52:2790-5. 6. Walter C, Althouse R, Humble H, Leys MJ, Odom JV. West Virginia survey of visual health: low vision and barriers to access. Vis Impair Res. 2004;6:53-71. 7. O’Connor PM, Mu LC, Keeffe JE. Access and utilization of a new low-vision rehabilitation service. Clin Exp Ophthalmol. 2008;36:547-52. 8. Dagnelie G. Johns Hopkins Lions Low Vision Service: A private practice, fee-for service model. In: Massof RW, Lidoff L, eds. Issues in Low Vision Rehabilitation: Service Delivery, Policy and Funding. New York, NY: AFB Press; 2001:233-51. 9. Maino JH. Low vision and blindness rehabilitation in the VA: Inpatient rehabilitation. In: Massof RW, Lidoff L, eds. Issues in Low Vision Rehabilitation: Service Delivery, Policy and Funding. New York, NY: AFB Press; 2001:187-202. 10. Wittich W, Watanabe DH, Gagne JP. Sensory and demographic characteristics of deafblindness rehabilitation clients in Montreal, Canada. Ophthalmic Physiol Opt. 2012;32:242-51. 11. Overbury O, Wittich W. Barriers to low vision rehabilitation: the Montreal Barriers Study. Invest Ophthalmol Vis Sci. 2011;52:8933-8. 12. Southall K, Wittich W. Barriers to low vision rehabilitation: a qualitative approach. J Vis Impair Blind. 2012;106:261-74. 13. Pollard TL, Simpson JA, Lamoureux EL, Keeffe JE. Barriers to accessing low vision services. Ophthalmic Physiol Opt. 2003;23: 321-7. 14. Regie de l’assurance maladie du Quebec/RAMQ. Services covered in Quebec: visual devices. Retrieved from www.ramq.gouv.qc.ca/en/ citoyens/assurancemaladie/serv_couv_queb/aides_visuelles_pq.shtml. Accessed August 30, 2010. 15. Mwilambwe A, Wittich W, Freeman EE. Disparities in awareness and use of low-vision rehabilitation. Can J Ophthalmol. 2009;44:686-91. 16. Bergeron CM, Wanet-Defalque M-C. Psychological adaptaion to visual impairment: the traditional grief process revised. Br J Vis Impair. 2013;31:20-31. 17. McIlwaine GG, Bell JA, Dutton GN. Low vision aids—is our service cost effective? Eye (Lond). 1991;5(pt 5):607-11. 18. Tanton JH. Nothing more can be done…A fable for our times. Ophthalmol Clin North Am. 1994;7:203-5.
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
Low vision continuum of care—Wittich et al. 19. Norwell C, Hiles C. Why every hospital should have an eye care liaison officer Int Congress Series. 2005;1282:226-9. 20. Subramanian A, Gillespie Gallery H, Conway ML. The role of the Eye Clinic Liaison Officer (ECLO) - A diary study. Investigative Ophthalmology & Visual Science. 2012;53 E-Abstract 4407. 21. Collins J, Skilton K. Low vision services in South Devon: a multiagency, multi-disciplinary approach. Ophthalmic Physiol Opt. 2004; 24:355-9. 22. Shuttleworth GN, Dunlop A, Collins JK, James CR. How effective is an integrated approach to low vision rehabilitation? Two year follow up results from south Devon. Br J Ophthalmol. 1995;79: 719-23.
23. Browne M. The nurse’s role in helping patients cope with sight loss. Nurs Times. 2003;99:30-2. 24. Allen P, Shepherd J. The ophthalmic registered nurse’s responsibility to the adult patient with low vision. Insight. 1998;23:53-8. 25. Teichman JC, Markowitz SN. Canadian research contributions to low-vision rehabilitation. Can J Ophthalmol. 2008;43: 414-8. 26. Wittich W, Sikora L, Watanabe DH, Martinez M. Canadian research contributions to low vision rehabilitation: a quantitative systematic review. Can J Optom. 2012;74:30-7.
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
467
Overcoming barriers to low-vision rehabilitation services: improving the continuum of care Walter Wittich, PhD, FAAO, CLVT,* Antonio Canuto, OD,* Olga Overbury, PhD†,‡ ABSTRACT ● RÉSUMÉ Objective: Low-vision rehabilitation is beneficial for patients with uncorrectable vision impairment, specifically in tasks such as reading and activities of daily living. However, referral to and use of these services remain less than optimal. Inspired by the findings of the Montreal Barriers Study, this article reports on an alternative way of introducing low-vision rehabilitation to clients within an ophthalmology department through the presence of an optometrist. Design: The Department of Ophthalmology at the Jewish General Hospital and the 2 Montreal low-vision rehabilitation agencies established a shared satellite office within the department to overcome administrative barriers, reduce the need for travel, and provide services within a familiar environment for patients. Participants: From June 2011 to December 2012, 35 patients with low vision were seen by 1 of the optometrists within the ophthalmology department. Methods: The optometrist was available on a part-time basis for a total of 20 half days. Results: Seven patients (20%) were already clients of a rehabilitation agency and were seen for follow-up, whereas 3 (9%) did not qualify for rehabilitation based on their level of visual function. A further 6 patients (17%) were treated whereby their needs were met within that appointment, and 19 clients (54%) received initial examination and were referred to the rehabilitation agency for additional services. Conclusions: The presence of a vision rehabilitation agency in an ophthalmology department through its optometrists helps triage patients, increases the integration of this service, and facilitates the continuum of care. Further fine-tuning will focus on increasing staff awareness and expansion of assistive technologies available at the satellite office. Objet : Le redressement de la déficience visuelle est bénéfique pour les patients qui ont des problèmes de vision, concernant particulièrement la lecture et les activités quotidiennes. Il arrive cependant que la référence et le recours à l'utilisation des services pertinents demeurent moins qu'optimaux. Inspiré par les données de l'Étude sur les obstacles à Montréal, le présent article traite d'une autre façon d'introduire le redressement de la déficience visuelle chez les patients d'un département d'ophtalmologie par l'intervention d'un optométriste. Nature : Le Département d'ophtalmologie de l'Hôpital général juif de Montréal et les deux agences montréalaises de redressement de la vision ont établi un bureau satellite partagé au sein du Département, afin de surmonter les barrières administratives, réduire les besoins de déplacement et offrir des services dans un environnement familier pour les patients. Participants : De juin 2011 à décembre 2012, 35 patients ayant une faiblesse visuelle ont été examinés par un des optométristes au sein du département d'ophtalmologie. Méthodes : L'optométriste a été disponible à temps partiel pour un total de 20 demi-journées. Résultats : Sept patients (20 %), qui étaient déjà clients de l'agence de redressement visuel, ont fait l'objet de suivis, alors que 3 (9 %) n'étaient pas qualifiés pour le redressement selon le niveau de fonctionnement visuel. Six autres (17 %) ont été traités pour leurs besoins au moment même du rendez-vous et 19 clients (54 %) ont été référés, suite au le premier examen, à l'agence de redressement pour plus amples services. Conclusions : La présence d'une agence de redressement visuel dans un département d'ophtalmologie par ses optométristes aide à la sélection des patients, accroît l'intégration de ce service et facilite le suivi des soins. Un plus ample affinement sera centré sur l'accroissement de la sensibilisation du personnel et sur l'expansion des technologies d'assistance disponibles au bureau satellite.
A recent systematic review has highlighted that low-vision rehabilitation services improve functional ability, specifically for tasks such as reading and activities of daily living (ADLs), and that patients highly value the use of the assistive aids and training they receive.1 These services include, but are not limited to, the use of compensatory techniques, psychological support, and assistive
technologies, such as strategies for completing ADLs, counseling and mobility skills, or magnification devices.2,3 To assure this success, low-vision rehabilitation service delivery relies on an intricate interplay of numerous professions, making this a prime example of a truly multidisciplinary and interdisciplinary domain of health care. However, the transitions within the continuum of
From the *MAB-Mackay Rehabilitation Centre–Centre de recherche interdisciplinaire en réadaptation du Montréal métropolitaine; †School of Optometry, University of Montreal; and ‡Department of Ophthalmology, McGill University, Montreal, Que.
Can J Ophthalmol 2013;48:463–467 0008-4182/13/$-see front matter & 2013 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jcjo.2013.05.013
Originally received Feb. 4, 2013. Final revision Apr. 30, 2013. Accepted May 23, 2013 Correspondence to Walter Wittich, PhD, MAB-Mackay Rehabilitation Centre–CRIR, 7000 rue Sherbrooke West, Montreal QC H4B 1R3; [email protected] CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
463
Low vision continuum of care—Wittich et al. care across the spectrum of vision health services are not always as smooth and automatic as they could be. Availability, awareness of, as well as access and referral to, low-vision rehabilitation services have been discussed internationally. Depending on the region, the challenges vary greatly, from the complete absence of services in some developing countries, to limited availability, access, and use,4–6 to models where referral to nongovernmental organizations is required,7 or private practice fee-for-service models,8 all the way to fully government-funded “Cadillac” models of low-vision rehabilitation, such as the Veterans Affairs inpatient model in the United States9 or the multidisciplinary rehabilitation services in Quebec,10 to name only a few. The consensus is that services are available only in a limited fashion where financial resources are sparse. In countries where they are available, eligible individuals are not always informed about their existence, and referral practices require substantial improvement.4,5 In Quebec, the Montreal Barriers Study was able to quantify an interesting obstacle to rehabilitation access, whereby 50% of patients, who were informed about the possibility of rehabilitation services at no cost to the client, chose not to avail themselves of this opportunity.11 This finding indicated certain reluctance on the part of the clients toward wanting this service. A qualitative study was able to elucidate details about these perceptual barriers involved in accessing vision rehabilitation from the client’s viewpoint. At the level of the individual, gradual vision loss left many participants unaware of a need for rehabilitation as long as they were still able to engage in most of their ADLs.12 At the level of their interaction with their eye care professionals, numerous participants reported that they were not well informed or educated, a finding that had previously been described elsewhere,13 in addition to reports of problems with transportation to and from rehabilitation service providers. This last point is particularly relevant in the context of service delivery in spacious countries such as Australia and Canada. Should an eligible client want to access rehabilitation for vision loss, the path can vary greatly, starting from the detection of visual loss (perceived or not) by an eye care professional or the clients themselves, the examination of the cause and eventual diagnosis, all the way through the referral process to professionals such as low-vision therapists, orientation and mobility specialists, rehabilitation teachers, occupational therapists, psychologists, social workers, and many others. Given the complexity of this interplay throughout the care delivery process, there are, nonetheless, instances where administrative regulations can create additional obstacles. In Quebec, for example, optometrists are not part of the Conseil des Médecins, Dentistes et Pharmaciens (Council of Medical Doctors, Dentists and Pharmacists) in a hospital. Under the directorate of professional services, membership in this council is mandatory to be recognized as a professional in the hospital in case they are not paid by the hospital directly, but via the Régie de l’Assurance Maladie du
464
Québec (RAMQ, the Quebec Medicare System). Therefore, the Quebec Ministry of Health does not currently have a billing code for optometric services within a hospital under RAMQ. The situation is entirely different within the private sector, whereby, theoretically, optometrists and ophthalmologists are free to combine their services as they see fit; however, in Quebec, such team efforts in service provision are relatively rare. This regulation creates a particularly interesting barrier in the case of low-vision rehabilitation service delivery because ophthalmologists need to complete a referral to a rehabilitation agency at a different physical location for clients eligible for such services. Once the clients arrive at such an agency (if they choose to follow through on the referral), they undergo an optometric examination to establish their level of eligibility (rehabilitation services only vs additional eligibility for assistive devices at no cost to the client), based on visual acuity, visual field examinations, and functional impairments.14 In addition, the low-vision optometrist then issues further recommendations for services within the agency (e.g., orientation and mobility, provision of and training with assistive devices, counseling), based on the individual needs of the client. This process could, however, be substantially streamlined if such optometric examinations would be available within the ophthalmology department where the referral was initially issued, thereby reducing waiting times and eliminating inappropriate referrals that may block the system. Ideally, this “triage” could be conducted immediately, in an environment familiar to the clients, and without need for an additional appointment or travel. In addition, the presence of such services in an eye clinic would further the legitimacy of low-vision services and integrate them directly into the spectrum of care, thereby facilitating and improving patients’ access. Therefore, a university-based hospital and 2 rehabilitation centres decided to implement a pilot project to facilitate the continuum of care for patients with low vision, and describe its effect on patient flow and referral.
METHODS This article reports on an alternative way to introduce low-vision services through a branch operation of a rehabilitation agency directly within an ophthalmology department. In the Greater Montreal Area, vision rehabilitation services are available through 2 agencies: the MAB-Mackay Rehabilitation Centre and the Institut Nazareth et Louis-Braille. Given the geographic distribution of Montreal on an island and its surrounding regions, these agencies have established 6 satellite service points to facilitate access for clients and reduce travel distance to appointments. These satellite offices are only open on specific days on a part-time basis but provide the basic services available at the agencies’ main sites. They are placed within a variety of locations, such as the School of Optometry of the University of Montreal, the
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
Low vision continuum of care—Wittich et al. Jewish Rehabilitation Hospital (an adult rehabilitation centre that does not offer vision-related services), or other community-based health centres. In collaboration, the 2 agencies opened a satellite office within space provided by the Department of Ophthalmology of the Jewish General Hospital, a McGill University–affiliated teaching hospital. Within this office, the agencies have placed their respective optometrists on a part-time basis, to provide optometric low-vision examinations for clients referred from the ophthalmologists of the department. Because these optometrists are not being employed by the hospital but by the rehabilitation agencies, the regulations of the hospital policy have not been violated while the service through optometry within an ophthalmology department is still made possible.
RESULTS During the period from June 2011 to December 2012, on 20 half days of appointments, a total of 35 referred clients from within the ophthalmology department had been seen by 1 of the optometrists. Of those, 7 (20%) were already clients of the rehabilitation agency and were seen for follow-up within the clinic. Three clients (9%) did not qualify for rehabilitation services based on their level of visual function at the time (acuity and visual field); however, they were informed in more detail about the services offered, should their condition worsen with time. A further 6 clients (17%) were treated at the satellite clinic whereby their rehabilitation needs were met within that appointment, through magnification devices or other immediately available assistive technologies. Finally, 19 clients (54%) received initial examination and rehabilitation services at the satellite office and were then referred to the rehabilitation agency’s main office for additional services, such as orientation and mobility, among others. All eligible patients automatically became clients of the rehabilitation centres. On a qualitative note, several clients commented on the convenience of accessing reahbiliation services in the same place where they receive their regular medical care, mostly because of familiarity with the environment. The optometrist noticed, however, that his direct presence within the department did not spark an immediate flow of referrals.
DISCUSSION This pilot project aimed to facilitate the continuum of care for patients with low vision and describe its effect on patient flow and referral. The results indicated that this new approach to low-vision rehabilitation referral and service delivery is feasible within the regulations of the RAMQ system, practical in terms of reaching and informing the targeted clientele (and their ophthalmologists), and promising in terms of facilitating patient flow and strengthening the cross-disciplinary collaboration and interaction
among eye care professionals. The decision to initiate this new path in service delivery was based on the qualitative and quantitative results of previous studies linked to the Montreal Barriers Study database11,12,15,16 to address the question as how best to facilitate the continuum of lowvision care. The administrations of the rehabilitation agencies interpreted from these studies that awareness of and access to low-vision rehabilitation could be improved through a direct presence of the agencies’ clinicians within the ophthalmology departments. The Montreal Barriers Study was initially partially funded by both rehabilitation agencies, in collaboration with the Vision Research Network of the Fonds de la Recherche en Santé du Québec; however, for the funding cycle 2012/2013, the rehabilitation centres decided to invest their contribution instead toward the salary of the optometrists providing the services within their satellite office. Therefore, a change in service delivery was directly effected as a result of translating evidence-based knowledge, following a previous example of close collaboration of ophthalmologists and optometrists in low-vision rehabilitation service delivery within a hospital setting in Scotland.17 This change of funding allocations is specifically of interest for low-vision service providers in times where resources are sparse and many health organizations find themselves providing more services with fewer resources. Limitations and future directions
The further development of this new type of introduction to low-vision rehabilitation within an ophthalmology department still requires additional fine-tuning. For example, not all ophthalmologists are fully cognizant of the eligibility requirements for these services, or they are still unaware or forgetful of the possibility of referring within the department. Over time, this will be addressed by raising awareness among staff through reminders at internal clinical meetings. As a result, it is anticipated that the number of hours during which the optometrists will be on-site will increase, according to demand and waiting lists. This could also result in an expansion of the services and assistive technologies available at this satellite office, to eliminate the need for agency referral to a different location or for return appointments. Furthermore, the level of visual loss at the time of referral has been problematic. Rarely, the referral arrives early, when the impairment is not advanced enough to pass the RAMQrequired eligibility criteria. More often, the services are introduced late, at a stage where the ophthalmologist has exhausted all treatment possibilities, whereas the client could have benefitted from compensatory strategies and assistive technologies in the meantime. In the research literature, this has been described as “nothing more can be done” from the ophthalmologist’s perspective.13,18 In addition, it has become apparent that, until now, the rehabilitation agencies provided only limited feedback information to the ophthalmologist after the client had
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
465
Low vision continuum of care—Wittich et al. been referred. This is of particular interest because clients with vision loss still remain patients of their ophthalmologist, often for the rest of their lives, for continuing followup examination to maintain ocular health, even if the client may eventually lose all sight (the structure of and around the eye may still require attention). This process of returning information to the ophthalmology file may be able to address several issues: (i) the ophthalmologist is reminded of the existence of rehabilitation services by returning clients who have used the services and by the agency report available in their chart, leading to increased awareness among eye care professionals; (ii) the ophthalmologist can engage the patient in conversation about the success of the rehabilitation process, leading to a better understanding of the client’s current functional status; and (iii) the communication link between the rehabilitation centre and the eye care professional is strengthened, leading to optimized information exchange and improved services. Given the variety of low-vision rehabilitation service delivery around the globe, efforts to overcome access barriers differ as well. For developed countries, such as Canada, efforts to overcome access barriers focus on bringing clients to services or vice versa. The United Kingdom, for example, has succeeded in introducing a new facilitator profession, eye clinic liaison officers, that assist clients in their quest for appropriate information and resources.19 Recent follow-up evaluation has indicated that eye clinic liaison officers primarily provide educational information and emotional support, in addition to referral for further appropriate services.20 Interestingly, in South Devon, an example has been reported whereby the lowvision rehabilitation services were moved out of a hospital setting and into what was termed a more “holistic” environment.21 This move was intended to make clients more comfortable and to provide access to a multiagency and multidisciplinary team.22 With regard to this report, this is comparable with the full services available within the 2 rehabilitation centres. The example in South Devon required patient referrals through the ophthalmology department, but no information was provided as to whether this change in location created access barriers, because the focus of the publication was on the evaluation of patient satisfaction and compliance to assistive device use. In the United States, some of these tasks are often taken on by ophthalmic nurses;23,24 however, the current time constraints within a hospital setting do not always allow for in-depth consultations. The present example of uniting optometric and ophthalmic services within the same hospital department provides an alternative of how to strengthen the continuum of care and how to facilitate access. Undoubtedly, service access will require the ongoing collaboration and exchange of information among all professions and service providers involved. Within Canada, awareness of these services and their benefits to
466
clients is increasing among eye care professionals, which is, in part, reflected in the increasing number of scientific publications in the domain of low-vision rehabilitation in the past decade.25,26 The number of Canadian publications in this field has dramatically increased in recent years, whereby more than 100 articles have been published since 2000. This level of visibility will increase communication and awareness among all stakeholders, and pave the way for increased access to and use of low-vision rehabilitation services, thereby improving the continuum of care.
Disclosure: The authors have no proprietary or commercial interest in any materials discussed in this article.
REFERENCES 1. Binns AM, Bunce C, Dickinson C, et al. How effective is low vision service provision? A systematic review. Surv Ophthalmol. 2012;57:34-65. 2. Faye EE. Clinical Low Vision.2nd ed. Boston: Little, Brown; 1984. 3. Corn AL, Erin JN. Foundations of Low Vision : Clinical and Functional Perspectives. 2nd ed. New York: AFB Press; 2010. 4. Chiang PP, O’Connor PM, Le Mesurier RT, Keeffe JE. A global survey of low vision service provision. Ophthalmic Epidemiol. 2011;18:109-21. 5. Chiang PP, Xie J, Keeffe JE. Identifying the critical success factors in the coverage of low vision services using the classification analysis and regression tree methodology. Invest Ophthalmol Vis Sci. 2011;52:2790-5. 6. Walter C, Althouse R, Humble H, Leys MJ, Odom JV. West Virginia survey of visual health: low vision and barriers to access. Vis Impair Res. 2004;6:53-71. 7. O’Connor PM, Mu LC, Keeffe JE. Access and utilization of a new low-vision rehabilitation service. Clin Exp Ophthalmol. 2008;36:547-52. 8. Dagnelie G. Johns Hopkins Lions Low Vision Service: A private practice, fee-for service model. In: Massof RW, Lidoff L, eds. Issues in Low Vision Rehabilitation: Service Delivery, Policy and Funding. New York, NY: AFB Press; 2001:233-51. 9. Maino JH. Low vision and blindness rehabilitation in the VA: Inpatient rehabilitation. In: Massof RW, Lidoff L, eds. Issues in Low Vision Rehabilitation: Service Delivery, Policy and Funding. New York, NY: AFB Press; 2001:187-202. 10. Wittich W, Watanabe DH, Gagne JP. Sensory and demographic characteristics of deafblindness rehabilitation clients in Montreal, Canada. Ophthalmic Physiol Opt. 2012;32:242-51. 11. Overbury O, Wittich W. Barriers to low vision rehabilitation: the Montreal Barriers Study. Invest Ophthalmol Vis Sci. 2011;52:8933-8. 12. Southall K, Wittich W. Barriers to low vision rehabilitation: a qualitative approach. J Vis Impair Blind. 2012;106:261-74. 13. Pollard TL, Simpson JA, Lamoureux EL, Keeffe JE. Barriers to accessing low vision services. Ophthalmic Physiol Opt. 2003;23: 321-7. 14. Regie de l’assurance maladie du Quebec/RAMQ. Services covered in Quebec: visual devices. Retrieved from www.ramq.gouv.qc.ca/en/ citoyens/assurancemaladie/serv_couv_queb/aides_visuelles_pq.shtml. Accessed August 30, 2010. 15. Mwilambwe A, Wittich W, Freeman EE. Disparities in awareness and use of low-vision rehabilitation. Can J Ophthalmol. 2009;44:686-91. 16. Bergeron CM, Wanet-Defalque M-C. Psychological adaptaion to visual impairment: the traditional grief process revised. Br J Vis Impair. 2013;31:20-31. 17. McIlwaine GG, Bell JA, Dutton GN. Low vision aids—is our service cost effective? Eye (Lond). 1991;5(pt 5):607-11. 18. Tanton JH. Nothing more can be done…A fable for our times. Ophthalmol Clin North Am. 1994;7:203-5.
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
Low vision continuum of care—Wittich et al. 19. Norwell C, Hiles C. Why every hospital should have an eye care liaison officer Int Congress Series. 2005;1282:226-9. 20. Subramanian A, Gillespie Gallery H, Conway ML. The role of the Eye Clinic Liaison Officer (ECLO) - A diary study. Investigative Ophthalmology & Visual Science. 2012;53 E-Abstract 4407. 21. Collins J, Skilton K. Low vision services in South Devon: a multiagency, multi-disciplinary approach. Ophthalmic Physiol Opt. 2004; 24:355-9. 22. Shuttleworth GN, Dunlop A, Collins JK, James CR. How effective is an integrated approach to low vision rehabilitation? Two year follow up results from south Devon. Br J Ophthalmol. 1995;79: 719-23.
23. Browne M. The nurse’s role in helping patients cope with sight loss. Nurs Times. 2003;99:30-2. 24. Allen P, Shepherd J. The ophthalmic registered nurse’s responsibility to the adult patient with low vision. Insight. 1998;23:53-8. 25. Teichman JC, Markowitz SN. Canadian research contributions to low-vision rehabilitation. Can J Ophthalmol. 2008;43: 414-8. 26. Wittich W, Sikora L, Watanabe DH, Martinez M. Canadian research contributions to low vision rehabilitation: a quantitative systematic review. Can J Optom. 2012;74:30-7.
CAN J OPHTHALMOL — VOL. 48, NO. 6, DECEMBER 2013
467
