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HomemistoryPatient Co-management in the 21st Century

Patient Co-management in the 21st Century

A patient’s ocular health can provide important indicators about their general health just as their general health can have ramifications on their vision and eyes.It makes perfect sense then, for optometrists, ophthalmologists and general practitioners to work hand-in-hand within a network of care.

From identifying diabetes and fending off strokes to managing high blood pressure and treating branch retinal vein occlusion, optometrists, ophthalmologists and general practitioners are working closely for superior patient outcomes. According to Kate Gifford, national president of Optometry Australia, co-management is a “win-win” situation.

“First and foremost effective co-management results in superior patient outcomes. Efficient co-management is also important for getting the best possible value for money from the country’s increasingly stretched health resources. From a business perspective, co-management is one way to promote an optometrist’s skills and services to medical practitioners, thus increasing the likelihood of obtaining referrals from these sources.”

These days, thanks to increasingly sophisticated diagnostic equipment and corresponding skills, optometrists are well-positioned to co-manage patients with general practitioners (GPs) and ophthalmologists.

In short, co-management is good for the patient, the health dollar, the ophthalmologist and the optometrist

“Optometrists have the opportunity to support GPs with common eye presentations such as red eye, foreign bodies, diabetic reviews and vision loss in a timely manner that is convenient to patients,” said Ken Thomas from Leunig and Farmer Eyecare at Moe, Victoria. “When these services can be provided without referral to ophthalmology, it becomes more cost effective for the
patients and the health system.”

Margaret Lam, owner of The Eyecare Company in Sydney, said she often works closely with GPs to manage patients with cardiovascular health conditions and dry eye as well as diabetes. “Signs of hypertensive or diabetic retinopathy detected in an eye exam, for example, would alert us to a patient’s poor control of their hypertensive or diabetic status. These findings, shared from the optometrist to the GP, can result in medication adjustments that can help a patient avoid life or sight threatening complications,” she said.

In regional NSW, optometrist Thao Hannaford says co-management, especially with her one local ophthalmologist, is essential to achieve optimal clinical outcomes. “With only one ophthalmology practice between Picton and Canberra, my local eye surgeon is under constant pressure with long waiting periods for patients to be attended to. This is where primary optometry plays an important role in delivering general eye care and triaging those who need further care,” she said.

Dr. Devinder Chauhan, a retinal and macular specialist, with Vision Eye Institute in Victoria, said co-management often means patients can be seen more quickly.

“Macular and retinal patients often require frequent follow up and assessment in the first instance and regular follow-up in the long term; I have found that skilled optometrists with fundus cameras and OCT scanners who provide and comment are the most effective co-managers in this patient group. Sharing of photographs and OCT scans along with the referral letter are crucial in triage; I have several examples of patients who were either seen much more quickly than the optometrist thought was necessary or vice versa allowing the patient to sleep easier before their appointment.”

“This approach is particularly effective in managing patients from rural and country areas. Local optometrists can co-manage patients who require interim reviews, which reduces the burden on these patients who would otherwise have to travel long distances for assessment.”

He said interactions with referring optometrists have evolved from the anachronistic “thank you very much for referring this delightful lady… who has a condition that you probably wouldn’t understand” to “that’s a really interesting OCT that shows disruption of the photoreceptors centrally with thinning of the fovea and a cavity-like appearance that is typical of macular telangiectasia”.

“I believe this instantaneous educational opportunity must result in patients getting better opinions and appropriate referral,” said Dr. Chauhan.

Having said that, Dr. Chauhan stipulated that he would never give an opinion on a new patient based on images provided by another health care practitioner. “There is absolutely no substitute for an initial history and examination. Subsequently, if I’m confident that the patient can be followed up by their optometrist, I send them back with a recommended regimen for review and imaging and an open invitation to return for review as required,” he said.

Working as a Collective Body

Inevitably, effective co-management frees specialists to do what they do best. Ophthalmologists, for instance, are freed to perform additional surgery or high-level consultations, rather than just straightforward reviews, which Mr. Thomas from Leunig and Farmer Eyecare says, makes sense. “A good example is the regular monitoring of diabetics, which should be done by optometrists, resulting in referral to ophthalmology only when significant retinopathy develops that requires intervention. Another example is found in optometrists providing day-one cataract reviews for patients.

“From a professional development perspective, being involved in the more complicated cases referred in by GPs and ophthalmologists is very rewarding. In short, co-management is good for the patient, the health dollar, the ophthalmologist and the optometrist.”

Ms. Lam agrees. “The practice benefits (of co-management) happen to be profound in terms of defining the importance of the role of the optometrist.

“Optometrists become an important part of the collective body of health professionals that have the responsibility to guide the patient in maintaining the patient’s health in an optimal state, but also, these happen to produce positive secondary effects that benefit the practice.

“The person who benefits from this the most is the individual patient in this network of care,” said Ms. Lam. “In every instance when an eye test is conducted for one of my patients, there are always wider health recommendations that can assist my patients to maintain their long term wider health and well-being.”

Mandatory Co-Management Does Not Work

Victorian optometrist Graham Lakkis says mandatory co-management of patients will not work.

“If it is in the best interest of the patient (i.e. their health outcome, time efficiency and cost) to co-manage, then that is the pathway that I will follow. If, however, the optimal management plan can be performed by the optometrist alone, then co-management is actually a burden to the patient and a burden on the co-managing practitioners as well, and drives up health care costs unnecessarily.

“Pre-determined or mandatory co-management of a particular eye disease such as glaucoma does not work, mainly because the severity of the disease varies so markedly between patients. If the glaucoma is mild to moderate and can be stabilised with topical eye drop therapy alone, management can safely remain solely in the hands of the optometrist. However, if laser or incision surgery is required due to the severity of the glaucoma, then co-management or complete handover to a glaucoma specialist is the optimal pathway for that particular patient.”

Getting to Know You

One challenge many face when trying to establish a professional network is making the initial connections. Unfortunately, for most, it takes time and effort to get your name out there and build an understanding of your scope of work.

Mr. Lakkis said he had built strong relationships with GPs in his area by helping them take care of their patients. “GPs have very limited training and equipment for the diagnosis and management of eye disease, yet are constantly encountering patients who are presenting with eye trauma or infections. They often make ‘educated guesses’ on the diagnosis, sometimes with disastrous results for the patient. I offer the GPs same-day appointments for their patients, treat them quickly and effectively, and report back to the GP in writing at the conclusion of therapy.

“GPs feel a great burden lifted from them by this assistance, and many of them now have their reception staff send all eye-related problems directly to us,” said Mr. Lakkis. “They also require assistance when setting up enhanced primary care plans particularly for diabetic patients, and we happily see these patients for their eye care, and fill in all the mandatory paperwork so that the GP can access the extra Medicare payments.”

Dr. Brian Morton AM, Chair of the Australian Medical Association, said it is important for the professions to have an accurate understanding of each other’s scope of practice and to realise the importance of a cohesive medical team. Armed with an understanding of scope of practice, he said, appropriate referrals can be written to reflect the skill base. “Health professionals must communicate with relevant information and be part of a team focused on the patient. Eyes are just one part of wholistic care, but the importance
is not to be underestimated.”

He said the best way for an optometrist to initiate a professional relationship with their local GP is to ask each patient who their GP is, then provide a brief note of interaction for that GP. “For example, if the patient is diabetic, report on any significant or no change in visual acuity. The information interaction (electronic is best) should then become two way and continuity of care maintained.”

Mr. Thomas said another effective way to build relationship is in face to face situations, although these do not always come readily.

“My rural practice has been fortunate to have a lot of social contact with GPs in our district, but we have also made the most of opportunities to attend local hospital clinical meetings. Many larger GP clinics run regular ‘in-house’ clinical meetings and we have been able to present case studies or general eye cases in these settings. If your local GPs do not arrange meetings, you can always ask one of them to come and present a specific topic at your own in-house optometric meeting. We have done this with good effect at local restaurants and made sure our optometrists also present quality cases at the same event.”

Ms. Gifford said writing to local GPs to advise them of the services you provide is a valuable first point of contact. Additionally, she said, supplying business cards or GP referral pads can facilitate the referral process. “The personal approach is also an excellent idea and making an appointment to introduce yourself to your local medical practitioners can be very effective.

“Other opportunities could include the delivery of eye health CPD to GPs in your local area or an open day at your practice to allow local health practitioners the opportunity to meet you, see your practice and understand your services,” said Ms. Gifford. “Establishing contact with ophthalmologists can start with something as simple as a courtesy call to enquire about their clinical interests or sub-specialities.”

Of course, most optometrists need to build relationships with more than one ophthalmologist, as Graham Lakkis points out. “I find that using sub-specialist ophthalmologists with practices limited to a particular field provides for the best patient and practice management outcomes. To build a strong relationship, it is essential for the optometrist to make appropriate referrals of patients that require surgical or advanced medical care, that don’t unnecessarily waste the sub-specialist’s time. The sub-specialist will then return the patient at the conclusion of treatment, and the optometrist is less likely to lose the patient since the sub-specialist does not provide routine eye care,” he said.

As with any relationship, sometimes things just don’t work out. “Initially, the co-managing participants may not know each other well, and it sometimes takes multiple patient encounters for the different parties to learn each other’s strengths, weaknesses and management philosophies. Sometimes these differences are irreconcilable and make co-management unsuccessful, and in the future the optometrist may need to find a different practitioner who is closer to the same management style,” said Mr. Lakkis.

From an ophthalmologist’s perspective, Dr. Chauhan said a “simple letter” of introduction is all it takes. “I believe the best way for an optometrist to initiate a relationship with an ophthalmologist is with a simple letter, email or phone call. At our practice, new graduates are encouraged to sit in a session with the ophthalmologist and also observe in the operating theatre. This helps the optometrists get a feel of who we are, what we do, and observe the patient-ophthalmologist relationship. I believe this strengthens the relationship between the optometrists and ophthalmologists.”

He said ongoing communication is best achieved by fax or secure email. “In my practice, I prefer optometrists either to fax or secure email referrals, which allows us to triage quickly and appropriately and contact the patient directly. I am also always happy to talk to an optometrist who either wants advice or to discuss a patient. I have found that referrers sending referral letters by mail or asking patients to call the clinic and arrange an appointment has resulted in some cases of visual loss through the delay incurred. Whilst dictated letters are still the mainstay of my communication to optometrists, detailing progress and findings of consultations, I am still searching for an effective, secure and immediate alternative.”

Overcoming Challenges

“The main challenge faced in co-management of patients is following up patients who ‘fall between the cracks’, said Dr. Chauhan. “There are instances where a patient fails to attend an appointment at another practice or specialist, and is lost to follow up. Doctors are generally very aware of their responsibilities with respect to making several attempts to organise appointments for patients and finally communicate with the referrer or GP if the patient does not attend. Unfortunately, busy optometric practices sometimes do not effectively ‘chase’ non-attenders and patients may not perceive an appointment with an optometrist as being necessary for their eye health,” he said.

Mr. Thomas concurs. “Some of the more difficult cases are glaucoma co-management, in which the ophthalmologist assumes the optometrist is performing regular reviews/fields/IOP checks and the optometrist assumes the ophthalmologist is performing the tests, and it falls to the GP to just provide repeat prescriptions without any appropriate ocular monitoring occurring.”

Patient education is of primary importance says Dr. Chauhan. “Patients may be confused as to why they are required to see multiple specialists. This is particularly relevant to diabetic patients, who often see ophthalmologists, optometrists, general practitioners, endocrinologists and even nephrologists. This barrier can be overcome by explaining the role and importance of each specific specialist regarding the management of their health.”

Protocols Worth the Effort

Developing effective protocols or systems to deal with the ‘paperwork’ side of co-management is also important to ensure responsibilities are understood and fulfilled. This can be time and labour intensive (for example, establishing templates and a referrer address database) but once up and running, the investment is well worth it. Coupled with a courteous approach to communication, Ms. Lam says, the effort can help grow your practice while at the same time, best serving the needs of all patients.

“We are fortunate that we have great general practitioners and pharmacists in the local area who will provide expert care to any of the patients we send to them. The relationship seems to be very mutual where patients are sent in to us in the same fashion,” said Ms. Lam.

She told the story of a man who walked in to a local pharmacy complaining of blurry vision. The pharmacist sent the man to The Eyecare Company, which having worked through the symptoms, suspected a severe case of undiagnosed Type 2 diabetes.

“We did a full comprehensive dilated exam, then immediately contacted a GP. We shared the symptoms with the GP, including the possibility that he had unidentified diabetes type 2, we discussed the risk of ketoacidosis due to the severity of symptoms, and indicated our concern about the serious consequences, including his risk of losing consciousness.”

The GP triaged the man immediately, and having assessed his health initiated treatment. “He agreed with our risk assessment and our tentative diagnosis, and he was prioritised through the appropriate emergency hospital department for close observation and management,” said Ms. Lam. “From start to stabilisation, everything was sorted very quickly and efficiently thanks to the excellent network of care we have established in our local area. The hospital was able to stabilise the man’s sugar levels, which meant his condition was stabilised in about the equivalent time he would have spent waiting at reception for the first available appointment to see any good GP.

“A system like this is like poetry in motion – although our patient passed through many channels, it was fast and efficient, and resulted in an optimal outcome – the patient was grateful and appreciative and the care at all levels was optimally managed,” concluded Ms. Lam.

Preventing Stroke

A gentleman in his 50s recently arrived at Hannaford Eyewear in Bowral. “He presented to me with vague symptoms, saying his vision was ‘going funny’”, said optometrist Thao Hannaford. “I did a general eye examination and the only unusual result was the visual field results were blotchy. I re-did the visual fields again the next day and although the defects were different, the overall look was wrong. Given the lack of any retinal abnormalities, I referred him back to his GP for scans to be done.“I was paid a visit a few days later when he showed up unannounced and patiently waited while I finished up with my other patients. He advised me that he had been discharged from hospital that morning and he wanted to come straight away to tell me that I had saved his life. Ninety per cent of both carotid arteries had been blocked,” said Ms. Hannaford.

Saving Time, Saving Sight

A male patient visited Leunig and Farmer Eyecare in Moe, in significant discomfort. He had undergone recent retinal detachment surgery. Slit-lamp examination revealed a pointed suture end buried under the conjunctiva that was elevated and causing pain on adduction.

A phone call and follow-up digital image emailed to a registrar at the Royal Victorian Eye and Ear Hospital (RVEEH) had an ophthalmological opinion and plan in place within 10 minutes. The decision was made to lubricate profusely with Lacrilube, rather than to risk infection by breaching the conjunctiva and trimming the suture.

This example of electronic aided co-management saved the patient a four-hour return trip to the RVEEH as well as a lengthy wait at the Accident and Emergency department for an assessment. According to optometrist Ken Thomas, the patient recovered well without need for any more drastic intervention.

Managing Retinal Vein Occlusion

Dr. Chauhan tells the story of a patient living rurally, who was referred by their local optometrist. “The optometrist believed the patient had a branch retinal vein occlusion, but was also concerned about the possibility of wet age related macular degeneration, an urgent blinding condition. After talking to the optometrist over the phone, they securely emailed the OCT scan, which confirmed the diagnosis as a branch retinal vein occlusion. This meant the patient did not have to rush over on that same day, and was given a suitable appointment within the week.

“As the most common cause for retinal vein occlusions is elevated blood pressure, I liaised with the patient’s GP and recommended investigations, including a 24-hour blood pressure monitor. These were commenced before I even saw the patient.

“The patient started a course of intravitreal injections with me, which proved challenging as the travel to and from the clinic became progressively difficult.”

Fortunately, the patient responded extremely well to the treatment, and their blood pressure was much better controlled by their GP. The patient eventually ceased intravitreal injections, the macular oedema having resolved, and it was agreed the patient be monitored regularly by their optometrist, who could perform OCT scanning and refer back at any time if required.

“The optometrist now emails me OCT scans and a summary whenever he sees the patient; I believe this co-management method was key in optimising the patient’s outcome and treatment, and I am very happy with the management.”

Working Together to Target At-Risk Communities

A program being piloted in Victoria by Vision 2020 Australia’s Vision Initiative program is encouraging GPs, nurses, pharmacists and optometrists to work together to protect the eye health of people living in communities at increased risk of vision loss.

Since October 2013, the program has been rolled out in the local government areas of Greater Geelong, Greater Shepparton, Latrobe and Darebin with information kits and collateral delivered to pharmacies, GP practices, supported by community awareness campaigns and online training for health professionals.

Dee Tumino, Vision Initiative Manager, said the program had been well received with health care professionals expressing an interest in playing their part by engaging patients on issues of eye health.

“We are asking nurses, pharmacists and doctors to simply ask their patients when they last had an eye test, to give their patients information about eye testing services and, where necessary, to refer patients on to
a local optometrist,” she said.

Ms. Tumino said that in Darebin, which comprises a culturally and linguistically diverse population, 56 per cent of people who spoke a language other than English had never had an eye examination. “In areas like Darebin there are particular cultural barriers, people don’t understand what eye health services are available – perhaps the services provided here are different from the services they accessed in their country of origin… so we’re providing printed and multi-media information in several languages – Greek, Italian, Vietnamese, Mandarin, Cantonese and Arabic – to explain the importance of regular eye examinations.”

In Latrobe, the pilot program is focusing on Type 2 Diabetes, in Greater Geelong all people over the age of 40 are being targeted with in-pharmacy campaigns timed to coincide with events such as World Sight Day, Glaucoma Week etc.; and in Shepparton, the focus is on encouraging all people over the age of 60 years to have an eye test.

“We have collected baseline data from optometrists and we’re looking forward to measuring the impact our campaigns have on visits to optometrists over the next six months,” said Ms. Tumino. “We have worked with the Pharmaceutical Society of Australia to develop recommendation cards and we’re encouraging doctors to use their usual referral forms or letters when sending patients to an optometrist. The use of a referral helps with communication and will encourage the optometrist to report any eye health issues back to the referring health care professional.” Additionally, Ms. Tumino said, the use of a referral would encourage patients to make the recommended trip to an optometrist.

“In these early stages we’re finding that health care professionals tend to be referring on patients with diabetes in particular and people presenting with physical symptomatic conditions. What they are not referring is people with general risk factors – those over the age of 40, smokers, people with a family history of eye disease and people of Aboriginal and Torres Strait descent. We’re hoping to increase referrals across all of these categories.”