The Patient Pathway Health Professionals Working Together

It’s called the patient pathway. The process by which a patient has a medical issue assessed and treated, from the very first health care professional they present to (whether that be an optometrist, general practitioner or hospital emergency physician) right through until their medical issue is resolved. It includes all the health care providers they see along the way.

Eye health professionals use this term to describe the relationship between the patient and the professions.

Back in 2006 RANZCO discussed the importance of the patient pathway in their monthly column in mivision, which sought to “improve communication with the eye care community in the interests of helping to achieve optimum patient outcomes”.

Dr. Karagiannis has no doubt that optometrists fall under the description of a health professional.

The way that Dr. Karagiannis practises provides the perfect example of the patient pathway in action. With his main private practice located in Adelaide, he also works out of the Victorian town of Mildura and the regional South Australian town of Berri.

In Berri he works from a hospital clinic. In Mildura from a large optometry practice.

“I started going to Mildura back in 2004 – I visited a few times looking for a practice to work from and I stumbled upon Stephen Jones and Associates – it’s a large practice with four optometrists. Stephen Jones welcomed me in,” said Dr. Karagiannis.

“Primarily we work independently. I have my own patients, they have theirs and while we don’t share notes, the notes are all held in the same area… there are plenty of patients I see that I need following up by optometric care and so it works well because we’re all under the same roof.”

Mildura, a town of just over 30,000 people, is well served by a local ophthalmologist who practises there four days a week. The community is also supported by two other visiting ophthalmologists as well as Dr. Karagiannis. All three visiting ophthalmologists work out of Stephen Jones and Associates. Dr Karagiannis says the system works well because he and the two other ophthalmologists visit there regularly working with the optometrists: Dr. Karagiannis concentrates mainly on cataract surgery, glaucoma management and pterygium surgery, the other two visiting ophthalmologists are sub specialists in retina and ocular plastics.

WORK DISTILLED BY OPTOMETRISTS

Dr. Karagiannis says the cases he sees in the city differ from the majority of cases he sees in regional Australia; a function of scarcity of time and experience of the optometrist.

“The way I practise ophthalmology in Mildura is predominantly pathology based so work is being distilled to me by optometrists, whereas in the city based setting I have a broader referral base with referrals also from GPs and consequently I also treat a lot of diabetic and age related macular degeneration patients,” he said.

“That means in Mildura my time is not taken up by problems that optometrists have been trained to deal with; like picking up cataracts or performing diabetic screenings. Sometimes GPs will refer a diabetic check to me and so I’ll write back and suggest they send their patient to an optometrist.

He said this way of working means that optometrists in regional areas quickly develop more skills because they see more pathology. It’s expertise that he helps facilitate in any way possible, because Dr. Karagiannis says, “the underlying principle is what’s in the best interest of the patient”.

“I’ve helped the optometrists who work in Stephen Jones’ practice and in other local practices to upskill in a significant way so they can see patients with me in real time, see what particular pathologies look like and how treatment can improve pathology. That makes a big difference in the way knowledge and experience is accumulated.”

Having been established for many years, Stephen Jones and Associates takes in several final year students and graduates of optometry from Melbourne University for their clinical experience and they all spend time with Dr. Karagiannis.

“Without fail they say they’ve seen more pathology in one day than in five years of training… of course if they were there longer it would be even better because although they know a lot of theory and their optometric knowledge of the eye is good, unless they get to see pathology it can be hard to recognise it… and this is where optometrists in the country benefit – they see pathology all the time, so even when they see something new, they’re more in tune and pick up a condition,” he said.

Stephen Jones, optometrist, agrees that the optometrists in his practice have benefited by being exposed to cases they would not otherwise see. “Our optometrists have learned how to best manage patients, what needs to be done and how quickly,” he said.

He said the arrangement is beneficial to the patient pathway because the optometrists have immediate access to advice from ophthalmologists, even when the doctors are out of the practice. “We have the ophthalmologic back up in the practice – we can easily talk to them while they are here or over the phone, so in many cases we co-manage patients that way.

The fact that we can contact Arthur at any time and say ‘I’ve got a particular patient sitting in the chair and this is what’s happening’, is reassuring from our point of view. A lot of optometrists wouldn’t have that relationship, and similarly, a lot of ophthalmologists wouldn’t necessarily feel comfortable having an optometrist instigate a treatment before they see the patient, which is what we are able to do.

“We’ve built up a very good mutual trust – they trust our skills and we are quite happy to do some of the leg work for them.”

With other optometrists in Mildura and one other ophthalmologist, Mr. Jones said boundaries for patient referral and management are important. “We don’t push our patients to visit the ophthalmologists who are here unless they require their particular speciality, and similarly, when patients from other practices come to see one of the ophthalmologists here we are very careful to ensure the patient returns to the referring practice.”

WAY OF THE FUTURE

Mr. Jones said the model of having optometry and ophthalmology working side by side in the same practice is a model for the future.”

There is a lot of work that optometrists can do to help ophthalmologists… maybe with the influx of optometrists coming through the university system, this is the way of the future.

Sydney ophthalmologist and RANZCO Young Fellows Advisory Group member Dr. Christine Younan agrees that when optometrists and ophthalmologists work more closely together, the patient benefits.

“Optometrists and ophthalmologists play an important role in ophthalmic health care. For a great many patients with vision problems, optometrists are the entry point into the patient pathway. As such, they play a vital role in the initial assessment of patients, in determining whether acute pathology exists or not, and in directing patients, where appropriate, to the next health care professional in a time appropriate manner. Where medical treatment is required, ophthalmologists will then become involved in patient care,” said Dr. Younan. “Optometrists and ophthalmologists have different training and different expertise, but we work together and complement each other’s skills to provide patients with eye problems the best level of care.”

Dr. Younan cited a recent example. “Our patients get the best care when we work together. I have a diabetic patient who has had extensive bilateral proliferative diabetic retinopathy, neovascular glaucoma and diabetic macular oedema in the past. She lives on the Central Coast. Her intraocular pressures (IOP) have been difficult to control, and she occasionally has recurrent episodes of vitreous haemorrhage. On a day she feels her vision is “bad”, she pops in to see her optometrist, who often calls me if there are any changes. Recently her IOP was 70mmHg on a “bad day” in association with a dense vitreous haemorrhage. Her optometrist gave me a call and I was then able to expedite appropriate care. By working together I believe we were able to give this patient timely and appropriate management of a serious condition that may have otherwise threatened her vision,” said Dr. Younan.

The idea of working closely with ophthalmology appeals to optometrist and National President of the Cornea and Contact Lens Society of Australia, Jessica Chi who says she is passionate about her role in the patient pathway. “I absolutely believe in what we do as optometrists, we screen, detect, manage and treat conditions of the eye, refractive and also non-refractive. I am proud of my profession and I count each and every one of my colleagues a health care professional because I see the dedication we have first and foremost to the patient, but also to the profession. I see colleagues constantly upgrading their equipment so they can provide the best possible care, I see them regularly at conferences and meetings so they can further their knowledge and I hear wonderful stories of how optometrists have changed their patients’ lives.

“I myself am therapeutically endorsed and I manage and I prescribe regularly when required, and my colleagues who are yet to become therapeutically endorsed would manage patients in similar ways except the prescription would usually be written by their general practitioner,” said Ms. Chi.

Optometrist and academic Professor Nathan Efron said optometrists are absolutely equipped to do this. “Four of the five university-based optometry schools in Australia sit in faculties of health, and three are part of, or closely integrated with, schools of medicine. There is now considerable overlap between what ophthalmologists and therapeutically endorsed optometrists can prescribe. Referral and shared care protocols demand that eye care professionals are able to ‘speak the same language’, and have access to the same, updated information from pharmaceutical companies about these medications,” he said.

KNOWLEDGE ESSENTIAL TO WORKING TOGETHER

Dr. David Andrews, CEO of Royal Australian New Zealand College of Ophthalmologists says a strong understanding of medications and treatments, as well as an understanding of the underlying cause and management of diseases, makes an optometrist a valuable part of the eye care team.

“It is important for optometrists to have a good understanding of a wide variety of therapeutic treatment options, the benefits and dangers. For some basic eye conditions it is appropriate that an optometrist provides a solution as they are generally more accessible than ophthalmologists. This may necessitate therapeutic endorsement, but I guess it really depends on how comfortable an optometrist feels about making a diagnosis and prescribing treatments… by understanding diseases and treatment options an optometrist is then able to properly advise a patient about different options, including those that can only be done by an ophthalmologist. They would also then be able to work with local ophthalmologists to assist in the management of chronic conditions or post-surgical follow up required,” said Dr. Andrews.

According to the Optometry Board Australia’s May 2015 report, of 4,902 registered optometrists in Australia, 1,921 – or 39.19 per cent are now therapeutically endorsed, with the majority of those based in Victoria (727 or 59.11 per cent of general registrants are endorsed). ACT has 25 therapeutically endorsed optometrists; New South Wales 407; Northern Territory 15; Queensland 387; South Australia 127; Tasmania 54; and Western Australia 158. Additionally 21 optometrists of no stated State are endorsed.

COMPETENCIES REQUIRE INFORMATION

Optometry Australia CEO Genevieve Quilty, said “Optometry Australia believes information about medicines enhance the care an optometrist can provide their patient.

“The Australian health system is strong, and made stronger by health professionals who are well educated and connected,” she said. “Our education system, even prior to the changes to entry level standards required optometrists to have an understanding of many matters including appropriate pharmacological agents.”

In 2008, the Optometry Australia entry level competency standards required that optometrists had competencies that included: “Appropriate pharmacological agents are selected and recommended for treatment of the patient’s condition; Ability, when choosing the most appropriate therapeutic agent(s) for the patient, to consider aspects such as available delivery systems (e.g. ointments, drops etc.)”.

The 2014 Optometry Australia entry-level competency standards specify “the ability to make prescribing decisions on the basis of the best available research evidence together with clinical expertise and the patient’s preferences”. (Refer to the article on the next page for further details.)

Jessica Chi said these competencies are essential to meeting the needs of the patient pathway. “As a therapeutically endorsed and actively prescribing optometrist, we need to stay abreast of the uses, appropriate application and complications of the drugs on our prescribing list. Even if I was not therapeutically endorsed, I still believe that having access to the information provided by pharmaceutical companies is necessary.

“Having an understanding of ocular therapeutics doesn’t just give us the ability to prescribe therapeutics. It gives us a deeper understanding of the mechanisms in which ocular problems occur, the way they are managed and treated, and the potential side effects associated. Even if we are not managing the therapeutic or surgical management of the eye, as primary eye care practitioners, it is important for optometrists to understand how these work,” said Ms. Chi.

“I also believe that we need to have an understanding of the systemic medications that our patients are on – hypertension, diabetes, high cholesterol, stroke – are some of the many systemic conditions that may cause effects in the eye, and may even be detected within the eye. In addition, various systemic medications can cause ocular side effects – yes we are optometrists looking mainly at the eye, however the eye is connected to the rest of the body,” added Ms. Chi.

“We can afford far greater chair time than the ophthalmologist can, and we are frequently asked questions regarding their treatment and management. Being able to answer these questions helps to support the ophthalmologist and more importantly, help the patient understand their condition, why they need to adhere to the management plan and hopefully encourage compliance. I strongly believe that ophthalmologists and optometrists can and do work symbiotically, and understanding the therapeutic agents and their mechanisms will instil confidence in the ophthalmologist that I can comfortably co-manage their patient, without compromising patient care and saving them valuable chair time,” said Ms. Chi.

Dr. Andrews said optometrists and ophthalmologists need to work together. “It is very important, neither profession can or should work in isolation. There are simply too many patients needing a vast range of services to manage their eye conditions. Ophthalmology and optometry have worked in an integrated eye care team for years and this is not likely to change,” he said.

OPPORTUNITIES FOR THE FUTURE

Dr. Younan said there were opportunities to bring the two professions closer together in a way that would benefit the patient pathway. “I believe all ophthalmologists look forward to working closely with optometrists into the future. We both have so much to offer, and our different skills complement each other so well,” she said.

“I would certainly be interested in seeing an annual combined meeting of all eye health care professionals (ophthalmologists, optometrists, orthoptists and specialised ophthalmic nurses). While we all attend our own specialised meetings, it would be useful to learn about each other’s advances and have the opportunity for greater collaboration,” she said.

Dr. Andrews said RANZCO is working on measures that will unite optometrists and ophthalmologists as well as others in the broader health professions. “RANZCO is keen for all members of the eye care team to work together as required. This means orthoptists, nurses, optometrists and GPs. By following the most appropriate pathway, patients will get the best treatment possible without wasting time or resources. RANZCO is developing tools to assist everyone understand the patient pathway for a number of major eye conditions, and we plan to work with optometry as these are rolled out in the near future.”