Optometry Collaboration Reduces Hospital Wait Times

While collaborative care pathways are well established overseas, they are still emerging in Australia. Given the current long wait times for public hospital eye services in Australia, substantial effort is now being invested in developing these models of care.

For CFEH and POWH-EC these models are nothing new – the two organisations have engaged in collaborative patient care since the inception of CFEH in 2009, and are at the forefront of development and research of collaborative eye care in Australia. Recently the collaboration has been expanded to reduce the long waiting times for appointments at POWH-EC.

patients are currently obtaining referrals to multiple locations… to shorten the wait times

The two new initiatives underway involve:

1. Implementation of new referral pathways for existing and new patients referred to POWH-EC, and
2. Transfer of care of stable, low risk patients from POWH-EC to CFEH.

Both processes incorporate either face to face or telemedicine review by ophthalmologists from POWH-EC. This article focuses on the process of triaging referrals.

A recent study conducted in the UK¹ reported that up to 22 individuals per month are permanently losing sight as a direct result of delayed appointments due to a lack of capacity within the hospital service. The majority of vision loss was a consequence of the three main chronic eye conditions: glaucoma, diabetes, and age related macular degeneration. Although similar numbers are not available in Australia, median wait times for non-urgent public hospital ophthalmology appointments is reported to be as high as 827 days,² suggesting there is a comparable risk of similar outcomes.

Research around models of care and referral refinement in the public hospital outpatient clinic system is ongoing

CLEARING THE WAIT LIST

At the commencement of this initiative, over 1,500 patients were on the POWH-EC wait list without a current scheduled appointment. The median wait at the time of review was more than 400 days. Administrative review of this wait list, however, immediately removed a significant proportion. Most notably, patients were removed if they were listed more than once as a result of having multiple referrals or if they had already been seen or scheduled for an appointment at another public hospital within the health district.

This suggests that patients are currently obtaining referrals to multiple locations and/ or from multiple practitioners in an attempt to shorten the wait times.

The majority of patients referred to POWHEC were from GPs and optometrists (Figure 1), most commonly for cataract related vision problems followed by retinal and optic nerve disease (Figure 2).

CLINICAL ASSESSMENT

Patients currently in need of an appointment are now being assessed by an optometrist at CFEH in a collaborative care clinic. The patient and associated results, including imaging, are then presented during a face to face consultation with a POWH-EC ophthalmologist.

Some initial outcomes from this process include:

• 10 per cent of patients needed to be seen sooner at POWH-EC than would have otherwise been scheduled, either as a result of the condition they were referred for or for a significant incidental finding such as retinal breaks or tears,
• 33 per cent of patients were added directly to the cataract surgical list, thereby addressing the ‘wait for an outpatient clinic appointment followed by the waiting time once listed for surgery’,
• 34 per cent of patients did not need ongoing public hospital ophthalmological care and were discharged to either community care or to remain under CFEH intermediate tier care, with telemedicine ophthalmology oversight as needed.

REFERRAL REFINEMENT

Public hospital eye clinics in NSW have also been taking steps to improve the system through:

1. Published referral criteria and standardised referral forms,³ and
2. Contacting referrers to request more detailed information to enable appropriate triaging as needed.

Notably only 19 per cent of all current new referrals to POWH-EC used the available template and only 14 per cent indicated a recommended timeframe for appointment on the referral (urgency of appointment).

ONGOING PROJECT

Research around models of care and referral refinement in the public hospital outpatient clinic system is ongoing. Outcomes will provide guidance on:

1. How to best integrate intermediate tier optometry-ophthalmology collaboration into the public hospital system,
2. The most efficient use of electronic patient reviews (telemedicine or virtual consultations), and
3. The impact of referral quality on patient outcomes.

 Michael Yapp is Head of Clinical Operations and Teaching at Centre for Eye Health. Michael Hennessy is Conjoint Associate Professor, UNSW and a Senior Staff Specialist Ophthalmologist at the Prince of Wales Hospital. 

References 

1. Foot B and MacEwan C. Eye 2017; 31: 771-775. 
2. performance.health.vic.gov.au/Home/Report. aspx?ReportKey=677 
3. aci.health.nsw.gov.au/resources/ophthalmology/eyeemergency- manual/eye-emergency-manual-resources/nswpublic- ophthalmology-clinics-information