Making Inroads with Collaborative Care Models

CENTRE FOR EYE HEALTH

Writer: Dr Jack Phu

In 2016, the Centre for Eye Health (CFEH) and the Prince of Wales Hospital (POWH) Ophthalmology Department established the Glaucoma Management Clinic (GMC) – a shared care service providing both optometric and ophthalmologic assessment and management of patients with, or suspected of, having glaucoma.¹

The clinic was a POWH Ophthalmology/ CFEH collaboration that was established within the framework and guidelines provided by the Optometry Board of Australia and The Royal Australian and New Zealand College of Ophthalmologists.

Optometrists can refer patients with established glaucoma or high-risk glaucoma suspects to the CFEH GMC, where a team of highly trained optometrists work collaboratively with ophthalmologists from POWH to develop an appropriate management program. In 2017, this clinic also began receiving suitable glaucoma patients transferred from POWH for ongoing monitoring and management within the GMC.

In 2018, CFEH researchers reported on the initial outcomes of the clinic, which highlighted that patients only waited an average of 43 days for an appointment within the GMC.¹ Given that many patients are referred to CFEH because of financial difficulty, the findings demonstrated that this pathway provides timely and accessible care for patients who may have otherwise had to resort to a long wait at a public hospital outpatient clinic.¹

Impact of Selective Laser Trabeculoplasty within the GMC

The LiGHT study recently highlighted some of the potential benefits of selective laser trabeculoplasty (SLT) over topical therapy for patients with ocular hypertension or primary open angle glaucoma.² To ensure that the GMC can provide this treatment for patients in a timely and optimal manner, we have facilitated direct pathways to the POWH Laser Clinic. Modifications to referral protocols and communication channels between POWH and CFEH have enhanced this pathway, reducing wait times and improving the patient experience. This was achieved by building trust with the POWH ophthalmologists through clear communication.

Management of Angle Closure Risk

In 2018 CFEH activated a unique specific pathway for assessing patients at risk of angle closure.³ The results of CFEH

research, and the recently published ZAP trial, have enabled evidence-based consistent assessment and stratification of patients into those who can be safely monitored within a collaborative care optometry clinic and those requiring onward referral to ophthalmology.⁴ The collaborative nature of the GMC has enabled CFEH optometrists to achieve high levels of concordance in gonioscopic evaluation with ophthalmologists, which is essential for management of patients at risk of angle closure disease.⁵

Additional Testing for Glaucoma Suspects

Diagnosis of glaucoma is one of the greatest clinical challenges in eye care. To assist with determining the need for treatment, CFEH activated an additional patient pathway in 2019: a suite of tests including frontloaded visual fields on SITA-Faster,⁶ water drinking testing and intraocular pressure phasing.⁷ In conjunction with tele-ophthalmology review, which had been instituted with collaborating ophthalmologists from POWH, this led to a reduced number of appointments within the GMC for patients not requiring treatment. This highlights another avenue towards efficient glaucoma care, with only those patients requiring ophthalmological assessment being able to access the pathway in a more timely manner. Additionally, it reduces wait time due to reduced false positive referrals.

Participation in the Care of Patients with Advanced Glaucoma

Patients with advanced glaucoma are typically managed within the ophthalmology system. In the GMC, patients with advanced glaucoma have a direct pathway of transfer of care to either the POWH Eye Clinic or to their local hospital ophthalmology department. In 2019, a new initiative of CFEH and Guide Dogs NSW/ACT staff has incorporated the provision of low vision services for patients with advanced disease to ensure that they still receive a complete cycle of care within the CFEH system.

What Lies Ahead for Glaucoma Collaborative Care within CFEH?

From its inception in 2009, CFEH clinical services have continued to evolve to meet the needs of the community. This evolution has been made possible by a close working relationship with ophthalmology colleagues and also staff at Guide Dogs NSW/ACT. As we enter 2020, the CFEH team is looking forward to forging new relationships with the Westmead Hospital Ophthalmology Department through the Community Eye Care (C-EYE-C) scheme and others, which will increase its geographical presence, and hence accessibility to quality eye care for more people within the community.

patients only waited an average of 43 days for an appointment within the GMC

WESTMEAD HOSPITAL EYE CLINIC

Writer: Belinda Ford

Westmead Hospital’s Eye Clinic is the sole ophthalmology service in Western Sydney Local Health District, providing coverage of public eye care services (including surgical and outpatient care) for the one million people living in western Sydney.

The region’s population is socially, culturally and economically diverse, with 40% of the population aged 40 years or older;8 half of the residents speaking a language other than English at home;⁹ and lower scores on socio-economic indexes.¹⁰ Fewer people in the region have access to private health insurance⁸ and more people report difficulties accessing care due to cost.⁸ Additionally, western Sydney is a diabetes hot spot with an estimated prevalence of 15% of the population.¹¹ This context has contributed to a growing demand on public services, with patients waiting nine months and three months to access glaucoma and diabetic eye outpatient services respectively.¹²

The access burden has been further compounded by poorly targeted referrals from primary care, many with limited information to support appropriate allocation and prioritisation of care.^12,13

These unique circumstances prompted the need for a new model of care, which could streamline and refine the referral and management pathway. As a result, the C-EYE-C model of care was introduced as a pilot at Westmead Hospital in 2017, as reported in mivision. C-EYE-C is governed by Westmead Hospital and is driven by partnerships with community based optometrists to deliver collaborative care¹⁴ for low risk glaucoma and diabetic retinopathy patients.

In this model, patients are assessed by optometrists using standardised protocols, including clinical examination and imaging, and optometrists recommend a preliminary diagnosis and management plan. Following this, all patient notes are transferred securely to the hospital for a virtual review by an ophthalmologist to confirm or amend diagnosis.

Demonstrated Results

The C-EYE-C model has successfully demonstrated:

• Improved access to ophthalmic care for newly referred patients (a reduction in wait-time of 9.3 months for glaucoma and three months for diabetes), and further reduced hospital wait lists due to freed up appointments in hospital clinics,
• Reduced need for hospital appointments for low risk patients, by 57% for glaucoma and 69% for diabetic retinopathy, and
• Reduced health system costs, by 22% for glaucoma care and 43% for diabetic retinopathy care.

The next phase of research will gather evidence to support the expansion and scalability of collaborative care models across Australia. Preliminary results presented at the 2019 Association for Research in Vision and Ophthalmology (ARVO) conference found that collaborative care relies on communication and trust between providers to build confidence in decision making and maintain patient care, investment in information technology to support integrated services, and standardised care pathways to promote equitable access. Further investment from health systems for provider incentives and administrative costs will be needed to support delivery of care, particularly in rural and remote areas.

Dr Jack Phu is an optometry-trained clinician-scientist, associate lecturer at the UNSW School of Optometry and Vision Science, and the head of the glaucoma/neuro-ophthalmology unit at the Centre for Eye Health. His clinical, research and teaching responsibilities are devoted almost exclusively to glaucoma and optic nerve disease.

Belinda Ford, a PhD Candidate at The George Institute for Global Health, has played a key role in the design, implementation and evaluation of the Western Sydney Community Eye Care (C-EYE-C) model of care as both a project manager, and through her PhD studies.

References

1. Huang J, Hennessy MP, Kalloniatis M, Zangerl B. Implementing collaborative care for glaucoma patients and suspects in Australia. Clin Exp Ophthalmol 2018;46:826-8.
2. Gazzard G, Konstantakopoulou E, Garway-Heath D, et al. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (Light): a multicentre randomised controlled trial. Lancet 2019;393:1505-16.
3. Phu J, Hennessy MP, Spargo M, et al. A collaborative care pathway for patients with suspected angle closure glaucoma spectrum disease. Clin Exp Optom 2019.
4. He M, Jiang Y, Huang S, et al. Laser peripheral iridotomy for the prevention of angle closure: a single-centre, randomised controlled trial. Lancet 2019;393:1609-18.
5. Phu J, Wang H, Khuu SK, et al. Anterior chamber angle evaluation using gonioscopy: consistency and agreement between optometrists and ophthalmologists. Optom Vis Sci 2019;96:751-60.
6. Phu J, Khuu SK, Agar A, Kalloniatis M. Clinical evaluation of Swedish interactive thresholding algorithm-faster compared with Swedish interactive thresholding algorithm-standard in normal subjects, glaucoma suspects, and patients with glaucoma. Am J Ophthalmol 2019;208:251-64.
7. Huang J, Katalinic P, Kalloniatis M, et al. Diurnal intraocular pressure fluctuations with self-tonometry in glaucoma patients and suspects: a clinical trial. Optom Vis Sci 2018;95:88-95.
8. PHIDU Torrens University Australia, Social health atlas of Australia: primary health network data (PHN)- Western Sydney. 2016.
9. Western Sydney Local Health District. Epidemiological profile of WSLHD residents 2018. 2018; Accessed from: https://www.wslhd.health.nsw.gov.au/.
10. Australian Bureau of Statistics, Census of population and housing: socio-economic indexes for areas (SEIFA), Australia, 2016.
11. Meyerowitz-Katz, G., et al., Detecting the hidden burden of pre-diabetes and diabetes in Western Sydney. 2019. 151: p. 247-251.
12. Kim, D., et al., Glaucoma referrals to a tertiary care glaucoma service in Australia. Clinical & Experimental Ophthalmology, 2019.
13. Ford, B., Angell, B., Liew, G., White, A., & Keay, L. (2019, November). Community eye care (C-EYE-C): Improving access and reducing costs through collaborative care for diabetic retinopathy. Clinical & Experimental Ophthalmology, 2019. 71- 71.
14. White, A., Goldberg, I., & Australian and New Zealand Glaucoma Interest Group and the Royal Australian and New Zealand College of Ophthalmologists. (2014). Guidelines for the collaborative care of glaucoma patients and suspects by ophthalmologists and optometrists in Australia. Clinical & Experimental Ophthalmology, 42(2), 107-117.