1,2,3: Expanding Collaborative Care Options

The Australian National Eye Health Survey suggests that approximately 3.4% of Australians over the age of 50 have definite or probable glaucoma.¹ When combined with those at risk of developing glaucoma and an ageing population, the burden on the eye care industry to provide the recommended care is projected to grow dramatically. This is highlighted in a recently published review of glaucoma collaborative care at the Centre for Eye Health (CFEH)² which showed patients with glaucoma or high risk suspects were seen, on average, five times over a threeyear follow-up period. This results in not only a significant cost with regards to clinical attendance time, but places great stresses on the public health and Medicare system.³ Furthermore, false negative referrals take, on average, 2.3 visits within a public system before being discharged.⁴ 

There is an increasing body of published evidence that highlights the benefits of collaborative care models as a method to address this issue, both domestically^5-7 and internationally.^4,8,9 While the Optometry Board of Australia (OBA) has published guidelines on what is considered essential for collaborative care,¹⁰ establishing these processes in clinical practice can be complicated for a variety of reasons.

CFEH is currently involved in three distinct glaucoma collaborative care initiatives: intermediate tier care, collaborative glaucoma management with Prince of Wales Hospital eye clinic (POWH) and the Westmead Hospital eye clinic’s Community- Eye-Care (C-Eye-C) initiative. The goal of each of these initiatives is mirrored in the Centre’s overall vision statement: To improve eye health and quality of life by reducing the incidence of preventable vision loss. The underpinning concept is early detection and ensuring that ‘the right person is seen at the right time, in the right place’. As a flow-on effect, these initiatives also work towards freeing up the scarce resource that is public hospital ophthalmology, enabling it to focus on managing more advanced, complicated and acute presentations.

THREE MODELS OF CARE

The three distinct glaucoma collaborative models of care that CFEH is involved with are:

1. Intermediate Tier Care 

CFEH offers community optometrists an option to refer glaucoma suspects to CFEH for a comprehensive, glaucoma specific assessment. This service comprises a large part of CFEH’s operational model. At the referring practitioner’s request, results are either discussed directly with the patient or supplied to the referring practitioner in the form of a secure electronic report with attached imaging. Ophthalmology input is obtained as needed by specialists who dial into the CFEH network remotely to view the report and results, both in the Centre’s electronic medical record system, and through the native imaging applications. In these cases, reports are then co-signed by the optometrist and ophthalmologist.¹¹ Also known as referral refinement, this approach serves to triage patients that require subsequent referral to ophthalmology and monitor those at risk of progression.

A recent internal review of 50 consecutive CFEH reports reviewed by ophthalmologists showed an agreement rate of 96%, with the two instances of variation both showing a more conservative approach from the CFEH optometrists.

2. Team-based Care

Established in March 2015, CFEH provides team-based care in conjunction with consultants from the POWH eye clinic known as the Glaucoma Management Clinic (GMC).

The GMC’s model involves a consultant glaucoma specialist from POWH assessing patients face-to-face in conjunction with optometrists on site at the CFEH clinic. The GMC operates as a satellite clinic of POWH and admits patients through three distinct pathways:

1. Stable glaucoma patients and glaucoma suspects formerly under review at the POWH eye clinic,
2. Patients identified from CFEH intermediate tier care as needing glaucoma treatment, and
3. Direct referral of patients with glaucoma from community optometrists and GPs.

After an initial assessment at the GMC, subsequent appointments are scheduled either back in the GMC, within the CFEH general clinic, or back with community optometry as indicated by established guidelines. A significant advantage of this care model is that patients who need laser treatment (peripheral iridotomy or selective laser trabeculoplasty) are referred efficiently ‘up-the-hill’ to the POWH eye clinic and then seen subsequently within the GMC at CFEH. This maintains a continuity of care within the public system, while ensuring that patients are less likely to be lost to follow up.²

3. Westmead Hospital’s C-Eye-C Initiative 

CFEH initiated a collaboration with the Westmead Hospital eye clinic within the C-Eye-C program¹² in March 2020, during establishment of the Cameron Centre in Parramatta. Patients eligible for glaucoma assessment under the C-Eye-C model of care come from two sources:

1. Stable glaucoma patients and glaucoma suspects formerly under review at the Westmead eye clinic, and
2. Non-urgent, new referrals to Westmead for glaucoma assessment.

Results from all optometric C-Eye-C assessments are sent to Westmead Hospital for electronic review, with subsequent appointments scheduled either back in the C-eye-C clinic or at Westmead Hospital as per established guidelines. One major advantage of this care model lies in it being scalable and responsive to local demand.

KEY LEARNINGS

Collaborative glaucoma care programs are an evolving discipline. Experience with the models detailed here has highlighted a number of key factors that need to be considered, both when establishing programs and as part of ongoing evaluation and subsequent improvements to existing set ups.

Communication is the Key 

As clearly stated in the guidelines for use of scheduled medicines for optometrists,10 “communication is the linchpin of effective collaborative care”.

In particular, a clear, secure method to ensure appropriate data is transferred between parties is instrumental in delivering effective patient management. While this can occur in the form of transfer of information through reports and instrument printouts, enabling instrument-based change analysis by sharing raw data is ideal. This will become more streamlined as secure platforms continue to develop, in part due to changes brought about by COVID-19.

Another critical part of the communication lines is to ensure a clear delineation of roles and responsibilities in the established model of care so that all the patient’s eye care needs are met. For example, peripheral retinal assessments, dry eye management, spectacle prescriptions etc. need to be managed, and the results communicated between participating eye care teams.

Experience and Feedback Loop Required 

While the advent of optical coherence tomography (OCT) imaging has enabled significant advances in the assessment of glaucoma, diagnosis and management of this disease is still nebulous and relies largely on individual clinical expertise and assessment.¹³ This is compounded by the fact that the definition of glaucoma is still under debate.¹⁴ CFEH’s history of working with more than 12 different ophthalmologists over the last 11 years has highlighted that ongoing and regular access to feedback from consulting specialists, along with the incorporation of the latest published evidence (such as the LiGHT and ZAP trials) is critical to a consistent approach to patient care within collaborative models.

A Complicated Funding Model 

It is important that practitioners understand how collaborating practices operate so that patients can be adequately informed about out-of-pocket costs.

Funding of models of care for public patients raises a number of factors that also need consideration. Public patients frequently present with complicated histories as well as multiple ocular co-morbidities and English as a second language. This typically results in longer examination times. When these factors are combined with limitations on Medicare billing for glaucoma suspects that are not typically covered by item number 10914, i.e. the number of visual fields that can be billed per year, and the extra time needed for reporting; bulk-billing of examination is highly unlikely to cover the costs involved with optometric patient care.

When to Intervene 

Glaucoma is increasingly moving towards a personalised approach to treatment.¹⁵ Given that it is a lifetime diagnosis with associated costs and potential complications, the need for initiation of, or change to, treatment should be carefully considered in conjunction with the disease trajectory. As a result, any collaborative care model needs to ensure that practitioners have a common understanding of when treatment is indicated and what is required to establish disease progression. There are an increasing number of guidelines and published articles,^15-18 which can be combined with regular, evidence based clinical discussions between the involved parties, to help improve consistency.

CONCLUSION

There is an increasing demand for glaucoma eye care services in Australia. Collaborative care has been shown to be a safe and efficient use of resources in the Australian health care landscape. While challenges exist to implementation, careful attention to communication, roles and responsibilities, in addition to establishing models of care that are effective for all concerned, can result in excellent patient outcomes.

Michael Yapp BOptom (Hons), MOptom, GradCertOcTher, FAAO is the Head of Clinical Operations and Teaching at Centre for Eye Health (CFEH) in Sydney. Mr Yapp has had a diverse range of clinical experience, having worked in private practice before undertaking locum work Australiawide and overseas. Prior to joining CFEH at its inception in 2009, he honed his diagnostic skills working with a corneal specialist ophthalmologist in Sydney. Earlier in his career, Mr Yapp was a staff optometrist at University of New South Wales. Since then he has educated generations of optometrists, and spoken at numerous Australian and international optometry conferences. 

The author would like to thank Prof Michael Kalloniatis, Dr Angelica Ly and Dr Jack Phu for their valuable input into this article. 

References 

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10. Optometry Board of Australia, Guidelines for use of scheduled medicines. 2018. 
11. Jamous, K.F., et al., Clinical model assisting with the collaborative care of glaucoma patients and suspects. Clin Exp Ophthalmol, 2015. 43(4): p. 308-19. 
12. ACI Network, Community Eye Care (C-EYE-C) Model for Glaucoma and Diabetic Retinopathy. 2019. 
13. Phu, J., et al., Visualizing the Consistency of Clinical Characteristics that Distinguish Healthy Persons, Glaucoma Suspect Patients, and Manifest Glaucoma Patients. Ophthalmol Glaucoma, 2020. 3(4): p. 274-287. 
14. Iyer, J.V., et al., Defining glaucomatous optic neuropathy using objective criteria from structural and functional testing. Br J Ophthalmol, 2020(July). 
15. Phu, J., et al., Management of open-angle glaucoma by primary eye-care practitioners: toward a personalised medicine approach. Clin Exp Optom, 2020. On line ahead of print(DOI: 10.1111/cxo.13114). 
16. Wang, H., To treat or not to treat: the value of optometry-led collaborative care for glaucoma. Optometry Pharma, 2020(March 2020): p. 2 – 4 
17. Optometry Australia, Clinical Practice Guide for the Diagnosis, Treatment and Management of Glaucoma. On Line, 2016. 
18. American Academy of Ophthalmology, Primary Open Angle Glaucoma: Preferred practice pattern. American Academy of Ophthalmology, 216.