Download Vision Care Services at Columbus Neighborhood Health Centers

Vision Care Services at Columbus
Neighborhood Health Centers
Lessons Learned Using a Collaborative Approach
in Franklin County, Ohio
January 2009
RESEARCH AND REPORT PREPARATION:
Community Research Partners
Tiffany K. Harrison, Research Associate
Gary Timko, Ph.D., Director of Research Services
Prevent Blindness Ohio
Sherill K. Williams, President and CEO
Kira Baldonado, Director of Marketing and Community Services
Acknowledgements
Prevent Blindness America
Prevent Blindness Ohio
The Ohio State University College of Optometry
Columbus Neighborhood Health Center, Inc.
VSP-Lab Columbus
Access HealthColumbus
Ohio Association of Community Health Centers
Ohio Opticians Association
Centers for Disease Control and Prevention
Table of Contents
Executive Summary ........................................................................................................................ i
Overview ............................................................................................................................................... ii
Vision Clinic Patient Demographics .................................................................................................... ii
Vision Care Provision – Successes and Areas for Improvement ........................................................... ii
Lessons Learned .................................................................................................................................. iii
Conclusions .......................................................................................................................................... iii
Introduction .................................................................................................................................. 1
Overview ............................................................................................................................................... 2
Data Collection and Analysis ............................................................................................................... 3
Vision Care Provision .................................................................................................................... 5
Provision of Vision Care ....................................................................................................................... 6
Vision Care – A Collaborative Effort ............................................................................................... 6
Vision Screening and Referral ...................................................................................................... 8
Adding More Staff........................................................................................................................ 9
Access to Eyewear ....................................................................................................................... 10
Vision Care – Addressing Community Needs ............................................................................... 10
Challenges to Patient Access ...................................................................................................... 10
Challenges to Clinic Operations................................................................................................. 11
Addressing the Challenges ......................................................................................................... 11
Vision Care – An Integrated Approach.......................................................................................... 11
Vision Care – A Priority ................................................................................................................. 12
Summary ............................................................................................................................................. 12
Vision Care Provision – Successes .................................................................................................. 12
Vision Care Provision – Areas for Improvement............................................................................ 13
Vision Clinic Patients .................................................................................................................. 14
Patient Characteristics ........................................................................................................................ 15
Patient Experiences ............................................................................................................................. 19
Lessons Learned .......................................................................................................................... 20
Impetus and Implementation of the Vision Clinic ............................................................................. 21
Provision of Services ........................................................................................................................... 21
Benefits of the Vision Clinic............................................................................................................... 22
Vision Clinic Sustainability ................................................................................................................ 22
Vision Care as a Priority ..................................................................................................................... 22
Public Policies ............................................................................................................................. 23
Local Policy Recommendations ......................................................................................................... 24
Policy Options for Franklin county CNHC Health Centers ......................................................... 24
State Policy Recommendations .......................................................................................................... 24
Ohio Aging Eye Public Private Partnership 2008 Report to the Governor and Ohio General
Assembly ......................................................................................................................................... 24
2005 Ohio Legislative Task Force for Preserving Adult Vision Final Report ............................... 24
A Plan for the Development of State Based Vision Preservation Programs .................................. 25
Vision Problems in the United States: Recommendations for a State Public Health Response .... 25
Federal Policy Recommendation ........................................................................................................ 26
Vision Preservation Act of 2007 ..................................................................................................... 26
Improving the Nation’s Vision Health: A Coordinated Public Health Approach ........................ 26
Conclusions ................................................................................................................................. 28
Appendices .................................................................................................................................. 30
A. Resources and Contact Information .............................................................................................. 30
B. Adult Vision Assessment Clinical Process ..................................................................................... 32
C. Vision Clinic Pro-Forma ............................................................................................................... 34
Executive Summary The section provides an overview of the report, key
findings, lessons learned, and conclusions.
Executive Summary
Overview
The Vision Clinic at East Central Neighborhood Health Center in Franklin County, Ohio opened as a
result of a group of doctors in the 1970’s at The Ohio State University’s (OSU) College of Optometry
working with the Columbus Neighborhood Health Center, Inc. (CNHC) to start a vision clinic at a
Federally Qualified Health Center (FQHC). Prevent Blindness Ohio (PBO), founded in 1957, is Ohio’s
leading volunteer nonprofit public health organization dedicated to preventing blindness and preserving
sight. In 2003, PBO began collaborating with CNHC, as well as Access HealthColumbus (AHC) to help
expand access to vision care and to direct resources to populations that are at greatest risk of vision loss. In
November 2007, PBO contacted Community Research Partners (CRP) to explore the history of the East
Central Health Center Vision Clinic, describe the collaboration between OSU, CNHC, PBO, VSP LabColumbus and AHC to increase access to vision care, and identify the lessons learned in the process.
Vision Clinic Patient Demographics
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During 2007 and half of 2008, the Vision Clinic completed 5,272 appointments to a total of
3,586 patients.
Approximately 47% of patients were African American.
Twice as many female as male patients have been seen at the Vision Clinic.
Approximately one-third of patients seen at the Vision Clinic were diagnosed with Presbyopia,
one-third for Myopia (nearsightedness), and one-sixth for Hyperopia (farsightedness).
Between January and June 2008, slightly over 50% of Vision Clinic patients were self-paying
patients and/or paid their fees on a sliding fee scale.
Vision Care Provision- Successes and Areas for Improvement
Successes
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Collaboration among local service providers (i.e., OSU, CNHC, PBO, VSP-Lab Columbus, and
AHC) has been critically instrumental in opening and operating the Vision Clinic at East Central
Neighborhood Health Center, as well as securing additional funding.
PBO working with a local optical lab to donate glasses to the Vision Clinic has resulted in greater
patient access to affordable eye ware.
Addition of an optician, optometry students, and other support staff has increased the capacity of
the Vision Clinic to serve more patients at greatest risk of vision loss.
CNHC health centers have implemented a process of automatically referring patients with
diabetes and high blood pressure to the Vision Clinic.
There is some integration of primary health care with vision care.
The Vision Clinic has been able to serve patients who live throughout Franklin County, Ohio
and increase access to persons who are at greatest risk of losing their vision.
Areas for Improvement
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Due to a high turnover rate, most CNHC health center staff that CRP conducted focus groups
with have not received training from PBO regarding the most effective and efficient ways to
screen patients for vision care.
Most of the CNHC health centers are physically small and do not have the space to conduct
appropriate vision screening.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page ii •
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While the CNHC health centers automatically refer patients with diabetes and high blood
pressure to the Vision Clinic, there is no standard approach for referring patients to the Vision
Clinic with other vision loss risk factors.
The demand for vision care often exceeds the Vision Clinic’s capacity to provide services. As a
result, some patients are placed on long waiting lists to receive services that may contribute to
them not receiving needed care.
Primary care and vision care could be better integrated.
Vision care is not perceived as a priority at the federal, state, and local levels.
Lessons Learned
The following are several of the lessons that were learned as a result of the collaboration between PBO
and CNHC in Franklin County:
• Having community organizations that have clout and can advocate for vision services helped to
establish and implement the East Central Health Center Vision Clinic.
• CNHC staff turnover resulted in many clinicians not having recent training in vision screening
procedures.
• Patients being placed on a long waiting list for an eye examination at the Vision Clinic
(sometime 2-4 months) possibly contributed to a high incidence of appointment no-shows as
well as patients potentially not receiving needed eye care.
• Having an optician has allowed the Vision Clinic optometrist to be more efficient, effective, and
to see more patients.
• Patients’ access to an ophthalmologist is limited, and in some cases prevented patients from
receiving the complete vision care they need.
• A positive doctor-patient relationship helped vision care to become a higher priority with
patients.
• The manner that Federal funds are reimbursed may contribute to the perception that primary
medical care and vision care are two unrelated entities.
Conclusions and Recommendations
The following are conclusion based on the data that were collected and analyzed for this report:
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Buy-in to providing vision care as a component of integrated healthcare is needed by FQHC top
management.
All FQHC clinical staff need to receive on-going training on vision screening and referrals.
There needs to be improvements in the policies and procedures for referring high-risk patients for
vision care.
There needs to be policies and procedures that help integrate primary care with vision care.
Vision Clinic staffing needs to have the capacity to meet patient demand.
Effective vision care requires a continuum of services, including optometry, ophthalmology, and
access to affordable eyeglasses and medications.
Vision clinics need to work in collaboration with other outside service providers so that patient
access and clinic sustainability is increased.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page iii Introduction
In November 2007, Prevent Blindness Ohio (PBO)
contacted Community Research Partners (CRP) to
document the process of providing vision care
through five Federally Qualified Health Centers
(FQHC) located in central Ohio. CRP explored the
collaboration between PBO, Columbus
Neighborhood Health Center, Inc. (CNHC) that
operates the five FQHCs, and other local service
providers in increasing access to vision care for
persons in Franklin County, Ohio who are at
greatest risk of losing their vision.
Overview
In the 1970s, doctors from The Ohio State University (OSU) College of Optometry decided that
a good way to give back to their community would be to open a vision care clinic at one of the
Federally Qualified Health Centers (FQHC) in Franklin County, Ohio. The result was the
Vision Clinic at the East Central Neighborhood Health Center, one of the five FQHCs that are
operated by the Columbus Neighborhood Health Center, Inc (CNHC). In 2003, Prevent
Blindness Ohio (PBO) began collaborating with CNHC, as well as Access HealthColumbus
(AHC) to help expand access to vision care and to direct resources to populations that are at
greatest risk of not receiving needed vision care services. PBO also partnered with VSP LabColumbus, a local optical lab, to donate eyeglass frames and lenses to the Vision Clinic to
increase access to low-cost eyewear for uninsured patients.
Figure 1 illustrates the collaboration between these service providers and the East Central
Neighborhood Health Center Vision Clinic. This report describes each of the collaborators and
the roles they have played in providing and increasing access to vision care in Franklin County. In
addition, the report includes demographic information on the patients that have been served by
the Vision Clinic, lessons learned from the collaboration, policy issues regarding vision care, and
conclusions that are based on the findings of this report.
Figure 1 Collaborations to Increase Services and Access to Vision Care in Franklin County Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 2 Data
Collection and Analysis
In November 2007, PBO contacted Community Research Partners (CRP) to explore the history
of the Vision Clinic at East Central Neighborhood Health Center, describe the collaboration
between PBO and CNHC in Franklin County, Ohio and identify the lessons learned. CRP is a
unique nonprofit research center that comprehensively addresses community data and
information needs, primarily in central Ohio, through research, program evaluation, and public
policy analysis. CRP is a partnership of the City of Columbus, United Way of Central Ohio, the
John Glenn School of Public Affairs at The Ohio State University, and the Franklin County
Commissioners.
To accomplish the purpose of this study, CRP used four overarching questions to guide the data
collection and analysis:
1. What vision care services provided through collaborative efforts between PBO and
CNHC have helped reduce the incidence of vision loss in high risk populations?
• How is CNHC structured to provide vision care to high risk populations
(departmental, leadership, staffing, support services)?
• How are persons referred to East Central NHC for vision care services?
• What effective and ineffective practices have emerged as a result of this collaboration
between PBO and CNHC?
• How did eye care services, education and prevention efforts change as a result of
implementing comprehensive vision care services through CNHC?
• To what extent are vision and primary care services integrated?
2. What lessons have been learned about implementing comprehensive vision care services
for high risk populations?
3. What are the characteristics of persons who have received vision care services through
CNHC?
• Demographics (race, age, income levels, employment status, etc.)
• Benefits (Medicare, Medicaid, privately insured, underinsured, etc.)
• Health status (diabetes, hypertension, high cholesterol, physical disabilities, etc.)
4. What future policy initiatives would support comprehensive vision care services for high
risk populations?
• What is needed to further develop and support vision care services through CNHC
as a model for other federally qualified health centers?
To address the overarching study questions, CRP used a variety of approaches to collect and analyze data
that included:
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 3 •
Interviews (n=4). CRP conducted four interviews with key representatives from PBO, AHC,
the Ohio Association of Community Health Centers (OACHC), and the Vision Clinic at
East Central Health Center. [CRP was unable to secure an interview with CNHC’s CEO
and the Medical Director.]
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Focus Groups (n= 28 total participants)
o CNHC Staff (n= 24 total participants). CRP conducted 4, 1-hour focus groups with
staff members at the CNHCs who administer vision screenings and refer patients to
the Vision Clinic
o Vision Clinic Patients (n=4). CRP conducted 1, 1-hour focus group with local
consumers who use the services at the Vision Clinic.
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Client Data Analysis. CRP analyzed aggregate data regarding the characteristics of the
Vision Clinic clients. Data included information about patients from January 2007 through
December 2007 and January 2008 through June 2008.
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Document Review. CRP reviewed documents, including informational brochures regarding
vision care and other marketing materials for the Vision Clinic, vision screening training
documents, and presentations to CNHC clinicians. CRP used the findings of the review to
inform the study questions and incorporated document review findings throughout the
report. Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 4 Vision Care Provision
In 2003, Prevent Blindness Ohio (PBO) began
partnering with organizations in the community to
provide a comprehensive vision care program for
persons in Franklin County, Ohio who are at greatest
risk of losing their vision. This effort was funded by
Prevent Blindness America through a grant from the
U.S. Centers for Disease Control and Prevention’s
Adult Vision Program. This section describes the role
PBO and other collaborators have played in the
process.
Provision of Vision Care
The successful provision of vision care to low-income persons in Franklin County, Ohio who are
often at greatest risk of losing their vision depends, in part, on several factors. These include:
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Local agencies working in collaboration to ensure vision care is provided to those persons
who are in most need but may not be able to afford it
Adopting practices to ensure the needs of the community are being met
Using an integrated approach to healthcare
Making vision care a priority
Currently, the Vision Clinic at East Central Neighborhood Health Center in Franklin County serves
both children and adults who have private or public health insurance. The clinic also uses a sliding
scale of payment for those who have no health insurance. The Vision Clinic has continued to increase
access to care for thousands of patients who may not have been able to otherwise obtain these services.
Vision Care – A Collaborative Effort
Vision care is provided through a collaborative effort to persons in Franklin County who are at greatest
risk of losing their vision. This collaboration includes:
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The Ohio State University (OSU) College of Optometry
Columbus Neighborhood Health Centers, Inc. (CNHC)
Prevent Blindness Ohio (PBO)
VSP Lab-Columbus (VSP)
Access HealthColumbus (AHC)
When a group of doctors at OSU’s College of Optometry decided to
start a vision clinic at a Federally Qualified Health Center (FQHC)
in the 1970s, vision care services were not being offered at any of the
FQHCs in Franklin County. The optometrists believed they would
be able to use and hone their skills by assessing and diagnosing eye
diseases in communities where the population has traditionally lacked access to comprehensive vision
care. The optometrists worked in collaboration with CNHC to open the Vision Clinic at East Central
Neighborhood Health Center in Franklin County, Ohio.
Currently, fourth-year College of Optometry students at OSU have the option of completing an
externship at the Vision Clinic. This program allows for the student to conduct eye exams with the
optometrist and gain firsthand experience working with patients. As of this report, there is one OSU
College of Optometry student working with the Vision Clinic through the externship program.
In 1998, seven Columbus Community Health Centers merged into
what is now Columbus Neighborhood Health Center, Inc (CNHC).
Currently, CNHC is a Federally Qualified Health Center (FQHC)
network of five health center sites in Franklin County that provide
primary healthcare to county residents who are uninsured or
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 6
underinsured. The East Central Neighborhood Health Center is the only one of the five health center
sites that also provides vision care. Patients from all five CNHC health center sites are referred to the
Vision Clinic at East Central Neighborhood Health Center.
In addition to the Vision Clinic and primary care services, CNHC health center sites also provide
dental services, podiatry services, and obstetrics and gynecological services. If the health center sites
have the resources, transportation services may be provided to senior citizens, handicapped or disabled
patients, prenatal patients of 36 weeks or more of gestation, and some pediatric patients whose
guardian has more than one child, provided that the patients described above do not have an insurance
carrier that already provides transportation services.
Many of the patients who visit the Vision Clinic and other CNHC health center sites do not speak
English. As a result, each site offers translation services for patients upon request.
PBO, founded in 1957, is Ohio’s leading charitable volunteer
nonprofit public health organization dedicated to preventing
blindness and preserving sight. PBO serves all 88 Ohio counties,
providing direct services to more than 800,000 Ohioans annually and
educating millions of consumers about what they can do to protect
their vision. PBO is an affiliate of, Prevent Blindness America, the country’s second-oldest national
voluntary health organization. PBO helped to form a collaboration of organizations to address the gaps
in access to vision care services for the high-risk populations in Franklin County served by CNHC
health center sites. This effort was supported by Prevent Blindness America and a grant from the US
Centers for Disease Control and Prevention’s Adult Vision Program.
PBO and Access HealthColumbus served as the conveners of the organizations in the collaboration,
meeting at least quarterly to chart progress and address concerns. Gaps identified through the
collaboration included:
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Increasing access to low-cost eyeglasses for Vision Clinic patients through a partnership with
VSP Lab-Columbus and eyeglasses from lens donors.
Increasing the number of patients served at the Vision Clinic through the addition of a fulltime optician secured by Access HealthColumbus and an OSU College of Optometry student
intern.
Implementing a system of vision screening referral through CNHC health center sites securing
training and equipment from PBO.
In 2003, VSP Lab-Columbus, an optical manufacturing lab, opened a
new 30,000 square foot optical lab in Columbus, Ohio. This is one of
the most automated ophthalmic lab facilities in the country.
VSP’s family of companies includes the largest not-for-profit vision benefits and services company in
the United States. Since 1997, VSP has provided nearly 500,000 low-income, uninsured children with
free eyecare. Through relationships with the American Diabetes Association, Prevent Blindness
America, and the Center for Health Transformation, VSP promotes the importance of annual eye
exams for maintaining eye health and overall wellness.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 7 Patient Questionnaire 1.
When was your last dilated (drops put in your eye to open the pupil) eye exam performed by an optometrist or ophthalmologist? 2.
Do you have blood relatives (includes grandparents, parents, siblings, or child) with glaucoma? 3.
Has a doctor treated you for or said that you have glaucoma or another serious eye problem that required periodic eye exams? 4.
Throughout your life, have you ever had any eye injury or eye surgery? 5.
Have you ever noticed any change in your vision or persistent pain (not related to allergies or headache) in or around the eye today or in the last twelve months? 6.
Are you African American or Hispanic and age 40 or older? 7.
Are you age 65 or older? 8.
Do you have diabetes or have you been told that you are pre‐diabetic? (Source: Adult Vision History and Risk Assessment Form, Prevent Blindness Ohio) PBO partnered with VSP LabColumbus using donated eyeglass
frames and lenses to create access to
low-cost eyeglasses for uninsured
patients at the Vision Clinic.
In the late 1990s, a variety of organizations in Columbus became
interested in the problem of health care access for under- and
uninsured residents of Franklin County. Columbus Medical
Association Foundation took the lead and instituted the Access to
Health Care Initiative, a five-year project setting aside $1.5 million
in funding to initiate community-wide system change in health care
access and delivery of services.
In 2002, as the result of a partnership between the Columbus
Medical Association Foundation and the Osteopathic Heritage
Foundations, Access HealthColumbus (AHC) became a separate
nonprofit corporation. As a growing organization, AHC sought to
formalize and expand its role in the medical community by
becoming the central administrative hub in Columbus’s system of
health care to its uninsured populations.
In collaboration with PBO and other agencies, AHC has secured
funding for staff and expansion of space in the Vision Clinic. AHC
has also been able to connect some Vision Clinic patients to
ophthalmologic services through their Voluntary Care Network.
Vision Screening and Referral
After PBO partnered with CNHC, PBO conducted a vision
screening training course for all primary care physicians, nurses, and
medical assistants employed at the five CNHC health center sites.
The vision screening training equipped clinicians to conduct vision
screenings for all new patients, high-risk patients, and pediatric
patients at least once per year. The training also served to introduce
a standardized approach of referring patients to the Vision Clinic at
East Central Neighborhood Health Center.
PBO trained and certified clinicians at the five CNHC health
center sites to administer a questionnaire with all patients upon their
first visit. The eight item questionnaire, Adult Vision History and
Risk Assessment Form, determines “if a patient has a need for more
education about their risk for eye disease or vision loss and/or to
determine if the patient should be referred to an eye care
professional for a comprehensive vision evaluation.” A patient’s
responses to the risk assessment questionnaire also determine
whether or not a full vision screening is required at the primary care
level or if a direct referral to the Vision Clinic is needed.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 8
“The ultimate goal of this collaboration is to prevent vision loss before it strikes through a system of preventive health care. The patients served by CNHC health centers are particularly vulnerable to the chronic conditions like diabetes that can lead to blindness if there is not access to eye care…” ‐Prevent Blindness Ohio “You need to have everybody involved and understand their role, how it impacts them, how it’s going to work into their system and into their manuals, into the way they function on a daily basis.” ‐Prevent Blindness Ohio “The biggest barrier is just having the schedule, just having a timely appointment for our patients. Because usually, it can be two to three, four months out [due to limited capacity and high demand for vision care]… You try to confirm their appointments, their addresses have changed, their phone numbers have changed, they’re disconnected. So that is a big barrier.” ‐Vision Clinic Optometrist “The more people we can get to vision screening in the community…we can help people realize that they might have an eye problem which then leads them to an optometrist.” ‐CEO Ohio Association of Community Health Centers Currently, CNHC health center staff screen all new patients on their
first appointment, high risk patients every year and regular patients
once every two years for vision acuity. However, the current staff at
four of the CNHC health centers who participated in the focus
groups indicated that they did not remember the training that PBO
provided, nor do they use the Adult Vision History and Risk
Assessment Form. This is due to the high turnover of the health
center staff since the training that has resulted in an overall lack of
awareness on how to use the form.
Many of the CNHC health center staff who participated in the focus
groups felt that their health centers lacked the proper space and
equipment to conduct the appropriate vision screenings, despite the
training and equipment that PBO provided to them. CRP found that
while a uniform approach across CNHC health centers for referring
patients to the Vision Clinic was developed through this
collaboration, it is not being implemented uniformly. While some
CNHC health centers fax their patient referrals to the Vision Clinic,
others call in their referrals.
The health center staff do refer all diabetic patients and those with
hypertension to the Vision Clinic because patients with these health
risks have higher rates of vision loss. Other patients are referred per a
physician’s request following a vision screening by CNHC health
center staff. It is important to note that patients do not necessarily
need to be referred by CNHC health center staff or by a physician to
be served by the Vision Clinic. The Vision Clinic accepts walk-in
appointments when time permits and patients who may be referred
by other primary care providers in the area.
Adding More Staff
Before PBO partnered with CNHC, the Vision Clinic at East
Central Neighborhood Health Center had only one optometrist and
a receptionist, but no optician. The number of patients being seen by
the optometrist was limited since the optometrist was also acting as
an optician, conducting eye exams, diagnosing, and treating patients
as well as fitting patients for glasses.
Since CNHC’s collaboration with PBO and other organizations, the
capacity to serve patients has increased. AHC solicited county
funding to support the addition of the current Vision Clinic optician
who fits patients with the appropriate eyewear. Although the county
funding for the optician lasted for one year, the position has since
become self-sustaining through private and public insurance
payments, allowing the optometrist to continue focusing on
diagnosing and treating patients.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 9 “…The lighting [in the health center] is kind of [bad to conduct vision screenings]. I mean it should be adequate lighting for the patient to be able to see. And the space between the eye chart and where the patient should stand…there’s a lot going on in between that space” ‐CNHC Clinician “But what you’re finding lately is that funding is down, and [the Vision Clinic has] too many people [to serve]. ‐CNHC Clinician “The facilities that they have [CNHC] were mostly built by the city, and pretty much given to them. Now they [CNHC] do pay rent, but to build those facilities [neighborhood health centers], obviously you’ve got to have some seriously deep pockets, and most health centers don’t have it…” ‐Access HealthColumbus “And then we all tried to promote, encourage [the optometrist] to send people back to their primary care doctor if they had diabetes and we were encouraging all the CNHC doctors to send people for an annual eye exam…It was kind of like eyes, teeth, body, which is really common in healthcare to act like those things aren’t connected.” ‐CEO Ohio Association of Community Health Centers Access to Eyewear
In 2003, PBO and AHC staff met with the optometrist at the Vision
Clinic to assess the extent that vision screening and education were
being provided at the primary care level and that community
resources were being used to increase access to the Vision Clinic.
One of the immediate needs identified was for low-cost eyeglasses for
uninsured patients. Patients were being examined at the Vision
Clinic and given a prescription for eyeglasses but were unable to fill
their prescriptions due to the high cost. To meet this need, PBO
partnered with VSP-Lab Columbus (a local optical lab) to use
donated eyeglass frames and lenses to create access to low-cost
eyeglasses for uninsured patients at the Vision Clinic.
Vision Care – Addressing Community Needs
Although the collaborative efforts among agencies has resulted in
increased access to vision care for people in Franklin County who are
at greatest risk of losing their vision, some challenges still remain.
These include patient access to the Vision Clinic and some
challenges to clinic operations.
Challenges to Patient Access
CNHC health center staff identified some patients’ lack of available
transportation to the Vision Clinic as the primary challenge for them
accessing vision care. Many patients do not live near the Vision
Clinic and cannot afford the bus or cab fare.
While some patients cannot afford the transportation fares, others are
unable to afford the Vision Clinic service fees. Although the Vision
Clinic does offer a sliding fee scale, all fees are due upon receipt of
services. Some patients lack the resources to pay any amount upon
receipt of services despite the fact that the Vision Clinic, CNHC,
and PBO have worked to keep the cost of services at a minimum.
Other patients can afford the fees but cannot afford to pay for the
glasses or other follow up care despite the minimal cost. For example,
some patients need to have eye surgery, a service not available at the
Vision Clinic. Very few eye surgeons or ophthalmologists in Franklin
County accept patients with no or with public insurance. While some
patients may be able to access ophthalmologic care through Access
HealthColumbus’ Voluntary Care Network, other patients can only
receive the services that are provided at the Vision Clinic.
Another challenge is the long patient wait list. Patients who were
able to schedule appointments sometimes have had to wait two or
three months to be seen by the optometrist. Other patients were not
able to schedule appointments and were told to call back in three or
more months.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 10
“…quite frankly, vision is not considered to be a priority with the state…” ‐CEO Ohio Association of Community Health Centers “That is a barrier and a challenge for both providers and the patients, you know, that they’re [patients] not seeing [vision care] with the same importance as we do, and they’re not going to put as much effort into maybe making the appointment, getting to their appointment, as they would with something else that they perceive as being more critical.” ‐CNHC Clinician “…frankly, there would not be vision services at Columbus Neighborhood [Health Center] without PBO getting them up and started…” ‐CEO Ohio Association of Community Health Centers “The [vision] screening is required [by CNHC], but anything other than that would be considered [by CNHC leadership] as ancillary service. It doesn’t really need to be provided unless [CNHC’s] Board of Directors or the Executive Director takes a keen interest in it.” ‐CEO Ohio Association of Community Health Centers Challenges to Clinic Operations
CNHC health center staff indicated that CNHC health centers do
not have the funds to purchase the necessary equipment and were
unaware that PBO had provided all the proper equipment to each
health center in 2003. Some CNHC health centers were using old,
less effective equipment and screening methods than what the health
centers had been trained and equipped to use by PBO in 2003.
Also, many CNHC health centers are small and lack the space to
conduct the proper screenings. Most of the CNHC health centers
devote the majority of their space to primary care and the equipment
necessary to carry out primary care. Clinicians at the health centers
indicated that often they cannot conduct a proper eye chart reading
with patients because the clinic facility does not have the necessary
uninterrupted space for the patient to read the chart without other
people walking through the area.
Further, vision care does not fall on the priority list of federal funding
sources. Other federal key areas in the medical arena include physical
medicine, behavioral medicine, and pharmaceutical medicine among
others. When the health centers apply for Medicaid or Medicare
(public insurance) reimbursements, items for physical, behavioral,
and pharmaceutical medicine are applied for on a bundled basis, or
all at once. Because vision care is not on the federal funding priority
list, vision care reimbursements have to be applied for separately, or
unbundled, making the process more cumbersome for neighborhood
health centers.
Addressing the Challenges
The eyewear dispensary is more heavily stocked with frames, due to
the partnership with VSP-Lab Columbus which was arranged by
PBO. If a patient is given a prescription to get glasses, the patient
meets with the optician at the Vision Clinic to select frames. Once
the frames are selected, VSP-Lab Columbus manufactures the lenses
for the low-cost of fifteen dollars per pair.
The optometrist indicated that the number of patient referrals to the
Vision Clinic doubled with the addition of the optician. AHC
recently secured grant funding to support renovations at the Vision
Clinic that resulted in an increase of office space at the Clinic. This,
combined with OSU’s College of Optometry externship program
that is providing optometry students to the Vision Clinic, will
continue to increase access to vision care.
Vision Care – An Integrated Approach
Based on the CNHC health center staff focus groups, CRP found
that the coordination of primary health and vision care varies among
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 11 centers. While some CNHC health center staff receive information back from the Vision Clinic
optometrist about their patients, this typically only occurs per physician request or when a faxed referral
sheet from a CNHC clinic specifically requests a status summary of a patient’s eye exam and treatment.
Most primary care physicians ask their patients during follow-up appointments about their eye exams.
There have been some instances where the optometrist at the Vision Clinic was alerted to some health
concerns during the eye exam and refered the patient to a CNHC health center primary care physician.
Vision Care – A Priority
Many of the people who CRP interviewed believe there is a lack of “buy-in” from other community
organizations and federal agencies to make vision care a priority at local community health centers.
Federal funding guidelines require community clinics to provide certain types of primary care, as well
as dental care, behavioral healthcare, and pharmaceuticals. Interviewees perceived that since vision care
is often not included in federal funding guidelines, it is not considered a priority.
Some interviews indicated that an apparent lack of priority at the federal level is often transferred to
the local level. The Chief Executive Officer for the Ohio Association of Community Health Centers
(OACHC) indicated that while vision care is needed, funders and their guidelines are given priority
over what may be considered as “extraneous” services; if vision care is not a priority, it is considered to
be extra. While some legislation has been introduced on the federal level, no system-wide changes have
been introduced that affect how vision care is currently being provided.
Buy-in regarding vision care as a priority on a management and leadership level is essential to operate a
successful vision care program. While the Vision Clinic at East Central Neighborhood Health Center
has been an overall success story, CRP was unable to determine whether vision care is a priority by
CNHC, Inc. executive management. Due to a conflict of schedules, CRP was not able to interview
CNHC’s Chief Executive Officer and the Medical Director.
Summary
Vision Care Provision- Successes
•
•
•
•
•
•
Collaboration among local service providers (i.e., OSU, CNHC, PBO, VSP, and AHC) has
been critically instrumental in opening and operating the Vision Clinic at East Central
Neighborhood Health Center, as well as securing additional funding.
PBO working with a local manufacturer (VSP Lab-Columbus) to provide low-cost eyeglasses
to the Vision Clinic has resulted in greater access to affordable eyeware for uninsured patients.
Addition of an optician, optometry students, and other support staff has increased the capacity
of the Vision Clinic to serve more patients at greatest risk of vision loss.
CNHC health centers have implemented a process of automatically referring patients with
diabetes and high blood pressure to the Vision Clinic.
There is some integration of primary health care with vision care.
The Vision Clinic has been able to serve uninsured and underinsured patients who live
throughout Franklin County, Ohio and increase access to persons who are at greatest risk of
losing their vision.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 12
Vision Care Provision- Areas for Improvement
•
•
•
•
•
•
Due to a high turnover rate, most CNHC health center staff have not received training from
PBO regarding the most effective and efficient ways to screen patients for vision problems.
Most of the CNHC health centers are physically small and do not have the space to conduct
appropriate vision screening.
The CNHC health centers do not have a standard approach for referring patients to the
Vision Clinic.
The demand for vision care often exceeds the Vision Clinic’s capacity to provide services. As a
result, some patients are placed on long waiting lists to receive services that contributes to them
not receiving needed care.
Primary care and vision care could be more formally integrated.
Vision care is not perceived as a priority at the federal, state, and local levels.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 13 Vision Clinic Patients
CRP collected and analyzed secondary data from the
East Central Neighborhood Health Center Vision
Clinic to describe the characteristics of its patients.
The characteristics are a snapshot of patients during
calendar year 2007 and the first half of 2008. CRP
also conducted a focus group with patients in order
to describe their experiences with the Vision Clinic.
Patient Characteristics
CRP analyzed aggregate data from a total of 3,586 patients seen by the Vision Clinic during
2007 and half of 2008. During this time the Vision Clinic optometrist completed a total of
5,272 patient appointments. (n= 3,364 appointments in 2007 and n= 1,911 appointments in
the first half of 2008). Many of the patients were seen more than once.
Gender
More female than male patients have been seen by the Vision Clinic, by a ratio of almost 2:1
(Table 1). CRP did not explore why more females than males have used the Vision Clinic.
Table 1 Vision Clinic Patients by Gender Gender Female Male Not Stated TOTAL Total Number Percent 2,266 63.19% 1,316 36.69% 4 0.01% 3,586 99.89% 2007 Number Percent 1430 63.69% 811 36.12% 4 0.01% 2,245 99.82% 2008* Number Percent 836 62.34% 505 37.65% ‐ ‐ 1,341 99.99% *January through June 2008 Race
Almost half (47 %) of patients who have been seen at the Vision Clinic were African
American, followed by White (21 %) and Hispanic (18 %) patients (Table 2).
Table 2 Vision Clinic Patients by Race Race/Ethnicity African‐American White Hispanic Not Stated Somali African Asian Middle‐Eastern Ethiopian Russian Indian Bi‐Racial Native American Iraqi Pacific Islander TOTAL Total Number Percent 1,689 47.09% 753 20.99% 654 18.23% 131 3.65% 106 2.95% 98 2.73% 59 1.64% 46 1.28% 16 0.44% 16 0.44% 9 0.25% 5 0.13% 2 0.05% 1 0.02% 1 0.02% 3,586 99.91% 2007 Number Percent 1,029 45.83% 465 20.71% 424 18.88% 94 4.18% 78 3.47% 65 2.89% 34 1.51% 28 1.24% 10 0.44% 10 0.44% 4 0.17% 3 0.13% 1 0.04% ‐ ‐ ‐ ‐ 2,245 99.93 2008* Number Percent 660 49.21% 288 21.47% 230 17.15% 37 2.75% 28 2.08% 33 2.46% 25 1.86% 18 1.34% 6 0.44% 6 0.44% 5 0.37% 2 0.14% 1 0.07% 1 0.07% 1 0.07% 1,341 99.92 *January through June 2008 Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 15 Location
While the Vision Clinic serves the entire Franklin County population, most patients live near
or close to a CNHC that, in turn, makes referrals to the Vision Clinic. (Figure 2)
Figure 2 Number of Clients per Zip Code using the East Central CNHC Vision Clinic, January through July 2008
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 16 CRP analyzed data that identified Vision Clinic patients for the first half of 2008 by zip code.
The zip code with the highest number of patients who have been served by the Vision Clinic is
also where the Vision Clinic is located (43205, n= 122 or nine percent). Zip code areas located
in close proximity to the Vision Clinic also have a large number of Clinic patients (43203, n=
52; 43206, n= 65; 43209, n= 32; and 43215, n= 26).
Other zip code areas throughout Franklin County with a high number of Vision Clinic
patients are located in close proximity to other CNHCs. For example, Hilltop CNHC is
located within zip code area 43204. This zip code is home to 62 Vision Clinic patients. The
43228 zip code area next to 43204 and the Hilltop CNHC also is the residence of another 62
Vision Clinic patients. This suggests that the Vision Clinic is not only serving those who live
in close proximity to East Central Neighborhood Health Clinic but are also receiving referrals
from other CHHC sites and therefore serving persons throughout Franklin County. Of all
patients seen in the first half of 2008, nearly three percent of the patients reside outside of
Franklin County.
Vision Exam Diagnosis
The top refractive diagnosis code for both 2007 and the first half of 2008 is Presbyopia. The
top diagnosis code for both 2007 and the first half of 2008 is Type II Diabetes. It is important
to note that Type II Diabetes diagnosis increased 4.2 percentage points from 2007 to 2008.
Percentages are based on total number of patients during that year. Refractive diagnosis codes
represent, for insurance purposes, the category in which a patient’s vision acuity has
experienced error, whereas diagnosis codes represent, for insurance purposes, a physical
medicine diagnosis.
Table 3 Vision Clinic Patients Diagnoses Number
Percent Top Refractive Diagnosis Codes 2007
Presbyopia 713
31.7%
Myopia 519
23.1%
Hyperopia 356
15.8%
Diabetes, Type II 121
5.3%
Cataract 110
4.9%
Headache 80
3.5%
Presbyopia 321
23.9%
Myopia 260
19.3%
Hyperopia 164
12.2%
Diabetes, Type II 128
9.5%
Glaucoma 91
6.7%
Hypertension 61
4.5%
Top Diagnosis Codes 2007
Top Refractive Diagnosis Codes 2008
Top Diagnosis Codes 2008
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 17 Health Benefit Status
The majority of the patients (over 50 %) seen by the Vision Clinic do not have health
insurance and pay for the vision care services out of pocket.
In 2007 nearly sixty percent of the patients seen at the Vision Clinic did not have health
insurance and paid for their own vision care services. While some local vision care service
providers accept public insurance such as Medicaid and Medicare, many do not accept patients
without insurance or require the patients to pay for their services in full at the time of the
appointment. These services can cost hundreds of dollars per visit and put a financial strain on
the patient. By offering services to those patients who do not have vision insurance or medical
insurance that covers vision, The Vision Clinic is able to provide services to patients who,
under other circumstances, might go without vision care. The Vision Clinic offers its services
to the uninsured on a sliding fee scale and eyewear is available at cost through a charitable
relationship with VSP-Labs Columbus arranged by Prevent Blindness Ohio.
Table 4 Vision Clinic Patients by Payer Source Pay Source Total Number Percent Self Pay/ Sliding Fee 1960 54.65% Medicaid HMO 735 20.49% Medicaid 462 12.88% Medicare 229 6.38% Other 175 4.88% Private 25 0.69% TOTAL 3586 99.97% 2007 Number Percent 1276 56.83% 439 19.55% 306 13.63% 109 4.85% 99 4.40% 16 0.71% 2245 99.97% 2008* Number Percent 684 51.00% 296 22.07% 156 11.63% 120 8.94% 76 5.66% 9 0.67% 1341 99.97% Demographic data presented in Tables 1-4 and Figure 2 was provided by the Vision Clinic at
East Central Neighborhood Health Center
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 18 “Yes, it [scheduling an appointment] couldn’t have been terribly unpleasant because I really don’t remember there being that long a delay. I would say probably a week or two. But whatever it was, it wasn’t terribly urgent.” ‐Vision Clinic Patient “I got my first pair of glasses at [another clinic]. But they were expensive. And income wise, we just about lost it all, except for social security and her disability. So it’s necessary for us to be able to find something where we can get care and not have to spend a lot of money. And I was very much surprised that, what kind of care it was down here [at the Vision Clinic].” ‐Vision Clinic Patient “…it’s like when you’re not paying as much, you don’t expect as much. And I was really surprised because, you couldn’t have gotten any better care anywhere else.” ‐Vision Clinic Patient “We don’t have a clinic like this up there [where we live]. And I gladly drive all this way to get care. I don’t know of anybody else that has subsidized stuff like this.” ‐Vision Clinic Patient Patient Experiences
CRP conducted a focus group with Vision Clinic patients
regarding their experiences with vision care in Franklin County.
All focus group participants felt positively about their
experiences with the Vision Clinic services and the optometrist.
Two participants expressed their appreciation of referrals that
the optometrist made for them: one to an ophthalmologist and
one to a primary care physician.
All of the participants expressed great surprise at the
thoroughness of the exams given at the Vision Clinic, especially
because they feel that public insurance patients usually do not
get the same level of care as patients with private insurance do.
While many of the staff at the CHNCs expressed frustration
with the wait list, the patients in the focus group indicated that
they never encountered a long wait to schedule an appointment
or a long wait between scheduling and actual appointment.
They indicated that their phone calls to schedule an
appointment were returned in a timely manner (within fortyeight hours) and staff was always courteous and friendly.
The focus group participants voiced their satisfaction with the
low cost eyewear available at the clinic. Each one of the
participants has purchased one or more pairs of glasses through
the Vision Clinic.
“And as far as the care I receive here, [the optometrist] is great. Like I said, as opposed to other providers…I feel like at other providers, they just rush you in and rush you out. And I just didn’t like that feeling. It’s more personal here.” ‐Vision Clinic Patient Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 19 Lessons Learned
This section of the report presents some lessons that
can be learned from implementing vision care services
throughout the CNHC health center sites. These
lessons are based on the data from document review,
focus groups, interviews, and secondary data analysis
that CRP collected and analyzed for the study.
Lessons Learned
Impetus and Implementation of the Vision Clinic
•
Having community organizations that have clout and can advocate for vision services helped
to establish and implement the vision clinic. For example, The Ohio State University College
of Optometry was instrumental in identifying the need for vision services and provided much of
the impetus for working with Columbus Neighborhood Health Centers, Inc. (CNHC) to start
the Vision Clinic at East Central Neighborhood Health Center. Access Health Columbus
(AHC) and Prevent Blindness Ohio (PBO) have advocated for increased access to vision care and
facilitated grants to fund service expansion.
Provision of Services
•
Accessing resources outside the CNHC health center sites can help increase and improve
services to patients. For example, PBO has successfully brokered a philanthropic collaboration
with a local optical lab (VSP-Lab Columbus) so that patients can acquire quality eyeglasses at a
reduced cost. The Ohio State University College of Optometry provides student interns to help
staff at the Vision Clinic provide comprehensive eye exams, thus increasing the number of
patients who can be served.
•
CNHC health center staff turnover resulted in many medical assistants and nurses not
having recent training in vision screening procedures. Most of the medical assistants and
nurses who participated in the focus groups were relatively new and indicated that they had not
recently received training to conduct vision screenings. To keep CNHC health centers medical
staff current with vision screening techniques, PBO may need to provide on-going training.
•
Primary health care is better coordinated between the Vision Clinic optometrist and a
patient’s primary care physician when there is a structure or mechanism in place to provide
an exchange of information. The Vision Clinic optometrist indicated that some CNHC health
centers physicians and medical assistants fax in a patient referral sheet with a section to provide a
summary of the patients vision care needs. In these cases, the optometrist is more likely to use this
form to fax patient information back to the primary care physician.
•
Patients being placed on a long waiting list for an eye examination at the East Central
Vision Clinic (sometimes 2-4 months) possibly contributed to a high incidence of
appointment no-shows as well as patients potentially not receiving needed eye care. The
longer a patient has to wait to see the optometrist, the greater the chances are that a patient will
forget about their appointment and therefore fail to appear for their office visits. While the Vision
Clinic does call patients to remind them of their appointments, many patients cannot be
contacted over time due to having moved, having their telephone disconnected, or having other
life issues that become a greater priority than their vision care.
•
Having an optician has allowed the Vision Clinic optometrist to be more efficient, effective,
and to see more patients. Prior to the Vision Clinic hiring an optician, the optometrist spent
time fitting and dispensing glasses in addition to conducting eye exams. This limited the number
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 21 of patients the optometrist was able to see for eye exams. Once the optician was hired, the
number of patients who received eye exams increased. Now that a second optometrist has been
hired, the number of patients seen is expected to increase again.
•
Patients’ access to an ophthalmologist is limited, and in some cases prevented patients from
receiving the complete vision care they needed. The Ohio State University medical clinic is
one of the few places where patients on Medicaid can receive services in Franklin County. This
often results in a long waiting time to receive services.
Benefits of the Vision Clinic
•
Early identification of certain health-related issues served as a preventive measure for vision
loss for some patients. For example, research indicates that diabetes and hypertension place a
person at greater risk of vision loss. All CNHC health centers automatically refer all patients to
the Vision Clinic who have been diagnosed with diabetes and/or hypertension and not had a
vision exam in the last year.
Vision Clinic Sustainability
•
Private and public insurance patient reimbursements help to financially sustain the Vision
Clinic. While the Vision Clinic uses a sliding scale of payment for those who have no health
insurance, the Vision Clinic has been able to remain financially sustainable from the
reimbursements payments of children and adults who have private or public health insurance.
Vision Care as a Priority
•
A positive doctor-patient relationship helped vision care to become a higher priority with
patients. Patients indicated that Vision Clinic staff treats them with respect. They said the
optometrist takes time to complete comprehensive eye examinations, helps them to understand
what is needed to maintain their vision, and genuinely cares about his patients. They believe this
has resulted in them making vision care a priority.
•
The manner that Federal funds are reimbursed may contribute to the perception that
primary medical care and vision care are two unrelated entities. CNHC health centers apply
for insurance reimbursements on a bundled basis. Essentially, all money received from the
government for medical, dental, pharmaceutical, and/or mental health care is bundled together.
Vision care is not apart of this bundle and many CNHC health centers find it to be cumbersome
to apply for separate insurance reimbursement.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 22 Public Policies
This section of the report presents examples of efforts
to help improve public policies regarding vision care in
Ohio and the nation. These examples include a study
conducted by the National Association of Chronic
Disease Directors regarding vision problems in the
United States, proposed federal legislation to address
vision care, and a summary of a report that was
submitted to Governor Strickland and the Ohio
General Assembly, among other reports. This section
also includes policy options for vision care provision in
Franklin County, Ohio.
Public Policies
Local Policy Recommendations
Policy Options for Franklin County CNHCs
Based on the data and information presented in this report, CRP presents the following policy options
for the vision care program at CNHC:
•
•
•
Require that all new clinical CNHC staff within four months after being hired be trained by
PBO on vision screening and referrals to the Vision Clinic
Adopt a consistent approach across all CNHCs for referring patients to the Vision Clinic
Adopt a procedure where the Vision Clinic optometrist provides a summary of the services
provided after each patient appointment to the patient’s primary care physician
State Policy Recommendations
Aging Eye Public Private Partnership 2008 Report to the Governor and the Ohio General
Assembly
In 2008, Ohio’s Aging Eye Public Private Partnership (AEPPP) sent a report to Ohio’s Governor
Strickland and the Ohio General Assembly. The report included the results of a survey that was
conducted with 9,823 randomly selected Ohio residents age 40 years and older each year since 2005 to
learn about the scope of vision loss in Ohio. The survey findings include the following:
•
•
•
•
There is a higher prevalence of vision problems among African Americans and Caucasian
populations age 65 and older.
Ohioans with diabetes are higher risk for multiple vision problems.
Vision problems impact Ohioans’ quality of life, including an in crease in depression, poor
health images, and life-threatening falls.
Prevention, early detection, and treatment of vision problems can save sight, but Ohioans
report obstacles to accessing vision care that include lack of transportation and insurance.
Ohio’s Aging Eye Public Private Partnership is a statewide collaboration of volunteers that started
in 2003. The goal of the collaboration is to “develop a strategic plan of action to address issues
relating to vision care public policy, vision care services, public and professional awareness, and
vision research that impacts the quality of life for Ohio’s seniors now and in the future.” A copy of
the “AEPPP 2008 Report to the Governor and Ohio General Assembly” can be found at
www.preventblindness.org/ohio/agingeye or by contacting Prevent Blindness Ohio.
2005 Ohio Legislative Task Force for Preserving Adult Vision Final Report
The 2005 final report from the Ohio Legislative Task Force for Preserving Adult Vision addresses the
services and state programs available in the state of Ohio as well as services and programs available in
other states surrounding Ohio. The conclusions drawn from the report include the following:
•
The need for coordination of state resources and programs. The report concludes that while
the agencies listed in the report serve “a critical role in Ohio’s eye health,” it would be helpful
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 24 •
•
to have a centralized office to “serve all levels of vision health and provide all types of vision
services.”
The need for comprehensive eye exams.
The need for early detection and treatment is essential to decreasing health care and other
vision loss related costs.
A copy of the “2005 Ohio Legislative Task Force for Preserving Adult Vision Final Report” can be
found at www.preventblindness.org/ohio/agingeye or by contacting Prevent Blindness Ohio.
A Plan for the Development of State Based Vision Preservation Programs
This report, presented in 2005 at the Rensselaerville Institute in New York, describe current activities
amongst state regarding vision care and vision preservation. This white paper recommends:
•
•
•
•
Increasing adult vision care programs with state departments of health in the chronic disease
sector of the department.
Increasing the collaborative activity level of Prevent Blindness America with its state affiliates.
Establishing a national vision care program headed by the Centers for Disease Control and
Prevention (CDC).
Taking action to address the next steps identified for the CDC, PBA and its affiliates, and
state health departments.
A copy of “A Plan for the Development of State Based Vision Preservation Programs” can be found at
www.preventblindness.org or by contacting Prevent Blindness Ohio.
Vision Problems in the United States: Recommendations for a State Public Health Response
In 2004, The National Association of Chronic Disease Directors (CDD) established a Vision
Loss/Blindness Prevention Committee to assess state-level activities for preventing age-related eye
disease and blindness and to identify potential roles for public health. The group developed a needs
assessment and site visit protocol to collect information about programs and challenges faced by public
health officials. Ohio was selected as one of seven states that were used for the study.
An advisory committee of the study identified common issues and barriers after reviewing the
experience from the site visits and reports from each state. The committee then formulated
recommendations to Prevent Blindness America and to the Centers for Disease Control and
Prevention (CDC) about the potential role for state public health agencies. The following key
recommendations and priority activities were identified to address the growing problem of age-related
eye diseases in America (Chronic Disease Directors, February 2005):
•
•
•
•
•
Monitor and investigate vision disorders and services
Inform, educate, and empower people about eye health issues
Mobilize partnerships to identify and solve vision conservation problems
Assure a competent public and personal workforce for vision conservation
Research new insights and innovative solutions to eye health problems
A copy of the “Vision Problems in the United States: Recommendations for a State Public Health
Response” can be found at
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 25 http://www.preventblindness.net/site/DocServer/CDD_Vision_Report.pdf?docID=1324 or by
contacting Prevent Blindness Ohio.
Federal Policy Recommendations
Vision Preservation Act of 2007
In 2007, The United States House of Representatives introduced a bill that would provide for the
expansion of Federal programs to prevent and manage vision loss. The bill states:
“An estimated 80 million Americans have a potentially blinding eye disease, and more
than 19.1 million Americans report trouble seeing, even with eye glasses or contacts.
At least 1.1 million Americans are legally blind, and 200,000 Americans experience
profound vision loss…While it is believed that half of all blindness can be prevented,
the number of Americans who are blind or visually impaired is expected to double by
2030.
The previsions of the bill include:
•
•
•
•
•
•
Expanding and intensifying programs to increase awareness of vision problems, including the
impact of vision problems and the importance of early diagnosis, management and prevention.
Conducting public service announcements and education campaigns.
Establishing appropriate measures and benchmarks to determine effectiveness of vision care
programs.
Expanding and intensifying activities to establish a solid scientific base of knowledge on the
prevention, control, and rehabilitation of vision problems and related disabilities.
Expanding and intensifying programs targeted to prevent vision loss in underserved and
minority communities, including those offered at federally qualified community health centers.
Making grants to eligible institutions of higher education or nonprofit organizations for the
purpose of expanding and intensifying vision care programs.
The Bill died before being passed and will be reintroduced in the 111th Session of Congress. A copy of
the “Vision Preservation Act of 2007” can be found at
http://www.govtrack.us/congress/billtext.xpd?bill=h110-3750 or by contacting Prevent Blindness
Ohio.
Improving the Nation’s Vision Health: A Coordinated Public Health Approach
This document, distributed by the Centers for Disease Control and Prevention (CDC), addresses
vision care provision on a national scale and addresses several factors on how to implement a national
vision care program in the public health arena. This document not only addresses what is already being
done, but also establishes a framework to which this national program should exist and provides
strategies for discussion and next steps for various stakeholders. The elements of this approach are:
•
•
•
•
Engaging key national partners
Collaborating with state and local health departments
Implementing vision surveillance and evaluation systems
Eliminating eye health disparities by focusing on at-risk populations
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 26 •
•
•
•
Integrating vision health interventions into existing public health programs
Addressing the told of behavior in protecting and optimizing vision health
Assuring professional workforce development
Establishing and applied public health research agenda for vision health
The strategies and activities for next steps have been categorized into three areas: assessment,
application, and action. The five assessment strategies deal with surveillance and epidemiology. The
application category’s four strategies deal with applied public health research, while the four action
strategies address program and policy development. A copy of “Improving the Nation’s Vision Health:
A Coordinated Public Health Approach” can be found at www.cdc.gov/diabetes/pubs/pdf/vision.pdf
or by contacting Prevent Blindness Ohio.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 27 Conclusions
This section presents seven conclusions based on the
findings of this report regarding the collaborative
efforts among Prevent Blindness Ohio, Columbus
Neighborhood Health Center, and other local
agencies to provide vision care at the East Central
Vision Clinic in Ohio’s Franklin County.
Conclusions
1. Buy-in to providing vision care as a component of integrated healthcare is needed at the
federal level and by CNHC top management. This must include making vision care a
priority and ensuring that policies and procedures that support a vision clinic’s operations are
in place and are followed.
2. All CNHC health center clinical staff need to receive on-going training. This is to
ensure that proper vision screenings are conducted and appropriate referrals are made for
needed vision care, especially if there is a high turnover of CNHC health center staff.
3. There needs to be policies and procedures for referring high-risk patients for vision care.
It has been beneficial that CNHC health center clinical staff automatically refer patients who
have diabetes and/or high blood pressure to the Vision Clinic for further assessment, and then
again on an annual basis. The standardized vision risk assessment and vision screening
introduced by PBO needs to be fully implemented to refer patients with additional risk factors
for vision loss.
4. There needs to be policies and procedures that help integrate primary care with vision
care. It has helped the East Central Vision Clinic and CNHC health center primary care
physicians to integrate patient care when results of a vision examination were specifically
requested by a health center primary care physician or when a faxed referral sheet to the Vision
Clinic requested this information.
5. Vision Clinic staff need to have the capacity to meet patient demand. Patients who are
placed on a long waiting list (e.g., 2-4 months) for a complete eye examination are less likely to
make their scheduled appointments and therefore do not receive needed eye care. A vision
clinic needs a sufficient number of optometrists and support staff to meet patient demand.
6. Effective vision care requires a continuum of services, including local ophthalmologists
who are willing and able to take referrals from a vision clinic. Some patients need to have
eye surgery, a service not available at the Vision Clinic. Very few eye surgeons or
ophthalmologists in Franklin County accept patients with no or with public insurance.
7. Vision clinics need to work in collaboration with other outside service providers so that
patient access and clinic sustainability is increased. In the case of the East Central Vision
Clinic, it has been beneficial to have leaders with influence in the community and experience
in healthcare working in collaboration to secure additional funding and other resources. It has
also been beneficial to have local businesses (i.e., VSP Lab) and other organizations that are
willing to provide products (i.e., eyeglasses) and services at no or a reduced cost, to the Vision
Clinic. This helps to build financial sustainability of the clinic as well as to increase
accessibility to services and eye wear for persons who at greatest risk of vision loss.
8. Priority for vision care needs to increase at the federal and state levels to provide
incentives and financial support/reimbursement for providing access to vision care at
FQHCs.
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 29 Appendix A Resources and Contact Information
Resources:
•
Aging Eye Public Private Partnership 2008 Report to the Governor and Ohio General Assembly
Location: AEPPP website: www.preventblindness.org/ohio/agingeye
•
2005 Ohio Legislative Task Force for Preserving Adult Vision Final Report
Location: AEPPP website: www.preventblindness.org/ohio/agingeye
•
A Plan for the Development of State Based Vision Preservation Programs
Location: Prevent Blindness America: Public Policy Library: www.preventblindness.org
•
Vision Problems in the United States: Recommendations for a State Public Health Response
Location:
http://www.preventblindness.net/site/DocServer/CDD_Vision_Report.pdf?docID=1324
•
Vision Preservation Act of 2007
Location: http://www.govtrack.us/congress/billtext.xpd?bill=h110-3750
•
Improving the Nation’s Vision Health: A Coordinated Public Health Approach
Location: Centers for Disease Control and Prevention:
www.cdc.gov/diabetes/pubs/pdf/vision.pdf
•
Prevent Blindness America Vision Screening Program
Location: Prevent Blindness America: www.preventblindness.org
Contact Information:
Community Research Partners
200 East Broad Street, Suite 490
Columbus, Ohio 43215
Tel: (614) 224-5917
Fax: (614) 224-8132
www.communityresearchpartners.org
Prevent Blindness Ohio
1500 West Third Avenue, Suite 200
Columbus, Ohio 43212
Tel: (614) 464-2020
Fax: (614) 481-9670
Toll Free: (800) 301-2020
www.pbohio.org
Prevent Blindness America
211 West Wacker Drive, Suite 1700
Chicago, Illinois 60606
Tel: (800) 331-2020
www.preventblindness.org
Vision Care Services at Columbus Neighborhood Health Centers: Lessons Learned Page 31 Appendix B Adult Vision Assessment Clinical Process
Adult Vision Assessment– Clinical Process
Target Populations and Frequency of Implementation:
- New Adult Primary Care Patients (All)
- Patients with Diabetes or Prediabetes (once annually)
- Patients aged 65+ (once annually)
- All other existing adult patients (once every two years)
Step 1: Patient registration desk gives patient a
copy of the Adult Vision
History and Risk Assessment form to complete in
the waiting room.
Step 2: Patient returns to
registration when complete
and staff puts the form in the
patient file for evaluation by
nurse/PA.
A - Additional procedures for “referrals”
Nurse/PA provides the
following for a “referral”
result:
1. Eye health educational
materials as appropriate based on responses.
2. Make notation for further discussion by the
primary care provider.
For “referrals”- Primary care
provider reviews nurse/PA
notations on AVHRA form
and provides the following:
1. Makes recommendation
to see an eye care provider;
2. Gives patient the last
page of the AVHRA
form;
3. Asks patient to stop by
scheduling to set a date
for an eye exam.
Patient sets date
for eye exam with
vision clinic scheduling and attends
exam.
Vision clinic updates
patient record with
results of exam and
any other information.
Patient vision assessment and education is
complete.
Step 3: Nurse/PA reviews answers
to AVHRA form and result is either a
“referral” (see “A” for additional
steps) or “further screening” (see “B”
for additional steps) of the patient.
B - Additional procedures for “further screening”
Nurse/PA provides the following
for a “further screening” result:
1. Conducts a vision screening
consisting of a near and distance visual acuity and visual fields assessment (if appropriate);
2. Provide eye health education
materials as appropriate;
3. Records results of screening
on AVHRA form and indicates if patients should be
referred to an eye doctor
based on results.
For “further screening”- Primary
care provider reviews nurse/PA
notations on AVHRA form and provides the following:
1. Makes recommendation to see
an eye doctor if patient does
not pass ALL portions of the
vision screening;
2. Gives patient the last page of
the AVHRA form;
3. Asks patient to stop by scheduling to set a date for an eye
exam if did not pass any portion of the vision screening.
Patient record is updated
with date of vision assessment and result. Patient vision assessment and education is complete.
Procedural Reference: American Academy of Family Physicians; US
Preventative Services Task Force: Guide to Clinical Preventive Services, 2nd Edition- Screening for Visual Impairment, 1996
Appendix C Vision Clinic Pro-Forma
Two Optometrist (OD) Practice at Maturity
2006 Eye Service Pro Forma Model
Eye Clinic = 2000 Gross Sq Ft: 2 Exam Rooms, Special Testing Rm, Optical/Waiting, Office
FY 1
Visits and Capacity
Gross Charges Comprehensive visit 92000 code
Professional Visit Average Payment
Ophthalmology Visit Average Payment
Other Visits Average Payment
Eyeglasses Average Payment
Total Health Center Visits
Comprehensive Visits (10% of Total Health Center)
Ophthamology Visits
Other visits (walk-ins, consults, etc)
FY 2
$155
$68
$175
$35
$125
35,000
3,500
350
1,050
FY 3
$155
$68
$177
$37
$135
38,500
3,850
385
1,155
$155
$70
$180
$39
$150
42,350
4,235
424
1,271
Projected % Utilization
Projected Comprehensive Eye Visits
Projected Ophthalmology Visits
Projected other visits
Total Visits
75%
2,625
263
788
3,675
90%
3,465
347
1,040
4,851
100%
4,235
424
1,271
5,929
Eyeglasses (50% of primary eye visits)
1,575
2,079
2,541
Uninsured Visits
Reimburseable Visits
Total Visits
1,470
2,205
3,675
1,940
2,911
4,851
2,372
3,557
5,929
Net Revenue
Uninsured reimbursement (e.g. 30% gross charges)
Professional Service Fee Payment
Eyeglasses
Total Net Revenue
$30,240
$151,200
$196,900
$378,340
$40,260
$201,200
$280,700
$522,160
$50,670
$253,300
$381,200
$685,170
Operating expenses
OD
MD
Billing Clerk
Receptionist
Optical Assistant
Total Payroll
Benefits eligible payroll
Benefits
Utilities
IT/Data
Maintenance/Janitorial
Cost of Goods Sold
Supplies
Start up supplies
Credit card fees
Occupancy Cost
Total Expenses
100,000
6,400
35,000
30,000
30,000
201,400
195,000
46,800
10,000
4,500
4,000
118,100
10,000
10,000
2,100
10,000
416,900
163,000
9,600
36,100
30,900
30,900
270,500
260,900
62,600
10,300
4,635
4,120
168,400
10,300
0
2,900
10,000
543,755
206,090
9,600
37,200
31,800
31,800
316,490
306,890
73,700
10,609
4,774
4,244
228,700
10,600
0
3,800
10,000
662,917
Net Income (Loss)
(38,560)
(21,595)
22,253
Capital Spending
Startup Equipment costs
Build out/lease hold improvements
Optical start up costs
Total capital investment
Capital spending per year, amortized over three years:
$130,000
$120,000
$15,000
$265,000
$88,333
Assumptions
60%
40%
60%
30%
3%
$100,000
$800
$35,000
$30,000
$10,000
24%
60%
10,000
10 000
10,000
1.2%
50%
$60
3%
$10,000
$10,300
2,000
= % Visits resulting in eyeware purchase
= Uninsured Care % of patient pool
= Fee for Service % of patient pool
= Average payment reimbursement for Uninsured Care
= Rate of annual salary increases
= OD base salary
= Monthly cost for MD (2 sessions per month = 8 hours)
= Base salary for Billing Clerk
= Base salary for Receptionist / Optical assistant
= Utilities in year 1
= Benefits as a function of payroll
= COGS as a function of eyeglass sales
= Cost of standard supplies
machines computers,
computers copier
= Cost of fax machines,
copier, printers
= Credit card fees as a function of sales
= % Sales that will use credit cards
= Build out cost per square foot
= Annual increase in operating expenses
= Annual occupancy cost
= First year utility cost
= Gross square feet
FTE of Staff Optometrists
Year 1
1st Year OD's 1.0
Year 2
1st Year OD's
0.6
2nd Year OD's
Year 3
1st Year OD's
2nd Year OD's
3rd Year OD's
1.0
1.0
0.0
1.0
300 E. Broad St., Suite 490 / Columbus, OH 43215
Phone: 614-224-5917 / Fax: 614-224-8132
www.communityresearchpartners.org
A partnership of United Way of Central Ohio, the City of Columbus and the John Glenn Institute at The Ohio University