The role of a domiciliary optometrist is not only challenging and varied but above all else, rewarding. In this article we will explore what could be involved in a typical day (if there is such a thing), as well as useful recommendations and advice to assist in the delivery of this essential service. To illustrate this we will explore a little background information before an account of a real life day.
In a later article we will discuss equipment to take on a domiciliary visit, some of which is required in the Additional Services Contract and some of which I consider helpful in my experience.
Logistics
The first challenge that many domiciliary providers will face is not a clinical one but a logistical one. How do you best arrange a day to minimise travel and maximise output? Working for a company such as The Outside Clinic, I enjoy the benefits of a sizeable scheduling department that uses mapping software to arrange my days in an efficient manner. A sole practitioner may need to schedule visits around their own diary, bearing in mind that they will be out of the practice for not only the visit but also the commute to and from the patient. You may need to be sensitive to times when carers are present and be prepared to rearrange if the patient is taken unwell.
Depending on the mix of locations you could expect to see around seven individual patients, or slightly more if you are based at one location for the day, or a large part of the day. In such an instance particular care should be paid to the Domiciliary Eyecare Committee’s and General Optical Council’s codes of conduct (Optician 21.11.14). Each patient should be treated with the privacy, dignity and respect that they deserve as individuals. A private room should be set aside to avoid disclosure of potentially sensitive information – after all you wouldn’t test a high street patient in the waiting area! It is best practice to consult the patient and gain consent to have a carer or relative present if required, particularly if they have memory difficulties.
Your record card will need to be just that – a record of everything that occurred at the visit. This should not only include clinical results and findings but also any advice that you have offered to the patient. Just think, if an advocate calls in two weeks after the visit would you be able to recall all of the details?
Modern devices, such as tablet PCs, can be utilised for record keeping. These allow a large amount of information to be recorded and may also transcribe handwriting to print, meaning that colleagues do not have to decipher hieroglyphics. They can then be linked to mobile printers to generate GOS forms, information sheets and referrals.
Increasingly the capabilities and greater portability of technology allow an optometrist to operate more efficiently on even the most diverse day.
Just as no two days are the same, no two patients are the same. In the morning you may visit a 20-year-old with learning difficulties, at lunchtime you could be calling on a 45-year-old with multiple sclerosis and in the afternoon it may be a 99-year-old with arthritis and advancing glaucoma. Your routine needs to be adaptable and your temperament calm and composed. Often you have to prioritise the most important investigations. For instance, I will usually complete ophthalmoscopy early in the visit; however, you need to ensure that the patient understands and is comfortable having a stranger in their personal space. At other times it may be prudent to leave these sorts of tests until you have built more of a rapport with an anxious or agitated patient.
[CaptionComponent="973"]The working day
On this particular day I have a total of seven patients booked (four individual patients, a husband and wife double appointment, and one patient in a residential care home). After lunch I am due to meet with a colleague for a clinical governance visit. This not only gives support and contact out in the field but also ensures that all patients receive a consistent and high level of service while practitioners can exchange clinical ideas and opinions.
Having checked the satnav I estimate that the journey across the city will probably take about 50 minutes in rush-hour traffic. To be safe I allow just over an hour as the first patient has been advised of their 9am appointment time. I arrive in good time and am met at the door by Mrs J’s carer, a lovely lady who accompanies me to the living room where I proceed to set up my equipment.
Mrs J is a quintessential domiciliary patient. She is 84 years old and has previously undergone bilateral cataract extraction. She has now developed dry macular degeneration (AMD) and has been experiencing increasing difficulty when reading her daily newspaper. This is having a significant impact on her quality of life as it remains one of her few contacts with the outside world. An updated refraction improves her binocular best corrected visual acuity from 6/19 to 6/12 and her near acuity from N12 to N10 in habitual lighting. With demonstration of improved lighting she can achieve N8 with some comfort but seems to still be struggling identifying the 3s and 8s on the crossword clues. Fortunately within my kit I have a range of visual aids including both hand and stand magnifiers. We try several and as Mrs J only requires a little additional help with spot reading and has good dexterity she finds the 2x LED hand held magnifier most useful. This will be supplied along with an order for new spectacles.
My next patient, Mr S, discusses symptoms which are cause for more concern; two days ago he started to notice that the lamp post across the street had developed a kink in it. Dilated fundoscopy shows a haemorrhage at the right macula suggestive of wet AMD. The tablet PC allows me to fill out a Wet AMD Rapid Access Form which I then electronically send to our Clinical Services and Support department as they have the contact details for HES departments across the country. They liaise with the hospital on my behalf while I discuss prognosis and likely treatment with the patient. Twenty minutes later I receive a telephone call to advise me that the situation is in hand and an outpatient appointment has been arranged for Mr S.
My next two visits are both unremarkable; one sight test only and one lady who requires a slight modification to her prescription. We choose a suitable frame and lenses for her and will return to deliver the new spectacles at a later date.
At two o’clock, coinciding with the double home visit, I am met by my colleague for the clinical governance observation. I complete both tests and after saying goodbye to Mr and Mrs W, we discuss the observation form and accompanying notes. These will then be added to my governance folder back in head office ready for my next Professional Service review.
The final appointment of the day is to take place at a local residential care home. Having telephoned ahead the staff have arranged for me to see Mrs H in her bedroom. This ensures that we will not be discussing personal details in front of other residents, but also shows me that she has an adjustable bed with a television at the foot of it. Ophthalmoscopy shows mild-moderate cortical cataracts but referral is declined due to ill health; we shall review again in a year. Mrs H currently wears bifocals but has been unable to enjoy watching the TV in bed. It soon becomes clear that this is because the bifocal segment is obstructing her view when the back of the bed is raised. Further discussion also reveals that a recent fall may have been linked to Mrs H missing her footing when trying to walk around the home with her Zimmer frame. For this reason we decide separate pairs would be the safest option. I discuss this with the patient and care manager before leaving a written summary of results in her care plan and making my way home for the evening.
[CaptionComponent="974"]Confidence boost
There is absolutely no reason why a patient with mobility difficulties should receive any less of a service than a patient who walks into a high street practice. As this account shows, domiciliary work gives an optometrist a unique insight into each patient’s lifestyle and living environment. Without this vital service there would be many people unable to access their optometric needs.
On a personal note I feel I have developed greatly as both a clinical practitioner and as a person during my time providing domiciliary services. Pathology is common and so I have become more comfortable and confident with my clinical advice. This in turn has led to further opportunities to become involved in research projects. One such project undertaken by The Outside Clinic in conjunction with the College Of Optometrists’ is ‘PrOVIDe’ study. This was funded by the National Institute of Health Research and investigated the prevalence of visual impairment in people with dementia. Another example of a project is the recent pilot of PolyPhotonix’ new Noctura 400 sleep mask aimed at helping with diabetic retinopathy.
In our next article we will look at equipment currently used in domiciliary services and how technology can best be utilised to assist with this ever growing optical sector.
Matthew Burford is a Professional Services Optometrist for The Outside Clinic and sits on Worcestershire LOC
