Domiciliary eye care involves the provision of eye examinations and related services within a patient’s home environment. The ideal for domiciliary optometrists is to provide an eye examination as close as possible to that available in a well-appointed consulting room. What are the key challenges in meeting this high standard?
‘I don’t think there are any specific clinical challenges to domiciliary work at the moment,’ says Kejal Shah, domiciliary optometry partner at Specsavers. ‘We see a wide variety of patients across all age groups, and, in terms of conditions, it is all the normal ones typically seen in community practice. Cataracts, glaucoma and age-related macular degeneration are the most common conditions. The general challenge for making any domiciliary visit is that you don’t know the test environment. You don’t know the set-up required until you get in. So, you need to be flexible and ready to adapt.’
‘In my opinion, the main challenge with domiciliary eye care from a clinical perspective is that you’re looking after residents or patients that are living with conditions such as dementia and may have varying levels of cognitive impairment,’ says Vishal Khurana (pictured above), care home development director at OutsideClinic. ‘We are all taught at university how to test eyes, however, the challenge in domiciliary is how can you take that routine and deconstruct and adapt it to be flexible for a patient living with dementia. Depending on the patient’s cognitive impairment, you need to do things differently. It could be the order in which you do something, it could be the type of instrument you use, whatever that is to ensure that you get the best possible sight test for the patient.’
Full training
Of course, optometrists benefit from specialist training and cutting-edge equipment and instrumentation to better meet the challenge of conducting a first-rate domiciliary eye examination.
‘We perform a complete eye test of very high quality for these patients in their own environment,’ says Shah. ‘We have a full induction process that, as soon as people join the business, gets them up to speed. Optometrists new to domiciliary work are assisted for a few months until comfortable to be doing it solo. On the equipment side, we’ve got a lot of portable equipment, so we can perform any tests that a patient requires, including pressures, ophthalmoscopy, and refraction. In terms of dispensing, we go out with over a hundred frames for patients to choose from if they need to upgrade their glasses.’
‘We support people on how to communicate with residents living with impairments including dementia,’ says Khurana. ‘We hold inductions for people before they start on the actual job. These take place over a few days and are conducted in a training environment where we discuss communication techniques and how to go about the sight tests. After the induction training, people then go out and observe a team in action so they can see for themselves and further discuss the sight test routine. Then, they can start engaging with patients living with dementia and get comfortable in that space. It is very important to get some core experience in that environment before optometrists go out on their own.
‘It is also important from an equipment perspective, to have that induction and observation period. The equipment includes portable versions of things usually found in consulting rooms: slit lamps, cameras, test chart.’
Pandemic response
Providing eye care to vulnerable patients is a big part of domiciliary practise and, as such, it was one of the areas of healthcare most affected by the pandemic. So, now that Covid-19 has receded in severity in the UK, it is informative to consider how the response to the pandemic may have changed domiciliary eye care permanently.
‘I think because of the pandemic, general awareness among the public of domiciliary eye care as an available service has grown,’ says Shah. ‘We certainly don’t have a backlog from the pandemic anymore, but we are seeing a lot of new people who need the service coming forth, which is great. Demand has increased quite a bit as a result of more people knowing about it as an option.
‘We are, of course, still following all the relevant protocols. I don’t think in the long term that mask wearing will necessarily be a permanent feature of domiciliary practise. However, I think the added emphasis on equipment hygiene is important for infection control and I hope that it continues beyond the Covid-era. There’s definitely a lot of things that were brought in during the pandemic that are beneficial to keep going in the long term,’ she adds.
‘The height of the pandemic was such a challenging time. Our rule of thumb was always to ask what more we could do beyond the minimum requirements to better protect our patients,’ says Khurana. ‘Recently, the guidance changed once again around mask wearing and related matters. We feel that we should probably continue with masks because of the proximity involved in eye care. Every care home is different and has its own policies and procedures. We know what the minimum standards are. We need to go above the minimum and be equipped for those care homes that had a really tough time during the pandemic and have very stringent procedures in place.’
Domiciliary optometry presents a demanding and rewarding opportunity for optometrists. Who should consider it as a career path?
‘I would recommend domiciliary optometry to everybody,’ says Shah. ‘I’ve been doing it for a fair few years now and I absolutely love it. I find domiciliary work very rewarding. We go out to patients who sometimes haven’t seen anybody that day. They really need our services and they are very appreciative for what we do for them.’
‘For me, it is simple in the sense that domiciliary is a great path to take if you are empathetic to patients and perhaps want to get back to grassroots optometry, with the focus on enabling patients to have a better visual quality of life,’ says Khurana. ‘You will be able to make a huge difference to your patients. People need to be able to use digital devices for all kinds of things, not least connecting with their families and staying mentally alert.’
A day in the life of a domiciliary optometrist
by Kejal Shah
The sort of domiciliary work that I do is very varied and involves travelling around and visiting individuals in their homes. No two days are ever the same and every day you see so many different things.
We tend to get our clinic schedule a few days beforehand so you can see exactly where you need to be in terms of planning your day. Accordingly, on the day, we will call the patients in the morning to say we will be with them between such-and-such a time. This means they know we are coming in and they are ready for us.
I always travel with an optical assistant. At the first patient’s house, the optical assistant will have the laptop and do all the necessary visit requirements and the necessary eGOS material as well. I go through the patient’s history, symptoms and medications, and get them positioned in the right place in their house for us to be able to do the eye examination.
We will then go ahead and perform the full eye examination. So, everything from pressures, to ophthalmoscopy, to refraction, to whatever else the patient requires on the day. After the handover, the optical assistant will go through the dispensing of any glasses required. Once we are finished, we get back in the car and move on to the next patient, and the next patient after that, until the day is done.
We aim to see an average of about nine patients a day. However, that number does vary somewhat across the nation depending on what the travel time is between the patients. In general, we try to keep travel time down to the absolute minimum in order to maximise the clinical benefits possible on a given day. The scheduling is put together by optometrists and support staff working together. My area is Surrey and I know it well, so it is useful for me to play a role in planning, but the wider business helps us with being as efficient as possible with things like the type of equipment needed on certain days.
