There may well be a more cost-effective and accessible system for eye care services for the increasing number of patients with limited mobility. Peter Framptom describes a novel service he provides
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Changes have been instigated recently in the organisation of domiciliary supply. I understand representative optometric groups - but not users - have been in discussion with the Department of Health regarding this service management. I therefore felt it timely to present our audit results from an experiment to provide our patients with an alternative to home visits.
Aaron Optometrists introduced a patient transport vehicle in March 2002. We have operated the service ever since and in November 2003 it was recognised by Northumberland Care Trust with an 'Innovation in Practice' award.
Prior to its introduction we found no evidence of a similar optometric service. Previous studies describe similar services within GP practices and social services.1,2,3
Within our practice, the desire for a patient transport system has evolved from several areas of concern.
Firstly, optometrists feel they cannot give as good an examination at someone's home as they could in the practice. The lighting often creates difficulties and portable equipment remains limiting. A serious caveat to this is that the domicile population is the most likely to need the advanced clinic-based technology.
We have also found that many patients examined at home are not housebound but simply less mobile. Reasons for choosing a home visit are often more to do with loss of confidence, especially when travelling alone.
Further, our referral patterns demonstrate that the domiciliary population are far more likely to require referral for other health provision. This raised the issue - if a patient can get to a centre of secondary care, why could they not have accessed our, much more convenient, optometric clinic?
It therefore seemed logical that if we could supply our patients with a door-to-door service, in a suitably equipped vehicle with wheelchair facilities, we would be able to supply better professional care and more sensitive and specific referrals.
Transport versus home visit
We do stress that our transport service is not meant to replace home visits, which are vital for housebound people. The purpose is to remove as many obstacles as possible to accessing the clinic. To minimise the financial risk for this untried service, I simply replaced my private vehicle with a patient transport vehicle. While I am at work it is either used to help patients access the clinic or it remains parked, as my private vehicle did, until I go home. If the service had not been successful, the worse case scenario was that I would be forced to drive to work in a van rather than a car.
Running costs are minimised by using a volunteer driver and by striving to ensure that spectacles are made while the patient waits. Hence travel costs are only minimally different to those incurred with home visits.
A significant cost and obstacle to establishing service was insurance. It took two years to find any institution willing to take on the insurance needs of the service, and the charges are relatively high when compared to insuring a private vehicle.
Our lack of experience in this field pushed us toward an already converted, second-hand 1998 Mercedes Vito. This came with an extendable side step and full wheelchair lift and chair locks, so a patient, if necessary, can remain in the chair from home to the clinic room.
We were concerned that the service could be construed as a patient-attracting gimmick. Consequently no promotion wascarried out, save from word of mouth and the distribution of in-house information leaflets to existing patients.
The most common way patients discover the service is through the practice itself. Those who request are home visit are advised of the alternative patient pick-up service. They are informed that a better examination can be achieved in the clinic and that there is no extra charge for the door-to-door service. After four years, there is a growing number of return patients, while many others are contacting us because the service has been recommended to them.
The scheme was initially seen as financially flawed by some outside observers given only the clinic-based examination fee can be levied rather than the domiciliary fee. However, a domiciliary examination is three times as expensive as it takes three times as long. Since we can examine two further patients in the clinic during the time allocated to a domiciliary for travel and setting up, the net payment to our clinic for the same time spent is equivalent. This actually allows three times the opportunity to dispense spectacles, which - as we all appreciate - is the most profitable component of optometry.
Figure 1 shows the breakdown of patient pick-ups versus home visits during the year ending August 31 2006. It shows that the majority of patients (157), when making an informed choice between a home visit and a pick-up service, chose to be collected, while only 51 requested a home visit.
Of the 157 patients opting to be collected, 69 (44 per cent) would have accessed our clinic by private means regardless of the service and therefore cannot be considered as part of a true domicile population. Eighty-eight (56 per cent) would have requested a domiciliary visit had the transport service not been available.
Forty-two (27 per cent) came to us as new patients specifically because they had heard of the service and 56 (36 per cent) were existing patients who had already utilised the transport service at least once. Without any proactive publicity the service is growing in popularity.
Eleven patients were found, on arrival, to have been inappropriately collected. This is judged on whether the patient was unable to move from the wheelchair to the examination chair. In this situation the examination within the clinic is not significantly different to one within the home.
Only 33 of the patients choosing a home visit were considered, in the opinion of the attending optometrist, to be true domiciles. Patients who were bed or wheelchair bound, in constant use of oxygen, agoraphobic or in need of frequent breaks for medicinal or continence issues were identified.
The remaining 18 were considered to have been capable of attending the surgery with help.
Adjusting for inappropriate collections and home visits our figures suggest that only 32 per cent of the patients considered for home visits are true domiciles. More realistically, patients making an informed choice between patient pick-up and home visits (and who would have had a home visit had the pick-up service not been available) was 63 per cent versus 37 per cent (Figure 3).
Satisfaction survey
A questionnaire of service users overwhelmingly demonstrated that patients appreciated the service and would make future use of it.
One hundred per cent of respondents said they prefer the pick-up service to a home visit. All respondents also felt the service was valuable to patients. When asked if they would make use of the service in the future 96 per cent said they would, 4 per cent were indifferent, but none said they would voluntarily choose a home visit over the transport.
When asked what was appreciated most about the service, an extraordinarily large proportion of respondents simply liked the chance to 'get out'. This has been a constant response throughout the four years of operation. It emphasises how isolated some elderly patients feel and is accompanied by significant loss of confidence.
Other comments made included the convenience of a door-to-door service, particularly in poor weather, and the ability to access care without dependency on others.
No negative feedback was recorded, but the respondents were people motivated to access care. Consequently, they tend to appreciate all help that is available and will not criticise.
A sample of patients who would not have chosen to use the service would not necessarily have responded as favourably.
As the service suppliers, our own criticisms are that difficulties are still faced when accessing the clinic room for the patients who were deemed not suitable for patient collection (but still chose the service voluntarily).
We have also found some delays for patients waiting to go home. It is impossible to predict exactly when a patient will be ready for home, especially if more than one patient was picked up on the same outing.
Analysis of needs
An assessment of the clinical management of the last 100 patients using the service was completed. The average age was 78 (maximum 96, minimum 48).
Seventy-five were existing patients. Twenty-five were new to the practice, of which 18 attended purely for diabetic retinopathy screening. Of the 100 patient records considered, 82 had eye examinations.
Of the 82 patients having had eye examinations, less than half (49 per cent, 40 individuals) were dispensed spectacles. The majority requiring new spectacles considered functionality before style, reflected in the sale values. Seventy-one per cent of those receiving help chose spectacles without private costs, while those paying extra or privately tended to choose inexpensive, but robust frames.
This would seem logical. People confined to home are less likely to be fashion motivated.
While specific referral to the Hospital Eye Service is relatively low at only eight (10 per cent of eye examinations), 45 patients (54 per cent) required enhanced services or referral to alternative services. A total of 53 patients (65 per cent) of the 82 that had full eye examinations required advanced services of some description.
Figure 4 shows the breakdown of management outcomes for the patients having eye examinations. Absolute figures are presented as some patients may have had more than one procedure.
A minority of 29 patients (35 per cent) had routine eye examinations only. Diabetic retinopathy screening was required for 21 (25 per cent) patients, while 32 per cent (26 individuals) were referred for low vision rehabilitation services.
Only eight (10 per cent) patients were referral into the Hospital Eye Service. Interestingly only three referrals were for cataract, re-examination of the records showed that 40 per cent had already undergone extraction.
Enhanced clinical assessments within the practice (assessment for floaters/flashes, tear and lid assessments, glaucoma refinement) were necessary for 19 (23 per cent) patients.
Diabetic screening
Of the 100 user records audited, 39 were patients with diabetes and required screening photographs and reports. Availability of the collection service dictates that we tend to see the majority of patients who find it difficult to access care. Consequently these 39 patients with diabetes constitute, possibly, the most difficult to assess. In this cohort 18 were brought in purely for the photographic screening and presumably had eye examinations elsewhere.
The optometry-led diabetic screening service in Central Northumberland incorporates a two-tier system. If the photo is deemed of poor quality, secondary grading via Volk fundoscopy is done before the patient is discharged.
Only 20 (51 per cent) were graded successfully from the photographs alone. Fourteen (36 per cent) had photographs considered inadequate and went on to secondary grading via Volk fundoscopy, while five (13 per cent) could neither sit at a slit lamp nor camera and required ophthalmoscopic or indirect headset examination (Figure 5). The failure rate for this group of patients is high. Without secondary grading 49 per cent would have required referral to secondary care incurring the associated costs to the care trusts.
Conclusions and plans
Service users should have an informed say in service development. Our results suggest that, if given the option, the majority of patients (75 per cent) would choose the pick up service to a home visit. Further, our questionnaire suggested that the vast majority of users (94 per cent) rated the service highly and would use it again.
So not only do the professional staff feel happier with the patient transport service, the patients themselves seem to prefer it. We can only see an increase in use of the service. Within Northumberland we have several successful co-management schemes already. As our professional skills improve, the need for patients to attend fully equipped optometry clinics will increase.
Continuation of the service is therefore guaranteed and our provision of care will continue to include strong encouragement to utilise it. An upgrade of the vehicle is now planned.
It is a matter of professional opinion as to what tests should be done as part of an optometrist's duty of care. Which tests can be accomplished successfully in someone's home is also up for debate. However, we believe the figures presented suggest strongly that patients should be encouraged to be seen in a fully equipped clinic if at all possible.
In the opinion of the examining optometrists, 51 per cent of patients (42 individuals) did not require a change in visual correction.
At least 65 per cent required examination techniques that would, in our opinion, be severely compromised in a domiciliary setting. Of the patients with diabetes 49 per cent required secondary grading.
If this is the case nationally, it highlights the very important question as to the purpose of an 'eye examination'. Should it be to thoroughly monitor ocular health or simply to prescribe optical correction?
I appreciate as well as anyone, that the eye examination is subsidised heavily by sales. However, as unjust as we may feel the system is, simply manipulating it to our own advantages will not encourage the Department of Health to change its view on our professional worth or what we are paid for our professional services. A fundamental change in the funding system is far more likely if we can prove that our professionalism is a valuable commodity in itself. If this can be demonstrated, through robust audit and patient feedback, then changes to our terms of service may follow.
In relative terms we see very few patients in their own homes. Regardless, our estimate of savings for the Department of Health by encouraging patients who would have requested a home visit to use the patient transport was £2,849.44 for the year audited. Our figures suggest that at least 60 per cent of patients using domiciliary services could attend a clinic with additional help. Project this onto a national level and the savings for the department are considerable, and could be re-directed toward better general GOS funding.
Care trusts now vet all home visits, patients are supposed to be given choice and care trusts have access to integrated patient transport services. Therefore, if our results are confirmed, it may be cost effective for the department to encourage care trusts to supply dedicated patient transport services themselves. When a patient is registered with a trust, a representative can contact the patient directly, giving the options of home visit or transport. If transport is chosen, the optometrist of the patient's choice can be accessed. ?
References
1 Harrington S. Firing on all cylinders. Insight, March 28, 1990: 23-25.
2 Lovett A, Haynes R, Sunnenberg G and Gale S. Car travel and accessibility by bus to general practitioner services: a study using patient registers and GIS. Social Science and Medicine, 2002 55 (1) : 97-111.
3 Ryan S. Your place or mine? Practice Manager, November 1997: 11-12.
? Peter Frampton studied optometry at QUT, Brisbane, Australia. Moving to Britain in 1986, he took ownership of an independent practice in 1993
