Having described the legal framework surrounding being able to provide domiciliary optometric care, it is important to remember that effective service relies on good communication, accurate and appropriate record-keeping, clarity of management or prescribing recommendation, and a good working knowledge of the administrative requirements after the consultation has finished.
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Communication
It is recognised that effective communication is important in any optometric consultation.1 A practitioner’s style of communication should be adapted to suit each individual patient and this may be particularly beneficial when examining a domiciliary patient, especially if the patient has dementia or another acquired cognitive impairment. Interacting with this type of patient may not seem straightforward or feel comfortable for many practitioners and the Code of Practice for Domiciliary Eye Care stipulates that providers of domiciliary eye care should ensure that their personnel receive appropriate guidance in the specialist communication skills necessary for domiciliary patients.2
It is recommended that where possible, when approaching a person with dementia, one should move towards the individual from the front.3 The initial conversation should start with the optometrist identifying him/herself4 and it is suggested that a more positive response may be obtained from some patients if they are addressed at first in a formal manner, using title and surname.3 Making eye contact and reducing extraneous noise can help the patient maintain focus on the optometrist and the task in hand (Figure 1).3,5
When conversing with an individual with dementia, it is important to remember to keep sentences short and simple. It is also imperative not to rush the interaction.3,5 Breaking down more complex sentences into a series of more succinct and straightforward ones can make it easier for someone with dementia to understand what is being said. It is suggested that four to six words together are the optimum number for each sentence.4
Open questions should be avoided and sentences should be constructed to elicit a ‘yes’ or ‘no’ answer.5,6 It is also advised that real names are used for people and objects as this makes conversations easier to follow.6
Although semantic understanding of conversation may diminish in patients with dementia, the message that is conveyed by the tone of the communicant’s voice and their body language will still be recognised.4 Therefore, the optometrist should endeavour to maintain a relaxed demeanour and an encouraging, supportive tone of voice, while avoiding sudden, tense movements.
It should be remembered that individuals with dementia are unlikely to have requested an eye examination themselves. It is more likely that a relative or member of staff has arranged the visit on their behalf. The arrival of an optometrist can therefore come as a complete surprise. Even if their carer has mentioned the optometrist’s visit in advance, it is quite possible that the individual will not have retained this information.
It is therefore good practice for the optometrist to explain the reason for their visit as part of their introduction to the patient. It is also important to gain consent from the patient before commencing any of the test procedures and to take into account any verbal or non-verbal behaviour that could indicate that consent has not been given. This may be demonstrated by the patient turning their head away from the optometrist or by a more vociferous outburst. If the patient appears to be unhappy at any point about the examination proceeding, it is paramount that the optometrist ‘downs tools’ and attempts to re-establish consent before continuing.
Record-keeping
The College of Optometrists advises that an optometrist has a duty to ensure that he or she keeps complete, contemporaneous and legible records of the patients under his/her care.7 Additionally, record-keeping is a fundamental part of contract compliance within the GOS.8 When working in a domiciliary setting, extra information can be usefully included in a patient’s record. The reason for a domiciliary sight test and any eligibility for an NHS voucher should be recorded2,3 along with the name of any person who is accompanying the patient. It can also be beneficial to note the name of any individual with whom the patient has consented to share the results and recommendations of the sight test.10
In previous GOC fitness to practise cases involving patients seen in a domiciliary setting, allegations have been made regarding the failure to obtain and/or record various clinical findings.11 As previously discussed, it is recognised that, depending on the nature of the patient, the exact content and format of the examination may need to be varied.10,13 However, if it is impossible to include the full range of procedures due to the patient’s medical limitations, the reasons should be noted on the record card.14
Prescribing considerations
As with any patient, when deciding whether to prescribe an optical appliance, an optometrist should consider whether there is a relevant change in prescription and whether this improves the patient’s functional vision. The serviceability of the patient’s current optical appliance and whether or not it is actually used, should also be taken into account. Additionally, for patients with dementia or other acquired cognitive impairment, the individual’s ability to make the choice as to whether to have a new prescription made up should also be a factor in this process.10
After the examination
As well as issuing a spectacle prescription or statement that no correction or change is necessary, a practitioner should provide additional details summarising the outcome of the sight test with the patient or, with the patient’s consent, with their carer or care home. Additionally, the patient should be given the contact details of the provider.3
Careful consideration as to whether the patient is entitled to an NHS optical voucher on benefit grounds should be made (Table 1). A number of domiciliary patients may be in receipt of Pension Credit. A clear distinction should be made between the two different types of Pension Credit; Guarantee Credit and Savings Credit. Only those receiving Guarantee Credit are entitled to an NHS optical voucher and an optometrist issuing such a voucher should satisfy him/herself that the relevant benefit is being claimed. This may involve checking the applicable paperwork or calling the pension service to enquire. As an enquiry to this service will mean that the patient will need to answer a number of security questions over the phone, this approach may not be suitable in cases where the patient is hard of hearing or may be confused. A useful approach in this situation can be for the optometrist to explain matters to the pension service, asking to establish implicit consent. Once this is confirmed, the relevant information can then be supplied.14
Alternatively, it may be possible to determine whether or not a resident of a care home is entitled to receive an NHS optical voucher by enquiring about how their care is funded. If local authority funding covers their fees completely, it is very likely that the resident is in receipt of Guarantee Credit. Although nursing and care staff will not be privy to this information, it may be possible to contact finance staff to clarify the situation.
Patients receiving domiciliary eye care are entitled to have their prescription made up by whomsoever they choose. Under the ‘Cancellation of Contracts made in a Consumer’s Home or Place of Work etc Regulations 2008’ (SI 2008 No1816),13 they are also entitled to a seven-day ‘cooling off period’. This means that the patient is able to cancel an order placed for any new optical appliance at any time within seven days of placing the order. The patient does not need to give any explanation, justification or reason for any cancellation. The provider of the optical appliance may begin the process of ordering the appliance before the seven days have elapsed, but the provider then runs the risk of the patient cancelling unless the patient has given written permission for the work to go ahead.13
It is paramount that any spectacles dispensed are fitted individually to patients14 and it is important to remember that the supply of any optical appliances to patients who are registered sight impaired or severely sight impaired or who are under 16 is carried out by, or under the supervision of an appropriately registered person.15 It is recommended that any spectacles supplied are labelled with the patient’s name although this should be done sensitively with respect to the patient’s dignity and should take in to account infection control.16,9
It is important that providers of domiciliary services can offer continuing care to patients, being available for adjustments, advice etc, and do not see the sight test as a ‘one-off’ event.10,14 Patients should be informed in advance whether any payment will need to be made for any follow-up service requested and in the event of any tolerance issues arising, fully trained staff must be available to attend to these.14
Conclusion
A recent determination made by a fitness to practise committee recognises that those providing domiciliary eye care visit those who would be considered as vulnerable individuals10 and the Code of Practice for Domiciliary Eyecare reminds providers of domiciliary services that they are acting in a privileged position of trust.2 It is hoped that this article will assist those working in a domiciliary environment to give their best possible attention to the professional, legal and ethical obligations of this very valuable work.
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Model answers
(The correct answer is in bold text)
1 Which of the following is thought not to be appropriate when communicating with a patient known to suffer a dementia state?
A Maintain eye contact
B Minimise background noise
C Use friendly, infomal first name references
D Use short succinct sentences
2 Which of the following question types is likely to be most effective when communicating with a known dementia sufferer?
A Closed
B Compound
C Open
D Leading
3 Dementia patients are more likely to still be able to recognise which of the following forms of information transfer?
A Cognitive
B Semantic
C Affective
D Auditory
4 Which of the following actions is appropriate if a full examination is impossible to complete in a domiciliary consultation?
A Record the reasons for incomplete assessment
B Rebook for completion of the test later that day
C Refer the patient to the hospital eye service
C Do not claim any fee for an incomplete test
5 Which of the following statements is true regarding an order for a corrective appliance made during a domiciliary consultation?
A The patient has to be dispensed by the examining practitioner
B Any order may be cancelled at any point up until the delivery to the patient is made
C Once an order has been paid for, refunds can only be obtained through a small claims court
D A 'seven day cooling off' period is allowed for a patient to change their mind about an order
6 Which of the following statements concerning the dispensing of an appliance after a domiciliary consultation is true?
A A registered dispensing optician is the only person legally allowed to make the dispense
B Only a registered eyecare practitioner, or someone they are supervising, can dispense a patient who is registered as sight impaired
C An order can be posted on to a patient under 16 as long as adequate measurements were taken at the time of the initial dispense
D There is no facility for managing non-tolerance of an appliance issued during a domiciliary consultation
Acknowledgement
The author would like to thank David Cross, an optometrist working in the domiciliary sector, for his help in compiling this article.
References
1 General Optical Council (2011). Optometry Stage 2 Core Competencies 2011. Accessed 13 February 2014.
2 Domiciliary Eyecare Committee (2014). Code of Practice for Domiciliary Eyecare. Accessed 4 September 2014.
3 Alzheimer’s Society. Top Tips for Nurses: Communication. Accessed 13 February 2014.
4 Weirather RR. Communication Strategies to Assist Comprehension in Dementia. Hawai‘i Medical Journal, 2010; 69: 72-74.
5 Alzheimer’s Society. Communicating. Accessed 13 February 2014.
6 Stokes G. Tackling communication challenges in dementia care. Nursing Times, 2013; 109: 8, 14-15.
7 The College of Optometrists (2012). A9 Patient Records.
8 Quality in Optometry Website
9 The Optical Confederation, AOP (2014). Making Accurate Claims in England. Accessed 14 July 2014.
10 The College of Optometrists (2011). C4 Examining the Patient with Dementia or Other Acquired Cognitive Impairment. Accessed 13 February 2014.
11 The General Optical Council Website. Hearings Section. Accessed 13th February 2014.
12 Department for Work and Pensions (2014). Working with representatives - Guidance for DWP staff. Accessed 5 September 2014.
13 The Cancellation of Contracts made in a Consumer’s Home or Place of Work etc. Regulations 2008. Accessed 13 February 2014.
14 Optical Confederation (2010). Advice to providers of goods and services in the home or place of work. Accessed 13 February 2014.
15 The Opticians Act 1989, Amended 2005. Accessed 13 February 2014.
16 Care Quality Commission (2012). Time to Listen in Care Homes. Accessed 4 September 2014.
Catherine Viner is a senior lecturer at the University of Bradford