A recently signed memorandum of understanding between AOA and the National Association of Community Health Centers (NACHC) could potentially mean greater access to eye and vision care for underserved populations throughout the nation. More than 15 million people receive care through some 3,600 community health centers across the country. However, an NACHC survey of federally funded health centers earlier this year found only 17 percent provide in-house optometric services, with another 14 percent providing care by referring patients to local optometrists.
That could change in light of the new understanding between AOA and the NACHC, under which the two organizations will work to improve the visual health of people who receive eye care through community health centers (CHCs); address bureaucratic issues that could stand in the way; and encourage optometry school graduates to enter into careers at community health centers. The memorandum was signed in June by then AOA President Victor J. Connors, O.D., and Tom Van Coverden, CEO and president of NACHC, and was formally announced at Optometry’s Meeting in June 2004. A presentation on the agreement is expected at the NACHC’s meeting in October 2004. NACHC publications are already planning articles on ways eye and vision care can be better provided through community health centers. Tom Curtin, MD, NACHC’s associate vice president and director of the department of clinical affairs, is scheduled to speak at AOA’s Third Annual Healthy Eyes Healthy People™ Conference: Meeting Needs, Reaching Communities, Building Practices, October 21-24, 2004, in Chicago, where representatives from state optometric associations as well as schools and colleges of optometry are scheduled to discuss, among other topics, ways to incorporate full-scope-of-practice optometry into more community health centers.
Scheduled as a featured topic at both the NACHC and AOA Healthy Eyes Healthy People™ conferences is a unique Boston project which, organizers say, has for three decades demonstrated why full-scope optometry should be a necessary part of any community health care center and how that can be accomplished.
A collaboration between the New England Eye Institute, Inc. (NEEI), the clinical affiliate of the New England College of Optometry, and the Massachusetts League of Community Health Centers is responsible for a dozen community health center eye clinics in underserved areas in and around the city, according to NEEI President Barry Barresi, O.D., Ph.D., and Roger Wilson, O.D., the institute’s vice president for professional services and strategy assessment.
“The mission of the New England Eye Institute is to improve the visual health of populations through excellence in collaborative and community-oriented patient care, education, and research,” said Dr. Barresi.
“We are a network of eye care centers and services reaching out in the community with tailored programs for diverse populations. As the teaching affiliate of the New England College of Optometry, NEEI provides specialty services for whole-person eye care through its ongoing collaboration with other service organizations, delivering excellent eye care for all, with distinctive programs for children, the elderly, and the homeless.”
Although the NEEI network actually took root some 30 years ago, it has recently been drawing increased attention. The institute’s Second Annual Boston Healthy Vision Conference, held May 12, 2004 at Boston’s John F. Kennedy Memorial Library to jointly mark the National Eye Institute’s Healthy Vision Month observance and the 30th anniversary of the first NEEI clinics, drew representatives from more than 40 state and national agencies for lectures and an exhibition of clinical posters on the program.
Community health centers (CHCs) are outpatient health care facilities designed primarily to provide care in areas in which it might otherwise not be available. The concept of the community health center originated with a demonstration project under the federal Office of Economic Opportunity. The centers were permanently authorized under federal law through a 1975 amendment to the Public Health Service Act. Centers commonly are located in inner city neighborhoods or isolated rural areas. Some are even located in migrant worker camps. Patient bases are often ethnically and racially diverse. Patients can range from infants to senior citizens, and include the uninsured, the underinsured, the working poor, and the homeless. However, in some cases, the centers draw middle-class workers and their families, who simply appreciate the convenience of the centers and have established relationships with health care providers there. While many CHCs receive federal funding to underwrite operations, others are supported by state agencies, local government, private institutions, or a combination of entities. The centers are governed by boards of directors designed to represent the local community. Services can range from routine physical examinations and prenatal programs to dental care and specialized services for patients with conditions such as diabetes. Care is typically provided onsite but patients may be referred out for treatment unavailable at the center. Public or private insurance programs may be used to help defray the costs.
Unfortunately eye and vision care is not always among the services offered. Although community health center administrators generally agree there is an unmet demand for eye and vision care in many areas, such services are not mandated under federal law for the centers and are seldom given top priority by the centers’ governing boards. Lack of funding is generally cited as a reason.
In the Boston area, however, that began to change in the late 1960s and early ‘70s, when then-New England College of Optometry special assistant to the president Charles Mullen, O.D., proposed shifting the college’s campus-based clinical education program to an interdisciplinary, community-based system with an increased emphasis on treatment of eye disease and correction of vision problems among underserved populations. A community-based clinical system would provide students greater practical expertise in treating a wide range of eye conditions as well as more opportunity to work with a range of health care professionals, Dr. Mullen reasoned.
“Inner-city demographic data suggested that our optometry students would have the opportunity to participate in the care of patients with serious eye and vision problems, unlike the college students they typically examined at the college’s Kenmore Square Clinic,” Dr. Mullen told the May anniversary conference on the program. “Coincident with our educational mission was the commitment to provide eye and vision care services to inner-city residents who were unable to access this needed health care in their own communities. We concluded that the most promising scheme for fulfilling both our education and community service objectives was to form an innovative network affiliation with existing health care centers.”
Working with a trio of pioneering ophthalmologists (David Miller, M.D., of Beth Israel Hospital and the Harvard University Medical School, as well as Marc Richman, M.D., and Andrew Quamina, M.D., both of Boston University), New England College of Optometry staff, and health center administrators, Dr. Mullen organized what would become some of the nation’s first multidisciplinary eye care clinics, with optometrists — at that time having only recently won authority to diagnose and treat eye health conditions — providing primary eye and vision care and ophthalmologists available for consultations or referrals as necessary.
The result: eye and vision care became practical and accessible in many communities where no such care had been available.
In conjunction with the communities served, the first programs were established at Boston’s Dorchester House Multi-Service Center and South End Community Health Center, as well as the Dimock Community Health Center in the city’s Roxbury District, by the early 1970s. Over the ensuing years, eye clinics were opened at nine other centers (Codman Square Health Center, East Boston Neighborhood Health Center, Geiger-Gibson Health Center, Joseph M. Smith Community Health Center, Martha Eliot Health Center, North End Community Health Center, South Boston Community Health Center, Upham’s Corner Health Center, and Whittier Street Health Center). To date, the program has been responsible for more than 400,000 patient visits at the 12 facilities.
Along the way, specialized programs have been developed to address more specific eye or vision problems found to be prevalent among the patients at the various centers. A pediatric optometrist and a geriatric-low vision practitioner have established specialty practices at some centers. A unique program, in cooperation with leaders in the contact lens industry, has been established to provide specialty contact lens care for community health center patients.
NEEI adopted a unique organizational structure in 2001 when the New England College of Optometry spun off its clinical education program as a separate entity.
The New England Eye Institute, Inc. was incorporated as a 501(c)(3) tax-exempt, not-for-profit corporation, with the college as sole owner. NEEI’s board of directors is appointed by the college’s board of trustees, with members selected from Boston area community and business leaders. The college’s trustees also approve NEEI’s budget, which is developed by NEEI’s board of directors. The New England College of Optometry, in turn, provides NEEI with access to contracted faculty time to serve as the professional attending optometrists staff of NEEI under an agreement with the Institute. The Institute then contracts with community health center affiliates to provide professional staffing.
“Innovation was an important element in the development of the clinical network as it is today for the New England Eye Institute,” Dr. Mullen said, now an NEEI board member. “The common element that emerged throughout the development process was the importance of effective collaboration among all of the constituencies.”
For example, in conjunction with Harvard University’s highly respected Joslin Diabetes Center, NEEI and the Massachusetts League of Community Health Centers are working on a pilot proposal to bring the Joslin Vision Network telemedicine system to CHCs to triage patients with diabetes diagnosed in medical clinics, along with Joslin’s fully automated Comprehensive Diabetes Management Project for case management. NEEI has also recently applied for a grant to fund the Urban Diabetes Outreach Project (UDOP), a comprehensive mobile advanced diagnostic and treatment initiative at CHCs. UDOP will offer complete onsite ophthalmology consultation, utilizing portable equipment for the diagnosis and treatment of diabetes related eye disease.
In collaboration with CHC affiliates, NEEI has engaged in community outreach projects. Patients who have never had eye or health care are assessed for risk factors associated with health and vision problems, and then appointed to a convenient CHC for the appropriate care. Risk assessment is done with the assistance of CHC staff, who provide a trusting and culturally sensitive component to community outreach activities.
Another powerful example of NEEI’s commitment to improving performance at CHC eye clinics is the recent establishment of a “best practices initiative.” “Our group, comprised of chief operating officers and CHC administrators, meets every two months to work on common operational problems ranging from revenue cycle management, productivity, standards of care, and group purchasing of ophthalmic goods and services. We then proceed to develop a common, best practice to share with all of our affiliates,” said Dr. Wilson, who chairs the group.
In many respects, optometric practice in a community health center is not unlike any other fullscope comprehensive optometry practice across the nation, Drs. Barresi and Wilson say. “Historically, there has been kind of an image of public health clinics being in run-down old buildings,” Dr. Wilson said. Today, however, community health centers come as something of a pleasant surprise. “Imagine a typical medical office building, housing a variety of health care specialties, and the first floor is an optometric practice. The key difference at a CHC practice is that all providers work toward the common good of the patient and the community, in a truly interdisciplinary setting,” Dr. Wilson said.
Virtually all the eye clinics in the NEEI system, as well as a great many across the nation, are now housed in modern, new multistory facilities, constructed over the past few years under a major effort supported by both the Clinton and Bush administrations to rebuild the nation’s community health center infrastructure. Federal administrators have supported the rebuilding program because community health centers can provide care less expensively than hospitals, Dr. Barresi notes.
“They are like most other practices,” Dr. Wilson said of the community health center eye clinics. Most patients are covered by Medicare or Medicaid.
In the cases of the NEEI clinics, low-income patients who are not enrolled in one of those two government programs will be covered under a risk pool established in Massachusetts and Boston to provide care for the uninsured. While community health centers were originally established to serve the uninsured and others who could not obtain care, the centers are often utilized by patients who have private insurance who are attracted by the convenience of the center or its status as an institution in the community.
“There is a perception in a community health clinic you will spend a lot of time giving away your care,” Dr. Wilson said. “That is not the case.”
NEEI clinics typically have three-to-five fully equipped examination lanes, a room for specialized services (such a contact lens service, visual fields, and photography), a dispensary, an office for the doctor, and — in at least some cases — a finishing lab. Ophthalmic equipment in the NEEI clinic is on a par with the most advanced practices in the country, according to Dr. Wilson. The newest clinics feature completely electronic medical record systems and state-of-the-art equipment, including automated perimeters, digital photography, optic nerve scanning and imaging instruments, and pachymetry.
NEEI eye clinics generally are staffed by one or two optometrists (in some cases, working part-time), an optician, or other assistants. Through a teaching affiliation agreement between the college and individual CHC affiliates, optometry students are assigned to clinical rotations and assist in the care of patients. The students are credentialed by the college and are then granted associate professional staff clinical privileges by NEEI. The privileges expand in scope as the student proceeds through the professional curriculum.
The college also has family practice post-graduate residencies at some CHCs. A consulting ophthalmologist is also on staff and has regular sessions to see patients who need additional care or pre-surgical consultations.
So are consulting optometrists from the NEEI’s other clinical services, to provide pediatric, geriatric, contact lens, or other specialized care. “The philosophy behind community health care is that we bring the care to the patients,” Dr. Barresi notes.
Practitioners in community health centers spend less time on the daily management and administrative functions of a practice, such as dealing with coding and billing, than some other practitioners.
Most insurance claims filing and related functions are handled by a central claims-processing department, which serves all the health care practitioners in the center. “Practitioners in community health centers may help to develop encounter forms and superbills, but responsibility for billing and its oversight will be done by a professional billing staff,” Dr. Wilson said. Similarly, patient records are handled by a central records filing center (or in the case of centers with electronic records, a central data-processing center). Community health center, practitioners may also spend less time with personnel issues than practitioners in some other settings. All administrative and support staff are employed by the center which handles hiring, benefit administration, staff development, and other related functions.
Other administrative functions, from building main tenance to community relations, are also handled centrally by the center. As a result, optometrists can focus on one main concern: providing care for patients, Dr. Wilson said.
Moreover, community health centers emphasize an integrated approach to patient care. The optometrist in a community health center is part of a cohesive system of care, Drs. Barresi and Wilson say. “The optometrists work side-by-side with the physicians and the other providers in the center and are respected as peers. The optometrist consults directly with other providers as warranted regarding the care of patients.
That is a terrific professional benefit for the optometrist and affords patients the best care, Dr. Wilson notes. “You do not have the ‘pecking order’ that you may have in a hospital or ophthalmology clinic,” he observes. More importantly, this system provides a more cohesive approach to patients with conditions that require well-coordinated care—such as diabetes.
The NEEI eye clinics may not be entirely typical of the average community health clinic, being perhaps a little better equipped and financed, Drs. Barresi and Wilson admit. And NEEI has clearly pioneered a new management model. However, while administrators hope the NEEI model will be adopted in other areas around the country, they mostly hope the Boston-area clinics will serve to demonstrate the important role optometry can play in providing care through community health centers.
“There are a number of ways in which an optometrist can work cooperatively with a community health center to provide eye and vision care,” Dr. Wilson said. Optometrists in some community health centers practice full-time. Some practice part-time, maintaining a second practice outside the center. Many established practitioners, with offices outside community health centers, accept referrals from the centers.
Most patients referred by such centers can be seen under the Medicare or Medicaid programs. Some community health centers reimburse practitioners at their normal fee schedule rates for patients referred to them. Still other practitioners see patients referred by a community health center on a contractual basis.
Dr. Wilson says a number of young practitioners are already expressing an interest in community health center practice. However, experienced practitioners will also have a role to play, he believes—particularly those with expertise in areas such as low vision, management of age-related eye disease, or care of diabetes-related retinal disorders, who can help address the specific eye and vision care needs in a health center’s service area.
In a sense, no single community health center is perfectly “typical.” Community health centers were conceived to meet the unique care needs of underserved communities and, as such, reflect those needs.
For example, the centers have traditionally provided care for a large number of young families with children.
However, center patient bases have begun to reflect overall trends in U.S. demographics and many are seeing an increasing number of older patients, Dr. Barresi notes. Just as NEEI has responded to the unique care demands in various neighborhoods of Boston by retaining specialized practitioners and developing eye care clinics that reflect their host communities, optometrists around the nation can develop successful community health center practices by providing the services that are most in-demand in the applicable service areas—and by really becoming a part of their host communities, Drs. Wilson and Barresi say.
“Practicing in a community health clinic is not like practicing in a setting in which patients come through the door and you may never see them again.
Optometrists in community health centers become very close to the patients and the community. The optometrist may be practicing in a community health center and the (office) may be owned by the center, but it is the optometrist’s ‘practice.’ There is a great deal of identification (on the practitioner’s part) with the practice and the community,” Dr. Wilson said.
During the NACHC annual meeting in September, Drs. Wilson and Barresi, along with Massachusetts League of Community Health Centers President and CEO James W. Hunt, are scheduled to address community health center administrators on ways to bring full-scope-of-practice optometry into their centers.
Drs. Barresi and Wilson, along with Tom Curtain, M.D., associate vice president and director of the department of clinical affairs for NACHC, then plan to address AOA members on “how to approach and work with a health center to develop an eye care program, join the professional staff, become a part of the health center and community” in October at AOA’s Healthy Eyes meeting, Dr. Wilson said.
Drs. Wilson and Barresi are currently seeking information on successful optometry practices in other community health centers. They are also planning to develop “how to” manuals that could be useful for both community health centers and optometrists interested in starting new CHC-based eye and vision care programs. Those with information to offer on existing optometric practices in community health clinics or who wish further information on establishing such practices can contact Dr. Barresi via e-mail at email@example.com or Dr. Wilson at firstname.lastname@example.org
Reprinted from the December, 2004 edition of Optometry: The Journal of the American Optometric Association