Affiliations of community health centers with the accredited schools and colleges of optometry in the states and territories of the United States

Purpose 

To investigate the current status of affiliations between CHCs and the U.S.-based schools and colleges of optometry, in 2006, the American Optometric Association (AOA) Community Health Center Committee (CHCC) developed a survey instrument to determine the number, type, and nature of academic affiliations that currently existed between CHCs and the U.S.-based accredited schools and colleges of optometry. With these data in hand, the results could show whether an opportunity exists for optometric institutions to develop additional clinical locations by collaborating with CHCs to provide additional clinical experience for student clinicians, residents, and faculty.

This study was designed to ascertain if, and to what extent, optometry schools and colleges were collaborating with CHCs to provide eye care services. The survey, in addition to gathering information about clinical care, investigated the structure of affiliation agreements that existed between FQHCs and FQHC Look-Alikes and the schools and colleges of optometry in the United States and its territories. If affiliations were present, the questions requested information on the scope of the services available to patients as well as the numbers of students assigned to the CHC, faculty status, and details about the business relationship.

Methods 

The survey was distributed to the schools and colleges through their individual representatives to the AOA's Faculty Relations Committee (FRC). All schools except the Inter-American University of Puerto Rico are represented on this committee. (The Inter-American University of Puerto Rico School of Optometry was contacted directly by the CHCC.) FRC members took the survey back to their respective institutions to complete or requested that it be completed by the appropriate administrator. All of the surveys were returned to the AOA CHCC and reviewed. The initial response rate was 100%; however, a review of the survey results suggested confusion about what qualified a program as a FQHC or Look-Alike CHC. Each school was subsequently recontacted by one of the authors to verify the accuracy of the results. The results were then modified and updated, if needed, to accurately reflect the intent of the survey.

The survey instrument was divided into 2 sections. The first section identified the school or college of optometry, the person who completed the survey, and whether an affiliation(s) existed between the school and a CHC(s). The second section was completed only by programs that reported affiliations with a CHC and asked detailed questions about the relationship, specifically information regarding students' and residents' clinical assignments, professional staff, hours of operation, types of ophthalmic services offered, description of support personnel, optical service availability/scope, and issues relating to the business operations of the eye service.

Results 

All of the programs within the United States responded to the questionnaire. Six of the schools reported that they did not have affiliations at the time of the survey with either an FQHC or Look-Alike. The remainder of the results represented the information provided by the 11 schools that did report an existing relationship with a CHC.

Of the 11 schools, the number of affiliations between the school and local CHC ranged from 1 to 14. Table 1 reflects the specific numbers by institution.

Table 1. U.S.-based schools/colleges of optometry and number of CHC affiliations

	School or college of optometry	# of CHC affiliations
	Illinois College of Optometry	1
	Inter-American University of Puerto Rico	2
	The New England College of Optometry	14
	The Ohio State University, College of Optometry	1
	Michigan College of Optometry at Ferris State University	1
	Indiana University, School of Optometry	4
	University of Missouri-St. Louis, School of Optometry	3
	University of California at Berkeley, School of Optometry	3
	University of Houston, College of Optometry	3
	University of Alabama at Birmingham, School of Optometry	3
	Pacific University, College of Optometry	2
	Total	37

Student/resident involvement in community health centers 

The programs varied as to how students and residents are assigned and rotated through the CHC affiliates. Schools with affiliations ranged from assigning 4 students per year to 310 students per year. Five schools send only fourth-year students to CHCs for clinical experience, whereas the remaining schools send both third- and fourth-year students. Only 3 schools integrate residents into CHC programs (The New England College of Optometry, University of Houston, and Inter-American University of Puerto Rico School of Optometry). Figure 1 shows the distribution by school.

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Figure 1. Total number of students assigned to CHC clinical rotations annually.

Access to optometric service 

The surveys showed that professional staff numbers varied from 1 to 5 optometrists at individual CHCs, with optometry providing all eye care in 22 sites. A total of 50 optometrists were reported.

The optometrists that staffed the eye services varied as to their appointments. The survey asked the respondents to indicate whether they had a staff appointment or faculty appointment. If they were a faculty member, they further recorded whether the faculty members were full-time or part-time educators and if they were tenure track, adjunct, or other. The results of that question are shown in Table 2. (Note that an individual may have a staff appointment and also be an adjunct faculty member; thus, the frequency of the responses may reflect the higher than actual number of optometrists that can be found at CHCs.)

Table 2. Optometric staffing at CHCs

	Type of appointment	Frequency
	Staff appointment at CHC	15
	Staff appointment to another medical facility affiliated with CHC	5
	Full-time faculty	24
	Part-time faculty	7
	Adjunct faculty	20

In the section of the survey in which the financial structures were evaluated, the survey queried who was responsible for the salaries of optometrists. Of the 37 responses, the schools and colleges covered the optometrists salaries alone in 51.2% or 22 sites; the salaries were covered by the CHCs alone in 5 centers; and the salary expense was shared by both in 23.3% or 10 sites.

Eye care is provided by optometry alone in 59.5% (22) of the affiliated CHCs, whereas 40.5% (15) have ophthalmology service available in addition to optometric care.

Access to ophthalmology service 

The survey inquired as to the amount of time that ophthalmology was available at these 15 sites. Hours of ophthalmology service varied widely from 4 hours per month to 32 hours per week. Table 3 presents the total hours that were reported. In addition, the survey requested information on who is covering the salary for the ophthalmologists. Nine surveys reported that the CHC covers the ophthalmologist's salary, 2 of the sites are dependent on volunteer service, 1 ophthalmologist bills directly for services, and the remainder did not know or did not have any ophthalmologic services on site. A question was posed asking if a patient was referred out for ophthalmologic care that was not available within the center, did the community health center refer the patient to outside facilities that offered ophthalmologic care? Only one response indicated that they did refer to clinics offering eye care at no cost to the patient. No other information was provided.

Table 3. Ophthalmology services on site

	Doctor's time commitment	Frequency
	≤1/2 day per month	2
	3-8 hours per month	9
	3 hours per week	2
	Unknown	1
	1 day per week	1
	Total	15

Administrative staff support 

Three CHCs reported no administrative staff available to support the eye clinic. (One survey did not include a response in this area of inquiry.) The number of administrative/clerical staff dedicated to the eye service on the remaining surveys ranged from half-time to 5 full-time staff members, with a median of 1.25 staff members (see Table 4).

Table 4. Number of administrative support staff for eye service

	Number of staff	Frequency	Percent
	.0	3	8.1
	.5	1	2.7
	1.0	14	37.8
	1.5	1	2.7
	2.0	12	32.4
	2.5	1	2.7
	3.0	3	8.1
	5.0	1	2.7
	Total	36	97.3
	Missing	1	2.7
	Total	37	100.0

Design of eye service, days of operation, and scope of eye services provided 

The survey asked the respondent to describe the design of the eye service, such as days of operation and rooms devoted to the service, and also to list the types of eye and vision care services provided. The days of operation ranged from 1 day to 6 days per week, with a mean of 3.96 days (±1.87). Eye examination rooms available for patient care varied from 1 to 7, with the mean being 3.03 rooms (±1.49). The choices for location included complete eye center, examination room only, mobile unit, or shared examination room. Twenty-three of the CHCs indicated they were a complete eye care center, defined as an examination room(s), office, optical/dispensing area, and a room for special testing. Twenty-three reported “exam room only” in their response. Nine respondents marked both “complete eye care center” and “exam room only,” suggesting inflated numbers for the “exam room only” option. Three of the programs had mobile eye services.

The next question on the survey asked the specific types of services available within the eye service. Services varied, including comprehensive eye examinations, optical sales and services, contact lenses, low vision services, and pediatric care. Table 5 is a summary of the responses.

Table 5. Clinical services provided within each CHC eye service

	Type of service	Number of CHCs offering each service
	Comprehensive eye examinations	37
	Contact lenses	19
	Optical services	33
	Visual field testing	29
	Fundus photography	18
	Low vision services	10
	Binocular vision/vision therapy	13

Optical services were found in 33 of the 37 eye services. “Complete optical services” were available at 15 or 40.5% of the CHCs, whereas the same number offered “dispensing only.” Three eye services offered no dispensing on site. The remainder reported optical services were available, but did not elaborate.

Business relationship and scope of responsibility for operational issues 

Regarding ophthalmic equipment, survey results reported that CHCs were responsible for maintaining equipment in 20 locations, the schools/colleges were responsible in 13, and there was joint responsibility in 2.

Schools/colleges provided professional staff, students, and/or equipment in 73% of the CHCs and support salary of faculty in 22 of 37 programs.

The final section of the survey requested information relating to the business aspect of the eye service including, but not limited to, financial responsibility and billing for services. Billing for services was the responsibility of the CHC in 24 of 37 programs. Table 6 summarizes who is responsible for the primary infrastructure and billing of services.

Table 6. Summary of survey data outlining responsibility for certain aspects of the business relationship

	Who is responsible for the following?	CHC	School/college of optometry	Both	Other
	Maintenance of equipment	20	13	2	2
	Build out/equipment purchase	16	17	1	3
	In-house optical overhead	15	9		1
	Billing for eye services	24	12		0

Discussion 

In 2006, a majority of the schools and colleges of optometry in the United States were affiliated with at least one CHC. However, the survey results also show a wide variation in the number of affiliations between CHCs and the schools and colleges of optometry. These results suggest that an opportunity exists to establish additional affiliations between schools and colleges of optometry and CHCs to the mutual benefit of each organization.

CHCs are located in every state and territory of the United States. There are more than 1,000 FQHCs throughout the country. Many CHCs have multiple service locations. There are more than 5,500 CHC locations delivering services throughout the United States and its territories. As noted, in 2005 only 18.3% of FQHCs offered on-site eye care services. These 2 sets of data infer that opportunity exists for the schools and colleges of optometry that have an interest in increasing the numbers and diversity of patients in their clinical systems. This opportunity can be potentially realized by developing collaborative eye care programs in conjunction with CHCs that have communities in need of eye care services.

To further illustrate the proximal opportunity to collaborate with the schools and colleges of optometry, Figure 2 represents a map of the continental states with CHC locations identified by a “star.” Each star represents a potential opportunity to address an unmet need in eye care services. A detailed listing of CHCs in all U.S. states and territories can be found at National Association of Community Health Center's affiliate Web page: http://www.nachc.com/primcare/srpcalist.asp.

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Figure 2. Map of health centers in the continental United States that receive Section 330 funding.

Affiliations with CHCs enable optometry schools and colleges to expand their community service mission by contributing to the visual health of populations who experience disparities in access to eye care and disparities in visual health outcomes. Rotations through health centers provide diversification in clinical care with an opportunity to place students in unique teaching and learning environments that demonstrate frontline public health principles including disease prevention, population health, and cultural competency.10 Health centers are also appealing sites for postgraduate optometric residents, particularly those interested in community health optometry.

Community health center practice allows faculty to develop strong clinical care and teaching skills, advance career interests in public health, care for underserved populations, and work in multidisciplinary settings side by side with other health care providers. Health centers offer professional opportunities for clinical faculty who have a strong interest in public health and community-based scholarship such as health services research, community-based participatory research, interdisciplinary education, and unusual/complex case reports.

Finally, increasing optometric affiliations with CHCs may contribute to an increase in demand for practicing optometrists. As CHCs add eye care to their array of clinical services delivered, there will be an increasing need for clinicians in these settings. Thus, new and/or additional academic partnerships between CHCs and the schools and colleges of optometry will help to prepare the next generation of optometrists who are interested in pursuing careers at CHCs. This outcome is already documented in medical education.11