Volume 81, Issue 2 , Pages 116-119, February 2010
A practical guide to vision rehabilitation practice
Article Outline
- Developing referrals
- Reimbursement
- Staff
- Dealing with depression
- Developing the low vision rehabilitation practice
- Summary
Enhanced professional education and improved corrective devices are making vision rehabilitation more practical for general optometric practices as well as the growing roster of dedicated low vision rehabilitation clinics and rehabilitation agencies around the nation.
However, with the population aging and vision impairment threatening to become a major national health crisis, access to low vision rehabilitation still is not adequate, Dr. Davidoff maintains. As a result, many patients with impaired vision may not be realizing the benefits today's low vision care and assistive devices can provide.
“I was in the airport coming back from Toronto just the other day when a man approached me and, somewhat embarrassed, asked if I could help him read his airline ticket. He said he did not have his contact lenses; however, he later admitted he had Staargardt disease,” recalls Dr. Davidoff. “No one had told him that he could benefit from any number of new low vision devices, some of which can even fit in your shirt pocket.” Despite the results of the AOA survey, Dr. Davidoff reports, he all too frequently encounters people with visual impairments who could benefit from state-of-the-art low vision care but who apparently have never been made aware of it.
To help improve access to low vision rehabilitation and up-to-date low vision technology, the AOA-VRS is encouraging optometrists and optometry students to consider providing low vision rehabilitative care either as part of a general practice or in a specialized low vision rehabilitation setting, or make it a firm policy to promptly refer visually impaired patients for such care. Virtually any practice can provide at least some basic vision rehabilitation services, Dr. Davidoff contends, because every practice has the expertise, basic equipment, space, and other resources necessary. True, many optometrists refrain from providing low vision care because they feel it may be time consuming, unprofitable, difficult to obtain reimbursement for, or “depressing,” Dr. Davidoff acknowledges. However, thanks to new professional education programs such as the AOA-VRS's Low Vision University (LVU) course, more practitioners are overcoming such problems and are more actively providing services for the visually impaired—or at least know enough to properly refer. In 2010, LVU will transition to a new program titled “Preventing Age-Related Vision Loss: Medical Treatment, Ocular Nutrition and Vision Rehabilitation.”
The AOA, the American Academy of Ophthalmology, and the National Eye Institute have all launched efforts to increase awareness of low vision rehabilitation among medical doctors and other health care providers. With February recognized as both Age-Related Macular Degeneration Awareness Month and Low Vision Awareness Month, it may now be an appropriate time for optometrists to consider expanding the availability of low vision rehabilitation services through their practices, Dr. Davidoff suggests.
All licensed optometrists have the clinical knowledge necessary to provide low vision care, Dr. Davidoff emphasizes. “It involves the same knowledge of optics that would be utilized day to day when prescribing any other lenses, just applied in a slightly different manner,” he notes. And although not all optometrists have served a rotation in a low vision rehabilitation center while in school, he acknowledges, any practitioner can develop greater expertise in low vision rehabilitation, greater familiarity with the range of low vision devices, and an appreciation of low vision practice management, he says. The AOA-VRS Low Vision University Course, introduced 3 years ago, provides a detailed format for a comprehensive low vision examination (including low vision patient history, refraction, magnification and minification options, rehabilitation options, and eye health examination), with suggestions on developing a rehabilitative care team for the patient, an overview of coding and billing issues, a review of low vision devices, and other helpful information, Dr. Davidoff notes. The AOA-VRS Low Vision Student Awareness program also provides a similar if somewhat less detailed overview for optometry students. The American Academy of Optometry, AOA's Optometry's Meeting®, Lighthouse International, and various other national, regional and state optometric organizations and meetings offer courses that can be used to provide or supplement expertise in the care of low vision patients. The newly expanded AOA-VRS Web site also provides convenient access to a compendium of low vision articles and other documents, he adds.
Practitioners generally will find they have most all of the ophthalmic equipment required for entry into a vision rehabilitation practice, Dr. Davidoff notes. The only additional requirements might be:
Practitioners should be aware that the office should be bright, easy to navigate, and accessible to the handicapped, Dr. Davidoff emphasized. In most cases, in addition to supplemental lighting, new brighter nonreflective wall paint, some rearranging of the furniture, and perhaps a wheelchair ramp may be necessary. Such improvements can make a difference for patients who are likely to need vision rehabilitation, he emphasizes.
Traditionally, comprehensive low vision rehabilitation required considerably more office space than other types of practice, Dr. Davidoff acknowledges, largely because practitioners need to keep an inventory of low vision devices on hand. However, today, especially for those who are just beginning to get involved in vision rehabilitative care, that is not necessarily the case. Developments in low vision technology over recent years have resulted in not only higher quality vision enhancement devices, but smaller ones. Some electronic devices with variable magnification can now do the work of multiple systems. Any practice can find the space necessary for a small inventory of magnifiers (and perhaps even distance devices such as telescopes), Dr. Davidoff says. Moreover, virtually any practice can afford a basic inventory of handheld low vision devices, he says.
Developing referrals
Dr. Davidoff reports that he often receives referrals from both optometrists and ophthalmologists in both the clinic and private practice where he offers low vision rehabilitation services. However, developing a care team or referral network remains one of the more challenging aspects of vision rehabilitation practice, Dr. Davidoff acknowledges. Some eye care practitioners will not refer patients for vision rehabilitation services because they fear the patients will not be referred back to them.
“Report letters” issued to referring practitioners at the conclusion of low vision rehabilitation can be an important element in developing a cooperative, coordinated approach to the care of visually impaired patients, Dr. Davidoff believes. He makes it a practice to always send the referring practitioner a report detailing the results of the examination, follow-up rehabilitation care, and adaptive devices provided to the patient for inclusion in the patient's records. The report will also indicate that the patient has undergone all of the rehabilitative training appropriate at the time.
Patients themselves can be an important source of referral in a low vision rehabilitation practice, Dr. Davidoff said. “If you help a visually impaired patient, particularly a severely impaired patient, that patient is good at getting the word out” through conversations with friends and relatives, he said. “I know I certainly receive more new patients through word-of-mouth referrals by existing patients than through referrals from other health care practitioners.”
Reimbursement
Reimbursement levels and potential problems in claim filing are often concerns for optometrists considering low vision practice. Most low vision patients are older adults, often covered under Medicare. Medicare generally will cover at least some elements of the low vision rehabilitation care process. However, practitioners should adhere carefully to all applicable Medicare claim filing rules. (The Low Vision University Course offers a detailed review of coding for low vision services.) Low vision practitioners should also be aware that Medicare coverage varies somewhat from carrier to carrier, so it is also important to check with local carriers regarding coverage polices before filing any claims.
In the majority of cases, Medicare will not cover all of the expenses associated with low vision rehabilitation. Notably, the refraction, the magnification evaluation, and the low vision device(s)—which will be the major expense for many patients—are not covered under the government health plan. The Centers for Medicare & Medicaid Services reemphasized that Medicare does not cover low vision devices in a bulletin to Medicare payment contractors just last year, noting that low vision devices are essentially corrective lenses, and Medicare, in most cases, does not cover lenses.
In some cases, Medicare supplemental plans or other insurance programs may provide some additional coverage. In the case of low income patients, funding to help cover costs may be available in the form of grants or donations from state agencies or not-for-profit charitable organizations. However, the rules and qualifications will vary. For example, some state agencies for the blind emphasize services that will allow the visually impaired to hold wage-paying jobs. Some agencies are actually within the state department of labor, rather than the department of health and may cover low vision devices for working age individuals but not for older adults.
As a result, many low vision rehabilitation patients will have some out-of-pocket expense. However, most low vision patients find devices that can enhance or modify usable sight to be a good value. Patients therefore are often willing to accept out-of-pocket expenses. Some practitioners feel it is appropriate to inform low vision patients as soon as they call for an appointment, that although Medicare will probably pay for some of their care, they will have out-of-pocket expenses.
Staff
Proper orientation for front office staff is critical in a low vision rehabilitation practice. Staff must be constantly mindful that low vision patients will have special needs and require additional assistance. Many will not be able to read or complete a new patient record form; staff members may have to read it to them and fill it out for them. Similarly, few low vision patients will be able to read the privacy notices that practitioners are required to provide patients under the federal Health Insurance Portability and Accountability Act (HIPAA), so staff should be prepared to read the notices to them. Fortunately, most patients today are aware of their privacy rights, and a complete reading of the document often is not necessary, according to Pennsylvania low vision rehabilitation practitioner Paul B. Freeman, O.D. Dr. Freeman also makes large print versions of HIPAA notices available for those low vision patients who wish to review them.
In addition, signing any of the above-mentioned documents may prove a special challenge for a visually impaired patient, Dr. Freeman adds. Many patients will not be able the find the line on which they are supposed to sign their name. For that reason, a signature guide—an index card–sized template with a space cut out—can be an indispensable piece of equipment in the front office. The space is placed directly over the signature line on a document, showing the patient where to sign. (The guides can be purchased or made.) Also important for the front office are writing devices, such as Sharpie markers, that produce a thick line that visually impaired patients might be able to see as they place their signatures on checks and required forms.
Dealing with depression
Frustration with patients who are perceived to be uncooperative is often cited by optometrists as a reason for not actively pursuing low vision rehabilitation care, both Dr. Davidoff and Dr. Freeman acknowledge. In many cases, uncooperative patient attitudes may be the result of depression. Because many low vision patients may be prone to debilitating depression that may impair their ability to take part in rehabilitation or make use of devices that could be of value, low vision practice entails directly addressing the mental state of the patient in a way that other types of eye care practice might not.
The practitioner must first assess whether a patient appears emotionally ready to learn to use an adaptive device, adopt new ways of using sight, or undergo a program of rehabilitative therapy. If not, the eye care practitioner must be ready to make an appropriate referral to ensure the patient receives the necessary emotional support. Referral to a social services agency that specializes in helping the visually impaired, a counselor, a psychologist, psychiatrist, or a social worker may also be appropriate. Above all, practitioners and staff must be prepared to offer reassurance and support to the patient. A solid bond of trust between patient and practitioner, a welcoming practice atmosphere, courteous and accommodating staff, and an overall effort to meet the needs of the patient can arguably be directly important in influencing successful patient outcomes in a low vision practice.
Care for visually impaired patients can fray the emotions of eye care providers as well, Drs. Freeman and Davidoff acknowledge. However, vision rehabilitation care offers unique rewards that outweigh any downsides, Dr. Freeman and Dr. Davidoff readily agree. “It's very rewarding; you can do something no one else has been able to do; you can have them seeing in a manner that allows them to again perform visual activities of daily living,” Dr. Freeman said.
Developing the low vision rehabilitation practice
As with any other type of practice, an optometrist who is considering a more active role in providing low vision rehabilitation should assess the local market to see if any other practitioners are already providing such care. Even if there are other practitioners in the area, there still may be an unmet demand for low vision rehabilitation services, Dr. Davidoff said.
Optometrists can provide low vision rehabilitation at various levels: as an adjunct to a general practice, providing basic low rehabilitative care referring those patients who require additional care as an area of emphasis, accepting referrals from other practices for an expanded range of low vision management, or as a part of a full service low vision clinic.
Dr. Davidoff has actually provided low vision rehabilitation in all 3 settings over the years. He first introduced low vision services to his father's Broomall, Pennsylvania optometry practice in 1981 after graduating from the Pennsylvania College of Optometry and completing a rotation at the college's Feinbloom Vision Rehabilitation Center. Low vision remained an important part of Dr. Davidoff's general practice as he opened a second office, Whiteland Family Eye Care in nearby West Chester, Pennsylvania, a few years later. Eventually, Dr. Davidoff helped establish ongoing low vision services at the Center for the Blind and Visually Impaired (CBVI) in Chester, Pennsylvania. This facility offers full service blindness and visual impairment rehabilitation. He also staffed a low vision rehabilitation service in a hospital setting for approximately 5 years.
Based on his experience, “start small” is good advice, Dr. Davidoff says. “Begin by ensuring that at least some low vision care is available in your practice. Should considerable demand be demonstrated, consider developing low vision rehabilitation as an area of emphasis in the practice. Should you discover that your community lacks a full service low vision rehabilitation clinic to which you can refer patients, you might considering helping to establish one.”
“Virtually any practitioner can provide an elementary low vision screening in a general practice,” Dr. Davidoff said. “Test to see if the patient will benefit from the use of a high-add lens (for example, going from only being able to read the headlines in a newspaper to reading the stories). If the screening indicates high-add lenses are helpful, the practitioner can then prescribe that or other equivalent power system such as a hand magnifier.
Although a practitioner who provides some low vision rehabilitation in a general practice may need a minimal investment in device inventory, the practitioner that emphasizes low vision rehabilitation should provide a more complete inventory of low vision devices that will probably require a more substantial investment, Dr. Davidoff says. As mentioned earlier, the required inventory depends on the level of involvement the practitioner chooses. Additionally, the practice that chooses to provide much more comprehensive rehabilitative services, such as outlined in the Low Vision University Course, will need to have at least some trained staff available on site to provide rehabilitative services or be able to readily refer patients for rehabilitative services to other practices with staff to support rehabilitative care, clinics, agencies, or hospitals that offer the services. As an example, The Center for the Blind and Visually Impaired (CBVI) offers the services of rehabilitation therapists, occupational therapists, and orientation and mobility specialists. Full-service low vision clinics, like this one, can now be found in most large and medium-size metropolitan areas. There may be additional demand for such clinics in some larger markets. However, the greatest opportunities may be in the many rural areas that are still without access to low vision rehabilitation.
In some cases, a hospital may provide room for a clinic. However, to establish a low vision clinic in a hospital, an optometrist generally must have some level of hospital privileges. Optometrists who already have privileges at a local hospital may find it easier to approach the local hospital board about services that can be provided in a low vision clinic. However, even optometrists who do not hold privileges may find it productive to approach local hospitals about the possible advantages of such a clinic. This may be a way of gaining an entry to the staff.
Summary
Not only can practically any optometrist offer at least some low vision care or counseling to patients, in Dr. Davidoff's mind, nearly every optometrist has a responsibility to do so. “It's a matter of not abandoning a patient,” Dr. Davidoff says flatly. “Even if the patient can no longer be helped by conventional eyeglasses or contact lenses or you no longer are going to monitor the patient following cataract surgery, that person is still your patient. You don't just abandon them because they can no longer be assisted by conventional lenses.”
Severe vision loss is bound to be traumatic, Dr. Davidoff emphasized. “In many cases, the trust that has been established over the course of a long-term relationship can become critical in reassuring what will often be a very emotionally distressed patient in helping to successfully guide him or her through the rehabilitative care that can help to maximize the use of the remaining vision, thereby helping the patient to maintain independence in daily living,” Dr. Davidoff said.
The AOA Vision Rehabilitation Section has been developed to provide optometrists a way to become familiar with vision rehabilitation practice, Dr. Davidoff said. The AOA-VRS's newly expanded Web site and bimonthly e-newsletter includes features on coding and billing and other topics related to low vision care. Membership dues are $70 per year. For additional information, contact section staff person Mary Beth Rhomberg, O.D., at MBRhomberg@aoa.org.
Opinions expressed are not necessarily those of the American Optometric Association.
PII: S1529-1839(09)00655-1
doi:10.1016/j.optm.2009.12.001
Volume 81, Issue 2 , Pages 116-119, February 2010
