Vision Care Specialist Focuses On LTC Residents in On-Site Program

Abstract

Marlene Piturro is a freelance writer in Hastings-on-Hudson, N.Y. Vision problems are not only prevalent among nursing home residents, they often lead to a downhill spiral through social isolation, increased risk of falls and depression, said Dr. Duncan MacLean, CMD, and medical director of three Delaware nursing facilities. Still, good vision care presents challenges such as the cost of ambulance transport and the resources and expense for staff to accompany a resident to a doctor's office. Examining cognitively impaired residents and positioning frail elderly patients in an exam chair also can be difficult. However, Dr. MacLean, who set out to improve vision care at his facilities, found an able ally in Bill Monaco, OD, PhD. The vision care specialist delivers an on-site program that is “extremely innovative,” Dr. MacLean said in an interview. “He brings portable optometric equipment into nursing facilities, sets up temporary lanes for exams, and even performs exams at the bedside when necessary.” According to the Centers for Disease Control and Prevention, More than 3.4 million, or 3% of Americans 40 years or older, are blind or visually impaired. The CDC also reports the leading causes of blindness and vision impairment are age-related eye diseases (Improving the Nation's Vision Health: A Coordinated Public Health Approach, http://www.cdc.gov/diabetes/pubs/pdf/vision.pdf). Dr. Monaco, an optometrist who also chairs a work group on vision care for the American Public Health Association, screens nursing facility residents at 15 facilities, spending 1 day each month at each facility. “Quite often, these patients have many diseases such as diabetes and heart disease and are asymptomatic for eye problems, but can have eye diseases that progress to blindness,” Dr. Monaco explained. “Regular eye exams identify many treatable problems.” Still, significant gaps in vision care have been documented in the long-term care setting. A study of 17 Alabama nursing facilities found that although two-thirds of residents were considered visually impaired, two-thirds of these patients had no record of an eye exam in their medical charts (Arch. Ophalmol. 2007;125;925–30). In a study of residents with vision-impairing cataracts in 28 Maryland and Delaware facilities, matched in pairs by size and payer type, researchers examined how frequently recommendations for cataract surgery were followed. In the control group facilities, only 2% of residents vs. 31% in the targeted intervention facilities received the recommended surgery (Arch. Ophthalmol. 2005; 123:1581–7). The authors concluded that identifying cataracts as a cause of vision loss rarely resulted in cataract surgery in nursing homes. However, the addition of a support system to facilitate such programs, including scheduling surgery and transportation to the hospital, dramatically increased uptake rates. To provide better vision care at nursing facilities, Dr. Monaco prepares for his visits a week in advance. He discusses the patient list compiled by the medical director and attending physicians with a contact person at the facility, highlighting residents with urgent needs. “Our strategy prioritizes high-risk residents with diabetes, hypertension, and cardiovascular disease,” he said. Dr. Monaco sets up two suitcases full of equipment and “lanes” for 45-minute eye exams at the facilities. “I see 10 patients in a full clinic day, and it's exhausting,” he said. Since many patients are cognitively impaired, Dr. Monaco said he uses objective tests so patients “don't have to communicate verbally to get their vision corrected.” He recalled how one resident with dementia who was socially isolated began to pay attention and interact with other residents the day Dr. Monaco fitted him with corrective lenses. Dr. Monaco notes the logistical challenges of introducing facility-based vision care. “When you interpose a change on any system, there's resistance and you need flexibility to get the job done.” He cited administrative issues that must be overcome such as patient safety, privacy issues, and professional credentialing. “Then, there's getting space and buy-in so that the medical director and director of nursing assign someone to have residents ready for their eye exams or to direct me to a resident's bedside, if necessary. “If you can't see and hear, there's no stimulation. When we open the door, residents can reconnect with the world,” Dr. Monaco said. He added that facilities should include similar services for dentistry, podiatry, and audiology. Dr. Bill Monaco uses a Binocular Indirect Ophthalmoscope on site to get a detailed view of the inside of the eye. Courtesy Dr. Bill MonacoView Large Image Figure ViewerDownload (PPT)