As these sub-specialties expand, their educational, practical and technological requirements may be beyond the comfort level of many general-practice optometrists. The optometrist’s ultimate concern is the patient’s best interest, so now is the time for optometrists to view each other as on-board specialists, rather than as competing ship captains. As optometry evolves, intra-optometric comanagement is a natural step in patient care.
Why, and Why Now?
Tips for Successful Comanagement
• Make the patient’s best interest your primary motivator.
• Carry on continuous communication between patient, referrer and referee.
• Establish a comanagement protocol prior to providing specialty care.
• Document! Document! Document!
• Do not allow economic incentives to drive comanagement.
• Encourage mutual trust among providers.
• Always return the patient.
• Dedicate an employee as a network liaison.
• Show respect, professionalism and courtesy.
• Encourage the referring doctor to educate their patients in regards to specialty care when appropriate.
“One of the measures of a profession’s maturity is the level at which its practitioners recognize their limitations,” says Albert A. Bucar, O.D., D.O.S.1 Optometry is no exception. It’s time for us to rise to the occasion because, now more than ever, intra-optometric comanagement is essential for our patients and important for our specialty.
As the profession continues to expand its scope, services and skills, an optometrist cannot expect to be an expert in every sub-specialty. And, many opportunities exist in optometric sub-specialties—such as specialty contact lens fittings, vision therapy, low vision, sports vision, medical-based services and surgical comanagement of ocular procedures.
True, optometry is the primary provider of eye care and the gateway to the delivery of a range of services. But, when that range becomes too expansive—when its components require extensive expertise—there may be an opportunity of professional growth by referring to optometric specialists within that range.
Why We Hesitate to Refer to Each Other
Why do we hesitate to refer to another optometrist?
• Lack of awareness. One explanation may simply be that we don’t know appropriate sub-specialist optometrists within our local area. For example, an optometrist encounters a patient with geographic atrophy in both eyes whose visual compromise prevents him from completing daily tasks. This patient needs low vision rehabilitation, but the optometrist doesn’t know of a low vision specialist within the area. The end result is that the patient is prescribed high add power glasses that may help, but may be far from optimal low vision standards of care.
• Fear of losing the patient. Perhaps another explanation for this hesitation to refer among optometrists is the fear that patients and their families won’t return after the specialty treatment has been completed. The potential is that the specialist optometrist won’t be perceived by the patient as truly a specialist, but rather as a generalist with more expertise than the referring optometrist. This risk of a specialty referral evolving into a complete transfer of care is a common concern within optometry. It certainly is an obstacle that needs to be addressed in the intra-optometric referral model of care.
• Uncertainty about specialty care. Misconceptions about the effectiveness of treatments within specialty care may be yet another reason for referral hesitation. For example, most optometrists have had some training on binocular vision and visual rehabilitation. Although these experiences may result in different perceptions of treatment effectiveness, there are many case examples and studies that show the appropriateness of visual training in learning, visual development and improvement in quality of life. If the responsibility is to promote the patient’s best interests, how can one optometrist deny patients educated referrals for alternative treatments?
• Medical-legal concerns. Lastly, there may be medical-legal reasons for the direction of the referral. “In our litigious society, it’s highly unusual for an O.D. to testify against an M.D. on the M.D.’s standard of care. However, many M.D.s are willing to testify against an optometrist regarding the standard of optometric care.” says Ken Lebow, O.D., a specialty contact lens provider in private practice in Virginia Beach, Va.2
In the case of a referral to another O.D., the referring optometrist may fear being held liable if damaging events were to occur after the referral. Such fears may drive optometrists to refer corneal ulcers, glaucoma suspects and other medical cases to ophthalmologists rather than medical-specialty optometrists within their own community. Such referrals are made on misperceptions. In many of these cases, the standard of care is the process undertaken during treatment—it is not based on the initials of the person enacting the treatment.
Benefits of Intra-Optometric Comanagement
Vision therapy comanagement is a win-win-win situation—for the patient, the vision therapy O.D., and the referring O.D. Photo courtesy: Mary Van Hoy, O.D.
Given the current health care reform landscape, delivery of high-quality patient care is now expected in the most efficient manner possible. Yet, at the same time, optometry is seeing increased cost in its services while receiving decreased reimbursement. These changes in our environment open the doors to many opportunities for intra-professional relationships.
Concentrations in sub-specialties could allow for the focusing of a practice’s resources in one area, which consequently reduces the burdens on general practices to expend valuable resources in areas that their patient base may not frequently require. Whether it is management of ocular disease, advanced contact lens fitting, sports vision, binocular vision or low vision, specialty-based optometrists have dedicated their personal interests in different aspects of the eye with advanced training through optometric residencies, obtaining fellowships in the American Academy of Optometry or the College of Optometrists in Vision Development, or committing great financial resources towards technology and staff training.
With this in mind, isn’t it time to recognize these valuable resources within an intra-optometric referral model? A pair of optometrists, Mary Van Hoy, O.D., and Mary Beth Woehrle, O.D., answered this question when they developed the Indiana Vision Improvement Center 10 years ago with an emphasis in visual rehabilitation.3 (The comanagement of vision care patients was first proposed more than 15 years ago by a special committee of the College of Optometrists in Vision Development, formed to develop a program to facilitate referral of primary care patients to vision therapy practices.4) Over the years, the Indiana Vision Improvement Center has evolved into the Eyes for Wellness Center, in Carmel, Ind., and provides only secondary eye care through visual rehabilitation.
“It’s a win-win-win situation,” Dr. Van Hoy says. “The patients get the necessary care. The vision therapy practitioner has patients. The referring practitioner has another service to offer and enjoys an enhanced reputation as a practitioner who can handle any vision problem.”3,5
We need to recognize that a different dynamic comes into play when we diagnose a condition that is outside our area of expertise. For example, a patient who would benefit more from visual training than from glasses would need to be transferred, perhaps permanently, if that service is not offered inside the primary optometrist’s practice. While there may be a temptation for the optometrist to keep the patient and rationalize a lack of vision training benefits, the responsibility to the patient’s best interests should encourage a referral for initial assessment, at the very least.6
This scenario holds true for other conditions, too—for post-penetrating keratoplasty patients in need of a specialty contact lens, patients with macular degeneration in need of low vision aids, and patients with glaucoma who require the long-term treatment and management for their condition. Whether comanaged or not, the primary optometrist plays an integral role in each patient’s care and is responsible to refer to another colleague when appropriate.
Although optometrists are trained to provide all types of eye care, our practices may be ill equipped to handle the different needs of our patients. There are many issues involved that hinder our ability to provide specialty eye care, such as practice modalities, diagnostic equipment, appropriately trained staff and areas of interests or expertise. To consolidate and streamline resources, intra-optometric referral is an obvious choice.
Beyond the efficiency benefits of intra-optometric referrals, the model also serves to promote the vast expanse of the profession’s expertise. One optometrist may not have either the technology or the comfort level to manage certain glaucoma or diabetes cases. But referring that non-surgical patient to another optometrist, rather than an ophthalmologist, would result in a patient experience that reinforces the great knowledge and skill base of the profession. The same holds true for referrals for binocular vision, low vision, sports vision, and other specialty services. Not only would these encounters be in the best interest of the patient, but they would instill an awareness of the potential services within optometry.
Establishing an Intra-Optometric Referral Model
10 Ways to Promote Your Sub-Specialty
1. Invest time and energy into developing a referral network.
2. Arrange face-to-face visits with O.D.s, M.D.s and other potential
referral sources to inform them of your particular interests.
3. Provide education to doctors, staff and community on what you do.
4. Demonstrate your leadership by getting involved in your local, state and national organizations.
5. Sponsor a booth at local and state CE meetings/exhibit halls to educate your peers.
6. Keep staff motivated by your success and let them know they are an integral part of the success.
7. Announce your specialty in your
on-hold phone message.
8. Promote your specialty through websites, e-mails and newsletters.
9. Present office displays and patient testimonials.
10. Invite referring doctors to visit to your office and see what you do.
What needs to be done to adopt an intra-optometric referral model?
• Change our mindset. First and foremost, an intra-optometric referral model requires a fundamental shift away from the misconception that the general optometrist can realistically provide the ultimate expertise in absolutely every aspect of the profession. Establishing a new referral model requires a paradigm shift toward the realization that specialty training, technology and expertise are available within optometry. And, the mindset must be to recognize that an optometrist may not be able to maintain the expertise to provide the best care for binocular vision, specialty contact lens, low vision, medical eye care and sports vision patients all under one roof. This professional self-admission, of sorts, will allow optometrists to recognize the need to refer to other optometrists based on the best interests of the patient.
• Find O.D. specialists. Communication is the second requirement for establishing an intra-optometric referral model. As a lack of awareness of local specialty-based optometrists may be an obstacle, the best form of communication may be for optometrists to get out and meet amongst themselves and other health practitioners.
“Face-to-face interaction is the best way to get to know each other and to establish the trust in caring for mutual patients,” said Jeff Michaels, O.D., a low vision provider at Family Vision Care of Richmond, in Glen Allen, Va.7
There may be optometrists in a certain area who provide specialty care services, but their peers may be completely unaware of that fact. As director of optometric services of a comanagement center, I often receive phone calls from referring optometrists asking where they can send their patients for specialty contact lenses or low vision rehabilitation.
Many times these optometrists may be sitting at the same local society or education meetings, but never realize their potential relationships. The opportunity exists for intra-optometric referrals by specialists and general practice optometrists seeking out these relationships. Becoming involved within the local societies, state associations and national organizations are key in building referral networks.
Likewise, specialty-based optometrists must invest time visiting O.D.s and M.D.s in the area to make them aware of these specialty services.
• Tell patients the rules. It’s important to establish comanagement protocols for referring providers with frequent communication and documentation. These protocols are essential in alleviating the fear of referring to another optometrist—losing the patient forever. Just as in cataract surgery comanagement, the referring doctor must initiate the recommended treatments and specify if the referral is for comanagement or simply a second opinion. It’s the responsibility of the specialty-based optometrist to provide documented reports of all findings to the referring doctor, as well as an outline as to how long the treatment will take.
During the treatment, there may be the tendency for the patient to desire to transfer general care to the specialist. In order to address this issue, it’s important to educate the patient about the reason for the referral, the specialist’s role in their overall care with the referring optometrist, and the intention to transfer care back to the referring optometrist once specialty care is complete.
By setting the stage for intra-optometric comanagement prior to providing the specialty care, patients have a better understanding of the roles that each provider will play in their optometric care.
The Next Step
Find an optometrist in your area who provides low vision services. It helps the patient and it helps your practice. Photo courtesy: Jeff Michaels, O.D.
Just as the ship relies on its on-board specialists to get to the next destination, optometry must coordinate and work with each other in order to elevate the profession. “Intra-professional referrals in optometry will require honest and clearly-stated expectations among former competitors, but ultimately it will make the profession stronger and benefit the patient in the process,” says Russ Beach, O.D., in private practice in Virginia Beach, Va.8 As the profession evolves, optometrists must acknowledge and embrace their own capacity for specialty care.
As stated in the AOA Code of Ethics, “It shall be the ideal, resolve, and duty of all optometrists: TO KEEP their patients’ eye, vision, and general health paramount at all times and TO ADVISE their patients whenever consultation with, or referral to another optometrist or other health professional is appropriate.”6 Intra-optometric referral is crucial to the advancement of the profession.
Dr. Whitley is the director of optometric services at Virginia Eye Consultants, in Norfolk, Va., a tertiary referral care center. He is an adjunct assistant clinical professor at Pacific University College of Optometry and Southern California College of Optometry. He thanks Drs. Russ Beach, Ken Lebow, Jeff Michaels and Mary Van Hoy for their assistance with this article.
1. Bucar A. Intraprofessional consultation and co-management. Optometry. 2008 Feb;79(2):61-2.
2. Personal communication with Ken Lebow, O.D.
3. Vision Therapy Co-management. American Optometric Association. Available at: www.aoa.org/x5737.xml (accessed January 7, 2010).
4. Bosse JC, Cook DL, Hoffman L, et al. Blueprint for co-management of optometric vision therapy using a cataract model. Optom Management 1997 Apr;32:(4)38-44.
5. Personal communication with Mary Van Hoy, O.D.
6. American Optometric Association. An Optometrist’s Guide to Clinical Ethics. St. Louis: AOA; 2000.
7. Personal communication with Jeff Michaels, O.D.
8. Personal communication with Russ Beach, O.D.
