Project Option: 1.9.3. a Proposal to Increase Access to Ocular Care to an Underserved

Project Option: 1.9.3. a Proposal to Increase Access to Ocular Care to an Underserved

Project Option: 1.9.3. A Proposal to Increase Access to Ocular care to an Underserved Population

Unique Project ID: 84597603.1.1

RHP Performing Provider / TEXAS TECH HS CTR FAMILY MED / 084597603

Project Description:

The purpose of this project is to address the Region’s inability to meet the ocular care needs of its patients, particularly the indigent and Medicaid populations, due to profound shortage of ocular care professionals in the Region. The project proposes to address this issue by the recruitment of four additional ocular care providers (two ophthalmologists and two additional therapeutic optometrists) along with the required support personnel, and the development an electronic referral system linking primary care to the ophthalmology providers to facilitate referrals.

Goals and Relationship to Regional Goals:

The goal of this project is increase access for ocular care, in particular for patients with diabetes, to low income, indigent and Medicaid populations. Patients will receive adequate ocular care and will no longer experience long waiting periods for appointments. Comprehensive ocular care, including evaluation by an ophthalmologist, will be available in a timely manner. Finally, we will develop electronic means of communicating referral requests to facilitate access from our primary care providers.

Project Goals:

  • Increase number of ocular specialists in the region by four
  • Create efficiencies through the use of an electronic referral system.

Challenges: The major challenge we will face is to identify and recruit the numbers of providers required to meet the needs of our community.

This project meets a number of regional goals: It will allow us to better provide the full continuum of healthcare services, from wellness to preventative care to disease management; to better manage patients with chronic diseases, such as Diabetes; and to Increase the number of specialist and scope of services offered in the community; to increase patient satisfaction through delivery of high-quality,

effective healthcare services and to address issues related to diabetes as it represents a major health concern in Region 15.

DY5 Expected Outcome for Provider and Patient:

At the completion of this project, we will be able to provide nearly comprehensive ocular care to our population. We anticipate measuring and significantly improving our organization’s referral of patients with diabetes for annual eye exams as recommended by HEDIS guidelines. We expect to see increased patient numbers in our ophthalmology program, particularly those with diabetes, and we will have a functional, widely utilized, electronic referral system.

Starting Point and Baseline:

The majority of the region’s ophthalmologic care resides in the private community. Ophthalmologic care provided by the Paul L. Foster School of Medicine is profoundly limited. The School of Medicine employs a single therapeutic optometrist, housed within the Department of Surgery. The current time to 3rd available appointment for new patients for this provider is 59 days. We have no ophthalmologists available to provide routine outpatient screening and treatment services.

Rationale:

Ophthalmology care in Region 15 is in a state of crisis. A 2010 health needs assessment, sponsored by the Paso del Norte Foundation, which serves as the basis of our RHP, documented that the area is underserved in 18 of the 24 assessed specialties and ophthalmology was the fourth greatest numerical need. This needs assessment indicated that Region 15 was underserved by nearly 24 ophthalmologists[i].

A significant proportion of our 1115 DSRIP waiver projects are focused on access issues and lack of providers in our region as documented in the Region’s needs assessment iand the impact of these shortages on chronic diseases such as diabetes. In the case of ocular services, this shortage creates serious challenges, particularly for our unfunded and Medicaid patient population. We have difficulty in identifying a provider who will accept a patient requiring therapeutic services which can only be supplied by an ophthalmologist. We have no ability to treat common conditions such as macular degeneration or keratoconus because of the time required in the fitting of hard contact lenses and the extremely limited provider availability. We also have extremely limited access to ophthalmologic specialties which are commonly required in a diabetic population such as retinal specialists.

Even for patients with adequate funding, accessing ophthalmologic care in our region is challenging. Data from one of our major Medicare plans indicates compliance with HEDIS guidelines for screening eye care in the region is poor; less than 50% of patients with diabetes receive an annual eye exam and only 61% of patients at risk of glaucoma have received an evaluation. We fully anticipate that compliance rates in our indigent population will be significantly below these levels, and part of our Category 3 initiatives are to develop the benchmarking strategies to be able to track this number.

The issue of appropriate ocular screening and treatment is of particular importance to our population given the high prevalence of diabetes in the region and the large numbers of patients at risk for diabetes. Diabetes is a particular health care challenge in Region 15 and in particular in our population. Diabetes is the fourth leading cause of blindness in adults and early diagnosis of diabetic retinopathy can prevent blindness.[ii] The self-reported rate of diabetes in El Paso is 12.8%, compared to a nationwide self-reported rate of 9.3%. This becomes even more significant as the population ages. The self-reported rate of diabetes in El Paso increases from 6.4 % when less than 45 years of age to 19.1 % for ages 45 to 64 and to 28.5% for ages 65 and older. Over 70% of El Paso residents are of Hispanic ethnicity, an additional risk factor for diabetes. Therefore, most of the population is at risk for diabetes.

In addition to a high prevalence of diabetes, our population has significant access challenges based on their insurance program, or lack of 3rd party coverage. 37.1% of BRFSS respondents from El Paso report no health insurance, compared to a nationwide rate of 15.1%. Across the outpatient care enterprise, roughly 35% of our patient visits are provided to patients without any 3rd party coverage, and an additional 35% are provided to patients with Medicaid. With extremely limited resources in the private community, and the current wait times for a new patient appointment in our system now, there is simply no potential to improve the overall access issue, and address long term risks of blindness from diabetes and other chronic diseases without a significant expansion of provider resources.

Our general approach reflects the opportunity to use a variety of eye care professionals to provide comprehensive care in a cost effective manner. As an example, a therapeutic optometrist is an excellent resource for screening and diagnosis of ocular disease. They may provide limited non operative treatment services, such as for glaucoma, if they possess the appropriate additional certification. They are not able to provide any operative treatments, such as laser management of diabetic retinopathy. The region has very little capability to support unfunded or Medicaid operative ocular services including cataract services or therapy (as opposed to diagnosis) of hypertensive or diabetic related eye diseases. Therefore, we include the recruitment of ophthalmologists in this proposal.

We chose the Option 1.9.3 because the limiting factor in providing care is not space, and we are not in a position to expand or even establish a training program at this point. Furthermore additional clinic hours or locations are feasible with a single provider. By selecting Option 1.9.3, we are focusing on the core issue of an inadequate number of providers to serve this patient population in the region, and on means to insure they are utilized most effectively.

We have chosen metrics which reflect three main outcome objectives of this project:

  • increasing availability of providers to improve access a
  • measure and improve the speed of access to an ophthalmologist once an issue is identified by a therapeutic optometrist.
  • Develop and implement an electronic referral system which addresses the unique needs of an ophthalmology practice linking primary and specialty care

We begin by generating baseline data of the number of unique patients seen each year, and the time to be seen by an ophthalmologist after referral by a therapeutic optometrist. Collectively, these metrics represent a comprehensive view of the goal of this project which is to improve access to ocular care for our at risk population. We also begin the planning, design and implementation for an e-referral system linking primary care to ophthalmology

This represents a new initiative for the Performing provider.

This project addresses CN.2, access to secondary / specialty care.

Related Category 3 Outcome Measure(s):

IT-11.3 Improve utilization rates of clinical preventive services (diabetic eye exams) in Hispanic population with identified disparity. We will use language identical to IT-12 limited to those patients who self-report ethnicity or race as Hispanic

This Category 3 outcome measure was chosen based on the rationale that the primary issue we are addressing with this project is the lack of access to comprehensive ocular care for underserved patients in Region 15, and that the majority of our patients are of Hispanic origin and uninsured or underinsured with a high prevalence of diabetes. As such, increases in the number of unique patients screened for diabetic eye disease is an important marker of the impact this program is having in this population.

By focusing on the number of patients screened, and having resources to treat those we identify with disease, we provide evidence based processes to impact the long term effects of diabetes, cataracts, macular degeneration, and other ocular diseases.

IT-11.4 Improve patient satisfaction and/or quality of life scores in target population with identified disparity. We propose to utilize the RAND VSQ-9 Patient Satisfaction Survey to measure patient satisfaction. The Performing Provider has experience with Press Ganey survey instruments within the past decade. Overall response rates were very low, in the single digit range. We believe there are a series of structural issues that drove this poor response. Our population is heavily enriched in low income patients. Challenges related to incorrect and changing addresses, and the comprehension level required to complete more complex survey tools such as Press Ganey (and CG-CAHPS ) limits response rates. Also, our Region shares an international border with Juarez, Mexico. Many patients, whether documented or not, may fear responding to such a survey, not fully understanding the importance of their response, and not recognizing that their participation has no impact on their residence in the Region, choose not to respond.

For these reasons we believe a short survey, administered at the point of service, represents the best option to obtain meaningful data across a wide patient representation. The RAND survey has been validated for accuracy and validity [iii] and contains questions which focus on high level patient satisfaction domains and will provide actionable information to improve our regional care delivery. We acknowledge that this survey will not provide results which are directly comparable to CG-CAHPS on a national level. They will, however, provide valid, actionable data on which to assess the impact of this project in Region 15.

11.6 Other Outcome Improvement Target: We propose to measure the time taken to see a performing provider ophthalmologist from referral from a performing provider therapeutic optometrist among Hispanic patients with diabetes.

Screening services provide little benefit if not coupled to diagnosis and treatment of conditions identified. Given the shortage of ophthalmologists in the region, and the significant burden of indigent and Medicaid patients in our population, this access likely represents a significant healthcare disparity. By tracking this, we are able to couple effective screening with diagnosis and therapy for diabetic eye disease among Hispanics.

Relationship to Other Projects:

1) 84597603.1.2: The establishment of a disease management registry within the Paul L. Foster School of Medicine. This project will initially focus on diabetes in the Department of Family Medicine, and subsequently, capture the diabetic population cared for by general internists in the Department of Internal Medicine. The screening of patients with diabetes is one of the fundamental objectives of this project. Use of the registry will facilitate the appropriate identification of these individuals.

2) 84597603.2.1. The Development of a Primary Care Medical Home in a Health Professions Shortage Area. The PCMH in the Department of Family Medicine represents an excellent target population to enable identification, tracking and referral of at risk individuals

Relationship to Other Providers’ Projects in the RHP: Other performing providers in the Region are proposing significant expansions of access to primary care. Undoubtedly, this will involve large numbers of patients with diabetes. Our project provides the mechanism in which these patients can receive the specialized screenings necessary and access to diagnosis and treatment as required.

Plan for Learning Collaborative: We will participate in a minimum of semi-annual learning collaborative sponsored by the RHP, and provide data on the status of our project.

Valuation:

The Performing Provider considered a series of factors in establishing a valuation for each project. These included the amount of human resources required to meet the milestones of the project, through new hires as well as the assignment of existing support personnel such as Information Technology, EMR and administrative support. We considered what non personnel resources would be required, such as equipment specialized for a certain specialty, and what, if any, additional space would be required to house the initiative. We considered timing issues related to when we had to add resources compared to when a corresponding milestone could be achieved. We also considered the amounts of potential professional fee revenues the project may generate, and offset these against resource demands.

We made a risk assessment for each project, considering the complexity, the scope, the extent to which any single point failure in the milestones would jeopardize downstream success, the degree of inter-dependence on other projects within the waiver program as well as institutional initiatives outside the waiver, and the amount of time required to manage the project. We made an assessment of potential general community benefit.

Finally, we considered organizational priorities, and to what extent the Performing Provider was able to justify partial support of these efforts as meeting existing institutional requirements or objectives.

[i]Paso del Norte Blue Ribbon Committee for a Strategic Health Framework. Phase One: Needs Assessment Report. March 24, 2011. On File.

[ii] Accessed October 1, 2012.

[iii] Accessed September 29, 2011