Consider nursing home optometry as practice option
Optometric practice in the nursing home setting is not always very glamorous; however, there are many reasons optometrists might want to consider adding this specialty to their practice arsenal due to tremendous need.
Optometric practice in the nursing home setting is not always very glamorous; however, there are many reasons optometrists might want to consider adding this specialty to their practice arsenal due to tremendous need.
The elderly population is growing at an astounding rate compared to 50 and 100 years ago. The first baby boomers hit age 65 in 2011, and according to U.S. News and World Report, there are 75 million boomers. For the next 20 years, 10,000 people each day will turn 65.1
In 2030, 20 percent of the entire U.S. population will be age 65, up from 13 percent today. In the same time frame, those aged 85 and older will double, and those aged 100 and over will nearly triple.2
With the increase in population there is a significant need for more nursing homes to take care of this segment of the U.S. population.
Growing need for care
Recent census data show that there are nearly 1.5 million nursing home beds in the U.S., and most facilities are at maximum capacity.3
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The Centers for Disease Control and Prevention’s (CDC) aging trends study found that at current usage rates, approximately three million residents will be in nursing homes by 2030-nearly double the current amount of residents.3
Not only will the number of residents increase, but with increasing age the incidence of eye disease increases.3 A 1997 study showed that 30 percent of all nursing home residents had difficulty seeing even with their current glasses, and slightly less than 10 percent had severely limited vision or blindness. 3 Studies also show a higher incidence-up to 15 times higher-of visual impairment in nursing home residents compared to their age-matched counterparts not in nursing homes.3-7
The three leading causes of visual impairment in the U.S. in the adult and aging adult population are diabetes, glaucoma, and age-related macular degeneration.3
Figures 1-4 show that with age comes the likelihood of a disease causing visual impairment. By the year 2050 the population of the U.S. will be living longer, and the prevalence of ocular disease is going to triple over this time frame (Figures 2 and 4). Many of these citizens may require a nursing home at some point in their lifetimes, so the need for optometric services will be significant.3
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Treating uncorrected refractive error and management of undiagnosed eye disease can reduce symptoms of depression and delay onset of Alzheimer’s and other dementia-like diseases.1 The facility can use the OD’s presence as a marketing advantage to potential residents showing eye care is provided in house, giving them a competitive advantage from other facilities.
Types of facilities
There are five types of nursing home and care facilities:
• Independent living communities
• Assisted living facilities
• Residential care facilities
• Continuing care communities
• Nursing homes (intermediate, skilled)
In the independent living community, the resident has full choice and control over all aspects of his life. He must be independent in all aspects of daily living, including bathing and dressing; possess mental alertness and bowel/bladder control; and be able to walk.
In an assisted living facility, the resident usually needs little to no help. Each resident lives in her own apartment and shares common-use spaces, including living, dining, and laundry rooms. Minimal services range from central dining programs to organized recreational activities; health, transportation, housekeeping, and security services are provided.
In a residential care facility, services offered include assistance with personal care and medical needs. This facility is staffed 24 hours a day. Residents must be mentally alert and be able to dress, feed, and toilet. These facilities can have as few as two or up to 16 residents under one roof.
Continuing care retirement communities, or multi-level care facilities, provide a balance between a skilled nursing home and independent living community. They offer a mixture of all types of care facilities.
Optometric care is usually given at large intermediate and skilled nursing home facilities. They provide help for seriously ill recipients with 24-hour supervision, nursing care, rehabilitation programs, and social activities. Intermediate care is given to individuals who need assistance with activities of daily living, some health services, and nursing supervision but not constant nursing care.
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Administrative tasks
To begin offering your services at nursing homes, set up an administrator meeting at your selected facility to discuss establishing optometric services.
If an agreement of need exists, discuss everyone’s expectations. This is the time to address contract negotiations including access to patients, terms and expectations, on-call services, and if and how you will supply glasses to residents. Discuss relevance of age and prevalence of eye disease in this population.
Optometric services are billed by the provider using the resident’s insurance coverage, and those services will be budget neutral to the facility. It is much cheaper for facilities to provide optometric services in-house than to coordinate transportation for outside eye care.
Most nursing homes today are large corporate entities, and in many cases there is an existing contract for eye care (as well as dental, podiatric, and other healthcare services). The contract explains the facility’s expectations, provider expectations, and details the level of liability coverage obtained by the providing doctor.
A main consideration is after-hours calls from a facility, especially if there is a large geographic coverage area. Know what you are agreeing to do for after-hours care.
As with all contracts, consider obtaining legal counsel because state laws differ.
Know the players
The key to success in a nursing home setting is having administrative support from the outset. Important players include facility administrator, director of nursing, director of social services, and the medical director or attending physician.
The facility administrator is in charge of all aspects of the facility and who will make the decision to sign a contract with the OD to perform services. He will make sure everyone else in the facility is on board.
The director of nursing understands each patient’s care plan and who will benefit from optometric services.
The director of social services is the best person for day-to-day interaction and can be the difference between a great or poor relationship with a facility. She makes sure patients are scheduled, rooms are reserved for exams, and proper paperwork is provided and completed before, during, and after the exam.
The medical director or attending physician provides the order for care. In many facilities, the OD can examine a resident only with a physician’s order stating there is a need.
A team effort with each of these members of a nursing home chain of command is vital. Nurturing these relationships will go a long way toward continued success.
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Equipment
Providing optometric care in this setting requires mobile equipment, but most ODs graduate from optometry school owning almost everything that they will need.
See Table 1 for a comprehensive list of equipment to get started.
Figures 5 and 6 illustrate what I carry in my bags.
From experience, I have learned that the nursing home staff will be very appreciative if the OD can help repair broken and bent glasses. This service does not generate income, but the goodwill for being able to help with small things make a huge difference in earning respect in a nursing home facility.
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Documentation
The social worker is the go-to person to have information prepared for the OD before starting the exams for the day.
Be sure you have three required forms the day of the exam for each patient:
• Fact sheet, which includes personal information, diagnoses, and insurance information
• Medication administration record, a section of the resident’s nursing home master chart which includes a full list of diagnoses, medications, dosages, and other medical information
• Physician’s order, which is necessary for Medicare coding guidelines
Exam protocol
The exam protocol is conducted in two phases to maximize the number of patients who can be seen in a timely manner.
The initial phase includes case history and chart review, preliminary testing and acuities, anterior segment evaluation, intraocular pressure (IOP) measurement, and dilation.
The second phase is completed once the eyes are dilated. It consists of posterior segment evaluation with fundus lens, dilated retinoscopy, trial frame refraction, and frame evaluation (if needed).
As with all modes of practice, it is very important to document, document, document per Medicare billing and coding guidelines.
At the conclusion of the exam, it is important to compare the exam findings to the minimum data set (MDS) 3.0 intake and make changes if necessary.
The MDS 3.0 is a tool for implementing standardized assessment and for facilitating care for a new resident upon entry into a facility. Its purpose is to improve quality and care in the nursing home setting and is beneficial for residents, families, providers, and policy makers.8
The vision findings of this assessment can be found in Section B (B1000 and B1200). If vision function is worse than what is recorded, inform the social worker and director of nursing.
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Be prepared to write orders for medications, treatment plans, or referrals that are needed at the conclusion of the exam. Remember to document and have a plan to schedule follow-up exams as needed.
Finally, it is a good practice to have that day’s patient list with diagnosis and follow-up plan signed by the social worker before exiting the facility to prove the services were performed and verified in case of a later audit.
Billing and coding
Billing and coding in the nursing home is different than in office settings.
CPT codes 992XX used for medical diagnoses cannot be billed for services rendered in the nursing home. Ophthalmic codes 92XXX are acceptable and typically used for initial and follow-up exams. Secondary CPT codes 99308, 99309, and 99310 can be used as well.
Be sure to consult your CPT coding authority and Medicare healthcare administrator for specific coding and billing guidelines appropriate for billing nursing home care.
Keep in mind
Other considerations address ethical challenges when providing nursing home care. They include:
• Provision of spectacles for need versus profit
• Decisions to treat and provide interventions
• Expectations to evaluate residents only as requested by the attending physician
• Following rules set by third-party and government organizations
Embrace the benefits from providing optometric care in a nursing home. They can be financial, emotional, flexibility, and growth.
In my experience, a typical half-day in the nursing home can generate up to $1500 or more at the outset if you are able to schedule 12 new patients during a morning or afternoon clinic. As efficiency improves, these numbers increase. Remember there is little provider overhead compared to a brick-and-mortar office.
There are also many emotional benefits to providing nursing home care, such as working directly in your community with those who have the greatest need. Many residents want to share their colorful stories during the exam. Helping to prevent disease or disease progression and providing vision correction that can help delay the onset of dementia can lead to greater personal and professional satisfaction.
The time commitment and amount of clinic days can be flexible for someone just starting. It can help a young OD add more clinical days if a full-time opportunity is not available or if starting a new practice with an unfilled appointment book.
An established practice can incorporate this modality to expand services for associate ODs to keep their schedules busy with little overhead. It is likely that by providing this service in your community, nursing home staff and resident families will learn about your services and may seek you out in your office or become a valued referral source.
Practicing optometry in a nursing home setting is not for everyone, but in my opinion it is well worth it for ODs who are willing to get out of the office and expand their practice capabilities as well as their comfort zones.
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References
1. Bernard, D. The Baby Boomer Number Game. U.S. News World Report. 2012 Mar 23. Available at: http://money.usnews.com/money/blogs/on-retirement/2012/03/23/the-baby-boomer-number-game. Accessed 4/18/17.
2.Yoder S. The Coming Nursing Home Shortage. The Fiscal Times. January 26, 2012. http://www.thefiscaltimes.com/Articles/2012/01/26/The-Coming-Nursing-Home-Shortage#sthash.5Yn5Q0gu.dpuf.
3.Swanson MW, Achiron LR, Beebe KL et al. Optometric Care of Nursing Home Residents. by American Optometric Association. Available at: http://www.aoa.org/Documents/optometrists/QI/FINAL%20Version%204-24-14.pdf. Accessed 4/18/17.
4. Tielsch JM, Javitt JC, Coleman A, Katz J, Sommer A. The prevalence of blindness and visual impairment among nursing home residents. New Engl J Med. 1995 May 4;332(18):1205-9.
5. Horowitz, A. The Prevalence and Consequence of Visual Impairment among Nursing Home Residents. Final Report.. New York: Lighthouse, 1988. Print.
6. Agency for Healthcare Research and Quality. Cataract in adults: management of functional impairment. Available at: https://archive.ahrq.gov/clinic/medtep/catguide.htm. Accessed 4/18/17.
7. Marx MS, Werner P, Cohen-Mansfield J, Feldman R. The relationship between low vision and the performance of activities of daily living in nursing home residents. J Am Geriatr Soc. 1992 Oct;40(10):1018-20.
8. Centers for Medicare and Medicaid Services. MDS 3.0 for Nursing Homes and Swing Bed Providers. Available at: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIMDS30.html. Accessed 4/18/17.
