A Medical Model for Low Vision Care
Now reimbursement makes it feasible to give these patients the help they really need.
BY RONALD COLE, M.D.

Today, the number of people with age-related permanent vision impairment is rapidly increasing, and with the over-age-65 population expected to double by 2030, the number of patients needing help can only grow. Unfortunately, the most common current "treatment" for low vision -- though well-intentioned -- scarcely begins to address the needs of these patients.

Consider this:

• In the absence of visual rehabilitation, vision loss adversely affects an individual's daily living activities, psychosocial status, and the course of other medical conditions.
• Older adults with vision loss are more prone to falls, injuries, social isolation and higher rates of clinical depression than any other disease.
• Almost 80% of adults with multiple chronic diseases report vision loss as being the most difficult to deal with.

Vision loss, particularly in the older population, is ideally suited to management in a medically oriented rehabilitation setting. However, ophthalmologists don't routinely send patients with vision loss for help. Even if they do, patients with some residual, useful vision who are sent for low vision care usually just receive aids and devices.

Using the Team Approach

Vision loss resulting from age-related diseases causes not only decreased visual acuity, but also loss of contrast sensitivity and central scotomas, which are particularly disruptive to reading, writing, and perceiving detail. Dealing with this kind of visual problem, as well as other physical impairments and the psychosocial aspects of vision loss, is best done using a team approach.

Ophthalmologists may not be accustomed to delegating care and treatment to others, but in this situation, an occupational therapist is ideally suited to perform the more comprehensive rehabilitation services the patient needs. To maintain the ability to perform activities of daily living the patient may need scotoma training, reading and writing skills, environmental adaptations, contrast enhancement, glare control and help with functional mobility.

This is function-based rehabilitation, an area where occupational therapists excel. In fact, occupational therapists have the medical background to deal with co-morbidities, and their problem-solving abilities and creativity, along with motivational skills, do a great deal to increase the success of these programs.

Following the Medical Model

Ideally, vision rehabilitation begins with a thorough evaluation by an ophthalmologist who has expertise and experience in this area. The evaluation determines the patient's residual vision, needs and goals, and ability to carry out the rehabilitation program. (Unlike medical or surgical treatment, rehabilitation demands much more involvement and participation from the patient.)

To begin, the ophthalmologist should demonstrate techniques the patient can use to be successful. This sets a positive tone for the overall program.

Following the doctor's evaluation and prescription, the therapist:

• performs an initial evaluation. This involves reviewing and incorporating information from the doctor's low vision evaluation, with particular emphasis upon visual function, other physical impairments and psychological adjustment.
• conducts a comprehensive analysis of the patient's level of function in areas such as financial management, living skills, homemaking, hygiene, grooming, sustained reading and handwriting, placing special emphasis on the patient's level of independence and the amount of assistance required to perform a given task.
• assesses any risk factors, particularly vision related, that are involved with the patient functioning independently.

Finally, the therapist outlines treatment goals and a plan of care, including treatment modalities and methods. The therapist also explains to the patient how the outcome will be affected by motivation level, cognitive ability, family and/or caregiver support, and the patient's level of function before the vision loss.

The Role of the Occupational Therapist

At this point the occupational therapist can start working with the patient, which often requires 6 to 12 hours (or more) of one-on-one therapy sessions, including homework assignments and reviewing the results.

The therapist must also document the patient's status and progress, which is essential to maintaining a quality program -- and necessary in order to satisfy Medicare requirements. (See "Getting Reimbursed," above.) To accomplish this, the therapist documents every visit in a "progress note" that comments on the patient's progress and cognitive, physical, and emotional states. The note also specifies each treatment modality worked on during the visit, including scotoma awareness and training; managing lighting, contrast and glare; safety; handwriting; and application of devices to tasks being performed.

During treatment, patients may be easily frustrated and depressed, but you shouldn't interpret this as lack of motivation. Older patients may process new information and incorporate new habits more slowly than expected, managing this simply requires a caring attitude and lots of reinforcement and repetition. The occupational therapist's encouragement and support is vital to maintaining the patient's enthusiasm.

During this period, the therapist may also want to visit the patient's home to verify that adaptations are being implemented and to assess any other deficiencies in the home environment that could impact safety and function. (For some patients these visits can be very important.)

At the conclusion of the therapy program, the therapist provides a discharge summary that describes the patient's overall status and the progress achieved in each treatment category, along with the appropriate aids and devices being used to help the patient achieve specific goals.

The prescribing ophthalmologist should review and acknowledge the therapist's initial plan, check the progress notes at least monthly and review the discharge summary. Continued input from the physician is instrumental in keeping the program on track.

Meeting Your Patients' Needs

Rehabilitation applied to vision impairment is effective and successful when performed by an appropriate team of professionals, and successful results can be rewarding, both for you and your practice. If your community is under-served, you might even find it worth establishing a larger volume service to meet local needs.

If you're interested in offering this service, you may be able to enlist the services of an occupational therapist on a part-time basis. A number of occupational therapists skilled in visual rehabilitation are available. (Unfortunately, many occupational therapy programs still don't incorporate this body of skills and information in their curriculum.)

Either way, moving beyond the traditional "helpful device" approach is certain to produce better results with your low vision patients -- and that's good news for both of you.

Dr. Cole practices in Sacramento, Calif., and is assistant clinical professor of ophthalmology at the University of California, Davis. For the last 5 years he has developed and directed a low vision rehabilitation center within his group practice, and he has been a member of the American Academy of Ophthalmology's vision rehabilitation committee since 1998.