Practice Models for Low-Vision Rehabilitation
To help your low-vision patients, choose from among several options with varying levels of practice involvement.
BY LYLAS G. MOGK, M.D.

Just in the last decade, the irreversible vision loss experienced by millions of adults has changed the daily lives of patients and their families, the nature and scope of vision rehabilitation, and is now impacting the practice of ophthalmology itself.

Adults with vision loss have long been treated in ophthalmologists' offices. Patients, their families, and their family physicians trusted that we could provide the information and care needed to manage their disease. But usually nothing in our backgrounds or experience tells us what we can do to preserve quality of life for those with irreversible vision loss -- and nothing in our training tells us how to do it.

Creating Model Scenarios

Vision rehabilitation is the art and science of enabling patients with less-than-normal vision to maximize their independence in daily activities.

The "how to do it" is a spectrum of game plans, from something as simple as providing resource information, to offering comprehensive vision rehabilitation. The common thread of all the game plans is gratitude from patients for addressing their needs, at any level. The players, the logistics, the investment, and the rewards vary with the model.

Listed below are several examples of different models that detail how you can integrate some level of vision rehabilitation into your practice, the potential benefits to the practice, and the level of difficulty to carry out each model:

Model 1

Players: Ophthalmologists and ophthalmic technicians.

Game Plan: Handing resource information to patients and encouraging them to read it and act on it. This is to become the basic standard of care for patients with any level of vision loss.

Logistics: Several organizations offer resource material today, including Lighthouse International and the National Eye Institute. However, early in 2005 the American Academy of Ophthalmology (AAO) will launch SmartSight, an initiative in vision rehabilitation, one part of which will be to provide every member with a master copy of resource information for duplication and distribution to patients.

Level of difficulty: 0 on a scale of 0 to 4.

Investment: Copying several pages.

Reward: The professional satisfaction of helping patients in great need, and the personal satisfaction of patient gratitude.

Model 2

Players: Ophthalmologists and ophthalmic technicians.

Game: Handing patients resource information and including a few quick, easy steps into routine eye examinations for patients with acuities less than 20/40.

Logistics: (1) Use an inexpensive, easy Colenbrander chart or equivalent to measure accurate acuities between 20/400 and 20/2000. A patient "counting fingers" inaccurately implies no useful remaining vision and is devastating to patients.

(2) Refract with retinoscope and trial frames, as phoropters don't work for patients with central scotomas.

(3) Prescribe adds up to +5, clip-ons to +4, or prism readers up to +6 . These aids can be excellent for many patients with acuities 20/50 to 20/100. Recommend direct lighting and filters for glare.

(4) Inform the patient's internist that the vision loss is irreversible and that the patient is at increased risk for isolation, depression, falls, medication mix-ups, and Charles Bonnet Syndrome.

Options: Put a resource corner in your office demonstrating yellow and amber filters, large-print books, crossword books, bingo cards, phone, plus penlights, and a gooseneck lamp.

Level of Difficulty: 1 on a scale of 0 to 4. For details and direction, look for SmartSight in 2005.

Investment: The cost of a demo supply of clip-ons and prism readers, and the charts isn't more than several hundred dollars total, along with a minimum investment in nonoptical equipment.

Reward: More satisfaction, patient gratitude and costs recouped by dispensing.

Model 3

Players: Ophthalmologist or low-vision optometrist.

Game: Handing patients resource information, performing a low- vision evaluation, and referring patients elsewhere for rehabilitation training.

Logistics: (1) Low-vision evaluation: includes history of functional difficulties, measures of distance and near acuities and contrast sensitivity; assessment of reading ability; scotoma and preferred retinal locus (several methods); magnification requirements; applicability of devices to patient's needs; discussion of impact of vision loss, and recommendation and dispensing of devices. Device requirements may change after rehabilitation training, so a system for returns or exchange of devices is optimal.

(2) Billing: Bill with E & M codes: visual impairment code primary, disease code secondary; M.D. or O.D. must perform the service. See Academy Preferred Practice Pattern for full description of exam and billing.

(3) Referral: Refer to private agency for the blind and visually impaired, to state commission for the blind, or to occupational therapist in private practice for rehabilitation training in activities of daily living, home environmental adaptations, and confirmation that devices are useful.

Level of difficulty: 2 to 3 on a scale of 0 to 4. For details and directions, look for SmartSight in 2005.

Investment: Charts and devices for demonstration and loan. The cost varies depending on stock chosen.

Reward: Medicare reimbursement in most areas for low-vision evaluation, device dispensing at mark-up, professional satisfaction, and patient gratitude.

Model 4

Players: Ophthalmologist or low-vision optometrist, and ophthalmic technician, and any of the following: occupational therapist (OT), certified low vision therapist (CLVT), rehabilitation teacher (RT), orientation and mobility specialist (O&M), collectively referred to as vision rehabilitation professionals (VRPs).

Game: Low-vision evaluation, as in model 3, and rehabilitation training provided within the practice.

Rehabilitation training includes training in reading, writing, scotoma awareness, effective use of PRL, activities of daily living, and community reintegration. Training must also include adjustment to vision loss and an understanding environmental adaptations such as lighting, contrast enhancement, glare control, and dial marking.

Logistics: After the low-vision evaluation, the physician refers the patient to the VRP, who is employed by the practice. The doctor provides pertinent information from the low-vision evaluation, a statement that the patient has the potential to benefit from training, and recommendations for devices and adaptations. An OT or other VRP may be shared by several smaller practices and spend a day a week or a day every other week in each. The practice bills Medicare for the VRP's services and pays the rehab provider, either by the hour or by percentage of billings. The practice may dispense devices and pay the VRP a percentage of devices sold.

Special Rules: Occupational therapists may provide rehab training in any locale, including the patient's home or community. All other vision rehab professionals must provide rehab services in the building where the ophthalmologist is at the time services are performed.

Level of difficulty: 3 to 4 on a scale of 0 to 4.

Investment: Charts and devices for demonstration and loan. The cost varies depending on stock chosen, nonoptical equipment, and rehabilitation professional's pay.

Reward: Medicare reimbursement for low-vision evaluation and for rehabilitation training. The latter benefits the practice by the dispensing of devices at a mark-up. Tremendous professional and patient satisfaction.

(Note: In a variation of Model 4, a well-trained Joint Commission of Allied Health Personnel in Ophthalmology (JCAHPO) technician may be able to provide partial basic rehabilitation training, although not at a level of OTs or other vision rehab professionals. In this variation, the ophthalmologist must be in the building while the tech is providing services. Medicare reimbursement for tech's services with appropriate documentation.

Model 5

Players: Outside low-vision optometrist and inside OT or other vision rehabilitation professional.

Game: Patients referred out to a low-vision optometrist in private practice for the low-vision evaluation and brought back to the ophthalmology practice for rehabilitation training, as above. This may be a viable alternative, as rehabilitation training is important and reimbursable, but not often provided by low-vision optometrists. Training specifically in the use of devices dispensed, isn't reimbursable.

Logistics: Communication is necessary between ophthalmologist, low-vision optometrist and the rehabilitation trainer. Ideally, the low-vision optometrist can lend the recommended devices until usefulness confirmed via training.

Level of difficulty: On a scale of 0 to 4: 0 for the ophthalmologist and 4 for the OT or other VRP.

Investment: Nonoptical equipment, and rehabilitation professional's pay.

Reward: Medicare reimbursement for rehabilitation training. Dispensing of nonoptical equipment.

Model 6

Players: Occupational therapist or other vision rehabilitation professional

Game: No low-vision evaluation is performed by either an ophthalmologist or optometrist, but the patient is instead referred directly to an occupational therapist or other low-vision professional within the ophthalmology practice. This isn't optimal, but it's a functioning model in areas where there is no M.D. or O.D. doing low-vision evaluations.

Logistics: The OT or low-vision professional would need the appropriate charts and be capable of performing accurate visual acuity and contrast tests, and scotoma and PRL assessment. What remains missing is the important low-vision refraction. Ideally, an ophthalmologist or optometrist in the practice could refract these patients with retinoscopy and loose lenses in a trial frame.

Level of Difficulty: On a scale of 0 to 4: 0 for the ophthalmologist and 4 for the OT or other VRP.

Investment: Chart and devices for demonstration and loan. Costs vary depending on stock chosen, nonoptical equipment and the OT's or other VRP's compensation. The OT or VRP may have his or her own charts and demonstration equipment.

Reward: Medicare reimbursement for rehabilitation services, dispensing of devices, professional satisfaction and patient gratitude.

Working With Low-Vision Professionals

Some knowledge of the training that OTs, CLVTs, RTs and O&M specialists undergo can create an understanding of their capabilities.

OTs are familiar with assessing the skills and needs of seniors, addressing the spectrum of functional deficits, and writing out medical documentation and billing statements.

CLVT certification is geared toward working with physicians and requires a bachelor's degree, supervised experience, and a national examination.

RTs are trained in bachelors' and masters' programs to educate and rehabilitate the blind and visually impaired. Their training may be primarily directed to children. However, this may change as the senior population with visual impairments continues to expand.

O & M specialists train patients in long-cane use and in all modes of mobility.

The Rewards Are Great

Understanding the nuances of the models and the various players involved can go a long way towards the satisfaction that low-vision rehabilitation can offer. No matter which model is carried out, the benefits to ophthalmologists and patients are rewarding.

Lylas G. Mogk, M.D., is director of the Henry Ford Visual Rehabilitation and Research Center in Grosse Point and Livonia Mich., and chair of the Academy Visual Rehabilitation Committee. She is co-author of the award-winning book, Macular Degeneration: The Complete Guide to Saving and Maximizing Your Sight. She can be reached via e-mail at lmogk@aol.com.