Including Optometric Services for the Homebound Elderly in the Curriculum

Optometric Education, Fall, 1995

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Benjamin Freed, O.D., Mark Kirstein, O.D.

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Abstract

 

A mobile primary eyecare service is offered to homebound elderly residents of New York City by the State University of New York College of Optometry. Fourth year students are required to participate in the visits as they learn the techniques of using hand held equipment to examine individuals who have a high rate of ocular disease and might otherwise not receive ophthalmic services.

 

Key Words: Home eye care, home health care, primary vision care, homebound elderly, low vision care

 

Introduction

 

The College of Optometry of the State University of New York has conducted an optometry service for homebound residents of New York City as a part of its professional curriculum for three years. Primary eye examinations, eyeglasses, and low vision

devices are provided by faculty members and senior optometry students in the homes of elderly individuals who could not otherwise access such services. This article will present a profile of the service as a part of the fourth year curriculum in an effort to encourage other optometrists, schools and agencies to incorporate home visits into their programs.

 

For older people with functional impairments, living at home offers many advantages: they can remain in familiar surroundings, retain some continuity of lifestyle, and have a choice in the acquisition of services. Living at home also remains the lower cost option compared to a nursing home for many individuals. According to the 1990 census, an estimated 5.9 million people over 65 (over 20% of this age group) reported having either a mobility or self-care disability (difficulty traveling outside the home alone or taking care of personal needs). Estimates range from 1.6 million severely impaired elderly living at home, needing substantial long-term care assistance with the activities of daily living to as many as 9 to 11 million Americans in need of home care services. The growth in the number of elderly people in need of long-term care at home has been and is projected to be greater than the growth of the nursing home population. Since the population over 65 is predicted to nearly double by the year 2030 the demand for home-based medical and related services will increase accordingly.

 

A complex combination of mental and physical disorders affects this population  which is already beset by poor housing financial difficulties, and social isolation. Two-thirds of individuals over 65 living at home suffer from at least one chronic condition that can decrease independent mobility. The primary disabling conditions in this age group are: arthritis, hypertension, hearing impairment, orthopedic impairment, heart disease, and visual impairment.

 

Ocular Disease in the Homebound Population

 

Although high rates of ocular disease in nursing home populations have consistently been reported, little is known about ocular disease in the homebound population. Out of 50 of our own cases randomly chosen for review, 37 (74%) were diagnosed with cataracts, 15 (30%) were diagnosed with macular degeneration, 6 (12%) were diagnosed with glaucoma, and 3 (6%) were diagnosed with diabetic retinopathy (age range 32-98, mean = 78 years). When reviewing the records of 25 randomly selected home-bound patients (50 eyes) for whom Snellen chart acuities were obtainable, we found the average corrected logMar visual acuity to be .53 (20/68). To compare, a review of 25 age-matched non-homebound patients seen at the University Optometric Center had an average logMar acuity of .26 (20/36). Given that measurements were not well controlled in this retrospective study, it could not be concluded that homebound patients have significantly lower visual acuities than the non-home-bound, only that a more rigorous analysis is needed to prove this hypothesis.

 

However, research has shown that the homebound are more than twice as likely as the non-homebound to report difficulty in reading regular print. Furthermore, visual impairment has been shown to be a significant contributor to functional disability in long term care patients. The homebound population therefore appears to present a greater demand for optometric services than the non-homebound. They are, however, underserved by eyecare professionals due to the lack of financial incentive. Indeed, out of 50 cases chosen for review, only two had been seen previusly for a home visit by either an optometrist or ophthalmologist.

 

To fill this gap of service in the community, the SUNY College of Optometry provides homebound optometric services to the five boroughs of New York City. It has been funded since 1992 by the Corporation for National and Community Service, a federal program funding higher education learning-through-community-service initiatives. In addition to the provision of optometry services to homebound elderly, the mission of the program has been to:

 

-  instill a sense of community service in fourth year optometry students;

 

- teach the students the clinical skills required in the use of portable optometric equipment; and

 

- develop linkages with other medical and social service agencies that serve this population.

 

Third year optometry students at the SUNY College of Optometry are introduced to the concepts of homebound care and the use of portable equipment during their geriatrics course. Trial frame refractions are taught in a separate course in low vision care. For at least one day during their senior year, students participate in the homebound program which operates two days per week. Students are encouraged to perform as much as possible of the exam, which generally lasts one and one half hours.

 

The suggested examination protocol and equipment needed for home visits has been described. The basic portable equipment includes a trial lens set and frame, slit lamp, binocular indirect ophthalmoscope with battery pack, direct ophthalmoscope, retinoscope, battery-powered lensometer, frame assortment, low vision aids, Goldman tonometer, eyecharts, and diagnostic pharmaceutical agents.

 

Referrals for the visits are accepted from a variety of sources including families, social workers, nurses, physicians, optometrists and opticians. Prior to the visit, the faculty member telephones the patients to conduct a needs assessment, describe the service, and schedule the appointment. Medicare and Medicaid reimbursements are accepted as payment for examinations. Eyeglasses are often an out-of-pocket expense and are paid for at the time of the visit, although arrangements can be made to reduce fees if necessary. Eyeglass frames are adjusted at the site during, the visit. The same frame has lenses inserted at the Optometric Center and is mailed to the patient along with instructions on its use. Low vision aids, if needed, are dispensed at the time of the visit. After the visit, reports are, written back to the referral sources, and follow-up visits are made when necessary. Students are required to follow up on their patients by telephone after the glasses are received.

 

In addition to primary care, the program provides basic refractive and appliance services to individuals in need of an update in their eyeglass prescriptions, a much appreciated program benefit. (Of our fifty-case sample, 74% were in need of an update in at least one pair of glasses.) For example, a 68-year-old male, bed-bound and without glasses for several years had resigned himself to his "blindness." A simple refraction corrected him to 20/20 vision in each eye; new bifocals were mailed to him  which likely changed his quality of life by enabling him to read normally.

 

An important distinguishing characteristic of the homebound population is their reluctance to consider surgical treatment of ocular conditions such as cataract and retinal neovascularization. They either have "had enough of doctors," can’t cope with the prospect of surgery, or simply won't or cant make the trip to the office or hospital. Of a sample of 20 patients in our program who were recommended to have surgical evaluations for cataract removal, 90% refused, and the remaining 10% still had not had the surgery at a one-year follow-up. This reluctance to consider intervention must be taken into account when making clinical decisions. The issue of patients' rights that arises for many homebound cases presents an excellent opportunity for students to learn sensitivity to patients' needs in the context of medical ethics.

 

In addition to new clinical skills learned, the home visit presents students with a unique opportunity to observe patients in their everyday functional environment and make recommendations in the following areas:

illumination needs; visual status as it affects activities of daily living; use of glasses and low vision aids for specific tasks; and need for other professional intervention, e.g., physicians, nurses, social workers, etc.

 

Conclusion

 

As the need for long term home health care grows, so too will the need for optometry to play an essential role as a part of the home health care team. Training optometry students in the field sensitizes them to the medical and functional needs of both the homebound and non-homebound geriatric populations, while instilling in them a sense of community service.

 

References

 

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2. U.S. Department of Health and Human Services/Public Health Service. Prevalence of mobility and self-care disability United States, 1990. In: Morbidity and Mortality Weekly Report 1993 Oct: 42(39):760-767.

 

Rowland, D. Help at home: long term care assistance for impaired elderly people, a report of the Commonwealth Fund Commission on Elderly People Living Alone. Baltimore, MD: The Commonwealth Fund Commission, 1989:18.

 

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6. United States Bureau of the Census. Statistical Abstract of the U.S.: 1993. Washington,, D.C.: 1993:24.

 

7. Orr A. Aging and Blindness: toward a systems approach to service delivery. In Orr A, ed. Vision and aging, crossroads for service delivery, New York, NY: American Foundation for the Blind, 1992:6.

 

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9. Horowitz A, Teresi J, Cassels L. Development of a vision screening questionnaire for older people. In: Nancy Weber N, ed. Vision and aging: issues in social work practice. Binghamton, New York: The Haworth Press, 1991:46.

 

10. Horowitz A. Vision impairment and func tional disability among nursing home residents. The Gerontologist 1994 Jun; 34(3); 316-323.

 

11. Windsor R. Management of low vision patients who are homebound or in long-term care facilities. In: Cole R and Rosenthal B ed. Problems in optometry, patient and practice management in low vision, vol. 4, no. 1, Philadelphia, PA: JB Lippincott, 1992: 139.