Partnering in care

Teamwork concept

More and more, optometrists are joining with other professions to create a business model with one goal in mind: to provide convenient, efficient, quality care for their patients. Whether it's sharing building or office space or participating in a structured health care model such as an accountable care organization, optometrists are learning that there are advantages to the collaborative approach.

By Jennifer Lubell , AOA Focus, June, 2015, pages 30-38

For Paul Ajamian, O.D., playing well with others is the key to success.

The five optometrists and four ophthalmologists who work with him at Omni Eye Services in Atlanta, Georgia, have built a practice based on working cooperatively and synergistically with their co-managing doctors. Dr. Ajamian says the arrangement gives everyone the breathing room they need—while patients benefit from on-the-spot referrals and more efficient eye care.

"We're strictly a secondary and tertiary care facility, with no primary care provided," says Dr. Ajamian. "As such, our optometrists mainly man-age disease. We work side by side with the ophthalmologists and we all play to each other's strengths."

This means the optometrists handle emergencies, anterior segment issues, and post-op care; and leave surgeries, injections and advanced retinal care to the ophthalmologists.

The concept of aligning with other professions isn't new. However, the Affordable Care Act's emphasis on coordinated, value-based care, along with the optometrist's increasing role in the medical care of patients, has given these relation-ships new importance.

Dr. Ajamian's practice, for example, has been around for more than 30 years. What's changed since the early 1980s is the optometrist's scope of practice, which has afforded the profession more independence than ever before (read more about scope expansion throughout history in the November/December 2014 edition of AOA Focus). Ophthalmologists who have capable, competent optometrists in their practice realize they should use them to the full extent of their training—and not just for refractions and fitting contact lenses, he says.

As optometrists become more involved in whole-patient care, some are exploring new collaborative business models with other specialists. Some work in ophthalmology practices or community health centers, while others have separate practices but share building space with various specialty doctors. More and more optometrists are investing in integrated care models, including accountable care organizations (see page 26 of the May 2015 edition of AOA Focus). Participating optometrists say these collaborations lead to earlier detection of chronic illness, and provide other benefits, such as built-in referrals.

For patients, facilities where optometrists share office or building space offer "one-stop shop" convenience for medical appointments.

A crucial requirement of these arrangements involves establishing trust with your fellow specialist. As Satya Verma, O.D., president of the National Academies of Practice—which represents 14 health care professions, including audiology, dentistry and medicine—discusses in an interview with AOA Focus, relationships with other professions involve give and take—and adopting a mutual understanding of what everyone's specialty is.

'Providers are always at my fingertips'
While most optometrists don't work with many specialties at one time, Open Cities Health Center, a non-profit community health center in Saint Paul, Minnesota, comes close.

Primary care physicians and dentists make up the biggest segment of providers at the Open Cities clinic, which also includes nurse practitioners, a chiropractor, a behavioral health team and an outreach team of caseworkers. Matthew Bauer, O.D., director of eye care services at Open Cities, is the resident optometrist.

"All of those providers are always at my fingertips," Dr. Bauer says of his colleagues. Sharing one building integrates you into a medical team, as opposed to flying solo, he observes. By working closely with Dr. Bauer, the primary care doctors and other specialists have learned more about optometry and what optometrists are capable of.

In learning about the diseases and conditions he treats, his colleagues have gained a newfound respect for his profession because they realize that the optometrist is often the first to detect illness or disease. Michon McBride, NP, who works with pediatric patients at Open Cities, says the biggest benefit of having Dr. Bauer on her team is getting children ready for school. "Having a co-worker able to do a complete eye exam and treat vision concerns before entering school has done a lot to help our pediatric population as they start school," McBride says.

All of the clinic's providers use one electronic health record system, which makes collaboration easier. It allows all of the doctors to communicate with each other and speak the same language. Dr. Bauer can check what the primary care doctor's notes were about a specific patient, and if they mesh with what the patient is telling him. "I can see the patient's results from his labs instantaneously. I know what went on during his last visit, what his blood pressure was, any updates in medications. It's all out there without me having to call or request records."

Quick turnarounds, immediate diagnosis
Patients benefit from these collaborative health care models because if they have a specific health problem, they don't have to go to multiple clinics to get an answer, Dr. Bauer says. It's an arrangement that benefitted one patient whom he suspected had diabetes and needed immediate care.

The patient hadn't seen a provider in the past five years and had come to Dr. Bauer, complaining of vision changes. "I ended up seeing some small hemorrhages in the eyes and asked the patient what else was going on," he says. Upon hearing that the patient was suffering from symptoms of dizziness and light-headedness, Dr. Bauer ordered labs and sent him to one of the clinic's primary care providers half an hour later. Sure enough, the patient's blood sugar was in the 400s. He was immediately diagnosed with diabetes and given a treatment plan and follow-up schedule.

Another mode for integrated care

Integrated care is about aligning one cohort of physicians who work collaboratively to provide the best patient care, often using the same medical record system and having the same goals in mind.

This is what the Rhode Island Primary Care Physicians Corporation (RIPCPC) model is seeking to achieve. To date, it is the largest known integrated care model of its kind among primary care providers and eye care professionals.

Inclusive independence is a specific goal of the RIPCPC. It means that doctors can exist in their own office, "but there's coordination to the extent that there's a sufficient exchange of information so every member on the patient's health care team understands what's happening," says Stephen Montaquila, O.D., who chairs the RIPCPC eye care group of optometrists and ophthalmologists.

This virtual model of care offers the autonomy that Lawrence Ginsberg, O.D., one of 70 eye care providers in the group, was looking for (read more on page 14 of the October 2014 edition of AOA Focus).

Most of the ODs and some of the ophthalmologists who joined the RIPCPC have independent practices. The arrangement gives them the ability to get referrals from primary care doctors, who in turn seek collaborative arrangement from the eye care providers. If an OD sees a primary care doctor's diabetic patient, for example, that provider can communicate with the OD to find out if the patient has had an annual eye exam, Dr. Ginsberg says.

To improve coordination, the RIPCPC has developed a standard patient form for all of its physicians. If Dr. Ginsberg sees a patient in the group, he fills out this form with the patient information, which gets faxed back to RIPCPC headquarters. Because all of the electronic medical records (EMRs) do not communicate yet, the RIPCPC headquarters serves as the central location to keep records. The goal, though, is to get all EMRs to be uniform, Dr. Ginsberg says.

The main office takes care of all patient stats, which get sent to the patient's primary care doctor.

For now, RIPCPC is still in the building phase-coordinating doctors and getting protocols in place. "We're working closely with the primary care physicians to ensure that we are collecting the appropriate patient care data that needs to be shared, and understanding what patient care data they need to share with us, as well," Dr. Montaquila says.

All of this was accomplished in a two-hour period—without the patient having to go somewhere else. "It's an example of how you can coordinate all that care instantaneously," Dr. Bauer says.

Matthew Willis, O.D., an optometrist with Midwest Eyecare, in Omaha, Nebraska, describes a similar situation where a patient received immediate care from his practice's team of optometrists and ophthalmologists. The practice has six locations in the Omaha metro area.

Like Dr. Bauer, Dr. Willis had spotted an urgent problem during a routine eye exam that called for more immediate attention.

The patient had a history of a retinal condition and had a spot in her vision that had gotten bigger. New swelling and hemorrhaging in the back of the eye and new areas of scarring alerted Dr. Willis to the fact that her condition needed to be addressed quickly.

"I gave one of our retinal doctors a call. He was on the road and was actually leaving for vacation," recalls Dr. Willis. The retinal doctor put his plans on hold so that he could meet the patient at the office and take care of her. "That stood out to me as being pretty amazing—that he saw her outside of the normal clinic hours."

To Dr. Willis, this story illustrates the strong working relationship he has with the doctors in his practice. "We all trust each other's judgment—he trusted that I knew what I was looking at, and I knew he could take care of her," he says.

Having direct access to other specialists in a large practice also provides a built-in set of referrals, Dr. Willis says. Had he chosen to practice solo, it may have been more difficult to fit patients in—as his practice did with the patient with the eye hemorrhage—or cultivate a referral system with other doctors.
The one-stop shop
Dawn Stratton, O.D., experiences many of these same advantages, except that in her arrangement, she shares building space with other specialty practices and establishes business relationships with them.

Dr. Stratton, who operates Stratton Eyes in Lexington, Kentucky, with business partner Heechung Ko, O.D., leases office condo unit space in a three-story building to a dentist and chiropractor.

All of the professionals own and operates their practices individually and are responsible for their own utilities, she says. The practices each pay quarterly common area maintenance fees to maintain the building. Together they have a board that meets every other month to address ongoing issues. Dr. Stratton says she hopes to bring in a pediatrician or a family practice physician to lease available space.

"It has been a great asset, having like-minded professionals bear the real estate burden together. Putting our finances together has given us the opportunity to have much more than we could ever afford individually," she says.

Just as with large multispecialty practices or community health centers, sharing space also means spreading the good word about each other's practices. "Since we have all been in the same building, we have been able to build a strong rapport with each other, which makes it really easy to send referrals," observes Ian Puntney, D.C., of Wellington Family Chiropractic. Patients who are sent his way from the optometry and dental offices seem to have a level of trust and comfort with Dr. Puntney, "which is a huge positive for my practice."

All of the practices have experienced growth due to this business arrangement. Dr. Stratton says her practice alone has increased in patient volume by nearly 36 percent over an 18 month-period. "We track new patient referrals through a questionnaire that is given to the patient when they check in for their eye exam. Approximately 23 percent of referrals are from the other doctors in this building," she says. Due to the increase in patients, her practice has added two more doctors and another 1,000 square feet in office space to create more exam lanes.

What the patient experiences is more value and convenience, Dr. Stratton emphasizes.

It means they can go to one building to have their eyes examined, teeth cleaned and back adjusted all in one day. The practice is also conveniently located near several schools and residential neighborhoods. "Many of our patients can actually walk from their homes to our office," she says.

It simplifies life for busy people.