Today, doctors of optometry—primary eye care providers—fill a vital role in the way hospitals provide patient care. But more often than not, optometry still must challenge outdated preconceptions.

Why doctors of optometry should seek hospital privileges

Excerpted from page 38 of the April/May 2018 edition of AOA Focus.

Ninety miles north of Minneapolis, the rural Minnesota town of Onamia is nothing like the metropolis. A town of 900, Onamia is developed around the intersection of U.S. 169 and State Highway 27. Instead of a stoplight, there's a billboard that proclaims, "Caring for body, mind and spirit; hospital this way.

“Having hospital privileges has enhanced my relationship with other health care providers in different fields and has enabled me to be a part of their protocol and care for those patients.”

"The old Onamia hospital, a 25-bed critical access facility, is among the only medical centers for nearly an hour's drive. That means the hospital is a quasi-health-care-hub for the region, yearning for a variety of specialties. Among these, primary eye care was a priority, and Kerry Beebe, O.D., was one of the doctors granted privileges to provide it.

"The thing about rural hospitals is we're 60 miles from any other eye care," says Dr. Beebe, Optometry Cares®-The AOA Foundation board vice president. "In this rural setting, literally, if patients don't get their care here, then they just go without.

"That was the case for a 6-month-old girl whose parents and family physicians were absolutely baffled as to why she wasn't thriving. Called to the hospital for an InfantSEE® exam, Dr. Beebe found the answer right away: She was a +10 hyperope in both eyes.

With glasses prescribed and dispensed in the hospital, Dr. Beebe returned to an expectant room packed with not only the patient and her parents, but also her grandmother, the referring family physician and nursing staff. On went the glasses, and "there wasn't a dry eye left in that hallway," Dr. Beebe says. For the first time, the little one could clearly see.

"That type of delivery of optometry just drives home the point of cooperation amongst optometry and primary care, and again, in an underserved area and to an underserved population, such as pediatrics," he says.

"When the physician sees it, suddenly, they realize the importance of eye care, and you couldn't do that sitting in an office. The philosophy in our practice has always been that optometry needs to be anywhere that eye care is needed, and the hospital is one place that we have to be as a profession."

Optometry in the hospital

America's health care delivery system is in flux: Health care reform not only changed the way care is furnished and regulated, but also challenged traditional roles. To that end, the hospital industry is undergoing a fundamental change, accelerated by third-party payers, employers and individuals. As third parties demand cost-efficient care backed by quality outcomes data, hospitals are in a transitional period.

Increasingly, hospitals are hemorrhaging outpatient procedures to freestanding facilities, while hospital systems are consolidating with an eye on expenses. The new paradigm of managed care and an increased emphasis on primary care has opened hospitals to optometry as a means for delivering efficient eye care services. "As buyers of health care services continue to demand an appropriate level of care from primary care providers, with specialist services performed only when necessary, optometrists will continue to find an increased role in hospital practice," notes the AOA's Optometric Hospital Privileges Manual.

Therefore, as integrated care becomes modus operandi, it's important for optometry to seek and gain hospital privileges. But what's the benefit for optometry?

From a patient-care standpoint, hospital privileges "ensure continuity of care for patients by providing a heightened awareness of the need for and value of in-hospital eye health care; optometrists are able to serve their already established patients who may suffer eye-related symptoms or complications while hospitalized, and optometrists may be called upon to see other hospitalized patients in need of similar care," notes the AOA manual.

From a practical standpoint, for doctors of optometry hospital privileges provide networking and referral opportunities among primary care and specialist physicians, participation in interprofessional research studies, direct inclusion on provider panels, and they reinforce the profession's ability to provide primary eye care services.

"We've made significant strides in obtaining hospital privileges in the past 25 years, there's no doubt about that," Dr. Beebe says. "Twenty-five years ago, doctors of optometry didn't know anything about how to get privileges and hospitals didn't know how to give us privileges; there was a lot of work educating both sides."

Such sentiment proved a genesis for the AOA's Optometric Hospital Privileges Manual, published in March 2003 by the AOA's Hospital Practices Committee. One of the manual's original authors, Dr. Beebe offered his insight as having hospital privileges (now) for over 25 years, both at Onamia and St. Joseph's Medical Center in Brainerd, Minnesota. As for the latter, Dr. Beebe served on the hospital's privileging committee, knowing the arduous process from either side of the equation.

The Optometric Hospital Privileges Manual is AOA-member doctors' source of practical information for navigating the difficult landscape of hospital privileges and what that entails, from a step-by-step privileging process to a thorough breakdown of the hospital-based optometric examination.

"Doctors ought to use this manual as a guide book and follow the steps, because hospitals are often rigid in their policies, procedures and protocols," says James Sandefur, O.D., Optometry Association of Louisiana executive director and co-author/reviewer on the 2015 update to the manual. "You must do this process the right way in order to be successful."

Playing by the (hospital's) rules

Dr. Sandefur would know; he's recognized as one of the first doctors of optometry in Louisiana to serve on a hospital staff. Joining Oakdale Community Hospital in 1992, Dr. Sandefur spent 14 years on the medical staff, and it all started through a personal friendship with the hospital administrator.

At the time, Oakdale Community Hospital didn't have a section devoted to optometric hospital privileges in their bylaws. So Dr. Sandefur approached his friend regarding the process for obtaining privileges, and was asked to write it. He used input from AOA's original privileges manual.

"That manual was out front for a while, and it was very important in a state such as Louisiana, where optometry can do laser surgery," Dr. Sandefur says. "For doctors of optometry to be able to do laser surgery in the hospital, elbow to elbow with physicians, is a big deal, and hospital privileges is the first step to do that."

Initially met with resistance on the hospital admissions committee, Dr. Sandefur explains, he wasn't granted the active medical staff level of hospital privileges per se; he was given 'courtesy privileges' for consulting and seeing patients in the emergency department. Although that alone was monumental, as it presented the opportunity for Dr. Sandefur to demonstrate the clinical capabilities of the profession.

"Being in that hospital setting, No. 1, it educates the physicians as to what doctors of optometry are capable of doing," he says. "There's so much more to optometry than glasses, and showing physicians face to face was an important aspect."

As Dr. Sandefur describes, there are different levels of privileges that vary from hospital to hospital but generally fall under similar categories. These range from active medical staff with full voting privileges, committee opportunities and the broadest privilege considerations granted to physicians, to courtesy or consulting privileges-slightly more restrictive depending on hospital bylaws-and finally allied health professionals who, generally, must take direction from an M.D.

Where does optometry fit? Generally, doctors of optometry should request the highest appointment level possible, a category that allows practice to the fullest scope possible. That said, hospitals may choose to limit optometry's scope of practice even if granted by state law, the AOA's manual notes.

Medical eye care to its fullest

Regardless of privilege category, the hospital setting requires a distinct line of thinking with different responsibilities than might be found elsewhere. Stephen Lewis, O.D., a co-author/reviewer on the 2015 Optometric Hospital Privileges Manual update, says if doctors of optometry are going to subject themselves to a hospital environment, then they must be prepared to handle whatever comes their way.

"You're exposed to a more unique type of care, whether it be medical or post-surgical. The challenge in that regard is wonderful and brought me to this mode of practice 30 years ago," says Dr. Lewis, who has held hospital privileges with Willis-Knighton Medical Center in Shreveport, Louisiana, since 1987. He's quick to point out that all modes of practice are valuable, but he's especially smitten with the medical eye care afforded by a hospital setting.

"Having hospital privileges has enhanced my relationship with other health care providers in different fields and has enabled me to be a part of their protocol and care for those patients. It affords me the opportunity to be more knowledgeable, more experienced, while helping me gain the respect of those in the medical field."

It's been a practice builder, Dr. Lewis says. Internists, cardiologists and general practitioners all gained confidence in optometry's abilities by interacting, confiding and collaborating with Dr. Lewis in the hospital, and in turn, bolstered their willingness to consult. It's a "win-win-win" for patients, the hospital and optometry.

First and foremost, patients benefit from the continuity of care. Certainly, there are consults for blurred vision, Dr. Lewis says, but is that a consequence of diabetes, or a stroke?

"What I'm getting at, when a patient is admitted in the hospital and notices a sudden change in vision, obviously there's a lot of panic that sets in," he says. "The opportunity for me to go over there in a timely fashion, to actually see the patient and to perform a bedside examination, and actually talk to them about what's going on, that's rewarding. Being able to explain, whether it's a good prognosis or not, what's going on with their eyesight provides peace of mind."

The hospital setting also offers another unique opportunity for doctors: research. Joan Stelmack, O.D., director of Low Vision Service in the Department of Ophthalmology at University of Illinois Hospital & Health Sciences System with a primary appointment at Edward Hines Jr. Veteran's Affairs Hospital, devotes her time to comprehensive, low-vision rehabilitation services and research in the VA's Blind Rehabilitation Center.

Out of school, Dr. Stelmack initially went to work for a contact lens manufacturer, before making her way to the VA. She's now the only attending doctor of optometry in the Blind Rehabilitation Center, and uses her compressed, four-day work schedule to run a low-vision service at Illinois Eye and Ear Infirmary.

"The VA position has enabled me to pursue academics, direct patient care and research all in one setting," Dr. Stelmack says. "The research program has contributed to an evidence base for low-vision rehabilitation and to services at our facility, while the education program for students and residents trains optometrists to staff other VA programs."

She says there's no question: "The hospital benefits from the care that optometry provides its patients."

July 6, 2018

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