Co-management: 4 steps to success

Excerpted from page 36 of the June 2019 edition of AOA Focus.

The nearest board-certified ophthalmologist to the practice of Sue Lowe, O.D., in Laramie, Wyoming, is in Fort Collins, Colorado—132 miles roundtrip for her patients. Dr. Lowe has been referring cases and co-managing her patients' care, mostly cataract surgeries, with that ophthalmologist for about a decade.

Once a month, he and ­five members of his staff drive to her office, where he consults with her patients. The ophthalmologist performs surgeries either at the Laramie hospital or in his Colorado office. The co-management arrangement works great for her patients who have access to care they might have skipped because of the remoteness in parts of Wyoming. The federal government has designated the expansive and far-flung state, population 577,737, as a "frontier" because it is sparsely populated and there are challenges to accessing services such as health care.

Dr. Lowe is willing to go the distance for her patients' care. Even before her patients sign their "transfer of care" document outlining the referral, the surgery and postoperative care, she does her due diligence. She ­finds out what others are saying about the surgeons, checks out their medical credentials and even personally observes them at work.

She wouldn't hand over their care to just anybody. Many of her patients have been coming to see her for decades.

"I send them to doctors who I know will do a good job co-managing their cases," Dr. Lowe says. "We work together for the good of the patients and the good of care."

AOA Focus talked to doctors of optometry who co-manage care with other providers to get their tips for success. Here's how they make it work.

1. Agree on a vision.

"I haven't written a prescription for glasses or ­fit a pair of contact lenses in well over 30 years," Paul Barney, O.D., says to an optometry student between calling upon members of Congress at AOA on Capitol Hill 2019 in April.

And when the optometry student's eyes widen with curiosity at the notion—Dr. Barney has seen this look before and not only from students—he explains the co-management arrangement at his practice. Two doctors of optometry collaborate with an ophthalmologist at Paci­fic Cataract and Laser Institute (PCLI) in Anchorage, Alaska.

This is how he had imagined practicing, a twist on co-managing care, after graduating from Southern California College of Optometry. Dr. Barney's interest then and focus now is on medical optometry. The ophthalmologist performs surgery; Dr. Barney handles the preoperative and postoperative care.

"We're basically a referral practice, and we only do surgical and medical eye care," he says, noting that the practice does not provide primary eye care.

For Dr. Barney, the beauty of practicing in Alaska goes beyond the state's natural scenery.
"Everybody's focused on what they were educated and trained to do—what they do best and what's best for patients," says Dr. Barney. "By optometrists being allowed to do what we are trained to do and by allowing us to provide that care, better access is provided to patients, and patients end up winning."

Lisa Wade, O.D., director of the Hayes Center for Practice Excellence at Southern College of Optometry in Memphis, Tennessee, says it takes a commitment to the success of the practice.

"Partners have to be able to trust each other to do the right thing for the practice—even when it might not bene­fit them personally. They also should share a similar work ethic and tolerance for risk."

She adds that communication is key.

"Be able to have brutally honest conversations about money and people—and everything else. Know when to talk and when to listen."

2. Be clear on the division of labor.

Robert Ford, M.D., PCLI's president and owner, is a willing partner to doctors of optometry. The patient demand for care is there, Dr. Ford says.

"Optometry's increased role in medical eye care is critical and well-timed," says Dr. Ford, the ophthalmologist-founder of PCLI, who once co-managed cases with Dr. Barney in the Anchorage practice. "A tidal wave of baby boomers, flooding through our health care system, is dramatically increasing the amount of age-related eye disease that won't peak for several decades. With more ophthalmologists forecasted to retire over the coming years than residents graduating, there's a great need for ophthalmology and optometry to work together."

PCLI operates 17 locations in six states. Patients see their family doctor of optometry for most of their eye care and are only referred to PCLI when specialty care is needed. At PCLI, patients' care is managed by a team—doctors of optometry and ophthalmologists—working together to serve patients. Dr. Ford says doctors of optometry are the front line of PCLI's clinical services.

"As a referral center, we don't provide any primary care, so our (PCLI's) optometrists serve as consultants to referring doctors of optometry by assessing patients for surgery, assisting referring doctors of optometry with follow-up care as needed and managing patients referred for secondary medical care," he says. "This might include coordinating evaluation and treatment with one of our ophthalmologists or a local subspecialist.

"Our surgeons spend very little time in the clinic," he adds. "Their focus is surgery. Optometrists and ophthalmologists within our group focus on what they do best and don't overlap services. Optometrists in the community are primary care experts, so our staff optometrists do not offer these services. This team approach optimizes everyone's strengths."

3. Support continuing education.

The National Academies of Sciences, Engineering and Medicine estimated in its 2016 report, "Making Eye Health a Population Health Imperative: Vision for Tomorrow," that 142 million Americans over age 40 experience vision problems.

To meet the unmet need for eye care, doctors of optometry are already referring patients to ophthalmologists, educating patients about the surgeries done by ophthalmologists and managing the procedures postoperatively. Further, more and more doctors of optometry are entering into co-management relationships with ophthalmology because patients are seeking quality, convenient care.

The growth in co-management agreements is a very good development, says Nathan Lighthizer, O.D., associate professor of optometry and assistant dean for clinical care services at Northeastern State University Oklahoma College of Optometry. Dr. Lighthizer has led a team of doctors of optometry providing training in advanced surgical procedures during the two most recent Optometry's Meetings.

"With the ever-aging population, there is going to be a dramatic need for ophthalmologists to spend their time in the operating room (OR) doing cataract surgery, glaucoma surgery (MIGS procedures) and other OR-based surgeries," Dr. Lighthizer says. "When you also think about how overburdened retinal specialists are with intravitreal injections for macular degeneration, you quickly realize that there is more than enough ocular disease management to go around."

"We are all working together for the better good of the patient and increased access to timely and quality patient care," he says.

"We openly share information on continuing education programs and our daily communication with referring doctors," Dr. Ford adds. "Shared knowledge elevates everybody's level of care."

4. Maintain trust.

The working relationship between doctor of optometry and ophthalmologist historically has been a work in progress. Christopher J. Quinn, O.D., AOA past president, says doctors of optometry have been reluctant to refer to ophthalmologists. And that concern was justi­fied, Dr. Quinn says, as doctors of optometry found themselves in competition with ophthalmologists for their own patients or were criticized by ophthalmologists to patients for the care they provided.

Over time, however, many eye doctors have seen the value in working together. The doctors of optometry believe the practice arrangement will continue to grow in popularity.

"Co-management is absolutely a good thing," says Dr. Quinn, who practices at Omni Eye Services in New Jersey. "It is of tremendous bene­fit to the patient, and that's always the most important thing. Continuity of care really bene­fits the patient. They get the best of both worlds."

Dr. Barney arrived in Alaska, a couple of years removed from optometry school, with the intention of practicing in Anchorage for just a few years. It has been 20.

He says. "We're in it together. If you allow providers to be their very best, that ultimately results in better care for patients."