The privileges of providing care

Excerpted from page 38 of the September/October 2021 edition of AOA Focus.

Hospitalists see it all, right? Naturally, inpatient hospital settings experience large volumes of medically complex patients, ergo a wide range of cases.

But this patient?

This patient had everyone stumped.

“The patient had double vision and already had extensive lab testing and imaging that were unremarkable, and the hospitalist still couldn’t figure it out,” recalls Amanda Legge, O.D., a practitioner in Wyomissing, Pennsylvania. “It seemed like it was maybe related to the diabetes, but the sugars weren’t up very high. It was borderline: Do we treat or not?”

Called in to consult on the patient admitted to Penn State Health St. Joseph Medical Center, Dr. Legge says aside from a sixth cranial nerve palsy (CNVI), there wasn’t much to go on. That is, until Dr. Legge took a moment to sit and converse more thoroughly with the patient. Lo and behold, the patient volunteered that he had not only a new kitten at home who was biting at his ears at night but also a swollen lymph node under the ear, the same side as the CNVI. Dr. Legge recommended bloodwork and it came back definitive: felinosis.

The culprit now known, staff treated the patient for cat scratch disease and away went the swollen lymph node, while the double vision resolved itself with no retinitis or other eye findings.

“Just sitting and talking to the patient about what’s involved, more than just that physical exam, is greatly important,” Dr. Legge says. “Sometimes hospitalists can lose that in terms of how much they’re managing at any one time. But when I go consult, I don’t have all those other patients that I’m managing. I have that time to sit, do that full history and put the pieces together.”

Leveraging optometry’s prowess as America’s primary eye care providers is one of many reasons why the profession can—and is—making a difference in hospital systems the nation over. Although typically considered office-based, private practitioners, doctors of optometry holding hospital privileges ensure a continuity of care for patients by providing heightened awareness of the need for and value of in-hospital eye health care in the community, notes the AOA’s Optometric Hospital Privileges Manual.

In short, hospital privileges for optometry realize the promise of hospitals in the first place: a center of medical expertise that relies on the best of inter-professional collaboration. Where emergency departments (EDs) and hospitalists may have general experience in spades, they lack the specialized expertise in the ocular system that doctors of optometry possess.

“I can’t tell you how frequently we hear from our emergency room doctors, ‘Oh, thank goodness we have good, reliable eye care,’ because it’s just not their area of expertise,” Dr. Legge says. “They’re trained to diagnose and quickly manage complex emergencies, such as heart attacks and strokes, and it’s okay they’re not brushed up on the eye care specialty—that’s where we come in.”

Optometry in the hospital

Optometry delivers more than two-thirds of the primary eye health care in the U.S., with doctors of optometry practicing in more than 10,176 communities and over 99% of Americans having access to a doctor of optometry. And that’s not changing any time soon. The Association of American Medical Colleges continues to project a broad shortage of primary care physicians over the next decade, as well as an overall shortage of ophthalmologists. But where have all these providers gone?

In 1961, nearly half of all U.S. practitioners were primary care; however, that is presently only about a third. That delineation, highlighted in a 2017 article in The American Journal of Medicine, served to emphasize how most physicians currently prefer a specialty or subspecialty as opposed to primary care medicine.

“There will not be enough family practitioners to provide primary care to the entire U.S. population; they will need help from other health care providers,” the commentary concludes.

But what does that mean for optometry in hospital settings? An analysis of nationwide ED visits and utilization by the AOA Health Policy Institute (HPI) found many urgent eye-related visits could be treated in an outpatient optometry office or clinic. In fact, 2016 data indicates that only 1.1% of eye-related episodes in the ED resulted in a hospital admission. In other words, these cases were likely the kinds of cases that doctors of optometry routinely deal with in their own practices, e.g., infections, foreign body removal, corneal abrasions, dry eyes, flashes and floaters, diplopia and other ocular symptoms.

Dr. Legge concurs: “In the ED setting, I would say 98% of the time it’s an emergency that would normally walk into our own office or those of any optometrist around the country. Inpatient is a little different. Most commonly we’re consulted for vision disturbances or double vision with the hospital’s stroke protocol or protocols for septicemia that warrant a dilated fundus examination to rule out endophthalmitis.”

What’s more, optometry fits well into a changing hospital operating scheme. A trend to outpatient services has forced hospitals to reevaluate their position in the medical marketplace, and doctors of optometry, as primary eye care providers, can help the hospital deliver these services in a very efficient manner. The Optometric Hospital Privileges Manual notes that doctors of optometry are primarily providers of and referral sources for outpatient services and are valuable contributors both directly and indirectly to hospital income. Cataract referrals or the utilization of in-house lab and imaging services help hospitals, while optometry’s advancing scope of practice nationwide has opened new avenues to care with certain laser procedures.

In Shreveport, Louisiana, Stephen Lewis, O.D., staff optometrist at Willis-Knighton Medical Center, says the hospital system’s Eye Center makes available YAG and SLT lasers for glaucoma procedures. As Louisiana’s optometric scope of practice authorizes these laser procedures, the hospital works with doctors to gain “non-core” privileges for utilizing these instruments.

“It’s an incredible service to be able to offer my optometric colleagues,” Dr. Lewis says. “It gives me great pride that my hospital system respects and acknowledges the capability of optometry and allows us to do what we can do.”

Obtaining hospital privileges

Optometry is widely recognized for imparting value in today’s health care delivery system, and the provision of optometric services in a hospital setting is mutually beneficial. But obtaining hospital privileges is not the easiest of processes and, in some cases, can be met with resistance. The AOA developed its Optometric Hospital Privileges Manual to help doctors navigate this difficult landscape.

The manual provides practical information, including important insights regarding hospital bylaws, legal issues and template documents to prepare doctors for the application process. A co-author/reviewer of the Optometric Hospital Privileges Manual, Dr. Lewis says it helps answer that age-old question: Where do I start?

The answer: The medical staff office.

“Every hospital has one and they function in credentialing new doctors and maintaining credentials,” Dr. Lewis explains. “It may be advisable to have a conversation with the chief of staff to get a feel for the politics of it, too. I’d say be prepared to share your value to the health care system in terms of what you can provide as an optometrist to their patients.

“If you can prove your value, it makes it easier and simpler.” Also, get a sense for the practitioner levels at the hospital and the pros and cons of each. Dr. Lewis says as a mid-level practitioner in his hospital, he retains the same admitting/discharging privileges as a physician assistant or nurse practitioner albeit without voting privileges. But such responsibility comes with the need to respond when and where you need to do so. Therefore, it’s important to know what you know but also know what you don’t know, Dr. Lewis says. Collaboration is the great benefit of a hospital setting, so use it.

“Don’t hesitate to call in others to help,” Dr. Lewis says. “And if you’re called in, that likely means someone else didn’t know what was going on.”

With each consult that Dr. Lewis provides, he’s solidifying himself as the “go-to guy” for eye care not only in the ED or inpatient setting but also in private practice. Upon discharge, these patients may seek follow-up care or establish as new patients while hospital staff themselves may seek routine care.

Alternatively, be prepared for resistance. It’s not uncommon for hospital bylaws to omit optometry altogether—bylaws are a necessary step in credentialing and can take a long, arduous process to rewrite—and, of course, there remain providers or staff who may chafe at optometry on staff.

When David Dexter, O.D., sought privileges at the local health system in Oswego, New York, he recalls encountering such resistance from two ophthalmologists on hospital staff. On Dr. Dexter’s side was the fact that he was a well-known, homegrown eye care provider in the area whom many in the community had known for decades, including many of the practitioners. And that was to his advantage.

For instance, when a new endocrinologist joined the community, Dr. Dexter sent a welcome letter and a copy of his HEDIS forms for diabetic eye exams, suggesting the opportunity to collaborate. The endocrinologist was intrigued and noted he never received such detailed forms from ophthalmologists in town.

“I went out in the community and introduced myself to everybody as Dr. Dexter, your new eye doctor,” he says. That level of familiarity—and a lot of persistence—ultimately paid off.

Again, Dr. Dexter leveraged his primary eye health care expertise as a valuable service to the hospital. While hospitalists are well-trained and know what they can provide, none of them get enough experience with eye education, Dr. Dexter notes. Therefore, he frequently takes ED calls or the random doctor’s consultation.

“The more that optometrists are involved, the more that’s going to have a positive effect on our scope,” Dr. Dexter says. “It’s not always easy, and you have to persevere and establish and maintain that trust, but it’s rewarding.”

Fulfilling care

“Rewarding” is precisely the word that Michelle Cohen, O.D., uses to describe her work in a rehabilitation hospital in Albuquerque, New Mexico. Providing neuro-vision treatment and therapy for brain-injury patients, in addition to traditional vision therapy services in private practice, Dr. Cohen collaborates with physical therapy (PT) and occupational therapy (OT) staff to ensure stroke patients can regain some mobility and independence.

As opposed to seeking hospital privileges, Dr. Cohen was approached by a staff OT who inquired about bringing her vision therapy services into the hospital. Now, six years later, Dr. Cohen says the opportunity to practice in the hospital setting opened her up to providing not only neuro-vision therapy but also the medical eye care that typically coincides with an older, sicker population. In consulting on patients’ vision, Dr. Cohen works with OT and PT to ensure patients find midline orientation to stand, walk and transfer. This can include prescribing yoked prisms to help with gait or posture or addressing other vision symptoms to ensure patients’ swift rehabilitation and discharge. It’s a win-win for patients, care providers and the hospital itself.

“To know that when I go in there, I can help these patients get better faster and ensure their placement is back home as opposed to a long-term facility, is amazing,” Dr. Cohen says. “This level of collaboration is best for the patient, and it’s actually a lot of fun for all of us.”