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Policy Briefing Reducing Visual Health Disparities in At-Risk Community Health Center Populations Susan A. Primo, Roger Wilson, James W. Hunt, Jr, Jan L. Cooper, Daniel Desrivieres, Linda D. Johnson, and
Policy Briefing Reducing Visual Health Disparities in At-Risk Community Health Center Populations Susan A. Primo, Roger Wilson, James W. Hunt, Jr, Jan L. Cooper, Daniel Desrivieres, Linda D. Johnson, and Lillian Kalaczinski Community health centers (CHCs) have an impressive record of addressing health disparities through consistently delivering high-quality and affordable care in a culturally competent manner, while also producing cost savings to the nation s healthcare system. Thus CHCs are optimally positioned to reduce visual health disparities and improve visual health outcomes by being included in the primary care services that they deliver. An estimated three million health center patients have risk factors for vision disorders and eye disease, yet a recent policy briefing survey conducted by The George Washington University reported that about 20 percent of centers provide on-site eye and vision care. KEY WORDS: community health centers, eye and vision care, visual health disparities Overview of Community Health Centers and Eye and Vision Care The contemporary community health center (CHC) era began in 1965 as a policy action of the Federal Office of Economic Opportunity (OEO) referred to as the War on Poverty. OEO Director Sargent Shriver approved a research and demonstration project proposal developed by physicians Jack Geiger and Count Gibson to establish a model at an urban housing development at Columbia Point in Boston, Massachusetts, and a second model at a rural township in Mound Bayou Mississippi. Their proposal was to create a new, broader vision of healthcare and a new institution to provide it as a way J Public Health Management Practice, 2009, 15(6), Copyright C 2009 Wolters Kluwer Health Lippincott Williams & Wilkins of addressing the devastating links between poverty, race, and ill health in the United States. 1 Today s CHCs are nonprofit, tax-exempt, community-governed providers of primary health services to the nation s poor, uninsured, and other vulnerable underserved populations. 2 Community health centers also offer preventive services such as oral health, mental health, substance abuse counseling, pharmacy services, and enabling services. Community and the other types of health centers (rural, migrant, homeless, and public housing based) have proven to deliver high-quality care that exceeds the performance This briefing is related to the ongoing work of the American Optometric Association s Community Health Center Committee to improve access to eye care for medically underserved populations, in conjunction with expert contributions from a leading authority in health policy and community health center programs. The authors thank Dr John Whitener and Mr Rodney Peele for their advice and review of this manuscript. Dr Primo is supported in part by NIH NEI Grants EY06360 and an unrestricted grant from Research to Prevent Blindness, Inc. Corresponding Author: Susan A. Primo, OD, MPH, Department of Ophthalmology, Emory University School of Medicine, 1365B Clifton Rd, NE, Atlanta, GA Susan A. Primo, OD, MPH, is Associate Professor of Ophthalmology and Director, Vision and Optical Services at the Emory Eye Center, Atlanta, Georgia. Roger Wilson, OD, is Vice President, Health Center Programs at New England Eye Institute, Boston, Massachusetts. James W. Hunt, Jr, MUA, is President and Chief Executive of the Massachusetts League of Community Health Centers, Boston. Jan L. Cooper, OD, is Adjunct Clinical Instructor, Loma Linda University School of Medicine, Department of Ophthalmology, Loma Linda, California. Daniel Desrivieres, OD, is Director of Optometry at the Neighborhood Health Services Center, Plainfield, New Jersey, and also with Newark Community Health Center, Newark, New Jersey. Linda D. Johnson, OD, is Director of Optometry, Jackson-Hinds Comprehensive Health Center, Jackson, Mississippi. Lillian Kalaczinski, OD, is Director of Optometry, Cherry Street Health Services, and is Adjunct Clinical Faculty, Michigan College of Optometry, Grand Rapids, Michigan. 529 530 Journal of Public Health Management and Practice of more traditional providers and to deliver these services at a cost that is better than other modalities, such as in hospitals and emergency rooms. 3,4 Access to comprehensive eye care and risk factors for visual health disorders are among the many health status issues affecting CHC populations. According to 2007 Centers for Disease Control and Prevention data, the prevalence of vision disorders among adults at 200 percent of the federal poverty level was 26 percent. In 2007, CHCs cared for 13.8 million individuals at 200 percent of the federal poverty level. This data translates into an estimated three million or more health center patients with potential risk factors for vision disorders and eye diseases. The 2007 Uniform Data System (UDS) data 5 from the Health Resources and Services Administration (HRSA) report that 36.5 percent of health center patients are 19 years or younger and 69 percent of health center users are of racial or ethnic minorities, including African Americans and those of Hispanic descent. Thus the potential number of health center patients who may need eye and vision care, eye disease prevention, and chronic eye disease management services for these conditions is in the millions. Vision disorders and eye diseases remain prevalent throughout all life stages, from infants to elders. Refractive errors, strabismus, and amblyopia more commonly manifest in children and younger adults. Eye diseases such as glaucoma occur more frequently in mid-life or after a patient has had a systemic disease such as diabetes that can lead to the onset of diabetic retinopathy. Other sight-threatening conditions such as cataracts and macular degeneration are present in later life, threatening home safety, and contribute to depression. 6 Table 1 summarizes important findings documented through literature review in a recently published article. 7 This information highlights the increased prevalence of eye and vision problems among the atrisk populations that CHCs serve. In addition, analysis recently revealed a significant underutilization of comprehensive eye services in select sociodemographic subgroups and the uninsured. 8 Disparities in access to and utilization of eye and vision care services and disparities in visual health carry a two-pronged threat to the nation: (1) the serious public health threat caused by conditions resulting in vision loss and permanent vision impairment and (2) the resultant escalation of healthcare costs associated with the management of sight-threatening eye problems and associated healthcare services. 9,10 Poor access to eye and vision care for the uninsured and underserved represents another challenge with the potential to lead to poor visual health outcomes and additional cost burdens if left unaddressed. Failure to respond to dispari- TABLE 1 Important epidemiologic data on eye and vision disorders Leading causes of vision impairment/blindness in the United States Age-related macular degeneration Glaucoma Cataract Diabetic retinopathy Statistics regarding vision impairment/blindness Vision impairment is the number 1 disability in children (less than 15% of preschool children receive an eye examination; less than 22% receive any type of vision screening) Of the 14 million people older than 12 years in the United States with visual impairment, 11 million could have visual acuity corrected to a level of 20/40 or better with proper refractive correction More than 3.4 million Americans older than 40 years are blind or visually impaired Visual health disparities African Americans, Hispanics, and populations with low socioeconomic status are at an increased risk of being visually impaired Patients of Hispanic descent were found to have a 7.3% prevalence of vision impairment caused by diabetic retinopathy compared with Whites at 4.7% Blindness affects African-Americans and Hispanics at least two times more often than Whites of the same age, primarily because of glaucoma and diabetic retinopathy African-Americans have an over three times greater prevalence rate for visual impairment caused by glaucoma than Whites ties in eye and vision care will have a profound impact on health status, quality of life, and healthcare costs for the nation. Because the vast majority of eye problems are asymptomatic, they are silent to patients, the public at large, leaders in public health, and healthcare planners and reformers. As policy makers foster expansion of CHCs through state and federal healthcare reform and stimulus funding, understanding the silent nature of eye problems and having complete information about comprehensive eye services are essential for supporting the inclusion of vision health and eye care services at CHCs. In this briefing, we seek to inform policy makers about a number of issues pertaining to eye and vision health and the role that CHCs could play in addressing disparities in access to vision services and visual health outcomes for a significant majority of the nation s underserved. We comment on primary care issues that link vision and health, draw inferences on cost impact of undiagnosed eye and vision problems within CHC populations, conjecture on cost savings associated with on-site eye and vision services at CHCs, and finally Policy Briefing 531 inform policy makers about key challenges and issues to achieve in order to improve visual health for CHC patients. Assessing Need for On-Site Eye Care Services at Community Health Centers The George Washington University (GWU) School of Public Health and Health Services Department of Health Policy conducted a survey in 2008, assessing the need for on-site eye services at CHCs. In this policy briefing report, the GWU reported that only 20 percent of CHCs provide on-site eye and vision care services by an employed optometrist or ophthalmologist. 11 The survey was administered electronically to a random sample of 300 federally qualified health centers during a six-week period between November and December The profile of the selected health centers reflected the general patient and urban/rural location of all federally funded health centers, excluding 27 from US territories. The respondent health centers were slightly more urban than rural, but this was not statistically significant. Reminders were sent to help maximize response rate with ultimately 100 of 300 centers responding, that is, a 33 percent response rate; therefore, the findings should be interpreted with some caution because of this smaller sample size. The results of the survey were weighted by health center size and geographic region to reflect the national sample of health centers in the 2007 UDS. Pertaining to on-site eye and vision care, the results indicated that the vast majority of US federally funded CHCs do not have an on-site employed optometrist or ophthalmologist. Although a significant percentage of respondents (48%) reported that their patients could access eye care through informal and verbal agreements with local optometrists and ophthalmologists. (However, the authors of this report are unaware of any data regarding follow-up by CHCs to ensure that referred patients actually receive care.) The survey went on to report that only about six percent reported having a formal legal and contractual agreement for referral services. Alarmingly, nearly 23 percent of CHCs reported that they did not use any arrangement largely because of perceived lack of need or lack of an available eye care professional in the geographic area. As only 20 percent of CHCs reported on-site eye care billable services, this result mirrors the 2007 UDS data of 18 percent of federal grantees providing optometry services. The primary barrier stated by most health centers (via the GWU survey) without on-site eye care was a perceived inability to afford the necessary space/equipment. The majority responded that while vision care is recognized as important, other services such as medical and dental screening were considered priorities. The Public Health Service Act not only requires health centers to provide screening services including pediatric eye, ear, and dental to determine the need for vision and hearing correction and dental care but also specifically requires health centers to provide preventive dental services. The GWU study also identified a perceived lack of reimbursement (or perceived lack of adequate reimbursement) for eye services as a concern for health centers. However, leading practices data from Massachusetts demonstrate that reimbursement for eye and vision care services and materials are more than adequate to ensure sustainability of eye care as a sound business model for health centers Findings of the GWU survey indicate that most health centers recognize the need to provide and improve access to eye and vision care; however, results from the needs assessment survey show several factors that significantly affect their ability to staff eye care professionals. These factors include perceived lack of policy and financial support for the development of on-site eye care, lack of perceived need for on-site care, and lack of infrastructural support and technical assistance needed to accurately assess and determine the community need for eye and vision care. The GWU survey aside, another aspect of needs assessment with eye services is the costs associated with undiagnosed eye and vision problems. Impact on the nation s economy can be illustrated through a discussion of the most common disabling condition in children, namely vision disorders including uncorrected refractive error, strabismus, amblyopia (lazy eye), and accommodative/binocular dysfunction. 9 Since the visual system is used for 80 percent of learning, when undiagnosed vision disorders present in children, school performance and social difficulties manifest, which may result in unnecessary costs for special education. In a review of healthcare costs and the economic impact of visual impairment and blindness in the United States, the financial burden is estimated at $51 billion. 15 Frick et al 16 found that among adults older than 40 years who have visual disorders, visual impairment, and blindness, healthcare costs have been estimated at a total of $35.4 billion, which includes $16.2 billion in direct medical costs and $11.1 billion in other costs. Rein et al 10 found that patients 65 years and older account for the biggest share in the population with cataracts. The largest share of direct medical costs for patients between the ages of years was due to refractive error. These estimates translate to $8 billion in lost productivity. Finally, by the year 2030, the number of 532 Journal of Public Health Management and Practice TABLE 2 Challenges and opportunities for eye services development at CHCs Issues and challenges Approaches and solutions Policy and administrative issues A policy within HRSA Bureau of Primary Health Care defines eye and vision care services within the Health Center Program as a specialty service. This policy requires health centers to apply for a change of scope to add eye care. Administrative challenges exist to obtain funding for health centers. HRSA-defined services provided at health centers do not currently include optometry as part of the primary care list of disciplines. Workforce development challenges Workforce challenges remain for the nation s health centers, including the development of community-based clinical education programs to create awareness among optometry students and graduates about health centers as a venue for practice. National Health Service Corps eligibility does not presently include optometry. Recruitment of students and graduates with cultural competence and language skills. Funding and operational challenges Funding challenges exist for health centers that would like an eye care service, including space needs, capital equipment for the delivery of comprehensive services, and an on-site optical to meet patients eyeglass needs. Misconceptions by health center governing boards and management about adequate coverage and reimbursement for eye and vision care services and procedures. Knowledge base Lack of culturally competent eye and vision health education for health center leaders and users about the range of asymptomatic eye problems in all age groups that impact learning, visual health, safety at home, and overall health status. Abbreviation: CHC, community health center; HRSA, Health Resources and Services Administration. Approaches and considerations Encourage HRSA to review policy, practices, and initiatives that apply to optometric services at CHCs. Embracing primary eye care services and primary eye clinicians within the HRSA definition of primary care. Building eye care workforce solutions Furthering collaborations between health centers and schools of optometry to create new clinical training programs in optometry, postgraduate residency programs in Community Health Optometry, the development of community service values, and contributions to workforce development. Inclusion of optometry in the National Health Service Corps for recruitment and retention of optometrists to work at health centers would create an incentive for health center based employment. Professional institutions could prioritize students from underserved populations in their recruitment strategies. Technical support solutions Encourage congressional support for CHC eye care services expansion. (Federal funding could be specifically targeted to assist health centers interested in adding eye care services, including the capital investment to support the service.) Encourage CHCs to consider eye health services as part of the Federal capital stimulus initiatives. The formal development of capital, business plan analysis, and technical assistance mechanisms could encourage prioritization of busy CHCs in establishing enhanced and more comprehensive eye health services. (The AOA Community Health Center Committee has developed interactive financial modeling and other tools to help CHCs plan eye care services available at: Training and development approaches Formulation of alliances between national and state association leaders could also help maximize services expansion through outreach and educational programs to improve the public s awareness about eye and vision problems and the need for better access to these services. visually impaired and legally blind is expected to double and with the doubling will come healthcare costs to care for and manage these individuals and their total healthcare needs. These alarming data and facts linking eye and vision problems to healthcare and other societal costs should be viewed as having a significant, costly, and lasting impact on the US economy unless measures are taken to address disparities in access and outcomes for vision and eye problems in underserved populations. Next Steps for the Inclusion of Eye Care Services at Community Health Centers: Multidimensional Policy Considerations and Approaches The evidence is clear that eye care and visual health are an essential part of the comprehensive health equation. In this era of healthcare reform, the disparities identified and addressed by Geiger in 1965 ring true today. 1 Policy Briefing 533 Issues impacting access to eye and vision care delivered in a culturally competent manner can be effectively addressed through a multidimensional approach. While there are many issues and challenges, there are viable solutions to providing on-site eye and vision care services to the nation s CHCs. The results of the GWU s School of Public Health s 2008 survey of CHCs reveal issues and challenges that have created barriers for the growth of on-site eye and vision care services at the nation s health centers. The authors have outlined the basis for the need to expand eye and vision c
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