Retinal Physician

JAN-FEB 2017

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36 R E T I N A L P H Y S I C I A N . C O M | J A N U A R Y / F E B R U A R Y 2 0 1 7 36 220 patients. e patients received, on average, five hours of care from an MD and an occupation therapist. Overall, 80% of goals were accomplished, and quality of life and independence were dramatically improved. Another somewhat self-serving reason for providing LVR care is that it is good for practice referrals. A qual- ity LVR service often attracts the attention of referring optometrists and ophthalmologists. Patients who do not require surgical or medical intervention also end up being referred. Even referrals from direct competitors will find their way to the practice when those competitors are honest about the needs of their patients. ere are only very few ODs or MDs who want to do offer their own LVR, and the retinal practice will have to be conscious of those care- givers working among them who would like their patients referred back for care. BENEFITS OF IN-HOUSE LVR e first and obvious benefit to providing in-house LVR is that patients receive the care that they need to improve their quality of life. However, one of the significant obsta- cles to the process is patient resistance. Whenever a patient is referred to another treatment facility, there is always a concern with whether he or she will follow through and attend the visit. Compliance is certainly an issue when a referral to LVR is made. For example, many good LVR programs are housed in excellent facilities that have names including the phrase "Institute for the Blind." To make the visit, patients must assume a new and very difficult label — that they are "blind." ere are many negative stereotypes associated with blindness that are difficult to internalize before that trip can be made. A 20/70 patient with some difficulty in read- ing has not internalized a stereotypical "blind image" of him-/herself selling pencils on the street corner with a tin cup and white cane in hand. When an LVR service is present in the retinal practice, the patient is simply told, "We would like you to make your visit next week to see Dr. Fletcher. He is one of our doctors who specializes in helping patients to read and use their vision effectively." A much higher percentage of patients will come to their familiar practice setting to undergo LVR than will go to an unfamiliar setting with a threatening sounding name, which may include the scary "B" word. When patients are referred within the practice, they correctly identify their rehabilitation treatment as part of the continuum of care that they are receiving for their ret- ina. It is comfortable and natural to just see another mem- ber of the practice. It is a seamless transition to participate in LVR care. SCREENING CRITERIA FOR LVR ere are some easily administered screening techniques that help a practice to identify who might benefit from LVR services. Across all diagnoses, any individual whose best-corrected visual acuity is worse than 20/60 is going to have reading difficulty and will likely benefit from LVR. In addition, there are contrast sensitivity and central visual field disruptions that may cause significant functional difficulties, while relatively good acuity is maintained. For example, it is common for patients with geographic atro- phy to have large ring scotomas surrounding foveal fixa- tion, where good acuity is maintained. ese patients have great need for LVR with acuity that may be as good as 20/30. An easily administered screening technique is to have the technician who is taking the patient history ask a rou- tine question, such as "Do you have trouble reading the newspaper, even with your best glasses?" A positive response would indicate that it may be appropriate for the patient to be referred for LVR. A check box on the EHR can then trigger a referral to the in- house LVR service. EQUIPMENT Compared with a new OCT, outfitting an LVR clinic is relatively inexpensive. With an expenditure of approximately $5,000, a good service can be offered. Basic LED- illuminated magnifiers provide great value at roughly $25. Close focus prismatic half- eye spectacles are a mainstay of vision rehab and run about $50. Portable video magnifi- ers can give print access to even profoundly impaired patients with a cost of less than $500. GOAL ACHIEVED PARTIAL UNSUCCESSFUL Effective Use of Device 75% 22% 3% Meal Preparation 84% 8% 8% Self Care 82% 8% 10% Handwriting 82% 13% 5% Shopping 83% 0% 17% Sewing 62% 15% 23% Overall 80% 15% 5% Rehab Model Outcomes Warren, Fletcher et al (average 5 hours of training, N=220) R E T I N A L P H Y S I C I A N | J A N U A R Y / F E B R U A R Y 2 0 1 7 INCORPORATING A LOW VISION REHABILITATION SERVICE INTO A RETINAL PRACTICE

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