Low Vision

Partnering for Progress
Rehabilitation specialists can help you help your low vision patients.
KATHLEEN F. FREEMAN, O.D., F.A.A.O., Sewickley, Pa.

Low vision rehabilitation has received considerable attention in the past few years. Optometrists are increasingly interested in meeting the demand for these services. If you provide low vision care, you understand the importance of being comprehensive, which sometimes requires referring the patient to other medical or rehabilitation professionals. This month, I'll outline a strategy for providing appropriate, comprehensive low vision rehabilitation.

What should you do first?

Patients who can't achieve their visual goals with conventional spectacle lenses or contact lenses are candidates for low vision intervention, which should include the following steps:

• thorough evaluation of the medical reason for the decreased vision, as well as consideration of whether further medical or surgical intervention is appropriate.
• assessment of visual functioning to quantify and qualify the level of impairment.
• evaluation of and prescription for "nonconventional" optical and nonoptical methods of improving the impaired vision, based on the patient's best corrected visual acuity (i.e., refractive status).
• instruction in the efficient, effective use of prescribed systems or methods.
• integration of these devices into everyday behaviors to facilitate visual activities of daily living.

See the AOA's Optometric Clinical Practice Guidelines: Care of the Patient with Low Vision for more information.

Your intervention may be multidisciplinary, sometimes requiring the coordinated efforts of other health care personnel and rehabilitative professionals, including but not limited to other physicians, vision rehabilitation teachers, orientation and mobility instructors, occupational therapists and also social workers.

When they need rehabilitation

Many patients who need low vision assistance don't require rehabilitative care beyond what comprehensive optometric low vision care can provide. These patients need only minimal adaptations for specific tasks because they're minimally impaired, have made appropriate adaptations on their own, or have had previous rehabilitation.

However, in some cases, you will need to prescribe additional rehabilitation therapy. Patients who require this therapy will benefit from a structured, formalized approach that follows a rehabilitative medicine model, either inside or outside of your office.

In December, 1995 the Journal of Vision Rehabilitation published "Low Vision Rehabilitation in the U.S. Health Care System," by Robert W. Massof, Ph.D. Dr. Massof likened low vision rehabilitation to rehabilitation medicine and drew parallels between the optometrist (or ophthalmologist) and the physiatrist (physical medicine and rehabilitation physician).

While many optometrists working with low vision had been using variations of this interdisciplinary approach even before Medicare parity in 1987, the article helped to bring this model into the mainstream and crystallized thinking when determining the services within the Medicare framework.

Whom to turn to

Who are some of the other members of the low vision rehabilitation team? Where can you find these rehabilitative specialists and what can they do to enhance your patient's visual capabilities?

Vision rehabilitation teachers. These teachers are trained in assessing visually impaired people who have difficulties with activities of daily living and teaching them compensatory skills. They can also address vocational and educational needs of visually impaired individuals.

Orientation and mobility specialists. These educators evaluate independent travel skills and teach visually impaired people how to travel safely through their environments.

You can find these specialists in colleges that have programs of vision rehabilitation or social work. Contacting local or state blindness organizations is another way of finding these professionals.

Schools or centers that supply vision rehabilitation services can also help you contact specialists who might help rehabilitate your visually impaired patients.

Occupational therapists. These therapists, who are licensed and trained in general rehabilitation, are typically affiliated with hospitals or rehabilitation centers. They're especially helpful with activities of daily living and can offer you tremendous assistance when you're working with visually impaired individuals.

What else can they do?

Many of these professionals can also help obtain information from patients in the home, school or workplace. They can objectively identify activities of daily living and educational or vocational tasks with visual demands that are difficult for the patient because of an object's size, or because of contrast, lighting or ambient conditions.

After you've examined the patient's visual system, evaluated visual functioning and prescribed appropriate lens systems, devices or adaptations, a rehabilitation therapist can facilitate the implementation of your recommendations. Once you've thoroughly taught the patient how to use a prescribed low vision device(s), the therapist can integrate it into the patient's activities or into rehabilitative services that require a visual component.

Depending on the patient's performance, the rehabilitation therapist may also suggest additional compensatory strategies or provide additional instruction within the therapist's expertise. As with any other rehabilitation service, all rehabilitation therapy should be established and reviewed by a qualified optometrist or ophthalmologist.

Getting reimbursed for low vision treatment

Many sources offer the low vision patient complete or partial financial assistance. To determine reimbursement criteria, it's essential that you have a thorough understanding of third-party payer guidelines for a doctor's professional services. For example, state blindness organizations may cover the low vision examination plus rehabilitation and low vision devices.

Medicare, while it doesn't cover a "low vision evaluation," may (in some states) sometimes cover portions of rehabilitation therapy based on national and regional guidelines. Additionally, in some regions, Medicare will cover rehabilitation programs that are furnished "incident to" professional services.

The AOA's Suggested Policy for Vision Rehabilitation Under Medicare (adapted by some carriers to allow coverage for rehabilitation therapy) specifies that "Rehabilitation services should be provided by an ophthalmologist, optometrist, or non-eye care physician, by a non-physician under the direct supervision of the ophthalmologist, optometrist, or non-eye care physician, or by an occupational therapist by prescription from the ophthalmologist, optometrist, or non-eye care physician."

To ensure that Medicare will cover the services, you should fully understand the level of visual impairment that qualifies for services, as well as the criteria for a treatment plan, including the appropriate coding, length of time of rehabilitative therapy, and exclusionary criteria.

While this approach would cover services under Medicare with an O.D.'s supervision within a clinical or office setting, it doesn't cover services that might be directed or coordinated outside of an optometric office or facility (i.e., in the patient's home). A bill has been introduced in Congress (Capuano Bill; the 2001 version is HR 2484) to help patients access Medicare funds for rehabilitative services outside the direct involvement of an O.D.

The bill defines a "qualified physician" as an optometrist or ophthalmologist. It specifies that services must be provided "pursuant to a plan of care established by a qualified physician" and may be provided by a "vision rehabilitation professional while under the general supervision of a qualified physician."

The AOA's staff and Low Vision Section have been involved since the bill's inception in 1999 and have tried to help develop language to maximize rehabilitation while protecting the patients' overall visual welfare. The bill states that a rehabilitative plan of care must be established and be periodically reviewed by a "qualified physician" (defined as an ophthalmologist or optometrist).

The AOA Low Vision Section's Statement on the Role of Optometry in Low Vision (adopted in 1994) supports the interdisciplinary approach to rehabilitation.

You're responsible

If you offer low vision care as part of your services, it's incumbent upon you to be aware of the role other professionals play in the rehabilitation process and of the benefit of additional services to your patients. When appropriate, provide or refer for these additional rehabilitative services.

Helping visually impaired patients understand the available services and funding will help them to maintain the best visual quality of life that our profession and the rehabilitative community can offer.

Dr. Freeman is in private consulting practice limited to the evaluation and management of visually impaired individuals. She's a Diplomate in Low Vision through the American Academy of Optometry, current chair of the Academy's Low Vision Section, and current chair of the Low Vision Section of the American Optometric Association. References available upon request.