Practice Management
A Guide to Effective Comanagement
With these steps, comanagement can set the standard for patient care and practice excellence.
BY DARYL F. MANN, O.D., Chattanooga, Tenn.

The Vision Educational Foundation opened its Research and Diagnostic Center in Atlanta, Ga., on Nov. 1, 1980. The VEF center, as it was commonly called, was the country's first optometric referral center (ORC). Its opening would become a monumental development in the evolution of optometry.

In the 1970s relations between ophthalmology and optometry professions were strained. Organized optometry was campaigning to expand its scope of practice, and optometrists and ophthalmologists passionately lobbied opposing viewpoints to state legislators.

ILLUSTRATION BY JOHN PATRICK

The referral center solution

By design, the VEF center would be a solution -- a safe harbor that stressed quality of diagnostic care and surgical outcomes. The VEF center was established with these principles:

1. The center director, an optometrist, would oversee all aspects of operations, including patient care. He would have significant training and experience in the diagnosis and management of ocular disease. In 1980, this meant an optometrist who was no less than residency trained.

2. An ophthalmologist would assume the role of medical director, establishing the surgical protocols for the center. This physician would possess exceptional surgical skills. In 1980, such a surgeon would typically perform extracapsular cataract extraction with posterior chamber IOL implant vs. intracapsular cataract extraction with anterior chamber IOL implant.

3. Patients would gain access to the center by referral only. No primary eye care or vision care would be delivered. Written correspondence to the referring optometrist regarding the diagnosis and treatment of their patient would be the standard. The center would refer patients back to their optometrists at the appropriate time.

4. Because the center offered secondary eye care only, it would also serve as an educational resource for the diagnosis and management of eye diseases.

Optometry quickly recognized the benefits of ORCs. The centers encouraged optometrists and ophthalmologists to create relationships in their communities that would improve the standard of eye care. By 1983, optometric communities around the country attempted to establish ORCs in their areas. Omni Eye Services, Omega Health, and other venture capitalists joined the movement.

. . . and on to comanagement

With the expanded scope of today's optometric practice, referral, which indicates a transfer of the care of the patient, is no longer the best term to describe the center's activity. While referral of a patient to an ophthalmologist may occur, primarily optometrists request a second opinion for their patient, or they recommend a surgical procedure.

For more common ophthal-mic surgical procedures, the optometrist is qualified to share (comanage) portions of the care with the ophthalmologist. So the term "Optometric Referral Center" is out-dated and has been replaced with "Consultation and Comanagement Center."

Seamless patient care

Today's doctors of optometry should have relationships with ophthalmologists that include consultation and comanagement. The relationship must foster seamless and comprehensive patient care of the highest quality.

Developing a professional relationship that shares the care of patients requires due diligence from both the optometrist and the ophthalmologist. Unlike the referral patient, whose care is completed by another physician and then returned to the referring physician, comanagement places both physicians in a unique relationship. It requires knowledge, trust, respect and an interdependence on each doctor to uphold the appropriate standards of care and to keep the welfare of the patient centermost in all decisions.

This type of relationship must be entered with consideration and caution. Here are suggested guidelines for developing a comanagement relationship.

Choosing the surgeon

The foundation of comanagement lies in the doctor's ability to select the proper comanager for his patients. First and foremost, an optometrist should select an ophthalmic surgeon based on his/her knowledge of the surgeon's skill for performing the indicated procedure. In the case of cataract surgery, the surgeon should rarely have any complications, including capsular rupture, wound leak, decentered IOL, and endophthalmitis.

It's preferable that the surgeon doesn't provide primary care, focusing all of his attention on medical and surgical care. The surgeon should also be interested in the optometrist's skill level in performing post-op care for the cataract surgery patient.

Beware of a surgeon who is not familiar with the optometrist yet to whom he is willing to relinquish all of the post-op care in exchange for surgical referrals.

Below are some useful practices for developing a working relationship with a surgeon.

• Visit the surgeon's office. Observe the equipment and furnishings. Observe how the staff cares for patients. Observe how the ophthalmologist cares for patients. Examine one-day or same-day post-op patients together; much can be learned about a surgeon's surgical skills at this time.
• Scrub in on surgery with the ophthalmologist. Observe how the surgeon interacts with the OR staff and vice versa. Observe the surgeon's surgical technique.
• Avoid working with a surgeon who does not meet the standards for quality of care, staffing, equipment and personality.

Choosing the optometrist

The ophthalmologist bears equal responsibility in finding a comanaging optometrist.

The ophthalmologist must likewise be knowledgeable of the optometrist's clinical acumen and have confidence in his abilities. Having a professional relationship through the care of mutual patients is a good way to assess the optometrist's clinical decision-making skills.

To develop a working relationship with an optometrist, an ophthalmologist should consider visiting the O.D.'s office and observing patient care, inviting the optometrist to the OR, examining post-op patients together, and inviting the O.D. to the ophthalmologist's office.

Patient's choice

The patient's desire too often becomes lost in the debate of shared care. Regardless of any historical working relationship between the surgeon and the optometrist, it should always be the patient who decides who should provide their care. For the patient to make this decision, he should be knowledgeable regarding the qualifications of each professional and give written consent for the comanagement.

Surgeon's choice

Regardless of a patient's wish, the surgeon must also agree with the patient's consent following surgery. If complications occur during surgery or the surgeon believes the patient isn't stable post-op, then regardless of the pre-surgery plans, the surgeon must apply appropriate professional judgment for the patient's welfare. This judgment can't be made until surgery is completed.

Optometrist's choice

The optometrist likewise must agree to share in the post-op care with the surgeon. The optometrist should not agree to accept the care of the patient until he is confident that there will be no interruption in the quality of care. There are many variables for this decision, including the surgical procedure that was performed, outcome of the surgery, the experience of the optometrist, the benefit to the patient, and the payment for care (certain commercial payers may discriminate against optometrists or may not recognize the 54/55 modifiers).

The real winner

Patient care is the victor when optometrists and ophthalmologists work together. When each professional focuses on using the skills that are unique to his/her domain rather than battle over the common turf, the quality of care can be exceptionally high. Exercise appropriate due diligence when developing relationships with another eye care professional and the relationship will more likely result in practice growth for both.

Dr. Daryl F. Mann completed his residency in optometric medicine at the VEF Center in Atlanta in 1981. He served as the center director of Omni Eye Services of Chattanooga, Tenn. In 1999, he and John R. Bierly, M.D., formed SouthEast Eye Specialists, P.C., an optometric consultation and comanagement center, in Chattanooga. Dr. Mann is an appointee to the AOA Comanagement Task Force and a member of AOA Federal Relations Committee. Contact him at (877) 933-7337.