nursing homes
Get to Know the "Long-Term Care" Environment
Nursing home care is guaranteed to challenge your optometric and creative skills.
BY DOUGLAS STREIFEL, O.D.,Greenwood Village, Colo.

The primary goal for those involved in nursing home care should always be to provide the highest quality of care. It should be no different than what we strive for in our private or commercial setting practices. When I'm working at a facility, I often hear staff say to the residents, "The eye doctor is here. Do you want to get glasses?" This idea is far from what actually occurs at these exams. I see many more patients who have eye health concerns than who just need glasses.

In most private practices, the majority of patients are refractive cases (unless you're in a more specialized setting). While a refraction is a part of every eye exam in a nursing home, the majority of patients exhibit one or more ocular pathologies. People commonly use the term "nursing home" instead of the more accurate name, long-term care center.

Residents are people who are unable to live on their own secondary to health issues or who need 24-hour care. Typically these are the elderly, in which the common ocular conditions are macular degeneration, cataracts, glaucoma and diabetic retinopathy.

Yet it isn't unusual to see residents in these homes who are under the age of 65. These are people commonly suffering from multiple sclerosis, long-standing, uncontrolled type-I diabetes mellitus, traumatic brain injuries, incapacitating health issues and psychiatric conditions. All of these people need your training in ocular disease, geriatrics, special populations and general optometry.

The patients are often challenging and just taking a case history can prove difficult, especially from those who have advanced dementia or Alzheimer's disease. You must often base exam findings entirely on objective testing, which is often difficult with poor head position and marginal cooperation. Patients suffering from Tardive dyskinesia, for example, have jerking motions that won't allow them to remain stationary for more than a few seconds.

Here's what you'll need

Nursing home care is probably one of the most challenging modes of optometry -- one that requires all of your technical and creative skills. The following are skills and characteristics that are helpful in this practice setting.

Background requirements. Because of the breadth of knowledge needed, eye care in a long-term care facility requires a strong optometric background. Although there aren't any training requirements, ocular disease residency training is recommended and beneficial. Being confident and comfortable in managing and treating ocular disease is required because this is a routine part of the patient care. This also includes being certified to treat therapeutically at the highest level allowed. Knowledge of low vision and experience with special populations is also beneficial.

Equipment. In a regular practice setting, all of the equipment is fairly large and for the most part stationary. When working in a nursing home, however, the equipment needs to be portable yet adequate to provide a complete and thorough examination.

Probably the largest piece of equipment needed is the lensometer; everything else should be hand held. A retinoscope is an essential piece because objective data is most reliable.

Additional refractive instruments include a trial lens set and skiascopy bars, which will enable an adequate refraction. Optionally, a hand held autorefractor may be of use, but the retino-scope can generally give as good data, especially in most of the more challenging patients.

Equipment needed for the ocular health assessment includes a slit lamp instrument for the anterior segment, a direct ophthalmoscope and a binocular indirect ophthalmoscope for the posterior segment. As glaucoma is common, you should include either a tonopen or a Perkins tonometer. To perform comprehensive examinations, a supply of diagnostic pharmaceuticals, such as those used in a conventional practice, is needed.

As for therapeutic pharmaceuticals, these are generally available in the nursing home facilities. I do, however, recommend an acute angle closure kit. If you provide glasses to the residents, then you should include an inventory of frames for them to choose from.

Nurses are your friends

Generally, the point of contact in the facility is the social services department. In most instances, social services will coordinate all in-house ancillary health specialties such as eye care, podiatry, dental and audiology. The department will assign a room for the exams unless a patient is unable to leave his room.

The nursing staff is the direct link for interaction when managing patients' ocular health. The nurses administer the medications, follow through on orders with the primary care provider (PCP) and interact with the patients daily. Their job is to monitor and support the general health of the residents. Unfortunately, people sometimes view eye care as a secondary priority.

Many times patients are already on 20 or more medications and treatments throughout the day, so adding artificial tears every hour won't win the hearts and minds of the nurses. Adjusting normal prescribing regimens to a less frequent dosage and a longer lasting delivery facilitates improved patient care without overtaxing what may be a thin staff. Equally important is educating the nursing staff as to why patients need treatment. The PCP manages every patient in the facility under his care. When writing an order for a new medication, the nursing staff contacts the PCP for approval.

A patient's medical chart contains all her orders, meds and history and the practitioner needs to review this information before a patient encounter, so a good understanding of medical charting as well as medications is needed.

How to get paid

In private practice, insurance payers are playing a larger part every year, but the private pay patient still exists. In a nursing facility, 99.9% of patients are seen through an insurance payer. While Medicare and Medicaid do provide coverage for many, this can vary from facility to facility. Many have a high percentage of managed care providers for the administration of Medicare or may have HMO providers. The managed care panels that serve this population are generally different than those in private practice; you need to join them. As in private practice, most HMO payers don't pay outside of their network nor do they allow access to their panel. In these cases, private pay may be the only alternative.

The coding used for nursing home care differs from private practice as it's nursing-home specific; the codes used are primarily the medical billing codes. As for billing, the simplest approach is to bill the nursing facility, which can do the insurance billing and pay directly. Alternately, direct the billing to the insurer. The billing can vary greatly from state to state depending on Medicaid or other insurers.

Networks are a necessity

Providing medical-based exams generates a lot of referrals, so a good consultation network should be in place. An example is Omni Eye Specialists here in Denver, which provides all the ophthalmic specialties needed in one location to minimize patient travel. Good communication with the consult network is a must. Patients' charts may only contain a notation regarding an appointment, making a consult report providing detailed findings and treatment plan essential.

Because the PCP must approve all consultation orders, carefully follow through with your recommended referring orders and perform them at the next visit. The PCP may decline an order if a patient's health declines or if the PCP chooses to work with another specialist in the area.

It makes a difference

Nursing home care is a diverse mode of practice. It will challenge a clinician's skills in endless ways. But the true requirement for this type of care is compassion to provide a quality of care that is much needed to those who often can't seek it for themselves. Nursing home care can make a major difference in the quality of life for those whose daily activities may be limited to what they can achieve with their sight.

As Lyn Graves, O.D., founder of Senior Vision Services explains, working in nursing homes can be the most rewarding way to practice optometry. The stories that come from treating these patients can fill hours of lively conversations, but the reward of helping someone regain their quality of life can fill a lifelong career.