house calls
This Doctor Makes House Calls
The OSU College of Optometry Home Care Program brings vision care to patients who would otherwise go without.
ROBERT D. NEWCOMB, O.D.

An unusual mode of practice

Every Wednesday afternoon, a fourth-year optometry student and I load portable optometric equipment and supplies into the BuckEYE van and provide primary eye and vision care to homebound patients. These patients have multiple chronic diseases and are not able to travel easily. For that reason, many have neglected their eye care for years. Yet the majority of their day is spent either reading or watching TV — two visual tasks that require the best possible corrected visual acuity. Although they could receive a more thorough eye examination at the OSU teaching clinics, performing some standard vision and eye health testing for these patients, in most cases, results in improved visual acuity, prevention of vision loss and a concurrent increase in quality of life.

Most O.D.s can provide in-home eye and vision care with a minimum of additional equipment and expense. We take four boxes of equipment with us to every exam: a trial lens case with a trial frame, a hand-held slit lamp, 120 sample frames and a large box with acuity charts, a portable lensmeter, a hand-held applanation tonometer and more (see table on page 90). Depending upon the distance between patients, we perform two or three exams an afternoon, plus one or two dispensing visits.

Every exam is different

We can only determine the type and sequence of testing after we meet the patient and any caregiver or family member who may be available in person or by phone. Some patients with Alzheimer's disease, Amyotrophic Lateral Sclerosis (ALS) or previous strokes are not able to participate in subjective testing, so we do what we can objectively. Others are fully capable of determining whether "lens one or two" is better, so we can perform most standard optometric tests within the limitations of our environments.

We always attempt to provide a thorough optometric and medical history, including a review of systems, previous eye care and correction, past hospitalizations and surgeries, current medications and allergies. We perform entrance visual acuity testing, often with only five or 10 feet of space in which to measure distance acuity. We perform near acuities with the help of a spotlight since many homebound patients live in poorly-illuminated residences. We check pupils, ocular alignment and confrontation visual fields before using the hand-held slit lamp and applanation tonometer. We dilate and perform ophthalmoscopy with a direct ophthalmoscope and/or a binocular indirect ophthalmoscope. We help patients select a frame if necessary and discuss our findings with them and their caregivers or family members.

Billing for private residence and nursing home patients is not difficult (see table above).

The fees are typically 35-50% higher than in-office care to cover the additional expenses of travel, some special equipment and inherent logistical inefficiencies. Note that we do not use any code higher than a Level 3 for private home care. There are no codes for established patients in nursing homes. The rewards are many: meeting nice people, providing eye care to an underserved population, preventing vision loss, participating in interdisciplinary healthcare and increasing quality of life for very appreciative patients. Home visits are also an important part of the University's outreach mission.

The need is great

According to the U.S. Census Bureau, the U.S. population will increase 29% between 2000 and 2030. But the proportion of Americans over the age of 65 will increase more than 100% during the same 30 years. In the states of Alaska, Arizona, and Nevada, the over-65 group will increase more than 200%! With these projected increases in our elderly population, delivering primary eye and vision care at home is an area with almost unlimited growth potential.