Optometrists tout benefits of a multispecialty approach to diabetes care

Issue: May 2012

Whether in the setting of a college, a dedicated diabetes center or private practice, a multispecialty professional, collaborative approach to diabetes management is an effective method for treating these patients.

Pacific’s interprofessional clinic

Consider, for example, the Interprofessional Diabetes Clinic (IDC) at Pacific University in Hillsboro, Ore. Predominantly serving uninsured Latinos with diabetes in Washington County since June 2010, the clinic offers optometric care, dental hygiene, physical and occupational therapy, mental health care, and pharmacy and medical services.

Carole A. Timpone, OD, FAAO, said Pacific University’s Interprofessional Diabetes Clinic offers optometric, dental and mental health care; physical and occupational therapy; and pharmacy and medical services.

Image: Timpone CA

“Diabetes is a multi-system disease that affects all organs of the body,” clinic director Carole A. Timpone, OD, FAAO, FNAP, a clinical professor of optometry at Pacific University College of Optometry, told Primary Care Optometry News. “An interprofessional approach gives a patient access to all the care that he or she needs, whether it is for vision, poor mobility or mental health.”

All patients seen at the IDC have periodontal disease, “so they all are in need of dental health intervention,” Dr. Timpone said. Moreover, about 50% of patients have had diabetic retinopathy, and roughly 15% have glaucoma.

“Patients with diabetes need an annual dilated eye exam. That is part of the minimum standard of care from the American Diabetes Association, American Optometric Association and American Medical Association,” Dr. Timpone said. Depression is also prevalent among patients with diabetes, “so all of our patients go through a mental health screening, of whom about 30% require additional follow-up care.”

Typically, the third Saturday morning of the month the IDC allows patients to be seen by up to three services during a single visit. The interprofessional collaboration is also enhanced by a Saturday afternoon case conference, during which time each patient is discussed in detail and the team develops an individualized coordinated and prioritized management and treatment plan, Dr. Timpone said.

For instance, if optometry prescribes an eye drop for glaucoma, but the patient cannot squeeze the bottle due to diminished sensation and dexterity, occupational therapy steps in to provide the patient adaptive mechanisms.

Consider the patient who is instructed to walk a mile but does not divulge that he or she has leg or foot pain; hence, it is up to the physical therapist to conduct the exam, disclose the problem and provide intervention.

“A lot of times in a busy practice, these concerns are not addressed,” Dr. Timpone said.

She said a collaborative, interprofessional approach not only improves outcomes and adherence, but keeps patients healthy and allows them to self-manage their disease, “so they stay out of the high-cost emergency rooms and crisis management. We are being proactive by addressing the bigger picture and keeping the patient’s quality of life intact.”

Anita R. Cintron is the bilingual patient care coordinator at the IDC who assists patients with scheduling, follow-up appointments, referrals and other needs. Experienced interpreters are also provided for all examinations. The clinic sees eight to 12 patients on any clinic date.

“All the patients seem to be very receptive to our program,” Ms. Cintron said in an interview.

Ms. Cintron noted that, up until now, collaborative health care in general has been focused on primary care. “Without the IDC, our uninsured population would not have access to the wide variety of specialists,” she said. “It is difficult for these patients to manage the medical system. Gaining access to an optometrist and a dentist on the same day is a relief to them. They don’t have to struggle to get multiple appointments in different locations.”

Most patients are scheduled for two clinic dates, spaced 1 month apart, which is usually sufficient to visit all of the services. A 1-day, three-appointment visit might encompass an eye exam, mental health and occupational/physical therapy. There are also evening weekday classes in health and wellness.

Joslin Diabetes Center

For nearly 100 years, Joslin Diabetes Center, a teaching and research affiliate of Harvard Medical School in Boston, has offered a team-care approach to diabetes management. Today, the coordinated umbrella of diabetic services range from endocrinology to mental health to ophthalmology. Patients generally already have an endocrinologist or internal medicine physician who monitors their diabetes care. A team of nurse practitioners, certified diabetes educators, podiatrists, registered dietitians and the Beetham Eye Institute then become part of the mix.

“You have nearly every specialist and subspecialist within Joslin committed to the total care of the patient with diabetes,” W. Lee Ball, OD, FAAO, who served as a staff optometrist from 2006 to 2010, told PCON.

W. Lee Ball

“Optometrists are gatekeepers, especially for people with type 2 diabetes, whether it is diagnosed or undiagnosed,” said Dr. Ball, a member of the American Optometric Association Health Promotion Committee and immediate past chair of the Pharmacy, Podiatry, Optometry and Dentistry (PPOD) Work Group of the National Diabetes Education Program.

“There are an estimated 79 million Americans right now affected by prediabetes who are at risk for developing type 2 diabetes and its complications – heart disease and stroke – in addition to the microvascular complications of diabetes,” Dr. Ball said. “These complications include diabetic retinopathy, renal disease, periodontitis and foot ulcers, which can lead to amputations from peripheral neuropathies. It is important for an optometrist to be part of this team care, so that when a patient has an eye exam and the optometrist suspects diabetes or sees signs of diabetes, the patient can be referred back to his or her primary care physician for the appropriate testing.”

Dr. Ball noted that many people today, especially working-age adults, may no longer have a relationship with a primary care physician because of losing or changing jobs, or losing or changing health insurance providers. “With new insurance, many of these people have failed to reestablish a connection with a primary care physician or a nurse practitioner or a physician assistant,” he said.

The PPOD group is replicating a comprehensive medical home without walls for patients with diabetes.

“Many patients with diabetes will travel amongst several different providers, located at several different physical locations,” Dr. Ball said. “People with diabetes need annual dilated eye exams, yearly foot exams and biannual oral health exams and to understand how to properly use their medications by having a review with their pharmacist.”

Dr. Ball, who is currently associate director of professional affairs for Vistakon, a division of Johnson & Johnson Vision Care Inc. in Jacksonville, Fla., also mentioned that insurance companies encourage patients with diabetes to take advantage of coverage for a multidisciplinary team-care approach, in an effort to monitor and reduce complications, morbidity and premature mortality from the disease.

“The importance of a collaborative approach is reinforcing consistent messages,” Dr. Ball said. For instance, when the patient sees his or her primary care physician, the patient hears the same message for controlling the ABCs (A1C blood glucose test, blood pressure and cholesterol) of diabetes and the importance of preventive care such as annual dilated eye exams.

Private practice

“For a lot of patients, the only health care provider they often see on a regular basis is their optometrist,” said A. Paul Chous, OD, MA, FAAO, who specializes in diabetes eye care and education at his private practice in Tacoma, Wash., which is located across the street from a large endocrinology practice. For about the past 10 years, the two practices have been sharing patients, Dr. Chou said in an interview.

A. Paul Chous

Dr. Chous writes a bimonthly web column about eye care for the website dLife.com, serves on the AOA Health Promotion Committee and is also a member of the PPOD group.

“Podiatry is a grossly underserved avenue for interprofessional referrals and collaboration, as studies show that most patients with diabetes do not see a podiatrist regularly for foot care, and they should. Diabetes is the leading cause of nontraumatic amputation in the U.S., and often these patients have concomitant eye disease,” he said.

“Interacting with dental health professionals is equally important because periodontal disease is six to eight times more common in patients with diabetes vs. those without, as are other dental maladies such as tooth loss and temporomandibular joint syndrome,” Dr. Chous continued. “Pharmacists have a lot of knowledge about diabetes medications and their interactions with other meds and can be a terrific source of referrals to optometrists.”

Likewise, optometrists should be aware of local mental health professionals who are savvy in treating patients with diabetes because depression is two to three times more common in those with the disease. “A mental health professional dedicated to chronic disease management is affiliated with the endocrinology practice across the street from me and has been a tremendous asset,” Dr. Chous said.

Unfortunately, based on feedback Dr. Chous receives from optometrists at his frequent lectures on diabetes across the country, “oftentimes it is a one-way relationship” in establishing multispecialty bonds to treat diabetes. “Optometrists will send letters but typically don’t hear back from primary care physicians and other providers.”

To increase the likelihood of a response, Dr. Chous recommends that optometrists generate a form letter to other specialists that provides detailed information about the results of the eye exam and how that fits into an overall diabetes management plan.

“After each patient visit, send a letter to every other health care provider the patient sees,” he added.

Dr. Chous recommended following up with a phone call, but a one-on-one meeting is more effective, he said.

However, Dr. Chous has an advantage: he has had diabetes himself for 44 years. “Often, I will see providers as a patient, get to know them, and then I find I am suddenly getting lots of diabetes referrals,” he said.

On the other hand, Dr. Chous acknowledged there is less familiarity among medical doctors as to the training and abilities of optometrists. “We can help reinforce messages about good diabetes management – not only to prevent diabetic eye disease, but also to prevent diabetes from developing in the first place by discussing the National Institutes of Health-funded Diabetes Prevention Program and good lifestyle habits with our patients,” he said.

Finally, patients with diabetes “can grow your practice tremendously,” Dr. Chous said. His practice is 90% patients with diabetes and he routinely performs blood glucose testing in the office. “These patients typically are more complicated, require more extensive care and garner higher reimbursements.” – by Bob Kronemyer

For more information:

W. Lee Ball, OD, FAAO, is director of professional affairs for Vistakon. He can be reached at Johnson & Johnson Vision Care Inc., 7500 Centurion Parkway, Suite 100, Jacksonville, FL 32256; (904) 443-1383; wball@its.jnj.com.
A. Paul Chous, OD, MA, FAAO can be reached at 6720 Regents Blvd., Tacoma, WA 98466; (253) 565-9403; dr.chous@diabeticeyes.com.
Anita R. Cintron, can be reached at Interprofessional Diabetes Clinic at Pacific University, 222 SE 8th Ave., Hillsboro, OR 97123; (503) 352-7368; anitacintron@pacificu.edu.
Carole A. Timpone, OD, FAAO, can be reached at Pacific University Portland Eye Center, 511 Southwest 10th Ave., Suite 500, Portland, OR 97205; (503) 352-2500; timponec@pacificu.edu.
Disclosure: Dr. Chous is an advisor to a number of diabetes-related companies.