Dr. Angela Turalba, Chief of Ophthalmology, Atrius Health
Efforts to minimize unnecessary emergency department (ED) visits remain a priority across the healthcare landscape. Unnecessary visits to EDs place undue burden on our health care system while increasing costs and delaying care for patients. Viable strategies to alleviate this burden and decompress EDs include steering patients with non-emergent issues to the outpatient setting; however, same-day access to outpatient care is not always available, and in many cases poses an additional barrier to care. These barriers are particularly prevalent in ophthalmology, necessitating a multi-pronged approach to keep eye patients out of the ED.
Almost half of all ED visits for patients with eye complaints are not emergencies and can be managed in the outpatient setting. Issues like conjunctivitis, a common condition, is often treated in the ED despite its ability to be easily diagnosed and treated in the ambulatory environment. Other common but more serious eye complaints often find their way to the ED, such as uveitis (inflammation inside the eye) or sudden vision loss — despite many EDs lacking the optimal equipment, specialized resources and personnel to diagnose and manage these conditions. This, coupled with the increasing demand for ophthalmic care due to the rise in age-related chronic eye conditions such as glaucoma, macular degeneration and diabetes, leads to a back-up of non-emergent eye-related diagnoses taking place in the ED. This then leads to a delay in care and treatment for patients seeking immediate eye care.
"Dedicating an urgent-care clinic for eye-related complaints in an outpatient setting will streamline patient care by delivering the appropriate care in the right setting, while avoiding ED visits for eye conditions"
At Johns Hopkins, a project was initiated to remedy this problem with a department policy that provided increased same-day access in their ophthalmology clinics. A subsequent study looked at the cost and length of appointments for these same-day visits. They found significant cost-savings as well as longer duration of visits for patients with non-emergent eye concerns accommodated in the outpatient clinic rather than in the ED. The study reinforced the viability and value of improving access for same-day eye-related complaints as a means to steer these patients out of the ED.
While steering patients with urgent ophthalmic complaints to outpatient specialty settings may seem like a simple fix, this solution may be limited by access to eye clinics; plus, specialty clinics maintaining consistent same-day access poses issues of its own. At Atrius Health, we recognize the importance of maintaining outpatient access for patients with urgent eye-related complaints. We currently have clinic templates in ophthalmology and optometry that incorporate same-day visit slots, which has allowed us to help steer patients away from the ED and provide timely care where we are equipped to manage a wide range of eye-related complaints. However, while we expect that our current model is helping with cost-savings, the increased visit times associated with same-day visits can disrupt overall clinic flow and impact scheduled visits and patient satisfaction, limiting access to ophthalmic care.
In addition to maintaining same-day slots in our visual services clinics, Atrius Health is carefully evaluating other models of care that accommodate more patients with urgent eye-related complaints, including leveraging the partnership between optometry and ophthalmology. Our visual services team includes ophthalmologists, optometrists, certified technicians and administrative staff. Optometrists are equipped to perform routine eye exams screening for common medical eye diseases such as diabetes, macular degeneration and glaucoma; however, optometrists’ scope of practice is currently limited in Massachusetts with regards to medical and surgical management of eye disease. In our practices, optometrists function as primary eye care providers who screen and monitor for medical eye conditions, and ophthalmologists are readily available for consultation and management.
Currently, Atrius Health is piloting a same-day access project where we dedicate a clinic session for urgent eye-related complaints. An optometrist is assigned to see patients seeking immediate eye care in a setting where an ophthalmologist is on-site for consultation as needed. Dedicating appropriate resources to this clinic could help alleviate the potential prolonged visit times associated with same-day appointments. Partnering with optometry would also allow us to avoid compounding our ophthalmology access problems.
Atrius Health also has the advantage of being the largest independent medical group in New England, and the coordination between our primary care providers and specialty providers are facilitated through a shared electronic medical record system. Ifa patient’s eye complaint has systemic implications, such as vision loss in the setting of a vascular event, communication with a primary care provider or another medical specialist can be made immediately, integrating across specialties.
Atrius Health continues to be committed to reducing unnecessary ED visits in all specialties in order to ease the burden on our health care system while reducing total medical expense. Dedicating an urgent-care clinic for eye-related complaints in an outpatient setting will streamline patient care by delivering the appropriate care in the right setting, while avoiding ED visits for eye conditions that do not require hospital-level care.