The Durham Experience
Durham is located in central North Carolina. North Carolina was the 40th state to expand Medicaid, which went into effect in December 2023. We describe the experience of screening for eye disease at an FQHC in Durham, which serves an adult population that, preceding the expansion of Medicaid coverage, was comprised of about 50% uninsured adults. There are several options for eye care for patients at the Lincoln Community Health Center (LCHC) FQHC.
First, a part-time FQHC-employed optometrist performs refractions and dilated eye exams on-site one evening per month. Patients call to schedule the appointment on the same day of service, and the first 10 who call are scheduled that evening.
Second, a volunteer ophthalmologist also sees patients two half days per month on-site. Patients needing more eye care may be referred directly from the primary care clinics or from the optometrist or ophthalmologist to community partners. Insured patients have multiple options, including university-based clinics in Durham County and neighboring Orange County, as well as several private practices. Uninsured patients who are residents of Durham County may be eligible for enrollment in Project Access of Durham County (PADC). PADC is a non-profit that coordinates subspecialty care for uninsured patients in the county. Local clinicians, including the University and private practices, donate an “episode of care” of 3 months duration, during which all fees are waived. Not uncommonly, the need for episodes of care outpaces the donated allotments, and there is a period of time before the beginning of the new fiscal year during which no episodes of care are available. Uninsured patients who are not eligible for PADC or if PADC does not have availability may be referred to a university in another county, which conducts a general clinic in which patients pay for services on a sliding scale.
Third, uninsured patients with diabetes may have retinal images acquired by a diabetes nurse educator during their primary care visit. The retinal imaging screening program is described below.
Durham:
Screening Program
Goal – The overall goal is to screen for diabetic retinopathy and other eye diseases that occur in patients with diabetes.
Equipment – Originally, we were using the Topcon non-mydriatic fundus camera with a high-speed Wi-Fi internet connection. The camera was purchased by Prevent Blindness and donated to the FQHC. We have since transitioned to using the EyeNuk camera system to read retinal images.
Screening Exam – A diabetes nurse educator was trained by the Prevent Blindness staff to collect the images.
How the patients get to the camera – Images are obtained during primary care visits if it is noted that the patient has not had an eye exam within one year. Patients over age 60 or with known eye disease are preferentially referred to a local provider if insured and to the LCHC volunteer ophthalmologist if uninsured.
Interpreting Screening Results – Images are uploaded as media files into the patient’s chart in Epic and routed to the volunteer ophthalmologist. The ophthalmologist, who is often working elsewhere, reviews the images in an asynchronous manner, records the interpretation using ICDR criteria, and makes a recommendation in the patient’s chart. The nurse educator who uploaded the images receives a notification of the interpretation and facilitates follow-up. Options for follow-up at the FQHC and in the community depend largely on the patient’s insurance status, as described previously.
Communicating Results to Patients and Clinicians – The nurse educator communicates the results with the patient and clinician.
Billing – Currently, the program operates through philanthropic and in-kind support from local ophthalmologists and community partners. The teleretinal image screening is reserved for uninsured patients; therefore, no billing is performed. The ophthalmologist’s time is donated.
Scheduling Follow-up Care – The nurse educator communicates with the case managers at the FQHC to coordinate the recommended follow-up.
Measuring Screening Outcomes – None at this time.