University of Michigan's Experience
The University of Michigan began implementing systems to improve access to ophthalmic care for people without health insurance in 2011. The initial program included opening a comprehensive clinic on five Saturday mornings each year, staffed completely by volunteers from the University of Michigan – ophthalmologists, optometrists, ophthalmic technicians, opticians, clerks, and patient financial counselors. The patients seen in this clinic were referred for eye care from primary care physicians at a local free clinic, called the Hope Clinic. The eyeglasses dispensed were paid for through a community-university partnership where a local optical shop (Stadium Optical, Ann Arbor, MI) donated the frames and the University of Michigan donated the lenses.
In 2019, the University of Michigan received a grant from the Centers for Disease Control and Prevention (CDC) to expand and evaluate the community outreach program using a telemedicine-based model in the local free clinic (Hope Clinic) and in a new site, a Federally Qualified Health Center (FQHC) in Flint, MI, (Hamilton Clinic) located about an hour away from the university. Both cities have large populations of people from racial and ethnic minority groups and large populations of people living on lower incomes. Both clinics have a 39-year history of service to these two cities.
With the receipt of the federal funding, the model of care shifted to becoming the Michigan Screening and Intervention for Eye Health and Glaucoma through Telemedicine (MISIGHT) Program.5 In 2020, the MI-SIGHT Program began to see patients at the Hope Clinic, and in 2021, the program began to see patients at the Hamilton Clinic.
Michigan:
MI-SIGHT Program
Goal – The goal of the MI-SIGHT Program is to expand high-quality eye disease detection programs and access to eyeglasses in communities with high rates of poverty and high proportions of people who identify as Black or African American, Hispanic or Latino, as the prevalence of many eye diseases is higher among these communities. The second goal of the MI-SIGHT Program is to evaluate whether the strategy of placing eye disease detection programs in communities with more people, both at higher risk for eye disease and at higher risk for poor access to high-quality care, will detect more eye disease than that seen in the US population.
Equipment – The following equipment is used in the program: a Snellen wall chart (6’); autorefractor (ARK- Autorefractor & Keratometer, Marco Opthalmic, Jacksonville, FL); table clamped phoropter; inter-pupillary distance (Essilor Digital Pupilometer, Essilor, Chicago, IL); Finhoff transilluminator to assess pupillary response, anterior chamber angle, extraocular motility and alignment; intraocular pressure measurement (iCare tonometer, Raleigh, NC); 0.5% tropicamide for dilation; combined fundus camera/spectral-domain optical coherence tomographer (Maestro2, Topcon, Oakland, NJ); mirror, eyeglasses frames case for display; and eyeglasses frames arranged by PD (Zennioptical.com). There is a stable internet connection to access the University of Michigan electronic health record (EHR, Epic, Verona, WI) and to utilize the picture archiving system (PACS, Continuum, Integrated Ophthalmic Solutions, Woburn, MA).
The ophthalmic technician has a desk, educational handouts, a computer, and a printer in a space within the community clinic. The ophthalmic technicians were trained to fit eyeglasses, so the clinic also has eyeglass fitting tools including: deluxe logic kit with various size screws & nose pads, nose pad arm adjusting pliers, slim pad arm adjusting pliers, eyeglasses screwdriver set, narrow Numont plier, slim pad arm adjusting plier, nylon gripping plier, side cutter for nylon liner, bent snipe plier, push-on nose pad removal tweezers, self-closing tweezers, wide jaw angling pliers, slim line narrow double nylon pliers, long snipe nose pliers, and wide jaw angling pliers.
Screening Exam – The ophthalmic technician is on-site at each clinic five days a week and performs exams during clinic hours so that a medical professional is always available for emergencies. There is a single ophthalmic technician at the Hope Clinic along with a research coordinator to help conduct surveys/consent/log data, and schedule patients. Two ophthalmic technicians at the Hamilton Clinic do the jobs of both the ophthalmic technicians and the research coordinator. When a person is scheduled for an appointment, the technician creates a University of Michigan (UM) medical record number (MRN) to be able to utilize the UM EHR. The ophthalmic technician will then complete the following activities with the patient: 1. Health history; 2. Presenting visual acuity assessment at distance; 3.
Autorefraction and refinement with subjective refraction with a table-clamped phoropter; 4. Eyeglass evaluation including inter-pupillary distance; 5. Examination with Finhoff transilluminator including pupillary response, anterior chamber angle assessment by penlight, extraocular motility and alignment; 6. Measurement of intraocular pressure, with three measurements taken, and the median value is used for medical decision making for the protocol for those with high intraocular pressure; 7. Dilation with 0.5% tropicamide only for those without a narrow angle on penlight exam and IOP less than 30 mmHg to mitigate the potential risk of acute angle closure; 8. Imaging of the anterior segment using the fundus camera; 9. Mydriatic imaging of the posterior pole by fundus photography (three images focused on the disc, the macula, and the superotemporal arcade) and macular and retinal nerve fiber layer optical coherence tomography (RNFL OCT) (Topcon, Oakland, NJ). The technician enters the data directly into the participant’s EHR.
After the examination, the ophthalmic technicians help patients who need eyeglasses select low-cost ($12-$50, ZenniOptical.com) frames. Patients can physically try on a selection of frames that we purchased for this purpose. The frames are displayed by interpupillary distance to make it easier to recommend frames that will fit a person’s face. If patients do not like any of the frames we have in our display, they can look online and call for assistance in ordering the eyeglasses once they’ve decided. The technician places the online order after the ophthalmologist confirms the eyeglasses prescription remotely, and the eyeglasses are shipped to the clinic. The technician has a cashbox and a credit card, so people who do not have a credit card can pay with cash, and the technician will use the UM credit card.
Those patients who screen positive for glaucoma or suspected glaucoma are enrolled in a randomized controlled trial testing whether personalized coaching based on motivational interviewing combined with patient navigation improves adherence to follow-up recommendations compared to standard education and patient navigation.
Emergent or Urgent Ophthalmic Care: If a participant requires urgent or emergent ophthalmic care, a University of Michigan (UM) ophthalmologist and either the ophthalmologist at the Hamilton Clinic or the Medical Director at the Hope Clinic are paged to coordinate appropriate care. The technicians at each clinic help arrange urgent transportation if needed. All participants are advised to return to the clinic should they experience decreased vision, headache, or nausea following dilation. The ophthalmic technician re-measures IOP for any participant who returns with a concern following dilation. If the IOP is > 21 mmHg and has risen > 5 mmHg from their baseline IOP, urgent care is offered. Additionally, if IOP > 30 mmHg, patients will be referred to the clinic within two weeks; if IOP > 35 mmHg, within 1 week; and IOP > 40 mmHg, an urgent referral will be made on the same day.
How Patients Access the Camera – Patients are referred via multiple mechanisms. At the free clinic, patients are referred to the program by their primary care clinicians if they need an eye exam and have no urgent eye complaint. At the FQHC, all patients who have not had a diabetic eye exam in the last year are called and invited to participate. Additionally, 11,000 flyers were passed out in community locations at the start of the program, including at the clinic itself, local food banks, churches, subsidized senior housing complexes, and barbershops. Our team participated in many community outreach events, and we were able to advertise for free on the local buses and were invited to discuss the program on the local radio station. We hand out flyers to anyone who comes through the program and encourage people to tell their friends about it. Three years into the program, about 50% of participants have heard about the program via word-of-mouth.
Interpreting the Screening Exam – There are five remote ophthalmologists at UM who each review exams one day of the week from both clinics. Clinicians are paid a partial FTE and are available for phone calls from the ophthalmic technicians. Two additional faculty, an ophthalmologist and an optometrist trained in glaucoma image grading, are available when one of the five ophthalmologists is on vacation. The ophthalmologists review the EHR within 4 business days of the participant’s MI-SIGHT visit. The remote ophthalmologist assesses whether the following vision and eye diseases are present or absent using a template in the EHR: visual impairment (BCVA ≤20/40 in the better seeing eye), refractive error, cataract, glaucoma, macular degeneration, and diabetic retinopathy.
For refractive error, the ophthalmologist refers for gonioscopy for hyperopia >5.0D, refers for topography for astigmatism >3.0D with inability to refract to 20/20, and refers for peripheral retinal exam for myopia >--5.0D. The ophthalmologist checks for any signs of cataract on anterior segment photography and uses their clinical judgement to determine whether the cataract requires referral for surgical consultation. Glaucoma or suspected glaucoma is assessed by the ophthalmologist using the following criteria: 1. Narrow angle on penlight exam; 2. Patient previously treated for glaucoma (e.g., already taking glaucoma medications or previous glaucoma surgery); 3. Cup-to-disc ratio ≥ 0.7; 4. Asymmetry of the cupto-disc by ≥0.2, where the larger cup is ≥0.6; 5. Abnormal OCT (overall RNFL thickness <80 microns or thinning at <1% certainty (in the red zone on the TSNIT map normative database image) in the inferior or superior quadrants); 6. IOP > 21 mmHg, interpreted as follows: if the IOP is 22-24 mmHg and the c/d ratio is <0.35 with no other glaucoma risk factors, then there is no referral; but if the c/d ratio is ≥0.35, then participants are referred within 6 months. Participants with IOP 30-35 mmHg are referred within 2 weeks, 36-40mmHg are referred in one week, and/or >40 mmHg are referred immediately or within 24 hours. The ophthalmologist uses their clinical judgement to determine whether the participant’s diagnosis is glaucoma or glaucoma suspect. The ophthalmologist grades macular degeneration using the Age-Related Eye Disease Study (AREDS) criteria and grades diabetic retinopathy and the presence of macular edema using the National Health Service criteria. Any other eye diseases are also noted. The ophthalmologist designates the appropriate follow-up interval and type of ophthalmic care and sends the templated letter to the PCP with the findings.
Communicating Results to Patients and Cinicians – When the remote ophthalmologist interprets the screening data, they populate a form letter with their recommendations in the EHR. The technician set up the letter so that it will be sent to the patient’s PCP and eye care clinician, if the patient wants it sent. Otherwise, it is sent to the ophthalmologist at the FQHC or the lead ophthalmologist at the UM. The technician schedules a follow-up visit about 2 weeks after the initial screening to give the patient their eyeglasses, fit the eyeglasses, and give the ophthalmologist’s follow-up recommendations. During this visit, the technician prints the letter out for the patient and helps them schedule any recommended follow-up.
Billing – Currently, there is no billing because the care is being paid for through a grant from the CDC or donated by volunteers at the University of Michigan (in the case of the free Saturday clinic, not the telemedicine program). Currently, the patient only sees the ophthalmic technician in person for the screening and to receive the screening results. While there is no current mechanism for billing at the free clinic, there is a mechanism for billing at the FQHC, which we are exploring to sustain the program. Eye doctors who work at the FQHC can bill Medicaid for an eye exam for anyone who has not had an eye exam in the last two years and anyone with diabetes who has not had an eye exam in the last year. The eye doctor can then bill the full FQHC rate in Michigan ($173) for interpreting the screening exam, examining the patient, and delivering the results of the screening to patients in-person as opposed to billing the lesser amount for a telemedicine-based exam (CPT code 92227/8, $16.94/$29.48 for diabetes without/with retinopathy, CPT 92229 for diabetic retinopathy with AI $45.36, and no payment for those without any disease). We are currently exploring this new model of care at our partner FQHC as a potentially financially sustainable model. In FQHCs in the US, 90% of patients are insured, so 90% of care could be billed.
Scheduling Follow-up Care – The process for accessing follow-up care differs by insurance status. If patients have insurance and they are free clinic patients, they will be scheduled with a clinician at the UM or an ophthalmologist of their choosing. If they do not have insurance and they are free clinic patients, they will be scheduled at the next free Saturday clinic at UM. If they have a more pressing need, they will be sent to work with social work to try to qualify for Emergency Medicaid, the Washtenaw County Health Plan, or UM charity care (MSupport). If they have insurance and are patients at the FQHC, they are referred to the comprehensive ophthalmologist at the FQHC for all comprehensive issues, and to the satellite UM clinic 10 miles from the FQHC for all specialty issues. The ophthalmologist at the FQHC can provide care whether or not a person has insurance because the FQHC has a sliding scale for those who are uninsured. If a person needs specialty care and does not have insurance, our ophthalmic technicians have been helping people fill out Emergency Medicaid applications and UM charity care applications, and this service is also available through the social workers and community health workers at the FQHC.
Measuring Screening Outcomes – The percentage of patients who screen positive for visual impairment, uncorrected refractive error, cataract, glaucoma, diabetic retinopathy, macular degeneration, and other eye diseases is being tracked and compared with national averages. Patient satisfaction with the program and with the eyeglasses is being tracked. The percentage of eyeglasses remakes as a major source of personnel time is being tracked. Costs are being tracked for the program in terms of start-up and recurrent costs. Rates of adherence to follow-up appointments are being tracked for those diagnosed with glaucoma or suspected glaucoma and will be compared between the control and intervention groups (standard education vs personalized education with motivational-interviewing-based health coaching).