Comanagement of patient care involves a multitude of issues best resolved prior to the delivery of care. The decision to comanage a patients care must be borne out of mutual respect and appreciation by each doctor of the others skill level and patient rapport.
The joint decision/agreement by an optometrist and an ophthalmologist to share the care of patients must be clearly defined to avoid confusion and the loss of patient confidence in either doctor. Clinical, philosophical and ethical considerations will dictate the form of your comanagement agreement. The agreement between a patient and his/her optometrist requires full disclosure of clinical responsibilities, an expected timetable of necessary care and the consent of the patient.
Eye-care comanagement may encompass the broad spectrum of secondary and tertiary eye care. For the purposes of this article, seeing a patient back for a spectacle or contact lens prescription following cataract surgery will not be considered comanagement. Comanagement of cataract surgery post-op care is but one of many areas of comanaged medical eye care. Although Medicares specific directive on sharing cataract surgery post-op care and reimbursement is the most visible form of comanagement, it is but one of many comanagement opportunities.
Other comanaged eye care includes refractive surgery, corneal disease/surgery, glaucoma, diabetic retinopathy, oculoplastics and retinal surgery. This article applies to comanagement of all these areas.
Comanagement Defined
Comanagement has been defined by many individuals and organizations throughout the years. Experience and understanding lend themselves to the description of comanagement as the mutual clinical respect, coordinated clinical protocols and maintenance of patient choice between two doctors in their shared care of patients.
How Great Comanagement Works Dr. Johnson, an optometrist, and Dr. Smith, an ophthalmologist, have shared the care of many patients over the past 20 years. Yesterday, Mrs. Howard, a 71-year-old patient, presented to Dr. Johnson with complaints of poor vision while driving her car at night and increasing difficulty with reading. Dr. Johnson has been treating Mrs. Howard for chronic open-angle glaucoma for 10 years and has seen good control of her glaucoma with Trusopt (dorzolamide, Merck) drops. Dr. Johnsons examination reveals bilateral nuclear sclerotic cataracts.
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Dr. Johnson discusses the anatomy of her eyes, the surgical procedure, the pre- and post-op medications, the IOL options available to her and the anticipated post-op care. He also advises Mrs. Howard about the multiple patients he has referred to Dr. Smith and the excellent results he has personally examined.
He discusses her options for post-op care either in his office or Dr. Smiths. She says that she would much rather been seen postoperatively at his office due to her long-term comfort with his care and the convenience of getting to his office.
The surgery is scheduled. Drs. Johnson and Smith exchange clinical information, and Dr. Smith performs the surgery.
The morning after her surgery, Mrs. Howard presents at Dr. Johnsons office. Mrs. Howard states that her eye is comfortable and her experience at the surgery center with Dr. Smith was exceptional. The uncorrected vision with the operated eye is 20/30, but her IOP is 28mm Hg compared with 13mm Hg prior to the surgery. The cornea is clear and the anterior chamber has 2+ cell and flare. By prior discussion with Dr. Smith, Dr. Johnsons protocol for treating post-op IOP elevation is to add Alphagan P (brimonidine, Allergan) to the Trusopt. She is advised to continue her other medications, as prescribed, and return the following day for an IOP check.
Mrs. Howard returns the next day with an IOP of 14mm Hg. Dr. Johnson advises Mrs. Howard to continue all medications until he sees her again in five days. Dr. Johnson faxes a note and copies of his exam sheets for both post-op visits to Dr. Smith. The remainder of Mrs. Howards post-op care is uneventful.
Later, phaco with IOL is performed in the second eye and the results are excellent.
Now, Mrs. Howard never misses the opportunity to talk about her two great eye doctors.
If youre new to an area or youre considering comanagement with an unfamiliar ophthalmologist, then your assessment of an ophthalmologists clinical/surgical care will take some time and effort.
A good starting point: Check around with your optometric colleagues to ask about the local ophthalmologist(s). Then, call and ask to spend a day or two in the ophthalmologists office seeing clinical and post-op patients with the ophthalmologist; this will give you the insight you need to make sure your patients receive quality care.
Spending time in the operating room with the surgeon will provide you with a first-hand look at the surgeons hands and his/her demeanor in the operating room. Both are incredibly important in choosing a comanaging ophthalmologist.
If the ophthalmologist denies you access to either of these areas, you have your answer to the question, Is this the right ophthalmologist for my patients?
Spend an evening with the ophthalmologist to discuss clinical issues, such as the choice of IOLs, pre and post-op medications, how to handle intraoperative and post-op complications, how the ophthalmologist discusses comanagement with the patient (and what exactly he/she says to the patient), treatment protocols for a wide variety of eye diseases/conditions and when a surgical/clinical patient is released back to the full-time care of the optometrist. Discuss modifications to the post-op care schedule secondary to complications that may occur during the surgery.
During this getting to know each other session, ask about the ophthalmologists political position on optometric scope of practice. This part of the conversation is a make or break aspect of the relationship. It is also a fundamental cornerstone of the relationship.
See For Yourself
In much the same way that an optometrist would not comanage patients with just any ophthalmologist, simply having an O.D. behind your name will not guarantee either the initial or the long-term comanagement relationship with an ophthalmologist. The decision to comanage and the agreement to continue the comanagement relationship involves the ongoing assessment of skills, clinical/surgical acumen and personality. This aspect of comanagement never ends.
Comanagement requires that both doctors subscribe to the same treatment routines, medications and follow-up care for shared patients. An optometrist should not be offended if a prospective comanaging ophthalmologist asks him/her to attend continuing education courses that outline the ophthalmologists specific treatment protocols and expectations. Spending a morning or afternoon togetherseeing post-op cataract/clear lensectomy, LASIK, superior limbic keratoconjunctivitis, trabeculectomy, penetrating keratoplasty and diabetic follow-upsis mutually beneficial and may be required as both doctors skill level and understanding of these conditions becomes evident.
The ophthalmologist should also have the ability to assess the optometrists skills. Perhaps a day in each others offices seeing patients together will set the stage or, at a minimum, spur a thorough discussion of a variety of clinical subjects with which to evaluate each others level of competence.
For the optometrist, this visit (or visits) allow a first-hand look at the ophthalmologists office routine and the quality of his/her clinical care. For the ophthalmologist, an assessment of the optometrists clinical skills provides the comfort level necessary to expand their comanagement relationship to many clinical/surgical conditions.
Maintaining the Relationship
The two comanaging doctors should set up a specific protocol for advising each other when questions arise or expectations are not met.
E-mail, faxes, phone calls or scheduled meetings should be routine and appreciated by both sides. Problems cannot be corrected unless both sides are aware of them. Set up this feedback mechanism prior to initiating comanagement so that neither side is surprised when these discussions are necessary.
Remember, specific comanagement protocols are not generally taught as part of either an optometrists or ophthalmologists training. A written document of agreed-upon Clinical/Surgical Protocols covering pre-op requirements, medications, post-op visit schedules and specific conditions when the surgeon wishes to see the patient will best serve both doctors and avoid confusion. Getting your cards out on the table at the very beginning of the relationship will avoid hard feelings down the line.
Beyond Patient Consent
Describing an optometry/ophthalmology comanagement relationship to a patient and getting the patients approval are both critical. The Office of the Inspector General and both professions political organizations have stressed patient awareness and consent of the comanagement relationship. This best done in written form at the optometrists office, the ophthalmologists officeor, ideally, both.
The patients informed consent agreement to comanaged care should be in writing, with both the patients and doctors signatures on the document. (See examples of consent, below.) The comanagement decision between an optometrist and an ophthalmologist may be written or understood following lots of conversation and mutual agreement.
Comanagement Consent Signed at the Optometrist"s Office ABC Eyecare Consent for Comanagement of Eye Surgery Patient Name: _______________________________________________ Patient Consent to Comanaged Eye Surgery: I wish to receive cataract/clear lensectomy eye surgery and have been referred to Dr. (ophthalmologists name) for my surgery. I acknowledge that Dr. (optometrists name) is my optometrist. It is my desire to have Dr. (name of optometrist/ophthalmologist) provide my postoperative care at an appropriate time following my surgery dependent on the events occurring during my surgery and/or per the clinical guidelines established between my optometrist and Dr. (ophthalmologists name). I understand that Dr. (optometrists name) and Dr. (ophthalmologists name) will advise me of my postoperative care schedule. I understand that my ophthalmologist and my optometrist will thoroughly discuss any complications that may occur during or after my surgery and that the appropriate doctor will advise me should my scheduled post-op care need to be modified. Patient Signature: ______________________________________ Date: _____________________ Optometrist Name: _____________________________________ Optometrist Signature: __________________________________ Date: _____________________ Comanagement Consent Signed at the Ophthalmologist"s Office AAA Ophthalmology Clinic Consent for Comanagement of Eye Surgery Patient: ___________________________________________________ Following cataract surgery or clear lensectomy with implantation of an intraocular lens, several examinations will be necessary to monitor the health of your eye and the healing process. We may suggest to patients that they return to their optometrist at some point during their process for appropriate postoperative examinations. We are fully confident in the postoperative care delivered by optometrists affiliated with our office and believe this to be very convenient for most patients. Pre-op, surgical and post-op information will be shared between your optometrist and our office. Any unacceptable or unexpected risks or complications during your surgery may result in modifications to our recommended postoperative care. The optometrist providing part or all of your postoperative care will bill for his/her services. Your payment obligations to the optometrist shall be determined by your insurance (Medicare/Medicaid) coverage. However, should you wish to receive all or part of your postoperative care at our office, we will be happy to accommodate your request. I understand and agree that all or a part of my postoperative care will be provided by my optometrist, Dr. (optometrists name). Patient Name: _________________________________________ Patient Signature:______________________________________ Date: ________________________
Both doctors and their staffs should be thoroughly versed in their comanagement protocols and verbally advise their patients of the roles of both doctors. These roles will be specifically defined by the two doctors. This is not just an OK given by the patient to allow the patients optometrist to participate in postoperative care but an open recognition of the comprehensive care to be delivered by both the ophthalmologist and the optometrist. Patient choice, within the confines of appropriate clinical care, is paramount.
Should a patient wish to remain with the ophthalmologist for the full course of post-op care, his/her wishes should be granted. Conversely, should the patient desire first day post-op care with his/her optometrist (and the optometrist is fully trained to provide such care), his/her wishes should be granted. Respecting patient choice should be integral to the comanagement protocol set up by the participating doctors.
Once a comanagement agreement is established between an optometrist and an ophthalmologist, and patients consent to the comanagement, expect to make refinements and modifications over time. Cataract, glaucoma, LASIK/ PRK, cornea, pediatric, retina, strabismus, anterior segment disease and many other patients all lend themselves to comanagement.
As the comanagement relationship continues over time, both doctors will recognize that each patient encounter will give the doctor providing the care the opportunity to assess the quality of care of the other doctor. This ongoing process of quality assurance elevates comanaged eye care to a high level with an internal feedback loop. Excellence in shared eye care is the ultimate result.
With agreements in place and quality patient care as the goal, a cohesive team approach to eye care is achievable. At the end of the day, all partiesthe optometrist, the ophthalmologist and the patientare exceptionally well served with shared, comanaged eye care.
Dr. Reichle is a full partner in the Eye Center of Texas comanagement practice in
