Contineous Assessment -2

Name: SRIMANTI SARKAR

Roll No: 13980322017
Registration No: 221393310017
Paper name: EPIDEMIOLOGY AND COMUNITY OPTOMETRY
Paper code: MO-103
College name: Vidyasagar College of optometry and vision science
Topic : Optometry in multidisciplinary health system
Optometry's role in the delivery of health care services is changing. During the past decade, optometry has
emerged as a primary care provider. This positioning of optometry as an entry point to the health care
system has heightened awareness of its role among other health care providers, patients, and the public.
organizations, optometrists have assumed a role in the coordination and management of patients' health
care? 3 Because of the optometrist's ability to diagnose ocular manifestations of systemic diseases and the
increasing knowledge base of the profession, many patients with special needs are receiving coordinated
care which is either managed or initiated by the optometrist. As such, optometrists are assuming an
increasingly important role in patients' overall health care services.
A health care facility which offers multiple services in one setting affords the optometrist an opportunit,y to
play a role in serving the primary care needs of patients. 4 Proximity to other providers speeds the
consultation, referral, and feedback processes.
DELIVERY OF HEALTH CARE SERVICES
Health care in the United States has developed into a triad of service levels which reflect most closely the
modes of practice available to patients. The division of services into primary, secondary, and tertiary care
follows a logical sequence based upon frequency of patient problems and the management schema applied
to each type of problem.
Primary care is typically rendered in an ambulatory care setting. This level of service is available to all
patients on a self-referral basis. The primary care practitioner usually represents the first point of entry into
the health care system and thus is likely to encounter not only problems associated with the patient's primary
complaint but, through the course of the examination, others which may or may not be symptomatic. The
responsibility of the primary care provider is to diagnose and manage those problems which are within the
immediate scope of that service (specialty) and to coordinate consultations or referrals to other providers in
the primary care network.
In the event that the result, is chronic morbidity, loss of function, or further debilitation, the next level of
care available to patients is that of the tertiary practitioner. Again, either the primary or secondary provider
is involved directly in arranging for treatment of tertiary problems
MULTIDISCIPLINARY NEIGHBORHOOD HEALTH CENTERS
Funding for neighborhood health centers in the 1960s by the Lyndon Johnson administration represented a
major inner city health care initiative by the federal government. Columbia Point Health Center in Boston
was the first federal program to be funded in 1965. 6 From the success of that single site an incredible
network of 28 centers in Boston and 56 statewide have developed.
Before the creation of neighborhood health centers, community residents received care primarily through
visits to hospital emergency rooms. From the start the driving force behind the formation of these centers
was unique when compared to other primary care facilities. The intent was to address several goals
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including (1) the availability of services not previously available to a community (such as eye care) and (2)
the notion that health centers were to act as "agents of social change" by offering multiple outreach
programs to the community.
Health center services were also integrated and designed in a manner that allowed easy access by all patients
as they moved through the system. 6 For example, at the Dorchester House Multi-Service Center an
expectant mother who had been seen by her family physician for several years and who was participating in
the family planning service is able to make a smooth transition to the obstetrics service. This patient and the
expectant father could easily be enrolled in birthing classes. Once the child was born, the pediatrics service
could be engaged in the active care of the infant. Day care services and after school programs are available
to those parents who need it. As the infant reaches childhood other services such as optometry and dentistry
become important. Should the child require the services of a specialist, a coordinated referral and
consultation plan is initiated. At this point, the primary provider comanages the case with the other involved
practitioners. Once the patient reaches adolescence, the pediatrician turns over the care of this patient to the
adolescent clinic headed by the family physician or internist and the cycle repeats.
PORS
In response to increasing concerns over sound practices in the documentation, quality of care, and
management of patient problems, Lawrence Weed introduced the problem-oriented medical record (POMR)
in 1968.8 The format of this system required practitioners to identify, diagnose, and follow their patients'
problems logically. This system was also called the PORS because it used patient problems to integrate data
and develop differential diagnostic and management strategies for patient care. PORS is comprehensive in
that it allows for review of structure, process, and outcome. Finally, use of PORS at multidisciplinary care
settings makes evaluation of the "whole" patient easier. One health record which is accessible to all
providers facilitates interservice referrals. Access to the patient's complete health record assists the provider
in understanding special needs of individual patients.
PORS AND OPTOMETRY'S ROLE IN MULTIDISCIPLINARY CARE
Over 10 years ago at the Dorchester House MultiService Center, a New England College of Optometry
teaching facility, a decision was made to implement the PORS in the eye clinic. 10 This system has been
applied successfully since that time. Our "defined data base" includes questions that enable us to build a
"patient profile." In the patient profile we are looking for evidence of family or patient problems that may
affect examination strategy, patient management, or compliance. The case history includes routine
questions regarding both the patient's ocular and health history and that of immediate family members. A
psychosocial profile is taken so that we can identify for any significant challenges or problems of daily
living that our patients may be experiencing.
At the conclusion of the optometric examination clinicians make an initial "problem list" according to the
rules of the PORS. This list of patient problems includes not only ophthalmic diagnoses, but also medical,
psychosocial, economic, or other concerns raised during the examination (by provider or patient). In this
manner, optometry assists patients in the acquisition of available services which can solve other problems
as identified by PORS.
After the session has concluded, every chart is audited by a student clinician in the optometry service. Just
as specific rules apply to the format of the chart and the recording of patient problems, specific guidelines
for reviewing charts have been established. Record auditors provide written feedback to clinicians to
encourage an open dialogue on good patient care and the refinement of management skills. The ultimate
goal of record auditing is to increase the quality of care rendered to each patient so that the highest, possible
standards are maintained.
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In the multidisciplinary health center, the management of patient problems that were once the domain of
other providers has become an integral part, of optometric practice. As optometrists become directly
involved in the care of patients with multiple problems and observe the benefits, the comanagement
concept gains momentum.
CASE REPORTS
Case 1
An 80-year-old white female presented to the eye clinic complaining of blurred vision in the right eye for
the past several months. Her ocular history was otherwise unremarkable. Health history included systemic
hypertension which was diagnosed 15 years ago. The patient had stopped her antihypertension medication
when it ran out because her initial symptom of dizziness had subsided. She had not been evaluated by a
physician since then. Examination revealed exudative retinopathy 01) > OS, suggestive of both diabetes
and hypertension.
The patient was escorted immediately to our triage unit where blood glucose and blood pressure were
measured. Internal medicine and retinology consults were also arranged. The patient was shown to have
systemic hypertension, probable diabetes, and exudative retinopathy consistent with hypertension and
diabetes.
Treatment was initiated for hypertension and testing for diabetes was arranged. Even though care was
initiated promptly, the patient experienced symptoms of cerebrovascular accident 3 days later and was
admitted to the hospital; she died 9 weeks later.
This patient demonstrates the importance of prompt intervention which was initiated by the eye care
service. Even though the patient was afraid of doctors and did not want to comply with our
recommendations, we were able to help her through her evaluations by personally escorting her to the
medical services and arranging her specialty consults. Before she was hospitalized, we contacted her by
telephone to discuss her problems, give reassurance, and encourage her to follow through with her
appointments.

CONCLUSION
Optometry's participation in the ongoing needs of patients in multidisciplinary care settings is becoming
established. What, is different is the leadership role which optometrists can and do assume as primary care
providers and multi-service coordinators for their patients. The emergency of optometry as an integral part
of the primary care network has been facilitated by the development of multidisciplinary neighborhood
health care centers. Patients who present for optometric care are fortunate to be in a setting where teams of
providers work together as facilitators in the
multidisciplinary care and optometry's participation in this system, reviewed the benefits of using
the PORS in a multidisciplinary setting, and, by case example have illustrated optometry's role in
the health care delivery system in this country. Although optometry’s role in mulridisciplinary
care settings continues to be refines, it is cetrain that the future holds greater responsibilities in
the comanagment of our patient’s problems.

REFERENCES :
Optometry in multidisciplinary health system ( 1040-5488/89/6612-0859$02.00/0
OPTOMETRY AND VISION SCIENCE)