Improving Access to Vision Care in Community Health Centers

In past policy statements, the American Public Health Association (APHA) has recognized the importance of access to vision care services in long-term care facilities,¹ as part of the management of chronic diseases by other health providers,^2,3 in federally funded health care programs,⁴ in health insurance programs,⁵ as well as in a Memorandum of Understanding to promote optimal vision health for all Americans⁶; however, APHA has not addressed access to vision care in community health centers (CHCs).

Federally qualified health centers provide comprehensive primary and preventive health care for the nation’s low-income and medically underserved and vulnerable populations via a federal mandate, because underserved communities demonstrate a higher prevalence of preventable disorders, diseases, and health conditions compared with medically served regions. Vision care requirements at federally funded CHCs consist of only visual acuity screening and no treatment services; however, many CHCs provide other high-quality care services that exceed the quality performance requirements of more traditional health providers.^7,8

Low-income and racial and ethnic minority populations tend to be at greater risk for undiagnosed and uncorrected eye and vision disorders and diseases than the general population.^9–11 These populations closely mirror the demographics served by CHCs. In addition, disparities are compounded by several factors, including inadequate or no health insurance, lack of access to optometrists or ophthalmologists, costs of treatments (including eyeglasses), and lack of understanding of the importance of routine comprehensive eye and vision care throughout all stages of life, especially because most eye problems are asymptomatic.^9,12 Unmet eye and vision care needs among millions of children, working poor, and elderly people can significantly impair learning, job performance, employment opportunities, and home safety. ¹³

Twenty-five percent of children ages 5 to 17 have a vision problem; 79% have not visited an eye care provider in the past year, and 40% who fail their initial vision screening do not receive the appropriate follow-up care.^14,15According to the Centers for Disease Control and Prevention, if the conditions that lead to visual impairment are left untreated, they can have substantial long-term implications for the quality of life of the child and family and can place a burden on public health resources.¹⁶ Children without vision insurance have significantly more severe unmet needs than children with insurance.^17,18 These unmet needs could be met with comprehensive vision services provided at CHCs.

Blindness and visual impairment are among the 10 most common causes of disability in the United States among older adults.¹⁹ Much of the vision loss from age-related eye disease can be prevented. Early detection of glaucoma and diabetic retinopathy can result in follow-up treatment to preserve vision. Without regular comprehensive eye examinations, diseases such as glaucoma go undetected and untreated as visual loss occurs.²⁰ Diabetes-related eye complications are the leading cause of newly diagnosed blindness among adults, and vision complications are often asymptomatic in the early stage of diabetes.²¹

CHCs address disparities in access to health care for the nation’s most vulnerable, but they provide limited access for comprehensive eye and vision care services. There are “best practice” vision care programs in some CHCs, which use optometrists to deliver primary vision care and ophthalmologists to provide secondary and tertiary eye care. CHCs that offer services of both professions ensure that patients have access to and continuity of comprehensive eye and vision care.²²

Data from the Health Resources and Services Administration (HRSA), Bureau of Primary Health Care, indicate that only 19% of patients received on-site comprehensive vision care services at federally qualified health centers; 13% were referred for vision services to contractual eye professionals; and the remaining two thirds of patients must seek vision services outside and without financial assistance from the CHC.23 In addition, only 29% of patients with diabetes receive dilated eye exams at on-site CHCs, and another 16% of diabetic patients are referred, and the CHC pays for the examination.²³

The HRSA data on vision services closely mirrors data from a survey by George Washington University School of Public Health and Health Services in cooperation with the National Association of Community Health Centers conducted in 2008.²⁴ The study, Accessing the Need for On-Site Eye Care Professionals in Community Health Centers, found that only 20% of CHCs had an on-site eye care professional staff, with 9% having a professional who provides free care on volunteer basis. The majority of health centers providing on-site vision care used optometrists (17%) for primary eye care, whereas 7% used full- or part-time ophthalmologists for secondary/tertiary care.²⁴ The survey found that the top barrier to providing vision care was the ability to afford equipment and space.²⁴ HRSA does not have designated funding for start-up costs for eye care clinics.

The George Washington University study²⁴ recognized that the lack of access to eye care services through community health centers in rural and low-income communities is a major public health crisis in the United States. A comprehensive eye exam provides early detection of systemic diseases, such as diabetes. Given limited access to dilated eye examination for people with diabetes, as well as other vision services, there is a substantial inequity in access to vision care in CHCs. Targeting resources to CHCs for people at risk for vision conditions should help improve access to care.

Therefore the APHA has adopted the following recommendations:

1. HRSA should increase resources to improve access to on-site primary eye and vision examinations for patients who receive care at CHCs and address workforce issues by creating recruitment and retention strategies for optometrists, including eligibility for the National Health Service Corps to provide comprehensive vision care services at CHCs. In addition, HRSA should fund research to evaluate the type and quality of vision care services provided and to help health centers identify cost-effective practices.
2. Congress should expand access to primary eye and vision care in underserved communities, including CHCs, by reinstating doctors of optometry in the National Health Service Corps and should include optometry as a named primary health care discipline in CHCs.
3. Community health center should staff educate patients in a culturally competent manner about the importance of comprehensive eye exams throughout all stages of life in delaying, reducing, or preventing vision loss through the delivery of eye and vision care services by appropriately qualified providers of eye and vision care and through culturally competent eye and vision health education and health promotion delivered by other providers of primary care.
4. Collaborations should occur between other relevant organizations including, but not limited to, Prevent Blindness America, the American Academy of Ophthalmology, and the American Optometric Association work to accomplish the goals of the resolution.

References

1. American Public Health Association. APHA policy statement 95-04: Improving access to vision and eye health services for long-term care facility residents. Washington, DC: American Public Health Association; 1995. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=99. Accessed November 30, 2009.
2. American Public Health Association. APHA policy statement 97-07: Prevention of visual loss from glaucoma. Washington, DC: American Public Health Association; 1997. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=141. Accessed June 10, 2009.
3. American Public Health Association. APHA policy statement 2000-2: Reducing the incidence of blindness, lower extremity amputation, and oral health complications in diabetes. Washington, DC: American Public Health Association; 2000. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=207. Accessed June 10, 2009. 
4. American Public Health Association. APHA policy statement 94-08: Eye protection against ultraviolet radiation. Washington, DC: American Public Health Association; 1994. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=74. Accessed June 10, 2009.
5. American Public Health Association. APHA policy statement 2001-1: Improving early childhood eyecare. Washington, DC: American Public Health Association; 2001. Available at: www.apha.org/advocacy/policy/policysearch/default.htm?id=240. Accessed June 10, 2009.
6. American Public Health Association. APHA joins with optometrists on vision health. The Nations Health. 2002; March 2002: 4.
7. Shin P, Markus A, Rosenbaum S, Sharac J. Adoption of health center performance measures and national benchmarks. J Ambul Care Manage. 2008;31:69–75.
8. Haung E, Zhang Q, Brown SE, Drum ML, Meltzer DO, Chin MH. The cost-effectiveness of improving diabetes care in U.S. federally qualified community health centers. Health Serv Res. 2007;42:2174–2193; discussion 2294–2323.
9. Zhang X, Saaddine JB, Lee PP, et al. Eye care in the United States: Do we deliver to high-risk people who can benefit the most from it? Arch Ophthalmol. 2007;125:411–418.
10. Heslin KC, Casey R, Shaheen MA, Cardenas F, Baker RS.. Racial and ethnic differences in unmet need for vision care among children with special health care needs. Arch Ophthalmol. 2006;124:895–902.
11. SteelFisher GK. Addressing unequal treatment: disparities in healthcare. Issue Brief, The Commonwealth Fund; 2004. Available at: www.commonwealthfund.org/Content/Publications/Issue-Briefs/2004/Nov/Addressing-Unequal-Treatment--Disparities-in-Health-Care.aspx. Accessed December 1, 2009.
12. National Eye Institute. Survey of Public Knowledge, Attitudes, and Practices Related to Eye Health and Disease. 2005. Available at: www.nei.nih.gov/kap/2005KAPExecSumm.pdf. Accessed December 1, 2009.
13. Centers for Disease Control and Prevention. Improving the Nation’s Vision Health: A Coordinated Public Health Approach. Atlanta, Ga: Centers for Disease Control; 2006. Available at: www.visionandhealth.org/documents/ReportImprovingtheNationsVisionHealth.pdf. Accessed December 1, 2009.
14. Centers for Disease Control and Prevention. Visual impairment and use of eye care services and protective eyewear among children—United States, 2002. MMWR Morb Mortal Wkly Rep. 2005;54:419–429.
15. Kleinstein, RN. Refractive error and ethnicity in children. Arch Ophthalmol. 2003;121:1141–1147.
16. Donohue SP, Johnson TM, Leonard-Martin TC. Screening for amblyogenic factors using a volunteer lay network and the MTI photoscreener. Ophthalmol. 2000;107:1637–1644.
17. Campaign for Children’s Health Care. No Shelter From the Storm: America’s Uninsured Children. Washington, DC: Campaign for Children’s Health Care; 2006. Publication No. CCHC-0601. Available at: www.childrenshealthcampaign.org/tools/reports/Uninsured-Kids-report.PDF. Accessed December 1, 2009.
18. Newacheck PW, Stoddard JJ, Hughes DC, Pearl M. Health insurance and access to primary care for children. N Eng J Med. 1998;338:513–519.
19. Bailey RN, Indian RW, Zhang X, et al. Visual impairment and eye care among older adults—five states, 2005. MMWR Morb Mortal Wkly Rep. 2006;55:1321–1325.
20. Association of State and Territorial Chronic Disease Directors. Vision Problems in the United States: Recommendations for a State Public Health Response. Atlanta, GA: Association of State and Territorial Chronic Disease Directors; 2005. Available at: www.preventblindness.net/site/DocServer/CDD_Vision_Report.pdf?docID=1324. Accessed December 1, 2009.
21. Walker EA, Basch CE, Howard CJ, Zybert PA, Kromholz WN, Shamoon H. Incentives and barriers to retinopathy screening among African-Americans with diabetes. J Diab Complications. 1997;11:298–306.
22. Wilson R, Sharda V. The history of community health centers with the New England College of Optometry. Optometry. 2008;79:594–602.
23. Proser M, Shin P. The role of community health centers in responding to disparities in visual health. Optometry. 2008;79:564–575.
24. Shin P, Finnegan, B. Assessing the Need for On-Site Eye Care Professionals in Community Health Centers. Washington, DC: George Washington University School of Public Health and Health Services; 2009. Available at: www.aoa.org/documents/GWU_vision_final.pdf. Accessed June 9, 2009. 

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