Eyeworld

by Michelle Dalton Contributing Writer Managing the noncompliant patient founding member and chair of the Integrated Ophthalmic-Managed Eyecare Delivery (IOMED) Task Force of the American Society of Cataract & Refractive Surgery. Both groups have to devote the resources neces- sary to ensure the lines of communi- cation remain open, "or it won't work. And we have to let the pa- tients know it's a two-way street." Dell Laser Consultants has a large OD referral network, Dr. Cunningham said. "We comanage a significant number of our patients," he said. What some ophthalmolo- gists and associations saw as a flaw in the system in the early 2000s, Dr. Cunningham's group turned into a strength by concentrating on what each eyecare professional brings to overall patient care. "Traditionally, the optometrist has multiple touch points with a patient, and they, in turn, have an inherent historical trust relationship with the OD," he said. "Patients view the OD as a non-biased and trusted source of information, even when it's outside the realm of the OD's specialty." With contact lens noncompli- ance a result of a lack of patient awareness of potential risks, and glaucoma drop noncompliance a result of a plethora of causes, 3 it's clear both the OD and MD need to find more effective ways to educate their patients. 'Good doc, bad doc'? Dr. Reeves believes the tripod of good patient care is communication, education, and documentation. When the physician is referring a patient outside his or her own of- fice, "there needs to be communica- tion when that handoff occurs," he said. "A letter from the referring physician may be OK for some is- sues. But if the referral is because of something more acute or potentially more vision threatening, a phone call is necessary and can provide the next level to ensure a seamless tran- sition." Minnesota Eye Consultants employs several optometrists, so often the handoff is a bit easier, he said. "In my mind, an integrated practice is the best interaction and communication means to approach patient care," Dr. Reeves said. Each step of the management process is an opportunity to educate the patient about his or her disease state and the potential ramifications of disease progression. "Of course, documentation is crucial for physi- cians during the transition of care. Each side needs to be protected in terms of the recommendations they make," he said. Using scare tactics and a "good cop, bad cop" mentality should be the last resort, Dr. Cunningham said. "The most convincing way you can change patient behavior is through peer pressure," he said. "If every member of the care team is telling a patient to do X, then they'll do it. Scare tactics—the concept of 'if we don't fully control this, you may end up having to have sur- gery'—are short lived at best." The lesson he's learned through the years is to be a judge of character as well as a medical confidante. "Certain medications have pre- dictable outcomes," he said. "If the patient isn't experiencing any of those outcomes, they're probably not taking the medications." In his experience, a tertiary care center is less worried about offending a patient and may be more confrontational about compliance issues. "At every step, we need to keep our referring doctors in the loop about what we've said, what re- sponse we've been given," he said. In the majority of cases, the patient will continue to seek care from the tertiary center, Dr. Cunningham said. "By being frank and confronting the patient about compliance when necessary, it allows the OD to be the ally and allows patients to view the recommendations we're making with more authority," he said. Who takes the lead? Regardless of which eyecare profes- sional is seeing the patient, "each physician needs to think of them- selves as the primary doctor," Dr. Reeves said. "We each need to take that extra responsibility to ensure patients are well educated when they leave our offices. MDs and ODs can get into trouble when they ex- pect the other guy to be responsible. That's how patients fall through the cracks." When the OD/MD communica- tion is in place, "everyone will be on the same page and can ensure a con- sistent message is being conveyed." Historically, the OD's realm is more medically oriented and the ophthalmologist's realm is more sur- gically oriented, Dr. Cunningham said. "MDs have relied on the OD re- lationship with the patient to ensure the message about medical compli- ance is reiterated at every point." The unified front is often easier when the team is integrated into one practice, Dr. Reeves said. "There are more opportunities for a face-to- face interaction. It's a little more challenging when a doctor is outside the practice. Those situations are where I recommend a phone call with the outside physician; you can cover a lot of ground in a very short amount of time." Both doctors must be on the same page and preferably delivering the same message. "Advertising mar- keting firms have shown the more times you hear a message, the more it's retained," Dr. Cunningham. EW References 1. Ramamoorthy P and Nichols JJ. Compliance factors associated with contact lens-related dry eye. Eye & Contact Lens 2014;40:17–22. 2. Olthoff CMG, Schouten JSAG, van de Borne BW, Webers CAB. Noncompliance with ocular hypotensive treatment in patients with glaucoma or ocular hypertension: an evidence-based review. Ophthalmology. 2005;112(6):953–61. 3. Okeke CO, Quigley HA, Jampel HD, et al. Adherence with topical glaucoma medication monitored electronically: The Travatan Dosing Aid Study. Ophthalmology. 2009;116(2): 191–199. Editors' note: The physicians have no financial interests related to their comments. Contact information Cunningham: derek.n.cunningham@gmail.com Reeves: swreeves@mneye.com Ophthalmology Business 56 June 2014 When patient care is shared between ophthalmologists and optometrists, ensuring patients don't fall through the cracks becomes most important I t's a fact that not every patient will be compliant with treat- ment regimens and instruc- tions, especially when chronicity is added to the fold. A recent study 1 found that while compliance rates with contact lens care practices are very low, the rampant noncompliance didn't contribute to contact lens-related dry eye. An older study 2 likewise found noncompliance in hypoten- sive treatment does not correlate to progression to visual field loss. And even when patients know they are being monitored and provided free glaucoma medication, compliance was less than 25%. 3 Still, the need for more effective means of patient education is war- ranted, not only for the contact lens or ocular hypertensive/glaucoma patient, but also for any patient with a chronic disorder. Typically, both the optometrist and the oph- thalmologist manage these patients, so how do eyecare professionals successfully balance comanagement in these cases? "There are numerous disease states and examples of noncompli- ance in ophthalmology," said Sherman Reeves, MD, in practice at Minnesota Eye Consultants, Bloom- ington, Minn. "It does become more challenging when there's more than one doctor involved in care. There's an extremely high amount of responsibility to ensure nothing gets lost in the handoff." Comanaging patients "can be efficient if both the ophthalmologist and the optometrist understand the value of communication and make a concerted effort in that realm. That's the one place patient management can fall apart," said Derek Cunningham, OD, director of optometry and research at Dell Laser Consultants, Austin, Texas, and a 56-57 OB_EW June 2014-DL_Layout 1 6/3/14 12:42 PM Page 56

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