Eye Health Progress Report

Key Action Area Four: Improving the Systems and Quality of Care

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Objective: Eye health care is safe, affordable, well-coordinated, consumer – focussed and consistent with internationally recognised good practice.

Australian Government

The Australian Government Department of Health and Ageing funds a range of initiatives aimed at improving the coordination, integration and quality of existing services, including the Eye Health Demonstration Grants Program.

The Eye Health Demonstration Grants Program

Funding of $3.5 million has been made available for demonstration projects that identify, trial and evaluate strategies to:

• overcome inefficiencies in the delivery of eye health care;
• improve access to eye health care, particularly for marginalised and disadvantaged groups, including people in rural and remote communities and Aboriginal and Torres Strait Islanders; and
• improve the quality and safety of eye health care.

Under this program initiatives are being funded in each state and territory aimed at improving the coordination of services through the development of referral pathways and protocols. The demonstration projects cover a range of geographical locations and also include projects that target groups at particular risk of eye disease injury. Several of the demonstration projects are listed here. Other demonstration projects are included under Key Action Areas 1,2,4 and 5.

• CanDo4Kids has received a grant of $191,800 to trial and evaluate strategies aimed at the most effective coordination of children’s eye health and vision care services and referral protocols across South Australia.

• Funding of $200,000 has been provided to the Guide Dogs Association of South Australia and the Northern Territory to develop and evaluate a cost effective and sustainable model of eye health and vision care for older people in South Australia. The project seeks to address current inefficiencies and inconsistencies in the identification, diagnosis, treatment and ongoing support for eye health and vision care amongst older people in South Australia, particularly for culturally and linguistically diverse groups and Aboriginal and Torres Strait Islander people.

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• Funding of $146,382 has been allocated to the Royal Society for the Blind of South Australia to pilot a coordinated system of eye care and low vision services for people in South Australia experiencing vision loss as a result of an acquired brain injury.

• The Royal Victorian Eye and Ear Hospital has been awarded a grant of $200,000 for the “Continuum of Care for the Management of Chronic Eye Diseases Project”. This project aims to improve the management of glaucoma, age-related macular degeneration and diabetes related eye diseases through the development of a shared care model, supported by a management tool. Referral criteria, e-learning modules, databases and care pathways will be trialed and evaluated for each of the three disease streams. The project includes the trialing and evaluation of expanded roles for eye care practitioners in the management of these diseases. In addition, general practitioners will be up-skilled in the pilot sites to undertake basic ophthalmic examinations.

• Funding of $199,656 has been provided to the National Ageing Research Institute, Melbourne, to evaluate the effectiveness of interventions targeting intrinsic and extrinsic factors to improve vision, independence, safety and quality of life in the residential care setting.

• The Queensland Vision Initiative has received funding of $29,925 for a referral pathways pilot project to improve the co-ordination, quality and delivery of eye health care services for people with low vision and blindness in metropolitan Brisbane. A further grant of $71,150 extends the referral pathways project to regional, rural and remote Queensland.

• The Royal Guide Dogs Association of Tasmanian has received funding to pilot a collaborative eye health and vision care program across Tasmania. The key objective of the project is to ensure the efficient and effective coordination of services and appropriate referral protocols across Tasmania.

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• The Optometrists Association of Australia (NSW Division) has received funding of $94,200 to pilot a collaborative eye health and vision care initiative for the Australian Capital Territory.

• The Limestone Division of General Practice has been allocated $53,950 to undertake a series of workshops for general practitioners, Aboriginal Health Workers and practice nurses across the Division to update their eye care skills, enhance referral processes and improve communication between the professional groups.

• The Macular Degeneration Foundation has been allocated $69,990 to undertake a range of activities in conjunction with five pilot Divisions of General Practice to improve knowledge and skills of general practitioners in the prevention, early detection and management of macular degeneration. The project will also strengthen referral pathways between general practitioners, optometrists and ophthalmologists for better outcomes in the early diagnosis and treatment of macular degeneration.

Indigenous Initiatives

• The Office of Aboriginal and Torres Strait Islander Health is funding the Fred Hollows Foundation from November 2006 until January 2009 to employ an Eye Health Program Manager to develop a new model to improve the integration of eye health services in Central Australia and to reduce eye surgery waiting lists. This project has involved funding of $462,519 allocated over three years.

• The Fred Hollows Foundation has been awarded a grant of $150,000 under the Eye Health Demonstration Grants Program to improve the coordination of eye health and vision care services for the Top End of the Northern Territory. The key objectives of this project are to establish a clear picture of existing services and identify gaps across the eye health and vision continuum and to trial and evaluate a co-ordinated and integrated service delivery model for eye health and vision care.

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• Funding of $50,000 was provided in 2006-07 for two Aboriginal and Torres Strait Islander eye health workshops in May and June 2007. The workshops aimed to promote effective models of eye health service delivery and inform the sector of recent developments in OATSIH eye health policy. All OATSIH funded Aboriginal and Torres Strait Islander primary health care services were invited to the events. In total, 86 eye health workers representing 54 services attended. Representatives from OATSIH and the Office for an Ageing Australia also attended. Workshop attendance provided coverage and representation from each Australian state and territory. A final workshop evaluation report was prepared by Evolution research and sent to all workshop participants in December 2007.
• Funding of $100,000 was provided by OATSIH in 2005-06 for a national stock-take of the eye health equipment funded by the OATSIH. The stocktake report was finalised in February 2006, and used to develop a depreciation and maintenance schedule for eye health equipment and to inform the development of any future equipment policies for the OATSIH. The report was not published as it contains detailed service level information.
• Funding of $159,970 has been provided under the Eye Health Demonstration Grants Program to the Canning Division of General Practice in Western Australia to trial and evaluate strategies to integrate eye health care for indigenous adults and children into mainstream general practice and develop appropriate referral protocols.

• The Queensland Aboriginal and Islander Health Council has received funding of $150,000 under the Eye Health Demonstration Grants program for a range of activities to strengthen integration of eye care within primary health care and improve eye care knowledge amongst health care providers within Queensland Aboriginal and Islander Community Controlled Health Services.

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Clinical practice guidelines

The development and implementation of national evidence based clinical practice guidelines can help ensure that clinical practice is up-to-date and consistent with internationally recognised good practice. The Australian Government has initiated the development of guidelines for several eye diseases.

• The NHMRC is in the process of developing Clinical Practice Guidelines for the Management of Glaucoma. The guidelines are expected to be completed by June 2009.

• The NHMRC has supported the development of a Clinical Practice Guideline for the diagnosis, management and prevention of diabetic retinopathy (2008). The NHMRC provided methodological support to the guideline development team and recently gave formal approval of the guideline under section 14A of the National Health and Medical Research Council Act 1992.

• The Department has contracted the Royal Australian College of General Practitioners to carry out international literature reviews and develop national evidence-based primary care guidelines for rheumatoid arthritis and juvenile idiopathic arthritis which will be NHMRC endorsed and available to medical practitioners and the public early in 2009. These guidelines will cover recommendations on early detection and treatment of uveitis, which can be associated with rheumatoid arthritis and juvenile idiopathic arthritis, and which involves inflammation of the inner eye and may cause permanent eye damage if not treated.

Self Management of eye disease

Self management programs have been shown to increase the quality of life and self-efficacy for people with chronic disease. Funding of $199,810 is being provided to the University of Western Australia under the Eye Health Demonstration Program to develop, test and implement self-management strategies for people with eye disease.

Stakeholder input into government programs

The Community Sector Support Scheme (CSSS) supports the national secretariat activities of a range of peak community-based organisations that have a focus on meeting the health and ageing needs of the Australian community. The objective of CSSS is to facilitate participation in the policy development processes of government by peak organisations which represent consumers and carers.

Annual funding of approximately $380,000 is provided for Vision 2020 Australia through the CSSS to strengthen the role of Vision 2020 Australia as the peak body for the eye health and vision care sector.

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Australian Capital Territory

Since 2007, a comprehensive Ophthalmology program has been provided to final year medical students at the ANU Clinical School of Medicine.

As of 2008, quarterly in-house training on red eyes is being provided to the Emergency Department medical staff at Canberra Hospital. A similar program will be provided at Calvary Hospital soon.

Canberra and Calvary Hospitals adhere to the Rehabilitation and Aged Care Service policy on ‘Correct patient, correct procedure, correct site’. Policy is in place regarding the prevention of transmission of Creutz-Jacob disease, for which retinal patients are at risk.

Continuing medical education for Ophthalmologists is key, and sources include the weekly clinical meeting for Department of Ophthalmology staff, monthly clinical meeting for ACT Ophthalmologists and RANZCO annual state and federal conferences.

Registered nurses in the Department of Ophthalmology attend day seminars at Sydney Eye Hospital, and there is a second-monthly in-service for ward registered nurses at the Canberra Hospital.

New South Wales

Personal Health Record

As outlined above at Key Action Area 2, the NSW child PHR was reviewed in 2006 to improve all childhood surveillance and screening systems. Vision surveillance and vision screening for childhood vision problems during the formative years were included in this review.

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Centre of Excellence for Corneal Transplantation

Feasibility study is being undertaken. Data is being collected to define the preferred model of care.

StEPS program

Also described above, the StEPS program will improve the systems and quality of paediatric eye health in NSW as Area Health Services will actively identify and target all four-year-old children in NSW to offer a free monocular visual acuity screening assessment. Guidelines, protocols, referral criteria and referral pathways for the StEPS program were developed in partnership with key clinical professionals working in paediatric eye health, to ensure childhood vision problems are detected and treated prior to school entry to maximise treatment outcomes.

Patient Identification, Correct Patient, Correct Procedure and Correct Site Model Policy

In 2004, the NSW Department of Health introduced the Patient Identification, Correct Patient, Correct Procedure and Correct Site Model Policy (PD2005_380). The purpose of this policy is to describe the steps that must be taken to ensure that an intended invasive or diagnostic procedure is performed on the correct patient, at the correct site and, if applicable, with the correct implants/prostheses and equipment. Performing a procedure on the incorrect patient, performing the incorrect procedure on a patient, performing a procedure on the incorrect site (e.g. right eye instead of left eye) and the use of incorrect implants/prostheses and equipment are relatively rare serious incidents in healthcare, and may be devastating when they occur, not only for the patient and their families or carers, but also for the staff involved.

This policy was based on best practice principles identified by the Royal Australasian College of Surgeons (RACS) and the Veterans’ Administration (VA) and Joint Commission on Accreditation of Healthcare Organisations (JCAHO) in the United States. In 2007, the policy was reviewed and amended to address an increasing number of incidents notified in non-surgical areas. The review also addressed a number of shortcomings identified in the original policy, including a change to site marking procedures for ocular surgery. The revised Correct Patient, Correct Procedure and Correct Site policy directive (PD2007_079) was released in October 2007. An ongoing audit process was established in early 2008 to monitor compliance with the policy in operating theatres across NSW.

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Quality Improvement

The Eye Clinic at the Children’s Hospital at Westmead is currently running a project to investigate a possible triage system to allow for more timely appointments so more urgent cases are seen within an acceptable timeframe. An internal review has recently been conducted into the current electrophysiology service offered. Electrophysiology represents an essential early diagnostic tool for vision impairment and related eye disease. More advanced equipment has been purchased with staff training to offer a higher quality of service in this area. An internal review has been conducted regarding amblyopic management which has engaged parents, families and clinicians to improve compliance and satisfaction with treatment strategies. Quality improvement projects are being conducted in these areas. Relationships with low vision agencies such as North Rocks Deaf and Blind Institute have been strengthened through clinical meetings. This is planned for other low vision agencies such as Vision Australia.

The Sydney Eye Hospital provides complex eye services and is a major statewide referral and research centre. The system and quality of care is being improved by the implementation of NHMRC National glaucoma guidelines and collaboration with the Royal Victorian Eye and Ear Hospital on bench marking. Clinical pathways are being introduced for retinal, cataract and glaucoma surgery such as a cataract teleform streamlined admission process. The Hospital also provides registrar secondment networks to public hospitals in metropolitan Sydney and rural NSW, including Wagga Wagga, Bourke and Newcastle.

Eye Emergency Project

Eye Emergency Manual Project includes 24 sites continuing to review processes for management of eye emergencies. Eye Emergency Manual Education is offered: six 30 minute education modules have been developed and used in Emergency Departments for emergency clinician education. Two more modules are in the process of development and are due for completion in December 2008. Six one day education workshops have occurred providing eye emergency education for 125 emergency clinicians, in rural and metropolitan areas. An additional six more education workshops are planned for outback and remote sites between September and November 2008.

The Statewide Ophthalmology Service is working with the Surgical Services Taskforce to provide ophthalmic dashboard data, and with the correct lens insertion working party.

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Northern Territory

Central Australia Eye Care Model

The Department of Health and Families is working with the Department of Health and Ageing and has funded the Fred Hollows Foundation (FHF) in Central Australia to develop an integrated and sustainable eye care model for the region. FHF has announced $3 million for capital towards additional facilities.

Integrated Top End eye health and vision care service

In partnership with Vision 2020 and the Fred Hollows Foundation, the NT developed a successful submission for project funding through the Commonwealth Department of Health and Ageing, Eye Health Demonstration Grants Program. The aim of the project is the development of an integrated eye health and vision care service for the Top End, which will link to the existing Central Australian Eye Health model to form an NT Eye Health Framework. This project will contribute to the NT implementation of the National Framework for Action to promote Eye Health and Prevent Avoidable Blindness and Vision Loss.

CARPA guidelines for diabetes and eye health care

As described under previous section, a systematic approach to eye health is enhanced by the widespread use of CARPA guidelines for diabetes and eye health care.

Queensland

Queensland Vision Initiative Inc (QVI Inc)

The QVI Inc is an alliance of health care professionals who have been working together since 2003 with the aim of developing a comprehensive eye health program for the Queensland population. Today, QVI Inc comprises representatives from over twenty key medical, rehabilitation and service provision agencies within the health sector in Queensland. In November 2007, Queensland Health provided funding to QVI Inc to formulate a strategy and implementation plan for the prevention and provision of treatment in eye care of Indigenous Queenslanders in line with the National Framework. The inaugural Indigenous Queenslander Eye Health project working group meeting was held on 27 November 2007, with representatives from some ten organisations in attendance. Although still in its early stages, the project has identified areas of concern regarding access to eye health services for Indigenous Queenslanders.

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Spectacle Supply Scheme

The Spectacle Supply Scheme provides eligible people with basic spectacles (from a contracted supplier), and is managed through the Medical Aids Subsidy Scheme in Queensland. The benefit for optometrists is a dispensing fee of $30 per prescription. In 2006/07 Queensland Health spent approximately $6 million on this scheme.

South Australia

Children’s Vision

For children the focus has been on building collaborative relationships between Ophthalmologists, Optometrists, Orthoptists and General Practitioners and child and family health nurses. An education session coordinated by the Royal College of General Practitioners was held September 2007, to promote the role of the Optometrist, Orthoptist and Child and Family Health Nurse in the eye health referral pathway. This was well attended. The vision referral pathways developed have assisted the Cando4Kids project for a vision referral pathway and brochure to promote eye health.

Systems changes directed towards child health have included:

• An audit of premature baby screening;
• Ophthalmology Department meetings within Women’s and Children’s Hospital to up-skill nurses, orthoptists, optometrists and ophthalmologists as well as junior trainees in paediatric ophthalmology;
• Provision of a library;
• Encouragement by team leaders to think systematically rather than only case by case;
• Purchasing of a new departmental computer for auditing purposes; and
• Purchasing of Retcam to enable photos to be sent digitally for ease of collaboration with care.

A referral pathway to support child development as a whole is in current progress in SA related to the proposed roll out of a developmental assessment tool, the Ages and Stages Questionnaire (a parent led monitoring system). Vision questions are included in this questionnaire.

Culturally appropriate care

The increased focus on culturally appropriate systems of care within Aboriginal Health Services in the CNAHS region included diabetes pathways and improved clinical standards by qualified and trained Aboriginal health workers.

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Eye Health Workforce

The Ophthalmologist work force is a problem area in SA. The ratio for SA is approximately 1:37000 compared with 1:28000 nationally. Only two of the last FRACOs over the last 4 years have stayed in SA. Ten years ago there were 65 practicing ophthalmologists and now there are 54 with planned retirements taking this into the 40s without renewal. Those remaining in the public sector are becoming busier which may exacerbate the problem of supply and impacts on teaching and training.

Optometry studies/qualification is not available at any SA university but there appears to no indication that this causes us problems in supply; students are mostly trained in Melbourne.

Tasmania

Tasmanian Eye Health and Care Initiative

This project will also provide the opportunity to identify gaps in services, ways to facilitate access and the removal of barriers that create duplication and inefficient use of resources.

Victoria

Eye health training for Aboriginal Health Workers

For 2007-2008, Public Health funded Vision 2020 a total of $55,000 to work in partnership with the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) for a one-off project to provide eye health training for Aboriginal Health Workers. This acknowledges that Aboriginal and Torres Strait Islander people are potentially at increased risk of developing avoidable blindness and vision loss and are less likely to access eye health care practitioners than other Australians. Vision 2020 will provide the content and resource development. This important piece of work extends the capacity of Aboriginal Health Workers to cover eye health and it links the specific eye health expertise of Vision 2020 with VACCHO with the necessary expertise and cultural position to provide the training.

Outpatient Improvement and Innovation Strategy

As part of implementation of the Outpatient Improvement and Innovation Strategy, a range of improvement projects have been funded in 2007-08 including development of a continuum of care model at the Royal Victorian Eye and Ear Hospital (RVEEH). Funding of $100,000 has been provided to RVEEH to support the National Eye Health Demonstration project and develop a continuum of care model for the management of patients with glaucoma, age related macular degeneration and diabetic retinopathy. The project aims also include establishment of referral criteria and e-learning modules in the 3 specialist care pathways.

The project is addressing key priorities for the Outpatient Improvement and Innovation including:

• developing specialist care pathways;
• improving the interface between primary and acute care; and
• trialling workforce redesign roles in a primary care/community setting.

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The Hospital Admission Risk Program - Chronic Disease Management service (HARP CDM)

HARP CDM targets people with chronic and complex care needs who frequently use hospitals or who are at risk of hospitalisation. This program provides services for people with diabetes who are at high risk of hospitalisation or have frequently attended hospital. The type of service includes client assessment, review, education, care planning and interventions. In the HARP-CDM model of care, the HARP worker will undertake assessment for diabetes risk factors, including eye checks. The HARP worker will, if appropriate, refer the client to an optometrist and develop a diabetes action plan or care plan with identified client’s needs.

Western Australia

WA Draft Eye Health Services Development Plan

The Draft WA Eye Health Services Development Plan includes a range of recommendations to enhance coordination of services. Key priorities are to engage general practitioners and to seek to include assessments by optometrists in detecting emergent eye conditions have been outlined. These priorities are being included in the development of the WA Primary Care Strategy and are included in the current e-Health implementation framework.

Comprehensive WA Health Service Planning

WA is completing comprehensive statewide service planning as part of a $5 billion capital redevelopment program. This has resulted in significant modelling and planning for all services across the State. Ophthalmology services are included in the planning framework that is seeking to deliver appropriate services closer to peoples’ homes in newly developed general hospitals and regional resource centres. This planning is now being integrated across the State through “Models of Care” and will be part of a comprehensive State workforce plan now beginning to look in detail at discipline specific priorities.

Through the Neurosciences and the Senses Network this planning will be linked to sector-wide development and seek to develop key partnerships with private providers and the NGO sector including the Royal Blind Association, Diabetes WA and key health professional associations.

Central coordination of waitlist and outpatient access

Under the current elective surgery wait list program enhanced management of waiting lists is seeing patients being offered earlier surgery if there are differences emerging between the waiting times across WA Health. Improved data access is providing managers and clinicians alike with better information to manage waiting times.

E-Health Reforms

Clinicians are being invited to inform the next stage of redevelopment of information and communication technology (ICT) across Western Australia. Key enhancements are planned around interoperability between systems and web-based access that will dramatically enhance capabilities to communicate across the state and between public and private sector providers.

These reforms directly support key recommendations in the Draft WA Health Eye Services Development Plan. Specific capabilities required to support ophthalmology services will be addressed in partnership with Area Health Service ophthalmology providers and the Neurosciences and the Senses Network. Specific options for the handling, access and assessment of retinal images will be considered in the planning. This should facilitate the development of recall systems for follow-up of patients with long term care needs.
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