Article

WEB EXCLUSIVE: Continuity of Care for Glaucoma Patients

Ensuring the best care for patients who travel often.

Gustavo Gamero, MD; Tarpon Springs, Florida

As a leading cause of irreversible blindness worldwide, glaucoma deserves the outmost attention as a public health concern. Like in any chronic, potentially progressive disease, continuity of care is paramount to provide appropriate management and preserve visual function.

The successful management of glaucoma is a labor-intensive challenge and requires an educated, committed patient. Adherence to treatment, clinical visits, and timely testing is the best route to success. Patients need to understand that glaucoma treatment is a team effort. It is even a greater challenge when patients spend extended periods of time away from home.

As a Florida practitioner, I have many patients who travel south for the winter (“snowbirds”). They have a home-town glaucoma doctor. It is my job to make sure that the quality of their care is not affected by their travel. Not all glaucoma is managed by specialists. The American Glaucoma Society website can help identify a doctor, if necessary. Here I share some suggestions to facilitate their care.

It is important to identify and build a relationship with the patient’s home-town practice. Make this information visible in the EHR platform at each visit. This will promote timely exchange of information via fax or electronic transfers. An involved patient can be helpful reminding doctors about record sharing.

As patients often stay 4 to 7 months in each location, it is important to know the time of arrival to and departure from each practice. This allows for timely scheduling of visits. I advise patients to make an appointment as soon as they know their travel plans. Sometimes a second visit is needed.

The frequency of visits will depend on the severity of glaucoma, as dictated by the Preferred Practice Patterns of the American Academy of Ophthalmology. It will vary from 1-2 times per year in untreated ocular hypertension or glaucoma suspects to 4 or more times per year in severe or unstable cases. This general timeline will change according to various clinical circumstances, such as adverse drug reactions, change in medications, surgical procedures, need for postoperative care, unstable eye pressures, or the suspicion of progression. If a surgical procedure is anticipated, it is best to schedule it as soon as the patient arrives in one location so that adequate time is allowed for the often intensive postoperative care.

Glaucoma auxiliary testing is critical. Timely exchange of visual field and OCT printouts will minimize duplicate testing and allow proper assessment. I send a clinical summary anytime that testing has been performed or the clinical condition has changed. A direct phone conversation with the doctor is sometimes needed.

These are some pointers to remember:

  • Invest in educating your patients about their disease and its management.
  • Establish a relationship with the patient’s home-town physician.
  • Obtain and provide records in a timely manner.
  • Make patients active participants in their glaucoma care.

Early detection of glaucoma progression is critical, and it cannot be asserted unless the care is a continuum.

Paul Schacknow, MD, PhD; Stuart, Florida

Managing snowbird patients requires more effort on the part of the physician than managing patients who are permanent residents. At my practice I see approximately 10% snowbird patients. I’ve been in practices in different parts of the area where up to 25% or 30% are snowbird patients. It varies by location.

Continuity of care starts not with the glaucoma physician, but with the patient. New patients will often come in and tell us they have glaucoma and that they have another ophthalmologist treating them in another location, and that they’d like their pressure to be checked. In these cases, we have a conversation with the patient to explain that we can’t check their IOP without performing a full glaucoma eye exam in order to understand their IOP in the context of their disease. As part of that process, I explain to patients that I don’t want to repeat treatments done by the other physician, and that I can contact the other practice for their records.

Sometimes patients will contact us ahead of time and we can get records before they come in. There are also times when I bring a patient in and try to contact their home physician at the same time to see if they will send records while the patient is in my office. If we can’t get the records, then I offer the patient the option of repeating the exams or rescheduling the appointment. I remind patients that I can’t make any decisions about how their glaucoma is doing without having a visual field, an OCT, or a dilated fundus exam to look at the optic nerve. It’s very important to educate patients that they can’t just “get their pressure checked;” this would be malpractice on the glaucoma specialist’s part. It’s also very rare that a patient won’t accommodate once they have an explanation of why these data are needed. They understand it’s in their best interest.

When these patients become established, we plan ahead for their departure by reminding them to schedule a last visit for the “season.” At the last visit, we will provide hard copies of their visual field, OCT, VEP, fundus photos, and the last 2 or 3 office notes that they can take back to their hometown ophthalmologist. I will also ask patients to request physical copies of their records from their hometown ophthalmologist, so that the records are sure to reach our office when the patient comes back.

Often patients who have had glaucoma for quite a while will already have established relationships with practices in both places they live. However, I certainly have established relationships over the years in those places where my patients might be going so that I can make recommendations for a glaucoma specialist “back home” if they don’t already have one. I like to add a personal touch sometimes, which isn’t always very efficient, in that I will call the other physician’s office while the patient is with me, tell them about my patient, and try to get an appointment set up.

There are also special considerations for surgical patients. I might ask patients who need urgent glaucoma surgery if they can delay travel. If the surgical case is not urgent, I might discuss a plan with the patient that involves scheduling the surgery for after they’ve traveled, with another surgeon. I will call the surgeon directly and discuss the plan.

Sometimes, however, surgical patients can’t reschedule their travel. So, I might put them on something like an oral carbonic anhydrase inhibitor like acetazolamide, which can have systemic side effects. Again I will call the physician in the home town and ask that the patient be seen within 10 days of arriving, to check electrolytes and side effects. The point is for the patient to be near the surgeon for appropriate follow-up after a procedure.

Any glaucoma patient can be lost to follow-up, snowbird or not. However, a bit more effort is required for patients who live in multiple locations throughout the year, whether it be printing and requesting records or phone calls to check in.

Stan Berke, MD; Westbury, New York

Continuity of care and compliance are particularly important for glaucoma patients, and I don’t want to send a mixed message about this to patients who spend either the entire winter or part of the winter someplace down south. I don’t want those patients to fall through the cracks. I actually have a separate file in my filing cabinet called “Florida,” and in that file, I have contact information for ophthalmologists, particularly glaucoma specialists, that I know in different parts of the state so I can help make recommendations. Usually it comes up in conversation that my patients will be traveling — for example when I ask them to come back in 3 months.

Severity of disease determines how I manage these patients. If a patient has fairly mild glaucoma or ocular hypertension and they are stable, they might only be seen every 6 months and so we might schedule appointments around their travel. I do tell patients that if they need it, I can connect them with an ophthalmologist while they’re away.

If patients who need to be seen more frequently, for example every 3 or 4 months, and who are going to be gone for 4 or more months, I will connect them to ophthalmologists down south. I will then stay in contact with that practice to share and request reports and visual fields. I’ve been practicing for 32 years and I’ve been a member of the American Glaucoma Society (AGS) for all that time, and the AGS a great group for establishing comradery and meeting people who are in areas where your patients go. Attending the AGS meeting is helpful toward making connections as well. The AGS website also has a “Find a Physician” search tool that can be useful. And the AGS also has a forum for members called AGSNet where glaucoma specialists can share recommendations.

As for surgical patients, I try not do major glaucoma surgical procedures, like a trabeculectomy or tubes, if I know a patient is about to head south. The postoperative care can be pretty complicated, and I don’t think it’s fair to the patient or another physician to send the patient elsewhere for follow-up. So, if possible, I try to get the surgery done well before they leave so they’re around for at least one month or two before they leave, or try to put it off or arrange for it to be done as soon as they get down to Florida so they can do the care for a couple months while they’re down there. Rarely it does happen that I have to send patients to other physicians at their destination. I communicate with the physician about the surgery and follow-up plan and thank them for participating in the patient’s care. Also, rarely patients have surgery in Florida and they come up to New York and I end up doing the postoperative care. This is not as big of a concern with MIGS because the postoperative care is not as involved.

Glaucoma specialists are a certain breed who have long-term relationship with patients. We are the primary care physician for their eyes and we see them on a regular basis for years. We establish that physician-patient relationship and we really care about our patients. We want them to get the best care possible when they’re not in our area, from someone we know is qualified elsewhere. The bottom line is we don’t want to send a mixed message to patients. We tell them all along to take their medicines, keep their appointments. To let things fall through the cracks just because they’re going away is not a good way to practice and it sends the wrong message. So, I’m very cognizant of people who are traveling. Work out the appointments based on their travel plans.