Building Quality Institutions Archives - Page 7 of 7

Affiliation Between Hahnemann University and Pennsylvania College of Optometry

This article outlines the nature, describes the implementation process, and summarizes the status of operations to date of the affiliation between Hahnemann University (HU) and the Pennsylvania College of Optometry (PCO).

Health care financing and provision are issues that affect virtually every individual in the United States today. As health care costs continue to rise, providers, third-party payers, and patients alike actively seek more effective and efficient provision systems. If providers fail to provide quality and cost-effective health care, they will be left behind in the increasingly competitive market. Similarly, if patients and third-party payers do not use more effective and efficient systems, they will assume an even greater share of the rising health care expense.

Affiliation between professional institutions presents numerous opportunities for enhancing the educational and clinical training of students, residents, and practitioners. Institutions that are developing their respective professions can collaborate in many ways of mutual interest.

Two Philadelphia health care institutions, located within 9 miles of each other, HU and PCO, cognizant of the changing health care environment and the possible benefits of collaborative education, have begun to explore new approaches to patient care provision and ophthalmic education. On March 2, 1988, the two institutions signed an agreement for an affiliation. The agreement, effective July 1, 1988, proposes that the professions of medicine and optometry combine resources to develop unique approaches to ophthalmic education, eye care provision, and ophthalmic research.

The Context and the Decision to Affiliate

Ophthalmology and optometry have existed as separate, often antagonistic, professions since their inceptions, so why affiliate now? The impetus comes from outside parties – particularly third-party payers, health care policymakers, and legislators – who will attempt to define the roles each profession will play in the future of eye care provision if the two professions do not actively define these roles themselves. The ophthalmology community maintains that the diagnosis and treatment of eye disease should be restricted to physicians. The optometry community, on the other hand, proposes that optometrists should be the primary eye care providers and should offer an even greater range of eye care services than they do now. Interprofessional disputes involving the treatment of eye disease by optometrists, preoperative and postoperative management, and the use of laser technology in refractive treatment remain unresolved in many areas of the country. Debates in journals and in legislative chambers, however, may or may not produce satisfactory outcomes for either profession. In our opinion, the time has come for ophthalmologists and optometrists alike to acknowledge that through collaborative efforts the two professions can define a future for eye care provision that will satisfy their needs as well as those of patients and policymakers.

Pennsylvania College of Optometry, which graduates approximately 140 optometrists each year, and HU, comprising a medical school, graduate school of health sciences and humanities, and a teaching hospital, considered the potential benefits of a cooperative arrangement between the professions of medicine and optometry. In 1987, they began to explore the possibility of an affiliation. Such an affiliation was unprecedented and, given the political environment, highly controversial. Therefore, before agreeing to proceed with the affiliation discussions, representatives from both institutions considered the following issues:

How will the professional communities respond to the affiliation?
How will alumni and other constituencies respond?
Should the services rendered under the affiliation be marketed? How will the professional communities react to joint marketing efforts? Will the managed health care systems accept a joint provision model?
What are the roles of ophthalmology and optometry in primary care?
How will patients be managed under the terms of the affiliation agreement?
Will the model of patient care provision defined by the affiliation be in compliance with state and federal laws and regulations?
Will the affiliation create competition between ophthalmology residents and optometry students for primary care encounters?
How will the introduction of new technology, such as lasers, be administered under the terms of the affiliation?
What is the proper and ethical role for each institution in the areas of patient management and financial agreements?
What are the positive and negative consequences of such an affiliation?

Of these issues, those involving the reactions of health care communities were perhaps the most sensitive. Some ophthalmologists feared that the affiliation would undermine ophthalmology’s role in primary eye care. Locally, some ophthalmologists threatened to refer patients elsewhere if HU proceeded with the affiliation; in fact, a number of ophthalmologists did stop referring patients after the affiliation took effect. Nationally, some ophthalmologists voiced their disdain for a cooperative agreement between medicine and optometry (Argus. November 1988:8, June 1989:4, and December 1989:22). Optometrists nationwide questioned whether or not the affiliation would place their profession in a subordinate role to ophthalmology.

Alumni of HU voiced their disagreement with the affiliation through letters, telephone calls, and refusals to continue to support the school financially; PCO alumni, on the other hand, tended to view the affiliation positively.

Given the emotional nature of the affiliation, the marketing issue was all the more troublesome, and the planning stages proceeded with deliberation. The first efforts at marketing involved educational radio announcements, simply informing the public that the two institutions now offered joint services. These proved successful in piquing the interest of potential patients and third-party payers, such as health maintenance organizations. Marketing in the future will use both radio and newspaper media.

Issues regarding the provision of services and the roles of ophthalmologists, optometrists, students, and residents are addressed in a series of protocols, which will be discussed in greater detail below. Currently, these protocols are in draft form and are revised as necessary. However, they still constitute the backbone of the affiliation, and set the rules by which we operate. If care is not provided according to the terms of the protocols, the affiliation will fail, perhaps causing irreparable damage to the future of relationship between ophthalmology and optometry.

Recognizing a mutual desire to influence the future direction of the eye care professions, the two institutions decided to move ahead with the affiliation despite the risks and expected negative reactions. A primary goal of the affiliation is to define the role each profession will play in the changing environment before third-party payers and regulatory agencies mandate new policies. By engaging in curriculum discussions and in joint research efforts, the institutions hoped to enhance their own educational and research programs and, at the same time, design a health care provision system that would become a national model acceptable to all parties: ophthalmologists, optometrists, patients, and policymakers.

The Agreement

Philosophically committed to the affiliation, representatives of the two institutions began to define the elements of the agreement. It was decided that the firm foundation and base of the agreement would be education, on which other aspects of the agreement would be built. Many months of negotiations culminated in the written agreement to affiliate. Salient aspects of the agreement are summarized below:

Each institution will retain autonomy over its operations and finances.
An Affiliation Executive Committee will provide guidance, advice, and oversight on matters relating to the affiliation, including education, research, clinical, and administrative issues.
The Chairman of the Department of Ophthalmology at HU and the Dean of Academic Advancement at PCO will be responsible for administering the affiliation.
Appointments to the faculty or staff of either institution will be made in accordance with the policies and procedures of each institution.
On request, the clinical faculty and house staff at HU will provide consultative subspecialty medical/surgical services to the patients of PCO in a location dedicated to subspecialty care. Consultative subspecialty services will be provided for a full spectrum of medical ophthalmic conditions, including, among others, cataracts, cornea and external disease, diseases of the ocular adnexae, diseases of the retina and vitreous, glaucoma, neuro-ophthalmic disease, ocular trauma, pediatric ophthalmic disease, and strabismus. In addition, HU will provide continuous emergency medical/surgical backup services to patients of PCO.
Clinical faculty, residents, and other staff at PCO will provide consultative optometric, vision rehabilitative, and other services to patients of HU on request. Consultative optometric services will include contact lens evaluation and fitting, low-vision rehabilitation, eyeglass dispensing, orthoptics, and learning and disability evaluation and treatment.
Patients will be referred to HU or to PCO, as appropriate, when such referrals are in the best interest of the patient, are agreed to by the patient, and are consistent with applicable laws and regulations, such as those mandated by the Medicare and Medicaid programs and by professional ethics.
Students at HU, with approval from the dean of the School of Medicine, may take courses taught by PCO faculty. Likewise, PCO students, with the approval of their dean of Academic Advancement, may take courses taught by HU faculty.
The faculties of both institutions will engage in joint educational programs, such as didactic and continuing education lectures, clinical preceptorships, seminars, electives, and grand rounds.
The faculties of both institutions may participate in joint research efforts. Joint research programs will be approved and administered in accordance with the polices and procedures of each institution.
The faculty and administration of both institutions will seek to develop new and innovative health care provision systems.
All publicity, marketing, and fund-raising materials regarding the affiliation must be approved by the Affiliation Executive Committee.
Neither institution will use the affiliation for its own or its profession’s political gain.
All health care providers operating under the affiliation must have appropriate and adequate professional liability insurance as required by law.
Each institution will make available to the other institution, on request, all pertinent information regarding legal, financial, contractual, managerial, and other issues relevant to the affiliation. All such information will be held strictly confidential.

An interim financial agreement was added as an addendum to the original agreement. A global financial agreement addressing the provision of clinical as well as educational services is still under negotiation. It will supersede the interim agreement as soon as it is finalized.

The faculty, medical staffs, and administrations of both institutions were informed of the affiliation discussions and most supported the initiative.

The Model and the Implementation Process

The model of eye care provision eventually agreed on assumes that ophthalmology and optometry are complementary, and it seeks to emphasize the strengths of each profession. It stipulates that primary eye care provided at PCO is delivered by optometric staff. Patients with conditions requiring subspecialty medical or surgical intervention are referred for consultation, management, or both to the HU ophthalmology staff. After the consultation and any necessary medical or surgical treatment are completed, the patient is referred back to the referring optometrist for ongoing care. Likewise, patients who receive their primary eye care by ophthalmologists at HU and who require contact lenses, low-vision rehabilitation, orthoptics, or learning disability services are referred to PCO optometric staff for treatment. Ongoing medical/surgical care is provided by ophthalmologists. In our opinion, therefore, ophthalmologists and optometrists work in tandem to provide appropriate, cost-effective, and high-quality care.

Educational Programs

A fundamental goal of the affiliation is to develop joint education and research programs. Therefore, much effort has been spent in restructuring existing programs and creating new ones. Basic science and clinical faculty at HU currently offer courses in ocular microbiology/immunology, pharmacology, clinical medicine, and microanatomy at PCO. In the future, HU faculty will be offering courses designed for students of optometry in general and medical pathology and physical diagnosis.

Programs in clinical education also are being redefined. Ophthalmology residents accompany HU faculty on rotation in subspecialty care at PCO’s clinical facility, The Eye Institute. In addition, PCO’s faculty offers ophthalmology residents rotations in contact lens and low-vision rehabilitation services. Similarly, optometry residents and a few students are afforded the opportunity to rotate through ophthalmology subspecialties under the tutelage of the ophthalmology staff. Further, ophthalmology faculty participates in clinical conferences at PCO. Students and residents of both institutions are thus exposed to a broadened clinical base and an array of ophthalmic disorders. The hope is that such exposure will result in a more well-rounded clinical education.

Faculty of PCO have commented that the educational programs have enabled them to enhance their own clinical skills and knowledge base. However, educational programs are not limited to the faculty and students of the affiliated institutions; programs have been designed to benefit community providers as well. Faculty of HU have lectured at PCO grand rounds and have participated in the college’s continuing education seminars. Programs such as these encourage interaction between the professions and therefore, are consistent with the goals of the affiliation.

Clinical Services

Before clinical services were actually provided under the terms of the affiliation, clinical faculty of both institutions worked together to draft patient care management and referral protocols, to outline the management process, and to establish quality assurance standards. To date, protocols have been approved for referral from PCO to HU regarding the following aspects of care: (1) cataracts, including preoperative and postoperative care; (2) cornea and external disease; (3) disease of the ocular adnexae; (4) disease of the retina and vitreous; (5) glaucoma; (6) neuro-ophthalmic disease; (7) ocular trauma; (8) strabismus; and (9) pediatric ophthalmic disease.

When a patient is referred to HU for management, the ophthalmologist assumes ultimate responsibility for treating the disorder. The referring optometrist may observe the operation and may assist in the preoperative and postoperative care. However, medical/surgical care is always rendered personally by the physician. Referrals from HU to PCO may include the following: (1) contact lens care; (2) eyeglass dispensing; (3) orthoptics; (4) low-vision and vision rehabilitation; and (5) learning disabilities.

The protocols define a “closed loop provision system” that enables providers to monitor more effectively the quality of care rendered. Under PCO’s previous program, patients were referred to independent consultant ophthalmologists for medical/surgical treatment. This system was open-ended, and methods of record keeping were informal. In the closed system model, providers are in regular communication, and referral information is compiled and reported on a monthly basis. Furthermore, independent computer systems currently being implemented at both HU and PCO will allow providers to monitor care more effectively and determine when patients miss appointments or leave the system so that appropriate follow-up communication can be initiated.

While the protocols were being finalized, administrative staff began to define the operation of the provision system. Issues such as scheduling, personnel, space requirements, equipment requirements, medical records management, and billing policies and procedures were addressed. Given the high volume of clinical activity at The Eye Institute, HU employs a full-time office manager at that facility to oversee the Department of Ophthalmology’s clinical and financial operations. This person is responsible for patient scheduling, registration, charge entry, and medical record preparation. Pennsylvania College of Optometry operates contact lens and low-vision services at HU one-half day each week. The Eyewear Center, located at HU, and also operated by PCO, is open 5 days each week and is staffed by PCO employees.

Joint clinical chiefs’ meetings are held regularly to monitor the progress of the affiliation in general and, in particular, to evaluate the protocols, discuss quality assurance issues, and to review clinical programs. These meetings help maintain open communication among the providers and facilitate patient care provision. To date, revisions have been made in the glaucoma and cataract protocols.

Research

The affiliation agreement encourages joint research ventures and, indeed, opportunities for collaborative research are considerable. Approximately 75,000 outpatient visits are recorded each year at The Eye Institute. Likewise, 282,000 outpatient visits for medical problems, including eye disease, are scheduled at HU. As a result of the affiliation, investigators have a large base from which to draw patients for studies. Faculty at both institutions are currently working together on research projects, which include learning disabilities and macular degeneration. Protocols for excimer laser investigations also have been discussed. Should these be pursued, optometrists will engage in basic research while ophthalmologists and other physicians will conduct clinical trials.

Of special note is the fact that research areas have not been limited to eye disorders and disease. Faculty at HU’s Department of Neurology and Psychiatry have joined faculty at the PCO’s Learning (Disabilities) Center in research investigating learning disabilities.

Recent Developments and Future Directions

Over the past year, many of the goals of the affiliation have been realized, and the future looks very bright to us. As participants of the PCO externship program, a few selected optometry students soon will have the opportunity to share in patient care in the Department of Ophthalmology at HU. New projects under discussion include a joint prison eye care program and the establishment of satellite clinics and faculty private offices, which will be structured according to the provision model previously described. Satellite clinics would be geographically located in the Philadelphia area to serve areas populated by the “underinsured” – the working poor who do not have adequate health care coverage. The faculty private offices would be strategically located to enhance the marketing potential of the affiliation.

Marketing initiatives already are underway; efforts will be directed to optometrists in private practice, primary-care physicians, managed-care systems, commercial insurers, and the general population. The opportunities for marketing are perhaps greatest in the managed-care sector. The model of eye care provision developed under the eye care affiliation is consistent with that used by many managed-care systems, i.e., optometrists provide primary eye care, while ophthalmologists provide medical and subspecialty care. The vehicle for marketing services to managed-care systems will be EyePA Ltd, Philadelphia, a for-profit subsidiary of PCO. On a contractual basis, EyePA Ltd provides eye care services to managed-care systems, self-insured corporations, and other insuring entities. EyePA Ltd is a multifunctional specialty organization that (1) manages utilization of eye care services; (2) provides, on a capitated or fee-for-service basis, a full range of professional eye care services through a network of contracted professionals; and (3) credentials specialty eye care providers and institutions.

Comment

Many individuals maintained that doctors of medicine and doctors of optometry could not work together as colleagues sharing the same goals and aspirations.

Looking back over the past 17 months, we believe that the skeptics were wrong. The affiliation has exceeded our expectations and has progressed much more quickly than any of the planners had imagined. Events to date suggest that joint educational, clinical, and research programs have been advantageous to both medicine and optometry, and that teams of medical doctors and optometrists can work together as colleagues in one eye care provision system.

Archives of Ophthalmology
Controversies in Ophthalmology
Volume 109, Number 2. February 1991.
Charles F. Mullen, O.D.
Myron Yanoff, MD
Laura A. Wilson, MS

Optometry and Medical School Affiliations

Affiliation with a medical school presents numerous opportunities for enhancing the education and clinical training of optometric students, residents and practitioners. The advantages of medical school affiliation seem to be easily outlined while the disadvantages are somewhat less apparent.

The decision-making process concerning affiliation must include a careful cost benefit analysis. Evaluation should include a best and worst case scenario, and a timetable for implementation, perhaps in a step-like fashion to permit both parties to assess the effectiveness and impact of the relationship.

Analysis should be of sufficient depth so as to insure that all facets of the affiliation have been thoroughly explored in both quantitative and qualitative fashion, as it relates not only to educational and patient care factors, but also to finance, research and public relations.

Obviously, the most desirable affiliation for an educational and public image perspective would be with the most prestigious medical school. Geographical accessibility is another factor. Financial strength and quality of medical and ophthalmological staff and resultant patient care are also important factors.

The integrity and qualifications of the administration and faculty who are involved in negotiating the agreement and who will be directly involved in the joint programs are of paramount concern in order to protect the college of optometry from an adverse outcome in either the short or long-run.

Benefits of a Medical School Affiliation

Education

Increased access by optometric students and resident to patients with eye disease, systemic disease and pre- and post-ophthalmic surgical cases.
Increased interaction by students, residents and faculty with ophthalmic and other health care professionals via grand rounds, workshops, seminars, conferences and observation.
Lectures by medical school faculty in areas not currently taught by optometric faculty, and in areas currently taught where qualitative and/or quantitative improvement is possible – eye disease management, patient interviewing, gerontology.
Increased educational opportunities and research capabilities through the creation of joint centers or institutes in such areas as glaucoma, neuro-ophthalmic disease, cataract/aphakia, corneal physiology/contact lenses; immunology/allergy; pediatric and geriatric eye care.
Opportunities for advanced specialty training for optometric students, residents and faculty.
Expanded continuing education program in eye disease management through increased ophthalmological participation.
Medical school faculty appointments for optometric faculty.

Patient Care

More effective management of surgical patients, whether the surgery is performed at the medical school/hospital or at the optometric facility.
More effective back-up for true ocular and general medical emergencies.
Increased and more readily available access to sub-specialty care.
Enhanced control and direction for optometry school’s medical staff in areas such as patient care protocols, quality assessment/assurance mechanisms, credentialing.
Hospital privileges for optometrists.

Constituent and Public Relations

An enhanced image which can have a positive effect on student and faculty recruitment, fund raising, grantsmanship, community relations, and professional relations.

Economic Impact

Increased census in primary care and optometric specialties.
Sharing of revenue from surgical services provided at the medical school/hospital or out-patient surgical facility of the optometry school.
Increased practitioner referrals both from the optometric and medical communities.
Opportunities for sharing of plant, capital equipment, people, and resources.

Research

Increased potential for joint research projects utilizing respective strengths of optometry and medical schools. Access to special populations.

Concerns of a Medical School Affiliation

Erosion of optometry school’s mission to train primary eye care clinicians.
Competition among optometric students/residents and ophthalmological residents for primary care patient encounters.
Danger of optometry being placed in a subordinate position related to ophthalmology.
Some loss of control over optometry school’s ophthalmological group/faculty.
Restriction on referral patterns due to implied exclusivity of agreement.
Loss of opportunities for affiliation with other institutions.
Possible negative reaction by alumni or other constituencies.
Negative public relations if affiliation does not succeed.

The Affiliation Agreement

The elements of an affiliation agreement or, if a step-by-step process is desired, a memorandum of understanding with intent to affiliate may be broadly stated with detailed attachments added as the various aspects of affiliation are realized. The following elements should be present in the initial document.

Statement of support for each other’s educational mission, particularly as it related to the expanding scope of optometric practice.
Mutual desire to meet the health care needs of the community in a cooperative manner, desire to provide mutually beneficial and cost effective means for educating health care practitioners, and a recognition of the public benefits of collaborative research in visual and related sciences.
Actively encourage and cultivate inter-institutional endeavors in education, research and patient care.
Recognize each other’s autonomy as it relates to overall institutional mission, structure and governing authority.
Those terms contained in the agreement which specify financial arrangements should not become effective until such arrangements have been mutually agreed to in writing.
Facilitate inter-institutional cooperation in education by such means as faculty exchange, discussions on curricula development, teaching and evaluation techniques, seminars, workshops or symposia.
The faculties of both schools agree to participate in education programs such as didactic lectures, clinical preceptorship, seminars, electives, grand rounds, and continuing and post-graduate education as deemed appropriate.
Encourage cooperative research efforts and the application for external funding in the basic and clinical sciences by means of faculty exchange, sharing of laboratory resources and sharing of technical expertise.
Develop a cooperative arrangement in clinical education by reciprocally granting credentialed individuals faculty rank and/or clinical privileges, and by integrating medical and optometric staff, fellows, residents and students into appropriate clinical activities at each other’s institution.
Optometry school agrees to recognize the hospital and clinical faculty of the medial schools as the preferred providers of general medical and surgical care, ophthalmic surgical care and associated ancillary services for optometric patients.
Medical school agrees to recognize school of optometry and its clinical faculty and residents as the preferred providers of optometric care.
Optometry school agrees to make available members of its faculty to provide optometric services at medical school/hospital in accordance with mutually approved policy, protocol and procedures. This would include endorsement and signing of standing orders by appropriate medical director to allow optometric staff to treat eye disease if not permitted by state statue.
Medical school agrees to make members of its faculty available to provide onsite services at college of optometry’s clinical facilities.
Medical school agrees to make members of its faculty available to provide 24-hour emergency consultation and support services for optometric staff and residents.

The following should also be considered:

Use of an external consultant experienced in hospital/institution mergers to review the affiliation structure.
Creation of a third entity for administration of the various joint programs and for resources development purposes, e.g., The Foundation for Optometric/Medical Eye Care.
Jointly sponsored grant application should be considered to offset start-up costs.

Conclusion

I have attempted in this brief presentation to outline the benefits and potential costs of medical school affiliation. Although there many be alternative means of enhancing optometric education and training with less political risk, affiliation appears to offer an immediate opportunity for quantitative and qualitative improvement in our ability to prepare optometrists to treat eye disease.

Journal of Optometric Education.
Volume 12, Number 2. 1986.
Charles F. Mullen, O.D.

The Eye Institute – A Health Care Delivery Center at the Pennsylvania College of Optometry

With the opening of The Eye Institute, the Pennsylvania College of Optometry has the opportunity to attain one of the highest goals set by its founder nearly sixty years ago. Dr. Albert Fitch had stated, “A proper college of optometry must compare with any of the colleges of the other health professions, such as medicine and dentistry, and be on a par with the best of them.” The Eye Institute provides the means to close the final gap in achieving a favorable comparison of the College with other educational institutions in the health professions. In fact, fresh approaches to the integration of patient care and clinical education may result in The Eye Institute serving as a model for all.

The need for improved clinical education facilities became urgent during the 1972-1974 period. Following the installation of a new administrative team headed by the College president, Norman E. Wallis, the curriculum had undergone extensive revision. Emphasis was placed on preparing future optometrists for an expanded scope of practice which addresses the problems of the whole patient. An academic program was devised to provide a thoroughly integrated background in the biological, behavioral, visual and clinical sciences that can be applied to patient care. Throughout this process the conviction developed that the mission of all optometric education is excellence in patient care.

Yet, while the prime objective was to bring clinical education and patient care experiences forward as the critical element in the education of the practicing clinician, the College was handicapped by seriously inadequate clinical facilities.

In 1974, a thoroughly investigated and carefully planned proposal for a new clinical education and patient care facility was submitted to the U.S. Department of Health, Education and Welfare. In 1975, the Pennsylvania College of Optometry was granted the entire amount requested, $3.8 million. The total cost of the new building was $5.1 million.

The New Building

The architectural firm of Hardy, Holzman, Pfeiffer Associates of New York was selected, principally because they promised to challenge the College on every preconceived idea regarding the development of a clinical facility for the profession. Planning involved all segments of the College community, as well as leaders in the optometric and other health care professions on the local, national, and even international level. The architects came to understand that the College wanted not only to develop a facility for patient care and education, but also to impact on the public and add to the recognition of the profession. They agreed that recognition of the worth of a profession by the public grows out of respect for the educational institutions in which the professionals are trained.

The basic function of The Eye Institute was to be a regional resource – for the College’s educational process, for the community, for all health care professionals – and a national resource for the profession of optometry. The architects were outstandingly successful in creating a physical environment which facilitates and demonstrates this function.

Of modern design, the building is on two levels totaling approximately 52,000 square feet. The upper level houses all primary care facilities, while the lower level incorporates secondary specialized care suites, administrative offices, a 147-seat amphitheater, a conference room, and optical and ophthalmic drug dispensing areas.

The Primary Care Service Module is the patient’s entry point into the Institute’s eye care delivery system. Each of five such units operates with a degree of independence from the whole and is physically somewhat separate. The purpose of dividing primary care into the service modules is to provide an environment in which the patient receives personalized continuity of care as he or she would within a small private group practice; yet, the advantages of scale – multidisciplinary skills, complex instrumentation and quality assurance mechanisms – are available.

Each module is comprised of a preliminary testing area, eight fully-equipped examining rooms, staff offices, and a consultation area. A reception station and a comfortably furnished waiting area are shared by paired modules. A sixth modular areas has been reserved for the future creation of a group family practice in which all primary prescribing professions will be represented. This experiment in interdisciplinary cooperation will provide students assigned to this module experiences in a multidisciplinary setting.

Twelve third or fourth year optometric students, assisted by second year students, are assigned to each Primary Care Service Module. Student interns are supervised by two professional staff members holding academic rank at the Pennsylvania College of Optometry, and one optometric post-doctoral Fellow. In addition, ophthalmological personnel are assigned to the module to provide diagnostic consultation and supervision of general therapeutic services for patients discovered to be suffering from ocular disease. In support of professional staff, there are optometric technicians, optometric assistants and clerical personnel.

Operating Procedures

All patients are seen by appointment except in emergencies. When the patient registers at the service module’s reception desk, a unitized case record is created which contains all reports relating to that patient from all sources, including specialists to whom the patient may be referred. A licensed optometrist is always assigned the responsibility for case management, as the patient’s attending doctor.

The patient next undergoes a series of preliminary screening tests to evaluate the state of his/her ocular and general health. Hypertension and glaucoma screening, visual acuity, and visual skills are included in this protocol. The results are used to generate a problem-oriented patient record, and to determine the level of care required to solve the problem(s) uncovered. If the screening tests indicate no evidence of an urgency, the patient proceeds to a comprehensive eye examination, aimed at disease detection and the determination of a prescription for achieving optimum visual efficiency. The patient is then assigned to the student most appropriate to conduct the examination.

The Optical Service of The Eye Institute, located on the lower level of the building, offers the patient the option of having his/her ophthalmic prescription filled on the premises. No prescriptions are filled for persons who are not patients of The Eye Institute.

When the patient is referred outside the Primary Care Module for consultation or therapy, the professional within the module is not relieved of his/her responsibility to the patient. He/she continues to monitor and coordinate the management of the case, whether the problem was ocular or systemic. In this way, three objectives are met: (1) the patient receives the most cost beneficial care by professionals best equipped to solve his or her problem; (2) the patient remains under the case management of the primary care provider who assures that care is not fragmented by split responsibility; and (3) each professional is challenged to perform at the highest level of his/her training and capabilities because the process assigns the patients in a rational manner.

The specialty service units are located on the lower level of The Eye Institute. Access by patients to specialized services is by referral only, either by a professional staff member of a Primary Service Module or by a private health care practitioner. Patients referred by other than eye care professionals generally visit a Primary Care Module for case work-up prior to receiving secondary services.

Specialized Services

Specialized services within The Eye Institute include the following:

Ophthalmological Service: The ophthalmological suite is comprised of four examination/treatment rooms, and private offices. Provisions have been made for expansion of this facility so that, in the future, ambulatory surgery may be accomplished. — While general ophthalmological services are provided in the Primary Care Services Modules, this Service offers consultation in the sub-specialties of corneal-, retinal-, and neuro-ophthalmology. A second opinion service is also available to patients, primary care physicians, and third-party health insurers.
Ophthalmic Photography: Instrumentation and skills exist for performing all types of ocular photography – external, slit lamp, and fundus (including sterioscopic).
Electrodiagnostic Service: The Eye Institute has one of the finest and most complete installations for electrodiagnosis in the country. Dark adaptometry and comprehensive color vision testing is also offered with this Service. Referring doctors receive copies of biopotentials tracings and an interpretation of them, with the conclusions reached by the consultant.
Pediatric Unit: This Unit addresses the problems of binocular dysfunction in adults as well as children. Fully equipped for both diagnosis and vision therapy, the Unit is staffed by specialists in binocular vision, oculomotor anomalies, and visual perception. A pediatric ophthalmologist is also on the staff to provide medical balance to the optometric view of functional anomalies. A post-doctoral residency program in binocular vision is conducted by this Unit. — The Pediatric Unit specializes in the visual problems of the retarded, the learning disabled, the perceptually immature, and the visually handicapped child. It is also equipped to perform infant and early childhood vision analysis – a neglected area in eye work.
Vision Rehabilitation: Since the merger into this Service of the practice of William Feinbloom, D.O.S., Ph.D., internationally recognized expert in the field of low vision, this facility is named “The William Feinbloom Vision Rehabilitation Center.” This Service receives referrals from the professional community, government, and social service agencies for the management of patients with impaired visual acuity and/or significant field restriction. The work of the Vision Rehabilitation Service is carried out through the integration of a multidisciplinary team including social service, ophthalmological, electrodiagnostic, and mobility-training personnel (the latter through an affiliation with the Philadelphia Center for the Blind.) — Special contact lenses are included in the armamentarium of this Service for such conditions as keratoconus, corneal leucoma, iris coloboma and aniridia. The Service also has a rarely available space eikonometer and other instrumentation for providing measurement and consultation in the area of aniseikonia.
Sports Vision: Staff members have developed special skills in testing, evaluation, adapting and enhancing an athlete’s visual performance to the particular demands of his sport. They offer consultation to athletic coaches, team managers, and school health authorities, as well as to referring eye care practitioners and other physicians.
Consultation Services: The Eye Institute has initiated a unique service in recognition of the obligation of an optometric educational institution to support optometrists in private practice. Eye Institute professional staff members, each of whom have developed some special skill or area of expertise, will consult by telephone or in writing with any practitioner who requests it.
Pharmaceutical Service: When the pending licensing arrangements are concluded, a pharmacy for the dispensing of ophthalmic drugs will be in operation. This Service will be available to Eye Institute patients and to optometrists, ophthalmologists, and other appropriately licensed health professionals. A full line of ophthalmic prescription drugs for both diagnostic and therapeutic purposes, as will as over-the-counter preparations for contact lenses, ocular irrigation and decongestion, will be stocked.

Other Activities

A Social Services Department is under the direction of a person experienced in health care counseling. It assists all patients who need and request guidance through the health care delivery system, or offers assistance with eye-related personal problems. Referral to other agencies for help in nutrition, shelter, and other life problems is accomplished. A volunteer aide program operates under the supervision of this department.

Student, faculty and volunteers are available to present programs in eye health care to various groups. Most such educational programs are given in The Eye Institute amphitheater through arrangement with schools, civic organizations, and senior citizen groups.

Aside from the critical peer review normally operative in an academic environment, The Eye Institute has established a structured Quality Assurance program. Through records review and other studies, the program monitors and evaluates health services rendered.

Impact on Clinical Education

The impact of The Eye Institute on the student body has been dramatic. Rather than acceptance of clinical assignments as another “course,” students are enthusiastic about participation in a patient care practice which avoids the depersonalization inherent in the institutional “clinic.”

Organization into Primary Care Service Modules closes the feedback loop in the student’s clinical education, allowing them the opportunity to provide a continuum of services to individuals and families. Such patients can then relate to “their doctor” rather than The Institute as a whole. The students are thereby enabled to monitor the outcome of their management plans.

Reinforcing and supporting the student clinician’s ability to provide continuity of care is the fact that a total range of ambulatory eye services is available under one roof. By retaining supervisory management of the patient within a single “system,” the clinician is assured of receiving consultants’ reports as input to his/her decision-making process. The presence of the wide variety of primary and secondary service activities also serves to broaden the students’ clinical interests. Their rotations through the various services and participation in many ancillary activities provide exposure to all aspects of eye care practice.

The Eye Institute’s success in enhancing the clinical education of student optometrists grows out of two premises upon which all planning is based:

While the Pennsylvania College of Optometry operates The Eye Institute as a teaching facility, patient care is co-equal with education as its mission. The guiding principle here is the conviction that only in the context of an excellent patient care delivery system can future optometrists receive clinical experiences of high quality. The Eye Institute may be regarded as being analogous to a teaching hospital affiliated with a medical school.
A team of health care professionals – optometrists, ophthalmologists, opticians, technicians, and consultants in other specialties – must work cooperatively at the highest level of their training and competence, with the visual welfare of their patients as their highest priority.

The improvement in the clinical education process will become evident as PCO’s graduates enter private practice and public health optometry, striving to emulate the scope and quality of work they experienced in The Eye Institute.

Charles F. Mullen, O.D.
Journal of Optometric Education
Volume 4, Number 1, Summer 1978