Rehab field starting to open eyes to problem of visually impaired
Medicare coverage paves way for low vision programs
Interest is growing in a relatively new field in rehab: providing help for visually impaired patients. But experts in the field say low vision rehab programs aren’t growing nearly fast enough to come to the aid of the estimated 14 million Americans who have vision problems not correctable by standard glasses, contact lenses, medicine, or surgery.
Many programs exist to help those who are totally blind, but those who have some vision often are forgotten. "There’s an ever-growing number of people with vision problems that can’t be cured. They’re just thrown on the scrap heap of life," says Don Fletcher, OD, director of the new Center for Low Vision Rehabilitation at the University of Alabama at Birmingham (UAB). "Ophthalmology has been a little slow getting to rehab. There is a tremendous need for this type of service, and Medicare coverage is past due."
Michigan in 1997 became the first state to offer Medicare coverage for low vision rehab, and by 2002, about half the states had followed suit. On May 29, 2002, physician-prescribed rehabilitation services for Medicare beneficiaries who are blind or visually impaired became a nationally covered service. Fletcher and his colleagues at the American Academy of Ophthalmology were delighted to learn that their 15 years of lobbying for vision rehab coverage had finally paid off.
Now it’s up to the rehab field to fill the void, says Fletcher, who began providing vision rehab services to his own patients in the 1980s despite the lack of Medicare coverage. "You might say I did it as a hobby — an expensive hobby," he says. But now Fletcher’s getting paid for his expertise at UAB, where the new low vision rehab program opened its doors in February.
Fletcher’s model uses a multidisciplinary team approach including ophthalmology, optometry, occupational therapy, and psychology. Occupational therapists (OTs) play a big role at UAB, which recently became one of the only OT schools in the country to offer vision rehab as part of its standard curriculum. "OTs are relative newcomers to the field, but they are wonderful because they are creative problem-solvers," Fletcher says.
Another hallmark of the program is the use of the latest, most advanced electronic devices available. UAB has the only scanning laser ophthalmoscope in Alabama. The center also uses the Dynavision 2000, which trains patients to understand and cope with their vision loss, and the Jordy, a portable distance magnifier worn in front of the eyes. The Jordy is named for the blind Star Trek character.
But just as important as the high-tech gadgets is the involvement of rehab psychologists. "I’ve been doing this for 17 years, and I know that all the magic I can do doesn’t cure depression and anxiety," Fletcher says. "The psychological impact is a huge component of vision loss. It’s scary to lose your vision."
Fletcher’s program is one of only a handful of low vision rehab programs in the country, despite the fact that the prevalence of visual impairment in the United States is greater than stroke and lower extremity amputation combined. Rehab programs for stroke victims and amputees abound, but the visually impaired aren’t so lucky.
And even if they are offered service, it’s more along the lines of being handed a magnifying glass, says Sameena Malhan, MD, medical director for the SSM Visual Rehab Program at the DePaul Health Center in Bridgeton, MO. "That’s like giving an amputee a prosthesis and sending him home," says Malhan. "We give amputees a lot of rehab — physical therapy, gait training, etc. — but we offer virtually nothing for the visually impaired."
The SSM Rehab program is multidisciplinary, using the skills of Malhan, a physiatrist with a background in ophthalmology, as well as an occupational therapist, a physical therapist, a social worker, and a neuropsychologist. "We’re not just looking at the visual problems; we look at the patient as a whole," Malhan says. "Our mission is to use our tools and our training to help each patient function at the highest level possible at home and in the community. We want to increase their usable vision, decrease their disability, and train them in how to use visual aids."
Malhan and the staff at SSM Rehab assess each patient to determine his or her functional visual skills and which strategies, techniques, and devices might best fit the patient’s needs. "We ask them what their main goals are and work from that," Malhan says. "If a patient says her main problem is reading labels at the grocery store, we find her a hand-held magnifier for her purse. If another patient says he likes to eat in restaurants but can’t read the menu, we’ll get him a magnifier with a light incorporated."
Solving problems like those is right up an occupational therapist’s alley, and that’s why OTs are perfect for low vision programs, says Pam Roberts, MHSA, OTR/L, manager of quality, education and research in the Department of Rehabilitation and Post-Acute Care at Cedars-Sinai Medical Center in Los Angeles. "We [OTs] started our inpatient low vision program about six years ago with our neurologic patients because we were seeing that a lot of their problems were vision-related," Roberts says. "If a person can’t see, they can’t do their daily activities."
The biggest hurdle Roberts and her colleagues faced was finding optometrists who were trained to work with neurologically involved patients and who bought into the idea of low vision rehab. "When we first started, we had some resistance from the medical division of optometry," Roberts says. "They had no idea what we were talking about. They said, You can’t do anything for those patients.’ It was a whole education process, and it took two years to get them on staff."
The education process went both ways: OTs taught the optometrists how to deal with disabled patients, and the optometrists gave the OTs recommendations to help patients with daily activities and self-care routines. "We had to show them how to move a patient because they were used to patients walking into their office," Roberts says. "We talked to them about our different diagnostic groups and the problem areas common to those patients. They did a lot of education back to us as well. It has been a major collaboration." The OTs and optometrists continue to meet on a quarterly basis to work out operational issues and discuss ways to make the system more efficient.
Cedars-Sinai has a structured program in which OTs do initial evaluations and vision screens, and optometrists on a rotating panel come in for a regularly scheduled vision clinic to give orders for patient treatment plans. "A unique feature of our program is that we incorporate vision treatment early on in our neurologic population while patients are still in the hospital," Roberts says. "A lot of people just do that on an outpatient basis, but we try to catch problems early so patients can return to their daily activities quicker. It’s important to have vision be part of the overall treatment plan."
Interest is growing in a relatively new field in rehab: providing help for visually impaired patients. But experts in the field say low vision rehab programs arent growing nearly fast enough to come to the aid of the estimated 14 million Americans who have vision problems not correctable by standard glasses, contact lenses, medicine, or surgery.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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