South West LHIN Vision Care Project. The Future State of Vision Care. Backgrounder. March 17, 2015

Transcription

1 South West LHIN Vision Care Project The Future State of Vision Care Backgrounder March 17, 2015 This is an abridged and updated version of the January 2015 Future State of Vision Care Discussion Paper and is a complementary document to the Final Project Report It is a report that provides details to support the Future State of Vision Care, Final Project Report, March 17,

2 Table of Contents Introduction... 3 Ontario s Age structure by South West LHIN Demographics... 5 Diabetes and eye care an important population health factor in planning for the future... 6 Screening for vision care and follow-up treatment... 8 Teleophthalmology, e-consults and ClinicalConnect Indigenous Peoples Access to Services and Care General or Comprehensive Ophthalmology Access to Emergent and Urgent Ophthalmology Services Future Location of Comprehensive Ophthalmology Services Comprehensive Ophthalmology - Scope of Practice The Future of Specialized Ophthalmology Services in the South West LHIN Medical Education and the Training of Future Ophthalmologists The Future State of Cataract Surgery A population-based approach to assessing the current and future need for cataract surgery Equitable distribution of cataract surgeries a population based model Access to Care Wait List management Cataract Surgery opportunities for standardization and process improvement Pre-anesthesia, pre-procedural patient information gathering The Use of Anesthesia Opportunities to reduce day of surgery waits for patients Cataract Surgery and Patient Satisfaction Cataract Surgery and Patient Information The Future State of Quality Indicators System Leadership planning and responding to the Future of Vision Care Services Appendix A: Diabetes Education Programs South West LHIN Appendix B: Eye health and diabetes Appendix C: MOHLTC Policy and Procedure Manual for Diabetes Education Programs (excerpt) Appendix D: International Clinical Diabetic Retinopathy Disease Severity Scale, Appendix E: Ophthalmology on-call data summary, April-may Appendix F: Cataract Surgery Process Mapping Results Appendix G: COS evidence-based clinical practice guidelines for cataract surgery in the adult eye Appendix H South West LHIN Cataract Surgery Patient Satisfaction Survey, 2015 Appendix I Listing of Competencies for Comprehensive Ophthalmologists as defined by the Royal College of Physicians and Surgeons of Canada, 2012, Editorial Revision 2013; Version 1.1 Appendix J Summary of Feedback to the Future State Discussion Paper, January 2015 Appendix K List of project participants Appendix L Cataract Surgery Patient Information Guide (not attached) 2

3 Introduction This report builds on the work done to develop the Current State of Vision Care report (July 2014) and is a backgrounder to the Future State of Vision Care Final Project Report, March 17, The content is primarily the same as was contained in the January 2015 document, The Future State of Vision Care Discussion Paper. It has been amended to take into account feedback received to the Discussion Paper see Appendix K for details. Project Objectives To assess current state of vision care with a focus on ophthalmology and the role of cataract surgery To develop future state recommendations that will ensure: o Equitable distribution and access to comprehensive eye care services - including elective and emergent/urgent care o Application of clinical guidelines and best practices o Population-based allocation of resources to address future needs o Improved communication among primary care, optometry and ophthalmology physicians o Effective linkages between screening/monitoring and follow-up treatment o Provision of cataract surgery within Quality Based Procedure Funding (QBP) o Regional access to sub-specialty ophthalmology services The major topics and themes addressed in this report are as follows: Impact of demographic changes Diabetes and eye care population health o Screening and follow-up treatment Access to services and care o Comprehensive and specialized ophthalmology o Leveraging technology teleophthalmology, econsults and ClinicalConnect Future state of cataract surgery o Population-based approach to assessing current and future need o Wait list management o Opportunities for standardization and process improvement Quality indicators System Leadership 3

4 Ontario s Age structure by By 2036, there will be more people in every age group in Ontario compared to 2012 and the aging of Ontario s population will accelerate. Figure 1.0 From 2012 to 2036 the median age of Ontario s population is projected to rise from 40 years to 43 years with the median age for women climbing from 41 to 44 years and from 39 to 43 years for men. The number of seniors aged 65 and over is expected to more than double from about 2.0 million, or 14.6 per cent of the population in 2012, to almost 4.2 million, or 24.0 per cent of the population, by By 2016, for the first time, seniors will account for a larger share of population than children aged By the early 2030s, once all baby boomers have reached age 65, the pace of increase in the number and share of seniors is projected to slow significantly from an average of 3.5 per cent over to less than 1.8 per cent by the end of the projection period. This age group will continue to grow much faster than the 0 14 and age groups. The number of people aged 75 and over is projected to rise from 910,000 in 2012 to more than 2.2 million by The 90+ group will more than triple in size, from 96,000 to 291, Ministry of Finance, Ontario. Ontario Population Projections Update, ,

5 South West LHIN Demographics While the population of the South West LHIN (from a county perspective) is expected to grow by 16.1% over the next 24 years (primarily in Middlesex County and the City of London) the percentage of seniors is estimated to grow to 27% of the total population over this same time period. The expected impact of having a larger elder population will be particularly pronounced in rural counties. For example, the population of Bruce County is expected to grow from 67,500 in 2012 to 68,960 in 2036 an increase of only 2.2% but in that same timeframe the number of seniors (65+) is expected to grow from 14,310 to 23,080 an increase of 12.3% (from 21.2% to 33.5% of the total population) 2. Table 1.0 South West LHIN Population Projections by County 2012 and 2036 County 2012 Population 2012 Number of Seniors (%) 2036 Population (Growth %) 2036 Number of Seniors (%) Grey 96,520 20,340 (21.1%) 105,160 (+9.0%) 35,820 (34.1%) Bruce 67,500 14,310 (21.2%) 68,960 (+2.2%) 23,080 (33.5%) Huron 60,500 11,750 (19.4%) 57,740 (-4.6%) 18,690 (32.4%) Perth 77,030 12,740 (16.5%) 76,110 (-1.2%) 22,940 (30.1%) Oxford 108,780 18,160 (16.7%) 113,510 (+4.4%) 33,060 (29.1%) Elgin 91,130 14,030 (15.4%) 101,850 (+11.8%) 26,980 (26.5%) Middlesex (includes 463,710 67,660 (15.6%) 596,940 (+28.7%) 141,680 (23.7%) the City of London) TOTAL 965, ,990 (16.5%) 1,120,270 (+16.1%) 302,250 (27.0%) Source: Ontario Ministry of Finance, Population Projections, Spring 2013 Implications of the future population on the need for surgical ophthalmology The following table shows the forecast number of adult inpatient and day surgery Ophthalmology cases for South West LHIN residents in five, 10 and 15 years. The forecast is based on demographic growth and assumes disease prevalence and treatment intensity will not change. The number of procedures are divided into four levels of increasing complexity. Levels one and two differ mainly in the amount of equipment required. Cataract surgery is separated out as it is the most common procedure done. Level three are less routine procedures done by both general Ophthalmologists and subspecialists. Level four cases are generally done by Ophthalmologists with subspecialty training. Table 2.0 legend Level 1 procedures are usually done by a general or comprehensive ophthalmologist Level 2 procedures are usually done by a general or comprehensive ophthalmologist Some Level 3 procedures could be done by a general ophthalmologist ; others are usually, although not exclusively, done by a subspecialist or fellow with supervision Level 4 procedures are done by a subspecialist in context of special equipment or operating room setting 2 Ontario Ministry of Finance, Ontario Population Projections Update,

6 Table 2.0 Forecast of Surgical Ophthalmology Cases for Adult South West LHIN Residents Procedure Level 2012/ / / /28 % Change 2012/13 to 2027/28 Level % Cataract Extraction 9,573 10,982 12,751 14,604 53% Level % Level % Level 4 1,101 1,232 1,370 1,505 37% TOTAL SW LHIN 11,427 13,040 15,039 17,125 50% 5 year % increase 14% 15.5% 13.8% - - Source: IntelliHealth DAD, NACRS DS, MOF Population Projections (Provided by Preyra Solutions Group) The most significant surgical ophthalmology growth is in cataract surgery where a 53% increase is forecast. Increases in the other cases, especially in raw numbers are relatively modest. Overall, a 50% increase in surgical ophthalmology cases over the next 15 years is forecast with the major determining factor being the growing number of elders. Information on paediatric cases shows the volume of cases by both procedure and Level will likely remain relatively stable. Strabismus will continue to be the dominant paediatric surgical intervention. The ability to address current and future paediatric ophthalmology requirements needs to be maintained. Diabetes and eye care an important population health factor in planning for the future Incidence of diabetes Canada s National Surveillance System notes a significant increase in the incidence of diabetes 3. The incidence and prevalence of diabetes in Canada are projected to increase steadily due to demographic trends, including an aging population and high rates of obesity. The prevalence of diabetic retinopathy (DR) is projected to increase as the prevalence of diabetes increases. This has important implications for healthcare human resources and costs, and potential policy implications. Aboriginal populations in Canada are disproportionately affected by diabetes and DR. Strategies are needed to provide culturally appropriate programs to prevent, screen, and treat diabetes and DR in these populations, who often reside in remote and underserviced areas. DR remains the leading cause of legal and functional blindness for persons in their working years (ages 25 75) worldwide 3 Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of diabetic retinopathy[can J Ophthalmol 2012;47:1 30] All authors were members of the Canadian Ophthalmological Society Diabetic Retinopathy Clinical Practice Guideline Expert Committee. 6

7 Table 3.0 Proportion of Ophthalmology Surgery Cases with D iabetes Diagnosis, South West LHIN Procedure Level * Level 2, Cataract Extraction Level / / / / /13 Total Cases 10,418 9,871 9,983 9,937 9,572 Cases with Diabetes 1,636 1,471 1,500 1,618 1,448 Proportion of Total Cases with Diabetes 16% 15% 15% 16% 15% Total Cases Cases with Diabetes Proportion of Total Cases with Diabetes 5% 7% 9% 7% 6% Total Cases 1, ,030 1,059 1,011 Level 4 Cases with Diabetes Proportion of Total Cases with Diabetes 26% 25% 28% 27% 26% Source: DAD, NACRS DS, 2012/13 provided by Preyra Solutions Group under contract * Level 2, Other these cases have been excluded from this table since most are done in clinic and are therefore not documented in DAD or NACRS. Examples of Level 2-Other category include prosthetic lens insertion, iridectomy/iridotomy, laser coagulation, surgical synechiolysis, corneal excision, scleral wound repair, lens explantation, canilicular repair. Excluding medical ophthalmology cases, people with diabetes within the South West LHIN account for about 15% of all cataract cases, 7% of all Level 3 surgical cases and 26% of all Level 4 surgical cases. Diabetes plays a significant role in the overall demand on vision care services. There are opportunities to improve prevention and screening, as well as anticipate the future demand for treatment. Future State Recommendation 1.0 Future demand for ophthalmology and related vision care services should use a population-based approach with particular attention to changes in the seniors population and people living with diabetes. Target of Recommendation: South West Local Health Integration Network (South West LHIN) Ontario Ministry of Health and Long-Term Care (MOHLTC) Financial and Resource Impact: Reallocation of resources based on population and investment of resources to address increased needs Intended Outcome: Vision care services will be available to address future needs of the population, especially the growing number of seniors and people living with diabetes. Return to Table of Contents 7

8 Screening for vision care and follow-up treatment Introduction Evidence provided by the Canadian Ophthalmological Society called Canadian Ophthalmological Society evidence-based clinical practice guidelines for the periodic eye examination in adults in Canada (2007) 4 notes vision screening is of limited value if symptoms are not present. A recent study showed that the majority of people identified with a decrease in visual acuity had noted it themselves before presentation for an ocular examination. Less than 1% of the study population was unaware of this decrease in vision, suggesting that the prevalence of asymptomatic or unrecognized ocular disease remains very low. Therefore, frequent routine eye examinations of those with initial normal examination results will have a low yield and may not be cost effective. With respect to Patients at higher risk for Visual Impairment the report notes routine screening of high risk and symptomatic patients is of value. For example: Routine screening for asymptomatic retinal tears, holes, and lattice degeneration has not been supported. On the other hand, symptomatic patients and high-risk patients with previous retinal problems, surgery, trauma, posterior uveitis, diabetes and myopia, or myopia greater than 6.00 can benefit from such an examination. The report makes specific recommendations regarding screening for the following eye diseases with higher risk patients: Diabetic Retinopathy, glaucoma, age-related macular degeneration, and cataracts. It should be noted that patient age is a major determining factor in all of these diseases except diabetic retinopathy. This is why the age demographic is so important and why annual eye examinations are recommended for persons over age 65. Some young children, especially some very young children, can be at high risk for vision care problems that can go undetected and undiagnosed. There are several initiatives in place to address this including the Eye See Eye Learn program led by optometrists that targets 3-4 year olds, and the Ivey Special Eye Examination service, the I* S.E.E. Community Vision Screening program that targets very young children children 2-3 years old - led by ophthalmology. The Canadian Ophthalmological Society report goes on to say: Other high-risk categories Other high-risk patients include those with extreme refractive error, high hyperopia or myopia, previous ocular injury, systemic medication (such as hydroxychloroquine, tamoxifen), neurological or neurosurgical disorders, and possibly adults with mental retardation. Given the broad heterogeneity of the high-risk group, screening intervals will vary depending on the underlying cause of visual impairment. The case for screening is particularly important when an ocular disease may be present but not symptomatic. This comment applies to diabetic retinopathy and glaucoma. Glaucoma Primary open-angle glaucoma causes such insidious damage to the optic nerve and vision that few people have early awareness of the condition. This is consistent with the finding that only half of patients are diagnosed in industrialized countries, a number that falls to 10% in developing nations. It is an ideal disorder for screening because it is asymptomatic, typically progresses slowly, and can be effectively treated

9 Diabetic Retinopathy Early detection of DR depends on educating patients with diabetes as well as their families, friends, and health care providers about the importance of regular eye examination even though the patient may be asymptomatic. Patients must be informed they may have good vision and no ocular symptoms, yet may still have significant disease that needs treatment, which depends on timely intervention. 5 VISION SCREENING RECOMMENDATIONS FROM THE CANADIAN OPHTHALMOLOGICAL SOCIETY, Screening intervals in the asymptomatic low-risk patient Age years: at least every 10 years [Consensus] Age years: at least every 5 years [Consensus] Age years: at least every 3 years [Consensus] Age > 65 years: at least every 2 years [Level 1 ] 2. Screening in symptomatic patients Any patient noting changes in visual acuity, visual field, colour vision, or physical changes to the eye should be assessed as soon as possible [Consensus]. 3. Screening intervals in high-risk patients Patients at higher risk of visual impairment (e.g., those with diabetes, cataract, macular degeneration, or glaucoma [and glaucoma suspects], and patients with a family history of these conditions) should be assessed more frequently and thoroughly. Age > 40 years: at least every 3 years [Consensus] Age > 50 years: at least every 2 years [Consensus] Age > 60 years: at least annually [Consensus] DIABETIC RETINOPATHY (DR) SCREENING RECOMMENDATIONS FOR PERSONS WITH DIABETES FROM THE CANADIAN OPHTHALMOLOGICAL SOCIETY, For individuals with type 1 diabetes diagnosed after puberty, screening for DR should be initiated 5 years after the diagnosis of diabetes [Level 1]. For individuals diagnosed with type 1 diabetes before puberty, screening for DR should be initiated at puberty, unless there are other considerations that would suggest the need for an earlier exam [Consensus]. 2. Screening for DR in individuals with type 2 diabetes should be initiated at the time of diagnosis of diabetes [Level 1]. 3. Subsequent screening for DR in individuals depends on the level of retinopathy. In those who do not show evidence of retinopathy, screening should occur every year in those with type 1 diabetes [Level 2] and every 1 2 years in those with type 2 diabetes [Level 2]depending on anticipated compliance. 4. Once NPDR [Nonproliferative diabetic retinopathy] is detected, examination should be conducted at least annually for mild NPDR, or more frequently (at 3- to 6-month intervals), for moderate or severe NPDR based on the DR severity level [Level 2]. There is clear evidence to support targeted vision screening of high risk populations and symptomatic groups. The course of treatment will vary according to the specific eye disease involved. 5 Screening for Diabetic Retinopathy- 2014, American Academy of Ophthalmology, Quality of Care Secretariat, Hoskins Center for Quality Eye Care October

10 Future State From a future state perspective, primary health care providers are in the best position to identify high risk groups and determine the need for vision assessment and should do so in a systematic and routine way. When children are involved this should be expanded to include pediatricians. Health Quality Ontario in its report, Primary Care Indicators 6 listed the following as one of 16 primary care indicators: Percentage of diabetics with eye care visits with an optometrist or ophthalmologist within 1 year. They have targeted primary care as the accountable group and have set a target of 80%. The current rate is 50% for the province as a whole and it is 56.5% for the South West LHIN(2011/12). To quote from the report: Despite its proven benefits, about half of Ontarians did not receive regular screening for this preventable complication within a year, as recommended by clinical practice guidelines and the oneyear screening rates stayed relatively stable over the last eight years. While almost 66% of diabetic patients aged 65 and older had an eye examination, only 42% of patients aged had it. The rates did not vary by gender, neighbourhood income quintile, immigration status or rural/urban location. Future State Recommendation 2.1 Steps should be taken to reinforce and support the need for regular eye examinations by high risk groups to primary health care providers, in keeping with the recommendations of the Canadian Diabetes Association, the Canadian Ophthalmological Society and Health Quality Ontario. Future State Recommendation 2.2 Standard vision screening information and questions should be integrated into primary health care Electronic Medical Records (EMR) so determination of the need for vision screening and referral of high risk populations for eye vision examination can become a routine part of primary care practices. Future State Recommendation 2.3 In addition to high risk groups, promotion of vision screening of young children and all children before they begin school (Junior Kindergarten) should be a routine part of primary health care practices. Target of Recommendation: Primary health care providers within the South West LHIN Primary health care physician leads South West LHIN Pediatricians ehealth office South West LHIN South West LHIN Financial and Resource Impact: Cost of assessing current state of EMR re: vision assessment Cost of developing standard clinical vision assessment tool for use in EMRs Intended Outcome of Recommendations 2.1 and 2.2: High risk populations will be reminded of the need for regular vision examinations, and referrals for vision exams will be made on a consistent basis ensuring that eye problems are detected and addressed early on in any disease process. Return to Table of Contents

11 Access to vision services for high risk populations Both optometrists and comprehensive ophthalmologists provide comprehensive eye examinations. Depending on a patient s needs, eye examinations and on-going monitoring may be done by an optometrist or a comprehensive ophthalmologist. Where an eye condition or disease is involved, they often share responsibility for the same patient called co-management where there is on-going dialogue between the optometrist and ophthalmologist. Optometrists Optometrists are widely distributed across the South West LHIN and have offices in 21 communities according to information obtained from the College of Optometrists of Ontario. [see Figure 2.0 for details] While part of their work focusses on assessing the type of lenses needed to correct vision, they also have the skills, training and equipment to do comprehensive vision examinations, disease screening and monitoring, and the diagnosis and treatment of eye conditions within their scope of practice. Many people routinely see an optometrist to have their vision corrected through the prescription of lenses, this provides the opportunity for these individuaqls to have their eyes assessed, screened and monitored for other eye conditions. A formal referral is not needed to see an optometrist. People can simply call and make an appointment for an eye examination. Ophthalmologists Comprehensive ophthalmologists are found in larger population centers across the LHIN (see Fig 2). Ophthalmologists can also provide comprehensive eye examinations and screen patients for eye disease especially if they have co-morbidities or other eye conditions. They provide on-going monitoring for individuals with eye disease as well as medical treatment and surgical care of all eye conditions. In some situations, Ophthalmologists will work with Optometrists to provide ongoing care for persons with stable eye disease. Access to Ophthalmology services is obtained by referral from a primary care physician or an Optometrist or through the emergency departments of hospitals throughout the LHIN. OHIP coverage of vision services Eye Care Services Covered by the MOHLTC through Ontario Health Insurance Plan (OHIP) fees (from the MOHLTC web site dated April 2013) People 65 years and older and those younger than 20, are covered by OHIP for a routine eye examination provided by either an optometrist or physician once every 12 months plus any follow-up assessments that may be required. Insured persons aged 20 to 64 years with specified medical conditions affecting the eye can receive an OHIP insured regular eye examination once every 12 months. Insured persons aged 20 to 64 with any of the following conditions can go directly to their optometrist or physician to receive an OHIP insured eye examination: diabetes mellitus, glaucoma, cataract, retinal disease, amblyopia, visual field defects, corneal disease, strabismus, recurrent uveitis or optic pathway disease. In the recent Ministry publication, Quality-Based Procedures Clinical Handbook for Integrated Retinal Care (December 2014) a regular eye exam by an optometrist or ophthalmologist, for the purpose of retinal screening is listed as including the following: o Vision o Intraocular Pressure o Anterior segment and Lens exam o Dilated Fundus exam with slit lamp biomicroscopy and/or indirect ophthalmoscopy Barriers The absence of coverage for routine eye examinations for individuals aged is a significant perceived barrier for access to eye care. Although coverage is available to those with disease, most are unaware of this and may not seek care. Screening for disease in low risk populations does not occur unless there is third party coverage. 11

12 There is also a financial barrier if specific tests are undertaken that are not covered by OHIP. For example if an optometrist performs an Optical Coherence Tomography scan (OCT) or takes a retinal photograph it is not covered by OHIP and therefore the patient is charged a fee. Since neither test is currently part of a regular or comprehensive eye exam as defined by OHIP, the fees charged may create a barrier as they are not inconsequential. In contrast, OCTs are covered by OHIP when used in the management of eye disease by an Ophthalmologist. In general, those living in poverty, and many people who are living with disabilities live in poverty, have a difficult time accessing health care and following up on medical directives, especially if they require transportation and out-of-pocket expenses. It s one of the reasons why home-based care is so successful it removes an access barrier that would otherwise be present. As an example of addressing this, the Southwestern Ontario Aboriginal Health Access Centre s diabetes educators make home visits to their clients. There is clear evidence that some at risk populations in the South West LHIN are not getting the recommended frequency of regular eye exams. Future State Recommendation 3.1 All people who are eligible to receive OHIP funded regular eye exams as defined by Canadian Ophthalmological Society (COS) clinical guidelines should do so. Information about the importance of regular eye exams for very young children and high risk groups should be readily accessible through each ophthalmologists, primary care physicians and optometrist s office literature and web site information. Target of Recommendation: Optometrists within the South West LHIN College of Optometrists of Ontario Ophthalmologists in the South West LHIN Primary care physicians Financial and Resource Impact: Financial impact for patients whose optometrists include non-ohip tests and therefore fees as part of their routine eye examinations. Intended Outcome: People who are at high risk will receive regular vision examinations at no direct cost. 12

13 Figure 2.0 Port Elgin Optometrist practice locations Diabetes Education Program locations Ophthalmologist practice locations Muncey West Lorne Dutton Southwold Aylmer 13

14 Vision Monitoring and Management of Diabetes Once a patient is diagnosed with diabetes, a number of primary and specialized health service providers may become involved in their care depending on the type of diabetes they have, their age and other complications or co-morbidities. Monitoring for signs of the onset of Diabetic Retinopathy is one of a number of tests a person with diabetes needs to undertake on a regular basis following diagnosis to monitor and address complications associated with their diabetes. All optometrists and comprehensive ophthalmologists are well positioned to undertake this role and can schedule regular recall vision examinations after a person with diabetes comes to their attention 7. When this monitoring is being done by an optometrist, they can refer patients to an ophthalmologist when appropriate. In the case of Diabetic Retinopathy a patient should be referred when they have Moderate Non-proliferative Diabetic Retinopathy or greater. Future State of vision examinations and monitoring for people with diabetes Context Primary health care providers assume responsibility for the clinical and medical health of their patients before and after they are diagnosed with diabetes. If there are complications or the situation is complex (involving Type 2 diabetes for example), this role may be taken on by a specialist such as an endocrinologist, with communication going back to the primary health care provider. It is worth noting that family physicians who participate in Family Health Teams are offered a financial incentive to reinforce patients with diabetes getting regular eye exams. As part of billing for comprehensive diabetic care they have to record the date of the most recent eye exam and determine if an eye assessment is required in order to be compensated. Primary responsibility for providing on-going eye care for a person with Type 1 diabetes very often involves an optometrist or comprehensive ophthalmologist with their primary care physician assisting by ensuring that eye examinations occur at recommended intervals. There needs to be on-going communication and information sharing (at no charge to patient or care providers) between the patient s primary care provider and their eye specialist i.e. their optometrist and/or ophthalmologist. From a future state perspective the front line of diabetes care and pre-diabetes diagnosis most often rests with primary care providers with diabetes education programs providing a follow-up and complementary role by educating people about the nature of the disease and how to self-manage. Both are well positioned to inform and educate people about the potential impact of diabetes on eyes, the need for regular eye examinations and to recommend or refer most people with diabetes especially Type I and asymptomatic individuals - to an optometrist or comprehensive ophthalmologist for Diabetic Retinopathy screening. In situations in which an endocrinologist is providing care, they can also reinforce the need for regular eye exams. In some instances in the South West LHIN, diabetes education programs contact an optometrist to let the optometrist know that a client has been referred or recommended to them. As a follow-up the optometrist can then contact the client to arrange an appointment for them to be seen. This pro-active step helps to reduce the risk someone will not follow through on the recommendation to have their eyes checked. This practice is recommended for all diabetes education programs as well as primary care. 7 See Appendix D for a profile of the International Clinical Diabetic Retinopathy Disease Severity Scale (2002). 14

15 Future State Recommendation 4.0 To support on-going awareness and communication, all diabetes education who are educating people with diabetes should: Maintain communication with local comprehensive ophthalmologists/optometrists regarding their clients (with appropriate client consent) to help reinforce that follow-up appointments are being made and kept Inform local ophthalmologists and optometrists about their service, upcoming diabetes education sessions or classes (as applicable) so they can reinforce the importance of diabetes education Target of Recommendation: South West LHIN diabetes education programs South West LHIN Primary Care /Chronic Disease Prevention and Management Lead Primary care providers within the South West LHIN Primary care physician leads South West LHIN Ophthalmologists in the South West LHIN Optometrists in the South West LHIN Financial and Resource Impact: Allocation of time required to maintain open communications but no additional financial resources Intended Outcome: All people with diabetes will be consistently referred for and receive a regular eye examination. Future State Recommendation 5.1 It should be a standard operating procedure for primary and community health care providers, and specialists such as endocrinologists who care for patients with diabetes, to refer them to comprehensive ophthalmologist or optometrist for on-going eye care and regular comprehensive eye examinations according to COS recommendations. Once seen by an eye care specialist it would be the eye care specialist s responsibility to indicate the desired frequency of follow-up and communicate this to the primary care physician to ensure follow-up occurs. Future State Recommendation 5.2 Ophthalmologists and optometrists should provide primary care providers, specialists and diabetes education programs information on a patient s eye care (with appropriate consent from the patient) and this should include and this should include relevant status of the eyes and the optimal time for follow-up. Future State Recommendation 5.3 Local diabetes education programs, local ophthalmologists and optometrists with leadership being provided by the South West LHIN Primary Care /Chronic Disease Prevention and Management Lead should work together to raise public awareness about the importance of people with diabetes having a routine diabetic eye examination on a regular basis. This message may be effectively communicated by many others who are in a position to work with people with diabetes; primary health care providers and teams such as Family Health Teams and Community Health Centres, Health Links initiatives, hospital staff, hospital newsletters and web sites. Target of Recommendation: South West LHIN diabetes education programs South West LHIN Primary Care /Chronic Disease Prevention and Management Lead Other diabetes education programs in the South West LHIN Primary care providers within the South West LHIN Primary care physician leads South West LHIN South West LHIN optometrists 15

16 South West LHIN ophthalmologists Canadian Diabetes Association Financial and Resource Impact: Allocation of time required Financial resources to support public education Intended Outcome of Recommendations 5.1, 5.2 and 5.3: All people with diabetes will know about the importance of having regular eye exams. There will be consistent information sharing among professionals who are working with the same patients/clients to ensure they all have an on-going understanding of the person s eye care needs. Return to Table of Contents Teleophthalmology, e-consults and ClinicalConnect In general, technology is making communication and information sharing easier. However, given the need to protect privacy and ensure electronic communication of patient information is secure, health care is an example of a sector that generally lags others. Steps that were taken to create firewalls to protect information now have to be addressed in new and creative ways in order share information between organizations and providers with different systems. It s not an easy process but important steps have and are continuing to be taken to enable information sharing while at the same time maintaining a high level of technical security and privacy. Teleophthalmology is a tool that has been successfully used to address access to ophthalmology issues, especially from a geographic perspective. It allows information and digital images to be uploaded to a secure web site and read by an ophthalmologist for consultation. In some jurisdictions, especially remote, isolated ones, teleophthalmology is used to screen people for diabetic retinopathy. This is not a substitute for a comprehensive, in person assessment but it allows screening to occur that might otherwise not be possible or realistic. In Ontario the diversity of both provider and hospital-based information systems makes it a particularly challenging environment in which to develop and apply integrated health information systems. Within the South West LHIN, while there are other barriers, there is no evidence to suggest geographic access is a barrier to using local optometry or ophthalmic services. econsults operates the same way as teleophthalmology except it s a generic tool and is not discipline or condition specific. It s most commonly used by primary care providers to seek direction from a specialist about how to treat a patient and to help them decide whether a referral is needed and at what level of urgency. econsults is a secure system that also allows files to be attached. As part of a provincial demonstration project, a number of primary care providers and specialists in the London area (and elsewhere in Ontario) are using this technology in 2015 and assessing its impact and usefulness. If successful it may become available on a province-wide basis. This tool may be helpful to supporting collaboration among primary care providers, optometrists and ophthalmologists. As an initial step it is proposed that it be used to facilitate collaboration between comprehensive ophthalmologists and ophthalmic sub-specialists. In addition to econsults there is a related initiative called ClinicalConnect 8 that is currently being implemented across the four LHINs in Southwestern Ontario (LHINs 1, 2, 3 and 4). Clinical Connect provides secure access to current patient specific information that can be used by approved providers to obtain information from multiple sources about a specific patient. This offers an important opportunity for health care providers to share current information they might not otherwise be able to access. 8 For more information about ClinicalConnect visit the following web site: 16

17 Future State Recommendation 6.1 Assuming the current econsult demonstration project is successful, ophthalmologists in the South West LHIN should take steps to test the usefulness of econsults to support and foster clinical collaboration. Future State Recommendation 6.2 The current implementation of ClinicalConnect that allows secure sharing of patient specific information among approved health care providers, should be used as an additional opportunity to share information and coordinate care among providers and should, as an initial application, be used between comprehensive and sub-specialty ophthalmologists. Target of Recommendation: Ophthalmologists in the South West LHIN Ophthalmologists outside the South West LHIN who refer patients South West LHIN sub-specialists Financial and Resource Impact: It is expected that econsults and Clinical Connect will be provided with no user fees It is expected that ophthalmologists will be compensated for participating and/or providing econsult based advice Intended Outcome: Comprehensive and sub-specialist ophthalmologists will be able to share patient specific information with each other in a secure and timely manner and thereby support and foster collaboration and shared clinical decisionmaking. Return to Table of Contents Indigenous Peoples Indigenous refers any person who self-identifies as being Aboriginal, including First Nation (status and non-status), Inuit and Métis This section of the report was prepared in partnership with Vanessa Ambtman-Smith, Aboriginal Health Lead for the South West LHIN. Indigenous peoples live throughout the South West LHIN, living within First Nation communities, in rural areas and in urban areas like London and Owen Sound. There are five First Nation communities located in the South West LHIN, three in the southern part of the LHIN (Oneida Nation of the Thames; Chippewas of the Thames First Nation; and Munsee-Delaware Nation) and two in the north of the LHIN (Saugeen First Nation; and Chippewas of Nawash Unceded First Nation). There are many health services that provide care for Indigenous peoples as well culturally appropriate services run by and for Indigenous peoples. Everyone can access provincially funded health care services and other services funded by the Federal government are only available through First nation communities. For example, through the federal government, First Nations and Inuit people are eligible to receive First Nations and Inuit Non-Insured Health Benefits (NIHB). In the area of vision, there are additional services that can be accessed through NIHB that are not available through OHIP; however, there is not always good understanding or recognition of how to bill for NIHB, and sometimes this can pose problems for the patient, who may not be able to cover off any costs upfront. 17

18 Many providers who learn about the NIHB are not familiar with how it works or how to access the resources it offers as it is not a frequent occurrence for many and it is not an easy process to navigate. Providers need to be educated about who to call to access this system on behalf of their patients so they can help them. Fortunately, many Aboriginal Health Access Centres have developed advocacy positions to support clients who may encounter resistance from providers billing through NIHB, or not understanding what is covered, when. It is important that providers know who to contact when there is a need to do so. This is an important example of how the experience and expertise of Access Centres can be used to reduce barriers to eye care. When First Nations people are advised they may have to pay up front, in circumstances when their benefits or NIHB would cover off a fee, many people opt out of an appointment or service. This is an equity concern that needs to be acknowledged, and one that would also probably resonate with other vulnerable groups (e.g. low income; fixed income). The Oneida Nation of the Thames Health Services offers a community diabetes program and diabetes education. Programs are offered by the Southwest Ontario Aboriginal Health Access Centre which has offices in London, Windsor and Owen Sound and by the Chippewas of the Thames in Muncey. To quote: The Southwest Ontario Aboriginal Centre (SOAHAC) provides high quality, holistic health services to on and off reserve, status, non-status, and Metis Aboriginal populations in the Southwest Ontario region. The mission of SOAHAC is to empower Aboriginal families and individuals to live a balanced state of well-being by sharing and promoting holistic health practices. With four locations (two in London, one in Owen Sound and one in Chippewas of The Thames), the Centre strives to ensure that health services are both accessible and culturally appropriate. SOAHAC is proud to offer a comprehensive list of programs including Primary Health Care, Traditional Healing, Mental Health, Diabetes Education, Nutrition & Healthy Lifestyles, Maternal & Child Health, and Supporting Aboriginal Seniors at Home (SASH). Current Development: The SOAHAC in partnership with the South West LHIN, will be leading the development of a current state report, a needs assessment, a report on best practices and readiness assessment as foundational knowledge to be used to support diabetes planning and culturally-appropriate service enhancements/ service model development. This project will provide an opportunity to document unmet needs and to investigate and apply evidence-based practices. Screening for diabetes and its complications Anishnawbe Health Toronto has been a leader in diabetes education and in addition to offering direct services, also undertakes research. One example is their December 2011 report, Urban Aboriginal Diabetes Research Project Report. This report references a number of Aboriginal diabetes resources. [bold added} The National Aboriginal Diabetes Association is an advocacy organization whose website also has useful information focused on the particular issues faced by Aboriginal peoples with diabetes (National Aboriginal Diabetes Association, n.d.). The National Aboriginal Health Organization produces knowledge aimed at overall health promotion, and recently released a toolkit focused on diabetes (National Aboriginal Health Organization, 2011). Health Canada s website provides fact sheets and information about the national Aboriginal Diabetes Initiative including a report on Aboriginal communities in action, which summarizes the work of First Nations and Inuit communities who have developed creative ways to promote healthy lifestyles and reduce the incidence of Type 2 diabetes (Health Canada, 2008; Health Canada, n.d.). More about the Ontario Aboriginal Diabetes Strategy can be found in a publication available online (Ontario Ministry of Health and Long-term Care, 2010). The mission of the Southern Ontario Aboriginal 18

19 Diabetes Initiative (SOADI) is the development, and enhancement of programmes and services focusing on the education, prevention, and management of diabetes in Aboriginal communities, both on and offreserve (SOADI, n.d.). SOADI has generated a vast array of resources, including a variety of prevention workshop materials, toolkits, videos, personal care items, and games provided by their staff that travels throughout the organization s vast service area, which includes Toronto. There is free access to videos they have produced with Aboriginal community members available at the SOADI website, and a number of other items can be purchased online. The same report also undertook a literature review and this is their conclusion: In summary, the rate of diabetes for Aboriginal people is 2-5 times higher than for the overall Canadian population (Oster et al., 2011), and those Aboriginal people who have diabetes tend to have more complications. Past literature has privileged [i.e. tended to focus attention on] First Nations on-reserve. In addition, the literature has focused on biology and genetics. However, there is increasing recognition of the importance of culturally-based, wholistic programmes that incorporate physical, mental, emotional and spiritual well-being. This research addresses the caveats of past literature, focusing on urban Aboriginal peoples (First Nations, Métis and Inuit) with diabetes and explores how to support people in better managing diabetes. From a future state perspective there are opportunities to improve linkages, communications and collaboration between Indigenous peoples health services and primary care providers and both optometrists and ophthalmologists. These opportunities include: Engaging with Aboriginal communities in the South West to listen and learn about the role they could play in preventing vision problems among Indigenous peoples resulting from diabetes and reducing the negative impact of complications when they occur. Developing outreach programs to provide improved access to comprehensive eye examinations when transportation is not available. Undertaking self-education by taking the Indigenous Cultural Competency Training (ICC) course. This initiative is being led by the SOAHAC in partnership with the British Columbia Provincial Health Services Authority. Supported by the MOHLTC and the South West LHIN, is contributing to advancing Aboriginal Cultural Competency across the healthcare system. Delivery of the ICC Program in South Western Ontario will contribute to: o Fostering understanding and connection between the historical and current government practices and policies towards Aboriginal peoples and the related impacts on social determinants of health, access to health services and intergenerational health outcomes; and o Building capacity within South West LHIN providers that will lead to better relationships with Aboriginal clients, patients, caregivers and families The overall goal of advancing cultural competency in the South West LHIN is to contribute to: o o o o Increasing cultural competency across the healthcare sectors in order to better improve health outcomes for Aboriginal peoples Reducing utilization of emergency and acute services Strengthening connections to primary care, community supports the experience of Aboriginal clientele and improving quality of care in the system as a whole 19

20 Future State Recommendation 7.1 Steps should be taken by primary care providers, optometrists and ophthalmologists who serve Indigenous communities to continue to engage with Southwest Ontario Aboriginal Health Access Centre (SOAHAC) and other Indigenous communities to share experiences and learn from one another and thereby develop LHIN respectful partnerships and collaborative practices throughout the South West to address the vision care education, prevention, screening, monitoring and treatment needs of Indigenous Peoples. Future State Recommendation 7.2 Providers who work with Indigenous Peoples on a consistent basis should be supported in taking the Indigenous Cultural Competency Training (ICC) course, to improve their understanding and competency in working with Indigenous Peoples. Target of Recommendation: Southwest Ontario Aboriginal Health Access Centre South West LHIN diabetes education programs South West LHIN Primary Care /Chronic Disease Prevention and Management Lead Primary care providers within the South West LHIN Primary care physician leads South West LHIN South West LHIN optometrists South West LHIN ophthalmologists South West LHIN Financial and Resource Impact: Indigenous Cultural Competency training is available at no direct cost to providers in the South West LHIN Cost of any initiatives that result from the collaboration Allocation of time required Intended Outcome: Positive relationships with indigenous health services will be established that allow culturally sensitive and relevant linkages with eye care specialists to be developed and fostered resulting in improved vision care education, prevention, screening, monitoring and treatment for Indigenous Peoples. Return to Table of Contents 20

21 Access to Services and Care Introduction This section will address: The future need for general or comprehensive ophthalmology services needed to serve the residents of the South West LHIN including: o Number of ophthalmologists o Emergent and urgent services o Location of services o Scope of practice o Configuration of services (partnerships) The future need for specialized ophthalmology services needed to serve the residents of the South West LHIN as well as Erie St. Clair and Waterloo Wellington LHINs including:. o Number of ophthalmologists o Scope of practice o Configuration of services (location, partnerships) The future of research, medical and residency training in ophthalmology at Western University o Research and Innovation o Undergraduate and post-graduate education Post-graduate positions and focus of training o Preparing for the future of ophthalmology Access to Ophthalmology Services - Future State Goal To have the required number of ophthalmologists practicing in the appropriate locations within the South West LHIN, with the required skills and scope of practice, to address future population needs not only within the South West LHIN but all those served by the South West LHIN. The residency program at Western University is able to serve as a future training program for ophthalmologists and in collaboration with other residency programs in Canada, is able to meet the future need for ophthalmologists. Return to Table of Contents General or Comprehensive Ophthalmology In The Current State of Vision Care report a population based methodology was developed and used to estimate the need for general or comprehensive ophthalmologists in the year

22 Table 4.0 South West LHIN Population and Seniors Projections by County 2012 and 2026 County 2012 Total Population (and % LHIN pop.) 2012 Total 65 plus Population (% county pop.) and % LHIN pop. Grey-Bruce 164,020 (17%) 34,650 (21%) 22% Huron-Perth 137,530 (14%) 24,490 (18%) 15% Oxford 108,780 (11%) 18,160 (17%) 11% Elgin 91,130 (9%) 14,030 (15%) 9% Middlesex 78,831 (7%) 11,502 (15%) 7% City of 384,879 (38%) 56,158 (15%) London 35% 2026 Total Population (and % LHIN pop.) 2026 Total 65 plus population (% county pop.) and % LHIN pop. 170,760 (16%) 51,701 (30%) 18% 135,320 (13%) 35,920 (27%) 13% 112,250 (11%) 27,060 (24%) 10% 97,760 (9%) 22,340 (23%) 8% 91,586 (9%) 18,890 (19%) 7% 447,154 (42%) 92,230 (21%) 32% TOTAL (100%) 965,170 (100%) 158,990 (15%) 100% 1,054,830 (100%) 248,141 (24%) 100% Source: Ontario Ministry of Finance, Population Projections, Spring 2013 County of Middlesex population was estimated to be 17% of the Middlesex and City of London population (based on City of London report, Employment, Population, Housing and Non Residential Construction Projections, City of London, Ontario, 2011 Updated June 7, 2012). Estimates made about the number of ophthalmologists needed to serve the South West LHIN assumes seniors will continue to account for the majority of patients served and the current ratio of one ophthalmologist for every 14,000 seniors is realistic and sustainable. There is no expectation in making these assumptions that the scope of practice of ophthalmologists will change significantly over this period of time. What will change is the use and integration of technology into clinical practice and the impact of clinical research in defining best and most appropriate clinical practices. The results of applying these estimates to the South West LHIN (by municipality) are as follows: Table 5.0 Projected number of seniors per comprehensive ophthalmologist in 2026; current and projected number of comprehensive ophthalmologists, per county Grey- Bruce Huron- Perth Oxford Elgin Middlesex City of London TOTAL Seniors (65+) ,701 35,920 27,060 22,340 18,890 92, , Comprehensive Ophthalmologists per 14,000 seniors Current Number (2014) 3 2 3*(2) 1 1 2** 11 Difference (0.1) **

23 Footnote to Table 5.0 * While three comprehensive ophthalmologists are assigned to Oxford County, two work in Oxford County fulltime and one part-time. ** While only two Ophthalmologists practice comprehensive ophthalmology in the City of London an additional two full-time equivalents (FTE) of comprehensive ophthalmology is provided by subspecialists. Given this, the required number of additional comprehensive ophthalmologists is closer to two and a half. ********************************************************************************************* Ophthalmologist roles Some comprehensive ophthalmologists have a general practice while in addition specialize in particular areas of ophthalmology. Some ophthalmologists are sub-specialists (having a fellowship is a specific area of ophthalmology) but in addition to their speciality work also do some aspects of general ophthalmology cataract surgery being a prime example. London-based ophthalmologists tend to be specialists who also do some general ophthalmology work. Assuming this pattern continues into the future, the number of comprehensive ophthalmologists needed in London equivalent to 4.6 additional (full-time) comprehensive ophthalmologists may be addressed by recruiting a combination of comprehensive ophthalmologists and sub-specialists who also do some general ophthalmology work. Based on the information presented in Table 5 an additional 6.6 general or comprehensive ophthalmologists will be needed to serve the residents of the South West LHIN by The Provincial Vision Strategy Task Force in its May 2013 report, A Vision for Ontario: strategic recommendations for Ophthalmology in Ontario, recommended cataract surgery volumes per surgeon range between surgeries per year. If a ratio of 600 surgeries per surgeon is applied to the number of cataract surgeries completed in the South West LHIN in , (approx. 10,000) 16.7 surgeons are needed. There are 11 comprehensive ophthalmologists in the LHIN and 5.7 sub-specialist surgeons are also doing cataract surgeries. Currently 10 surgeons are performing cataract surgeries at St. Joseph s Health Care London, two of which are comprehensive ophthalmologists. If this ratio is applied to the recommended number of cataracts that should be allocated to the South West LHIN using a population-based formula (13,000) then the number of surgeons increases to If it is applied to the projected demand in 2026 (20,000) then the number grows to 33 significantly more than the 17.6 projected to be needed according to Table 5. This suggests there will be a need for sub-specialists to continue doing this work in the future. Overall, the combination of comprehensive and sub-specialist ophthalmologists needed based on cataract surgery volumes only (at 600 per physician) would be 17.6 comprehensive ophthalmologists plus 15.4 sub-specialists. To meet current cataract surgery wait time targets the amount of work each surgeon does and/or the number of available surgeons will need to increase. From a recruitment perspective it might be necessary for current surgeons to take on additional cases in the short term to be able to recruit and transfer a critical volume of cases to a new ophthalmologist. Volume changes and service demands need to be closely monitored by each hospital to assess the appropriate timing of future recruitment. Although this project, within its scope of work, did not have a mandate to directly speak to the function of optometry to address current and future eye care needs, their role has been described as it applies to specific aspects of their work primary eye care, screening and monitoring, for example. What has not been addressed is any detailed investigation of optometry to address the future. Having said this, there is no doubt that they will continue to pay a vital primary eye care role and will increasingly work in collaboration with both primary care physicians and ophthalmologists. 23

24 Future State Recommendation 8.0 One additional comprehensive ophthalmologist will be needed to meet the growing needs of the residents of Grey-Bruce. The equivalent of 4.6 FTE additional comprehensive ophthalmologists [provided by a combination of comprehensive and sub-specialty ophthalmologists] will be needed to meet both the current and future needs of the residents of the City of London due to both growing demand based on population changes The remaining areas of the LHIN, Huron-Perth, Oxford, Elgin and Middlesex need to maintain the current complement of comprehensive ophthalmologists to serve the residents of these areas. Hospitals working in partnership with their ophthalmologists should take the necessary steps to either maintain or grow the number of comprehensive ophthalmologists as defined and to assess the timing for when future recruitment will be needed. Target of Recommendation: The following hospitals and affiliated ophthalmologists: Grey Bruce Health Services St. Joseph s Health Care London Huron Perth Healthcare Alliance Middlesex Hospital Alliance St. Thomas Elgin General Hospital Woodstock Hospital Alexandra Hospital (Ingersoll) Department of Ophthalmology, Western University South West LHIN Financial and Resource Impact: Expansion or reallocation of operating room time and resources, equipment, space and related resources to support and sustain a medical and surgical practice when an additional medical resource is being planned for and added. Intended Outcome: The number and location of practicing comprehensive ophthalmologists will continue to meet the growing needs of the population. Future State Recommendation 9.0 The Department of Ophthalmology at Western University should assist hospitals in the region with recruiting ophthalmologists. Hospitals in the region should make the Department of Ophthalmology aware of their future recruitment needs so they can help influence future career decisions of their post-graduate residents. Target of Recommendation: Department of Ophthalmology, Western University South West LHIN hospitals and affiliated ophthalmologists Financial and Resource Impact: Allocation of time required but no additional financial resources Intended Outcome: A collaborative approach to physician recruitment will help to address local recruitment needs Return to Table of Contents 24

25 Access to Emergent and Urgent Ophthalmology Services Another important component of access to care is the availability of emergency services. All ophthalmologists are trained to assess and treat emergent cases and to refer patients as needed. A key public and community expectation is that ophthalmologists are available to respond to emergencies in other words, to be on-call. At the present time, on-call coverage is provided in a variety of ways. In Owen Sound three ophthalmologists share call and provide 24x7, 365 coverage In Stratford two ophthalmologists share call and provide 24x7, 365 coverage In Woodstock two ophthalmologists share call and provide 24x7, 365 coverage A St. Thomas and a Simcoe-based ophthalmologist share call and thereby provide 24x7, 365 coverage In London, post-graduate ophthalmology residents provide first-call responses to all emergent and urgent cases with back-up and intervention by consultants as needed who are on-call at the same time. Through this system 24x7, 365 coverage is provided In Strathroy the one ophthalmologist does provide a formal on-call schedule As a follow-up to the current state report, the on-call schedules of ophthalmologists in the LHIN has been shared with appropriate stakeholders including those in the Erie St. Clair and Waterloo Wellington LHINs. The number and type of on-call cases addressed over a one month period of time has been reviewed(see Appendix F). This information shows while most cases are urgent (need to be seen within four-24 hours), very few are classified as emergent (need to be seen within four hours). This documentation is consistent with information provided by CritiCall which shows, both provincially and locally, that true ophthalmic emergencies are infrequent. Having said this, being able to respond in a timely manner in true emergencies is important to the residents of the South West LHIN especially to those who present at emergency departments with an emergent eye problem now and in the future 9. Two elements are critical: the ability to contact the nearest ophthalmologist on call and knowing who to call if that person cannot be reached and that the ophthalmologist on-call knows how and who to contact if the intervention required is beyond their scope of practice i.e., requiring an immediate referral to a sub-specialist. Knowing how to reach the ophthalmologist on call is also of interest to primary care physicians and optometrists who may have a patient present to them that cannot be treated by them and needs direct and urgent intervention by an ophthalmologist. All emergency departments as well as optometrists and family physicians need to know how to reach the nearest and most appropriate ophthalmologist on call 24x7, 365 and where to call if that ophthalmologist is not able to respond to emergencies. All ophthalmologists on call need to know how to connect patients with a sub-specialist if a higher level of expertise is required. Future State Recommendation 10.1 If not already in place, hospitals should give all hospital emergency departments those with and those without ophthalmologists on site information about how contact the nearest and most appropriate ophthalmologists on-call at any given time. This same information should be given to optometrists and family physicians. 9 People with urgent eye problems may contact their optometrist or their family physician, especially if they do not see the situation as being a medical emergency. Depending on the nature of the problem, it may be addressed by these providers. If not, they would take steps to immediately refer the patient to an ophthalmologist for treatment. 25

26 Target of Recommendation: All hospital emergency departments in the South West LHIN South West LHIN ophthalmologists Family physicians Optometrists Financial and Resource Impact: Allocation of time required but no additional financial resources Future State Recommendation 10.2 If not already in place, contact protocols with CritiCall should be put in place so at any given time their call centre staff know how to contact the most appropriate ophthalmologist on call. Target of Recommendation: CritiCall Hospitals and ophthalmologists providing on-call services Financial and Resource Impact: Allocation of time required but no additional financial resources Intended Outcome of Recommendations 10.1 and 10.2: Patients who present at emergency departments with emergent eye problems, regardless of which hospital they go to, will get timely access to the ophthalmic care they need. In terms of emergent access to specialized ophthalmology services, residents who provide front-line on-call at St. Joseph s are able to access a specific consultant in case of an emergency and a specialist is always on-call. The retina specialists have their own on-call roster and this information is readily available to the resident and consultant on call. In order to provide a financial incentive to physicians where on-call volumes are relatively low and therefore feefor-service does not provide adequate reimbursement, the MOHLTC has an incentive fund for the provision of oncall services called Hospital On-Call Coverage (HOCC). Hospitals and their affiliated ophthalmologists are eligible to apply and receive funds through this program. In the case of ophthalmology the fund covers physicians who provide call to a specific hospital as well as to ophthalmologists who are affiliated with different hospitals. In the South West LHIN both of these models are being used. Future State Recommendation 11.0 Hospitals and ophthalmologists should continue to use the Ministry s HOCC program to provide ophthalmologists with financial compensation for being on-call both within and across hospitals. Target of Recommendation: Hospitals and ophthalmologists providing on-call services Ministry of Health and Long-Term Care Financial and Resource Impact: Allocation of resources by the MOHLTC HOCC program to hospitals and physicians Intended Outcome: Ophthalmologists will receive compensation for being on-call (could be for individual or multiple hospitals) beyond their regular fee-for-service, thereby rewarding them for providing a defined number of on-call hours. Return to Table of Contents 26

27 Future Location of Comprehensive Ophthalmology Services Ophthalmologists need to be located in areas with high populations to be readily accessible to the most people and to hospital services and equipment needed to undertake specific surgical procedures. At the present time, comprehensive ophthalmology services, both office and hospital-based, are located in the following communities: Owen Sound, Stratford, Woodstock, St. Thomas, London and Strathroy. Map #1 and Map #2 provide an overview of how long it takes, based on estimated travel time (driving), for patients to travel to the nearest hospital and/or ophthalmologist. Estimated driving time for patient access to comprehensive ophthalmology by geographic location: Grey-Bruce area - two hours Huron County 60 minutes Perth County minutes Oxford, Middlesex, Elgin and the City of London 30 to 45 minutes Distance is most critical when emergency services are involved and in all situations, there is access to emergency eye care within two hours drive. The standard response time to emergency care is to be able to access care within four hours. In addition, for medical eye care which requires repetitive, ongoing visits as frequently as monthly, access is an issue when distance to travel is long, particularly in the winter. Northern LHIN Access From a geographic perspective Owen Sound represents the closest access to ophthalmology services for people living east, north, west and south of Owen Sound. Most live within at least 90 minutes driving time and in some cases it is more than two hours drive. For the northern part of the South West LHIN and surrounding area, Owen Sound is a service hub for many secondary level health care services, including ophthalmology. This includes the northern part of Huron county (Seaforth and Clinton also serves the southern part of Huron county), Grey County as well as the western part of the North Simcoe Muskoka LHIN area. There is a possibility, in the future that ophthalmology services may be established in Collingwood. 10. This may have some impact on the volume of patients being referred to Owen Sound but based on current referral patterns it is not seen as significant. The impact of any changes in this regard should be assessed if it occurs. Future State Recommendation 12.0 Given the distribution of the population served by Grey Bruce Health Services Owen Sound and the need to provide equitable access to ophthalmology services, it is recommended that Grey Bruce Health Services Owen Sound continue to be the primary site for the delivery of comprehensive ophthalmology services to the northern part of the South West LHIN and surrounding areas. Target of Recommendation: Grey Bruce Health Services and affiliated ophthalmologists Financial and Resource Impact: No direct financial impact requires a corporate commitment 10 Conversations with the North Simcoe Muskoka LHIN (November 2014) indicate that there are no current plans to expand ophthalmology services beyond the four sites where it is currently offered [ Midland, Barrie, Orillia and Huntsville]. 27

28 Intended Outcome: Grey Bruce Health Services Owen Sound will continue to be the hub of ophthalmic services serving the northern part of the South West LHIN and surrounding areas. Central LHIN Access For Stratford and Huron-Perth while Stratford is relatively close to London, for people who live between 60 and 90 minutes drive to the east, west and north of Stratford it is the closest source of comprehensive ophthalmology services. Like Owen Sound, Stratford provides many secondary level care services to the residents of Huron and Perth counties and is the centre for ophthalmology services for this central part of the LHIN. In addition to the ophthalmology services available in Stratford [emergent and urgent treatment, medical ophthalmology and surgical ophthalmology other than cataract surgery], cataract surgery for Huron-Perth is located at the Huron Perth Healthcare Alliance Clinton Public Hospital and an ophthalmologist has an office practice in Seaforth, Ontario. Future State Recommendation 13.0 With the current distribution of the population served by Huron Perth Healthcare Alliance Stratford and the need to provide equitable access to ophthalmology services, it is recommended that Huron Perth Healthcare Alliance Stratford continue to be the primary site for the delivery of comprehensive ophthalmology services to the central part of the South West LHIN and surrounding catchment area, notwithstanding the delivery of some ophthalmology services at other sites. Target of Recommendation: Huron Perth Healthcare Alliance and affiliated ophthalmologists Financial and Resource Impact: No direct financial impact requires a corporate commitment Intended Outcome: Huron Perth Healthcare Alliance Stratford General Hospital will continue to be the hub of ophthalmic services serving the central part of the South West LHIN and surrounding areas. Future State Recommendation 14.0 Grey Bruce Health Services and the Huron Perth Health Care Alliance and their ophthalmologists, in light of their growing seniors population, should jointly undertake a periodic assessment of the distance travelled by patients who live in the south Bruce and south Grey County area, with a view to determining whether there is a future need for an ophthalmology clinic in this area. Target of Recommendation: Grey Bruce Health Services and affiliated ophthalmologists Huron Perth Healthcare Alliance and affiliated ophthalmologists South West LHIN Financial and Resource Impact: Staff resources needed to periodically access patient travel time and distance and whether it imposes a barrier to accessing services Financial and resource impact if a new clinic is established Southern LHIN Access From a patient accessibility perspective ophthalmology services in the southern part of the LHIN are much closer to each other. There are currently comprehensive ophthalmology services in Woodstock, St. Thomas, London and Strathroy. They all serve the needs of people within their immediate catchment area and respective communities, city, county and beyond. Again, from a resident or patient accessibility perspective, the ophthalmology services 28

29 located in these communities and hospitals address the general medical and surgical ophthalmic needs of the residents who live there. Given its geographic location, a significant number of patients served at Middlesex Hospital Alliance (MHA) Strathroy Middlesex General Hospital live in the Erie St. Clair LHIN area. While LHINs have administrative rather than service delivery boundaries, steps may be taken by the Erie St. Clair LHIN to repatriate patients to ophthalmology services located within their LHIN. If this should happen a detailed impact analysis and response plan will need to be developed by MHA in collaboration with other hospitals in the southern South West LHIN area. The City of London and St. Joseph s in particular is the regional centre for specialized ophthalmology, not only for the South West LHIN area but for adjacent LHINs as well. As noted earlier, in terms of access to comprehensive ophthalmologists the City of London has a need for additional resources and has unmet needs relative to the size of its immediate population. A portion of Norfolk county in the south east corner of the LHIN is served, in terms of ophthalmology services, by two ophthalmologists who work out of Norfolk General Hospital in Simcoe. The Hamilton Niagara Haldimand Brant LHIN has indicated (December 2014) that comprehensive ophthalmology services will continue to be located and provided to people who live in Haldimand and Brant Counties. The location of services may change in time but that is a future consideration. Overall, especially from a medical ophthalmology perspective, access to community-based comprehensive ophthalmology services is important now and in the future. Future State Recommendation 15.0 The communities of Woodstock, St. Thomas, London and Strathroy should continue to offer community-based, comprehensive ophthalmology services. Target of Recommendation: The following hospitals and affiliated ophthalmologists: Alexandra Hospital (Ingersoll) Middlesex Hospital Alliance St. Joseph s Health Care London St. Thomas Elgin General Hospital Woodstock Hospital Financial and Resource Impact: Requires a corporate commitment and on-going support of comprehensive ophthalmology services Intended Outcome of Recommendations 14.0 and 15.0: People throughout the LHIN, regardless of where they live, will have equitable access to ophthalmology services. Return to Table of Contents 29

30 Figure hour drive 1 hour drive 1 hour 30 minute drive 1 hour drive 45 minute drive 30

31 Figure minute drive 45 minute drive 30 minute drive 30 minute drive 30 minute drive 45 minute drive 31

32 Future Location of Surgical Ophthalmology Services At the present time surgical ophthalmology services in the South West LHIN are located in, and supported by hospitals. However, a recent experience in Ontario 11 illustrates this might not always continue to be the case as some services traditionally delivered by hospitals may move into private or non-profit community-based settings and private ownership. This has already happened with laser (refractive) surgery in many large urban centres and currently some cataract surgeries are offered on a private, consumer-pay basis. The suggestion put forward through the MOHLTC cataract RFP suggests high volume, low-risk procedures can be provided at a lower cost in non-hospital settings. At this time in the South West LHIN moving any ophthalmologic surgery out of the hospitals would fragment services currently being provided under the broader hospital-based mandate. Having ophthalmologists affiliated with hospitals allows them to provide surgical services without added costs for overhead, staffing and equipment. and ensures they are available to respond to emergent and urgent cases. Hospital provided services are also evaluated based on clear guidelines in terms of patient safety, quality and accountability for costs and fees associated with any procedure. The future role of QBP funding of cataract and other ophthalmic surgical procedures needs to be factored into any future decision making about where ophthalmology services are best provided. At the present time QBP funding only applies to simple cataract procedures. However, there are clear indications this model of funding on a per-case basis will be expanded to include other surgical procedures within ophthalmology. A process has begun to make retinal surgeries and corneal transplants QBP procedures. The future of volume-based allocations of specific surgical services can be unpredictable and therefore difficult to plan for. For example, current simple cataract surgery volumes are allocated on a year-by-year basis with no commitment that the volume allocated one year becomes the base for the next one. The Ministry has recently indicated (November-December 2014) that they plan to change the methodology used to allocate cataract surgeries across Ontario and to expand to scope of QBP cataracts to include all cataract surgeries. This instability and unpredictability makes it difficult to plan for long term service delivery. Depending on the volume of procedures awarded to a hospital and the related fees paid, it could become costprohibitive for a hospital to continue offering a specific ophthalmic procedure or offering to offer ophthalmic surgeries in general. If this occurs patients would need to go elsewhere and decisions would need to be made to consolidate services in larger volume centres where, due to higher volumes, the cost per case would be less. This migration could lead to the unintended consequence of limiting access to the other important services, especially medical services comprehensive ophthalmologists provide. At the present time the reimbursement ophthalmologists receive for performing cataract surgery accounts for a significant portion of their remuneration. Cataract surgery can represent as much as 30% of the remittances received from OHIP. Consolidating cataract surgery into larger volume centres could therefore result in the migration of ophthalmologists away from small centers. It may also result in an ophthalmologist working in two communities one for surgery and another for their medical ophthalmology practice. This is already happening in a couple of instances in the South West LHIN. 11 Community-Based Specialty Clinics are non-profit health providers that will offer select low-risk procedures that are currently provided in acute-care hospital settings. Specialty Clinics will focus on providing high volume procedures, such as routine cataract procedures, colonoscopies, and other procedures that do not require overnight stays in a hospital. Specialty Clinics will be subject to high quality standards, oversight and accountability. They will provide OHIP-insured services with no additional fees. Information source: 32

33 At the local LHIN level, a primary objective going forward is being able to respond to provincial allocation decisions, policy changes and directives in a way that reflects local needs and maintains the integrity of the local services system. This is best done collectively rather than on an individual hospital or physician basis. Any unilateral decision to, for example discontinue offering a service, would be highly disruptive and a disservice to both providers and patients. Recently through a joint task force of the Ontario Hospital Association and the Ontario Medical Association, the following report was published, A Framework for the Redistribution of Hospital Services (September 2014). This report speaks directly to changes to hospital funding through the Health System Funding Reform initiatives primarily the Health-Based Allocation Model (HBAM) and the Quality-Based Procedures Model (QBP). The report lists a set of six guiding principles to inform decision-making involving service redistribution. To quote from the report: The goals of this framework are: To improve quality, value and patient access To foster increased collaboration and transparency To minimize disruption and instability of service delivery To facilitate medical human resource adjustments To support a sustainable delivery of health services within available resources The OMA and the OHA recommend the following six guiding principles be used when considering and/or implementing service redistributions. 1. Quality of Patient Care Focus of service redistributions must always be based on the needs of patients and sustaining or enhancing the quality and value of their care Strive to ensure patients have equitable access to quality care Focus on the principles of evidence-based practice Ensure that improvements in quality and value in one service are not made at the expense of quality care in interdependent services Ensure that clinical competencies are maintained or enhanced 2. Evidence Evidence that all efforts were made to mitigate the need to implement a service redistribution Evidence with respect to the potential impacts of the service redistribution should be examined and well understood before a redistribution decision is made Evidence that potential risks to patient care have been identified and addressed Redistribution decisions should be based on compelling evidence that the dimensions of quality and value have been identified and that quality of care will be improved Evidence that stakeholders have been meaningfully engaged prior to and throughout the decision-making and implementation processes 3. Stability Ensure inclusive and collaborative transition planning Ensure on-going and appropriate access to urgent and emergent services in the impacted HSPs Ensure due consideration of the impact on quality and access to all clinical programs and services including those which are not the direct subject of service redistributions and including those in the community Establish strategies to minimize disruptions to clinical practice, strive to maintain equitable patient access to programs and services in the impacted communities, and develop mitigation strategies where appropriate Ensure, where appropriate, that the teaching and research mandates of impacted HSPs and physicians are supported 33

34 4. Fairness and Equity Recognize impacted physicians as partners in the planning and decision-making processes Ensure that the process is respectful of and gives due consideration to the potential impact of service redistributions on patient care, physician workload, practice sustainability, responsibilities, travel and clinical activity Ensure all steps have been taken to optimize the ability of impacted physicians to follow transferred services Ensure that expectations and allocation of resources for physicians are fair and appropriate, including access to hospital resources Ensure fair and equitable criteria for the credentialing appointment and reappointment processes at impacted HSPs which are consistent with relevant HSP bylaws 5. Transparency Ensure early communication and stakeholder engagement strategies are executed Ensure early, timely and meaningful consultation with all key stakeholders potentially impacted, including community and primary care providers Establish transparent processes for revisiting and revising decisions 6. Collaboration and Inclusivity Ensure meaningful stakeholder engagement is conducted and includes impacted physicians at both the relinquishing and receiving HSPs, patients, and other health care providers (including primary care physicians), LHINs, communities and academic programs (where applicable) in the decision-making process Future State Recommendation 16.1 Ophthalmologists and the hospitals with which they are affiliated should meet regularly, on a LHIN-wide basis, to assess the impact of provincial allocation decisions, policy changes and directives to determine the most appropriate system-wide response, including the redistribution of surgical ophthalmology services, especially QBP funded procedures. Future State Recommendation 16.2 St. Joseph s Health Care London be asked to take on a support-leadership role with respect to the recommended regional committee. Target of Recommendation: All hospitals in the South West LHIN that offer ophthalmology services and affiliated ophthalmologists South West LHIN Financial and Resource Impact: Meeting time for those involved, administrative support services, data support services Intended Outcome of Recommendations 16.1 and 16.2: Any changes to the location and organization of surgical ophthalmic services will be assessed on a LHIN-wide basis and supported by the people and organizations most directly affected. Future State Recommendation 17.0 The joint OHA - OMA report, A Framework for the Redistribution of Hospital Services September 2014 should be adopted as the framework to be used for future decision-making and implementation of any proposed redistribution of ophthalmic services. Target of Recommendation: All hospitals in the South West LHIN that offer ophthalmology services and affiliated ophthalmologists Financial and Resource Impact: No direct financial impact requires a collective and corporate commitment 34

35 Intended Outcome: Changes to the configuration of surgical services will be assessed using a comprehensive framework and approach. Return to Table of Contents Comprehensive Ophthalmology - Scope of Practice In addition to defining where comprehensive services need to be located and how many ophthalmologists are needed, it s important to define the scope of services residents should have access to. As noted in the Current State of Vision Services report, comprehensive ophthalmologists spend most of their time practicing medical ophthalmology and a minority of their time doing surgical work. In addition to their office and hospital-based work, most also provide after-hours on-call for emergent and urgent problems that may come from the emergency department, another physician or an optometrist. Future State Recommendation 18.0 The clinical expertise of a comprehensive ophthalmologist in terms of clinical knowledge, diagnosis, assessment and treatment should be defined as follows: Target of Recommendation: All hospitals in the South West LHIN that offer ophthalmology services and affiliated ophthalmologists Financial and Resource Impact: No direct financial impact requires a collective and corporate commitment to ensure scope of services as described are available Intended Outcome: There will be a shared understanding of the scope of practice of a practicing comprehensive ophthalmologist when they work in a community providing both medical and surgical services. Listed competences in Appendix J are generally considered to be within the scope of practice of a practicing comprehensive ophthalmologist. Strabismus surgery (uncomplicated) and glaucoma surgery both are within the realm of a general ophthalmologist. Visual field testing is also done by comprehensive ophthalmology. The few that are not, have been assessed as competencies that would not apply to a comprehensive ophthalmologist unless it was an area of special interest and activity. When a comprehensive ophthalmologist has limited experience dealing with specific problems it is prudent to refer to someone else who has more experience and expertise this allows for better and safer clinical intervention and outcomes to occur. These competences are listed below: Orbital surgery Physiological testing (including but not limited to Electroretinography (ERG), Electrooculography (EOG) Orbital surgery Glaucoma surgery Corneal surgery Strabismus surgery Elnuceation/evisceration Surgical management of trauma to the eyelids, nasolacrimal system, globe and orbit 35

36 The Future of Specialized Ophthalmology Services in the South West LHIN As documented in The Current State of Vision Care report there are currently 18 ophthalmological specialists in the South West LHIN. Seventeen are located in London and one individual with a fellowship in oculoplastic surgery functions as a comprehensive ophthalmologist and does some specialized work out of Grey-Bruce (Owen sound and Hanover). All specialists are trained fellows. London provides subspecialty care (medical and Surgical) in the following disciplines: o Orbit and Oculoplastics o Neuro-ophthalmology o Uveitis o Cornea and External disease o Glaucoma o Paediatrics o Vitreo retinal surgery In addition, some specialized diagnostic procedures are available only in London: o Electrophysiology o Fundus autofluorescence o Fluoroscein and Indocyanine Angiography including wide field angiography o Heidelberg Retinal Tomograph (HRT)HRT o Corneal topography and pachymetry o Ocular Ultrasonography o Anterior segment OCT o Hess screen and synoptophore testing Future Need for Specialized Ophthalmology From an eye disease perspective, significant eye diseases requiring medical and/or surgical treatment are cataracts, glaucoma, macular degeneration and DR. All of these are expected to grow in volume as the population ages. The bulk of care provided for patients with these diseases is provided by comprehensive ophthalmologists, although disease detection and the monitoring (and in the case of glaucoma, management) of stable disease is provided by optometrists as well. In each disease a proportion of patients will require specialized expertise for successful management (medically and surgically) and will be referred to subspecialists. Specialization can take two forms: a fellowship trained specialist in a specific sub-specialty area or a comprehensive ophthalmologist with a specific interest in a particular area of ophthalmology. As noted earlier, in many cases sub-specialists also do some general ophthalmology work. Sub-specialists in London are also faculty members of Western University and as such their work lives include teaching and research through Lawson Health Research Institute in addition to their clinical work. Depending on how they divide their time, clinical work may account for most or a small part of their time. Mentoring medical residents is usually integrated into their clinical practice time. As noted in the current state report, the only hospital with a sub-specialist outside of London is an oculoplastics specialist who works out of Grey Bruce Health Services (Owen Sound) and Hanover and District Hospital. This is seen as a continuing need in this area of the LHIN. As with most sub-specialists, this role includes a combination of sub-specialty and comprehensive ophthalmology work and this is expected to continue to be the case. The need for a comprehensive ophthalmologist with a special interest in glaucoma has also been identified for the Grey Bruce catchment area. In the following table the number of sub-specialist in London are noted in the first column. In the second column the FTE is an estimation of the time spent in doing speciality clinical work. In a number of cases this is less than the number of specialists because of the amount of general ophthalmology work they do. Non-clinical work has 36

37 not been estimated in this table. The volume allocations of adult cataract surgery cases was used as a proxy for time spent doing comprehensive ophthalmology. Table #6 Ophthalmic Sub-specialists in London, current and future needs, FTE Current Areas of Clinical Subspecialization in London (number of sub-specialists = n) Current number of specialists (FTE) Future Clinical Need (FTE) Orbit and Oculoplastics (n=1) 1 FTE 1 FTE Neuro-ophthalmology (n=2) 1.5 FTE 2 FTE Uveitis (n=3) 1 FTE 1 FTE Cornea and External disease (n=4) 2 FTE 2 FTE Glaucoma (n=3) 1.75 FTE 2 FTE Paediatrics (n=2) 2 FTE 3 FTE Vitreo retinal surgery (n=4) 3.5 FTE 3.5 FTE Total sub-specialists n=19 Total = 12.5 FTE 14.5 FTE From a specialty care perspective, most procedures and treatments area available in London but not all. There are specific procedures that need to be referred elsewhere certain ophthalmologic cancers for example are treated in Toronto with both pre and post Toronto-based care being provided by local specialists. This is expected to continue. In addition to the areas of specialization listed above, an ophthalmologist with expertise in complicated anterior segment surgery who deals with complicated cataracts which require non-standard lens is seen as a current service gap. These patients are currently referred to Credit Valley Hospital in the Mississauga - Halton LHIN. Future State Recommendation 19.0 A new comprehensive ophthalmology position with a special interest and expertise in complicated anterior segment surgery should be recruited by St. Joseph s Ivey Eye Institute and the Department of Ophthalmology of Western University. Target of Recommendation: St. Joseph s Health Care London Department of Ophthalmology, Western University South West LHIN Financial and Resource Impact: Resources to support a new medical position including office and clinic space, operating room time and related resources As applicable, research space and resources Intended Outcome: Specialty ophthalmic services will meet the changing needs of the population of the South West LHIN and beyond. Paediatric Ophthalmology Paediatric patients are defined as patients between the ages of 0-16 years of age. Although paediatric ophthalmology is a specialty area, general or comprehensive ophthalmologists also work with paediatric patients. What distinguishes the scope of practice undertaken by a specialist is the complexity of the case, the stability of the patient, the experience of the ophthalmologist and the equipment and clinical support available to him/her. Strabismus surgery is the most common procedure performed on paediatric patients. Although paediatric ophthalmologists are members of the Division of Paediatric Surgery at London Health Sciences Centre (LHSC) and their positions are funded through the Ministry s AFP (Alternate Funding Program) for LHSC s Children s Hospital 37

38 physicians, their offices and non-surgical work is based at St. Joseph s Hospital. Paediatric ophthalmology clinics are not held at LHSC. At the present time LHSC is currently reviewing the configuration of its ambulatory paediatric surgery clinics and how they can be reconfigured to better meet the needs of children and families. This is the outcome of recent clinical strategy work. There is an opportunity for paediatric ophthalmology to be part of this initiative and to thereby establish a clinical presence at LHSC and at the Children s Hospital beyond the surgical operating room work. Future State Recommendation 20.0 LHSC/St. Joseph s paediatric ophthalmologists should be asked to actively engage in the ambulatory paediatric surgery clinic work at LHSC with a view to being able to offer paediatric ophthalmology clinics at LHSC s Children s Hospital. Target of Recommendation: St. Joseph s Health Care London London Health Sciences Centre Children s Hospital Department of Ophthalmology, Western University South West LHIN Financial and Resource Impact: Time commitment on the part of the paediatric ophthalmologists to participate in the redesign process If the process results in an agreement between LHSC and St. Joseph s to offer paediatric ophthalmology clinics at LHSC, both a financial and resource impact analysis would need to be undertaken. Intended Outcome: Paediatric ophthalmology will be a part of the comprehensive range of specialized children s services provided though the Children s Hospital of the London Health Sciences Centre. Return to Table of Contents Upon review the need for an additional paediatric ophthalmologist has been identified to ensure service needs are met and to improve wait times. To support recruitment of an additional paediatric ophthalmologist operating room time will need to be allocated and an approval from the MOHLTC branch responsible for AFP agreements needs to be obtained. Funds also need to be made available by LHSC and St. Joseph s to support office and clinic space for this individual. In Ontario it is the Children s Hospitals and academic health sciences centres that account for most paediatric ophthalmology work. As a result paediatric ophthalmic surgery takes place in eight of the 14 LHINs in Ontario and they are regional programs typically drawing patients from outside their home LHIN. The South West LHIN is typical in that the two LHINs on either side [Erie St. Clair and Waterloo Wellington] do not offer this service. The provincial target wait time for paediatric ophthalmic surgery is 182 days (or 6 months). For the province as a whole this target wait time has never been met since the MOHLTC started collecting wait time data in October Having said this, the wait times as posted by the MOHLTC vary. 38

39 Table 6.0 Wait Times for paediatric ophthalmic surgery Provincial Wait Time [based on data for July, August and September 2014] (9 out of 10 patients complete their procedures in this time) 190 LHIN specific Wait Time times LHIN Wait time (in days) South East 79 Central 100 Mississauga Halton 126 Hamilton Niagara Haldimand Brant (HNHB) 145 Toronto Central 159 South West 208 Central West 220 Champlain 417 Source: MOHLTC Wait Time web site November 2014 The wait time for paediatric ophthalmic surgery in the South West LHIN at 208 days is slightly more than the provincial average of 190 days. It is significantly shorter than the wait time in the Champlain LHIN and significantly longer than the wait time in several other LHINs. Provincially there is significant inequity in wait times. The following graph profiles paediatric ophthalmic surgery wait times from October 2011 to September 2014 and shows that throughout 2013 wait times in the South West were lower than the provincial average but they have increased since January Figure