Needs Assessment and Activity Plan for the VicOutreach Optometrists Scheme in Victoria. July 2015

Needs Assessment and Activity Plan for the VicOutreach Optometrists Scheme in Victoria July 2015

Contents Contents... 2 Executive summary.... 3 1. Background and methodology... 8 Eye health and the eye care workforce in Victoria... 8 The VicOutreach Optometrists Scheme... 8 Evaluation of the VOS program... 9 Needs assessment methodology... 10 About this report... 12 2. Understanding optometry needs in rural and regional Victoria... 13 What the data told us about need... 13 What the consultations told us about need... 17 Identifying important themes with key stakeholders... 18 Verifying data, service plans and gap analysis... 21 3. Recommendations for VOS services in Victoria... 25 Unmet service needs in Victoria... 26 Efficiencies in outreach... 27 Urban VOS services... 29 Final remarks... 31

Executive summary. 1. Background and methodology This needs assessment identifies priority locations for VicOutreach Optometrist Scheme (VOS) services, including those specific to Aboriginal populations, by considering gaps in service delivery at the jurisdictional and local level, while taking into account capacity to sustain outreach services, potential linkages between VOS services and existing primary care services and other visiting health professionals. The needs assessment methodology involved: (i) analysing data on priority eye health domains and service access data, (ii) ranking and prioritising data to establish a heat map of service need, and (iii) consulting with key and local informants to verify need and assess feasibility for service. 2. Understanding optometry needs in rural and regional Victoria The needs assessment drew on the best publicly available data, while acknowledging its limitations, and results should be considered an estimate of need. The data analysis was limited to the health and demographic data in the public domain. Aboriginal and Torres Strait Islander patient identification in primary care remains under-reported 1 and there is no publicly available health indicator data at Victorian LGA level due to the small number of records in the 2011 Census. The desktop analysis was conducted over a one month period over May June 2015. The process included: Analysing demographic and health status data by local government area (LGA) in the priority health domains of eye health, eye health behaviours and diabetes Analysing available data on eye health determinants and most-at-risk populations: people over 40 years, smokers, people with diabetes and Aboriginal and Torres Strait Islander populations Analysing the Indigenous Eye Health Unit Eye Care Workforce Calculator and service access and usage 2 in rural communities, including Medicare Benefits Schedule (MBS) data, and assessing optometry practice density by geographic area Mapping current VOS service delivery models (including private providers and Australian College of Optometry) and current VicOutreach service delivery data Ranking and prioritising data to establish a heat map of service need through a gap analysis of LGA locations by eye health need against current outreach optometry services (VOS, RHOF, MOICDP) and location RA category, in order to establish priority service locations. Key findings relevant to the delivery of outreach optometry and other eye health services across rural Victoria arising from the data analysis include: In the Campaspe, Mitchell and Queenscliff LGAs, significantly higher proportions of people had never seen an eye health professional, compared with all Victorian adults. 1 Data on Aboriginal eye health in Victoria: what comes out is only as good as what goes in (2014) 2 Service usage data for VOS will not be available to inform the 2015-6 service plan. July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 3 of 32

Darebin, Greater Geelong, Greater Shepparton and Latrobe LGAs have a higher proportion of people aged over 40, smokers, people with diabetes and people of Aboriginal and Torres Strait Islander descent. A large number of residents do not have regular eye tests, putting them at increased risk of eye disease. Proportions of Victorians reporting visiting an eye professional in the last six months were significantly lower in rural Victoria than metropolitan Melbourne. There were no significant differences between metropolitan and rural areas in the proportion of people who had noticed a change in their vision; the prevalence of glaucoma, diabetic retinopathy or macular degeneration. The prevalence of macular degeneration was significantly higher in men and adults who lived in the Gippsland Region compared with all Victorian men and adults, respectively. A higher proportion of people living in rural Victoria wore both a hat and sunglasses than those in metropolitan locations. There is a relationship between declining socio economic status and change in vision, sunprotective behaviours and people who had never seen an eye professional. 3 In western Victoria there are fewer practices per million of population and several postcodes in the north-west are without a practice. It is important to note that practice density does not capture other access barrier issues and can only contribute to an overall picture of service planning needs. 4 More than one in eight (12%) comprehensive examinations were for children aged 14 and under and more than one in three (33.5%) for Victorians aged over 55 years. 5 Of note, Victoria s per capita use of comprehensive eye examination MBS billing is below the national average, and behind NSW, Queensland, WA, SA, Tasmania and the ACT. Over an eight-week period from May July 2015, RWAV consulted with stakeholders using semistructured interviews and an online survey. Four key stakeholder groups were consulted: the Koolin Balit Aboriginal Eye Health Advisory Group, Australian College of Optometry, local Aboriginal, community and district health services, and current VOS service providers, to: Validate the service needs identified through the data, identify existing health services to address needs and service gaps and assess the current VOS outreach services according to community need Establish whether the eye health service mix established under VOS, MOICDP and RHOF is responding to the current health needs and trends. Key themes to relevant to the delivery of outreach optometry and other eye health services across rural Victoria arising from the consultation include: 3 See the full Victorian Population Health Survey 2011-12 report for a more detailed discussion 4 ACIL Allen Consulting, Optometry Market Analysis, 2014 5 Optometry Australia July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 4 of 32

Integration of eye health services: A number of schemes and eye care services currently support eye health in Aboriginal community members: the VOS, VicOutreach Aboriginal Health, and the Victorian Aboriginal Spectacle Subsidy Scheme (VASSS). There is currently no systematic statewide approach to determining eye care need and coordinating care in Victoria, rather there are multiple site-based approaches determined by patient lists rather than population-level data on health need. The Victorian Government has implemented one statewide and four regional Indigenous eye health projects to develop and strengthen regional networks and improve coordination and referral pathways. Eye health services for Aboriginal and Torres Strait Islander communities: The ACO provides optometry services through the VOS and VicOutreach Aboriginal Health to 18 Aboriginal Community Controlled Health Organisations (ACCHOs) in rural and metropolitan Victoria. ACCHOs identified people living with diabetes, health promotion days, kindergarten children, middle-aged people and elders as priorities for eye care. ACCHOs receiving outreach services reported high satisfaction with the ACO and stated the frequency of current visits is meeting need. Some ACCHOs reported successfully integrating the VOS service into overall health services as a tool for timely diagnosis of other disease, emphasising that fortnightly visits (rather than monthly) embeds eye care into routine visits with the diabetes educator and chronic disease nurse. However, many of the 22 ACCHOs consulted reported high numbers of patients with diabetes and other chronic diseases and full waiting lists for optometry appointments and the data showed long waiting times for eye examinations. The unmet needs in Aboriginal and Torres Strait Islander eye health are similar in urban and rural areas and RWAV s consultations revealed that unmet needs for Melbourne communities are in eye care coordination and service linkages rather than geographic access to optometry consultations. Eye health services for the broader population: Consultations with 22 local community and district health services highlighted that few of the community health informants collected relevant concrete data on eye health. Informants identified ageing populations, residential aged care facility residents, people living with diabetes and schools as priorities for eye care. Risk factors identified include small, and largely ageing, populations with high incidence of age related chronic disease. Service access barriers such as large geographical catchments with small outlying towns, few transport options and limited access to services mean that people have to travel long distances for eye care. July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 5 of 32

In some cases, a low socioeconomic profile that overlapped with high numbers of pensioners and people living with disability mean that local community services find it difficult to monitor and support patients eye health and that the cost of spectacles is seen as prohibitive. Three community health informants reported an optometrist providing outreach in a private capacity at the local town. Lack of integration with local services (and lack of access to data on eye health) and the reliance on a single provider who, in some cases, did not offer any subsidised schemes, were reported as challenges for these optometry services. 3. Recommendations to inform VOS service delivery in Victoria To identify priority locations for VOS services RWAV has considered the key layers of data on eye health and services in Victoria, the current VOS service delivery plan, estimates against the workforce needs calculated by IEHU and indicators of community verification. LGAs were compiled and sorted by priority based on a collective analysis of data and consultation, and prioritised according to the following: Priority 1 Priority 2 Priority 3 RA4 Never seen an eye professional LGA top 4 priority areas (based on age, smoking, diabetes, size of Aboriginal population, regular eye tests) 3+ indicators of high need >50km away from optometry service 2011 VOS prioritisation High need for regular eye tests (e.g. priority score on 2 service access categories), in RA3 or greater Identified for priority by informant, requires further investigation High Aboriginal population, no service RA3 and any indicator of need RA2 with 3 indicators of need All RA3 locations not being serviced This activity identified 46 rural LGAs and 15 metropolitan sites as priority locations (see table below) with either no current optometry service access or where the frequency of VOS services could potentially be increased. LOCATION PRIORITY LOCATION PRIORITY For consideration for new VOS service For review of existing VOS service frequency Timboon 1 Hamilton 1 Cobden 1 Rainbow 1 Boort, Pyramid Hill, Mitiamo, Wedderburn 1 Omeo, Benambra 1 Corryong 1 Mildura 3 Mooroopna 1 Echuca 1 Broadford, Kilmore, Seymour 1 Swan Hill, Kerang 2, 3 Mansfield, Tolmie, Merrijig, Jamieson 1 Wodonga 3 Benalla, Glenrowan, Mollyullah 1 Bairnsdale 1 Cobram, Yarrawonga, Numurkah 1 Lake Tyers 2 Foster, Leongatha, Fish Creek 2 Ouyen 1 Euroa, Violet Town, Nagambie, Ruffy 3 Gelantipy 1 Minyip 3 Alpine 1 July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 6 of 32

LOCATION PRIORITY LOCATION PRIORITY For consideration for new VOS service For review of existing VOS service frequency Edenhope 3 Heywood 2 Framlingham 2 Orbost 2 Lake Tyers 2 Jeparit 3 The 2011 evaluation of the VOS recommended aligning optometry outreach with other outreach eye health services. Anecdotally, a previous lack of co-ordination between the outreach services delivered through VOS, MOICDP and RHOF has led to duplication (for example in eye exams, refraction assessments). Adequate population level service planning in rural and regional Victoria is needed to ensure the appropriate level of service, in the right region, in the right sequence, with the right frequency. The RHOF, MOICDP and VOS outreach programs need to be better integrated but further data collection analysis is required to best shape this integration, which was beyond the scope of this needs assessment. 4. Service delivery plan RWAV's new statewide fundholder arrangement provides an opportunity to implement a coordinated and integrated service model and the focus for the program for the coming year is to apply consistent funding and reporting rules across all Victorian outreach programs, maintain established VOS services and address priority areas of need. Each of the existing VOS sites continue to exhibit a need for outreach services and RWAV will continue all the existing services for twelve months. This will allow a complete data set for the current services to be collected and any issues identified and reviewed. The needs assessment identified eight Victorian locations with little access to optometry services and high levels of need. The proposed visiting frequencies were informed by consultations, demographic data, comparison to other VOS services, and budget. The following locations are prioritised for services: Location Frequency Location Frequency Boort/Pyramid Hill Monthly Euroa/Nagambie Monthly Mansfield Monthly Timboon-Cobden Monthly Benalla Monthly Foster Monthly Seymour Monthly Edenhope Monthly July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 7 of 32

1. Background and methodology Eye health and the eye care workforce in Victoria Vision problems and eye disease are amongst the most common health complaints within Australia, and in 2004, the total cost of vision impairment and blindness in Australia was reported to be $9.85 billion. 6 Recent estimates indicate vision loss currently affects nearly six per cent of Victorians aged over 40 (145,670 people), and without appropriate intervention, the number might increase to 201,000 by 2020. 7 Around 80 per cent of vision loss in Australia is caused by five conditions, all of which become more common as we get older. Importantly, around 75 per cent of vision loss is preventable or treatable. Vision loss from diabetes, cataract and refractive error (the need for glasses) is also common in Aboriginal communities in Victoria with 94% of vision loss preventable or treatable. Regular eye examinations, early detection and treatment of eye problems help prevent vision loss. Eye health services in Victoria are provided by a range of public and private service providers, including GPs, optometrists and ophthalmologists in a range of settings. Optometry services provide primary eye care examinations to check ocular health, visual acuity and refractive error, and may provide treatment for minor eye conditions. In addition to identifying glaucoma, cataracts, diabetic retinopathy, optometrists are able to prescribe and supply spectacles, contact lenses and some visual aids. Data from Optometry Australia indicates that there were 1,200 optometrists in Victoria as of March 2014 (with 224 medical practitioners specialising in ophthalmology). 8 Optometry services in urban and rural areas are predominantly private services, located where they are economically viable. While most large rural towns have a local optometrist, practices for smaller towns and communities are not always viable. Visiting or outreach services are provided in settings where access to mainstream services are limited. While the majority of Australians can readily access an optometrist, significant numbers still experience barriers in accessing services, particular those on low incomes, living in rural/remote areas, Aboriginal and Torres Strait Islander Australians and those in residential aged care. 9 The VicOutreach Optometrists Scheme The VicOutreach Optometrists Scheme (VOS) supports optometrists to deliver outreach optometric services to remote and very remote locations, and rural communities with an identified need. The VOS emphasises service delivery in areas classified as RA3 to RA5. VOS-funded services can be provided in RA2 areas that a needs analysis identified have additional needs. A fundholder can also consider other options for providing culturally appropriate services for Aboriginal and Torres Strait Islander patients in RA1 locations. Options include use of the MOICDP if the patient has an eligible 6 Access Economics 2010, Clear focus: the economic impact of vision loss in Australia in 2009. An overview of the report prepared for Vision 2020 Australia by Access Economics Pty Limited, Access Economics, Melbourne. 7 Optometry Australia 8 Optometry Australia 9 Equitable Access to Optometric Care, Optometry Australia, 2015, www.optometry.org.au/media/590221/equitable_access.pdf July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 8 of 32

chronic disease and linking with the Closing the Gap workforce employed through programmes such as the Improving Indigenous Access to Mainstream Primary Care Programme. Figure 1: Eligibility for VOS by remoteness area RA Eligibility for VOS 1 Aboriginal and Torres Strait Islander 2 In case of identified need 3 Priority 4 Priority 5 Priority Optometrists participating in VOS are provided with incentives and support that cover the costs of delivering services in rural and remote areas. Costs reimbursed include but are not limited to: travel, accommodation and meals, facility fees and an absence from practice allowance to compensate for loss of business opportunity. Further detail is available in the Australian Department of Health Visiting Optometrists Scheme Service Delivery Standards. Evaluation of the VOS program In 2011, the Australian Government commissioned an evaluation of the Visiting Optometrists Scheme, and overall found that VOS is vital in providing support for outreach optometry services. 10 RWAV s needs assessment methodology has drawn on the key recommendation that better mechanisms are required to assess levels of need and gaps in access in local communities. VOS needs to develop services and allocate funding to communities with the poorest level of access. Other recommendations this needs assessment takes into account: setting VOS planning benchmarks that reflect an appropriate level of outreach service provision for localities of different population sizes ongoing monitoring of VOS effectiveness through the creation of a small set of performance indicators for the program integrating Medicare data analysis with VOS program data and information on localities where optometrists are in practice taking account of population size, age structures and prevalence of diabetes in local communities assessing and addressing the optometric needs of Aboriginal and Torres Strait Islander people residing in urban and inner regional areas addressing under- and over-servicing seen in various communities aligning optometry outreach with other outreach eye health services 10 Health Policy Analysis. 2011. Evaluation of the Medical Outreach Assistance Program and the Visiting Optometrists Scheme Final Report. Department of Health and Ageing. Canberra. July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 9 of 32

improved sharing of information between outreach eye health providers (VOS optometrists, ophthalmologists and others), primary care health services and communities. This needs assessment report contributes to a more comprehensive and open approach to planning and developing services, allowing new VOS funding to be targeted at regions and communities with the highest levels of need. Needs assessment methodology This needs assessment identifies priority locations for VOS services, including those specific to Aboriginal populations, by considering gaps in service delivery at the jurisdictional and local level, while taking into account capacity to sustain outreach services, potential linkages between VOS services and existing primary care services and other visiting health professionals. The needs assessment methodology involved: (i) data search and analysis on priority eye health domains and service access data, (ii) ranking and prioritising data to establish a heat map of service needs, and (iii) consultation with key and local informants to verify need and assess feasibility for service. 1. Data search and analysis on priority eye health domains and service access data The desktop analysis was conducted over a one month period in May-June 2015. A search was conducted to source data, and key stakeholders were contacted to provide advice on appropriate data sources (in particular, the Victorian Koolin Balit Eye Health Advisory group). The process included: Analysing demographic and population level health status data by local government area (LGA) in the priority health domains of eye health, eye health behaviours and diabetes Analysing available data on eye health determinants and most-at-risk populations: people over 40 years, smokers, people with diabetes and Aboriginal and Torres Strait Islander populations (including the National Indigenous Eye Health Survey, 2009) Using the Indigenous Eye Health Unit Eye Care Workforce Calculator to assess current optometry consultations being delivered against required workforce calculations (discussed further on page 17 in the workforce needs analysis section) Analysing service access and usage 11 in rural, regional and remote communities, including Medicare Benefits Schedule (MBS) data, and assessing distribution of optometry practice density by geographic area. Mapping current VOS service delivery models (including private providers and Australian College of Optometry) Mapping current RHOF and MOICDP service delivery data Ranking and prioritising data to establish a heat map of service needs through a Gap analysis of LGA locations by eye health need against current outreach optometry services (VOS, RHOF, MOICDP) in order to establish priority service locations, taking into account the prioritisation of RA locations. 11 Service usage data for VOS will not be available to inform the 2015-6 service plan. July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 10 of 32

2. Consultation with key and local informants to verify need and assess feasibility for service Over an eight-week period in May July 2015, RWAV consulted with a range of stakeholders using semistructured interviews (in person or by telephone), and via an online survey. The consultation plan was designed to: Validate the service needs identified through the data, identify existing health services to address needs and service gaps, and support future health service planning Establish or strengthen productive relationships with organisations with health service planning responsibilities Assess the current VOS outreach services according to community need Establish whether the eye health service mix established under VOS, MOICDP and RHOF is responding to the current health needs and trends. RWAV identified four key stakeholder groups to consult: 1. Koolin Balit Aboriginal Eye Health Advisory Group is the primary statewide stakeholder body representing all key eye health representatives (see Appendix A for the membership list). In the absence of Medicare Locals and Primary Health Networks 12, Victorian Government Department of Health and Human Services (DHHS) regional offices were consulted regarding knowledge about regional trends and service systems. 2. Australian College of Optometry is the primary institutional provider of VOS services in rural and regional Victoria. 3. Local health services, including community health, district health, and Aboriginal Community Controlled Health Services, who hold knowledge on local area health needs and gaps in the local system. 4. Current VOS service providers were consulted on their existing outreach model and operational knowledge to identify any remaining service gaps and improve the future administration of the scheme. Limitations of the data This needs assessment is limited by the health and demographic data that is currently made available by the Australian Government. This research draws on the best publicly available data, while acknowledging its limitations and results should be considered an estimate of need. Entry to the eye health system often begins with GPs, either in private practice or in a community health service or ACCHO, and Aboriginal patient identification in primary care remains under-reported. 13 The relatively small Aboriginal and Torres Strait Islander population recorded in the 2011 Census means that there is no publicly available specific health indicator data at Victorian LGA level. In regards to Aboriginal 12 Due to the timing of this project during the bridge period between the closure of Medicare Locals on 30 June 2015 and the establishment of Primary Health Networks on 1 July 2015 13 Data on Aboriginal eye health in Victoria: what comes out is only as good as what goes in (2014) July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 11 of 32

and Torres Strait Islander people, this needs assessment therefore relies on the available national, state and regional information and information gained from consultations. About this report This report presents the findings from the needs assessment conducted by Larter Consulting at the request of RWAV to inform the administration of the VicOutreach Optometrists Scheme in Victoria from July 2015. This needs assessment report contributes to a more comprehensive and open approach to planning and developing services that will allow new VOS funding to be targeted at regions and communities with the highest levels of need. The report is arranged in the following sections: section two presents the key findings from the data analysis and stakeholder consultations that underlie and shape RWAV s recommendations for VOS service delivery in Victoria discussed in section three. In turn, these inform the service delivery plan in section four of the report. July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 12 of 32

2. Understanding optometry needs in rural and regional Victoria This section reports on the data analysis and key and local informants consultations in order to establish service and location priorities for the delivery of outreach optometry in rural and regional Victoria. It informs the recommendations for VOS service delivery in section 3 of this report. What the data told us about need A review of both state and national data on eye health and related healthcare utilisation revealed that the data set is limited. Eye health data is not reported nationally through regular health performance framework reports. The lack of current, comprehensive and reportable indicators on eye health and eye care utilisation challenges service planning for eye health services. The following describes the data sources that have informed the needs assessment and the selection of the prioritised services, attached to this report. The prevalence of eye problems in Australia is not known with any great certainty, and the first nationwide study of the prevalence of eye conditions in Australians (the National Eye Health Survey) is only currently underway. 14 National health statistics published by AIHW often do not include specific indicators for eye health. 15 The eye health data available at Victorian LGA level is limited (and commenced from 2010-11), but remains the most comprehensive indicators accessed for the purpose of this needs assessment. The National Aboriginal and Torres Strait Islander Health Performance Framework does not include any specific indicators around eye health. While eye health is included in MBS health assessments, no statistics for participation in eye health examinations are reported. 16 The National Indigenous Eye Health Survey was designed to provide essential baseline evidence to be used to plan and prioritise the effective delivery of eye care for Indigenous Australians. While the survey assessed the prevalence and main causes of vision impairment, as well as the utilisation of eye care services, barriers to health and the impact of vision impairment, the results were not reported in detail by jurisdiction. While the results for Indigenous children indicate better vision than the overall population, Indigenous adults experience blindness at a rate six-fold higher. Four conditions cause 94% of the vision loss (refractive error, cataract, diabetes, trachoma), and each is readily amenable to treatment. The unmet needs in eye health are similar for Indigenous Australians in urban and regional areas as in remote areas. 17 A report by Access Economics estimated that in 2009 there were almost 145,370 people aged 40 or over with vision loss in Victoria, accounting for more than 5.9 per cent of the population in this age group. Of 14 Australian Institute of Health and Welfare, http://www.aihw.gov.au/eye-health-facts/; Conducted by Vision 2020 Australia and the Centre for Eye Research Australia 15 A guide to Australian eye health data, 2e 2009. Australian Institute of Health and Welfare. Canberra. AIHW cat. no. PHE 86; Eye health labour force, AIHW, 2009 16 Taylor HR, Anjou MD, Boudville AI, McNeil RJ. The Roadmap to Close the Gap for Vision: Full Report. Melbourne: Indigenous Eye Health Unit, Melbourne School of Population Health, The University of Melbourne, ISBN 978073404756 4; 2012. 17 National Indigenous Eye Health Survey, 2009 July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 13 of 32

these, around 16,940 people were blind. 18 Approximately 60 per cent of this vision loss is related to uncorrected refractive error, which can usually be corrected through glasses prescribed by an eye health professional. The populations most at risk, for whom regular eye tests are most recommended, are: 1. People over the age of 40 2. smokers 3. people with diabetes 4. those with a family history of eye disease and 5. Aboriginal and Torres Strait Islander people. 19 The Victorian excerpt of the 2011-12 ABS Australian Health Survey showed proportional increases in all the following indicators (except smoking, which decreased marginally) since the last survey in 2007-08. Figure 2: Selected eye health risk data from ABS Australian Health Survey 2007-08 survey 2011-12 survey Total population 5,164,700 5,556,600 Long term conditions Diabetes mellitus 196,800 210,700 Long sightedness 1,154,500 1,385,000 Short sightedness 1,189,500 1,337,400 Lifestyle factors Current daily smoker 682,500 719,100 Victorian Population Health Survey 2011-12 The eye health component of the 2011-12 Victorian Population Health Survey 20 assessed the following four domains: 1. whether respondents had ever seen an eye specialist, and the timing of their last visit 2. whether they had been diagnosed with a specific eye condition 3. whether they had noticed a change in their vision in the last 12 months 4. whether they engaged in sun-protective behaviours (sunglasses and hat). Accessing an eye professional was measured in three categories: 1. having never visited an eye professional 18 Access Economics 2010, Clear focus: the economic impact of vision loss in Australia in 2009. An overview of the report prepared for Vision 2020 Australia by Access Economics Pty Limited, Access Economics, Melbourne. 19 Victorian Population Health Survey 2011-12, p407 20 Department of Health 2014. Victorian Population Health Survey 2011 12. State Government of Victoria, Melbourne July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 14 of 32

2. having visited an eye professional five years or more prior 3. having visited an eye professional less than six months prior. Darebin, Greater Geelong, Greater Shepparton and Latrobe LGAs are identified as having a higher proportion of people aged over 40, smokers, people with diabetes and people of Aboriginal and Torres Strait Islander descent. A large number of people residing in these LGAs do not have regular eye tests, putting them at increased risk of eye disease. Some key findings relevant to the delivery of outreach optometry and other eye health services across rural and regional Victoria include: In the Campaspe, Mitchell and Queenscliff LGAs, significantly higher proportions of people had never seen an eye health professional, compared with all Victorian adults. Proportions of Victorians reporting visiting an eye professional in the last six months were significantly lower in rural Victoria than metropolitan Melbourne. There were no significant differences between metropolitan and rural areas in the proportion of people who had noticed a change in their vision. The survey found no significant differences in the prevalence of glaucoma, diabetic retinopathy or macular degeneration between people who lived in the metropolitan area compared with rural Victoria. The prevalence of macular degeneration was significantly higher in men and adults who lived in Gippsland Region compared with all Victorian men and adults, respectively. A higher proportion of people living in rural Victoria wore both a hat and sunglasses than those in metropolitan locations. The survey assessed relationships between these indicators of eye health and socio economic status (SES) (measured by total annual household income), finding a relationship between change in vision, sun-protective behaviours and people who had never seen an eye professional, and declining SES. 21 The key results from this population health data have been used to represent a heat map of priorities in Figure 3, resulting in an overall priority grading in the final column (discussed further on page 29-30). Figure 3: Heat map of select LGAs indicating risk, based on LGA eye health data and overall risk/priority grading RA VOS 2011-2014 1 LGA Visited an eye professional Never visited >5 years Last 6 months ATSI population %(number) 2 Diabetes 3 Smoking Proportion of needed optometry consultations delivered 4 RISK/ PRIORITY GRADING Barwon South West 7% 2/3 Moyne 1.24 (200) 2 2/3 Southern Grampians MEDIUM 1.19 (196) HIGH 1 3 Glenelg 2.16 (428) 2 3 MEDIUM Corangamite 0.77 (128) 1 21 See the full Victorian Population Health Survey 2011-12 report for a more detailed discussion July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 15 of 32

RA VOS 2011-2014 1 LGA Visited an eye professional Never visited >5 years Last 6 months ATSI population %(number) 2 Diabetes 3 Smoking Proportion of needed optometry consultations delivered 4 2 Queenscliff HIGH 0.49 (15) 3 2 Surf Coast HIGH HIGH 0.57 (152) 3 Grampians 16% 3 Northern Grampians HIGH 1.27 (152) 2 2 Ballarat 1.27 (1208) HIGH HIGH 3 3 Hindmarsh HIGH 1.55 (91) HIGH 2 4 Hindmarsh HIGH 1.55 (91) HIGH 1 3 Yarriambiack 1.55 (91) 3 3 West Wimmera 0.73 (31) HIGH 3 RISK/ PRIORITY GRADING Loddon Mallee 50% 3 MEDIUM Mildura 3.79 (1966) HIGH 1 2 Campaspe HIGH 2.35 (861) HIGH 1 3 Swan Hill 4.57 (951) HIGH 3 Gannawarra HIGH 3 Loddon MEDIUM HIGH HIGH 1.48 (111) 1 3 Buloke 0.58 (37) HIGH 2 2 Greater Bendigo HIGH 1.49 (1518) HIGH 2 Mt Alexander HIGH 1.04 (185) 3 2 Pyrenees HIGH HIGH 1.03 (70) HIGH HIGH 3 Hume 8% 3 Towong HIGH HIGH 1.48 (88) 1 2 Greater Shepparton HIGH 3.63 (2240) HIGH HIGH 1 2 Wodonga HIGH HIGH 3 2 Mitchell Shire HIGH 1.23 (432) 1 3 Mansfield MEDIUM HIGH HIGH 0.74 (59) HIGH HIGH 1 3 HIGH Alpine MEDIUM HIGH 0.73 (88) 1 2/3 Benalla MEDIUM HIGH 1.27 (174) 1 2 Moira MEDIUM HIGH 1.48 (421) HIGH 1 2 Strathbogie HIGH 0.97 (94) 3 Gippsland 33% 3 Wellington HIGH 3 East Gippsland HIGH HIGH 3.33 (1424) 1 4 HIGH East Gippsland HIGH HIGH 3.33 (1424) 1 2 La Trobe 1.53 (1124) HIGH 2 Sth Gippsland MEDIUM HIGH 0.78 (214) 1 1 The Commonwealth VOS priorities for 2011-14 program 2 The 20 catchments with largest population numbers are marked for priority 3 Diabetes priority determined by high hospital; admissions &/or renal dialysis 4 Proportion of optometry consultations delivered against estimated needs, by region (discussed on page 18 on projected eye care workforce needs) 2 or 3 July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 16 of 32

Overall, this data substantiates the need for Victoria s ageing population to have better access to eye professionals in order to prevent avoidable sight loss. Regular eye tests are particularly important for the at-risk groups. Addressing the gap between use of eye health professionals by Victoria s rural population and metropolitan areas seen in this data will contribute to this. Analysis of optometry services in Australia A market analysis of optometry services completed for the Commonwealth Department for Health in 2014 22 found that in Victoria, services are concentrated around Melbourne. East of a line connecting Warrnambool, Ballarat, Bendigo and Echuca, optometry practices are located approximately in line with population numbers. To the west of this line there are fewer optometry practices per million of population, and in the north-west of the state, there are several postcodes without even one practice. A map of the Victorian market is attached for reference in Appendix B. The key patterns of data have not contributed directly to the service needs analysis, as the data can be misleading as the representation of practice density per million people does not adequately reflect numerous access barrier issues, and as such, can only contribute to an overall picture of service planning needs. Medicare data There are several Medicare items that can be charged for optometry. The largest number of these services (838,155 in calendar year 2014) was provided for item 10900, a comprehensive eye examination, available to all Medicare card holders, and usually bulk billed. More than one in eight comprehensive examinations were for children (aged 14 and under, 103,016 (12%), and more than one in three for Victorians aged over 55 years (281,369 33.5% of this item). 23 A summary of the comprehensive eye examination data is attached in Appendix C. Of particular note is that Victoria s per capita use of comprehensive eye examination Medicare billing (14,159 services per 100,000 population) is below the national average (14,612 services per 100,000 population), and behind NSW, Queensland, WA, SA, Tasmania and the ACT. Optometry Australia and the Australian National University have recently compiled all the epidemiological, demographic and eye care data sets available to provide an estimate of unmet need for eye care across SA3 regions. Data was collated from the following sources to create the eye health heat map: ABS National Health Survey (2011-12); Census of Australia (2011); Department of Health Visiting Optometrist Scheme (2014); DHS Medicare Statistics (2013-14); Health Workforce Australia Health Workforce (2012). A visual representation of The National Eye Health Heat Map for Victoria has been included in Appendix D, and the eye care need score has been incorporated into the needs assessment as another data source. What the consultations told us about need Local health service stakeholders were consulted to validate the service needs identified through the data and to identify existing access to optometry services, including any VOS service plans. The engagement also identified appropriate service delivery models and began identifying existing local networks to 22 ACIL Allen Consulting, Optometry Market Analysis, 2014 23 Optometry Australia July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 17 of 32

ensure outreach service planning is aligned and integrated with local needs assessments and service plans. Current VOS service providers were also contacted, both private providers and the Australian College of Optometry, to contribute to the assessment of needs. Identifying important themes with key stakeholders Following is a summary of RWAV s consultations with key stakeholders and the key themes that emerged and shaped the recommendations in this report as well as be prioritised for review during future VOS service planning. Australian College of Optometry The Australian College of Optometry (ACO) is a not-for-profit organisation providing affordable eye care and glasses in Victoria. The ACO services are provided in partnership with the Victorian Eye care Service (VES) funded by DHHS and delivered in collaboration with a network of private practitioners in metropolitan, regional and rural areas. The VOS and VicOutreach programs also support the ACO's visiting services. To date, the ACO has informally negotiated arrangements with the ACCHO sector to provide optometry services to Aboriginal and Torres Strait Islander clients throughout the state. Most of these services are delivered through a visiting optometrist bus service that conducts clinics onsite at the local ACCHO. The service delivery circuits of these visits are summarised further in the report in Figure 6. The ACO also provided summary estimates of known patients waiting for optometry review (as at June 2015), including those with diabetes, which contributed to the service needs analysis. Aboriginal Eye Health Vision loss from diabetes, cataract and refractive error is common in Aboriginal communities in Victoria yet 94% of vision loss in the Aboriginal community is preventable or treatable. A number of schemes and eye care services currently support eye health in Aboriginal community members, including the VOS, VicOutreach Aboriginal Health, and the Victorian Aboriginal Spectacle Subsidy Scheme (VASSS). The VASSS is funded by DHHS as part of Koolin Balit, the Victorian Government strategic directions for Aboriginal Health, and is supported by the VES. It is administered by the Australian College of Optometry in partnership with Aboriginal Community Controlled Health Organisations (ACCHOs) and a network of optometrists in regional Victoria. A regional approach to eye care: Regional Aboriginal Eye Health Projects The Roadmap to Close the Gap for Vision (2012) (the Roadmap ) recommends a regional approach to delivery, coordination and reporting on eye health 24 and the service delivery models developed through the Roadmap reflect this. In Victoria, the Roadmap implementation is being enhanced through one statewide and four regional Indigenous eye health projects funded by Koolin Balit. These projects aim to develop and strengthen regional networks and improve coordination and referral pathways. The project officers are engaging local Aboriginal community controlled health services, optometry, ophthalmology, and hospital services in the mapping of service gaps, determination of needs and developing local 24 Taylor HR, Anjou MD, Boudville AI, McNeil RJ. The Roadmap to Close the Gap for Vision: Full Report. Melbourne: Indigenous Eye Health Unit, Melbourne School of Population Health, The University of Melbourne, ISBN 978073404756 4; 2012. July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 18 of 32

strategies to promote better outcomes for Indigenous eye health. The current coverage of eye health projects in Victoria is included in Appendix E. The Grampians Aboriginal Regional Eye Health project is the benchmark regional eye health project for Australia. The project is trialling the process implementation required to improve Indigenous eye health outcomes and involves calculating workforce needs, better integration of different parts of the eye health system (ophthalmologists, optometrists, hospitals and primary care), and a case management approach to servicing populations at risk. Consultations emphasised the importance of a local regional stakeholder group of ophthalmologists, optometrists, hospitals and primary care coming together to coordinate care. The IEHU workforce tool (see the following page) is used to calculate the consultations, spectacles, and procedures required for the local communities at the three ACCHO sites. The clinical software is used to find patients with diabetes for review (of health status and retinal exam) and follow up. Across the three Aboriginal health services, the retinal screening rate of people with diabetes is now 75 per cent. Another key outcome is a Professional Eye Health Services Directory for the Grampians region, listing optometry practices, low vision clinics and ophthalmological services, by town, workforce FTE hours, and participation in subsidy schemes (Victorian Aboriginal Spectacle Subsidy Scheme, bulk billing, Victorian Eye Care Service). The next stage of the project will focus on educating both service providers and community members to promote better eye health outcomes. This is particularly important as the ACCHO patient lists only comprise approximately 60-70 per cent of the local Aboriginal population. The VACCHO project supports at state level by conducting eye health training for Aboriginal Health Workers; developing culturally appropriate resources and education materials; and implementing an awareness campaign to community and service providers across the state about improving access to quality spectacles and sight aids and to specialist treatments. The consultation emphasised the need for a layered approach to working with ACCHOs around eye health needs, in the same vein as the case management approach seeing success in the Grampians region. Quality onsite engagement about needs and processes will result in more sustainable pathways, especially given the diversity of communities across Victoria. Local and jurisdictional coordination of eye care services Consultations provided little evidence of local or regional management of eye care provision. Some elements of the delivery of eye care are managed well by practitioners and providers (especially in the approach by the new Indigenous eye health projects), but there is not a systemic approach to achieve consistent, effective and targeted outcomes. There was no consistent appreciation at local level of the population-based determination of needs. The approach was more site-based, determined by patient lists rather than explicit need. Eye health coordination functions at regional government, Primary Health Network or Primary Care Partnership-level do not exist, resulting in a fragmented statewide approach to population based planning. A workforce needs analysis for the delivery of eye care services The Indigenous Eye Health Unit (IEHU) at the University of Melbourne has established an evidence base and policy framework for Indigenous eye health in Australia. IEHU s signature project, The Roadmap to July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 19 of 32

Close the Gap for Vision 25, seeks to eliminate the known differences in the standard of eye health in Indigenous Australians compared to the wider Australian population. The project has developed 42 policy recommendations across nine domains of activity to support this goal. The Roadmap model, an interlinked set of recommendations to improve access to and utilisation of comprehensive eye care, is summarised below: 1. Provide eye health workforce to meet population needs a. Population-based needs determine eye health workforce. Workforce needs analyses in all regions, aiming for sufficient ophthalmology & optometry in all regions 2. Improve contracting & management of visiting services a. VOS and RHOF work effectively & properly coordinated. Linkages between RHOF/MOICDP & RHOF/VOS with ML/PHN & LHN. New fundholder arrangements for planning & coordination 3. Appropriate resources for eye care in rural & remote areas a. Services are adequate to meet eye care needs. Aiming for sufficient workforce & resources in all regions, and needs analyses completed in all regions 4. Increase utilisation of services in urban areas a. VOS supports AHS eye care in both regional & urban areas. 5. Billing for visiting MSOAP supported services a. RHOF services are bulkbilled. Bulkbilling policy paper developed & endorsed. 6. Rural education & training of eye health workforce IEHU has developed an evidence-informed model for eye health coordination, included in Appendix F, a Regional Implementation Toolkit and a workforce calculator to deliver its models of service delivery developed in The Roadmap to Close the Gap for Vision, integrating and coordinating the three levels of eye care. The eye workforce calculator uses the following FTE workforce ratios to calculate the basic eye care workforce needs per 10,000 population: 3.8 optometrists 1.3 ophthalmologists 31.5 coordinating function IEHU is currently working on twelve regional assessments with state health departments and Medicare Locals/Primary Health Networks to estimate regional workforce needs against what services are currently provided using ten eye health indicators to measure and monitor health system performance and equity 25 Taylor HR, Anjou MD, Boudville AI, McNeil RJ. The Roadmap to Close the Gap for Vision: Full Report. Melbourne: Indigenous Eye Health Unit, Melbourne School of Population Health, The University of Melbourne, ISBN 978073404756 4; 2012. July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 20 of 32

of access to eye care services. The Unit recommends that there should be greater regional responsibility to monitor and account for outreach activity. The Australian College of Optometry is now employing this projected workforce needs model to measure its service delivery regionally. Figure 4 highlights the proportion of service currently being delivered, with four DHHS regions (figures bolded in table) - Hume, Grampians, Barwon and Southern - showing particular gaps in needs being met. Figure 4: Eye care projected needs by DHHS region, Victoria DHHS regions Projected annual need for eye examination ACO optometry consultations delivered 2014 Proportion delivered % Gippsland 649 217 33 Loddon Mallee 985 490 50 Hume 776 63 8 Grampians 409 67 16 Barwon 600 44 7 Southern 940 151 16 North West 1544 607 39 Eastern 504 123 25 Verifying data, service plans and gap analysis The data discussed so far was collated to create a service need heat map by LGA. The eye health service needs were prioritised based on a collective analysis of the layers of data and an overall priority score (1-3) was determined to represent a general estimate of the need for visiting optometry within each catchment. Consulting with local community health providers, including ACCHOs where relevant, then validated these service needs. If need was verified, appropriate service delivery models for the area were also discussed. Aboriginal Community Controlled Health Organisations This needs assessment consulted with 22 Aboriginal community controlled health organisations (Appendix G). The ACO currently delivers VOS and/or MOICDP services to 18 of these services, so the consultations confirmed the current service models and identified if the few ACCHOs without VOS service identified any gaps. The following section summarises the key themes that emerged from these discussions. Most informants expressed high satisfaction with current visiting optometry services provided by the ACO, emphasising the management, coordination and integration of services. The ACO was commended for its clear and specific requests for staff and other resources at each site, so that outreach appointments and day schedules ran seamlessly. The ACO van is equipped to perform retinal scanning for diabetes and is well integrated with local services and VASSS. The ACO is flexible and responsive to needs, with July 2015 Needs assessment for VicOutreach Optometrists Scheme Page 21 of 32