Refractive
June 2022
by Ellen Stodola
Editorial Co-Director
Comanagement can be an important part of an ophthalmology practice, facilitating collaboration between optometrists and ophthalmologists in the community and giving patients the best possible care. In the April 2022 issue of EyeWorld, “Comanagement in refractive cataract surgery” highlighted how this might work in a practice and tools to aid in its success.
Here, EyeWorld asked two optometrists to discuss their experiences in practices that have a comanagement approach. They shared recommendations for practices interested in expanding their comanagement network.
Mitch Ibach, OD
Vance Thompson Vision
Mitch Ibach, OD, discussed his experience at Vance Thompson Vision, where he said about 90% of the patients they see in cataract, glaucoma, and cornea are referred from a primary optometrist or ophthalmologist in the community. “Refractive surgery is a little less, but it’s still 60–70% of those who come to us for refractive surgery,” he said.
Dr. Ibach stressed why cultivating and managing a large optometric referral network is the lifeblood of the practice. “That’s what we’re built on, so we work hard to be excellent at communication, making sure that they know what’s new, and making sure that they’re getting their patients back.” Educational events help in this process. These events allow for teamwork “but also teach the referring network what’s new in our practice and how we’re handling some outcomes and how we’re trying to give patients a fantastic experience,” he said.
Education is also important for staff in the practice. “Once a year, we run an 8- to 10-week staff training where those who want to advance and get certifications can do virtual or live education with some of our doctors,” he said. “Our staff is so important in preliminary education for our patients and delighting them in their experience.”
Dr. Ibach said the practice also does education for physicians, which include half- or full-day symposia aimed at optometry and focusing on cataract, refractive, glaucoma, and cornea subspecialties. These are very well attended, he added. The practice uses other platforms, like social media, to facilitate education, as well as dinner events. “Offering that education has created a nice bridge of keeping relationships that have been the lifeblood of the practice,” Dr. Ibach said.
When considering comanagement, Dr. Ibach said there are advantages as well as things to look out for. “I think there are a lot of advantages, and the number one is that it facilitates continuity of care that the patient has with their long-term optometrist or ophthalmologist,” he said. There are many years of trust built into those relationships, and in a 15-minute cataract evaluation, you just can’t get all of that history. “Having a good relationship with the referring doctor coming in and knowing some of those things can be beneficial,” he said.
Additionally, in the postoperative period, it allows the patient to get back to their optometrist if they need glasses or continued care. It allows our surgical partners to do more surgery, Dr. Ibach said. “In our practice, that’s been key, trying to allow our surgeons to do as much surgery as they can or want to do, and that’s been helped by having a comanagement model for our patients,” he said. “Ultimately, it allows everyone to do what they want to do.”
Dr. Ibach said that it may be challenging when first starting out to build the relationships and the trust. “Comanagement is definitely a two-way street,” he said, adding that he sometimes hears concerns from optometrist colleagues that they’re worried that they will not get their patients back if they refer them out. “As an optometrist, we have to communicate that on the front end that I want to see a patient back and lead in the postoperative care.”
For a surgeon who’s starting to do comanagement, it’s a lot easier if you have the policy of “we’re going to try to get as many patients back as we can,” Dr. Ibach said. It’s hard to pick and choose which you want to keep from cataract surgery. For refractive surgery, it’s a little different, Dr. Ibach added, because patients have the goal of being less dependent on glasses and contacts. “For us not having an optical, it has been a bridge to doing more comanagement and building our referral network because there is no threat of us doing a patient’s glasses or contacts after cataract surgery,” he said.
Dr. Ibach also stressed the need to convey to patients the importance of still having routine eyecare. Some patients think if they have LASIK/PRK/SMILE that they don’t have to see the optometrist. “As a surgical practice, stressing the need for routine eyecare is important,” he said. “That’s only going to continue to build relationships and get optometrists to want to refer those patients because they’ll know they’ll still get to see them.”
Another tip for ophthalmology practices starting is to protect each other, Dr. Ibach said. Make sure to protect the relationship with the patient and optometrist and protect the character of the doctor, he said, adding that it’s also important to make sure to put the referring network and doctor in a good position. This includes not pointing the finger at anyone if there is a complication or issue. If you need to adjust an approach or do something differently, he said phrasing is important. Saying something like “We’re going to take a different approach,” or “We have some other technology and that’s why we’re doing something different,” is more appropriate than saying another doctor is in the wrong.
Derek Cunningham, OD
Dell Laser Consultants
Dr. Cunningham has experience in a referral- based practice that uses comanagement. He also said that Dell Laser Consultants has been using comanagement for about 20 years.
“That allows our surgeons to do what they do best—stay in the OR,” he said. “That allows our community [ophthalmology and optometry] primary caregivers to do what they do best, which is to see patients.” He added that this approach works for all parties involved.
Dr. Cunningham highlighted how well this model seems to work for the patients because they are referred with the trust of their primary eyecare doctor.
The first thing that happens when a patient is referred in is the patient is assessed by a specialist who will handle initial evaluations and any post-surgical issues, and that allows for one surgical opinion at a time, someone who specializes in that specific procedure. Then the surgeon will evaluate the patient independently. The process helps to make sure mistakes are not made and allows for an independent set of eyes to review the data, review the systems, make sure there are no errors, and give an independent recommendation. Patients find it reassuring when they’re seeing multiple doctors who are validating the decision for them to have whatever surgery they’re having, he said. “It’s allowing for an extra level of care and reassures the patient that multiple opinions agree on the surgical plan.
“In a center like ours, no patient ever goes into surgery without having a standardized protocol for their postop and long-term eyecare,” Dr. Cunningham said, adding that the postop plan is important to have in place, and communication is key.
When choosing to implement comanagement, there may be some initial adjustments and obstacles. Dr. Cunningham noted that the one “stumbling block” his practice has noticed in the 20 years that they’ve been practicing shared care is that patients can be sensitive when there are inconsistencies between their community doctor and the practice they’re being referred to, particularly in communication and language.
“One of the things we learned early on is that we all had to have the same language in terms of how we were talking about disease states and surgical procedures,” he said. “You don’t have to agree on things, but we have to talk about them in the same way because if we’re not using the same language, patients will pick up on the smallest inconsistencies, and that can be very unnerving for them.”
Dr. Cunningham noted the importance of education in the process. “We spend a lot of time educating our community ophthalmologists and optometrists,” he said, adding that this can be anything from monthly emails to live and virtual continuing educational events.
The most important thing is education on both sides, he said. The ophthalmologists and optometrists have to be able to get together, and there needs to be an open line of communication all the time. “It’s having very candid conversations about what the concerns are and realizing that, above all, it’s the patients’ needs and safety that will dictate the relationship,” he said.
While comanagement is often most set up for LASIK and cataract surgery, Dr. Cunningham noted that his practice also does a number of other procedures, and he mentioned the success of comanagement for corneal crosslinking.
Dr. Cunningham also noted the importance of constantly reevaluating the system to ensure that the comanagement model is still providing better service than a sole practice. We need to make sure as clinicians and physicians that we’re providing the best possible care for patients, he said. “In the beginning, we thought we had a template that could increase the level of care for patients in our system if it was done properly. It was what we foresaw would be the new model, and now it makes more sense because of the crush of the healthcare system,” he said.
About the doctors
Derek Cunningham, OD
Dell Laser Consultants
Austin, Texas
Mitch Ibach, OD, FAAO
Vance Thompson Vision
Sioux Falls, South Dakota
Relevant disclosures
Cunningham: None
Ibach: None
Contact
Cunningham: derek.n.cunningham@gmail.com
Ibach: mitch.ibach@vancethompsonvision.com
