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Providing domiciliary eyecare: This article outlines the regulation relating to domiciliary eyecare, the clinical challenges, and the dispensing considerations when examining patients in their own home.

Optometrists ****

Dispensing opticians **

Introduction

Over two million people in the UK are living with some form of sight impairment. (1) For some, all that is required to provide an improvement to their sight is to ensure that they are wearing correctly prescribed glasses. (2) The major sight conditions causing sight loss in the UK can be seen in Table 1. (3)

It is well known that the UK population is ageing, and statistics indicate that from the year 2014 to 2039 the number of people aged 80 years and over is set to double from 3.1 million to 6.3 million. (4) Many of these people will be unable to leave home unaccompanied due to physical disability or mental illness and so will be eligible for an NHS funded domiciliary sight test.

In 2016/17, 548,295 NHS domiciliary sight tests were conducted in the UK, representing only 3.3% of all NHS eye tests. Over the past five years the number of domiciliary eye tests in the UK has increased by 13.8% (see Table 2, page 68). (5)

According to the last UK Census in 2011, approximately 331,100 people aged 65 years and over were living in care homes, representing 3.2% of this section of the UK population. (6) It is interesting that the figures from the consecutive censuses of 2001 and 2011 show there was only a 0.3% increase in the number of people aged 65 years and over living in care homes; this is surprising given that the same censuses show there was an 11% increase in the population of this age group and suggests that those additional people are staying in their own homes rather than entering a care home. An increasing number of older people staying in their own homes for longer, increases the need for domiciliary services of all kinds, including eye care.

Providing domiciliary eyecare

The GOS regulations allow a domiciliary sight test to be provided to an individual at their normal place of residence or certain day centres. (7) The criteria for eligibility is that they must be entitled to GOS services and be unable to leave home unaccompanied due to physical or mental illness, or disability. The sight test form (GOS 6) must identify the illness or disability that the patient is living with; symptoms of an illness or disability are not accepted. Domiciliary tests cannot be provided to patients residing at a place other than their normal residence such as respite care or hospitals. Regulations also require the provider to pre-notify the visit to the NHS. In England, the notification period is a minimum of 48 hours for one or two people at the same address and three weeks for three people or more. In both cases the maximum notification period is eight weeks. In Scotland, at least one month's notification is required when three or more people are to be visited at the same address. In Northern Ireland, notification must be at least 48 hours before the sight test except for urgent situations, where notification is not required. (7) In the Republic of Ireland pre-authorisation is required before the test can be provided rather than notification. It may be the view that the notification process disadvantages the domiciliary patient, but it allows the NHS to have knowledge of when and where the domiciliary provider is delivering their service and the NHS considers that this affords a level of protection to the patient.

Practitioners who are interested in providing a domiciliary service can avail themselves of recent guidance provided by the Optical Confederation's Domiciliary Eyecare Committee 'Providing domiciliary eyecare services--Guidance for the profession' which is available on the Optical Confederation's website. (7)

Regulation

In addition to the standard GOS regulations, which other than the notification requirements are much the same as those that apply to a high street practice, a domiciliary provider may need to be more aware of other legislation than might be applicable when seeing the typical cohort of patients in this environment.

Data protection can be challenging in domiciliary practice because it is common for family members to think that they have an entitlement to be given information about their loved one simply by virtue of their relationship. While this is clearly not the case, communicating it to a concerned family member can be fraught with difficulties. It can be particularly challenging when the patient has compromised cognitive abilities but is still able to make decisions for themselves. The Mental Capacity Act (MCA) 2005 is designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. (8) It is a law that applies to individuals aged 16 years and over. There is similar legislation in Scotland and Northern Ireland, all with the same purpose.

The MCA covers decisions about day-to-day things such as what to buy for the weekly shop, to serious life-changing decisions like whether to move into a care home or have major surgery.

The MCA says:

* Assume a person has the capacity to make a decision themselves, unless it is proved otherwise

* Wherever possible, help people to make their own decisions

* Don't treat a person as lacking the capacity to make a decision just because they make an unwise decision

* If you make a decision for someone who doesn't have capacity, it must be in their best interests

* Treatment and care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedoms.

It also sets out terms for Powers of Attorney in cases where the individual does lack capacity.

Before deciding if a person lacks capacity, a number of approaches should be considered. For instance:

* Have different methods of communication been explored, such as non-verbal communication?

* Could anyone else help with communication, such as a family member, carer or advocate?

* Are there particular times of day when the person's understanding is better?

* Are there particular locations where the person may feel more at ease?

* Could the decision be delayed until they might be better able to make it?

Before making a decision or acting on behalf of someone who lacks capacity, always question if something else could be done that would interfere less with their basic rights and freedoms; this is called finding the 'least restrictive alternative' and it includes considering whether there is a need to act or make a decision at all. Where there is more than one option, it is important to explore ways that would be less restrictive or allow the most freedom for a person who lacks capacity.

It is the law for the NHS and adult social care services to comply with the Accessible Information Standard (AIS), (9) which was introduced in 2016 to ensure that people with a disability or sensory loss are given information in a way they can understand. The standard sets out a specific, consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of patients, service users, carers and parents with a disability, impairment or sensory loss.

Optometrists or OMPs who provide domiciliary services are normally experienced in examining people who have disabilities, or who have limited communication or concentration, and should be able to adapt the sight test accordingly. In a situation where the environment or the physical and cognitive impairments of the patient make it impossible to include the full range of procedures, the reasons for this should be noted on the patient record and the patient or the person with the appropriate legal power is made aware of this.

The visit

Communication is key during a domiciliary sight test so that patients are aware of who is carrying out the examination and the purpose of the visit. Each test being carried out must be explained clearly to avoid any confusion and it can be useful to make comparisons to what is done in the High Street practice.

Where possible, the sight test should take place in a room which has good lighting but is easily darkened. Ideally, there should be three metres of space in front of the patient's chair or bed and a tape measure should be used to check that the test chart is at the correct distance from the patient. It isn't unusual for the space to be limited and using a computerised test chart will allow adjustments to be made to accommodate that. It is preferable to have enough space on either side of the patient so that the practitioner can get adequate access, but this is not always possible, and the domiciliary practitioner has to work with what is available. If the layout of the room needs to be changed, this can sometimes cause the patient distress; they should be reassured that the changes will only be while the sight test is carried out and that everything will be replaced before you leave.

There is a great advantage to providing a sight test at home for a person that cannot go out in that they are, by definition, being examined in the environment in which they will use any glasses prescribed. This means that in addition to normal visual acuity measures, the domiciliary practitioner can also ensure that the patient can see their TV as clearly as possible, taking into account its position relative to where they habitually sit. Of course, it also means that the practitioner is in a perfect situation to advise on lighting and magnification to assist with reading. These small things can be invaluable in ensuring the best outcome for the patient.

Much of the equipment used for a sight test in a High Street practice has a portable equivalent. An internal/ external eye examination can be done using a direct ophthalmoscope, indirect ophthalmoscope and aided with portable digital imaging systems. Dilation is common practice, so all relevant checks are required before instilling a mydriatic. In case of an adverse reaction, it is important that written information about the drops used is provided and that a carer or family member is informed that they were used if this is relevant and the patient agrees. A portable distance vision chart and near vision chart are obviously required. Autorefraction is less common during a domiciliary sight test and a retinoscope is most commonly used for objective assessment. It perhaps goes without saying that phoropter heads are not used and instead trial lenses and a trial frame, along with other accompanying refraction aids are the mainstay of domiciliary sight tests. Portable focimeters are handy and easy to use, although measuring lenses with high prisms can be challenging so it may be necessary to obtain sight test results from the previous practitioner with the patient's consent in these cases. In recent years, the iCare has become the tonometer of choice. The disposable probes present a per patient cost, but the benefit of being able to easily measure intraocular pressures on the overwhelming majority of patients while avoiding instillation of a topical anaesthetic or blowing a puff of air at them, makes it a worthwhile addition to the domiciliary practitioner's armamentarium. A means of checking visual fields is of course required, and confrontation may not be adequate in many cases, so generally the Damato campimeter is used for a screening assessment and a portable electronic device can be used for a more detailed analysis.

Challenges faced within the domiciliary environment

Referrals can be a challenge to a mobile optometrist because of the variation of schemes and the associated paperwork required in the different clinical commissioning group (CCG) areas. It is not unusual for the typical day to cover more than one CCG area and ensuring that the practitioner understands not only every scheme, but also which area they happen to be in at the time can be complex, particularly near the borders of areas. Some referral schemes exclude domiciliary patients, and this occasionally results in referrals being sent to the GP, in the absence of any other way to refer, being questioned.

The environment in which the service is provided is certainly varied and can present with many challenges. Some places may be cluttered or even unhygienic. Access to an electrical socket is vital to be able to use the equipment and so an extension lead must be available. As mentioned previously the size of the room in which the test is being carried out will vary, and it isn't always possible to darken the room adequately. In a care home setting it can be difficult to find a space that allows the correct level of privacy. Practitioners will often see patients who are bedbound, or in a wheelchair, and must adapt to the patient's general position; considerations include whether the patient is lying completely flat, or at a recline.

Challenges with communication are also extremely common, with some patients unable to communicate at all, so the examination may rely solely on an objective approach in these cases. Some patients may be able to use hand gestures or possibly be able to write notes on paper in order to communicate. Tests such as Sheridan-Gardner or Kay pictures can be considered in circumstances where communication is difficult. And in our multi-cultural society there could be a language barrier at times.

Dispensing considerations

Dispensing plays an important role in domiciliary eye care and it is essential to take into account the patient's requirements in detail. For example, poor dexterity can influence the frame choice. Some health issues can cause sensitive skin and so the frame material used must be considered carefully. In situations where sensitive skin along the nose is an issue, it is prudent to dispense lighter lenses to reduce the weight of the glasses. If a patient has any balance issues linked to health conditions, such as vertigo, osteoporosis, spinal stenosis, it may be necessary to avoid the use of progressive lenses or bifocal correction. Patients who are bedbound may require the reading portion of the lens to be set lower for bifocals or progressive lenses. In cases such as these the consideration of posture and positioning plays a huge role, and this needs to be taken on board during the dispensing process.

Conclusion

The population is ageing, and domiciliary care within the community is increasing as people are becoming more aware of the multiple services provided by various health care professionals. Domiciliary eye care is one such service which provides an opportunity to change and enhance a patient's life in a significant way. The domiciliary sight test forms the backbone of this service, and the importance of accurate portable equipment is essential and key to the whole process. A professional understanding and a persona of empathy and consideration is also key in the role of a domiciliary provider as one faces many different situations, environments and circumstances during a typical working day. Ultimately, the patient has a right to expect the same high-quality service they would get within a clinical environment in a High Street practice. Domiciliary eye care is a much-needed service that struggles to keep pace with an unmet need for eye care for those who cannot leave home unaccompanied. The need for this service is likely to keep increasing, and more eye-care professionals will be needed to fulfil the requirement. Working within the domiciliary sector provides different options to fit an individual optometrist's lifestyle from full time to term-time only contracts and most things in between, and of course locums are always needed.

While there are challenges that are specific to domiciliary work that you might not have encountered before, the rewards far outweigh them. Patients are grateful, no two days are the same, and it provides an opportunity to leave the consulting room and see the light of day while travelling between visits.

Acknowledgements

The author would like to thank Dawn Roberts for her comments on drafts of this article.

Exam questions and references

Under the enhanced CET rules of the GOC, MCQs for this exam appear online at www.optometry.co.uk. Please complete online by midnight on 12 October 2018. You will be unable to submit exams after this date. Please note that when taking an exam, the MCQs may require practitioners to apply additional knowledge that has not been covered in the related CET article.

Visit www.optometry.co.uk, and click on the 'Related CET article' title to view the article and accompanying 'references' in full.

Course code: C-60334 Deadline: 12 October 2018

Learning objectives

* Show care and compassion and respond to the needs of patients requiring domiciliary care (Group 2.4.1)

* Understand the need to modify clinical methods where required when examining domiciliary patients (Group 7.1.1)

* Show care and compassion and respond to the needs of patients requiring domiciliary care (Group 2.4.1)

* Understand the need to modify clinical methods where required when examining domiciliary patients (Group 7.1.1)

Sanjiv Koasha BSc (Hons) Optom

About the author

* Sanjiv Koasha qualified as an optometrist in 2009 and for the past four years has been working in the field of domiciliary eyecare across two practices with a team of optometrists.
Table 1 Estimated major causes of sight impairment in
the UK (3)

Condition                                 (%)

Uncorrected refractive error              53.4
Age-related macular degeneration (AMD)    16.7
Cataracts                                 13.7
Other                                     7.4
Glaucoma                                  5.3
Diabetic retinopathy                      3.5

Table 2 NHS sight test and domiciliary sight test data, 2016/17 (5)

Country             Total number of   NHS domiciliary
                    NHS sight tests     sight tests

England               12,995,512          454,515
Wales                   776,827           27,411
Scotland               2,198,390          51,442
Northern Ireland        476,411           14,927
UK total              16,447,140          548,295

Country             Proportion that    Five-year
                    were domiciliary   increase in
                      sight tests      domiciliary
                                       sight tests

England                   3.5%            14.7%
Wales                     3.5%            15.1%
Scotland                  2.3%            7.4%
Northern Ireland          3.1%            6.9%
UK total                  3.3%            13.8%
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Title Annotation:Domiciliary
Author:Koasha, Sanjiv
Publication:Optometry Today
Geographic Code:4EUUK
Date:Sep 1, 2018
Words:2985
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