Several years ago, Dr. Marisa Rowen, pharmacist and diabetes educator at El Rio Community Health Center in Tucson, who serves as the associate pharmacy director of advanced practice services, was asked to explore options for improving the organization’s rate of diabetic retinopathy screening. After some research, the decision was made to adopt a telemedicine approach, and the EyePACS DR screening system was chosen for the task.
El Rio serves more than 94,000 patients. Some of them have been members of this health center for more than 40 years. This is truly a patient-centered medical home, and it was for the benefit of the patients that Dr. Rowen and her colleagues adopted the EyePACS program. “At least 80% of our patients work two or more jobs,” she explained. “To pay a $40 co-pay is a great burden for some, and to have to make an additional appointment and take off work to be there is almost more than they can manage. Many of our patients also have limited transportation options. So we provide all their services right here, to the greatest extent possible. It was for the patients we added this program.”
Marisa explained that El Rio’s patients trust the health center to make the right choices for them. Adding a DR screening program in-house was not necessarily what the staff needed, but it was what the patients needed. What was the secret to success? “Everyone in a leadership position here is mission driven – we live and breathe our cultural belief: 'Honor Patients - I always put the patients first.' Our CEO is an experienced nurse. The entire C-Suite bought into the new program. Our CCO sincerely wanted it, and the COO and CFO were completely on board.”
Passing along no cost to the patients, the health center board of directors approved the initial purchase of equipment, even though it was an unbudgeted capital expense. While they are still forming a long-term sustainability strategy, she added, “We went down this road because it was the right thing to do for patient care.”
El Rio placed cameras in three of its eleven primary care clinics – the three with the highest diabetes rates and largest overall patient populations. In the first 12 months, all three clinics boosted their screening rates by 25-30%. El Pueblo moved from 25% to 50% of diabetic patients screened annually. Congress went from 32% to 65%. And Southwest improved its screening rate from 45% to 76%.
This is phenomenal success in such a short time. So what are the key characteristics of this program that have made it so successful? “Our program is 100% team based and embedded in the diabetes self-management education program executed by pharmacists and medical assistants,” Dr. Rowen explained. The El Rio diabetes self-management education program includes ten advanced practice pharmacists, medical assistants and a pharmacist residency program.
But pharmacists are certainly not the only ones invested in the success of this program. “Our providers, nursing staff and medical support staff are super-engaged,” she said. “Our referral clerks are very familiar with all the local providers, with whom we have long-standing relationships. They make smart referral decisions that really work in the patients’ best interests.”
El Rio also has University of Arizona public health interns who have enthusiastically joined in the effort. They developed three-minute “lobby talks” about the importance of DR screening and offer that education to waiting patients.
The health center originally trained 14 staff members to use the retinal camera, but five of them emerged as the core of the photographer cadre. “Our medical assistants are highly motivated and engaged,” Dr. Rowen said, and committed to the DR screening program for the long term. All five of this core team perform retinal imaging every day; the others help when they can. “Sometimes they feel overwhelmed,” she said, “but they are truly mission-driven. One individual MA performed 663 screens last year in addition to her other MA duties.”
At the Congress site, the camera sits in the suite where advanced practice pharmacists see patients (which makes sense for a pharmacist-driven program). The setup at El Pueblo is not ideal. There the camera has been placed in a treatment room in the adult medicine suite, which does sometimes present a logistical challenge. The team finally came up with a little sign that says “in use” so the photographers can be confident no one will open the door while they’re trying to capture retinal images in a dark space. At the Southwest location, a room was completely remodeled to accommodate the new camera.
Once the images are taken and uploaded to the EyePACS site, Marisa explained, then the magic really begins. “Often our reads come back the same day, and 98% are submitted to us within 24 hours. We actually get patients the results of their screening before they leave their diabetes care appointment in some cases,” she explained. “Sometimes EyePACS reads our images and sends us a report within an hour – before the patient has left the building!”
Although referrals for the recommended screening are routinely generated by the provider staff, diabetes patients at the other El Rio sites do not fare as well as do those at the three sites with digital retinal cameras. Asked to travel to El Pueblo, Congress or Southwest for their annual retinal screening, some of those patients never make the trip and never get screened. Consideration has been given to a mobile camera, traveling from site to site, but Dr. Rowen doesn’t favor that approach. “We’d be imposing our schedule on our patients,” she explained. “It’s best to have the camera here when the patients are able to come in for a primary care appointment.”
The financial situation, as challenging as it has been, has also seen some surprises, Dr. Rowen explained. “One payer, committed to screening for diabetic retinopathy, has actually offered us an agreement to reimburse El Rio for the cost of each EyePACS read for any patient of the plan - that is, an established El Rio patient, referred by the provider during the context of their primary care visit. Understanding that this is a very small step in the right direction for financial sustainability, it does not reflect nor recoup the cost incurred by El Rio to maintain this telemedicine approach to screening for diabetic retinopathy.”
El Rio, like many other FQHCs, is now part of an Accountable Care Organization (ACO). Dr. Rowen also gives credit to their ACO, Arizona Connected Care, for a great deal of support related to advertising and marketing within the ACO and partnering health centers. One of the ACO’s quality measures for 2016 was to increase DR screening. Part of the ACO’s support was to secure funding to intentionally provide standardized sensitivity training to staff, focused on engagement of health center nursing and referral staff to be developed and delivered by the ACO eye champions. The training was to be a meaningful experience that included background facts and information about DR, messaging and talking points when providing care to patients living with diabetes during the course of a routine clinic day, and paper “glasses” the staff could wear to experience vision as someone with diabetic retinopathy might see.
The project included gathering follow-up data about how this experience impacted the staff’s willingness and desire to engage in conversations related to screening for DR. The El Rio staff, surveyed later, rated the training as exceptionally helpful. From that training also came a clever little device that staff now proudly wear. It’s a button clipped onto their name badge lanyards saying “EYE care about diabetes; ask me why.” But they wear it upside down! When a patient mentions that the button is upside down the staff member says, “Thanks for telling me. That’s my cue to talk to you about the importance of having your eyes checked yearly for diabetic retinopathy!”
What’s the future for the El Rio DR screening program? “We’re building a new clinic in southcentral Tucson,” Dr. Rowen said. “Called Cherrybell, it will open in 2018. That clinic, will house some specialty services along with our DO medical students from A.T. Still University and medical residents from the Wright Center. It will have its own ‘EyePACS Program’ room, specially designed for digital retinal screening!”
Looks like more success ahead for folks who “just wanted to do the right thing.”