Glaucoma Enhanced Referral Service Peter Rockett Secretary - PowerPoint PPT Presentation

Glaucoma Enhanced Referral Service Peter Rockett – Secretary – Wolverhampton LOC Simone Mason – CGPL – PES

u This presentation will shortly be on the LOC website u Policies and Protocols document will cover all points in more detail

Background u Capacity in ophthalmology u Inflexibility of GOS system u NICE guidelines u Skills within primary care community (achievements in MECS) u Audit of Wolverhampton glaucoma assessment clinic demonstrated >60% new referrals are discharged after first visit

NICE Guidelines u Clarifies management of glaucoma patients u Including u Referral u Enhanced case finding u accreditation u Treatment u monitoring

GERS u Enhanced assessment in primary care in parallel to Repeat Measures u Avoids immediate referral to HES u Accredited optometrists u CCG financial support for accreditation u Target – reduce referrals by 50% (ambitious)

GERS u College Professional Certificate in Glaucoma u Specified as standard for enhanced case finding (GERS) u Also monitoring of diagnosed low risk cases u Single semester distance study with practical training, OSCE, written assignment u Referral by optometrist into GERS u Other potential routes into service u Supported by OptoManager software and governance system

How to refer into GERS? u For eligible patients with signs of glaucoma and not eligible for repeat measures in your own practice, make a referral to a participating GERS Practice. u Non participating practice offers patient choice of GERS practice using patient information leaflet or the www.eyecarewm.co.uk website. u Post referral (GOS 18 or equivalent) with the information you would send on a glaucoma referral to the participating practice. u The GERS practice will contact the patient and book them for an assessment. u REMEMBER: Please do not send Glaucoma referrals to the GP .

Outcomes

Clinical Management Guideline: Glaucoma Enhanced Case-Finding Clinical work up – all assessments are performed Visual Field Assessment – central visual field assessment using standard • automated perimetry (full threshold or supra-threshold) Assessment of the optic nerve head – dilated optic nerve assessment and • fundus examination using stereoscopic slit lamp biomicroscopy Intraocular pressure (IOP) measurement – using slit-lamp mounted Goldmann • applanation tonometry Assessment of the anterior chamber – peripheral anterior chamber • configuration and depth assessments using the van Herick test or OCT.

Outcomes

Outcomes: • Refer for diagnosis and management, if: o IOP 24mmHg or more (consider urgency if IOP 32mmHg or more) o Glaucomatous type visual field defect confirmed o Damage / suspicious Optic Nerve Head o Narrow anterior chamber angle – primary angle closure suspected • Discharge. If the suspicious findings are not repeatable, discharge and advise to continue regular visits to their primary eye care professional.

Single referral criteria • Unequivocal pathological cupping at the optic nerve head. • Abnormal neuroretinal rim configuration. • Large cup, taking into account the overall size of the disc. • Notched neuroretinal rim. • A >0.2 asymmetry of cup to disc ratio. • The existence of a disc haemorrhage merits closer inspection for early nerve fibre loss. Refer for an optic disc hemorrhage through GERS only where there are additional optic disc and/or other indicators of glaucoma.

Single referral criteria Visual field loss consistent with a diagnosis of glaucoma, confirmed at a second • visit. If explained by other disc or retinal pathology to be referred as such and not through scheme. Patients with elevated IOP of 24mmHg or more and no other signs of glaucoma • (normal optic discs and normal fields) are not eligible for this service and should be seen within the IOPRM service. Patients with solely elevated IOP of 24mmHg or more seen at a non-IOPRM • accredited practice are eligible for this service and should not be referred to HES.

Combined referral criteria u Raised IOP plus an optic disc appearance suspicious of glaucoma or optic disc • asymmetry. Glaucomatous optic disc and corresponding visual field defect (IOP not raised) • (no need for confirmatory measures).

Additional referral criteria • Optic disc change over time e.g. increase in cup size change in the rim appearance or the occurrence of a new haemorrhage (documented within the scheme.) (Refer for an optic disc haemorrhage through GERS only where there are additional optic disc and/or other indicators of glaucoma.) • Anterior segment signs of secondary glaucoma (e.g. pseudoexfoliation) with raised IOP (age-related criteria) on two occasions.

Additional referral criteria Suspected narrow-angle glaucoma (symptoms of sub-acute attacks or • occludable angle and raised IOP. Emergency referral for suspected angle closure glaucoma should be made • directly to emergency secondary care services In the event of an unusual clinical presentation or for those patients less than • 40 years of age suspected of having developmental glaucoma, GERS optometrists should ring the hospital for advice on referral.

KPIs Quality measure Indicator Threshold Quality Access % of patients referred seen >95% within 4 weeks Effectiveness % of patients discharged at <20% first attendance, following referral from GERS Service User Experience Patient experience questionnaire completed and >60% Service User Experience reported % of people happy or >95% confident with service Reducing Inequalities Patient equality monitoring 100% completed and reported Reporting Minimum data set to be 100% recorded and reported.

Other Key Info u Go Live 4/11/2019 u Optomanager not yet complete, hopefully imminent to allow for registration, certificate upload u Tariff u £75 u MUST complete patient satisfaction and Equality & Diversity questionnaire! u High quality service and effective service expected!

Other Key Info u Tariff u £75 u MUST completer patient satisfaction and Equality & Diversity questionnaire! u High quality service and effective service expected! u REMEMBER! u If a patient has raised IOPs only with no other signs of glaucoma then they should be managed through the repeat measures pathway and NOT GERS. u This will be monitored.

‘Referral Management’

OptoManager u Interim Module (Glaucoma Repeat measures – Primary Eyecare Service (North) u New module will follow incorporating Repeat measures and GERS and this will allow you to manage all patients from across system – depending on what your accredited to manage. u WATCH THIS SPACE!

OptoManager u ACCREDITATION u Safeguarding certificates – adult & child within last 3 years u Prof Cert Glauc certificate u education.ea@college-optometrists.org

ALWAYS SELECT RAISED IOP AND OTHER SIGNS

*Click ALL that apply based on the referral received (Note - ignore High IOP (following assessment within service – no longer applies!)

Find patient on your list and when seen ADD (note this can be found under 1 st repeat)

Onward referral and GP report will be sent automatically.

Referral Form

THANK YOU info@primaryeyecare.co.uk