Making Eye Health a Population Health Imperative Vision for Tomorrow (2016) / Chapter Skim
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9 Eye and Vision Health: Recommendations and a Path to Action
9 Eye and Vision Health: Recommendations and a Path to Action
Pages 427-472
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From page 427... ...
Figure 5-1 in particular highlighted the relevant partners that are critical to the effort of advancing population health objectives, including the community, other government agencies, the education sector, nonprofit organizations, the media, employers and businesses, and the clinical care system. There are steps that can be taken right now to significantly reduce the burden of vision impairment within the next few years, based on current knowledge and available treatments.
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From page 428... ...
Developing support for the policies, programs, and resources to generate these changes at the federal, state, and local levels will necessitate a different mindset about the role of eye and vision health promotion in daily activities and formal prioritization in national, state, and local population health strategic goals and programs. This chapter presents a roadmap to advancing eye health.
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From page 429... ...
The eight guiding principles defined in Chapter 1 should guide all actions within the framework for action -- that is, they should be population-centered, collaborative, culturally competent, community-tailored, evidence-based, integrated, standardized, and adequately resourced. Many of the following nine recommendations are broadly framed but are critical to establishing conditions that will support a sustainable population health initiative that achieves a long-term reduction in vision impairment and its consequences.
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From page 430... ...
and also information about the stakeholders that influence eye and vision health locally and nationally.
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From page 431... ...
A number of factors contribute to the absence of focused and sustained programmatic investment that translates into widespread action. Historically, eye care was considered separate from the more general field of medicine, and various tensions between different eye care professionals continue to contribute to the fragmentation of eye care, which excludes eye health from conversations about broader strategies to improve and measure the overall health of populations.
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From page 432... ...
Department of Health and Human Services should issue a Call to Action to motivate nationwide action toward achieving a reduction in the burden of vision impairment across the lifespan of people in the United States. Specifically, this Call to Action should establish goals to: • Eliminate correctable and avoidable vision impairment by 2030, • Delay the onset and progression of unavoidable chronic eye dis eases and conditions, • Minimize the impact of chronic vision impairment, and
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From page 433... ...
There are, of course, limitations in resources that may affect the ability to reach this goal. Similar considerations exist for slowing the progression of vision loss or improving the function of people with vision impairment through access to high-quality treatments or services.
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From page 434... ...
Achieving the goals outlined in Recommendation 1 will require having reliable, consistent, evidence-based information that is available and accessible by a variety of stakeholders to increase overall knowledge and to support policies, practices, and behaviors that promote good eye and vision health, encourage appropriate care to correct or slow progression of a vision-threatening disease or condition, or improve function when vision impairment is uncorrectable. This approach must target various audiences and consider a wide range of factors affecting eye and vision health in communities, including individual-directed strategies, mass media campaigns, and environmental and policy changes across multiple settings within defined geographic areas (e.g., city, state, province, or country)
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From page 435... ...
, and the impact of the social and built environments on one's ability to maintain optimal health and visual function following significant vision loss. For example, messages could target private businesses to convince them to cultivate healthy workplace design and practices that take into account screen time, lighting conditions, or other interventions and accommodations that can improve or preserve eye health and visual functioning.
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Without data, population health tools cannot characterize affected populations, identify risk and protective factors (including health care access) , establish evidence-based guidelines, or quantify the effectiveness of health care systems and community based interventions.
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From page 437... ...
Key among these is the inability to determine the prevalence and costs of eye disease and vision impairment; to identify at-risk groups, barriers to care access, and health disparities; and to assess the effectiveness of treatments and therapies and the availability and adequacy of vision care system resources at the national, state, and local levels. Recommendation 3 The Centers for Disease Control and Prevention (CDC)
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From page 438... ...
In the long term, a more comprehensive approach to eye and vision health surveillance is needed to allow for a better and more accurate characterization of the population burden of eye disease and conditions and resulting vision impairment in the United States, with special emphasis on the need to identify the most at-risk and burdened populations. Surveillance efforts should be real-time and include a focus on at-risk communities and populations and should identify the root causes of disparities in vision health and care and the trends in vision health and care over time.
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From page 439... ...
Expanding Knowledge Related to Eye and Vision Health Understanding the factors that affect the risk of vision impairment for different populations, the barriers to accessing care, interventions to prevent visual impairment and maintain eye function, and ways to improve the quality of care is fundamental to designing and identifying opportunities that minimize vision loss now and that will result in new knowledge and strategies to further reduce the long-term impact of vision impairment. HHS supports a number of federal programs and institutes that focus on vision loss and fund various activities to combat the effects of poor eye and vision health on at-risk populations (CDC, 2015a)
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From page 440... ...
Department of Health and Human Services should create an interagency workgroup, including a wide range of public, private, and community stakeholders, to develop a common research agenda and coordinated eye and vision health research and demonstration grant programs that target the leading causes, consequences, and unmet needs of vision impairment. This research agenda should include, but not be limited to: • Population-based epidemiologic and clinical research on the major causes and risks and protective factors for vision impairment, with a special emphasis on longitudinal studies of the major causes of vision impairment; • Health services research, focused on patient-centered care pro cesses, comparative-effectiveness and economic evaluation of clini cal interventions, and innovative models of care delivery to improve access to appropriate diagnostics, follow-up treatment, and reha bilitation services, particularly among high-risk populations; • Population health services research to reduce eye and vision health disparities, focusing on effective interventions that promote eye healthy environments and conditions, especially for underserved populations; and
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From page 441... ...
; filling in these gaps is a high priority in order to guide policies and community efforts intended to reduce the societal cost of chronic vision impairment. Population health services research should focus on barriers to performance on the part of local and state health departments and should explore methods used in jurisdictions where public health agency efforts have been successful (and have failed)
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From page 442... ...
Consideration should be given to innovative research methodologies and strategies to improve efficiency. EXPAND ACCESS TO APPROPRIATE CLINICAL CARE Timely, appropriate, and equitable access to and the delivery of effective care in all settings is an important component of a population health approach to improve eye and vision health.
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From page 443... ...
Recommendation 5 The U.S. Department of Health and Human Services should convene one or more panels -- comprising members of professional organizations, researchers, public health practitioners, patients, and other stakeholders -- to develop a single set of evidence-based clinical and rehabilitation practice guidelines and measures that can be used by eye care professionals, other care providers, and public health professionals to prevent, screen for, detect, monitor, diagnose, and treat eye and vision problems.
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From page 444... ...
criteria to facilitate appropriate followup care, both within and external to eye and vision care, and to ensure a continuum of health care that is focused on the specific eye health needs and the overall health of populations. These guidelines should apply to both the general practice of medicine and to eye care specifically, with an emphasis on steps to increase the integration of services to promote both eye and vision health and overall health.
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From page 445... ...
, new skills will be needed to ensure that health care professionals understand the types of patient experiences and data that are relevant to population health activities, including the moral imperative to reduce inequities in both health and health care. Moreover, population health practitioners should be familiar with eye and vision health, its risk factors, and the relationship between vision loss and other chronic health conditions.
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From page 446... ...
Second, other health care providers need to understand the importance of eye and vision health in maintaining the overall health of their patient populations and the role that eye care can play in identifying non-eyerelated diseases and conditions. The training of primary care physicians should include developing competency at identifying vision impairment and the need for eye care as well as teaching them to be familiar with the underlying determinants of health, especially those that are risk factors for vision loss among vulnerable and at-risk populations.
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From page 447... ...
In addition to having basic knowledge about eye health and related risk and protective factors, health professional school students should be knowledgeable about population health approaches and about the roles and competencies of public health experts and vision rehabilitation therapists and other types of therapists in vision care. Training for vision rehabilitation and other vision therapists should include practical experiences working as part of an interdisciplinary rehabilitation team as well as instruction in the competencies and roles of physical and occupational therapists, orientation and mobility specialists, and optometrists and ophthalmologists.
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From page 448... ...
Unfortunately, there has been insufficient partnering to coordinate existing and emerging programs, policies, and quality improvement activities that either directly or indirectly affect eye and vision health. Recommendation 7 State and local public health departments should partner with health care systems to align public health and clinical practice objectives, programs, and strategies about eye and vision health to: • Enhance community health needs assessments, surveys, health impact assessments, and quality improvement metrics; • Identify and eliminate barriers within health care and public health systems to eye care, especially comprehensive eye exams, appro priate screenings, and follow-up services, and items and services intended to improve the functioning of individuals with vision impairment; • Include public health and clinical expertise related to eye and vision health on oversight committees, advisory boards, expert panels, and staff, as appropriate; • Encourage physicians and health professionals to ask and engage in discussions about eye and vision health as part of patients' regular office visits; and
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From page 449... ...
• Local public health departments should work to strengthen rela tions among primary care providers, eye care providers, health care professionals working in vision rehabilitation, social services, and other community health workers in order to improve the continu ity, timeliness, and adequacy of eye care. • Public health departments should lead the development and dis semination of health education materials that educate patients on making changes to lifestyle risk factors for eye disease, on health impacts, on the need for eye exams, and on treatments, and they should clarify best practices for clinicians.
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From page 450... ...
State health departments provide an important link between federal and community programs, which can incorporate vision health strategies where appropriate. Second, state and local health departments are the logical, local conveners for collaborations between a variety of community stakeholders and surveillance efforts related to eye and vision health.
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The programmatic emphasis in governmental public health departments typically complements national public health priority lists, which do not typically include eye and vision health or chronic vision impairment (e.g., CDC, 2015d)
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From page 452... ...
Again, this recommendation emphasizes the need for a coherent and comprehensive program to account for primary prevention activities, for access and utilization of health care services to reduce vision impairment and improve function following vision loss, and for a focus on establishing environments that can affect the eye and vision health of a broader population. The prioritization and expansion of the CDC's vision grant program may require more than the provision of additional resources.
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From page 453... ...
be actively consulted and engaged in options to translate and implement national goals into workable community action plans to reduce the burden of vision loss and the functioning of populations with vision impairment across different community settings. Recommendation 9 Communities should work with state and local health departments to translate a broad national agenda to promote eye and vision health into welldefined actions.
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From page 454... ...
to engage when exploring the needs and resources available to combat avoidable vision impairment and the impacts of vision loss in their communities. For example, health departments can play an important role in the built environment (i.e., the physical environment constructed by human activity)
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The 10 services each are part of one of three core population health functions: assessment (i.e., monitoring communities to identify and characterize public health needs and priorities) , policy development (i.e., the use of scientific evidence to guide the design and implementation of programs and policies to address public health issues)
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456 FIGURE 9-2 A conceptual framework to advance eye and vision health. SOURCE: Adapted from CDC, 2014.
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CONCLUSION Vision impairment is a significant public health problem that affects the health, economic well-being, and productivity of individuals, families, and society as a whole. The focus of population health approaches to eye and vision health should be on creating the conditions in which people can have the fullest capacity to see and that enable individuals to achieve their full potential.
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From page 458... ...
; to facilitate pre-symptomatic identification of eye diseases and treatments (secondary prevention) ; and to preserve and enhance the health and functioning of individuals with vision impairment (tertiary prevention)
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2015b. Establish a vision and eye health surveillance system for the nation (RFA DP-15-004)
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2013. High-risk populations for vision loss and eye care underuti lization: A review of the literature and ideas on moving forward.
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2007. What is the population health approach?
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Paper prepared for the Committee on Public Health Approaches to Reduce Vision Impairment and Promote Eye Health. http://www.nationalacademies.org/hmd/~/ media/Files/Report%20Files/2016/UndiagnosedEyeDisordersCommissionedPaper.pdf (accessed September 15, 2016)
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From page 463... ...
(Recs 5 and 9) Support value-based care Enforce policies that Implement quality- Work with public health and payment policies require training in, and improvement processes to departments to implement Assurance centered on improving utilization of, guideline- assure quality vision care quality-improvement patient outcomes (Recs 7 recommended vision particularly for high-risk processes to assure quality and 9)
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From page 464... ...
Support organizational Assess provider ability Assess provider knowledge Assess provider knowledge agenda focused on and willingness to provide and appropriate use of of current treatments and assessment of care quality patient counseling vision screening and available resources for and need for a single set regarding links between comprehensive eye vision impairment and how Assessment of eye and vision care eye disease and diabetes, examination tools and to educate patients (Rec 6) guidelines (Rec 5)
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From page 465... ...
Assess the social Assess the specific eye and Petition government Assess need for advocacy determinants of health that vision health needs within officials to fund actionable related to vision care most affect specific patient communities, especially research on eye and vision quality and access and populations, considering in the context of other health and behaviors to vision rehabilitation the interconnectedness of national, state, and local reduce the incidence and (Rec 9) Assessment eye and vision health and public health initiatives impact of vision loss other aspects of health (Rec 9)
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From page 466... ...
Incorporate vision- Monitor occupational- Establish surveillance Assess ability of clinical related components and sports-related eye systems that focus on or and public health systems into community health injuries; Assess ability of include metrics for eye to provide eyeglasses to assessments; Establish state and local health care health and care; Conduct vulnerable populations surveillance systems for and public health systems research to identify risk and coordinate social and environmental to implement public factors for developing multidisciplinary services Assessment determinants of health awareness campaigns and vision loss and insufficient involved in vision as well as risk factors for deliver preventive services access to needed preventive rehabilitation (Recs 7 and Public vision impairment (Recs 2 for chronic disease, and prescriptive eye and 9) Health and 7)
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From page 467... ...
Facilitate state- and local- Incorporate eye health Collaborate with eye care Lead collaborative of level, interprofessional into community health professionals, and general vision health stakeholders coordinating (e.g., chronic needs assessments and hospitals to evaluate to maximize efficient use disease) committees to health impact assessments; impact of community of available vision care and promote and facilitate Educate the workforce interventions; Engage rehabilitation resources; communication, about the link between eye diverse community Help enforce provisions collaboration, and and vision health and other groups to expand of the ADA; Develop information sharing among measures of health (Recs 6, access to appropriate systems to track quality Assurance providers across the 7, and 9)
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From page 468... ...
Incorporate eye and vision Require and provide safety Offer affordable at-work Remove barriers that health into existing or glasses, and monitor their vision screenings and impeded access, mobility, future health education use; Set and monitor work appropriate comprehensive and function for and wellness programs; standards to protect eye eye examinations for individuals with severe Encourage employee safety; Seek assistance employees; Provide vision impairment; Comply Policy committees and resource from local public health expertise about preventing with the ADA regulations; Development Private groups to consider eye and departments to better vision loss to other Supply eyeglasses to at-risk Industry vision health in the context understand the role of community stakeholders populations, working with of other organizational eye and vision health (Rec 9) public health departments policies and programs; Offer in promoting a healthy (Rec 9)
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From page 469... ...
Work with local health Partner with eye and vision Collaborate with Advocate for policies and departments, nonprofit professional groups and community-based public programs that promote organizations, and industry public health departments health and clinical independence, function, to better understand the to develop a single resources to identify and reduce injury in people relationship between eye platform/resource that and refer individuals with vision impairment; and vision health, overall provides information about with undiagnosed vision Advocate for and help Community Policy health, and underlying eye and vision health and impairment; Identify guide programs that secure Groups Development determinants of health; related resources within opportunities for at-risk appropriate follow-up care Advocate for needed specific communities groups for vision screening in schools and workplaces public health resources to (Rec 9) and comprehensive eye for at-risk groups (Rec 9)
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From page 470... ...
NIH Support the inclusion of Issue a Call to Action; Collaborate with private Support and implement eye health components Collaborate to implement a industry and other research policies that allocate in existing health literacy public awareness campaign centers to expand grant funding for vision campaigns; Label vision targeting sensory deficits programs to facilitate rehabilitation research; impairment as a chronic (e.g., vision and hearing) ; public health capacities; Collaborate with disease for federal Fund research that targets Facilitate discussions stakeholders to design Policy program focus; Support the identification of risk with stakeholders about a and develop programs Development and implement policies factors for specific eye single set of guidelines for that promote awareness that identify and protect diseases and conditions eye and vision practice; and access to services that sustainable funding and protective factors Promote translational improve vision impairment for research on social related to general eye research to improve or improve quality of life determinants of eye and health; Establish a formal access to services through (Recs 4 and 8)
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From page 471... ...
3, and 4) Create research positions, Collaborate with Conduct research to Require all grant recipients training programs, and community groups and evaluate and ensure the to evaluate the impact of grant opportunities to state and local public effectiveness and cost- interventions on process ensure development of a health departments to effectiveness of preventive and health outcomes diverse, competent, and ensure the effectiveness eye care services delivery over time; Develop and committed eye and vision of programs to promote programs, including implement a health services Assurance health research workforce; public awareness of risk community-based research program for Support programs factors for eye disease and vision screening and eye rehabilitation including that encourage cross- vision impairment (Rec 8)
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