South West LHIN Vision Care Project. The Future State of Vision Care. Backgrounder. March 17, 2015

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South West LHIN Vision Care Project

The Future State of Vision Care

Backgrounder

March 17, 2015

This is an abridged and updated version of the January 2015 Future

State of Vision Care Discussion Paper and is a complementary

document to the Final Project Report

It is a report that provides details to support the Future State of

Vision Care, Final Project Report, March 17, 2015

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Introduction

This report builds on the work done to develop the Current State of Vision Care report (July 2014) and is a backgrounder to the Future State of Vision Care – Final Project Report, March 17, 2015. The content is primarily the same as was contained in the January 2015 document, The Future State of Vision Care Discussion Paper. It has been amended to take into account feedback received to the Discussion Paper – see Appendix K for details. Project Objectives

 To assess current state of vision care with a focus on ophthalmology and the role of cataract surgery  To develop future state recommendations that will ensure:

o Equitable distribution and access to comprehensive eye care services - including elective and emergent/urgent care

o Application of clinical guidelines and best practices

o Population-based allocation of resources to address future needs

o Improved communication among primary care, optometry and ophthalmology physicians o Effective linkages between screening/monitoring and follow-up treatment

o Provision of cataract surgery within Quality Based Procedure Funding (QBP) o Regional access to sub-specialty ophthalmology services

The major topics and themes addressed in this report are as follows:  Impact of demographic changes

 Diabetes and eye care – population health o Screening and follow-up treatment  Access to services and care

o Comprehensive and specialized ophthalmology

o Leveraging technology – teleophthalmology, eConsults and ClinicalConnect  Future state of cataract surgery

o Population-based approach to assessing current and future need o Wait list management

o Opportunities for standardization and process improvement  Quality indicators

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Ontario’s Age structure by 2036

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By 2036, there will be more people in every age group in Ontario compared to 2012 and the aging of Ontario’s population will accelerate.

Figure 1.0

From 2012 to 2036 the median age of Ontario’s population is projected to rise from 40 years to 43 years with the median age for women climbing from 41 to 44 years and from 39 to 43 years for men.

The number of seniors aged 65 and over is expected to more than double from about 2.0 million, or 14.6 per cent of the population in 2012, to almost 4.2 million, or 24.0 per cent of the population, by 2036. By 2016, for the first time, seniors will account for a larger share of population than children aged 0–14.

By the early 2030s, once all baby boomers have reached age 65, the pace of increase in the number and share of seniors is projected to slow significantly from an average of 3.5 per cent over 2012–31 to less than 1.8 per cent by the end of the projection period. This age group will continue to grow much faster than the 0–14 and 15–64 age groups.

The number of people aged 75 and over is projected to rise from 910,000 in 2012 to more than 2.2 million by 2036. The 90+ group will more than triple in size, from 96,000 to 291,000.

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South West LHIN Demographics

While the population of the South West LHIN (from a county perspective) is expected to grow by 16.1% over the next 24 years (primarily in Middlesex County and the City of London) the percentage of seniors is estimated to grow to 27% of the total population over this same time period.

The expected impact of having a larger elder population will be particularly pronounced in rural counties. For example, the population of Bruce County is expected to grow from 67,500 in 2012 to 68,960 in 2036 – an increase of only 2.2% but in that same timeframe the number of seniors (65+) is expected to grow from 14,310 to 23,080 – an increase of 12.3% (from 21.2% to 33.5% of the total population)2.

Table 1.0 South West LHIN Population Projections by County 2012 and 2036

County 2012 Population 2012 Number of Seniors (%) 2036 Population (Growth %) 2036 Number of Seniors (%) Grey 96,520 20,340 (21.1%) 105,160 (+9.0%) 35,820 (34.1%) Bruce 67,500 14,310 (21.2%) 68,960 (+2.2%) 23,080 (33.5%) Huron 60,500 11,750 (19.4%) 57,740 (-4.6%) 18,690 (32.4%) Perth 77,030 12,740 (16.5%) 76,110 (-1.2%) 22,940 (30.1%) Oxford 108,780 18,160 (16.7%) 113,510 (+4.4%) 33,060 (29.1%) Elgin 91,130 14,030 (15.4%) 101,850 (+11.8%) 26,980 (26.5%) Middlesex (includes the City of London)

463,710 67,660 (15.6%) 596,940 (+28.7%) 141,680 (23.7%)

TOTAL 965,170 158,990 (16.5%) 1,120,270 (+16.1%) 302,250 (27.0%)

Source: Ontario Ministry of Finance, Population Projections, Spring 2013

Implications of the future population on the need for surgical ophthalmology

The following table shows the forecast number of adult inpatient and day surgery Ophthalmology cases for South West LHIN residents in five, 10 and 15 years. The forecast is based on demographic growth and assumes disease prevalence and treatment intensity will not change.

The number of procedures are divided into four levels of increasing complexity. Levels one and two differ mainly in the amount of equipment required. Cataract surgery is separated out as it is the most common procedure done. Level three are less routine procedures done by both general Ophthalmologists and subspecialists. Level four cases are generally done by Ophthalmologists with subspecialty training.

Table 2.0 legend

 Level 1 procedures are usually done by a general or comprehensive ophthalmologist  Level 2 procedures are usually done by a general or comprehensive ophthalmologist

 Some Level 3 procedures could be done by a general ophthalmologist ; others are usually, although not exclusively, done by a subspecialist or fellow with supervision

 Level 4 procedures are done by a subspecialist in context of special equipment or operating room setting

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Table 2.0 Forecast of Surgical Ophthalmology Cases for Adult South West LHIN Residents

Procedure Level 2012/13 2017/18 2022/23 2027/28 % Change

2012/13 to 2027/28 Level 1 181 203 232 265 47% Cataract Extraction 9,573 10,982 12,751 14,604 53% Level 2 192 208 228 247 29% Level 3 380 417 458 503 32% Level 4 1,101 1,232 1,370 1,505 37% TOTAL SW LHIN 11,427 13,040 15,039 17,125 50% 5 year % increase _14% _15.5% _13.8% _- _-

Source: IntelliHealth DAD, NACRS DS, MOF Population Projections (Provided by Preyra Solutions Group)

The most significant surgical ophthalmology growth is in cataract surgery where a 53% increase is forecast. Increases in the other cases, especially in raw numbers are relatively modest.

Overall, a 50% increase in surgical ophthalmology cases over the next 15 years is forecast with the major determining factor being the growing number of elders.

Information on paediatric cases shows the volume of cases by both procedure and Level will likely remain relatively stable. Strabismus will continue to be the dominant paediatric surgical intervention. The ability to address current and future paediatric ophthalmology requirements needs to be maintained.

Diabetes and eye care – an important population health factor in planning for the

future

Incidence of diabetes

Canada’s National Surveillance System notes a significant increase in the incidence of diabetes3.

 The incidence and prevalence of diabetes in Canada are projected to increase steadily due to demographic trends, including an aging population and high rates of obesity.

 The prevalence of diabetic retinopathy (DR) is projected to increase as the prevalence of diabetes increases. This has important implications for healthcare human resources and costs, and potential policy implications.  Aboriginal populations in Canada are disproportionately affected by diabetes and DR. Strategies are

needed to provide culturally appropriate programs to prevent, screen, and treat diabetes and DR in these populations, who often reside in remote and underserviced areas.

 DR remains the leading cause of legal and functional blindness for persons in their working years (ages 25–75) worldwide

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Canadian Ophthalmological Society evidence-based clinical practice guidelines for the management of diabetic retinopathy[Can J Ophthalmol 2012;47:1–30] All authors were members of the Canadian Ophthalmological Society Diabetic Retinopathy Clinical Practice Guideline Expert Committee.

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7 Table 3.0

Proportion of Ophthalmology Surgery Cases with D iabetes Diagnosis, South West LHIN Procedure Level * 2008/09 2009/10 2010/11 2011/12 2012/13 Level 2, Cataract Extraction Total Cases 10,418 9,871 9,983 9,937 9,572

Cases with Diabetes 1,636 1,471 1,500 1,618 1,448

Proportion of Total

Cases with Diabetes 16% 15% 15% 16% 15%

Level 3

Total Cases 684 490 407 501 471

Cases with Diabetes 34 34 37 36 29

Proportion of Total

Cases with Diabetes 5% 7% 9% 7% 6%

Level 4

Total Cases 1,011 970 1,030 1,059 1,011

Cases with Diabetes 259 247 284 284 263

Proportion of Total

Cases with Diabetes 26% 25% 28% 27% 26%

Source: DAD, NACRS DS, 2012/13 provided by Preyra Solutions Group under contract

* Level 2, Other – these cases have been excluded from this table since most are done in clinic and are therefore not documented in DAD or NACRS. Examples of Level 2-Other category include prosthetic lens insertion, iridectomy/iridotomy, laser coagulation, surgical synechiolysis, corneal excision, scleral wound repair, lens explantation, canilicular repair.

Excluding medical ophthalmology cases, people with diabetes within the South West LHIN account for about 15% of all cataract cases, 7% of all Level 3 surgical cases and 26% of all Level 4 surgical cases.

Diabetes plays a significant role in the overall demand on vision care services. There are opportunities to improve prevention and screening, as well as anticipate the future demand for treatment.

Future State Recommendation 1.0

Future demand for ophthalmology and related vision care services should use a population-based approach with particular attention to changes in the seniors population and people living with diabetes.

Target of Recommendation:

South West Local Health Integration Network (South West LHIN) Ontario Ministry of Health and Long-Term Care (MOHLTC) Financial and Resource Impact:

Reallocation of resources based on population and investment of resources to address increased needs

Intended Outcome:

Vision care services will be available to address future needs of the population, especially the growing number of seniors and people living with diabetes.

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Screening for vision care and follow-up treatment

Introduction

Evidence provided by the Canadian Ophthalmological Society called ”Canadian Ophthalmological Society evidence-based clinical practice guidelines for the periodic eye examination in adults in Canada” (2007)4 notes vision screening is of limited value if symptoms are not present.

A recent study showed that the majority of people identified with a decrease in visual acuity had noted it themselves before presentation for an ocular examination. Less than 1% of the study population was unaware of this decrease in vision, suggesting that the prevalence of asymptomatic or unrecognized ocular disease remains very low. Therefore, frequent routine eye examinations of those with initial normal examination results will have a low yield and may not be cost effective.

With respect to “Patients at higher risk for Visual Impairment” the report notes routine screening of high risk and symptomatic patients is of value. For example:

Routine screening for asymptomatic retinal tears, holes, and lattice degeneration has not been supported. On the other hand, symptomatic patients and high-risk patients with previous retinal problems, surgery, trauma, posterior uveitis, diabetes and myopia, or myopia greater than –6.00 can benefit from such an examination.

The report makes specific recommendations regarding screening for the following eye diseases with higher risk patients: Diabetic Retinopathy, glaucoma, age-related macular degeneration, and cataracts. It should be noted that patient age is a major determining factor in all of these diseases except diabetic retinopathy. This is why the age demographic is so important and why annual eye examinations are recommended for persons over age 65. Some young children, especially some very young children, can be at high risk for vision care problems that can go undetected and undiagnosed. There are several initiatives in place to address this including the Eye See Eye Learn program led by optometrists that targets 3-4 year olds, and the Ivey Special Eye Examination service, the I* S.E.E. Community Vision Screening program that targets very young children – children 2-3 years old - led by

ophthalmology.

The Canadian Ophthalmological Society report goes on to say: Other high-risk categories

Other high-risk patients include those with extreme refractive error, high hyperopia or myopia, previous ocular injury, systemic medication (such as hydroxychloroquine, tamoxifen), neurological or neurosurgical disorders, and possibly adults with mental retardation. Given the broad heterogeneity of the high-risk group, screening intervals will vary depending on the underlying cause of visual impairment.

The case for screening is particularly important when an ocular disease may be present but not symptomatic. This comment applies to diabetic retinopathy and glaucoma.

Glaucoma

Primary open-angle glaucoma causes such insidious damage to the optic nerve and vision that few people have early awareness of the condition. This is consistent with the finding that only half of patients are diagnosed in industrialized countries, a number that falls to 10% in developing nations. It is an ideal disorder for screening because it is asymptomatic, typically progresses slowly, and can be effectively treated.

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9 Diabetic Retinopathy

Early detection of DR depends on educating patients with diabetes as well as their families, friends, and health care providers about the importance of regular eye examination even though the patient may be asymptomatic. Patients must be informed they may have good vision and no ocular symptoms, yet may still have significant disease that needs treatment, which depends on timely intervention.5

VISION SCREENING RECOMMENDATIONS FROM THE CANADIAN OPHTHALMOLOGICAL SOCIETY, 2007 1. Screening intervals in the asymptomatic low-risk patient

• Age 19–40 years: at least every 10 years [Consensus] • Age 41–55 years: at least every 5 years [Consensus] • Age 56–65 years: at least every 3 years [Consensus] • Age > 65 years: at least every 2 years [Level 1 ] 2. Screening in symptomatic patients

Any patient noting changes in visual acuity, visual field, colour vision, or physical changes to the eye should be assessed as soon as possible [Consensus].

3. Screening intervals in high-risk patients

Patients at higher risk of visual impairment (e.g., those with diabetes, cataract, macular degeneration, or glaucoma [and glaucoma suspects], and patients with a family history of these conditions) should be assessed more frequently and thoroughly.

• Age > 40 years: at least every 3 years [Consensus] • Age > 50 years: at least every 2 years [Consensus] • Age > 60 years: at least annually [Consensus]

DIABETIC RETINOPATHY (DR) SCREENING RECOMMENDATIONS FOR PERSONS WITH DIABETES FROM THE CANADIAN OPHTHALMOLOGICAL SOCIETY, 2012

1. For individuals with type 1 diabetes diagnosed after puberty, screening for DR should be initiated 5 years after the diagnosis of diabetes [Level 1]. For individuals diagnosed with type 1 diabetes before puberty, screening for DR should be initiated at puberty, unless there are other considerations that would suggest the need for an earlier exam [Consensus].

2. Screening for DR in individuals with type 2 diabetes should be initiated at the time of diagnosis of diabetes [Level 1].

3. Subsequent screening for DR in individuals depends on the level of retinopathy. In those who do not show evidence of retinopathy, screening should occur every year in those with type 1 diabetes [Level 2] and every 1–2 years in those with type 2 diabetes [Level 2]depending on anticipated compliance.

4. Once NPDR [Nonproliferative diabetic retinopathy] is detected, examination should be conducted at least annually for mild NPDR, or more frequently (at 3- to 6-month intervals), for moderate or severe NPDR based on the DR severity level [Level 2].

There is clear evidence to support targeted vision screening of high risk populations and symptomatic groups. The course of treatment will vary according to the specific eye disease involved.

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Screening for Diabetic Retinopathy- 2014”, American Academy of Ophthalmology, Quality of Care Secretariat, Hoskins Center for Quality Eye Care” October 2014

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10 Future State

From a future state perspective, primary health care providers are in the best position to identify high risk groups and determine the need for vision assessment and should do so in a systematic and routine way. When children are involved this should be expanded to include pediatricians.

Health Quality Ontario in its report, “Primary Care Indicators”6 listed the following as one of 16 primary care indicators: “Percentage of diabetics with eye care visits with an optometrist or ophthalmologist within 1 year”. They have targeted primary care as the accountable group and have set a target of 80%. The current rate is 50% for the province as a whole and it is 56.5% for the South West LHIN(2011/12). To quote from the report:

Despite its proven benefits, about half of Ontarians did not receive regular screening for this

preventable complication within a year, as recommended by clinical practice guidelines and the one-year screening rates stayed relatively stable over the last eight one-years.

While almost 66% of diabetic patients aged 65 and older had an eye examination, only 42% of patients aged 20-64 had it. The rates did not vary by gender, neighbourhood income quintile, immigration status or rural/urban location.

Future State Recommendation 2.1

Steps should be taken to reinforce and support the need for regular eye examinations by high risk groups to primary health care providers, in keeping with the recommendations of the Canadian Diabetes Association, the Canadian Ophthalmological Society and Health Quality Ontario.

Future State Recommendation 2.2

Standard vision screening information and questions should be integrated into primary health care Electronic Medical Records (EMR) so determination of the need for vision screening and referral of high risk populations for eye vision examination can become a routine part of primary care practices.

Future State Recommendation 2.3

In addition to high risk groups, promotion of vision screening of young children and all children before they begin school (Junior Kindergarten) should be a routine part of primary health care practices.

Primary health care providers within the South West LHIN Primary health care physician leads – South West LHIN Pediatricians

eHealth office –South West LHIN South West LHIN

Financial and Resource Impact:

Cost of assessing current state of EMR re: vision assessment

Cost of developing standard clinical vision assessment tool for use in EMRs

Intended Outcome of Recommendations 2.1 and 2.2:

High risk populations will be reminded of the need for regular vision examinations, and referrals for vision exams will be made on a consistent basis ensuring that eye problems are detected and addressed early on in any disease process.

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11 Access to vision services for high risk populations

Both optometrists and comprehensive ophthalmologists provide comprehensive eye examinations. Depending on a patient’s needs, eye examinations and on-going monitoring may be done by an optometrist or a comprehensive ophthalmologist. Where an eye condition or disease is involved, they often share responsibility for the same patient – called co-management – where there is on-going dialogue between the optometrist and

ophthalmologist. Optometrists

Optometrists are widely distributed across the South West LHIN and have offices in 21 communities according to information obtained from the College of Optometrists of Ontario. [see Figure 2.0 for details] While part of their work focusses on assessing the type of lenses needed to correct vision, they also have the skills, training and equipment to do comprehensive vision examinations, disease screening and monitoring, and the diagnosis and treatment of eye conditions within their scope of practice. Many people routinely see an optometrist to have their vision corrected through the prescription of lenses, this provides the opportunity for these individuaqls to have their eyes assessed, screened and monitored for other eye conditions. A formal referral is not needed to see an optometrist. People can simply call and make an appointment for an eye examination.

Ophthalmologists

Comprehensive ophthalmologists are found in larger population centers across the LHIN (see Fig 2). Ophthalmologists can also provide comprehensive eye examinations and screen patients for eye disease especially if they have co-morbidities or other eye conditions. They provide on-going monitoring for individuals with eye disease as well as medical treatment and surgical care of all eye conditions. In some situations,

Ophthalmologists will work with Optometrists to provide ongoing care for persons with stable eye disease. Access to Ophthalmology services is obtained by referral from a primary care physician or an Optometrist or through the emergency departments of hospitals throughout the LHIN.

OHIP coverage of vision services

Eye Care Services Covered by the MOHLTC through Ontario Health Insurance Plan (OHIP) fees (from the MOHLTC web site – dated April 2013)

 People 65 years and older and those younger than 20, are covered by OHIP for a routine eye examination provided by either an optometrist or physician once every 12 months plus any follow-up assessments that may be required.

 Insured persons aged 20 to 64 years with specified medical conditions affecting the eye can receive an OHIP insured regular eye examination once every 12 months.

 Insured persons aged 20 to 64 with any of the following conditions can go directly to their optometrist or physician to receive an OHIP insured eye examination: diabetes mellitus, glaucoma, cataract, retinal disease, amblyopia, visual field defects, corneal disease, strabismus, recurrent uveitis or optic pathway disease. In the recent Ministry publication, “Quality-Based Procedures Clinical Handbook for Integrated Retinal Care” (December 2014) a regular eye exam by an optometrist or ophthalmologist, for the purpose of retinal screening is listed as including the following:

o Vision

o Intraocular Pressure

o Anterior segment and Lens exam

o Dilated Fundus exam with slit lamp biomicroscopy and/or indirect ophthalmoscopy Barriers

 The absence of coverage for routine eye examinations for individuals aged 20-64 is a significant perceived barrier for access to eye care. Although coverage is available to those with disease, most are unaware of this and may not seek care. Screening for disease in low risk populations does not occur unless there is third party coverage.

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12  There is also a financial barrier if specific tests are undertaken that are not covered by OHIP. For example if an

optometrist performs an Optical Coherence Tomography scan (OCT) or takes a retinal photograph it is not covered by OHIP and therefore the patient is charged a fee. Since neither test is currently part of a regular or comprehensive eye exam as defined by OHIP, the fees charged may create a barrier as they are not

inconsequential. In contrast, OCTs are covered by OHIP when used in the management of eye disease by an Ophthalmologist.

 In general, those living in poverty, and many people who are living with disabilities live in poverty, have a difficult time accessing health care and following up on medical directives, especially if they require

transportation and out-of-pocket expenses. It’s one of the reasons why home-based care is so successful – it removes an access barrier that would otherwise be present. As an example of addressing this, the

Southwestern Ontario Aboriginal Health Access Centre’s diabetes educators make home visits to their clients. There is clear evidence that some at risk populations in the South West LHIN are not getting the recommended frequency of regular eye exams.

Future State Recommendation 3.1

All people who are eligible to receive OHIP funded regular eye exams as defined by Canadian Ophthalmological Society (COS) clinical guidelines should do so. Information about the importance of regular eye exams for very young children and high risk groups should be readily accessible through each ophthalmologists, primary care physicians and optometrist’s office literature and web site information.

Optometrists within the South West LHIN College of Optometrists of Ontario Ophthalmologists in the South West LHIN Primary care physicians

Financial impact for patients whose optometrists include non-OHIP tests and therefore fees as part of their routine eye examinations.

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Figure 2.0

Optometrist practice locations Port Elgin Diabetes Education Program locations

West Lorne Dutton Aylmer Muncey Southwold

Ophthalmologist practice locations

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14 Vision Monitoring and Management of Diabetes

Once a patient is diagnosed with diabetes, a number of primary and specialized health service providers may become involved in their care depending on the type of diabetes they have, their age and other complications or co-morbidities. Monitoring for signs of the onset of Diabetic Retinopathy is one of a number of tests a person with diabetes needs to undertake on a regular basis following diagnosis to monitor and address complications associated with their diabetes. All optometrists and comprehensive ophthalmologists are well positioned to undertake this role and can schedule regular recall vision examinations after a person with diabetes comes to their attention7. When this monitoring is being done by an optometrist, they can refer patients to an ophthalmologist when appropriate. In the case of Diabetic Retinopathy a patient should be referred when they have “Moderate Non-proliferative Diabetic Retinopathy” or greater.

Future State of vision examinations and monitoring for people with diabetes Context

Primary health care providers assume responsibility for the clinical and medical health of their patients before and after they are diagnosed with diabetes. If there are complications or the situation is complex (involving Type 2 diabetes for example), this role may be taken on by a specialist such as an endocrinologist, with communication going back to the primary health care provider.

It is worth noting that family physicians who participate in Family Health Teams are offered a financial incentive to reinforce patients with diabetes getting regular eye exams. As part of billing for comprehensive diabetic care they have to record the date of the most recent eye exam and determine if an eye assessment is required in order to be compensated.

Primary responsibility for providing on-going eye care for a person with Type 1 diabetes very often involves an optometrist or comprehensive ophthalmologist with their primary care physician assisting by ensuring that eye examinations occur at recommended intervals.

There needs to be on-going communication and information sharing (at no charge to patient or care providers) between the patient’s primary care provider and their eye specialist – i.e. their optometrist and/or

ophthalmologist.

From a future state perspective the “front line” of diabetes care and pre-diabetes diagnosis most often rests with primary care providers with diabetes education programs providing a follow-up and complementary role by educating people about the nature of the disease and how to self-manage. Both are well positioned to inform and educate people about the potential impact of diabetes on eyes, the need for regular eye examinations and to recommend or refer most people with diabetes – especially Type I and asymptomatic individuals - to an optometrist or comprehensive ophthalmologist for Diabetic Retinopathy screening. In situations in which an endocrinologist is providing care, they can also reinforce the need for regular eye exams.

In some instances in the South West LHIN, diabetes education programs contact an optometrist to let the optometrist know that a client has been referred or recommended to them. As a follow-up the optometrist can then contact the client to arrange an appointment for them to be seen. This pro-active step helps to reduce the risk someone will not follow through on the recommendation to have their eyes checked. This practice is recommended for all diabetes education programs as well as primary care.

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15 Future State Recommendation 4.0

To support on-going awareness and communication, all diabetes education who are educating people with diabetes should:

 Maintain communication with local comprehensive ophthalmologists/optometrists regarding their clients (with appropriate client consent) to help reinforce that follow-up appointments are being made and kept

 Inform local ophthalmologists and optometrists about their service, upcoming diabetes education sessions or classes (as applicable) so they can reinforce the importance of diabetes education Target of Recommendation:

South West LHIN diabetes education programs

South West LHIN Primary Care /Chronic Disease Prevention and Management Lead Primary care providers within the South West LHIN

Primary care physician leads – South West LHIN Ophthalmologists in the South West LHIN Optometrists in the South West LHIN Financial and Resource Impact:

Allocation of time required to maintain open communications but no additional financial resources

All people with diabetes will be consistently referred for and receive a regular eye examination.

It should be a standard operating procedure for primary and community health care providers, and specialists such as endocrinologists who care for patients with diabetes, to refer them to comprehensive ophthalmologist or optometrist for on-going eye care and regular comprehensive eye examinations according to COS

recommendations. Once seen by an eye care specialist it would be the eye care specialist’s responsibility to indicate the desired frequency of follow-up and communicate this to the primary care physician to ensure follow-up occurs .

Ophthalmologists and optometrists should provide primary care providers, specialists and diabetes education programs information on a patient’s eye care (with appropriate consent from the patient) and this should include and this should include relevant status of the eyes and the optimal time for follow-up.

Local diabetes education programs, local ophthalmologists and optometrists with leadership being provided by the South West LHIN Primary Care /Chronic Disease Prevention and Management Lead should work together to raise public awareness about the importance of people with diabetes having a routine diabetic eye examination on a regular basis.

This message may be effectively communicated by many others who are in a position to work with people with diabetes; primary health care providers and teams such as Family Health Teams and Community Health Centres, Health Links initiatives, hospital staff, hospital newsletters and web sites.

South West LHIN diabetes education programs

South West LHIN Primary Care /Chronic Disease Prevention and Management Lead Other diabetes education programs in the South West LHIN

Primary care providers within the South West LHIN Primary care physician leads – South West LHIN South West LHIN optometrists

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16 South West LHIN ophthalmologists

Canadian Diabetes Association Financial and Resource Impact: Allocation of time required

Financial resources to support public education

Intended Outcome of Recommendations 5.1, 5.2 and 5.3:

All people with diabetes will know about the importance of having regular eye exams.

There will be consistent information sharing among professionals who are working with the same patients/clients to ensure they all have an on-going understanding of the person’s eye care needs.

Teleophthalmology, e-consults and ClinicalConnect

In general, technology is making communication and information sharing easier. However, given the need to protect privacy and ensure electronic communication of patient information is secure, health care is an example of a sector that generally lags others. Steps that were taken to create firewalls to protect information now have to be addressed in new and creative ways in order share information between organizations and providers with different systems. It’s not an easy process but important steps have and are continuing to be taken to enable information sharing while at the same time maintaining a high level of technical security and privacy.

Teleophthalmology is a tool that has been successfully used to address access to ophthalmology issues, especially from a geographic perspective. It allows information and digital images to be uploaded to a secure web site and read by an ophthalmologist for consultation. In some jurisdictions, especially remote, isolated ones,

teleophthalmology is used to screen people for diabetic retinopathy. This is not a substitute for a comprehensive, in person assessment but it allows screening to occur that might otherwise not be possible or realistic. In Ontario the diversity of both provider and hospital-based information systems makes it a particularly challenging

environment in which to develop and apply integrated health information systems.

Within the South West LHIN, while there are other barriers, there is no evidence to suggest geographic access is a barrier to using local optometry or ophthalmic services.

eConsults operates the same way as teleophthalmology except it’s a generic tool and is not discipline or condition specific. It’s most commonly used by primary care providers to seek direction from a specialist about how to treat a patient and to help them decide whether a referral is needed and at what level of urgency. eConsults is a secure e-mail system that also allows files to be attached. As part of a provincial demonstration project, a number of primary care providers and specialists in the London area (and elsewhere in Ontario) are using this technology in 2015 and assessing its impact and usefulness. If successful it may become available on a province-wide basis. This tool may be helpful to supporting collaboration among primary care providers, optometrists and

ophthalmologists. As an initial step it is proposed that it be used to facilitate collaboration between comprehensive ophthalmologists and ophthalmic sub-specialists .

In addition to eConsults there is a related initiative called ClinicalConnect8 that is currently being implemented across the four LHINs in Southwestern Ontario (LHINs 1, 2, 3 and 4). Clinical Connect provides secure access to current patient specific information that can be used by approved providers to obtain information from multiple sources about a specific patient. This offers an important opportunity for health care providers to share current information they might not otherwise be able to access.

8_{For more information about ClinicalConnect visit the following web site:}

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Assuming the current eConsult demonstration project is successful, ophthalmologists in the South West LHIN should take steps to test the usefulness of eConsults to support and foster clinical collaboration.

The current implementation of ClinicalConnect that allows secure sharing of patient specific information among approved health care providers, should be used as an additional opportunity to share information and

coordinate care among providers and should, as an initial application, be used between comprehensive and sub-specialty ophthalmologists.

Ophthalmologists in the South West LHIN

Ophthalmologists outside the South West LHIN who refer patients South West LHIN sub-specialists Financial and Resource Impact:

It is expected that eConsults and Clinical Connect will be provided with no user fees

It is expected that ophthalmologists will be compensated for participating and/or providing eConsult based advice

Comprehensive and sub-specialist ophthalmologists will be able to share patient specific information with each other in a secure and timely manner and thereby support and foster collaboration and shared clinical decision-making.

Indigenous Peoples

Indigenous refers any person who self-identifies as being Aboriginal, including First Nation (status and non-status), Inuit and Métis

This section of the report was prepared in partnership with Vanessa Ambtman-Smith, Aboriginal Health Lead for the South West LHIN.

Indigenous peoples live throughout the South West LHIN, living within First Nation communities, in rural areas and in urban areas like London and Owen Sound. There are five First Nation communities located in the South West LHIN, three in the southern part of the LHIN (Oneida Nation of the Thames; Chippewas of the Thames First Nation; and Munsee-Delaware Nation) and two in the north of the LHIN (Saugeen First Nation; and Chippewas of Nawash Unceded First Nation).

There are many health services that provide care for Indigenous peoples as well culturally appropriate services run by and for Indigenous peoples. Everyone can access provincially funded health care services and other services funded by the Federal government are only available through First nation communities.

For example, through the federal government, First Nations and Inuit people are eligible to receive First Nations and Inuit Non-Insured Health Benefits (NIHB). In the area of vision, there are additional services that can be accessed through NIHB that are not available through OHIP; however, there is not always good understanding or recognition of how to bill for NIHB, and sometimes this can pose problems for the patient, who may not be able to cover off any costs upfront.

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18 Many providers who learn about the NIHB are not familiar with how it works or how to access the resources it offers as it is not a frequent occurrence for many and it is not an easy process to navigate. Providers need to be educated about who to call to access this system on behalf of their patients so they can help them. Fortunately, many Aboriginal Health Access Centres have developed advocacy positions to support clients who may encounter resistance from providers billing through NIHB, or not understanding what is covered, when. It is important that providers know who to contact when there is a need to do so. This is an important example of how the

experience and expertise of Access Centres can be used to reduce barriers to eye care.

When First Nations people are advised they may have to pay up front, in circumstances when their benefits or NIHB would cover off a fee, many people opt out of an appointment or service. This is an equity concern that needs to be acknowledged, and one that would also probably resonate with other vulnerable groups (e.g. low income; fixed income).

The Oneida Nation of the Thames – Health Services offers a community diabetes program and diabetes education. Programs are offered by the Southwest Ontario Aboriginal Health Access Centre which has offices in London, Windsor and Owen Sound and by the Chippewas of the Thames in Muncey. To quote:

The Southwest Ontario Aboriginal Centre (SOAHAC) provides high quality, holistic health services to on and off reserve, status, non-status, and Metis Aboriginal populations in the Southwest Ontario region. The mission of SOAHAC is to empower Aboriginal families and individuals to live a balanced state of well-being by sharing and promoting holistic health practices.

With four locations (two in London, one in Owen Sound and one in Chippewas of The Thames), the Centre strives to ensure that health services are both accessible and culturally appropriate.

SOAHAC is proud to offer a comprehensive list of programs including Primary Health Care, Traditional Healing, Mental Health, Diabetes Education, Nutrition & Healthy Lifestyles, Maternal & Child Health, and Supporting Aboriginal Seniors at Home (SASH).

Current Development: The SOAHAC in partnership with the South West LHIN, will be leading the development of a current state report, a needs assessment, a report on best practices and readiness assessment as foundational knowledge to be used to support diabetes planning and culturally-appropriate service enhancements/ service model development . This project will provide an opportunity to document unmet needs and to investigate and apply evidence-based practices.

Screening for diabetes and its complications

Anishnawbe Health Toronto has been a leader in diabetes education and in addition to offering direct services, also undertakes research. One example is their December 2011 report, “Urban Aboriginal Diabetes Research Project Report “.

This report references a number of Aboriginal diabetes resources. [bold added}

The National Aboriginal Diabetes Association is an advocacy organization whose website also has useful information focused on the particular issues faced by Aboriginal peoples with diabetes (National

Aboriginal Diabetes Association, n.d.). The National Aboriginal Health Organization produces knowledge aimed at overall health promotion, and recently released a toolkit focused on diabetes (National

Aboriginal Health Organization, 2011). Health Canada’s website provides fact sheets and information about the national Aboriginal Diabetes Initiative including a report on Aboriginal communities in action, which summarizes the work of First Nations and Inuit communities who have developed creative ways to promote healthy lifestyles and reduce the incidence of Type 2 diabetes (Health Canada, 2008; Health Canada, n.d.).

More about the Ontario Aboriginal Diabetes Strategy can be found in a publication available online (Ontario Ministry of Health and Long-term Care, 2010). The mission of the Southern Ontario Aboriginal

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19 Diabetes Initiative (SOADI) is “the development, and enhancement of programmes and services focusing on the education, prevention, and management of diabetes in Aboriginal communities, both on and off-reserve” (SOADI, n.d.). SOADI has generated a vast array of resources, including a variety of prevention workshop materials, toolkits, videos, personal care items, and games provided by their staff that travels throughout the organization’s vast service area, which includes Toronto. There is free access to videos they have produced with Aboriginal community members available at the SOADI website, and a number of other items can be purchased online.

The same report also undertook a literature review and this is their conclusion:

In summary, the rate of diabetes for Aboriginal people is 2-5 times higher than for the overall Canadian population (Oster et al., 2011), and those Aboriginal people who have diabetes tend to have more

complications. Past literature has privileged [i.e. tended to focus attention on] First Nations on-reserve. In addition, the literature has focused on biology and genetics. However, there is increasing recognition of the importance of culturally-based, wholistic programmes that incorporate physical, mental, emotional and spiritual well-being. This research addresses the caveats of past literature, focusing on urban Aboriginal peoples (First Nations, Métis and Inuit) with diabetes and explores how to support people in better managing diabetes.

From a future state perspective there are opportunities to improve linkages, communications and collaboration between Indigenous peoples health services and primary care providers and both optometrists and

ophthalmologists. These opportunities include:

 Engaging with Aboriginal communities in the South West to listen and learn about the role they could play in preventing vision problems among Indigenous peoples resulting from diabetes and reducing the negative impact of complications when they occur.

 Developing outreach programs to provide improved access to comprehensive eye examinations when transportation is not available.

 Undertaking self-education by taking the Indigenous Cultural Competency Training (ICC) course.

This initiative is being led by the SOAHAC in partnership with the British Columbia Provincial Health Services Authority. Supported by the MOHLTC and the South West LHIN, is contributing to advancing Aboriginal Cultural Competency across the healthcare system. Delivery of the ICC Program in South Western Ontario will contribute to:

o Fostering understanding and connection between the historical and current government practices and policies towards Aboriginal peoples and the related impacts on social determinants of health, access to health services and intergenerational health outcomes; and

o Building capacity within South West LHIN providers that will lead to better relationships with Aboriginal clients, patients, caregivers and families

The overall goal of advancing cultural competency in the South West LHIN is to contribute to:

o Increasing cultural competency across the healthcare sectors in order to better improve health outcomes for Aboriginal peoples

o Reducing utilization of emergency and acute services

o Strengthening connections to primary care, community supports

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Steps should be taken by primary care providers, optometrists and ophthalmologists who serve Indigenous communities to continue to engage with Southwest Ontario Aboriginal Health Access Centre (SOAHAC) and other Indigenous communities to share experiences and learn from one another and thereby develop LHIN respectful partnerships and collaborative practices throughout the South West to address the vision care education, prevention, screening, monitoring and treatment needs of Indigenous Peoples .

Providers who work with Indigenous Peoples on a consistent basis should be supported in taking the Indigenous Cultural Competency Training (ICC) course, to improve their understanding and competency in working with Indigenous Peoples. http://www.culturalcompetency.ca/training/ontario

Southwest Ontario Aboriginal Health Access Centre South West LHIN diabetes education programs

South West LHIN Primary Care /Chronic Disease Prevention and Management Lead Primary care providers within the South West LHIN

Primary care physician leads – South West LHIN South West LHIN optometrists

South West LHIN ophthalmologists South West LHIN

Indigenous Cultural Competency training is available at no direct cost to providers in the South West LHIN Cost of any initiatives that result from the collaboration

Allocation of time required

Positive relationships with indigenous health services will be established that allow culturally sensitive and relevant linkages with eye care specialists to be developed and fostered resulting in improved vision care education, prevention, screening, monitoring and treatment for Indigenous Peoples.

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21

Access to Services and Care

Introduction

This section will address:

 The future need for general or comprehensive ophthalmology services needed to serve the residents of the South West LHIN including:

o Number of ophthalmologists o Emergent and urgent services o Location of services

o Scope of practice

o Configuration of services (partnerships)

 The future need for specialized ophthalmology services needed to serve the residents of the South West LHIN as well as Erie St. Clair and Waterloo Wellington LHINs including:.

o Number of ophthalmologists o Scope of practice

o Configuration of services (location, partnerships)

 The future of research, medical and residency training in ophthalmology at Western University o Research and Innovation

o Undergraduate and post-graduate education

 Post-graduate positions and focus of training o Preparing for the future of ophthalmology

Access to Ophthalmology Services - Future State Goal

To have the required number of ophthalmologists practicing in the appropriate locations within the South West LHIN, with the required skills and scope of practice, to address future population needs – not only within the South West LHIN but all those served by the South West LHIN.

The residency program at Western University is able to serve as a future training program for ophthalmologists and in collaboration with other residency programs in Canada, is able to meet the future need for

ophthalmologists.

General or Comprehensive Ophthalmology

In The Current State of Vision Care report a population based methodology was developed and used to estimate the need for general or comprehensive ophthalmologists in the year 2026.

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22 Table 4.0 South West LHIN Population and Seniors Projections by County 2012 and 2026

County

2012 Total Population (and % LHIN pop.)

2012 Total 65 plus Population (% county pop.) and

% LHIN pop.

2026 Total Population (and % LHIN pop.)

2026 Total 65 plus population (% county pop.) and % LHIN pop. Grey-Bruce 164,020 (17%) 34,650 (21%) 22% 170,760 (16%) 51,701 (30%) 18% Huron-Perth 137,530 (14%) 24,490 (18%) 15% 135,320 (13%) 35,920 (27%) 13% Oxford 108,780 (11%) 18,160 (17%) 11% 112,250 (11%) 27,060 (24%) 10% Elgin 91,130 (9%) 14,030 (15%) 9% 97,760 (9%) 22,340 (23%) 8% Middlesex 78,831 (7%) 11,502 (15%) 7% 91,586 (9%) 18,890 (19%) 7% City of London 384,879 (38%) 56,158 (15%) 35% 447,154 (42%) 92,230 (21%) 32% TOTAL (100%) 965,170 (100%) 158,990 (15%) 100% 1,054,830 (100%) 248,141 (24%) 100% Source: Ontario Ministry of Finance, Population Projections, Spring 2013

County of Middlesex population was estimated to be 17% of the Middlesex and City of London population (based on City of London report, Employment, Population, Housing and Non‐Residential Construction Projections, City of London, Ontario, 2011 Updated June 7, 2012).

Estimates made about the number of ophthalmologists needed to serve the South West LHIN assumes seniors will continue to account for the majority of patients served and the current ratio of one ophthalmologist for every 14,000 seniors is realistic and sustainable. There is no expectation in making these assumptions that the scope of practice of ophthalmologists will change significantly over this period of time. What will change is the use and integration of technology into clinical practice and the impact of clinical research in defining best and most appropriate clinical practices.

The results of applying these estimates to the South West LHIN (by municipality) are as follows: Table 5.0

Projected number of seniors per comprehensive ophthalmologist in 2026; current and projected number of comprehensive ophthalmologists, per county

Grey-Bruce

Huron-Perth

Oxford Elgin Middlesex City of London TOTAL Seniors (65+) 2026 51,701 35,920 27,060 22,340 18,890 92,230 248,141 2026 Comprehensive Ophthalmologists per 14,000 seniors 3.7 2.5 1.9 1.6 1.3 6.6 17.6 Current Number (2014) 3 2 3*(2) 1 1 2** 11 Difference 0.7 0.5 -(0.1) 0.6 0.3 4.6** 6.6

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23 Footnote to Table 5.0

* While three comprehensive ophthalmologists are assigned to Oxford County, two work in Oxford County

full-time and one part-full-time .

** While only two Ophthalmologists practice comprehensive ophthalmology in the City of London an additional two full-time equivalents (FTE) of comprehensive ophthalmology is provided by subspecialists. Given this, the required number of additional comprehensive ophthalmologists is closer to two and a half.

********************************************************************************************* Ophthalmologist roles

Some comprehensive ophthalmologists have a general practice while in addition specialize in particular areas of ophthalmology. Some ophthalmologists are sub-specialists (having a fellowship is a specific area of

ophthalmology) but in addition to their speciality work also do some aspects of general ophthalmology – cataract surgery being a prime example.

London-based ophthalmologists tend to be specialists who also do some general ophthalmology work. Assuming this pattern continues into the future, the number of comprehensive ophthalmologists needed in London – equivalent to 4.6 additional (full-time) comprehensive ophthalmologists may be addressed by recruiting a combination of comprehensive ophthalmologists and sub-specialists who also do some general ophthalmology work.

Based on the information presented in Table 5 an additional 6.6 general or comprehensive ophthalmologists will be needed to serve the residents of the South West LHIN by 2026.

The Provincial Vision Strategy Task Force in its May 2013 report, “A Vision for Ontario: strategic recommendations for Ophthalmology in Ontario,” recommended cataract surgery volumes per surgeon range between 200-600 surgeries per year. If a ratio of 600 surgeries per surgeon is applied to the number of cataract surgeries completed in the South West LHIN in 2013-14, (approx. 10,000) 16.7 surgeons are needed. There are 11 comprehensive ophthalmologists in the LHIN and 5.7 sub-specialist surgeons are also doing cataract surgeries. Currently 10 surgeons are performing cataract surgeries at St. Joseph’s Health Care London, two of which are comprehensive ophthalmologists.

If this ratio is applied to the recommended number of cataracts that should be allocated to the South West LHIN using a population-based formula (13,000) then the number of surgeons increases to 21.7. If it is applied to the projected demand in 2026 (20,000) then the number grows to 33 – significantly more than the 17.6 projected to be needed according to Table 5. This suggests there will be a need for sub-specialists to continue doing this work in the future. Overall, the combination of comprehensive and sub-specialist ophthalmologists needed – based on cataract surgery volumes only (at 600 per physician) would be 17.6 comprehensive ophthalmologists plus 15.4 sub-specialists.

To meet current cataract surgery wait time targets the amount of work each surgeon does and/or the number of available surgeons will need to increase. From a recruitment perspective it might be necessary for current surgeons to take on additional cases in the short term to be able to recruit and transfer a critical volume of cases to a new ophthalmologist. Volume changes and service demands need to be closely monitored by each hospital to assess the appropriate timing of future recruitment.

Although this project, within its scope of work, did not have a mandate to directly speak to the function of optometry to address current and future eye care needs, their role has been described as it applies to specific aspects of their work – primary eye care, screening and monitoring, for example. What has not been addressed is any detailed investigation of optometry to address the future. Having said this, there is no doubt that they will continue to pay a vital primary eye care role and will increasingly work in collaboration with both primary care physicians and ophthalmologists.

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 One additional comprehensive ophthalmologist will be needed to meet the growing needs of the residents of Grey-Bruce.

 The equivalent of 4.6 FTE additional comprehensive ophthalmologists [provided by a combination of comprehensive and sub-specialty ophthalmologists] will be needed to meet both the current and future needs of the residents of the City of London due to both growing demand based on population changes  The remaining areas of the LHIN, Huron-Perth, Oxford, Elgin and Middlesex need to maintain the current

complement of comprehensive ophthalmologists to serve the residents of these areas.

 Hospitals working in partnership with their ophthalmologists should take the necessary steps to either maintain or grow the number of comprehensive ophthalmologists as defined and to assess the timing for when future recruitment will be needed.

The following hospitals and affiliated ophthalmologists: Grey Bruce Health Services

St. Joseph’s Health Care London Huron Perth Healthcare Alliance Middlesex Hospital Alliance St. Thomas Elgin General Hospital Woodstock Hospital

Alexandra Hospital (Ingersoll)

Department of Ophthalmology, Western University South West LHIN

Expansion or reallocation of operating room time and resources, equipment, space and related resources to support and sustain a medical and surgical practice when an additional medical resource is being planned for and added.

The number and location of practicing comprehensive ophthalmologists will continue to meet the growing needs of the population.

The Department of Ophthalmology at Western University should assist hospitals in the region with recruiting ophthalmologists. Hospitals in the region should make the Department of Ophthalmology aware of their future recruitment needs so they can help influence future career decisions of their post-graduate residents.

Department of Ophthalmology, Western University

South West LHIN hospitals and affiliated ophthalmologists Financial and Resource Impact:

Allocation of time required but no additional financial resources

A collaborative approach to physician recruitment will help to address local recruitment needs

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25

Access to Emergent and Urgent Ophthalmology Services

Another important component of access to care is the availability of emergency services. All ophthalmologists are trained to assess and treat emergent cases and to refer patients as needed. A key public and community

expectation is that ophthalmologists are available to respond to emergencies – in other words, to be on-call. At the present time, on-call coverage is provided in a variety of ways.

 In Owen Sound three ophthalmologists share call and provide 24x7, 365 coverage  In Stratford two ophthalmologists share call and provide 24x7, 365 coverage  In Woodstock two ophthalmologists share call and provide 24x7, 365 coverage

 A St. Thomas and a Simcoe-based ophthalmologist share call and thereby provide 24x7, 365 coverage  In London, post-graduate ophthalmology residents provide first-call responses to all emergent and urgent

cases with back-up and intervention by consultants as needed who are on-call at the same time. Through this system 24x7, 365 coverage is provided

 In Strathroy the one ophthalmologist does provide a formal on-call schedule

As a follow-up to the current state report, the on-call schedules of ophthalmologists in the LHIN has been shared with appropriate stakeholders including those in the Erie St. Clair and Waterloo Wellington LHINs.

The number and type of on-call cases addressed over a one month period of time has been reviewed(see

Appendix F). This information shows while most cases are urgent (need to be seen within four-24 hours), very few are classified as emergent (need to be seen within four hours). This documentation is consistent with information provided by CritiCall which shows, both provincially and locally, that true ophthalmic emergencies are infrequent. Having said this, being able to respond in a timely manner in true emergencies is important to the residents of the South West LHIN – especially to those who present at emergency departments with an emergent eye problem – now and in the future9. Two elements are critical: the ability to contact the nearest ophthalmologist on call – and knowing who to call if that person cannot be reached and that the ophthalmologist on-call knows how and who to contact if the intervention required is beyond their scope of practice – i.e., requiring an immediate referral to a sub-specialist.

Knowing how to reach the ophthalmologist on call is also of interest to primary care physicians and optometrists who may have a patient present to them that cannot be treated by them and needs direct and urgent intervention by an ophthalmologist.

All emergency departments as well as optometrists and family physicians need to know how to reach the nearest and most appropriate ophthalmologist on call 24x7, 365 – and where to call if that ophthalmologist is not able to respond to emergencies. All ophthalmologists on call need to know how to connect patients with a sub-specialist if a higher level of expertise is required.

If not already in place, hospitals should give all hospital emergency departments – those with and those without ophthalmologists on site –information about how contact the nearest and most appropriate ophthalmologists on-call at any given time. This same information should be given to optometrists and family physicians.

9_{People with urgent eye problems may contact their optometrist or their family physician, especially if they do not see the} situation as being a medical emergency. Depending on the nature of the problem, it may be addressed by these providers. If not, they would take steps to immediately refer the patient to an ophthalmologist for treatment.

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26 Target of Recommendation:

All hospital emergency departments in the South West LHIN South West LHIN ophthalmologists

Family physicians Optometrists

Allocation of time required but no additional financial resources Future State Recommendation 10.2

If not already in place, contact protocols with CritiCall should be put in place so at any given time their call centre staff know how to contact the most appropriate ophthalmologist on call.

Target of Recommendation: CritiCall

Hospitals and ophthalmologists providing on-call services Financial and Resource Impact:

Allocation of time required but no additional financial resources

Intended Outcome of Recommendations 10.1 and 10.2:

Patients who present at emergency departments with emergent eye problems, regardless of which hospital they go to, will get timely access to the ophthalmic care they need.

In terms of emergent access to specialized ophthalmology services, residents who provide front-line on-call at St. Joseph’s are able to access a specific consultant in case of an emergency and a specialist is always on-call. The retina specialists have their own on-call roster and this information is readily available to the resident and consultant on call.

In order to provide a financial incentive to physicians where on-call volumes are relatively low and therefore fee-for-service does not provide adequate reimbursement, the MOHLTC has an incentive fund for the provision of on-call services on-called Hospital On-Call Coverage (HOCC). Hospitals and their affiliated ophthalmologists are eligible to apply and receive funds through this program. In the case of ophthalmology the fund covers physicians who provide call to a specific hospital as well as to ophthalmologists who are affiliated with different hospitals. In the South West LHIN both of these models are being used.

Hospitals and ophthalmologists should continue to use the Ministry’s HOCC program to provide ophthalmologists with financial compensation for being on-call – both within and across hospitals. Target of Recommendation:

Hospitals and ophthalmologists providing on-call services Ministry of Health and Long-Term Care

Allocation of resources by the MOHLTC HOCC program to hospitals and physicians

Ophthalmologists will receive compensation for being on-call (could be for individual or multiple hospitals) beyond their regular fee-for-service, thereby rewarding them for providing a defined number of on-call hours.