This spring, the California Board of Optometry shut down the only optometrist providing services to homebound patients in the San Francisco Bay Area. I learned about this because affected patients included several referred from our UC San Francisco Housecalls program, one of a few non-profit, non-concierge home-based practices in the state providing geriatrics care to homebound adults.
With over 1 million adults homebound in California, why would any board deliberately limit access to care for such vulnerable adults?
California Board of Optometry Policy prevents an optometrist from providing care in private homes. Optometrists can provide care in residential facilities, but only with advance notice to the board and for a limited number of days. An optometrist in California cannot choose to exclusively serve homebound clients.
For many homebound adults, physical and cognitive impairments progressively limit their livable space until they are confined within four walls of a single room. Adequate vision to see loved ones, look out a window, watch TV, and read becomes vital to quality of life.
Visual impairment contributes to depression, anxiety, and risk of falls. For individuals with dementia, poor vision can cause disturbed perceptions, paranoia, aggressive behavior, or care resistance.
Home optometric care can preserve vision. For our housecall patients, access to eye care and new glasses was, in one patient’s words, “a Godsend.” The home optometrist we referred our patients to not only corrected vision but addressed problems such as red eye or irritation, and helped us gauge whether an ophthalmology referral was necessary or if conditions — such as glaucoma or cataracts — could be managed at home.
For homebound adults, travel to an ophthalmologist’s office requires 1 to 2 caregivers and wheelchair/gurney transport, often not covered by insurance and costing at least $300. That’s assuming the ophthalmologist can accommodate a bedbound patient or adult with dementia. Initial home optometric evaluations can help a patient avoid unnecessary trips and support primary care providers in counseling patients about the risks and benefits of interventions.
In the 1990s, after advocacy from the UC Berkeley School of Optometry, the California Board of Optometry finally allowed students in private homes to learn about eye care of older adults. Over the next several years, until becoming a casualty of the fiscal crisis for state-funded universities, UC Berkeley educated over a hundred students in home eye care. One of these graduates was the Optometrist who built his practice exclusively to serve homebound adults, and whom the board shut down this spring.
Today, we face a nonsensical situation in which an optometric school can educate students to provide home eye care, but these same individuals, once graduated and licensed, are prohibited by their board from practicing those very skills and providing critical services to patients without other options.
As our population ages, the number of homebound adults increases. Fortunately, multiple types of clinicians can provide home care: physicians, nurse practitioners, physician assistants, dentists, dental hygienists, podiatrists, and physical therapists. For California’s Board of Optometry to disallow home optometric care in this time of rising need is outrageous.
Over the past two decades, medical housecalls programs have proven their value in caring for aging populations. Home eye care has equal potential to advance health care access, reduce unnecessary medical costs (from falls, depression, and emergency visits), and provide a pathway to fulfilling careers for optometrists passionate about helping underserved adults.
Other states already have home optometric care, including Colorado, Illinois, Maryland, Virginia, and Utah.
Yet in the state of California, thanks to California’s Board of Optometry, there is now no access to home eye care.
Given our shifting demographics, the need for home optometric care will continue to grow. Such care is reimbursable under Medicare and critically needed. The time is overdue for all state boards of optometry, not just California’s, to permit optometrists to provide home eye care.
Helen Kao is a geriatrician.
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