Children's Service-Cycloplegic Refraction Pathway

1. Children’s Service-Cycloplegic RefractionGill MarshallPENE CGPL agmarshall@btinternet.com

2. This service pathway is complicated! • 3 visit types and 3 different possible outcomes • Different screening teams with different referral forms • Outcome reporting is paper based, but.... • Fee claimed via an IT management system. (Webstar Health. Optomanager. Optoclaim) • Service has low activity each quarter and the guidelines can seem complicated • Different optometrists may do follow up appointments • Practice support staff are not always aware the service exists and the paper work is not familiar to them • Encourage someone in the team to be the lead for this

3. PENE has been working to simplify the service for this new contract by working with SEI and RVI to agree new clinical guidelines.With the development of the new Webstar Health module the reporting mechanism should be more streamlined.At the end of this presentation there are extra slides relating to the new module

4. Current Screening Process • Children (aged 4 to 5) are screened in reception • In an ideal world, we would know when screening was going to occur. We are working on being able to get that information. • Ask support staff to look for children of this age and ask the parents if they have been screened in school • It’s important that you book the correct double appointment to allow time for cyclo • Ask that they bring the forms in; important information about vision at screening • Orthoptist screening teams from SEI and Newcastle Eye Centre (RVI) • Gateshead CCG new to service and they use the same screening team from RVI and the same forms

5. South Tyneside CCG South Tyneside CCG have signed up to the service • Currently children are screened by nurses in school using same vision criteria as SEI and children who fail are referred to optometrists for GOS sight test • NECS and PENE are working to engage with the screening team to refer into the service • As soon as we know, we will inform practitioners in South Tyneside how to proceed. • We need to agree where the reporting outcome forms will be sent

6. Durham CCG Durham CCG are not signed up to this service yet PENE and Durham LOC are working with NECS to address this inequality in the service SEI are unable to check if a child falls within Durham CCG Practices will see children referred from screening who arrive with all the forms, but a fee can not be claimed. It is your decision what you do and whether you send reports or not. Consider best interest of the child Please inform PENE if you have children referred to you whose GP is in Durham CCG

7. Screening Criteria Vision must be 0.20 or better in both eyes to pass Children failing school vision screening will be referred to a community Optometrist unless: • Unable to perform crowded LogMAR test * • Vision is worse than 0.5 in either eye • Manifest strabismus • Other pathology • *SEI team will refer any child who cannot perform Cr LogMAR directly to secondary care. RVI team will refer to community optometrists and state on the forms “K Pics used”. • NB: We still need to use LogMAR whenever possible and we can not discharge from the scheme if we can only record K Pics as 0.20 K Pics is not equal to 0.20 Cr Log MAR

8. Information from Screening team to Parent • Parents are given a letter advising that child needs to be reviewed following vision screening • They are given a list of participating practices. • It is recommended that they choose from that list • They are given the referral form with child’s details and vision screening results to bring to the practice • The info on this form is really important • Contact numbers are on the LOC website to call for info if parents attend without the form. • If you call, the RVI orthoptist team and the admin at SEI know how to access the screening information • Please make a note if no form is brought, as that is a KPI for the service SEI and RVI forms differ and the RVI screening form is also the outcome form to be completed. Both forms can be viewed and downloaded from the NTW LOC website

9. Clinical guidelines Following discussion with SEI and RVI orthoptist teams, we have been able to agree on many areas and the guidelines have been slightly amended so that they are now consistent across the regions We will highlight amendments tonight The complete guidelines are available on NTW LOC website and will be available on Webstar Health Optomanager when the module goes live

10. Visits in Brief Initial visit: GOS with cyclo refraction following the service clinical guidelines Outcomes: Review/Discharge/Refer 6 week visit: Check compliance and fit of glasses. Measure VA Outcomes: Review/Discharge/Refer 18 week visit: GOS sight test only Outcomes: Discharge/Refer Please note: Review means see the child again under the service pathway, either at 6 or 18 week visit Discharge means the child has reached the required VA standard and is discharged from the service pathway and will be followed up under GOS Refer is when the VA does not reach the required standard. By completing the form and ticking the outcome box “refer” and sending it to the SEI or RVI orthoptist teams, that will trigger them to arrange an appointment with secondary care. Neither the optom nor the GP needs to send a referral letter to secondary care.

11. Initial visit: Procedure GOS sight test plus • Measure unaided vision with crowded LogMAR test with patch on either eye (Cr LogMAR must be used. Do not measure vision with Snellen or decimal and convert. Keeler booklets and electronic chart are both acceptable ) • Cover Test and Stereopsis • Cycloplegic refraction 25 minutes after instillation of G. Cyclopentolate 1% (single dose) (requires double appointment in diary to allow for cyclo return) • Fundal examination – either BIO 20D or 90D or direct ophthalmoscopy • Prescribe glasses if appropriate • Arrange 6 week review appointment if appropriate • Complete outcome report(s)

12. Clinical Guidelines: Initial visit outcomes • If vision is 0.2 or better in both eyes discharge to GOS. • If VA is 0.2 or better in both eyes, and glasses are prescribed, review at 6 weeks. Clinical judgement to be used to decide if it is appropriate to discharge the child from the pathway at this point and clinical justification will be required and collected in OptoManager module * (* With astigmatic and myopic refractive findings you may wish to discharge if VA records at 0.20 or better. It is recommended that anisometropia and hypermetropia are reviewed. If you are in doubt.......REVIEW) • If VA is between 0.225 and 0.475, prescribe glasses if appropriate, and review at 6 weeks. • If vision is between 0.225 and 0.475 with no significant refractive error, review at 6 weeks ** (**This allows you to arrange a review appointment without the need to prescribe small clinically insignificant refractive findings) • If VA is worse than 0.5 in either eye, a manifest (non accommodative) strabismus or other pathology is present, refer to secondary care (prescribe glasses where required)

13. Initial visit outcome reports Always send report to SEI/RVI after initial visit no matter what outcome because the screening team need to know that the child has attended a community optometrist. The teams follow up on the referred children and write to parents. • Review in 6 weeks (if VA not reached 0.20 in both eyes, whether glasses prescribed or not) • Send outcome report to SEI/RVI • Make appointment for review or diary to do so. • No report needed for GP* (this is new and so GP not overwhelmed by forms) • Dischargefrom service (if VA is 0.20 or better in both eyes) • Send outcome report to SEI/RVI and GP • Give and collect patient survey • Refer (if VA worse than 0.50 or manifest strabismus or pathology) • Send outcome report to SEI/RVI and GP • Give and collect patient survey Reporting forms on NTW LOC website and optomanager (RVI)

14. 6 week visit procedure • Check compliance with glasses and fit • Measure visual acuity with glasses (must be with crowded LogMAR test) • No GOS sight test • Arrange review appointment for final visit if appropriate • Make the appointment and/or diary to ensure appointment kept • Allows you to monitor FTA

15. 6 week visit outcomes and reports • Review if VA is worse than 0.20 • Arrange review appt in further 12 weeks (18 wk visit) No outcome reports are required if the outcome is to review • Discharge if achieved 0.20 or better in both eyes Send outcome reports to SEI/RVI and GP Give and collect patient survey Arrange 6 months recall under GOS • Refer if VA worse than 0.50 or manifest strabismus or pathology Send outcome reports to SEI/RVI and GP Give and collect patient survey

16. 18 week procedure • GOS sight test • Check compliance with glasses and fit • Measure VA with glasses using crowded LogMAR

17. 18 week visit outcomes and reports Send report to SEI/RVI and GP after this final visit no matter what the outcome • Discharge If VA is 0.2 or better in both eyes discharge to GOS. If VA’s are not equal, the child can still be discharged where the VA is 0.20 or better in one eye with less than 1 line difference in acuity between the eyes. * (*this is new. The reason is that no orthoptic treatment would be offered for second eye if VA levels are this good.) • Refer if VA does not meet this standard, refer to secondary care Give patient survey Offer parent/carer a copy of the report (best practice)

19. SEI new report forms • The forms to report to SEI have been amended • It is a new format, but mostly same info to fill in • Reports to be sent as stated in new guidelines • Download one form, fill it in and take a copy of it for • SEI/RVI • GP (only needed if refer or discharge) • Your practice records/file (no need to send copy to school nurse now) • New version form to download on LOC website

21. FTA policy FTA procedure • Call parents within 24 hours to remake appt. If possible follow FTA policy even for 1st visit. • If phone contact not possible, send letter to parents (Sample on NTW LOC website) • If no appointment made after 8 weeks, inform SEI/RVI and GP by sending an outcome report with FTA across the form and indicate which visit was missed. Please refer to FTA flow Chart on NTW LOC website (Get the support team on board to follow up on FTAs)

22. FTA sample letter to parents Re Name DOB Address Failed to attend appointment with optometrist Dear Parent or Guardian Your child has failed to attend an appointment for the children’s eye service on Date Time At We have been unable to contact you by phone and so we kindly request that you contact the practice to make another appointment. It is important that we complete the vision assessment of your child, as screening revealed there may some difficulty with their vision. Yours Sincerely This is available on NTW LOC website

23. Paper based reporting • Until new Webstar Health module developed, paper based reporting continues • Please complete accurate reports with all the boxes filled in (please)KPI for the service. • Remember to complete and send 18 week reports to SEI/RVI and 6 week visit reports if necessary • Suggested time scale for reports • Reports within 1 week • Referrals within 2 days • Webstar Health and Optomanager development ongoing which will make reporting much more accurate and automated where possible.

24. To claim payment • The only way to claim a fee for the initial visit on this service is by entering the details of the visit onto Optomanager via the Optoclaim section on the menu bar. • Choose which service the claim is for. Enter child’s name. DOB. Post code. CCG. GP surgery. Date of visit. Which visit it is. • Ensure you tick that it is an initial visit. • This generates an invoice to the CCG. • Currently 6 and 18 week visit details are not entered onto optomanager. • The subcontractor (practice) must be signed up to the service to claim payment. If you are unsure please contact PENE.

25. Fees to subcontractors Children’s Service – Cycloplegic Refraction • 1st visit tariff £42 plus GOS fee • 6 week visit (when required) no fee • 18 week visit (when required)GOS fee only • Fee to Webstar Health first visit only £6 • Fee to PENE 1st visit only £2

26. Pointers to help the administration in practice • Get support staff involved. Appoint a lead team member. Suggestion: keep a sheet with all children and ongoing visits noted on it for easy follow up . • Look out for reception aged children and ask parents if they were referred from school vision screening. Ask for forms. Take/keep a copy. Have a supply of forms ready printed • Make a note and report quarterly if no there is no form. KPI • Make correct “double” appointment to allow for first cyclo visit • Send reports to SEI/RVI always after initial and final visit • Send GP reports if discharge or refer • Enter first visit onto Optoclaim to claim fee and generate invoice • Make 6 and 18 week appointments or diary them • Complete and send reports after 6 (if needed) and 18 week visits • Chase up FTAs: following policy. KPI • Give and collect patient surveys on discharge and referral. KPI • Monthly: Send patient surveys to Webstar Health by post KPI • Quarterly: Send summary of 1st visits and outcome to CGPL KPI. You will receive an email at the end of each quarter with report request.

27. Things that go wrong • 6 and 18 week visits not reported to SEI/RVI • Forms not fully completed. Address, visit type • Missing data, even refraction and VA details! Data reporting is needed to audit the service. • Crowded LogMAR not used. • Incorrect/confused outcome chosen for instance discharge and review both ticked. Only one outcome option is possible for each visit. • FTA procedure not followed. • Patient surveys not completed and posted to Webstar Health • Quarterly reports not completed and sent to CGPL! • 1st visit not entered onto Optoclaim, so no fee paid.

28. Thank you Please feel free to contact me with any queries you have. Gill Marshall agmarshall@btconnect.com This presentation and all documents relating to this service can be found at: www.loc-net.org.uk/northumberland-tyne-and-wear PENE director Sarah Townsend sarah.townsend5@nhs.net

29. Webstar Health New Module

30. Webstar Health New Module Time frame to finish development and start testing and then go live: We hope to go live by the end of March 2016 Although we are not able to demonstrate live screen shots of the module yet, when it is launched, there will be video links on the Webstar Health Optomanager site. PENE will inform all practices in advance

32. Differences in admin • Screening and child details added when appointment made. • Ability to monitor time frame from presenting at the practice. • Allows practice to contact parent if FTA • Future: Screening team could populate the module with database of children referred • New ODS code to find GP surgery. Forms will come with ODS code when possible and the Gp surgery can be found by title or code within the new module • Email form Webstar Health generated weekly to practice to warn if FTA or appointment over due • All documents will be available on Optomanager to view and download

33. Reports • Reports for SEI/RVI and GP will be populated from results input at each visit • Reports to hospital will be sent automatically by nhs.net email from Webstar • GP reports will be automatically faxed (EXCEPT; N/Land, Newcastle West and N/Tyne report will be “print and post” as these CCGs will not accept fax reports) • GP letter will clearly state “for information only, no action required” • FTA letters automatically generated for SEI/RVI and GP • Invoices generated after initial visit • Patient survey results will be added on the module and results collected. No need to post forms.