OPT 8560 — Public Health Primary, Secondary & Tertiary Levels of Care

OPT 8560 — Public HealthPrimary, Secondary & Tertiary Levels of Care W. Howard McAlister, O.D., M.P.H.

Primary, Secondary & Tertiary Levels of Care • Primary Care A. Are those ambulatory services that are required by most of the people most of the time B. Provided in various settings, ex. private practice offices, community health centers, military out patient clinics, etc. C. Should function as the primary entry point into the health care system

D. Health resources found in a primary care unit require 30,000 – 50,000 people to efficiently sustain them E. Primary care unit should provide comprehensive range of diagnostic, therapeutic, and preventive services F. Travel time to obtain primary care should be about 15 to 30 minutes

II. Secondary Care A. Relatively specialized services (provided after referral or consult) – usually in community hospital B. In some cases patient may go directly to secondary provider but ideally should be referred by a primary care provider C. Resources of a secondary care center require about 250,000 – 300,000 people in order to be efficient D. Secondary services should be within 30 to 60 minutes travel time

Tertiary Care A. Highly sophisticated (specialized) services that require extensive technical capability and almost always provided on in-patient basis B. Should be centralized in major medical centers due to low frequency of need for the services and major equipment needed to provide the services C. Requires a population of about 1.5 to 2 million D. Travel time to tertiary care center should be about 2-1/2 to 3 hours

IV. Gate Keeper A. In many alternate health care delivery systems a primary care practitioner must approve any referrals or consults with a “specialist” B. Usually each patient selects, or is assigned, a family practitioner or internist who serves as the gate keeper C. In some plans the O.D. serves as the gate keeper for all eye and vision care 1. A patient cannot see an ophthalmologist without a request for a consult from the optometrist 2. Decreases cost and improves the quality of care

Examples of Primary, Secondary, and Tertiary Care Providers (often difficult to put in one category) A. O.D.’s – generally primary care B. Pediatrician – generally primary care C. Internist—generally primary care D. Family Practitioner—generally primary care E. OB/GYN – generally primary and secondary care F. Ophthalmology – generally secondary and tertiary care by training but often function at the primary level

G. Dentist – generally primary care H. Podiatrist – generally primary care I. General Surgeon – generally secondary care J. Neuro-surgeon – generally tertiary care

Linkage A. For this regional structure to work efficiently vertical and horizontal linkage must operate 1. Within vertical dimension patients are referred up from primary to secondary to tertiary 2. In the same manner patients are referred from tertiary down ex. – O.D. sends patient to general ophthalmologist for aphakic surgery – during mydriatic fundus exam, ophthalmologist discovers and corrects detachment – he refers to a retinal specialist – once the retinal specialist “does his thing”, he refers back to the general ophthalmologist for aphakic surgery – after this he refers patient to O.D. for post surgical care

3. The functional distribution of responsibility within vertical linkage is motivated by desire to: a. Prevent duplication b. Better utilize already existing resources c. Increase emphasis on primary care services 4. Horizontal linkage provides for coordination of effort and encourages a team approach to preventive as well as curative care, ex. O.D. finds signs of hypertension and refers the patient to a family practitioner or internist – family practitioner notices decreased V.A. in a patient and refers to an O.D. for evaluation and possible treatment

VII. Practical Eye Care Delivery A. Presently eye care provided in most part by O.D.’s and ophthalmologists with a significant overlap between these two B. For regionalized health system to be effective and efficient there must be a functional distribution of responsibilities and a clear role relationship between the two C. Efficiency and effectiveness dictate O.D.’s should be the primary level providers

Ophthalmologist: Physician (M.D. or D.O.) who specializes in the diagnosis and treatment, including surgery, diseases or defects of the eye

Optometrist: Doctors of Optometry (ODs) are the primary health care professionals for the eye. Optometrists examine, diagnose, teat, and manage diseases, injuries, and disorders of the visual system, the eye, and associated structures as well as identify related systemic conditions affecting the eye.

Doctors of Optometry prescribe medications, low vision rehabilitation, vision therapy, spectacle lenses, contact lenses, and perform certain surgical procedures.

Optometrists counsel their patients regarding surgical and non-surgical options that meet their visual needs related to their occupations, avocations, and lifestyle.

An optometrist has completed pre-professional undergraduate education in a college or university and four years of professional education at a college of optometry, leading to the doctor of optometry (O.D.) degree. Some optometrists complete an optional residency in a specific area of practice.

Optometrists are eye health care professionals state-licensed to diagnose and treat diseases and disorders of the eye and visual system.

D. Ophthalmologists presently working in primary, secondary and tertiary levels E. O.D.’s almost exclusively at the primary level F. Since it takes longer to train ophthalmologists, (average 8 vs.12 years) and costs three times as much to train, a primary concern must be better utilization of them

G. Some Ophthalmologists are grossly underutilized – 70 – 85% of their time spent making routine vision exams and prescribing spectacles (not including C.L. work – also provided by better trained O.D.’s) H. Ophthalmologist have a low referral pattern when compared to other secondary care level providers

I.It is inefficient for ophthalmologists to function at a primary level, rendering the same services that can be provided cheaper and with greater level of expertise by O.D.’s J. With Proper Utilization 1 O.D./7,000 population (1 O.D./11,000 population?) 1 ophthalmologist/35,000 population i.e. 1 ophthalmologist/5 O.D.’s These ratios have proven effective in HMO’s and military health facilities. What presently exists is about 1 ophthalmologist/2 O.D.’s.

K. In reality economics dictate the present situation – we have too many ophthalmologists! L. If we were to absorb all primary care it would be better for patients, O.D.’s, and third party payors – but it would not be good for the finances of ophthalmologists 1. The number of eye surgeries would probably increase tremendously—particularly refractive surgery 2. Note the increased supply of physicians in recent years hasn’t decreased cost – just more people receiving medical care (whether they need it or not!)

OPT 8560 — Public Health Primary, Secondary & Tertiary Levels of Care