Treating the entire patient

The Ophthalmic Consultants of Connecticut team delivers a holistic approach to glaucoma care.

Because patients who have glaucoma often exhibit wellness concerns beyond ocular health and vision, the staff of Ophthalmic Consultants of Connecticut has made it their mission to treat the entire patient, not just the disease. Here’s a look at how the staff at the multi-location practice in Fairfield County, Conn., contribute to the delivery of exemplary glaucoma care while addressing some of the more critical patient needs, behaviors, and emotions.

Comfort during testing

While glaucoma can occur at any age, it is primarily a disease of the elderly. Close to 40% of people age 65 and older have at least one disability, with two-thirds reporting difficulty with walking or climbing, according to a recent U.S. Census Bureau report. To help accommodate patients who have mobility issues during testing, Ophthalmic Consultants of Connecticut uses state-of-the-art diagnostic technologies that require little patient movement and time.

For example, the practice uses optical coherence tomography (Cirrus 5000, Zeiss) that captures images of the optic nerve, retinal nerve fiber layer, the angles and corneal thickness, explains Joany Johnson, COA, the practice’s head tech. “Because the device captures so much information, we no longer have to move the patient from device to device or room to room.”

Keena Tulloch-Sawyer, scrub technician, assists Dr. Noecker during a glaucoma procedure.

Technician Monika Sonemaneevong, COA, adds that because such devices amass data quickly and, therefore, save time, the techs can make patient adjustments during testing, when needed. She explains, “If a patient is out of breath, uncomfortable, or becoming upset, we invite them to take a break, and this break doesn’t negatively affect patient flow.”

Because prolonged sedentary behavior can cause discomfort, the staff of Ophthalmic Consultants of Connecticut seeks diagnostic devices that acquire data fast. For example, the practice is equipped with the Humphrey Field Analyzer 3 (Zeiss), “which takes four to five minutes per eye, vs. the traditional visual field, which takes up to 10 minutes per eye,” Ms. Johnson says.

Opportunities to socialize

Because many patients often socialize during visits, the staff of Ophthalmic Consultants of Connecticut balances conversation and care with a subtle social cue:

“My technique is to make sure my hands are always doing something while I have a conversation with patients,” Ms. Johnson says. “So, if a patient is talking or I’m explaining what I’m about to do, I’m in some way handling the occluder, slit lamp, etc., because it reminds the patient that they are here for an assessment of their eye health, which prompts most to wrap up the socializing. For those who don’t get the social cue, I simply turn to them, smile and say, ‘OK. I’m going to check your vision now,’ which is also effective and doesn’t cause any hard feelings.”

Monica Mondello, ophthalmic scribe, observes as Dr. Noecker explains test results to a patient.

Cynthia Rivera, patient care coordinator, left, and Brenda Zurlo, front desk supervisor, center, welcome a patient to the practice.

Alleviating fear and anxiety

In a recently published JAMA Ophthalmology study, 88% of the more than 2,000 respondents said they considered good vision vital to overall health. Further, respondents cited quality of life and loss of independence, respectively, as top concerns related to vision loss. It’s no surprise then that, fearing vision loss, some glaucoma patients present to their appointments anxious or angry. The staff of Ophthalmic Consultants of Connecticut helps alleviate these emotions by:

  • Providing education. “When a patient presents to schedule their surgery, I briefly reiterate, in layman’s terms, the purpose of the surgical intervention and what the patient can expect pre- and postoperatively,” explains Michelle Gonyea, surgical coordinator for Robert J. Noecker, MD, the glaucoma specialist at Ophthalmic Consultants of Connecticut. “This certainly helps to allay fears.”
    Education can also help the patient gain a sense of control, for example, when patients are shown how to use their glaucoma medication. Here, the practice’s scribes show patients how to pull down their lower lids to make little pockets, so that the drop “falls” in, Ms. Johnson says.
  • Empathize. When a patient has been through a few different procedures and presents to Ms. Gonyea angry, she says she tries to comfort them by explaining that, in some cases, success can take multiple surgical interventions and that the doctor is invested in the patient’s success.
    “This works most of the time to calm patients down, but, when it doesn’t work, I just try to comfort them as best I can. For example, I continuously reassure them by telling them Dr. Noecker is closely monitoring their pressure and will take other measures if needed.”

Dr. Noecker and Michelle Gonyea, surgical coordinator, answer a patient’s questions about glaucoma.

Addressing cognitive impairment

Elderly patients can experience a gradual decline in processing speed, attention, memory, and executive functioning (i.e. self-monitoring, planning, organizing, mental flexibility, and problem-solving), according to a Clinics in Geriatric Medicine article. What’s more, medication side effects, dementia, and depression can exacerbate this decline. To serve patients who may exhibit cognitive impairment, the staff of Ophthalmic Consultants of Connecticut:

  • Repeats in-office instructions. “When a patient looks up from a diagnostic device, for example, that’s a tell-tale sign that they’re having trouble either processing the directions as given, or they’re forgetting them,” Ms. Sonemaneevong says. “To overcome this, I’ll start repeating the directions while trying to complete the testing.”
  • Practices focused questioning. “When a patient arrives for a follow-up visit regarding medication, for example, we dig deep to determine whether the patient is being compliant with their prescribed drops,” Ms. Johnson says. “So, instead of saying, ‘Are you using your (name of drop),’ staff will say, “How often are you taking your (name of drop),” and “when is the last time you took your (name of drop)?”
  • Provides brochures and handouts. Any time patients must adhere to specific directions, the Ophthalmic Consultants of Connecticut staff provides documents, which patients can refer to post-appointment. For example, Dr. Noeker created a patient-friendly brochure that provides brief descriptions on the common glaucoma surgeries he provides, says Ms. Gonyea.

Janeth Mendiola, RN, left, and Kate Mentes, LPN, right, prepare a patient for surgery.

For her part, Ms. Gonyea provides an information packet that includes, among other items, a green sheet, which “contains the surgery date, time, name and address of the surgical facility, pre-operative directions, such as the eye drop regimen and when not to eat or drink, and the date and time of their follow-up appointment,” she says. “The green sheet stands out from the white papers, which contain insurance information and such, so patients can immediately find it.”

Maintaining efficiency

Ms. Sonemaneevong explains that extra time spent with patients usually does not impede patient flow due to the time savings created by the practice’s state-of-the-art diagnostic devices. Additionally Ms. Sonemaneevong has come up with her own time-saving routine for operating the devices.

“If I’m going to be working up an established patient, for example, I’ll look at their last exam before seeing them, so I know exactly what testing they need, and I can immediately take them to the first device,” she explains. “For the new patient, I know the most efficient order of diagnostic testing because I’ve timed everything out.”

Financial assistance

Numerous studies have identified cost as a barrier to patient compliance with glaucoma treatment. In response to patients who may require financial assistance, the staff of Ophthalmic Consultants of Connecticut:

  • Offers information on pharmaceutical assistance programs. “We work hand-in-hand with the pharmaceutical reps to find out what type of financial relief they offer,” Ms. Johnson says.
  • Provides samples. The practice is “generous” with samples, which also benefits patients whose prescriptions change based on follow-up appointment findings, Ms. Johnson adds.
  • Keeps a database of the doctor’s medication preferences. “If a patient determines they cannot afford a specific medication, the practice keeps a list of alternative, less-expensive options to communicate to the patient,” she says.
  • Reduce or eliminate medication through low-risk surgical procedures. “In the past, we’d [ophthalmic surgeons] often put surgery as the last resort because of the safety profile of the surgeries available,”
    Dr. Noecker says. “But with the recent availability of safer and effective procedures, we’re more likely to perform them earlier in the treatment algorithm versus waiting for patients to be on maximum medical therapy. These procedures can reduce or even eliminate medication use.”

Dr. Noecker with members of the OCC team, including (from left): Janeth Mendiola, RN, Keena Tulloch-Sawyer, scrub technician and Kate Mentes, LPN.

Specifically, Dr. Noecker offers the Xen Gel Stent (Allergan), iStent (Glaukos), iStent Inject (Glaukos), EX-PRESS glaucoma filtration device (Alcon), TCP (transscleral cyclophotocoagulation), ECP (endoscopic cyclophotocoagulation), SLT laser, LPI laser, goniotomy, canaloplasty, Ahmed Glaucoma Valve (Labtician Ophthalmics), and trabeculectomy.

Seeing patients as people

“Patients who have glaucoma, they’re scared,” Dr. Noecker says. “So, to be able to put them at ease by meeting their personal needs, in addition to providing them with the latest diagnostic and surgical technologies, of which there are so many options, is very rewarding.” OP