Delivering and managing community glaucoma networks with an integrated digital system

East Kent Hospitals University NHS Foundation Trust sees around 90,000 eye care outpatients every year. Around 12,500 of these are low-risk stable glaucoma patients.

Removing low-risk patients from secondary care and managing them in the community improves access for those who need urgent ophthalmic intervention.

Situation

The time it took for patients to get an appointment in the ophthalmic department was increasing.

The backlog of patients who needed a follow-up had increased. This created a safety risk for patients with high-risk conditions like glaucoma.

The Trust also found it hard to meet the demand for new patients who needed to use services.

The Trust needed a solution to increase eye care capacity and reduce inappropriate new referrals to the hospital eye service (HES).

Aspiration

The team wanted a community glaucoma service that followed the NICE best practices. The service would:

• move all suitable stable glaucoma patients from the HES into community services
• keep all newly-suspected glaucoma patients in community services
• achieve target levels of activity

It was also important to maintain access to community glaucoma services to:

• provide care closer to a patient’s home
• give patients more choice
• improve patients’ access to assessment
• reduce wait and treatment times
• make services across East Kent consistent and provide equal access

To support the community glaucoma services, the Trust needed a secure cloud-based platform that works on internet browsers. The platform would:

• manage patients
• carry out administration
• manage all clinical findings
• connect stakeholders in primary care, secondary care and community care
• provide a virtual clinic so consultant ophthalmologists can remotely review the results of each patient appointment

This would help the Trust to take advantage of these skilled community-based resources.

Solution

NHS Kent and Medway’s community glaucoma network (CGN) provides care in a local community optometrist or health centre. They support patients with suspected, stable, or low-risk glaucoma.

The CGN is:

• led and managed by Trust ophthalmologists
• delivered by GPs with a special interest (GPwSIs) and more than 80 optometrists from 36 community optometry practices

The Trust delivers the community service by working with:

• local GPwSIs
• optometrists
• the HES

The CGN is managed using iRIS, a clinical and administrative platform.

It helps optometrists and GPwSIs in the community perform enhanced services from their own premises with their own equipment.

It delivers the entire patient pathway and creates a comprehensive electronic record at each point. iRIS can be used for:

• identifying new potential glaucoma patients
• referral refinement
• inviting patients for full glaucoma assessments
• recording the findings and images of all clinical appointments and full assessments
• enabling ophthalmologists to virtually review, diagnose, prescribe and initiate treatment if needed
• responding to any treatment
• ongoing community monitoring or onwards referral

If it's necessary, iRIS can also be used to refer patients to the HES. This decision is made by the ophthalmologist at the virtual clinic.

The patient's assessment results, previous appointment summaries and images, are then securely emailed to the East Kent Hospital. Patients are then triaged and sent to the correct HES department.

Every patient who has a CGN full assessment requires a virtual review by an ophthalmologist. If the patient requires urgent attention, they are referred to Eye Casualty immediately.

For treatment initiation, education appointments and intraocular pressure (IOP) assessments. Patients only need a follow-up virtual review if there is a specific issue noted during the appointment.

In real-time, iRIS allows network administrators, ophthalmologists, and commissioners to:

• track patients
• manage and oversee the network
• assess the service and deliverables against performance targets

The platform is securely hosted on Carelink and fully compliant.

iRIS is not reliant on other clinical or patient administration systems. However, programmes could be developed to seamlessly interact with these systems if necessary.

Impact

The CGN reduced the burden on HES and improved productivity. It did this by reducing demand for appointments from low-risk patients in hospital eye clinics. This freed up more time for the HES to assess and intervene in more complex cases.

The CGN increased capacity. Unlike the hospital, which has finite premises and staff, new CGN’s are easily added to accommodate patient demand.

CGN has held over 13,000 appointments. These would have otherwise been added to the HES waiting list.

CGN’s improved the patient experience by delivering the highest quality of care in more accessible locations while significantly reducing appointment waiting times.

Most CGN clinics are on the high street or in shopping centres. This reduced the stress and anxiety of driving, parking, and finding the right hospital department. This also reduced did not attends (DNAs).

CGN data shows that even during the COVID-19 pandemic, DNA rates for CGNs are far lower than any published NHS DNA rates.

95% of all patients responded either ‘good’ or ‘excellent’ to every patient satisfaction question.

The service provided a high-quality, consistent outcome, based on authoritative guidance.

Functionality

iRIS is a secure clinical and administrative platform for managing community glaucoma networks. It’s cloud-based and used on internet browsers.

System users are registered and given access based on their role. For example, ‘CGN administrators’ can register new patients and ‘ophthalmologists’ can remotely review patients.

Teams can use iRIS to change the number of patients who need a virtual review after their full assessment.

Multiple ophthalmologists can log into the iRIS virtual clinic simultaneously. A queuing system locks a patient record for a set duration or until the review is complete. This ensures multiple ophthalmologists do not attempt to review the same patient at the same time.

iRIS automatically creates all necessary correspondence for patients, their GP’s and the HES. This includes:

• invitations
• booking confirmations
• results letters
• referrals to HES

iRIS also delivers real-time KPI reports covering:

• activity
• onward referral rates
• waiting times
• DNAs
• first attendance and follow-up ratios

iRIS creates detailed reports to bill the commissioners for the contract provision and pay the CGN clinics for their services. This saves admin time, avoiding any manual intervention and the potential under or overcounting numbers.

Charges are only incurred once an entire pathway appointment is concluded. This means that part appointments or cancelled appointments and DNAs cannot be charged to the commissioners.

The CGN clinic picks up the cost of incomplete, cancelled or DNA appointments. This ensures that the commissioner of services will only ever pay once for a patient episode.

Networks can easily be expanded. Service capacity is only limited by the number of community optometrists who participate.

Capabilities

Using iRIS, optometrists identify and verify suspected glaucoma patients and reduce the number of inappropriate referrals to the full CGN service.

iRIS uses algorithms based on validated methodologies and the latest NICE guidelines. This removes uncertainty around the guidelines and avoids misdiagnosis, errors and duplication.

iRIS allows consultant ophthalmologists to conduct virtual patient reviews.

Reports help verify that 100% of all patients are accounted for. No patient is overlooked, lost, or duplicated.

iRIS cuts down on the amount of administration needed and reduces manual errors.

Scope

Primary care optometrists and GPwSIs can manage glaucoma patients in:

• hospital
• primary care settings
• community settings

Key figures

• CGN has held over 13,000 appointments.
• By 31 March 2021, 33 optometrist clinics were registered as part of the network.
• 99.99% of all patients avoided any intervention at the HES.
• 97% of patients did not need any GP involvement.
• 3,269 patients were assessed in 8 CGN clinics.
• The first attendance to follow-up ratio is 0.91.

Key contact

Paula Smith, Senior Commissioning and Transformation Manager, Planned Care, Head and Neck Services, NHS Kent and Medway

paula.smith5@nhs.net

Joe Devereux, Consultant Ophthalmologist, Community Glaucoma Network

joedevereux@me.com

Warren Diddams, CEO, Medical Diagnostic and Treatment Solutions, Supplier of iRIS Glaucoma

warren@mdtsolutions.co.uk