Specialty Dispensing, Working With the Nursing Home Patient
By Zoriana N. Mangione, Quality Care Opticians, Ballston Lake, NY
Release Date: August 1, 2012
Expiration Date: September 15, 2013
Zoriana N. Mangione, Quality Care Opticians, Ballston Lake, NY
Upon completion of this program, the
participant should be able to:
- Introduce ophthalmic dispensers to other business models and dispensing specialties
- Highlight the challenges in dispensing eyewear to nursing home patients
- Offer solutions to the challenges when working with the chronically ill
This course is approved for one (1) hour of CE credit by the American Board of Opticianry (ABO). Course SWJM260-1
The field of Ophthalmic Dispensing includes many possible business models, encompassing everything from small independent practices, medical practices, chain store operations, discount stores and high-end dispensing. Lesser-known applications of Opticianry include safety eyewear dispensing, personal shopping services, and institutional dispensing, which usually involves the need for mobile opticians. Providing on-site optician services to nursing home residents brings with it unusual challenges and unanticipated rewards.
Becoming a mobile optician for nursing home residents requires, above all else, patience and compassion. Next, one should expect much planning and organization, the willingness to travel from site-to-site in a variety of weather conditions, adaptability to various working conditions at the facilities, the willingness to carry the contents of an entire office to each site, and different communication skills and protocols. For example, getting signatures on file for insurance poses an entirely new set of challenges, since patients are usually either physically unable to sign the forms or are cognitively impaired due to dementia, their need for numerous medications or catastrophic illnesses. In the majority of cases, family members are not present when the nursing home resident is receiving his or her optical services. As a result, most business practices that are relatively routine in an office setting require significantly different approaches in a mobile practice.
Another factor making nursing home work challenging is finding a way to carry an entire optician's office to each facility. Experience directs the type and quantities of items like hand tools, lensometers and frame warmers, and replacement parts (e.g., nose pads, temple tips, screws, etc) that are necessary for your mobile office. Frame inventories meeting the requirements of the major insurance companies in your area, and various forms of paperwork must also be brought to each facility, each time. A variety of options exists for carting the necessary equipment, ranging from rolling sales cases to stacked crates loaded onto a hand-truck. Creativity is key in making this part of the job far less physically taxing.
Then, the optician must be very open-minded as to what constitutes a useable workspace. Nursing homes generally do not have extra office space available for a makeshift optician shop. Often, the beauty shop or dental office is used for the optician clinics. Sometimes, a conference room might be used. In many cases, the space provided leaves much to be desired, as lighting is often inadequate for use as a dispensary, especially when trying to locate the slot in the screw head. Here, creativity and a sense of humor can save the day. Overcoming challenges like these are part of what make this job so fulfilling.
THE FRAME CHALLENGE
Other challenges include finding a frame inventory with deeper “B” dimensions, softer colors, and with sturdy endpieces and temples to accommodate those with physical impairments following a stroke or surgery. Boldly colored frames often make a poor choice for nursing home residents because their complexions are usually quite pale, due to a combination of age and frailty. Also, people often find it harder to accept change as they age. It's amazing to see how many people are still wearing the oversized frames that were popular in the 1980s. Still, there also are quite a few patients still wearing their original American Optical or Shuron frames with interchangeable top rims!
Even though it is possible to find frames with a deep “B” measurement relative to today's styles, most nursing home patients are looking for frames as deep as goggles, reaching from the top of the eyebrow to mid-cheek, preferably in a blue-rose color. While finding frames matching these descriptors can be quite a challenge, it can be just as challenging to convince the wearer that a slightly smaller “B” dimension will still provide ample room for reading through their bifocal. Seniors get so accustomed to the deep frames that they find themselves looking under the bifocal, not through it, when reading with a narrower frame. Shortening the vertex distance of the eyewear helps to minimize this effect.
The quality and durability of frames that meet most insurance pricing guidelines usually leave a lot to be desired. Many of these frames would be of passable quality for someone who is able to handle their eyewear properly, but for a nursing home resident that generally has limited use of their arms; the frames bend or loosen continually. These frames require frequent, routine adjustment. Conditions like Parkinson's disease, multiple sclerosis, arthritis, and paralysis following a stroke significantly impair the wearer's ability to handle eyewear in the manner usually recommended by professionals. After a few weeks of one-handed handling, the eyewear winds up at the end of the wearer's nose, or with the temples bent out so far that it's physically impossible for both temples to touch both ears at the same time. In addition, one must also consider the damage from repeated naps with the glasses on, eyeglasses being run over by the wheelchairs, eyewear getting stuck in the hospital beds, and carelessness in handling the eyewear by the residents' caregivers.
Even if the frame is generally a good fit, there are several considerations that affect frame comfort for the nursing home population. Mature skin is extremely thin and lacks the fatty deposits in the bridge area that was once more abundant. This means that the bridge of the nose has a greater tendency to get painful red marks from bent or poorly adjusted nose pads. One would be amazed at how quickly the red marks turn into open sores or cystic formations, which can sometimes even cause blocked tear ducts. Changing smaller, hard plastic or vinyl nose pads to the soft silicone variety, in the 15 – 17mm size range, are an important first step in remedying the situation. Next, the optician should pay careful attention to adjusting the nose pad angles so that they closely match the contours of the wearer's bridge.
METAL FRAMES AND FITTING TEMPLES
It is common knowledge that the frames covered by most government plans are very inexpensive and, as a result, the plating wears off quickly, exposing the base metal. The exposed base metal soon oxidizes when it comes in contact with skin oils, and if the temple fit is too tight, it turns both the eyeglass temple and the wearer's temple a lovely shade of green. This is not only unsightly and uncomfortable for the wearer; it is also unhealthy for the skin. Once the thin, mature skin has turned green, it can soon develop an open sore, which exposes the patient to the risk of infection. Obviously, it is best to avoid these circumstances altogether. Nursing home residents have enough other health issues to contend with, so the best remedy in this regard is prevention. When fitting the temples, be certain that there is enough clearance between the eyeglass temple and the wearer's head to allow a piece of paper to slide in, unrestricted. When fitting temples, be certain that there is a gap of approximately 2-3mm between the eyeglass temple and the wearer's head. The only part of a metal temple that should touch the skin is the plastic temple tip. This will be more comfortable for the wearer and slow down the corrosion process.
Getting a comfortable temple tip fit can also be a challenge. Many nursing home residents had mastoid surgery decades ago, which leaves large depressions in the contour of the skull behind the ears. Hearing aids and oxygen tubes further complicate adjustment. Where possible, select temples that are neither too thin nor wiry, since they can dig into the skin much more easily, causing sores. If the temples are too thick, they can interfere with hearing aid and oxygen tube placement, and are sometimes harder to adjust to a snug-fitting curl behind the ears.
For many residents, arthritis and/or other medical conditions cause them to slump far forward in their wheelchairs, so that eyewear is in constant danger of falling off. A riding bow adjustment to the temple is a good way to minimize the amount of slipping. For these residents, a head strap can sometimes be beneficial, but is usually too uncomfortable for the wearer, getting tangled in their hair or causing discomfort when they rest their head on a pillow. If the resident is easily agitated, a head strap or eyeglass cord could present a strangulation hazard, if they tug vigorously at the cord. It also complicates the process of putting the glasses on and off, which only leads to more bent frames. When cervical collars or neck braces must be contended with, be sure to adjust the temple length and curl so that they do not come in contact with the brace. Contact between the temple and brace would continually push the eyewear down the nose or cause the temples to ride high over the ears, adding a significant amount of pantoscopic tilt, affecting fit and vision.
Choosing the right lens design can be a bit more complicated for the nursing home patient. The vast majority of nursing home residents use a flattop lens design; but some residents ask for single vision lenses, while others wear the progressive lenses that they obtained prior to their move to the nursing home. Single vision eyewear is often problematic because neither the patient nor the aide can differentiate reading glasses from the distance pair. As a result, a resident might wind up wearing their near vision eyewear all day long. The staff might then notice that the resident has become more withdrawn, not realizing it's because they can't see farther than arm's length away. Many times, the residents cannot articulate their problem. A flattop design bifocal might be the safer solution, since there would be only one pair of glasses to keep track of, and the resident would not be looking through a near vision prescription all day long.
As prescriptions change, residents might be able to stay in a progressive design, but certain changes in their general health make it less desirable to do so. As long as their medical condition does not affect their cognitive state, their balance or their gait (for those who are still ambulatory), the wearer would still be considered a good candidate for a progressive lens. More often than not, those residents whose remaining vision and cognitive state are robust enough to warrant a multifocal, a flattop design is much easier and more practical for them to use. There should also be financial considerations in making the final lens design decisions, as well. At costs exceeding $9,000 per month for nursing home care, options like progressives are not typically covered by insurance and are usually sidetracked in favor or more basic solutions. Another consideration is the frequency with which eyewear gets misplaced or lost in a nursing home setting. Since virtually every resident who is ambulatory or enjoys mobility via use of a wheelchair wears eyeglasses, it becomes very easy for them to assume that the glasses on the dining room table are theirs, and not their dining companions'. It is a very common fact of life for nursing home residents to be wearing someone else's glasses, in error, and not even realize it! Especially for those wearing progressives, this can be a very expensive loss to endure.
Life in a nursing home setting is not usually visually demanding. If the wearer is an avid reader or enjoys crafts like knitting or crocheting, flattop bifocal segments fitted at or slightly higher than the lid margin will help the wearer maintain a more comfortable neck posture while engaging in their favorite pastime. Those who enjoy doing things like crossword puzzles, jigsaw puzzles, playing cards or board games might even have the need for a trifocal, depending on how much of those activities they do throughout the day.
For those who have lost the ability to concentrate or read, the use of a bifocal is often still indicated. Even though their use of the bifocal segment would be significantly limited compared to that of a person living independently, it is best to assume that having a low set bifocal might provide an occasional benefit. It might allow the individual a few moments of happiness as they look at a family photo or a greeting card. Perhaps having a low-set bifocal might enable that person to see his dinner plate more clearly, allowing him to retain further independence by feeding himself. Often, no one is certain how much benefit wearing eyeglasses might offer, but the rule is to assume that as long as there is the potential for some benefit from wearing the glasses, the eyewear should remain part of the individual's care plan. Sadly, there may come a time when dementia reaches a point where the individual is truly unaware of his or her surroundings. Here, the decision to abandon eyewear is made in concert with the staff, families and opticians.
Contrary to standards for those living in the community, lens options, including photochromics or anti-reflective coatings, are not practical in nursing home settings. First and foremost, eyewear in nursing homes rarely gets cleaned properly, negating any benefit from non-glare coatings. Secondly, most residents are unable to spend much time outdoors, making the additional cost of a photochromic lens unnecessary. Thirdly, the problem of lost glasses, repeated purchases and minimal insurance coverage makes these options less desirable.
In addition to significant physical ailments, debilitating ocular conditions like age-related macular degeneration, diabetic retinopathy, glaucoma, and cataracts can wreak havoc with a resident's quality of life. In cases such as these, eyeglasses generally have minimal effect on a resident's eyesight. However, this does not mean that all hope is lost. Non-eyeglass aids, including magnifiers and goose-necked reading lamps, can go a long way in allowing a person to continue at least some aspects of their former abilities. Technology can also play a large role in maximizing the remaining vision for some people. E-readers make it easy to enlarge the print of any book or text quite significantly. Their size and lightweight is also desirable for those who find it difficult to hold a heavy book in their hands. Because it is not necessary to turn any pages, using e-readers is desirable for those suffering from arthritis in their hands. Although not yet widely used, it is easy to envision increased popularity in these products as seniors become more comfortable with the technology and the price of the products decreases.
At this point, one may wonder why on earth anyone would ever agree to work within such different and difficult parameters. Good question. The answer may be different for each optician choosing this path. Some might cite the flexibility of their work schedule, or never having to worry about being stuck in a rut at work. Others might mention that it's a way to give back to their communities. But most will agree that it offers a way to work with some of the most amazing people one could imagine: a Tuskegee airman, an anthropologist trained by Margaret Mead, a burlesque dancer, a scientist, an inventor, a professional baseball player, an artist, a musician for Tony Bennett's band, a teacher, or a husband or wife who gave of themselves to build a good family and community. Today's nursing home residents have lived full and interesting lives. They helped shape our culture and society, in ways big and small. They face the daily challenges that their chronic medical conditions bring with bravery and wisdom. They need and deserve this service. As someone who has had the honor of working with this great generation, what keeps this author coming back to work each day is a deep sense of gratification, knowing that my work has made a real difference in the lives of so many wonderful people.