The Case for Primary Eye Care Integration in Community Health Centers

Abstract

In this Commentary, we provide an in-depth look at the National Academies of Sciences, Engineering, and Medicine (NASEM) report, “Making Eye Health a Population Health Imperative Vision for Tomorrow (2016),” which emphasizes the need for the integration of vision and eye care into more holistic healthcare delivery approaches, since many individuals who are visually impaired have disproportionately high rates of chronic co-morbidities. We have highlighted current barriers as well as a coordinated approach and methodology to improve team-based care in the United States to reduce eye and vision health disparities, particularly through the delivery model of community health centers; however, the model might be applied in other countries.

Commentary

In 2016, the National Academies of Sciences, Engineering, and Medicine (NASEM) released a report highlighting the importance of vision and eye health as a public health challenge in the United States. The report titled, “Making Eye Health a Population Health Imperative Vision for Tomorrow,” aptly noted that “Sight is clearly important to the health and quality of life for children, adults, and seniors, but it has consistently failed to achieve the status of a national health priority.” ¹ This powerful observation underscores the importance of improving infrastructure in ways that address visual health disparities and the unmet need for eye and vision care services. This is particularly important in primary care and preventive care settings, since the vast majority of vision impairment can be avoided or treated with early detection and effective management.^{2 -6} The NASEM report outlined 5 foundational action areas: facilitate public awareness through timely access to accurate and locally relevant information, generate evidence to guide policy decisions and evidence-based actions, expand access to clinical care, enhance public health capacity for vision-related activities, and promote community actions to encourage healthy eye and vision environments. Since 2016, some of the recommendations outlined by the NASEM report have been addressed including advocacy efforts, cross-organizational collaboration, database expansion, and growth of clinical services, but a considerable amount of work remains to address upstream determinants of vision health with more holistic strategies that take into account barriers to care. Since their inception in the US, community health centers (CHCs) have worked to improve health outcomes for underserved communities, and continued work to increase eye care service expansion in CHCs is necessary to reduce preventable vision loss.

Studies have consistently shown that the public considers vision impairment to be one of the most feared adverse health outcomes, surpassing cancer and neurodegenerative conditions, like Alzheimer’s disease. ⁷ Significant inequities in avoidable vision loss exist. In the United States, women experience a higher prevalence of vision loss than men, and Hispanic/Latino and Black individuals have a higher risk of vision loss than Whites. ⁸ Children from under-resourced urban areas experience more than twice the rate of vision problems than normal, but are less likely to be referred to and receive an eye examination by an eye doctor. ⁹ Furthermore, diabetes is the leading cause of irreversible vision loss in the working-age adult population in the US, despite the fact that vision loss from diabetes is preventable 95% of the time. ¹⁰ Currently, only 66.0% of adults with diabetes undergo a recommended yearly eye exam in the US, ¹¹ despite ongoing educational campaigns by many governmental agencies^12,13 and non-profit organizations.^14,15 In addition to being a health outcome, it is important to recognize the bidirectional nature of vision impairment and how it acts as a determinant for other important health and social outcomes. The multifaceted impact of vision impairment occurs across the age spectrum and is well documented—ranging from limiting a child’s educational opportunities^16,17 to exacerbating social isolation ¹⁸ and chronic conditions ¹⁹ in older adults. Untreated vision loss has also recently been identified as a potentially modifiable risk factor for dementia. ²⁰ These effects reverberate across communities, compounding health inequities and undermining quality of life. Many of these poor health outcomes could be mitigated through more thoughtful approaches to eye and vision care delivery, particularly in populations who are most medically vulnerable and underserved. ²¹ Even though the majority of vision impairment is avoidable or manageable with timely interventions, many of those in greatest need for vision care services lack access to eye care providers, are unable to utilize their services, ²² or cannot afford vision correction or medications. Reasons for this unmet need range from health literacy to cost/insurance coverage to geographic distribution of providers. ²³ Vision health surveillance data demonstrate consistent and clear associations between high rates of vision impairment and social determinants of health, including lower levels of formal education, lower annual household incomes, living in rural communities with low provider density, and lack of insurance coverage and access to health care services.^{24 -26}

Intuitively, the population understands the importance of vision, and for over 2 decades health surveillance data have been used to more clearly characterize vision impairment as a public health challenge.^{27 -30} This challenge will only worsen for the foreseeable future, as the rates of vision impairment are projected to increase as the American population ages and is expected to disproportionately impact individuals who are at greater risk of poor health outcomes. ³¹ Since 1990, the US Office of Disease Prevention and Health Promotion has recognized the need to improve vision health on a population scale through its public health agenda called Healthy People. The current iteration, called Healthy People 2030, includes 14 goals from the Healthy People Vision Workgroup.^11,32 The potential benefit of improved integration of eye care services into CHCs is recognized specifically in the Healthy People 2030 initiative with objective V-R01. This particular objective is currently in research status, meaning that it is a high-priority public health issue that does not have an evidence-based intervention to address it. It may or may not have reliable baseline data available. Developing a sufficient evidence base to describe the effectiveness of vision services in CHCs would help move this objective from a research objective to a core objective that could be more easily propagated across future iterations of the Healthy People initiative. This transition will require more deliberate data collection strategies that bridge existing knowledge gaps and provide greater insight into the current status and effectiveness of vision care services in CHCs. While these objectives help raise the profile of vision as a national health priority, more work is needed to ensure that these objectives can be leveraged to improve eye health equity.

There is good reason to consider CHCs as an approach to reducing health disparities.^33,34 Federally qualified health centers (FQHCs) and look-alikes (FQHC-LAL) are collectively known as community health centers (CHCs), and are uniquely positioned to improve health equity for the most medically vulnerable by providing centralized, interdisciplinary, comprehensive primary care services to individuals with significant barriers to healthcare access. CHCs are deliberately designed to overcome many barriers to accessing care, including transportation, lack of health insurance, and coverage for eye exams, as well as language/enabling services through providing culturally competent care. Furthermore, community and rural health centers are often the only point of access to eye and vision care for many vulnerable and underserved communities. ³⁴

Mounting evidence demonstrates that CHCs are an effective way to improve vision care access and utilization to those who are in greatest need of those services. ³⁵ In the US, optometrists provide primary eye health care and vision correction, and ophthalmologists are medical doctors who provide advanced medical and surgical eye care. Doctors of optometry examine, diagnose, treat, and manage diseases and disorders of the eye, as well as detect systemic disease such as diabetes, hypertension, autoimmune disease and cancer, and diagnose, treat and manage ocular manifestations of many of those systemic diseases, ³⁶ with referral to ophthalmology for surgical and medical management of more complex ocular conditions. An example of successful eye care integration with CHCs, the first FQHC was started in 1965 by Dr. Jack Geiger and Count Gibson at Columbia Point in Dorchester, Massachusetts. Seven years later, the New England College of Optometry (NECO) launched partnerships with Boston-area CHCs to provide primary eye care while providing clinical experiences for optometry students. Students rotate through CHCs and are exposed to a wide range of ocular conditions, and learn to advocate for patients for whom socioeconomic risk factors present barriers to positive health outcomes. There are currently 8 optometry schools with CHC student programs and 10 CHC optometry residencies. ³⁷ Several CHCs also have ophthalmologists on staff with co-management and referrals to regional medical centers. Community health is a space where all eye care providers can work together. In addition, by facilitating care coordination among multi-disciplinary provider teams, CHCs can improve poor health outcomes that disproportionately impact the visually impaired population, such as falls ³⁸ and depression. ¹⁸ This care coordination would require expertise in primary care, social work, and health promotion to ensure that a range of healthcare needs are met. In doing so, eye care in CHCs positively influences broader health outcomes associated with vision impairment.

Visually impaired individuals are a particularly high-risk population with complex healthcare needs, including multiple chronic comorbidities, complicated by socioeconomic factors that likely preclude them from receiving healthcare in other practice settings. Despite the need for a more robust evidence base specific to CHCs, there is a considerable, albeit fragmented, evidence base for the benefits of vision care integration into broader healthcare systems.^39,40 This integration is effective at improving health outcomes and potentially reducing the cost of chronic disease management, underscoring the need for improved centralization of providers and team approaches to healthcare delivery. Studies using claims-based data demonstrate that eye and vision care embedded in a multidisciplinary healthcare system provide additional capacity for the management of systemic diseases that have ocular manifestations. Eye care providers are often the first to identify systemic disease processes such as diabetes and hypertension^41,42 and are effective at re-engaging patients who have lapses in their chronic disease management. ⁴³ Additionally, primary care providers are most effective at recommending eye care services, ⁴⁴ which is a professional resource that has been historically underutilized. These findings, in combination, highlight how vision care can proactively play a role in chronic disease management for conditions like diabetes, while simultaneously lowering the costs to healthcare systems.^39,43

Additional work is needed to identify the most effective approaches to delivering vision care services to communities with the greatest unmet need and to establish a more robust evidence base for those interventions. Telemedicine platforms have filled many of the gaps in access to screening for sight-threatening vision conditions like diabetic retinopathy, but there remain significant gaps between screening and access to subsequent treatment. ⁴⁵ Additionally, in 2023, 26% of FQHCs, localized to a few states in the US, provided vision care onsite, which translates to 2.9% of the American population overall receiving care services within FQHCs nationwide; this was primarily based upon the low penetrance of on-site delivery across the nation as compared to dental, for example. ⁴⁶ These findings have not increased significantly since that time. Current barriers to increased penetration are predominately financial: In the United States, vision care is not a mandatory service in Section 330 of the Public Health Service Act as is dental and other primary care services. As a result, vision care has had limited opportunities for greater service integration. Encouraging all stakeholders to advocate for the addition of vision care as a mandatory service under HRSA represents a key step in moving policy forward. It is also critical to understand what demographic groups are being served by CHCs and whether more targeted approaches need to be considered. For example, in a recent systematic review of eye care in FQHCs, none of the articles included data on pediatric vision screenings even though pediatric vision screenings are mandated by FQHCs, and children make up a large portion of the population served by FQHCs, ³⁵ with 1 out of 9 children receiving care in FQHCs. ⁴⁷ Additional data need to be captured, including adding ocular diagnostic codes to the Health Resources and Services Administration (HRSA) Uniform Data Set (UDS), which would address the residual questions surrounding service availability, utilization, prevalence of disease, and impact of team-based care at the community level.

Additional collaborative work between public health advocates and healthcare providers could work to elevate eye health as a core component of population health in order to better achieve sustainable equity. One example is the collaboration between Prevent Blindness America (PBA), the Association of Clinicians for the Underserved (ACU), and the National Association of Community Health Centers (NACHC). Aside from continued dialogue, this partnership has resulted in an innovative webinar series, Eyes on Access, which has provided FQHC clinicians, staff, and leadership with clear, concise information on topics ranging from common eye findings to space planning, business models, and workforce acquisition for incorporating onsite eye clinics. Each webinar has garnered nearly 500 participants with ongoing downloads. Several national-level organizations have also begun promoting the need for vision services at CHCs including the American Academy of Optometry and the American Academy of Ophthalmology. The American Academy of Optometry established a Community Health Center Special Interest Group in 2024. Goals include encouraging research in community health and health equity, advising the Academy on policy, and promoting and enhancing the identity of optometry within community health and interprofessional collaboration. The American Academy of Ophthalmology established a Task Force on Ophthalmology and Community Health Centers in 2022 and has since published several articles examining the need for eye care in CHCs and associated barriers for its inclusion.^35,48

Future projections for vision impairment are troubling and highlight the NASEM report’s emphasis for urgent action. Vision impairment prevalence is anticipated to increase for the foreseeable future and is expected to disproportionately impact individuals who are already at greatest risk for poor health outcomes. While many public health initiatives and goals seek to reduce vision impairment, the current trajectory would suggest that a reduction in vision impairment is unlikely without fundamental changes to care delivery. Unless eye care can be more effectively delivered to high-risk populations in a way that is sustainable and patient-centered, we will be unable to maintain the status quo, and lowering the prevalence of vision impairment will be nearly impossible. The NASEM report concludes by listing a number of recommendations that address eye health challenges across the public health prevention continuum. These recommendations closely align with a subset of national health objectives and the overarching goals of CHCs. As outlined in the NASEM report, we must continue to urge policymakers in the US to allocate resources toward vision care initiatives, support evidence-based data collection on innovative screening and treatment methods, and implement programs that make eye and vision care accessible to all. We will certainly need the involvement of primary care providers to assist with advocacy efforts for increased vision screening and eye care service expansion in underserved communities. We will also need the robust delivery care model of CHCs if we are to achieve these ambitious goals.