Home Low Vision Ocular Rehabilitation Telehealth Expansion Due to COVID-19 Pandemic

Introduction

The COVID-19 pandemic resulted in canceling in-person low vision services at the Veterans Affairs (VA) Western New York Healthcare System in Buffalo, New York (Buffalo VA) low vision clinic and all low vision telehealth services at community-based outpatient centers (CBOCs), rural VA’s and home telehealth options for home-based patients who were assisted with a therapist. Low vision and legally blind patients have several challenges to receiving care at a specialty low vision clinic, due to travel restrictions, but the pandemic unfortunately also ended all telehealth options to local CBOCs.

A new challenge to “think outside the box” and “work outside comfort zones” was needed during the pandemic, to modify low vision ocular rehabilitation clinical video telehealth (CVT) services and switch all low vision services (in-person and original telehealth services). With the concern of potential decline of functional ability over time, the goal was to minimize delay in beginning low vision ocular rehabilitation services when diagnosed.

Low vision ocular rehabilitation telehealth services have been successfully provided at the Buffalo VA low vision clinic, beginning in 2012.^1–3 This specialized synchronous CVT low vision service provides low vision ocular rehabilitation telehealth services as early as possible after visual impairment diagnosis, which is important to prevent potential decline in functional ability over time.^4–6

In mid-March 2020, due to the COVID-19 pandemic, in-person or face-to-face low vision optometry services at the Buffalo VA, and CVT clinics at CBOCs and rural VA’s were canceled and not available.

Within 2 weeks at the Buffalo VA low vision clinic, all low vision care was switched to the home for Veterans who had video access.

A low vision optometry telerehabilitation or in-person evaluation is a thorough assessment of patient’s functional vision.^7–13 Throughout the low vision evaluation, the low vision optometrist asks specific functional vision questions, listens to the patient’s answers, and responds to each patient’s answers along with their ocular questions and concerns appropriately. The main goal is to prevent depression by addressing the psychological effects of low vision and provide each patient with the knowledge of their clinical information to help them during this challenging visual transition and introduce magnification and low vision rehabilitation as early as possible after visual impairment diagnosis.

Synchronous CVT is defined as the use of real-time interactive videoconferencing to assess, treat, and provide care to a patient remotely.^14–21 Increasing access to low vision rehabilitation services by utilizing telehealth enables expansion of low vision ocular rehabilitation telehealth services. Whether a low vision patient is evaluated in-person or by using synchronous CVT the low vision optometrist educates and counsels each patient based on their specific visual condition and its implications.

A plan of care is recommended by the low vision eye doctor to improve each patient’s visual functioning specific to each patient’s special vision demands, needs, and adjustment to vision loss. Specifically, low vision eye doctors give recommendations (with positive and negative points) of different devices (both optical and nonoptical) specific to each patient.

Generally, a basic low vision ocular rehabilitation telehealth evaluation is an introduction to magnification by the low vision optometrist who explains how magnification works and more importantly how it does not work. The overall goal is to help the patient accept the use of magnification by learning why they are needed and how to properly use recommended devices.

Expansion of Home Low Vision Ocular Rehabilitation Telehealth During COVID-19

It is important to remember that urgent optometry or ophthalmology care is not a part of a home low vision ocular rehabilitation telehealth evaluation. Any potential ocular emergency requires the patient to be referred to their primary care optometrist or ophthalmologist.

With the goal to not delay initial low vision optometry rehabilitation services, modifications were designed to begin low vision optometry rehabilitation services by providing basic low vision care into the home as soon as possible when diagnosed. Although low vision eye care providers cannot do all testing initially utilizing telehealth, they can verbally address all low vision rehabilitation areas, including near and glare issues and order minimal devices and provide training. It is important to note, if needed, the patient is scheduled in the future to return to the clinic for in-person services when able. At that time, other testing and questions regarding their spectacle correction, bioptic telescopes, and so on can be addressed.

Materials and Methods

VA video connect (VVC) technology enables patients to virtually meet up with their VA health care providers, in a virtual medical room that is encrypted and, therefore, allows the Veteran to connect to a provider from anywhere utilizing their mobile phone or tablet device in their home. If the Veteran does not have access to technology the Veteran asked family members or friends who had access to technology. In one case, a nurse at the Veteran’s inpatient care facility used her tablet to connect the providers to the Veteran for care.

Visual impairment service team (VIST) coordinators are case managers at VA facilities and receive consults from various health care providers to coordinate services for visually impaired and legally blind Veterans. VIST coordinators in rural western New York areas began to cancel all in-person low vision rehabilitation services and offered Buffalo VVC low vision rehabilitation services in their home. Those Veterans and their families, who did have video access on a computer, laptop, tablet, or smartphone utilizing VVC, FaceTime™, Skype™, and so on scheduled a home VVC low vision ocular rehabilitation telehealth evaluation and therapist assessment. Those Veterans and their families, who did not have video access waited to schedule a future in-person low vision evaluation or low vision CVT appointment in-person at a local CBOC or local VA (post-COVID-19).

Owing to COVID-19, all Veterans who lived in urban or rural areas of western New York were not able to access low vision rehabilitation services at the Buffalo VA, rural VA, or rural CBOC. Adding home low vision ocular rehabilitation telehealth services increased access by providing an option to not delay Veterans who had access to connect virtually, beginning March 31, 2020.

Switching all patients to a home low vision ocular rehabilitation telehealth clinic, the delay in beginning low vision rehabilitation (calendar days) can be calculated by comparing the date of their completed home ocular rehabilitation telehealth appointment to the date those Veterans who had to wait to schedule in-person services when available post-COVID-19.

Results

Beginning the week of March 16, 2020, in-person low vision rehabilitation clinics at the Buffalo VA and CBOC were canceled due to the COVID-19 pandemic. At that time, there was no definite time frame of reopening in-person services at the Buffalo VA and CBOC clinics. Within 2 weeks, modified home low vision ocular rehabilitation telehealth services were developed and set up. For all low vision patients who had video access on a computer, laptop, tablet, or smartphone, Veterans scheduled home low vision ocular rehabilitation telehealth evaluations utilizing one of the approved video connections.

Table 1 displays 28 low vision appointments canceled due to the COVID-19 pandemic. Of the 28 canceled appointments, 43% (12/28) were originally scheduled for an in-office appointment at the Buffalo VA VISOR clinic; 54% (15/28) were originally scheduled for a low vision CVT appointment at a rural VA or CBOC; and 3% (1/28) were originally scheduled for original home low vision ocular rehabilitation telehealth with assistance with a therapist in the home.

Within the weeks after the shutdown of in-person clinics, Table 2 displays 54% (15/28) scheduled our new home low vision ocular rehabilitation telehealth evaluation; 25% (7/28) waited until in-person clinics were open; 11% (3/28) waited until rural VA’s and CBOCs were open; 4% (1/28) waited until our original home low vision telehealth services with assistance with a therapist was offered in the future (post-COVID-19); 3% (1/28) unfortunately passed away; and 3% (1/28) could not be contacted during this time.

Table 3 calculates the delay in rescheduling Veterans who were canceled due to the pandemic. Table 3 displays 58% (15/26) who scheduled the new home low vision ocular rehabilitation telehealth evaluation, were delayed on average 25 days; 27% (7/26) who waited until in-person clinics were open, were delayed on average 153 days; 11% (3/26) who waited until rural VA’s and CBOCs were open, were delayed on average 138 days; and 4% (1/26) who waited until the original home ocular rehabilitation telehealth with assistance with a therapist, was delayed 98 days.

During the pandemic (Spring 2020), new patients were also referred for low vision optometry services. Table 4 displays 56 Veterans who requested initial low vision specialty services during this 4-month period, which were in addition to the 28 canceled patients. Per Table 4, 91% (51/56) of the initial requests scheduled the new home low vision ocular rehabilitation telehealth evaluation; 5% (3/56) waited until in-person clinics were open; and 4% (2/56) waited until our rural VA’s and CBOCs were open.

Originally, the VA only offered VVC services utilizing an encrypted virtual medical room. With the pandemic, the VA allowed other modes of video connection that enabled more options for Veterans and their family to choose. Table 5 displays 30% (20/66) chose VVC; 41% (27/66) chose FaceTime; 21% (14/66) chose Google Duo™; 3% (2/66) chose Skype; 3% (2/66) chose the VA issued iPad; and 2% (1/66) chose Facebook Messenger Video chat™. Therefore, nearly 70% of telehealth assess appointments were due to the VA allowing other video connections.

Discussion

Expanding home low vision telerehabilitation services during the COVID-19 pandemic noted an overall increase in Veterans who were able to access low vision optometry services utilizing CVT in their home when in-person services were canceled. Home low vision ocular rehabilitation telehealth evaluations increased new patient workload from 0% during COVID-19 to 91% (51 home telehealth/56 total new patients). This means 91% of new partially sighted or legally blind Veterans did not have to delay beginning low vision optometry rehabilitation services due to COVID-19.

Moving forward, in July 2020, 25–50% of our clinic schedule was approved for in-person clinical care at the Buffalo VA and telehealth at local CBOCs and rural VA’s. Home low vision ocular rehabilitation telehealth continues to be offered as needed for those Veterans who have video access for home CVT services and choose not to schedule low vision in-person services in the hospital.

Conclusion

This study shows and supports low vision ocular rehabilitation telehealth as an accepted, practical, time and cost-saving alternative option to traditional in-person consultations with a low vision optometrist and low vision rehabilitation therapist. Utilizing low vision telerehabilitation increases access as early as possible and enables Veterans who cannot travel to a specialty clinic the opportunity to prevent potential decline in functional ability over time.

As technology advances, future cost-saving technology can be utilized for consultations with a low vision optometrist and therapist. Ultimately, a modern interdependent low vision telerehabilitation service system providing simpler, faster, and cheaper services for Veterans who are partially sighted or legally blind could be implemented.

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received.